DICTIONARY OF MEDICINE 
VOL. I DICTIONARY OF MEDICINE 
INCLUDING GENERAL PATHOLOGY, GENERAL THERAPEUTICS 
HYGIENE, AND THE DISEASES OF WOMEN AND CHILDREN 
BY VARIOUS WRITERS 
EDITED BY 
RICHARD QUAIN, Bart., M. D. Lond., LL. D. Ed., F. R. S. 
President of the General Council of Medical Education ; Member of the Senate of the University of London 
Hon. M.D. Trin. Coll. Dublin; Hon. M. D. Royal University of Ireland 
Fellow, late Vice-President, and Senior Censor of the Royal College of Physicians 
Hon. Fellow of the Royal College of Physicians of Ireland ; Physician Extraordinary to Her Majesty the Queen 
Consulting Physician to the Hospital for Diseases of the Chest, Brompton, and to the Seamen's Hospital, Greenwich 
ASSISTED BY 
FREDERICK THOMAS ROBERTS, M. D. Lond., B. Sc. 
Fellow of the Royal College of Physicians; Fellow of University College 
Professor of Materia Medica and Therapeutics, University College 
Physician and Professor of Clinical Medicine, University College Hospital 
Consulting Physician to the Hospital for Consumption and Diseases of tne Chest, Brompton 
AND 
J. MITCHELL BRUCE, M. A. Abdn., M. D. Lond. 
Fellow of the Royal College of Physicians 
Physician and Lecturer on the Principles and Practice of Medicine, Charing Cross Hospital 
Physician to the Hospital for Consumption and Diseases of the Chest, Brompton 
WITH AN AMERICAN APPENDIX 
By SAMUEL TREAT ARMSTRONG, M. D., Ph. D. 
Visiting Physician to the Harlem, Willard Parker, and Riverside Hospitals, New York, etc. 
New Edition, Revised throughout and Enlarged 
VOL. I. ABDOMEN- LYSIS 
NEW YORK 
D. APPLETON AND COMPANY 
1895 Copyright, 1894, 
By D. APPLETON AND COMPANY. PREFACE 
1894 
The Preface to the original issue of this Dictionary, which will be found 
at page vii of the present volume, contains a statement of the motive 
which originally induced the Editor to enter on the preparation of the 
work. Briefly, that motive was supplied by a desire to place in the hands 
of the practitioner, the teacher, and the student, a means of ready reference 
to the accumulated knowledge which we possessed of scientific and prac- 
tical Medicine, rapid as was its progress, and difficult of access as were its 
scattered records. 
That the object in view was successfully attained, has been rendered 
abundantly evident by the reception accorded to the Dictionary. Since 
its appearance in 1882 more than 38,000 copies have been issued in this 
country and America, whilst the Editor personally has received most 
gratifying assurances of the value and utility of the work. 
Having made this reference to the past, he has now to say that the 
motive which then influenced him is felt with greatly increased force at the 
present time. Never in the history of Medicine has progress been so 
rapid as during the last twelve years. Not only has our knowledge of 
old and familiar facts been improved, but an entirely new development of 
our science has occurred, more especially with reference to the causation 
of disease and, it may be added, the preservation of health. It had there- 
fore become necessary to make a complete revision of the work. In the 
performance of this duty, it has been the aim of the Editor to combine 
what was good in the original, amended as experience suggested, with such 
new matter as proved to be acceptable after full consideration. 
In order to accomplish these objects, the several articles have been 
revised by the original writers, so far as this has been practicable. When 
death unhappily prevented such revision, the task was committed to other 
not less competent writers. The services of equally competent contributors VI 
PREFACE 
were secured for the preparation of new articles. To these gentlemen, 
friends and colleagues, the Editor offers his grateful thanks for the ability 
and zeal with which they have discharged the duties undertaken by them. 
He has the gratification of feeling that the contributors to the Dictionary 
may regard with great satisfaction the result of their labours. 
The Editor has also to speak with sincere thanks of the valuable services 
which have been rendered him by his fellow-labourers, Dr. Frederick T. 
Roberts and Dr. J. Mitchell Bruce. In the Preface to the former Edition 
he stated that without the help afforded by them he would have found it 
impossible to accomplish the undertaking. He appreciated then the marked 
ability by which their assistance had been characterised, and he desires 
now to repeat the expression of his appreciation, recognising that their 
services have been rendered of much greater value by their increased 
experience. He has on these grounds felt it a pleasing duty to place the 
names of these gentlemen on the title-page as his Assistant-Editors. At 
the same time he feels it right to say that he is personally responsible 
for the work, of which no portion has been issued without being carefully 
revised by him. He has also heartily to thank his friend Mr. John 
Harold, Medical Registrar to Charing Cross Hospital, not only for his 
contributions to the Dictionary, and for the assistance which he has ren- 
dered in revising the proof-sheets and passing the work through the press, 
but also for the pains which he has bestowed upon the conduct of the 
necessary correspondence with various writers, and in collecting the 
materials. 
It only remains to state that the work, consisting now of two volumes, 
has been entirely reprinted in larger type, that the number of pages has 
been increased from 1,834 to 2,518, and that 43 new illustrations have been 
added to those in the former Edition, so that the illustrations now amount 
to 181. 
London : May 1891 PREFACE 
1882 
The vast number of facts and observations, by which the recent progress 
of scientific and practical medicine has been marked, is diffusely recorded 
in the Transactions of learned societies, in journals, in monographs, and in 
systematic treatises. With progress so rapid, and information so diffused, 
it is extremely difficult alike for the practitioner, the teacher, and the 
student to keep pace. It was the perception of this difficulty which induced 
the Editor, when invited to undertake the production of a new Medical 
Dictionary, to engage in a task which, he was fully conscious, must be one 
of great labour and of great responsibility. He felt, however, that he 
would be rendering useful service to his Profession if he could bring 
together the latest and most complete information in a form which would 
allow of ready and easy reference. Accordingly, he invited the co-operation 
of certain of his colleagues and professional friends, both in this country 
and abroad ; and evidence of the readiness with which this invitation has 
been accepted, is afforded by the list of contributors. Each contributor 
volunteered or was invited to write on a subject with which he was specially 
familiar. The present work, which is the result of these combined efforts, 
may therefore be regarded not only as a dictionary, but also as a treatise 
on systematic medicine, in which the articles on the more important sub- 
jects constitute monographs in themselves, whilst definitions and descrip- 
tions of matters having less claim to extended notice are given as fully as 
is required. Thus an endeavour has been made to supply, in a clear, con- 
densed, and readily accessible form, all the information that is at present 
available for the use of the practitioner of medicine. 
As indicated on the title-page, the work is primarily a dictionary of 
Medicine, in which the several diseases are fully discussed in alphabetical 
order. The description of each includes an account of its aetiology and 
anatomical characters ; its symptoms, course, duration, and terminations; 
its diagnosis, prognosis, and, lastly, its treatment. General Pathology 
comprehends articles on the origin, characters, and nature of disease, and VIII 
PREFACE 
the many considerations which these topics suggest. General Therapeutics 
will be found to include articles on the several classes of remedies-medi- 
cinal or otherwise-which are available for the purpose of treatment; on 
the modes of action of such remedies; and on the methods of their use. 
The articles devoted to the subject of Hygiene will be found to treat of the 
causes of disease, of its prevention, of the agencies and laws affecting 
public health, of the means of preserving the health of the individual, of 
the construction and management of hospitals, and of the nursing the sick. 
Lastly, the diseases peculiar to Women and Children are discussed under 
their respective headings, both in aggregate and in detail. 
It may be well to explain that, although it has been found necessary to 
include some notice of diseases which fall more generally under the care of 
the surgeon, the work does not pretend to be a dictionary of Surgery; and 
also that, although certain drugs are enumerated in discussing subjects of 
general therapeutics, and of poisons and their actions, there has been no 
intention to invade the domain of Materia Medica. 
It is right to observe that all the articles have been edited and revised 
with great care, so as to ensure a completeness and unity in the work, 
which it is not always possible to obtain in books composed by a number 
of writers. 
The Editor desires also to state that, although the work has occupied 
several years in preparation, arrangements were made with the printers 
which have enabled him to revise every article which required revision, up 
to the time of going to press. Further, by the addition of an Appendix, 
it has been possible to incorporate the latest contributions to medical 
knowledge. 
Having thus set forth the aims and objects of his undertaking, and how 
far they have been carried out, the Editor has the great satisfaction of 
offering his thanks to his friends and colleagues, for the valuable assistance 
which he has received from them. He is fully conscious of the trouble 
which must often have been necessary in order to condense extended know- 
ledge of a familiar subject within the limited space which the nature of this 
work could afford. 
The Editor has further the pleasing duty of offering his special thanks 
to Dr. Frederick T. Roberts and to Dr. J. Mitchell Bruce, who from the PREFACE 
IX 
first have been his Assistant-Editors and fellow-labourers. Without the 
help which they have afforded him, it would have been impossible for him 
to have fulfilled the duties which he undertook. He is well aware of the 
time and labour which their assistance has involved; and he appreciates 
most fully the marked ability by which it has been characterised. 
The Editor cannot conclude without a reference to some of those who 
were his friends and colleagues when this work was commenced, but who 
have since been taken away by death. He would specially mention the 
names of Edmund Parkes, Charles Murchison, George Callender, Thomas 
Bevill Peacock, John Rose Cormack, Lockhart Clarke, Tilbury Fox, 
Thomas Hayden, Harry Leach, Alexander Silver. The loss of these 
eminent men, many of them dear and valued friends, and all of them taken 
too soon from their unfinished labours, is to him a source of personal 
sorrow. The articles written by them for these pages were in most 
instances their last contributions to medical literature, and will be valued 
accordingly. 
London : September 1882. NOTE OF 
EDITOR OF AMERICAN APPENDIX. 
The thorough character of the revision that has been made in this work 
left but little for the author of the appendix to do save introduce some 
recent medical terms, make a few cross references, give more definite 
information regarding American mineral springs, and add one or two arti- 
cles on particularly American topics. It is hoped that these may serve 
to increase the usefulness of the volumes. 
It is necessary to acknowledge indebtedness to Foster's Encyclopaedic 
Medical Dictionary, to Dr. A. C. Peale's Lists and Analyses of the Mineral 
Springs of the United States, and to Von Jaksch's Clinical Diagnosis. 
Samuel Treat Armstrong. 
166 West Fifty-fourth Street, New York. LIST OF ILLUSTRATIONS 
IN VOLUME I 
FIGURB PAGE 
1. Actinomycosis . .... 17 
2. Retinal Haemorrhage in Pernicious 
Anaemia CO 
3. Microscopic appearances of the red 
blood - corpuscles in Pernicious 
Anaemia 61 
4. Section of the liver in Pernicious 
Anaemia after treatment with ferro- 
cyanide of potassium and hydro- 
chloric acid 62 
5. Aphasia. Diagram showing the com- 
missural connexions between the 
different Word-centres . . • 100 
6. Diagram showing the possible location 
of an Aphasia-producing lesion . 101 
7. Papilloma of soft palate . to face 270 
8. Epithelioma of lip . . . „ 270 
9. Edge of Rodent Ulcer ...» 270 
10. Simple Polypus of rectum . . „ 270 
11. Columnar Epithelioma of intestine „ 270 
12. Colloid of breast . . . . „ 270 
13. Cancer of liver (Scirrho-ence- 
phaloid) 270 
14. Scirrhus infiltrating fat . . „ 270 
15. Encephaloid Cancer . . . „ 270 
16. Cicatrising Cancer . . . 270 
17. Scirrhus of mamma . . . „ 270 
18. Adenoid of upper jaw (benign) . „ 270 
FIGURE PAGE 
19. Adenoid of breast (common type) to face 270 
20. Ulcerated Adenoid of parotid 
(malignant) . . . . „ 270 
21. Adenoid of breast (epithelial ele- 
ment in excess) . . . „ 270 
22. Adenoid of breast (Adeno-sarcoma) „ 270 
23. Cardiogram 277 
24. Renal casts-blood- .... 280 
25. „ hyaline .... 280 
26. „ epithelial . . . 280 
27. „ fatty . . . .281 
28. „ granular . . . 281 
29. „ enclosing crystals, and a 
smaller cast; also of seminal tubule 
with spermatozoa .... 281 
30. Side view of the Left Hemisphere of 
the Monkey 394 
31. Side view of the Left Hemisphere in 
Man 394 
32. Cysticercus -\tela) celluloses, removed 
from the human eye . . . 580 
33. Unarmed head of Tania mediocanel- 
lata 580 
34. Armed head of Tcenia solium . . 580 
35. Proglottis of Tcenia mediocanellata . 581 
36. Proglottis of Tcenia solium. . . 581 
37. Tania echinococcus .... 581 XII 
LIST OF ILLUSTRATIONS IN VOLUME I 
FIGURE PAGE 
38. Hydatid of four weeks' growth, show- 
ing ectocyst and endocyst . . 582 
39. The so-called Echinococcus head, 
showing hooks, suckers, cilia, and 
corpuscles 582 
40. Group of Echinococci, with their hook- 
crowns inverted .... 582 
41. Bilharzia hcematobia, male and female 
sexually combined .... 584 
42. Ovum of Bilharzia hcematobia, with 
contained embryo and free sarcode- 
granules 584 
43. Ascaris lumbricoides, male with ex- 
serted spicules .... 585 
44. Oxyuris vermicularis, female . . 585 
45. Eggs of Oxyuris vermicularis, en- 
closing tadpole-shaped embryos . 585 
46. Trichocephalus, male (a) and female (b) 586 
47. Ankylostoma duodenale, male (a) and 
female (6) 586 
48. Filaria medinensis .... 586 
49. Trichina spiralis, male (a) and fe- 
male (5) 587 
50. Portion of human muscle, enclosing a 
single capsuled Trichina . . 587 
51. Filaria sanguinis hominis diurna . 697 
52. Filaria sanguinis hominis nocturna . 697 
FIGURE PAGE 
53. Filaria sanguinis hominis perstans . 697 
54. Filaria sanguinis hominis nocturna . 698 
55. Anterior end of mature Filaria san- 
guinis hominis nocturna . .698 
56. Portion of mature Filaria sanguinis 
hominis nocturna, showing uterine 
tubules filled with ova in various 
stages of development; also the in- 
testinal tube 698 
57. Ova and embryos of Filaria sanguinis 
hominis nocturna .... 698 
58. Fungoid filaments and capsules ob- 
tained after prolonged maceration 
in caustic potash of the dark masses 
of Fungus-disease of India . . 711 
59. Connective-tissue Hypertrophy of the 
Heart 794 
60. Fatty Degeneration of the Heart . 804 
61. Fatty Growth in the substance of the 
Heart 808 
62. Pulse-tracing in aortic stenosis . . 848 
63. Pulse-tracing in aortic insufficiency . 849 
64. Pulse-tracing in mitral stenosis . . 850 
65. Pulse-tracing in mitral insufficiency . 850 
66. Crystals of Leucin .... 1101 
67. Blood in Leucocythremia . . . 1103 LIST OF CONTRIBUTORS 
1882 
ADAMS, WILLIAM, Consulting Surgeon to the Great Northern Central Hospital. 
AITKEN, The late SIR WILLIAM, M.D., LL.D., F.R.S., Professor of Pathology in the Army 
Medical School, Netley. 
ALLBUTT, T. CLIFFORD, M.A., M.D., LL.D., F.R.S., Regius Professor of Physic in the 
University of Cambridge ; Consulting Physician to the Leeds General Infirmary. 
ALLCHIN, WILLIAM H., M.D., F.R.S.E., Physician to, and late Joint Lecturer on the Princi- 
ples and Practice of Medicine at, the Westminster Hospital; late Physician to the Victoria 
Hospital for Children. 
ANDREW, JAMES, M.D., late Physician to, and Joint Lecturer on Physic at, St. Bartholo- 
mew's Hospital; Consulting Physician to the City of London Hospital for Diseases of 
the Chest. 
BALFOUR, GEORGE W., M.D., F.R.S.E., Consulting Physician to the Royal Infirmary, and 
to the Royal Hospital for Children, Edinburgh. 
BANHAM, G. A., late Veterinary Assistant at the Brown Institution. 
BARNES, ROBERT, M.D., Consulting Obstetric Physician to, and late Lecturer on Midwifery 
and Diseases of Women at, St. George's Hospital; Consulting Physician to the Seamen's 
Hospital, and to the Royal Maternity Charity. 
BASTIAN, H. CHARLTON, M.A., M.D., F.R.S., Physician to University College Hospital, 
Professor of the Principles and Practice of Medicine and of Clinical Medicine, and late 
Professor of Pathological Anatomy, at University College; Physician to the National 
Hospital for the Paralysed and Epileptic. 
BAUMLER, C. G. H., M.D., Professor of Clinical Medicine, and Director of the Medical Clinic, 
University of Freiburg in Baden. 
BECK, The late MARCUS, M.B., M.S., Surgeon to University College Hospital, and Pro- 
fessor of Surgery at University College. 
BEDDOE, JOHN, B.A., M.D., F.R.S., late Physician to the Bristol Royal Infirmary. 
BELLAMY, The late EDWARD, Surgeon to, and Lecturer on Surgery at, the Charing Cross 
Hospital. 
BENNET, The late J. HENRY, M.D., formerly Physician-Accoucheur, Royal Free Hospital. XIV 
LIST OF CONTRIBUTORS 
BENNETT, The late SIR J. RISDON, M.D., LL.D., F.R.S., President of the Royal College of 
Physicians ; Consulting Physician to St. Thomas's Hospital, and to the City of London 
Hospital for Diseases of the Chest. 
BEVERIDGE, The late ROBERT, M.B., Physician to, and Lecturer on Clinical Medicine at, 
the Aberdeen Royal Infirmary. 
BINZ, CARL, M.D., Professor of Pharmacology in the University of Bonn. 
BIRKETT, JOHN, Consulting Surgeon to Guy's Hospital. 
BISHOP, The late JOHN, M.D., C.M., Assistant Surgeon to the Royal Infirmary, Edinburgh. 
BLANDFORD, GEORGE F., M.A., M.D., Lecturer on Psychological Medicine at St. George's 
Hospital. 
BOWLES, R. LEAMON, M.D., Consulting Physician to the Folkestone Hospital. 
BRISTOWE, J. SYER, M.D., LL.D., F.R.S., Consulting Physician to, and late Joint Lecturer 
on Medicine at, St. Thomas's Hospital. 
BROADBENT, SIR WILLIAM H., Bart., M.D., Physician to H.R.H. the Prince of Wales ; 
Physician to, and Lecturer on Clinical Medicine at, St. Mary's Hospital; Consulting 
Physician to the London Fever Hospital. 
BROWN-SEQUARD, The late 0. E., MD., LL.D.,F.R.S., Professor of Medicine, College de France. 
BRUCE, J. MITCHELL, M.A.,' M.D., Physician to, and Lecturer on the Principles and Practice 
of Medicine at, the Charing Cross Hospital; Physician to the Hospital for Consumption 
and Diseases of the Chest, Brompton. 
BRUCE, WILLIAM, M.A., LL.D., M.D., Senior Surgeon to the Ross Memorial Hospital, 
Dingwall. 
BRUNTON, T. LAUDER, M.D., LL.D., D.Sc., F.R.S., Assistant Physician to, and Lecturer on 
Materia Medica and Therapeutics at, St. Bartholomew's Hospital. 
BUCHANAN, SIR GEORGE, B.A., LL.D., M.D., F.R.S., late Medical Officer of H.M. Local 
Government Board; Consulting Physician to the London Fever Hospital. 
BUTLIN, H. TRENTHAM, D.C.L., Surgeon to St. Bartholomew's Hospital. 
BUZZARD, THOMAS, M.D., Physician to the National Hospital for the Paralysed and Epileptic. 
CADGE, WILLIAM, Surgeon to the Norfolk and Norwich Hospital. 
CALLENDER, The late G. W., F.R.S., Surgeon to, and Lecturer on Surgery at, St. Bartholo- 
mew's Hospital. 
CANTLIE, JAMES, M.A., M.B., C.M., late Senior Assistant Surgeon to, and Demonstrator of 
Anatomy at, the Charing Cross Hospital. 
CARPENTER, The late W. B., C.B., M.D., LL.D., F.R.S. 
CARTER, R. BRUDENELL, Consulting Ophthalmic Surgeon to, and late Lecturer on 
Ophthalmic Surgery at, St. George's Hospital. LIST OF CONTRIBUTORS 
XV 
CAYLEY, WILLIAM, M.D., Physician to, and Lecturer on Medicine at, the Middlesex Hospital; 
Consulting Physician to the London Fever Hospital. 
CLARKE, The late J. LOCKHART, M.D., F.R.S., Physician to the Hospital for Epilepsy and 
Paralysis. 
CLARKE, The late W. FAIRLIE, M.A., M.D., Assistant Surgeon to the Charing Cross Hospital. 
CLOVER, The late J. T., Lecturer on Anaesthetics at University College Hospital. 
COBBOLD, CHARLES S. W., M.D., late Medical Superintendent, Asylum for Idiots, Earlswood; 
late Senior Assistant Medical Officer, Middlesex County Asylum, Colney Hatch. 
COBBOLD, The late T. SPENCER, M.D., F.R.S. 
COLLIE, ALEXANDER, M.D., late Medical Officer, Fever Hospital, Homerton. 
COOPER, ARTHUR, Surgeon to the Westminster General Dispensary ; late House Surgeon to 
the Male Lock Hospital. 
CORMACK, The late SIR JOHN ROSE, K.C.B., M.D., F.R.S.E., Physician to the Hertford 
British Hospital, Paris. 
CUNNINGHAM, D. DOUGLAS, C.I.E., M.B., C.M., Brigade Surgeon-Lieutenant-Colonel H.M. 
Bengal Army. 
CURLING, The late T. B., F.R.S., Consulting Surgeon to the London Hospital. 
CURNOW, JOHN, M.D., Physician to King's College Hospital; Professor of Anatomy in King's 
College; Senior Visiting Physician to the Seamen's Hospital, Greenwich. 
DALBY, SIR WILLIAM B., B.A., M.B., Consulting Aural Surgeon to, and late Lecturer on 
Aural Surgery at, St. George's Hospital. 
DAVIDSON, ALEXANDER, M.A., M.D., Physician to the Royal Infirmary, Liverpool, and 
Emeritus Professor of Pathology in University College, Liverpool. 
DE ZOUCHE, ISAIAH, M.D., Honorary Physician to the Dunedin Hospital, New Zealand. 
DUNCAN, The late J. MATTHEWS, M.A., M.D., LL.D., F.R.S.E., Physician-Accoucheur to, and 
Lecturer on Midwifery at, St. Bartholomew's Hospital. 
DURHAM, ARTHUR E., late Senior Surgeon to, and Lecturer on Surgery at, Guy's Hospital. 
ECHEVERRIA, M. G., M.D., late Physician-in-Chief to the Hospital for Epileptics and Para- 
lytics, and to the City Asylum for the Insane, New York. 
EWART, JOSEPH, M.D., Retired Deputy Surgeon-General H.M. Bengal Army; late Professor 
of Medicine, Principal, and Senior Physician, Calcutta Medical College. 
EWART, WILLIAM, B.A., M.D., Physician to St. George's Hospital; late Assistant Physician 
and Pathologist to the Hospital for Consumption and Diseases of the Chest, Brompton. 
FARQUHARSON, ROBERT, M.D., M.P., late Physician to the Belgrave Hospital for Children ; 
late Assistant Physician to, and Lecturer on Materia Medica at, St. Mary's Hospital. XVI 
LIST OF CONTRIBUTORS 
FAYRER, SIR JOSEPH, K.C.S.I., M.D., LL.D., F.R.S., Honorary Physician to H.M. the 
Queen, and to H.R.H. the Prince of Wales ; President of the Medical Board, India Office; 
Consulting Physician to the Charing Cross Hospital. 
FENWICK, SAMUEL, M.D., Physician to, and late Lecturer on Medicine at, the London 
Hospital; late Assistant Physician to the City of London Hospital for Diseases of the Chest. 
FERRIER, DAVID, M.A., M.D., LL.D., F.R.S., Physician to King's College Hospital; Phy- 
sician to the National Hospital for the Paralysed and Epileptic; Professor of Neuropathology 
in King's College. 
FINNEY, J. MAGEE, B.A., M.D., Physician to the City of Dublin Hospital; King's Professor 
of the Practice of Medicine at the School of Physic in Ireland, and Professor of Clinical 
Medicine in Sir Patrick Dun's Hospital. 
FOSTER, SIR WALTER, M.D., D.C.L., M.P., Consulting Physician to the General Hospital, 
and Emeritus Professor of the Principles and Practice of Physic in Queen's College, 
Birmingham. 
FOX, E. LONG, M.D., Consulting Physician to the Bristol Royal Infirmary, and late Lecturer 
on the Principles and Practice of Medicine at the Bristol School of Medicine. 
FOX, T. COLCOTT, B.A., M.B., Physician for Diseases of the Skin, Westminster Hospital; 
late Physician to the Victoria Hospital for Children. 
FOX, The late TILBURY, M.D., Physician to the Skin Department, University College 
Hospital. 
GALTON, SIR DOUGLAS, Late Royal Engineers, K.C.B., D.C.L., F.R.S. 
GASCOYEN, The late GEORGE G., Surgeon to the Lock Hospital; Assistant Surgeon to, and 
Lecturer on Surgery at, St. Mary's Hospital. 
GEE, SAMUEL JONES, M.D., Physician to St. Bartholomew's Hospital; Consulting Physician 
to the Hospital for Sick Children, Great Ormond Street. 
GODLEE, RICKMAN J., B.A., M.B., M.S., Surgeon to, and Professor of Clinical Surgery at, 
University College Hospital; Surgeon to the Hospital for Consumption and Diseases of the 
Chest, Brompton; Consulting Surgeon to the North-East Hospital for Children. 
GODSON, CLEMENT, M.D., Consulting Physician to the City of London Lying-in Hospital; 
late Assistant Physician-Accoucheur to St. Bartholomew's Hospital. 
GOWERS, WILLIAM R., M.D., F.R.S., Consulting Physician to, and late Professor of Clinical 
Medicine at, University College Hospital; Physician to the National Hospital for the 
Paralysed and Epileptic. 
GREEN, T. HENRY, M.D., Physician to, Special Lecturer on Clinical Medicine and late 
Lecturer on Pathology at, the Charing Cross Hospital; Physician to the Hospital for 
Consumption and Diseases of the Chest, Brompton. 
GREENFIELD, WILLIAM S., M.D., Professor of General Pathology and Clinical Medicine 
in the University of Edinburgh. 
GRIMSHAW, THOMAS W., M.A., M.D., Registrar-General for Ireland; Consulting Physician 
to the Fever Hospital, Cork Street, and to Steeven's Hospital, Dublin. XVII 
LIST OF CONTRIBUTORS 
HAW ARD, J. WARRINGTON, Surgeon to St. George's Hospital; late Assistant Surgeon to the 
Hospital for Sick Children, Great Ormond Street. 
HAYDEN, The late THOMAS, M.D., Physician to the Mater Misericordise Hospital, Dublin; 
Professor of Anatomy and Physiology, Catholic University, Dublin. 
HERMAN, G. ERNEST, M.B., Obstetric Physician to, and Lecturer on Midwifery at, the 
London Hospital; Physician to tne Royal Maternity Charity. 
HICKS, J. BRAXTON, M.D., F.R.S., late Physician-Accoucheur to, and Lecturer on Midwifery 
and Diseases of Women and Children at, Guy's Hospital. 
HILL, The late BERKELEY, M.B., Surgeon to, and Professor of Clinical Surgery at, University 
College Hospital; Surgeon to the Lock Hospital. 
HOLMES, TIMOTHY, M.A., Consulting Surgeon to, and late Lecturer on Surgery at, St. 
George's Hospital. 
HORSLEY, VICTOR A. H., M.B., B.S., F.R.S., Professor of Pathology in University College; 
Surgeon to University College Hospital, and to the National Hospital for the Paralysed and 
Epileptic. 
HOWARD, BENJAMIN, M.D., late Professor of Medicine, and Lecturer on Medicine, in the 
University of New York. 
HUTCHINSON, JONATHAN, LL.D., F.R.S., late President of the Royal College of Surgeons; 
Consulting Surgeon to the London Hospital, to the Hospital for Diseases of the Skin, 
Blackfriars, and to the Royal London Ophthalmic Hospital. 
IRVINE, The late J. PEARSON, B.A., B.Sc., M.D., Assistant Physician to, and Lecturer on 
Forensic Medicine at, the Charing Cross Hospital; Physician to the Victoria Hospital 
for Children 
JENNER, SIR WILLIAM, Bart., G.C.B., M.D., D.C.L., LL.D., F.R.S., Physician-in-Ordinary 
to H.M. the Queen, and to H.R.H. the Prince of Wales; late President of the Royal College of 
Physicians ; Consulting Physician to University College Hospital. 
JONES, JOSEPH, M.D., Professor of Chemistry and Clinical Medicine, New Orleans, and 
President of the Board of Health, State of Louisiana, New Orleans. 
LANGDON-DOWN, JOHN, M.D., Consulting Physician to, and late Lecturer on Clinical 
Medicine at, the London Hospital. 
LATHAM, PETER W., A.M., M.D., Senior Physician to Addenbrooke's Hospital; late Downing 
Professor of Medicine in the University of Cambridge. 
LEACH, The late HARRY, Medical Officer of Health for the Port of London, and Physician to 
the Seamen's Hospital, Greenwich. 
LEGG, J. WICKHAM, M.D., late Assistant Physician to, and Lecturer on Pathological Anatomy 
at, St. Bartholomew's Hospital. 
LEWIS, The late TIMOTHY, M.D., F.R.S. (Elect), Surgeon-Major H.M. Army. 
LITTLE, JAMES, M.D., Physician to the Adelaide Hospital, Dublin ; late Professor of Practice of 
Medicine in the Royal College of Surgeons in Ireland; Consulting Physician to the Rotunda 
Lying-in Hospital. XVIII 
LIST OF CONTRIBUTORS 
LIVEING, ROBERT, M.A., M.D., late Physician for Diseases of the Skin, and Lecturer on 
Diseases of the Skin, at the Middlesex Hospital. 
McCARTHY, JEREMIAH, M.A., M.B., Surgeon to, and late Lecturer on Surgery at, the London 
Hospital. 
MAC CORMAC, SIR WILLIAM, M.A., M.Ch., Consulting Surgeon to, and late Lecturer on 
Surgery at, St. Thomas's Hospital. 
McKENDRICK, J. GRAY, M.D., F.R.S., Professor of the Institutes of Medicine in the 
University of Glasgow. 
MACKENZIE, STEPHEN, M.D., Physician to, and Lecturer on the Principles and Practice 
of Medicine at, the London Hospital. 
MACLEAN, Surgeon General W. CAMPBELL, C.B., M.D., Inspector-General of Hospitals; late 
Professor of Military Medicine in the Army Medical School, Netley. 
MACNAMARA, CHARLES NOTTIDGE, Surgeon to the Westminster Hospital; Consulting 
Surgeon to the Royal Westminster Ophthalmic Hospital. 
MACPHERSON, The late JOHN, M.A., M.D., Inspector-General of Hospitals, H.M. Bengal 
Army. 
MADDEN, T. MORE, M.D., Obstetric Physician to the Mater Misericordiae Hospital, Dublin. 
MANSON, PATRICK, M.D., LL.D., Physician to the Seamen's Hospital, Greenwich; late Lec- 
turer on Medicine in the College of Medicine for the Chinese, Hong Kong. 
MEREDITH, W. APPLETON, M.B., C.M., Surgeon to the Samaritan Free Hospital for 
Women and Children. 
MERYON, The late EDWARD, M.D., Physician to the Hospital for Epilepsy and Paralysis. 
MUIRHEAD, CLAUD, M.D., Consulting Physician to, and formerly Lecturer on Clinical Medicine 
at, the Royal Infirmary, Edinburgh. 
MURCHISON, The late CHARLES, M.D., LL.D., F.R.S., Physician to, and Special Professor 
of Clinical Medicine at, St. Thomas's Hospital; Consulting Physician to the London Fever 
Hospital. 
MYERS, ARTHUR B. R., late Brigade-Surgeon, Brigade of Guards. 
NETTLESHIP, EDWARD, Ophthalmic Surgeon to St. Thomas's Hospital, and to the Royal 
London Ophthalmic Hospital; late Ophthalmic Surgeon to the Hospital for Sick Children, 
Great Ormond Street. 
NIGHTINGALE, FLORENCE. 
OLIVER, GEORGE, M.D., Harrogate. 
ORD, W. MILLER, M.D., Physician to, and Lecturer on Medicine at, St. Thomas's Hospital. 
PAGET, SIR JAMES, Bart., D.C.L., LL.D., F.R.S., Sergeant-Surgeon to H.M. the Queen ; 
Surgeon to H.R.H. the Prince of Wales ; Consulting Surgeon to St. Bartholomew's Hospital. 
PARKES, The late EDMUND A., M.D., F.R.S., Professor of Hygiene in the Army Medical 
School, Netley. LIST OF CONTRIBUTORS 
XIX 
PAVY, FREDERICK W., M.D., LL.D., F.R.S., Consulting Physician to, and late Lecturer on 
Medicine at, Guy's Hospital. 
PAYNE, J. FRANK, B.A., B.Sc., M.D., Physician to, and Lecturer on Medicine at, St. Thomas's 
Hospital. 
PEACOCK, The late T. BEVILL, M.D., Honorary Consulting Physician to St. Thomas's 
Hospital; and Consulting Physician to the City of London Hospital for Diseases of the 
Chest. 
PLAYFAIR, WILLIAM S., M.D., LL.D., Physician-Accoucheur to H.I. and R.H. the Duchess 
of Edinburgh; Physician for Diseases of Women and Children to King's College Hos- 
pital, and Consulting Physician to the General Lying-in Hospital; Professor of Obstetric 
Medicine in King's College. 
POORE, G. VIVIAN, M.D., Physician to, and Professor of Clinical Medicine at, University 
College Hospital; Professor of Medical Jurisprudence at University College. 
POWELL, R. DOUGLAS, M.D., Physician Extraordinary to H.M. the Queen; Physician to the 
Middlesex Hospital, and Consulting Physician to the Hospital for Consumption and 
Diseases of the Chest, Brompton. 
QUAIN, SIR RICHARD, Bart., M.D., LL.D., F.R.S., Physician Extraordinary to H.M. the 
Queen; Consulting Physician to the Hospital for Consumption and Diseases of the Chest, 
Brompton, and to the Seamen's Hospital, Greenwich. 
RADCLIFFE, The late J. NETTEN, Assistant Medical Officer, Local Government Board. 
RALFE, CHARLES H., M.A., M.D., Physician to the London Hospital; late Physician to the 
Seamen's Hospital, Greenwich. 
REDWOOD, The late RALFE THEOPHILUS, Ph.D., Professor of Chemistry and Pharmacy, 
Pharmaceutical Society of Great Britain. 
ROBERTS, FREDERICK T., M.D., B.Sc., Physician to, and Professor of Clinical Medicine at, 
University College Hospital; Professor of Materia Medica at University College; Con- 
sulting Physician to the Hospital for Consumption and Diseases of the Chest, Brompton. 
ROBERTS, SIR WILLIAM, B.A., M.D., F.R.S., late Physician to the Manchester Royal Infir- 
mary ; late Professor of Medicine in the Victoria University. 
ROSE, WILLIAM, M.B., B.S., Surgeon to King's College Hospital; Professor of Clinical 
Surgery, King's College ; Consulting Surgeon to the Royal Free Hospital. 
ROY, CHARLES S., M.A., M.D., F.R.S., Professor of Pathology, University of Cambridge; 
late Professor Superintendent of the Brown Institution, London. 
RUSSELL, The Right Hon. JAMES A., M.A., M.B., C.M., Inspector of Anatomy for Scotland; 
late Lecturer on Sanitation, Watt's Institution, Edinburgh. 
SALTER, S. J., M.B., F.R.S., F.L.S., late Dental Surgeon to Guy's Hospital. 
SANGSTER, ALFRED, B.A., M.B., Physician for Diseases of the Skin to, and Lecturer on 
Skin Diseases at, the Charing Cross Hospital. 
SAUNDBY, ROBERT, M.D., Physician to the General Hospital, and Professor of Medicine in 
Mason College, Birmingham. XX 
LIST OF CONTRIBUTORS 
SCHAFER, EDWARD ALBERT, F.R.S., Jodrell Professor of Physiology in University College. 
SEATON, The late EDWARD C., M.D., Medical Officer to the Local Government Board. 
SHAPTER, THOMAS, M.D., LL.D., Consulting Physician to the Devon and Exeter Hospital. 
SIBBALD, JOHN, M.D., F.R.S.E., Commissioner in Lunacy for Scotland. 
SILVER, The late ALEXANDER, M.A., M.D., Physician to, and Lecturer on Physiology at, 
the Charing Cross Hospital. 
SIMON, SIR JOHN, C.B., D.C.L., LL.D., F.R.S., Consulting Surgeon to St. Thomas's Hospital; 
late Medical Officer to Her Majesty's Privy Council, and to the Local Government Board. 
SIMPSON, ALEXANDER RUSSELL, M.D., Physician to the University Clinical Ward for 
Diseases of Women, Royal Infirmary, Edinburgh; Professor of Midwifery and Diseases of 
Women and Children in the University of Edinburgh. 
SMITH, EUSTACE, M.D., Physician to H.M. the King of the Belgians; Physician to the 
City of London Hospital for Diseases of the Chest, and to the East London Hospital 
for Children. 
SMITH, W. JOHNSON, Surgeon to the Seamen's Hospital, Greenwich. 
SOUTHEY, REGINALD, M.D., Commissioner in Lunacy ; late Physician to, and Lecturer on 
Forensic Medicine and Hygiene at, St. Bartholomew's Hospital. 
SPARKS, The late EDWARD I., M.A., M.B., Physician for Diseases of the Skin to the Charing 
Cross Hospital, and Physician to the Royal Infirmary for Women and Children. 
SQUIRE, WILLIAM, M.D., Physician to the St. George's Dispensary, and late Physician to 
the North London Hospital for Diseases of the Chest. 
STEVENSON, THOMAS, M.D., Lecturer on Chemistry and Medical Jurisprudence at Guy's 
Hospital; Scientific Analyst to the Home Office. 
STEWART, T. GRAINGER, M.D., F.R.S.E., Physician in Ordinary to H.M. the Queen for 
Scotland; Professor of Practice of Physic and of Clinical Medicine in the University of 
Edinburgh. 
STREATFEILD, The late J. F., Surgeon to the Royal London Ophthalmic Hospital; Pro- 
fessor of Clinical Ophthalmic Surgery at, and Ophthalmic Surgeon to, University College 
Hospital. 
THIN, GEORGE, M.D., London. 
THOMPSON, E. SYMES, M.D., Consulting Physician to the Hospital for Consumption and 
Diseases of the Chest, Brompton. 
THOMPSON, SIR HENRY, Surgeon Extraordinary to H.M. the King of the Belgians; Con- 
sulting Surgeon to University College Hospital; Emeritus Professor of Clinical Surgery at 
University College. 
THORNTON, W. PUGIN, late Surgeon to the St. Marylebone General Dispensary. 
THOROWGOOD, JOHN C., M.D., Physician to the City of London Hospital for Diseases 
of the Chest, and to the West London Hospital; late Lecturer on Materia Medica at the 
Middlesex Hospital. LIST OF CONTRIBUTORS 
XXI 
TUKE, J. BATTY, M.D., F.R.S.E., formerly Lecturer on Mental Diseases at the Royal College 
of Surgeons, Edinburgh. 
WALKER, THOMAS J., M.D., Surgeon to the Peterborough Infirmary and Dispensary. 
WARD, The late STEPHEN H., M.D., Consulting Physician to the Seamen's Hospital, Green- 
wich ; and Physician to the City of London Hospital for Diseases of the Chest. 
WARDELL, The late J. R., M.D., Consulting Physician to the Tunbridge Wells Infirmary. 
WATERS, A. T. H., M.D., Consulting Physician to the Royal Infirmary, Liverpool; late Professor 
of the Principles and Practice of Medicine in University College, Liverpool. 
WEBER, HERMANN, M.D., Consulting Physician to the German Hospital. 
WELLS, SIR T. SPENCER, Bart., late President of the Royal College of Surgeons; Surgeon 
to the Queen's Household ; Consulting Surgeon to the Samaritan Hospital for Women and 
Children. 
WILLIAMS, C. THEODORE, M.A., M.D., Senior Physician to the Hospital for Consumption 
and Diseases of the Chest, Brompton. 
WILLIAMS, JOHN, M.D., Consulting Obstetric Physician, University College Hospital. 
WILSON, The late SIR ERASMUS, LL.D., F.R.S., President of the Royal College of Surgeons; 
Professor of Dermatology, Royal College of Surgeons. 
WILTSHIRE, The late ALFRED, M.D., Physician-Accoucheur to, and Joint Lecturer on 
Obstetric Medicine at, St. Mary's Hospital; Physician for Diseases of Women to the West 
London Hospital. 
WOOD, The late JOHN, F.R.S., Surgeon to King's College Hospital, and Professor of Clinical 
Surgery in King's College. 
ADDITIONAL CONTRIBUTORS 
1894 
ACKLAND, ROBERT CRAIG, Assistant Dental Surgeon to St. Bartholomew's Hospital. 
BAILEY, G. HEWLETT, Chloroformist to the Dental Hospital of London. 
BAKER, W. MORRANT, late Surgeon to St. Bartholomew's Hospital. 
BALL, JAMES BARRY, M.D., Assistant Physician, and Physician to the Department for 
Diseases of the Throat and Nose, to the West London Hospital. 
BANKS, SIR JOHN, K.C.B., M.D., D.Sc., LL.D., Physician in Ordinary to H.M. the Queen in 
Ireland; Regius Professor of Physic in the University of Dublin; Consulting Physician 
to Sir Patrick Dun's Hospital. XXII 
LIST OF CONTRIBUTORS 
BOWLBY, ANTHONY A., Assistant Surgeon, and Surgeon in Charge of the Throat Depart- 
ment, to St. Bartholomew's Hospital. 
BOYD, STANLEY, M.B., B.S., Surgeon to, and Lecturer on Anatomy at, the Charing Cross 
Hospital; Surgeon to the Paddington Green Children's Hospital. 
BRUCE, DAVID, M.B., C.M., Surgeon-Captain, H.M. Army. 
CASSON, WILLIAM A., Barrister-at-Law, Local Government Board. 
CHARTERIS, MATTHEW, M.D., Professor of Materia Medica and Therapeutics in the Uni- 
versity of Glasgow. 
CRAIGIE, J. HAMILTON, Surgeon Dentist to the Chelsea Hospital for Women. 
CROCKER, H. RADCLIFFE, M.D., Physician to the Skin Department, University College 
Hospital. 
CURRIE, ANDREW STARK, M.D., late Assistant to the Professor of Physiology in the Uni- 
versity of Glasgow. 
FENWICK, W. SOLTAU, M.D., B.S., Physician for Out-Patients to the Evelina Hospital 
for Sick Children. 
GERVIS, HENRY, M.D., Consulting Obstetric Physician to St. Thomas's Hospital. 
GOODHART, JAMES F., M.D., Physician to, and late Lecturer on Pathology at, Guy's 
Hospital; Consulting Physician to the Evelina Hospital for Sick Children. 
HAROLD, JOHN, Medical Registrar to the Charing Cross Hospital. 
HEBB, RICHARD GRAINGER, M.A., M.D., Assistant Physician and Pathologist to, and 
Lecturer on Pathology and Morbid Anatomy at, the Westminster Hospital. 
JACOBSON, WALTER H. A., M.A., M.B., M.Ch., Assistant Surgeon to, and Lecturer on 
Anatomy at, Guy's Hospital. 
KIDD, PERCY, M.A., M.D., Assistant Physician and Pathologist to the London Hospital; Phy- 
sician to the Hospital for Consumption and Diseases of the Chest, Brompton. 
LITTLE, JOHN FLETCHER, M.B., Physician to the North London Hospital for Con- 
sumption. 
LUFF, ARTHUR PEARSON, M.D., B.Sc., Physician for Out-Patients to, and Lecturer on 
Medical Jurisprudence at, St. Mary's Hospital; Official Analyst to the Home Office. 
McKEE, ALEXANDER BAILLIE, B.A., M.B., B.Ch., late Curator of the Museum, Royal 
College of Surgeons, Ireland. 
MAC MUNN, CHARLES A., M.A., M.D., Pathologist to the Wolverhampton and Staffordshire 
General Hospital. 
MAGUIRE, ROBERT, M.D., Physician for Out-Patients to, and Joint Lecturer on Pathology 
at, St. Mary's Hospital; Assistant Physician to the Hospital for Consumption and Diseases 
of the Chest, Brompton. LIST OF CONTRIBUTORS 
XXIII 
MAPOTHER, E. DILLON, M.D., late President of the Royal College of Surgeons of Ireland. 
MARTIN, SIDNEY H. C., M.D., B.Sc., Assistant Physician to University College Hospital, and to 
the Hospital for Consumption and Diseases of the Chest, Brompton. 
MORGAN, The late JOHN EDWARD, M.A., M.D., Consulting Physician to the Manchester 
Royal Infirmary, and Professor of Medicine in the Victoria University. 
MOTT, FREDERICK W., M.D., B.S., Assistant Physician to, and Lecturer on Physiology at, 
the Charing Cross Hospital. 
MUIR, ROBERT, M.D., C.M., Senior Demonstrator of Pathology in the University of Edinburgh. 
MURPHY, J. SHIRLEY FORSTER, Medical Officer of Health of the Administrative County 
of London. 
MURRAY, H. MONTAGUE, M.D., Physician for Out-Patients to the Charing Cross Hospital, and 
to the Victoria Hospital for Children. Lecturer on Pathology and Morbid Anatomy at the 
Charing Cross Hospital. 
NIXON, CHRISTOPHER J., B.A., M.D., LL.D., Physician to the Mater Misericordias Hospital, 
Dublin. 
NORTON, ARTHUR T., Surgeon to, and Lecturer on Clinical Surgery at, St. Mary's Hospital. 
POLLOCK, JAMES EDWARD, M.D., Consulting Physician to the Hospital for Consumption 
and Diseases of the Chest, Brompton. 
PRINGLE, JOHN J., M.B., C.M., Assistant Physician, Lecturer on Practical Medicine, and 
Physician to the Skin Department, at the Middlesex Hospital. 
RUSSELL, JAMES S. RISIEN, M.B., C.M., London. 
SANSOM, ARTHUR ERNEST, M.D., Physician to, and Lecturer on Clinical Medicine at, the 
London Hospital; Consulting Physician to the North-East Hospital for Children. 
SEATON, EDWARD, M.D., Lecturer on Public Health at St. Thomas's Hospital; Medical Officer 
of Health to the Administrative County of Surrey. 
STONHAM, CHARLES, Assistant Surgeon to, and Lecturer on Operative Surgery at, the 
Westminster Hospital. 
SUTTON, JOHN BLAND, Assistant-Surgeon to the Middlesex Hospital. 
TAYLOR, FREDERICK, M.D., Physician to, and Lecturer on Medicine at, Guy's Hospital; 
Consulting Physician to the Evelina Hospital for Sick Children. 
TAYLOR, JAMES, M.A., M.D., Assistant Physician to the National Hospital for the Paralysed 
and Epileptic. 
TREVES, FREDERICK, Surgeon to, and Lecturer on Surgery at, the London Hospital. 
TURNER, SIR WILLIAM, M.B., D.Sc., LL.D., D.C.L., F.R.S., Professor of Anatomy in the 
University of Edinburgh. XXIV 
LIST OF CONTRIBUTORS 
TWEEDY, JOHN, Professor of Ophthalmic Medicine and Surgery in University College; 
Ophthalmic Surgeon to University College Hospital; Surgeon to the Royal London 
Ophthalmic Hospital. 
WHISTLER, W. MacNEILL, M.D., Physician to the London Throat Hospital. 
WHITELEGGE, BENJAMIN A., M.D., B.Sc., D.P.H., County Medical Officer of Health, West 
Riding of Yorkshire; Lecturer on Public Health at the Charing Cross Hospital. 
WILLIAMS, DAWSON, M.D., B.S., Assistant Physician to the East London Hospital for Children. 
WRIGHT, ALMROTH EDWARD, B.A., M.D., B.Ch., Professor of Pathology in the Army 
Medical School, Netley. DICTIONARY 
OF 
MEDICINE 
ABDOMEN, Diseases of the.-Before 
entering upon the study of the particular 
diseases which are liable to be met with in 
connexion with each of the principal regions 
of the body, it is expedient to regard them 
from a general point of view, as such a course 
helps materially in clearing the way for their 
clinical investigation. This general survey 
is particularly advantageous in the case of 
abdominal diseases, which are necessarily 
very numerous and varied, both as regards 
the structures affected and the nature of the 
morbid changes they present; they are con- 
sequently difficult to recognise with certainty 
in many instances, and are occasionally 
involved in much obscurity. 
Excluding a few peculiar affections, the 
diseases of the abdomen may be arranged 
under the following groups:- 
I. Diseases of the anterior abdominal 
walls. 
II. Diseases of the peritoneum and its 
folds. 
III. Diseases of the organs contained 
within the abdominal cavity, namely:- 
1. Stomach and Intestines; 2. Hepatic organs, 
including the liver, gall-bladder, and gall- 
ducts ; 3. Spleen; 4. Pancreas; 5. Supra- 
renal capsules; 6. Urinary apparatus, viz., 
the kidneys and their ducts, and the bladder; 
7. Female generative organs, including the 
uterus and its broad ligaments, the Fallopian 
tubes, and the ovaries; 8. Absorbent glands. 
IV. Diseases of the abdominal vessels, 
especially the aorta and the iliac arteries 
V. Diseases of the sympathetic or other 
nerves contained within the abdomen. 
VI. Diseases originating in connexion with 
the cellular tissue, such as inflammation or 
abscess. 
VII. Diseases springing from the posterior 
boundary of the abdomen; from the pelvis 
or the structures lining it; or from the 
diaphragm, and invading the abdominal 
cavity. 
VIII. Diseases encroaching upon the ab- 
domen from other parts, especially from the 
thorax. 
It must be borne in mind that the groups 
of diseases above mentioned may be pre- 
sented in various combinations, two or more 
structures being not uncommonly implicated 
at the same time. 
The special nature and mode of origin of 
the diseases thus summarised will be dis- 
cussed under their appropriate headings, but 
a few general observations on this subject 
may prove serviceable. Several of the ab- 
dominal organs are very liable to so-called 
functional disorders, being much exposed 
to the repeated action of various disturbing 
influences, and these disorders often give 
rise to prominent and troublesome symptoms, 
which are urgently complained of by the 
patient. Definite organic diseases are also 
of common occurrence, many of them being 
of a very serious character. Some of the 
organs contained within the abdomen are 
liable to malposition or displacement, as well 
as to malformations, these being either con- 
genital or acquired; while the hollow viscera 
may be the seat of obstruction or accumu- 
lations of different kinds. Each of these 
conditions may become clinically important. 
Abdominal lesions are frequently purely 
local in their origin, but several of them are 
but local manifestations of some general 
condition, being associated either with cer- 
tain acute febrile diseases, e.g. typhoid fever; or 
with some constitutional cachexia, such as 
cancer. Again, symptoms connected with the 
abdomen may depend upon disease in some 
remote part of the body; or some of its organs 
may become the seat of morbid changes as a 
consequence of disease in other structures. 
For instance, vomiting is frequently associated 
with cerebral disorders; while affections of 
the heart are liable to lead to troublesome 
symptoms, as well as to serious lesions, in 
connexion with many of the abdominal 
viscera. Lastly, a morbid condition of one 
organ within the abdomen may be the direct 
means of originating secondary mischief in 
other structures. 
Clinical Investigation.-The clinical ex- 
amination of cases in which the symptoms 2 
ABDOMEN, DISEASES OF THE 
point to the abdomen as the seat of mischief 
should always be conducted with particular 
care and thoroughness, as well as in a sys- 
tematic manner, otherwise serious mistakes 
are liable to be made. It is also very 
desirable to avoid forming any definite con- 
clusion as to the nature of the complaint 
hastily or on insufficient data, but rather to 
wait and observe the course of events in any 
doubtful case, repeating the investigation 
from time to time, when any obscurity which 
may exist will often be cleared away. The 
past and family history of the patient, with 
the course and progress of the symptoms, 
are often of material assistance in diagnosis, 
and demand due attention in every instance. 
The chief clinical phenomena which may be 
associated with abdominal affections, and 
with reference to which it is requisite to 
inquire, may be thus indicated. First, there 
are usually symptoms directly connected 
with the structure implicated, such as pain 
and other morbid sensations, disorders of 
secretory or other functions, or excited action. 
Secondly, several of the organs mutually affect 
each other, either from being anatomically 
or physiologically related, or from a morbid 
condition of one part causing pressure upon 
or irritation of some neighbouring structure. 
In this way numerous symptoms are liable 
to arise, sometimes in remote parts, and 
often of material significance. Thirdly, 
sympathetic or reflex phenomena in con- 
nexion with organs in other regions of the 
body are frequently excited by many ab- 
dominal disorders, such as palpitation of the 
heart, convulsions, and other nervous dis- 
turbances. Fourthly, the general system 
often suffers seriously, and in various ways. 
For instance, pyrexia may be excited; the 
blood may become impoverished or impreg- 
nated with noxious materials; or more or 
less general wasting and debility may be in- 
duced. Where an abdominal disease is but 
a local manifestation of some constitutional 
condition, it commonly aggravates materially 
the general symptoms; while in connexion 
with lesions of certain of the abdominal 
viscera these general symptoms constitute in 
many cases the most prominent clinical 
features. Fifthly, morbid conditions within 
the abdomen not unfrequently interfere 
directly with the diaphragm and the thoracic 
organs ; occasionally also they encroach upon 
the chest, or actually make their way into 
this cavity through the diaphragm. In rare 
instances morbid products, such as pus, may 
find their way to distant parts of the body. 
In these different ways a variety of symptoms 
may be caused, sometimes of a curious 
nature and difficult to explain. Lastly, ab- 
dominal diseases are frequently attended 
with abnormal physical or objective signs, 
which are revealed on physical examination, 
and these are of such importance that they 
demand separate consideration. 
Physical Examination.-The neglect of 
submitting patients to a satisfactory physical 
examination is a frequent source of error in 
diagnosis in cases of abdominal disease, and 
there ought to be no hesitation or delay in 
resorting to this method of clinical investiga- 
tion whenever it seems called for. The precise 
course to be pursued must vary according to 
circumstances, but the following outline will 
serve to indicate the plan of procedure ordi- 
narily required. 
First, there are certain modes of examina- 
tion which are applied to the abdomen ex- 
ternally, including Inspection; Palpation or 
Manipulation; Mensuration or Measure- 
ment ; Percussion; and Auscultation (see 
Physical Examination). Of these, inspec- 
tion, palpation, and percussion are by far 
the most important, and have, in the large 
majority of cases, to be relied upon for the 
information required. In exceptional in- 
stances Succussion, or shaking the patient, 
proves serviceable, by bringing out certain 
sensations or sounds. In order to carry out 
these methods properly, it is necessary to ex- 
pose the abdomen sufficiently, due regard 
being paid to decency in the examination of 
females; to place the patient in a suitable 
position ; and to see that the muscles of the 
abdominal walls are duly relaxed. The best 
position usually is for the patient to lie on 
the back, in a half-reclining attitude, with the 
head and shoulders well raised, and the thighs 
and knees more or less flexed. This posture 
serves to relax the abdominal muscles, which 
may be further aided by taking off the 
patient's attention by conversation or in 
other ways, as well as by directing him to 
breathe deeply. The position, however, has 
often to be varied in the investigation of 
particular cases, and much information is 
frequently gained by noticing the effects of 
altering the posture. 
The objective conditions which may be re- 
vealed by the modes of examination thus far 
considered are as follows:-1. The state of 
the superficial structures. 2. The size and 
shape of the abdomen, generally and locally, 
as indicating an alteration in the volume of 
the ordinary contents of the abdomen, or the 
presence of some new or fresh element, such 
as dropsical fluid or a tumour. 3. The cha- 
racters of the abdominal respiratory move- 
ments; and the presence of any unusual 
sensations during the act of breathing, such 
as friction-fremitus. 4. The sensations ex- 
perienced on palpation and percussion over 
the abdomen, either as a whole, or in any 
particular part of it, such as its mobility, 
degree of resistance, regularity, consistence, 
&c.; as well as the presence of certain 
peculiar sensations, e.g.t fluctuation, or 
hydatid-fremitus. 5. The presence and cha- 
racters of any pulsation. 6. The occurrence 
of abnormal movements within the abdomen, 
as those of a foetus. 7. The sounds elicited. ABDOMEN, DISEASES OF THE 
generally and locally, on percussion. 8. The 
presence of certain sounds within the abdo- 
men, heard on auscultation, such as friction- 
sounds ; murmurs connected with aneurysm or 
due to pressure on an artery; or murmurs and 
sounds associated with the pregnant uterus. 
Secondly, it not uncommonly happens that 
special modes of examination have to be ap- 
plied to particular organs within the abdomen, 
in order to arrive at a diagnosis with any 
certainty. And here it may be remarked 
that it is highly important in all cases to see 
that no accumulation of faeces exists within 
the bowel, and that the bladder is properly 
emptied, otherwise very serious mistakes are 
liable to be made. Purgatives and enemata 
are needed in order to remove any fecal col- 
lection. The urine should also be properly 
tested in every instance ; and much informa- 
tion may often be gained in the investigation 
of affections of the alimentary canal, from a 
personal inspection or more complete exami- 
nation of feces or vomited matters. The 
abdominal organs to which special modes of 
examination are chiefly applicable are the 
female generative organs, which are investi- 
gated per vaginam (see Womb, Diseases of); 
the bladder, by means of the catheter, the 
sound, and other surgical instruments; the 
stomach, by the use of the stomach-pump, 
probang, &c.; and the intestines, by examin- 
ing with the finger, hand, or surgical instru- 
ments per rectum, or by injecting water or 
air through the anus into the bowel. The 
ordinary modes of examination already men- 
tioned may afford assistance when employed 
along with some of the special methods just 
indicated. 
Thirdly, occasionally it is requisite to have 
recourse to exceptional modes of investiga- 
tion, such as the use of the exploring trocar 
or aspirator ; or to the administration of 
chloroform. The latter may afford direct 
information in certain abdominal conditions, 
and it may also materially assist in carrying 
out other methods of exploration. Now and 
then more serious operative procedures have 
to be adopted for diagnostic purposes. 
The abnormal conditions discoverable by 
physical examination may involve the entire 
abdomen, giving rise, for instance, to general 
enlargement or retraction; or they may be 
limited to some particular region, as exem- 
plified by enlarged organs, tumours, or 
abscesses. This part of the body has been 
artificially divided by anatomists into regions, 
and the seat of any local morbid condition 
can thus be defined and described. The 
diseases peculiar to the several regions will be 
considered under their respective headings. 
Frederick T. Roberts. 
ABDOMINAL ANEURYSM.-Ab- 
dominal aneurysm includes aneurysm of the 
aorta, and of any of its branches within the 
abdomen. 
Aneurysm of the Abdominal Aorta 
is essentially a disease of middle age. Of 
59 cases collected by Dr. Crisp, 33 were 
under the age of forty. It is more common 
in the male than in the female sex, in the 
proportion of about 8 to 1; and is usually 
traceable to strain, or to a blow upon the 
abdomen or back. The aneurysm is most 
frequently located in that portion of the 
vessel included between the aortic opening in 
the diaphragm and the origin of the superior 
mesenteric artery, being seldom met with 
below this point. In this situation the 
tumour is deeply seated; liable to tension 
from the crura of the diaphragm; and likely 
to involve the great splanchnic nerves, the 
semilunar ganglia, and the solar plexus. 
Hence the occasional difficulty of diagnosis ; 
and the frequency of boring pain in the back 
from erosion of the vertebra?, and of pa- 
roxysms of radiating pain in the abdominal 
viscera from stretching of the adjacent nerves. 
When situated lower down in the course of 
the aorta, the disease is less obscure, and the 
symptoms are less urgent. Aneurysm of the 
abdominal aorta is usually of the/aZse variety; 
and, as contrasted with thoracic aneurysm, it 
is less often associated with extensive athe- 
roma of the aorta, and with fatty or other 
structural disease of the heart. The symptoms 
referable to excentric pressure are also fewer, 
and, with the exception of pain, are less 
urgent than in the thoracic variety. 
Symptoms and Signs.-Of the symptoms, 
pain is the most characteristic and the most 
urgent; it is of two kinds, which are not, 
however, necessarily associated. In its usual 
form the pain of abdominal aneurysm is essen- 
tially neuralgic ; it is intermittent, lancinating, 
and paroxysmal,-encircling the body like 
a girdle, or radiating through the abdomen, 
back, pelvis, and base of the thorax, and not 
infrequently into either groin or testicle. The 
accession is sudden, and usually attributable 
to some definite cause of vascular excitement. 
The duration extends over a period varying 
from one to three hours, rarely longer; and 
the cessation is equally abrupt, leaving the 
patient in a state of exhaustion, but quite 
free from actual suffering. The second kind 
of pain referred to is continuous and boring; 
fixed at a particular point of the vertebral 
column; aggravated by pressure at this point, 
by active movement or stamping, and by 
gently turning the patient half round upon 
his axis in the standing posture ; but relieved 
by assuming the prone position or by leaning 
forward. Pain so characterised is pathogno- 
monic of erosion of the vertebrae. Pressure 
of an aneurysm may affect the functions of 
several organs within the abdomen. Thus 
jaundice may result from pressure upon 
the hepatic or common biliary duct: it is, 
however, more frequently due to an aneurysm 
of the hepatic or of the superior mesen- 
teric artery. Interference with the urinary 
ABDOMINAL ANEURYSM 
3 4 
ABDOMINAL ANEURYSM 
secretion, and the consequences thereof, from 
pressure upon the renal vessels; dysphagia, 
from pressure upon the oesophagus; vomiting, 
from obstruction of the pylorus; displace- 
ment of the liver forwards, or of the heart 
upwards-though rare symptoms-may be 
likewise due to the same cause. The radial 
pulse is not often affected. Symptoms of con- 
stitutional irritation and impaired nutrition 
are rarely exhibited, and appear only at the 
termination of protracted and painful cases, 
associated with great suffering and want of 
sleep. 
The physical signs are those discoverable 
by inspection, palpation, percussion, and aus- 
cultation. The tumour usually projects to 
the left of the mesial line, and tends to de- 
scend ; it is smooth and elastic; communi- 
cating to the hand alternate movements of 
lifting and expansion with increasing ten- 
sion, and of subsidence with relaxation. The 
pulsation is all but invariably single, and 
synchronous with the radial pulse ; it is 
limited to the tumour, and occasionally ac- 
companied by thrill. Pressure upon the 
aorta below the tumour will increase the 
force of impulse, diminish or abolish the 
thrill, and arrest the collapse. In a few re- 
corded examples the tumour was hard and 
uneven on the surface, and non-expansile; 
and in a still smaller number no pulsation 
was perceptible, the aperture of communica- 
tion with the artery having been blocked, or 
the vessel compressed on the proximal side 
by the growth of the aneurysm itself. Owing 
to the position of the hollow viscera in front, 
and the mass of lumbar muscles behind, the 
evidence from percussion is less conclusive 
in regard to abdominal than thoracic aneu- 
rysm. If, however, the abdominal muscles 
be relaxed, and the stomach and bowels free 
from flatus, absolute dulness to the extent of 
the tumour may be detected. A sound, single 
or double, as distinguished from murmur, is 
rarely heard in front in connexion with 
abdominal aneurysm; whereas the existence 
of sound without murmur, and usually double, 
at a point of the posterior wall of the abdomen 
corresponding to the tumour, is the rule, and, 
when detected, is of the utmost diagnostic 
value. Murmur in the recumbent posture is 
rarely absent in front; it is single, blowing, 
prolonged, post-systolic, and not transmitted 
into the vessel beyond. It may, however, be 
musical, or it may present both these charac- 
ters, but at different points of the tumour; 
in one instance it was of a buzzing quality. 
Should the aneurysm have taken an exclu- 
sively backward course, which is the excep- 
tion, a single murmur, not audible in front, 
may be heard in the back. In a few recorded 
cases a double murmur has been heard over 
the aneurysm in front. In the erect posture 
the murmur is usually suspended; but in a 
few published cases it was audible in both 
the erect and the recumbent posture, and in 
one at least in the erect posture only. These 
peculiarities depend upon the various con- 
ditions of the sac, its orifice, and its contents. 
A small aneurysm engaging the posterior wall 
of the vessel only, and eroding the vertebrae, 
may be latent as to physical signs, though 
attended with severe fixed pain in the 
back. In some cases a slight retardation of 
the pulse in the femoral arteries has been 
noted. 
Diagnosis.-The diagnosis of abdominal 
aneurysm has reference mainly to its physical 
signs. Strong pulsation of the aorta, simu- 
lating that of aneurysm, may exist in con- 
nexion with hysteria, uterine or intestinal 
irritation, dyspepsia, or marked anaemia. 
But in all these cases, irrespective of the 
positive and specific evidence presented by 
each, throbbing exists throughout the aorta, 
and is propagated into the main arteries of 
the lower limbs, whereas it is localised and 
expansile in aneurysm; and a careful explo- 
ration of the aorta-if necessary, under the 
influence of chloroform-will show that its 
dimensions are at all points normal. In these 
cases, too, although a murmur may be pro- 
duced by strong pressure with the stetho- 
scope, it does not exist when pressure is 
withdrawn. A cancerous or other tumour 
pressing upon the aorta may likewise produce 
murmur, and may exhibit pulsation com- 
municated from the aorta; but in most cases 
both these phenomena are promptly arrested 
by placing the body in the prone position; 
the tumour, in that position, gravitating from 
the vessel. The fixed local pain in the back, 
aggravated by pressure and motion, may be 
simulated by ordinary lumbago; and the 
paroxysmal visceral pain by biliary colic. 
The differential diagnosis must rest upon the 
specific evidence in each case, and upon the 
absence of the signs of aneurysm. 
Aneurysm of the Branches of the 
Abdominal Aorta.-The branches most 
liable to aneurysm are the common iliacs 
and their divisions; the coeliac axis and its 
branches; the renal, and the superior mesen- 
teric. Aneurysm of the Iliac Arteries belongs 
to the domain of surgery, and will not be 
further referred to here. Aneurysm of the 
Coeliac Axis and of its branches of division, 
and of the Superior Mesenteric Artery, are, 
in addition to the ordinary signs, equally 
characterised by mobility of the tumour; and 
the first two varieties by the occurrence of 
jaundice, haematemesis, and melaena, from 
pressure. Renal aneurysm may cause ob- 
struction in the kidney, or renal colic, by 
pressure on the structures in the hilus. 
Duration and Terminations.-The dura- 
tion of life in abdominal aneurysm in a number 
of cases observed, varied from fifteen days to 
eleven years. Death occurs usually: (1) by 
rupture of the sac into (a) the retro-peritoneal 
tissues; (6) the cavity of the peritoneum; (c) 
the left pleura or lung; (d) the intestinal ABDOMINAL ANEURYSM 
ABDOMINAL WALLS 
5 
canal; (e) the inferior cava; (/) the psoas 
muscle; (y) the pelvis of the kidney; (h) the 
spinal canal; or (i) the ureter, biliary pas- 
sages, or oesophagus ; the order given repre- 
sents the relative frequency of the fatal result; 
or (2) by exhaustion or syncope. The dura- 
tion of life after the rupture of the aneurysm 
has ranged from a few minutes to several 
weeks. A consecutive false aneurysm, retro- 
peritoneal in site, is specially characterised 
by feeble pulsation of the tumour, and 
diminished or arrested circulation in the 
femoral artery of one or both sides. 
Treatment.-The curative treatment of 
abdominal aneurysm maybe considered under 
three heads-operative, postural and die- 
tetic, and medicinal. Operative treatment 
consists in pressure applied to the aorta on 
the proximal side of the sac, or simultaneously 
on its proximal and distal sides, by means 
of tourniquets, so as completely to stop the 
circulation. The bowels should be first well 
moved and freed from flatus ; and during the 
continuance of pressure the patient should 
be kept under the influence of chloroform or 
ether. As a rule, compression should not be 
employed above the level of the duodenum. 
Five cases, if not more, in which a cure was 
effected by these means have been reported. 
The object sought to be attained being that 
of effecting rapid coagulation in the sac, the 
period during which pressure needs to be 
continued in these cases varies from three 
quarters of an hour to ten hours and a half. 
Where space for the application of proximal 
pressure does not exist, distal pressure alone 
may be tried. Under all circumstances, 
pressure must be used with care, as inflam- 
mation of the peritoneum or of the bowels 
has been known to result from it. Galvano- 
puncture, and the introduction of iron wire 
into the aneurysmal sac (Moore's treatment), 
have also been employed. In a small pro- 
portion of cases the latter method has been 
attended with a favourable result. 
Bellingham introduced the plan of treat- 
ment by posture and restricted diet. Under 
this plan perfect repose of mind and body is, 
as far as practicable, to be maintained; the 
bowels being kept moderately free, and the 
dietary restricted to 10 oz. of solids and 6 oz. 
of liquids daily. According to the method of 
the late Mr. Tufnell, which is based upon the 
same principle, but is more rigid, the patient is 
strictly confined to the horizontal posture for 
a period varying from eight to thirteen weeks, 
as determined by the effect upon the aneu- 
rysm, movement in bed being effected with 
caution; whilst, by a special arrangement, 
the bowels and the bladder may be evacuated 
without disturbance of the body. For break- 
fast, 2 oz. of white bread and butter, with 
2 oz. of cocoa or milk, are allowed; for 
dinner, 3 oz. of meat, with 3 oz. of potatoes 
or bread, and 4 oz. of water or claret; and 
for supper, 2 oz. of bread and butter, and 
2 oz. of milk or tea. The total amount in 
the twenty-four hours would be : solids 10 oz., 
liquids 8 oz. This system might be in some 
degree relaxed if the patient proved restive. 
Mild laxatives and opiates as required are 
the only medicines used. Ten cases of the 
successful treatment of aortic aneurysm by 
this method have been reported by Mr. 
Tufnell. Abdominal aneurysm was solidified 
in two instances, after treatment extending 
over thirty-seven and twenty-one days re- 
spectively. 
Of the various medicinal agents used with 
a view to favouring or effecting a deposit of 
laminated fibrin in the sac, acetate of lead, 
iodide of potassium, aconite, and ergotin (ad- 
ministered hypodermically), alone claim at- 
tention. Iodide of potassium may be given 
with advantage in doses of 10 to 20 grs. 
thrice daily, with a view to reducing vascular 
tension, and thereby relieving pain and pro- 
moting deposition in the sac, whilst perfect 
rest in the recumbent posture and a restricted 
dietary are observed. The latter are, how- 
ever, the more important factors in the treat- 
ment. Dr. G. W. Balfour has reported 
several cases successfully treated by means of 
iodide of potassium; and an example of a 
similar kind was subsequently published by 
Sir Dyce Duckworth. Dr. Grimshaw has 
recorded an example of cure mainly through 
the use of aconite. In all cases the allowance 
of liquids must be reduced to the lowest pos- 
sible standard, whilst excretion is promoted. 
Alcoholic stimulants may be given in small 
quantity and at long intervals, if the pulse 
exhibit debility and the patient complain of a 
sensation of sinking; otherwise they should 
be prohibited. 
The palliative treatment as applied to 
abdominal aneurysm will be found described 
in the article Aorta, Diseases of (Aneurysm). 
The application of a few leeches, followed 
by a warm poultice, is very efficacious in 
relieving pain. The hypodermic use of 
morphine is still more rapidly effective. 
Thomas Hayden. C. J. Nixon. 
ABDOMINAL TYPHUS. - A 
synonym for typhoid fever. See Typhoid 
Fever. 
ABDOMINAL WALLS, Diseases 
of.-But little more will be needed in this 
article than to give a brief outline of the 
nature of the affections to which the abdo- 
minal walls are liable, as most of these are 
but local forms of diseases which are fully 
described in other parts of this work. The 
parietal peritoneum will be excluded from 
consideration, as its morbid conditions are 
treated of separately. 
1. Superficial Affections.-a. The skin 
covering the abdomen may be the seat of 
various eruptions. The rash of typhoid 
fever is chiefly observed over this region. 6 
ABDOMINAL WALLS 
b. When the abdomen is greatly enlarged, 
its cutaneous covering becomes stretched and 
thinned, often presenting a shining appear- 
ance ; or it may even give way, so that it ex- 
hibits superficial cracks or fissures. If it has 
been distended for a considerable time or on 
several occasions, as after repeated pregnan- 
cies, the skin becomes impaired in its nutri- 
tion, and is often the seat of permanent white 
lines or furrows-linece albicantes. In this 
connexion allusion may be made to the 
umbilicus, which, in certain forms of disten- 
sion of the abdomen, may become pouched 
out, everted, or actually obliterated, c. The 
veins of the skin frequently become enlarged 
and tortuous, when the return of the blood 
which is normally conveyed through them is 
in any way impeded. The particular vessels 
which are distended will necessarily depend 
upon the seat of the obstruction, d. The 
cutaneous sensibility over the abdomen is 
sometimes materially altered. In certain 
nervous diseases it may become more or less 
impaired or lost; but the most important 
deviation is a marked increase of sensibility 
-hypercesthesia-which is occasionally ob- 
served in hysterical females, and which may 
simulate more serious affections, particularly 
peritonitis, especially if it is accompanied 
with symptoms of much depression. This 
condition is characterised by extreme super- 
ficial sensibility or tenderness of the abdo- 
men, the slightest touch being resented ; but 
if the patient's attention can be taken off, and 
deep pressure be then made, this is borne 
with little or no indication of distress. The 
aspect of the patient, the presence of other 
symptoms indicative of hysteria, and the 
absence of pyrexia usually serve to dis- 
tinguish this affection from others of a graver 
nature. The surface of the abdomen may 
also be affected with neuralgia, which is 
sometimes very severe. 
2. Subcutaneous Accumulations.-a. The 
chief morbid condition coming under this 
head is oedema or dropsy of the subcutaneous 
tissue. This generally follows anasarca of 
the legs, and may be associated with ascites. 
The fluid tends to collect especially in the 
lower part of the abdominal walls and to- 
wards the flanks. The skin often presents a 
white pasty aspect; the abdomen may be 
more or less enlarged; the umbilicus appears 
depressed and sunken, if the oedema extends 
up to this level; the superficial structures 
pit on pressure, and yield the peculiar sensa- 
tion of dropsical tissues ; and the percussion 
note is frequently muffled, b. The abdominal 
subcutaneous tissue is, in many persons, the 
seat of an abundant collection of fat, which 
may be important from causing apparent 
enlargement, and simulating or obscuring 
other more serious morbid conditions which 
enlarge the abdomen, c. In rare instances 
gas accumulates under the skin in this region, 
constituting subcutaneous emphysema. The 
abdomen then appears to be enlarged, but 
the condition is readily recognised by the 
peculiar crackling or crepitant sensation felt 
on digital pressure; the resonant or tym- 
panitic sound elicited by percussion ; and the 
dry crepitant sound heard when pressure is 
made with the stethoscope. 
3. Affections of the Muscles and Apo- 
neuroses.-a. The abdominal walls may be 
the seat of muscular rheumatism, which is 
particularly likely to follow undue straining, 
such as that caused by violent coughing or 
vomiting. It is characterised by pain, some- 
times severe, evidently located in the mus- 
cular and tendinous structures, accompanied 
with much soreness and tenderness. The 
affected parts are kept as much at rest as 
possible, and any action which disturbs them 
materially aggravates the pain. b. As the 
result of violent strain, the muscular or 
aponeurotic tissues may be more or less 
torn or ruptured, or the normal openings en- 
larged. As a consequence a protrusion of 
some internal structure is likely to take place, 
forming a hernia, c. The abdominal muscles 
are liable to be the seat of spasmodic contrac- 
tion, cramp, or rigidity. These disorders are 
not uncommonly excited in sympathy with 
grave disturbance of the alimentary canal, as 
in cholera. In certain painful internal affec- 
tions, also, some of the abdominal muscles are 
occasionally kept in a state of more or less 
rigid tension, as if they were involuntarily 
contracted in order' to protect the diseased 
parts underneath from injury. The spas- 
modic contractions in tetanus not infre- 
quently cause great suffering over the abdo- 
men. d. On the other hand, the abdominal 
muscles are occasionally paralysed, as the 
result of centric nervous disease. The move- 
ments of respiration are then altered in 
character ; while the expulsive acts in which 
the abdominal muscles naturally take part 
are much interfered with. 
4. Relaxed Abdominal Walls.-All the 
structures forming the walls of the abdomen 
are often in a relaxed and flabby state, yield- 
ing to any pressure from within?, so that the 
abdomen becomes enlarged and prominent, 
especially if, as is frequently the case, this 
condition is associated with much flatulence. 
It materially weakens the act of defalcation, 
and promotes constipation. 
5. Inflammation and Abscess.-Local in- 
flammation may be set up in any of the ab- 
dominal structures, and this may terminate 
in suppuration and the formation of an ab- 
scess. Purulent accumulations from within, 
as in cases of pelvic abscess, as well as certain 
abscesses originating in diseases of bones or 
joints, may likewise extend among the tissues 
of the abdominal walls, causing thickening 
and induration, or may make their way 
outwards, directly or through a sinus. Sub- 
sequently permanent sinuses or fistulae may 
be left. ABDOMINAL WALLS 
ABSCESS 
7 
6. The abdominal wall may be the seat of 
extravasation of blood; and various kinds of 
tumour or new growth may form in its struc- 
tures. Frederick T. Roberts. 
ABERRATION. - A divergence or 
wandering from the usual course or con- 
dition ; applied in medicine chiefly to 
certain disorders of the mental faculties. 
See Insanity. 
ABORTION.- The act of abortion 
signifies the expulsion of the contents of the 
pregnant uterus before the seventh month 
of gestation. An abortion is a designation 
given to a foetus prematurely expelled. See 
Miscarriage. 
ABSCESS (abscedo, I depart). Synon. : 
Fr. abces; Ger. Eiterbeule; Geschwiir. 
Definition.-A collection of purulent 
matter, one of the results of inflammation. 
See Inflammation. 
Pathology.-If the material which collects 
in a tissue as the consequence of inflamma- 
tion softens and becomes liquid (suppuration), 
it does so either rapidly or slowly: if the 
former, the result is an acute abscess ; if the 
latter, the abscess is termed chronic or cold. 
If the material thus softened and forming 
pus, often mingled with fragments of dead 
tissue, is limited by the condensation of the 
parts around, which are usually consolidated 
by the products of inflammation, the abscess 
is said to be circumscribed; but if the sur- 
rounding parts in their turn soften, so as 
practically to offer no barrier to the pus, 
then the abscess spreads and is said to be 
diffused. The term ' diffused suppuration ' 
is, however, in this case, more usually em- 
ployed. In an acute circumscribed abscess 
the lymph which collects around it as the 
result of inflammation becomes organised 
and forms a sac (pyogenic membrane); and 
this, with the compressed tissue about it, 
constitutes the wall; the entire abscess con- 
sisting therefore of contents (pus), of a limiting 
sac, and of condensed tissue around. The 
resistance offered to the extension of the 
suppuration is greatest when the parts ad- 
jacent are dense and tough, such as bones 
and fascia; yet, as the pus in an abscess 
increases in quantity, probably by breaking 
down of the pyogenic layer, sufficient pres- 
sure is exerted to cause the most dense 
structures ultimately to yield, and an abscess 
will thus make its way even through osseous 
tissue. As might be expected, an abscess 
always advances in the direction of least re- 
sistance, and this extension is spoken of as 
its pointing. This pointing may be towards 
the surface of the body, but an abscess may 
direct itself towards a serous cavity, such 
as the peritoneum; or along a track of cel- 
lular tissue, as when pus beneath the deep 
cervical fascia points into the mediastinum. 
On the side at which the abscess is pointing; 
its wall, as the resistance lessens, projects; 
and by ulcerative absorption the parts cover- 
ing it become quickly thinner, until they 
and the abscess-wall give way and the pus 
escapes. In by far the greater number of 
cases this absorption of tissue before the 
pointing abscess is towards the surface, and 
it is by ulceration of the skin that the open- 
ing for the discharge of the matter is effected. 
The wall of the abscess then contracts, pus 
continuing for a time to be discharged; and 
in the end, aided by the resilience of the 
tissues around, the sac of the abscess is 
obliterated, and the orifice through which its 
contents were discharged heals by granula- 
tion process. To ensure this result the walls 
must be left at rest, or the granulations which 
cover them may fail to unite, and the oblitera- 
tion of the sac will not then take place. This 
happens, for example, in the case of an abscess 
situated between the movable rectum on the 
one side and the ischium on the other, where 
the opposite abscess-walls are prevented from 
joining by muscular movements on the side 
of the bowel, and will only unite after such 
movements have been stopped by cutting 
across the muscular fibres which occasion 
them. The track which results from such 
failure of the healing of an abscess is called a 
sinus or fistula. 
In a diffused abscess the inflammation of 
the parts around does not limit the suppur- 
ation by organisation of the effused lymph, 
but such lymph, itself degenerating, forms 
more pus, and so the abscess extends rapidly 
and widely, unless checked by some barrier 
of dense tissue. In this way matter often 
spreads along tracts of cellular tissue, as 
along the course of veins, and in the sub- 
cutaneous structures. An abscess when 
formed between bone and periosteum, or 
otherwise hindered from reaching the surface 
by pointing, also tends to diffuse itself by 
following the course of least resistance. In 
most of these cases, by direct pressure upon 
the resisting tissue, or by cutting off the blood- 
supply (as of the skin when its subcutaneous 
tissue is infiltrated with pus), sloughing of 
the parts covering in the abscess ensues, 
oftentimes to a considerable extent, and so 
the pus eventually makes its way to the 
surface. 
A chronic abscess begins in some local in- 
flammation without active symptoms, such 
as results in the deposit of aplastic lymph 
and subsequent ulcerative changes, as caries 
of bone, the irritation leading to suppuration. 
The formation of matter or ' pus ' proceeds in 
a languid manner, so that it is only by slow 
degrees that it collects in any considerable 
quantity, although eventually these chronic 
abscesses may acquire great size. They 
slowly point, and in their tardy advance occa- 
sionally traverse even serous cavities, which 8 
ABSCESS 
have been first obliterated in the line of 
transit by adhesive inflammation of their 
opposed surfaces: in this way an abscess 
formed in the liver (and this holds good also 
for those of a more acute character) may 
travel through the layers of the peritoneum, 
and may point through the anterior wall of 
the abdomen. 
When an abscess discharges, its contents 
are seen to be either a thick yellow (laudable) 
pus, or pus stained with blood, or otherwise 
coloured, such as black or bluish-green; or 
the pus may be thin, almost watery, mingled 
with flakes of lymph; it may be inodorous 
or foetid, or irritating to the skin (ichorous). 
Abscesses may also contain sloughs of tissue, 
foreign bodies, masses of inspissated pus as 
hard occasionally as calculi, fragments of 
dead bone, or calculi of various kinds. Some- 
times a chronic abscess ceases to enlarge; 
and if the irritation which occasioned it 
comes to an end, it may diminish by absorp- 
tion of the fluid part of its contents, the solid 
part drying up into a shrunken putty-like 
mass. It may remain in this state without 
giving rise to further trouble, or it may become 
again the seat of suppuration by the formation 
of what under such circumstances has been 
termed by Sir James Paget a residual abscess; 
this term ' residual ' being also applied to an 
abscess which has formed at the site of old 
inflammatory processes, although these may 
never have advanced previously to actual 
suppuration. 
The progress of any abscess is largely in- 
fluenced by the state of the general health. 
In persons otherwise robust an abscess com- 
monly runs an acute course; in those 
weakened by acute illness, such as scarlet 
fever or typhus, they form quickly, but are 
slowly'recovered from, and severely tax, by 
an exhausting discharge, the powers of the 
patient. Persons in feeble health, hereditary 
or acquired, usually suffer from the chronic 
and diffused forms; and chronic affections of 
internal organs, as of the liver or kidneys, 
are not infrequently associated with the de- 
velopment of such abscesses. 
^Etiology.-The cause of an acute abscess 
may be an injury, such as a blow or pressure, 
as often happens in persons weakened by 
continued fever; exposure; or the irritation 
of a foreign body, or that of a poison intro- 
duced from without. In the last case the 
abscess is often diffused. Abscess running 
an acute course may also be due to a foreign 
body or to an irritant from within, as when 
it follows necrosis of a portion of bone, or 
the escape of urine into the tissues of the 
perineum. It also arises in connexion with 
blood-poisoning, as in various fevers, and 
affections distinguished as septic. The cause 
of a chronic abscess is usually found in 
changes which go with deposits of a tuber- 
culous character ; or it is found in the changes 
which slowly occur around an irritating 
body, such as a renal calculus; or chronic 
inflammation may culminate in one of 
these collections of matter. They may also 
form in parts which are long congested in 
connexion with obstructed venous circulation 
(varix); and they may follow, or conditions 
closely allied may follow, the occlusion of 
a main artery and the consequent cutting 
off of the supply of blood to a particular 
region. 
Symptoms.-The symptoms of an acute 
abscess are those of a local inflammation, 
with constitutional disturbance if the abscess 
is of any size; followed by a sense of cold or 
actual shivering, with increase of pain and 
swelling, tenderness, and throbbing. The 
tenderness can be recognised in the case of 
most abscesses; and, if pus is formed any- 
where near the surface, the presence of the 
fluid is detected by its fluctuation. The 
severity of the pain is much influenced by 
the site of the abscess, as when the pus is 
held down and hindered from pointing by 
dense structures, such as fasciae. Special 
symptoms may also arise in connexion with 
the situation of the suppuration, as when 
urgent dyspnoea is caused by the pressure 
on the larynx of an abscess deeply seated at 
the base of the tongue. A diffused abscess, 
if subcutaneous, is recognised by its rapid 
spreading, and may be suspected if other 
signs point to a part as the site of the abscess 
in which diffusion is the rule. 
Of chronic abscess there is seldom any evi- 
dence in its early stage. The symptoms, if 
any, are those of failing health, and for the 
rest are marked by those of other changes 
from which the abscess is an outcome. Thus 
in disease of the hip-joint or of the spine, 
unless an attack of shivering chances to 
attract attention, an abscess is not, as a rule, 
suspected until it has broken through its first 
limits, and has attained considerable size. 
Our limits do not permit an examination of 
the symptoms which serve to distinguish 
between chronic abscess and other swellings, 
such as extravasated blood or soft tumours, 
especially malignant tumours; but this is 
the less requisite, for if a doubt in any case 
arises, it can be at once solved by the intro- 
duction of a grooved needle or of a fine 
trocar into the swelling. The true pulsation 
of an aneurysm sufficiently tells its nature, 
and is not easily mistaken for the impulse 
sometimes given to an abscess by an adjacent 
artery. 
Varieties.-The chief local varieties of 
abscesses which are likely to be met with in 
medical practice may be thus arranged:- 
1. Subcutaneous or more deeply seated 
abscesses in the limbs, in connexion with low 
fevers, erysipelas, pyaemia, &c. 2. 'Abscesses 
of local origin in the walls of the abdomen 
or chest. 3. Abscesses originating in serous 
membranes. 4. Certain special abscesses 
associated with diseased bone, e.g. psoas and lumbar abscess. 5. Abscesses formed in the 
cellular tissue around organs, e.g. peri-nephri- 
tic. peri-caecal, &c. 6. Abscesses originating 
in inflammation of organs, the chief of which 
include hepatic, renal, pyelitic, pulmonary, 
mammary, cerebral, splenic, pancreatic. 
7. Obscure abscesses formed in the deep 
cellular tissue, e.g. retro-pharyngeal, ischio- 
rectal, mediastinal. 8. Glandular abscesses, 
which are usually chronic, and of a scrofu- 
lous nature. 9. Suppurating hydatid cysts. 
Treatment.-The treatment of an acute 
abscess consists in rest; soothing local appli- 
cations, of which poppy or plain water fomen- 
tations, and warm poultices, as of boric 
wool or linseed-meal, are usually the best; 
and the use of remedies to allay pain and 
constitutional disturbance, if required. As 
soon as the presence of pus is recognised 
the abscess must be opened, if possible where 
the matter is most dependent; and as soon 
as its contents have escaped, all troublesome 
symptoms will usually disappear. The open- 
ing is needed to relieve pain, in some cases 
to prevent diffusion of pus, and sometimes to 
relieve urgent distress, as when dyspnoea is 
caused by the pressure of an abscess upon the 
air-passages. It is also desirable to open an 
abscess to avoid the considerable scar which 
must result if the matter is left to escape by 
ulceration or sloughing of the superficial 
tissues. In most cases it is necessary to open 
an abscess by an incision. A narrow knife 
should be used; and if the matter is deeply 
seated, the superficial parts only need be cut, 
the deeper being torn through, as the late 
Mr. Hilton recommended, by a steel director 
and by dressing-forceps, the risk of dividing 
important structures, as in the neck, being 
thus avoided. After the abscess has been 
punctured, it should be left to contract by the 
resiliency of its own walls, all squeezing and 
handling being carefully refrained from, as 
harmful and unnecessary, and giving the 
patient needless pain. The wound should be 
kept open, if necessary, by means of a drainage- 
tube, or a slip of thin gutta-percha tissue or 
of oil-silk, and should be covered with absor- 
bent carbolic gauze, iodoform wool, or some 
other of the numerous antiseptic dry dressings 
now employed for this purpose; or, where 
moist applications are needed, by wet boric 
lint or wool, or by a linseed-meal poultice. 
In some cases it is necessary to protect the 
wound, whilst operating, by means of the 
carbolic spray, or by a piece of linen steeped 
in carbolic lotion (1 in 20), or by taking some 
other antiseptic precautions. The drainage- 
tube should be withdrawn after the first day 
if the abscess is superficial, but if the pus has 
been deeply seated it should be only gradu- 
ally withdrawn, portions being cut off as the 
abscess contracts. If a foreign body has 
caused the formation of the abscess, it must 
be sought for and removed before the sup- 
puration can be expected to cease. Occa- 
ABSCESS 
sionally the vascular wall of an abscess bleeds 
freely, or a vessel is opened in its progress. 
The haemorrhage usually ceases on laying 
the abscess freely open ; but if this does not 
suffice, it may be permanently controlled by 
pressure, and cases are rare in which further 
operative interference is called for. In- 
flammation of the sac used formerly not 
infrequently to follow the discharge of its 
contents, but under the treatment now em- 
ployed such an occurrence is unknown. 
During the healing of any considerable 
abscess the general health should be attended 
to, and tonics and change of air may be useful 
to expedite recovery. 
Diffused abscesses, whether subcutaneous 
or more deeply seated, require free incisions 
as soon as suppuration is even suspected, so 
as to avoid the damage which results from 
their spreading, and from the sloughing of 
tissue, as of the skin, which will otherwise 
occur; and this treatment is especially called 
for in the case of those due to poison 
introduced into the system, and those caused 
by infiltration of urine. These abscesses 
sometimes lead to fatal results. 
A chronic abscess may have its contents 
drawn off by the aspirator ; or it may, when 
it has come near the surface, be opened, 
drained, and dressed as above, but its ulti- 
mate closing will depend upon the removal 
of the cause; if, for example, it is due to 
disease of a joint, it cannot be cured until the 
disease in which it has originated has in some 
way ended. In some cases of suppurating 
lymphatic glands it is well to scrape out 
their interior, after making a clean incision 
into them, and to apply iodoform or some 
other antiseptic to the cavity which is left. 
Sinus.-An abscess after being opened 
may contract until it forms a narrow track, 
sinus or fistula, leading to the site of primary 
irritation. Such a track has a dense fibrous 
wall from which purulent fluid escapes. It 
may also convey secretions, as from the liver 
(hepatic fistula) or stomach (gastric fistula), 
or excretion, as from the kidneys; or it may 
simply carry out the pus which forms around 
some irritant at the deep extremity, such as 
a foreign body, or a portion of carious or 
necrosed bone. Some such fistulse are due to 
the movements of adjacent muscles prevent- 
ing union of the abscess-walls. Unless the 
cause of the sinus can be removed, as by ex- 
tracting necrosed bone, these fistulous tracks 
are difficult to manage, requiring special 
treatment according to their situation. Other 
fistulce are those forming communications 
between mucous canals (recto-vesical, vesico- 
vaginal fistulce) ; and these need special treat- 
ment, such as plastic operations, and opera- 
tions diverting the course of excreta escaping 
through unnatural channels. 
The tissue about healed abscesses, scar- 
tissue generally, and tissue spoiled by inflam- 
mation, are apt on slight provocation to in- 
9 10 
flame and suppurate, and to these collections 
of matter the term ' residual ' has been 
applied. The treatment of such abscesses in 
no way differs from that of others, and they 
usually heal in the ordinary manner. 
G. W. Callender. W. Morrant Baker. 
ABSINTHISM. - Definition. - The 
condition induced by an excessive consump- 
tion of absinthe. 
From the mode in which absinthe is taken, 
we should expect that the symptoms in- 
duced by its excessive consumption would be 
generally obscured by, and intermixed with, 
those of alcohol (see Alcoholism). That it 
has a special effect on the organism, and that 
this may be diagnosed from alcoholism, has 
been pointed out by Motet, Magnan, and other 
French physicians; and Magnan has clearly 
exemplified its action by numerous experi- 
ments on dogs. In persistent absinthe- 
drinkers, vertigo and epileptiform convulsions 
are marked symptoms, and come on much 
earlier than when alcohol, in other forms, is 
habitually drunk. Hallucinations occur also 
without any other symptom of delirium 
tremens; and, when tremors coexist, these 
are limited more particularly to the muscles 
of the arms, hands, and shoulders. Absinthe 
acts chiefly on the cervical portion of the 
spinal cord, and this readily explains the 
special symptoms arising from its regular use 
in excessive quantities. John Curnow. 
ABSORBENT AGENTS. -In sur- 
gery, absorbents are substances used to ab- 
sorb fluids, as sponges, charpie, or tow; in 
medicine, drugs which neutralise excessive 
acidity in the stomach-a synonym for alkalis 
(sec Alkalis). The term is sometimes also 
made use of to designate remedies, such as 
the preparations of mercury and iodine, 
which are believed to possess the property 
of promoting the absorption of morbid pro- 
ducts. 
ABSORBENT VESSELS and 
GLANDS, Diseases of.-See Lymphatic 
System, Diseases of; Bronchial Glands, 
Diseases of; and Mesenteric Glands, 
Diseases of. 
AC ARIIS.-Acari or mites constitute an 
order of the class Arachnida, several species 
of which are parasitic. The Acarus scabiei 
or Sarcoptes hominis, and the Acarus 
folliculorum, or more properly the Steatozoon 
folliculorum, are the only human parasites 
belonging to this family. 
Description.-1. The Acarus scabiei is a 
small roundish animal, just visible to the 
naked eye. Examined under the microscope 
it is seen to be flattened, and to resemble a 
tortoise in shape; when fully developed it 
has eight legs, and on its under surface are 
ABSCESS 
scattered filaments and short spines, which 
are for the most part directed backwards. 
The female is larger than the male, and is 
provided with terminal suckers on the four 
anterior legs, while filaments occupy a similar 
position on the posterior ones; in the male, 
however, the two extreme hind legs have 
suckers like those on its fore limbs. The 
young acarus has only six legs, the two hind- 
most ones, which are distinctive of the sex, 
being wanting; it acquires these after shed- 
ding its first skin. The male acarus lives 
near the surface of the skin, while the female 
burrows within the cuticle, and deposits from 
ten to fifteen eggs in the cuniculus or 
burrow; these eggs hatch in about a fort- 
night. The young acari escape from the 
burrow, but the parent does not leave it, and 
dies when she has finished laying eggs. The 
acarus scabiei is the cause of the skin-affec- 
tion termed Scabies or Itch. See Scabies. 
2. The Acarus folliculorum is a very 
minute parasite commonly found in the 
sebaceous and hair-follicles of the face, but 
its presence can hardly be regarded as indi- 
cating disease. In this animal the head is 
continuous with the thorax, and to the latter 
are attached eight very short legs, each armed 
with three strong claws. On each side of the 
head are short jointed palpi. The abdomen 
varies in length from twice to three or four 
times that of the thorax; it is pointed at its 
distal extremity. The presence of this para- 
site in the follicles of the skin is quite un- 
important. Robert Liveing. 
ACCOMMODATION, Disorders of. 
See Vision, Disorders of. 
ACEPHALOCYST (A, priv.; 
a head; and Kvans, a bag).-A headless 
cystolar hydatid; a sterile hydatid. See 
Entozoa-Hydatids. 
ACHOLIA (a, priv.; and x°W' bile).- 
Absence or deficiency of bile. See Bile, 
Disorders of. 
ACHOR.-A small follicular pustule of 
the scalp. Willan's definition is as follows:- 
'A small acuminated pustule containing a 
straw-coloured matter, which has the appear- 
ance and nearly the consistence of strained 
honey, and is succeeded by a thin brown or 
yellowish scab.'Both the pustule and the scab 
are constituents of the disease porrigo. The 
word has fallen into disuse, but is preserved 
by Schbnlein in the name ' achorion ' 
assigned by him to one of the varieties of 
parasitic cutaneous fungi. The Greek word 
ax&p signifies scurf, or dandruff; axvpov 
meaning chaff. Erasmus "Wilson. 
ACHORION (ax^p, scurf) is the name 
given to one of the three principal dermo- 
phytes or epiphytes of the skin. It is the 
ACHORION ACHORION 
ACIDITY 
11 
constituent of the crust of favus (achor), 
and belongs to the group of fungoid plants 
denominated Oidium. It consists of spores, 
sporidia or tubes filled with spores, and 
empty branched tubes or mycelium. 
Achorion was the first discovered of the 
epiphytes of the skin, and in compliment to 
one of its early observers, Schonlein, has been 
named Achorion Schonleinii. It is supposed 
to be the agent of contagion in favus ; it has 
also been found in the loose cell-structure 
beneath the nail in onychogryphosis. 
Erasmus Wilson. 
ACHROMA (a, priv.; and xpupa, colour). 
Absence of colour; an achromatous or 
colourless state of an usually coloured tissue, 
due to absence of pigment. In reference to 
the skin, achroma is synonymous with 
leucoderma, albinism, and alphosis. See 
Pigmentary Skin-Diseases. 
ACHROMATOPSIA, (a priv.; ypwpa, 
colour ; and ar^, sight).-More or less com- 
plete inability to distinguish colours from 
each other. See Vision, Disorders of. 
ACIDITY.-Acids are constantly pass- 
ing out of the body by the lungs, the skin, 
and the kidneys. These acids, if we except 
the small quantity introduced from without 
in the form of acid salts of certain articles 
of food, are formed within the body by the 
disintegration and oxidation of the tissues 
and food. If the oxidation of organic sub- 
stances in the system were complete, the 
sole products of their combustion would be 
carbonic acid, water, and urea; but as this 
oxidation is never actually complete, other 
products, as lactic acid, oxalic acid, uric 
acid, &c., are formed; and the increased or 
diminished production of these intermediary 
products may be regarded as the measure of 
the completeness with which the oxidation 
processes are being performed in the body. 
The quantity of acid matter passing through 
the blood on its way to the lungs, the skin, 
and the kidneys is considerable ; since it has 
been shown approximately, that a healthy 
man of eleven stone weight, under ordinary 
circumstances, passes by the first two chan- 
nels an average of 890 grammes (about 28 
ounces) of carbonic acid daily, and that the 
acid excreted by the kidneys in the same 
period is equivalent to two grammes (about 
31 grains) of crystallised oxalic acid; whilst 
the volatile fatty acids passing off with the 
sweat have not yet been satisfactorily calcu- 
lated. It is evident that if the regular elimi- 
nation of acids, by any of these channels, be 
interfered with, they will tend to accumu- 
late in the system. Acidity, or excess of 
acid in the body, therefore depends on two 
causes :-1. excessive formation, the result 
of incomplete oxidation of the elements of 
the tissues and the food; 2. deficient elimi- 
nation of acid formed either in normal or 
abnormal quantities. Both these causes, 
however, are generally found acting in con- 
junction. Oxidation is imperfectly performed 
when an insufficient quantity of oxygen is 
introduced into the body, owing to insuffi- 
ciency of the respiratory act, the result of 
disease or sedentary habits; or when the 
blood is poor in red corpuscles, the carriers 
of oxygen, as in leukaemia; or from func- 
tional derangement of some large gland, such 
as the liver, where oxidising processes are 
extensively carried on. Again, the materials 
submitted to the influence of the oxygen 
within the body may be so increased, as is 
the case in febrile conditions, or in general 
plethora induced by over-feeding and insuffi- 
cient exercise, that the supply of oxygen 
may prove insufficient for their complete 
combustion. Defective elimination of the 
acids formed within the body is due either 
to diseased conditions which prevent the 
lungs, skin, and kidneys from exercising their 
respective functions properly, or to want of the 
physiological stimulus which excites them. It 
will be seen, therefore, that acidity may arise 
in consequence of the disturbing influence 
of disease; or may be acquired or inherited 
as the penalty of transgression of certain 
laws of health-as the result of unfavourable 
hygienic conditions. In the former case, 
acidity is only secondary, and is generally 
subordinate to the disease producing it, and 
has rarely to be considered apart from it; 
whilst in the latter instance acidity is usually 
at first the only trouble, leading, however, 
if disregarded to secondary mischief. 
Effects.-The mucous membranes and 
skin chiefly suffer in acidity. The former 
become subject to catarrh, produced, no 
doubt, by the irritating presence of the acid. 
Acidity may thus cause bronchitis, gastro- 
intestinal catarrh, and catarrh of the genito- 
urinary tract. Sometimes the acid is poured 
out in such quantities from the mucous mem- 
brane of the stomach as to be ejected from 
the mouth. In these cases digestion is con- 
siderably interfered with by the too acid 
condition of the gastric juice. Sometimes, 
however, this acidity of the stomach is pro- 
duced by an opposite condition-the defi- 
ciency of the digestive fluid, and consequent 
acid fermentation of the food. Abnormal 
acidity of the urine not only produces catarrh 
of the urinary passages, but by decomposing 
the salts of uric acid causes a deposit of 
insoluble uric acid in the passages, thus 
giving rise to attacks of gravel, or leading to 
the formation of a calculus. Acidity mani- 
fests itself in the skin by attacks of erythema, 
herpes, eczema, and urticaria. Rheumatism, 
too, may be considered as a disease resulting 
from the formation of acid, affecting chiefly 
fibrous and serous membranes; no one can 
witness the enormous quantities of acid 
sweat poured out, and the highly acid urine. in the acute form of this disease, without 
acknowledging that an increased formation 
of acid is taking place somewhere in the 
body; though perhaps unwilling to commit 
oneself to accept any of the views hitherto 
advanced as to the nature of the acid. 
Estimation of Acid.-For clinical pur- 
poses an estimation of the acidity of the 
urine furnishes the physician with an approx- 
imate clue as to the amount of acid formed 
in and passing out of the body. This is done 
by collecting the urine for twenty-four hours, 
placing 100 c.c. of this in a beaker, and then 
adding a solution of sodium hydrate (stan- 
dardised so that 1 c.c. = *01 gramme of crys- 
tallised oxalic acid) from a Mohr's burette, 
till the fluid is neutralised. The number of 
c.c.'s of the standard solution required to 
effect this is to be multiplied by '01, which 
gives the percentage acidity in terms of oxalic 
acid. To ascertain from this the total amount 
of acid in the twenty-four hours' urine is only 
a matter of calculation. Too much depend- 
ence must not, however, be placed on the 
urine as a means of estimating excess or 
deficiency of acid in the system; it some- 
times happens that in highly acid conditions 
the urine is alkaline. This, as Dr. Bence 
Jones has shown, may occur when large 
quantities of acid fluid are poured out of the 
stomach; and Prout long ago observed, that 
in the eczema of gouty persons, the urine, so 
long as the disease persisted, was either of 
low acidity or alkaline, but that the subsi- 
dence of the eczema was frequently followed 
by an over-acid condition of the urine, ac- 
companied with renal and vesical catarrh. 
Treatment.-The general indications for 
the treatment of acidity consist in the pro- 
motion of oxidation, and the elimination of 
the acids formed. Active habits, which pro- 
mote the pulmonary and cutaneous functions, 
should be encouraged. The diet should be 
just sufficient to meet the physiological re- 
quirements of the body; it should consist 
chiefly of fish, fowl, game, and eggs; sac- 
charine and farinaceous articles being ex- 
cluded. Sweet and cheap wines should be 
avoided; for those who cannot afford to 
purchase good wine, pure spirits and water 
is the best substitute. Carlsbad salts or 
Friedrichschall water may be given if there is 
much abdominal plethora; the habit of taking 
mercurials as a relief for this condition is to 
be deprecated. Alkaline medicines are fre- 
quently administered with a view of neutra- 
lising the effects of acid; their employment 
for this purpose seems, however, questionable. 
The late Dr. Parkes stated that the adminis- 
tration of bicarbonate*) f potassium (a favourite 
remedy in acid diseases), though rendering 
the urine alkaline, in reality increases very 
largely the excretion of the organic acids. 
This is not to be wondered at when we con- 
sider that the bicarbonate, although alkaline 
in reaction, is in constitution an acid salt. 
12 
ACIDITY 
Dilute nitric and hydrochloric acids, given 
in moderate doses about one hour before 
meals, certainly have a powerful oxidising 
effect, and diminish the quantity of uric acid 
excreted in the urine. In cases where the 
acidity is manifestly due to defective oxida- 
tion, consequent on poverty of blood from 
diminution of the red corpuscles, iron and food 
must be freely given. C. H. Ralfe. 
ACIDS.-Definition.-Substances which 
combine with alkalis, and destroy their power 
of turning red litmus-paper blue. Most of 
the acids also redden blue litmus, and have 
a sour taste ; but some-for example, carbolic 
acid-possess neither of these properties. 
Enumeration.-Acids may be divided into 
inorganic or mineral, and organic. The 
mineral acids used in medicine are Boric, 
Carbonic, Chromic, Hydrochloric, Hydrobro- 
mic, Nitric, Nitro-hydrochloric, Phosphoric, 
Sulphuric and Sulphurous acids. The organic 
acids thus employed include Acetic, Benzoic, 
Carbolic, Carbonic, Chrysophanic, Citric, 
Gallic, Hydrocyanic, Lactic, Oleic, Salicylic, 
Tannic, Tartaric, and Valerianic. 
Action.-The stronger acids-sulphuric, 
nitric, hydrochloric, chromic, glacial acetic 
and lactic acids-destroy animal tissues, and 
act as caustics when applied to the surface. 
When swallowed they produce the symptoms 
of irritant poisoning (see Poisons). An 
antidote for these poisons which is always at 
hand is carbonate of lime, in the form either 
of whiting or of plaster chipped from the 
nearest ■wall. Other antidotes are alkaline 
carbonates and bicarbonates, milk, oil and 
soap. Diluted acids, taken into the mouth, 
increase the secretion of saliva; and hydro- 
chloric acid forms an important constituent 
of the gastric juice, without which digestion 
does not go on. When absorbed into 
the blood, dilute acids act on the heart 
generally, slowing its pulsations and reducing 
the temperature. They are excreted in the 
urine and milk. 
Uses.-Nitric acid is employed as a caustic 
application to piles, to poisoned wounds, and 
to spreading or unhealthy sores. Glacial 
acetic acid is used to destroy corns or warts. 
Diluted acetic acid or vinegar is applied as a 
lotion to relieve headache; to allay the 
itching of prurigo, lichen, and psoriasis; to 
check perspiration; and sometimes to hasten 
the appearance of exanthematous eruptions. 
Diluted acids, especially citric, tartaric, and 
hydrochloric, as well as acid tartrate of 
potassium, are administered in fevers as re- 
frigerants, because they relieve the dryness 
of the mouth, and diminish the thirst by 
increasing the secretion of saliva, as well as 
lower the temperature and pulse-rate. Under 
the like circumstances, the organic acids, 
acetic, citric, and tartaric, when combined 
with alkaline carbonates in a state of effer- 
vescence or otherwise, form compounds which 
ACIDS act on the skin and kidneys. In febrile con- 
ditions, anaemia, and some forms of dyspepsia, 
the proportion of acid in the gastric juice is 
insufficient for the proper digestion of food, 
and the administration of dilute hydrochloric 
acid, immediately before or after meals, is 
useful both by aiding digestion and by 
preventing the formation of butyric and 
other acids, which give rise to sour eructa- 
tions. Nitro-hydrochloric acid, before meals, 
is likewise beneficial in preventing acidity. 
It appears to have some action on the liver; 
and is used, both internally, and externally 
as a lotion or footbath, in jaundice and 
biliousness. It generally relieves the frontal 
headache common in young women, which 
is felt just above the eyebrows, and not 
accompanied by constipation. Dilute acids, 
especially aromatic sulphuric acid, are useful 
in checking diarrhoea, colliquative sweats, 
haemorrhages, and mucous discharges. By 
lessening the alkalinity of the urine, they 
tend to prevent the formation of phosphatic 
calculi; phosphoric, nitric, and lactic acids 
being most frequently employed for this 
purpose. Care must be exercised in their 
administration to nursing mothers, as they 
are excreted in the milk, and sometimes 
cause griping and diarrhoea in infants at the 
breast. Several acids have a special action 
of their own, and are considered under their 
respective groups, such as hydrocyanic and 
hydrobromic acids, which are sedative; boric 
and carbolic, antiseptic; chrysophanic, para- 
siticide ; salicylic, antipyretic : gallic and 
tannic, astringent. 
T. Lauder Bbunton. 
ACINESIA.-See Akinesia. 
ACIBEALE, in Sicily.-Cold sulphur 
waters, and climatic health-resort. See 
Mineral Waters. 
ACNE.-Synon.: Acne vulgaris; Acne 
adolescentium; Acne disseminata; Er. 
Acme ; acne; Ger. Acne. 
Definition.-A chronic disease of the skin, 
confined to the face, back, shoulders, and 
chest. The eruption is met with in young 
adults, and consists of pimples, which are 
caused by an inflammation of the sebaceous 
glands and hair-follicles. The disease leaves 
small depressed scars. 
^Etiology.-The aetiology of acne is 
obscure. It is seldom met with before 
puberty, and is usually fully developed at 
about the age of eighteen or twenty, and then 
gradually disappears before the age of thirty. 
There are, however, many exceptions to this 
rule, especially in men, who are liable to a 
severe form of acne of the shoulders and 
back, which may continue until middle life. 
Acne appears to be equally common in males 
and females, and is especially met with in 
those who have what is called a slow circu- 
lation in the extremities-that is, who suffer 
ACIDS 
from cold hands and feet, and perhaps chil- 
blains. In accordance with this, the disease 
often improves, or even disappears, during 
warm summer weather, to return again in 
the following winter. 
Symptoms.-Common acne is a pimply- 
eruption, met with chiefly on the face and 
shoulders, less often on the back and chest. 
Many of the pimples are of a pale colour 
with a small dark centre, and consist simply 
of follicles, over-distended with sebum, the 
black centres marking the orifices of the 
follicles. These pale little papules, called 
comedones, are apt to become red and in- 
flamed, thus forming the ordinary acne 
pimple, which ultimately suppurates, and 
discharges a minute quantity of pus; the 
spot then heals, leaving a small scar. In all 
severe cases of acne we find, in addition to 
the ordinary acne spots, larger pimples, 
resembling blind boils, which suppurate 
slowly, and often leave very ugly scars. 
Acne develops in successive crops, so that, 
as one set of pimples dies out, others appear, 
and thus the disease becomes chronic. Acne 
is almost always distributed symmetrically, 
so that both sides of the face and back are 
pretty equally affected. The exceptions to 
this rule are very rare. 
Diagnosis.-The differential diagnosis of 
acne is usually easy when the symmetrical 
distribution of the eruption, and its period of 
development, are taken into consideration. 
The two eruptions with which it is most 
likely to be confounded are : (1) certain forms 
of acne rosacea (gutta rosea), and (2) acne- 
like dermato-syphilis. Acne may best be 
distinguished from acne rosacea by the 
fact that this latter disease is chiefly met 
with in middle life, and is always attended 
with more or less general congestion of the 
face, and the subjective sensations of burning 
or tingling-characters which are absent in 
common acne. Acne rosacea is exclusively 
confined to the face, while common acne 
attacks also the shoulders and back. 
Acne-like syphilitic eruptions are best dis- 
tinguished by the absence of comedones; and 
by the tendency the pimples have to form 
into groups, which are not always sym- 
metrical, and not strictly confined to the 
acne regions. Some other syphilitic symp- 
toms would probably be also present. 
Varieties.-There is an interesting erup- 
tion, commonly called acne varioliformis, 
which requires a very brief notice. In 
general appearance the pimples resemble 
those of acne, but are not especially asso- 
icated with comedones. The eruption is 
usually confined to the .scalp and upper part 
of the forehead. The scars formed by this 
disease are much deeper than those of com- 
mon acne, and very closely resemble the 
pits left by small-pox. The region affected 
and the character of the scars are a sufficient 
guide to diagnosis. 
ACNE 
13 14 
Treatment.-As acne arises, for the most 
part, from the formation of comedones and 
plugging of the follicles, the treatment should 
be directed to stimulating the sebaceous 
glands of the skin to action. For this 
purpose the application of sulphur is most 
useful. The sulphur may be applied in the 
form of an ointment or lotion. The objection 
to a lotion is, that during the night the 
powdered sulphur is apt to get into and 
inflame the eyes a little. There is not, how- 
ever, the same objection to the use of a 
sulphur lotion during the day-time. A good 
plan is to apply a mild sulphur ointment or 
Wilson's hypochlorite of sulphur ointment 
every night, and wash it off in the morning 
with hot water, soap, and a soft flesh-brush. 
The daily use of a soft flesh brush with hot 
water and soap is especially beneficial, as it 
prevents the formation of comedones. 
When sulphur does not produce the desired 
effect, the linimentum saponis should bo 
applied every night and allowed to dry on, 
and be washed off in the morning with warm 
water. In very severe cases of acne, there 
are always a certain number of boil-like 
spots, which suppurate very slowly, and some- 
times last for months without coming to 
a head. These boils should be carefully 
touched with a small piece of wood dipped 
in pure carbolic acid, or a saturated solution 
of potassa fusa in water ; or the acid nitrate 
of mercury solution may be used, great care 
being taken that only the top of the boil 
is touched with the caustic. Cod-liver oil 
is the most generally useful tonic in cases 
of acne, but other tonics are occasionally 
beneficial. Robert Liveing. 
ACNE ROSACEA. - Synon. : Gutta 
rosea; Fr. Couperose; Ger. Das Itupfrige 
Gesicht. 
Definition.-A chronic congestion of the 
face, attended with sensations of burning or 
stinging, and leading to a permanent enlarge- 
ment of vessels and the formation of pimples. 
Symptoms.-There are two varieties of 
acne rosacea. The more severe form is 
met with chiefly in men, and is often the 
result of over-indulgence in alcohol. It es- 
pecially attacks the nose, and leads to con- 
siderable enlargement of the vessels, and 
also, if of long standing, to hypertrophy of 
other parts of the skin, especially the seba- 
ceous glands. The milder form of gutta 
rosea is very common in women after the 
age of thirty. In the first instance it may 
consist of a simple flushing of the face, 
coming on at certain periods of the day, as, 
for example, after meals or in the evening. 
This congestion has, however, a tendency to 
become more persistent; and then the vessels 
being permanently dilated, the redness does 
not entirely disappear, although it varies in 
degree from time to time. Gutta rosea in 
women is not confined to the neighbourhood 
ACNE 
of the nose, but usually extends in a butter- 
fly-shaped patch to both cheeks, and some- 
times to the forehead and chin. It is always 
attended with subjective sensations, which 
are generally those of burning, and less fre- 
quently of stinging or itching. Acne-like 
pimples are only occasionally met with, and 
when present are due to follicular inflam- 
mation. 
/Etiology.-Gutta rosea in women is for 
the most part associated with cold hands 
and feet, and not uncommonly with dyspepsia 
and constipation, or irregularity in menstrua- 
tion. In men, as before stated, the hyper- 
trophic variety is sometimes, but by no means 
always, caused by over-indulgence in alcohol. 
Treatment.-The severer form of gutta 
rosea, in men, is best dealt with by: (1) absti- 
nence from alcohol; (2) the longitudinal divi- 
sion of the enlarged veins with a lancet; and 
(3) the subsequent daily use of sulphur oint- 
ment, which should be well rubbed on every 
night. Great hypertrophy of the nose (lipoma 
nasi) can only be removed by means of the 
knife. In treating gutta rosea, as it is com- 
monly met with in women, the following 
points require special attention. (1) The diet 
should be carefully regulated, and medicines 
ordered to remove, as far as possible, any 
dyspepsia or any menstrual irregularity that 
may exist, and also to regulate the bowels, 
which are often constipated. (2) A very 
mild sulphur (or hypochlorite of sulphur) 
ointment should be applied in a small quan- 
tity every night, and washed off in the 
morning with warm, soft, oatmeal-water. In 
the daytime, a calamine and oxide of zinc 
lotion should be applied, and a little allowed 
to dry on. Gutta rosea is difficult to cure, 
but a steady perseverance in a rational plan 
of treatment will always produce a marked 
improvement in the disease, and sometimes 
quite remove it. Robert Liveing, 
ACONITE, Poisoning by.-Syncn. : 
Fr. Empoisonnement par l'Aconit; Ger. 
Eisenhutvergif tung.-The common garden- 
plant, Aconitum napellus, known also as 
' wolfsbane ' or ' blue-rocket,' as well as other 
species of aconitum, are poisonous, and owe 
their poisonous properties to the presence of 
an alkaloid, aconitine or aconitia, or perhaps 
to a mixture of alkaloids passing under this 
name. The same or similar alkaloids have 
been obtained from the Indian aconite, A. 
ferox, and from Japanese aconite roots. All 
parts of A. napellus are poisonous. Aconitine 
is perhaps the most poisonous alkaloid known- 
All parts of the aconite plant when chewed, 
and aconitine when placed upon the lips or 
tongue, produce, after a few minutes, a dis- 
agreeable acrid burning sensation, followed 
by numbness, loss of sensibility of the part, 
salivation, and an after-sensation of seared- 
ness. These sensations may last for several 
hours. 
ACONITE, POISONING BY ACONITE, POISONING BY 
ACROCHORDON 
15 
The fresh root of aconite has frequently 
been eaten in mistake for horse-radish, to 
which it bears a remote resemblance. The 
root of horse-radish is whitish on the exterior, 
is long and of fairly uniform diameter, has a 
pungent odour when scraped, and the scraped 
surface retains its white appearance ; whereas 
aconite root is brown and conical, is destitute 
of pungent odour, and speedily acquires a 
pink colour when scraped and exposed to the 
air. Mistakes more frequently occur from 
liniments containing aconite being swallowed 
in error. In two cases the root has been 
administered with homicidal intent; and in 
one case a young man was killed by the ad- 
ministration of, as it is supposed, two grains 
of English aconitine. Accidents have also 
arisen from the administration of the potent 
English aconitine in mistake for the impure 
inert exotic or German alkaloid, or mixture 
of alkaloids passing under that name. 
Anatomical Characters.-After poisoning 
by aconite there may be gastric congestion 
or inflammation; but these may be absent. 
Symptoms.-When aconite, or any of its 
preparations, is taken by the mouth, the first 
sensation, transitory and mainly due to the 
action of the solvent, is followed in about 
three minutes by an intolerable burning and 
numbing pain, extending from the place of 
application to all the surrounding parts of 
the mucous membrane. There is salivation; 
and the burning sensation extends down the 
gullet to the stomach. Occasionally, when 
the poison has been rapidly swallowed, no 
marked symptoms may supervene for half 
an hour. The general symptoms are very 
varied, but may all be referred to weakening 
of the heart's action, disturbances of respira- 
tion, and paralysis of sensation on the surface 
of the body. This last may be described as 
' numbness ' or ' drawing of the skin,' or by 
some equivalent term. There is pain in the 
epigastrium, violent vomiting, occasionally 
purging; the pulse, at first rapid, quickly 
diminishes in frequency and force till it is 
imperceptible ; the skin is cold, clammy, and 
livid; respiration is laboured. The pupils, 
at first contracted, afterwards dilate; and 
this dilatation sometimes occurs suddenly and 
transitorily, and is accompanied by blindness. 
Convulsions are not common ; but vomiting 
is often due to spasmodic contraction of the 
diaphragm, causing frothing at the mouth. 
Consciousness is retained till near the end of 
life. 
Diagnosis.-The peculiar sensation in the 
mouth-burning, feeling of searedness, numb- 
ness, &c., the great cardiac depression, and 
the difficulty of respiration, will generally 
serve to determine the nature of the case. 
Prognosis.-Death usually occurs within 
four or five hours. If the patient survive 
twelve hours, recovery is usually rapid and 
complete. 
Fatal dose.-Of the root, sixty grains- 
probably much less might suffice. Of the 
pharmacopceial tinctura aconiti (1 in 8), two 
or three fluid drachms. Fleming's tincture 
is about six times as strong as the official 
tincture, and twenty-five minims have proved 
fatal. Four grains of the alcoholic extract 
have proved a fatal dose. English aconitine 
or aconitia (the alkaloid) is terribly potent: 
1-2000th grain will produce a very decided 
sensation on the tongue, and it is probably as 
poisonous as the crystallised French aconi- 
tine-nitrate, one-sixteenth of a grain of which 
has killed an adult within five hours. 
Treatment.-In proceeding to treat a case 
of poisoning by aconite we must, first, wash 
out the stomach by means of the stomach- 
pump, and promote vomiting by warm 
emetics, of which carbonate of ammonium is 
the best. Stimulants must be freely ad- 
ministered ; also strong black coffee or tea. 
Brandy and ether may be injected subcu- 
taneously. Digitalis is a counter-poison, and 
may be administered with effect subcuta- 
neously, in doses of twenty minims of the 
tincture, repeated in an hour or so if neces- 
sary. Inhalations of nitrite of amyl may 
afford some relief. The patient must be kept 
strictly in the recumbent position, warmth 
being applied to the surface ; and, as a last 
resort, artificial respiration must be used. See 
Poisons. Thomas Stevenson. 
ACQUI, in the Province of Alessan- 
dria, Italy.-Thermal sulphur waters. See 
Mineral Waters. 
ACQUIRED DISEASES.-Diseases 
which originate independently of hereditary 
transmission. See Disease, Causes of. 
ACROCHORDON.-An outgrowth of 
the integument in the form of a slender 
cylinder, which may be compared to the 
loose end of a piece of string or cord-aKpov 
signifying a point or end, and x°P^ a string. 
Such outgrowths are usually met with in a 
feeble state of the skin, and particularly in 
elderly persons, their common seat being the 
neck or trunk. They are at first sessile, but 
become elongated; and are sometimes bulbous 
at the extremity, and more or less pedun- 
culated. Microscopically, an acrochorcon is 
composed of loose areolar tissue, firmer at the 
surface than within, and of a fine artery and 
vein, connected by a capillary loop or plexus, 
and sometimes a little ramified. It is popu- 
larly regarded as a wart, and in medical 
works is termed verruca acrochordon, but it 
differs from a wart very widely in structure. 
Treatment.-This consists in snipping off 
the outgrowths with scissors, or touching them 
with a strong solution of potassa fusa (equal 
parts). When numerous and minute, they 
admit of being shrivelled up and removed by 
means of liquor plumbi subacetatis,or a lotion 
of perchloride of mercury, two grains to the ounce. The latter, possibly by its stimulating 
property, also arrests their formation. 
Erasmus Wilson. 
ACRODYNIA (aKpos, extreme; and obvvr), 
pain).-This disease was epidemic in Paris in 
1828, and was described by Alibert as a der- 
matitis affecting the hands and feet, particu- 
larly the palms and soles, accompanied with 
burning heat, stinging and smarting pains, 
and numbness. The pains sometimes extend 
to the whole system, and there is more or less 
disorder of the digestive and assimilative 
functions. The redness is at first bright, 
then deeper tinted and. brown, with con- 
siderable pigmentation of the rete mucosum. 
Occasionally there are pimples, pustules, and 
blisters; the cuticle desquamates, and is 
sometimes cast in a single piece ; the disease 
running on for several weeks. 
Treatment.-This should be directed to 
the regulation of the digestive and assimila- 
tive organs; and to the relief of local inflam- 
mation by means of water-dressing, followed 
by the application of zinc ointment and a 
bandage. Erasmus Wilson. 
ACROMEGALY (aKpov, an extremity; 
and ptyas, large).-Synon. : Er. Acromegalie. 
Definition.-A remarkable dyscrasia, the 
striking characteristic of which is an enlarge- 
ment of the bones, and most obviously of the 
bones of the hands and feet. Hence the name 
applied to it by Marie, who first described 
the disease in 1880, though other cases had 
been noted previously under different titles. 
Pathology. - Acromegaly occurs most 
frequently, but not exclusively, in females 
between the ages of thirty and forty, but has 
been observed as early as fifteen and as late 
as forty-eight. It is very chronic; and though 
probably often fatal, it sometimes appears 
to become arrested after advancing for some 
years. In females it is usually preceded 
by early stoppage of the menses. Its relation 
to rheumatism is very doubtful. 
Acromegaly is generally associated with 
enlargement or atrophy of the thyroid body; 
and enlargement of the thymus gland has 
been observed. In three post-mortem ex- 
aminations tumours of the pituitary body 
have been met with. 
Description.-In this disease the bones 
of the hands and feet are very greatly 
enlarged, but the long bones do not escape, 
the natural prominences and elevations 
being exaggerated sometimes to the di- 
mensions of exostoses. The scapulae, clavi- 
cles, and the sternal ends of the ribs become 
quite massive; the lower jaw also assumes 
vast proportions, the lower teeth spreading 
out and projecting far in front of those of 
the upper jaw. This gives a characteristic 
appearance to the face, which is that of an 
egg with the large end downwards, as opposed 
to the oval of myxcedema, and the inverted 
16 
ACROCHORDON 
egg shape of osteitis deformans, with both 
which diseases acromegaly may be con- 
founded. The upper jaw and the cranial 
bones occasionally participate in the change. 
The bones, though enlarged, do not become 
curved; but the spine is often bent, so that 
the patient loses considerably in stature. 
The cartilages of the nose, ears, eyelids, 
and larynx may be thickened; the last 
change probably accounting for an occasional 
great alteration in the voice. 
The subcutaneous tissues are not obviously 
altered. The skin may be unchanged, but 
on the face it is apt to become coarse, and to 
show clearly the orifices of the sweat-glands. 
The hair does not become thin, as in myx- 
oedema. Profuse perspiration and thirst are 
generally present. 
The tongue is enlarged, and taste may be 
much impaired. Blindness is not uncommon, 
from atrophy of the optic nerve, possibly 
connected with a pituitary tumour. The sense 
of smell is often impaired; that of hearing 
does not appear to be modified, nor does that 
of touch. 
There may be shortness of breathing, de- 
pending upon asthmatic attacks, and the 
heart may be hypertrophied. The urine is not 
usually abnormal. The temperature is not 
raised. The intellect remains perfect. 
Diagnosis.-It is not necessary to indicate 
the difference between this disease and 
osteitis deformans or myxoedema-practically 
the only two with which it can be confused, 
because, though there is certainly a superficial 
resemblance to each, the points of divergence 
are wide. The symptoms have been stated 
somewhat dogmatically for the sake of 
brevity ; and, as only a few cases have as yet 
been accurately observed, it is probable that 
some of those here set down may be found to 
be incorrect or not characteristic. 
Treatment. - None of the numerous 
methods of treatment hitherto applied in 
acromegaly have proved of the slightest use. 
Rickman J. Godlee. 
ACTINOMYCOSIS (am'?, a ray; and 
pvicris, a fungus).-Definition.-A chronic 
disease, attended by the formation of ab- 
scesses, chronic interstitial inflammations, 
or tumour-like growths of granulation-tissue, 
due to infection by a fungus known as Acti- 
nomyces bovis. 
History.-This disease, which especially 
affects horned cattle and swine, and has long 
been known under various names as occur- 
ring in them, has during the last few years 
been proved to be not infrequent in man. 
Its parasitic nature was discovered in 1876 
by Bollinger, who named the parasite Actino- 
myces, the ray-fungus. In 1877 J. Israel, 
and in 1879 Ponfick, described cases in the 
human subject, and showed their identity 
with the animal disease. Since that time 
numerous instances of the disease have been 
ACTINOMYCOSIS ACTINOMYCOSIS 
17 
observed; with chronic abscesses, especially in 
the liver, lungs, bones and periosteum, intes- 
tinal canal-especially the large intestine- 
and more rarely in other positions, e.g. in 
the brain, as in recent cases recorded by 
Dr. Delepine and others. 
General Characters of the Disease.-In 
the lower animals actinomycosis frequently 
produces indurated masses of connective- 
tissue growth, which tend to become calci- 
fied ; hence the name ' woody tongue ' applied 
to the affection in cows. In man there is a 
tendency rather to the formation of chronic 
abscesses. Infection usually appears to occur 
by the alimentary canal or air-passages, the 
virus entering through carious teeth, the 
crypts of the tonsils, pharynx, &c., or more 
rarely by direct aspiration into the lungs. 
Most commonly it tends first to produce de- 
structive changes, for example, in the jaws 
(upper and lower), the wall of the pharynx, or 
the mucous membrane of the alimentary canal. 
In the jaws a process of gradual necrosis may 
occur. From the upper jaw it is apt to spread 
to the periosteum in front of the vertebrae, or 
to the base of the skull, leading to chronic 
periosteal abscesses, followed by caries, some- 
times with retro-pharyngeal abscess. It may 
next invade the tissues of the neck, forming 
deep-seated abscesses. Not infrequently in 
man, however, the liver is the first organ ob- 
viously attacked. It has been shown that a 
primary infection of the mucous membrane of 
the intestines, especially the large intestine, 
may occur, and not improbably the infection 
of the liver is secondary to this. Affection of 
the lungs may take place by direct aspiration 
of the virus, or possibly through infection ex- 
tending from the mediastinum, which has been 
reached through the oesophagus. Infection of 
the brain and other parts may take place 
either through the lymphatics or through the 
blood. 
Anatomical Characters.-Four varieties 
of the chronic inflammatory process have 
been determined in actinomycosis :- 
First, when upon a free surface, as the 
mucous membranes, the formation of masses 
of epithelium containing the fungus has been 
observed, together with subjacent ulceration. 
Second, when occurring upon a free surface, 
as in serous cavities or within the periosteum, 
tumour-growths may occur, formerly mis- 
taken (when periosteal) for osteo-sarcomas. 
Third, the formation of masses of dense 
granulation-tissue or sarcoma-like tumours, 
which may become fibroid or calcified, but re- 
main indurated. Allied with this there may 
be an infiltration with firm granulation-tissue. 
Fourth, the production of chronic abscesses, 
which soften slowly, causing widespread 
infiltration and necrosis of the tissues, but 
are not usually accompanied by marked in- 
flammatory reaction. In the pus from these 
abscesses, which is usually thick, yellow, and 
somewhat lumpy, may be found minute 
yellowish granules or masses, varying in size 
from the most minute particles visible with 
the naked eye, to the size of about inch 
in didmeter, of yellowish colour, ovoid ci 
rounded, and of slightly greasy feel. Under 
the microscope these are found to consist of 
masses of the ray-fungus. 
On microscopical examination of prepared 
sections, especially in the firmer nodules, 
the characters can be better seen. Various 
modes of staining may be employed, for which 
the reader is referred to special technical 
works, gentian-violet, fuchsin, and methyleno 
Fig. 1.-The wood-cut shows the characters of a 
minute centre of growth in an actinomycosis 
nodule from the tongue of a cow. The upper 
portion is sufficiently described in the text. The 
mass of fungus is represented as much less dense 
than in reality, otherwise no detail could be shown. 
(Magnified about 800 diameters.) 
The lower four small figures show the charac- 
ters seen in the same growth under a somewhat 
higher power. (1) A group of cells (? one cell in 
a state of division) containing a cluster of the 
clubbed filaments. (2) A single cell with acti- 
nomyces growing in it. (3) A group of clubbed 
hyphae much larger than the others. (4) Fila- 
ments from centre of mass, showing bacillus- 
like characters, and false branching; resembling 
cladothrix. 
blue being amongst the most suitable re- 
agents. The structure is composed of granu- 
lation-tissue, either small or large-celled, 
frequently with branching and spindle cells, 
resembling spindle-celled sarcoma. Scattered 
through the granulation-tissue are deeply 
stained masses, which form the centre of 
more typically arranged masses of cells. The 
fungus itself, when seen in the smaller 
nodules, is usually composed of a central 18 
ACTINOMYCOSIS 
ACUPUNCTURE 
portion containing coccus-like bodies, and 
delicate, branching, bacillus-like filaments. 
At the periphery of the mass the filaments 
are arranged side by side and radially, their 
outer extremities being swollen and bulbous- 
looking or club-like. Immediately surround- 
ing these a zone of large epithelioid granu- 
lation-cells may be observed, the cells some- 
times being arranged radially and resembling 
columnar epithelium. Still further out are 
epithelioid cells in layers; and beyond 
these are smaller cells, gradually merging 
into the surrounding granulation-tissue. 
Considerable varieties of structure are, how- 
ever, observed, which need not be detailed 
here. The epithelioid cells may be scanty, 
or irregularly arranged, and of small size. 
In general arrangement these centres recall 
somewhat that of an elementary tubercle- 
follicle. The masses of fungi also present 
varieties. When of large size they frequently 
show zones of calcification. Club-shaped 
bodies may also be found scattered more ir- 
regularly through the mass. The branching, 
delicate threads may be numerous or scanty; 
and masses of coccus-like bodies may be 
observed. 
Much discussion, which it would here be 
undesirable to detail, has taken place as to 
the nature of the fungus, and the exact 
relations of its different forms. The general 
belief now is that it belongs, or is closely 
allied, to the cladothricece, and that the 
several forms are various stages of its growth, 
the coccus-like bodies being spores, the fila- 
ments the earlier stages of its growth, and 
the club-like bodies swollen filaments or 
hyphce-swollen in consequence of defective 
nutriment; some regard them, however, as 
possibly asci. The fungus has been suc- 
cessfully cultivated by Bostrom, and in its 
general characters appears closely to resemble 
the cladothricece. 
For further details reference may be made 
to special works. 
Mode of Infection.-The general evidence 
at the present time renders it probable that the 
infection of actinomycosis is introduced by 
food, and especially by some varieties of grain 
on which the fungus grows. Grain grown on 
freshly cultivated ground has in some cases 
apparently led to an outbreak amongst cattle. 
In one case in the human subject, recorded 
by Soltmann, a child swallowed a head of 
wall-barley (hordeummurinum), which stuck 
in the oesophagus and was followed by the 
development of an actinomycotic abscess 
(Klebs, Allg. Path. 1887, p. 286). Direct 
transmission by contagion has been observed 
by Johne and Ponfick ; and by inoculation of 
material from abscesses (Fleming, Actinomy- 
cosis,18S&, also Crookshank, Med. Chi. Trans. 
vol. Ixxii. p. 207). Organisms similar to the 
actinomyces grow on various kinds of grass. 
General Course. - Actinomycosis is 
usually extremely chronic. When primarily 
affecting the lungs, it tends to spread locally 
and involve the pleura, the periosteum of 
the ribs, and the tissues of the thoracic wall, 
forming sinuses which open externally. In 
some cases the fungus has been found in 
the sputum without definite physical signs 
in the lungs. In the liver the abscesses may 
also reach a considerable size, and tend to 
form adhesions and fistulous tracks through 
the abdominal wall. In the neck, as has 
been stated, a slow process of extension may 
take place to the base of the skull, the ver- 
tebrae and their periosteum, and the deeper 
tissues of the part, forming in some cases 
very large chronic abscesses, which when 
opened show little tendency to heal. Direct 
spread of the infection by the lymphatics has 
been observed, but the production of abscesses 
in the brain can scarcely be accounted for 
except by carriage through the blood-stream. 
The fungus, like other organisms, is fre- 
quently found, especially in the coccus and 
rod forms, within granulation-tissue cells and 
leucocyte-like cells in the local affection; and 
it is not improbable that these simpler forms 
may be carried throughout the body by 
wandering cells and leucocytes. The ab 
scesses are sometimes unattended by fever, 
but abscesses in the lungs and liver have some 
times been accompanied by recurrent rigors. 
Diagnosis.-This in many cases can only 
be determined by microscopical examination 
of the discharges or the pus. A very chronic 
slowly-spreading abscess-formation of un- 
determined cause should lead to suspicion of 
actinomycosis. The absence of fever cannot 
be relied upon. In the microscopical examina- 
tion of the sputum care must be taken not to 
confound the fungus with very similar or- 
ganisms which may occur in carious teeth, &c. 
Treatment.-Little can be said on this 
subject. Complete evacuation of abscesses, 
and (where, possible) irrigation with dilute 
antiseptic solutions, would no doubt be in- 
dicated. From our present knowledge it is 
improbable that any internal remedy could 
be safely given in sufficient doses to destroy 
the fungus. The general treatment must 
rather be directed to the nutrition and support 
of the vital powers of the patient. 
W. S. Greenfield. 
ACUPUNCTURE (acus, a needle; and 
punctum,& prick).-Synon. : Fr. acupuncture; 
Ger. Nadelstich. 
Description.-Acupuncture is an ancient 
mode of treatment for the relief of painful 
affections, now but little used, consisting in 
the introduction of fine round needles through 
the skin, to a varying depth. It is said to 
have been introduced into this country from 
China or Japan, about 200 years ago. The 
needles used are about two inches in length, 
and are set in round handles, so that they 
can be introduced with a gentle, rotatory 
movement. Acupuncture is now employed ACUPUNCTURE 
chiefly in lumbago and sciatica, in which 
affections it undoubtedly may give relief. 
The operation is thus performed. The 
patient being laid upon his face, tender spots 
are sought for-in lumbago over the erector 
spinae, in sciatica along the course of the 
sciatic nerve. The needles are then pushed 
in vertically for a depth of from one and a- 
half to two inches, and allowed to remain 
for from half an hour to two hours. The 
number of needles employed may vary from 
one to six. In sciatica it is recommended, if 
possible, to make the needle actually pene- 
trate the nerve. This result is known by the 
patient complaining of sudden pain shooting 
down the back of the leg. The mode of 
action is uncertain, but in sciatica it has been 
supposed that the puncture of the nerve- 
sheath allows the escape of fluid. Acupunc- 
ture has also been employed in painful 
neuritis following injury, but without 
effect. In a modification invented by 
Baunscheidt, forty punctures, about half- 
an-inch in depth, were made in an 
area of the size of a crown-piece, by an 
instrument working by a spring. Oil of 
mustard, diluted with olive oil, was then 
painted on, which gave rise to an eruption 
like herpes. The term acupuncture is also 
applied by some to the introduction of 
needles into a cyst, in order to allow the 
fluid contents to escape, as in the treatment 
of ganglion, of hydrocele in infants, or of 
hydatid cyst of the liver. Puncture of the 
skin for the relief of oedema is sometimes 
called by the same name. For this purpose 
the ordinary three - cornered acupressure - 
needle is more convenient than a round 
acupuncture-needle, as the puncture resulting 
from it allows fluid to escape more readily. 
The number and situation of the punctures 
being determined upon, they should be made in 
rapid succession and of sufficient depth to allow 
a free escape of the fluid. Marcus Beck. 
ACUTE.-This word, when associated 
with a disease, signifies that such disease 
runs a more or less rapid course, and is 
generally attended with urgent symptoms. 
It is also employed to express intensity of a 
particular symptom, as, for example, pain. 
ADDISON'S DISEASE. - Synon.: 
Morbus Addisonii; Bronzed Skin Disease. 
Fr. Maladie d'Addison', Ger. Addisonsche 
Kra/nkheit. 
Definition.-In his original memoir on 
this subject, Dr. Addison wrote : ' The lead- 
ing and characteristic features of the morbid 
state to which I would direct attention are 
anaemia, general languor and debility, re- 
markable feebleness of the heart's action, 
irritability of the stomach, and a peculiar 
change of colour in the skin, occurring in 
connexion with a diseased condition of the 
suprarenal capsules.' 
In reality, the general symptoms of the 
disease, as given above, outweigh in im- 
portance any pigmentary change whatever ; 
and it is quite possible for the disease to run 
its course without any unusual deposit of 
pigment in any part of the body. 
Addison's disease mignt, however, be 
defined as a constitutional malady, charac- 
terised by great Weakness and anaemia, with 
deposit of pigment in the skin and some 
other parts of the body, depending on chronic 
tuberculosis of the suprarenal capsules, and 
the extension of fibrous thickening to the 
adjacent nerve-ganglia and plexuses, causing 
their compression and atrophy. 
^Etiology.-The constitutional or general 
nature of Addison's disease must ever be 
borne in mind, though some of its factors are 
strictly local; but, though constitutional, it is 
not transmissible either (a) by contagion or 
infection, or (6) by inheritance. If, however, 
Addison's disease itself is never an inherited 
malady, it is in very many cases associated 
with a highly hereditary constitution, that of 
the tubercular or scrofulous type; and in 
such individuals accidents, like falls or 
blows, which would fail to make an impres- 
sion on stronger men or women, may 
suffice to set the morbid process in motion. 
In not a few instances the bodies of the 
subjects of this disease have been found 
perfectly healthy apart from the morbid 
change in the suprarenal capsules charac- 
teristic of the malady; and, in a certain 
number of cases, local abscesses seem to 
have been the starting-point of the specific 
changes in the capsules themselves. Addison's 
disease is, moreover, essentially one of early 
adult life, the great majority of cases occurring 
between fifteen and forty. It is much more 
frequent in men than in women ; and seems 
to be in a great measure confined to the 
working classes. 
Symptoms.- The earlier symptoms of 
Addison's disease are often so indefinite and 
so insidious, that it may not be until the 
disease is fully developed that the patient 
seeks medical aid, and by that time they are 
usually unmistakable. It is different when 
the malady apparently originates in a fall 
or a blow; but even such a starting-point as 
this may only be sought for late in the 
history of the disease. 
The mischief may be said to commence in 
most cases with a feeling of general weakness 
and of being unwell; the discolouration of 
the skin usually appears later, but may be 
the first prominent symptom. In a small 
number of cases the onset may be acute, with 
loss of appetite, sickness, headache, pain in 
the epigastrium, sometimes also vomiting 
and diarrhoea. When the disease has at- 
tained its full development, the characteristics 
of the malady are most striking. Then the 
downcast, mournful look, the drooping 
shoulders and stooping gait, the arms hang- 
ing helplessly by the sides, and the slow 
ADDISON'S DISEASE 
19 20 
ADDISON'S DISEASE 
and listless movements of the patient are ex- 
ceedingly impressive. If to this be added the 
darkening of the skin, the clear and pearly 
conjunctiva, and the breathlessness on exer- 
tion, we have almost all that meets the eye 
when such a patient presents himself. But 
to these, on inquiry, other important symp- 
toms are easily added. The breathlessness 
will be found to be partly due to anaemia, 
partly to impaired innervation. From the 
same causes in part, but not entirely, we find 
a quick feeble action of the heart, readily 
giving place to palpitation. With these are 
usually associated pain and tenderness in 
the epigastrium and hypochondria, irritability 
of the stomach and nausea-giving rise to 
retching, and frequently obstinate vomiting. 
Such modifications of breathing as sighing, 
yawning, or hiccup, .are frequent. Again, 
from the anaemia, there is a strong tendency 
to giddiness and syncope, which last 
increases as the disease wears on, and in 
many cases carries off the patient when 
raising himself or being raised in bed, for 
the purpose of taking food or performing 
other necessary functions. This is not the 
invariable mode of death, for nervous 
symptoms, such as coma or convulsions, 
may usher in the final scene. When the 
prostration is great, the patient may be for 
some time before death apparently un- 
conscious, but this is simply due to unwilling- 
ness to make the slightest exertion, owing to 
his profound weakness. 
Throughout the whole disease the bodily 
temperature is diminished (97°-98° Fah.) 
rather than increased; and this is often 
markedly the case towards the close of the 
disease, though then it has been noted as 
high as lOO'S0 Fah. 
From the above sketch it is plain that the 
two most prominent factors in the disease, as 
presented during life, are : - 
1. General weakness and ansemia. 
2. Abnormal deposit of pigment in various 
parts of the body. 
1. To the former of these is to be referred 
(a) the loss of muscular power, as evidenced 
by diminished muscular energy and force, 
both in the voluntary and involuntary 
muscles, for the heart's action is feeble and 
imperfect, and the bowels are usually con- 
fined. (6) At once a cause and consequence 
of the weakness and anaemia are loss of 
appetite, sickness and vomiting, though 
these, too, depend in part on other morbid 
changes; whilst, lastly (c), imperfect nutrition 
of the nervous system results, notably of the 
brain itself, whence arise vertigo, numbness, 
dimness of sight, deafness, tremors, and the 
like. The pain in the epigastric and hypochon- 
driac regions is probably due to local causes. 
2. The deposit of pigment is peculiar and 
characteristic. It is not uniform in disposi- 
tion, and varies greatly in tint. It may only 
amount to a light brown or smoky discoloura- 
tion in certain parts, or it may assume the 
appearance of a dark olive-green hue, 
approaching to black in some situations, 
especially over the genitals and nipples. 
Elsewhere it is most abundant on the face 
(where it often seems to begin), on the neck, 
the backs of the hands, the folds of the legs, 
and along either side of the linea alba. A 
striking peculiarity is that the conjunctivae 
are clear and pearly, and that the nails are 
never discoloured. On the other hand, there 
is a great tendency to the deposit of pigment 
where the skin has been irritated or the 
epidermis removed, as by a mustard poultice 
or blister; but the skin is always smooth 
and supple. In a typical case under the 
writer's care, blisters had been applied to the 
chest for the uneasy feeling experienced there; 
and the pigmentary tint was deeper here 
than in any other part of the body, save the 
genitals. Cicatrices affecting the whole 
depth of the skin do not seem to be so pig- 
mented. The mucous membrane of the 
mouth not infrequently becomes the site of 
pigmentary deposits. These are not diffuse ; 
but, when the lips are affected, they usually 
take the shape of smears or lines. On the 
insides of the cheeks blotches or irregularly- 
defined spots are most common, as well as on 
the sides and root of the tongue. The latter 
spots are commonly better defined than are 
the others, and somewhat resemble the small 
well-marked black spots occasionally observed 
in parts already pigmented. 
The site of this pigmentary deposit is in 
the growing layer of the epidermis, the usual 
site of colour in all races of mankind, and 
which is usually known as the rete mucosum; 
but occasionally pigmentary granules are to be 
found deeper, in the cells of the true skin. 
An interesting clinical fact was brought out 
by the late Dr. Greenhow, which will, pro- 
bably, be noted in a considerable proportion of 
cases. This is the mode in which the disease 
progresses. Often it presents periods of 
remission, only to be followed by a more 
marked advance ; but, notwithstanding these 
remissions, the progress is invariably towards 
a fatal termination. The time occupied in 
this progress varies much : it may be weeks 
or months, or it may be years. But in all 
well-defined cases the result is the same. 
Pathology.-From the earliest description 
of the morbid state known as Addison's 
disease, the malady has been associated with 
disease of the suprarenal capsules. At first 
it was supposed that any form of disease 
affecting these organs must give rise to a 
similar train of symptoms, and some of the 
investigations carried on with a view to 
sustain this position sound absurd enough by 
the light of subsequent experience. Gradu- 
ally it has been made clear that only one 
kind of lesion is accompanied by the specific 
symptoms just detailed. Briefly, the morbid 
changes are as follows : ADDISON'S DISEASE 
21 
The suprarenal capsules normally consist 
of two parts, a cortical and medullary, differ- 
ing greatly in their structure. In Addison's 
disease both are superseded by a new struc- 
ture, which is to be seen in various stages. In 
the earliest of these the capsules are invaded 
by a kind of translucent material, which is 
sometimes almost cartilaginous in its hard- 
ness, and which, when examined under the 
microscope, resolves itself into a kind of very 
finely fibrillated or trabecular connective 
tissue, with corpuscles like leucocytes freely 
congregated in the interstices of the meshwork 
or between the fibres. This material, when 
seen in bulk, is grey or greenish-grey, after- 
wards becoming red on exposure. With it is 
mixed up an opaque yellow substance, vary- 
ing in amount, and apparently more abundant 
the more advanced the disease. In the earlier 
stages it presents the appearance of nodules 
embedded in the translucent material, but later 
almost the whole of this material may have 
disappeared, and the yellow opaque matter 
become converted into a thick creamy fluid, 
a putty-like substance, or even one or more 
cretaceous masses. This opaque material, 
then, is evidently, from its first appearance, 
indicative of fatty degeneration, and closely 
resembles in every respect what used to be 
known as yellow or crude tubercle. The 
more recent discovery of the tubercle-bacillus 
in several cases confirms Virchow's original 
view as to the essentially tubercular nature of 
the affection. 
The exterior of the capsules presents certain 
important features. The capsules themselves 
may be large or small, according to the stage 
of the disease and the nature of their con- 
tents, but, even when they are small, it may 
be safely assumed that at one time they were 
enlarged. In all cases they will be found 
closely and strongly adherent to neighbouring 
structures. Some of these structures are of 
great importance: for example, the semi- 
lunar ganglia, and the vast plexus of nerves 
associated therewith, in which important 
changes have been found. These patho- 
logical conditions have been so often observed 
and so carefully noted, that they cannot be 
looked upon as accidental concomitants of the 
diseased process, but rather part and parcel 
of it, and in all probability as giving a clue 
to some of the most marked phenomena of 
the malady. Broadly it may be said that 
these changes consist in a great thickening 
of the connective tissue surrounding the 
nerve-fibres and the ganglion-cells, giving 
rise to something like compression and ulti- 
mate destruction of these elements. This 
occurs both in the cerebro-spinal nerve-fibres, 
and in those more intimately connected 
with the ganglionic system. The nerve-cells, 
moreover, are not infrequently deeply pig- 
mented. 
The view commonly held as to the actual 
pathology of Addison's disease is that its 
phenomena are due to the nerve-lesions just 
described, and not to the destruction of the 
suprarenal capsules, though the exact mode 
in which they produce these effects is at 
present a mere matter of speculation. Ac- 
cording to another view the destruction of 
the suprarenal bodies is the cause of the 
prominent symptoms, and this is supported 
by Dr. MacMunn, as the result of his spectro- 
scopic observations on the blood and urine. 
He believes that the function of these bodies 
is to separate effete pigments and their 
accompanying proteids. When they are 
diseased, these elements are not removed, 
but circulate in the blood, the pigments or 
their incomplete metabolites producing pig- 
mentation of the skin and mucous mem- 
branes, and appearing often in the urine as 
uro-haemato-porphyrin ; the proteids setting 
up toxic effects, and leading to further de- 
terioration of the blood, with its conse- 
quences. 
In making the section of the body after 
death from Addison's disease, one cannot 
help being struck with the amount of sub- 
cutaneous fat, especially over the abdomen, 
as contrasted with the difficulties of nutrition 
under which the patient suffered; yet a con- 
siderable quantity is almost always found. 
But more closely connected with this mal- 
nutrition are certain changes in the absorbent 
system along the digestive tract. These 
consist in enlargement of the solitary and 
agglomerated glands constituting Peyer's 
patches, and of the mesenteric glands; as well 
as in lymphoid growths in the mucous mem- 
brane of the stomach, which give rise to little 
projections, termed mammilla Hons, on the 
walls of that organ, especially near the 
pylorus. Small ecchymoses are also not un- 
usually found in the same situation. Of other 
organs it may be noted that the liver and 
spleen are often enlarged and hyperaemic, and 
the heart small and light in weight. 
Diagnosis.-There would have been less 
difficulty or doubt in the diagnosis of Addison's 
disease, had it been clearly enunciated from 
the first that a bronzed skin did not alone 
constitute the malady. The disease rests on 
a threefold basis-general weakness, diseased 
suprarenal capsules, and bronzed skin, the 
last being the least important of the three. 
There may be darkening of the skin from a 
great variety of causes, viz.: (a) exposure, 
and attacks of vermin (morbus erronum, 
Greenhow; Vagantenkrankheit, Vogt); 
(&) wasting diseases, as chronic phthisis; 
(c) syphilis ; (d) malaria ; (e) liver disease or 
jaundice if long-continued ; &c.; but in none 
of these cases should there be any difficulty 
if the preceding dictum is borne in mind. 
Prognosis.-This is always unfavourable, 
but it is impossible to assign any definite 
period for the termination of the disease, since 
it often progresses irregularly, with periods 
of improvement followed by relapse. 22 
ADDISON'S DISEASE 
ADHERENT. ADHESIONS 
Treatment.-From what has just been 
said, it is plain that not much is to be effected 
by treatment as regards the cure of Addison's 
disease ; but much may be done by careful 
management to retard its progress and com- 
fort the patient. As soon as the disease is 
discovered, the sooner the patient makes up 
his mind to an invalid life the better. Rest 
and careful dieting are the basis of the treat- 
ment. As regarde diet, it may be briefly said 
that what the patient can take best suits best. 
As the stomach is so irritable, anything likely 
to upset it should be avoided. Hence, as a 
rule, it is better to give concentrated nourish- 
ment, as essence of meat (not the extract} or 
chicken, or raw pounded meat, when other 
things cannot be taken. It is also important 
to bear in mind that the stomach will often 
tolerate food cold or even frozen, when hot 
substances would be promptly rejected. In 
certain stages of this malady it may well be 
said that the physician's success will depend 
more on his knowledge of the cookery book 
than of the Pharmacopoeia-not, however, 
that our pharmaceutical gifts are to be de- 
spised. For the profound depression stimu- 
lants will be necessary, but these may take 
the shape of ether, or spirit of chloroform, as 
well as of wine or brandy. For the irritable 
stomach, alkalis, with nux vomica and ipe- 
cacuanha, or calumba, are of great service. 
So, too, in another way, are light tonics and 
neutral salts of iron; but the stomach should 
not be clogged with too much medicine. The 
bowels should not be much disturbed, but, if 
an aperient be required, a mild one, as a small 
dose of castor oil, or the compound liquorice 
powder of the Pharmacopoeia, will suit. If 
the stomach rebel against these, a wine-glassful 
of Hunyadi Janos water the first thing in 
the morning, followed by a cup of warm 
milk, may better agree with the irritable 
organ. When there is diarrhoea, a totally 
different line of treatment will be necessary. 
But in all things, and at all times, the 
grand rule is to save the patient's strength, to 
add to it if possible, and to resist the inroads 
of the disease, whatever shape these may as- 
sume. Alexander Silver. W. Cayley. 
ADENALGIA (a^v, a gland; and 
aXyos, pain).-Pain in a gland. 
ADENITIS.-Inflammation of a gland. 
See the several glands. 
ADENOCELE agland; and/ojX^a 
tumour).-A tumour connected with a gland. 
ADENODYNIA (a8^v, a gland; and 
oSvvrj, pain).-Pain in a gland. 
ADENOID a gland; and «i8oy, 
form).-Glandular : resembling the structure 
of a gland, whether secreting or lymphatic. 
ADENOMA (aSr/v, a gland, and the 
termination oma, adopted to indicate a 
tumour).-A morbid growth, the structure of 
which is of glandular nature. See Tumours. 
ADHERENT. 1 Q. . „ ., 
ADHESIONS. J -Structures are said 
to be adherent when they become abnormally 
united together, the morbid formations by 
which this union is effected being termed 
adhesion?. These are most frequently met 
with in connexion with serous surfaces, 
being usually the result of an inflammatory 
process, but they may be observed in other 
structures. The adhesions vary considerably 
in extent, number, mode of arrangement, 
firmness, and other characters : they may 
merely consist of a few loose, slender, and 
delicate bands; or these bands may be thick 
and strong; or the contiguous surfaces may be 
blended and matted together to a greater or 
less extent, so that they cannot be separated 
without tearing or cutting them asunder, 
this last condition constituting agglutination. 
In structure adhesions consist mainly of con- 
nective or fibrous tissue, more or less perfectly 
developed, with a few new vessels. 
Effects.-Adhesions are often found at 
post-mortem examinations, which have been 
of little or no consequence during life, as, for 
instance, many of those which form in con- 
nexion with the pleural surfaces. If, how- 
ever, they are extensive and firm, or if they 
occupy certain regions of the body, they may 
prove of serious moment. The principal evils 
which are liable to result from adhesions may 
be thus indicated :-1. They often bind parts 
together, and interfere with the movements 
of important organs, such as the lungs, heart, 
stomach, or intestines; in this way prevent- 
ing the due performance of their functions. 
2. When an organ is displaced in any way, 
as, for example, the heart by pleuritic effusion, 
it may become fixed in its new position by 
the formation of adhesions, its functions being 
thus distu-bed. 3. It is highly probable that 
agglutination may lead to hypertrophy of an 
organ, e.g. the heart, by embarrassing its 
movements, and hence affecting its action. 
4. On the other hand, atrophy or degeneration 
of structure may ensue, in consequence of 
the adhesions interfering with the due supply 
of blood by pressing upon the vessels, so 
that the nutrition of the tissues becomes 
impaired. In the young, also, their develop- 
ment may be checked. 5. Adhesions may 
involve important structures, such as nerves 
or vessels, pressing upon or destroying them, 
thus giving rise to symptoms of a serious 
nature. 6. Tubes or canals for the passage 
of secretions or other materials are some- 
times narrowed or obliterated by adhesions. 
7. When formed within the abdominal cavity, 
especially when they take the form of bands, 
adhesions may prove highly dangerous by 
compressing, constricting, exerting traction 
upon, or strangulating some portion of the ADHERENT. ADHESIONS 
intestine, in either of these ways leading to 
intestinal obstruction. 
It is frequently difficult or impossible to 
determine the existence of adhesions by 
clinical investigation during life; but the 
history of some past illness during which 
they were likely to be formed, the results of 
physical examination, especially in connexion 
with the heart and lungs, and the symptoms 
present, not uncommonly enable them to be 
discovered. Frederick T. Roberts. 
ADIPOCERE (adepts, fat; and cera, 
wax).-Synon. ; Er. Adipocire', Ger. Fett- 
wachs. 
Definition.-A substance formed by a 
spontaneous change in the dead tissues of 
animals. 
Description.-As seen generally in a dried 
state in museums, adipocere somewhat re- 
sembles spermaceti in consistence, but it is 
less crystalline in fracture, and is of a dull 
white or buff colour, the surface being some- 
times marked by the outlines of blood-vessels 
or of other textures. Adipocere in the earlier 
stages of its formation, or when formed in a 
damp situation, is soft, and if rubbed between 
the fingers communicates a greasy feeling. 
The odour is peculiar and rather disagree- 
able. 
Chemical Composition. - Adipocere dis- 
solves in ether, and leaves a delicate fila- 
mentous web ; it burns with a blue flame, and 
yields a white ash. It is properly described 
as a soap, composed of margaric and oleic 
acids in combination with ammonium, the 
fixed alkalis, and alkaline earths; the rela- 
tive proportion of the latter ingredients varies 
with the age of the specimen (the ammonia 
disappearing), and with the composition of 
the fluids in contact with which the adipocere 
has been formed. It is said that oleic acid 
predominates in adipocere formed from dead 
fish. 
Microscopical Appearances.-When the 
flesh of animals in which this transformation 
has recently commenced is examined with 
the microscope, it is found to be composed of 
broken-down or disintegrated tissues, fatty 
granules or particles, together with a few 
acicular scales or crystals. The granules 
may be seen in what had been muscular 
tissue to assume somewhat the arrangement 
of the muscular fibrillae, thus presenting an 
appearance resembling an early stage of fatty 
degeneration. In old and dry specimens of 
adipocere the crystalline scales form the great 
portion of the mass, and they may be observed 
preserving the outlines of the muscular fibres. 
Origin.-Adipocere has long been known. 
It is formed readily from the flesh of animals 
exposed to moisture, or placed in running 
water, in very dilute nitric acid, or in alcohol 
and water in the proportion of 1 to 6. It is 
often met with in inconvenient abundance in 
the specimen jars of the anatomist. The 
bodies of men and other animals buried in 
peat moss have frequently been found com- 
pletely converted into adipocere. Lord Bacon 
mentions it in the Sylva Sylvarum (cent. vii. 
§ 678), and so also does Sir Thomas Brown 
in the Hydriotaphia; but attention was 
especially called to its presence when a vast 
number of bodies were removed (in 1786-87) 
from the Cimetiere des Innocents at Paris to 
the Catacombs. Fourcroy found many of 
these bodies converted into what he named 
adipocire, a name since retained.1 Gibbes 
(as did others) suggested the possibility of 
applying adipocere formed from the waste 
flesh of animals to some useful purposes, but 
the tenacity of the disagreeable odour and 
the presence of other difficulties have pre- 
vented these suggestions from being carried 
out (Philosoph. Trans. 1794, p. 95). With 
respect to the immediate changes which give 
origin to adipocere, chemistshave differed in 
opinion. One class believes, with Gay-Lussac 
and Berzelius, that the compound results 
from the fat originally present in the tissues, 
and that the other components are completely 
destroyed by putrefaction. Another class 
which includes the names of Thomas Thom- 
son and Brande, maintains ' that the fatty 
matter is an actual product of the decay, and 
not merely an educt or residue.' These opinions 
may, the present writer thinks, be reconciled 
by the better knowledge we now possess of 
the elementary composition of tissues. We 
know that the combination of fat and albu- 
min constituting one of the earliest steps in 
the process of nutrition is traceable in the 
further development and formation of nearly 
every texture. When that combination is 
destroyed by a cessation of the processes of 
life, the tissues are, as it were, resolved into 
their primary elements. We may thus have 
adipocere derived not only from free fat, but 
from the elements of fat existing in and 
obtained from the decomposition of other 
tissues. Adipocere may thus be described 
as both an educt and a product. This 
opinion is confirmed by the researches of 
Bauer and Voit, who showed that fatty 
matter was derived from the metamorphosis 
of albumin in starved animals, to which 
phosphorus had been administered.3 
Pathological Relations.-The medical 
jurist has studied this substance with the 
view of determining the time and progress 
of its formation, and of thus ascertaining the 
1 A curious illustration of this process is inci- 
dentally mentioned by Mr. L. Field. The Illinois 
limestone, he says, proves to be composed of coral, 
in each cell of which a particle of oil is found 
sealed up- ' the result of the decomposition of the 
animalcula.'-Journal of the Society of Arts, 1883. 
p. 869. 
2 The writer would desire to refer here to the 
remarkable analogy which exists between the change 
of animal matter into adipocere, and that which 
occurs in vegetable matter by its conversion into 
peat and coal. 
ADIPOCERE 
23 24 
ADIPOCERE 
AFRICA, SOUTH 
probable period at which death had occurred. 
But hitherto no decided or satisfactory in- 
formation has been obtained, owing to the 
varied circumstances which influence the 
progress of the change, in connexion not 
only with the condition of the body itself, 
but also with the character of its surround- 
ings. The formation of adipocere has a 
further and a special interest for the patholo- 
gist. It was the study of this process which 
led the present writer to discover the analogy 
which exists between it and fatty degenera- 
tion in the living body, and thus to establish 
the pathological doctrine that fatty degenera- 
tion is the result of a retrograde metamor- 
phosis, not a form of perverted nutrition. 
(See Medical and Chirurgical Transactions, 
vol. xxxiii.) Richard Quain. 
ADIPOSIS.-A term which properly 
signifies either general corpulency, or 
accumulation of adipose tissue in or upon an 
organ. See Fatty Growth ; and Obesity. 
ADIRONDACK MOUNTAINS, in 
N ew York State.-A series of ranges rising 
from a plateau 2,000 feet above the sea, with 
picturesque lakes between them. Highest 
altitude, Marcy, 5,337 feet. Commodious 
hotels on the shores of the lakes. Much 
frequented as a summer climatic resort. 
Recomifiended in phthisis. See Climate, 
Treatment of Disease by. 
ADYNAMIA! ... 
ADYNAMIC J ^a' Pnv,» an(1 
power).-Terms indicating serious depression 
of the vital powers. The noun is employed as 
synonymous with the ' typhoid condition.' 
The adjective is applied to diseases in which 
the phenomena of this condition are promi- 
nent. See Typhoid Condition. 
JEGOPHONY (at^, a goat; and cfxevr), 
voice).-A peculiar alteration of the reson- 
ance of the voice, as heard on auscultation 
of the chest, compared to the bleating of a 
goat. See Physical Examination. 
ETIOLOGY (atria, cause; and \6yos, 
word).-That branch of pathological science 
which deals with the causation of disease. 
See Disease, Causes of. 
AFFINITY.-This term is the designa- 
tion of a property by which elementary and 
compound substances unite with one another 
and form new compounds. It is, therefore, 
a property with which chemists are princi- 
pally concerned. But the ideas suggested to 
the chemist by the term affinity are also, 
though less explicitly, excited in the mind of 
the pathologist and of the therapeutist by 
certain classes of facts frequently falling 
under their observation. The pathologist, 
for instance, knows that saline or earthy 
matter is very prone to accumulate in the 
midst of degenerated tissue in the walls of an 
artery or of a cardiac valve, so as to give rise 
to a patch of ' calcification '; he knows that 
in a gouty patient urate of sodium is most apt 
to accumulate and form ' chalk stones ' in the 
tissues around affected joints ; he knows that, 
however it may be administered, arsenic in 
poisonous doses tends to produce inflamma- 
tion of the alimentary canal, that strychnine 
acts with preference upon the nervous system, 
and that in ordinary cases of lead-poisoning 
this metal interferes especially with the 
nutrition of the extensor muscles of the 
forearm. Applications of the same notion in 
the department of therapeutics are equally 
familiar in respect to the action of many 
drugs. It may be regarded as an ascertained 
fact that iodide of potassium tends especially 
to influence the nutrition of the fibrous 
structures in the body, and that bromide of 
potassium has a no less certain action in 
modifying the nutrition of the nervous centres 
in many unhealthy states. Again, there is a 
whole class of substances which when taken 
into the system have, whatever their other 
actions may be, an undoubted effect in 
modifying the functional activity of the 
kidney. We have in nitrite of amyl and in 
nitroglycerine remedies possessing a remark- 
able influence over the unstriped muscular 
fibres of the arteries and bronchi, or else over 
the nerve-centres by which they are con- 
trolled. We have in woorara an agent which 
acts especially upon the motor side of the 
nervous system; and we have in digitalis an 
important remedy which, amidst its other 
effects, seems to have a decided power of 
improving the activity of the cardiac ganglia. 
The recent progress of therapeutics encour- 
ages us to hope that more and more of these 
specific effects of drugs will be accurately 
determined, so that the notion implied by 
the term affinity may, after a time, have 
a deeper meaning than at present for the 
practitioner of medicine.1 See Antagonism. 
H. Charlton Bastian. 
AFFUSION.-A method of treatment 
which consists in pouring a fluid, usually 
water, either cold or warm, upon the patient. 
See Water, Therapeutics of; and Baths. 
AFRICA, SOUTH.-The portion of 
this continent lying between 22° and 35° south 
latitude, and 18° and 32° east longitude, and 
including Cape Colony, Natal, Bechuanaland, 
1 Dr. James Blake states that we must look else- 
where than to chemistry for the nature of the re- 
actions between living matter and the reagents 
with which we may bring them in contact; and that 
this problem will be solved when the spectroscopic 
characters of the elements are better known. He 
holds that not only are toxic actions not chemical 
actions, but also that the whole direct action (of 
metallic salts) on the most important functions of 
living matter is a physical molecular action deter- 
mined by the number and character of the harmonic 
vibrations of which the reagents are the seat. 
(Comptes Bendits de la Soc. de Biologie, 1890.) AFRICA, SOUTH 
25 
the Orange Free State, and the Transvaal, 
thus embracing the region at present avail- 
able for health-resorts, and excluding the 
recently acquired British and German terri- 
tories. 
The physical features of this tract of 
country consist of: (1) a low-lying coast of 
varying extent, characterised generally by a 
warm and moist climate, and being in many 
parts swampy and malarious; and (2) an 
inland region, rising in terraces to 6,000 feet 
and upwards. This more or less elevated 
district, ascending in plateaux as the interior 
is approached, and varying in altitude from 
1,200 to 6,000 feet, affords excellent sites 
for health-resorts. The climate of tracts at 
between 1,900 and 3,000 feet is warm and 
dry; but the most suitable one for invalids is 
to be found at the altitude of 4,000 to 5,000 
feet, on the vast rolling grassy plain, or veldt, 
of which the Orange Free State, the Trans- 
vaal, and the Karoo District of the Cape 
are the best examples. Here the climate is 
characterised by great sunniness, dryness, 
and liability to extremes of temperature, 
though the night record seldom falls below 
the freezing-point. 
Cape Colony.- Cape Colony consists 
of eastern and western provinces, presenting 
varieties of climate according to elevation, 
of which the inland portions are far prefer- 
able. As the rainy season occurs in the winter 
in the west, and in summer in the eastern 
province, the wet season may be avoided by 
travelling from one to the other. The general 
meteorological features of the colony are 
great dryness; moderate heat; small rainfall, 
precipitated in heavy showers on a small 
number of days; and. a variable amount of 
wind. 
None of the coast towns are suitable for 
invalids, but in the neighbourhood of Cape 
Town, Rondebosch, Claremont, and Wynberg, 
situated on the wooded slopes of Table 
Mountain, can be recommended for tem- 
porary sojourn. 
Graham's Town (1,000 feet), in the eastern 
province, 100 miles from the sea, has an 
equable and genial climate, with a summer 
heat which is tempered by rain, the larger 
proportion of which falls at that season. 
Mean annual temperature, 60° Fah., the 
summer mean being 63° and the winter 53°; 
the mean range, 15°. Bainfall 26 inches, 
distributed over 84 days. 
Ceres (1,700 feet), in the western province, 
85 miles by rail from Cape Town, has a 
somewhat moister climate than Graham's 
Town, and possesses an excellent sanatorium 
with many social advantages. 
The higher plateau of the colony contains 
the following suitable stations :- 
Aliwal North (4,348 feet), 280 miles by 
rail from the port of East London, with a 
fine, clear, dry climate, which in the writer's 
experience has proved useful to many cases 
of phthisis. The rainfall is 18 inches, dis- 
tributed over 61 days, but occurring chiefly in 
summer, and sharp frost is occasionally 
recorded in the winter nights. 
Tarkastad (4,280 feet), Dordrecht (5,200 
feet), and Burghersdorp (4,650) have similar 
climates, the last place being connected by rail 
with Aliwal North, and within easy access 
of several stations higher and lower in eleva- 
tion. The rainfall is 11'39 inches, and the 
number of rainy days 41. 
Cradock (2,850 feet) and Beaufort West 
(2,792 feet) are both accessible by rail, and, 
though at lower altitudes, enjoy very fine cli- 
mates. At the former the humidity is 62p.c., 
the average summer maximum 91° Fah., the 
rainfall 9T8 inches in 45 rainy days, showing 
great dryness of climate. 
Orange Free State. - Bloemfontein 
(4,540 feet) is to be recommended, and un- 
doubtedly the Orange Free State offers 
many advantages in its vast veldt and dry 
climate, but it still lacks railway communi- 
cation, though this is projected. A draw- 
back, too, is the occurrence of dust-storms to 
which it is liable. At Bloemfontein the 
average maximum for the six hottest months 
of the year is 82c Fah., the average mini- 
mum 55°, the humidity 55 p.c., the rain- 
fall 16'97 inches, and the number of rainy 
days 70. Patients are able to sleep in the 
open air, except during a small part of the 
winter, when night frosts occur, and in 
the rainy season; and by day the outdoor 
life can be thoroughly carried out, either on 
the trek or while residing at a farm. 
The Transvaal.-The Transvaal is at 
much the same elevation as the Orange 
Free State, but is said to have a moister 
climate. Pretoria (4,007 feet), the capital, 
and Heidelberg have been recommended as 
suitable stations for invalids. 
Natal.-The colony of Natal, situated 
to the N.E. of the Cape Colony, has a tropical 
climate, and is distinguished for its luxuriant 
vegetation and moister climate. As in the Cape 
Colony, the coast district, including Durban, 
is not suitable for invalids, but the slopes of 
the Drakensberg Mountains, which separate 
Natal from the Orange Free State, are cooler 
and more salubrious. 
Here Howick (3,400 feet), Estcourt (3,562 
feet), and Ladysmith-all connected with 
Durban by rail-offer the invalid many 
advantages, in a dry climate, warmer than 
that of the Orange Free State, and fairly 
protected from cold winds; and they have 
proved of great benefit in bronchitis and 
asthma. 
The mean annual temperature of Pieter- 
maritzburg, the capital of Natal (2,090 feet), 
71 miles from the sea, is 64'7° Fah., the 
winter being 60n and the summer 69°, whilst 
the rainfall is 30 inches, occurring chiefly in 
October and March. 
C. Theodore Williams. 26 
AGEUSTIA 
AINHUM 
AGEUSTIA (d,priv.; and ytvais,taste).- 
Loss of taste. See Taste, Disorders of. 
AGONY (aycov, strife or struggle).- 
Agony implies bodily pain or mental suffer- 
ing so intense that it cannot be endured, but 
excites a struggle against it. It is also 
applied to the final struggle that often pre- 
cedes death. See Death, Modes of. 
AGORAPHOBIA {dyopa, a market- 
place; and cp6Sos, fear).-Synon. : Fr. La 
peur des espaces.-By these names a peculiar 
nervous complaint has been recognised, 
characterised by a feeling of alarm and 
terror, associated with a group of nervous 
symptoms, which some individuals experience 
when they are in a certain space. The con- 
dition may be developed rapidly or gradually, 
and the chief phenomena observed are as 
follows :-A sudden sensation is experienced, 
as if the heart were being grasped, while 
this organ palpitates violently; the face be- 
comes flushed; the legs feel weak, tremble, 
and seem as if they would give way under 
the body. There may be sensations of itch- 
ing, coldness, or numbness; or profuse 
sweating may occur. There is no true 
vertigo ; the special senses are unaffected; 
and consciousness is not at all impaired. A 
curious impression is sometimes experienced, 
as if space were elongating itself out inde- 
finitely. Persons who are thus affected are 
quite sensible of the foolishness of their fear, 
but cannot be reasoned out of it. During the 
attacks they feel a strong inclination to cry 
out, but hesitate to do so. They think that 
their dread is known to others, and many 
of them endeavour to conceal their feelings, 
lest they should be considered insane. 
The circumstances under which the symp- 
toms just described may be experienced are 
various. They may be felt, for instance, in 
the street, especially if the shops are shut; 
in public buildings, such as churches, concert- 
rooms, or theatres; in omnibuses, cabs, or 
other conveyances ; on a bridge ; or in look- 
ing at an extended facade or flying per- 
spective. Most persons who suffer thus in 
the street feel better when with some one, 
or when near some object, such as a carriage, 
or even when carrying an umbrella or a 
stick. Occasionally, however, they shun 
other people, especially acquaintances. 
But little is known as to the origin and 
nature of agoraphobia. The complaint is 
not regarded as idiopathic, but as sequential 
to some other condition. It occurs in males 
and females, and the individuals affected may 
be strong and in good bodily health, while 
they are often intelligent and well-educated. 
A history of hereditary nervous disorder can 
be traced in some cases, indicated by the oc- 
currence of insanity or epilepsy in members 
of the family; and the patients themselves 
may present indications of a nervous tem- 
perament. Their emotions are often easilv 
excited; and they may be subject to nervous 
symptoms, such as headache, a feeling of 
heat in the top of the head, sparks before the 
eyes, occasional faintness, or motor disorders. 
Treatment.-Special attention should be 
directed to maintain the general health in its 
widest sense, and particularly to give strength 
to the nervous system. Active mental oc- 
cupation, and pleasing social and moral sur- 
roundings, will generally succeed in relieving 
and ultimately curing the malady. 
Frederick T. Roberts. 
AGRAPHIA (a, neg.; and ypttyo, I 
write.)-This term is applied to defects of 
intellectual expression by writing rather than 
by speech. These defects may occur alone, or 
in association with defects of speech, according 
to the extent and situation of the lesion or 
nutritional defect in different cases. See 
Aphasia. 
AGRIA (aypw, wild).-This term signi- 
fies angry and severe. Willan describes a 
Lichen agrius, which is likewise termed 
agria. It is a circumscribed inflammatory 
eczema, situated on the back of the hands. 
The qualities implied by agria are excessive 
pruritus, burning pain, thickening, fission, and 
copious exudation. See Lichen. 
AGUE.-A popular synonym for inter- 
mittent fever. See Intermittent Fever. 
AGUE-CAKE. -A form of enlargement 
of the spleen, resulting from the action of 
malaria on the system. See Spleen, Diseases 
of; and Malaria. 
AIKIN, in south-west division of 
South Carolina.-A mild, bracing, dry 
climate, said to resemble that of Mentone in 
warmth and dryness, but with larger monthly 
temperature range. Soil, sandy. Recom- 
mended for pulmonary affections. See 
Climate, Treatment of Disease by. 
AINHUM (Nat., to saw).-This disease 
was first described by Dr. da Silva Lima of 
Bahia in 1867. It is peculiar to the African 
race, being found not only amongst the in- 
habitants of the West Coast of Africa, but 
also amongst the Hindoos of African descent, 
as well as amongst the slave population of 
South America. At its commencement, a 
groove or furrow is seen at the base of the 
little toe (the part almost invariably attacked), 
situated on its inner and inferior aspect, and 
corresponding to the digito-plantar fold. The 
furrow soon extends to the entire circumfer- 
ence of the toe; and, as it becomes gradually 
deeper, the latter is left hanging by a slender 
pedicle, which can only be brought into view 
by separating the walls of the furrow. The 
distal portion swells into an ovoid mass, about 
twice its natural size; finally some accident 
snaps the pedicle, and the toe drops off, in 
from four to ten years from the commence- 
ment of the disease. 
The furrow is caused by a constricting band AINHUM 
AIR, THERAPEUTICS OF 
27 
of hardened and contracted skin-a local 
scleroderma, which leads to faulty nutrition 
and degenerative changes in the parts beyond. 
Ainhum is not a painful affection in itself, 
but the extreme mobility of the little toe 
causes trouble and inconvenience, for which 
patients often seek relief in amputation. 
Occasionally the sides and bottom of the 
furrow ulcerate. Not infrequently both little 
toes are attacked by the disease. Males are 
more subject to it than females. The micro- 
scope reveals only atrophic and degenerative 
changes. The cause of ainhum is entirely 
obscure. It has been cured by the early 
division of the constricting band. 
A. Sangster. 
AIR, JEtiology of. - See Disease, 
Causes of. 
AIR, Therapeutics of. - Air is em- 
ployed in the treatment of disease in many 
ways and for many purposes. It is used, 
firstly, as the atmosphere, a gaseous mixture 
of definite composition and with a variable 
pressure. Secondly, advantage is taken of 
air as a vehicle for other substances in the 
gaseous or finely divided state. And, thirdly, 
it is selected as a medium by which the 
temperature of the body may be readily and 
effectively influenced. In the first of these 
relations only-as pure air-will its thera- 
peutics require to be considered in this article. 
The application to the body generally of air 
that has been warmed, or warmed and loaded 
with moisture, will be found described in the 
article on Baths ; whilst its administration 
to the respiratory organs, either in this form 
or as a vehicle for such substances as creasote, 
carbolic acid, alkaloids, and sulphurous acid, 
will be discussed under Inhalations. 
Principles.-The dual relation in which 
the air stands to the economy-as a definite 
compound of certain gases, and as an atmo- 
sphere with a certain pressure-is very fre- 
quently disturbed; and this disturbance 
accounts for some of the most familiar 
phenomena of disease. Alteration in the 
quality or quantity of the respired air, 
whether from the state of the atmosphere 
itself, or from derangement of the complex 
apparatus of respiration and circulation, is 
the cause of some of the most serious and 
distressing symptoms attending diseases of 
the chest. It might be predicted by the 
physiologist that under these circumstances 
relief would be afforded, at least to symptoms, 
by suitable alteration of the composition or 
volume of the air. The method of treatment 
thus rationally indicated proves to be readily 
practicable : the supply of air is unlimited ; 
its composition may be altered at pleasure ; 
its pressure may be increased or diminished; 
and such alteration will alter its chemical 
properties. We find accordingly that, ever 
since the discovery of the composition of the 
atmosphere, frequent trials have been made 
of its value therapeutically. Oxygen was 
early recognised as its active constituent, and 
came to be administered, as it still is, in the 
form of inhalation. From time immemorial, 
indeed, advantage has been taken of the 
purity and certain other unknown qualities 
of the air for the prevention and treatment 
of disease; and the character of the atmo- 
sphere is naturally reckoned one of the most 
important elements of climate {see Climate). 
More lately, use has been made of the 
powerful properties that air possesses when 
physically changed. "Within recent years 
remarkable advances have been made, on the 
one hand, in the physiology of respiration and 
the relation of the circulation to the atmo- 
spheric pressure, and, on the other hand, in 
the pathology of diseases of the chest. Clearer 
views have been reached on the signification 
of various symptoms, and especially of 
dyspnoea in its different forms. At the same 
time observations upon the effects of com- 
pressed and rarefied air have been becoming 
more exact. Pursuing the physiological track, 
modern therapeutists have availed them- 
selves of this knowledge, and revived the use 
of air physically altered in the treatment of 
diseases of the lungs, heart, and other parts 
of the body. This application they are now 
able to make with accuracy, and the success 
of the reformed system of aerotherapeutics 
appears clear. 
The physiological effects of compressed or 
of rarefied air will manifestly be different 
according as it is admitted to the body as 
a whole, or only to a part of it. Familiar ex- 
amples of the former condition are afforded 
by descent in the diving-bell, or ascent in the 
balloon ; and of the latter by the action of 
the cupping-glass, and the effects of inter- 
rupted or frequently repeated respirations 
upon the pulse and system generally. Under 
the first circumstances the alteration of 
pressure is absolute; under the second it 
is relative, and capable of producing most 
important disturbances in the distribution 
of the vital fluids. The two methods of 
application must accordingly be separately 
discussed. 
General Aerotherapeutics.-The effects 
of compressed air on the body as a whole 
have been studied in the air-hath. This is a 
mechanical arrangement in the form of an 
iron chamber, which can be filled with air 
at any pressure, whether above or below the 
normal, by means of steam-power. 
The principal physiological effects of air 
condensed by three-sevenths of an atmosphere 
were ascertained by von Vivenot to he:- 
Pallor of the skin and mucous membranes; a 
sensation of pressure in the ears; diminished 
frequency of respiration, the act becoming 
easier; enlargement of the lungs, and in- 
crease of the vital capacity; depression of 
the cardiac force, and diminution of the size 
and strength of the pulse ; rise of tempera- 28 
AIR, THERAPEUTICS OF 
ture; increased vigour of muscular action, 
secretion, and nutrition generally; compres- 
sion of the gaseous contents of the intestines ; 
and, perhaps, increased absorption of oxygen 
and excretion of carbonic acid. When the 
pressure is excessive, dangerous or even fatal 
symptoms may supervene. Frequent expo- 
sure to condensed air will induce consider- 
able increase of the vital capacity; and most 
of the other effects, both physical and chemi- 
cal, will tend to persist. In a word, it may 
probably be said that the air-bath acts on 
the system, first, by increasing the general 
mechanical pressure ; and, secondly, by ad- 
mitting an increased amount of oxygen. In 
employing the air-bath, the patient is kept 
in it for a period of two hours, at first daily, • 
but after some weeks less frequently. The 
pressure, which is employed in different cases 
at one-fifth to one-half of an atmosphere 
above the normal, must be slowly raised on 
admission, and reduced on removal of the 
patient. 
Uses.-The number of diseases in which the 
air-bath may be given with success is limited : 
(1) In certain forms of dyspnoea. It gives 
great relief in spasmodic asthma, and may 
also afford temporary relief in emphysema; 
but its prolonged use appears to be positively 
injurious, as it increases the pulmonary dis- 
tension. (2) In hyperaemia and catarrh of 
the air-passages, including pertussis. (3) In 
imperfect expansion or threatened retraction 
of the chest, as in the subjects of phthisis 
and chronic pleurisy. Compressed air has 
also been extolled in some forms of cardiac 
disease, and in general malnutrition. 
The effects of rarefied air admitted to the 
body as a whole do not demand description 
in this place, either in their physiological or 
in their therapeutical aspect. Artificially 
rarefied air is never employed in the form of 
the bath; and the natural supply in elevated 
regions, which has found favour as a means 
of treatment in phthisis, is a subject that 
belongs to Climate and Phthisis. 
Local Aerotherapeutics.-When it is 
desired to bring compressed or rarefied air 
into contact with the respiratory surface 
only, other apparatus must be employed. 
Different forms have been in use for some 
years, respecting which it will be sufficient to 
state that the air contained in a portable gas- 
holder is compressed or rarefied by simple 
mechanical means, and thereafter brought 
into relation with the air-passages by an 
arrangement of tubes and valves. There 
are four possible methods of application: 
(1) inspiration of condensed air; (2) expira- 
tion into condensed air; (3) inspiration of 
rarefied air; and (4) expiration into rarefied 
air. 
Another apparatus, called the pneumatic 
cabinet, has been introduced more recently. 
It consists of an air-bath, built of steel and 
glass, to accommodate both the patient and 
the administrator. The disturbance of pres- 
sure within the chest is effected by rarefying 
the air in the cabinet by means of a bellows, 
and then allowing the patient to inspire from 
the external atmosphere through a tube from 
without. This procedure is in effect mainly 
inspiration of a relatively condensed air. 
The physiological effects of the several 
methods of application may now be briefly 
stated. 
Inspiration of condensed air.-Inspiration 
of air that has been condensed by one-sixtieth 
to one-fortieth of an atmosphere produces a 
sensation of extreme distension of the chest, 
accompanied by an actual expansion of the 
thorax and lungs, and an increased admis- 
sion of air, so that inspiratory dyspnoea, if 
present, is relieved. At the same time the 
other thoracic contents are compressed, the 
systemic vessels fill, the arterial pressure 
rises, and the jugulars become distended. The 
lungs and heart will be comparatively anaemic. 
If the application of condensed air be fre- 
quently repeated, the vital capacity, the size 
of the chest, and the respiratory force may 
all be increased, and partial relief may be 
permanently afforded to dyspnoea. 
Expiration into condensed air is most 
difficult of accomplishment, and the effect 
on the circulation does not differ essentially 
from that just described. 
Inspiration of rarefied air.-Inspiration 
of air that has been rarefied by one two- 
hundred-and-fortieth to one one-hundred-and- 
twentieth-or even, after a time, by one- 
sixtieth-of an atmosphere, immediately 
causes the phenomena of inspiratory dyspnoea; 
the thoracic viscera are congested, and haemo- 
ptysis may result, for the effect may be re- 
garded as that of dry-cupping the pulmonary 
alveoli. The heart at the same time becomes 
full, and the jugulars collapse. 
Expiration into air that has been rarefied 
by one-sixtieth of an atmosphere is attended 
with a sense of extreme compression of the 
thorax ; at the same time there is actually a 
partial retraction of the lungs, an increase in 
the volume of expired air, and a correspond- 
ing diminution in the amount of residual air 
in the chest. Expiratory dyspnoea, if present, 
is relieved. While the lungs thus diminish 
in size, the other thoracic viscera are dilated 
-the heart and the pulmonary and other 
vessels within the chest being filled at the 
expense of those external to it, both arteries 
and veins. If the expiration into rarefied 
air be frequently repeated, the circumference 
of the chest will be diminished, while the 
vital capacity will be actually increased, 
along with increase of the inspiratory and 
expiratory force. 
Uses.-The method of inspiring condensed 
air is obviously indicated in diseases where 
inspiratory dyspnoea is an urgent symptom. 
Spasmodic asthma, stenosis of the air-pas- 
sages from anatomical causes, acute and AIR, THERAPEUTICS OF 
ALBINISM 
29 
chronic bronchitis, and atelectasis, have all 
been successfully treated by this method. 
In croup, where urgently indicated, it is 
most difficult or even impossible to employ 
it. In threatened phthisis it is used prophy - 
lactically, and in chronic phthisis it may 
usefully develop the healthy portions of 
lung; but it is contra-indicated in pyrexial 
cases, and may prove dangerous by inducing 
haemoptysis. In chronic pleurisy it may pre- 
vent or remove the effects of collapse and 
retraction of the chest-wall. The inhalation 
of condensed air should also be of use in 
certain forms of cardiac dilatation, especially 
that due to mitral incompetence. Improving, 
as it does, the general nutrition, it may be 
combined with other remedies for anaemia. 
In the administration of condensed air, a 
' sitting ' should last from ten to thirty 
minutes, once a day-seldom twice. 
Expiration into condensed air is not used 
therapeutically. 
Inspiration of rarefied air may be re- 
garded as a means of exercising the inspira- 
tory muscles. Like the atmosphere of great 
altitudes, it may therefore be employed in 
persons with badly developed chests; and 
even in phthisis it may, by increasing the 
amount of blood in the lungs, prevent casea- 
tion and promote absorption of the products. 
In disease of the right side of the heart, it 
would assist the flow of blood from the veins 
into the lungs, but it is not likely to be 
employed for this purpose. 
Expiration into rarefied air promises to 
be the most successful and most extensively 
employed of all the methods. In it, accord- 
ing to Waldenburg, we have the physical 
antidote for emphysema, and in his hands the 
majority of such patients are said to have 
been either cured or radically benefited. It 
has also afforded great relief in some cases 
of bronchitis, where it increases expectora- 
tion. 
Other local applications of the physical 
properties of the air, as seen in aspiration, 
cupping, Junod's boot, and inflation, are 
described elsewhere in this work. 
J. Mitchell Bruce. 
AIR IN CELLULAR TISSUE.- 
See Emphysema, Subcutaneous. 
AIR IN VEINS.-See Veins, Air in. 
AIR-PASSAGES, Diseases of.-See 
Respiratory Organs, Diseases of; also 
Larynx, Trachea, and Bronchi, Diseases of. 
AIX-LA-CHAPELLE, Waters of.- 
Thermal sulphur waters. See Mineral 
Waters. 
AIX-LES-BAINS, Waters of.-Ther- 
mal sulphur waters. See Mineral Waters. 
AKINESIA (a, priv.; and Kivgais, motion). 
A synonym for paralysis of motion, whether 
partial or general. See Paralysis, Motor. 
ALASSIO.-In Italy on the Mediter- 
ranean coast, between San Bemo and Genoa. 
A mild, bracing, winter resort, sheltered by 
hills except on the south and east. Com- 
paratively free from wind and dust. See 
Climate, Treatment of Disease by. 
ALBINISM (albus, white).-Defini- 
tion.-A state of whiteness or absence of 
colour of the integument and certain other 
tissues, consequent on defect of pigment- 
formation. The want of colour may be 
complete ox incomplete ; partial or universal; 
congenital or accidental. Partial albinism 
may be limited to a spot of small dimensions ; 
or there may be many such spots of variable 
extent, dispersed over the surface of the body, 
and giving rise to the appearance which is 
denominated pied or piebald; whereas in uni- 
versal albinism the defect of pigment is not 
restricted to the integument, but is especially 
remarkable in the iris and choroid membrane 
of the eyeball. 
General Characters.-Persons and ani- 
mals affected with albinism are called al- 
binoes. It would seem more correct to limit 
the term albino to those in whom the absence 
or defect of pigment is universal, and demon- 
strable not only in the integument but like- 
wise in the eyeball. In the true albino, 
therefore, the skin is white and pink and 
more or less transparent, and this both in the 
fairer and in the darker races of mankind ; 
but in certain of the latter, where the pig- 
mentary function is simply defective and not 
totally wanting, the colour of the skin may 
be grey or tawny, and more or less variegated 
and freckled. The hair, sometimes of a pure 
silvery or opaque white, may be diversely 
tinged with yellow or red; occasionally it is 
flaxen or possesses a greyish hue; and in 
some instances the whole body is covered 
with a white down. The iris is grey or pink, 
in accordance with the density of its fibrous 
structure, and the consequent facility of pene- 
tration of the colour of its vascular layer; or, 
as generally happens in the negro, it is blue. 
The pupil is contracted and brightly red, from 
the absence of the screen of protection usually 
afforded to the choroid membrane by its pig- 
mentary layer; and for the same reason the 
rays of light penetrating the sclerotic and iris 
give a brilliancy of appearance to the fundus 
of the eyeball. The absence of pigment in 
the eyeball is productive of several pecu- 
liarities of character in the albino. In the 
first place the excess of luminous rays pene- 
trating the coats of the eyeball interferes with 
the correctness of his vision ; his retinae are 
intolerant of light; he stoops his head, or 
droops his eyelids, to shelter his eyes; he 
sees with more comfort in the dimness of 
evening than in the light of the sun ; he is 
near-sighted ; and there is in many cases an 
oscillation of the eyeballs. 
^Etiology.-Albinism is met with among 30 
all races of mankind and in every country, 
but is most common amongst those who are 
subjected to insalubrious conditions of climate 
and hygiene. For these reasons it is not 
uncommon among the natives of the marshy 
coast of Africa; among negroes who are 
transferred to unhealthy districts in South 
America and the West Indies; among the 
inhabitants of the western coast of South 
America and Mexico; in certain of the islands 
of the Indian Ocean; and even in the 
northern regions of Europe. When albinism 
is congenital, it has been assumed to be due 
to an arrest of development; but when acci- 
dental, its existence must be referred to ex- 
haustion of chromatogenous or pigment-pro- 
ducing function. Arrest of development has 
been inferred from the occasional persistence 
in albinoes of the membrana pupillaris, and 
of the foetal down of the skin; from the 
more frequent occurrence of the condition in 
females than in males; and from the observa- 
tion that albinoes are sometimes misshapen 
and feeble intellectually as well as physically. 
On the other hand it is well known that 
albinism is often associated with perfect 
physical strength and remarkable intellectual 
vigour. Among other causes to which it has 
been assigned are heredity, and debility, 
however induced. 
Treatment.-The treatment of congenital 
albinism must consist in the application of 
those agencies which tend to strengthen and 
improve the general health. With regard to 
the special inconvenience resulting from the 
absence of pigment in the eyes, it has been 
observed that the difficulty felt in reading is 
greatly lessened by using screens or goggles 
made of some opaque material, such as alu- 
minium, each perforated by a small opening, 
admitting only the rays of light from the 
obj ect looked at. The treatment of accidental 
albinism will be considered elsewhere. See 
Pigmentary Skin-Diseases. 
Erasmus Wilson. 
ALBUMINOID DISEASE.-Synon.: 
Waxy, Lardaceous, and Amyloid Degenera- 
tion ; Fr. Degeneration amylo'ide; Ger. 
Speckartige Degeneration (Rokitansky); 
Amyloide Entartung (Virchow). 
Definition.-A peculiar form of degenera- 
tion, affecting certain organs, and constituting 
in its effects a distinct and general disease. 
Etiology.-In the majority of cases al- 
buminoid disease is preceded by long-con- 
tinued suppuration, most frequently in the 
form of bone- or joint-disease; or else of 
destructive pulmonary phthisis, empyema, 
pyelitis, cystitis, and other affections, where 
there has been a constant drain of pus. In 
the absence of obvious suppuration, there is 
usually present an exhausting disease, as 
syphilis, ague, or some more obscure cachexia. 
It has been observed as a consequence of 
inherited syphilis. These antecedent con- 
ALBINISM 
ditions must be regarded as the cause of the 
malady, and it is only in the rarest instances 
that no such cause can be traced. It is not 
easy to recognise the connexion, but it may 
be pointed out that a drain of pus involves 
not only a loss of highly organised proto- 
plasmic material, but also of potassium salts, 
which are contained in large proportion in 
the solid elements of pus, and which salts, 
as we shall see, are deficient in the affected 
tissues. 
Anatomical Characters.- The organs 
affected are usually much enlarged, but 
sometimes they ultimately decrease in size. 
They are pale, being evidently ansemic, 
dense, dry, sometimes hard, and either gene- 
rally or in certain spots translucent. In an 
advanced stage of the disease the parts appear 
as if soaked in wax, or other translucent 
material. If iodine, in alcoholic or aqueous 
solution, be applied to the affected parts, they 
are stained yellow, orange, or a deep maho- 
gany brown, according to the degree of the 
morbid change. If the portions thus coloured 
be further treated with dilute sulphuric acid, 
a purplish black colour is produced. In fine 
sections stained with the anilme dye, methyl 
violet, the affected elements are coloured 
pink, while the rest of the tissue is blue. 
The contrast of colour thus produced is the 
best means of recognising the degeneration 
under the microscope. These characters 
depend upon the presence in the tissue- 
elements of a peculiar substance, allied to the 
albuminates, and containing, when approxi- 
mately pure, about 15 per cent, of nitrogen. 
It is soluble in alkalis, not digested by pep- 
sin, and not readily altered by putrefaction; 
it yields with iodine the characteristic colour 
just noted, which gave rise to Virchow's 
erroneous supposition of its being allied to 
starch, whence the name-amyloid. Opinions 
have differed as to whether this change 
should be regarded as an infiltration or a 
degeneration. The albuminoid material, 
however, being contained in the tissue- 
elements themselves, and not infiltrated be- 
tween them, is probably not poured out by 
the vessels as such, but results from a trans- 
formation of the materials of the tissues. 
Moreover, minute analysis has never detected 
any trace of this substance in the blood itself. 
Chemical analysis of the affected organs 
shows a remarkable change in their mineral 
constituents, the potassium and phosphoric 
acid being very greatly diminished, as com- 
pared with healthy organs; while the sodium 
and chlorine remain normal, or are propor- 
tionately increased. 
Albuminoid disease affects most frequently 
the liver, spleen, and kidneys. Next in order 
of frequency come the lymphatic glands, and 
the intestinal mucous membrane, especially 
its villi; more rarely the suprarenal bodies, 
the pancreas, the urinary mucous membrane, 
or the omentum are involved; and, quite 
ALBUMINOID DISEASE ALBUMINOID DISEASE 
exceptionally, other parts, such as the thyroid 
body, the generative organs, the heart, and 
the lungs. In most organs the small arteries 
and their appendages (glomeruli of the kid- 
neys, Malpighian corpuscles of the spleen) 
are the seat of the morbid change ; but in 
some, such as the kidney, secreting cells may 
also be affected. In the liver the hepatic 
cells have been thought to be involved, but 
the change is really in the swollen and de- 
generated capillaries, especially those of the 
middle zone of each lobule. The diseased 
elements are enlarged, translucent, and 
structureless. 
Symptoms, Diagnosis, and Prognosis.- 
The general symptoms of albuminoid disease 
are anaemia, debility, a cachectic appearance, 
and sometimes capillary haemorrhage. The 
local symptoms are chiefly important in the 
case of the liver, spleen, and kidneys. Uniform 
smooth enlargement of the liver and spleen, 
which can be referred to no other cause, may 
be due to the albuminoid change. Where 
the kidney is affected, albuminuria, dropsy, 
uraemia, and a train of symptoms arise, 
which, regarded as a whole, differ from those 
of other kidney diseases. Diarrhoea is a 
frequent symptom, probably referable to the 
degeneration affecting the intestinal mucous 
membrane. The diagnosis is greatly con- 
firmed by (1) the simultaneous occurrence of 
disease in several organs ; (2) a history of 
suppuration, or of some cachectic disease, 
especially syphilis. The prognosis is ex- 
tremely unfavourable, and, when the disease 
is far advanced, it is hopeless. 
Treatment.-Though in advanced cases 
treatment can avail but little, there is reason 
to think that were the occurrence of the disease 
anticipated, or its presence earlier recognised, 
prevention, or even cure, might be possible. 
The only real means of prevention is to 
check suppuration; and there is no doubt 
that since the adoption of antiseptic methods 
in surgery, and of more radical treatment of 
diseased bones and joints, albuminoid disease 
has become less common, at all events in 
London. In all such complaints as chronic 
joint-disease, psoas abscess, syphilitic dis- 
ease of bone, or prolonged empyema, the 
probability of this frequently fatal sequela 
should be borne in mind, and guarded against 
by a suitable regimen. The diet should not 
only be generally nutritious, but should 
include more especially abundance of nitro- 
genous food (albuminates), as well as the 
potassium salts, which the affected tissues 
lack. These are, indeed, largely contained 
in the juices of fresh meat, and also in the 
green parts of vegetables. Among drugs, 
nutrient tonics, of which iron and cod-liver 
oil are the type, must hold the first place; 
but the administration of potassium salts, as 
proposed by Dr. Dickinson, is also indicated. 
Of these we should be induced, on a priori 
grounds, to select those of which the local 
action is least violent, and which cause little 
vascular depression, such as the bicarbonate 
or the citrate, or other organic salts. 
J. F. Payne. 
ALBUMINS.-Definition. - Albumins 
are substances closely resembling egg-albu- 
min, the chief constituent of white of egg or 
albumen. To distinguish between the white 
of egg and its chief constituent, the former 
is spelt albumen, and the latter albumin. 
Albumins constitute a subdivision of the 
class of albuminous bodies, which includes 
all substances having a general resemblance 
to albumen. See Albumose ; and Globulin. 
Enumeration.-The subclass properly con- 
tains only two members, egg-albumin and 
serum-albumin ; but the name Bence-Jones's 
albumin has been given to an albuminous 
body differing very considerably in its pro- 
perties from the other two. 
Characters. - Egg-albumin and serum- 
albumin are semi-transparent, yellowish, 
and structureless when dried. They are 
soluble in water ; and this solution is coagu- 
lated by boiling. From the same solution 
they are precipitated by: (a) nitric acid; 
(&) salts of the heavy metals, for example, 
copper-sulphate ; (c) acetic acid with potas- 
sium-ferrocyanide; (d) boiling with acetic 
acid and a neutral salt, for example, potas- 
sium-sulphate ; (e) alcohol. Egg-albumin is 
distinguished from serum-albumin by the 
coagulum which it forms with nitric acid 
being insoluble in excess, while that of serum- 
albumin is soluble. Bence-Jones's albumin 
gives no precipitate with excess of nitric acid 
unless left to stand, or unless heated and left 
to cool, when it forms a solid coagulum. 
This coagulum redissolves on heating, and 
again forms on cooling. It is therefore an 
albumose (see Albumose). It may be sepa- 
rated from ordinary albumin by adding 
nitric acid, boiling, and filtering when hot. 
The ordinary albumin will remain on the 
filter while Bence-Jones's albumin will pass 
through, and will coagulate when the filtrate 
cools. 
Modifications.-By the action of acids 
and alkalis albumin may be converted into 
acid-albumin and alkali-albumin respec- 
tively, neither of which is coagulated by 
boiling. 
Acid-albumin may be formed in two ways : 
First, by dissolving solid albumin in con- 
centrated nitric or other mineral acid with 
the aid of heat. Secondly, by heating an 
aqueous solution of albumin with one of these 
acids very much diluted (1 in 5C0). Although 
soluble in very concentrated or very dilute 
acids, acid-albumin is insoluble in moderately 
dilute acids. Therefore, when the solution 
in concentrated nitric acid is diluted with 
water, a precipitate is formed, which redis- 
solves when much water is added. And, 
conversely, when acid-albumin is made by 
ALBUMINS 
31 32 
ALBUMINS 
ALBUMINURIA 
boiling a solution of albumin in water with 
very dilute nitric acid, the addition of 
more acid will throw down a precipitate, 
which redissolves if a very large excess of 
the concentrated acid be added, and especially 
if it be heated at the same time. On 
neutralising a solution of acid-albumin, a 
precipitate is thrown down, which dissolves 
very readily in excess of alkali. 
Alkali-albumin, or alkali-albuminate as it 
is also called, is formed by dissolving albumin 
in caustic potash or soda ; or by adding either 
of these to its aqueous solution and allowing 
this to stand, or heating it. This modifica- 
tion is not precipitated by heat, but is 
precipitated by neutralisation ; the precipitate 
dissolving very readily in slight excess of acid. 
If alkaline phosphates are present in the 
solution, as they are in urine, alkali-albumin 
requires a slight excess of acid to throw it 
down, and is not precipitated by exact 
neutralisation, as acid-albumin would be 
under similar circumstances. 
T. Lauder Brunton. 
ALBUMINURIA. - Definition. - A 
condition characterised by the presence of 
albumin in the urine. Other albuminous 
bodies, not albumins, may be present in 
haemoglobinuria, hrematuria, pyuria, and 
spermatorrhoea. 
Symptoms.-Albumin may occur in the 
urine without any symptoms whatever, but 
its continuous loss leads to anaemia and 
changes in the circulation, which usually 
originate a series of symptoms. These are : 
a pallid pasty complexion, dry skin, and 
tendency to oedema of the cellular tissue, 
noticeable on the eyelids and ankles; de- 
rangement of digestion, flatulence, occa- 
sional nausea, and irregularity of the bowels; 
nervous disorder, shown by muscular weak- 
ness, languor, lassitude, vague pains about 
the loins, and headache ; calls to make water 
during the night; attacks of difficult breath- 
ing ; palpitation, and frequently accentuation 
of the second sound of the heart over the : 
aortic cartilage, and reduplication of the first 
sound over the septum ventriculorum. 
Tests for Albumin.-The two tests usually 
employed to detect albumin in the urine are - 
first, boiling; and, secondly, the addition of 
nitric acid; both of which produce a cloud or 
precipitate. If the urine is turbid, the albu- 
minous cloud may not be noticed; and there- 
fore such urine should be filtered before the 
application of either test, unless the turbidity, 
being dependent on the presence of urates, is 
removed by heat cautiously applied. 
Method, of employing the test by 
boiling.-With the object of saving time the 
urine is often boiled at once, but the results 
thus obtained are liable to several fallacies, 
which will be subsequently described. In 
order to avoid such fallacies the following 
method should be pursued:-Ascertain the 
reaction of the urine; and, if it be alkaline or 
very strongly acid, add acetic acid in the one 
case, or liquor potassa? in the other, until its 
reaction is only slightly acid. Fill a test-tube 
to about one-third of its capacity with the 
urine, and hold it obliquely in the flame of a 
spirit-lamp, in such a manner as to heat the 
upper part of the fluid only, until it boils. 
If it be turbid from urates, it should be first 
warmed throughout until it becomes clear, 
and then the upper part only should be boiled. 
Finally, add a drop or two of acetic or nitric 
acid. 
If albumin be present, it will form a cloud 
or a coagulum, more or less dense according 
to its amount. When there is much albumin, 
its quantity may be roughly estimated by 
allowing the urine to stand for a definite 
number of hours, so that the coagulum may 
subside, and then observing whether it forms 
a fourth, a third, or a half of the whole length 
of urine in the test-tube. A small quantity 
causes a cloud, but no distinct coagulum ; 
and, if merely a trace be present, a faint haze 
only will be observed, which is best seen 
by looking through the test-tube at a dark 
object. The advantage of heating the upper 
part only of the urine is, that the lower 
portion, which remains clear, affords a 
standard by comparison with which a faint 
cloud in the heated part may be more readily 
detected. 
Fallacies of the test by boiling.-The first 
fallacy is that albumin may be present, and 
yet no cloud or coagulum be produced on 
boiling. This may occur if the urine be 
alkaline or very strongly acid, because alkali- 
albumin or acid-albumin, which are soluble in 
water, may be formed. It is to prevent the 
formation of alkali-albumin that acetic or 
nitric acid should be added to alkaline urine 
before boiling. This addition of acid also 
causes the coagulum to separate more readily; 
and it should therefore be made when tbe 
urine is neutral. On the other hand, urine 
rarely or never contains sufficient acid to 
form acid-albumin, unless the patient has 
been taking mineral acids; and therefore the 
addition of liquor potassae is not necessary 
except under these circumstances. The second 
fallacy of the test by boiling is, that a cloud 
resembling that of albumin may be produced, 
although the urine is free from this substance. 
This occurs when the acidity of the urine is 
too slight to hold the earthy phosphates in 
solution, the heat probably affecting the re- 
lation between the basic and acid phosphates 
which are normally in solution, whereby 
deposition of insoluble phosphate results, 
forming a cloud like that of albumin. The 
two clouds are readily distinguished by the 
addition of a drop or two of acetic acid, 
when if due to phosphates the cloud will dis- 
appear by solution, but if caused by albumin 
it will remain. If an excessive quantity oi 
nitric acid be added, an albuminous cloud ALBUMINURIA 
33 
may also clear up; for albumin coagulated 
by heat is soluble in strong acid, though only 
to a slight extent. 
Application of the nitric acid test.- 
Pour some urine into a test-tube, and then 
allow about one-fourth of its bulk of strong 
colourless nitric acid to trickle slowly down the 
side of the tube, so as to form a layer below 
the urine without mixing. Or the acid may 
be put in the test-tube first, and the urine 
poured on it. Both processes give the same 
result. If albumin be present, a haze or 
cloud will form close to the line where the 
liquids meet. 
Fallacies of the nitric acid test.-l. Al- 
bumin may be present and yet escape detec- 
tion, if the nitric acid is simply poured into 
the urine and mixed with it, as is sometimes 
done. For if there be too much or too little 
acid, acid-albumin is formed and dissolved; 
whereas, if the liquids form two distinct 
layers, as in the process already described, 
the acid gradually mixes with and shades off 
into the urine, so that, at a greater or less 
distance from the line where they join, it is 
certain to be of the proper strength to pre- 
cipitate the albumin. 2. Albumin may be 
supposed to be present when it is not, from 
the formation of a cloud by the precipita- 
tion of acid urates. This cloud disappears 
on the application of heat; and another 
specimen of the urine tested by boiling 
gives no cloud. To avoid this fallacy, it 
is common to employ the test by boiling, 
in addition to that by nitric acid. 3. The 
third fallacy is not of common occurrence. 
It is due to the presence of fat or saponified 
fats in the urine. Urine containing these 
when simply boiled gives no cloud; but if 
nitric acid is added to it in the cold, or ace- 
tic acid when it is hot, the fatty acids are 
precipitated and form a cloud resembling 
albumin. This is distinguished by not being 
formed if along with dilute acetic acid some 
ether is added to the urine before boiling; 
the ether retaining the fatty acids in solu- 
tion. If the precipitate produced by nitric 
acid be collected on a filter, and treated with 
ether, it will be dissolved, while an albumi- 
nous precipitate will not. Copaiba, which 
can be recognised by its odour, sometimes 
causes an opalescence in the urine, which is in- 
creased by nitric acid, but is removed by heat. 
Additional tests for albumin.-When 
urine contains mucus, which would render 
the presence of an albuminous cloud obscure, 
a solution of ferrocyanide of potassium fol- 
lowed by acetic acid should be added: this 
will produce a cloud if albumin be present, 
whilst it rather clears up a turbidity due 
to mucus. A solution of pyro-phosphate of 
sodium also precipitates albumin. If a few 
drops of albuminous urine be poured into a 
test-tube containing one or two drachms of 
a saturated solution of picric acid, a precipi- 
tate is formed which does not dissolve on 
boiling, and thus differs from that due to 
albumoses. A strong solution of trichloracetic 
acid also gives a precipitate with albumin. 
These tests are sometimes useful m deter- 
mining the presence of albumin in the urine 
in doubtful cases. 
Quantitative Estimation of Albumin.- 
There are three methods in common use for 
this purpose. The first is easy but inexact. 
It consists in boiling the urine with dilute 
acetic acid in a test-tube, allowing the coagu- 
lum to subside for a definite number of 
hours, and then estimating the proportion it 
bears to the quantity of urine boiled-for 
example, a fourth, a third, &c. The second 
is the most exact, but is troublesome. It 
is like the first; but the urine is carefully 
measured before boiling, and the amount of 
coagulum is ascertained by collecting it on a 
weighed filter, washing, drying, and again 
weighing it. The third method is easy and 
tolerably exact. A tube of known length is 
filled with urine and placed in a polarising 
apparatus. From the amount of rotation 
which the polarised ray undergoes in passing 
through the urine, the amount of albumin it 
contains may be calculated. A fourth method 
has been recommended by Sir William 
Roberts. It consists in diluting the urine 
with water until it gives a haze on the ad- 
dition of nitric acid, which does not become 
visible until between one-half and three- 
quarters of a minute after the acid has been 
added. This dilute urine contains 0'0034 
per cent., or 0'0148 grain of albumin per 
fluid ounce ; and from the degree of dilution 
required the amount contained in the urine 
may be calculated. A fifth method is that of 
Esbach. It is less accurate than Roberts's, 
but is convenient. It consists in precipitating 
the albumin from urine in a graduated tube 
by means of picric acid, and reading off the 
quantity of albumin precipitated after the 
tube has stood for twenty-four hours. The 
precipitant consists of 1 part of pure picric 
acid and 2 parts of citric acid in 100 parts 
of water. The tube is filled up to a mark 
with the urine, and about two-thirds of its 
bulk of the precipitant is then added; the 
exact amount necessary being indicated by 
another mark on the tube. The lower part 
of the tube is graduated with lines num- 
bered | up to 7, and these indicate the parts 
by weight of albumin in 1,000 parts of the 
urine by measure. Thus, if the upper level 
of the precipitate after twenty-four hours 
stood at 2, the proportion of albumin would 
be 2 in 1,000, or | of a grain of dry 
albumin to the ounce of urine. The results 
given are rather too low, and the method 
gives the best results when the proportion of 
albumin is small, so that urines containing 
much ought to be diluted before the test is 
applied. It is unsuitable if quinine, anti- 
pyrin, or thallin is likely to be present in the 
urine. 34 
ALBUMINURIA 
Pathology.-Albuminuria has been said 
to occur in consequence of various condi- 
tions : e.g. changes in the blood, changes in 
the circulation, changes in the kidney. Thus 
abstinence from salt, or a diet of eggs alone, 
is said to produce albuminuria by altering the 
constitution of the blood; and an alteration 
in this fluid is supposed to be partly the 
cause of the albuminuria observed in high 
fevers, scarlatina, diphtheria, and osteo-ma- 
lacia. The albuminuria of heart-disease de- 
pends on changes in the circulation; and that 
of nephritis on alterations in the kidney. In 
order to distinguish more clearly between the 
different kinds of albuminuria we may divide 
them into-(1) false albuminuria, in which 
some other albuminous body than serum- 
albumin is present; (2) true albuminuria, in 
which serum - albumin, frequently accom- 
panied by globulin, appears in the urine. 
In true albuminuria there is always some 
change either in the circulation through the 
kidney, or in the structure of the kidney 
itself. In false albuminuria the albuminous 
body passes out through the kidney, without 
there being any alteration either in its cir- 
culation or structure. 
(1) False albuminuria.-The chief albu- 
minous bodies occurring in false albuminuria 
are haemoglobin, egg-albumin, globulin, and 
Bence-Jones's albumin (albumose). Haemo- 
globin occurs in the urine whenever blood is 
present in it (see Hematuria), in which case 
it is contained in the corpuscles; or it may 
occur free (see Hemoglobinuria), the blood- 
corpuscles, while still circulating in the 
vessels, having undergone solution. This 
may result from the inhalation of arseniu- 
retted hydrogen, or from the introduction 
of bile-acids or of a large quantity of water 
into the veins. Haemoglobin is also found 
in the urine in paroxysmal haemoglobinuria, 
but the cause of the solution of blood- 
corpuscles in this disease is unknown. Egg- 
albumin is excreted by the kidneys, and 
appears in the urine, whenever it is injected 
directly into the circulation or under the 
skin, or when it is absorbed unchanged from 
the stomach or rectum. When taken into 
the stomach it is usually completely digested 
before it undergoes absorption; but when 
taken in such large quantities that the whole 
of it cannot be digested, part of it is absorbed 
unchanged and is excreted in the urine. Thus 
a diet consisting exclusively of eggs, especially 
when continued for several days, produces 
false albuminuria, and large enemata of eggs 
have a similar effect in animals, and probably 
also in man. Bence-Jones's albumin is of 
very rare occurrence. It is found in osteo- 
malacia. Like egg-albumin, it is excreted 
by the kidneys when it is injected into the 
circulation, or in large quantities into the 
intestine. It is almost if not quite identical 
with the hetero-albumose which Kiihne 
finds to be one of the products of imperfect 
digestion. It seems probable that those cases 
of albuminuria which appear to depend on 
imperfect digestion, are due to the passage 
into the systemic circulation of albuminous 
bodies, which have not undergone the proper 
transformation in the alimentary canal or 
liver. Sec Albumoses ; and Albumosuria. 
(2) True albuminuria. - In true albu- 
minuria there must be some change, either 
in the circulation or structure of the kidney, 
for serum-albumin differs from the other 
albuminous bodies just mentioned in not 
being excreted by the healthy kidney. Some 
regard the alterations in the circulation which 
produce albuminuria as of two kinds :- 
(a) increased pressure of blood in the renal 
arteries; (6) increased pressure in the renal 
veins. Increased pressure in the arteries 
may depend either on general high arterial 
tension, or upon an increased local supply of 
blood to the kidney, owing to dilatation of the 
renal arteries, such as follows division of their 
vaso-motor nerves. Experiments seem to 
show, however, that increased tension in the 
renal arteries does not produce albuminuria, 
and that the only change in circulation which 
will cause it is increased pressure in the renal 
veins. Congestion of the renal veins may be 
produced by ligature of the renal arteries; 
and when the flow of blood through the 
kidney is temporarily arrested by ligature of 
the artery, the urine secreted after the re- 
moval of the ligature is albuminous. Venous 
congestion of the kidney also occurs when- 
ever the onward flow of venous blood is 
obstructed, either by a ligature on the renal 
veins; by the pressure of a tumour or of the 
pregnant uterus upon them or the vena cava; 
by disease of the liver obstructing the vena 
cava; or by disease of the heart or lungs, 
such as tricuspid or mitral regurgitation, or 
chronic bronchitis and emphysema. The 
temporary albuminuria sometimes observed 
after cold bathing may also be due to venous 
congestion; and it is probable that albumin- 
uria consequent upon lesions of the nervous 
system, is due rather to the changes which 
these produce in the circulation, than to any 
direct action of the nerves upon the tissues 
of the kidney itself. The albuminuria ob- 
served after varnishing the skin is probably 
due to the retention of some substance which 
acts as a poison. The structural changes in 
the kidney which cause albuminuria are acute 
and chronic inflammation, waxy degenera- 
tion, and cirrhosis. Sec Bright's Disease. 
Treatment.-(1) In false albuminuria, 
where haemoglobin appears in the urine, the 
treatment indicated is to counteract the solu- 
tion of blood-corpuscles; and for this purpose 
quinine is very often useful. When other 
kinds of albumin appear in the urine, and 
are probably due to imperfect digestion, the 
treatment is to give some artificial digestive 
fluid. Arsenic is also useful. Regarding those 
cases of osteo-malacia in which Bence-Jones's ALBUMINURIA 
ALBUMOSURIA 
35 
albumin occurs, we unfortunately know very 
little. 
(2) In true albuminuria, depending on 
venous congestion, the obstacle to free cir- 
culation should be removed, if possible ; and 
the congestion lessened, both by drawing 
the blood from the interior to the surface 
of the body, and by causing contraction of 
the renal vessels. The blood may be drawn 
from the interior to the surface by means 
of warm baths; but in some cases these 
prove injurious rather than useful, and the 
employment of a wet pack, which has a 
similar effect on the distribution of blood 
without exciting the heart, is to be pre- 
ferred. Cupping over the loins is service- 
able : it probably acts by causing reflex 
contraction of the renal vessels rather than 
by actually draining blood away from them. 
The tone of the renal vessels may be 
increased by the employment of digitalis 
(see Diuretics) ; and this drug is useful even 
when no cardiac disease is present, although 
its good effects are still more marked when 
the congestion is dependent on disease of the 
heart. The constant drain of albumin from 
the body occasions anaemia, which not only 
produces many unpleasant symptoms, but 
tends to cause fatty degeneration of various 
organs, from which there is no reason to be- 
lieve that the kidneys are exempt. The ad- 
ministration of iron, therefore, is the chief 
medicinal remedy in structural disease of 
the kidneys. It is useful by diminishing or 
removing the symptoms of anaemia, and the 
tendency to fatty degeneration consequent 
thereon; and also by increasing the tone of 
the vessels, thus diminishing the loss of 
albumin. T. Lauder Brunton. 
ALBUMOSES. - Definition. - Albu- 
moses are proteid bodies derived by the 
action of digestive ferments (pepsin chiefly) 
upon albumins and globulins, and in their 
properties may be classed as intermediate 
between these proteids and the final product 
of digestion (peptone). They are formed 
during natural digestion in the stomach, and 
also in artificial digestion. 
Enumeration.-Many varieties of albu- 
moses have been described, collectively termed 
proteoses. The individual bodies differ some- 
what, according as they are formed from 
albumins (albumoses) or globulins (globu- 
loses): for all practical purposes the term 
albumose is the best to use. The forms of 
albumose important in medicine are hetero- 
albumose, proto-albumose, and deutero- 
albumose, the last being closely allied to 
peptone. 
Characters.-1. Hetero-albumose (' Bence- 
Jones's albumin') is insoluble in water, but 
soluble in dilute saline solutions, from which 
it is precipitated by heat if no free acid 
is present. In some cases it is precipitated 
at a temperature of 43° to 50° C., and re- 
dissolves on heating the liquid to the boil- 
ing point. Artificially prepared hetero-albu- 
mose is rendered partly insoluble by heating; 
but the coagulum is soluble in dilute acids 
and alkalis, thus distinguishing it from the 
coagulum formed on heating a solution of 
serum-albumin or serum-globulin. Hetero- 
albumose is also precipitated from solution 
by saturation with magnesium sulphate or 
sodium chloride. 
2. Proto-albumose and deutero-albumose 
are soluble in water, are not precipitated 
by heat, and are thus sharply distinguished 
from hetero-albumose. 
These three albumoses have one reaction in 
common (besides those given by all proteids), 
viz., that with a trace of copper sulphate 
and an excess of liquor potassae they give a 
pink-red colour (biuret reaction), the colour 
given by hetero-albumose being the least 
marked. They all behave in a peculiar way 
to nitric acid: if added drop by drop to a 
solution of hetero- or proto-albumose, nitric 
acid causes a precipitate, which is soluble in 
excess of the acid, but is also soluble on 
heating, re-appearing on cooling, and so on. 
With deutero-albumose, however, nitric acid 
causes no precipitate, unless common salt be 
added until the liquid is nearly saturated 
with it: the precipitate which is then pro- 
duced by the acid behaves like the nitric acid 
precipitates of proto- and hetero-albumose. 
(For other distinctive reactions see Albu- 
mosuria.) Albumoses are distinguished from 
peptones by the nitric acid reaction; as well 
as by their precipitation with acetic acid and 
potassium ferro-cyanide, and with neutral 
ammonium sulphate added to saturation. The 
characters of true peptones are that they are 
not precipitated by heat, by nitric acid under 
any condition, by acetic acid and potassium 
ferro-cyanide, or by saturation with neutral 
ammonium sulphate. This last test is the 
most distinctive. In the presence of ammo- 
nium sulphate to saturation they give the 
biuret reaction, and are thrown down by 
tannin. Sidney Martin. 
ALBUMOSURIA. - Synon. : Propep- 
tonuria. 
Definition.-A condition in which albu- 
moses are present in the urine. The condi- 
tion where peptones are present (peptonuria) 
is not at present distinguishable from albu- 
mosuria. Peptonuria will therefore be con- 
sidered under this heading. 
Tests for Albumose or Peptone in 
Urine.-Urine containing albumoses or pep- 
tones shows ordinarily no special character- 
istics indicating their presence; unless, in 
some cases, frothing when shaken. It may 
be dark- or light-coloured, of high or low 
specific gravity, and with or without deposit. 
In one case Kiihne found a whitish deposit, 
consisting partly of albumose ; and in a simi- 
lar case Bence-Jones found casts, ordinary 36 
ALBUMOSURIA 
albumin being absent. As a rule, however, 
albumose and peptone are present in solution 
in the urine. In searching for these, coagu- 
lable albumin must be absent, or if present 
removed by filtration after coagulation. The 
following methods are, therefore, to be used:- 
Heat the top of the column of urine in a test- 
tube in the usual way, but without the addi- 
tion of acid. If a cloudiness appears, it is 
due to the precipitation of coagulable albu- 
min, of phosphates, or of hetero-albumose 
(Bence-Jones's albumin). Continue the heat- 
ing to the boiling-point; the cloudiness, if 
due to hetero-albumose, will clear up, that 
due to phosphates and albumin will remain. 
Add a drop of acetic acid; the phosphates 
will be dissolved up, the coagulated albu- 
min will remain insoluble. A precipi- 
tate in urine, then, caused by a moderate 
heat and redissolving on boiling is hetero- 
albumose. This may be verified by deter- 
mining the exact temperature at which the 
precipitation occurs : hetero-albumose is pre- 
cipitated between 43° and 50° C. (109'4° and 
122° Fah.), serum-albumin or globulin at 
73°-75° C. (163'4° and 167° Fah.), and phos- 
phates only when near the boiling-point; this 
last precipitate also redissolves on cooling. 
If the urine contains albumin or globulin, it 
must be boiled after the addition of a drop of 
acetic acid, and filtered. The filtered urine 
must then be tested for albumose in the way 
to be described. The presence of hetero- 
albumose is indicated by the last test just 
mentioned ; in addition, it gives a character- 
istic nitric acid test. If to the cold urine 
nitric acid be added drop by drop, a precipi- 
tate forms which dissolves on heating, re- 
appears on cooling, redissolves on heating, 
and so on : this is perfectly characteristic of 
the body, since the similar precipitate of 
albumin or globulin does not redissolve on 
heating. By neither of these reactions is 
deutero-albumose or peptone indicated, and 
urines containing these two bodies (one or 
both of them) are those usually classed as 
examples of ' peptonuria.' Their presence is 
shown by the following tests, which must 
be applied after hetero-albumose has been 
shown to be absent, and after coagulable 
albumin has been removed:-(a) A drop of 
dilute solution of copper sulphate added to 
the urine, followed by an excess of liquor 
potassse, causes a pinkish-red colouration 
(biuret reaction); or a drop of diluted Feh- 
ling's solution may be added to the urine, 
and then an excess of liquor potassae if ne- 
cessary. If the deutero-albumose and pep- 
tone are present in small quantity, this re- 
action is not obtained, (b) The urine is added 
drop by drop to a saturated solution of picric 
acid; both deutero-albumose and peptone are 
precipitated, and are redissolved on heating, 
thus distinguishing them from mucin and 
from albumin. 
The only accurate way of distinguishing 
deutero-albumose from peptone is to shake 
the clear urine in a test-tube with solid 
neutral ammonium sulphate. If the urine 
gives the two tests just described, and gives a 
precipitate with ammonium sulphate, it con- 
tains deutero-albumose. If it gives the tests 
and no precipitate with the salt, it contains 
peptone, and the case is one of true pep- 
tonuria. It is best, in applying these tests, to 
evaporate the urine to a small bulk. 
Proto-albumose has not as yet been found 
in urine. 
Quantitative Estimation.-This is of but 
little clinical value. It may be done by pre- 
cipitating a measured quantity of urine with a 
large excess (ten times its bulk) of alcohol, col- 
lecting, drying, and weighing the precipitate- 
Pathology.-The presence of albumoses 
and peptones in the urine is a pathological, 
not a physiological, phenomenon. These 
bodies are formed during normal digestion by 
pepsin and hydrochloric acid in the stomach, 
and peptones are also formed in pancreatic 
digestion. But although they are thus formed 
in the gastro-intestinal canal, they are not 
found in the absorbent vessels of the stomach 
and intestine in any appreciable quantity; 
neither in the veins nor in the chyle-vessels. 
In the general systemic veins and lymphatics 
they are not present; and their occurrence in 
arterial blood in small quantities is extremely 
doubtful. Lastly, they are not present in the 
living tissues, nor in ihe fluids which bathe 
them. If they are foimd in the urine, they 
are therefore either derived from the gastro- 
intestinal canal, or are formed from some 
pathological condition in the tissues, or per- 
haps in the blood. With regard to their first 
source, it is quite reasonable to suppose that 
the metamorphosis (probably into serum- 
albumin) which albumoses and peptones 
normally undergo when passing through the 
intestinal wall, may not take place in certain 
diseases where absorption is deficient, and that 
they may thus pass into the circulation, and 
be excreted by the kidneys in the urine. This, 
however, is a mere conjecture, to explain the 
occurrence of ' peptonuria ' (albumosuria) in 
some cases of chronic dyspepsia with dilated 
stomach. The second source of the origin of 
albumoses and peptones in the body is a com- 
plicated one. If these bodies are formed in 
any organ, tissue, or fluid of the body, they 
are absorbed into the blood, and then find 
their way into the urine. It is known that 
if albumoses or peptones are injected into 
the blood of an animal they are excreted in 
the urine; that hetero- and proto-albumose 
pass out in the urine mainly as deutero- 
albumose ; that deutero-albumose passes out 
chiefly as peptone; and that peptone is 
unchanged as it passes from the blood into 
the urine. The same facts probably hold 
good for the human organism. 
Bence-Jones's albumin (hetero-albumose) 
was first found in the urine of a case of ALBUMOSURIA 
ALCOHOL 
37 
osteo-malacia ; and Virchow found a similar 
body in the diseased bones. This, then, is a 
clear case of excretion of the albumose 
from the diseased part, the excretion of a 
proteid which is outside the normal proteid 
metabolism of the body. A similar albumose 
has also been found in a case, not of osteo- 
malacia, but of glycosuria (Gowers). In 
the case of all abscesses, whether acute or 
chronic, in empyema and purulent peritonitis, 
albumoses (or peptones) are found in the 
urine. Here the explanation is simple, 
since the pus contains albumoses, and these 
are simply excreted by the urine after ab- 
sorption into the blood. In the case of 
abscesses and of osteo-malacia there are col- 
lectionaof cells which undergo disintegration; 
the proteids the cells contain (consisting 
almost solely of coagulable albumin and. 
globulin) becoming partly transformed into 
albumoses. Whether this transformation 
takes place by the agency of bacteria present 
in the pus, or of a digestive ferment set free by 
the dying cell, is not at present known. This 
disintegration and gradual death of exuded 
cells, with the formation of albumoses, pro- 
bably explains the occurrence of albumosuria 
and peptonuria in phthisis, in pneumonia, in 
epidemic cerebro-spinal meningitis, in cases 
of cancer and other malignant growths, in 
the puerperal state, in typhoid fever, and in 
organic liver-disease. In phosphorus-poison- 
ing there is also grekt disintegration of 
many tissues and organs, and albumosuria 
(peptonuria) occurs ; in scurvy and acute in- 
fectious diseases (especially measles) also it 
is sometimes present. 
One form of peptonuria has been ascribed 
to an origin in the kidney-cells in cases of 
chronic nephritis, where some of the co- 
agulable albumin which is being continually 
excreted is changed into albumose or pep- 
tone. Peptonuria may indeed alternate with 
albuminuria in these cases, and peptone may 
be present as well as albumin. Peptonuria 
with albuminuria is not uncommon in ad- 
vanced chronic phthisis. 
Albumose and peptone are also found in 
the urine in many other conditions, in which 
no explanation of their presence is evident; 
such as in many forms of inflammatory 
eruptions of the skin, in pemphigus, in urti- 
caria, and in nervous diseases-cerebral hemi- 
plegia, or psychoses. 
Symptoms.-From the account given of the 
pathology of albumosuria and peptonuria, it 
will be seen that they are only to be regarded 
as symptomatic of other graver pathological 
conditions; and no symptoms can be very 
directly ascribed to the presence of albumoses 
and peptones in the body, as associated with 
the diseases which have been already enu- 
merated. But there are certain physiological 
effects of these proteids which are important 
to recollect. When injected into the circula- 
tion of a dog, albumoses (and peptones to a 
less extent) markedly reduce the blood- 
pressure, and produce coma and death, while 
the blood remains uncoagulated for a long 
time after death. These effects are not 
necessarily associated with, or threatened by, 
the presence of albumosuria in man; possibly 
because the amount of albumose present in 
the blood at one time is never sufficient to 
produce them. And when such appearances 
as coma and uncoagulated blood after death 
are observed in the diseases already enu- 
merated, they are ascribed either to the 
result of the grave lesion on the body gene- 
rally, or the brain in particular, or to the 
retained chemical products of the waste of 
morbid tissues. It may be that albumoses 
and peptones form one group of these waste 
products, aiding the production of coma and 
of post-mortem fluidity of the blood. 
Another physiological effect of albumoses 
is that of producing fever when injected into 
the circulatory system. The fever is to some 
extent proportional to the dose, and is pro- 
duced even when the dose is insufficient to 
cause coma and fall of blood-pressure, and in 
animals (such as rabbits) whose circulation 
and cerebrum are not affected by the poison. 
Whether the fever of chronic phthisis is 
partly due to the absorption of these albu- 
moses is not yet settled; this is simply a 
suggestion based on the facts mentioned. 
According to our present knowledge, it 
may be said that the chief clinical significance 
of a large amount of peptone or albumose 
in the urine is an extensive cell- (and pro- 
teid) disintegration in the body; in many 
cases indicating pus-formation. 
Sidney Martin. 
ALCOHOL. - Synon. : Ethyl-Alcohol; 
Vinic Alcohol; Spirit of Wine. (C2HcO). 
Alcohol is the product of a process offermen- 
tation induced by the action of a microscopic 
fungus, yeast, upon certain kinds of sugar, 
especially grape sugar, but also upon that 
derived from the different varieties of starch 
and, in the same manner, upon milk sugar. 
In this process a peculiar metamorphosis 
takes place, by which alcohol and carbonic 
acid are produced in considerable amount, 
together with very minute quantities of 
succinic acid, glycerine, and other bodies. 
Alcohol may also be produced syntheti- 
cally'from its elements-carbon, hydrogen, 
and oxygen. 
As alcohol is very volatile, boiling at 172° 
Fah. (78° C.), it may be separated by distil- 
lation from the water with which it is at first 
combined. Other means must be resorted to, 
however, in order to separate the ultimate 
parts of this water, as a strong attraction 
exists between the two liquids. 
Alcohol, diluted with about 95 per cent, of 
water, and subjected to the action of another 
microscopic fungus, is oxidised into aldehyde 
and acetic acid. 38 
ALCOHOL 
Physiological Effects.-Applied to the 
skin, alcohol produces a sensation of cool- 
ness, due to its rapid evaporation; but, if the 
application be continued sufficiently long, 
irritation is excited. The latter effect ensues 
immediately if alcohol is brought into con- 
tact with a mucous membrane. Its strong 
attraction for water seems to be the chief 
cause of this action. 
Alcohol is a powerful antiseptic, probably 
from the fact that it is capable, even when 
diluted, of preventing the development of 
septic germs, such as vibrios and bacteria, as 
well as of paralysing the activity of those 
already formed. 
There is scarcely any other therapeutical 
agent the internal action of which varies so 
much according to the dose given. In small 
quantity, and slightly diluted with water, 
alcohol promotes the functional activity of 
the stomach, the heart, and the brain; whilst 
a like quantity, largely diluted, exerts but a 
limited influence upon these organs: if, how- 
ever, the dose of alcohol be often repeated, 
it is readily assimilated, and, becoming 
diffused throughout the system, undergoes 
combustion within the tissues of the body, 
imparts warmth to them, and yields vital 
force for the performance of their various 
functions. Simultaneously with this con- 
sumption of alcohol, the body of the consumer 
is often observed to gain in fat-a circum- 
stance due to simple accumulation, the fat 
furnished by the food remaining unburned 
in the tissues, because the more combustible 
alcohol furnishes the warmth required, leav- 
ing no necessity for the adipose hydrocarbon 
to be used for that purpose. A quantity of 
100 cubic centimetres of alcohol per diem 
(about three and a-half fluid ounces)-equi- 
valent to about one litre of Rhine wine of 
medium strength-is sufficient to supply 
between one-third and one-quarter the whole 
amount of warmth requisite for the human 
body during the twenty-four hours. The 
warmth so supplied cannot be measured by 
a thermometer, however, any more than can 
that furnished by the internal combustion of 
other hydrocarbons, such as the oils and 
sugars. The subjective impression of in- 
creased warmth usually experienced after 
taking a dose of any alcoholic liquid is de- 
ceptive, and is only due to an irritation of the 
nerves of the stomach, and to the increased 
circulation of blood through the cutaneous 
vessels, particularly those of the head. 
The increase of the action of the heart after 
taking alcohol is well known, and has often 
been expressed in figures. Recent experi- 
ments have also established this fact with 
regard to the respiration. The quantity of 
the inhaled and exhaled air in healthy men 
was increased by 7 to 9 per cent.; in one 
instance, after taking champagne, by 15 per 
cent. 
Doses somewhat larger,still sufficiently 
moderate not to cause intoxication, act, for 
the most part, in the same way ; but, as an 
additional effect, they produce a distinct de- 
crease of temperature in the blood, lasting 
half-an-hour or more. As far as the matter 
has hitherto been explained, this latter effect 
depends upon a directly depressing influence 
exerted by alcohol upon the working cells of the 
body, and. upon a temporary paralysis of the 
vaso-motor nerves. The latter is followed, of 
course, by dilatation of the superficial vessels, 
particularly those of the head, in consequence 
of which a larger surface of blood is exposed, 
and the loss of heat by radiation into the 
air is increased, the temperature of the cir- 
culating fluid being thus lowered ; whilst the 
combustion carried on by the cells being 
retarded, the generation of heat from this 
source is diminished. The quantity of car- 
bonic acid eliminated is thus diminished, as 
is also the amount of urea excreted. After 
the organism has become mured to the 
action of alcohol, these effects upon the tem- 
perature of the blood are less distinctly, or 
in some cases not at all, marked. 
The agreeable excitement at first caused 
by such doses of alcohol is succeeded by a re- 
action, characterised by lassitude and drowsi- 
ness, the latter condition usually lasting longer 
than the previous one of exhilaration. 
The symptoms of intoxication produced by 
larger doses of alcohol are sufficiently well 
known. When the abnormal condition of 
excitement in the brain induced by this 
stimulant has been kept up, almost without 
intermission, for a lefigth of time; or when 
it is suddenly withdrawn after the organ has 
been long subjected to it; the disturbance 
brought about is so great and persistent as to 
result in a complete overthrow of the reason- 
ing faculties, and the condition known as 
delirium tremens ensues. At the same time 
that this pernicious influence is being exerted 
upon the cells of the brain, fatty accumula- 
tions may take place in other organs, par- 
ticularly in the liver, heart, and connective 
tissues; the blood-vessels become diseased; 
and, in many instances, cirrhosis of the liver, 
kidneys, and meninges makesits appearance, 
as part of the general disorder of nutrition. 
The shrinking of connective tissue, character- 
istic of this last-mentioned complication, 
seems to depend upon the direct irritation 
caused by the presence of un-oxidised alcohol. 
Under ordinary circumstances, and after 
the consumption of moderate quantities of 
alcohol, only slight traces of it are to be 
detected in the urine, and still less in the 
breath and perspiration. A long series of 
experiments, made by the writer's assistant, 
Dr. Bodlaender, on healthy men and animals, 
proved that altogether at the most 3 per cent, 
reappears. The faeces do not contain any 
alcohol at all. As regards the breath, pure 
alcohol imparts no taint to the exhalations 
of the body; the ethers and fusel oil, on the ALCOHOL 
39 
other hand, do so by reason of their being 
less readily combustible. It is very likely 
that alcohol is completely oxidised into car- 
bonic acid and -water during the process of 
assimilation; at least, no other secondary 
products resulting from its disintegration 
have as yet been detected. 
Much importance is sometimes still at- 
tached to the experiments of Lallemand, 
Perrin, and Duroy in discussions on alcohol. 
They asserted just the contrary to the above. 
Anstie and Dupre in England had already 
proved their conclusions to be erroneous ; the 
new experiments which Bodlaender carried 
out with great minuteness have removed 
every doubt on the subject. 
Therapeutical Applications.-There can 
be no doubt that a healthy organism, sup- 
plied with sufficient food, is capable of per- 
forming all its regular functions without 
requiring any specially combustible material 
for the generation of heat and the develop- 
ment of vital force. But the case assumes 
a different aspect when, in sickness, while 
the metamorphosis of tissue goes on 
with its usual activity, or with Increased 
energy, as happens in many diseases, the 
stomach, refusing to accept or to digest 
ordinary food, fails to supply material to 
compensate for this waste. Here it is, then, 
that a material which can be most readily 
assimilated by the system, and which, by its 
superior combustibility, spares the sacrifice 
of animal tissue, is especially called for; and 
such a material we have in alcohol. Small 
but oft-repeated doses of alcohol, largely 
diluted with water, are generally well tolerated 
by the weakest stomach ; and, thus given, 
the absorption and oxidation of the spirit goes 
on without difficulty or effort on the part of 
the patient's system. 
According to the experiments of Dr. Frank- 
land and others, the burning of 1'0 gramme 
of alcohol yields sufficient heat to raise the 
temperature of seven litres of water 1°C.; and 
the burning of 1'0 gramme of cod-liver oil 
suffices for nine litres. Now, in taking three 
tablespoonfuls of the oil daily, we yield 
about the same amount of warmth to the 
body as is given by four tablespoonfuls of 
absolute alcohol-the quantity contained in 
a bottle of light claret or hock. The oil, 
however, is digested and oxidised by the 
organs of the body with difficulty, while, for 
the assimilation of the alcohol, scarcely any 
exertion of the working cells is required. 
Thus, it can be demonstrated by calculation, 
as above mentioned, that heat-producing 
material, sufficient to supply nearly one- 
third the whole amount of warmth required 
by the body within twenty-four hours, is 
offered in a quantity of 100 grammes (about 
three-and-a-half fluid ounces) of alcohol. In 
this sense alcohol is a food', for we must 
regard as food not only the building material, 
but all substances which, by their combustion 
in its tissues, afford warmth to the animal 
organism, and, by so doing, contribute 
towards the production of vital force, and 
keep up the powers of endurance. Alcohol, 
therefore, diluted with at least 90 per cent, of 
water (in any convenient form of beverage), 
may be given with advantage, in small but 
oft-repeated doses, in most of the acute and 
chronic diseases where it is desired to sustain 
the strength of the patient, but where at the 
same time the digestive organs, from any 
cause, refuse to tolerate a more substantial 
form of nourishment, at least in quantities that 
would answer the necessities of the case. In 
such cases it is certainly not sufficient to call 
alcohol merely a stimulant. If alcohol served 
here only in the quality of a stimulant, its 
effect would soon pass away, leaving the 
patient more exhausted than ever; for the 
human organism is so constituted that it 
cannot be driven to perform its functions 
by the application of measures that simply 
stimulate, without supplying some new force 
to take the place of that put forth by the 
organs of the body under the impulse of 
excitement. To take a familiar illustration, 
alcohol thus given stimulates no more than 
does the readily combustible coal which we 
put in small quantities upon a languid fire, to 
prevent its going entirely out. 
Recent experiments in the writer's labora- 
tory (Geppert) have contributed the following 
facts to this part of the question. Twenty to 
75 cubic centimetres of absolute alcohol, 
taken in water or in the form of port, brandy, 
or sparkling hock by healthy adults, who 
were accustomed to take no alcohol or only 
a moderate quantity, hardly altered the 
quantity of the consumed oxygen, and like- 
wise left unaltered or very slightly decreased 
the excretion of the carbonic acid. 
The principal point in this result is the 
unchanged standard of the consumption of 
oxygen. We know that the consumed alcohol 
is burnt in the organism, a minute quantity 
excepted. The alcohol was thus unable to 
increase oxidation, as its adversaries have 
still continued to assert; it had not contributed 
to a more rapid wasting of the organism ; nor 
had it made the regular equal march of this 
wasting irregular and slow. On the contrary, 
it had substituted itself simply as fuel in 
order to sustain the normal temperature of 
life, the existence of which is necessary to 
keep the whole machine in motion. Alcohol 
acts here, generally speaking, as if we had 
given the person experimented upon oil or 
sugar. A part of the disposable oxygen which 
would serve for oxidising other substances, 
serves for the combustion of the alcohol, and 
keeps them intact for the organism. 
Medium doses of alcohol act powerfully 
upon the brain and heart, and are therefore 
serviceable as real stimulants in cases where 
it is desirable to excite the cerebral and circu- 
latory systems to greater activity. We must 40 
ALCOHOL 
not forget, however, that while exciting this 
increased activity, such doses do not elevate 
the temperature of the body; on the contrary, 
where the effect can be measured, it is found 
that they depress it a little. By continuing 
to exhibit such doses, we can sometimes (in 
erysipelas, puerperal peritonitis, and similar 
diseases) lower febrile heat by alcohol where 
even quinine proves ineffectual. The con- 
sequences of this decline of fever-heat are 
an immediate restoration to consciousness, if 
delirium or stupor has been present; and, in 
any case, a general improvement in the feel- 
ings of the patient. Todd and his school, 
before the application of the thermometer, 
called this the effect of stimulus, while in 
reality the improvement is, to a great extent, 
due to the diminution of febrile disturbance. 
As fever patients can tolerate large quantities 
of alcohol without showing any sign of intoxi- 
cation, it is allowable, and sometimes even 
necessary, to rise in the scale of doses beyond 
the limits ordinarily prescribed. 
Of late years alcohol has been given during 
the night to hectic phthisical patients as a 
preventive against copious and exhausting 
attacks of sweating, and with a gratifying 
amount of success. Such patients certainly 
tolerate the remedy much better than has 
hitherto been generally supposed. It need 
hardly be said that, in cases of cardiac excite- 
ment, not resulting from fever, alcohol is at 
least to be used with caution. 
Mode of Administration.- One of the 
most important, but at the same time most 
difficult, points for decision is the exact na- 
ture and quality of the alcoholic drink to be 
prescribed or allowed to a patient who may 
require alcohol in some form. For general 
use, a pure claret, hock, or Moselle wine are 
the forms of alcohol most to be recommended. 
Cognac, champagne, old gin or whisky, and 
the heavier Southern wines, may also be 
used according to circumstances. But what- 
ever drink may be selected, it must at least 
be free from fusel oil to such an extent that 
a healthy man, even after imbibing a consider- 
able quantity, will not feel any other effects 
than those of a pure stimulus; that is to say, 
an agreeable exhilaration of spirits, neither 
accompanied by a sense of weight in the head, 
nor followed by that persistent overfilling of 
the cerebral vessels and dulness of ideas 
characteristic of the physiological effects of 
fusel oil. 
The fusel oils (so called from their oily 
qualities) consist chiefly of propyl, butyl, and 
amyl alcohols, of which the last-named forms 
the largest proportion. In order to examine 
any specimen of alcohol with reference to its 
purity from these objectionable constituents, 
it is only necessary to rub a few drops between 
the palms of the hands for half a minute, by 
which rapid evaporation is caused, and then 
to smell the moist spot left on either palm. 
If the alcohol be pure, no odour whatever 
should remain, as ethyl alcohol evaporates 
very quickly ; amyl alcohol, on the contrary, 
is much less volatile, and, if present in the 
liquid, will not have evaporated, so that its 
peculiar and unmistakable odour will remain 
to attest its presence as an impurity in the 
specimen examined. 
This test is not applicable to the more 
complicated liqueurs and wines, as these all 
contain certain odoriferous organic principles 
of their own, which might disguise the smell of 
the fusel oil. The inoffensive quality of any 
given preparation, as a wine or spirit, can 
only be relied upon when one knows by 
experience that it is pure ; and then it should 
always be obtained, if possible, from the same 
source, so as to ensure uniform purity. 
To facilitate the process of estimating the 
quantity of any particular beverage necessary 
to be administered in order to produce a given 
effect, a table is subjoined showing the per- 
centage of absolute alcohol contained in aver- 
age specimens of the different kinds of wine, 
beer, &c„ in common use. 
Absolute Alcohol contained in- 
Kumiss (a fermented liquor made from milk or whey). 
from 1 to 3 vol. per cent. Kefii- is the same, but 
derived from the milk or whey of the cow, whilst 
kumiss comes from the milk or whey of the mare. 
Both contain much carbonic acid, which renders 
them easily digestible. 
German beer 1: from 3 to 5 vol. per cent. 
Hock or claret; from 8 to 11 vol. per cent. 
Champagne: from 10 to 13 vol. per cent. 
Southern wines (port, sherry, madeira, &c.): from 
14 to 17 vol. per cent. 
Brandy and the stronger liqueurs: from 30 to 50 vol 
per cent. 
For antipyretic purposes one will need to 
give an adult daily not less than the equiva- 
lent of fifty cubic centimetres (about two 
fluid ounces) of absolute alcohol, in divided 
doses within an hour or two. Taking this 
as a starting-point, the dose suitable for each 
individual case /an be estimated accordingly. 
The great quantity of carbonic acid con- 
tained in certain ' sparkling ' wines acts upon 
the temperature of a fever patient much in 
the same favourable manner as the alcohol 
itself; and when alcohol is to be taken as a 
food, it would seem that the impregnation 
with carbonic acid facilitates its absorption. 
All that has been stated thus far with regard 
to the use of alcohol in sickness applies to 
children as well as to adults. Of course no 
reasonable person would accustom healthy 
children to the use of alcoholic beverages; 
but, in cases of disease, really good and pure 
wine or brandy can be advantageously 
employed, even for infants, either as a stimu- 
lant, an antipyretic, or an article of food, 
according to circumstances. 
For external use, alcohol has been super - 
1 English beer will contain a little more, but the 
writer has made no personal examination as to 
exactly how much. ALCOHOL 
ALCOHOLISM 
41 
seded by various more modern agents, of 
which carbolic and salicylic acids may be 
mentioned as the most important. 
As regards the copious experimental litera- 
ture on alcohol and its medicinal properties, 
the writer would refer to his Vorlesungen 
uber Pharmakologie, Berlin, 1886, pp. 354- 
392, and to Professor v. Jaksch's and his own 
papers in the Transactions of the Congress for 
Internal Medicine, Wiesbaden, 1888, pp. 70- 
133. The two papers have also been reprinted 
in the same volume. C. Binz (Bonn). 
ALCOHOLIC INSANITY. - See 
Alcoholism ; and Insanity. 
ALCOHOLISM. - Definition. - This 
term is applied to the diverse pathological 
processes and attendant symptoms caused 
by the excessive ingestion of alcoholic bever- 
ages. These are very different according as 
a large quantity is consumed at once or at 
short intervals, or smaller quantities are 
taken habitually; hence they are subdivided 
into those due to (a) acute, and (6) chronic 
alcoholism. To the acute forms of alcoholic 
poisoning belong acute catarrh of the ali- 
mentary mucous membrane, rapid coma, 
some cases of delirium tremens, and certain 
special forms of acute insanity; whilst to 
the chronic class are referred the prolonged 
congestions, the fatty and connective-tissue 
degenerations of the various organs and 
tissues, most cases of delirium tremens, ner- 
vous affections of slow onset and course, and 
the cachexias, which, in varying combinations, 
attend a continuously immoderate consump- 
tion of alcohol. 
/Etiology.-That ordinary vinic or ethyl 
alcohol, in any and every shape, is a suf- 
ficient exciting cause of such chronic affections 
is beyond a doubt; moreover, we find that 
the more concentrated the form in which it 
is taken, the more surely and rapidly are 
they induced, and that, although some bever- 
ages give a greater liability to certain forms 
of disease than to others, yet the ultimate 
tissue-changes produced by all are practically 
similar, and of a markedly degenerative cha- 
racter. The purest alcoholic fluids will also 
induce the acute forms; but some of the 
phenomena observed in the worst cases of 
alcoholic poisoning have been referred, with 
some probability, to admixture with fusel oil, 
essential oil of wormwood, cocculus indicus, 
and other substances, more deleterious even 
than ordinary alcohol itself. See Alcohol ; 
and Absinthism. 
The predisposing causes of a sudden de- 
bauch, such as festive gatherings, example of 
companions, desire of relief from anxiety and 
melancholy, &c., scarcely require mention. 
Acute alcoholic coma is generally due to the 
rapid consumption of a large quantity, but 
occasionally it is caused by taking a smaller 
quantity in the presence of some special 
condition, such as starvation, prolonged ex- 
posure to cold, or debilitating disease. 
Chronic habitual drinking is undoubtedly 
hereditary in many cases ; not that the an- 
cestors have necessarily been drunkards, but 
that the family is of unstable nervous or- 
ganisation, and that the neurotic taint which 
shows itself in some members in such affec- 
tions as epilepsy, hysteria, or insanity, is 
manifested in others by an intense craving 
for alcohol. Sometimes a pernicious educa- 
tion, by fostering habits of indulgence in early 
youth, has led to subsequent excess; and the 
prescribing of stimulants has occasionally 
been productive of similar harm. In the 
experience of the writer the exhibition of 
large doses in fevers and acute affections has 
never done this-indeed, in several instances, 
a great dislike to stimulants has been pro- 
duced ; but the custom of recommending 
small quantities to young people and women, 
as a remedy in hysteria, hypochondriasis, 
neuralgia, and allied disorders, or to relievo 
debility post partum, or the fatigues incident 
to their daily life, cannot be too strongly 
protested against. The effect of occupation 
is very marked. Brewers, publicans, potmen, 
and others who trade in alcohol are, as a 
class, very intemperate ; and so frequently 
are commercial travellers, owing to pecu- 
liarities in their mode of transacting busi- 
ness. Sedentary employments, being more 
monotonous, are more baneful than out- 
door occupations. Mechanics drink more 
freely than agricultural labourers; whilst 
night-labourers, cabmen, sailors when on 
shore, brewers' draymen, navvies, pitmen, 
and puddlers, consume an enormous amount 
of alcoholic fluids. Social influences, such 
as domestic unhappiness, rate of wages, un- 
healthy dwellings, bad drinking water, or an 
intermittent supply, are important factors in 
the causation of drunkenness. Under some 
circumstances, alcoholic excesses do less 
injury than usual, for example, in persons 
whose employment leads to copious sweating, 
or necessitates abundant exercise in a keen 
air; and some constitutions resist the baneful 
influence of alcohol to a remarkable extent. 
Pathology.-A large amount of ardent 
spirits acts on the nerve-centres as a narcotic 
poison, and causes rapid death by coma. 
Smaller quantities produce intoxication, ac- 
companied with or followed by an acute con- 
gestion and catarrh of the alimentary canal, 
especially of the stomach and duodenum. 
Habitual dram-drinking, by altering the 
chemical composition of the blood, and 
checking the normal changes of its corpuscles, 
exerts an injurious influence on the nutrition 
of the tissues. This is increased by the 
lessened consumption of food, and by the 
alterations in the calibre of the blood-vessels, 
set up at first by a special action on their 
vaso-motor nerves, and afterwards main- 
tained by degeneration of their coats, and fre- 42 
ALCOHOLISM 
quently of the heart itself. Moreover, alcohol 
probably interferes directly with the nutrition 
of the cell-elements of the various organs as 
it circulates through them; and it retards 
the elimination of effete materials-carbonic 
acid, uric acid, and urea. 
Anatomical Characters.-(a) Acute Alco- 
holism.-Dr. Beaumont thus describes the 
appearances which he observed in the stomach 
of Alexis St. Martin, after an excess of 
alcoholic stimulants :-' Inner membrane 
morbid; considerable erythema, and some 
aphthous patches on the exposed surface; 
secretions vitiated.' On another occasion, 
' Small drops of grumous blood exuded from 
the surface, the mucous covering was thicker 
than common, and the gastric juices were 
mixed with a large proportion of thick ropy 
mucus and muco-purulent matter slightly 
tinged with blood.' The post-mortem ap- 
pearances in a case of rapid coma in a patient 
at King's College Hospital, after taking three 
pints of raw whisky, were :-Intense injec- 
tion of the vessels of the pyloric end of the 
stomach and duodenum, with a peculiar 
blanching of the mucous membrane between 
them, giving rise to a vivid scarlet arborescent 
appearance on a white ground; two ounces 
of bloody serum in the pericardial sac, and 
about sixteen ounces in the right pleural 
cavity (the left being obliterated by old ad- 
hesions) ; double pneumonia of the lower 
lobes ; extreme congestion of the kidneys; and 
engorgement of the large veins over the 
posterior part of the brain. Contrary to the 
usual statements, no alcoholic odour could be 
detected in the brain, and there was no in- 
crease of fluid in its ventricles. The heart, 
liver, and kidneys were fatty; but these 
changes were probably of older date. In 
similar cases Deverjie has noticed a bright 
red colouring of the pulmonary tissue ; whilst 
Tardieu found pulmonary apoplexies in two 
cases, and meningeal haemorrhages in five 
others. Death from acute delirium tremens 
leaves no marked characters : meningitis and 
coarse brain-lesions are extremely rare, whilst 
pneumonia is much more common. After 
repeated attacks, as well as in old drunkards, 
fatty degeneration of the viscera and various 
other chronic changes are found. 
(6) Chronic Alcoholism.-The amount of 
fat in the blood is increased, or it becomes 
more visible. Chronic congestion and catarrh 
of the stomach, leading to atrophy of the 
gland-cells and an increase in the submucous 
connective-tissue, is very constant, but chronic 
ulcer is not frequent. The liver is at first 
enlarged from congestion, and may continue 
so from a subsequent infiltration with fat; 
but more frequently it shrinks, owing to 
cirrhosis. Lobar emphysema, chronic bron- 
chitis, and hypostatic pneumonia are com- 
mon. The heart is flabby, dilated, and 
presents fatty infiltration or even degenera- 
tion of its muscular tissue; but it may be 
hypertrophied, probably as a result of co- 
existent disease of the kidneys. The arteries 
and endocardium are studded with athero- 
matous deposits; the capillaries are con- 
gested, and the veins varicose. The kidneys 
exhibit the fatty, or, more commonly, the 
granular form of Bright's disease. The 
muscles are pale and flabby, and even in the 
bones formation of fat takes place at the 
expense of the bony texture. The nervous 
centres are atrophied and tough; the con- 
volutions are shrunken ; the nerve-cells and 
nerve-fibres are wasted; and an increased 
amount of serous fluid exists in the ventricles 
and subarachnoid space. The abnormal ad- 
hesion of the dura mater to the cranium, 
the large Pacchionian bodies, the opaque 
arachnoid, and the thickened pia mater, all 
testify to an exaggerated development of 
fibrous tissue. Occasionally haemorrhage 
into, or softening of, the brain, consequent 
on the diseased state of its blood-vessels, is 
met with. The increase of connective tissue 
is especially marked in spirit-drinkers, and 
explains the emaciated appearance, prema- 
turely aged look, sunken cheeks, and wrinkled 
countenance which they generally present. 
The beer- and wine-drinkers, on the contrary, 
are loaded with fat, not only in the viscera, 
but in the subcutaneous tissue and the 
omentum; and hence these subjects are cor- 
pulent, with oily skins and prominent abdo- 
mens, even when the face and extremities 
are wasted. Gouty deposits are also frequent. 
These differences, however, are not nearly so 
absolute as is maintained by many writers. 
Alcoholic paralysis is due to a multiple 
peripheral neuritis, leading to atrophy of the 
muscles supplied by the affected nerves. The 
presence of a variable amount of dropsy, 
a congested pharynx, chronically inflamed 
conjunctivae, turgid capillaries, and occasion- 
ally papules of acne rosacea on the face, com- 
plete the morbid anatomy of the confirmed 
toper. The necropsy in alcoholic insanity 
discloses no specific characters. 
Symptoms.-1. Acute Intoxication. - In 
this state the successive and varying mental 
phenomena, the disorders of common and 
special sense, and of the motor apparatus, are 
well known. These are followed by uneasy 
sensations and tenderness in the epigastrium, 
vomiting or retching, headache and vertigo, 
with dimness and occasionally yellowness of 
vision on stooping and rising again. The 
tongue is furred, the appetite is lost, and 
there is a constant feeling of thirst. The 
urine is copious and pale, but afterwards 
becomes scanty and loaded with lithates. 
The countenance is sallow, and the general 
lassitude and depression are very marked. 
2. Acute Alcoholic Coma.-In slight cases 
of this condition, prolonged drowsiness is 
the chief symptom: but in the more severe 
forms the patient is quite insensible; the 
power of motion is in complete abeyance ; ALCOHOLISM 
43 
the breathing is stertorous; the face is 
usually pale, the features remaining sym- 
metrical ; the pupils are generally dilated, 
though they may be contracted or unequal; 
the pulse is slow and laboured ; the skin 
feels cold and clammy; and the tempera- 
ture is low-in one case it fell to 92° Fah. 
There may be albuminuria ; and occa- 
sionally the urine and faeces are passed in- 
voluntarily. 
3. Chronic Alcoholism. - The earliest 
symptoms of this form are muscular tre- 
mors, especially on waking ; disturbed sleep ; 
noises in the ears ; dull headache; occasional 
vertigo ; and disorders of vision. If there 
be also a foul breath, slightly-jaundiced con- 
junctivae, watery eyes, and flabby features, 
with or without papules of acne rosacea 
around the nose and mouth, the combination 
is very characteristic. Irritative dyspeptic 
symptoms-the vomitus matutinus of Hufe- 
land, and the signs of commencing or 
actual cirrhosis, of Bright's disease, or of 
fatty heart, frequently co-exist. 
Alcoholic paralysis in its milder forms is 
marked by distressing pains in the extremities, 
especially in the legs, increased on deep pres- 
sure, redness and cedema of the feet and 
hands, restlessness, insomnia, and a gradually 
increasing loss of power, beginning in the 
lower limbs and afterwards extending to 
the forearm and arms. The gait is peculiar 
and uncertain, with the legs wide apart ; and 
support by sticks or by an attendant is often 
required whilst walking. The hands are 
irregular and jerky in their movements; and 
the reflexes, especially the patellar-tendon 
reflex, are diminished or lost. The peronei 
and extensors of the leg, the extensor muscles 
of the thigh, and subsequently the extensors 
of the forearm and the triceps, are markedly 
atrophied, and exhibit the ' reactions of de- 
generation.' See Paralysis, Toxic. 
In its most severe forms anaesthesia suc- 
ceeds to hyperaesthesia,and complete paralysis 
of the above muscles, leading to a condition 
of talipes equino-varus of the feet, and wrist- 
drop of the hands, may come on; and 
gangrene has occasionally been noticed. 
Loss of memory and other psychical distur- 
bances are common. Death is generally due 
to some cerebral complication, or to apnoea 
from paralysis of the respiratory muscles. 
4. Delirium Tremens. - This form of 
alcoholism occasionally supervenes on a 
single debauch, but it much more frequently 
affects the chronic drinker. It generally 
comes on during a drinking-bout, but this 
may have terminated before the attack com- 
mences. In some cases it is undoubtedly 
determined by prolonged abstinence from 
food, mental distress, surgical operation or 
injury, or the onset of an acute disease, along 
with the ingestion of alcohol; in other cases 
no cause but the last can be traced. The first 
stage is indicated by inability to take food; 
marked anxiety and restlessness; tremor of 
the voluntary muscles; furred and tremulous 
tongue; cool skin, which is frequently bathed 
in perspiration; cold hands and feet; and a 
soft weak pulse. There is complete insomnia, 
or short periods of sleep are interrupted by 
terrifying dreams, and the patient's nights 
are tormented by visions of horrid insects, 
reptiles, and other objects pursuing him and 
eluding his attempts to escape from them or 
to seize them. Illusions of hearing are not 
uncommonly added; but the sense of smell 
is much more rarely involved. If there is no 
improvement, these troubles not only haunt 
his nights, but persist in the day-time; he 
becomes more incoherent, his mental aliena- 
tion increases, and attempts at suicide are 
common. The pupils are now greatly con- 
tracted, but there is no intolerance of light. 
The pulse quickens, and is very feeble or 
even dicrotic; and the general symptoms 
become more marked. A prolonged sleep 
may occur in this stage, and the disease thus 
terminate. If it continue, the strength fails; 
the pulse becomes small, weak, and thready; 
the tremor increases; the tongue gets dry 
and brown in the centre; persistent coma- 
vigil and subsultus tendinum come on ; the 
patient talks incessantly, and picks at the 
bed-clothes ; finally death is ushered in by a 
delusive calm, or takes place in a paroxysm 
of violence. The writer has known cases in 
which an attack of delirium tremens always 
began by several severe epileptiform fits. 
5. Alcoholic Insanity.-The forms of in- 
sanity caused by alcoholism are acute mania 
and melancholia, chronic dementia, and 
oinomania. In the first, homicidal impulses, 
and in the second, strong suicidal tendencies, 
due to actual delusions and not to mere 
passive terrors, are added to the other signs 
of delirium tremens. Oinomania is a peculiar 
form of insanity, in which the patient breaks 
out into paroxysms of alcoholic excess, 
attended with violent, strange, or even in- 
decent acts, due to apparently uncontrollable 
impulses. The attack lasts a few days, and 
is succeeded by a long interval of sobriety 
and chastity. These patients have generally 
some hereditary taint; and not infrequently 
evidences, though often slight, of a morbid 
mental state may be detected in the intervals, 
if very carefully looked for. See Insanity, 
Varieties of. 
Complications.-Most of these have been 
already described, but chronic drinkers are 
especially liable to pneumonia of a low type, 
and to acute phthisis. Delirium tremens is 
very rarely complicated with meningitis; 
acute alcoholic gastric catarrh may be 
followed by jaundice; and cerebral haemor- 
rhage may come on in a drunken fit. 
Temporary albuminuria is occasionally 
caused by the ingestion of large quantities of 
spirits, and even of beer. 
Diagnosis.-The diagnosis of acute alco- 44 
ALCOHOLISM 
holic gastric catarrh, of insanity from alcohol, 
and of oinomania depends on obtaining a true 
history. Acute alcoholic coma can only be 
diagnosed with certainty by emptying the 
stomach, and examining its contents. Mere 
odour of the breath is quite fallacious ; and 
the writer attaches but little importance to 
the state of the pupils, or to the general 
features of the coma. Convulsions some- 
times usher in the condition; and apoplexy 
may arise from the accidental rupture of a 
blood-vessel whilst a person is drunk. Opium- 
poisoning can only be satisfactorily elimi- 
nated by examining the contents of the 
stomach. Uraemic poisoning may be dia- 
gnosed by testing the urine, though here an 
element of uncertainty is introduced by the 
occasional occurrence of albuminuria in 
alcoholic cases; the presence of hypertrophy 
of the heart, of dropsy, of casts in the urine, 
or other changes typical of Bright's disease, 
must decide the question. Delirium tremens 
is occasionally separated with difficulty from 
some forms of insanity not caused by drink ; 
but in the latter cases delusions, not mere 
terrors or hallucinations, are of primary 
importance. The delirium of acute fevers 
and pneumonia may be mistaken for delirium 
tremens ; but the pyrexia, history of the case, 
and physical condition of the patient will 
guide to a correct diagnosis if the possibility 
of error be remembered. Chronic alcoholism 
has been mistaken for some chronic nervous 
affections, such as locomotor ataxy, chronic 
softening and multiple sclerosis of the nerve- 
centres, paralysis agitans, chronic tremors 
from metallic poisons, senile dementia, and 
commencing general paralysis. The correct 
history, and a careful examination of the 
patient, are especially important in diagnosing 
alcoholic paralysis from other nervous affec- 
tions, especially from locomotor ataxy and 
lead-paralysis. In all these maladies, special 
symptoms are present, besides those common 
to them and to chronic alcoholism. 
Prognosis.-In the acute forms of alcohol- 
ism the prognosis is favourable so far as the 
immediate attack is in question. In acute 
coma, the patient generally, but by no 
means invariably, rallies from the state of 
insensibility ; but he may die from the super- 
vention of a very rapid pneumonia. The 
prognosis in delirium tremens is favourable 
in young subjects; but its gravity increases 
with every attack, and with the co-existence 
of disease of the viscera, especially of 
the heart, liver, or kidneys. Patients with 
marked symptoms of fatty heart, or in whom 
pneumonia sets in, but rarely recover. 
Chronic alcoholism may be temporarily 
arrested; but the ultimate issue is unfor- 
tunately, as a rule, only too certain, for the 
habit is in most cases too strong to be 
broken off, or even to be checked for any 
lengthened period. Mental impairment, per- 
sistent tremors, ataxy, and signs of coarse 
brain-lesions, are especially significant of a 
speedy termination. 
Treatment.-The acute gastric catarrh 
due to alcohol is most rapidly subdued by 
washing out the stomach with copious 
draughts of tepid water, and then giving a 
saline purge. All forms of alcohol should be 
rigidly abstained from; and the diet must be 
simple, and taken in a fluid form for a day or 
two. Passive exercise in the open air, or, if 
the patient be vigorous, a brisk ride on horse- 
back, is very beneficial. 
In cases of acute coma the stomach should 
be at once emptied by means of the stomach- 
pump. Cold affusion, followed by energetic 
friction and the application of bottles filled 
with warm water, so as to keep up the tem- 
perature, will generally revive the patient. 
Galvanism, in the form of the interrupted 
current, may often be employed with advan- 
tage. If the patient be strong, a smart 
purge, or, if weak, a milder one, will be all 
the after-treatment that is necessary. 
Delirium tremens must be treated differ- 
ently in the young and in the old. In first 
attacks in young, strong subjects, after a 
sudden debauch, complete abstention from al- 
cohol, light and easily assimilated food (milk 
diet), moderate purgation, and occasionally 
tartarated antimony in doses of from one- 
twelfth to one-eighth of a grain, carefully 
watched, have been most efficacious in the 
writer's hands. If the patient has two or three 
restless nights in succession, bromide of 
potassium (thirty grains), or chloral hydrate 
(twenty grains), may be given, separately, 
or better in combination, at intervals of four 
hours, until sleep is procured, or sulphonal 
(thirty grains) ; but as the disease is spon- 
taneously curable, sedatives must not be 
pushed. An experienced attendant should 
be always present, but no form of mecha-. 
nical restraint is permissible. In older cases, 
a mild purge should begin the treatment; 
and light but very nourishing food should 
be administered at short intervals. Milk, 
beef-tea, raw eggs beaten up with milk, 
strong soups, and such articles are to be 
given freely ; when, by careful management 
and good nursing, a very severe attack 
may be tided over, and natural sleep will 
return in from three to five days. The early 
administration of sedatives is to be depre- 
cated ; but should the restlessness persist, in 
spite of careful and assiduous feeding, a full 
dose of laudanum (n(xxx.-xl.) at bed-time 
is of great value. In the absence of albu- 
minuria, lung-complications, or any sign of 
failure of the heart's action, the writer pre- 
fers this drug to other hypnotics. If the 
opium alone fail, its combination with an 
alcoholic stimulant (brandy, whisky, or stout) 
often succeeds. If there be any tendency to 
syncope, or if pneumonia should come on, 
as well as in cases complicated with shock, 
e.g. surgical injuries, a free use of stimulants ALCOHOLISM 
ALIMENT 
45 
is imperative. Hypodermic injections of 
morphine, and large doses of digitalis, are 
recommended by many authorities; but 
the writer has seen great harm attend their 
free exhibition. The cautious inhalation of 
chloroform vapour has occasionally cut short 
an attack by inducing sleep, but it much 
more frequently fails. Mechanical restraint 
is seldom, if ever, necessary, if the patient 
be properly nursed and attended to. All 
methods of self-destruction must be carefully 
guarded against. A padded room, when 
required and available, is of the utmost 
benefit. 
The great desideratum in chronic alco- 
holism is to substitute an easily-digested 
and nourishing diet for the alcoholic stimu- 
lants, which can then be safely dispensed 
with altogether. The practitioner's judg- 
ment, and his knowledge of the cuisine, are 
very important in the management of these 
cases. Strong meat-soups, and good speci- 
mens of the concentrated preparations of 
meat, are of great value. The strictly medi- 
cinal treatment will consist in the adminis- 
tration of bitter tonics, such as nux vomica, 
quinine in small doses, calumba, or gentian; 
with carminatives, such as spirit of chloro- 
form, armoracia, and capsicum. Alkalis, 
effervescent mixtures, and hydrocyanic acid 
are peculiarly useful if the stomach be irrit- 
able. The cond'tion of the liver and bowels 
should be carefully regulated. Bromide of 
potassium is in general the best sedative to 
employ against the insomnia, though chloral 
hydrate is more certain; but the latter 
should only be given occasionally, lest the 
patient acquire the habit of frequently re- 
sorting to it. In long-standing cases, cod- 
liver oil, arsenic in small doses, and oxide of 
zinc have all done good, but they require a 
long and protracted administration. Phos- 
phorus has been of no use whatever in the 
cases in which the writer has tried it; but 
small doses of the more easily assimilable 
preparations of iron are occasionally well 
borne, and are then most useful. The crav- 
ing for drink, if urgent, may be checked by 
small doses of opium, but this drug must be 
exhibited with extreme caution. Judicious 
supervision, and, in inveterate cases, a re- 
sidence in a proper asylum, are the only 
means from which any permanent benefit 
can be expected. Absolute abstention from 
alcohol cures almost every case of alcoholic 
paralysis, unless it has become quite hope- 
less ; and massage and mild currents of elec- 
tricity are of service in restoring the atro- 
phied muscles. The treatment of insanity 
induced by alcoholism will not differ from 
that recommended in other forms, except in 
an enforced abstinence from its cause. 
John Curnow. 
ALEPPO EVIL.-See Delhi Boil. 
ALEXANDERSBAD, in Bavaria.- 
Chalybeate waters and hydropathic estab- 
lishment. See Mineral Waters. 
ALGID (algidus, cold).-A word imply- 
ing extreme coldness of the body, used only 
when it arises in connexion with an internal 
morbid state, such as cholera, or a special 
form of malignant remittent fever. 
ALGIERS. - Warm winter climate. 
Mean winter temperature 61° Fah., liable to 
rapid changes. Heavy rains not infrequent. 
See Climate, Treatment of Disease by. 
ALIMENT.-Food or aliment furnishes 
the elements required for the growth and 
maintenance of the organism; and, through 
its action with the other life factor-air, 
forms the source of the power manifested. 
The aliment of organisms belonging to the 
vegetable class is derived from the inorganic 
kingdom. Under the influence of the sun's 
rays the elements of inorganic principles are 
appropriated in such a manner as to lead to 
the construction of organic compounds and 
meet the requirements of growth. This con- 
stitutes the main operation of vegetable life, 
and in it we have the source of the aliment 
of animals, which can only appropriate or- 
ganic compounds, and which, either directly 
or indirectly, derive these compounds from 
the vegetable kingdom. As the solar energy 
employed in the construction of organic 
compounds, through the agency of the vege- 
table organism, becomes locked up in the 
compound formed, such compound represents 
matter combined with a definite amount of 
latent force. In the employment, therefore, 
of organic matter as aliment by animals, we 
have to look upon it not only as yielding the 
material required for the construction and 
maintenance of the body, but as containing 
and supplying the force which is evolved 
under various forms by the operations of 
animal life. 
Aliment constituting the source from which 
the several elements belonging to the body 
are derived, it follows that, to satisfy the 
requirements of life, it must contain all the 
elements that are encountered. It is not, 
however, with the elements in a separate 
state that we have to deal, but with the pro- 
ducts of nature in which they are variously 
combined. 
The alimentary products as supplied 
by nature are resolvable by analysis into a 
variety of definite chemical compounds. 
These constitute the alimentary principles. 
Some are common to both animal and vege- 
table food, as, for instance, albumin, casein, 
fats, &c.; others are peculiar to either the 
animal or vegetable kingdom. Starch, for 
example, is met with only in vegetable, and 
gelatine only in animal products. 
With reference to the alimentary principles, 
it must be understood that in no case do they 
exist in natural products in an isolated form, 
and no single alimentary principle is capable 46 
ALIMENT 
ALKALINITY 
of supporting life. Although, however, it is 
with the alimentary products as a whole 
that we are practically concerned, yet, re- 
garded from a scientific point of view, a 
knowledge of their constituent principles is 
required, to enable us to assign to them their 
proper value as alimentary articles; and for 
the purpose of systematic consideration some 
kind of classification is needed. 
Classification.-Prout classified the con- 
stituent principles of food into four groups, 
which he named (1) the aqueous; (2) the 
saccharine; (3) the oleaginous; and (4) the 
albriminous. This classification is defective, 
inasmuch as it omits from consideration 
saline matter, which is equally as essential 
to nutrition as any other part of an ali- 
mentary product. The saccharine and olea- 
ginous groups also stand as primary and 
independent divisions, whilst physiologically 
they are related, and may be conveniently 
considered under a combined heading. 
Liebig proposed a classification based 
on physiological grounds; and, taking into 
account only the organic constituents of 
food, grouped them under the heads of (1) 
plastic elements of nutrition ; and (2) ele- 
ments of respiration. His plastic elements 
of nutrition comprise the nitrogenous prin- 
ciples ; and to these he assigned the office of 
administering not only to the growth and 
renovation of the tissues, but also to the 
production of muscular and nervous power. 
Believing that the source of these powers 
sprang from the oxidation of the respective 
tissues, he held that the exercise of muscular 
and nervous action created a corresponding 
demand for nitrogenous alimentary matter, 
which thus became invested with an im- 
portance that led it to be regarded as afford- 
ing a measure of the value of an alimentary 
article. By recent experimental research 
this view has been found to be untenable. 
The nervo-muscular organs are now looked 
upon as holding the position of instruments, 
by whose agency the force liberated by 
chemical action is. made to manifest itself 
under certain other forms; and what is 
wanted for the purpose is simply oxidisable 
organic material, which may be derived 
from non-nitrogenous as well as nitrogenous 
food. The elements of respiration, or, as 
they were afterwards more appropriately 
styled, the calorifacient principles, repre- 
sent the organic non-nitrogenous constituents 
of food. Their destination, according to 
Liebig, was heat-production. It is now 
maintained, however, as stated above, that 
they play a part in connexion with nervo- 
muscular action; and it may be also said 
that they are to some extent concerned in 
tissue-development. From the considerations 
set forth, Liebig's classification loses the 
scientific value it was at one time supposed 
to possess. 
The following grouping of the alimentary 
principles, based on chemistry, furnishes a 
classification which involves no theoretical 
proposition, and is practically convenient:- 
Food is primarily divisible into inorganic 
and organic principles. 
The inorganic principles consist of water, 
and the various saline matters required by 
the system. They are as much needed for the 
support of life as the organic portion of food. 
The organic principles are sub-divisible 
into nitrogenous and non-nitrogenous; and 
the non-nitrogenous are again further sub- 
divisible into fats and carbo-hydrates. 
The nitrogenous principles contribute to 
the growth and nutrition of the various bodily 
textures, and furnish the active constituents 
of the secretions. They also undergo reso- 
lution in the system into urea, which is ex- 
creted ; and a complimentary portion, which is 
susceptible of application to force-production. 
They are thus capable of administering to all 
the purposes fulfilled by the organic portion 
of an aliment. 
The fats are applied to the production of 
heat and other forms of force. They seem 
also to be essential to tissue-development 
generally, besides yielding the basis of the 
adipose tissue. 
The carbo-hydrates (starch, sugar, gum, 
&c.) contribute to the formation of fat, and 
are also applied indirectly, if not directly, to 
force-production. 
There are a few principles, such as alcohol, 
the vegetable acids, and pectin or vegetable 
jelly, which do not strictly fall within either 
of the preceding groups. Alcohol occupies a 
chemical position intermediate between the 
fats and carbo-hydrates; whilst the others 
are more highly oxidised compounds than 
the carbo-hydrates. 
All alimentary products in the form sup- 
plied by nature contain organic and inorganic 
principles, and the organic principles com- 
prise more or less of the nitrogenous and non- 
nitrogenous divisions. The non-nitrogenous 
division, however, is not always represented, 
looked at broadly, by both fat and carbo- 
hydrate. Milk, which may be regarded, 
from the position it holds in nature, as fur- 
nishing a typical representation of an alimen- 
tary article, contains principles from each of 
the groups specified in the preceding classi- 
fication. See Diet. F. W. Pavy. 
ALIMENTARY CANAL, Diseases 
of. -See Digestive Organs, Diseases of; 
and the several organs. 
ALIWAL NORTH, in Cape 
Colony.-See Africa, South. 
ALKALINITY.-The reaction of hu- 
man blood is always alkaline; and, though 
the normal degree of alkalescence has not 
yet been determined, it is probable that, like 
the temperature of the body, it is tolerably 
constant. In disease considerable variation, ALKALINITY 
ALKALIS 
47 
no doubt, occurs, but still the blood is always 
found alkaline. Pettenkofer and Voit found 
the serum of blood acid in a case of leukaemia 
some few hours after death, but not during 
life; and Sir Alfred Garrod states that in 
chronic gout the serum may become some- 
what neutralised, but never acid. F. Hoff- 
man has also found that the blood retains 
its alkalinity with great obstinacy: he fed 
pigeons for a considerable length of time on 
food yielding only acid ash, but the animals 
suffered from blood-poisoning before the 
alkalinity of the serum was neutralised. 
The alkalinity of the blood is maintained by 
the constant passage into it of the alkaline 
salts of the food, and of alkaline carbonates 
derived from the oxidation of the lactic, 
oxalic, and uric acids furnished by the dis- 
integration of the tissues. The blood is pro- 
bably prevented from becoming too alkaline 
by the withdrawal of its alkaline salts by 
the alkaline secretions, namely, the saliva, 
the bile, and the pancreatic fluid; whilst the 
acid salts, which, if accumulated, would tend 
to depress its normal alkalinity, are removed 
by the acid secretions, namely, the sweat, 
the gastric juice, and the urine, and by the 
exhalation of carbonic acid from the lungs. 
It has been shown that the withdrawal of 
acid by one secretion has a decided effect on 
the reaction of other secretions: thus the 
saliva becomes more alkaline during diges- 
tion, when the stomach is pouring out the 
acid gastric juice ; and Dr. Bence Jones has 
shown that during digestion the acidity of 
the urine is lessened. A similar relation- 
ship is also shown to exist between the eli- 
mination of carbonic acid by the lungs and 
the acidity of the urine, the latter falling as 
the former is increased, and vice versa. The 
importance of a proper degree of alkalescence 
for the blood is obvious, when we consider 
that this condition increases the absorption- 
power of its serum for gases, and is neces- 
sary to maintain its albumin in the liquid 
state, whilst oxidation is always more per- 
fectly performed in alkaline solutions. 
C. H. Balfe. 
ALKALIS. - Definition. - Inorganic 
substances, which turn syrup of violets green, 
and turmeric brown; and restore the blue 
colour to litmus which has been reddened 
by acids; they combine with acids to form 
salts; and their carbonates are soluble in 
water. 
Enumeration.-The only substances which 
correspond with the above definition are - 
Potash, Soda, Lithia, and Ammonia. The 
alkaline earths-Lime, Magnesia, Baryta, 
and Strontia- and the alkaloids, have a 
similar action on vegetable blues and yel- 
lows ; but the carbonates of the former group 
are almost insoluble in water; whilst the 
latter contain carbon, and are therefore classed 
with organic substances. 
Properties.-Ammonia is distinguished 
from the other alkalis by its volatility. The 
non-volatile alkalis are readily recognised by 
their spectra; and by the colour they impart 
to the blowpipe flame, potassium giving it a 
violet, sodium a yellow, and lithium a carmine 
colour. Potassium and sodium are present 
as constituents of the body in considerable 
quantities; ammonium exists to a smaller 
amount; and lithium probably in traces. 
Sodium is found chiefly in the blood, potas- 
sium in the muscles. 
Action.-When applied to the skin, dilute 
alkalis and their carbonates act as rubefaci- 
ents. Pure ammonia is a vesicant, and potash 
and soda have a caustic action. Both caustic 
potash and caustic soda absorb water from 
the tissues, and form a corrosive fluid, which 
destroys the parts around, as well as that to 
which the caustic has actually been applied. 
To prevent this effect they are sometimes 
mixed with lime, which absorbs the water. 
A mixture of potash and lime forms the 
Vienna paste. When inhaled, ammonia 
causes irritation of the respiratory passages, 
and increased secretion of mucus. This ir- 
ritation excites reflex contraction of the blood- 
vessels and consequent rise of blood-pressure. 
When swallowed in quantity, the caustic 
alkalis and their carbonates produce symp- 
toms of irritant poisoning. In the case of 
ammonia these symptoms may be accom- 
panied by those of inflammation of the air- 
passages, caused by the irritant vapour. The 
best antidote is dilute acid, such as vinegar. In 
small quantities and diluted, alkalis increase 
the secretion of gastric juice before meals. 
After absorption into the blood they render 
this fluid more alkaline; while potash appears 
especially to accelerate tissue-change, and is 
accordingly classed among the alteratives. 
When injected directly into the blood, potash 
acts specially on the muscles, which it para- 
lyses. Ammonia stimulates the motor centres 
in the brain and spinal cord, the respiratory 
centre in the medulla oblongata, and the 
accelerating nerves of the heart. When 
injected into the veins it therefore causes 
convulsions like those of strychnine, and 
quickening of the respiration and pulse. 
Alkalis are chiefly excreted by the urine; 
and potash, soda, and lithia lessen its acidity, 
or render it alkaline. Ammonia is partly 
excreted unchanged, but a portion passes out 
in the form of urea and uric acid; and it does 
not render the urine alkaline like the others. 
Potash and lithia act as diuretics; soda to a 
less extent; and ammonia least of all. The 
diuretic action does not depend on any change 
in the blood-pressure. Potash and ammonia 
are diaphoretic. Potash lessens the tenacity 
of mucus. 
Uses.-Dilute solutions of potash and soda 
relieve itching in skin diseases. Caustic 
potash or soda is used to destroy warts; 
to cauterise poisoned wounds and ulcers: 48 
ALKALIS 
ALKALOIDS 
to open hydatid cysts in the liver; and to 
establish issues. Ammonia neutralises the 
formic acid which renders venomous the 
stings of bees, ants, and mosquitoes, and is 
therefore applied to relieve the pain which 
they cause. The intravenous injection of 
ammonia has been recommended as an anti- 
dote in snake-poisoning; but the value of the 
remedy is not established. Mixed with oil, 
so as to form a liniment, ammonia is used 
as a rubefacient in sore throats, bronchitis, 
rheumatic pains, and neuralgia. It is inhaled 
to relieve headache; as a restorative in syn- 
cope and shock, when it raises the blood- 
pressure ; and to facilitate expectoration in 
chronic bronchitis. Alkalis administered 
after meals act as antacids, and relieve heart- 
burn. "When given before meals they in- 
crease the secretion of gastric juice, quicken 
digestion, and relieve weight at the epigas- 
trium, pain between the shoulders, and 
flatulence. Bicarbonate of sodium is usually 
given for this purpose, but when the stomach 
is very irritable, liquor potass® is preferred, 
as it is considered to have a sedative action 
on the mucous membrane. Alkalis appear to 
lessen the transformation of glycogen into 
sugar, and they are used on this account in 
diabetes. Liquor potass® sometimes helps 
to reduce obesity. Alkalis are used in the 
treatment of scrofula, rheumatism, gout, 
and lithiasis ; but in the two last-mentioned 
diseases lithia is considered the most valu- 
able, whilst potash is preferred to soda, 
as the urate of lithium is most soluble, and 
the urate of sodium least so. The salts of 
certain organic acids, such as the acetate 
or citrate, may be employed as remote 
antacids to render the urine alkaline, as they 
undergo combustion, and are converted into 
carbonates in the blood. Alkalis are given 
to lessen the acidity of the urine in inflamma- 
tion of the bladder or urethra, and potash is 
employed as a diuretic in dropsies. On ac- 
count of its stimulating action on the heart 
and respiration, ammonia is administered in 
adynamic conditions and in chronic bron- 
chitis. T. Lauder Brunton. 
ALKALOIDS and other ACTIVE 
PRINCIPLES.-Definition.-An alka- 
loid is a substance formed in the tissues of a 
plant or of an animal, having a definite com- 
position as regards the proportions of the 
chemical elements of which it is composed, 
and capable of combining, like an alkali, with 
acids to form salts. All alkaloids contain 
nitrogen; and all, except conine, nicotine, and 
sparteine, contain oxygen. 
Besides alkaloids there are other active 
principles found in plants, which have also a 
powerful influence on the animal economy, 
but do not possess all the chemical properties 
just stated. 
Chemical Composition and Relations.- 
These are briefly expressed in the above de- 
finition. Thus morphine, for example, one 
of the alkaloids of opium, has always the 
chemical composition represented by the 
formula C17HI9NO3,H2O, and it may unite 
with acetic acid to form acetate of morphine, 
just as potash may unite with the same acid 
to produce acetate of potassium. But the 
empirical formula C17H19NO3 represents only 
the percentage composition of the substance 
in the simplest numbers, and does not express 
how the atoms of the different elements are 
related to each other. For, just as ethylic 
alcohol, with the composition C2H6O, is be- 
lieved by the chemist, from its behaviour to- 
wards other bodies, to contain a ' radicle,' or 
group of atoms, C2H5, having certain chemical 
properties resembling those of a base, such as 
potassium, K; and just as this radicle, C2H5, 
may replace one of the hydrogens of water, so 
as to form alcohol (C2H. + H.,0 = ^'4r^5O + H); 
so chemists have good reason for believing 
that alkaloids belong to the group known as 
amines or amides, which are really ammonia, 
NH3, in which one or more of the atoms of 
hydrogen are replaced by a radicle ; in other 
words, they are ammonia bases, combining 
with HC1 without elimination of H2O. Most 
alkaloids are derivatives of pyridine. 
It is obvious that two or more alkaloids 
may resemble each other in percentage com- 
position, and still be very different, both in 
their chemical structure, and, necessarily, in 
their physiological action. Thus strychnine 
(C21H22N2O2), quinine (C20H24N2O2), and cin- 
chonine (C20H24N2O), differ only in a few atoms 
of carbon or of oxygen, more or less; but they 
have different physiological actions, showing 
that their chemical structure, which is not 
indicated in these formulae, must also be 
different. The physiological action of an 
alkaloid may also be modified by combining 
it with another substance. Thus, as was 
pointed out by Crum-Brown and Fraser, com- 
pounds of strychnine with methyl, ethyl, and 
amyl, do not present the well-known phy- 
siological action of that substance, but one 
analogous to that of woorara. 
Enumeration.-The alkaloids and other ac- 
tive principles most familiar to the physician 
are : - Morphine, Apomorphine, Narcein, 
Codeine, Thebaine, Narcotine, Papaverine ; 
Atropine, Hyoscyamine, Hyoscine, l)aturine; 
Nicotine; Conine; Physostigmine or Eserine; 
Strychnine, Brucine; Quinine, Cinchonine, 
Cinchonidine ; Beberine; Caffeine; Cocaine; 
Theobromine; Aconitine; Veratrine; Digi- 
talin ; Curarine ; Muscarine ; Santonin; Ergo- 
tin ; Emetine ; Pilocarpine; Salicin; and 
Strophanthin. For the alkaloidal substances 
formed in dead bodies and in animal tissues, 
see Ptomaines.1 
1 Names of alkaloids are now made to end in ina 
(Latin) or ine-thus: morphina or morphine. The 
names of non-alkaloidal active principles terminate 
in inum (Latin) or in-thus: digitalinum or digitalin. ALKALOIDS 
49 
Sources.-The majority of alkaloils are 
farmed by plants. The function which they 
subserve in the economy of the plant is not 
known. Some plants produce only one al- 
kaloid, while in others two or more are 
formed. A few of the alkaloids have been 
produced synthetically by the chemist. 
Physiological Action.-Alkaloids have 
various degrees of physiological activity when 
introduced into the animal body. Many are 
slow in their action, and a large dose is re- 
quired to produce any observable effect; while 
others act more rapidly, and are so potent 
that even a minute dose may destroy life. 
Compare, for example, narcotine, one of the 
alkaloids of opium, with nicotine, the alka- 
loid of tobacco. Twenty to thirty grains of 
the former have been taken by the human 
subject without producing any marked symp- 
toms, while the twentieth part of a grain of 
the latter may induce symptoms so severe as 
to threaten death. It is also well known that 
alkaloids may have a different kind of action 
on different animals. Thus one-fourth of a 
grain of atropine will produce serious symp- 
toms of a complex character in a dog, while 
three or even four grains may be given to a 
rabbit without causing any more marked 
effect than dilatation of the pupil. In con- 
sidering the physiological actions of these 
substances, the following generalisations 
may, in the present state of science, be made 
tentatively :-1. As a general rule, the more 
complex the organic molecule, and the 
greater the sum of its atomic weight, the 
more intense will be the action of the sub- 
stance. 2. Substances which split up quickly 
into simpler bodies produce rapid but 
transient physiological effects; whereas sub- 
stances which resist decomposition in the 
blood or tissues may produce no appreciable 
results for a time, but when they do begin 
to break up, the effects are sudden and vio- 
lent, and usually last for a considerable time. 
3. Alkaloids have frequently a double action 
on different parts of a great physiological sys- 
tem ; and their action in a particular group of 
animals will depend on the relative degree of 
development of the parts of the system in 
that group. Thus most of the alkaloids of 
opium have such a double action-a convul- 
sive action resembling that of strychnine, due 
to their influence on the spinal cord or on 
the motor centres in the brain; and a nar- 
cotic or soporific action resembling that of 
anaesthetics, due to their influence on sensory 
centres in the brain. Hence, in animals 
where the spinal system predominates, as in 
frogs, these alkaloids act as convulsants; 
while in the higher mammals their principal 
action is apparently on the encephalic centres, 
which have now become largely developed. 
Passing to the consideration of the action of 
the individual substances, we cannot do more 
than give, by way of example, a brief resume 
of our knowledge regarding a few of them. 
1. Morphine (C17H19NO3)-an alkaloid 
of Opium. In the frog this substance has 
an action resembling that of strychnine. At 
first there is a state of agitation, followed by 
tetanic spasms; finally, all reflex actions, in- 
cluding those of the heart and of respiration, 
are paralysed. Pigeons have been found to 
possess a remarkable power of withstanding 
the influence of this drug-an ordinary sized 
bird requiring about two grains to kill it. 
Rabbits become partially somnolent, show a 
tendency to reflex spasms, and tolerate a 
large dose-say about one-half to one grain 
per pound weight of the animal. In the dog 
the intravenous injection of even one-tenth 
of a grain (for a small animal) causes agita- 
tion followed by sleep; the pulse and respi- 
ratory movements are slowed; the smaller 
arteries become (at least during one stage) 
contracted, so as to cause an augmentation 
of general blood-pressure; the pupil is con- 
tracted ; and, if the dose be large, death may 
be preceded by convulsions. In the higher 
mammals morphine acts chiefly on the sensory 
apparatus, both peripheral and central. 
2. Other alkaloids of opium have also been 
investigated:-(a) Narcein (C23H29NO9) is a 
pure hypnotic, causing profound sleep. Even 
in large doses it does not produce convulsions. 
(b) Codeine (CI8H21NO3) has an action 
mainly like that of morphine, (c) The- 
baine (C19H21NO3) causes tetanic convulsions, 
thus resembling strychnine, (d) Narco- 
tine (C22H23NO7) is slightly narcotic, but 
strongly convulsant. (e) Papaverin (C20 
H21NO4) causes a somniferous action like that 
of narcein. It is evident, therefore, that 
opium, which may contain more or less of all 
of these substances, must have an action on 
the body of a very complicated character. 
Apomorphine (C17H17NO2), a derivative 
of morphine, has none of the characteristic 
actions of that substance, but acts chiefly as 
a vascular depressant and as an emetic. 
3. Strychnine (C21H22N2O2)-the alka- 
loid of Strychnos nux vomica. In the frog 
very minute doses cause convulsions of all 
the voluntary muscles, excited by peripheral 
irritation. These convulsions are due to the 
action of the poison on the spinal cord, as 
they persist after decapitation. In warm- 
blooded animals the reflex character of the 
convulsions is less evident; they have more 
of a tonic character, and chiefly affect the 
extensors. The exact modus operandi of the 
poison on the cord is unknown, but in some 
way or other it heightens its reflex sensibility. 
Death is usually the result of asphyxia from 
arrest in spasm of the respiratory mechanism, 
but it may result from exhaustion. Brucine 
(C23H26N2O4), another substance found in nux 
vomica, appears to have an action like that 
of strychnine, but more feeble. 
4. Atropine (C17H23NO3)-the chief alka- 
loid of Atropa belladonna. In the frog it causes 
tetanic reflex spasms. Herbivorous animals, 50 
ALKALOIDS 
as a rule, have a tolerance of this poison, so 
that its effects are best studied in carnivora. 
Even in these the action is somewhat un- 
certain. Respiration may be paralysed 
without general convulsions; the pulse is 
quickened, from paralysis of the inhibitory 
action of the pneumogastric nerve on the 
heart; and the arterial pressure is increased. 
After very large doses the arterial pressure 
may be diminished, with paralysis of all parts 
containing involuntary muscular fibre. Se- 
cretion is diminished. The pupil is dilated- 
apparently by a direct influence of the poison 
on the centres or nervous arrangements in 
the iris itself, as the effect may be observed 
even in an eye removed from the head. 
Hyoscyamine, and Hyoscine, the alka- 
loids of Hyoscyamus niger, and Daturine, 
the alkaloid of Datura stramonium, have 
actions allied to the action of atropine. 
5. Digitalin (C27II44O]5)-the so-called ac- 
tive principle of Digitalis purpurea, probably 
a mixture of several bodies. A large dose 
causes slowing of the heart. If the dose be 
increased, the heart is arrested in diastole, and 
will not respond to direct excitation. With 
medium doses there is a period of acceleration 
of the heart, but this period may rapidly pass 
into that of slowness just mentioned. This 
effect on the heart has not yet been clearly 
accounted for, and it remains to be decided 
whether it be due to the influence of the 
drug on the terminations of the pneumo- 
gastric, or of the sympathetic, or on the 
intracardiac ganglia themselves. Coincident 
with the action on the heart, the smaller 
arteries are contracted, and the arterial ten- 
sion is increased. Digitalis would appear to 
have little effect on involuntary muscle, but it 
exerts a potent action on voluntary muscle, 
which, after small doses, becomes feeble in 
contractile power, while large doses may 
abolish contractility altogether. 
6. Physostigmine, or Eserine, (C,5H21 
N3O2)-the active substance of Physostigma 
venenosum, or Calabar bean. As has been 
pointed out by Professor Fraser, this alkaloid 
has an action antagonistic to that of atropine. 
Sensibility and consciousness remain until 
death; the voluntary muscles are paralysed; 
involuntary muscles are said to show tetanic 
contractions; respiration is at first acceler- 
ated, and afterwards slowed; the vessels 
become alternately dilated and contracted; 
secretion, especially that from the lachrymal 
and salivary glands, is increased; and the 
pupil is contracted. Physostigmine appears 
to paralyse the anterior cornua of the spinal 
cord. 
7. Curare-a resinous substance, con- 
taining an alkaloid, Curarine, of the com- 
position C10H]5N, obtained from certain parts 
of South America, and used by the natives 
of these regions as an arrow-poison. It is 
probably obtained from certain plants belong- 
ing to the genera Strychnos and Paullinia. 
Its distinctive physiological action is abolition 
of the power of all voluntary movement, in 
consequence of its action, as was proved by 
Claude Bernard, upon the peripheral ter- 
minations of motor nerves-the ' terminal 
plates ' of muscle. Respiratory movements 
are arrested as the result of paralysis of the 
muscles of respiration, but the heart may 
continue to beat for a considerable time. If 
artificial respiration be established, the circu- 
lation may be maintained for several hours, 
while the animal is completely under the 
influence of the substance. All the secretions 
are increased, and the mean temperature falls. 
8. Muscarine -the alkaloid of Agaricus 
muscarius. It causes arrest of the heart's 
action in diastole, an effect which may be 
removed by the influence of atropine, thus 
affording an instance of physiological an- 
tagonism. In warm-blooded animals mus- 
carine slows the heart's action; the blood- 
pressure falls; respiration is first embarrassed, 
and may be completely arrested ; parts con- 
taining involuntary muscle are in a state of 
tetanic spasm ; the pupil is contracted ; and 
secretion is increased. 
9. Santonin (C15H18O3)-the neutral crys- 
talline principle of Artemisia maritima. This 
drug may cause nausea, vomiting, halluci- 
nations, vertigo, and a peculiar state of visual 
sensation-the field of vision usually appear- 
ing yellow, but sometimes violet. It is said 
that the stage of violet rapidly passes into 
that of yellow, and therefore it is probable 
that santonin may first excite the retinal 
fibres sensitive to violet (according to Thomas 
Young's theory of colour-perception), and 
afterwards paralyse them. In large doses, 
santonin causes loss of consciousness, tetanic 
convulsions, and death. 
10. Ergotin.-the so-called active prin- 
ciple of Ergot. It causes contraction of 
the smaller blood-vessels, contractions of the 
uterus, and slowing of the pulse; and the 
animal may die in consequence of arrest of 
the action of the heart. 
11. Quinine (C.,0H2,N2O2)-one of the al- 
kaloids of Cinchona. In small doses quinine 
accelerates the heart in the warm-blooded 
animal; in moderate doses it slows it; and in 
large doses it may arrest it, and cause con- 
vulsions and death. Research shows that its 
action is essentially upon the central nervous 
system. It destroys all microscopic animal 
organisms, apparently killing vibrios, bacteria, 
and amoebae; but it seems to be without 
action on humble organisms belonging to the 
vegetable kingdom. It arrests the move- 
ments of all kinds of protoplasm, including 
those of the colourless corpuscles of the 
blood. It arrests fermentative processes 
which depend on the presence of animal or 
vegetable organisms, but it does not interfere 
with the action of digestive fluids. 
12. Nicotine (C10H]4N„)-the alkaloid of 
Tobacco. It stimulates and then paralyses ALKALOIDS 
ALOPECIA AREATA 
51 
the secretory nerves of glands, and also the 
nerves of involuntary muscles. It causes 
cold sweats, a feeble circulation, and faint- 
ing ; a large dose causes death by failure of 
respiration, attended by severe convulsions. 
The blood-pressure falls at first, but it may 
then rise, and the pulse-rate is rapid. Nico- 
tine first stimulates and then paralyses the 
ends of the vagi in the heart. 
13. Cocaine (Cj7H21NO4) - from Ery- 
throxylon coca. This is a local anaesthetic, 
acting on the terminations of the nerves of 
the skin and of mucous membranes. Its 
general action resembles that of caffeine, in 
small doses lessening fatigue, in larger doses 
causing weariness, deafness, and inability to 
think clearly. Its action is first on the cere- 
brum, then on the medulla, and lastly on 
the spinal cord. Very large doses may cause 
convulsions, of cerebral origin, or due to 
paralysis of the respiratory centre ; the 
sensory columns of the cord are paralysed, 
while the motor are unaffected. Small doses 
raise the blood-pressure and quicken the 
pulse; large doses have the reverse effect. 
The secretions are generally diminished. 
14. Pilocarpine (CnHlfiN2O2)- from Pilo- 
carpus pennatifolius or Jaborandi. Pilocar- 
pine stimulates the secretory nerves of glands, 
causing especially copious secretion from the 
salivary and sweat-glands. It also increases 
the secretion from the bronchial mucous 
membrane, from the glands of the stomach 
and intestines, and from the kidneys. It 
does not increase the secretion of bile, and 
its action on the mammary gland is uncertain. 
In large doses it may cause unsteadiness of 
movement, with a tendency to rotate, twitch- 
ings of muscles, shivering, and dyspnoea, 
showing an action on nerve-centres. In 
these circumstances the pupil is contracted, 
and there is indistinct vision, from spasm of 
the ciliary muscle. Large doses paralyse 
the vagus endings in the heart, and there 
may also be spasmodic contractions of the 
muscular walls of the stomach, intestines, 
and bladder. During profuse sweating the 
temperature rises. There may be death from 
sudden collapse. 
15. Strophanthin (C16H2BOrt ?) - the ac- 
tive principle of Strophanthus hispidus. It 
resembles digitalin in its general action: it 
stimulates all striated muscles; in large doses, 
it may arrest the heart in systole; and it 
also acts as a diuretic. 
John G. McKendrick. 
ALLANTIASIS (dXXar, forced meat).- 
Sausage-poisoning. See Poisonous Food. 
ALLEGHANY SPRINGS, in Mont- 
gomery county, Virginia, U.S.A.- 
Calcic or earthy waters. See Mineral 
Waters, 
ALLEVAUD, in France (Isdre).- ' 
Sulphur waters. See Mineral Waters. 
ALLOCHIRIA («XXo?, another ; and 
the hand).-A peculiar disturbance of 
cutaneous sensibility in which a tactile 
sensation is referred to another part of the 
body than the seat of actual impression ; or 
to a corresponding part of the opposite side of 
the body. See Sensation, Disorders of. 
ALOPECIA.-See Baldness. 
ALOPECIA AREATA (dAwyr^, a fox). 
Synon. : Area; Alopecia circumscriptia ; 
Porrigo decalvans. Fr. Alopecie; Ger. 
Fuchsrdude. 
Definition.- A non-contagious atrophic 
disease of the hair, distinguished by the 
rapid development of more or less circular 
bald patches; in rare cases the baldness is 
general. 
Symptoms.-Alopecia areata is most com- 
mon on the scalp, and is generally limited to 
that region, the occiput being the part most 
frequently affected. In some instances the 
beard and eyebrows suffer, and in very 
rare cases the whole of the hair is lost. 
Alopecia areata is usually confined either 
to a single round, perfectly bald spot, or to 
several spots irregularly scattered about the 
scalp ; when, however, the disease attacks 
the occiput, it is often roughly symmetrical. 
The same remark applies to the eyebrows 
and eyelashes, and to all very severe cases, 
which have a strong tendency to become 
symmetrical. A characteristic feature of the 
disease is the rapidity with which the hair 
falls off over a limited area, leaving very few, 
if any, stumps on the bald patch, which is 
bounded by hair of apparently natural growth. 
When, however, the hair round the area 
comes out very easily, it may safely be pre- 
dicted that the spot will increase in size. 
The part affected is sometimes pinker than 
the surrounding skin, but much more com- 
monly it is of the same colour, or paler. 
There is sometimes a slight atrophy of the 
skin, as well as of the hair, so that the area 
has a shallow, cupped character; this is com- 
paratively rare, and therefore cannot be due 
simply to the loss of hair. 
.Etiology and Pathology.-The causes 
of alopecia areata are not known. The im- 
mediate origin of the disease is probably 
some nerve-disturbance, leading to atrophy of 
the roots of the hair and sometimes of the 
skin. This view is confirmed by the fact that 
there is occasionally, though rarely, a tem- 
porary loss of sensibility over the area; and 
even when this is not the case, the skin is less 
sensitive to irritants than is normal. Some- 
times the loss of hair is preceded by neuralgic 
pains, or tenderness on pressure, but more 
commonly there are no subjective sensations. 
The disease is rather more common in child- 
hood and youth than in middle life, while 
it is seldom seen in old age; the writer 
has, however, met with one case in a man 52 
ALOPECIA AREATA 
over seventy years of age, who completely re- I 
covered. Alopecia is probably equally common 
in males and females, though on this point 
there is some difference of opinion. The old 
idea that the disease was due to a parasitic 
fungus has now been given up, in consequence 
of the complete failure of all attempts to 
demonstrate the fungus; moreover many of 
the clinical features of the disease, especially 
its great liability to recur after complete 
absence for perhaps years, is not at all in 
accordance with a parasitic origin. There is 
certainly sometimes a family tendency to 
alopecia. In extreme cases of alopecia areata, 
in which all the hair is lost, the nervous origin 
of the disease is generally admitted. 
With regard to its morbid anatomy, it may 
be said that it is often difficult to find stumps, 
but when present they are very charac- 
teristic. They are also sometimes valuable 
for the purpose of differential diagnosis, since 
they are unlike the stumps of ringworm, 
being straight and thicker at the free end 
than at the point of insertion, which is con- 
tracted into a sort of neck, ending in a small, 
rounded, atrophied root. A very slight 
amount of traction removes them entire ; in 
this respect they differ much from ordinary 
ringworm stumps. 
Diagnosis.-Ringworm is the only disease 
which is liable to be mistaken for alopecia 
areata. The difficulty arises thus : in com- 
mon ringworm, either from treatment or 
from some other unknown cause, the hair 
sometimes falls rapidly off instead of breaking 
as it usually does. When the hair comes 
out in this way, with root attached, a smooth 
bald spot is left, exactly like alopecia areata; 
under these circumstances, unless a stump 
can be obtained for examination, the diagno- 
sis is very difficult. The presence of other 
cases of ringworm in the same house, and 
the history of the patient, may be a guide to 
diagnosis. 
Dr. Crocker mentions a very interesting 
and instructive series of cases of ' eight 
children in one family, who, while at the sea- 
side, had each a few small perfectly bald 
spots on their heads; they were quite bare 
from the first, and never larger than half-an- 
inch in diameter.' After a time the governess 
contracted the disease, which was believed by 
her doctor to be alopecia areata, and not con- 
tagious ; she, however, slept with her sister, 
who afterwards showed similar spots. Dr. 
Crocker says : 'The hairs round were loose : 
there were no short hairs, but one pulled out 
of the border showed distinct fungus-elements, 
indistinguishable from tinea tonsurans. In 
no case were there more than three spots, 
and they were all small. In one child there 
was a history of a red ring on the side of 
the cheek.' The writer has himself met with 
three similar examples. The first was in a 
school of about forty-five girls, where there 
were upwards of twenty girls affected with 
small bald spots on the head, mostly free from 
stumps ; there were, however, in a few cases 
a sufficient number of stumps full of ring- 
worm fungus to make the diagnosis certain. 
The medical officer to the school correctly 
diagnosed ringworm, although the appearance 
of most of the children would have deceived 
anyone had the cases occurred singly. The 
second instance was in a boys' school, in 
which sixteen or seventeen cases of bald 
spots on the head occurred. The writer saw 
in the first instance only two boys, who were 
sent to him before it was known that any 
others in the school were affected. Both 
boys had small bald spots like area, but on 
one of the spots were ringworm stumps. 
The writer recommended that all the boys in 
the school should have their heads examined; 
this was done, and then many others were 
found to have bald spots. He subsequently 
saw one or two other boys from the same 
school with bald spots, which he had no 
doubt, under the circumstances, were ring- 
worm. In this instance the disease had been 
called alopecia areata, and pronounced not 
contagious. The third case was in a family 
of children. 
There is one point especially worthy of 
notice in all these curious outbreaks of bald 
ringworm: the spots were for the most part 
small, and by no means always circular at 
the margin, like area. On the contrary, some 
of the spots were angular, and others narrow 
and long like scars; indeed the shapes of the 
bald spots were in most cases not like those 
of typical area, although in every other 
respect there was a very close resemblance, 
so that it would be almost impossible to 
diagnose an isolated case as tinea tonsurans, 
unless some of the affected hairs remained. A 
favourable point in these cases is that when 
the hairs have all been shed, the risk of 
further contagion is much diminished; on the 
other hand, the disease spreads very rapidly 
at first, for every hair that is shed is a centre 
of infection. 
Treatment.-The prognosis in most cases 
of alopecia areata is favourable, but the 
disease is very tedious. The treatment is 
partly local and partly general; the local 
treatment consists in the application of stimu- 
lating remedies to the bald patch, of which 
the best is cantharides. The acetum can- 
tharidis, diluted with one or two parts of 
spirit, and painted on daily with a camel's- 
hair brush, answers very well. The lotion 
used should not be strong enough to blister, 
because its daily use cannot then be con- 
tinued. Of ointments, the chrysophanic acid 
is the most useful, but it is disagreeable. The 
general treatment should consist of suitable 
tonics, and wine or beer, with plenty of rest 
and change of air. Continued physical 
fatigue appears in many cases to favour the 
development of alopecia areata. 
Egbert Liveing. ALPHOS AND ALPHOIDES 
AMAUROSIS 
53 
ALPHOS and ALPHOIDES (d\fbs, 
white).-Terms signifying white and white- 
looking, associated with the whiteness of 
the discs of common psoriasis : hence lepra 
alphos and lepra alphoides. See Psoriasis. 
ALPHOSIS (d\fbs, white).-Whiteness, 
or the process of turning white. See 
Achroma. 
ALTERATIVES.-Definition.-Medi- 
cines which gradually restore the nutrition of 
the body to a healthy condition, without pro- 
ducing evacuations, or immediately exerting 
any very evident action upon the nervous 
system. 
Enumeration.-The principal alteratives 
are-Nitric and Nitro-hydrochloric acids; 
Chlorine and Chlorides; Iodine and Iodides; 
Sulphur and Sulphides; Potassium and its 
salts; Mercury and its salts; Phosphorus 
and Hypophosphites; Antimony; Arsenic; 
Taraxacum ; Sarsaparilla ; Hemidesmus ; 
Guaiacum ; Colchicum ; and Mezereon. 
Action.-Healthy nutrition depends on the 
digestion of the food, its assimilation by the 
tissues, the decomposition of the tissues 
during the exercise of their functions, and 
the removal of their waste products being 
performed in a proper manner-in due pro- 
portion one to another. If the food is not 
properly digested, as in dyspepsia; or is not 
properly assimilated, as in diabetes; if the 
tissues break up too rapidly, as in fever ; or 
if the waste products are not properly re- 
moved, as in some cases of kidney-disease, 
nutrition suffers. Digestion and excretion 
may be improved by tonics, purgatives, and 
diuretics ; but alteratives seem to exert their 
action upon assimilation and tissue-change. 
The digestion of food is effected by means of 
ferments, such as those of the salivary glands, 
stomach, pancreas, &c. Some also of the 
changes, such as the conversion of glycogen 
into sugar, which the food undergoes after 
absorption in the liver, and even certain so- 
called vital actions-such as the coagulation 
of the blood-are produced by a similar 
agency. It is not improbable that the histo- 
lytic changes in the tissues are also effected 
by ferments. They do not depend upon oxi- 
dation, for although during health the pro- 
ducts of tissue-decomposition are oxidised as 
fast as they are formed, yet under certain 
circumstances the tissues are split up so 
rapidly that the products which they yield 
are only partially oxidised. This is seen in 
poisoning by antimony, arsenic, and still 
more markedly by phosphorus, where such 
tissues as the muscles become decomposed, 
yielding nitrogenous substances, such as 
leucin, tyrosin, or urea, and fat. The former 
are excreted in the urine ; while the last, 
instead of undergoing combustion, accumu- 
lates in the place formerly occupied by the 
muscular tissue, which is accordingly said 
to be in a state of fatty degeneration. It is 
possible then, although by no means certain, 
that alteratives influence nutrition, either 
by modifying the activity of ferments, or by 
altering the susceptibility of the tissues to 
their action. 
Mercurials in purgative doses, taraxacum, 
nitric and nitro-hydrochloric acids, probably 
act by modifying the digestion of the food 
in the upper part of the small intestine, or 
by affecting the changes which it undergoes 
in the liver after absorption. Potash has pro- 
bably an action on the muscles. Antimony, 
arsenic, and phosphorus especially affect the 
nervous and cutaneous systems. Mercury 
has a peculiar power of breaking up newly- 
formed fibrinous deposits, and particularly 
syphilitic growths. Iodine, iodides, and 
probably chlorides, act upon the lymphatic 
system and promote absorption. 
Uses. - Purgative doses of mercurials, 
taraxacum, nitric and nitro-hydrochloric 
acids are useful in cases of frontal headache, 
general malaise, and depression of spirits, 
associated with symptoms of so-called bilious- 
ness, or with the appearance of urates or of 
oxalates in the urine. Potash and colchicum 
are employed in the treatment of gout. 
Phosphorus and arsenic are used in cases of 
nervous debility, as well as in nervous dis- 
eases, such as neuralgia and chorea, in which 
antimony is also serviceable. Arsenic is also 
given in diseases of the skin; and antimony 
in inflammation of the mucous membrane of 
the bronchi. Mercury in alterative (that is, 
small) doses, which are absorbed into the 
circulation without purging, is used to break 
up newly-deposited fibrinous masses, as in 
iritis, pericarditis, &c., and to counteract the 
effect of syphilitic virus upon the soft tissues 
in the secondary stage of this disease. Iodine 
and iodides act on the lymphatic system, and 
are useful in removing glandular swellings. 
By stimulating the absorbent system they 
may also assist in the removal of the fibrinous 
deposits and syphilitic growths disintegrated 
by mercury. The iodides are sometimes 
given in the secondary, but are still more 
valuable in the tertiary, stage of syphilis. 
T. Lauder Brunton. 
ALVENEU, in Switzerland. - Sul- 
phur waters, and chalybeate water, with iodine 
and common salt. See Mineral Waters. 
ALVEOLAR -A word used in path- 
ology as descriptive of any morbid growth 
which consists of small cavities or spaces 
(alveoli'), usually occupied by contents, and 
bounded by walls formed of cells or fibres. 
Alveolar cancer is the most familiar applica- 
tion of the term, being a synonym for 
colloid cancer. See Cancer. 
AMAUROSIS (dpavpaxTis, a darkening 
or dulling of the sight.)-Definition.-This 
term cannot be strictly defined. Literally, it 
means an obscurity of vision, a state of blind- 54 
AMAUROSIS 
ness, in the popular sense of the term, whereby 
nothing more is learnt than that the patient 
cannot see well enough for practical purposes, 
and is thereby unfitted for the usual occupa- 
tions of life. Besides this, it is always tacitly 
understood that an external observation of 
the organ of vision, during the life of the 
patient, does not reveal any ostensible cause 
of blindness. It is further understood that 
the use of glasses is no remedy in amaurotic 
cases. It is rather the kind, than the degree, 
of blindness that is called amaurotic ; but it 
must be observed that lesser degrees of blind- 
ness, of the amaurotic type, are generally, 
vaguely and indefinitely, called amblyopic. 
Aetiology.-The causes of amaurosis have 
been more recently specifically attributed to 
morbid conditions of the percipient nervous 
apparatus of the eye. All cases are excluded 
in which, in the present state of science, and 
using the ophthalmoscope, we can see any 
morbid condition. But very few cases are 
now, in the statistical tables of the chief eye- 
hospitals, included under the head amau- 
rosis. Some few cases seem likely, at least 
for some time to come, to be called by this 
term. The ophthalmoscope has enabled us 
more accurately to classify a large majority of 
the cases formerly called amaurotic. Many 
new names are thus employed whereby we 
gain more definite information. If only, as in 
some of them (e.g. ' white atrophy '), we have 
substituted the name of a particular ophthal- 
moscopic sign for an indefinite symptom, at 
least we can speak more accurately of the 
part that is or has been diseased-of the 
retina, or of the ocular end of the optic nerve. 
In a large majority of the cases commonly 
classed as those of amaurosis, it is found 
ophthalmoscopically that there is ' white 
atrophy ' of the optic nerves. The ' discs ' 
are nearly or quite bloodless-white, not 
pinky-white; and. the nerve-fibres going to 
the retinae, being more or less wasted, there 
is some excavation of the discs, perhaps 
so much that the lamina cribrosa, in one or 
both, is exposed to view, while the retinal 
vessels are somewhat diminished in size. 
The causes of this condition are, most com- 
monly, intracranial tumours or other diseases 
which induce pressure upon the optic nerve, 
or lead to an extension of inflammation, 
followed by oedema or double optic neuritis 
(descending), these terminating in the atro- 
phy and amaurosis. The nerve-disease is 
often due to syphilis. But some cases of 
white atrophy occur in which there has 
been no precedent neuritis. Of such ' tobacco 
amaurosis ' is an example, in which, unless 
smoking be given up, by an idiosyncrasy of 
the patient, he soon becomes blind. But 
nerve-atrophy or inflammation should be no 
longer called amaurosis-they have obtained 
a better nomenclature. The preceding stages 
of the diseases causing them, if, as is rarely 
the case, unaccompanied by any definite 
ophthalmoscopic signs, and yet producing a 
considerable amount of blindness, may, for 
want of better knowledge, at present be 
called amaurotic. Other such cases include 
those reported as snow-blindness; those in 
which blindness has been produced by a light- 
ning-flash near the eye or by a blow on the 
eye without other mischief resulting; disuse 
of an eye in children, as in some neglected 
squint cases; irritation from some branches 
of the fifth nerve (dental caries, &c.); anaemia 
after excessive losses of blood; suppression 
of menses; blood-poisoning by tobacco, lead, 
quinine; uraemia; and some cases of cere- 
bral apoplexy. Embolism of the central 
artery of the retina occurs, but it is easy of 
diagnosis with the ophthalmoscope, and 
therefore should not be called amaurotic. 
The writer does not think there are any 
cases of long-standing blindness that show 
no ophthalmoscopic changes 
Symptoms and Diagnosis.-There is one 
symptom of amaurotic blindness, affecting 
both eyes, which is noteworthy, as consti- 
tuting, prima facie, a general distinction 
between it and the other cases of blindness 
not of nervous origin: the gait and general 
aspect of the patient are peculiar-he is hesi- 
tating and hopeless-looking. He no more 
tries to see objects. He holds up his head; the 
eyes are open and turned upwards. He feels 
his way with his feet, and his hands are ex- 
tended before him. He does not look to- 
wards you, or at anything in particular. But 
amaurosis does not by any means imply a 
similar state of vision in both eyes, nor that 
the blindness is to be taken in the ophthal- 
mological sense, i.e. wanting perception of 
light. It would be well if any less degree 
of imperfection of vision, without evident 
cause, might be called amblyopic, but the 
two eyes must be considered separately. 
To diagnose the absence or presence of a 
power of perception of light, the patient should 
be placed opposite to a bright light, such as 
a gas-lamp, and near to it, but not so near 
that he can feel the heat of it; the light is 
then turned up and down, and it is fully ex- 
posed and obscured, and the patient is asked 
many times, in quick succession, if he sees 
light or not. Any other blindness than this 
of absolute amaurosis, or originating in any 
other diseases than those of the percipient 
nervous apparatus of the eye, is never so great 
as to prevent the perception of light. If the 
patient can distinguish light from darkness, we 
next test whether he can see shadows of some 
small objects-of the hand, or of one finger 
only, passed between him and the burning 
light, or the light of the window only. If 
he can see to count fingers, his blindness 
is insufficient to indicate what is called 
amaurosis. Another point in the diagnosis 
of amaurosis is that, ophthalmoscopically, 
the appearance of the fundus of the eye is 
normal, or such as, independent of errors of AMAUROSIS 
AMBULANCE 
55 
refraction, we find in other cases compatible 
with standard vision, or at least with a fair 
amount of useful vision. This will allow of 
a considerable latitude, and will not include 
any slight or imaginary hyperaemia or an- 
aemia of the optic disc, any physiological ex- 
cavations of the same, or congenital opacities 
of the retina. The pupil of the affected 
eye is, if the other be perfectly excluded 
from light or vision, nearly always dilated to 
almost the greatest extent, though atropine 
dilates it yet more fully; and it is fixed, being 
insensible to light. 
Prognosis.-After a due consideration of 
the cases thus classed together-and they 
are very unlike in fact, and often very ob- 
scure-we may say generally, that if the 
blindness be of one eye only, sudden and 
recent, the prognosis is hopeful; but if both 
eyes are affected, and the disease, whatever 
it may be, is of steady progress and of long 
standing, it is very serious. The cases of 
amaurosis are very rare indeed in which 
vision is perfectly restored; most of them 
end fatally to vision, or would so end but 
that the disease is sooner fatal to life. 
Treatment. - This must necessarily be 
varied according to the cause of the amau- 
rotic condition. For instance, if there is 
intracranial disease, treatment directed there- 
to must be followed out; and should there 
be indications of syphilis, iodide of potas- 
sium and small doses of mercury must 
be given for some time. When amaurosis 
depends on any injurious habit, such as 
smoking, this must be relinquished. Large 
doses of strychnine and iron are useful in 
advanced white atrophy. 
J. F. Streatfeild. 
AMBLYOPIA (auf^vwtrla, dim-sighted- 
ness).-Obscurity of vision. See Amaurosis. 
AMBULANCE (ambulo, I move about). 
Synon. : Fr. Ambulance ; Ger. Feldlazareth. 
Definition.-A term adopted from the 
French word, which signifies the movable 
hospital of an army. 
The use of an ambulance is to convey from 
place to place those who are sick, wounded, 
or otherwise incapable of moving. 
Description.-An ambulance consists of a 
vehicle or caravan, upon or within which one 
or more stretchers can be laid or fixed. 
Stretchers.-It is important that stretchers 
should be of uniform pattern, so as to admit 
of easy transference from one carriage to 
another. Each stretcher consists of two 
poles kept apart by metal traverses, support- 
ing a canvas stretched between. The length 
of a stretcher (7 ft. 9in.) is often inconvenient 
when conveying a patient through passages or 
up staircases. To obviate this difficulty, the 
poles of stretchers used for civil ambulances 
should be made of metal tube capable of 
being telescoped. 
The vehicles or carriage-frames are of two 
kinds: (1) those for hand ambulances; and 
(2) those for horse ambulances. 
1. Hand ambulances, or litters, of which 
there are several varieties, consist of a 
skeleton carriage, firmly supported on easy 
springs, and provided with two, three, or four 
wheels. 
Upon a framework thus formed, the 
stretcher fits; and is immovably fixed by 
straps or bolts. The carriage is made with a 
view to convenience of size and lightness of 
structure, consistently with strength. Facility 
in turning should be secured. A complete 
covering or hood protects the patient from 
exposure. In all ambulances special care 
should be taken, by springs and other con- 
trivances, to prevent the suffering caused by 
jolting. 
2. Horse ambulances are used for (a) civil, 
and (b) military purposes. 
(a) The first of these, as used in towns, are 
drawn by one horse. They usually consist 
of coaches which are unlined, so as to allow of 
washing and complete disinfection. One or 
two doors are placed behind, through which 
a stretcher or bed may slide on to a shelf, 
occupying about one lateral half of the interior 
of the coach. A seat for an attendant com- 
pletes the fittings. 
Ambulances for civil purposes should be 
easily obtainable at hospitals, police-stations, 
and other recognised centres. 
(6) Military ambulances, more commonly 
termed ambulance waggons, consist of a wood- 
framed body provided with a cover, curtains, 
and hood of canvas extended on a skeleton- 
framed roof. They carry likewise a reservoir 
for water. These ambulances are drawn by 
two or more horses. In the English army 
they are arranged to carry two patients on 
stretchers, and five others less seriously 
injured, two in front and three behind. In 
the German army they accommodate four 
stretchers-two on the floor of the waggon, 
and two on a plane above-besides five other 
persons slightly wounded. 
Ambulance Field Hospital. - Captain 
Tomkins, of the Victoria Rifles, and the 
writer have designed an ambulance waggon 
which supports on its exterior a folding 
double tent 35 x 22 feet. Twenty folded 
stretchers, each convertible into a bedstead, 
one foot high by two feet two inches wide, 
line the sides of the waggon. There are 
also provided the requisites for twenty beds, 
surgical instruments and appliances, a fur- 
nace for cooking and for warming the tent 
in winter, together with rations for three 
days. This arrangement obviates the neces- 
sity for assistance from the main army. 
For this Hospital the Empress Augusta 
Prize and Gold Medal for prompt assistance 
to the wounded on the field of battle were 
awarded. A. T. Norton. 56 
AMBULANT 
ANAEMIA 
AMBULANT (ambulo, I move about). 
Moving, unfixed, shifting. Applied to dis- 
eases that shift from one part to another, 
such as erysipelas; in connexion with 
blisters applied in succession to different 
parts of the body, also called ' flying 
blisters'; and to moving or 'field' 
hospitals, as distinguished from fixed or 
' base ' hospitals. 
AMBULATORY (ambulo, I move 
about).-A term used in connexion with mild 
or latent cases of acute diseases, in which the 
patient continues to walk about, or work, up 
to a late period of the attack, as in typhoid 
fever-typhus ambulans s. ambulatorius. 
See Typhoid Fever. 
AMELIE-LES-BAINS, in France 
(Pyrenees).-Thermal sulphur waters and 
climatic health-resort. See Mineral Waters, 
and Climate, Treatment of Disease by. 
AMENORRHCEA (a, priv.; pyv, a 
month; and pew, I flow).-Absence of the 
menstrual flow during any portion of the 
period of life when it ought to be present. 
See Menstruation, Disorders of. 
AMENORRHCEAL INSANITY.- 
See Insanity. 
AMENTIA (a, priv.; and pi t'os, the 
mind).- An obsolete term for dementia. 
See Dementia. 
AMNESIA (apvryria, forgetfulness; Fr. 
Amnesic ; Ger. Geddchtnisswache).-A gene- 
ral term signifying loss or defect of memory; 
commonly, however, used in reference to one 
particular class of defect of memory, viz., that 
for words (amnesia verbalis). Sometimes 
there is a mere forgetfulness of proper names; 
sometimes a substitution of wrong words; at 
other times the pronunciation of a meaning- 
less jargon, not at all representing words. The 
production of these defects is due to disease 
in different parts of the brain, owing to the 
memories of words being threefold-auditory, 
visual, and kinaesthetic. See Aphasia. 
AMCEBA COLI.-A species of amoeba, 
found in connexion with ulceration of the 
colon and with tropical abscess of the liver. 
See Entozoa. 
AMPHORIC.-A peculiar hollow metal- 
lic sound, elicited occasionally by percussion, 
but more commonly heard in auscultation. 
Amphoric breath-sound resembles that pro- 
duced by blowing into an empty glass or 
metallic vessel with a narrow neck (am- 
phora). See Physical Examination. 
AMYGDALITIS (amygdala, the ton- 
sils).-A synonym for inflammation of the 
tonsils. See Tonsils, Diseases of. 
AMYLOID DISEASE (dpv\ov, starch). 
The name given by Virchow to albuminoid 
disease, from the belief that the material 
characteristic of this morbid condition is of 
the nature of starch or cellulose. See 
Albuminoid Disease. 
AMYOTROPHIC (a, priv.; pvs, a 
muscle; and rpo^y, nutrition).-Associated 
with muscular wasting. See Spinal Cord, 
Diseases of. 
ANEMIA (a, priv.; and atpa, blood).- 
Synon. : Spaneemia; Hydraemia; Oligaemia ; 
Aglobulism. Fr. Anemic; Ger. Andmie; 
Blutarmuth. 
Definition. - Deficiency of blood in 
quantity, either general or local ; also, 
deficiency of the most important constituents 
of the blood, particularly albuminous sub- 
stances and red corpuscles. 
This definition is purely pathological, and 
the condition thus expressed presents many 
varieties, anaemia in the widest sense of the 
term including oligaemia, oligocythaemia, 
hydraemia, and spanaemia, as well as 
chlorosis (see Chlorosis, Hydremia, 
Spanaemia, Oligocythemia ; and Blood, 
Morbid Conditions of). From the clinical 
point of view, anaemia is a condition of 
system in which impoverishment of the 
blood, whether from want or from waste, is 
associated with symptoms of imperfect dis- 
charge of the vital functions. 
^Etiology.-The causes of anaemia are 
generally multiple and complex. First, the 
supply of blood to the body may be insuf- 
ficient, and that from a variety of causes, 
of which the chief are :-derangements of 
alimentation, including insufficient food, 
constipation, and morbid states of the 
lymphatic and blood-glands; such defective 
hygienic conditions affecting the formation 
and nutrition of the blood as want of light, 
air, and muscular exercise; prolonged 
exposure to the influence of certain poisons, 
as lead, mercury, and malaria; and, lastly, 
interference with the free circulation of the 
blood by cardiac or vascular disease, such as 
valvular disease or dilatation of the heart and 
aneurysm of the aorta. Secondly, the con- 
sumption of blood may be increased by 
haemorrhage; by profuse discharges, such as 
suppuration, catarrh, and albuminuria; by 
rapid growth and development; by frequent 
pregnancy and superlactation; by excessive 
muscular exertion; and by the presence of 
pyrexia, or of new growths, which rob the 
system of nutritive material. In a third 
group of cases of anaemia both the supply 
and the consumption are at fault. Thus 
derangement of the organs and of the 
whole process of sanguification is frequently 
associated with profuse discharges from 
various parts; and in acute febrile diseases, 
malignant diseases, and the ' chronic consti- 
tutional diseases,' such as syphilis, tuber- 
culosis, Bright's disease, albuminoid disease, 
Addison's disease, and others, the cause of 
the anaemia is extremely complex. But the 
majority of the cases of anaemia that are ANAEMIA 
57 
regarded and treated as such, fall into the 
class to which the name of idiopathic has 
been applied. In such cases the anaemic 
condition is due, not to any disease so called, 
but to disturbance of nutrition generally- 
that is, of the healthy relation between the 
demands of the system and the supply of 
nutrient material. This condition occurs 
chiefly in children and young women, at the 
period of bodily growth and of the develop- 
ment and early activity of the sexual 
functions; and when, as so frequently and 
unfortunately happens, the air, light, food, 
occupation, and nervous relations of the 
individual are all more or less unhealthy. 
Anatomical Characters.-The blood suf- 
fers three principal changes in declared 
anaemia, namely: (1) deficiency in amount 
(oligaemia); (2) deficiency in red corpuscles 
or haemoglobin (oligocythaemia, aglobulism); 
and (3) deficiency in albuminous constituents 
(hypalbuminosis). Of these oligaemia is the 
simplest, and perhaps never occurs alone ; 
it is speedily complicated with aglobulism, 
which is a very early and common, as well 
as the most obstinate, change in the blood. 
Hypalbuminosis is the most advanced and 
perhaps the most serious alteration of the 
three (see Blood, Morbid Conditions of). 
The blood is scanty and pale ; has a 
diminished specific gravity; and coagulates 
slowly and loosely, or in aggravated cases 
not at all, settling into three layers-consist- 
ing respectively of red corpuscles, white 
corpuscles, and plasma. The body presents 
certain changes directly due to the state of 
the blood. Whether the anaemia be local or 
general, the corresponding parts are blanched 
and ' bloodless.' The cells of the tissues 
become atrophied and degenerate, in con- 
sequence of, and in proportion to, the inter- 
ference with their plastic and functional 
activity respectively; and the so-called 
' anaemic ' form of fatty heart, liver, kidneys, 
and other organs, is the result. If death 
occur suddenly from acute anaemia, the heart 
is found empty and contracted. 
Pathology.-When the volume of blood 
in the body has been reduced by repeated 
small haemorrhages, the phenomena that 
supervene, whilst they express the want of 
blood as a whole, and of its several con- 
stituents, are chiefly referable to the loss of 
two of these constituents-the albuminous 
substances and the red corpuscles or haemo- 
globin, that is, of the oxidisable and the 
oxidising materials. The pathology of hyp- 
albuminosis and aglobulism is fully discussed 
in the article on the morbid conditions of 
the blood, to which the reader is referred. 
The same effects will be produced by a drain 
of the liquid part only of the blood, or by 
poverty of the blood from any of the causes 
enumerated above, whether of the nature of 
waste or of want; inasmuch as loss of plasma 
speedily affects the nutrition of the red cor- 
puscles. These phenomena constitute the 
symptoms of the anaemic condition whatever 
may be its cause; their relative prominence 
naturally varying according to an immense 
number of circumstances. 
Symptoms.-The subjects of anaemia are 
usually girls and young women. Their 
general appearance, which is striking, is one 
of pallor, debility, and variable loss of 
feminine fulness. The visible parts of the 
surface are pallid, often with a tinge of dusky 
brown on the eyelids and the backs of the 
hands; the clearness of the complexion 
varies with the normal pigmentation of the 
body; the skin is soft, satiny, and rather 
loose. The mucous surfaces also are blanched ; 
the sclerotic is pearly blue. The loss of flesh 
may be moderate, or it may be considerable. 
The extremities are cold, and the legs and 
lower eyelids are often cedematous. Pyrexia 
is occasionally present, the temperature rising 
as high as 102° Fah. or even more. Bodily 
strength is reduced; muscular force is dimin- 
ished, while myalgia is common; an air of 
languor and want of vigour pervades the 
whole demeanour; and the patient is sleepy, 
dull, and depressed. The subject of anaemia 
generally complains of weakness, various 
pains about the body and head, and marked 
shortness of breath on the least exertion. The 
last symptom is unaccompanied by other 
evidence of respiratory derangement; in 
character the breathing is regular, and short 
or even panting. The symptoms referable to 
the circulation consist chiefly of palpitation 
on exertion; a tendency to faint; and pain 
or distress over the cardiac region. The 
physical signs indicate cardiac enlargement of 
variable degree. A rough systolic murmur is 
usually heard over the pulmonary artery; 
a soft systolic murmur at the aortic base, in 
the mitral area, possibly over the whole prse- 
cordia, and even at the scapular apex; the 
second sound is often universally accentuated. 
Over the cervical vessels a systolic murmur 
is commonly audible, followed by a sharp 
sound; in the neck a loud venous hum. The 
cervical vessels may throb ; the radial pulse 
is small, weak, and of variable but usually 
increased frequency and suddenness. There 
is a tendency to haemorrhages, especially 
epistaxis; and petechiae are occasionally ob- 
served. The digestive system is markedly 
affected, as shown by loss or perversion of 
appetite; an anaemic, often bare, but variable 
tongue; dyspepsia, nausea, and sickness 
after meals or on rising; and constipation, 
which is present in the majority of cases, 
and is frequently prolonged and severe. The 
menstrual functions are almost always de- 
ranged : amenorrhoea is common, in some 
form; menorrhagia is rare (except as a 
cause of anaemia); dysmenorrhoea is fre- 
quently associated; and leucorrhcea is the 
rule. The urine varies greatly. Headache, 
tinnitus aurium, and other cerebral symptoms 58 
ANAEMIA 
are common. There may be swelling of the 
optic disc. Blood drawn from the finger 
presents aglobulism. See Hemacytometer. 
Course and Terminations.-The course 
of anaemia in this form is essentially slow and 
progressive, unless it is checked; the duration 
is perfectly indefinite. The course of the 
symptomatic form will naturally vary with its 
cause. Idiopathic anaemia rarely terminates 
fatally; and, when it does so, the event 
may be referred, with few exceptions, to some 
complication. Occasionally, however, it pro- 
gresses steadily to death. See Anemia, Per- 
nicious. 
Intercurrent diseases may be expected to 
be severe in an anaemic condition, in propor- 
tion to its degree. 
Diagnosis.-Anaemia is generally recog- 
nised with the greatest ease, and the chief 
question - of diagnosis relates to its cause. 
The first point to be determined, therefore, is 
whether it is not symptomatic of some more 
grave state, such as tuberculosis, syphilis, 
albuminoid disease, or some other of the 
many possible causes of poverty of blood. 
Having settled that the anaemia is idiopathic, 
we must next exclude two diseases with 
which it may be confounded, namely chlorosis 
and leukaemia. Chlorosis, in which the 
plasma is not considered to be altered, and 
which possesses otherwise a special pathology, 
is expressed by the yellow tint of skin, by 
the absence of wasting and of dropsy, as well 
as by other features (see Chlorosis). The 
diagnosis of pernicious anaemia is fully given 
in the article on that subject. Leukaemia is 
recognised by examination of the blood and 
spleen. The starting-point of the blood- 
change in idiopathic anaemia can only be 
discovered by investigation of all the facts of 
the case. 
Prognosis.-The prognosis of anaemia is 
favourable as regards life. In simple anaemia 
from loss of blood, the patient may be assured 
of speedy and complete recovery. In idio- 
pathic anaemia, however, this promise can be 
given only when the cause can be removed 
or avoided. Under favourable circumstances 
and judicious treatment, improvement will 
begin almost immediately; and health should 
be restored after a few weeks or months. 
Treatment.- The treatment of anaemia, 
when it is symptomatic of some more grave 
condition, such as Bright's disease or phthisis, 
does not require notice here. When blood has 
been lost in serious quantity, without other 
injury of consequence, it will be naturally 
restored if but sufficient time be given, and 
interference otherwise avoided. Attention 
to the ordinary rules of health, abundance 
of food and air, and moderate exercise, will 
surely, if slowly, restore the patient, without 
the administration of a single drug. Even 
in this case, however, treatment may be of 
great service, by arresting, if necessary, the 
cause of the anaemia, such as menorrhagia or 
epistaxis ; and by assisting nature, if the con- 
dition should threaten at any time to become 
intensified by its own effects. 
But before the blood can be restored in the 
large and ill-defined group of cases known as 
idiopathic anaemia, the unhealthy influences 
under which the patient is placed, and the 
functional and other derangements, which 
are usually accountable for the imperfect 
sanguification, must be discovered and cor- 
rected. Each case must be treated on its 
own merits, routine being avoided. Where 
the aetiology is complex, treatment must be 
equally general, and the whole system of 
life will have to be reformed. On the other 
hand, in the rapidly growing child and youth, 
and still more in girls at puberty, the great 
demand for nutritive material must be duly 
considered, and every obstacle to its supply 
removed. When other than direct discharges 
are draining the blood they must be checked. 
Lactation may have to be forbidden; and 
leucorrhcea and spermatorrhoea will some- 
times demand local treatment. 
The removal of the cause being thus made 
the first element in treatment, means must 
next be adopted for the restoration of the 
blood. To accomplish this, it will be neces- 
sary to bring the alimentary tract and the 
organs of sanguification into a healthy state. 
Dyspepsia and constipation require imme- 
diate treatment. The best plan is to begin 
with a brisk purge, and to follow this up 
with a course of iron and aloes (in various 
combinations) every night, the pill form being 
generally preferred, so as to secure one, and 
only one, daily evacuation of the bow'els. 
Therewith a bitter and alkaline stomachic 
mixture may be given before meals for a few 
weeks. The food must be carefully ordered, 
so that it shall not only supply the albu- 
minous elements that are specially deficient 
in the blood, but be retained, digested, and 
absorbed. 
The process of sanguification may be suc- 
cessfully assisted by means of drugs. Iron 
is the sovereign remedy for aglobulism ; and, 
practically speaking, it speedily becomes a 
question in the medicinal treatment of a case 
of anaemia in what form iron is to be given. 
The compound iron mixture of the pharma- 
copoeia, perhaps, answers more frequently 
than any other; but, on the one hand, when 
there is constipation, as is so often the case, 
combinations of aloes and iron in pill, or a 
mixture containing the protosulphate with 
purgative saline sulphates, will be more suit- 
able for a time; on the other hand, when 
there is a tendency to discharges, the per- 
salts with bitters, combined, if necessary, 
with sulphate of magnesium, will answer the 
purpose better. Compounds of iron with 
quinine or strychnine should be given in cases 
where less marked anaemia occurs in older 
subjects, with nervous depression and general 
want of vigour. In special cases the ferrum red actum, saccharated carbonat e, or the vinum 
ferri (with compound decoction of aloes in 
constipated subjects), ammonio-citrate of 
iron, or Blaud's pill may be ordered. Some 
patients cannot take iron except in the effer- 
vescing form; others only if it is presented 
to them highly diluted-for instance, as a few 
drops of the tincture of the perchloride in a 
glass of water. To meet this difficulty, as 
well as to secure the benefit of many other 
recuperative influences, a course of chalybeate 
waters may be the best means that can be 
devised (see Mineral Waters). The addi- 
tion of arsenic to the iron is invaluable in 
many cases ; in other instances arsenic alone, 
given as Fowler's solution, proves eminently 
successful after iron has failed. According 
to some authorities, manganese assists the 
action of iron. Cod-liver oil is sometimes pre- 
scribed with success. Other symptoms must 
be treated on ordinary principles. Uterine 
complaints demand special attention; and 
bromides, ergot, opium, and other sedatives 
and astringents are indicated where excite- 
ment and excessive discharge are present. 
Whilst these dietetic and medicinal mea- 
sures are being carried out, it is impossible 
to insist too strongly upon attention to bodily 
and mental hygiene : the use of the tepid 
morning bath; the proper disposal of time in 
relation to exercise, education, and amuse- 
ment; healthy clothing, or rather 'dress'; 
the avoidance of unwholesome excitement; 
early hours, and sufficient sleep. In a large 
number of cases change of air fulfils many 
of these conditions. On the other hand, in 
acute anaemia, as well as in severe cases of 
every kind, rest in bed is imperative for a few 
days. Time is an essential element in the 
cure. A frequent change in the form of the 
medicinal remedies is also advisable. 
J. Mitchell Bruce. 
ANAEMIA, LYMPHATIC.-A form 
of anaemia which is associated with a pecu- 
liar affection of the lymphatic system. See 
Lymphadenoma. 
ANJEMIA, PERNICIOUS.-Synon.: 
Fr. Anemic pernicieuse progressive ; Ger. 
Progressive pernicidse Andmie. 
Definition. - A progressive haemolytic 
process affecting both sexes, especially in 
middle life, characterised by fatty degenera- 
tion of the heart and retinal haemorrhages, 
and in nearly all cases terminating fatally. 
Pernicious anaemia includes two varieties : 
the primary, essential, or 'idiopathic anaemia' 
of Addison ; and the deuteropathic, symptom- 
atic, or secondary anaemia of German authors. 
The clinical symptoms in the two varieties 
are, on the whole, alike. Whilst it is possible 
that pernicious anaemia is really not a dis- 
ease per se, but a group of symptoms, yet for 
clinical purposes these symptoms are con- 
stant enough to constitute a distinct disease. 
./Etiology. - Pernicious anaemia occurs 
ANEMIA 
about equally in men and women, unless we 
include all cases of fatal or severe anaemia 
secondary to uterine haemorrhage. In women 
the disease is most frequently met with 
between the ages of 20 and 40 (the period of 
child-bearing), whereas in men it occurs most 
frequently between 40 and 60. The youngest 
age on record is 7, the oldest is 68. Although 
the disease is more common among country 
people than town-dwellers, this cannot be 
ascribed to their respective occupations. 
Among the better classes the disease is 
uncommon; when it does occur, no cause 
can be ascertained, excepting, in a few in- 
stances, mental worry, grief, or fright. It 
occurs with especial frequency in countries 
the inhabitants of which are poor and in- 
sufficiently supplied with food, particularly 
nitrogenous food, and who live in small, 
overcrowded, badly lighted, and ill-ventilated 
houses. On this account a great number of 
cases have been recorded by Swiss observers 
-Biermer, Quincke, and others. Repeated 
pregnancies, especially in women who are 
badly nourished or suffer from ordinary blood- 
lessness, are also a cause of pernicious anae- 
mia. It seldom affects primiparae. Excessive 
lactation, severe puerperal or other haemor- 
rhages, dyspepsia, and the uncontrollable 
vomiting frequently met with during preg- 
nancy, are considered by many authors among 
the causes of the secondary form of this 
disease. Some German authorities include 
parasites, such as the Ankylostoma duode- 
nale and the Bothriocephalus latus. Malaria 
and yellow fever have also been antecedent to 
this form of anaemia; and Muller has lately 
called attention to the connexion of constitu- 
tional syphilis with this disease. 
Anatomical Characters. - The appear- 
ances of the organs after death from this 
disease are the result of the anaemia. The 
skin may be pale, or presents a lemon-yellow 
colour. As a rule the body is not emaciated; 
and on section a thick layer of subcutaneous 
fat, of canary-yellow colour, is usually found. 
The muscles are of good colour. The heart and 
the great vessels contain but little blood, and 
that of a pale colour and often uncoagulated. 
The heart itself presents well-marked fatty 
degeneration, having the characteristic ' tabby 
cat ' appearance. The fatty degeneration 
affects the ventricles more than the auricles, 
the left ventricle more than the right, and 
the musculi papillares more than any other 
part. This is the most constant of the morbid 
anatomical conditions. The cavities are some- 
times dilated; the valves normal. Flecks of 
fatty degeneration are commonly seen affect- 
ing the intima of the large arteries, and the 
same change probably occurs in the capillary 
vessels, explaining perhaps the occurrence of 
petechise and retinal heemorrhages. Small 
ecchymoses occur in the brain, serous mem- 
branes, and elsewhere. Passive effusions into 
the serous cavities are not uncommon. 
ANEMIA, PERNICIOUS 
59 60 
ANAEMIA, PERNICIOUS 
All the organs of the body, with the excep- 
tion of the spleen, look very pale, as if their 
vessels had been washed out with water. 
The liver is generally fatty; not much 
enlarged. The spleen may be normal, small, 
or somewhat enlarged, but never attains 
great dimensions, as in leukaemia. The 
kidneys are pale, often showing slight fatty 
change. The mucous membrane of the 
stomach and intestines often exhibits haemor- 
rhagic erosions; and atrophy of the tubular 
glands of the former has been described. 
The marrow of the bones has been found 
normal in the majority of cases, but in some 
the yellow marrow has been replaced by 
red-probably a result of the disease rather 
than the cause of it. This indicates per- 
haps an effort on the part of this blood- 
elaborating tissue to take an unusually 
active part in the formation of red cor- 
puscles, to compensate for their excessive 
disintegration. 
Symptoms.-The following are the symp- 
toms which are, as a rule, present in most of 
the well-marked cases of pernicious anaemia. 
The patient suffers from weariness, lassitude, 
headache, vertigo, and dizziness, with faint- 
ness, palpitation, and breathlessness on exer- 
tion. These symptoms make their approach 
in so slow and insidious a manner that the 
patient is unable to fix the date of their onset, 
and probably will not seek medical advice 
until he is incapacitated for mental or bodily 
work. 
The aspect of the patient is characteristic: 
the mucous membranes are pale; the skin is 
usually of a light lemon-yellow colour, ' like 
white wax changed by age.' The conjunc- 
tivae are white, though the presence of yellow 
fat beneath might lead a careless observer to 
believe there was slight jaundice. The patient 
is seldom emaciated; indeed the subcu- 
taneous fat may be in considerable quantity. 
There is often slight oedema of the lower 
eyelids and of the feet, but these symptoms 
are generally late in appearing. The in- 
tellect is usually unimpaired, but answers 
to questions are slow, apathetic, and delivered 
in a low tone of voice, sometimes interrupted 
by long-drawn sighs. Sleep is occasionally, 
but not usually, heavy, insomnia being a 
more constant symptom. The tongue is pale, 
smooth, and dry; the breath offensive, with 
a cadaveric odour in severe cases. Stomatitis 
and bleeding gums are sometimes met with. 
In many cases dyspepsia, flatulent eructa- 
tions, vomiting, and a painful sinking feeling 
at the epigastrium are prominent symptoms. 
These gastric disturbances are attributed by 
certain authorities to irritation of the cerebral 
centres by anaemia, by others to atrophy of 
the gastric glands. Usually there is anorexia 
and nausea, but some patients eat well or 
even to excess. Constipation or diarrhoea 
may occur, but usually the stools are of 
normal colour. Dyspnoea is sometimes the 
first symptom complained of. The breath- 
ing is generally accelerated, and, in advanced 
cases, is deep and noisy. The laboured 
breathing increases with the diminution of 
haemoglobin, but not so rapidly as other 
symptoms, and is often absent as long as 
the patient is at rest. The action of the 
heart is regular and quick. Sometimes there 
is visible evidence of dilatation, the impulse 
being diffused, and the area of praecordial 
dulness being increased laterally. Systolic 
murmurs are heard over the cardiac region, 
sometimes loudest at the base, sometimes 
at the apex. A venous bruit in the neck is 
generally present. The pulse ranges between 
100 and 120, and is regular, compressible, 
not small, often jerky, and possibly dicrotic. 
One of the most striking clinical features 
of pernicious anaemia is the supervention of 
haemorrhages. Epistaxis, menorrhagia, some- 
times cerebral haemorrhage, and towards 
the close of life petechial haemorrhages and 
purpuric eruptions, may occur; but by far 
the most important are retinal haemorrhages, 
because they serve as a diagnostic symptom 
of the greatest value. 
The condition of the optic disc is shown 
in the accompanying figure (fig. 2). The 
fundus is pale, the arteries are narrow, the 
veins broad; the haemorrhages are generally 
multiple, and flame-shaped, from their situa- 
tion in the layer of nerve-fibres. They appear 
as linear striae, rounded spots, or patches, 
clustered around the optic disc, and may 
have whitish or yellowish centres, due in 
part to leucocytes, in part to degeneration. 
These haemorrhages may be quickly absorbed, 
often lasting only a few weeks. There may 
be no disturbance of vision, unless the hae- 
morrhage is situated in the maculae luteae. 
In all the six cases observed by the writer 
retinal haemorrhages have been present. 
Fig. 2.-Retinal haemorrhage. After Quincke. ANEMIA, PERNICIOUS 
61 
More or less pyrexia is the rule in per- 
nicious anaemia. It may be continuous for 
months, the evening temperature reaching 
100°-101° Fah.; or it may be intermittent 
with sudden exacerbations. Occasionally the 
temperature may rise to 105° or 106° Fah. 
On the other hand, it may fall even as much 
as 10° below normal previous to death. 
The state of the urine requires careful 
consideration. The quantity may be normal, 
except at the close of life, when it is often 
considerably diminished. It seldcm contains 
albumin and never sugar. It is often of a 
deep colour, containing excess of urobilin, 
and there may be a direct association be- 
tween the depth of colour and the haemolytic 
process. In other instances, however, it is 
quite pale. The amount of nitrogen excreted 
per diem may be less than normal; but, as 
a rule, it is more than can be accounted for 
by the nitrogenous ingesta. Consequently 
it must be derived from the excessive waste 
of blood and tissue; but an incomplete oxi- 
dation of the nitrogenous substances leads 
to an excretion of urea and a deposition of 
fat. Uric acid often occurs in considerable 
quantities ; indican, pathological urobilin, 
and pentamethylene-diamine have also been 
found in the urine, suggesting a morbid pro- 
cess in the gastro-intestinal tract. Free iron 
has been discovered in the urine by Dr. 
William Hunter. 
Blood.-Notwithstanding its name, the 
blood in pernicious anaemia presents no 
changes absolutely characteristic of the dis- 
ease. When drawn, it appears pale and 
watery, and the specific gravity is often greatly 
reduced. Examined microscopically, it in- 
variably shows a considerable diminution in 
the number of red corpuscles, which may be 
reduced to 500,000 per c.mm.-of the 
normal or even less-in the last stages of the 
disease. Generally there is a striking varia- 
tion in the form and size of many of the red 
corpuscles, as shown in the accompanying 
figure (fig. 3). It will be seen that some are 
much larger than normal (macrocytes); these 
are nucleated. Many, again, are pear-shaped 
or have an irregular contour (poikilocytes). 
And, finally, there are to be seen numbers 
of small, imperfectly developed corpuscles 
(microcytes). The corpuscles are usually of 
good colour. There is no leukaemia, but gra- 
nular masses are common. Hayem holds that 
the presence of nucleated red corpuscles is a 
grave omen. There is a great diminution of 
haemoglobin in the blood-sometimes in 
proportion to the falling-off in numbers of 
the corpuscles ; but, owing to many of the 
corpuscles being more highly charged with 
colouring matter than normal, the haemo- 
globin value of the blood may be excessive in 
relation to the number of the corpuscles. 
The spleen and liver are in some cases 
enlarged, especially the former. There is 
also evidence of affection of another impor- 
tant structure connected with the elabora- 
tion of the blood-namely, the bones. These 
Fig. 8.-Microscopical appearances of the red blood- 
corpuscles in pernicious anaamia. After Quincke. 
Magnified 750 diameters. 
may be tender, and the sternum is especially 
liable to be so affected. 
Course, Duration, Terminations, and 
Prognosis.-Of 110 cases collected by Dr. 
Sidney Coupland, the total duration of the 
symptoms in 52 was from 1 to 6 months; 
in 24 from 6 to 12 months; in 25 from 1 to 2 
years; in the remaining 12 cases they lasted 
for periods of over 2 years. Of 130 cases of 
primary idiopathic anaemia collected by Dr. 
Pye-Smith, 30 are said to have recovered. 
Death is usually the result simply of anaemia, 
and special complications are exceptional. 
The prostration and weakness increase; the 
headache, vertigo, and vomiting become more 
distressing; the breathing becomes hurried, 
laboured, and deep (' air hunger '); the car- 
diac palpitation is more marked; and the 
patient usually falls into a deep, drowsy, 
lethargic state, either lying impassive, or 
tossing about in restless delirium, but ceasing 
to take interest in anything. Occasionally 
the patient remains conscious to the last, 
unable to sleep, and feeling utterly miserable 
and dejected, in consequence of the distress- 
ing headache and vomiting. Death may 
occasionally occur suddenly from syncope. 
Some authors dispute the possibility of 
true pernicious anaemia being cured, and urge 
that those cases which recover cannot be 
considered ' pernicious.' The prognosis is 
always grave, if not absolutely bad; and 
even when a patient improves under treat- 
ment, and the condition of the blood would 
give hopes of a cure, a guarded opinion 
should always be given ; for a fresh exacer- 
bation of pyrexia, with haemolysis, and a 
return of the symptoms in an aggravated 
form, generally occur without any apparent 
cause. 
Pathology.-The term ' idiopathic anaemia' 
in our medical nomenclature is an indication 
that our pathological knowledge of this 
disease is still involved in obscurity. The 
examination of the blood and urine during 62 
ANEMIA, PERNICIOUS 
life, taken in conjunction with changes found 
in certain organs and tissues after death, 
has thrown some light upon the disease. In 
health there is a constant equilibration be- 
tween haemogenesis and haemolysis. The 
pigment of the urine-urobilin, and the 
pigment of the faeces-stercobilin, are both 
iron-free derivatives of haemoglobin. It was 
first shown by various observers that the urine 
of pernicious anaemia contains an excess of 
urobilin, and the writer has been able to 
confirm this in two cases. Quincke has 
shown that there is an excess of free iron in 
the liver, and to a less degree in the pancreas 
and kidney. These organs sometimes ap- 
pear slaty-black at the necropsy, from the 
action of sulphuretted hydrogen upon the 
free iron. If sections are placed in solution 
of ferrocyanide of potassium acidulated 
with hydrochloric acid, they turn blue, owing 
to the formation of Prussian blue. The 
following is an analysis made for the writer 
by Mr. Vasey, F.C.S., showing the amount 
of free iron contained in the organs. 
yet many of the symptoms-viz. the gastro- 
intestinal disturbances, the peculiar cadaveric 
odour of the breath, the irregular attacks of 
pyrexia, and the presence of indican and other 
bodies in the urine-suggest the absorption by 
the portal circulation of some poison connected 
perhaps with the growth of micro-organisms. 
It has been shown that the blood in per- 
nicious anaemia, as in many septic diseases, 
after being drawn, allows haemoglobin crystals 
to form spontaneously. When arsenic is ad- 
ministered, the blood is said to lose this pro- 
perty, suggesting an explanation of the value 
of the drug in the treatment of the disease. 
Again, if putrid serum be added to healthy 
blood, crystals of haemoglobin form. It is 
possible therefore that some septic poison 
sets up a haemolytic process in the portal cir 
culation, and that the haemoglobin is broken 
up in the liver-into urobilin, which escapes 
by the urine, and free iron, which remains 
in the cells and capillaries of the portal zone. 
The urobilin, which passes from the hepatic 
veins into the general circulation, gives rise 
before its excretion to the lemon-yellow colour 
of the skin and fat (urobilin jaundice). 
Dr. Delepine considers that the liver 
possesses a ferrogenic function, and suggests 
that in pernicious anaemia there may be an 
exaggeration of this physiological process. 
It would thus be analogous to diabetes in 
relation to the glycogenic function of the 
same organ. 
It is necessary to add that some authors 
do not believe this to be a disease per se, but • 
only a grave form of chlorosis or a pseudo- 
leukaemia of the myelogenic variety. 
Diagnosis.-The principal diagnostic fea- 
tures of pernicious anaemia are the following : 
(1) the patient is middle-aged; and, except 
in the case of women, there is nothing to 
account for the onset of the disease; (2) the 
absence of any organic disease ; (3) the severe 
and progressive anaemia; (4) the great dimi- 
nution of the corpuscles and colouring matter 
of the blood; (5) alteration in the shape 
and size of the corpuscles ; (G) signs of fatty 
degeneration of the heart, without arterial 
degeneration or valvular disease ; (7) retinal 
haemorrhages; (8) irregular and occasional 
pyrexia; (9) no emaciation, but frequently 
rather an excess of subcutaneous fat; (10) 
lemon - yellow coloured sk'n and high- 
coloured urine. 
The diseases for which pernicious anaemia 
has been mistaken are Bright's disease, 
ulcerative endocarditis, tuberculosis, Addi- 
son's disease, cirrhosis of the liver, cancer of 
the stomach and malignant disease of other 
internal organs, chronic ulcer of the stomach, 
parasitic affections, such as ankylostoma duo- 
denale, and pseudo-leukaemia myelogenica. 
It ought not to be confused with simple 
idiopathic anaemia or chlorosis, as it occurs 
at an age when these diseases are less likely 
to be met with. 
„ Organ 
Weight in 
gi amines 
Percentage of 
ferric oxide in 
organ 
Total ferric oxide 
in the whole organ 
1 Total ash in the 
whole organ 
Percentage of ferric 
oxide in whole organ 
Anaemic liver . 
1240 
•29 
3-60 
1-05 
27-20 
„ kidney 
282 
Traces 
-- 
1'25 
- 
„ spleen 
141 
Traces 
- 
•90 
- 
Traces; along 
Normal liver . 
- 
with distinct I 
traces of [ 
116 
- 
copper ) 
It has been said that this is merely the 
iron which has been administered medicinally, 
but the accompanying wood-cut (fig. 4) re- 
Fig. 4.-Section of the liver after treatment with 
ferrocyanide of potassium solution and hydro- 
chloric acid. The dark shading indicates the 
deposit of iron in the portal zone. Magnified 75 
diameters. 
presents a section of the liver from a patient 
who had not taken iron for six months. 
Although no specific organisms have been 
found in the blood or organs in this disease, ANAEMIA, PERNICIOUS 
ANAESTHETICS 
63 
Treatment.-Iron preparations are abso- 
lutely useless in pernicious anaemia, and 
cases have been recorded in which they have 
proved injurious. Dr. Byrom Bramwell 
introduced the employment of arsenic, and 
most of the recorded cases of recovery have 
been treated with this drug. Although it is 
not a specific, it does good in nearly all cases, 
for if it does not cure the patient it generally 
prolongs life. Liquor arsenicalis should be 
given in 3-minim doses, rapidly increased to 
10 minims, three times a day; and if it 
cannot be tolerated, on account of gastric 
disturbances, it may (according to Hayem) 
be administered subcutaneously. Hayem 
also recommends the inhalation of 15 litres 
of oxygen a quarter of an hour before the 
two principal meals; and after meals a one 
per cent, solution of hydrochloric acid. It is 
necessary to give a nutritious diet, very easy 
of digestion, such as milk, beef-tea, eggs, 
scraped raw beef and meat-juice. If vomit- 
ing be very severe, nutrient enemata may 
be used. Transfusion has been tried in some 
cases, but it is doubtful whether it has ever 
done more than prolong life for a short time. 
Defibrinated human blood should be used, and 
not more than half a pint should be injected 
at once. Frederick W. Mott. 
ANAESTHESIA (a, priv., and aia0dvop.ai, 
I feel).-Anaesthesia literally means absence 
or loss of sensation, which may be general or 
local. The word is, however, more especially 
employed to signify loss of tactile sensi- 
bility, as distinguished from insensibility to 
pain, or analgesia. It is further used to 
indicate the condition induced by the action 
of anaesthetics upon the system. See 
Anaesthetics ; and Sensation, Disorders of. 
ANAESTHETICS.- Definition.- The 
name given to a series of agents which are 
employed for the prevention of pain, but 
more especially applied to those used in 
surgical practice. 
History.-The idea of annulling pain in 
surgical operations is a very old one. Com- 
pression of the nerves and blood-vessels, 
and the inhalation of the vapour of carbonic 
anhydride and mixtures containing it, were 
practised at an early date. In the sixteenth 
century ether was probably the active ingre- 
dient of a volatile anaesthetic described by 
Porta. The use of anaesthetics was, however, 
little understood and rarely practised. Even 
the suggestion of Sir Humphry Davy, that 
nitrous oxide should be used in minor opera- 
tions not attended with loss of blood, was of 
little practical value, on account of the in- 
efficient apparatus then available. In 1845 
Horace Wells inhaled laughing-gas so suc- 
cessfully that he may be said to have intro- 
duced the practice; but he appears to have 
so often failed to produce the desired effect 
that this agent fell into disuse on the intro- 
duction of ether in 1846 by Morton, after 
some communications on its properties from 
a chemist named Jackson. In 1847 chloro- 
form was used by Simpson, and quickly 
superseded ether almost all over Europe. 
At the present time the comparative safety 
of ether has caused this anaesthetic again 
to be preferred by many surgeons in this 
country. 
Enumeration. - The three agents just 
mentioned - namely, nitrous oxide, ether, 
and chloroform-are those chiefly in use, and 
they have each advantages in particular cases. 
Experiments made with other agents, such 
as amylene, tetrachloride of carbon, ethidene- 
dichloride, and bichloride of methylene, have 
not shown that they possess sufficient ad- 
vantages to counterbalance the defect of re- 
quiring special management in their adminis- 
tration. This list of anaesthetics might be 
still further increased, for in order to produce 
insensibility it is only necessary to reduce 
the supply of arterialised blood to the ner- 
vous centres, or to introduce into the blood 
a substance which deprives it of its power of 
oxygenating the tissues. 
Modes of Use.-Anaesthesia may be 
produced for surgical purposes :-(1) by be- 
numbing the part to be operated on by 
means of cold ; (2) by intercepting its nervous 
communication ; (3) by arresting the activity 
of the nervous centres concerned in sen- 
sation. Thus anaesthetics may be local or 
general in their action. 
Local Anaesthesia may be induced by 
cold. The most convenient plan is to blow 
a jet of anhydrous ether spray upon the part, 
as suggested by Dr. Richardson, and thus to 
freeze it. The surface to be frozen should 
be dry, and hence the difficulty of freezing 
the gum of the lower jaw, on account of the 
saliva. A mixture of equal parts of pounded 
ice and common salt contained in a bag of 
muslin is effective, but less easily applied. 
This plan is adapted for opening abscesses 
and boils, and for the extraction of a few 
teeth ; but the process both of congelation and 
of thaw is painful. Chloroform applied locally 
is said to cause numbness, but it is very 
little used except inside the mouth, and then 
it owes its soothing effects to the quantity of 
chloroform vapour which is inhaled. Com- 
pression of nerve-trunks for inducing anaes- 
thesia is never practised at the present day. 
Hydrochlorate of cocaine in a 4 per cent, 
solution, applied either by pipette, camel's- 
hair brush, or spray, is largely used in opera- 
tions on the eye, naso-pharynx, and other 
mucous membranes. Its use hypodermically 
requires great caution, as its constitutional 
action is still imperfectly known. In neuralgia 
it should be applied in the vicinity of the 
nerve affected. 
General Anaesthesia is at present rarely 
obtained in any other way than by inhalation, 
although successful attempts have been made 
to induce the condition by subcutaneous 64 
ANAESTHETICS 
and intravenous injection of chloral or 
morphine. 
Subjects for Anesthetics.-We may 
say generally that any person fit for a severe 
operation is a fit subject for an anaesthetic; 
but no one is so free from danger that care 
in watching its effects can be dispensed with. 
The cases requiring the greatest vigilance 
are not the young and delicate, for whom a 
small dose suffices, but the strong, who inhale 
deeply and struggle much. Ether is pro- 
bably better adapted than chloroform for 
those suspected to suffer from fatty degenera- 
tion of the heart. Many of the deaths under 
chloroform have occurred in intemperate 
drinkers, and the presence of alcohol in the 
system undoubtedly intensifies its effect. 
Precautions.-Before commencing inha- 
lation the following particulars should be 
attended to. The patient must not have re- 
cently taken a full meal; he should lie comfort- 
ably, in a horizontal position if possible, unless 
when gas or ether is given for a short opera- 
tion ; and the dress should not be tight. 
When the administration is begun, he should 
be encouraged to breathe regularly and 
freely. The pulse as well as the respira- 
tion must be watched. If the vapour excites 
either swallowing or coughing, it is more 
pungent than is requisite, and its strength 
should be diminished. Most patients are at 
first afraid of breathing, and some hold their 
breath for half a minute. The vapour should 
not be removed on this account, but care 
should be taken, by holding the inhaling 
apparatus farther off, to prevent the vapour 
becoming too strong in the interval. After 
volition has been abolished, any pause in 
the breathing should be noted, and more or 
less fresh air given. Further directions 
will be given in describing the anaesthetics 
specially. 
Special Anesthetics.-Nitrous Oxide. 
Protoxide of nitrogen, nitrous oxide, or 
laughing gas is now prepared wholesale, and 
sold condensed into a liquid in strong iron 
bottles. The gas, whether supplied thus or 
from a gasometer, should be inhaled from a 
bag having such free communication with 
the face that it will readily be supplied even 
in panting respiration. A long tube, how- 
ever large, is objectionable, as the gas is less 
mobile than common air. 
The special aim in giving gas should at 
first be to exclude air, and to exchange the 
atmosphere within the air-passages and lungs 
for one of pure gas. The patient should not 
merely be told to breathe slowly and deeply, 
but be shown how to do so, about fifteen times 
in a minute. The inspiration should not be 
jerking, and the expiration should be complete. 
It is a special merit of laughing gas that no 
harm can come of inhaling too freely at first. 
The gas-bag must bo kept filled either by 
pressure on the gasometer, or by turning the 
screw tap of the gas-bottle. This may be 
done by the hand of an assistant, or more 
conveniently with the foot of the adminis- 
trator. The writers' plan is to fix the bottle 
vertically and turn the screw by pressing 
the foot against an iron plate with spikes on 
its upper surface, and a square hole fitting 
the tap on its lower surface. It is imperative 
that the face-piece or mouth-piece should fit 
accurately, and the air-pad is almost essential 
to effect this in a great many cases. It should 
be warmed if the india-rubber is stiff. After 
five or six good respirations there is no need 
to supply fresh gas with each inspiration. 
The expiratory valve should be kept closed, 
and the inspiratory valve opened. Care must 
always be taken that the supply of gas is 
sufficient to replace any that is lost by ab- 
sorption into the blood or by leakage. This 
is more easily effected if the gas-bag is made 
of thin india-rubber, so as to distend easily 
and contract gently with the movement of 
breathing. It should be sufficiently filled, so 
that if the mouth-piece does not fit, the gas 
would escape instead of air entering and be- 
coming mixed with it. 
Lividity of the skin will not help us to know 
when the patient is fully under the influence 
of the gas, neither will insensibility of the 
eyelids, nor yet the state of the pupils. The 
breathing should become stertorous or inter- 
rupted, or the pulse very feeble, or convulsive 
twitchings should occur, before the face-piece 
is removed. A little air may be admitted by 
raising the face-piece, if the operation is not 
upon the face, and by doing so every fourth 
or fifth respiration anaesthesia may be kept 
up for several minutes. The effect of a single 
full inspiration may be to bring the patient 
into a state of excitement, and the continuance 
of the gas without air brings on convulsive 
movements, so that it is not well adapted 
for any operation lasting as much as five 
minutes, and requiring steadiness. 
Patients are sometimes so unsteady that it 
is found to be almost impossible to make the 
face-piece fit. In such cases the best plan is 
to cover the patient's eyes and let him breathe 
air, merely preventing him from rising from 
the chair or bed, and not speaking till he is 
conscious, and as soon as he becomes so to 
recommence the inhaling as if nothing had 
happened. A violent patient often becomes 
perfectly rational in less than two minutes. 
Sickness and headache ought not to result 
from the inhalation of gas; but if the use of 
it is prolonged, or if the patient is kept for 
several minutes in a semi-conscious state, 
breathing a little air with the gas, both these 
symptoms may occur. The recumbent pos- 
ture, quiet, and warmth to the feet, constitute 
all that is likely to be required in the way of 
treatment. 
Ether.-Ether, sulphuric ether, ethylic 
ether, vinic ether, or oxide of ethyl, was first 
used for anaesthetic purposes in 1846. Before 
its use was well understood in England, ANESTHETICS 
65 
chloroform was brought forward as a more 
convenient agent, and much less unpleasant 
to the patient. Ether is less liable to become 
dangerous to life, as it does not, under 
ordinary circumstances, depress the action 
of the heart. The best kind is the PEther 
Purus of the Pharmacopoeia, of sp. gr. -720. 
Although it is not difficult to destroy dogs 
suddenly with ether, it is believed by many 
writers on the subject that in man it can 
only prove fatal by causing asphyxia, and 
that the signs of this condition are so easily 
seen and remedied that practically this an- 
testhetic is quite safe. The writers are not of 
this opinion, believing that sometimes when 
narcosis is far advanced, the glottis will allow 
ether vapour to pass of sufficient strength 
to stop the heart. Such cases, however, are 
very rare indeed. Ether is extensively ad- 
ministered by pouring an ounce at a time 
upon a very large cup-shaped sponge, which, 
if cold from previous use, is dipped into hot 
water and squeezed as dry as possible. It is 
to be expected that the patient will resist 
breathing when this is held over his face, 
but after a minute's struggling he becomes 
unconscious, and easily managed. Compared 
with the method of giving ether timidly, so 
as to let the patient remain delirious for 
several minutes, this may be a good plan; 
but there is no necessity for giving the ether 
so strongly if we diminish the access of 
fresh air. The administration of nitrous 
oxide from which air is at first excluded, 
and to which it is afterwards admitted 
very sparingly, has taught us how slight 
the after-effects are from the asphyxia so 
induced. Cones of leather or pasteboard 
lined with felt, and having a small opening 
at the apex, are better than sponges; but 
they should be larger. They may be made 
more effective and economical by placing a 
thin india-rubber bag over the apex of the 
cone, so that more of the expired atmosphere 
may be breathed again. 
Morgan's inhaler is very efficient. The 
ether is poured into a tin chamber as large as 
a hat, containing sponge. This is covered by 
a sort of diaphragm, which rises and falls with 
respiration as the patient breathes into and 
out of it by means of a tube and face-piece. 
There are no valves. Anaesthesia results 
partly from asphyxia, and partly from the 
action of the ether. The amount breathed 
depends on its temperature, and on the free- 
dom of respiration. If the respiratory move- 
ments are slight, as in young children or 
in persons suffering from emphysema, the 
amount of ether supplied is apt to be too 
small. Ormsby's inhaler is an improvement 
upon Morgan's. The sponge for ether is con- 
tained in a cage near the face-piece. 
With the view of regulating the strength 
of the ether vapour, the late Mr. Clover con- 
trived the following apparatus, which is made 
by Mayer and Meltzer. It consists of an oval 
india-rubber bag fifteen inches long, at the 
one end connected with the face-piece, at the 
other with the ether-vessel. Within the bag 
is a flexible tube also leading from the face- 
piece to the ether-vessel. By turning a regu- 
lator the patient is made to breathe into the 
bag either directly or indirectly through the 
tube and ether-vessel, or partly one way and 
partly the other. The more the regulator is 
turned towards the letter E, the more ether - 
vapour he takes. By turning it back again 
the amount of vapour is diminished. The 
ether-vessel contains a reservoir of water, 
which prevents the ether becoming too cold 
from evaporation. When in use, it may be 
conveniently suspended by a strap from the 
neck of the administrator. 
At first the regulator allows the passage 
from the face-piece into the bag to remain 
open, and the bag should be filled by pressing 
the face-piece more firmly against the face 
during expiration than inspiration. By 
degrees the regulator is turned towards the 
letter E, and thus the passage to the inner tube 
is opened, and the air breathed through it 
carries ether vapour from the vessel into the 
distal end of the bag. When the regulator 
allows half the inspired air to pass through 
the ether, the vapour is strong enough to in- 
duce sleep in two minutes, usually without 
exciting cough. As the act of swallowing is 
excited by a smaller quantity of ether than 
that of coughing, it should be watched for, 
and the regulator very slightly turned back 
should it occur. 
This same apparatus may be used for 
giving laughing-gas, all communication with 
the ether-vessel being cut off by turning a 
stopcock, and by attaching the tube leading 
from the gas-bottle to a mount near the bag. 
By far the least unpleasant and the quickest 
way of preparing a patient for a surgical 
operation is to use gas and ether combined; 
the change from gas to ether being made by 
turning the regulator above described as soon 
as the patient is sufficiently under the in- 
fluence of the gas to disregard the flavour of 
ether. The supply of gas should be stopped 
as soon as the ether is introduced; but if 
subsequently the patient is allowed to become 
conscious, the gas may be given freely as at 
first, in order to cause him to sleep again. 
The writers have found less sickness and more 
rapid recovery from the unpleasant taste of 
ether than when the latter is given alone. The- 
chief difficulty is to prevent the unsteadiness 
of the patient, which results from the panting 
character of the breathing. To lessen this, 
the ether must be given as strong as possible 
without producing irritation of the throat, 
and the operator should wait until the in- 
fluence of the ether has increased to the pro- 
duction of deep stertor. Air being then ad- 
mitted with every fourth or fifth inspiration, 
the breathing soon becomes as regular as it is 
under ether when given in any other way. 66 
ANESTHETICS 
On recovering from the inhalation of ether, 
patients are often in a state of intoxication 
for a period corresponding to the time and 
extent of the etherisation. The eyes should 
be covered, but the mouth and nose left free ; 
and the room should be kept quiet, with a 
brisk fire, and the window more or less open. 
Chloroform.-Chloroform was brought 
forward by Simpson in 1847. It should not 
be made from methylated spirit; and, when 
a drachm is poured upon blotting-paper, it 
should evaporate without leaving an un- 
pleasant odour. It is the most convenient 
of all anaesthetics, and the most easy to ad 
minister. Unfortunately, when given beyond 
a certain strength, it has a tendency to pro- 
duce cardiac syncope or asphyxia, and it is 
not improbable that some persons are par- 
ticularly liable to be affected. 
Some authorities think it desirable to give 
alcoholic stimulants before administering 
chloroform; others partially narcotise the 
patient with morphine or chloral. No doubt 
these agents assist the action of the chloro- 
form, but if from any accident an excess of 
chloroform should be given, they interfere 
with the means of recovery, and for this 
reason are not to be recommended. There 
is less objection to the inhalation of a mixture 
of chloroform and ether, or of these agents 
with alcohol; but such mixtures, if kept for 
some length of time, alter their relative pro- 
portions, owing to the escape of the more 
volatile ingredients. Even the change from 
the administration of chloroform to that of 
ether, if made suddenly, is not free from 
danger, for, when a person is partially under 
the influence of chloroform, the glottis allows 
a high percentage of ether to pass; and, if 
the lung-circulation be slow, as is likelyto be 
the case, the blood may be so highly charged 
with ether as to depress rather than stimulate 
the heart. 
Chloroform, therefore, should be given 
gradually. The object should be to keep 
down the proportion of chloroform-vapour 
rather than to give abundance of fresh air. 
In preparing for an operation requiring per- 
fect stillness, six to eight minutes should be 
allowed for the process. Sponges or lint 
saturated with chloroform, and held close to 
the mouth, are dangerous, from the possi- 
bility of liquid chloroform falling on the lips 
or into the mouth. In midwifery practice a 
piece of linen or blotting-paper, sprinkled 
with chloroform and placed at the bottom of 
a tumbler, is a convenient plan of administra- 
tion, care being taken to prevent any liquid 
chloroform from settling at the bottom. In 
general surgery a handkerchief or towel may 
be folded into a small cone, open at the apex, 
into which not more than a drachm should 
be poured at first, and fifteen minims at a 
time afterwards. A better plan is to roll and 
tie a piece of lint into a compress the size of 
a walnut. A drachm to a drachm and a -half 
of chloroform should be poured upon this, 
which is to be held about an inch in front of 
the patient's upper lip, the hand and com- 
press being covered with a towel, which 
should gradually be drawn over the patient's 
face. This plan gives considerable command 
over the supply of chloroform, for, when the 
chloroform, having cooled by evaporation, is 
given off too slowly, the vapour can be in- 
creased by warming the compress in the 
palm of the hand. When it is becoming dry 
it ceases to feel cold, and warning is thus 
given that fresh chloroform is needed. This 
should be supplied half a drachm at a time. 
In doing this the towel should still be left 
over the face of the patient, in order to keep 
him breathing a slightly chloroformed atmo- 
sphere. The movement of swallowing should 
be looked for, and regarded as evidence that 
the vapour is stronger than is necessary. If 
any sound like hiccough indicates laryngeal 
obstruction, the chloroform and towel should 
be removed, and, if the sound continue, the 
chin should be raised as much as possible 
from the sternum. Laryngeal obstruction 
arises from two main causes, viz., spasm of 
the glottis, and falling down of the epiglottis. 
The first is excited by the pungency of the 
vapour, and also by reflex action when cer- 
tain nerves are injured, notably when a 
ligature is tightened upon a pile. The epi- 
glottis covers the larynx every time we 
swallow, but the muscles coming from fthe 
chin raise it again directly. In deep narcosis 
these muscles are sluggish, and cannot act 
thus if the position of the chin places them 
at a disadvantage. If raising the chin fail 
to open the air-passage, the tongue must be 
pulled forward. In doing this the head 
should be kept back. Depressing the chin 
renders a partial obstruction complete. A 
laryngeal sound indicating obstruction is of. 
little consequence if the pulse is good, since, 
although the breathing be imperfect, suffi- 
cient fresh air continues to be breathed; but 
if the pulse flags, or if it appears that the 
amount of chloroform in the air-passages is 
excessive, not a moment should be lost in 
seizing the tongue with forceps. 
When a patient is delirious and struggling, 
extra care must be taken that the chloroform 
be not too strong, because he inhales deeply, 
carrying the vapour almost to the air-cells of 
the lungs, and, when he next closes the glottis 
and strains, the pressure of the air and 
vapour within the lungs is increased, and the 
chloroform enters the blood very quickly. 
The compress should be held at least two 
inches off the mouth, although the towel 
may still cover the face. Directly any ster- 
torous noise is heard, a breath or two of fresh 
air should be allowed, and no more chloro- 
form given till the pulse beats well and the 
respiration is free. 
Skinner's apparatus-a cap of ' domette 
flannel stretched over a frame-is a much better apparatus than a towel; but its virtue 
is simplicity, and it has little pretension to 
exactitude. Snow's apparatus is very effi- 
cient, portable, and economical. The addi- 
tion of a water-jacket to equalise the tem- 
perature was a great improvement; but it 
should be provided with a thermometer. 
The safest and least unpleasant mode of 
giving chloroform is by means of the ap- 
paratus fitted with a large bag of air contain- 
ing not more than thirty-three minims of 
chloroform in a thousand inches of air. The 
apparatus is, however, too complex to be 
generally adopted. The advantage of more 
precise measurement of the strength of 
chloroform vapour than is afforded by towels 
or napkins will appear when we consider the 
several circumstances that alter it when so 
given. 
The strength of vapour given off from a 
known quantity of cldoroform is influenced 
by 
1. The extent of surface of chloroform. 
2. The temperature of the chloroform, 
which is constantly changing. 
3. The temperature of the air of the room, 
of the patient's face, and of the administra- 
tor's hand. 
4. The distance at which the chloroform is 
held from the patient's face. 
5. The rapidity of the current of air. 
6. The height of the barometer. 
-Moreover, when the chloroform mixture is 
of known strength, its effect is increased by 
high barometrical pressure ; by low tempera- 
ture of the blood ; by deep or quick respira- 
tion, and especially by muscular efforts when 
the glottis is closed; and by slow movement 
of the blood through the lungs. 
On the other hand, it is lessened by low 
barometrical pressure ; by high temperature 
of blood; by superficial or slow respiration; 
and by rapid circulation through the lungs. 
Under ordinary circumstances danger from 
these causes is easily averted with moderate 
care, for they do not often concur to produce 
the same effect. But if a patient, fatigued 
with struggling, takes a very deep breath just 
as fresh chloroform has been poured upon the 
towel, and then closes his glottis and makes 
another struggle-the barometer being high 
at the same time-it is evident that blood 
unduly charged with chloroform will gain 
access into the coronary arteries, and depress 
the cardiac ganglia. Death has occurred so 
rapidly under these circumstances, that it 
has been thought to be the result of shock 
from the operation. 
Chloroform lessens, if it does not entirely 
prevent, the shock of an operation ; but it is 
to be feared that, if chloroform be given freely 
for this purpose, a dangerous amount of it 
may be administered. 
If a severe operation is about to be per- 
formed, the chloroform should be given in 
the same gradual manner as in a slighter 
ANAESTHETICS 
one, but continued to the point of fixing the 
pupils and producing stertorous breathing; 
and, when the chief shock is expected, two or 
three breaths of pure air should be admitted, 
so that, if the pulse fail, there may not be an 
excessive amount of chloroform-vapour in the 
lungs. 
Compounds of Chloroform.- Under this 
head comes Methylene (Bichloride of Methy- 
lene'), which contains a variable quantity of 
chloroform. Its chemical characters and 
physiological effects are similar to those of 
a mixture of chloroform, ether, and alcohol. 
It narcotises quickly, but not safely; and, as 
the amount of chloroform in it is not always 
uniform, it is better to mix, in small quantities 
at a time, one part of alcohol, two of chloro- 
form, and three of ether, and to keep the 
bottle so well corked that the ether is not 
likely to evaporate and leave chloroform in 
excess. The word ACE fixes the proportions 
in one's memory. 
A mixture of one part of chloroform with 
four of ether is convenient for a brief opera- 
tion, as this produces much less excitement 
than ether alone. On the whole the writers 
object to keeping mixtures of this kind 
ready-made; and it is probable that the plan 
of giving at the outset sufficient chloroform 
to abolish consciousness, and subsequently 
administering ether, will be found safer 
than mixing them together in the liquid 
state. 
Bromide of Ethyl (CJUBr).-This sub- 
stance has been recommended and moderately 
used as an anaesthetic. Its merits are that it 
exhilarates and produces rapid anaesthesia. 
Its effects pass off quickly, without any ten- 
dency to depress the action of the heart. 
The objections to the use of bromide of ethyl 
are that it is liable to decompose, leaves a 
strong smell and taste of bromine, and some- 
times produces headache and sickness. Two 
deaths from it in America have been reported. 
Its use has been abandoned in England. 
Dichloride of Ethidene (C2H4C1,).- 
This substance is obtained by * distilling 
aldehyde and pentachloride of phosphorus. 
The effects of this agent are intermediate 
between those of chloroform and ether. Its 
odour is usually preferred to that of either 
of the former. The writers have used it very 
extensively; and in minor cases, in which 
the operation has lasted only five minutes, 
the recovery is rarely attended by sickness or 
excitement. In the more prolonged cases it 
was found to cause vomiting, but this ceased 
much more rapidly than when chloroform 
had been given. Its effect upon the heart 
when given in large doses is depressing, and 
the pulse should be carefully watched during 
its administration. 
After-treatment.-Quietude, or conver- 
sation of an encouraging or soothing character, 
is desirable during the half-minute of recovery 
from gas. The eyes should be covered, unless 
67 68 
ANAESTHETICS 
ANAPHRODISIACS 
the view is tranquil as well as pleasant. If 
gas be given until there are intermissions in 
the breathing, or its administration continued 
for several minutes with a small allowance 
of air, there may be headache and even 
vomiting: still no other treatment than 
repose is needed. 
After the inhalation cf ether a taste will 
remain. This may be got rid of by washing 
out the mouth, and gargling with warm 
fluids; while the vapour remaining about the 
patient and in the room may be removed 
by heating the surface by means of hot 
bottles, and making a bright fire. 
When the system has been long or pro- 
foundly under the influence of chloroform or 
ether, nausea and vomiting are likely to ensue. 
The writers have found warmth, fresh air, 
and abstinence from food efficient in relieving 
these symptoms. Hot tea and coffee, taken 
from a feeder without raising the head, and 
afterwards beef-tea and jelly, are sufficient for 
twenty-four hours, unless the patient wishes 
for something solid. The rule then should 
be to give little, or less than asked for. Ice 
relieves thirst, and serves to postpone the 
necessity for giving solids. 
Treatment of Dangerous Symptoms.- 
Anaesthetics in excess destroy life by stopping 
the action of the heart, or the respiration; 
generally both are affected.1 When laughing- 
gas is given to animals till the breathing has 
ceased, the heart continues to beat long after- 
wards, and artificial respiration rapidly re- 
stores them. Ether-vapour, given almost 
pure through a tracheal tube, will arrest the 
action of a dog's heart in sixteen seconds; 
but if it be administered as rapidly as possible 
with a cloth, without opening the trachea, 
the breathing fails before the heart, and the 
haemadynamometer shows adequate pressure 
in the vessels whilst the breath is gasping, 
and for several seconds after it has ceased. 
With chloroform the haemadynamometer 
indicates diminished pressure directly the 
animal ceases to struggle, and the heart 
sometimes stops before the breathing. In 
case alarming symptoms should arise, the 
first effort should be directed to lessening 
the amount of the anaesthetic in the lungs, 
by pressing the trunk with both hands, and 
squeezing out as much air as possible without 
causing a shock. If, after this has been done 
two or three times, the air does not readily 
re-enter the chest, the obstruction is to be 
overcome either by lifting the chin or draw- 
ing out the tongue; and other artificial move- 
ments of the chest must be carried on 
(see Artificial Respiration). If pallor be 
noticed whilst breathing is going on, the 
recumbent posture and elevation of the feet 
are immediately required (see Resuscita- 
tion). Nelaton's plan of inverting the body 
has often been followed by recovery; but, 
considering the impediment to inspira- 
tion from the weight of the abdominal 
viscera, the writers are of opinion that the 
pelvis should never be many inches higher 
than the head. Nitrite of amyl-by reason 
of its effect in dilating the vessels of the 
skin-has been recommended, but without 
careful physiological inquiry, and upon very 
small clinical experience. Hypodermic in- 
jection of ether is also useful. 
Electricity might be expected to prove the 
best agent to assist the action of a feeble 
heart. Mr. Clover's experimental observa- 
tions were not favourable to its employment; 
and certainly artificial respiration should 
not be delayed one moment in order to apply 
electricity. 
Insufflation is not to be depended on. The 
condition would be rendered worse by dis- 
tension of the stomach, which cannot always 
be prevented by pressing the larynx against 
the spine. 
Laryngotomy may be required in cases 
where air cannot be made to enter the chest, 
in spite of throwing the head backward, and 
removing the chin away from the sternum. 
Hot-water injections may be of use, but 
there can be no necessity for brandy whilst 
artificial breathing is being carried on. 
Afterwards, if swallowing is difficult, brandy 
may be added to the enema. 
Friction of the limbs in the direction of 
the heart is unnecessary, provided the feet 
are slightly raised. Where there has been 
great loss of blood, the limbs should be 
bandaged firmly, from the fingers and toes 
upward, as in Esmarch's plan for saving the 
blood of a limb about to be amputated. In 
warm weather, or if the body is warm, a 
towel dipped in cold water may be flapped 
against the chest, but harm would result 
from cooling the body generally. Bottles of 
hot water and hot blankets should be applied 
as soon as the breathing is restored, and a 
brisk fire should be kept up, in order to 
favour the ventilation of the chamber. 
J. T. Clover. G. H. Bailey. 
ANALGESIA (a, priv.; and aXyos, 
pain).-Absence of sensibility to painful 
impressions. See Sensation, Disorders of. 
ANAPHRODISIA (a, priv. ; and 
Venus). - Absence of sexual 
appetite. Sometimes used to express im- 
potence. See Impotence ; and Sexual 
Functions in the Female, Disorders of. 
AN APHRODISIACS.-Definition.- 
Medicines which diminish the sexual passion. 
Enumeration.-The agents employed as 
anaphrodisiacs are :-Ice, Cold Baths-local 
and general; Bromide of Potassium and 
Ammonium ; Iodide of Potassium ; Conium ; 
1 On this subject reference should be made to 
' An Address on Experiments on Anaesthetics,' by 
Dr. Lauder Brunton, Trans. Medical Soc. of Lon- 
don, vol. xiii. p. 261, and Brit. Med. Journ., 1890, ii. 
p. 531, for report of experiments by Dr. MacWilliam. ANAPHRODISIACS 
ANEURYSM 
69 
Camphor; Digitalis; Purgatives; Nauseants ; 
and Bleeding. 
Action.-The erection which occurs in 
the genital organs during functional activity 
is due to dilatation of the arteries in the 
erectile tissues, and is regulated by a nervous 
centre situated in the lumbar portion of the 
spinal cord. From this centre vaso-inhibitory 
nerves pass to these arteries, and cause them 
to dilate whenever it is called into action. It 
may be excited reflexly by stimulation of the 
sensory nerves of the genital organs and ad- 
joining parts, or by stimuli from the alimentary 
canal. It may also be excited by psychical 
stimuli passing to it from the brain. Some 
anaphrodisiacs may act by lessening the ex- 
citability of the nerves of the genital organs, 
as the continuous application of cold, and 
probably, also, bromide of potassium ; some 
by diminishing the excitability of the genital 
centres in the spinal cord and brain, as bro- 
mide and iodide of potassium, and conium ; 
others by influencing the circulation, as digi- 
talis. There are also adjuvant measures, of a 
hygienic and moral character, which greatly 
assist and may even replace anaphrodisiac 
medicines, such as a meagre diet, especially 
of a vegetable nature, the avoidance of stimu- 
lants, and the pursuit of active mental and 
bodily exercise. Everything tending to stimu- 
late the genital organs, or to increase the 
flow of blood to them or to the lumbar por- 
tion of the spinal cord, should be avoided, 
such as warm and heavy clothing, or pads 
about the hips or loins ; and a hard mattress 
should be used in place of a feather-bed. 
Everything likely to arouse the passions, 
such as certain novels, pictures, theatrical 
representations, &c., should also be shunned. 
Uses.-Anaphrodisiacs are employed to 
lessen the sexual passions when these are 
abnormally excited in satyriasis, nympho- 
mania, and allied conditions. As such ex- 
citement may sometimes depend on local 
irritation of the genitals, in consequence ot 
prurigo of the external organs, excoriations 
of the os uteri, or balanitis; or on the 
presence of worms in the rectum or vagina; 
these sources of excitement should be looked 
for, and, if present, should be subjected to 
appropriate treatment. 
T. Lauder Brunton. 
ANARTHRIA (av, neg.; and apOpa, the 
limbs).-Synon. : Fr. Anarthrie; Ger. Glied- 
losigkeit).-A term applied to those defects 
of speech (not strictly aphasic) which consist in 
a merely blurred, or more or less unintelligible 
articulation. The patient does not suffer from 
forgetfulness of words, but from a difficulty 
in their utterance. See Aphasia. 
ANASARCA (ard, through; and aap^, 
the flesh).-An effusion of serous fluid into 
the subcutaneous connective tissues, not 
limited to a particular locality, but becoming 
more or less diffused. See Dropsy. 
ANEURYSM (avevpvvai, I dilate).- 
Definition.-Aneurysm is a local dilatation 
of an artery, leading to the formation of a 
tumour which contains blood, and the walls 
of which are composed either of the tissues 
of the vessel, or those which form its sheath, 
or immediately surround it. Therefore every 
aneurysm, properly so called, consists of two 
parts-a sac and its contents. 
Classification.-Aneurysms are usually 
divided, according to the varying composi- 
tion of the sac, into the following varieties :- 
1. True aneurysm, in which all the three 
coats of the artery form the sac or a portion 
of the sac. This variety is rare : at least it 
is so rarely possible to trace all the coats of 
the artery over any part of the sac beyond 
its orifice, that some pathologists deny the 
existence of this so-called ' true ' form of 
aneurysm, and most admit its existence in 
the aorta only. 
2. False aneurysm, in which the sac is 
formed by one only of the coats of the artery. 
This is almost always the external coat; but 
a sub-variety has been proved to exist as a 
consequence of wound of the outer part of 
the vessel, and is believed by some to take 
place spontaneously, in which the inner coat, 
or the inner and part of the middle coat, is 
dilated, pushed through the outer coat, and 
forms the sac. This is called hernial false 
aneurysm. 
3. Diffused or consecutive aneurysm. 
Here the sac is formed of the sheath, cellular 
tissue, or other structures around the artery, 
which are matted together into the form of a 
membrane. The name ' diffused ' is applied 
to this form of aneurysm to express the fact 
that the blood is at first diffused amongst 
the tissues, in consequence of the rupture or 
division, whether from injury or disease, of 
all the coats of the vessel, either in a part or 
the whole of its circumference ; but it is not 
a good term, since, as soon ns the aneurysmal 
sac is formed, the blood is diffused no longer, 
but, on the contrary, is encysted in the 
newly formed sac. So that the other term, 
'consecutive,' seems a better one; expressing, 
as it does, the important fact that the forma- 
tion of such aneurysms is always consecutive 
on a rupture, partial or entire, of the artery. 
4. Dissecting aneurysm is seen only within 
the trunk of the body, and always involving 
the aorta-although it may spread from the 
main artery down to its branches. In this 
form the internal and middle coats have given 
way, or cracked; and the blood has forced 
its way, usually into the substance of the 
middle coat, sometimes perhaps between 
the middle and outer coats, distending the 
external portion of the vessel into a kind of 
aneurysm. 
This is the nomenclature still in common 
use; but as the first and second varieties are 
practically indistinguishable during life, and 
the first, though called the ' true ' form of 70 
ANEURYSM 
aneurysm, is very rare, it would be better to 
include both under the common name 'true ' 
aneurysm, and apply the term ' false ' to the 
third or ' consecutive ' form. 
5. Besides these, which are all forms of 
pure arterial aneurysm, there are aneurysms 
in which the vein and artery are simul- 
taneously involved, and which are therefore 
called arterio-venous, which will be after- 
wards spoken of; and tumours having a 
certain analogy to aneurysm, which are 
formed of dilated and tortuous arteries- 
cirsoid and anastomotic aneurysms. 
Other classifications of great importance 
are, according to the cause of the disease, 
into spontaneous and traumatic; or, ac- 
cording to the shape of the tumour, into 
fusiform and sacculated. In fusiform 
aneurysm there is a dilated tract of artery, 
often of considerable length, from either end 
of which springs the vessel of its natural 
calibre. Sacculated aneurysm springs like 
a bud from one side of the vessel, and the 
artery is often buried for some distance in the 
wall of the aneurysm; but there are many 
sacculated aneurysms which approach in 
shape to the fusiform, the vessel being dilated 
for some part of its extent, so that its two 
openings lie at different parts, and sometimes 
on different aspects of the sac. 
^Etiology and Pathology.- The proxi- 
mate cause of spontaneous aneurysm appears 
to be usually a loss of the elasticity of the 
wall of the artery, whereby it loses its power 
of resilience after having been dilated by the 
force of the circulation. The loss of elasticity 
is commonly caused by atheroma, or else by 
partial calcification of the wall of the artery. 
In the latter case the blood often forces its 
way through the entire arterial wall, and an 
aneurysm of the consecutive variety forms,1 
or the external part of the artery is dissected 
off, and a dissecting aneurysm results. In- 
flammatory softening of the artery, without 
the presence of any definite atheromatous 
deposit, is looked upon by many writers of 
credit, such as Wilks and Moxon, as a com- 
mon cause of aneurysm. Such low inflam- 
mation may have its origin possibly in rheu- 
matism-and, as a matter of fact, aneurysm 
is often preceded by acute rheumatism ; more 
certainly m violent strain, or in mechanical 
violence. Anything else which weakens the 
arterial wall, such as the exposure of the 
vessel in an abscess, is looked on as a cause 
of aneurysm. The yielding of a weakened 
arterial wall is doubtless accelerated by 
irregularities of the circulation. The in- 
fluence of syphilis and of intemperance in 
causing aneurysm is widely believed, though 
perhaps as yet neither fact is absolutely 
established : the latter, at any rate, is ren- 
dered very probable from the consideration 
that chronic alcoholism tends to impair the 
nutrition of all the tissues, including the 
arteries, and is accompanied by a constantly 
irritable condition of the circulation. That 
syphilis may cause a fibroid degeneration of 
the vessels must also be allowed to be at least 
possible, and that it does so is the opinion of 
many eminent pathologists. If so, the trans- 
ition to aneurysm is natural, if not inevitable. 
Another proved cause of aneurysm is em- 
bolism, or the obstruction of a diseased 
artery by a fibrinous plug, which has been 
known to be followed by the dilatation of the 
artery immediately above the plug, just as 
in very rare cases the ligature of a healthy 
vessel has given rise to the formation of 
aneurysm above the tied part.1 Violence is 
a very frequent cause of aneurysm, even in 
cases which are not technically denominated 
'traumatic.' The latter term is generally 
restricted to cases in which the vessel is 
wounded by a cut, or is known to be ruptured, 
and the aneurysm makes its appearance at 
once ; and in these cases the aneurysm is of 
the ' diffused ' or ' consecutive ' variety. But 
there are, no doubt, many cases in which the 
artery is partially torn, and the walls, being 
thus weakened, afterwards slowly yield at 
the injured spot. This fact is illustrated bj 
the well-known experiment of Richerand, 
designed to explain the frequency of popliteal 
aneurysm. The experiment consists in hyper- 
extension of the knee in the dead subject. If 
this be carried on forcibly till the ligaments 
are heard to crack, it will usually be found 
that the two inner coats of the popliteal 
artery are torn. 
All these causes of aneurysm act much 
more powerfully in later life than in child- 
hood, and many are unknown in early years. 
Aneurysm, therefore, is very rare in children. 
In cases where the arterial system is exten- 
sively affected with atheroma, a great num- 
ber of aneurysms may be found in the same 
person, or another may form after the cure of 
the first. To such cases the term ' aneurysmal 
diathesis ' has been applied. This fact shows 
the great importance, in all cases of spon- 
taneous aneurysm, of examining the whole 
body, to detect disease of the heart or any 
second aneurysm which may exist. 
Almost all aneurysms contain more or less 
clot, and much of this clot is usually of the 
laminated variety, consisting almost entirely 
of fibrin mixed with more or less of the 
blood-corpuscles. These laminated coagula 
adhere very firmly to the interior of the sac ; 
they are arranged concentrically like the 
coats of an onion; and usually lose their 
colour in proportion to their remoteness from 
the blood which still circulates through the 
sac. Their deposition depends in a great 
measure on the presence of rough projections 
from the wall or mouth of the sac, and on the 
1 Sometimes, however, the bleeding will go on 
without the formation of any aneurysmal sac, and 
lead to the loss of life or limb. 
1 For cases of this nature see System of Surgery 
3rd edit. vol. iii. p. 29. shape of the aneurysm. When the latter is 
purely cylindrical, much less coagulum, pos- 
sibly none, will be found in it. When the 
tumour stands well away from the artery, so 
that the force of the circulation is much 
broken, the formation of coagula is greatly 
favoured. The deposition of such firm co- 
agula must be looked on as the commence- 
ment of spontaneous cure, and at any rate 
defends the patient from the risks of rupture, 
or of renewed growth of the tumour at the 
parts which are so lined. 
Symptoms.-The symptoms of arterial aneu- 
rysm are as follows:-There is a pulsating 
tumour, which is situated in the course of one 
of the arteries, and which cannot be drawn 
away from the vessel. The pulsation is 
equable and expansile, that is, it not only 
causes an up-and-down movement of the 
tumour, for such a movement may be com- 
municated to any tumour by a large vessel 
lying in contact with it, but also expands the 
tumour laterally and in all other directions. 
The pulsation is in most cases accompanied 
by a bruit or blowing sound, heard on auscul- 
tation, which can be tolerably well imitated 
by the lips, and which is synchronous with 
the pulsation. Pressure on the artery above 
suspends both the pulsation and the bruit. 
Sometimes it may be noticed that the pulse 
below is retarded, that is, that it reaches the 
finger later than, in the corresponding vessel 
on the other side. Besides these, which are 
the main signs of aneurysm, there are others, 
which are of less constant occurrence or of 
subordinate importance. Thus, on compres- 
sion of the artery above, the tumour will 
empty itself more or less completely, and the 
greater or less change of size under these 
conditions is a useful test of the proportion 
of fluid and solid in the sac. Sometimes 
pressure on the artery beyond the tumour 
may cause an increase in its size. The 
pulse below the tumour is often found to 
differ strikingly from that on the sound side. 
There are many and various symptoms due 
to the pressure of the aneurysm on neigh- 
bouring veins, nerves, bones, and viscera- 
symptoms which are of subordinate import- 
ance in a diagnostic point of view in the case 
of external aneurysm, but are often of the 
greatest value in thoracic and abdominal 
aneurysms. Thus dyspnoea and ringing cough 
from pressure on the trachea, spasm or 
paralysis of the vocal cords from pressure on 
the recurrent laryngeal nerve, pain in the 
back from pressure on the vertebrae, or neu- 
ralgic pains from pressure on the nerves at 
the root of the neck, are well-known symp- 
toms of aortic aneurysm ; and, similarly, pain 
in the leg from pressure on the popliteal 
nerve, and oedema, from compression of the 
vein, are frequent symptoms of popliteal 
aneurysm. 
Diagnosis.-The affections which are usu- 
ally confounded with aneurysm are tumours 
ANEURYSM 
of various kinds lying upon arteries, ab- 
scesses, and cancerous tumours which have 
large vascular spaces in their interior, and 
therefore pulsate. The tumours which re- 
ceive pulsation from arteries against which 
they lie are of various kinds ; cysts and en- 
larged glands in the popliteal space, and 
enlargements of the thyroid body pressing 
on the carotid or innominate artery, are the 
most familiar examples. The diagnosis is 
usually easy. They have commonly little or 
no bruit, though in some cases a dull thud 
is produced by their pressure on the artery ; 
they have not the expansile pulsation of 
aneurysm; they present no change in size 
or form when the circulation is stopped ; and 
they can usually be drawn away from the 
artery sufficiently far to lose their pulsation. 
An abscess has often been mistaken for aneu- 
rysm, but the mistake has generally proceeded 
from a neglect of auscultation.1 There are a 
very few cases in which aneurysms have lost 
their pulsation in consequence of the rupture 
of the sac, and in which no bruit may be 
audible,'4 and such tumours can hardly be 
diagnosed from abscess except by an explo- 
ratory puncture, which under these circum- 
stances is justifiable: these cases are, however, 
extremely rare. The disease most commonly 
mistaken for aneurysm is pulsating cancer, 
and the resemblance has been sometimes so 
striking as to deceive the best surgeons, even 
after the fullest possible investigation of the 
case. These pulsating cancers almost always 
grow from the bones ;3 and the neighbouring 
bone can generally be felt to be enlarged, 
which is rare in aneurysm. They have not 
usually the well-marked bruit of an aneurysm, 
nor is the bruit usually audible over the whole 
tumour; the pulsation also is more indistinct, 
and not so expansile as in aneurysm ; and the 
growth of the tumour is more rapid. 
Course and Terminations.-Aneurysm is 
generally a fatal disease if left to itself. The 
sac enlarges; parts of it give way, either 
by a process of inflammatory softening or 
by rupture; or it produces fatal pressure 
on the surrounding parts; or the whole 
tumour suppurates, and the patient dies of 
fever, of pyaemia, or of haemorrhage. But 
to this general statement, independent al- 
together of what the effects of any special 
treatment may be, there are numerous ex- 
ceptions. In some cases, and especially in 
the fusiform kind of aneurysm, the tumour, 
after having attained a certain size, remains 
stationary, and this stationary condition is 
sometimes produced by a deposit of coagulum 
71 
1 See a paper by the author in St. George's 
Hospital Reports, vol. vii. pp. 175 et seq. 
2 See a case under the care of the writer, re- 
ported in the same paper, p. 190. 
3 In one case under the care of the writer the dis- 
ease was unconnected with the bones, and affected 
the kidney only.-Pathological Transactions, 
vol. xxiv. p. 149. 72 
ANEURYSM 
lining the sac, and leaving a canal through 
which the blood-stream passes, as through the 
normal artery.1 In these cases, however, the 
symptoms persist, but there are others in which 
a complete spontaneous cure is obtained; and 
this may happen in various ways. 
Spontaneous Cure.-1The first, and probably 
the most usual, method of spontaneous cure is 
by the gradual diminution of the circulation 
through the tumour, and the gradual filling 
of the sac by successive layers of fibrinous 
coagulum. The second is by impaction of 
clot in the mouth of the aneurysm, whereby 
in some cases possibly the sac of the aneurysm 
is cut off from the blood-stream, and its 
contents brought to coagulate. In other cases, 
where more than one artery opens out of the 
sac, the impaction of clot in one of the distal 
arteries leads to consolidation of all that 
part of the tumour through which the circu- 
lation used to pass into the obstructed vessel, 
and thus a practical cure is sometimes 
effected,2 i.e. the symptoms are cured and the 
disease arrested, though the whole sac is 
not consolidated. The third method of 
spontaneous cure is by inflammation of the 
tumour. This is usually accompanied by 
suppuration of the sac and evacuation of all 
the contents of the aneurysm, the accompany- 
ing inflammation closing the mouths of the 
arteries which open out of it. If the arteries 
are not so closed, death from haemorrhage will 
occur. It seems possible that inflammation of 
the sac and the cellular membrane around it 
may sometimes produce coagulation within 
the aneurysm without any suppuration. A 
fourth way in which coagulation of an aneu- 
rysm has been known to be caused is by re- 
tardation of the circulation or impaction of 
clot, caused by another aneurysm above; 
and there is an old idea, which can hardly yet 
be said to be exploded, that an aneurysmal 
sac may by its growth compress the artery, 
and so lead to its own coagulation. This, 
however, if it ever happens, is purely ex- 
ceptional. 
Rupture.-The rupture of an aneurysm 
may take place either through the skin, in 
which case the haemorrhage is usually, but 
not always, fatal at once ;3 or into one of the 
cavities of the body, when death generally 
occurs immediately, if the rupture is into a 
serous cavity, and after one or two attacks of 
haemorrhage if a mucous membrane has been 
involved ; or lastly into the cellular tissue of 
a part. This event is marked by the cessa- 
tion of the pulsation; by sudden swelling, 
1 See the representation of a case of this kind in 
System of Surgery, 3rd ed., vol. iii. p. 25. 
2 See a case of innominate aneurysm with re- 
marks in The Lancet, June 15, 1872, p. 818. 
5 Instances of successful ligature of the artery 
above bleeding from ruptured aneurysm are on 
record. See a case in The Lancet, 1851, vol. ii. p. 30, 
in which the femoral artery was successfully tied 
after the bursting of a femoral aneurysm through 
the skin. 
accompanied with ecchymosis if the blood is 
effused subcutaneously; and the abrupt fall 
of temperature below the aneurysm. A sen- 
sation of pain, or of ' something giving way,' 
is often experienced. Stethoscopic examina- 
tion will probably detect a bruit. 
Treatment.-a. Medical.-The methods 
of treatment of aneurysm are very numerous, 
and it would be impossible in a summary of 
this kind to discuss fully all the indications 
for each. In the first place, those aneurysms 
which are inaccessible to any local treatment, 
or in which local treatment would involve 
great danger, are treated medically, that is 
by regimen, diet, and medicine, by which it 
is hoped that gradual coagulation will be 
promoted in the contents of the tumour, and 
thus a complete or a partial cure will be 
brought about, as in the natural process 
above spoken of. The method of Valsalva, 
of which the main features were starving 
and excessive bleeding, and which therefore 
produced considerable and often dangerous 
irregularity of the heart's action, is now 
given up in favour of another plan intro- 
duced by Bellingham and modified by the late 
Mr. Jolliffe Tufnell,1 in which, by complete 
rest and restricted but nutritious diet, the 
absolute regularity of the heart's action is 
secured, and at a rate below that of health, 
both as to rapidity and force. Mr. Tufnell 
has given some interesting and conclusive 
examples of the complete cure of abdominal 
aneurysms thus accomplished, verified by 
dissection; and one, at least, in which an 
aneurysm of the arch of the aorta was in all 
probability entirely consolidated, though this 
fact was not verified by dissection. At any 
rate the patient was permanently restored 
to health. In this method of treatment 
drugs are only employed when necessary (as 
narcotics, laxatives, and tonics often are) to 
ensure the regularity of the functions, to 
control irritability, or to support the general 
health. The drugs which have been recom- 
mended as producing a direct effect on 
aneurysm by promoting the coagulation of 
blood in the sac, such as acetate of lead and 
iodide of potassium, do not, in the writer's 
opinion, produce any such effect, nor in fact 
any specific effect on the disease whatever. 
He has often seen a certain amount of im- 
provement under the use of these drugs, but 
not, he thinks, more than the regimen and 
diet used at the same time would account for. 
Other drugs, as aconite and digitalis, are 
recommended in order to steady and reduce 
the heart's action, and the latter especially 
is sometimes a useful adjuvant, if employed 
with caution, to the treatment by restricted 
diet and rest. The rest is total, the patient 
never leaving his bed, nor ever rising from 
it or changing his position more than by 
occasionally turning on his side ; the bowels 
1 The Successful Treatment of Internal Aneu- 
rysm, 2nd edit. 1875. ANEURYSM 
73 
are so regulated as to avoid both constipation 
and looseness ; and the diet is restricted to 
about 10 oz. of solid food, of which one half 
is meat or fish, and 8 oz. of fluid (comprising 
2 or 3 oz. of light wine if necessary), per 
diem. The period may be extended in- 
definitely, so long as improvement continues ; 
but in all cases the patient and his friends 
should be prepared for a confinement of not 
less than three months. See Abdominal 
Aneurysm ; and Aorta, Diseases of: Aneu- 
rysm. 
b. Surgical.-Most aneurysms which oc- 
cupy an external position, and are therefore 
amenable to surgical treatment, are curable, 
when the degeneration of the vascular system 
is not too extensive, by mechanical means. 
Of these the chief and by far the most suc- 
cessful are either the ligature of the artery, 
whether in the sac, above it, or in some 
special cases below ; or compression, applied 
either to the artery above the aneurysm, or to 
the tumour itself, or simultaneously in both 
situations, and either by the pressure of an 
instrument, of the fingers, or of Esmarch's 
bandage. But as these methods of treatment 
belong exclusively to the province of surgery, 
it is thought better in a work of this kind 
merely to name them, and to refer the 
reader to the standard works on surgery for 
their description. 
The other methods of surgical treatment 
are far less successful than the above, and 
have the great drawback of being addressed 
exclusively to the contents of the sac ; while 
in the treatment by the ligature and by com- 
pression the resilient power of the sac, and 
its consequent reaction on the blood which 
it contains, no doubt play a great part in the 
cure. The methods now to be mentioned, 
on the contrary, as far as they act on the sac 
at all, rather tend to contuse or to inflame 
it. 
Galvanopuncture.-The first is galvano- 
puncture, in which a current of electricity of 
low tension, long continued, is passed through 
the blood in the sac, decomposing it, and 
causing its coagulation. Needles are plunged 
into the sac, and are then connected with the 
battery; and the action is continued until the 
reduction in the pulsation and the flattening 
of the tumour show that the blood has been 
partly coagulated. Authorities differ as to 
the details of the method. Some apply first 
the positive and then the negative pole to 
each needle ; others the negative pole only, 
the positive being brought in contact with 
the neighbouring skin; while some, on the 
contrary, use the positive pole only. It will 
be found on experiment that a certain amount 
of coagulation takes place around both poles, 
the clot round the positive pole being smaller 
but firmer than that round the negative. The 
object of the operation is to fill the sac as 
much as possible with coagulum, which shall 
gradually harden, and shall attract to itself 
fresh coagula. The dangers of the proceeding 
are those of inflammation of the sac, or of 
the cellular tissue around it; of suppuration 
within the tumour, or of sloughing of the 
punctures and haemorrhage ; and it must be 
allowed that the effects of galvanopuncture 
are very uncertain, both as to the amount 
and firmness of the coagulum produced. 
Still there is satisfactory evidence of benefit 
in many cases, and of a cure in a few. The 
danger of inflaming or cauterising the sac or 
the tissues around may be in some measure 
obviated by coating the needles with vul- 
canite, as recommended by Dr. John Duncan 
of Edinburgh. For a very clear exposition of 
the details of this method, as well as for 
statements regarding the success which has 
attended -electrolysis hitherto, the reader is 
referred to the article on electrolysis by this 
authority, in Heath's Dictionary of Prac- 
tical Surgery. The writer thinks himself 
justified in adding that electrolysis should be 
restricted to cases of thoracic, subclavian, or 
abdominal aneurysm, which cannot be cured 
by medical means, and in which rupture 
seems to be imminent, while the situation 
of the tumour forbids the application of 
ligature or pressure. 
Coagulating injections-Another method 
of producing coagulation of the blood in the 
sac is by the use of coagulating injections. 
Other fluids have been employed, but the 
only one in general use now is the perchloride 
of iron. The circulation is to be suspended 
by pressure on the artery above, and also, 
if possible, below the tumour, before the 
injection is made and for some time after- 
wards. The method is a very dangerous one 
for large aneurysms, on account of the risk 
of embolism, sloughing, and inflammation, 
but it may be used with success in small 
cirsoid and anastomotic aneurysms, and also 
in varicose aneurysm. 
Introduction of foreign bodies.-Aneur- 
ysms have also been treated by the intro- 
duction of foreign bodies into' the sac, with 
the view of producing coagulation of the 
blood upon the foreign substance, such as 
fine wire, carbolised catgut, and horsehair; 
but no case of complete cure has hitherto 
been reported, though in a celebrated case of 
aneurysm of the abdominal aorta, operated 
on by Signor Loreta, of Bologna, the sac was 
completely consolidated. This was, however, 
followed by the rupture of the artery just 
above the tumour. 
Manipulation.-Finally, aneurysms may 
be treated by manipulation. The object of 
this treatment is either to detach a portion 
of coagulum from the wall of the aneurysm, 
which may be carried into the mouth of the 
sac or the distal artery, and so effect a cure 
as in our second mode of spontaneous cure, 
or at any rate so to disturb and break up the 
clot, that its detached laminae may form 
nuclei for further coagulation. "With this 74 
ANEURYSM 
ANGINA 
view the aneurysmal tumour is grasped be- 
tween the two hands to squeeze all the 
fluid blood out of it, and one wall rubbed 
against the other till a ' friction of surfaces 
is felt within the flattened mass.' 1 The pro- 
ceeding is obviously a very dangerous and 
uncertain one, but some indubitable cures 
have been thus effected. 
Arteriovenous Aneurysms. - A few 
words must be added with respect to the 
rarer forms of aneurysm. Arteriovenous 
aneurysms are generally, but not always, 
traumatic, and are divided into two chief 
forms :-1. Varicose aneurysm, in which there 
is a small aneurysmal tumour communicating 
both with the artery and with a vein which 
is always varicose ; and 2. Aneurysmal varix, 
in which the opening between the two vessels 
is direct without any tumour interposed; the 
vein pulsates as well as being varicose, and 
the temperature of the limb and nutrition of 
the skin and hair are increased. In all forms 
of arteriovenous aneurysm the artery after a 
time becomes thin and much dilated. The 
signs of arteriovenous differ from those of 
arterial aneurysm mainly in this-that be- 
sides the intermittent blowing murmur caused 
by the arterial current, there is a continuous 
purring or rasping bruit due to the venou's 
current; and that besides the intermittent 
pulsation there is a continuous thrill. Vari- 
cose aneurysm may be cured by digital pres- 
sure applied directly to the venous orifice, 
and indirectly to the artery above at the 
same time ; or the old operation may be 
performed, the clots being turned out of the 
sac and the artery tied above and below, the 
vein being of course laid open and secured 
either by ligature or pressure ; or the artery 
may be tied above and below without open- 
ing the sac. Electropuncture and coagulating 
injections have also been used with success. 
Aneurysmal varix does not usually require 
or admit of surgical treatment. If it does, 
the ligature of both parts of the artery is 
the only measure that can be adopted, on the 
failure of compression. 
Cirsoid and Anastomotic Aneur- 
ysms.-Cirsoid aneurysm, or arterial varix, 
is a tumour formed by the coils of a single 
dilated and elongated artery; 2 while aneur- 
ysm by anastomosis is a tumour formed by 
the coils of numerous dilated and elongated 
arteries, with the dilated capillaries and veins 
which communicate with those arteries. It 
is often difficult to distinguish these two 
forms of arterial disease from each other. 
Aneurysm by anastomosis frequently origi- 
nates congenitally as one of the forms of 
naevus. The usual situation of these tumours 
is on the scalp. They have often a peculiar 
continuous buzzing or rushing murmur, 
which is propagated over the whole head, 
and much disturbs the patient's rest; while 
they are liable to ulcerate and to become 
the source of serious, and even fatal, haemor- 
rhage. Some cases of spontaneous cure are 
on record. Very numerous methods of treat- 
ment have been employed, of which the 
writer can only mention those which are 
most generally useful. When feasible, the 
total removal of the tumour with the knife 
is certain to effect a radical cure, but this 
operation is often too dangerous to be at- 
tempted. The entire removal by ligature is 
still more rarely practicable. The galvanic 
cautery is often successful: incandescent 
wire being drawn through the mass in various 
directions divides it into portions, and obliter- 
ates the vessels by producing cicatrices at the 
parts cauterised. Setons have also been used 
with success, when combined with the liga- 
ture of the trunk-artery ; and the ligature of 
the artery alone has been said to be followed 
by success, but certainly is generally unsuc- 
cessful. Finally, coagulating injections and 
galvanopuncture have both effected a certain 
number of cures. T. Holmes. 
ANG-EIECTASIA (ayyetov, a vessel; 
and tKraais, extension).-Extension or hyper- 
trophy of the capillaries and minute vessels 
of the surfaces of the body, especially the 
skin; hence angeiectasia capillaris, a term 
applicable to several forms of vascular 
naevus. See Tumours : Angeioma. 
ANGEIOLEUCITIS (iyyoov, a vessel, 
and XevKos, white).-Inflammation of lym- 
phatic vessels. See Lymphatic System, 
Diseases of. 
ANGINA I seize by the throat, 
strangle, or choke).-Synon. : Fr. Angine ; 
Ger. die Brdune. 
The term angina was originally applied by 
Latin writers on Physic, and is still much 
used on the Continent, to indicate a condition 
in which difficulty of breathing and of 
swallowing exist either together or separately, 
caused by disease situated between the mouth 
and the lungs, or between the mouth and the 
stomach. By a special affix to the original 
term, significative of the seat or the nature 
of the disease, several morbid processes are 
known and described, for example :-angina 
parotidea, or mumps; angina tonsillaris, 
or quinsy; angina laryngea, or laryngitis; 
angina pectoris, or breast-pang; angina 
maligna, or malignant sore-throat; angina 
membranosa, or croup. 
These and numerous other diseases, differ- 
ing essentially in their nature and patho- 
logical relations, and having nothing in 
common but certain difficulties in breathing 
or swallowing, are thus classed under the 
word angina. Such a classification is open 
to several objections, and has nothing to 
recommend it. With the exception, there- 
fore, of angina pectoris, 'which has a special 
and familiar signification, the various dis- 
1 Sir W. Fergusson, Med.-Chir. Trans, xl. 8. 
2 See the figure on p. 93, vol. iii., of the System 
of Surgery, 3rd edition ANGINA 
ANGINA PECTORIS 
75 
eases occasionally recognised by the term 
angina will be found described under the 
names by which they are generally known in 
this country. See also Cynanche. 
Richard Quain. 
ANGINA PECTORIS.-Synon.: Syn- 
cope Anginosa; Angor Pectoris ; Suffoca- 
tive Breast-pang ; Fr. Angine de poitrine ; 
Ger. Brustbrdune. 
Definition.-A paroxysmal affection of 
the chest, characterised by severe pain, faint- 
ness, and anxiety; coming on more or less 
suddenly ; essentially connected with dis- 
orders of the pneumogastric, the sympathetic, 
and spinal nerves, and their branches ; and 
frequently associated with structural disease 
of the heart. 
^Etiology.-In searching for the predis- 
posing causes of angina pectoris, we frequently 
notice: (1) A diseased state of the heart. 
(2) Morbid changes in the nerve-tissues. 
(3) The existence of a peculiar condition of 
the nervous system, which may be described 
as an undue susceptibility to impressions. 
It would seem to be often hereditary, and to 
be found in those temperaments in which 
there is a high development of the nervous 
element. Thus it is that this disease has 
caused the deaths of many who, by their 
intellectual development, have left their 
mark on the world's history. It will suffice 
to mention, as instances in this country, the 
names of Lord Clarendon, John Hunter, and 
Dr. Arnold. (4) The influence of age in re- 
lation to angina is conspicuous ; the disease 
is rare before puberty; and, in the writer's 
experience, quite eighty per cent, of the cases 
occur after forty years of age.1 (5) Sex also 
displays a marked influence amongst the 
predisposing causes of this disease. True 
angina pectoris is comparatively rare amongst 
women, a statement by the late Sir John 
Forbes showing that out of 49 fatal cases, 
only 2 occurred in females, and 4 out of 
15 non-fatal cases-facts which entirely cor- 
respond with the writer's experience. In 
the hysterical temperament a form of spurious 
or false angina is not uncommon. (6) It is 
associated in many instances with certain 
habits of life, such as sedentary employments 
and indulgences at the table, and occasionally 
with those states of the system termed hy- 
sterical. (7) The peculiar diathesis which 
gives rise to neuralgia in various parts of the 
body, that in which lithic acid is in excess 
in the system, -would seem to be in many 
cases an efficient cause of the symptoms of 
angina. 
The exciting causes of the symptoms which 
constitute angina pectoris are: (1) Mental 
emotion, especially anger or nervous shock. 
(2) Irritation propagated to the vaso-motor 
centre, causing a sudden rise of arterial tension, 
which reacts upon the heart. Such irritation 
may proceed from the periphery, through 
the cerebral nerves, as the branches of 
the fifth nerve in operations on the teeth; 
through the brachial plexus; and through 
the sympathetic and pneumogastric nerves 
distributed to the abdominal viscera. (3) Cold 
applied to the surface, especially by cold winds. 
(4) Physical exertion, or any other agency by 
which the heart's action is excited and its 
regularity disturbed. (5) Certain toxic agents, 
more especially excessive tobacco-smoking, 
malaria, and the like. (6) Indigestion, 
acidity, and flatulent distension. 
Pathology.-For a better comprehension 
of the symptoms comprised under the term 
angina pectoris, a description of the innerva- 
tion of the heart, with the relations of its 
nerves to those of other organs and regions, 
will be found practically useful. 
1. Innervation of the Heart and its 
nervous relations.-There are embedded in 
the heart-substance, especially towards the 
base of the ventricles, in the auriculo-ven- 
tricular groove, and in the auricular wall 
near the entrance of the great veins, minute 
ganglia, from which grey filaments are dis- 
tributed to the muscle-tissue, whilst other 
fibres form a fine network beneath the endo- 
cardium. Connected with these so-called 
terminal ganglia is the cardiac plexus, and 
situated behind and in the concavity of the 
arch of the aorta, formed by the ultimate 
ramifications of branches from (a) the pneu- 
mogastric, and from (6) the sympathetic. 
(a) The fibres of the pneumogastric come 
from the trunk, as well as from the superior 
and recurrent laryngeal branches of that 
nerve. Those fibres from the trunk and from 
the recurrent branch are of the ' small medul- 
lated or visceral ' variety, retaining their 
white sheath as far as the terminal ganglia 
in the heart. They leave the medulla ob- 
longata and spinal cord as part of the upper 
roots of the spinal accessory nerve, viz., those 
which arise with the vagus and with the 
first, second, and probably third cervical 
nerves, thus forming what Dr. Gaskell has 
designated the cervico-cranial outflow of vis- 
ceral nerves (Journ. of Physiology, vol. vii.). 
(b) The fibres of the sympathetic which 
enter the cardiac plexus are non-medullated. 
They are traceable thereto, with some differ- 
ence in distribution on the two sides, from the 
superior, middle, and inferior cervical ganglia, 
as well as from the first thoracic ganglion 
of the sympathetic, and from the annulus of 
Vieussens, a ring of fibres which encircles 
the subclavian artery, and connects the 
two last-mentioned ganglia. These ganglia 
(lateral) are connected by communicating 
branches with the anterior primary branches 
1 Dr. J. W. Moore has directed attention (Dublin 
Journal of Medicine, February, 1890) to symptoms 
of angina pectoris in the acute infective diseases 
of children, which appear, he says, to arise from 
deficient innervation of the heart, granular or fatty 
degeneration of that organ, or from sudden increase 
of tension in the peripheral arteries. 76 
ANGINA PECTORIS 
of the corresponding spinal nerves, but those 
which join these ganglia with the eighth 
cervical and the first dorsal nerves are 
formed of grey fibres only. The central 
source of the cardiac sympathetic fibres is 
probably situated in the upper part of the 
spinal cord, from whence they pass out as fine 
medullated or visceral fibres in the rami 
communicantes from the second, third, fourth, 
and fifth thoracic spinal nerves. Thence 
passing upwards to the first thoracic ganglion, 
in the annulus of Vieussens, to the inferior 
and superior cervical ganglia, they lose their 
medulla, and issue forth as grey fibres, to 
form the superior, middle, and inferior sym- 
pathetic cardiac nerves, to the cardiac plexus 
above mentioned. Numerous communications 
take place between the various branches of 
the vagus and sympathetic in their course to 
the cardiac plexus. 
With reference to the functions of the 
several nerve-structures just described, it is 
probable that the intrinsic cardiac ganglia 
are mainly concerned in distributing the im- 
pressions which reach them by the vagus and 
sympathetic nerves, and in regulating the 
nutrition of the muscular fibres of the heart's 
walls, which, according to recent researches, 
seem to possess from the cerebro-spinal cen- 
tres independent automatic motor power. 
The efferent impulses from the cerebro- 
spinal centres are of two kinds. The one 
accelerating (katabolic), which reaches the 
heart by way of the sympathetic fibres from 
the cervical and first thoracic ganglia ; the 
other inhibitory (anabolic), transmitted by 
those branches of the vagus derived from the 
spinal accessory which pass to the cardiac 
plexus from the trunk and recurrent laryngeal. 
It should be remembered that these accele- 
rating impulses reach the heart by channels 
which correspond to those taken by the vaso- 
constrictor nerves of the body, that is from 
the spinal cord by the rami viscerates of 
the upper thoracic spinal nerves. The inhi- 
bitory stimuli to the heart, on the other hand, 
are carried by the like branches of the cervical 
region through the spinal accessory. 
The various afferent impressions, which 
probably originate at the endocardial sur- 
face, travel to the nerve-centres mainly, if 
not entirely, by the branches of the pneumo- 
gastric. Those special centripetal impulses, 
which, by inhibiting the vaso-motor centre in 
the medulla oblongata, cause paralysis of the 
vessels of the splanchnic area, are known as 
' depressor,' and reach the centre by those 
branches which join the cardiac plexus from 
the superior laryngeal and cervical cardiac 
nerves. There is reason to believe that pain- 
ful impressions also take this course. 
Lastly, the connexions of this nervous 
apparatus with other organs and regions 
must be briefly mentioned, as the paths 
by which cardiac disturbance may be in- 
duced. These connexions are numerous and 
extensive. Directly or indirectly, most of 
the cranial nerves communicate with the 
vagus and sympathetic, such as the trifacial, 
and, more remotely, the motores oculi; the 
facial, both with the sympathetic and posterior 
auricular branch of the vagus; the glosso- 
pharyngeal, with filaments from the superior 
cervical ganglion, as well as with the ganglion 
of the root and posterior auricular branch of 
the vagus; the spinal accessory, with a com- 
municating strand from the ganglion of the 
root of the vagus, and by incorporation in the 
pneumogastric of the entire internal branch ; 
the hypoglossal, with branches from the su- 
perior cervical ganglion and ganglion of the 
root of the vagus; and lastly the cervical and 
brachial plexuses. In this way the greater 
part of the head and neck, the arms, dia- 
phragm, and chest-walls, are brought into 
indirect nerve-relationship with the heart. 
The intimate association of the pneumo- 
gastric and sympathetic in their distribution 
to the pharynx, larynx, and lungs, to the 
gullet, stomach, and intestines, as well as the 
liver and other abdominal viscera, accounts for 
irritation in these organs reflexly affecting the 
heart's action. That certain emotional states 
influence the heart is well known, though 
the paths taken cannot be clearly defined. 
Seeing thus how widespread are the 
relations existing in these various systems 
of nerves, and seeing how complicated are 
the causes which may, directly or indirectly, 
disturb their functions, and with them the 
functions of the heart itself-we can recognise 
the difficulty of identifying and establishing 
the pathology of the class of cases known as 
' angina pectoris.' 
2. Anatomical Characters.-Vascular and 
inflammatory changes in the nerves, such as 
occur in the gouty diathesis, new growths 
affecting the nerve-tissues, and atheromatous 
patches on the cardiac vessels, involving the 
fibres and ganglia of the cardiac plexus, and 
the vagus and sympathetic, have been ob- 
served and described in cases of angina 
pectoris. 
With reference to the condition of the 
heart, angina may exist and lead to a fatal 
result without any discoverable disease in 
this organ or in its appendages. On the other 
hand, in the great majority of cases various 
forms of structural disease of the heart and 
aorta have been observed-such as athero- 
matous or calcareous degeneration at the 
orifices of or in the coronary arteries, in 
the valves, or in the aorta; dilatation of the 
cavities of the heart, or of the aorta; fibroid 
degeneration of the heart's walls, and ac- 
cumulation of fat in their texture; and 
lastly, and probably the most important 
change of all, fatty degeneration of the 
muscular tissue, the nature of which was 
first described by the present writer. This 
lesion is constantly associated with the cal- 
careous and atheromatous states just men- tioned, and which, being more prominent, 
alone attracted the notice of former ob- 
servers. Nay more, this lesion of the walls 
of the heart is in itself a frequent and suf- 
ficient cause of one of the most prominent 
symptoms of angina pectoris-fainting. This 
condition has been elsewhere described by the 
writer (Medical and Chirurgical Society's 
Transactions, vol. xxxiii.), under the name of 
Syncope lethalis, or fatal-faintness-a de- 
signation analogous to that given by Parry 
to angina pectoris, which he called Syncope 
anginosa. 
The cavities of the heart have been found 
dilated and containing blood; or contracted 
and empty. 
Intimately associated with the state of the 
heart just described are some interesting ob- 
servations by Professor MacWilliam of Aber- 
deen, as to that condition of the cardiac muscle 
which is known as ' delirium cordis or fibrillar 
contraction.' This consists in a rhythmic, 
inco-ordinate, and rapidly repeated contrac- 
tion of the various muscular bundles, whereby, 
the usual beat being abolished, the ventricles 
are thrown into a tumultuous state of quick, 
irregular, twitching action, with at the same 
time a great fall in blood-pressure. Such 
action is quite incompetent to empty the ven- 
tricle, which becomes distended with blood, 
and remains in a condition of diastole. This 
state appears to be induced by very trifling 
causes, frequently not recognisable. Such 
mechanical disturbance as the presence of 
a flatulent stomach or over-distended colon 
would certainly appear a sufficient cause, and 
this is a common association of an attack of 
angina or fatal syncope. It is probable that 
recovery from this condition, possible in ex- 
periments on lower animals, is impossible in 
man. The susceptibility of the muscle to 
assume this state is doubtless due to some 
malnutrition of a degenerative character. 
3. Summary.- To summarise the pre- 
ceding statements, it may be said that 
whilst there is often in angina pectoris an 
absence of any tangible or evident structural 
disease, the morbid state producing the an- 
ginous symptoms may be situated in the 
medulla oblongata ; in the course of the 
nerves, or in their branches; or in the car- 
diac ganglia themselves. It may be the result 
of congestion or inflammation of the nerves, 
such as occurs in the lithic acid or gouty 
diathesis; or of other textural changes, such 
as connective-tissue growth or other growths 
involving the nerve-fibres and ganglia. An 
attack may be produced by emotions acting 
centrifugally; or by irritation acting cen- 
tripetally, reflected, as just said, through 
the vaso-motor centre, from impressions 
made on the peripheral extremities of nerves. 
Thus acidity of the stomach, the result of 
indigestion, often gives rise to symptoms 
which very closely resemble, if they do not 
constitute, an attack of angina. It is by a 
ANGINA PECTORIS 
similar mechanism that anginal symptoms 
have been produced by irritation reflected 
from the fifth nerve, as in pivoting teeth; by 
such irritation of the surface of the skin as 
results from severe herpes; by cold, or by 
exposure to wind. But the most frequent 
source of the symptoms of true angina is to 
be found in those structural affections of the 
heart already described. 
Symptoms.-An attack of angina pectoris 
commences suddenly with pain in the region 
of the heart, generally on a level with the 
lower end of the sternum; occasionally it 
may be traced from a remote point, following 
the course of the nerves, even from the ends 
of the fingers. The pain is severe, and of an 
oppressive, grasping, crushing, or stabbing 
character. It extends sometimes across the 
chest, but more frequently backwards to the 
scapula, and upwards to the left shoulder and 
arm. The pain is accompanied by a distress- 
ing sense of sinking, of faintness, which causes 
the patient to seek support, or of impending 
death. The action of the heart is generally 
irregular. The pulse at the wrist corresponds ; 
but in many well-marked cases of angina it 
is tense and. resisting, yielding a sphygmo- 
graphic tracing indicative of extremely high 
tension, more especially in the early stage of 
the attack. A fear of aggravating the pain 
prevents the patient from breathing deeply, 
though the respiratory function may not be 
really interfered with. The expression is 
anxious, the face is pallid, the lips are more 
or less livid. The whole surface of the body 
is pale, cold, and covered with a clammy 
sweat. Flatulence is often present; urine in 
some cases is passed at short intervals, and 
generally in abundance. 
The attack, more or less severe, having 
lasted a variable time-from a few minutes 
to one or two hours-comes to an end, either 
suddenly or by degrees. The pallor and 
coldness of the surface are replaced by a 
uniform glow-the face may even flush ; the 
pulse becomes soft and full; and there is a 
general feeling of relief. A sense of numb- 
ness or tingling occasionally remains along 
the course of the nerves derived from the 
brachial and cervical plexuses of the affected 
side. 
Clinical Varieties.-All the phenomena 
of an anginal seizure as above described may 
be more or less modified. The attack may 
come on when the patient is at rest, and 
occasionally it sets in during sleep ; but it is 
more commonly induced by emotion or by 
physical exertion, especially by walking up 
an ascent or by exposure to cold air or wind. 
The pain may be comparatively slight, and 
as such may recur with interruptions, it may 
be, during months or even years, representing 
anginoid symptoms rather than true angina 
pectoris. On the other hand it may be so 
severe as to mark a first, a single, and a 
fatal attack. 
77 78 
ANGINA PECTORIS 
The pain may be almost limited to the 
region of the heart, or the lower part of the 
sternum; it may extend all over the chest 
to both arms, or spread to the sides of the 
head and neck and down one or both legs; 
and it may, in some cases, involve the 
diaphragm. The action of the heart may 
be slow, weak, and fluttering; or excited 
and bounding-causing a distressing sense 
of palpitation ; it may be regular or ir- 
regular. Obstruction to the circulation from 
spasm of the arterioles is amongst the most 
constant phenomena of the seizure. The 
breathing sometimes assumes an asthmatic 
character, with comparatively little pain. 
There may be laryngeal spasm. The mental 
functions are generally undisturbed ; but 
there is sometimes slight wandering as the 
attack passes off, and unconsciousness is said 
to be occasionally observed. The sense oi 
danger of impending death is a character- 
istic symptom of angina, and one not often 
absent; whilst a sensation of gasping or 
choking, with difficulty in swallowing, is 
occasionally present. The position of the 
patient varies. Sometimes he stands, resting 
his arms on any convenient object; some- 
times he stoops or leans forward, unwilling 
to be disturbed, even to speak. As a rule the 
attack passes off abruptly, as it commenced, 
leaving the sufferer free from discomfort; 
in other cases its disappearance is slow. The 
varieties in the symptoms of angina pectoris, 
thus seen to be remarkably numerous, cha- 
racterise a form of disease which may be 
comparatively mild and of long duration, or 
one of intense suffering, hastening to a fatal 
termination.1 
Complications. - Amongst the diseased 
conditions with which angina pectoris may be 
said to be associated, rather than complicated, 
are disorders of the liver and of the digestive 
organs, gout, renal disease, diabetes, and cer- 
tain affections of the nervous system. Indeed, 
so marked is the latter connexion, that Trous- 
seau dwelt on the relation which he believed 
to exist between epilepsy and angina-a re- 
lation which seems to depend on that BUS' 
ceptibility to nervous maladies already noticed 
as presented by some individuals, rather than 
on any special pathological connexion between 
these two diseases. More than one striking 
instance of this apparent connexion has fallen 
under the writer's notice. A marked example 
might be mentioned in which this suscepti- 
bility was such, that an oppressive meal of 
indigestible food brought on a first and dis- 
tressing anginal seizure, which was followed 
by other attacks. Brain disease with epileptic 
symptoms was subsequently developed. 
Progress, Duration, and Terminations.- 
The progress and duration of angina pectoris 
will depend wholly upon the nature of its cause. 
Many cases in which a first attack proved fatal 
have been recorded. In four such cases which 
have come under the writer's observation, a 
post-mortem examination revealed the fact 
that there was in each slight partial haemor- 
rhage into the walls of the heart, which had 
been the seat of fatty degeneration, connected 
with calcification of the coronary arteries. 
The symptoms in these cases were those of 
the most severe form of angina pectoris. On 
the other hand, cases present themselves in 
which symptoms may occur at intervals for 
years. Thus in many instances individuals 
present all the symptoms of marked angina, 
accompanied by most of its distressing phe- 
nomena, and by the anxieties and fears that 
they beget; yet these cases, having more a 
neurotic or gouty origin, are controlled by 
treatment, the sufferers being restored to 
health, or continuing for years to enjoy com- 
parative comfort. On the other hand, in the 
cases in which angina is connected with 
structural disease of the heart or of the 
nerves controlling cardiac action, the attacks 
progress in frequency and severity, and 
tend, with more or less certainty, to a fatal 
termination-it may be within a few days or 
weeks. 
Diagnosis.-A typical case of angina pec- 
toris, such as has been already described, can 
hardly be mistaken. But when the several 
symptoms constituting an attack are variously 
modified, some being lessened in severity and 
others exaggerated; or when these symptoms 
depend on, so to speak, remote and remov- 
able causes; it is often difficult to say how 
far the disease is what may be regarded as a 
remediable neuralgia, or an attack of what is 
commonly recognised as true angina pectoris. 
So also it may be difficult to say, in cases of 
true angina, whether the seizure is dependent 
on structural lesions which admit of no im- 
provement, or on some condition that may 
be amenable to treatment. But it is with 
this affection, as with so many others, more 
difficult to determine the nature of the cause 
on which the symptoms depend, than merely 
to recognise the presence of the disease itself. 
With reference to the diagnosis of the struc- 
tural diseases of the heart above referred to, 
1 There may be mentioned here a case of a 
gentleman accustomed to pass lithic acid, who, for 
several years liable to pains over the right side of 
the chest as low as the hypochondrium, was seized 
at night with a severe aggravation of these pains, 
with coldness of the surface, irregular action of the 
heart, depression, and other symptoms, which, had 
the attack commenced on the left side of the chest, 
would have been recognised as typical angina pec- 
toris. Similar attacks recurred at intervals for some 
weeks; they were easily brought on even by walk- 
ing on a level surface for a few hundred yards. 
The most careful examination failed to elicit any 
evidence of organic disease in the organs of circu- 
lation or respiration. The patient is now alive after 
several years and in fair health. Similar cases have 
since fallen under the writer's notice. An inter- 
esting case has been recorded by Dr. Alexander 
Morison {Edin. Med. Journal, February 1879), in 
which disease of the right side of the heart was 
accompanied by symptoms of angina affecting the 
corresponding side of the chest and arm. ANGINA PECTORIS 
79 
it is unnecessary to describe here that which 
will be found fully treated of under special 
heads. It remains but to say that in every 
case the closest scrutiny must be made into 
the condition of the heart and great blood- 
vessels, with a view to determine the presence 
or absence of disease. The investigation 
must further extend to other viscera, such 
as the liver and stomach, and to the diges- 
tive organs generally, as well as to the 
several other sources from which symptoms 
of angina may be excited by the reflected 
irritation already described. Certain symp- 
toms resulting from the presence of other 
diseases should not be confounded with angina 
-such, for example, as the pain and dyspnoea 
caused by pressure of aneurysms or of tumours 
within the chest; by rheumatic or gouty 
neuralgia of the chest-walls; by pleurodynia, 
or acute pleurisy; or by indigestion, acidity, 
and flatulence. Each and all of these several 
conditions must be considered by way of 
exclusion in determining the nature and origin 
of the disease. 
Prognosis.-In anticipating the future of 
an attack of angina pectoris, we must be 
guided chiefly by a knowledge of its cause ; 
in some respects also by its severity ; and by 
the previous history of the case. Thus, if 
we can ascertain that the attack has been 
brought on by some clearly established and 
removable cause, such as fatigue, a chill, 
or indigestion, a favourable prognosis may 
be fairly entertained. On the other hand, if 
the history of the case tells that there have 
been several previous attacks, each increasing 
in severity and connected with heart-disease, 
we can scarcely avoid being led to the con- 
clusion that the complaint will tend, with 
more or less rapidity, to a fatal termination. 
Between these two classes of cases there 
exist a large majority of instances in which 
the symptoms of angina, of greater or less 
severity, depend on neurosis, on gouty dia- 
thesis, or on other sources of nerve-disorder, 
amenable to treatment; and in which, there- 
fore, a favourable prognosis may to some 
extent be given. But in all cases great 
caution should be exercised; for many in- 
stances occur in which, from slight and obscure 
beginnings, severe and even fatal examples of 
the disease have been developed. 
Treatment.-The treatment of angina 
pectoris must, first, have reference to relief of 
the attack itself; and, secondly, during the 
interval, to the removal, if practicable, of the 
causes on which the attacks may depend. 
During the attach, it is necessary first, if 
possible, to lessen the patient's anxiety and 
fear. He should be allowed to retain the 
position in which he feels most comfort, and an 
attempt must immediately be made to relieve 
the suffering. If the exciting cause be one 
that can be removed, this should be accom- 
plished. For example, if the stomach be full 
of undigested food, an emetic of mustard 
might be given with advantage ; or if fla- 
tulence be present, peppermint, ether, and 
other antispasmodics will be useful. If 
cold have produced the seizure, the feet and 
hands should be immersed in hot water, hot 
bottles applied to the surface of the body, 
and poultices of linseed or mustard, or em- 
brocations of chloroform or laudanum, should 
be applied to the chest. For the more im- 
mediate relief of pain some of the agents now 
known to be effectual for the purpose should 
be administered. The nitrite of amyl, origin- 
ally introduced by Dr. Lauder Brunton, has 
been found a more efficient remedy than any 
other hitherto recommended for the direct 
relief of the distressing symptoms of the 
disease. Five or six minims of this drug, 
which is usually dispensed in capsules, should 
be carefully inhaled from a handkerchief or 
piece of lint, and, if necessary, the inhalation 
may be repeated. 
Nitroglycerine, suggested by Dr. Murrell, 
seems also to act efficiently in doses of 555 
grain, in the form of the official tabellae or 
1 per cent, alcoholic solution. The dose may 
be repeated three or four times at short in- 
tervals ; but these drugs must be used with 
caution, as in many cases they produce head- 
ache and superficial congestion. 
The action of these agents depends on the 
power they possess of relaxing the arterioles, 
thus diminishing the peripheral resistance, 
freeing the heart's action, and readjusting 
the circulation. If the pain be of a more 
persistent character, hypodermic injection of 
morphine may be used with advantage. 
In those cases in which debility and exhaus- 
tion exist, the ordinary stimulants will be 
required, and various antispasmodics, such as 
ether, ammonia, &c., may be given with more 
or less benefit. In cases of sudden cardiac 
failure Professor MacWilliam recommends 
faradic excitation of the heart, in the form of 
a series of periodic single induction shocks, 
at the normal rate approximately of cardiac 
action. These should be sent through the 
heart so as to affect the auricles as well as the 
ventricles, one electrode being applied over 
the seat of the cardiac impulse, the other over 
the fourth dorsal vertebra. Large sponge- 
electrodes should be used, they and the skin 
being well moistened with salt solution. The 
shocks employed should be strong-sufficient 
to excite powerful contraction in the volun- 
tary muscles. 
During the intervals.-It is of course de- 
sirable to avoid all causes likely to bring on 
an attack of angina, such as mental excite- 
ment, bodily exertion, exposure to cold, and 
indulgence in indigestible food or heavy 
meals. The leading principle in treatment 
should, however, be to endeavour to deter- 
mine and to remove, when possible, the cause 
of the attacks. "Whether they depend on or- 
ganic disease of the heart, whether on simple 
neuralgia, whether on gout or dyspepsia. 80 
ANGINA PECTORIS 
ANODYNES 
whether on debility, or on fulness of habit- 
to each of such conditions must appropriate 
treatment, as described in other parts of this 
work, be persistently directed. A variety of 
specific remedies has been recommended, 
such as iodide of potassium or sodium in 
diseased states of the arteries, arsenic, phos- 
phorus, iron, zinc, and the different sedatives 
and antispasmodics. Galvanism, in the form 
of the continuous current from thirty cells, 
has proved of use in some uncomplicated 
cases, the positive pole being placed on the 
sternum, and the negative on the lower 
cervical vertebrae. Huchard, in his exhaus- 
tive work on angina pectoris, discusses the 
action of antipyrin and phenacetin, which 
he regards as useful in false angina. He de- 
scribes as useless, or even dangerous, the em- 
ployment of chloral, sulphonal, atropine, and 
certain other drugs. Excellent, however, as 
many of the remedies above named may be 
under special and suitable circumstances, the 
result of treatment must entirely depend on 
the cause of the disease, and how far it is 
within reach of well-directed agencies. Some 
cases of apparently severe angina will be 
found to yield to treatment; whilst, as might 
be expected from the nature of the complaint, 
others unhappily proceed to a fatal termina- 
tion in spite of every effort directed to their 
relief. Richard Quain. 
ANHIDROSIS (a, priv.; and idpws, 
sweat).-Absence or want of perspiration. 
See Perspiration, Disorders of, 
ANHIDROTICS (a, priv.; and ISpms, 
sweat).-Agents which check perspiration. 
See Perspiration, Disorders of. 
ANILINE POISON.-The aniline 
dyes, which are a modern discovery, present 
the most brilliant hues of yellow, blue, and 
red; as such they have been used for dyeing 
stockings, gloves, &c. These articles when 
worn are apt to produce an intense form of 
inflammation and vesication of the skin, 
which is rebellious against treatment, and 
liable to relapse for many months after the 
original attack has subsided. See Der- 
matitis. 
ANIMAL POISONS.-See Poisons. 
ANKYLOSIS (ayKvXos, crooked).- 
Marked stiffness or absolute fixation of a 
joint. Ankylosis may be fibrous, bony, or 
vital. Ankylosis is said to be ' vital ' when 
it is due to the impairment of motility caused 
by rigidity of the muscular apparatus sur- 
rounding the joint. See Joints, Diseases of. 
ANKYLOSTOMA (ayKvXos, crooked; 
and oropa, a mouth).-A genus of nematoid 
worms. See Entozoa. 
ANODYNES (a, priv.; ando3v^,pain).- 
Definition.-Medicines which relieve pain 
by lessening the excitability of nerves or of 
nerve-centres. 
Enumeration.-■ Anodyne medicines in- 
clude Opium and its alkaloids-Morphine and 
Codeine; Antipyrin, Antifebrin, Phenacetin, 
and Exalgin; Bromide of Potassium; Can- 
nabis Indica ; Belladonna and its alkaloid- 
Atropine ; Hyoscyamus and Hyoscyamine ; 
Stramonium; Cocaine; Aconite and Aconi- 
tine; Veratrum and Veratrine ; Conium and 
Conine ; Lupulus and Lupulin ; Gelsemium : 
Chloroform, Ether, and their allies ; Chloral 
Hydrate; Butyl-chloral Hydrate; and Cam- 
phor. 
Action.-Pain is due to a violent stimula- 
tion of a sensory nerve being conveyed to 
some of the encephalic nerve-centres (prob- 
ably the cerebral hemispheres), and perceived 
there. The impression produced on all sen- 
sory nerves, except the cephalic nerves, is 
conveyed, for a part of its course, to the head 
along the spinal cord. The primary impres- 
sion which is felt as pain, is usually made 
upon the peripheral ends of the sensory 
nerves ; but it may also be made upon their 
trunks, upon the spinal cord, or possibly 
upon the encephalic centres directly, without 
any affection of the nerves themselves, as, 
for example, in hysteria. Pain may there- 
fore be relieved, while the source of irrita- 
tion still remains, by lessening the excit- 
ability of the ends of the sensory nerves 
which receive the painful impression; of 
their trunks; of the spinal cord along 
which the impression travels; or of the en- 
cephalic centre in which it is perceived. 
Opium acts by lessening the excitability of 
the sensory nerves, the spinal cord, and the 
encephalic ganglia. Bromide of potassium 
is also believed to act on all three, although 
to a much less degree than opium. Antipyrin 
and its allies probably affect the conduction 
of painful stimuli through the spinal cord 
or sensory tracts in the brain. Belladonna 
and atropine affect the sensory nerves, as 
probably does hyoscyamus. Stramonium, 
aconite and aconitine, veratrine, chloral and 
butyl-chloral, lupulus and lupulin, and gel- 
semium probably act on the encephalic 
centres. 
Uses.-As opium and morphine act upon 
all the nervous structures concerned in the 
production of pain, they may be used to 
relieve pain whatever its cause. Cannabis 
indica and bromide of potassium may be 
employed under the same circumstances as 
opium, but they have very much less power. 
Antipyrin, antifebrin, phenacetin, and ex- 
algin are powerful analgesics, and relieve 
pain without disturbing the brain. They are 
very useful in neuralgic pains, in headaches, 
and in pain depending on some affections 
of the spinal cord-for instance, to relieve 
the lightning pains in locomotor ataxy. 
Chloral seems to relieve pain only by in- 
ducing sleep, and does not produce an an- 
aesthetic effect unless it is given in dangerous 
doses. Butyl-chloral also induces sleep, but seems to have a special sedative action on 
the fifth nerve; as likewise has gelsemium 
-and hence both these agents are used in 
the treatment of facial neuralgia. As the 
action of belladonna is exerted chiefly on the 
peripheral ends of the sensory nerves, this 
remedy is usually applied directly to the 
painful part in the form of plaster, liniment, 
or ointment. Aconite, veratrine, cocaine, and 
opium are also used as local applications in 
several forms, for the relief of pain. The 
various anodynes may be administered not 
only by the mouth, but by other channels, 
such as by inhalation, by enema or supposi- 
tory, by hypodermic injection, or by endermic 
application. 
Several therapeutic measures are employed 
as local anodynes, such as the application of 
dry or moist heat; cold; electricity; various 
forms of counter-irritation; acupuncture; and 
the abstraction of blood. 
T. Lauder Brunton. 
ANOREXIA (a, priv.; and ope^ts, appe- 
tite).-Want or deficiency of appetite, not 
accompanied with disgust for food. See 
Appetite, Morbid Conditions of. 
ANOSMIA (a, priv.; and oapd), smell).- 
Loss of the sense of smell. See Smell, 
Disorders of. 
ANTACIDS.- Definition.- Medicines 
used to counteract acidity of the secretions. 
Enumeration.-The antacids include Pot- 
ash, Soda, Lithia, Ammonia, Lime, Magnesia, 
and their Carbonates; as well as the salts 
which the alkalis form with vegetable acids, 
such as Acetates, Citrates, and Tartrates. 
Action. - Antacids are divided into : 
(1) those which act directly, lessening acidity 
in the stomach; and (2) those which act re- 
motely, diminishing acidity of the urine. The 
alkalis and alkaline earths and their car- 
bonates, with the exception of ammonia, 
have both a direct and remote influence; 
for when swallowed they act on the stomach, 
and being absorbed from the intestinal canal, 
they are excreted by the kidneys, thus lessen- 
ing the acidity of the urine. Ammonia and 
its carbonate are direct but not remote ant- 
acids; for, although they neutralise acidity 
in the stomach, they are partly excreted in 
the form of urea, and do not diminish the 
acidity of the urine. The acetates, citrates, 
and tartrates of the alkalis and alkaline 
earths, on the other hand, are remote but 
not direct antacids. They have no antacid 
effect in the stomach, but undergo combus- 
tion in the blood, being converted into car- 
bonates, in which form they are excreted in 
the urine, and diminish its acidity. 
Uses.-Excessive acidity of the contents 
of the stomach gives rise to acid eructations 
and heartburn. It may sometimes depend 
on the secretion of a too acid juice by the 
stomach, but is generally caused by the for- 
mation of acid from the decomposition of 
ANODYNES 
food when the process of digestion is slow 
and imperfect. Antacids are given after 
meals to lessen acidity in the stomach, and 
afford immediate relief to its attendant 
symptoms. They may prove even more 
efficacious by preventing acidity when given 
before meals (see Alkalis). If the action of 
the bowels be regular, soda is preferable ; 
but lime should be used if they are relaxed, 
and magnesia if there is a tendency to con- 
stipation. Remote antacids are given to 
lessen the acidity and irritating qualities of 
the urine in cystitis and gonorrhoea; and to 
prevent the deposition of uric acid gravel or 
calculus in gouty persons. For this purpose 
potash and lithia are preferable, as their 
urates are more soluble than those of the 
other bases. T. Lauder Brunton. 
ANTAGONISM.- This term is em- 
ployed to express the fact that the physio- 
logical action of certain substances may be 
affected, even to the extent of neutralisation, 
by the presence in the body, at the same 
time, of other substances having an action 
of an opposite character. It is important to 
distinguish between antidotal action and 
physiological antagonism. By an antidote 
is meant a substance which so affects the 
chemical or physical characters of a poison, 
as to prevent its having any injurious action 
on living animal tissues. Thus acids and 
alkalis neutralise each other, so as to form 
innocuous salts; tannin may render tartar- 
emetic and many vegetable alkaloids in- 
soluble ; and the hydrated sesquioxide of 
iron may be used to precipitate arsenious 
acid. In these cases, the action is limited 
chiefly to the alimentary canal; and the 
object of administering the antidote is to 
form insoluble salts, or compounds which 
will be physiologically inert. But tho physio- 
logical antagonism of certain substances is 
presumed to take place in the blood or in the 
tissues. When such a substance as strych- 
nine, for example, is intreduced into the 
alimentary canal, it is quickly absorbed, and 
carried by the blood throughout the body. 
It does not, so far as observation has dis- 
covered, influence all the tissues; but it so 
affects the spinal cord, and possibly the 
brain, as to give rise to severe tetanic con- 
vulsions, chiefly of a reflex character. This 
effect is, no doubt, due either to some inter- 
ference in the nutritional changes between 
the blood and the tissues composing the 
nerve-centres, or to some specific action of 
the poison on the nerve-centres themselves 
(see Affinity). These changes, which are 
termed physiological, and on which the 
normal action of the nerve-centres depends, 
are probably of a molecular or chemical 
nature ; and it is possible to conceive that 
they may be modified in different ways by 
different substances. Thus has arisen the 
idea of physiological antagonism ; and ex- 
ANTAGONISM 
81 82 
ANTAGONISM 
ANTHELMINTICS 
periment has shown that, within certain 
limits, which will no doubt vary in each 
case, such an antagonism is possible. An- 
tagonism may be either local, affecting one 
organ, as is seen in the opposite effects upon 
the pupil of opium or morphine upon the 
one hand, and stramonium, hyoscyamus, or 
belladonna upon the other ; or it may extend 
apparently to more important organs or 
groups of organs, as in the case of the an- 
tagonism between strychnine and the hydrate 
of chloral. The most important investiga- 
tions upon the subject of physiological an- 
tagonism are the following:- 
(1) Physostigmine and Atropine, by Pro- 
fessor Fraser-an inquiry which showed that 
the fatal effect of three and a half times the 
minimum fatal dose of physostigmine may 
be prevented by atropine. (2) Atropine and 
Prussic Acid, a research by Preyer of Jena 
-of a more doubtful character as regards 
the point to be proved, but still sufficient to 
show that, within certain limits not yet 
indicated, it is possible to prevent the fatal 
action of prussic acid by atropine. (3) Atro- 
pine and Muscarine (the active principle of 
Agaricus muscarius) - which were found 
by Schmiedeberg and Koppe to have entirely 
antagonistic actions on the ganglia of the 
heart-muscarine exciting the intracardiac 
inhibitory centres, and stopping the heart in 
diastole, while atropine has the contrary 
effect. (4) Chloral and Strychnine - an 
antagonism first pointed out by Oscar Lieb- 
reich, who showed that minute doses of 
strychnine might so rouse an animal from 
the effects of an overdose of chloral as even 
to save its life. And (5) Strychnine and 
Chloral - with respect to which Hughes 
Bennett demonstrated the converse of the 
last-mentioned observation, namely, that in 
the rabbit a fatal dose of strychnine might 
be so antagonised by a dose of chloral as to 
save life. Other examples of antagonism 
are: chloroform and amyl-nitrite, cocaine 
and morphine, atropine and jaborandi, strych- 
nine and hydrocyanic acid, thebaine and 
chloral, and digitalin and aconitine. 
Conclusions.-It has unfortunately to be 
admitted that the practical results of the 
preceding researches have not been very en- 
couraging. In all of these investigations it 
was quite apparent that the limits of physio- 
logical antagonism were very narrow. Three 
elements affect the chances of success in the 
way of saving life :-(1) the age and strength 
of the animal; (2) the amount of the doses 
of the two active substances-so that if either 
the one or the other active substance be given 
slightly in excess, death will probably take 
place'; and (3) the time between the adminis- 
tration of the two active substances. If the 
stronger be introduced first, and be allowed 
to manifest distinctly its physiological action, 
it is almost impossible to counteract this 
by that of another substance; but if the two 
substances be introduced simultaneously, or 
if the supposed antagonist to the more active 
substance be introduced first, the chances of 
success are much greater. It is apparent, 
therefore, that the facts relating to physio- 
logical antagonism at present known in 
science do not hold out much hope of good 
results from their application in practice; 
but still the physiological facts are so defi- 
nite as to indicate a precise mode of treat- 
ment. For example, no one acquainted with 
the investigations mentioned above would 
hesitate in attempting to relieve the tetanic 
spasms of a case of poisoning by strychnine 
by repeated doses of hydrate of chloral, or 
by the administration of chloroform. A 
practical result of such researches is that the 
principle of physiological antagonism may 
serve as a guide to the application of remedies 
in disease. Thus excessive secretion, say 
from mucous membranes or from salivary 
glands, may be modified or arrested by the 
use of sulphate of atropine, a striking experi- 
mental demonstration of which may be seen 
in the antagonism between bromal hydrate 
and sulphate of atropine in the rabbit. 
John G. McKendrick. 
ANTEFLEXION.-A bending forwards 
of any organ. The term is specially used in 
relation to the uterus, when this organ is 
bent forwards at the line of junction of its 
body and cervix. See Womb, Diseases of. 
ANTEVERSION.-A displacement for- 
wards of any organ. The term is particu- 
larly applied to a change of position of the 
uterus, in which this organ is bodily dis- 
placed in the pelvic cavity, so that the 
fundus is directed against the bladder, and 
the cervix towards the sacrum. See Womb, 
Diseases of. 
ANTHELMINTICS (dm, against; and 
a worm).- Definition.- Medicines 
which kill or expel intestinal worms. 
Enumeration.-The principal anthelmin- 
tics are:-Oil of Male Fern; Kamala; 
Kousso; Oil of Turpentine ; Pomegranate 
Root; Santonica (Worm-seed, so-called), and 
its active principle, Santonin; Areca; Mu- 
cuna; Rue; and drastic purgatives. As 
purgatives only expel the worms, they are 
termed vermifuges ; while the other an- 
thelmintics which kill the worms are called 
vermicides. 
Action.-The oil of male fern, kamala, 
kousso, oil of turpentine, and bark of pome- 
granate root, act as poisons to tape-worms. 
Santonica and santonin remove round- 
worms, and also thread-worms. They were 
formerly supposed to kill the worms, but it 
would appear that they only weaken or in- 
toxicate them, so that they are more readily 
expelled. Castor oil, jalap, scammony, and 
other purgatives do not kill the worms, but 
dislodge and expel them, by the increased 
peristaltic action which they occasion. ANTHELMINTICS 
ANTIPERIODICS 
Uses.-Drastic purgatives may be used 
for worms of any sort; areca for both tape- 
and round-worms; and the other agents for 
the worms on which they severally act as 
poisons. Vermicides are generally given after 
the patient has fasted for several horns, in 
order that, the intestines being empty, the 
drugs may act more readily on the worms. 
A purgative is usually given some hours 
afterwards, in order to expel the dead worms. 
As thread-worms chiefly inhabit the rectum, 
they are most effectually killed by enemata, 
which may consist of a strong infusion of 
quassia ; salt and water; vinegar and water; 
solution of the sulphate or perchloride of 
iron ; oil of turpentine ; castor oil; decoction 
of aloes; or infusion of senna. As abundance 
of mucus in the intestines forms a con- 
venient nidus for the growth of worms, any- 
thing that diminishes this tends to prevent 
their occurrence; and for this purpose pre- 
parations of iron and bitter tonics are useful. 
T. Lauder Brunton. 
ANTHRACOSIS (d^paf, a coal).- 
A deposit of black material in the tissues or 
organs. See Lungs, Inflammation of. 
ANTHRAX (avOpa^, a coal). - A 
synonym for carbuncle, and for malignant 
pustule. See Carbuncle ; and Pustule, 
Malignant. 
ANTIDOTE (ain't, against, and Sihwpt, 
I give).-Definition.-An antidote is any 
remedy which, by its physical or its chemical 
effect upon a poison, or in both ways, is 
capable of preventing or counteracting the 
physiological effects of that substance (see 
Antagonism). Sometimes, however, the term 
is used in a more comprehensive sense, so as 
to include the general treatment of a person 
affected by a particular poison. Thus, in 
poisoning by opium, the use of the stomach- 
pump, enforced exertion, chafing the limbs, 
and artificial respiration may be included in 
the general antidotal treatment. 
Modes of Action, and Application.- 
Most antidotal substances form with the 
poison insoluble or innocuous compounds. 
Without attempting to give a complete list, 
the following are examples of the more 
common poisons and their respective anti- 
dotes :- (1) arsenious acid : solution of 
dialysed iron administered freely, or light 
magnesia ; (2) prussic acid : newly pre- 
cipitated oxide of iron with an alkaline 
carbonate ; hypodermic injection of 2 to 
4 IT] of liquor atropinae sulphatis every 
half-hour; (3) oxalic acid: chalk, common 
whiting, or magnesia suspended in water; 
(4) tartar emetic : tannin, catechu, or other 
vegetable astringents ; (5) acetate of lead: 
sulphate of magnesium, or the phosphates of 
sodium and magnesium ; (6) caustic potash : 
dilute acetic acid, fixed oils, lemon juice; 
(7) corrosive sublimate: albumin, white of 
egg, flour, or milk ; (8) mineral acids : chalk, 
common whiting, plaster from the walls or 
ceiling, or carbonate of magnesium ; (9) chlo- 
ride of zinc : albumin, milk, or carbonate 
of sodium. 
Vegetable poisons cannot thus be counter- 
acted. If they have been taken in the form 
of seeds, leaves, or roots, the proper course 
is to remove them from the stomach or 
bowels as soon as possible by emetics and 
purgatives, and at the same time to sustain 
the flagging strength of the patient by the 
administration of stimulants. On the other 
hand, if the alkaloid has been taken, it is so 
soon absorbed that emetics and purgatives 
are of little avail, or may even be injurious. 
In these circumstances we must rely on the 
administration of the physiological antagonist 
of the poison (such as chloral hydrate in tlie 
case of strychnine-poisoning), and on support- 
ing the strength of the patient. The following 
are the best antidotes to the vegetable poisons 
most frequently met with :-(1) aconite 
root: emetic of sulphate of zinc and stimu- 
lants ; (2) belladonna leaves, berries, or root: 
emetic of sulphate of zinc, ammonia, stimu- 
lants, and after some time an active purga- 
tive ; (3) digitalis : emetics, stimulants, and 
the maintenance of the recumbent position; 
(4) hyoscyamus leaves : emetics and stimu- 
lants; (5) hydrochlorate or meconate of mor- 
phine, or any of the preparations of opium : 
hypodermic injection of apomorphine; ex- 
ternal stimulation by warmth, turpentine or 
camphor liniments; enforced exertion ; arti- 
ficial respiration, and small repeated doses of 
sulphate of atropine ; (6) chloral hydrate : 
the same as for opium ; (7) strychnine or nux 
vomica: animal charcoal suspended in water, 
repeated large doses of chloral hydrate, or 
chloroform; (8) atropine: stimulants, sub- 
cutaneous injection of caffeine, morphine, or 
pilocarpine, or of very minute doses of phy- 
sostigmine ; (9) calabar bean : atropine, or 
stimulants, artificial respiration; (10) mush- 
rooms : subcutaneous inj ection of 2 to 4 of 
liquor atropinse sulphatis, stimulants, castor 
oil; (11) tobacco or nicotine: stimulants, 
subcutaneous injection of minute doses of 
strychnine. See Poisons. 
John G. M'Kendrick. 
ANTIMONY, Poisoning by.-See 
Tartar Emetic, Poisoning by. 
ANTIPERIODICS. - Definition. - 
Medicines which prevent or relieve the par- 
oxysms of certain diseases which exhibit a 
periodic character. 
Enumeration. - The chief antiperiodics 
are : - Cinchona-bark and its alkaloids- 
Quinine, Cinchonine, Quinidine, and Cin- 
chonidine ; Bebeeru Bark and its active prin- 
ciple, Beberine; Salicin, Salicylic Acid and 
its salts ; Eucalyptus globulus ; and Arsenic. 
Action.-The mode of action of antiperio- 
dics is at present unknown. 
83 84 
ANTIPERIODICS 
ANTISEPTICS 
Uses.-Cinchona, and still more quinine, 
is almost a specific in the treatment of inter- 
mittent fevers, periodic headaches, neural- 
gias, and other affections caused by malaria. 
Though less certain in its action than in in- 
termittent fevers, quinine is also the best 
remedy in the remittent fevers of the tropics, 
in which, however, it must be given in very 
large doses. Its action in these fevers appears 
to be assisted by antipyrin or other antipyre- 
tics, given so as to reduce the temperature to 
the normal during the remission. The other 
alkaloids of cinchona have a similar action 
to that of quinine, but they are not so 
powerful. Beberine is only about one-third 
as powerful, and is by no means so certain ; 
and the same remark applies to the other 
remedies enumerated. In some cases of 
ague and other intermittent affections arsenic 
proves successful when quinine fails. Emetics 
and purgatives are useful auxiliaries to qui- 
nine in the treatment of ague, and are em- 
ployed alone for the cure of this disease in 
some parts of the world where quinine is not 
available. T. Lauder Brunton. 
ANTIPHLOGISTIC (avr'i, against; 
and I burn).-A term for any method 
of treatment that is intended to counteract 
inflammation and its accompanying constitu- 
tional disturbance. 
ANTIPYRETICS (dvr), against; and 
nvpeTos, a fever).-Definition.-Therapeutic 
agents which reduce the temperature in fever. 
Enumeration. -The principal agents used 
as antipyretics are-Cold Baths, Cold Appli- 
cations, Ice ; Diaphoretics; Alcohol; Chloral; 
Quinine ; the Salicyl compounds; Antipyrin, 
Antifebrin, Phenacetin, and allied bodies; 
Eucalyptol; Essential Oils ; Aconite ; Digi- 
talis ; Green Hellebore; Purgatives; and 
Venesection. 
Action.-The temperature of the body 
may be reduced, either by increasing the 
abstraction of heat, or by lessening its pro- 
duction. The direct application of cold, by 
means of baths, affusion, or sponging, or by 
enveloping the body in sheets wrung out of 
cold water, is the most powerful and rapid 
means of abstracting heat. But the loss of 
heat which constantly occurs, even in health, 
by evaporation of the sweat, and the radiation 
and conduction of heat from the skin, may 
be increased by the use of diaphoretics, such 
as salts of potassium, preparations of anti- 
mony, or acetate of ammonium; or by such 
medicines as dilate the cutaneous vessels, so 
as to allow the heated blood to circulate freely 
through them, and to become cooled by the ex- 
ternal media surrounding the skin. Alcohol, 
in the form either of wine or spirits, and 
chloral have an action of this sort, though 
alcohol also influences the production of 
heat. Alcohol, quinine, the salicyl com- 
pounds, antipyrin, antifebrin, phenacetin, 
pyrodin, and their allies, eucalyptol, and 
essential oils lessen the production of heat 
within the body, probably by diminishing 
oxidation of the tissues (see Alcohol). 
Aconite, digitalis, and green hellebore reduce 
the temperature, but their mode of action is 
not precisely ascertained. 
Uses. - Antipyretics act much more 
powerfully in reducing the temperature of 
the body in fever than they do in health. 
They may be used when the temperature has 
risen either from exposure to a high external 
temperature, as in thermic fever; in conse- 
quence of inflammation, as in pneumonia, 
pericarditis, or phthisis; or in specific fevers, 
as acute rheumatism, typhus, and scarlatina. 
The most rapid and powerful antipyretic 
remedies are cold baths ; next probably come 
antifebrin, antipyrin, phenacetin, large doses 
of salicylic acid or salicylate of sodium, and 
quinine. In acute rheumatism the salicylates 
are the most useful antipyretics. Quinine 
seems to act very efficiently in thermic fever 
when injected subcutaneously. 
T. Lauder Brunton. 
ANTISEPTICS (W, against ; and 
arj-n-TiKov, from afu, I make putrid).-Synon.: 
Antiputrescents. 
Definition.-An antiseptic is a substance 
which prevents or retards putrefaction-that 
is, the decomposition of animal or vegetable 
bodies, accompanied by the evolution of 
offensive gases. The putrefactive change 
occurs only in dead matter, and requires the 
presence of moisture, heat, and a ferment. 
That there is no putrefaction in the absence of 
moisture is obvious, for bodies, such as albu- 
min and blood, which in the moist state are 
highly susceptible of putrefaction, may be 
kept for an indefinite time without change 
if they be perfectly dry. Heat also has an 
important influence on putrefaction. At very 
low temperatures the putrefactive change 
ceases, while elevated temperatures, such as 
prevail in tropical climates, are favourable 
to it. An additional element besides heat 
and moisture is, however, required, and the 
opinion generally accepted is that this con- 
sists of minute vital organisms, which excite 
putrefactive decomposition. 
Mode of Action.-The substances used 
as antiseptics act either directly on the bodies 
in which putrefaction is occurring or might 
occur, forming with them combinations that 
are not susceptible of the decomposing action 
of a ferment; or they act indirectly, by 
destroying the vitality or otherwise prevent- 
ing the development and propagation of the 
organisms of which the ferment is composed. 
In this respect antiseptics may be distin- 
guished from disinfectants, the action of the 
latter being directed only against the exciting 
causes, and offensive or deleterious products, 
of a class of changes which are themselves 
more comprehensive than those implied by 
the term putrefactive. ANTISEPTICS 
85 
Enumeration. - There are numerous 
chemical agents possessing antiseptic proper- 
ties, among the chief of which are :-Chlo- 
rine, Sulphur Dioxide (Sulphurous Acid), 
Nitric Oxide, and Peroxide of Nitrogen, as 
gases; Carbolic Acid, Aseptol, Creasote, 
Benzol, Sulphites, Hyposulphites, and Hypo- 
chlorites, which emit vapours at common 
temperatures; and Mercuric Chloride (Cor- 
rosive Sublimate), Mercuro-Zinc Cyanide, 
Chloride of Zinc, Chromic, Boric, Tannic 
and Salicylic Acids, Permanganate of Potas- 
sium, Naphthol, Resorcin, and Charcoal, 
from which no vapour is emitted. 
Uses.-1. In therapeutic practice anti- 
septics are chiefly employed in the treatment 
of surgical operations and of open wounds, 
to prevent the occurrence of putrefactive 
decomposition. See Antiseptic Treatment. 
Those antiseptics are best suited for this 
purpose which, acting efficiently on the fer- 
ment, have no injurious effect on the parts 
in which the healing process is going on. 
Gases, except in solution, cannot be locally 
used, as it would be necessary to enclose the 
substance to be preserved in an air-tight 
vessel containing the gas. The volatile anti- 
septics, which slowly emit a vapour, have 
been preferred to those which emit no vapour, 
although among the latter salicylic and boric 
acids, when properly diluted, being devoid of 
any irritating properties if applied to inflamed 
surfaces, present on this account a marked 
advantage. Latterly a cyanide of mercury 
and zinc, which is more powerfully antiseptic 
than those last named, and equally devoid of 
irritating properties, has been successfully 
used and recommended by Sir Joseph Lister. 
Corrosive sublimate, which appears to be one 
of the most powerful of antiseptics, is also 
now frequently used in the form of a weak 
solution, one part in 2,000 parts of water 
being efficient. 
Carbolic acid, which was the first active 
disinfectant used in surgical operations, still 
retains its position as one of the most valuable 
of this class of chemical agents. It is usually 
employed in solution in water, one part of 
the pure crystallised acid being dissolved in 
from 20 to 100 parts of water, and applied 
as a lotion, and sometimes in the form 
of spray, diffused through the atmosphere 
during a surgical operation or the dressing 
of a wound. The solution may also be used 
on lint or cotton-wool, for covering the 
affected part. Antiseptic gauze for a similar 
purpose may be made by adding one part 
of crystallised carbolic acid to five parts of 
common resin and seven parts of paraffin, 
melted together and applied to coarse muslin, 
so as to form a thin coating, which, when it 
has hardened, is used for covering the parts 
to be protected. 
Mercuric preparations, and especially the 
cyanide of mercury and zinc, have to some 
extent taken, and will probably still further 
take, the place of carbolic acid for the 
purpose under notice. The cyanide, how- 
ever, although having the advantage of its 
non-irritating properties, has the defect of 
insolubility. 
Boric acid is prepared as a dressing for ro- 
dent ulcers. This is composed of boric acid and 
white wax, each one part, paraffin and almond 
oil, each two parts. The boric acid and oil are 
added to the melted wax and paraffin, and the 
whole is stirred in a mortar until it thickens, 
and then set aside to cool and harden, after 
which it is to be rubbed in the mortar until 
it acquires the consistence of an ointment. 
This is thinly spread on fine rag and applied 
to the wound. The oil separates and is 
absorbed by lint or rag placed over the 
dressing, while a firm plaster, which is easily 
removed when necessary, remains attached 
to the skin. 
Salicylic acid is sometimes substituted for 
boric acid in the dressing last described; 
or the finely powdered acid may be merely 
sprinkled over the part affected. Its very 
slight solubility in water presents an obstacle 
to its use in solution, unless something be 
added to render it more soluble; borax, 
which is itself a good antiseptic, may be used 
for this purpose. One drachm of salicylic 
acid, two drachms of borax, and half an 
ounce of glycerine, with three ounces of 
water, form, if aided with a little heat, a 
clear solution which may be used as an 
antiseptic lotion. 
2. In medical practice antiseptics are also 
employed, either as local applications or as 
internal remedies. Those which are chiefly 
available include creasote, carbolic acid, the 
sulphocarbolates, sulphurous acid, the sul- 
phites or hyposulphites, chlorine water, 
permanganate of potassium, borax or boric 
acid, chlorate of potassium, charcoal, salicylic 
acid, menthol, and thymol. They are prin- 
cipally used for the prevention and treatment 
of infectious fevers, and in low forms of 
ulceration of the throat. 
3. In using antiseptics for the preservation 
of anatomical specimens, a wider range of 
chemical agents may be taken, and a selection 
made of substances that would be inapplic- 
able in the treatment of the living subject. 
Arsenious acid, corrosive sublimate, in other 
than the weak solutions previously noticed, 
and chloride of zinc in solution, are of 
service for this purpose ; and chromic acid, 
even when diluted with from five hundred to 
one thousand parts of water, possesses the 
property of preserving animal matter from 
decomposition, as also does a solution of one 
part of borax in forty parts of water. Alcohol 
and glycerine are also employed for the pre- 
servation of animal and vegetable substances 
as specimens. For the like purpose, drying, 
or drying and smoking are used, as in the 
preparation of bacon, pemican, fish, &c. 
4. Antiseptics of a milder nature, such as 86 
ANTISEPTICS 
ANTISEPTIC TREATMENT 
common salt, nitre, and sugar, are adopted 
for preserving articles of food. 
T. Redwood. 
ANTISEPTIC TREATMENT. - 
Principles :-The * Antiseptic System ' of 
treatment, introduced by Sir Joseph Lister 
about 1867, which has in great measure 
revolutionised modern surgery, depends upon 
certain postulates, the appreciation and ac- 
ceptance of which are essential to its success- 
ful application. They are :- 
I. Septic processes in a wound, and the 
constitutional changes resulting from them, 
are caused by the development in it of minute 
living organisms. 
II. These living organisms are (with some 
few exceptions) always introduced from out- 
side the body, either by the hands or instru- 
ments of the operator, by floating particles 
of dust, by lotions or dressings, or in some 
similar way. 
III. There are means at our disposal, such 
as the employment of certain germicidal 
agents, superheating, &c., by which the vi- 
tality of these organisms may be destroyed, 
and their entrance into a wound in an active 
state effectually prevented, or their influence 
combated if they be present. 
Applications.-In order to carry out an 
antiseptic operation it is necessary :- 
1. To purify the skin of the region to be 
operated upon, for a considerable distance 
beyond the part which will be occupied by 
the wound. 
2. To purify the hands of the operators, 
the instruments, sponges, and everything 
coming in contact with the wound; and to 
ensure against their defilement until the 
operation is completed. 
3. To prevent any living septic organisms 
falling upon the wound during an operation, 
or to destroy their vitality before the dress- 
ing is put on. 
4. To apply a dressing containing a store 
of some antiseptic material; and to change it 
before this material has been so much washed 
away by the discharges that a track is left 
along which septic organisms may be able to 
spread from the edge or surface of the dress- 
ing to the wound. 
Materials Employed.- In the present 
work it is necessary to deal only with 
generalities, because the details of the treat- 
ment are numerous, somewhat complex, and 
ever changing. Still, it is deemed advisable 
to add a few words on the concrete side of 
the question, particularly with respect to the 
antiseptic substances at present commonly 
in use, and their chief characteristics. 
1. Carbolic Acid.-This is occasionally 
used pure (liquefied by adding 6 to 10 per 
cent, of water to the crystals) to purify some 
already septic wounds; or a 1 in 20 watery 
solution is used for purifying the skin of the 
part to be operated upon, the hands and 
instruments of the operator, or in the spray, 
if that be ever employed. A 1 in 40 watery 
solution may be used for the sponges, or for 
bathing the wound during the operation and 
at the changing of the dressing; but it is less 
trustworthy and less convenient than a weak 
mercurial solution. Carbolic acid gauze is 
not so much used as formerly, but in some 
cases is still the best dressing at our disposal. 
A solution of 1 in 10 in oil is useful for lubri- 
cating catheters. 
Carbolic acid has the advantages of being 
very diffusible, and of having an attraction 
for oily and greasy substances, and hence a 
superiority over mercurial salts for application 
to the skin; it does not blacken steel or silver 
instruments. It has the disadvantage of 
being irritating, and hence causing more 
effusion of serum than do the mercurial 
salts. Dressings containing carbolic acid 
must be kept in airtight boxes. 
2. Mercurial Salts.-(a) Bichloride of 
mercury is employed in solutions of 1 in 
500, 1 in 2000, or still weaker. The 1 in 500 
solution is used after the carbolic acid lotion, 
for purifying the skin; for purifying an already 
septic wound; or as a final application to an 
aseptic wound at the end of an operation. 
The 1 in 2000 solution is used for the sponges, 
and for application to a w'ound during an 
operation and at the changing of the dress- 
ings. Mercuric chloride forms an insoluble 
albuminate when mixed with blood ; hence 
the solutions are practically much weakened 
immediately they come into contact with a 
bleeding surface. Its advantage is its high 
germicidal quality; its disadvantages are that 
a 1 in 500 solution applied for some time to 
the skin causes vesication, and that if mixed 
with tap water a large proportion of the salt 
is thrown down as insoluble chlorides. The 
latter difficulty is overcome by adding a small 
quantity of chloride of sodium; or by sub- 
stituting for the simple corrosive sublimate, 
the very soluble but decidedly irritating sal 
alembroth, a double chloride of ammonium 
and mercury, which for a while was very 
largely employed, but is now almost super- 
seded. It is thus obvious that mercuric 
chloride alone is not a very suitable substance 
for the active principle of a permanent dress- 
ing. Weaker solutions- -1 in 10,000 and 
1 in 40,000-are excellent for irrigating 
abscess cavities, or wounds during the process 
of suturing. 
(b) Biniodide of mercury has many of the 
characteristics of the bichloride; but it does 
not form so copious a deposit of insoluble 
albuminates when added to blood. It is 
more irritating, and not at present much used 
in the pure state. 
(c) Cy abide of mercury, in the form of a 
kind of double salt with cyanide of zinc, is 
the essential constituent of the latest anti- 
septic dressing introduced by Lister. This 
is very insoluble and very unirritating, but ANTISEPTIC TREATMENT 
ANTISPASMODICS 
87 
at the same time powerfully antiseptic, and 
at present promises to take the place of all 
other materials for a permanent dressing. 
3. Boric Acid is a mild and not very 
trustworthy antiseptic. It is, however, useful 
either in the form of boric lint, boric ointment, 
or boric lotion (a saturated watery solution) 
for application to superficial granulating 
surfaces. It is very unirritating. 
4. Salicylic Acid is not a very powerful 
antiseptic. It is used in the form of 
salicylic wool, of various strengths, as an 
external dressing outside one containing 
some more potent material. 
5. Iodoform is a powerful deodorant, but 
its antiseptic qualities are not great. It is 
used with great benefit in the form of crystal 
or powder to stinking wounds. 
6. Chloride of Zinc in solution-gr. xl 
to Jj-is invaluable as an application to sur- 
faces which it is necessary to leave exposed 
to the air, such as those of the mouth or 
rectum, or for purifying septic cavities. It 
usually prevents septic changes for two or 
three days. 
This list might be multiplied almost 
indefinitely, and would have to include 
various coal-tar products, such as creoline, 
which is good for application to ulcers, 
naphthaline, &c., oil of eucalyptus, thymol, 
iodol, iodine, and countless others, but it is 
impossible to mention in detail more than 
those most commonly in use. 
Use.-(1) The steps of a simple operation, 
where the shin is unbrohen, such as the re- 
moval of a tumour or the opening of an 
abscess, will now be described as an illustra- 
tion. 
The skin of the part to be operated upon, 
and the hands of the operator, are washed 
first with soap and water, then with 1 in 20 
carbolic acid solution, and then with 1 in 500 
sublimate solution. The instruments should 
have been placed some time previously in a 
flat tray filled with carbolic acid solution 
1 in 20; and a large supply of sublimate 
solution. 1 in 2000, should be prepared, in 
which the sponges are to be washed out, and 
the hands of the surgeon and his assistants 
dipped from time to time. It is convenient 
to surround the part to be operated upon 
with towels wrung out of one of the antiseptic 
solutions, so that instruments may not be 
thoughtlessly laid down upon an unpurified 
surface. During the operation it is advisable 
to irrigate the wound occasionally with some 
of the 1 in 2000 sublimate solution by means 
of a sponge, and it is an additional safe- 
guard, at the end of the operation, to sponge 
it over with some of the 1 in 500 sublimate 
solution. Finally during the application of 
the sutures some of the 1 in 2000 solution 
should be dropped over the wound from a 
wet sponge or an irrigator ; and this is to be 
kept up until the incision is covered by the 
deep part of the dressing. 
Before changing an antiseptic dressing, 
scissors and forceps, and a piece of rag or 
wool should be placed in a bowl of the anti- 
septic solution preferred, and the fingers of 
the surgeon should be purified. As soon as 
the deep part of the dressing is removed, 
some of the solution should be dropped upon 
the wound by means of the rag or wool, and 
the process should be frequently repeated 
until the deep part of the new dressing is in 
position. 
By most surgeons the spray has now been 
completely abandoned; some still employ 
it throughout their practice. The present 
writer reserves its use for cases like those 
of empyema, where large volumes of air, 
possibly bearing particles of dust, are sucked 
into an inaccessible cavity. 
(2) If the shinhavebeen previously injured, 
as in a compound fracture, or in abscesses 
which have burst, the strongest antiseptic 
solutions must be applied with great vigour 
to the exposed surface, their influence being 
often advantageously supplemented by the use 
of the sharp spoon or the nail-brush. 
Besides these matters, thus briefly hinted 
at, the acceptance of the antiseptic principle 
has effected marvels in the improvement 
of the hygiene of hospital wards, inas- 
much as septic wounds are now dressed at 
frequent intervals with the most suitable 
antiseptic and deodorising dressings, the dis- 
charges not being allowed to collect and 
fester as in former times beneath putrid 
poultices and water-dressings. And it should 
effect still more when it is thoroughly carried 
out in all the details of the sick-room, by 
proper ventilation, by the methodical puri- 
fication of bed-pans, catheters, urinals and 
other utensils, and in a host of other ways 
too numerous to mention. 
Rickman J. Godlee. 
ANTISPASMODICS (dvr:, against, and 
(rnatrpa, a spasm).-Definition.-Medicines 
which prevent or allay spasm. 
Enumeration.-Antispasmodics may be 
arranged in groups as follows :-Valerian, 
Valerianic Acid and its salts ; Musk, Castor, 
Asafcetida, Sumbul and Galbanum; Cam- 
phor, Brominated Camphor, Oil of Amber; 
Ammonia and its Carbonate ; Alcohol, Ether, 
Acetic Ether, Chloroform, Nitrite of Amyl; 
Bromide of Potassium, Bromide of Ammo- 
nium ; Conium, Lobelia, Opium, Gelsemium, 
Indian Hemp, Belladonna, Stramonium; 
and the Essential Oils. As adjuvants may 
be mentioned-Cold Baths, moderate Exer- 
cise, Friction, Heat, and Moisture ; and also 
Quinine, Arsenic, Zinc, and Silver. 
Action.-Certain nerves and nerve-centres, 
when excited, produce contraction of volun- 
tary or involuntary muscular fibres; other 
nerves and centres arrest movements ; and 
by the combined action of these two systems 
the motions of the various contractile struc- 88 
ANTISPASMODICS 
ANUS, DISEASES OF 
tures in the body are regulated, and subor- 
dinated to the requirements of the organism 
as a whole. Excessive contraction or spasm 
of one part of the body may therefore arise 
either from excessive action of the motor, or 
deficient action of the inhibitory centres. 
Spasm may affect the involuntary muscular 
fibres of the intestines-as in colic; of the 
vessels-as in some forms of headache, and 
in vaso-motor neuroses of the uterus and 
bladder; of the bronchi-as in spasmodic 
asthma; of single voluntary muscles, or 
groups of muscles-as in various forms of 
cramp ; or it may involve the muscular 
system generally-as in tetanus, epilepsy, 
and hysteria. Antispasmodics may act by 
lessening the irritability of motor centres, 
as, for example, bromide of potassium and 
conium ; or by stimulating those portions of 
the nervous system which restrain and co- 
ordinate movements, as alcohol probably does. 
There are no direct experiments to show the 
action of antispasmodics on the inhibitory 
centres; but it seems probable that they have 
such an action, although it may not be con- 
fined to these parts alone. Thus small doses of 
alcohol and ether, which stimulate the ner- 
vous system generally, and usually increase 
motor activity, will restrain and co-ordinate 
excessive muscular action, as in colic, nervous 
agitation, trembling, and hysteria. It is at 
present impossible to localise the part of the 
nervous system affected by valerian, asafoe- 
tida, and other drugs of this class. As spasms 
occur when the nervous system is deficient 
m power, nervine and general tonics, such 
as quinine, zinc, and iron, are often found 
to be useful adjuvants. 
Uses.-In such convulsive diseases as epi- 
lepsy, laryngismus stridulus, and infantile 
convulsions, bromide of potassium is the 
most powerful antispasmodic ; in hysteria- 
valerian, asafoetida, and the bromides; in 
chorea-arsenic, conium, copper, and zinc ; 
in spasmodic asthma--lobelia and stramo- 
nium ; in spasm of the blood-vessels-nitrite 
of amyl. In all spasmodic affections, cold 
baths or sponging, exposure to sunlight, 
moderate exercise, and a plain but nutri- 
tious diet should be employed; and late 
hours, a close atmosphere, exhausting emo- 
tions, or excessive bodily or mental work 
should be avoided. 
T. Lauder Brunton. 
ANTRUM, Diseases of.-See Nose, 
Diseases of. 
ANURIA. - Absence of urination, 
whether from suppression or retention of 
urine. See Micturition, Disorders of; and 
Urine, Suppression of. 
ANUS, Diseases of.-The principal 
affections of this part are 1. Congenital 
Abnormalities ; 2. Epithelioma; 3. Irritable 
Sphincter Ani; 4. Irritable Ulcer; 5. Pro- 
lapsus ; 6. Prurigo; and 7. Tumours and Ex- 
crescences. For Fistula in Ano sec Rectum, 
Diseases of. 
1. Congenital Abnormalities [atresia) 
may be classed as follows:-1. Imperforate 
anus without deficiency of the rectum 
2. Imperforate anus, the rectum being par- 
tially or wholly deficient. 3. Anus opening 
into a cul-de-sac, the rectum being partially 
deficient. 4. Imperforate anus in the male, 
the rectum being partially deficient, and 
communicating with the urethra or neck of 
the bladder. 5. Imperforate anus in the 
female, the rectum being partially deficient, 
and communicating with the vagina or uterus. 
6. Imperforate anus, the rectum being par- 
tially deficient and opening externally in 
an abnormal situation by a narrow outlet. 
7. Narrowness of the anus. These imper- 
fections can be remedied, if at all, only by 
operation. 
2. Epithelioma.-The anus, like other 
parts where a junction takes place between 
the skin and mucous membrane, is liable to 
epithelioma. It is easily recognised by the 
ordinary characters of the sore. "Warty 
growths and ilaps of skin at this part are 
subject to this form of degeneration. The 
treatment applicable to this disease is to re- 
move the growth by excision, 
3. Irritable Sphincter Ani.-In this 
complaint the anus is strongly contracted 
and drawn in by the action of the sphincter. 
Any attempt to examine the part produces 
spasm, and the finger passed through it is 
tightly grasped as if girt by a cord. In cases 
of old standing the muscle becomes hyper- 
trophied, and forms a mass encircling the 
finger like a thick unyielding ring. This 
state is the source of serious trouble in 
defecation, owing to the expulsive power 
of the bowel being insufficient to overcome 
the impediment caused by the muscle to 
the passage of the feces. Irritability of the 
sphincter, independent of fissure or ulcer, oc- 
curs generally in hysterical females, and is 
relieved by mild laxatives, the local appli- 
cation of cocaine or an opiate ointment, and 
the occasional passage of a bougie coated 
with a sedative ointment. 
4. Irritable Ulcer.-This is a small 
superficial sore, situated just within the 
circle of the sphincter, usually at the back 
part, commonly known as fissure, from its 
appearance in the contracted state of the 
part. The feces passing over the sore excite 
spasm of the muscle, and cause a sharp 
burning pain which lasts for two or three 
hours. The distress often does not come on 
till an interval of ten minutes or more has 
elapsed after defecation. The pain is some- 
times so acute that patients resist an action of 
the bowels, and allow them to become costive. 
The irritable ulcer occurs usually in middle 
life, and is more frequent in women than in 
men. It seldom gets well under the influence 
of local applications, but an incision through ANUS, DISEASES OF 
AORTA, DISEASES OF 
89 
the centre of the sore sets the muscle at rest, 
and allows the part to heal. Forcible dilatation 
of the sphincter with the fingers under an 
anaesthetic is a very effective mode of treat- 
ment. When the suffering is moderate, a 
cure may be attempted by giving a laxative 
to ensure soft evacuations, by enjoining rest 
in the recumbent position, and by the appli- 
cation of an ointment containing morphine, 
belladonna, or cocaine. 
5. Prolapsus.- See Rectum, Diseases of. 
6. Prurigo.-Itching, though a common 
symptom in disorders of the lower bowel, 
may occur as a distinct affection, a neurosis 
liable to paroxysms. It is caused by worms 
in the rectum, and by congestion of the 
haemorrhoidal veins. Patients suffer more 
after taking stimulating drinks and when 
heated in bed. The itching is extremely 
teasing and annoying, especially at night, 
keeping the sufferer awake for hours. Fric- 
tion aggravates the mischief, excoriates the 
skin at the margin of the anus, and causes it 
to become dry, harsh, and leathery. As re- 
gards treatment, stimulants and condiments 
are to be avoided. The bowels should be 
regulated, and the part should be washed 
with soap and water after each evacua- 
tion. Every effort should be made to avoid 
friction. Cotton-wool should be used after 
defecation in the place of paper. A piece of 
cotton-wool soaked in oxide of zinc lotion 
may be kept applied to the anus, or the part 
may be smeared with some mercurial oint- 
ment, such as one of calomel (5j) and vaseline 
(y). Lotions of cocaine and glycerine, of 
borax and morphine, or of carbolic acid, are 
often efficacious. In weak persons quinine 
and arsenic help the cure. 
7. Tumours and Excrescences.-Be- 
sides the flaps and folds of integument con- 
sequent on external piles, tumours of a 
fibrous texture sometimes form in the sub- 
cutaneous areolar tissue, which as they 
increase become pedunculated. They are 
usually small in size, lobulated, and have a 
firm feel. These growths may be easily and 
safely removed by excision. Papillomata 
are liable to be developed around the anus, 
and sometimes grow so abundantly as to 
constitute a large cauliflower-looking excres- 
cence. They then form projecting processes 
of various sizes, densely grouped together, 
with their summits isolated, expanded, and 
elevated on narrow peduncles. They give 
rise to a thin, offensive discharge. They 
probably originate in want of cleanliness. 
In some persons there is so strong a dis- 
position to the formation of warts, that it 
is difficult to prevent their growth. They 
require to be removed by excision, the 
quickest and most effectual mode of treat- 
ment. Flattened growths from the skin, 
commonly called mucous tubercles, a secon- 
dary result of syphilis, are liable to occur 
around the anus. They yield readily to the 
local application of mercury and general 
specific treatment. See Mucous Tubercles. 
T. B. Curling. Frederick Treves. 
ANXIETAS. - Anxiety or distress, 
whether subjectively felt, or expressed in the 
features, attitude, or general behaviour. The 
term is also especially associated with a 
peculiar sensation experienced in the region 
of the heart. See Pilecordial Anxiety. 
AORTA, Diseases of.-The diseases to 
which the aorta is liable may be thus con- 
sidered :-1. Aortitis, Acute and Chronic; 
2. Atheroma; 3. Primary Fatty Degenera- 
tion ; 4. Primary Calcification; 5. Coarcta- 
tion ; 6. Simple Dilatation; and 7. Aneurysm. 
1. Aortitis.-Acute Aortitis (Hyperplastic 
Arteritis') is exceedingly rare. It may result 
from the direct irritation of an atheromatous 
aorta by a thrombus or an embolus, in per- 
sons of gouty diathesis; but has never been 
observed as an extension of acute endocar- 
ditis. The morbid changes consist in hyper- 
aemia, with thickening and softening of the 
coats of the vessel, and deposit of fibrin upon 
its internal surface. The ascending portion 
of the arch is the part most frequently 
affected. The symptoms are acute substernal 
pain, with oppression, palpitation, quick and 
feeble pulse, and elevated temperature. With 
these symptoms may be associated a harsh 
systolic murmur, originating at the seat of 
inflammation, and transmitted to a distant 
part of the aorta. 
Sub-acute and Chronic Aortitis (Endar- 
teritis).-These are the usual forms of im- 
flammation of the aorta. The disease may 
be general, arising from a blood-dyscrasia 
such as gout or syphilis, from pyaamia, or 
from various septic agents; but it is usually 
limited to a definite portion of the vascular 
surface, being the result of local irritation. 
^Etiology. - Excessive and continued 
strain of the vascular walls is, according to 
its degree, the most frequent cause of sub- 
acute and chronic aortitis. Hence, the 
portion of the arterial system most directly 
affected by the impulse of the left ventricle, 
namely, the arch of the aorta, is that in 
which inflammatory irritation is first, and 
often exclusively, exhibited. Labour of any 
kind requiring great and repeated muscular 
effort whilst the breath is held, must neces- 
sarily subject the aorta to extreme tension, 
partly through the obstruction arising from 
the pressure of the contracted muscles upon 
the subjacent arteries, and partly from the 
back-pressure in the distended veins. Hence, 
sledgers, rammers, ship-porters, &c., are those 
who most frequently suffer from the effects 
of aortitis. As a necessary result of such 
efforts the left ventricle soon becomes hy- 
pertrophied, and the evils arising from vas- 
cular tension are thereby proportionately 
increased. Furthermore, the free use of 
alcoholic stimulants, in which such labourers 90 
AORTA, DISEASES OF 
habitually indulge, contributes to the same 
result. The British soldier has been es- 
pecially liable to the evils above sketched, 
owing to a vicious system of forced drill with 
a breathing-capacity diminished by faulty 
construction of his dress and accoutrements.1 
Anatomical Characters. - Sub-acute 
aortitis occurs in disseminated patches, and 
involves all the coats of the vessel. These 
are infiltrated with leucocytes at an early 
period; become soft and tumid, assuming 
a bluish-white tint; and, owing to loss of 
normal elasticity, project outwards, thus 
causing unevenness or pitting of the internal 
surface. In the aorta the inflammation is 
usually primary; but exceptionally it may 
be produced by the mechanical irritation of 
an embolus derived from an inflamed focus. 
Inflammatory softening is a frequent cause 
of aneurysm at all periods of life; and in 
the young it is the ordinary precursor of that 
disease. 
In chronic aortitis, which is the most 
common form of the disease, the internal 
coat is alone involved. The outer portion of 
the intima exhibits the result of irritation in 
the abundant production of new cells. These 
cells occupy the fusiform spaces between its 
lamellae, and, gradually distending them, 
ultimately project the internal and unaffected 
portion of the tunic into the lumen of the 
vessel. The prominence so caused is com- 
paratively solid, presents a faint bluish tint, 
and constitutes the condition described as 
sclerosis. The thickened intima is prone to 
undergo granular and fatty disintegration, 
and the consecutive change is called 
atheroma. Dr. Mott has suggested that this 
process may be partly accounted for by the 
fact that the deeper layers of the inner coat 
of the larger arteries are probably nourished 
by the vasa vasorum, through the fenestrae 
of the elastic lamina. "Where these nutrient 
vessels are diseased, as in Bright's disease 
and syphilis, where the walls are often greatly 
thickened-possibly almost obliterated, the 
parts indicated are imperfectly supplied with 
blood and undergo degenerative changes. 
2. Atheroma.-This morbid condition is 
most common in the first portion of the 
aorta. 
Anatomical CHARACTERS.-Atheroma com- 
mences with inflammatory overgrowth by 
multiplication of the cells of the outer portion 
of the intima, as described in a preceding 
paragraph. The neoplasts, from their situa- 
tion, readily undergo fatty change and casea- 
tion ; the septa of unaltered, tissue inter- 
vening between them soon lose their vitality 
and are absorbed; and the disease thus 
spreads, while it advances by the same 
process towards the internal surface of the 
vessel. Examined microscopically, athero- 
matous matter is found to consist of fat- 
granules, crystals of cholesterin, and tissue- 
debris. At an early stage the disintegrating 
process makes its way towards the lumen of 
the vessel, and a rupture of the innermost 
layers of the intima takes place, forming 
what is termed an atheromatous ulcer. 
From this may result a false aneurysm. 
In the most advanced stage of athero- 
matous change many patches undergo cal- 
cification by deposit of lime-salts in the 
altered cells. The calcareous lamellae so 
formed, being concentric with the vessel, 
and contracting by loss of their liquid con- 
stituents, may erode the intima by their 
sharp edges. From the injury thus inflicted 
aneurysm may arise, or interstitial throm- 
bosis, by which the vessel may be entirely 
blocked and gangrene of the extremities 
produced. In consequence of the forego- 
ing changes the vessel loses its elasticity 
and becomes dilated; its internal surface 
is mottled with yellow or fawn-coloured 
plaques and patches of various sizes, being 
also rough, spiculated, and fissured; and 
thus the condition described by Virchow 
under the name of endarteritis chronica 
deformans is established. 
The uric acid and oxalic acid diatheses 
favour these changes, not only by stimu- 
lating the minute arteries to contract, and so 
raising the blood-pressure in the larger ves- 
sels, but likewise by furnishing material for 
cretification. The subjects of constitutional 
syphilis are liable to 4 ulcerated steatoma- 
tous ' (atheromatous) changes of the intima. 
3. Primary Fatty Degeneration.- 
Virchow has described, under the name of 
fatty erosion, a form of fatty degeneration 
of the cells of the internal coat, unpreceded 
by inflammation, commencing on the free 
surface, and gradually extending outwards. 
The internal surface of the vessel is marbled 
with minute yellow dots, which are groups 
of fatty cells; these undergo liquefaction; 
and disintegration of the internal coat, fol- 
lowed by aneurysm, is the usual result. 
4. Primary Calcification. - Excep- 
tionally, in the distant portions of the aorta 
the muscular fibre-cells of the middle coat 
are liable to calcification, as a remote result 
of endarteritis. Owing to the transverse 
arrangement of the calcified cells, fissuring 
of the middle coat under the pressure of the 
blood-current, and dissecting aneurysm, are 
ordinary results of this change. Finally, 
the entire middle coat, and even all three 
coats of the artery, may be infiltrated with 
lime-salts as a primary change. This is 
most probably due to precipitation of these 
salts from the congested vasa vasorum, in 
consequence of the escape of their ordinary 
solvent, carbonic acid. 
5. Coarctation or Stenosis.-This con- 
dition may be either congenital or acquired. 
1 Also by the constrained and fixed position in 
which the walls of the chest are placed when the 
shoulders are forced backwards, with the view of 
producing the appearance of an expanded chest. 
-Ed. AORTA, DISEASES OF 
91 
Congenital stenosis of the aorta is most 
frequently located at the point of junc- 
tion of the ductus arteriosus, and is of very 
limited extent; in many cases presenting 
the appearance of a linear constriction, or of 
a perforated diaphragm. In a few examples, 
the vessel, at the seat of contraction, has 
been entirely closed and converted into a 
ligamentous cord. On the cardiac side of 
the constriction the aorta is dilated, and 
often thickened and atheromatous, whilst 
on the distal side it is reduced in calibre as 
far as the junction of the collateral vessels. 
Congenital stenosis of the aorta is compatible 
with life of moderate duration. In 24 out of 
38 cases analysed by Dr. Peacock the age 
attained varied from twenty-one to fifty years. 
The diagnosis of the condition rests mainly 
on disproportionate pulsation of the arteries 
arising from the aorta on the cardiac, as con- 
trasted with those on the peripheral side of the 
obstruction; and on the enlargement of the 
collateral vessels, namely, the transverse cer- 
vical, internal mammary, and intercostals. 
The ordinary consequences are exhibited in 
dilated hypertrophy of the left ventricle, and 
relative inadequacy of the aortic valves. Death 
usually occurs from progressive debility and 
failure of the left ventricle ; from pulmonary 
congestion; from rupture of the aorta or 
one of its dilated branches; or from acute 
inflammatory change in the heart or aorta. 
Congenital stenosis of the entire arch may 
result from imperfection of the inter-ven- 
tricular septum or patency of the foramen 
ovale allowing the blood to take an excep- 
tional course. 
Congenital narrowing of the aorta through- 
out its course was described by Rokitansky 
and Virchow. The latter pointed out its 
existence in women who have through life 
presented the signs of persistent chlorosis 
(see Chlorosis). In many of these cases 
valvular disease of the heart, especially ste- 
nosis of the mitral orifice, has been observed. 
In the acquired form, stenosis of the aorta 
at any portion of its course may result from 
inflammatory thickening or calcareous change 
of the coats of the vessel, followed by throm- 
bosis; or it may follow the natural cure of 
an aneurysm. The aorta may be much re- 
duced in calibre without being disproportion- 
ately narrowed. Such will be its condition 
in connexion with mitral inadequacy in 
early childhood, should the patient survive a 
few years. In such cases the left ventricle 
will have become dilated and hypertrophied, 
and a marked disproportion will be observed 
between the force of cardiac and that of 
radial pulsation. This circumstance, taken 
in conjunction with the age of the patient, 
the existence of disease at the mitral orifice, 
and hypertrophy of the left ventricle, would 
warrant the positive diagnosis of narrowing 
of the aorta. 
6. Simple Dilatation.- This disease 
consists in a uniform enlargement of the 
vessel or a portion of it, from impairment or 
loss of its normal elasticity; and depends 
primarily upon arterial obstruction or resist- 
ance beyond its seat, and directly upon con- 
secutive hypertrophy of the left ventricle. 
The continued tension, to which the walls 
of the aorta are subjected between these two 
opposing forces, necessarily leads to pro- 
gressive impairment of nutrition and loss 
of elasticity in its middle coat. The imme- 
diate consequence of this change is exhibited 
in further hypertrophy of the left ventricle; 
and its remote effects in still further impair- 
ment of nutrition and deterioration of tissue 
in the vascular tunics, through the increased 
tension to which they are now exposed. No 
elementary change of structure is, however, 
discoverable. Simple dilatation of the aorta 
commences in the ascending portion of the 
arch, and to this it is usually limited; but 
it occasionally extends into the transverse 
portion. The other portions of the vessel 
are never dilated, except in association with 
atheromatous change. The condition under 
notice is manifestly in close relationship with 
inflammatory irritation of the vessel. It has, 
however, a distinct pathological existence, 
analogous to that of the early stage of vesi- 
cular emphysema of the lung. 
No morbid results, with a single exception, 
are directly traceable to simple dilatation of the 
aorta. But, should the dilatation extend into 
the transverse portion of the arch, and engage 
especially its superior wall, the primary 
branches may become tortuous, and exhibit 
abnormal pulsation in the neck, simulating 
aneurysm. In a noteworthy example observed 
by the late Dr. Hayden the existence of this 
pulsation on both sides of the neck, and the 
facility with which it was arrested by forcibly 
extending the neck and shoulders, and so un- 
bending the vessels, sufficed to establish the 
diagnosis. Tortuosity of the cervical arteries, 
dependent upon a local dilatation of the aorta, 
may be confined to one side of the neck. 
Simple dilatation of the aorta most fre- 
quently occurs in connexion with the con- 
tracted or granular form of chronic renal 
disease. It may, however, likewise arise 
from simple functional hypertrophy of the 
left ventricle dependent upon habitual vas- 
cular excitement; or from dilated hyper- 
trophy consecutive to inadequacy of the 
aortic valves. 
7. Aneurysm.-^Etiology and Patho- 
logy.-Aneurysm of the aorta is essentially a 
disease of the middle period of life. Of 92 cases 
observed or analysed by the late Dr. Hayden, 
60 occurred between the ages of thirty and 
fifty years; 12 over fifty; and 5 under thirty 
years. Thus, whilst deterioration of the ar- 
terial coats, as typified in atheroma, is most 
common after the age of sixty, one of its or- 
dinary consequences, aneurysm, belongs to an 
earlier period of life. The apparent discrepancy 92 
AORTA, DISEASES OF 
may be explained by the more frequent em- 
ployment of men under fifty in severe labour, 
and their greater capacity for extreme mus- 
cular effort earlier in life, the condition of the 
arterial wall which favours aneurysm having 
been already established. Aortic aneurysm is 
more common amongst males than females 
in the proportion of about 8 : 1-a difference 
no doubt due to the more active and laborious 
habits of the male sex. Soldiers, mechanics, 
and porters suffer from it in larger proportion 
than persons of other callings; and in most 
instances the first symptoms of aneurysm of 
the aorta may be traced to a great muscular 
effort, involving vascular strain, or to a severe 
shock or blow, causing a direct contusion. 
Aneurysm of the aorta is always consecu- 
tive to disease of its coats. Inflammatory 
softening, atheroma, and calcification are the 
usual antecedent conditions, and in excep- 
tional instances primary fatty or calcific 
transformation of the internal and middle 
coats ; whilst a definite overstrain or a direct 
contusion of the vessel is frequently the im- 
mediate cause of the disease. 
Anatomical Characters.-Aortic aneur- 
ysm may be presented under the following 
forms,*viz., (a) true ; (b) false (circumscribed, 
and diffused or consecutive); (c) dissecting ; 
and (d) varicose. 
a. f rue aneurysm of the aorta is rare; it 
may be either fusiform or saccular. It is 
essentially transitional, leading to the false 
variety of the disease; and differs from simple 
dilatation of the aorta only by its sharp 
limitation, and by the existence of inflam- 
matory products in its walls. True aneurysm 
never contains clots, save by incidental 
thrombosis; and rarely, as such, attains 
dimensions capable of producing extrinsic 
symptoms or signs. It may, however, unlike 
simple dilatation, be the cause of valvular 
inadequacy, and so give rise to a murmur of 
reflux at the orifice of the aorta. 
b. False aneurysm is either circumscribed 
or diffused. Circumscribed false aneurysm 
(or, as it is also termed, false aneurysm) is 
the most common form of the disease in 
connexion with the aorta. It is necessarily 
confined to a portion of the circumference 
of the vessel, the yielding of which relieves 
the remainder from extra tension. Hence, it 
is usually saccular in general outline ; but, 
owing to unequal resistance at different 
points of its surface, it may, and commonly 
does, present one or more secondary promi- 
nences. The internal and middle coats are 
usually broken;-the adventitia supplemented 
by the surrounding structures, more or less 
condensed, forming the sac. 
Disintegration of the inner coat, already in 
a state of atheromatous change by mechanical 
strain or vascular tension, is ordinarily the 
immediate cause of false aneurysm. Ulcera- 
tion of the intima from fatty erosion may 
also cause it, as well as progressive arterio- 
sclerosis. Rupture of the coats of the vessel 
by mechanical strain is usually indicated by 
definite symptoms of the utmost significance, 
namely, a feeling of something having given 
way within the chest or abdomen; followed 
by faintness often amounting to syncope, 
dyspnoea, palpitation, and occasionally haemo- 
ptysis. These symptoms of shock usually 
subside within a period of one to two hours, 
but the patient is thenceforward incapable of 
his accustomed exertion, being easily put out 
of breath, and distressed by excitement or 
rapid movement, especially that of ascent; 
there is likewise a fixed pain at some point 
of the chest, back, or abdomen. A fusiform 
false aneurysm may become ' invaginating ' 
by abruptly expanding and ensheathing the 
artery at its proximal or distal side, or in 
both these situations. 
Diffused false aneurysm (or, as it is other- 
wise called, diffused aneurysm., or consecu- 
tive aneurysm) is produced by escape of blood 
from the artery, and its diffusion to a greater 
or less extent amongst the surrounding 
structures, according to their previous con- 
dition or anatomical arrangement. It may 
be the result of mechanical violence by strain 
or shock to the artery in a previously 
diseased condition; or of progressive disin- 
tegration of the sac of a circumscribed 
aneurysm. In the latter case the diffusion 
of the extravasated blood is usually limited 
by antecedent adhesive inflammation of the 
surrounding parts, where, as in the trans- 
verse portion of the arch of the aorta, the 
position of the aneurysm is favourable to 
that process. Under ordinary circumstances 
diffused false aneurysm of the aorta cannot 
occur within the pericardium, owing to the 
isolation of that portion of the vessel, and 
the fragile structure of its serous investment. 
Hence, a yielding of the sac proper in this 
situation is, in most instances, followed by 
instant death from haemorrhage into the peri- 
cardium and paralysis of the heart. In a 
few recorded cases, owing to previous adhesion 
of the pericardium, the patients survived rup- 
ture of the sac in this situation for several 
days. 
Diffused false aneurysm of the abdominal 
aorta is frequently formed by irruption of 
blood into the retro-peritoneal tissue, between 
the layers of the transverse meso-colon or the 
mesentery, or into the fibrous envelope of the 
psoas muscle. When the aneurysm grow's 
backwards the sac is quickly eroded by 
pressure against the vertebras, the naked and 
carious surface of which then forms its pos- 
terior boundary. Diffusion in such cases 
rarely occurs until the vertebrae are entirely 
absorbed; the blood may then escape into 
the spinal canal, causing general paralysis 
and immediate death. Diffusion may also 
occur amongst the muscles and areolar tissue 
of the loins, or behind the diaphragm mto 
either pl Sural cavity, usually the left. Any AORTA, DISEASES OF 
93 
portion of the aorta outside the pericardium 
may be the seat of diffused false aneurysm, 
but the transverse portion of the arch and 
the abdominal aorta are the parts most fre- 
quently affected. 
Consecutive false aneurysm, consisting in 
a primary bulging of all the coats of the 
artery, the internal and middle coats having 
subsequently given way, constitutes the or- 
dinary form in which false aneurysm origi- 
nates : it therefore demands no further notice 
here. 
c. Dissecting aneurysm consists in a breach 
of the internal and middle coats, and a sub- 
sequent detachment of these from the ex- 
ternal tunic, by the force of the blood- 
current, to a variable extent over the length 
and circumference of the vessel; or in a 
splitting of the middle coat by the same 
agency. This form of aneurysm is of two 
kinds-that with a single aperture through 
which the blood enters the abnormal channel 
and returns to the artery; and that which 
exhibits two openings, one by which the 
blood escapes from, and another through 
which it re-enters the vessel. The former is 
the more usual variety of dissecting aneurysm: 
and it is likewise the more grave, because 
liable at any moment to terminate fatally by 
rupture of the external coat. 
Any portion of the aorta may be the seat 
of dissecting aneurysm; the ascending part of 
the arch is most frequently affected, and next 
in order of frequency comes the abdominal 
aorta.. The primary lesion consists in a 
transverse rent of the internal and middle 
coats; when this is close to the heart, the 
outer or the anterior wall of the vessel is its 
usual site, and detachment of the tunics 
rarely extends beyond the ascending portion 
of the arch, and seldom engages more than 
a limited area of its circumference. In this 
situation, too, an aperture of re-entrance is 
rarely formed, the disease usually terminating 
by rupture of the external coat within the 
pericardium. When, on the contrary, the 
second curve of the arch, or any portion of 
the aorta beyond this point, is the seat of 
primary lesion, separation of the coats is 
usually found to extend along the remainder 
of the length of the vessel and over the whole 
or greater part of its circumference, whilst 
the blood has re-entered through an opening 
in one or both common iliac arteries. 
The establishment of a second aperture of 
communication with the artery is an attempt 
at ' natural cure; ' and when this happens 
the patient may survive for many years. 
Amongst the eccentricities of dissecting 
aneurysm may be mentioned detachment of 
the laminated clot from the walls of the sac 
proper, and subsequent escape of blood by 
rupture of the latter; and separation of the 
mucous from the muscular coat of the oesopha- 
gus, with irruption of blood into the gtomach. 
Dissecting and ordinary false aneurysm may 
coexist, the former being usually a consecu- 
tive lesion, and the immediate cause of death. 
d. Varicose or anastomosing aneurysm 
consists in a direct communication between 
an aneurysm of the aorta and (a) one of the 
chambers of the heart; (6) the pulmonary 
artery or one of its branches; or (c) one of the 
venae cavae or innominate veins. This form 
of the disease is necessarily consecutive, and 
usually late as to the period of its develop- 
ment. In the great majority of recorded ex- 
amples the primary aneurysm was connected 
with the ascending portion of the arch, and 
in a large number it arose from one of the 
sinuses of Valsalva. The communication, 
with few exceptions, is formed with one of 
the chambers of the heart, the pulmonary 
artery, or the descending vena cava. Of the 
cavities of the heart, the right ventricle is 
most often implicated; next in order is the 
right auricle ; then the left ventricle; and 
lastly the left auricle. The pulmonary artery 
and the descending cava have been frequently 
involved, as might have been inferred from 
their close relationship to the ascending 
aorta; the innominate veins in fewer instances, 
and only when the aneurysm engaged the 
upper portion of the arch. An aneurysm of 
the abdominal aorta has communicated with 
the inferior vena cava in a few cases. In the 
process of formation of a varicose aneurysm, 
of the aorta, the apposed surfaces are agglu- 
tinated by adhesive inflammation; and. the 
composite septum is subsequently eroded 
by progressive absorption, or suddenly rent 
by the force of. the arterial current. The 
immediate effects of communication are 
engorgement and increased tension of the 
receiving chamber or vessel; diminished 
blood-current and vascular tension in the 
aorta and its branches; and admixture of 
arterial with venous blood when the right 
side of the heart or one of the great veins is 
the seat of discharge. The special symptoms 
and signs by which the disease is characterised 
have direct reference to these results. Death 
has followed most rapidly in those cases in 
which the aneurysm had established a com- 
munication with the pulmonary artery or the 
left auricle. 
Effects upon the left ventricle.-Hyper- 
trophy of the left ventricle cannot be regarded 
as a consequence of aneurysm of the aorta. 
The association, when it exists, is accidental; 
hypertrophy depending upon antecedent or 
consecutive disease or inadequacy of the 
aortic or the mitral valves, chronic atheroma 
of the aorta, granular degeneration of the 
kidneys, or excessive functional activity. 
Symptoms.-The symptoms of aortic aneu- 
rysm may be discussed under the three heads 
of: (a) Pain; (6) Excentric Pressure; and 
(c) Tumour. 
Pain.-The pain of aneurysm is of two 
kinds, intrinsic and extrinsic. The former is 
due to subacute inflammation and tension of 94 
AORTA, DISEASES OF 
the sac, and varies with intra-vascular pres- 
sure. It is dull, aching, and localised, and 
promptly alleviated by measures which de- 
press the circulation or reduce local tension. 
Extrinsic pain usually arises from pressure 
upon adjacent nerves, and may be direct or 
reflex. This kind of pain has the characters 
of a diffused and aggravated neuralgia, being 
paroxysmal, and wandering to a greater or 
less extent over the back, chest, shoulders, 
arms, abdomen, and thighs. In the abdomen, 
when due to pressure upon the splanchnic 
nerves or tension of the solar plexus, it is of 
the most excruciating character. The ex- 
trinsic pain of aneurysm may be fixed and 
boring. When of this character, it is usually 
located in the back, and arises from progres- 
sive absorption of the vertebrae. 
Excentric Pressure.- The parts affected 
by the pressure of an aneurysm, and the 
symptoms thereby developed, vary according 
to its situation and the direction of its growth. 
Parts which are exposed to counter-pressure, 
or are otherwise fixed, suffer most; whilst 
those which are flexible or movable are less 
injuriously affected. The symptoms have 
reference to the respective functions of the 
organs or structures pressed upon; whilst 
their severity is in direct proportion to the 
importance of those functions, and the degree 
of pressure exercised. Structures subjected 
to the remittent pressure of an aneurysm are 
slowly removed by absorption, but between 
the sac and the resisting surface union has 
been previously established by adhesive in- 
flammation. Hence the sac itself is at the 
same time absorbed, and escape of blood will 
inevitably occur where further resistance is 
not presented. When serous cavities are laid 
open by this process, entrance is effected by 
a rent; and if the cavity be large, e.g. the 
pleura or the peritoneum, death by haemor- 
rhage, almost instantaneous, is the result; in 
case of irruption into the pericardium or the 
spinal canal, death occurs with equal rapidity 
from compression and paralysis of the con- 
tained organ. Communication with a mucous 
canal or with the cutaneous surface is effected 
by a process of sloughing, and bleeding occurs 
by ' leakage,' in variable quantity and at 
uncertain intervals, till the slough is finally 
detached, when death by copious hsemorrhage 
immediately ensues. The irruption of an 
aneurysm into a gland-duct, such as the ureter 
or one of the biliary passages, may be fatal 
by obstruction and suspended secretion, the 
duct and its tributaries having been blocked 
by coagulum. Pressure upon the thoracic 
duct proves slowly fatal by inanition. When 
the aneurysm opens into a vein, a varicose 
aneursym, characterised by special symptoms 
and signs, and of greater or less gravity ac- 
cording to its situation, will be the result. 
The symptoms of nerve-pressure vary ac- 
cording to the nerves affected. Thus, pres- 
sure upon the roots or branches of sentient 
nerves is attended with neuralgic twinges or 
paroxysms referred to the seat of their peri- 
pheral distribution, and, when the pressure 
is extreme, with numbness in the same situa- 
tion. Irritation of motor nerves is indicated 
by spasm or paralysis, according to the de- 
gree of pressure, of the muscles supplied by 
them. Irritation of the cervical sympathetic, 
or of its cilio-motor roots, is revealed by 
dilatation of the pupil on the corresponding 
side; or, if the pressure be such as to cause 
paresis, by contraction of the pupil with ptosis, 
hyperaemia, hyperaisthesia, and elevation of 
temperature in the eye and corresponding 
side of the face. The effects of pressure upon 
the pulmonic and cardiac plexuses have been 
less precisely determined, owing to the diffi- 
culty of distinguishing the symptoms due to 
this cause from those which arise from direct 
pressure upon the trachea or bronchi, the 
great vessels, or the heart, or from structural 
disease of the heart or the coronary arteries; 
but that the paroxysms of bronchial spasm 
and of angina, so often witnessed in connex- 
ion with aneurysm of the arch of the aorta, 
are in some degree dependent upon pressure 
on the pulmonary and cardiac nerves, and 
occasionally are due to it exclusively, there 
can be no doubt. The symptoms arising from 
the pressure of an aneurysm upon the pneu- 
mogastric or recurrent nerve of either side 
have reference to the larynx, and are emi- 
nently characteristic. They are of two kinds, 
according to the degree of pressure; namely, 
those due to spasm, and those to paralysis, 
of the laryngeal muscles on one or both 
sides. They are presented under the several 
forms of dysphonia, aphonia, stridor, metallic 
cough, and paroxysmal dyspnoea. The latter 
is frequently of the most urgent character, and 
sometimes is the immediate cause of death. 
Adjacent organs, such as the heart, lungs, 
liver, and kidneys, are occasionally displaced 
by an aneurysm, the direction being deter- 
mined by that of the pressure, and in part 
also by the direction in which the organ is 
movable. Obstruction or occlusion of adjacent 
arteries, as indicated by diminished or sup- 
pressed pulsation, may likewise result from 
the pressure of an aneurysm. Pressure on a 
vein is evidenced by venous stasis distal to 
the seat of obstruction; upon the pulmonary 
artery, by engorgement of the right chambers 
of the heart and general venous congestion. 
Obstruction or occlusion of either bronchus 
or of one of its primary branches is evi- 
denced by distress in breathing or short- 
ness of breath; by bronchial breathing over 
the seat of compression; and by diminution 
or suppression of respiratory sound in the 
corresponding portion of the lung. Inasmuch 
as the symptoms of excentric pressure may 
be produced by a tumour of any kind, they 
possess, in regard to aneurysm, a diagnostic 
value only correlative to other and more 
positive evidence of that disease. AORTA, DISEASES OF 
95 
Tumour.-The tumour formed by an aneu- 
rysm of the aorta is fixed, smooth, and com- 
pressible. It is alternately tense and soft, in 
unison with cardiac pulsation; and is especi- 
ally characterised by a movement of general 
and equal expansion, synchronous with the 
impulse of the heart. It is further distin- 
guished by a remarkable liability to vary in 
the rate and direction of its growth, retro- 
cession at one point coinciding with enlarge- 
ment at another; a new set of symptoms 
being at the same time developed by its 
encroachment upon fresh territory. In the 
progress of cure the tumour may become 
solid, incompressible, and uneven, by depo- 
sition of laminated fibrin within the sac. 
Physical Signs.-The physical signs of 
aneurysm of the aorta are those which may 
be elicited by inspection, palpation, percus- 
sion, and auscultation. They supply the 
most valuable, and, indeed, the only positive 
evidence of the disease. 
Inspection. - Abnormal pulsation, and 
sometimes the existence of tumour, may be 
detected by inspection of the chest or abdo- 
men ; the signs observed being confirmed by 
those afforded by palpation. 
Tactile signs.-The tactile signs of aneu- 
rysm, impulse, fremitus, and remittent ten- 
sion, are contingent on the presence of a 
tumour. The impulse may be single or double. 
It is most frequently single, and is then always 
systolic in rhythm, coinciding approximately 
with the impulse of the heart. In character 
the systolic impulse is heaving and expansile; 
and it is diffused, in most instances equally, 
over the entire tumour. It is due to sudden 
expansion of the sac from active influx of 
blood during ventricular systole: hence, in 
those portions of the aorta which are close 
to the heart, it is synchronous with the apex- 
pulsation ; but in the descending thoracic 
and abdominal aorta perceptibly post-systolic 
in time. The force of systolic impulse and 
the expansion of the sac will be directly 
as the contractile power of the left ventricle, 
and inversely as the deposit of coagulum 
within the sac. A second and more feeble 
impulse of diastolic rhythm is occasionally, 
but much less frequently, exhibited by an 
aortic aneurysm. This is the ' back-stroke,' 
or ' impulse of arrest ' of authors. It coincides 
with the first period of ventricular diastole 
and the second sound of the heart, and is 
due to asynchronism of reaction between the 
aorta and the sac-that of the latter being 
notably later, owing to its defective elasticity. 
The consequence is a sudden arrest to the 
recoil of the sac by influx from the aorta. 
Diastolic impulse is therefore eminently 
characteristic of aneurysm. 
Fremitus dr thrill is of more frequent oc- 
currence than diastolic impulse, and, when 
not communicated from the heart, no less 
distinctive of aneurysm. It accompanies the 
systolic impulse, and is due to the vibration 
of a thin sac from an eddy in the current of 
influx, produced either by a spiculated con- 
dition of the orifice, or by a pendent flake of 
fibrin. 
Percussion-sound.-The intrinsic percus- 
sion-sound of aortic aneurysm is absolutely 
dull to the extent of the tumour. Posteriorly 
the dulness is not sufficiently distinguishable 
from that of the vertebral column and muscles 
to be of positive diagnostic value; whilst 
laterally and in front, when the tumour is not 
in actual contact with the walls of the thorax 
or abdomen, it is modified or masked by the 
intervention of the lung or the intestinal 
canal. Under any circumstances, dullness 
per se cannot afford positive evidence of 
aneurysm, inasmuch as it may be due to a 
tumour of any kind, solid or liquid, in the 
same situation; but, the presence of a tumour 
having been determined, the shifting of per- 
cussion-dulness from one point to another, 
or its cessation where it had been previously 
detected, would be in the highest degree sug- 
gestive of aneurysm. 
Acoustic signs.-These are tone or sound, 
and murmur. Sound without murmur is of 
frequent occurrence in aneurysms of the arch, 
but comparatively rare in those of the de- 
scending thoracic and abdominal aorta. It 
is usually double, corresponding in time to 
the sounds of the heart, but exaggerated, the 
second aneurysmal sound being especially 
intensified. The first sound is occasionally 
' splashing,' and both are not infrequently of 
a ' booming ' quality,-characters no doubt 
due to the density, rigidity, and great capacity 
of the sac. 
The murmur of aneurysm is most fre- 
quently single, systolic, and blowing; it is 
occasionally double (systolic and diastolic); 
and still more rarely single and diastolic. 
As to quality, the systolic murmur may be 
accompanied by a musical note, ' cooing,' or 
shrill, and audible over the whole or only a 
portion of the tumour. Lastly, it may be, 
and usually is, of a ' buzzing ' character in 
cases of varicose aneurysm. The essential 
cause of the murmur of aneurysm consists in 
friction of the blood against the orifice, and 
the production of an eddy or a ' fluid vein ' 
within the sac. A certain force of ventricular 
contraction is, however, likewise necessary. 
Hence the not infrequent coincidence of 
cessation of murmur with failure of the left 
ventricle for some time before death. A 
strongly contracting ventricle, a relatively 
small orifice, a capacious sac, and a liquid 
state of its contents, supply the most favour- 
able conditions for the production of murmur. 
The orifice of entrance need not be absolutely 
narrow; a large fusiform aneurysm, even of 
the true kind, with rough walls, and contain- 
ing liquid blood, may yield a loud systolic 
murmur, as the writers have frequently ob- 
served. A murmur may be absent in an 
aneurysm lined by thick laminee of fibrin 96 
through which there is a smooth channel, or 
in a lateral aneurysm communicating by a 
small orifice with the vessel. 
Diagnosis.- The positive diagnosis of 
aneurysm of the aorta may be made from 
the existence of a tumour, forming a second 
centre of pulsation and of sound; the pul- 
sation being systolic, expansile, and equally 
diffused over the tumour, accompanied by 
thrill, and succeeded by a minor pulsation of 
diastolic rhythm ; whilst the sound, single or 
double, and accompanied or not by murmur, 
is always sharp and ringing, and occasion- 
ally of a ' booming ' quality. The foregoing 
signs are rarely all associated in the same 
case. Various other groupings of rational 
symptoms and signs would be scarcely less 
conclusive as to the existence of aneurysm of 
the aorta. General systolic expansion, thrill, 
diastolic impulse, and exaggerated sound, at a 
point more or less distant from the heart, con- 
stitute the most positive signs of the disease. 
The existence of aneurysm of the aorta may 
be inferred with greater or less confidence from 
certain symptoms and signs, according to 
their individual or correlative value. Even 
negative signs, if associated with others in 
themselves of minor significance, may be 
scarcely less conclusive than the most positive 
evidence would be. Thus, for example, sup- 
pressed respiration with undiminished per- 
cussion-resonance on the left side of the chest, 
dyspnoea, haemoptysis, fixed pain in the back, 
and left intercostal neuralgia-the entrance 
of a foreign body into the left bronchus and 
the existence of cancer of the posterior me- 
diastinum having been excluded-would be 
all but conclusive as to the existence of aneu- 
rysm. A foreign body in the bronchus might 
be diagnosed from the history of a misad- 
venture in swallowing, follow'ed immediately 
by dyspnoea, haemoptysis, and the special 
signs of bronchial obstruction, which, in nine 
cases out of ten, would be on the right side; 
whilst the diagnosis of mediastinal cancer 
would rest upon evidence eminently sugges- 
tive, namely, the presence of cancerous en- 
largements in the neck and axilla, and of 
extreme dulness over the root of the lung, 
without corresponding pulsation or sound. 
Finally, aneurysm of the aorta may be, though 
it very rarely is, strictly latent in regard to 
both symptoms and signs. 
Prognosis, Duration, and Terminations. 
The prognosis of aortic aneurysm is in the 
highest degree unfavourable. Recovery is, 
however, under favourable circumstances 
and appropriate treatment, quite within the 
range of medicine. Numerous examples of 
the cure of aortic aneurysm, both thoracic 
and abdominal, have been lately recorded. 
The duration of life, in connexion with 
aneurysm of the aorta, varies from ten days 
to eleven years (Hayden), but it may be 
much longer. The situation and relations of 
the aneurysm; its complications; the con- 
AORTA, DISEASES OF 
stitution of the sac, and the state of its con- 
tents; the previous health and present habits 
of the patient; and the advantages enjoyed 
in regard to rest and treatment-will all 
materially influence the prognosis, whether 
as to duration of life or prospect of recovery. 
Death in aneurysm of the aorta may result 
from-(a) rupture of the sac; (b) exhaustion 
from pain, loss of sleep, or leakage of blood ; 
(c) asphyxia; (d) syncope ; (e) inanition ; or 
(/) intercurrent disease. The foregoing re- 
presents the order of relative frequency of 
the several causes mentioned. Rupture of 
the sac is not, of necessity, immediately 
fatal. Haemorrhage may be stayed, and life 
thus protracted for several days, by obstruc- 
tion from the extravasated blood (itself ar- 
rested and coagulated in the surrounding 
tissues), or by its pressure upon the aorta on 
the proximal side of the sac. Rupture into 
one of the chambers of the heart, the pul- 
monary artery, either vena cava, or the inno- 
minate vein, the portal vein, or the biliary 
passages, is usually fatal within a very brief 
period ; whilst rupture into one of the serous 
cavities in the absence of previous adhesion, 
into the trachea or bronchi, or into the alimen- 
tary or the spinal canal, is instantaneously 
fatal. 
Treatment.-The treatment of aneurysm 
of the aorta is palliative and curative. Pain 
from nerve-pressure is most effectually re- 
lieved by hypodermic injections of morphine, 
one quarter to half a grain in solution, re- 
peated and increased in quantity according 
to necessity; cocaine administered hypoder- 
mically may also be employed. The pain 
and oppression due to congestion of the sac 
and the surrounding structures is best treated 
by local or general abstraction of blood, or 
the use of an ice-bag over the tumour, com- 
bined with the use of cardiac and vascular 
depressants, especially iodide of potassium 
(20 to 30 grains every fourth hour), chloral 
hydrate (20 grains), veratrum viride, or 
aconite (5 to 10 minims of the tinctme every 
third hour). Antipyrin (10 to 20 grains 
every third hour) has been found to give 
relief. Mechanical support by means of a 
well-constructed shield is likewise useful 
when the tumour projects externally. Fixed 
pain in the back, due to erosion of the verte- 
brae, is most effectually relieved by leeching, 
or by the application of a seton or issue in 
the vicinity of its seat. 
The curative treatment of aneurysm of the 
aorta may be classified under the heads of- 
(a) compression of the artery, proximal or 
distal; (b) distal ligature; (c) absolute rest 
and regulated diet; (d) the use of medicinal 
agents promotive of coagulation within the 
sac; and (e) local measures-such as (1) the 
application of the galvanic current, the posi- 
tive pole, carefully insulated, being introduced 
into the sac, the negative pole being placed 
on an indifferent part in its neighbourhood; AORTA, DISEASES OF 
APHASIA 
97 
(2) the passage of fine iron wire, horsehair, 
or catgut into the sac, so as to" cause coagula- 
tion. For the details of these several modes 
of treatment the reader is referred to the 
articles in this.volume respectively entitled 
Aneurysm; Abdominal Aneurysm; and Tho- 
racic Aneurysm. 
Thomas Hayden. C. J. Nixon. 
AORTIC VALVES, Diseases of.- 
See Heart, Valvular Diseases of. 
APEPSIA (a, priv.; and 7rt7rra>, I digest). 
Indigestion. See Digestion, Disorders of. 
APERIENTS (aperio, I open).-Medi- 
cines which produce a gentle action of the 
bowels. See Purgatives. 
APHAGIA (a, priv.; and (pdya, I eat).- 
Inability to swallow. See Deglutition, Dis- 
orders of. 
APHASIA (d, priv.; and or <j)da>, 
I speak).-Synon. : Aphemia; Alalia ; Fr. 
Aphasie; Ger. Sprachlosigkeit. 
Description.-Aphasia is the name given 
to a defect of speech from cerebral disease. 
The patient is found to be unable to utter 
any proposition, though his occasional dis- 
tinct pronunciation of some one or two 
words shows that his speechless condition 
is not due to a mere difficulty in the more 
mechanical act of articulation. Moreover, 
the patient's intelligent manner and gestures 
may plainly show that he understands what 
is said, and is capable of thinking, even 
though he is quite unable to give expression 
to his thoughts. This kind of powerlessness 
as regards speech is most frequently encoun- 
tered in persons suffering from right hemi- 
plegia, though it is occasionally met with in 
those who are paralysed on the left side, and 
at other times in persons who are not hemi- 
plegic at all. 
The aphasic condition is not always, as it 
ought to be, clearly distinguished from that 
of another group of cases which may be 
encountered in association with some amount 
of hemiplegia or independently, and to which 
the name amnesia is given. The essence of 
this latter defect lies in the fact that the 
patient's speech is defective because of his 
inability to recall the proper words for the 
expression of his thoughts or wishes ; and he 
very frequently substitutes wrong words or 
names in the place of those he wishes to 
employ, as when speaking of his 'hat,' he 
calls it a ' brush ; ' or when seeking a ' pen,' 
he asks for a ' knife.' In a bad case of this 
kind the patient may be quite unable to 
arrange words into a sentence capable of 
conveying a definite meaning, so that his 
speech is rendered unintelligible. Where 
this species of defect exists there seems to be 
either a defective or an inco-ordinate action 
of one or other of those higher cerebral 
centres whose function it is to translate 
thought into the corresponding motor acts 
of speech, so that we get hesitation in the 
utterance of right words, or the substitution 
occasionally of entirely wrong words or even 
of a meaningless set of sounds. These 
amnesic or inco-ordinate defects were not at 
first recognised as being distinct in nature 
from those of an aphasic type, in which 
there is rather a loss than a misdirection of 
power in one or other of the higher centres 
whence the incitation to the motor acts of 
speech proceed. The two kinds of defects, 
indeed, not unfrequently coexist to some 
extent in the same individual. 
When occurring in association with hemi- 
plegia, aphasia varies much in intensity 
according to the degree of general mental 
impairment with which it may be combined. 
During the first week or ten days after the 
onset of such an attack the special defect 
may be scarcely recognisable, owing to the 
masking influence of the general mental 
impairment. But after a time such a patient 
may regain a considerable amount of general 
mental power. He may be left more or less 
hemiplegic, and may also present the aphasic 
defect to a marked degree. He readily com- 
prehends everything that is said to him, and 
can often understand what he reads. 
But at other times, though able fully to 
understand when read to, he does not seem 
to understand when he himself attempts 
to read-a disability now often spoken of 
as ' word-blindness.' He can, perhaps, play 
draughts or chess well, and by means of 
gestures and pantomime can make his wants 
and most of his wishes fairly well understood 
by those accustomed to interpret them. Yet 
he may only be able to articulate some one 
or two words, or else combinations of mere 
unmeaning sounds, such as 'poi, boi, bah,' 
' sapon.' On rare occasions, under the in- 
fluence of strong emotion, the patient may 
blurt out some simple expletive or short 
phrase, such as ' oh dear ! ' He cannot be 
made to repeat a word, or even the simplest 
vowel-sound, which he has just heard uttered. 
In a few cases the patient has seemed unable 
to understar d what is said, as though from 
some difficulty in realising the meaning of 
words. Words may have to be uttered very 
slowly and repeated several times to such a 
patient, and even then they may fail to 
convey their meaning-a defect known as 
' word-deafness.' Yet the language of gesture, 
appealing as it does to the sense of sight, 
may be at once understood. 
The patient's power of writing is neces- 
sarily interfered with when aphasia, as is so 
often the case, co-exists with right hemi- 
plegia. Many such patients, however, learn 
to write with the left hand to a variable 
extent. The variations as regards the power 
of writing are, in fact, almost as marked 
as the variations in power of speaking, 
though these two classes of defects by no 
means run parallel with one another in the 98 
APHASIA 
same individual. The writer has known 
patients who were quite unable to express 
themselves in spoken words, or even utter a 
single articulate sound, write a good letter 
with no, or very few, mistakes (aphemia); 
on the other hand, the performance of an 
aphasic patient, without a copy before him, 
may be, and most commonly is, limited to 
writing his own name. At other times the 
patient shows an amnesic defect in writing, 
and writes much as an amnesic patient 
speaks. Still more rarely it is found that an 
aphasic patient is, though not from want of 
manual power, unable to write even a single 
letter (agraphia)-in attempting to do so he 
makes mere unmeaning strokes. 
The disability spoken of above as 
' aphemia ' may be complete, and then the 
patient is absolutely speechless. But incom- 
plete aphemia or aphemic defects exist in 
many degrees of completeness. These 
terms are now often applied to defects in the 
power of articulation-the mere mechanical 
part of speech-in which difficulties exist 
such as go with diseases in the bulb or the 
pons, or the slighter defects in utterance, 
constituting mere ' thickness of speech.' 
This kind of defect differs from (and may 
be easily distinguished from) aphasia, seeing 
that the subjects of it will always attempt at 
once to utter any word or simple sound, 
when they are bidden to do so. The term 
' anarthria ' has been used by some writers 
for what would be called* bad aphemic defects 
-such, for instance, as are met with in 
bulbar diseases, where the articulatory motor 
centres are themselves the seat of lesion. 
Aphasia occasionally supervenes, inde- 
pendently of paralysis or convulsions, in in- 
dividuals who have been subjected to great 
excitement or prolonged overwork, when it 
may be due, perhaps, to mere functional 
derangements. In other cases it presents 
itself as a temporary condition, lasting 
only for a few hours or a few days, 
in a patient who has just had an attack of 
right-sided unilateral convulsions; or, lastly, 
as has already been indicated, it occurs in 
conjunction with a right-sided hemiplegia 
produced either by brain-softening or by 
cerebral haemorrhage. Cases belonging to 
the latter category vary very much amongst 
themselves as regards the degree of co-exist- 
ing hemiplegia. If the third left convolution 
alone is damaged by softening, the hemi- 
plegic condition may be absent, or transient 
and incomplete - never, perhaps, affecting 
the leg appreciably. This condition is often 
induced by a small haemorrhage, or by a 
patch of, softening produced by an embolism 
of that branch of the middle cerebral artery 
which supplies the third frontal convolution ; 
but where the haemorrhage is larger, or 
where the main trunk of the middle cerebral 
artery is obliterated, either by an embolus 
or a thrombus, the aphasia, or aphasia with 
amnesia, is combined with much graver and 
more persistent hemiplegic symptoms. 
Pathology.-The modern concentration of 
attention upon these defects of speech was 
started by the enunciation of Broca's views as 
to the dependence of the aphasic defects upon 
lesions in or about the third left frontal convo- 
lution. And all pathologists are now agreed 
as to the fact that such lesions are much more 
prone to give rise to aphasic symptoms than 
are corresponding lesions on the right side of 
the brain. It is commonly believed, more- 
over, that amnesic defects of speech are most 
commonly produced by superficial lesions 
of the left hemisphere, though by lesions 
situated farther back-that is, in the neigh- 
bourhood of the posterior extremity of the 
Sylvian fissure. 
The third left frontal convolution is not 
now supposed, as Broca put it, to be the 
seat of any ' faculty of language,' though the 
anatomical investigations of Meynert and of 
Broadbent have shown that its relations with 
other convolutions are exceptionally complex. 
Whether certain higher ' motor ' centres for 
speech are situated in this part of the brain, as 
is commonly believed, or whether such centres 
are rather, as the writer believes, kinaesthetic 
centres, it must at least be conceded that this 
convolution is intimately concerned with the 
physical expression given to thought in 
articulate speech. 
We know that the left hemisphere is the 
one from which the volitional incitations 
proceed in the case of written language, and 
it is presumed that the same half of the 
brain also takes the lead in the production 
of articulate speech. It is, therefore, a point 
of much interest when we find that, in some 
of the exceptional cases in which aphasia 
has occurred in association with lesions on 
the right side of the brain and left hemi- 
plegia, the individuals had been left-handed 
during life. Some of the other exceptional 
cases, however, have not admitted of this 
interpretation. 
Different kinds of Word-memories.-For 
the proper understanding of these different 
defects of speech and writing many de- 
tails are essential. There are four different 
kinds of word-memory-three essentially 
different types, but one of them existing in 
two forms, so as to make four varieties in 
all. These varieties of verbal memory are 
as follows: (1) Auditory memory - the 
memory of the sounds of words, that is, 
of the auditory impressions representative 
of different words; (2) Visual memory-the 
memory of the visual appearances (printed 
or written) of words, that is of the visual 
impressions corresponding with different 
words; (3) Kinaesthetic memory-(a) the 
memory of the different groups of sensory 
impressions resulting from the movements 
of the vocal organs during the utterance of 
words (impressions from muscles, mucous APHASIA 
99 
membranes, and skin)-these the writer has 
proposed to speak of as ' glosso-hincesthetic ' 
impressions; (&) the memory of the different 
groups of sensory impressions emanating 
from the muscles, joints, and skin during 
the act of writing individual letters and 
words-these the writer has proposed to 
speak of as ' cheiro-hincesthetic' impressions. 
The organic seat of each of these different 
kinds of word-memory is in relation with its 
own set of afferent fibres; and the several 
centres are also connected with one another 
by commissural fibres, so that the recollection 
of a word in one or other of these modes 
doubtless involves some amount of simul- 
taneously revived activity in one or two of 
the' other word-centres. The relative in- 
tensity (in the process of recollection of 
words for ordinary speech) of the memorial 
revival in each of these centres is probably 
subject to more or less marked variation in 
different individuals. In the majority of 
persons the revival of words in the auditory 
centre is the most potential process, and 
that of which such persons are most con- 
scious. In a smaller percentage of persons 
the revival of words in the visual centre 
seems to be the most essential process. 
While in a very much smaller percentage it 
seems possible that revival in the kinaesthetic 
speech-centre may be the most conscious 
process occurring during the recollection of 
words. 
Owing to the fact of the existence of this 
multiple memory of words, it happens that 
loss of speech by no means always, or often, 
implies the loss of the memory of words. 
Many a patient who cannot speak can yet 
revive his auditory or his visual memory of 
words, so as more or less perfectly to under- 
stand what he hears, or what he sees (in 
print or writing), or perhaps what he both 
hears and sees. 
It is also of importance to be borne in 
mind that for ordinary persons (that is, 
those who are neither congenitally blind nor 
congenitally deaf) the four memories of 
words are mainly called into play in de- 
finite couples, namely, the auditory and the 
glosso-kinaesthetic revivals taking place in 
ordinary speech; and the visual and the 
cheiro-kinaesthetic revivals taking place 
during ordinary writing. So that in express- 
ing oneself in spoken words the memories of 
such words are first principally revived in 
the auditory centre, and then the nerve- 
units thus called into activity rouse in im- 
mediate succession the corresponding glosso- 
kinaesthetic elements before the pronuncia- 
tion of the word can be effected through the 
aid of the motor centres in the medulla. 
Similarly, when expressing our thoughts by 
writing, though the memories of words are 
probably first revived in the auditory word- 
centre, like memories are almost simul- 
taneously revived (through the intervention 
of the audito-visual commissure) in related 
parts of the visual word-centre ; and from 
this region stimuli must pass through cor- 
responding cheiro-kinaesthetic elements, be- 
fore the actual writing of the word can be 
effected through the instrumentality of motor 
centres in the cervical region of the cord. 
There can be no doubt that the functional 
association existing between the auditory 
and the glosso-kinaesthetic centres is of the 
closest kind. But the bond of association 
between the auditory and the visual centres 
is no less intimate. These latter centres are 
often necessarily called into activity in im- 
mediately successive units of time. This 
happens, for instance, in two such common 
processes as reading aloud and writing from 
dictation. 
In reading aloud the primarily excited 
visual word-centre must arouse (through the 
visuo - auditory word - commissure) rel ated 
parts of the auditory word-centre, since this 
is the part which ordinarily calls the glosso- 
kinaesthetic centre into activity, and from it 
properly co-ordinated incitations issue to call 
into play the motor centres in the medulla. 
Again, in writing from dictation, the sounds 
of words reach the auditory word-centre, and 
the activity thus aroused becomes transmitted 
(through the audito-visual commissure) to 
related parts of the visual word-centre, this 
being the part which usually arouses the 
cheiro-kinaesthetic centre into activity for 
the production of writing movements. 
In deaf-mutes, in the congenitally blind, and 
also in certain cases of disease, as it would 
seem, the relations between the centres are 
rather those indicated by the dotted lines 
(/e) in fig. 5. 
Concerning the Localisation of the dif- 
ferent Word-centres.-Looking to the ex- 
tremely important part that ' words,' either 
spoken, written, or printed, play in our in- 
tellectual life, and to the manner in which 
they are interwoven with all our thought- 
processes, it becomes highly probable that 
most important sections of the auditory and 
visual perceptive centres are devoted to the 
reception (and consequently to the revival in 
thought) of impressions of words; so that, 
for convenience of reference, we may speak 
of these sections as auditory and visual 'word- 
centres ' respectively. Similarly, there must 
be kinaesthetic word-centres of two kinds- 
the one in relation with speech movements, 
and the other in relation with writing move- 
ments. It is possible that the parts of the 
general auditory and visual centres which are 
in relation with word-impressions may be as 
distinctly defined as are the analogous parts 
of the general kinaesthetic centres that are in 
relation with speech movements. Certain it 
is that there are some varieties of amnesia 
in which the part of the visual centre in 
relation with words seems to be specially 
at fault (causing ' word-blindness '); just as 100 
APHASIA 
there are other cases in which the part of 
the auditory centre in relation with words 
is either wholly or partially inactive (causing 
4 word-deafness '), in each case without evi- 
dent defect in other parts of the general 
auditory or visual word-centres. 
In regard to. the visual centre as a whole, 
it seems to be now established that it is 
more or less diffused through the occipital 
lobe. As to the localisation of the general 
auditory centre, there is some clinico-patho- 
logical evidence to show that the auditory 
word-centre may be in, or in the immediate 
neighbourhood of, the upper temporal con- 
volution. 
The situation of the two kinaesthetic word- 
centres can, however, be much more pre- 
cisely localised. The writer holds the opinion 
that the so-called cortical 4 motor centres ' of 
Ferrier and others are really sensory centres 
of kinaesthetic type, by means of which move- 
ments are guided (see KintEsthesis). That 
being so, Broca's region, or Ferrier's centre 
for the movements of the mouth and tongue 
(viz. the posterior part of the third frontal 
and the inferior part of the anterior ascend- 
ing frontal convolution) is, in reality, the 
part of the brain which we have been alluding 
to as the glosso-kinaesthetic word-centre. The 
situation of the cheiro-kinaesthetic word- 
centre cannot be localised as yet with as 
much confidence, though the tendency is to 
follow Exner, who believes it to be situated in 
the posterior part of the second frontal con- 
volution. 
It must be supposed, therefore, that the 
auditory and the visual word-centres are 
situated, the one not far away from, and the 
other actually within, some part of the cortex 
of the occipital lobe, and that they are con- 
nected together by a double set of commis- 
sural fibres (fig. 5, a, b). We must also 
other (<7) by means of which the visual word 
centre acts upon the cheiro - kinaesthetic 
centre, for the production of writing. 
Thus, for speech we have the combined 
auditory and glosso-kinaesthetic word-centres, 
acting from the cortex through internuncial 
fibres, upon motor centres in the medulla; 
and for writing we have combined visual and 
cheiro-kinaesthetic word-centres, acting from 
the cortex through internuncial fibres, upon 
motor centres in the cervical region of the 
cord. In the study of speech-defects generally 
it is, therefore, needful to consider the effects 
of lesions: (1) in the different kinds of word- 
centres ; (2) in the different commissures by 
means of which the centres are connected; 
(3) in certain intemuncial fibres; and (4) in 
certain motor centres. 
Defects of Speech from Lesions in Word- 
Centres.-According to the writer's views it 
is not at all needful, as many authorities 
have thought, to postulate the existence of a 
separate 4 centre for conceptions or ideas.' 
The supposed theoretical necessity for as- 
suming the existence of some such centre 
may in most cases be obviated by a fuller 
recognition of the different degrees of func- 
tional excitability that may exist in the 
auditory and the visual word-centres re- 
spectively. It should, in fact, be constantly 
borne in mind by those who study these 
defects of speech that each perceptive centre 
is capable of being called into activity in 
three modes: (a) by 4 voluntary ' recall of 
past impressions, as in an act of recollection; 
(6) by 4 association,' that is by impulses com- 
municated from another centre during some 
act of perception or during some thought- 
process ; (c) by means of external im- 
pressions. Now the excitability of these 
centres is liable to vary much-as a result of 
advanced age, or of different general or local 
morbid states. The molecular mobility may 
be so much lowered that they are only capable 
of responding to powerful stimuli; in such 
cases either 4 volitional ' recall alone, or 4 as- 
sociational ' recall as well, may be impossible 
or more or less difficult, responses occurring 
only to external impressions-that is, the 
patients are only able to repeat words pro- 
nounced, or to copy words written before them. 
The effects of lesions of the different word- 
centres are as follows : (1) A lesion of the 
glosso-kinaesthetic centre produces simple 
aphasia; whilst (2) one of the cheiro-kin- 
aesthetic centre produces simple agraphia. 
In neither condition is the power of thought 
very appreciably interfered with. These are 
commonly supposed to be motor defects, but 
this the ■writer believes to be an erroneous 
interpretation-since they are defects due to 
the loss of certain sensorial aptitudes (of the 
kinaesthetic order) just as much as are the 
other forms of aphasia now about to be men- 
tioned, the existence of which were first 
pointed out and explained by the writer in 
Cheiro-Kinoes. C. 
Word C. 
Glosso-Kinces. C. 
Fig. 5. Diagram showing the commissural con- 
nections between the different word-centres. 
a. The visuo-auditory commissure. 
b. The audito-visual commissure. 
c. The audito-kinsesthetic commissure. 
d. The visuo-kinaesthetic commissure. 
Aud. Word C. 
suppose that two other sets of commissural 
fibres exist which are of much importance in 
regard to speech and writing, viz., one set (c) 
through which the auditory word-centre acts 
upon the glosso-kinaesthetic centre, for the 
production of articulate speech ; and the APHASIA 
101 
18G9, though they were subsequently more 
prominently explained in 1874 by V ernicke 
under the name of ' sensory aphasias.' One 
of these has been known as ' word-deafness ' 
and the other as ' word-blindness.' But de- 
fects in the activity of the auditory and of 
the visual word-centres respectively give rise 
to varied and complicated results, which can 
only be very inadequately summarised by 
these phrases. Thus under the head of (3) 
lesions of the auditory word-centre, we must 
refer to totally different defects according to 
the degree of functional degradation of the 
centre: (a) slight auditory amnesia from func- 
tional defect of the centre, leading to impaired 
spontaneous speech, owing to forgetfulness 
of names or nouns; (6) profound auditory 
amnesia, in which, from similar causes, both 
voluntary and associational speech are greatly 
impaired, though imitative speech is retained, 
and. the almost speechless patient may be 
able to read aloud correctly and fluently; (c) 
word-deafness and aphasia owing to a de- 
structive lesion of the auditory word-centre, 
in which the patient is not only unable to 
comprehend speech, but is himself speechless, 
and may also be unable to write sponta- 
neously. Lesions of (4) the visual word- 
centre, whether functional or structural, re- 
veal themselves in less varied modes ; when 
severe they would result in the production of 
word-blindness together with agraphia. 
Defects of Speech from Lesions of the 
Commissures between Word-centres. - It 
seems to the writer better to reserve the word 
' commissure ' as an appellation for the fibres 
that connect centres of the like kind, that is, 
either sensory centres or motor centres; and 
to name ' internuncial ' the fibres which con- 
nect sensory with motor centres. 
As already stated, double commissures 
exist between the auditory and the visual 
word-centres (fig. 5, a, V) which are habitu- 
ally called into play in certain mental opera- 
tions, so that their destruction leads to very 
definite defects. Thus, in naming objects 
at sight, or in reading aloud, stimuli have to 
pass from the visual to the auditory word- 
centre (by the visuo-auditory commissure) 
before the naming or the reading aloud can 
occur. Again, in writing from dictation, and 
probably also in writing any spontaneous 
effusion, stimuli require to pass between 
these two centres in an opposite direction, 
namely, from the auditory to the visual 
centre, and through a different set of fibres 
(the audito-visual commissure). In 1880 the 
writer published (The Brain as an Organ 
of Mind, p. 640) some details concerning a 
man (who has ever since been under observa- 
tion from time to time) who suffers from a 
lesion destroying the commissures in question. 
This man understands perfectly all that is 
said to him and all that he reads, yet he 
cannot read aloud a single word or even 
name a single letter, though immediately 
that he hears the word or letter pronounced 
he can repeat it at once. Again, he cannot 
write a single word, or even letter, from 
dictation, though he can at once, with his 
left hand, proceed to copy any such word or 
letter that may have been written for him on 
a sheet of paper. Cases have been recorded 
also in which the separate halves of the 
commissure between the auditory and the 
visual word-centres have been damaged; so 
that reading from dictation or naming at 
sight have been interfered with and not 
writing from dictation, or vice versa. 
The other commissures whose lesions have 
to be considered are those (fig. 5, c, d) con- 
necting the auditory with the glosso-kinaes- 
thetic, and the visual with the cheiro-kinaes- 
thetic word-centres. Defects in the course 
of these commissures are of interest, more 
especially from the point of view of a regional 
diagnosis. The writer some years ago 
pointed out, for instance, that a lesion of any 
part of the audito-kinaesthetic commissure 
(fig. 5, c) should produce an aphasia indis- 
Fig. 6.-Diagram showing the possible location of 
an aphasia-producing lesion, either in the glosso- 
kinaesthetic centre (a), in the audito-kinaesthetic 
commissure (6), or, in association with word-deafness, 
in the auditory word-centre (c). 
tinguishable from that which would be pro- 
duced by damage to Broca's convolution, that 
is, to the glosso-kinaesthetic centre itself. 
This is, of course, a very important point, 
since it shows that it is an error to suppose 
that typical aphasia can only be caused by a 
lesion in Broca's region. A precisely similar 
result should also be produced by complete 
destruction of the audito-kinaesthetic com- 
missure, in any part of its course between 
that region and the neighbourhood of the 
occipital lobe where the auditory word- 
centre is situated. If the latter centre itself 
be damaged, as before stated, we then get 
the aphasia complicated with word-deafness, 
and thus have the means of arriving at an 
accurate regional diagnosis. Once clear of 
the centre, however, a lesion involving any 
part of the audito-kinaesthetic centre should 
produce a typical aphasia absolutely indis- 
tinguishable clinically from that resulting 
from a lesion in Broca's region itself. This 
explains the occurrence of aphasia in associa- 102 
APHASIA 
tion with lesions in the island of Reil, and 
other sites nearer the posterior extremity of 
the Sylvian fissure (see Brit. Med. Jour., 
Nov. 5, 1887, p. 986). 
This point, like the question of the exist- 
ence and interpretation of aphemia, will be 
found to be a touchstone for testing the truth 
of the doctrines here set forth concerning 
the pathogenesis of speech-defects, as com- 
pared with those of Stricker and of Hugh- 
lings Jackson. According to their views, 
the commissural fibres now referred to pass 
between the auditory and a true ' motor ' 
centre for articulation. According to Stricker 
(Le Langage et la Musique, 1885, p. 73), 
a damage occurring in the course of these 
fibres would cause, not aphasia but word- 
deafhess. His view being that words are 
realised mainly by memorial revival in motor 
cortical centres, in the case assumed there 
would be word-deafness because stimuli could 
not pass from the auditory to the assumed 
motor centres in which the essential part of 
the apperceptive process is carried on. It 
seems clear also that these doctrines necessi- 
tate the view that an isolated lesion in Broca's 
region only should also cause word-deafness 
as well as aphasia. This, however, is cer- 
tainly not the case-a fact which is itself 
sufficient to negative the truth of the views 
of Hughlings Jackson and of Stricker. 
Damage to any part of the visuo-kinses- 
thetic commissure (fig. 5, d) would also be 
capable of producing agraphia of just as 
complete and typical a kind as if the lesion had 
been in the cheiro-kinaesthetic centre itself. 
Defects of Speech from Lesions of Inter- 
nuncial Fibres.-We have here to do with 
a kind of defect known as aphemia. This 
is a speech-defect, and there is no analogous 
defect of writing, except that which is occa- 
sioned by actual paralysis of the right hand. 
In complete aphemia there is absolute loss 
of articulate speech without any mental 
impairment, and with the power of com- 
municating the thoughts by writing preserved 
absolutely intact. An excellent example has 
been recorded by the writer in the Brit. 
Med. Jour., Nov. 5, 1887. 
Such a condition is produced when the 
glosso-kinaesthetic centre is itself uninjured, 
but where the whole of the internuncial fibres 
emanating from it and proceeding to the 
true motor articulatory centres in the bulb 
are damaged in some part of their course 
-whether just beneath the cortical centre, 
in the internal capsule, in the peduncle, or in 
the pons. Sometimes the defect may be of 
a functional rather than of a structural type, 
constituting Charcot's ' hysterical mutism in 
the male.' 
Incomplete aphemias, however, exist of 
all degrees of severity, and they are about 
the commonest of all speech-defects occurring 
in association with hemiplegia. They are 
due to partial damage to the group of inter- 
nuncial fibres above referred to, and are 
represented by defects of articulation, vary- 
ing from almost complete unintelligibility to 
the mere blurred utterance or thickness of 
speech which is so common. 
Aphemia is clearly not a sensory defect-■ 
it is not a form of amnesia-because the 
subjects of it can revive words in all possible 
modes, and are, therefore, able to think and 
express their thoughts with an unimpaired 
freedom by writing. If the aphemia be in 
any way incomplete, moreover, such a case 
can be easily discriminated from a case of 
aphasia by the fact that the aphemic patient 
will always at once make an attempt, when 
bidden, to pronounce some simple word or 
syllable (however poor the attempt may be), 
while the typical aphasic patient is unable 
to make any such attempt-he will not try 
even to repeat the simplest vowel-sound. 
Defects of Speech due to Lesions in the 
Bulbar Articulatory Centres. - In these 
cases, as where the lesions occur in the 
internuncial fibres, all the centres in which 
the memory of words can be revived are 
intact. There is consequently nothing what- 
ever to interfere with the flow of thought, 
and in incomplete cases nothing to prevent 
attempts at articulation being made. These 
two classes of cases are indeed less separable 
clinically than they are from a theoretical or 
scientific point of view. 
It would be well to reserve the term 
' anarthria,' as introduced by Kussmaul, for 
the defects of speech caused by morbid states 
of the bulbar articulatory nuclei-with the full 
understanding, how'ever, that aphemia and 
anarthria will often be indistinguishable from 
one another by their own intrinsic characters, 
though they will generally be quite capable 
of being diagnosed from one another by 
taking into consideration the mode of onset 
and the particular grouping of other attendant 
signs. 
Diagnosis.-The means of distinguishing 
the different aphasic and amnesic speech- 
defects from one another has already been 
fully enough set forth in the preceding 
sections. The diagnosis of the exact nature 
of the defect is often exceedingly difficult, 
unless the patient be thoroughly examined 
in a systematic manner, and in accordance 
with some definite plan. Elsewhere (Para- 
lyses; Cerebral, Bulbar, and Spinal, 1886, 
p. 125) the writer has given such a ' Schema 
for the Examination of Aphasic and Amnesic 
Persons,' which has been used with success 
for many years. The other side of the ques- 
tion, viz., the pathological diagnosis, must be 
made in accordance with the rules generally 
applicable to this part of the diagnostic 
problem in cases of brain-disease. 
Treatment.-Where aphasia occurs after 
excitement or overwork, without paralysis, it 
is a warning of much importance, since it 
may be the precursor of much graver symp- APHASIA 
APHTHA 
103 
toms. Under such circumstances the patient 
requires an absolute cessation from work for a 
time, and most careful watching. Stimulants 
may need to be diminished; and bromide 
of potassium, with sumbul and other sedative 
remedies, should be administered. Where 
aphasia is a temporary condition in associa- 
tion with right-sided convulsions, or where 
it is lasting and co-exists with right-sided 
paralysis, the treatment of the aphasic con- 
dition becomes merged in that of the asso- 
ciated convulsive tendency or paralytic con- 
dition, since, as a rule, an amelioration takes 
place in the patient's power of speaking co- 
incidentally with his improvement in other 
respects. This, however, is not always the 
case where aphasia has co-existed with a 
partial hemiplegic condition: the paralysis 
may be recovered from, whilst the aphasic 
defect may remain more or less as it was. 
Where this is the case, an attempt should 
be made to teach the patient to speak again, 
especially if the defect be of the aphemic type. 
Such efforts have occasionally been crowned 
with success (see Trans, of Clin. Soc., vol. iii. 
p. 92, and Brit. Med. Journ., Nov. 5, 1887, 
p. 988), but much judgment and untiring 
patience have to be called into play in order 
to obtain satisfactory results. 
H. Charlton Bastian. 
APHEMIA (h, neg.; and cfirjnh I speak). 
A term differently applied by different 
writers, but commonly understood to be a 
designation for certain articulatory defects 
(see Anarthria) dependent upon injury, 
direct or indirect, to the internuncial fibres 
connecting Broca's convolution with the 
motor centres of the bulb. Where the aphe- 
mia is incomplete the nature of the defect 
is generally obvious; where it is complete 
the patient is absolutely speechless, and 
is apt loosely to be described as aphasic, 
though the fact that he can express himself 
freely by writing shows that this is not a 
correct designation of his condition. See 
Aphasia. 
APHONIA (a, priv.; and the voice). 
Absence of voice, that is, of intonated utter- 
ance. See Voice, Disorders of. 
APHRODISIACS ('A^poS^, Venus).- 
Definition.-Medicines which increase the 
sexual appetite and power. 
Enumeration. - The direct aphrodisiacs 
include : Nux Vomica and Strychnine, 
Phosphorus, Cantharides; Urtication and 
Flagellation; Cannabis Indica, Damiana, 
Opium, and Alcohol in small doses. Iron and 
bitter tonics; meat diet; warm clothing, 
especially around the hips and loins; and 
abstinence from severe mental and bodily 
work, act as indirect aphrodisiacs. 
Action.-Aphrodisiacs may act by increas- 
ing the excitability of the nerves passing to 
or from the genital organs, or of the genital 
centre in the spinal cord (see Anaphrodisiacs), 
as, for example, strychnine, nux vomica, and 
probably phosphorus; by causing irritation 
of the nerves of the genital or urinary organs 
or of adjoining parts, as cantharides and 
urtication; or by stimulating the brain, as 
Indian hemp or small doses of opium. Al- 
cohol in large doses has a double action, 
increasing the sexual desire by stimulating 
the brain, while lessening the power of 
erection, probably by weakening the nervous 
mechanism through which erection is pro- 
duced. As the sexual passion becomes dimin- 
ished when the nervous system is weakened 
with the rest of the body, and increases with 
returning strength, iron with bitter tonics, 
and generous diet act indirectly as aphro- 
disiacs. 
Uses.-When the sexual functions are ab- 
normally depressed, strychnine and phos- 
phorus are the most generally useful of the 
direct aphrodisiacs. Cantharides, although 
sometimes valuable, must be employed with 
caution. T. Lauder Brunton. 
APHTEL® (a7rrw, I inflame). - Synon. : 
Aphthous Stomatitis; Fr. Muguet; Ger. 
Fasch. 
Definition.-A form of catarrh of the 
buccal mucosa, characterised by the appear- 
ance of one or more patches (aphthce) possess- 
ing a peculiar structure. 
Anatomical Characters.-Aphthae have at 
first the appearance of vesicles; but micro- 
scopical sections show that they are due to 
elevation of the epithelium by a solid, fibrinous 
exudation, over which the epithelium usually 
dies, soon separating with the fibrinous flake. 
By the time this is effected the mucosa is 
again, as a rule, thinly covered by epithelium, 
so that a true ulcer is never present; but 
slight suppuration may be established, with 
the destruction of the superficial layer of the 
mucosa. 
Symptoms, Course, and Duration. - 
Aphthae occur chiefly in children during 
the first dentition, upon any part of the 
buccal mucosa-most frequently inside the 
lower lip and on the tip of the tongue. At 
first they look like small vesicles, but after 
a few hours they resemble ulcers with ad- 
herent grey or yellowish sloughs, each being 
surrounded by a ring of injection. The 
patches vary in size from that of a lentil 
downwards; they are single or multiple; 
grouped or scattered; two or three may 
coalesce, but the patches never reach a large 
size. Aphthae cause slight pain, and are 
specially sensitive to substances like salt or 
sugar. Dyspeptic troubles are usually pre- 
sent, and the breath is often foul. 
Each aphtha runs its course in three or 
four days, and when multiple the patches 
come out in a crop. This may be succeeded 
by other crops, so that all stages of the lesion 
may be present at one time. The trouble 104 
APHTHAE 
APOPLEXY, CEREBRAL 
may thus continue for weeks. In other cases 
patients are liable to crops of aphthe at 
varying and sometimes long intervals. 
Diagnosis.-Aphthe have chiefly been mis- 
taken for patches of thrush. Absence of the 
red areola, and presence of the characteristic 
fungus, will distinguish thrush even when 
no history or statement of symptoms can be 
obtained. 
Treatment.-The occasional application of 
a little powdered borax to the aphthae causes 
their speedy healing. In prolonged cases, 
the health in general, and stomach and in- 
testines in particular, must be attended to. 
Stanley Boyd. 
APHTHOUS.-A term applied to dis- 
eases in which aphthae are present. 
APLASTIC.-(a, priv.; and 7rX<lo-<rw, I 
mould).-Incapable of being organised or of 
forming tissues; generally applied to inflam- 
matory exudation. 
APNEUMATOSIS (A,priv., and Trvevyn, 
respiration).-A synonym for atelectasis. See 
Atelectasis. 
APNCEA (a, priv.; and irvea, I breathe).- 
Apnoea, literally signifying breathlessness, is 
used by some medical writers as synonymous 
with asphyxia, the condition which super- 
venes on suspension or obstruction of the 
respiratory function. See Asphyxia. 
By physiologists, and with more correct- 
ness, the term is employed to signify the 
cessation of respiratory movements which is 
brought about by hyperoxygenation of the 
blood.; as when an animal is made to inhale 
oxygen, or to breathe more rapidly than the 
needs of the economy require. 
APOLLINARIS, Waters of.-Acidu- 
lous alkaline table-waters. See Mineral 
Waters. 
APOPLEXY.-Definition.-The word 
apoplexy means, by its etymology, a striking 
from (mo, from, and a striking), and 
was at first and is still chiefly used to signify 
sudden abolition of consciousness and power 
of motion, which, in common English, is also 
called a stroke. The idea fossilised in the 
term is that of an unseen actor, and brings to 
our lips unconsciously the thoughts of an age 
that is much less distant in the time that is 
measured by centuries, than in that which is 
estimated by the cycles of thought. 
Cerebral haemorrhage is the most frequent 
cause of apoplexy ; thence ' haemorrhage into 
the brain ' and ' apoplexy ' came to be used as 
synonymous expressions. Subsequently the 
effusion of blood itself was spoken of as the 
apoplexy, the word being used to designate 
the pathological condition causing the symp- 
toms which it at first epitomised. Ultimately 
it was applied to such spontaneous haemor- 
rhage elsewhere ; and thus extravasations into 
the substance of the lung, the spleen, or the 
retina were, and still are, termed pulmonary, 
splenic, or retinal ' apoplexies.' It would be 
difficult to find a more striking instance of 
the looseness of the process of nomenclature, 
or of the strange way in which precision in 
words lagged behind the process of patho- 
logical discovery. 
The term cerebral apoplexy is sometimes 
used to particularise haemorrhage into the 
brain, but it is more commonly employed to 
denote an apoplectic condition depending on 
any cerebral lesion, and in that sense it will 
be here employed. W. R. Gowers. 
APOPLEXY, CEREBRAL.-Synon. : 
a ' stroke '; Fr. Apoplexie; Ger. Schlag. 
Definition.-Loss of consciousness, of 
sensation, and of voluntary motion, coming 
on more or less suddenly, and due to a mor- 
bid state of the brain. 
The condition of coma is termed ' apoplectic' 
when of sudden or rapid onset. Loss of con- 
sciousness may be due to other causes acting 
directly on the brain, such as defective or 
excessive supply, or altered condition of 
blood; but it is customary to include among 
the forms of apoplexy that only which is 
due to cerebral congestion, and to consider 
as apoplectic states those only which result 
from distinct toxaemia. Unconsciousness 
resulting from acute anaemia of the brain, 
or such as succeeds an epileptic fit, is not 
termed apoplectic. The term has, of necessity, 
become restricted, as increasing knowledge 
has explained the nature of many conditions 
previously confounded with apoplexy. It 
should be further observed that the term has 
always been restricted to such conditions 
as occur without conspicuous external cause. 
The same state when due to an injury, is 
not called by the name which is employed 
if there is no injury. The explanation of the 
inconsistency is to be found in the idea that 
is to be traced alike in the native and the 
foreign word. The ' stroke ' determines the 
designation when the agent is unseen. It is 
to the conception of an unseen striker that the 
word is due. 
The essential cause of apoplexy is a sudden 
cerebral lesion, occurring without external 
injury. The sudden abolition of function 
seldom occurs except at the onset of a positive 
and permanent damage, and a sudden lesion 
cannot occur except as a result of an alteration 
in the physical conditions of the circulation, 
no other element in the brain being capable 
of thus suddenly producing a distinct lesion. 
The great cause of apoplexy is the rupture of 
a vessel, and hence the ' stroke ' became so 
confused with the mechanism that the term 
became synonymous with a spontaneous 
haemorrhage in any organ. The same state 
may, however, be caused by obstruction of a 
vessel by thrombosis or embolism. Profound 
coma is rarely due to any other spontaneous 
cerebral lesion. A very small hemorrhage 
may cause apoplexy. APOPLEXY, CEREBRAL 
105 
Apoplectic symptoms may, however, occur 
without obvious lesion of the brain. The 
coma which is associated with congestion of 
the head, is sometimes termed 'congestive 
apoplexy,' and that which occurs in the 
absence of any recognisable cause, has been 
called ' simple apoplexy.' 
Pathology.-In all these cases the apo- 
plexy is in relation chiefly to the extent 
and suddenness of the lesion, and the in- 
tensity of the damage. Roughly speaking, 
its occurrence may be said to depend on the 
suddenness, together with the intensity, of 
the cerebral mischief; its degree on the extent 
of the same. But the occurrence of apoplexy 
depends sometimes on the size of the lesion ; 
and the degree varies not only directly with 
the extent of the mischief, but with the ex- 
tent of brain-tissue which is exposed indirectly 
to the irritative influence of the primary 
lesion. Hence position of lesion has an 
influence in determining the apoplectic symp- 
toms. For these several reasons apoplexy is 
especially profound when the haemorrhage 
affects both hemispheres, either by simul- 
taneous extravasation on each side, or as the 
result of haemorrhage into the lateral ven- 
tricles. 
The precise condition on which the essen- 
tial element in apoplexy-the arrest of all 
manifestation of brain function-is imme- 
diately dependent has been a matter of much 
dispute. It was formerly ascribed to the 
pressure exerted by the clot on the rest of 
the brain, either influencing directly the 
cerebral tissue, or pressing on and emptying 
its capillaries (Niemeyer). That such pres- 
sure is exerted by a large haemorrhage is 
unquestionable. The convolutions on the 
side of the extravasation are flattened, and 
the falx is bulged to the opposite side. It 
cannot be doubted that the intensity of the 
apoplexy in these cases is due in part to this 
cause. But this will not explain the occur- 
rence of the symptom in small haemorrhages, 
by which no general pressure is exerted, or 
not more than is at once relieved by the 
displacement of the mobile fluid which sur- 
rounds the vessels. It will not explain 
symptoms in laceration of the brain, nor the 
instant loss of consciousness at the very onset 
of a severe haemorrhage, in which, as Jaccoud 
insists, it should, if merely due to pressure, 
be a late rather than an early symptom. 
There can be little doubt from these con- 
siderations, and from the cases in which there 
is no recognisable brain-lesion, that what 
is called shock is an important element in 
the causation of apoplexy. Thus in cerebral 
haemorrhage the apoplectic symptoms are 
due in part to the influence on the rest of the 
brain of the irritation of the nerve-elements 
by laceration. A haemorrhage, for instance, 
stops for a few hours all reflex action by the 
irritative inhibition downwards, and it stops 
also the cerebral action by the same process 
acting upwards. We can thus understand 
why vascular occlusion causes a slighter 
degree of apoplexy, since the immediate 
irritation of the local anaemia is less than 
that of laceration; and also why lesions of 
the pons produce, as they do, such deep and 
long-continued coma, since the irritated 
fibres are connected with a large part of the 
cerebrum, and thus influence it indirectly. 
Simple apoplexy was a term given by 
Abercrombie to the cases, once thought to be 
frequent, in which apoplexy occurs without 
recognisable brain-mischief or blood-poison- 
ing. Some of these cases were probably 
instances of uraemic poisoning, and others 
may have been due to undiscovered and 
extensive, embolism, causing death before 
there was time for softening to occur. 
But cases are not infrequent to which 
neither of these explanations applies: in 
which death occurs in an apoplectiform 
attack, all the organs are found healthy, and 
the brain only exhibits, in common with the 
other organs, that passive congestion which 
results from an asphyxial mode of death. 
The nature of these cases is still mysterious, 
but they may be grouped with those in 
which fatal coma follows an epileptic attack, 
and is apparently due to the brain-shock 
produced. 
Serous apoplexy is a term sometimes ap- 
plied to cases of fatal apoplexy in which no 
lesion is discoverable except excess of serum 
on the surface of the brain. It is now under- 
stood that such serous effusion is associated 
merely with senile atrophy of the brain, and 
that the name, as a pathological designation, 
is no more than a refuge for a destitute dia- 
gnosis. There is no reason for associating 
its presence with the apoplectic symptoms. 
The cases described under this term were 
probably instances of uraemia, or of ' simple 
apoplexy ' in old persons with atrophied 
brains. 
Symptoms.-Apoplexy is itself a symptom, 
and can only claim to be treated as a disease 
on account of the frequency with which it 
presents itself as the prominent element in a 
patient's state. The striking feature of apo- 
plexy is loss of consciousness without obvious 
failure of the heart's action. The onset is 
often instantaneous, so that the sufferer falls 
to the ground. The face may be flushed or 
pale-it is rarely very pale. The heart and 
arteries vary in their state according to the 
cause ; at first the pulse is often feeble from 
shock, even in cases in which it soon becomes 
full and tense. Respiration continues, but 
is laboured and stertorous. The limbs are 
motionless. In severe cases no reflex action 
can at first be excited. The pupils may be 
dilated, contracted, or unchanged: in pro- 
found coma they are usually dilated; and 
they often vary in size spontaneously, being 
sluggish in their action to light. The patient 
can usually swallow, although often with 106 
APOPLEXY, CEREBRAL 
difficulty. The sphincters permit the escape 
of urine and faeces, or the urine may be re- 
tained. In a case of moderate severity the 
reflex action soon returns, the conjunctivae 
become sensitive, the patient can be roused 
to exhibit some sign of consciousness, and he 
shows returning power of motion. At first 
there is merely a half-purposive withdrawal 
of a limb when it is pinched or pricked. 
Afterwards more prolonged and voluntary 
movements are produced : he opens his eyes 
when spoken to, and tries, when told to do 
so, to protrude his tongue. On the other 
hand, the apoplexy may continue or may 
deepen in intensity; the patient dying at the 
end of a few hours or a few days. Death 
rarely occurs in a shorter time than two or 
three hours. In very rare instances an ex- 
tensive haemorrhage into the pons or medulla, 
or an effusion into the fourth ventricle, may 
stop the respiration and kill the patient in a 
few minutes. 
It is not often, however, that there is this 
simple loss of cerebral function, uniformly 
distributed, and gradually deepening or pass- 
ing away. Much more commonly the 
symptoms of a local cerebral lesion are 
added to those of apoplexy. Frequently such 
symptoms precede the loss of consciousness- 
unilateral weakness, deviation of the mouth, 
convulsion. These may be recognised during 
the attack. The limbs on the one side exhibit 
more complete muscular relaxation than 
those on the other; they fall more helplessly 
when raised; or there is unilateral rigidity 
or clonic spasm, unvaried in its seat. Or in- 
equality of pupils may be observed, or rotation 
of the head and. conjugate deviation of the eyes. 
As a patient recovers, these local symptoms 
become more and more distinct, the tongue 
deviates on protrusion, speech and swallowing 
are difficult, or the patient may have lost the 
use of language. 
In ingravescent apoplexy the commence- 
ment of the cerebral mischief is marked by 
symptoms of general shock, without any, or 
with merely transient, loss of consciousness. 
There is commonly pain in the head, and 
there may be other localising symptoms. 
After some hours, during which the patient 
may continue his occupation, coma gradually 
comes on and deepens into death. This form 
of apoplexy, first described by Abercrombie, 
is usually due to a slowly increasing cerebral 
haemorrhage. 
The temperature in cerebral apoplexy is at 
first lowered in most cases, but usually the 
fall is small, and is succeeded, after twelve 
to twenty-four hours, by a rise. In some 
cases there is a considerable rise within the 
first six hours, and the temperature then 
commonly continues to rise, reaching 104° 
or 106° Fah., and even higher. Such a 
symptom is a precursor of death. 
Diagnosis.-The first diagnostic problem 
is whether the patient's state comes under the 
general name of apoplexy; or is one of the 
morbid conditions in which there is a loss of 
consciousness, similar in general characters 
to apoplexy, but due to one of the causes 
excluded in the definition given above. From 
the unconsciousness due to cardiac syncope, 
apoplexy is easily distinguished. In the 
former the heart's action fails, the pulse is 
weak and imperceptible, the face is very pale, 
the respiration is sighing and irregular, reflex 
action is rarely abolished, and the sphincters 
are seldom relaxed. 
From the several forms of toxcemia the 
diagnosis is often easy, sometimes extremely 
difficult. It is easy when, on the one hand, 
the symptoms of apoplexy are preceded or 
accompanied by those of a local cerebral 
lesion; or when, on the other hand, the 
direct or circumstantial evidence of poisoning 
is clear, or the symptoms of toxaemia un- 
mistakable. Where there are no local symp- 
toms, and where no guiding history is to 
be obtained, the diagnosis is difficult, but a 
correct opinion may commonly be formed 
by an attentive comparison of the symptoms 
present. 
There may be, as just observed, indirect 
evidence of toxaemia: the breath may smell 
of opium or alcohol; the urine may contain 
albumin. But albuminuria or a smell of 
spirit may mislead. Cerebral haemorrhage 
often occurs after drinking; spirit is con- 
stantly given to a person in a fit. A smell of 
spirit must therefore only be allowed weight 
in the absence of any evidence of cerebral 
mischief. So, too, albumin is always present 
in the urine in uraemia, but it is also very 
frequently present in cases of cerebral haemor- 
rhage. Alone, this evidence of Bright's dis- 
ease is of little value, except there be general 
oedema and the patient be young; then 
uraemia is more probable than vascular de- 
generation and cerebral haemorrhage. The 
urine should always be examined microscopi- 
cally with reference to structural changes 
in the kidneys. But with other symptoms 
which indicate uraemic poisoning, albuminuria 
is conclusive. 
The age of the patient should be considered. 
Late life is in favour of brain-disease. The 
history of a fall or blow on the head adds 
weight to other symptoms of cerebral mis- 
chief. 
The character of the coma will sometimes 
guide us. In uraemia, and commonly in 
alcoholism, it is less profound than in cere- 
bral mischief, so that the patient can readily 
be roused. In apoplexy, in opium-poisoning, 
and in the most intense form of alcoholic 
poisoning, the coma may be profound. On 
the other hand, in cerebral haemorrhage the 
patient may sometimes be roused to answer 
questions. Violent struggling is strongly in 
favour of drink. 
The mode of onset of the coma is important. 
In apoplexy it is sudden; in uraemia it is APOPLEXY, CEREBRAL 
107 
slow. The uraemic patient becomes first 
drowsy, then comatose. But with convul- 
sions uraemic coma may come on suddenly. 
The onset of the coma of opium- and alcohol- 
poisoning is also slow. Ingravescent apoplexy 
is of deliberate onset, but a profound degree 
of coma is quickly reached. 
General convulsions at the onset exclude 
drunkenness, and usually opium-poisoning, 
while they favour the probability of uraemia, 
especially if they are followed by rigidity that 
changes its seat. When uraemic convulsions 
begin locally, the place at which they begin 
often varies. Cerebral mischief sometimes 
commences with a convulsion, but the con- 
vulsion is then commonly unilateral, at least 
in onset, and the preponderant affection of 
one side at a time is indicated by the deviation 
of the head. It is seldom that well-marked 
deviation of the head and eyes occurs, first 
to one side and then to the other, as the fit 
progresses, unless there is an organic lesion 
of the brain, and one-sided symptoms are 
almost always to be recognised afterwards. 
Rigidity of limbs or local muscular twitching 
during the coma is, if constant in seat, in 
favour of cerebral mischief; if variable in 
position, it is in favour of uraemia (Reynolds). 
In diabetic coma, the odour of the breath, 
and the result of an examination of the urine 
(never to be omitted) will prevent mistake, 
even in the absence of a history of diabetes. 
But the absence of local cerebral symptoms 
must be carefully noted, since the presence 
of diabetes does not exclude a cerebral lesion. 
Post-epileptic coma is of course preceded 
by a convulsion, and should be borne in 
mind. 
The state of the pupils alone is of little 
importance. Great contraction occurs in and 
suggests opium-poisoning, but it is present in 
haemorrhage into the pons Varolii. The 
pupils may be either normal or dilated in 
uraemia, in alcoholic or in belladonna-poison- 
ing, and in apoplexy. Inequality of pupils, a 
unilateral symptom, points to brain-mischief. 
The retina should be examined, since the 
presence of albuminuric retinitis points, in 
the absence of the signs of a localised cerebral 
lesion, strongly to uraemia. 
Lastly, the temperature should be noted. 
In uraemia there is persistent uniform 
depression; in cerebral lesions the initial 
depression is succeeded by a rise to a point 
above the normal. 
The second problem in diagnosis is the 
precise cause of the apoplexy, the existence 
of which has been ascertained by the con- 
siderations just reviewed. This element, 
however, will be described more fully under 
the heads of the chief lesions that produce 
the state-cerebral congestion, haemorrhage, 
and softening. In may be here pointed out 
that slight and transient apoplexy, without 
local symptoms, with flushed face, and 
coming on during effort, points to cerebral 
congestion; slight and transient apoplexy 
with marked local symptoms points to 
softening; early and profound loss of con- 
sciousness to cerebral haemorrhage. Post- 
epileptic coma may be distinguished by the 
history of epileptic attacks ; or, if this be not 
forthcoming, it may be suspected if symptoms 
of a local cerebral lesion or indications of 
toxaemia are absent, if the patient be under 
40, and exhibits indications of speedy recovery, 
and also if he has bitten his tongue and 
passed urine. ' Simple apoplexy ' cannot be 
diagnosed during life, since freedom from the 
symptoms of a local lesion does not afford 
ground for inferring that there is no such 
lesion. 
Prognosis.-The prognosis in cerebral 
apoplexy depends in part upon the intensity 
of the attack. As long as unconsciousness 
is complete, and reflex action abolished, the 
patient is in danger of speedy death. The 
longer the apoplectic condition lasts without 
improvement, the less prospect is there of 
recovery. Persistent depression of tempera- 
ture, or a rise of several degrees above the 
normal either with or without an initial fall, 
are both of grave significance; such cases 
rarely recover (Charcot, Bourneville). 
The nature, extent, and position of the 
cerebral lesion, when they can be inferred, 
furnish other prognostic indications. In 
haemorrhage the prognosis is more serious 
than in softening. A sudden occurrence or 
increase of apoplectic symptoms, a few hours 
or days after a slighter attack, is always 
grave, indicating a fresh extravasation. If 
such apoplectic symptoms become profound 
and uniform, the prognosis is fatal, rupture 
into the ventricles or on the surface of the 
brain having probably occurred. If the 
localising symptoms point to a lesion of the 
medulla or pons, the prognosis is almost as 
unfavourable. Early return of consciousness 
and slight alteration in temperature are 
favourable signs. Previous cerebral disease 
renders the prognosis worse. Lastly, the 
prognosis must be influenced unfavourably 
by any impairment of the organic functions 
of circulation and respiration, whether 
independent of or due to the cerebral lesion. 
Previous alcoholism, from its effect on the 
nutrition of all tissues, is especially serious. 
Treatment.-The treatment of cerebral 
apoplexy must be guided by the indications 
of its cause. Where none can be obtained, 
it should be treated by a system that is a 
compromise. The chief causes are haemor- 
rhage and thrombotic softening of the brain. 
Embolism seldom causes pronounced apo- 
plexy. The measures therefore must be 
such as are suitable to both states, those 
being excluded which, while they would do 
good in one, would do harm in the other. 
But such a compromise is seldom needed. 
Diagnostic indications can usually be traced 
with clearness, and as a rule also several 108 
APOPLEXY, CEREBRAL 
APPENDIX VERMIFORMIS 
coincide distinctly in this direction, whilst 
those that do not point in this direction are 
neutral. Hence, as a matter of fact, there 
should seldom be the hesitation that interferes 
with the proper energy of treatment, and the 
statements often made in books are not true, 
-at any rate in the present day they should 
not be true. Stillness is the most important 
condition. The patient should be moved as 
little as possible, but placed in the recumbent 
posture with the head slightly raised. The 
neck should be freed from constriction. If 
the extremities are cold, warmth may be 
applied to them; and cold to the head if 
there is local heat or flushing. Sinapisms 
to the neck and extremities sometimes seem 
to hasten the return of consciousness. The 
administration of stimulants should be 
regulated by the state of the heart. In 
thrombosis or embolism the heart should 
be kept up to the normal by very careful 
administration of alcohol, ether, or ammonia. 
In haemorrhage it may be allowed to fall a 
little below the normal, but indications of 
failing power should be watched for and 
counteracted. Where no causal indications 
exist, the latter is the wiser plan. Vene- 
section and purgation are remedies of similar 
effect, but different in degree, and are 
indicated by high arterial tension and 
cephalic congestion, shown by incompressi- 
bility of the pulse and flushing of the face. 
Venesection is useful where the heart acts 
strongly, and the pulse is full as well as 
incompressible. Its effect is proportioned to 
the rapidity with which the blood is taken, 
rather than to the quantity removed. Purga- 
tives remove serum from the blood, and 
lessen the amount of blood within the skull 
by causing an afflux to the capacious intes- 
tinal vessels. The best purgative is croton 
oil or calomel. With a failing heart and 
pale surface they should be avoided. When 
in doubt we should give a mild aperient that 
acts quickly, such as senna or a little solid 
extract of cascara rubbed up in water, and 
the action should be ensured by a glycerine 
enema. Diuretics may always be used to 
relieve the vascular tension. As the apoplexy 
clears, the nature of the case becomes 
evident, and the treatment of the several 
conditions is described elsewhere (see Brain, 
Haemorrhage of, and Softening of;. For 
treatment of the other causes of the apoplectic 
state, see Alcoholism, Poisons, and Uremia. 
W. R. Gowers. 
APPENDIX VERMIFORMIS, In- 
flammation, Ulceration, and Perfora- 
tion of. 
Definition. - Inflammation of the ap- 
pendix vermiformis from lodgment of 
hardened feces or a foreign body ; leading to 
ulceration, which frequently ends in perfora- 
tion of its coats ; and to inflammation 
(localised peritonitis) and suppuration (en- 
cysted suppurative peritonitis) of the adjacent 
tissues. 
Etiology.-The usual cause of this 
affection is a fecal concretion, or a foreign 
body (e.g., fruit-pips or -stones, a small bone, 
pins, shot, small gall-stones, &c.) imprisoned 
within the cavity of the vermiform appendix. 
Congenital deformities, and also twisting of 
the appendix on itself from contraction in its 
mesentery or from adhesions, are likewise 
important factors in inducing attacks. Per- 
foration has been recorded in typhoid fever 
and tuberculous disease. 
Anatomical Characters.-Before perfora- 
tion takes place the appendix may be found 
distended with pus or mucus; a foreign 
body or concretion lodged within it; and the 
mucous membrane ulcerated. The concre- 
tion or concretions vq^y in size from a small 
pea to a bean; are usually brown and hard ; 
and consist of layers of condensed feces, 
secretions, and phosphates, deposited around 
a small nucleus, which may prove to be a 
seed or other foreign body, or a piece of 
unusually inspissated feces. These concre- 
tions greatly resemble, and are often mis- 
taken for, fruit-stones. The appendix may, 
however, be found perforated, and yet no 
foreign body can be discovered. Ulceration 
and perforation may occur at any part of the 
appendix, usually, however, at the extremity 
of the lower third. When twisted on itself, 
or when acutely bent by adhesions, the 
appendix may be found gangrenous, or may 
be so greatly distended by mucus (being 
large, round, and hard) as to seem as if it 
contained a concretion, with occlusion of its 
lumen. The appendix may be adherent to 
the caecum, ileum, rectum, bladder, mesen- 
tery, or abdominal wall, with the signs of an 
ordinary local peritonitis; or there may be a 
circumscribed peritoneal abscess. 
Symptoms.-Pain, generally ill-defined, in 
the right iliac region, may be the only 
symptom to attract attention, but, as a rule, 
it is not until local peritonitis or typhlitis is 
set up that we suspect the nature of the dis- 
order (see Typhlitis). Now and then, how- 
ever, the course from the first is latent, and 
the mischief is suddenly revealed by perfora- 
tion into the peritoneum, followed by the 
symptoms of general and rapidly fatal peri- 
tonitis. Adhesions formed in front of the 
slowly advancing ulceration tend to localise 
the consecutive inflammation and abscess in 
other instances. 
The substance imprisoned within the 
appendix may be dislodged (a) by an abscess 
opening externally (such as through the an- 
terior abdominal wall, thigh, or scrotum), or 
into the abdominal cavity; or (6) by the 
perforated appendix establishing a communi- 
cation with the caecum, bladder, rectum, &c. 
The diseased and distended appendix-es- 
pecially when its lumen is occluded, and 
there is little or no consecutive peritonitis- APPENDIX VERMIFORMIS 
APPETITE, DISORDERS OF 
109 
may be not infrequently felt as a hard 
elongated body deep in the right iliac region, 
and can often be discovered by rectal exami- 
nation, especially in young subjects. 
Diagnosis.-Inflammatory affections of the 
appendix can rarely be clearly distinguished 
from those of the caecum. Pains radiating to 
the testis or groin are more common in the 
form of ' typhhtis ' than in the other varieties. 
The clinical and post-mortem observations of 
late years have clearly shown that peritonitis 
in tbe caecal region-especially in its severe 
and relapsing forms-is more commonly the 
result of ulcerative inflammation of the 
appendix than of the caecum. See Caecum, 
Diseases of; and Typhlitis. 
Prognosis. - General peritonitis from 
sudden perforation into the cavity of the 
peritoneum is the great danger, recovery from 
which is extremely rare. Inasmuch as this 
may occur at any time during the course of 
ulcerative inflammation of the appendix, a 
guarded opinion should always be given 
when there is suspicion of the existence of 
this affection. Continued uneasiness in the 
right iliac region without indications of faecal 
accumulation, should not be regarded lightly. 
Though this serious accident is less apt to 
occur after the formation of adhesions around 
the advancing ulceration, we must not forget 
that well-marked local inflammation of the 
peritoneum does not always prevent it, in- 
asmuch as the adhesions which are thus 
formed may not be sufficiently strong to 
withstand the pressure of pus in the ap- 
pendix. 
Treatment.-When there is suspicion of 
trouble in the appendix the patient must be 
kept at rest in bed, hot poultices applied, 
and an unirritating, very restricted fluid diet 
allowed. Opiates, for the purpose of con- 
trolling pain, should be continuously ad- 
ministered ; and if irritability of the stomach 
exist, they should be introduced by enema 
or suppository, or by subcutaneous injection. 
Perforation and peritonitis, or other compli- 
cations, must be treated as they arise. See 
Typhlitis. 
Radical Surgical Treatment.-It has 
recently been shown 1 that an offending 
appendix may be removed, or a deformity of 
it corrected, with the happiest results in 
cases of relapsing typhlitis. The operation, 
performed in tbe quiescent period after 
subsidence of inflammatory and other 
symptoms, has prevented further relapses, 
and possibly averted a fatal perforative 
peritonitis. See Typhlitis. 
George Oliver. 
APPETITE, Disorders of.-In disease 
the desire for food may be either lessened or 
increased; or the appetite may be perverted, 
and a longing for various substances unfitted 
for or incapable of digestion may be dis- 
played. 
Loss of appetite-Anorexia accompanies 
fevers, almost all forms of congestion of the 
mucous membrane, and acute or chronic gas- 
tritis ; and as these affections constantly coexist 
with other diseases, great variety as regards 
the desire for food is manifested in various 
complaints. In acute gastritis there is often 
not merely a loss of desire for, but a positive 
aversion to food, and the patient resolutely 
resists any attempt at obliging him to take 
either solid or liquid nourishment. In the 
more chronic forms of gastritis the distaste 
for food may be only slight; in some cases 
the appetite is increased, but is quickly satis- 
fied as soon as a small quantity of food is 
taken. In chronic ulcer of the stomach the 
appetite, as a rule, remains good, and the 
patient is only prevented from indulging it 
by the fear of the pain that will result from 
so doing. Whenever the secreting structure 
of the organ is extensively diseased the appe- 
tite fails. Thus, in atrophy of the stomach 
the desire for food generally lessens along 
with the diminishing strength of the invalid. 
In cancer of the stomach there is always 
an extensive destruction of the glandular 
structure, and loss of appetite is a constant 
and prominent symptom. It must be re- 
membered that a loss of appetite may be 
more apparent than real. The physician is 
constantly consulted on account of this 
symptom, when a little inquiry will show that 
the patient is really digesting as much as his 
system requires, but that by a habit of eating 
without allowing a proper interval between 
his meals, or by indulging in food of too 
nutritious a nature, or in an undue amount of 
alcoholic stimulants, hunger is prevented. 
For Anorexia nervosa see Neurasthenia. 
Increase of appetite - Bulimia usually 
occurs where there is a necessity for an in- 
creased supply of food. Thus it is common 
after all febrile diseases, where the stomach 
has been long inactive. Again, in diabetes, 
where a large portion of tbe food is passed 
off in the form of sugar instead of being con- 
verted into the material required to keep up 
the nutrition of the body, there is an un- 
usually large appetite. A craving sensation 
is a common symptom in chronic catarrhal 
gastritis. It probably arises from the irrita- 
tion set up by the mucus and fermenting 
substances long retained in the stomach, and 
is temporarily relieved by eating. The best 
treatment for such cases is to give alkalis 
about half an hour before the craving usually 
occurs, at the same time that the affection 
of the mucous membrane is combated by 
appropriate diet and remedies. In some 
persons the sensation of extreme hunger 
appears to arise from an irritable condition 
of the stomach, by which the food is passed 
into the duodenum before digestion is com- 
pleted. The sensation is mostly complained 
1 See Treves, Med.-Chir. Trans., vol. Ixxi. p. 165, 
and The Lancet, Feb. 9,1889. 110 
APPETITE, DISORDERS OF 
ARKANSAS SPRINGS 
of at night, and the writer has found it a 
good plan to let the patient have some beef- 
tea or meat lozenges, for example, either 
just before retiring to rest or during the 
night. In children a craving for food is a 
frequent symptom, and arises either from the 
irritation of worms, or from chronic catarrh 
of the mucous membrane of the small intes- 
tines. 
Perversion of appetite - Pica is most 
common in pregnant or hysterical females. 
Articles, such as chalk, cinders, and slate- 
pencil, are sometimes swallowed. In the 
insane and in idiots articles of an indigestible 
nature are not infrequently introduced into 
the stomach, such as string, paper, cocoa-nut 
fibre, &c. 
It is a matter of great importance that all 
persons, but especially dyspeptics, should ac- 
custom themselves to control their appetites. 
Whenever a larger amount of food is taken 
than the stomach is capable of digesting, the 
residue is apt to ferment and thereby to pro- 
duce gastric catarrh. This is more especially 
the case where the digestive powers have been 
enfeebled by previous attacks of gastric in- 
flammation. S. Fenwick. 
APYRETICS.-See Antipyretics. 
APYREXIA (a, priv.; and Trvpeaaai, I 
am feverish.)-This word literally means 
absence of fever. It is also used to denote 
the interval between paroxysms of inter- 
mittent fever. See Fever. 
ARACHNITIS.-Inflammation of the 
arachnoid membrane. See Meningitis. 
ARCACHON, West Coast of France. 
Summer and autumn resort. Sheltered by 
pine-woods. Calm in winter. See Climate, 
Treatment of Disease by. 
ARCUS SENILIS. - Synon. : Geron- 
toxon. 
Description.-Arcus senilis is a crescentic 
or annular opacity just within the margin 
of the cornea, often seen in old persons. It 
usually begins as a greyish or whitish crescent 
at the upper part of the cornea, and subse- 
quently a similar crescent makes its appear- 
ance in the lower part. These crescents 
gradually increase in opacity, in width, and 
in length, until their horns coalesce and 
form an annulus or ring. A true arcus is 
not quite continuous with the sclerotic, but is 
separated from it by a narrow' rim of trans- 
parent cornea. The breadth of the crescent 
or ring generally ranges from one-twentieth 
to one-tenth of an inch. The opacity is more 
pronounced at its outer border, but fades 
insensibly towards the central portion of the 
cornea, which is of normal transparency. 
^Etiology and Pathology.-The proxi- 
mate causes of arcus are not known. Some 
families are especially prone to it, and it 
most frequently occurs in persons of fifty 
years of age and upwards. The opacity is 
commonly believed to be due to fatty de- 
generation of the corpuscles and fibrill® 
of the cornea, and to be indicative of de- 
generative changes within the heart and 
blood-vessels and other textures. There is, 
however, a growing consensus of opinion 
that both its pathological and clinical signifi- 
cance have been overrated. Certainly it is, 
in itself, no criterion of age, either as re- 
gards years or constitution. On the one 
hand it may occur in young persons, and on 
the other hand it may be absent in extreme 
old age. Again, it may exist in persons free 
from any appreciable signs of arterial or 
cardiac disease, and it may be absent from 
those who have pronounced degeneration of 
the heart and blood-vessels. It is, never- 
theless, true that arcus senilis is due to 
degenerative changes within the cornea, and 
that it does sometimes co-exist with atheroma 
or with fatty heart. According to some in- 
vestigations made by the writer, in conjunc- 
tion with Mr. E. T. Collins, in the laboratory 
of Moorfields Eye Hospital, the change in 
the cornea consists of the presence of fine, 
highly refractive molecules, distributed along 
the course of the lymphatic spaces and 
channels of the superficial layers of the 
periphery of the cornea near the loop-endings 
of the capillaries of the conjunctival and 
episcleral blood-vessels. The greater portion 
of these molecules are not fatty, as is generally 
supposed; for, unlike fat, they are neither 
blackened by osmic acid nor dissolved by 
ether. They probably arise from mucoid 
degeneration of the protoplasm within the 
lymphatic channels and spaces of the cornea, 
and to some extent of the fibrillae them- 
selves. A few doubtful, blackened, fatty 
molecules may be seen here and there in 
sections stained by osmic acid. The fibrillae 
are slightly wrinkled, and are more loosely 
held together than natural, and the spaces 
between the laminae are wider. In support 
of the non-fatty nature of arcus senilis it 
may be stated that wounds of the cornea, 
whether through the opacity, or to its inner 
side, or to its outer, and whether surgical or 
traumatic, heal in a natural way. 
Treatment.-The condition is incurable, 
and is unaffected by any kind of treatment. 
John Tweedy. 
ARDOR (ardor, heat).-A sensation of 
heat, burning, or scalding. It may be felt 
either along the urethra during the passage 
of urine (ardor urina); or in connexion with 
the stomach (ardor ventriculi). 
ARGYRIA (Hpyvpos, silver).-The slate- 
coloured stain of the skin produced by the 
internal use of the salts of silver. See 
Pigmentary Affections. 
ARKANSAS SPRINGS, in Ar- 
kansas, United States. - Thermal 
waters. See Mineral Waters. ARSENIC, POISONING BY 
111 
ARSENIC, Poisoning by.-Arsenic is 
classed as a metallic irritant poison, though 
its action is by no means limited to that of 
an irritant. It acts specifically on the gastro- 
intestinal mucous membrane, whatever be 
the channel by which the poison gains access 
to the system. The most usual source of 
acute arsenical poisoning is the administra- 
tion of white arsenic or arsenious acid; but 
the sulphides, various arsenites, and impure 
commercial articles, such as dyes, wall-papers, 
and pigments, may be fertile sources of 
arsenical poisoning. Poisoning by arsenic 
may be either acute or chronic. 
Anatomical Characters.-These are the 
same by whatever channel the poison has 
gained access to the system. There is marked 
petechial inflammation of the stomach and 
duodenum, usually of the small and large 
intestines also; but not uncommonly the 
inflammation is limited to the stomach, duo- 
denum, and rectum, the intervening alimen- 
tary tract havihg escaped. If the poison has 
been administered in a solid form, white 
patches of the arsenical compound may be 
found embedded in yellow or bloody mucus 
and inflammatory exudation. Portions of the 
white arsenic are also sometimes converted 
by the sulphuretted hydrogen evolved during 
decomposition into the yellow sulphide. 
Ulceration of the stomach is rare. Neuritis 
may be observed. An ecchymosed condition 
of the heart is often observed; and fatty 
degeneration of the liver, as in poisoning by 
phosphorus, has been described. 
A. Acute Arsenical Poisoning.-This 
is the usual form of poisoning ensuing on the 
nefarious administration of any preparation 
of arsenic, but usually the oxide (arsenious 
acid) is employed. 
Symptoms.-The symptoms do not, as in 
the case of corrosive poisoning, come on im- 
mediately after the administration of the 
poison. There is most commonly an interval 
of half an hour or an hour between the 
swallowing of the agent and the onset of 
prominent symptoms. The quantity of the 
noxious agent, and its state as regards solu- 
bility, have also an obvious relation to the 
commencement of symptoms. Most com- 
monly, after a sense of faintness and depres- 
sion, intense burning pain is felt in the 
epigastric region, accompanied by tenderness 
on pressure. Nausea and vomiting quickly 
supervene, increased by every act of swallow- 
ing. Unlike what occurs in an ordinary 
bilious attack, with which arsenical poisoning 
may be at first confounded, the pain and sick- 
ness are not relieved by the act of vomiting. 
The vomited matters are extremely varied, 
and present no characteristic appearances. 
At first they usually consist of the ordinary 
contents of the stomach, but at a later stage 
are largely charged with bile which has re- 
gurgitated into the stomach in consequence 
of the violence of prolonged emesis ; and they 
may be tinged with blood. Ordinarily vomit- 
ing is speedily followed by violent purging, 
and great straining at stool, the motions 
being often streaked with blood. Purging 
may, however, be entirely absent. Other 
prominent symptoms are great thirst, a feeble 
irregular pulse, and cold clammy skin. The 
patient, as a rule, dies within eighteen to 
seventy-two hours, in a state of collapse; 
but tetanic convulsions are not uncommon, 
and even coma and paralysis may close the 
scene. 
Diagnosis.-From an ordinary bilious at- 
tack, induced by improper diet or by decom- 
posing food, arsenical poisoning is diagnosed 
by the persistence of the symptoms after the 
removal of the apparent cause; and not in- 
frequently by the symptoms remitting and 
again supervening on the administration of 
food or drink of a particular kind, or given by 
a particular hand. From choleraic diarrhoea 
it is distinguished by the sudden onset of 
symptoms, thirty to sixty minutes after food 
or drink has been taken; by the absence of 
rice-water stools, or of lividity of the skin; 
and by the symptoms not yielding to treat- 
ment. Moreover, in poisoning by arsenic 
there is usually greater tenderness over the 
epigastrium; the diarrhoea is less passive, 
and accompanied with more tenesmus than 
in choleraic diarrhoea; the stools are more 
often bloody; and nervous symptoms may 
be more pronounced. The diagnosis is, how- 
ever, often very difficult, except when aided 
by a chemical analysis of the matters ejected 
from the stomach or of the excreta, which 
should always be made in doubtful cases. 
Prognosis.-This must always be un- 
certain, since it is rarely possible to ascertain 
the quantity taken, or to ensure its entire 
evacuation from the stomach. 
Treatment.-Emetics, diluents, and de- 
mulcents are the appropriate remedies. The 
stomach-pump may also be usefully em- 
ployed. In administering emetics, tartar 
emetic should be avoided, as it increases the 
depression, and its presence complicates a 
chemical analysis. Moreover, tartar emetic 
sometimes contains traces of arsenic, and, in 
the event of an analysis being made, an un- 
founded suspicion may be raised. No confi- 
dence can be placed in the so-called antidote, 
ferric hydrate, but dialysed iron may be 
freely given. 
B. Chronic Arsenical Poisoning.- 
This form of poisoning is not uncommon, 
and is, unlike the acute form, generally acci- 
dental. The inhalation of arsenical vapours 
in factories, or of arsenical dust, as from 
green and other wall-papers, and in the 
process of manufacturing artificial flowers, 
is a common source of chronic arsenical 
poisoning. 
Those who are chiefly exposed to this form 
of poisoning are persons employed in the 
manufacture of pigments, especially green 112 
ARSENIC, POISONING BY 
ARTERIES, DISEASES OF 
pigments ; paperhangers and decorators ; 
artificial-flower manufacturers; milliners; 
persons exposed to the fumes of heated 
metals, particularly zinc and brass; manu- 
facturers of dyes ; and leather-dressers. In 
the process of depilating sheep-skins, pre- 
vious to the tanning or the tawing process, a 
mixture of lime and orpiment (sulphide 
of arsenic) is used; and serious ulceration of 
the hands, scrotum, nose, and cheeks not in- 
frequently results. Persons living in rooms 
the walls of which are covered with arsenical 
paper, especially bright-green papers contain- 
ing arsenite of copper, are liable to suffer 
from chronic arsenical poisoning. It is un- 
certain whether this is entirely caused by the 
mechanical transfer of pigmentary dust to 
the air-passages, or is partly due to volatilisa- 
tion of the arsenic, probably in the form of 
arseniuretted hydrogen. Many brown wall- 
papers also contain arsenic, and arsenious 
acid is sometimes added to the size; such 
papers have been known to produce the spe- 
cific symptoms of arsenical poisoning. 
That some persons can take arsenious acid 
internally with impunity in relatively large 
doses (arsenic-eating) is now a well-estab- 
lished fact. 
Symptoms.-The first symptoms of chronic 
arsenical poisoning are usually loss of appe- 
tite, praecoraial pains, irritability of the bowels, 
and occasionally headache. Suffusion of the 
eyes, a peculiar and characteristic appearance 
of the conjunctiva, often amounting to actual 
conjunctivitis, and intolerance of light are 
early manifested. The muscular power of 
the limbs is impaired pretty constantly, and 
actual paralysis, extending upwards from the 
lower extremities, is occasionally observed 
(see Paralysis, Toxic). A characteristic vesi- 
cular eruption on the skin (eczema arsenicale) 
is frequent, as well as irritation of the skin, 
especially over the neck, scalp, hands, and 
armpits. Males who handle arsenical pre- 
parations are liable to ulcerations of the 
scrotum and penis, obviously due to a me- 
chanical transference of the poison to the 
genitals when these are touched. If the 
source of the disease be not removed, pro- 
gressive emaciation, exfoliation of the cuticle, 
and nervous prostration supervene ; and con- 
vulsions may precede the fatal termination. 
The effects of green arsenical pigments are 
sometimes manifested by bleeding from the 
nose. 
Diagnosis.-When a patient suffers more 
or less from the symptoms above described, 
and is also known to be exposed to any of 
the sources of danger from arsenical poisoning 
enumerated above, the diagnosis is not 
difficult. 
Treatment. - The source of poisoning 
should invariably be removed. It is found 
that those who suffer from working in arsenic 
make no progress towards recovery until 
they are removed from contact with the 
poison. Wall-papers which contain arsenic, 
and are suspected to be the cause of symp- 
toms, should be taken away. Quinine, or 
other tonics, iron, and attention to the 
digestive organs will be needed. Removal 
to fresh country air is often productive of 
marked benefit. Soothing lotions to the 
skin, and careful attention to eroding ulcers, 
especially of the cheek, may be necessary. 
Shampooing and warm baths form the best 
treatment for paralytic lesions. 
T. Stevenson. 
ARTERIES, Diseases of.-It is im- 
portant to keep in mind the following 
anatomical facts in studying the morbid pro- 
cesses to which arteries are subject:-In 
immediate contact with the blood-stream in 
arteries lies the endothelium-a layer of 
flattened cells ; outside this is the tunica 
intima, composed of elastic tissue, in 
longitudinal arrangement: together the 
endothelium and tunica intima constitute 
the internal coat of the older writers. Still 
more external we find the middle coat, made 
up of muscular fibre arranged transversely, 
in the larger arteries mixed with elastic 
tissue. And, most external of all, there is 
the external coat, consisting of longitudinally 
fibrillated connective tissue. 
1. Acute Arteritis. - Acute arteritis, 
affecting a very limited portion of a vessel, 
and leading to ulceration, occasionally occurs. 
It is generally due to the propagation of an 
inflammation from the tissues of the vicinity 
to the external coat of the vessel, but in 
some cases it arises from the irritation caused 
by an embolus, which, becoming detached 
from a cardiac valve, blocks a distant artery. 
The late Dr. Moxon has specially drawn 
attention to its occurrence in the aorta, 
when the ascending portion of the vessel has 
been exposed to the impact of a hard, freely 
moving vegetation on one of the segments 
of the aortic valve. Dr. Moxon has also 
described, under the designation inflam- 
matory mollities, the occurrence of softening 
and swelling of the arterial tunics in cir- 
cumscribed spots, which become flabby and 
inelastic, and ultimately bulge outwards and 
form aneurysms. He believed that this con- 
dition depends on a peculiar general state, 
and is the great cause of aneurysm in young, 
hard-working men. Except such circum- 
scribed inflammatory lesions, we do not 
meet with any condition of the arterial 
tunics to which the designation acute 
arteritis can be applied. A general inflam- 
matory change has, indeed, been described, 
and the writers have seen the lining mem- 
brane of the ascending and transverse por- 
tions of the aorta of a bright vermilion hue, 
strongly suggestive of acute inflammation; 
but the best observers are agreed in believing 
that this appearance arises from staining by 
haematin. ARTERIES, DISEASES OF 
2. Endarteritis obliterans.-This is an 
affection of the small arteries which causes 
narrowing of their calibre by thickening of 
the internal coat. It is not an independent 
disease, and is most commonly found in the 
cirrhotic kidney, where it is usually accom- 
panied by periarteritis. See Gummatous 
Disease, page 115. 
3. Periarteritis.-Periarteritis is mostly 
a chronic change, and consists in the pro- 
duction of diffuse or circumscribed thickenings 
of the arterial walls by a new formation of 
connective tissue in the external coat. It is 
to a periarteritis that Charcot and Bouchard 
ascribe the lesions which, in their opinion, 
eventuate in cerebral haemorrhage. According 
to these physicians, cerebral haemorrhage is 
not usually due to atheromatous decay of the 
vessels of the brain; but, in the vast majority 
of cases, to the rupture of miliary aneurysms, 
which in their turn have been produced by a 
morbid process beginning in the perivascular 
sheath surrounding the cerebral vessels, and 
which, proceeding from without inwards, 
ultimately involves all the coats of the vessels. 
See Brain, Haemorrhage into. 
4. Atheromatous Disease.-This dis- 
ease, the endarteritis deformans of Virchow, 
is the arterial disease which is most frequently 
met with, and the one whose consequences are 
most serious. It may be divided, for purposes 
of description, into three tolerably well-defined 
stages:-(a) In the first stage we notice, 
when the vessel is slit open, greyish patches, 
by which the lining membrane is irregularly 
thickened; these patches seem to lie on 
the surface of the membrane, but this appear- 
ance is deceptive; the endothelium lies be- 
tween them and the blood-stream, and is, at 
least at the beginning of the morbid process, 
unaffected. The material of which the patches 
consist is situated in the tunica intima; it 
is gelatinous, or semi-cartilaginous, in con- 
sistence; and is formed, according to Virchow, 
by an abnormally rapid multiplication of the 
deeper cells of the tunica intima,-the new 
growth pushing up this tunic with its super- 
imposed endothelium, and so causing a bulg- 
ing into the interior of the vessel. But, in 
addition to these proliferated elements, round 
cells, derived from the vasa vasorum, are often 
present in all three coats; and it would appear 
that the process often begins as an inflamma- 
tion, and perhaps less commonly as a hyper- 
plasia, of the tunica intima. (6) In the second 
stage the cellular elements of which the new 
growth is composed undergo a process of 
fatty degeneration; and in consequence it 
becomes yellowish in colour and pasty in 
consistence : it was the paste-like appearance 
of the mass in this stage which originally 
gained for the process the designation 
atheroma (adppp = meal). It not infrequently 
happens that the whole of the internal coat 
with its endothelium is involved in the soft- 
ening, and gives way under the pressure of 
the blood, leaving an excavation, the floor of 
which is formed by the middle and external 
coats of the artery, (c) In other instances, 
however, the pasty mass, instead of being 
washed away, becomes the seat of calcific 
deposit. This is the third stage in the pro- 
cess. The appearance of a vessel in which 
atheromatous disease has reached this stage 
is very striking: plates, which present to the 
naked eye the appearance but do not show 
the minute structure of bone, are observed at 
intervals in the walls of the vessel, and their 
sharp spicula project into its interior ; in the 
aorta it is not uncommon to find such plates 
an inch long and half an inch broad, and in 
the smaller arteries the calcareous matter 
sometimes forms a ring round the vessel. In 
the latter the calcareous particles appear to be 
deposited in the patch while it is still firm, so 
that the second stage of the process is wanting. 
The changes above described may be con- 
fined to the internal tunic, but the two outer 
coats are often implicated as well. In the 
media we may have round-celled infiltration, 
induration, fatty degeneration, and calcifica- 
tion, while the external coat may be thickened 
by newly formed connective tissue. Indeed 
according to Thoma, the primary change is a 
lesion (weakening or atrophy) of the middle 
coat. See Aorta, Diseases of, page 90. 
Atheromatous disease sometimes invades 
both the aorta and the small vessels, but 
the aorta may be extensively diseased and 
the small arteries unaffected; or, on the other 
hand, the cerebral, temporal, and coronary 
arteries may be the seat of calcareous change 
while the great vessels are healthy; occa- 
sionally the disease is limited to a few vessels. 
Next to the aorta, the cerebral, coronary, 
and splenic vessels, and the arteries of the 
lower extremities, are prone to this form of 
arteritis. 
Effects.-The dangers to which an athero- 
matous state of vessels exposes the person in 
whom it exists are varied. The stream of 
blood is retarded by the projection of the new 
growth into the vessel, and still more by the 
destruction of the elasticity of its coats; and 
hence ensues a failure in the nutrition of the 
organ, which depends for its supply of blood 
on the diseased vessel-this is one cause of 
cerebral softening. When the paste-like mass 
is washed away it sometimes happens that 
the blood insinuates itself between the coats 
of the vessel, producing a dissecting aneu- 
rysm ; or the portion of the vessel which has 
been weakened by the removal of the internal 
coat yields to the pressure of the current, and 
a sacculated aneurysm is originated; some- 
times the diseased vessel bursts. Cerebral 
vessels, probably on account of the thinness 
of their walls, are specially liable to rupture 
when they are the seat of atheromatous 
change ; and occasionally a diseased coronary 
artery has given way, filling the pericardium 
with blood. Arteries have been completely 
113 114 
ARTERIES, DISEASES OF . 
occluded by the deposition of fibrin on the 
spiculated edges of calcareous plates : this is 
one of the causes of senile gangrene ; and 
embolic plugging of distant vessels at times 
results from the detachment of such fibrinous 
clots, and the washing away of atheromatous 
debris. Rigidity of the larger arteries from 
atheromatous change is likewise one of the 
most frequent causes of hypertrophy of 
the left ventricle of the heart, on which 
increased work is imposed in consequence 
of the destruction of the elasticity of the 
vessels. Anasarca has not, so far as the 
writers are aware, been mentioned by any 
author among the consequences of dis- 
eased arteries; but some cases which have 
come under their observation have led to 
the conclusion that persistent anasarca, es- 
pecially of the lower extremities in elderly 
men, is sometimes mainly due to a diseased 
condition of the arterial tunics. In the cases 
observed there was likewise present dilata- 
tion with hypertrophy and commencing fatty 
change of the left ventricle, itself a conse- 
quence of the arterial disease; but this seemed 
insufficient to account for the persistent 
oedema of the lower extremities. 
JEtiology.-The principal cause of endar- 
teritis deformans is now generally admitted 
to be overstrain of the vessel. It was formerly 
thought, and is still held by many, that 
syphilitic impregnation of the system is a 
powerful favouring condition; but this opinion 
rests chiefly on observations made among 
soldiers, who, in addition to the syphilitic 
taint, were subject to other influences now 
known to be adequate in themselves to 
develop the disease. Intemperate habits and 
gout appear to be powerfully predisposing 
causes. They probably render the blood 
impure; and its passage through the capillary 
vessels being thereby retarded, the tension 
of the arterial system is increased. Besides 
violent exertion, which imposes a strain on 
the entire arterial tree, there are other in- 
fluences which act upon certain vessels. 
Thus the renal arteries are kept overfull in 
the cirrhotic form of Bright's disease, owing 
to the destruction of the capillary tufts, and 
hence atheroma of these vessels is frequently 
present in that form of renal mischief. One 
of the writers has on two occasions found ex- 
tensive calcareous formations in the cerebral 
vessels of persons in whom cerebral degene- 
ration had followed excessive anxiety and 
mental effort. The pulmonary artery is very 
rarely invaded by atheroma; and only in 
cases in which it has been kept in a state of 
tension by hypertrophy of the right ventricle 
or disease of the mitral orifice. 
Diagnosis.- The diagnosis of atheroma- 
tous inflammation of the aorta is discussed 
in a separate article. The existence of the 
disease in the arteries of particular organs 
can only be a matter of reasonable presump- 
tion when the patient is past middle life; 
when the ascertained causes of atheroma 
have been in operation ; when symptoms of 
impaired nutrition of the organ are present; 
and when the organ (the brain or heart) is 
one the arteries of which are known to be 
prone to the disease. Calcification of the 
superficial arteries renders these vessels rigid 
and tortuous. The temporals when so affected 
attract the eye by their prominence, and may 
be felt hard and rigid beneath the finger; the 
brachial may equally be made the subject 
of examination; and, although the presence 
or absence of atheromatous change in such 
superficial vessels does not necessarily prove 
that the other arteries of the body are in 
a similar condition, it renders it more than 
probable that they are. Those who are not 
familiar with 4he resisting feel of the radial 
artery, when it is the seat of the change now 
under consideration, are liable to form a very 
erroneous estimate of the strength of the 
pulse : this may convey to the inexperienced 
finger an impression of a force which it does 
not possess. The error also is sometimes 
committed of inferring the existence of aortic 
regurgitation in these cases in consequence 
of the tortuous course and visible pulsation 
of the superficial vessels; but they do not 
collapse suddenly under the finger, as do the 
vessels during the receding wave in aortic 
patency. The sphygmographic tracing, more- 
over, is essentially different; in atheromatous 
disease of the artery the upstroke is vertical, 
and the summit of the tracing extended. 
The existence of such evidences of vascular 
mischief affords a fair subject for considera- 
tion to those who are called upon to form 
an opinion as to the eligibility of a life for 
assurance. 
Treatment.-The treatment of endarteritis 
deformans is mainly preventive. It consists 
in the avoidance of all those influences to 
which we have adverted as causes of the 
disease, namely: indulgence in alcohol; causes 
originating a gouty state of the blood; exces- 
sive muscular efforts, especially in constrained 
positions ; and postures which involve the 
long-continued contraction of muscles which 
surround arteries. As far as the brain and 
heart are concerned, all those states must be 
forbidden which favour overfulness of their 
respective arteries : in the case of the brain, 
excessive mental application, deficient sleep, 
and, the writers believe, prolonged periods of 
sexual excitement; in the case of the heart, 
inter alia, efforts which involve holding the 
breath, thus leading to distension of its right 
cavities, and imposing an obstacle to the 
return of blood from its walls. 
5. Fatty Degeneration. - Fatty de- 
generation, unconnected with the athero- 
matous process, is sometimes found to affect 
arteries. Circumscribed opaque and velvety 
spots appear on the surface of the intima, 
and erosion ultimately occurs. Once this 
has taken place, the muscular coat, which may itself be fattily degenerated, unable to 
bear the pressure of the blood-stream, fissures 
transversely; and the blood may rupture the 
external coat, or, insinuating itself between 
the middle and external coat, produce a 
dissecting aneurysm. The fatty change is 
met with in extreme anaemia and in senile 
marasmus, but has also been found in the 
arteries of persons who seemed otherwise 
quite healthy ; it is ' a morbid change which 
is simply degenerative from the first, and of 
whose immediate cause we know nothing' 
(Rindfleisch). Fatty degeneration of the 
external coat of the smallest arteries has also 
been noticed; it appears to be a senile 
affection. 
6. Calcification. - This disease of the 
arterial tunics also occurs unconnected with 
endarteritis, but more rarely than fatty de- 
generation. When this is the case, it is most 
frequently the middle coat of the medium- 
sized vessels that is the seat of the deposit, 
but all three tunics may be involved. The 
process is usually limited to the vessels in 
which muscular fibre is abundant; but these 
it may affect extensively, the superficial 
vessels and the arteries of the brain and of 
the extremities being the favourite seat. It 
is eminently a senile change. 
7. Gummatous Disease.-In this con- 
dition the vessels present nodose swellings, 
and are thickened sometimes to three times 
their normal size by gummatous material 
infiltrating the outer coat. According to 
Heubner, the disease begins in the intima 
by a proliferation of the cells of the endo- 
thelium, which may be so excessive as to 
cause complete obliteration of the lumen of 
the vessel. The middle and external coats 
only subsequently become infiltrated with 
round cells. The lesion described by him, 
however, is common to all forms of end- 
arteritis obliterans, and is not distinctively 
syphilitic. ' A random succession of nervous 
symptoms,' to use the words of Dr. Hughlings 
Jackson, affords strong grounds for suspecting 
syphilitic disease within the cranium; and 
one of the writers has himself seen three cases 
in which such symptoms disappeared under 
the use of perchloride of mercury and iodide 
of potassium, and in which it seemed to him 
that the supposition of arterial disease was 
much more probable than that of any other 
form of intracranial syphilis. 
8. Albuminoid Disease.-This, when 
it attacks an organ, very commonly appears 
first in the walls of the small arteries, the 
muscular coat being the part affected. 
9. Hyaline Degeneration.-This de- 
generation may attack the smallest arteries, 
and give rise to a continuous thickening of 
their coats, with ultimate occlusion of the 
vessel; or it may result in the production of 
isolated masses of hyaline material, which 
he principally between the tunica intima and 
tunica media. 
ARTERIES, DISEASES OF 
10. Contraction.-Contraction and final 
impermeability of an artery from atheroma- 
tous calcification, from the accumulation of 
fibrin on its rough inner surface, from pres- 
sure, or from other causes, occasionally occurs, 
leading to gangrene of the extremity which it 
supplied. 
11. Dilatation.-Dilatation of arteries is 
in the majority of cases due to previous 
disease of their coats; but sometimes in the 
aged the arteries are found dilated without 
any degeneration of their tunics being 
present,-a state of affairs which Rindfleisch 
suggests may depend on atony of the mus- 
cular coat, and in some cases may possibly 
be connected with deficient innervation, 
12. Aneurysm.-Aneurysm receives full 
consideration in a separate article. Here it 
is merely necessary to point out the ways in 
which atheromatous inflammation and the 
other morbid processes which have been de- 
scribed contribute to the production of dilata- 
tion and aneurysm. In some cases the course 
of events consists in the washing away of 
the diseased patch of the intima; when the 
middle coat either dilates, or, by separation 
of its muscular bundles, undergoes rupture, 
and the external coat yields before the pres- 
sure of the blood-stream. In other cases 
the dilatation occurs, not at the point where 
the endarteritis has invaded the vessel, but 
nearer to the heart. At the affected point 
there is narrowing of the canal of the vessel, 
and loss of elasticity in its coats; and, as a 
consequence, we have slowing of the circula- 
tion and deficiency in the supply of blood 
beyond, and increased arterial tension on the 
proximal side of the affected spot. The effect 
of this tension is more serious than would at 
first sight appear. In health the blood, pro- 
pelled by each ventricular systole, enters 
contracted vessels, which, yielding before it, 
are uninjured by its sudden impact; but a 
vessel in a state of tension is exposed to the 
full violence of the column of blood dis- 
charged by the heart, and must gradually 
dilate before it. 
13. Arterial Disease in Insanity.- 
According to Dr. J. Batty Tuke, and other 
physicians who have specially investigated 
the morbid changes in the brains of the 
insane, arterial disease is almost invariably 
present. It consists in such alterations as 
would result from obstruction in the ultimate 
ramifications of the vessels : thickening of 
the proper coats of the arteries, and of the 
sheath of connective tissue which surrounds 
the cerebral vessels; the deposition of fine 
molecular matter and crystals of hsmatoidin 
between the adventitia and the sheath; and 
extreme tortuosity of the vessels. 
14. Arterio-Capillary Fibrosis.-This 
term was applied by the late Sir William Gull 
and Dr. Sutton to the hypertrophy of the 
walls of the small arteries found in the sub- 
jects of the cirrhotic form of Bright's disease. 
115 116 
It is admitted by all observers of repute that 
the walls of the blood-vessels of the kidney 
are greatly thickened in this malady ; but it 
is by no means so universally admitted that 
the small arteries throughout the whole body 
are in all such cases hypertrophied. That 
they are hypertrophied in a certain propor- 
tion of the cases admits of no doubt; but 
there is a difference of opinion as to the na- 
ture of the thickening. Dr. George Johnson, 
who early called attention to this condition, 
considers that there is present a hypertrophy 
of all the tunics of the small arteries, especi- 
ally of the muscular coat-a consequence of 
the obstruction which impure blood invariably 
meets with in the capillaries. Sir 'William 
Gull and Dr. Sutton, on the other hand, 
asserted that the thickening is due to a fibroid 
growth, especially seated in the external coat 
of the vessel; and they believed that the co- 
existing disease of the kidney is not the cause 
of the arterial change, but that both are parts 
of a general diseased process. 
James Little. A. B. McKee. 
ARTERIES, Examination of.-See 
Physical Examination ; and Pulse. 
ARTHRALGIA (apdpov, a joint; and 
aXyos, pain).-Pain in a joint. The term is 
more particularly applied to articular pain in 
the absence of objective disease. See Joints, 
Diseases of. 
ARTHRITIS (apdpov, a joint).- A 
term generically used to signify any disease 
whatever involving a joint, but more correctly 
confined to articular inflammation. It is 
also employed to designate inflammation of 
all the structures forming a joint, as dis- 
tinguished from mere synovitis. See Joints, 
Diseases of. 
ARTHRODYNIA (apOpov. a joint; and 
aSui^pain).-Pain in a joint. See Arthralgia. 
ARTICULAR RHEUMATISM.- 
Rheumatism affecting joints. See Rheu- 
matism, Acute. 
ARTIFICIAL RESPIRATION. - 
The method of exciting and keeping up the 
movements of the chest, so as to supply air 
to the lungs, is a subject of the highest im- 
portance, since the hopes of recovery depend 
on its due performance in many cases of 
narcotic poisoning, in the apparently drowned 
or asphyxiated, and in the collapse of the 
advanced stage of the condition induced by 
anaesthetics. 
Precautions.-For its effective employ- 
ment it is essential to see that no foreign body 
obstructs the air-passages. Children and 
old people are liable to swallow large pieces 
of meat or crust, which become impacted in 
the pharynx or oesophagus. A clot of blood 
may threaten life in operations about the 
mouth. These should, if possible, be dragged 
away with the finger or a spoon-handle, but 
they may require the use of a probang. 
ARTERIES, DISEASES OF 
Tracheotomy is rarely necessary. A knife- 
handle held between the molar teeth is a 
ready and useful gag to keep the mouth open. 
A button-hook, in the absence of pharyn- 
geal forceps, is sometimes very serviceable. 
Vomited matter should be quickly removed 
with a sponge or cloth twisted round a piece 
of wood. In treating the half-drowned the 
body should be inverted for a few minutes 
to favour the escape of watei; from the air- 
passages, but artificial breathing should be 
commenced even whilst the body is in this 
position. 
Methods.-In most cases the best method 
of commencing artificial respiration is to 
compress the chest and abdomen simul- 
taneously, tTien remove pressure so as to 
allow air to enter the chest, and again repeat 
the pressure every two or three seconds. If 
the sound indicates that air is passing into 
and out of the lungs, this method may be 
continued for half a minute; but if we are 
not sure that the air is exchanged, and in all 
cases if the patient's condition is not decidedly 
improved in half a minute, we should resort 
to one or other of the following methods:- 
1. Howard's method.-This method is so 
important that it is considered separately 
under Resuscitation. 
2. Sylvester's method.-Place the patient 
on his back on the floor, with a block or 
pillow under his shoulders, and raise the arms 
upwards above his head, by grasping them 
above the elbow, and pulling firmly and 
steadily as long as there is any sound of air 
entering the chest. Some arrangement is 
needed to prevent the body from being 
dragged towards the operator. For this 
purpose the plan of raising the chest on a 
high cushion or box has been adopted, but as 
a condition of cardiac anaemia is often present, 
this is objectionable. It is better to effect the 
object by placing a book in front of the thighs 
while kneeling at the head of the patient. It 
may be needful to draw forward the tongue; 
but generally if the head falls back over a 
cushion placed behind the neck, this is not 
required. An artery-forceps, or a noose of 
string, or a handkerchief will enable an 
assistant to keep the tongue well forward. 
As soon as the sound produced by the 
entrance of air into the chest ceases, the 
arms should be brought down a little towards 
the front of the chest, and pressed firmly and 
steadily against it for about one second after 
air is heard escaping. In cases of drowning 
it is enough to repeat this operation every 
four seconds, but in the collapse resulting 
from chloroform or other amesthetics, the 
necessity for getting the vapour quickly out 
of the chest justifies a more rapid perform- 
ance of the movements during the first five 
minutes. After this time the movements 
should be carried on more slowfly, but they 
should be continued for half an hour at least, 
and even longer if the warmth of the surface 
ARTIFICIAL RESPIRATION ARTIFICIAL RESPIRATION 
ASCITES 
117 
and diminution of lividity gives any reason 
to hope that the heart has not entirely 
ceased to act. 
3. Marshall Hall's ready method.-This is 
performed by placing the body on one side, 
and alternately rolling it on its face to com- 
press the chest, and on its back to allow the 
elasticity of the ribs free movement to draw 
air into the lungs. The plan is not nearly so 
effective as Sylvester's, but if no assistant is 
at hand it is the best mode of artificial breath- 
ing that can be adopted. 
4. Mouth - to - mouth insufflation. - This 
method is not to be depended upon, because 
of the difficulty both of keeping the larynx 
open, and also of preventing the air going 
down the gullet. 
Of the instruments introduced for the 
purpose of carrying on artificial respiration, 
mention should be made of those invented 
by Dr. Marcet, Dr. Richardson, and Dr. 
Vanderburg; but, except in the hands of the 
inventors or of those who had gained much 
experience in their use by practising upon 
animals, they would probably do as much 
harm as good. The objection to them all 
is that they interfere with the prompt imi- 
tation of the movements of respiration just 
described. 
The administration of oxygen is indicated 
in most cases of artificial respiration, but the 
results of its use have not been satisfactory 
hitherto. Now that the gas can be had in a 
compressed state, and can be given by means 
of the laughing-gas inhaler, it is worthy of a 
further trial; but it is certain that in all 
cases of impending asphyxia time is of so 
much importance that anything which would 
delay the supply of oxygen would not be 
compensated for by giving it pure, instead of 
in the form of common air. Tracheotomy is 
not to be thought of in the first instance in any 
case in which air can be made to pass, even 
in very small quantity, through the trachea. 
For supplemental and after treatment, see 
Resuscitation. 
J. T. Clover. G. H. Bailey. 
ASCARIDES.-See Entozoa. 
ASCITES (aaKos, a leathern sac : a large 
belly).-Synon. : Dropsy of the peritoneum; 
Hydrops peritonei vel abdominis; Hydro- 
peritoneum: Fr. Ascite; Ger. Die Bauch- 
wassersucht. 
Definition. - An accumulation of fluid 
within the cavity of the peritoneum, more or 
less serous in character; the accumulation 
being of the nature of a local dropsy, and not 
originating in inflammation. The amount 
of fluid varies much in different cases. 
.Etiology, and Pathology. - The chief 
matter relating to the causation of ascites is 
to point out the morbid conditions by which 
it may be produced, as it almost always 
follows, and is a consequence of certain pre- 
existing organic diseases, of which it becomes 
a most important symptom and pathological 
phenomenon. The causes to which it has 
been attributed may be discussed according 
to the following arrangement:- 
I. Direct mechanical obstruction affecting 
the portal circulation. 
1. Obstruction of the trunk of the portal 
vein before it enters the liver, either from 
external pressure or an internal block. 
2. Pressure upon or obliteration of the 
branches of the vein within the liver. 
3. Pressure upon the hepatic veins, or 
upon the inferior vena cava after it receives 
these veins. 
II. Cardiac or pulmonary diseases obstruct- 
ing the general venous circulation. 
III. Disease of the kidneys. 
IV. Morbid conditions of the peritoneum. 
V. Miscellaneous. 
I. Any direct obstruction interfering with 
the portal circulation must necessarily lead 
to congestion and over-distension of its tribu- 
taries, one of the consequences of which is 
excessive transudation of the fluid portion of 
the blood into the peritoneal cavity, while 
absorption is checked. The ascites is, under 
such circumstances, in short, merely a local- 
ised dropsy, resulting from mechanical con- 
gestion. The impediment may affect either 
the portal trunk before it enters the liver; 
its branches in the substance of this organ ; 
or the hepatic veins or the inferior vena cava 
near its termination. 
1. The portal trunk may be pressed upon, 
as it lies in the fissure, by prominences from 
the liver itself, enlarged absorbent glands in 
its vicinity, a neighbouring tumour (as cancer 
of the pancreas, or a growth in the small 
omentum), a hepatic aneurysm, or inflamma- 
tory thickening resulting from peri-hepatitis. 
The pressure may absolutely close up the 
vessel, but it more commonly causes a local 
clot to form, and thus its channel is blocked 
up. A thrombus is also in exceptional in- 
stances produced in connexion with a diseased 
condition of the portal vein, such as inflam- 
mation or calcification; obstruction to the 
circulation within the liver ; or feebleness of 
the circulation, with an abnormal tendency 
to coagulation of the blood. 
2. Pressure upon, or obliteration of the 
branches of the portal vein within the liver, 
can only arise as a consequence of some 
morbid condition involving the actual sub- 
stance of this organ. The hepatic disease 
which by far most commonly leads to this 
result, and which is one of the most frequent 
causes of ascites, is cirrhosis. Occasionally 
it accompanies syphilitic and other forms of 
contracted and indurated liver, or it may 
be associated with infiltrated cancer. The 
extent of the obstruction thus set up will 
necessarily vary with that of the morbid 
changes in the organ. Occasionally a mass 
within the liver obstructs a considerable 
branch of the portal vein. 118 
ASCITES 
3. Obstruction of the hepatic veins, or the 
upper end of the inferior vena cava, is a rare 
event, but may arise from the pressure of a 
growth connected with the liver itself, or of 
some neighbouring tumour. 
II. Diseases of the lungs or heart which 
impede the general venous circulation must 
necessarily exercise a speedy and direct in- 
fluence upon the hepatic circulation, and may 
thus lead to ascites. Usually, however, in 
cases of this kind the legs are the seat of 
considerable anasarca before peritoneal dropsy 
is observed. In course of time the continued 
venous congestion originates serious organic 
changes in the liver, its vessels being more 
or less obliterated, and consequently it is at 
this period that ascites is particularly liable 
to set in, and it may even become the most 
prominent form of dropsy. 
III. Ascites may constitute a part of 
the dropsy which so often accompanies renal 
disease. It is, however, of comparatively 
infrequent occurrence to any great extent 
under these circumstances, the amount of 
fluid being not considerable as a rule, and 
the ascites being but a subsidiary part of a 
general dropsy. 
IV. More or less serous effusion into the 
peritoneal cavity is a pathological result of 
peritonitis; but, in accordance with the de- 
flnition of ascites given above, this does not 
come strictly within the present article. Ex- 
ceptional cases do occur, however, in which 
a large effusion rapidly collects in the peri- 
toneum, .and it is difficult to say whether it 
is a mere dropsy or the product of an acute 
inflammation. Moreover, true ascites is ob- 
served occasionally as a sequel of peritonitis, 
in consequence of the morbid conditions 
which it leaves behind. Chronic peritonitis 
may also occasion a simple local dropsy; but 
this is particularly liable to be set up in 
connexion with morbid formations in the 
peritoneum, such as cancer or tubercle. The 
immediate causes of ascites associated with 
diseases of the peritoneum may be active 
congestion; implication of the capillaries or 
minute veins, or even of the larger veins, 
leading to mechanical congestion; obstruction 
of the lymphatic orifices, and consequent 
impairment of absorption ; or undue activity 
of the secreting structures. 
It may be mentioned in this connexion 
that ascites is sometimes associated with a 
tumour which does not directly interfere with 
the portal circulation; probably it is then due 
to irritation of the peritoneum. 
V. Among the chief miscellaneous causes 
to which ascites has been attributed may be 
mentioned exposure to cold or wet; rhe 
sudden suppression of habitual discharges, or 
the rapid cure of chronic cutaneous affections; 
and extreme anaemia and debility. These 
causes are supposed to originate this symptom 
either by inducing active internal congestion; 
or by disturbing the renal functions; or in 
consequence of the abnormal state of the 
blood and tissues. It is very doubtful, how- 
ever, whether either of them can actually of 
itself occasion ascites, though they may help 
in its production. Fluid may collect within 
the peritoneum as the result of the rupture 
of a cyst within the abdomen, especially an 
ovarian cyst. 
It must be remembered that ascites may 
be due to a combination of two or more of 
the causes which have been indicated in the 
preceding remarks. For instance, there may 
be obstruction affecting the portal circulation 
within the liver and outside this organ at the 
same time; or the different organs may be 
involved staiultaneously. 
Predisposing causes.-Whatever tends to 
set up either of the morbid conditions which 
originate ascites, may be regarded as a pre- 
disposing cause. It may be met with at any 
age, but is most common during middle life. 
The hepatic form is much more frequent in 
males than females. An anaemic condition 
of the blood and weakness of the tissues pre- 
dispose to peritoneal dropsy, as they do to 
dropsy in other parts. 
Anatomical Characters.-The essential 
anatomical character of ascites is the accumu- 
lation of a serous fluid within the peritoneal 
sac. Its amount may range from a few 
ounces to some gallons. As regards phy- 
sical characters, the fluid is generally thin, 
limpid, and watery in consistence; colour- 
less or slightly yellow; clear and transparent; 
and of alkaline reaction. In exceptional in- 
stances, however, it may be coloured by blood 
or bile; or more or less turbid and dirty-look- 
ing or milky (chylous); or of unusually thick 
and somewhat gelatinous consistence. Soft 
fibrinous masses occasionally float in the fluid, 
or these may form spontaneously when it is 
allowed to stand. Very rarely the reaction 
is neutral or acid. The specific gravity varies 
considerably. Chemically the fluid consists 
of water holding in solution albumen and the 
usual salts which are found in dropsical fluids; 
but their proportion is very variable, though 
the albumen is generally in good quantity, 
which is evidenced by the degree of coagula- 
tion which takes place when the fluid is boiled. 
Occasionally it contains fibrin, cholesterin, 
bile-elements, or, in cases of renal dropsy, urea. 
The effects of the accumulation upon sur- 
rounding structures are to distend and macer- 
ate them more or less, or to compress them. 
Of course along with the ascites there will be 
the signs of any morbid condition upon which 
it depends; and there may also be indications 
of anatomical changes resulting from long- 
continued pressure of the fluid upon certain 
structures. 
Symptoms and Signs.-Ascites usually sets 
in very gradually, being chronic in its pro- 
gress, but advancing steadily. Occasionally, 
however, the fluid collects with considerable 
rapidity. The clinical phenomena associated ASCITES 
119 
with this pathological condition differ in 
different cases, both in their exact nature 
and their degree, according to its cause, the 
amount of fluid collected, and other circum- 
stances; but they may conveniently be con- 
sidered under the following heads, namely: 
1. Physical signs. 2. Mechanical effects of 
the dropsical accumulation. 3. General 
symptoms. 
1. Physical signs.-Physical examination 
constitutes one of the most important parts 
of the clinical investigation of cases of ascites, 
and it will be requisite to discuss in some 
detail the signs thus recognised. 
(a) If fluid collects in the peritoneum in 
any quantity, the abdomen presents more or 
less general enlargement. This is often the 
first change which attracts the patient's 
attention, and it may also have been noticed 
that the increase in size commenced below. 
The degree of enlargement depends upon the 
amount of fluid, but it may become extreme, 
so that the skin is tightly stretched and 
thinned, presenting a smooth and shining 
appearance, or sometimes white lines-linece 
albicantes-due to laceration of its deeper 
layers. The umbilicus becomes affected in 
a characteristic manner, being more or less 
stretched and everted, and finally obliterated, 
or in some cases more or less pouched out, 
when it may form a considerable prominence. 
Should there happen to be a weak portion of 
the abdominal walls, such as a hernial sac, 
this will be unduly protruded. The impor- 
tant characters of abdominal enlargement, 
due to uncomplicated ascites, are that it is 
of a rounded form, though tending to be 
more prominent or to bulge towards the 
hypogastric region or in the flanks, according 
to the posture of the patient; that it is quite 
symmetrical in shape, when the patient 
stands or lies on his back, but that the form 
alters considerably with a change of position, 
the abdomen becoming then more prominent 
in the dependent region, in consequence of 
the gravitation of the fluid in this direction, 
and it may actually be seen to move as the 
posture is changed. In contrast with the 
enlarged abdomen, the chest often looks small 
and depressed, and the fluid may cause the 
margin of the ribs to become everted, or it 
may push forwards the xiphoid cartilage. 
Mensuration is of service for giving more 
accurate information as to the size of the 
abdomen in cases of ascites, and for deter- 
mining their progress. 
(6) The abdomen feels perfectly smooth 
and even over its entire surface. It usually 
gives a sensation of tension of the walls, 
without any hardness underneath. In some 
instances an obscure feeling of fluctuation is 
experienced on palpation with the fingers. 
(c) The tendency of ascites is to interfere 
with the abdominal respiratory movements, 
if it is at all considerable, by preventing the 
diaphragm from acting properly. At the 
same time the writer has not uncommonly 
observed that, even in cases where the ac- 
cumulation of fluid has been very consider- 
able, abdominal respiration did not seem to 
be obviously impeded. 
(d) Percussion affords some of the most im- 
portant signs of peritoneal dropsy; and when 
the fluid is present only in small quantity, 
this is the only mode of examination that 
can be relied upon for its detection. In the 
first place, marked dulness is elicited over the 
seat of the fluid; while a tympanitic sound, 
which is often abnormally clear and distinct, 
is heard over the intestines. When there is 
but little fluid, it may be impossible to detect 
any abnormal dulness as the patient lies in 
the recumbent posture ; but on placing him 
on his hands and knees, the fluid gravitates 
towards the front of the abdomen, and dul- 
ness may then be noticed in the umbilical 
region. In most cases, however, there is no 
difficulty in making out the dulness, and this 
sign is observed in those regions towards 
which the fluid naturally gravitates. Hence, 
when the patient lies on his back, the lower 
part and sides of the abdomen are dull, while 
its upper and front part is tympanitic. As 
more and more fluid collects, so the dulness 
increases in extent, gathering in, as it were, 
from below and from the sides, until finally 
the entire abdomen may be dull, except the 
umbilical region, which usually remains 
tympanitic to the last. The boundary line 
between the dulness and tympanitic sound 
is usually well-defined. As the posture is 
changed, so will the site of the dulness vary, 
the part which is undermost presenting this 
sign, while that which becomes highest is 
tympanitic, and thus the relative situation of 
these two sounds, as well as the shape of the 
dulness, can be altered in a variety of ways. 
When the patient sits up, the prominence 
between the recti muscles gives a tympanitic 
sound on percussion. In exceptional instances 
a distended colon gives rise to a tympanitic 
sound along each side of the abdomen, even 
when there is abundant fluid present. 
Another important sign brought out by a 
form of percussion is the sensation specially 
termed fluctuation, which is the peculiar 
wave-like movement realised on placing the 
fingers of one hand over one side of the 
abdomen, and fillipping or tapping the oppo- 
site side with the fingers of the other hand. 
This sensation is very easily brought out if 
there is much fluid present, provided it is free 
to move, and sometimes the motion is actually 
visible. Change of posture will modify the 
situation over which fluctuation can be pro- 
duced. 
(e) Auscultation yields negative results in 
cases of ascites, there being no sound of any 
kind heard over the abdomen. 
(/) In the large majority of cases ascites 
is clearly revealed by the physical signs 
already described. In exceptional instances. 120 
ASCITES 
however, when the diagnosis is obscure, it is 
requisite to resort to a digital examination 
through the rectum, and in females through 
the vagina. The fluid collects in the recto- 
vesical pouch, and on examination per rectum 
the finger detects the sensation yielded by this 
fluid through its anterior wall. The vagina is 
usually felt to be shortened, while the uterus 
is pushed down and flexed. In extreme cases 
of ascites the posterior wall of the vagina, or 
even the uterus itself, may protrude through 
the vulva. 
(y) Now and then it is requisite to make 
use of the aspirator or a small trocar, by 
the aid of which not only can it be deter- 
mined whether fluid is present in the ab- 
dominal cavity, but its nature can also be 
ascertained. This method of examination 
is further useful when ascites is associated 
with some other morbid condition within 
the abdomen, which frequently cannot be 
made out so long as the fluid remains in the 
peritoneum. 
It must be borne in mind that the ordinary 
physical signs of ascites will be materially 
modified or obscured under certain circum- 
stances. For example, the quantity of fluid 
may be so small that most careful exami- 
nation is required in order to detect its 
presence; on the other hand, it may be so 
abundant that dulness is observed over the 
entire abdomen, and fluctuation may be very 
indistinct. The existence of peritoneal ad- 
hesions-for instance, those which may be 
formed as the result of repeated paracentesis 
-also renders some of the most characteristic 
signs of ascites very ill-defined. Again, the 
association of peritoneal dropsy with some 
other abdominal morbid condition, such as a 
new growth, an enlarged liver or spleen, or 
an ovarian tumour, will also modify the signs 
elicited. The mesentery may be abnormally 
short, or the intestines may be adherent, and 
thus prevented from floating forwards, so that 
the usual relative positions of dulness and 
tympanitic sound are not observed. 
2. Mechanical effects of the dropsical 
accumulation.-The clinical phenomena re- 
sulting from the mechanical effects of ascites 
are both subjective and objective. The patient 
often experiences a feeling of uneasiness and 
discomfort in the abdomen, as well as more 
or less tension and fulness, if there is much 
fluid present; while there may be a sense of 
fatigue and aching about the loins or ab- 
dominal walls. As a rule no particular pain 
is felt, but colicky pains are liable to occur 
from time to time, and extreme distension 
of the structures constituting the abdominal 
wall may also cause painful sensations. In 
exceptional instances peritonitis is set up. 
When the fluid is abundant, the patient is 
conscious of its weight when he walks; and 
during progression he throws the head and 
shoulders back, at the same time keeping the 
legs apart. Symptoms connected with the 
alimentary canal are of common occurrence, 
but these are often to a great extent due to 
the same cause which originates the ascites, 
though the fluid must necessarily tend to 
interfere with the functions of the stomach 
and intestines. The bowels are usually con- 
stipated, but in some instances diarrhoea or 
dysenteric symptoms may arise. Flatulence 
is very commonly complained of, even a 
small amount of gaseous accumulation in 
the intestines being felt unduly, producing 
much discomfort, and increasing the enlarge- 
ment of the abdomen temporarily. Occa- 
sionally vomiting occurs, in consequence of 
interference with the stomach. When con- 
siderable fluid has remained in the peritoneum 
for some time, it presses upon the inferior 
vena cava and prevents the return of blood 
through this vessel, and may thus lead to 
anasarca of both lower extremities, with en- 
largement of the superficial abdominal veins. 
Exceptionally the anasarca attracts attention 
at an early period. The flow of blood through 
the renal veins may also be obstructed, in- 
ducing mechanical congestion of the kidneys, 
with consequent diminution in the quantity 
of urine and. sometimes albuminuria. In rare 
instances the fluid has been known to ac- 
cumulate to such an extent as to rupture some 
part of the abdominal wall. 
Ascites also frequently interferes with the 
thoracic organs. The bases of the lungs are 
more or less compressed, and the breathing 
becomes chiefly upper-costal, while a sense 
of dyspnoea is experienced, especially in the 
recumbent posture and after taking food, the 
breath is short on exertion, and the respira- 
tions are often hurried and shallow. The 
heart is likewise liable to be disturbed in its 
action, as evidenced by palpitation, irregu- 
larity, or a tendency to faintness. This 
organ may also be displaced, so that its 
apex-beat is raised and too far towards the 
left, and in rare instances a basic systolic 
murmur has been originated as a result of 
this displacement. 
3. General symptoms.-The general system 
is frequently seriously affected in cases in 
which ascites is a prominent symptom, but 
this usually depends upon the cause or causes 
which have originated the dropsy, though it 
may itself induce more or less debility, wast- 
ing, anaemia, and other general effects. The 
loss of fluid in this way has also been sup- 
posed to lead to deficient perspiration, and 
consequent dryness of the skin; as well as 
to diminution in the quantity of urine. 
Diagnosis.-The first matter bearing upon 
the diagnosis of ascites is to determine 
whether this morbid condition actually exists. 
The presence of fluid in the peritoneum, as 
well as its amount, can only be positively 
made out by physical examination, and in 
the great majority of cases the signs thus 
elicited are quite characteristic. When the 
fluid is small in quantity, as well as under ASCITES 
121 
other circumstances in which the physical 
signs are obscured or modified, the diagnosis 
may be difficult and uncertain, but it may 
then be aided by a knowledge of the existence 
of some disease likely to give rise to ascites, 
of which it is really but a symptom. That 
the accumulation of fluid is of a dropsical 
nature, and not due to acute or chronic peri- 
tonitis, is usually sufficiently obvious from 
the history of the case, and the collateral 
symptoms, while the local signs are also 
of a different character (see Peritoneum, 
Diseases of). The remaining abdominal 
enlargements from which ascites has to be 
more commonly distinguished are those due 
to flabby relaxation of the walls of the ab- 
domen, combined with flatulence; accumu- 
lation of fat in the subcutaneous tissue and 
in the omentum ; abundant subcutaneous 
oedema, which may be associated with and 
obscure ascites; an ovarian cyst; or a preg- 
nant uterus. Among the more rare con- 
ditions with which ascites is liable to be 
confounded may be mentioned a greatly 
dilated stomach; colloid disease of the omen- 
tum ; distension of the uterus with fluid; 
great accumulation of urine in the bladder ; 
a very large hydatid tumour, usually con- 
nected. with the liver; extreme cystic en- 
largement of the kidney; and the so-called 
' phantom tumour.' Most of these conditions 
are described in other parts of this work, and 
their several diagnostic characters need not 
be discussed here; but a consideration of 
the history and existing symptoms of each 
particular case, combined with the results of 
an adequate physical examination, constitute 
the data upon which the diagnosis is founded. 
It must be remembered that ascites may 
coexist with other morbid conditions in the 
abdomen, their physical signs being com- 
bined. Should there be an enlarged organ 
or other solid mass, it may often be recog- 
nised by making sudden firm pressure with 
the fingers over the corresponding part of 
the abdomen, when the fluid is pushed aside, 
and the underlying resistance can be felt; or 
paracentesis may be performed, and further 
examination carried out after the evacuation 
of the fluid. 
Another most important point in the dia- 
gnosis of ascites is to make out its cause. For 
this purpose all the facts bearing upon the 
case must be taken into account and carefully 
weighed, special attention being paid to the 
liver and the structures in its vicinity, to the 
heart, and to the kidneys. The amount of 
the ascites, and its relation to other forms 
of dropsy, afford considerable aid in the 
diagnosis. If it results from cardiac or renal 
disease, ascites always follows dropsy in other 
parts of the body, to which it is also generally 
subordinate; when it is due to hepatic disease 
or some neighbouring morbid condition, the 
peritoneal dropsy appears first, and is, as a 
rule, throughout most prominent. Should the 
vena cava inferior be obstructed at its upper 
part, anasarca of the legs will be observed 
simultaneously with, or even before, the 
ascites. 
Prognosis.-The prognosis of ascites will 
mainly depend upon its cause; the amount 
of fluid present; the state of the patient; 
the condition of the principal organs; and 
the results of treatment. In some cases this 
symptom is in itself attended with urgent 
danger, on account of the mechanical effects 
of the dropsical accumulation, especially 
upon the thoracic organs, and still more if 
these organs are in a diseased condition. In 
other instances it tends to reduce the patient, 
and thus to bring about a fatal termination. 
When ascites is due to local interference 
with the portal circulation, great relief can 
unquestionably be afforded in a considerable 
number of cases, and life may be prolonged 
by appropriate treatment; while, if the local 
cause is not such as in itself to lead to a fatal 
issue, the ascites may not infrequently be 
permanently cured. 
Treatment.-The principles of treatment 
applicable to cases of ascites are : (a) to treat 
the conditions upon which the dropsy de- 
pends, and thus endeavour to get rid of its 
cause or causes; (6) to promote absorption of 
the fluid; (c) to improve the constitutional 
condition and. the state of the blood, if neces- 
sary ; (d) to remove the fluid by operation, if 
absorption cannot be effected; and (e) to treat 
any symptoms needing special attention. 
(a) As an important part of the treatment 
directed to the causes of ascites, particular 
attention must be paid to the state of those 
organs which are most commonly accountable 
for this symptom, though unfortunately but 
little effect can, as a rule, be produced on the 
dropsy in this way. 
(b) Absorption of ascitic fluid is chiefly 
promoted by acting freely upon the bowels, 
skin, or kidneys. The class of remedies in- 
dicated will vary in different cases, and must 
be adapted to the state of the different organs; 
but, as a rule, active hydragogue purgatives 
are most efficient in relieving ascites, espe- 
cially when due to local causes. The most 
useful are compound jalap powder, cream 
of tartar, elaterium or compound elaterin 
powder; but calomel, gamboge, resin of 
podophyllum, and saline purgatives may be 
of service in particular cases. These agents 
must, however, be administered with caution. 
In certain instances balsam or resin of 
copaiba has proved useful as a diuretic in the 
treatment of peritoneal dropsy. Assistance 
may be derived in certain forms of ascites 
from acting upon the skin by means of various 
diaphoretic baths. Digitalis and squill may 
be of service as diuretics; the application of 
poultices of digitalis leaves over the abdomen 
is occasionally attended with benefit. The 
administration of iodide of potassium also 
seems to aid absorption in some cases, more 122 
ASCITES 
ASPHYXIA 
especially if there be any tendency to syphi- 
litic disease of the liver. It has been recom- 
mended to treat ascites merely by a skim- 
milk diet, without any medicine. Two 
marked cases were thus treated by the writer 
with complete success, the fluid being entirely 
absorbed. In other cases, however, no effect 
was produced. The employment of galvanism 
in connexion with the abdominal walls has 
been found efficacious in producing absorp- 
tion of peritoneal dropsy in some instances. 
(c) Treatment directed to the general con- 
dition of the patient, and to the state of the 
blood, is essential in many cases of ascites. 
Tonics are often of decided service, and pre- 
parations of iron are specially indicated for 
improving the quality of the blood, if there 
is a tendency to ansemia. Not only do these 
remedies sustain the patient, but they may 
also have an influence in promoting the pro- 
cess of absorption. The diet must be adapted 
to the circumstances of the case, but usually 
needs to be of a nutritious character. 
(d) In a considerable proportion of cases, 
however, no effect is produced upon the drop- 
sical accumulation by any of the measures 
thus far considered. Then it becomes neces- 
sary to determine whether it is desirable to 
remove the fluid by operation. The fluid 
may be taken away either by means of the 
aspirator, by the ordinary trocar and cannula, 
by Southey's trocars, or by a special appa- 
ratus. . The advisability of having recourse 
to this plan of treatment must depend upon 
circumstances. The ascites is frequently not 
sufficiently abundant to justify paracentesis, 
and when the condition is of cardiac or renal 
origin, the operation can, in the majority of 
cases, only afford temporary relief, so that 
there is no object in resorting to it unless the 
mechanical effects of the accumulation are 
such as to cause troublesome or dangerous 
symptoms, and it had better be delayed as long 
as possible. When ascites is a local dropsy, 
the fluid is often so considerable in amount 
as to necessitate its removal for the mere 
purpose of giving relief for the time. In 
cases of ascites associated with malignant 
disease, for instance, this is all that can be 
hoped for, as the fluid will certainly collect 
again. When, however, the condition is due 
to some local disease which is not in itself 
fatal, and especially to cirrhosis of the liver, 
the writer has found signal benefit result 
from the repeated performance of para- 
centesis, and has for a long period advocated 
this plan of treatment as a curative measure, 
so far as the ascites is concerned. Rarely 
does the operation give rise to any immediate 
ill-effects, and it is frequently found that 
remedies will act much more efficiently after 
the removal of the pressure caused by the 
fluid than they did previously. In the 
writer's experience paracentesis, repeated as 
often as the fluid re-accumulated, has ulti- 
mately led to a complete cure in several 
instances; in others the cure was partial, a 
certain quantity of fluid remaining in the 
peritoneum, limited by adhesions; while in 
others still, life has been greatly prolonged, 
and much comfort afforded. The repeated 
accumulation does not seem to affect the 
system materially by reason of the drain 
upon it, and frequently not at all. Of course 
due care must be exercised in the per- 
formance of the operation, and in the sub- 
sequent treatment. In a few days after the 
removal of the fluid, the application of a 
bandage firmly round the abdomen, so as to 
exert even pressure, may prove of service in 
aiding the absorption of what remains, and 
preventing the recurrence of the ascites; and 
this measure may also be useful when a 
certain amount of fluid continues after the 
repeated performance of paracentesis. When 
the ascites is not cured by repeated tapping, 
advantage has been found in some instances 
from allowing the fluid to drain away con- 
tinuously, and this measure may be worthy 
of trial. 
(e) The symptoms resulting from ascites 
which are likely to require attention are those 
connected with the alimentary canal; dys- 
pnoea ; and cardiac disturbance, or a syncopal 
tendency. These should be treated on or- 
dinary principles; but it must be observed 
that marked dyspnoea or cardiac disorder, if 
evidently due to the fluid, is an indication for 
the immediate performance of paracentesis. 
Frederick T. Roberts. 
ASHEVILLE, in North. Carolina.- 
Situated between the Blue Ridge and Alle- 
ghany Mountains, in 35° 36' N. lat-, 2,250 
feet above the sea. A mild winter and cool 
summer climate; of repute in the treatment 
of phthisis. Temperatures: summer, 70'7°; 
winter, minimum has never fallen below 
8° Fah.; range 80°. Rainfall, 40 inches. 
Possesses a sanatorium. See Climate, Treat- 
ment of Disease by. 
ASIATIC CHOLERA.-See Cholera, 
Asiatic. 
ASPHYXIA (a, priv.; and 
pulse).-Synon. : Apnoea ; Fr. Asphyxie ; 
Ger. Ersticliung. 
Definition.-The term asphyxia, though 
literally signifying pulselessness, is generally 
understood to mean the condition that su- 
pervenes on interruption of the function 
of respiration. The term apnoea, preferred 
by many as a more exact one, has the dis- 
advantage of being employed by physiologists 
in a totally different sense, viz. the cessation 
of the respiratory movements consequent 
on artificial hyperoxygenation of the blood. 
There is therefore no advantage to be 
gained by substituting the term apnoea for 
the well-understood and older one, asphyxia. 
^Etiology.-Asphyxia may result from 
many causes which obstruct or interrupt the ASPHYXIA 
123 
respiration. They may be divided into two 
categories, internal and. external. 
Internal.-These include paralysis of the 
respiratory nerve-centres by disease or 
injury of the medulla oblongata; paralysis of 
the nerves or muscles of respiration; a rigid 
fixation of the respiratory muscles; collapse 
or disease of the lungs; occlusion of the air- 
passages by organic disease or spasm of the 
glottis, pressure of tumours, and the like. 
External.-To this group belong occlusion 
of the air-passages by foreign bodies; 
pressure on the chest not capable of being 
overcome by the muscles of respiration; 
closure of, or external pressure on, the air- 
passages, as in suffocation, strangulation, or 
hanging. These are all cases of obstruction 
of the respiratory movements in a medium 
capable of supporting life. To these external 
causes are to be added those conditions in 
which, though the respiratory movements 
are tree, the surrounding medium is in- 
capable of oxygenating the blood, viz., sub- 
mersion in a liquid medium (drowning) ; or 
being surrounded by a medium devoid of 
oxygen, such as nitrogen or hydrogen. 
These gases have a purely negative effect; 
but many other gases which are classed as 
asphyxiants, such as carbonic oxide, sul- 
phuretted hydrogen, chlorine, chloroform 
vapour, &c., have positive poisonous effects, 
and should therefore be called by some 
special name, such as toxic asphyxiants, 
to distinguish them from those which have 
no such properties. 
Phenomena.-When an animal is placed 
in an atmosphere devoid of oxygen, or not 
containing a sufficient quantity of this gas 
(under 10 per cent.) to maintain the respira- 
tory process, or if the mechanism of respira- 
tion is simply obstructed, it begins to show 
signs of agitation, and to make powerful 
inspiratory and expiratory efforts, in which 
the accessory muscles of respiration are all 
brought into action; the arterial tension in- 
creases ; and the superficial veins become 
distended and livid. 
After a variable period these dyspnoeic 
efforts pass into general convulsions, in 
which the muscles of expiration are more 
especially in action, during which the 
sphincters are forced, and the excretions 
voided. On these there follows a calm, dur- 
ing which the animal lies insensible, with 
dilated and immovable pupils, and with 
reflex excitability abolished generally. At 
the same time the pulse is small, feeble, and 
almost imperceptible. All muscular move- 
ments cease except those of inspiration, which 
are repeated at intervals. As death ap- 
proaches, the respiratory movements become 
shallower and less regular, and are succeeded 
by stretching convulsions, during which the 
back is straightened, the head is thrown back, 
the mouth gapes, and the nostrils dilate. 
The heart still continues to beat after other 
movements have ceased. The heart ultimately 
stops in the state of diastole. Death is then 
complete and final. 
Course and Termination.-The time 
necessary to bring about a fatal termination 
varies in different animals, and in the same 
animal under different conditions. It has been 
noted that the young of some animals resist 
asphyxia longer than the adults. The late M. 
Paul Bert has shown that these differences 
are all explicable in accordance with the law 
that the more active the vital combustion, the 
greater the gaseous interchange, and there- 
fore the more rapidly fatal the obstruction of 
the respiratory process. Excluding special 
considerations of this kind, it may be stated, 
as the result of the experiments of the 
Medical and Chirurgical Committee on 
Suspended Animation (Med.-Chir. Trans. 
vol. xlv. 1862), that when the respiration of a 
warm-blooded animal is totally obstructed, 
all external movements cease in from three 
to five minutes, and the heart stops within 
ten minutes. Certain modifications occur 
according to the method in which asphyxia 
is produced. See Drowning. 
Anatomical Characters.-The blood is of 
a dark colour, owing to complete reduction 
of the haemoglobin, and the proportion of 
carbonic acid is greatly increased. Owing to 
the excess of carbonic acid, the blood coagu- 
lates slowly or imperfectly ; hence it remains 
long fluid, or forms few and soft coagula. 
The venous side of the heart, the great 
venous trunks, and the pulmonary artery are 
distended with dark blood; whilst the left 
side is empty, or contains only a small 
quantity of dark blood. 
The appearance of the lungs is not con- 
stant. These organs are by no means 
always congested, as is very generally stated, 
being more often pale and ansemic. The 
posterior and dependent parts become 
hypostatically congested post mortem. The 
abdominal viscera are usually congested. 
The appearance of the brain varies, this 
organ being either anaemic or more or less 
congested. Special signs characterise special 
modes of causation of asphyxia. 
Pathology.- Inasmuch as the cessation 
of respiration means both oxygen-starvation 
and accumulation of carbonic acid, the ques- 
tion is whether the phenomena of asphyxia 
depend on the one or the other, or on both. 
Various opinions have been entertained on 
this subject, but the experiments of 
Rosenthal and Pfliiger would seem to show 
that the deprivation of oxygen is the chief 
factor. That the accumulation of carbonic 
acid has no effect at all cannot, however, be 
maintained, for it is demonstrable that 
carbonic acid has a distinct toxic effect on 
living tissues. 
The circulation of non-oxygenated blood 
through the lungs and the respiratory centre 
in the medulla oblongata is the cause of the 124 
ASPHYXIA 
ASPIRATOR 
powerful respiratory efforts in the first stage 
--directly, by stimulation of the respiratory 
nerve-centres; indirectly, by peripheral 
irritation of the pulmonary branches of the 
vagi. The respiratory movements increase 
in force, and the irritation irradiates into the 
centres of other movements besides those 
directly concerned in respiration, giving rise 
to the expiratory convulsions which have 
been ascribed by some to excitation of a 
special 'convulsion-centre' (Krampfcentrum). 
The respiratory centres ultimately become 
paralysed, but subsequently to those of con- 
scious activity-the brain; and of reflex action 
-the spinal cord. 
The circulation of non-oxygenated blood 
likewise causes contraction of the arterioles 
from irritation of the vaso-motor centre. 
Increased resistance is thus offered to the 
heart, and this is intensified by the con- 
vulsive muscular efforts. The arterial 
tension rises. The resistance to the flow 
through the capillaries by contraction of the 
minute blood-vessels occurs not only in the 
systemic, but also in the pulmonary circu- 
lation at an appreciable period after its 
occurrence in the systemic vessels. The 
ventricles become distended, and the heart's 
action laboured. The heart becomes en- 
feebled by the circulation of non-oxygenated 
blood in its walls, the diastolic intervals be- 
come longer, until the organ finally stops 
in a state of diastole, with the right side full, 
while the left may have succeeded in empty- 
ing itself. Owing to the obstruction of the 
pulmonary circulation from this cause, the 
systemic blood-pressure falls, and the pulse 
becomes small and feeble. 
Treatment.-Resuscitation from pure as- 
phyxia is possible so long as the heart con- 
tinues to beat. After cessation of the heart's 
action treatment is unavailing, except in 
cases of cessation from mere over-distension, 
in which bleeding from the external jugular 
vein may be resorted to with success. The 
chief indication in the treatment of asphyxia 
is to effect oxygenation of the blood by the 
introduction of air into the lungs. If the 
medium by which the patient is surrounded 
is incapable of supporting respiration, he 
must be immediately removed, or the at- 
mosphere changed. If the air-passage is 
obstructed by a foreign body, this must be 
extracted; if this is impossible, or if the 
obstruction result from disease, tracheotomy 
or laryngotomy must be resorted to. Means 
must be adopted of exciting the respiratory 
centres or respiratory muscles to action; or 
if these are paralysed and non-excitable, the 
natural movements of respiration must be 
imitated artificially, or air introduced by 
insufflation. 
The respiratory centres, if not absolutely 
paralysed, may be excited reflexly by stimula- 
tion of cutaneous nerves, especially those of 
the face and thorax. This may be effected 
by the stimulus of sudden cold, or better by 
alternate dashing of hot and cold water on 
the face and chest, or by flicking the skin 
with a towel. These reflex stimuli are often 
of themselves sufficient to excite respiratory 
movements; if not, they are powerful sub- 
sidiary aids to artificial respiration. The 
diaphragm may be stimulated to contraction 
by galvanisation of the phrenic nerve, one 
pole being placed on the nerve as it crosses 
the scalenus anticus at the root of the neck, 
the other on the epigastrium. Chief reliance, 
boweTer, is to be placed on the methods of 
artificial respiration, which, after all, are 
the most simple and the most effectual, and 
possessed of the pre-eminent advantage 
of being always available. See Artificial 
Respiration. 
Air may also be introduced into the lungs 
directly by properly constructed insufflation- 
apparatus, either by the insertion of a tube 
within the larynx (an operation requiring 
dexterity, but without danger if skilfully per- 
formed, though there is always risk of rup- 
ture of the air-vesicles from over-distension); 
or more easily by the insertion of the tube in 
one nostril, the other nostril and the mouth 
being closed (Richardson's apparatus). Mouth- 
to-mouth-insufflation is sometimes of advan- 
tage, especially in infants. The operator 
must close the nostrils of the patient, and, 
applying his mouth directly to that of the 
patient, inflate the lungs by his own expira- 
tory efforts. The tendency to inflation of the 
stomach is considerably counteracted by back- 
ward pressure on the larynx. 
D. Ferrier. 
ASPHYXIA, Local.-A synonym for 
Raynaud's Disease. See Raynaud's Disease. 
ASPIRATOR.-Synon. : Fr. Aspirateur. 
The operation of pneumatic aspiration was 
introduced into practice by Dieulafoy in 
1869. Before this period various instruments 
had been used under the name of ' suction- 
trocars,' but to Dieulafoy is due the credit 
of fully appreciating their value. 
Description and Mode of Employment. 
The aspirator consists of a glass syringe, 
having at its lower end two openings pro- 
vided with stopcocks. When the piston is 
raised and the cocks are closed, a vacuum is 
created in the syringe, which can be main- 
tained by fixing the piston in the withdrawn 
position. An india-rubber tube is fitted into 
each of the two openings, and these must be 
provided with coils of wire inside to prevent 
them from collapsing. At the end of one tube is 
fixed a fine hollow needle. The needle should 
have only one opening, at the point, and not, 
as is often seen, another at some distance 
from it. The instrument is thus usedA 
vacuum having been created in the syringe 
by raising the piston whilst both stopcocks 
are closed, the needle is introduced into the 
part to be operated upon. As soon as the opening of the needle is beneath the skin 
the stopcock leading to it must be opened. 
The vacuum will then extend to the point of 
the needle ; and consequently, if it be gently 
pushed onwards, the moment it encounters 
fluid this will jet up into the glass syringe, 
when its nature may be ascertained. This 
mode of operating with what Dieulafoy calls 
the ' previous vacuum ' is the essential dif- 
ference between aspiration and suction. 
In aspiration it is impossible to pass the 
needle through a collection of fluid without 
discovering it; whereas without the ' previous 
vacuum ' in the needle this might readily be 
done. If the fluid is sufficient in amount to 
fill the syringe, the stop-cock leading to the 
needle is to be closed and the other opened, 
by which the fluid may be discharged. The 
vacuum may then be re-established, and the 
operation repeated as often as is necessary. 
By opening both stopcocks at once and al- 
lowing the discharge-tube to hang down, the 
aspirator may be converted into a syphon. The 
action of the instrument may also be reversed, 
and it may be employed for injecting fluids. 
Other varieties of aspirator are in use besides 
the one above described. In Weiss's the 
receiver is a glass bottle, from which the air 
is exhausted by means of a separate exhaust- 
ing syringe. The objection to this is that if 
the needle becomes choked, it cannot be 
cleared by pushing down the piston and 
driving some of the fluid back through it. 
Other kinds of aspirator cannot be converted 
into syphons, and these are objectionable. 
Weiss's has the advantage of being less 
liable to get out of order, as the fluid does 
not touch the exhausting syringe. The 
needles employed vary in size. Dieulafoy 
recommends that they should be about 
eV' 5o» and 15 an in°h i*1 diameter, and calls 
them Nos. 1, 2, 3, and 4 respectively. The 
aspirator may also be applied to trocars, 
but then its distinctive feature is gone, and 
it becomes but a ' suction trocar.' 
The following rules must always be ob- 
served in using the aspirator:-1st. See that 
the needle is pervious and clean and the 
syringe in order before using it. It is ad- 
visable to wash the needle and syringe well 
in strong carbolic acid solution. 2nd. The 
needle must be pushed straight on in one 
direction only. Its course should not be 
altered while the point is under the skin. If 
no fluid is found, it may be withdrawn and 
reinserted. It must be held as steady as 
possible during the aspiration. 3rd. If the 
fluid will not flow with the pressure of the 
atmosphere, it is of no use squeezing and 
pressing the part. This can only do harm. 
4th. Aspiration must cease at once when 
blood comes in any quantity, especially in 
abscesses. 5th. Keep up the vacuum during 
the withdrawal of the needle, lest some of 
the morbid fluid be left in its track. 6th. If 
the needle becomes choked, force a little of 
ASPIRATOR 
the fluid back through it in order to clear it. 
7th. After use the whole apparatus must be 
thoroughly cleaned with plain water to com- 
pletely remove pus, blood, and other albumi- 
nous fluids, which would be coagulated by 
carbolic acid. After this is thoroughly done, 
the needle, tubes, and syringe should be dis- 
infected with carbolic lotion (1 in 20). The 
leather of the piston may be greased with 
carbolised oil or vaseline. 
Uses.-Aspiration is used for purposes of 
diagnosis and treatment. Dieulafoy asserts 
that with the No. 1 needle it is possible to 
search for fluid without danger, whatever 
may be its seat or its nature; and experi- 
ence has proved this to be practically true. 
In treatment it has been employed in the 
following affections:- 
Abscesses.-In acute abscesses simple as- 
piration is usually of little value, as the pus 
soon re-accumulates. In chronic abscesses 
connected with diseased bone it usually fails; 
and often it is impossible, from the presence 
of cheesy matter in the pus. If performed 
with proper antiseptic precautions, however, 
it can do no harm, and may, if repeated, 
diminish the size of the sac before other 
means are adopted, or even effect a cure. A 
modification of simple aspiration has been 
recently introduced by Billroth, which not 
infrequently cures even chronic abscesses 
undoubtedly connected with diseased bone. 
Instead of the small needle, a large trocar, 
from £ to | inch in diameter, is fitted to the 
aspirator. If necessary a small incision is 
made in the skin to facilitate the introduc- 
tion of the trocar. The abscess having been 
emptied of its contents, the cavity is distended 
with a solution of perchloride of mercury 
(1 in 4,000) which is again withdrawn by the 
aspirator. This must be repeated again and 
again, till the fluid returns perfectly clear. 
Finally, an emulsion of iodoform and glyce- 
rine (1 to 10) is injected, the trocar is with- 
drawn, and the opening sealed with collodion. 
Most commonly the abscess fills again in a 
few days, after which the fluid may be gradu- 
ally absorbed, but it is frequently necessary 
to repeat the operation more than once. 
There is no doubt that many chronic ab- 
scesses have been cured in this way, but the 
exact value of the treatment has yet to be 
determined. Diseases of the Liver.-Hydatid 
cysts have been successfully-treated by aspi- 
ration. In many cases the fluid becomes 
purulent after one or two aspirations, and in 
some the cyst has opened externally. For 
purposes of diagnosis the small needles may 
always safely be introduced into the liver. 
Abscess of the liver has been successfully 
treated by the aspirator. Retention of Urine 
may be safely relieved by using No. 2 needle 
above the pubes. Ovarian cysts may be dia- 
gnosed and treated in the same way. Hernia.- 
It has been asserted that strangulated hernia 
may be, in the great majority of cases, re- 
125 126 
ASPIRATOR 
ASTHMA, SPASMODIC 
lieved by the use of the aspirator. The finest 
needles only should be used. They remove 
first the fluid from the sac, after which some 
gas may be obtained from the strangulated 
gut, but faecal matter rarely fails to choke 
the tube. Experience has, however, shown 
that this mode of treatment is both dangerous 
and inefficient. Diseases of Joints.-Aspira- 
tion is occasionally useful in acute synovitis. 
Great care must be taken not to scratch the 
inside of the joint with the needle, as this 
has been said to lead to acute arthritis and 
suppuration. No. 1 or 2 needle should be 
used. Hydrocephalus and Spina bifida may 
be aspirated with safety with No. 1 needle. 
In hydrocephalus it is to be passed through 
the anterior fontanelle. No case has hitherto 
been cured by this treatment. In Pleurisy 
and Ascites, except for purposes of diagnosis, 
in the writer's opinion the aspirator presents 
no advantages over a trocar properly con- 
structed so as to exclude air (see Paracen- 
tesis). Pericarditis.-The operation of as- 
piration has frequently been successfully 
performed for pericardial effusion. It is thus 
carried outA spot is chosen 2 to 2| in. 
(5 or G centimetres) beyond the left edge of 
the sternum, in the 4th or 5th interspace. 
No. 2 needle is then passed obliquely upwards 
and inwards, taking care to turn on the 
vacuum as soon as the eye is covered. The 
moment the fluid jets into the syringe the 
needle must be held steadily till the flow 
ceases. If this be done there is no danger 
of wounding the heart. If there is any doubt 
as to the existence of fluid, No. 1 needle must 
be employed, with which the heart may be 
punctured without great danger. 
Marcus Beck. 
mediately affects the mucous membrane; in 
the latter it does so in a more circuitous 
manner, as through the blood or the nervous 
system generally:- 
Dust. 
Vegetable irritants. 
Chemical vapours. 
Animal emanations. 
Climatic influences. 
Bronchial inflammation. 
Direct 
Through the ner- 
vous system 
Through the 
blood 
Heredity. 
Centric. 
Excito-motor. 
Gout. 
Syphilis. 
Skin-diseases. 
Renal diseases. 
Indirect 
Direct causes.-Common roadside dust; 
fluff from woollen clothing; the dust of mills, 
threshing-floors, or bakehouses ; and any 
mechanical particles when inspired, will pro- 
duce in some persons an asthmatic seizure ; 
dust of low specific gravity being more apt 
to have this effect than heavy particles like 
coal, steel filings, &c., from which arise 
lesions in the lung of a more permanent and 
serious character. 
The odour evolved by certain vegetables, 
such as ipecacuanha; the pollen of many 
grasses and plants (see Hay-fever) ; certain 
chemical vapours, as that of pitch, sulphurous 
acid, and phosphorus fumes; the peculiar 
smell of some animals, as dogs, cats, horses, 
and hares, may each provoke a spasm in 
individual cases. 
A still more powerful cause is climatic 
influence, the action of which on different 
patients cannot, unfortunately, be reduced 
within the limits of a law, but depends 
mainly on the idiosyncrasy of the individual. 
Extremes of temperature, or excessive dry- 
ness or dampness, may produce an asthmatic 
seizure, but in the largest number of cases 
one of two elements appears as the chief 
factor. One large class of sufferers trace the 
attack to dampness, whether of soil or of 
atmosphere, in combination with either heat 
or cold; another to closeness of atmosphere 
and a want of proper circulation of air, such 
as is found in deep valleys and thick forests, 
and during thundery weather-this last class 
experiencing great relief when a breeze 
springs up. Malaria plays an important 
part occasionally in the causation of asthma. 
Far more general and intelligible in its 
action is bronchial inflammation, which is 
the cause in 80 per cent, of asthmatic cases. 
It frequently happens that after whooping- 
cough, measles, or infantile bronchitis the 
tendency towards asthma begins to appear. 
These diseases, implicating as they do both 
bronchial muscle and nerve supplying it, 
leave their mark behind, either in irritability 
of the mucous membrane ; in induration of 
some portion of the lung, generally at the 
root; or in enlargement of the bronchial 
glands, causing pressure on the pneumo- 
ASTHENIA 
ASTHENIC 
(a, priv. ; and adevos, 
strength).- Terms signifying want of 
strength. As applied to the entire system, 
they indicate considerable general debility; 
in connexion with particular diseases, they 
imply that these are attended with marked 
weakness. See Debility. 
ASTHENOPIA (d, priv.; aQtvos, 
strength; and the eye).-Weakness of 
sight. See Vision, Disorders of. 
* ASTHMA, SPASMODIC (fVdMn;from 
OW, I blow).-Synon. : Bronchial Asthma ; 
Er. Asthme; Ger. Bronchial-Asthma. 
Definition. - An affection characterised 
by severe paroxysmal dyspnoea, recurring at 
more or less well-marked periods, generally 
in the night, the dyspnoea being due to 
spasmodic contraction of the bronchi, pro- 
duced by a variety of causes. 
^Etiology.-The causes that induce an 
attack of asthma are very various, and may 
be roughly classed according to their action, 
direct or indirect, on the respiratory organs. 
In the former class the exciting cause im- ASTHMA, SPASMODIC 
127 
gastrics, or on some of the branches of the 
pulmonary plexuses {see Bronchial Glands, 
Diseases of); and thus lay the foundation of 
asthma in after-life. Asthma following on 
arrested phthisis is not rare in adults, pro- 
bably from enlargement of the bronchial 
glands by absorption of tubercle and caseous 
material. In other instances the indirect 
cause may be found in morbid states of the 
nose or throat. 
Indirect causes. - This class of causes 
includes those acting through the general 
nervous system; those acting through the 
blood ; as well as the more or less structural 
one of heredity. 
The centric subdivision embraces attacks 
arising from emotion, anger, or fright; as 
well as the curious alternations of asthma, 
neuralgia, angina, and gastralgia due to 
some centric irritation in the medulla, in- 
volving the origins of the fifth and eighth 
pairs of nerves, and manifesting itself by 
affecting first one branch and then another 
of these nerves. 
Excito-motor causes may be illustrated by 
indigestion or costive bowels giving rise to a 
paroxysm of asthma. In the first case, irri- 
tation of the medulla is induced through the 
gastric branches of the pneumogastric, and 
a motor effect is reflected through the pul- 
monary branches. These peptic attacks, as 
they are called, occur more frequently after 
suppers than dinners, probably because re- 
flex irritability is always exalted by sleep, as 
we know to be the case in epilepsy and the 
teething convulsions of childhood. 
Gout, towards old age, often takes the form 
of asthmatic seizures, which alternate with 
the articular affections. In like manner 
attacks of the disease have been attributed to 
syphilis, but here the poison generally acts 
by enlarging the bronchial glands. 
The connexion between asthma and various 
kinds of skin-disease is intimate: the sub- 
sidence of eczema, of urticaria, or of psoriasis, 
has often been accompanied by fits of spas- 
modic breathing, which have ceased on the 
reappearance of the eruptions. Here, again, 
the state of the blood is presumed to be the 
origin of both maladies, as in disease of the 
kidneys, which will be presently referred to. 
Heredity can be traced in about 40 per 
cent, of asthmatics, though the tendency 
often does not show itself till late in life. 
The characteristic form of chest is frequently 
transmitted from parents to children; and 
even when this is not so, a disposition towards 
spasmodic symptoms in catarrhal attacks is 
often seen in the children of some asthmatics. 
Symptoms.-The patient may retire to bed 
with few or no premonitory symptoms, and 
sleep for some hours, but is disturbed in the late 
night or early morning-2 a.m. is a common 
time-by a feeling of oppression approaching 
to suffocation, referred either to the throat, 
sternum, or epigastrium, which obliges him 
to sit up in order to ]breathe. Sometimes 
the onset is more gradual: the patient, 
having fallen asleep in spite of uneasy sensa- 
tions, begins to wheeze during sleep, and is 
only aroused when the dyspnoea becomes 
severe. The breathing is accompanied by a 
humming sound, which gradually develops 
into a great variety of discordant noises. 
In order to increase the capacity of his 
chest to the utmost, the asthmatic patient 
sits up and fixes his shoulders, either by 
placing his hands on either side of him, or 
by supporting his elbows on his knees; or 
sometimes he stands leaning over the back 
of a chair or other support. In one or other 
of these positions he remains immovable, 
with chest, back, shoulders, and head fixed ; 
unable to speak or even to move his head; 
the lips being parted; the face pale, anxious, 
and, if the dyspnoea continue, livid; and the 
eyes prominent and watery. Every muscle 
of respiration, ordinary and extraordinary, is 
brought into requisition ; those passing from 
the head to the shoulders, to the clavicles, 
and to the ribs become rigid, and, in place of 
moving the head and neck, act the reverse 
way, being used from fixed points to raise and 
dilate the thorax. The trapezii and levatores 
anguli scapulae by their contraction elevate 
the shoulders, in order that the muscles 
connecting these with the ribs may act as 
elevators to the latter. Even the muscles of 
the back are pressed into the service, and 
they almost cease to support the back ; con- 
sequently the patient stoops. At each in- 
spiration the sterno-cleido-mastoids stand out 
like cords, leaving a deep hollow between 
their sternal attachments; the diaphragm is 
contracted, and hence the stomach, liver, and 
heart are somewhat displaced. With all this 
display of muscular force, the chest remains 
almost motionless, being expanded to a 
variable extent. 
In spite of the great dyspnoea, respirations 
are not proportionately frequent, seldom ex- 
ceeding thirty, and sometimes falling to nine 
a minute. The expiration is prolonged, being 
generally two or three times as long as the 
inspiration. The pulse is usually slow and 
feeble; the temperature rarely exceeds 99° 
Fah., and is often below 98° Fah. Analysis 
of the expired air shows the oxygen to be 
almost entirely replaced by carbonic acid, 
which may increase from the normal to as 
much as 11 per cent., the nitrogen varying 
from 89 to 93 per cent. The arrest of expira- 
tion is probably the cause of the accumulated 
carbonic acid, but the total disappearance of 
the oxygen is hardly to be explained, for 
that oxidation of the tissues does not pro- 
ceed is shown by the pale urine passed after 
the fit. 
Physical Signs.-These reveal less than 
might be expected. The percussion-note is 
somewhat raised over the whole chest, most 
so in the posterior regions, where a drum-like 128 
ASTHMA, SPASMODIC 
sound occasionally prevails; this hyper-reson- 
ance is probably due to accumulation of air 
induced by obstructed expiration, and in in- 
cipient cases passes off with the attack. The 
normal areas of cardiac and hepatic dulness 
often disappear during the attack, owing to 
the emphysema temporarily induced. When 
the attack has passed off, careful examination 
will sometimes detect dulness in the supra- 
scapular or inter-scapular regions, on one or 
both sides of the chest, indicating probable 
enlargement of the bronchial glands. 
Auscultation shows an entire abolition of 
the normal breath-sounds, and the existence 
of dry sibilant or sonorous rhonchi, every- 
where varying in tone according to the 
calibre of the bronchial tubes; the smaller 
tubes giving the high notes, and the larger 
ones the deep notes. These sounds continu- 
ally change their position, springing up under 
the listening ear, and as quickly vanishing 
again, to give place to profound silence. 
Progress and Duration.-A paroxysm of 
asthma, when once established, lasts from 
half an hour to several days, and generally 
terminates with expectoration - thin and 
transparent if the seizure be short; but 
abundant and more or less opaque if the fit 
be prolonged, or if the case be chronic. The 
sputum has also been found to contain, in 
greatest abundance at the close of the attack, 
(1) the so-called Charcot-Leyden crystals, 
which are minute octahedra of unknown 
composition, but soluble in warm water; also 
(2) Curschmann's spirals, which consist of 
closely packed epithelial cells, arranged in a 
spiral form surrounded by mucoid material. 
These are not, however, pathognomonic of 
asthma. The urine is light-coloured and 
plentiful; the surface is bathed with per- 
spiration; and flatus is often expelled from 
the bowels. Little or no food is taken during 
the attack, at the close of wdiich the patient 
falls asleep. 
The recurrence of the attacks when once 
they have been excited is generally periodic; 
but much depends on the presence or absence 
of the exciting cause. In many cases the 
patient is quite free from wheezing and dys- 
pnoea in the intervals, and feels and acts like 
other people; but when the attacks follow 
each other closely, a more or less wheezy 
condition remains behind, and a few signs of 
obstructed breathing are generally to be 
detected in the interscapular regions. 
Complications and Sequel®.-If the asth- 
matic attacks become habitual, their effects 
are seen on the patient's frame and on the 
organs implicated. The shoulders become 
raised, the head being buried between them ; 
the muscles of the back, owing to their being 
called on to act as extraordinary muscles of 
respiration, are diverted from their use as 
erectors of the spine, which, accordingly, 
yields in the anterior direction, and the 
patient stoops. The frequent occurrence of 
spasmodic contraction of the bronchi causes 
hypertrophy of their muscular coat; and this, 
with or without the congestion of the mucous 
membrane accompanying it, leads in time to 
thickening of the tubes and permanent nar- 
rowing of their calibre. The more common 
result of asthma is emphysema, arising 
from the difficulty of expiration. The emphy- 
sema, at first temporary, becomes in chronic 
cases permanent, and gives rise to displace- 
ment of the adjoining organs (see Emphy- 
sema). Contraction of the bronchi largely 
influences the pulmonary vessels, and con- 
siderable obstruction of the pulmonary cir- 
culation is the result. The vessels become 
gorged, and the lungs sometimes oedematous. 
If the emphysema be extensive, we may in 
time expect dilatation of the right side of the 
heart and marked prominence of the veins of 
the breast and neck, and the effects may be 
carried so far as to cause oedema of the 
lower extremities with albuminous urine, as 
the writer witnessed in a case where these 
symptoms disappeared on the subsidence of 
the asthma. 
Pathology.-Patients rarely, if ever, die of 
spasmodic asthma, though death may ensue 
from some of its complications and sequelae; 
and the disease, being a functional one, 
cannot be said to have any morbid anatomy. 
The onset and departure of the attack, and 
the ever-changing physical signs, led Laennec 
to think that, whatever obstruction in the 
bronchial tubes caused the phenomena, must 
be of a spasmodic and transitory nature. He 
therefore concluded that asthma was due to 
a spasm of the bronchial muscles which had 
been described by Reisseissen. Laennec also 
showed that an asthmatic sufferer could 
sometimes, after holding his breath, actually 
breathe naturally for one or two respirations, 
thus clearly demonstrating that the spasm 
was capable of momentary relaxation. Other 
theories were put forward, and doubt was 
thrown on the existence of muscular fibres 
in the bronchi, until Dr. C. J. B. Williams 
proved their existence by his experiments on 
the lungs of oxen, dogs, rabbits, and other 
animals, when he caused contraction of the 
trachea and bronchial tubes by the applica- 
tion of electrical, chemical, and mechanical 
stimuli. The muscular coat was shown to 
be more abundant in the smaller tubes than 
in the larger, the former contracting suffi- 
ciently to entirely obliterate their passages. 
In asthma, excitation of the muscles pro- 
bably takes place through the anterior and 
posterior pulmonary plexuses, which are made 
up of branches from the pneumogastrics, 
recurrent laryngeals, the spinal nerves, and 
the ganglia of the sympathetic, thus giving 
the bronchial tubes a very wide area of 
connexions. The branches of the pulmonary 
plexus form a network round the bronchial 
tubes, and contain some minute ganglia. 
When the cause is direct, as dust of any ASTHMA, SPASMODIC 
129 
kind or climatic influence, the spasm may 
be induced by reflex action through these 
small ganglia, or through the pulmonary 
plexus, though it soon extends deeper into 
the nervous system, involving the pneumo- 
gastrics, and causing a motor effect on the 
thoracic muscles through the upper cervical, 
phrenic, and dorsal nerves. Where emotion, 
fright, or laughter starts the fit, the irritation 
is centric, and causes a motor effect on the 
pulmonary plexus through the pneumo - 
gastrics. Where, again, indigestion excites 
it, the sensation passes through the gastric 
branches of the pneumogastric, and is reflected 
by the motor filaments of the pulmonary 
plexus. Lastly, where gout, syphilis, albu- 
minuria, skin-disease, and heredity are the 
excitants, we may regard the blood itself 
as causing the local irritation. Spasmodic 
asthma may, therefore, be considered as a 
neurosis of the pulmonary branches of the 
plexus of that name, similar to other neuroses, 
as hemicrania and sciatica, and giving rise, 
through the motor nerves of the plexus, to 
spasm of the bronchial muscle. 
Diagnosis.-Asthma is distinguished from 
bronchitis by the fugitive physical signs ; by 
the spasmodic character of the dyspnoea; and 
by the scant expectoration. The breathing in 
bronchitis, when at all difficult, is hurried; in 
asthma it is slow, wheezy, and prolonged; 
this feature also contrasting strongly with the 
gasping, panting dyspnoea generally accom- 
panying pneumonia, pleurisy, and some forms 
of heart-disease. From croup it is recognised 
partially, but not entirely, by the age of the 
patient; and partly by the character of the 
dyspnoea, which in croup is inspiratory, 
whereas in asthma it is mainly expiratory. 
This characteristic also distinguishes asthma 
from spasm of the glottis and the various 
forms of laryngeal dyspnoea. The diagnosis 
from emphysema, which is so often mixed up 
with spasmodic asthma, is founded chiefly 
on the paroxysmal character and violence 
of the asthmatic dyspnoea, and on the com- 
plete freedom of the intervals, the dyspnoea 
of emphysema being more or less perma- 
nent. 
Aneurysm of the aorta and other media- 
stinal tumours often give rise to symptoms 
so exactly simulating spasmodic asthma as to 
make the diagnosis difficult, and this is to 
be accounted for by these tumours pressing 
on the pneumogastric and its branches, and 
thus inducing an asthmatic spasm. These 
cases are, as a rule, however, accompanied 
by a certain amount of stridor arising from 
laryngeal spasm, not present in asthma, and 
this symptom is often of great diagnostic 
value in obscure cases. As the tumour 
enlarges, it causes greater pressure on the 
lungs, trachea, oesophagus, sympathetic 
ganglia, or other structures, and produces 
shrill cough, dysphagia, difficulty of inspira- 
tion, pain in the chest, impulse in the thoracic 
wall, and other noted aneurysmal symptoms. 
Moreover, certain physical signs become evi- 
dent, e.g. dulness over the first portion of the 
sternum or to the right of it, or between the 
scapulae; tubular sounds and bronchophony 
close to the sternum, or above one or both 
scapulae ; or some form of bruit or murmur 
in the course of the aorta. These and other 
symptoms and signs contrast sufficiently 
with those of spasmodic asthma, to make the 
diagnosis from developed aneurysm compara- 
tively easy. 
In some cases of renal disease in which 
albumin appears in the urine, a form of 
dyspnoea appears, which is occasionally 
marked by paroxysmal features, and has 
been mistaken for spasmodic asthma. Renal 
dyspnoea differs, however, as a rule, in being 
more continuous; and in having for its origin 
oedema of the lung rather than bronchial 
spasm. See Respiration, Disorders of. 
Prognosis.-The question of recovery in 
cases of asthma depends, to a certain extent: 
first, on the possibility of the removal of the 
exciting cause ; secondly, on the age of the 
patient ; thirdly, on whether the attacks 
increase or not in frequency; fourthly, on 
the condition of the lungs and the breathing 
in the intervals. 
If the patient be young (say, under fifteen), 
the chest well-formed, the attacks tending'to 
diminish in frequency and intensity, and the 
lungs free in the interval, a most hopeful 
prognosis can be given. If, on the other 
hand, the patient be middle-aged, the attacks 
increasing in number and severity, and the 
breathing more or less short in the intervals, 
we may conclude that there exists a consider- 
able amount of permanent emphysema, which 
renders the prognosis of an unfavourable 
character. In every instance the detection 
and removal of the exciting cause or causes, 
as the case may be, exercise a chief influence 
over the prognosis. 
Treatment.-The principal difficulty in the 
treatment of asthma lies in clearly ascertain- 
ing the nature and origin of the exciting cause. 
When this is discovered two great principles 
should guide us, namely: first, to avoid or 
remove the exciting cause ; secondly, to allay 
and prevent the spasm. 
Many of the cases arising from direct 
causes, as from dust and chemical vapours, 
are cured by simple avoidance of the exciting 
cause. Where bronchial inflammation in- 
duces the spasm, the inflammation must be 
subdued by salines and expectorants, com- 
bined with some anti-spasmodic, as bella- 
donna, henbane, or stramonium. In more 
chronic instances, where some thickening of 
the walls of the larger bronchi and enlarge- 
ment of the bronchial glands exist, iodide 
of potassium in doses of grs. v. to xv., or 
iodide of sodium in doses of gr. v., or a 
combination of both iodides, has been found 
very beneficial when persisted in for long 130 
periods. Symptoms of iodism may be 
generally averted by temporarily diminishing 
the dose and diluting more largely with 
water. Inunction of preparations of iodine, 
such as the linimentum potassii iodidi c. 
sapone, or the unguentum potassii iodidi, or 
painting the skin with iodine-tincture, have 
not proved so successful in the writer's hands. 
The waters of Woodhall and Purton in 
England, of Kreuznach in Germany, and 
of Saxon in Switzerland, contain iodides 
largely diluted, and may be beneficially ad- 
ministered in asthma. Affections of the nose 
or throat will require attention. Where the 
attacks depend on gout, syphilis, or renal 
disease, or are connected with skin-disease, 
treatment must be directed to the condition 
of the blood. Arsenic proves of signal ser- 
vice in asthma co-existing with eczema, 
psoriasis, or other skin-affections. 
Where heredity is the predisposing cause, 
the origin of the disease lies generally in 
defective development of the frame or of the 
lung-structure of the patient. For such per- 
sons gymnastic exercises, carefully conducted 
swinging on the trapeze, and other means of 
expanding the upper part of the chest and 
correcting the asthmatic stoop are to be em- 
ployed, combined with tepid or cold sponging 
and as much outdoor life as possible, with 
walking and riding without fatigue. The 
tendency to catarrh is thus lessened, and the 
frame of the patient developed and fortified. 
In a large number of cases-as, for instance, 
those arising from climatic influences-we 
have to treat a simple neurosis, and to allay 
the spasm either by climatic or by medicinal 
means, of which the former is often the more 
important, and, owing to the leading part 
played by the idiosyncrasy of the patient, 
generally the most difficult. In obstinate 
cases the doctrine of contrasts appears the 
only safe one. Where the disease has been 
contracted in a moist climate, a dry one 
must be tried; if in an inland district, the 
seaside must be resorted to ; but for by far 
the majority of asthmatics the atmosphere of 
large towns is suitable, and the smokier the 
air and the closer the streets the more good 
do the sufferers appear to receive. London, 
Glasgow, Birmingham, and Bristol are all 
favourable resorts for cases of neurotic 
asthma; and the points of difference between 
their atmospheres and that of the country 
consist, (1) in dryness; (2) in deficiency of 
oxygen; and (3) in excess of carbonic acid 
and carbon : all of which peculiarities appear 
to exercise a sedative effect on the neurosis. 
Damp, whether of soil or atmosphere, is 
usually found to be hurtful, and is one of the 
chief exciting causes of asthma. Nothing 
exemplifies this more completely than the 
excellent results in cases of asthma pro- 
duced by climates of which the atmosphere 
is dry. 
The medicines most useful in asthma are 
ASTHMA, SPASMODIC 
antispasmodics, either stimulant or sedative. 
The former, including alcohol, strong coffee, 
nitro-glycerine, ether, and nitrite of amyl, will 
prove more efficacious where emphysema is 
present; the sedative comprise stramonium, 
belladonna, Indian hemp, lobelia, datura 
tatula, tobacco, opium with its alkaloids, and 
drugs of a similar action. These may be 
taken internally in the form of extracts or 
tinctures; or smoked in pipes or as cigarettes; 
or inhaled as vapour diffused through the room 
by burning powders or pastilles containing 
them. A popular and often reliable remedy 
is the vapour arising from the combustion of 
nitre-paper, and other useful forms of powder 
may be devised; but these should be recom- 
mended with caution, lest an unfortunate 
habit of indulgence in fuming preparations be 
acquired. In the severest attacks the patient 
can neither smoke nor swallow, and in this 
difficulty of introducing medicines into his 
system we find the hypodermic injection of 
atropine (gr. -), morphine (gr. j-|), and 
chloral, or suppositories of morphine and 
belladonna per rectum, prove effectual; but 
if albuminuria or emphysema be present, or 
if the pulse be weak, they must not be used. 
Chloroform often acts like a charm in the 
worst case, and after inhaling 20 to 60 minims 
the patient will gain the sleep which has been 
denied to him for hours, or even days; but 
as the effect is generally transitory, and the 
use of the remedy not free from risk, it should 
be given, if at all, in capsules containing a 
measured dose. Iodide of ethyl (n{ v-x.) can 
be inhaled with advantage. Ether is safer, but 
not so effective. Chloral hydrate in doses of 
15 to 20 grs., repeated every four hours until 
the spasm subsides, has produced not only 
temporary, but even permanent good in a 
large number of asthmatic cases, and, if 
watched, may be persisted in for some time. 
In the writer's hands it has proved a most 
successful remedy. In the use of anti- 
spasmodics we must avoid judging the effects 
of one from the failure of another of the 
same class; but in difficult cases we must try 
each in succession-for it often happens that 
the successful remedy is only arrived at after 
repeated trials. 
The mineral waters of Mont Dore and 
La Bourboule contain arsenic, and appear to 
act favourably in the more purely neurotic 
cases of asthma, while those of the Pyrenean 
sulphur springs of Eaux Bonnes, Eaux 
Chaudes, and Cauterets, are reputed to exer- 
cise a beneficial influence over the malady, 
but they have not been successful in the 
writer's experience, and it is more probable 
that they relieve by reducing the catarrhal 
symptoms than that they either allay the 
spasm or prevent its recurrence. 
Compressed air baths at pressures varying 
from half to two-thirds of an atmosphere, and 
lasting two hours, are of the greatest benefit 
to asthmatics, and appear to reduce the sen- ASTHMA, SPASMODIC 
ATAXIA-ATAXIC 
131 
sitiveness of the pulmonary plexus and to 
diminish cough and spasm, but they must be 
taken in numbers varying from 24 to 50 to be 
of permanent value. See Air, Therapeutics of. 
The dietetic treatment varies in individual 
cases, but as a rule asthmatics should dine 
early, and for the rest of the day limit them- 
selves to liquid food, such as beef-tea, soups, 
and milk, combined with such an amount 
of stimulant, in the form of a pure spirit, as 
may be necessary, thus avoiding any dis- 
tension of the stomach and intestines before 
retiring to rest. The diet should consist of 
brown bread, dry toast, and biscuits-excess 
of starch in any form being studiously avoided, 
a fair supply of plainly cooked meat, fish or 
poultry, and a limited amount of vegetables 
and fruit, care being taken to select only the 
most digestible of each class. Stimulants 
may sometimes be taken, but with discern- 
ment. C. Theodore Williams. 
ASTIGMATISM (a, priv.; and ariyya, 
a spot or point).-Synon. : Astigmism.-Want 
of symmetry in the anterior refracting sur- 
faces of the eyeball, in consequence of which 
rays of light proceeding from a point are 
not brought to a focus upon the retina as 
a point, but only as a diffused spot. See 
Vision, Disorders of. 
ASTRINGENTS.- Definition.- Me- 
dicines which cause contraction of tissues. 
Enumeration.-The chief astringents are : 
Nitrate of Silver; Sulphate of Copper; Sul- 
phate of Zinc ; Acetate of Lead; Perchloride 
of Iron ; Alum ; Tannic and Gallic Acids, 
and vegetable substances containing them, 
such as Oak Bark, Galls, Kino, and Catechu ; 
and Dilute Mineral Acids. Some authors 
also include m this class of remedial agents 
such articles as Ergot of Rye, which con- 
tracts the blood-vessels and lessens haemor- 
rhage after it has been absorbed into the 
blood, although it has no local astringent 
action. 
Action.-With the exception of gallic acid, 
the substances already mentioned coagulate 
or precipitate albumin. Dilute mineral acids 
do not coagulate albumin, but precipitate 
many albuminous bodies from the alkaline 
fluids by which they are held in solution. 
When applied to a surface from which the 
epidermis has been removed, the other astrin- 
gents combine with the albuminous juices 
which moisten this surface, as well as with 
the tissues themselves, and form a pellicle 
more or less thick and dense, which in some 
measure protects the structures beneath it 
from external irritation, at the same time 
that they cause the structures themselves 
to become smaller and more dense. On a 
mucous membrane they have a similar action, 
and they lessen its secretion. It was for- 
merly supposed that their action was partly 
due to their causing the blood-vessels going 
to a part of the body to contract, thus lessen- 
ing the supply of fluid to it; as well as to 
their effect on the tissues themselves. But 
experiment has shown that, while nitrate of 
silver and acetate of lead possess this power, 
perchloride of iron and alum do not, and 
that tannic and gallic acids actually dilate 
the vessels. The astringent action of these 
latter drugs must therefore be exerted upon 
the tissues. 
Uses. - Astringents may be employed 
locally in various forms. In the solid form, 
as a powder, or in various preparations such 
as lotions, ointments, plasters, glycerines, &c., 
they are applied, especially the metallic 
astringents, to wounds and ulcers for the 
purpose of reducing the size and increasing 
the firmness of exuberant granulations, as 
well as of protecting the surface by forming 
a pellicle over it. They are used to lessen 
congestion and diminish the secretion of the 
various mucous membranes: as a lotion to 
the eye and mouth ; as a gargle or a spray 
to the throat; in the form of an injection to 
the nose, urethra, and vagina; and as a 
suppository to the rectum. Administered 
internally, several astringents have a power- 
ful effect in checking diarrhoea, and certain 
of them may have a local action upon the 
stomach and intestines. 
The remote action of such astringents as 
acetate of lead and gallic acid, when absorbed 
into the blood, in lessening haemorrhage, is 
made available in the treatment of haemo- 
ptysis, haematemesis, haematuria, and loss of 
blood from other parts of the body. 
T. Lauder Brunton. 
ASTURIAN ROSE.-The rose or ery 
thema of the Asturias; one of the numerous 
synonyms of pellagra - Mal de la rosa; 
Lepra asturiensis; 'Elephantiasis asturiensis. 
See Pellagra. 
ASYSTOLE (d, neg.; and avardkr), a 
contraction).-Synon.: Fr. Asystolie; Ger. 
Mangelende Zusammenziehung.-The most 
advanced stage of progressive failure of the 
heart, in which the ventricular walls have 
become so feeble that the systole is incom- 
plete and highly irregular, and the cavities 
are dilated from over-distension with undis- 
charged blood. See Heart, Dilatation of. 
ATAVISM (atavus, a grandfather).- 
The inheritance of a disease or constitutional 
peculiarity from a generation antecedent to 
that immediately preceding. See Disease, 
Causes of. 
ATAXIA 
ATAXIC 
(a, priv.; and ra'^is-, order).- 
Terms which originally meant any irregu- 
larity or disorder, but are now specially 
applied to irregularity of associated or co- 
ordinated muscular movements. The noun 
is frequently used as synonymous with the 
disease known as locomotor ataxy. See 132 
ATAXIA-ATAXIC 
ATROPHY, GENERAL 
Co-ordination, Disorders of; and Locomotor 
Ataxy. 
ATELECTASIS imperfect; and 
tKraaif, expansion).-Absence or imperfec- 
tion of the expansion of the pulmonary 
alveoli which normally takes place at birth, 
the lungs thus remaining more or less in their 
foetal condition. See Lungs, Collapse of. 
ATHEROMA.-See Arteries, Diseases 
of; and Aorta, Diseases of. 
ATHETOSIS (adtros, without fixed po- 
sition).- Definition.-A name given by Dr. 
Hammond, of New York, to a condition in 
which the hand and foot are in continual 
slow, irregular movement, and cannot be re- 
tained in any position in which they may 
be placed. 
Description.-The special character of 
the movements in athetosis is that they are 
slow and deliberate. They usually affect the 
arm and leg on one side only. Voluntary 
power is retained, but is interfered with by 
the slow spasm. The fingers are irregularly 
flexed and extended: at one moment they 
spread wide apart, the thumb being over- 
stretched ; thereafter, first one, then another, 
is bent into the palm, and again extended. 
The movement can be arrested for a moment 
in certain positions by the will, but is re- 
newed with increased force. The foot is 
usually inverted; the toes being flexed or 
extended, but in less constant movement. 
The spasm may cause pain. The muscles 
sometimes become hypertrophied. The move- 
ments in some cases cease during sleep, in 
others they do not. Sensation is often, but 
not always impaired. 
The onset of this condition has been 
sudden in a few cases, but usually the move- 
ments develop gradually after a unilateral 
seizure, whether a slight, sudden hemiplegia, 
or a convulsion. The subjects have been 
generally in middle life. 
Athetosis differs from the spastic contrac- 
ture so common after hemiplegia in children, 
only in the slowness of the movements, 
and in the fact that they are spontaneous 
and not limited to voluntary movement. 
But these distinctions are not absolute. The 
disorder of movement after hemiplegia may 
be identical in character with athetosis, and 
both are essentially the same in relations. 
In what is termed athetosis the cerebral 
lesion is so placed as to cause no distinct 
hemiplegia in most cases; but its occurrence 
is indicated by the sudden symptoms which 
precede the slow movement. It cannot be 
regarded as a distinct disease or even a dis- 
tinct symptom. Typical athetosis may suc- 
ceed hemiplegia. 
Pathology.-It is probable that, as Dr. 
Hammond suggests, the seat of the lesion in 
athetosis is generally the optic thalamus or 
its neighbourhood. The sudden onset of the 
disease and the slight affection of sensation 
are in favour of this explanation of cases in 
which there is no distinct hemiplegia. Char- 
cot believes that all post-hemiplegic chorea- 
like movements depend on the implication of 
fibres outside the optic thalamus. In a case 
of simple ataxy after hemiplegia-an analo- 
gous condition-the writer has found a cica- 
tricial sclerosis extending across the optic 
thalamus, and probably left by a patch of 
softening. The symptoms, perhaps, may be 
produced in various ways, since the regula- 
tion of the motor processes in the cortex is 
complex. One cause of them may be a state 
of perverted action of the motor cells of the 
cortex, due to a deficiency of the upward 
influence from the cerebellum. Another may 
even be partial damage to the motor centres 
themselves. 
Prognosis.-This is unfavourable ; but the 
slighter cases improve and may even approxi- 
mately recover. 
Treatment.-Nervine tonics and sedatives 
are the remedies chiefly indicated. Of the 
former arsenic, and of the latter Indian 
hemp and bromides, may be given. The 
continuous current has been known to lessen 
the spasm, but, as a rule, it fails. The posi- 
tive pole may be placed on the spine or 
brachial plexus, the negative on the muscles 
involved. The action of the continuous 
current is probably in part direct, in part 
reflex, lessening by the peripheral impres- 
sion the over-action of the centre. 
W. R. Gowers. 
ATONY 
ATONIC 
(•}, priv.; and twos, tone).- 
Terms implying want of tone, power, or 
vigour, associated either with such a condi- 
tion of the system generally, or of particular 
organs, especially those which are contractile. 
See Tone, Want of. 
ATRESIA (a, priv.; and TLrprjpt, I pierce). 
Absence of a natural opening or passage, 
whether congenital or caused by disease. 
ATROPHY, GENERAL. - Synon. : 
Marasmus. 
Definition.-Atrophy means, etymologi- 
cally, simply want of nourishment (a, priv.; 
and rpocpr], nourishment), but the term is 
commonly applied to the condition resulting 
from want of nourishment, namely, wasting 
or diminution in bulk and substance, even 
though this may have been produced by some 
other cause, and even though the supply of 
nutritive material may have been abundant. 
General atrophy is used to denote wasting in 
which the whole body participates. All acute 
diseases, if severe, are accompanied by ema- 
ciation, for at such times nutrition is tem- 
porarily interfered with. The use of the word 
' atrophy ' is, however, confined, as a rule, to 
cases where the interference with nutrition 
has been gradual, and the loss of flesh conse- 
quently slow. ATROPHY, GENERAL 
133 
Etiology.-Atrophy is common enough 
at ail periods of life. In infants and children 
it is due, in the majority of cases, to chronic 
functional derangements which interfere with 
the digestion and elaboration of food. Less 
frequently it is a consequence of organic 
disease. In adults general atrophy seldom 
results from any other cause than organic 
disease, and functional disorder as a cause of 
serious wasting is the exception. In old age 
atrophy is a common consequence of the 
degenerations of tissue which accompany the 
decline of life. The interference with nu- 
trition may, however, be aggravated by the 
presence of disease. 
In infants under twelve months old there 
are four principal causes to which persistent 
wasting can usually be referred, namely, 
unsuitable food; chronic vomiting (gastric 
catarrh); chronic diarrhoea (intestinal catarrh); 
and constitutional diseases, such as inherited 
syphilis or tuberculosis. Bad feeding, by 
setting up a chronic catarrhal condition of 
the stomach and bowels, is a frequent cause 
of both vomiting and diarrhoea, but it may 
produce atrophy without either of these 
symptoms. When an infant is fed, for 
instance, with large quantities of farinaceous 
matter-a form of food which is alike indiges- 
tible and innutritions-a very small part only 
can enter as nutriment into the system. The 
remainder passes down the alimentary canal, 
and is ejected at rare intervals in an offensive 
.putty-like mass or in hard roundish lumps. 
The child, therefore, although overloaded 
with food, is really under-nourished, and 
loses flesh as long as such a diet is persisted 
in. If, as often happens, diarrhoea or vomit- 
ing be set up by the irritation to which the 
digestive organs are subjected, wasting is 
more rapid and the danger of the case is 
increased. Not only excess of farinaceous 
matter, but any form of bad feeding will pro- 
duce this result. Wasting, indeed, will be 
found in every case where the food selected 
is unfitted for the child, and thus it is not 
infrequently seen in infants who are fed 
upon milk and water alone. The casein of 
cow's milk is difficult of digestion by many 
infants on account of its tendency to coagulate 
into a large firm clot like a lump of cheese. 
In this respect it differs from the curd of 
human milk, which forms light small floc- 
culent coagula, and is digested without 
difficulty. Special preparation is therefore 
generally required to render cow's milk a 
suitable diet for a young child. 
It is not only, however, unsuitable food 
which is a cause of atrophy in infants. 
Catarrh of the stomach and bowels may be 
present, although the feeding is in all respects 
satisfactory. Infants are excessively sensi- 
tive to chills, and catarrh of their delicate 
digestive organs is easily excited. Now, 
catarrh of a mucous membrane is always 
accompanied by an increased flow of mucus, 
and this alkaline secretion in excess acts as a 
ferment, and sets up decomposition of food. 
A subacute gastric catarrh from this cause 
is not rarely seen in new-born infants, who 
thus are rendered for the time incapable of 
digesting even their mother's milk. In such 
cases the fault is usually attributed to the 
milk, which is said to be unsuited to the 
child; and the mother is compelled, much 
against her will, to wean her baby and feed 
it in a different way. So long as the catarrh 
continues, however, no food appears to agree, 
and the child often after a time dies ex- 
hausted. 
Between the ages of one and three years 
atrophy is commonly associated with rickets. 
In these cases the wasting is noted chiefly 
about the chest and limbs, for the belly is 
large and swollen from flatulent accumulation. 
At this age children are still liable to waste 
from catarrh of the stomach and bowels; 
indeed, rickets is itself often complicated 
by such derangements. Sarcoma of the in- 
ternal organs is also sometimes found at this 
time of life, and is attended with extreme 
emaciation. 
After the age of three years caseous 
enlargements of the mesenteric glands, if 
extensive, may become a cause of wasting. 
After the fifth or sixth year chronic pul- 
monary phthisis begins to appear. Cases of 
heart-disease as a result of acute rheumatism 
are also more frequently seen. Diabetes, 
too, is sometimes met with. All these 
diseases may produce much interference with 
nutrition. 
From the time that the child begins to 
take other food than that furnished by his 
mother's breast, he is liable to worms in the 
alimentary canal. The presence of worms is 
frequently accompanied by loss of flesh, not, 
perhaps, so much on account of the parasites 
themselves, as on account of the derangement 
of the digestive organs which is associated 
with them. Emaciation due to this cause 
may sometimes be extreme. 
In the adult atrophy is rarely the result of 
mere functional derangement, but is almost 
invariably a sign of serious organic disease. 
All chronic ailments are not, however, ac- 
companied by marked wasting. Purely local 
diseases lead to little loss of flesh unless they 
affect some part of the digestive apparatus, or 
of the glandular system which is concerned 
in the elaboration of nutritive material; or 
otherwise directly influence the processes of 
nutrition. Thus, emaciation quickly results 
from gastric ulcer or chronic dysentery, but 
chronic pneumonic phthisis may produce 
little diminution in weight if there is no 
pyrexia, and if the case is not complicated by 
diarrhoea or profuse expectoration. The 
most marked atrophy is produced by the con- 
stitutional diseases, such as cancer, tubercle, 
and syphilis in the third stage; by those 
which set up a persistent drain upon the 134 
ATROPHY, GENERAL 
ATROPHY, LOCAL 
system, such as severe albuminuria, chronic 
haemorrhages, and long-continued suppura- 
tions ; or by those which directly impede the 
passage of nutritive material into the blood; 
and in the latter class of diseases, influences 
which act directly upon the thoracic duct, 
such as obstruction to its passage from 
pressure by aneurysm and other tumours, 
must not be overlooked. There is a form of 
atrophy sometimes seen in hysterical females, 
depending upon disordered innervation, in 
which the most extreme emaciation may be 
reached. Such cases are marked by a dis- 
like to food which may amount to absolute 
loathing. See Neurasthenia. 
Anatomical Characters. - The most 
marked post-mortem appearance in this con- 
dition is diminution or loss of fat, especially 
of the subcutaneous adipose tissue : and this 
is accompanied by wasting of the tissues and 
organs generally. The histological elements 
are reduced in size without undergoing, as a 
rule, actual numerical diminution. With the 
atrophy is often associated a certain amount 
of fatty degeneration. 
Symptoms.-The symptoms of general 
atrophy are loss of flesh, loss of colour, and 
loss of strength, combined with other special 
phenomena arising from the particular dis- 
order to which the impairment of nutrition 
is due. 
Treatment.-The treatment of general 
atrophy consists in removing, if possible, the 
impediment to efficient nutrition. In the 
case of a child the diet must be selected with 
care. Excess of farinaceous food is to be 
avoided, and cow's milk can be diluted, if 
necessary, by admixture with barley water. 
Warm woollen clothing should be insisted 
upon, and special attention should be paid to 
the warmth of the feet. Any gastric or intes- 
tinal derangement must be at once remedied, 
plenty of fresh air should be obtained, and 
perfect cleanliness strictly enjoined. In an 
adult the disease which is the cause of the 
malnutrition must be sought for and sub- 
mitted to treatment. Efforts should be made, 
on the one hand, to arrest any drain upon 
the system; and, on the other hand, by a 
judicious arrangement of the dietary, and by 
attention to the eliminatory organs, to remove 
all obstacles to nourishment. Even in cases 
of organic and incurable disease much benefit 
may often be derived from due observance of 
physiological laws. Eustace Smith. 
ATROPHY, LOCAL.-This condition 
signifies atrophy of a part of the body, which 
may be apparently congenital, or may be 
produced by various causes acting during 
life. It will be convenient to consider local 
atrophy according to the several forms which 
are met with. 
Congenital Atrophy.-Congenital atro- 
phy is that condition in which some part of 
the body never reaches its full standard 
of size. It is more correctly denominated 
arrested growth or congenital smallness. 
When the whole of one side of the body is 
thus affected, a marked and permanent dis- 
proportion between the two sides results. 
This hemiatrophy is, in theory, difficult to 
distinguish from hypertrophy of the opposite 
side, but mostly the paralytic or enfeebled 
state of the atrophic side shows it to be 
abnormal. The limbs are most strikingly 
implicated; while the corresponding side of 
the face and head is sometimes similarly, 
sometimes conversely, affected. In some cases 
atrophy of the opposite half of the cerebrum 
was found on post-mortem examination. The 
same condition may be partial-hemiatro- 
phia partialis, and it then chiefly affects the 
face, or some part of the territory of the fifth 
cranial nerve. These conditions must be 
ascribed to some perversion of innervation 
occurring during development. Other con- 
genital atrophies, local but not Ziemi-atrophic, 
are more probably referred to obstruction 
of blood-vessels during the same process. 
The defective development of the brain in 
cretinism has been attributed to the pressure 
of an enlarged thyroid upon the carotid 
arteries. 
Physiological Atrophies.-These form 
a distinct class, where atrophy of a part of 
the body takes place in the ordinary course 
of development. Such are the wasting of 
the thymus gland in early life, of the 
mammae and sexual organs after a certain 
age. Most commonly the atrophy is here 
closely connected either with the involution 
or perhaps the development of some corre- 
lated organ ; but it is not possible to say 
what the nature of this connexion is, whether 
one of nutrition or innervation. 
Acquired Atrophies.-The conditions 
thus distinguished possess most interest for 
the practical physician. Wasting of any 
part of the body during life, when not physio- 
logical, usually depends either upon some 
interference with the blood-supply, or some 
disturbance of innervation; but to these 
must be added, in the case of organs which 
have an active and continuous function, 
disuse or over-stimulation. Deficient blood- 
supply, which causes atrophy, may be pro- 
duced by the obstruction of a nutrient 
artery, especially if it be gradual, since 
sudden blocking will produce more compli- 
cated phenomena. Constant pressure is a 
cause of atrophy, because it interferes both 
with the blood-supply, and with the vital 
actions of the tissue-elements. Intermittent 
pressure, on the other hand, by causing 
hyperagmia, is more likely to lead to hyper- 
trophy. Moreover, inadequate renewal of 
blood-that is, filling of the vessels, even to 
excess, with venous blood-or venous engorge- 
ment, though at first it may cause enlarge- 
ment, mostly leads to atrophy in the end ; as 
is seen in the granular induration of liver ATROPHY, LOCAL 
AURA 
135 
and kidneys caused by disease of the heart 
obstructing the circulation. Many forms of 
atrophy in old age are clearly dependent 
upon senile obstruction of the arteries, for 
example, that of the skin, spleen, and kid- 
neys. The instances of atrophy from dis- 
turbed innervation are less easy to discrimi- 
nate, except where there is actual paralysis. 
In two distinct diseases, however,-progres- 
sive muscular atrophy and infantile or essen- 
tial paralysis, loss of power in the muscles is 
followed by a remarkable wasting, far more 
rapid than that which results from disuse 
alone. Division of the nerve of a limb pro- 
duces rapid wasting of the muscles no longer 
used, and this is accompanied in the end by 
some diminution in the size of the bones and 
accessory parts. Local atrophy of the skin 
is sometimes seen in regions limited by the 
distribution of a nerve, especially some 
branch of the fifth; and more extensive 
atrophy of one side of the face or head, 
equally marked out by nervous distribution, 
and resembling some cases of congenital 
atrophy, has also, though rarely, been ob- 
served. In such cases the writer has found 
anaesthesia of parts corresponding to branches 
of the fifth nerve, but absence of muscular 
paralysis, such as would be due to affection 
of the seventh nerve. 
Disuse produces atrophy only in organs 
whose functions are active and constant, such 
as nerves and muscle. Nervous tissue wastes 
constantly, and sometimes rapidly, when 
currents cease to traverse it. This is seen 
not only in the nerves of paralysed limbs, 
but even in the nerve-centres, where any 
interruption of the nervous channels, either 
above in the cerebrum, or below in the nerve- 
trunks, is followed by degeneration, ending 
in atrophy, of the whole nervous tract lead- 
ing from the cerebral cortex to the peripheral 
termination-so-called secondary degenera- 
tion of the cord. In muscular tissue the 
wasting is almost as constant, but hysterical 
paralyses make an exception, the helpless 
limbs preserving their nutrition in a sur- 
prising manner. In organs whose functions 
are intermittent or periodic, disuse does not 
appear necessarily to produce atrophy, as is 
seen in the testicles, ovaries, and mammae. 
That excessive stimulation or over-work 
may produce atrophy is seen in degenerative 
diseases of the nerve-centres arising from 
undue mental activity; and of the sexual 
organs from excessive indulgence. Over- 
work of muscles very rarely produces atrophy; 
but the writer has seen instances where 
special muscles were exposed to strain while 
the general nutrition was low. Atrophy of 
muscles is said to occur in soldiers when 
badly fed, after long exhausting marches. 
Unexplained. Atrophies. - Cases of 
local atrophy occur of which it is impossible 
to give any satisfactory explanation. Such 
are the conditions known as linear atrophy 
of the skin; some remarkable cases of atrophy 
of bone, especially of the skull (j'ragilitas 
ossium), and of some parts of the cerebrum. 
Atrophy of the thyroid gland appears to be 
certainly the cause of the disease called myx- 
cedema, but the cause of the original atrophy 
is unknown. 
It is possible that deficiency of special 
kinds of food may lead to atrophy of special 
organs-thus deficiency of lime may make 
the bones soft, and deficiency of iron arrest 
the development of blood-corpuscles; but 
even these familiar instances must be ac- 
cepted with a little reserve. In the same 
way it is still doubtful whether any special 
drugs, such as iodine, can produce atrophy 
of special glands. 
Pathology.-Wasting may occur simply, 
or as a consequence of change of substance, 
or from the intrusion of some new material; 
in other words, there may be simple atrophy, 
atrophy from degeneration, or atrophy by 
substitution. The first is probably rare ; 
generally some change of substance occurs. 
The most frequent degenerative process is 
fatty degeneration; the albuminous substance 
being replaced by fatty matter, which, if 
afterwards absorbed, leaves a void. Organs 
thus affected may be apparently enlarged, 
though the original substance is wasted. 
Atrophy from substitution is seen when the 
connective tissue of an organ, for instance, 
increases, compressing and destroying the 
other tissue-elements; and these not being 
renewed when the newly-formed connective 
tissue contracts, the whole organ is diminished 
in bulk. This is seen in all the changes 
called cirrhosis or fibroid degeneration, as in 
cirrhosis of the liver and kidneys. 
Treatment.-No general rules can be laid 
down for treating all cases of local atrophy. 
Where the blood-supply is deficient, we have 
rarely any means of supplementing it; where 
innervation is at fault, it is seldom under our 
control. In general, harm rather than good 
results from any attempt to attract blood by 
artificial irritation. In the case, however, of 
atrophy from disuse of the nervo-muscular 
system, a line of treatment, and more es- 
pecially of prophylaxis, is very clearly indi- 
cated ; this is, to keep the muscles in exercise 
by artificial means, particularly by electricity, 
or by the processes of friction and kneading 
known as passive motion (see Massage). In 
this way so much of the atrophy as is due 
simply to disuse may be checked for the 
future, and even the former loss reinstated. 
We shall, moreover, never do harm by 
attempting to supply some special elements 
of food which appear to be deficient, as iron 
for the blood and phosphorus for the bones or 
nervous system. J. F. Payne. 
AUDITORY NERVE, Diseases of. 
See Ear, Diseases of; and Hearing, Dis- 
orders of. 136 
AURA 
AUSTRALASIA 
AURA (avpa, a breeze). - A peculiar 
sensation, subjective in origin, immediately 
preceding an epileptic or hysterical convul- 
sion, and named respectively aura epilep- 
tica and aura hysterica. The word was 
originally adopted because the sensation is 
often described as that of the passage of cold 
air or light vapour from the trunk or 
extremities to the head; but it has been 
extended so as to include any phenomenon, 
whether sensory or motor, that ushers in a 
fit of epilepsy or of hysteria. 
AURAL DISEASES. - See Ear, 
Diseases of. 
AUSCULTATION (ausculto, I listen). 
A method of physical examination, which 
consists in listening over various parts of the 
body, either by the direct application of the 
ear (immediate auscultation), or by the aid 
of special instruments (mediate ausculta- 
tion), for the purpose of studying certain 
sounds produced in health and disease. See 
Physical Examination. 
AUSCULTATORY PERCUSSION. 
A method of physical examination, in 
which the sounds elicited by percussion are 
studied by means of auscultation. See 
Physical Examination. 
AUSTRALASIA.-The portion of Poly- 
nesia lying between 10° and 50° S. latitude, 
and 110° E. and 170° W. longitude, which 
may be said to include Australia, Tasmania, 
New Zealand, the Fiji Islands, the New 
Hebrides, and some less important islands. 
Australia.-The climate of the vast con- 
tinent of Australia, which is partly temperate 
and partly tropical, depends, first, on its lati- 
tude, and, secondly, on its conformation, the 
mountain ranges being distributed along the 
coast lines, especially on the eastern shores. 
In the interior, which is comparatively flat, 
and believed to be for the most part a sandy 
desert, there is great heat and little rain. 
The hot winds from the interior are often 
sufficient, in the summer, to raise the ther- 
mometer to 127° Fah., and on the amount of 
protection from these enjoyed by the various 
towns depends their climate. There are 
also sea winds from the N. and N.E. The 
southerly winds, prevailing chiefly from No- 
vember to February, blow from the Antartic 
Circle, and are cold winds of great velocity, 
ending in heavy thunderstorms. In the 
tropical region the rainfall is from November 
to April; and in the temperate, which lies 
to the east and south, it prevails only in the 
winter season. 
The following are among the principal 
towns or centres to which invalids pro- 
ceed :- 
Adelaide, the capital of South Australia, 
lat. 35° S., long. 135|° E. It suffers from 
great heat and drought. The mean tem- 
perature is 65°, the maximum 115°, and the 
minimum, 34°; the range being 81°, and the 
mean daily range 20°. The humidity is GO 
per cent., and the rainfall 21 inches. The 
soil is sandy. 
Brisbane, the chief town of Queensland, 
lat. 27£° S., long. 153° E. The climate is 
almost tropical. The mean temperature is 
70°, the maximum is 108°, the minimum, 34°; 
the range 74°, with a mean daily range of 
21°. The rainfall is 51 inches, and the mean 
humidity 76 per cent. Queensland is for the 
most part elevated; and the climate of the 
Darling Downs, on an average 2,000 feet 
above sea-level, is considered very fine. The 
townships at Toowoomba and Warwick in 
this region may be recommended. 
Melbourne, the capital of Victoria, lat. 38° 
S., long 145° E. It has the reputation of 
being a healthy and agreeable residence; the 
climate being dry and temperate, and far 
cooler in summer than that of Sydney. 
Mean temperature 57°, maximum 1110, mini- 
mum 27°, showing a range of 84°; daily 
range 18°. Mean humidity 72 per cent. 
Bainfall, 26 inches. 
Perth, in Western Australia, very healthy, 
but as yet little suited to the requirements of 
invalids. The temperature is 63° (mean), 
and the rainfall 30 inches in 110 days. 
Sydney, the capital of New South Wales, 
lat. 34° S. and long. 151° E. The climate of 
New South Wales is clear and dry, the tem- 
perature depending more on the altitude than 
on the latitude. The plains in the interior, 
swept by hot winds, are very dry, while the 
coast districts have abundant rain. Mean 
temperature 62'5°, maximum 107°, minimum 
36°; range 71°; mean daily range 14°. Hu- 
midity 72 per cent., and rainfall 50 inches. 
Paramatta, on Port Jackson, is drier and 
cooler than Sydney (Lindsay); and the Illa- 
wara district, including the stations of 
Eden and Twofold Bay, is suitable for 
invalids; but the finest climate in Australia 
for pulmonary cases is to be found in the 
Riverina, a district lying between Queens- 
land, the Blue Mountains, and the central 
desert, consisting of rolling prairie and un- 
dulating downs, with a rainfall ranging from 
5 to 24 inches, the average being 14 inches, 
and a clear bright atmosphere, most exhila- 
rating in its effect on invalids, who at the 
settlements of Deniliquin, Menindee, and the 
various sheep-farms, pursue an open-air life by 
day, and often by night, with great advantage. 
Tasmania. - Tasmania lies 150 miles 
south of Australia, between lat. 40° 40' and 
43° 38', and is mountainous, with a deeply 
indented coast-line. The climate is more 
temperate and equable than that of the 
south coast of Australia. In winter the 
cold is sufficient to produce thin ice in the 
low lands, and snow showers in the higher 
ranges. The mean temperature of Hobart 
Town on the S.E. coast is 54°, the summer 
mean being 62° and the winter 47°. The AUSTRALASIA 
BADENAVEILER 
137 
rainfall varies greatly, from 100 inches at 
Macquarie Harbour on the AV. coast to 24 
inches at Hobart Town, distributed over 
145 days. The prevalent winds are from 
the N.E. and S.AV. The climate is favour- 
able to infant life, and the country is re- 
garded as a sanatorium for invalids. 
New Zealand.-New Zealand lies be- 
tween 34° 50' and 47° 50' S. lat., and con- 
sists of a North and a South besides smaller 
Islands. The North Island is for the most 
part volcanic, and abounds in hot springs, 
which are extensively used, and active craters, 
which impart an important influence to its 
climate. The South Island contains a lofty 
range of snowclad mountains, whose lower 
slopes form on the eastern shore a series of 
terraces known as the Canterbury Plains, 
and other fertile regions. 
The climate is mild and bracing, but deci- 
dedly of a windy character, and not suited 
for all invalids: at Auckland in 1876 no 
calm day was recorded, the prevalent winds 
being AV.S.AV. The mean temperature of 
the North Island is 58°, of the South 54°. 
The maximum varies from 87°, at Christ 
Church, to 75°, at Hokitika, and the mini- 
mum from 25° to 34° in the South Island. 
Cold is as a rule unknown in the North 
Island, while in the South there are a few 
snowy days each year on the coast. The 
rainfall varies from 32 inches in 135 days 
at Christ Church, to 131 inches in 186 days 
at Hokitika. 
Fiji Islands.-The Fiji Islands, partly of 
volcanic and partly of coraline origin, have 
a tropical climate, moderated by the trade 
winds, so that the mean temperature does 
not exceed 80°, the minimum being given as 
65°. The rainfall is chiefly from October to 
April-the hot season, and varies from 124 
to 215 inches in 170 days. See Climate, 
Treatment of Disease by. 
C. Theodore AVilliams. 
AUTOFHONIA (avror, himself; and 
cf)covr], the voice).-A physical sign obtained 
by studying the modifications of the reson- 
ance of the observer's own voice during 
auscultation. See Physical Examination. 
AUTOPSY. See Necropsy. 
AX, in Aridge in Francs.-Thermal 
waters. See Mineral AVaters. 
AZORES ; St. Michael.-Warm, very 
moist, equable climate. Mean winter tem- 
perature 58° F. Prevailing winds N. and 
E. See Climate, Treatment of Disease by. 
AZ OT URI A.-A condition of the urine 
in which there exists an absolute and relative 
excess of urea, without accompanying 
pyrexia. See Urine, Morbid Conditions of. 
B 
BACILLI (bacillum, a little rod or staff). 
Synon. : Fr. Bacilles; Ger. Bacillen. 
The term tiacillus was applied by Cohn to 
the longer rod-shaped bacteria, bacterium to 
the shorter forms; filaments being distin- 
guished as ' leptothrix,' ' vibrio,' &c. But the 
great variety in length of the individual ele- 
ments of the same organism, and the varia- 
tions under different conditions and periods 
of life, rendered such a distinction impossible. 
Hence the term bacillus is now used for all 
the species of schizomycetes which commonly 
have the form of straight rods, although in 
some conditions of growth they may form 
filaments. By some mycologists the term is 
used in a more restricted sense; but it seems 
well at present to use it in this somewhat 
wide manner, until our knowledge allows of 
more scientific classification. See Micro- 
organisms. 
BACTERIA (SanTTjpwv, a rod).-Synon. : 
Fr. Bacteries ; Ger. Bacterien. 
Originally applied to common rod-shaped 
organisms of the class Schizomycetce, and 
especially to one supposed variety called 
Bacterium termo, this name was later ex- 
tended to include the whole of the class of 
schizomycetes or fission-fungi. Thus the 
term bacteriology has been practically ap- 
plied to the whole science of the lower orders 
of chlorophylless algae. But of late, owing 
partly to the confusion involved in the 
double use of the term for the rod-shaped 
organisms and for the entire class ; partly to 
the fact that fungi of other orders than schizo- 
mycetes are related to parasitic disease ; and 
perhaps still more to the dominant influence 
of Pasteur and the French school, the term 
microbes has largely replaced the names 
' bacteria ' and ' micro-organisms '; and for 
the particular species formerly named bac- 
terium x, y, &c., the more accurate terms 
bacillus, spirillum, &c., are used. See Micro- 
organisms. 
BADEN - BADEN, in Germany.- 
Thermal saline waters. See Mineral Waters. 
BADEN, in Austria.-Thermal sulphur 
waters. See Mineral Waters. 
BADEN, in Switzerland.-Thermal 
sulphur waters. See Mineral Waters. 
BADENWEILER, in Germany. 
Simple thermal waters. See Mineral 
AV ATERS. 138 
BAGNERES-DE-BIGORRE 
BALANITIS-BALANOPOSTHITIS 
BAGIN EBES - DE - BIGOBBE, in 
France. - Simple thermal and earthy 
wa ers. See Mineral Waters. 
BAGNEBES - DE - LUCHON, in 
France.-Thermal sulphur waters. See 
Mineral Waters. 
BALANITIS - BALANOPOSTHI- 
TIS (/SaXaros, an acorn; and noadr), the 
foreskin).-Synon. : Bastard Clap ; Blennor- 
rhagia Balani; Inflammatory Phimosis. 
Definition.-Inflammation of the oppos- 
ing surfaces of the glans and prepuce; 
sometimes acute-even gangrenous, and 
sometimes chronic. A purely local affection; 
frequently, but not necessarily, of venereal 
origin. 
Aetiology.-Balanitis is much less com- 
mon than urethritis, being met with at the 
Lock Hospital in the proportion of one to 
twenty-four of the latter. It may be either 
primary; or consecutive to chancres, 
syphilitic eruptions, warts, accumulated 
smegma, variolous pustules, or gonorrhoea. 
When primary, the common predisposing 
cause is a long, tight foreskin. Fournier 
attributes two-thirds of the cases of balanitis 
to a long prepuce with insufficient cleansing; 
about one-third to irritation by chancres and 
gonorrhoeal pus; and a very few to other 
causes. 
Symptoms.-The symptoms of balanitis 
depend on the intensity and extent of the 
inflammation. In the simplest form there is 
heat and itching of the furrow, slight redness 
of that part, with a milky or yellowish secre- 
tion. When the inflammation is more severe 
and extended, swelling and pain are added, 
the other symptoms are more marked, and 
characteristic excoriations appear. These 
excoriations are irregular, shallow, never 
extending deeply, but often coalescing into 
large raw chafings. An abundant yellowish- 
green matter of offensive odour bathes the 
surface. When the urine trickles over these 
excoriations there is severe smarting pain. 
If still further irritated, the foreskin swells 
enormously, is divided at the free border by 
deep creases, and can no longer be turned 
back. Aching, smarting, great tenderness, 
and painful erection, often accompanied by 
constitutional disturbance and fever, are 
present. 
Complications.-The cellular tissue and 
the lymphatic ducts of the foreskin and 
sheath, or the lymphatic glands, may inflame 
to suppuration, to ulceration, and, in persons 
enfeebled by any cause, even to gangrene. 
Sloughing begins on the inner surface of the 
foreskin at the upper part ; seldom to much 
extent, though the whole prepuce, except the 
fraenum, may be lost, and when cicatrisation 
sets in the organ appears circumcised. Para- 
phimosis is caused by imprudent retraction 
of a swollen foreskin. Warts keep up chronic 
posthitis of the furrow. Adhesions, usually 
at the corona and the furrow, may attach the 
prepuce completely to the glans. Thicken- 
ing and phimosis are not uncommon after 
repeated attacks. 
Course.-The duration of balanitis de- 
pends on the anatomical condition of the 
parts. When remedies can be easily applied, 
it is not more than three or four days. With 
phimosis, the course is severe, and the dura- 
tion is indefinite ; even when limited to the 
furrow, posthitis is often obstinate. 
Diagnosis.-This is easy when the parts 
can be exposed. Herpes is distinguished 
from balanitis by small round ulcers, grouped 
on a red area, and limited to one or two 
points of the mucous surface, without general 
congestion. Simple chancre has well-defined 
undermined edges and a spongy surface. 
The syphilitic sore has the indurated base 
and enlarged lymphatic glands. When there 
is phimosis, the discharge may come from 
the urethra or from a chancre. If from the 
urethra, it can usually be seen escaping 
thence, and there is pain along the penis, 
with other signs of urethritis. An ulcer 
under the foreskin is betrayed by a hard and 
tender swelling felt through the skin, and 
after the lapse of a few days consecutive 
sores usually appear at the orifice of the 
prepuce. 
Prognosis. -The prognosis of balanitis in 
the simple form is always good. If the com- 
plaint is secondary or symptomatic, gangrene 
is not uncommon. 
Treatment.-The chief indication is to 
keep the inflamed surfaces separate. After 
washing and thoroughly drying, the excoria- 
tions should be touched with a 10-grain 
solution of nitrate of silver, and a bit of dry 
lint laid on the glans before the foreskin 
is drawn forward. If there is phimosis, 
frequent injections of tepid water, and twice 
daily of a 5-grain solution of nitrate of 
silver, must be thrown to the farthest part 
of the foreskin with a long-nozzled syringe. 
Leeches to the groins, and morphine in- 
ternally, or hypodermically, relieves pain. 
Acupunctures give vent to simple oedema, but 
tend to accelerate gangrene with brawny 
tension and erysipelatous redness. Incisions, 
if needed, should be free; one on each side, 
carried quite back to the furrow. The upper 
half of the foreskin can then be easily turned 
back, and the subsequent deformity is less than 
if the foreskin were divided at the dorsum. 
In paraphimosis, before replacing the swollen 
foreskin, the tension should be relieved by 
acupuncture and astringent lotions, or by 
incisions if needed. Chancres and inflamed 
inguinal glands must be treated with the 
balanoposthitis according to their needs. 
When there is an ulcer, concealed by 
phimosis, and the syringing with warm 
water has cleared away the discharge, an 
injection of 20 drops of the following emul- 
sion (iodoform, 1 part; powdered tragacanth. BALANITIS-BALANOPOSTHITIS 
BATHS 
139 
1 part; glycerine, 3 parts; water, 10 parts) 
rapidly subdues irritation and ulceration. 
If the signs of syphilitic infection be 
present; i.e., the persistence of defined in- 
duration when the general inflammatory 
swelling is subsiding, quill-like thickening of 
the dorsal lymphatic ducts of the penis, and 
multiple enlargement of the lymphatic glands 
in the groin, mercury should be administered 
without delay, in quantity sufficient to bring 
on and maintain slight sponginess of the 
gums. 
Berkeley Hill. 
BALDNESS.- Synon.: Alopecia; Fr. 
Calvitie', Ger. Kahlheit. 
Description.-Baldness or loss of hair 
presents an extensive range of variation in 
degree, from moderate thinness of the hair, 
such as occurs in defiuvium capillorum, 
to complete baldness-alopecia calva or 
calvities, the latter not limited to the scalp 
alone, but involving eyebrows, eyelashes, 
beard, and every hair of the body. Instead, 
however, of being general, baldness may be 
partial, affecting more or less of the surface 
of the scalp for example, the summit and 
forehead in men, and the summit and occiput 
in women. One remarkable form of partial 
baldness has been denominated alopecia 
areata, or simply area, and as this was 
described by Celsus, it has likewise been 
called area Celsi. Area occurs suddenly, 
and is a mere falling-off of the hair over a 
space of circular figure; there may be one 
or more of such areae, and sometimes area 
is only the beginning of calvities. Area is like- 
wise occasionally met with in the whiskers 
and beard. See Alopecia Areata. 
Etiology.-The causes of alopecia are 
exhausted nutritive power of the skin; 
nerve-paresis in the case of area; syphilis; 
and local injury. The alopecia of syphilis 
follows the plan of distribution of its 
exanthem. Partial alopecia may result 
from a blow; from the accidental tearing out 
of a lock of hair; from the sting of a bee; 
from nervous shock ; or from other causes. 
Pathology.-The pathology of alopecia is 
a loss of nutritive power of the skin, some- 
times progressive, and consequent on 
advancing age, as in general baldness; and 
sometimes limited to a nerve-district of 
small extent, as in area. This fact is very 
evident in the latter form, inasmuch as, con- 
joined with the sudden dropping-out of the 
hair, the integument is pale and thin, poorly 
nourished, somewhat anaesthetic, and 
thinner in the centre than at the circum- 
ference ; while the hairs which remain at 
the periphery are altered in structure, 
clubbed and broken off. 
Treatment.-This consists in the restora- 
tion of nerve-power and nutritive power, and 
in local stimulation. The best applications 
for the latter purpose are the stimulating lini- 
ments of the British Pharmacopoeia; e.g. 
liniment of ammonia, compound camphor 
liniment, and the liniments of chloroform 
and mustard; or the acetum cantharidis 
properly diluted for general alopecia, or 
applied with a brush in its concentrated 
form for area. In the treatment of the 
latter, ammonia, turpentine, and the com- 
pound tincture of iodine are likewise useful; 
while for syphilitic alopecia the white pre- 
cipitate ointment with camphor is the best 
local application, conjoined with amti-syphi- 
litic constitutional treatment. See Hair, 
Diseases of. Erasmus Wilson. 
BALNEOLOGY (SaXamor, a bath; and 
Xdyos, a word).-A scientific exposition of all 
that relates to baths and bathing. See Baths ; 
and Hydrotherapeutics. 
BALNEOTHERAPEUTICS (SaXa- 
velov, a bath; and depatrevm, I heal).-That 
department of therapeutics which deals with 
the application of baths in the treatment of 
disease. See Baths ; and Hydrothera- 
peutics. 
BARBADOES LEG.-A form of Ele- 
phantiasis. See Elephantiasis. 
BARBIERS.-A synonym for Beriberi. 
See Beriberi. 
BAREGES, in France.-Thermal sul- 
phur waters. See Mineral Waters. 
BARTFELD, in Hungary.-Alkaline 
saline chalybeate springs, with iodine. See 
Mineral Waters. 
BASEDOW'S DISEASE.-A syno- 
nym for exophthalmic goitre. See Ex- 
ophthalmic Goitre. 
BATH, in Somersetshire.-Simple 
thermal and earthy waters. See Mineral 
Waters. 
BATHS.- Baths may be regarded as 
simple and composite, medicated, or arti- 
ficial. They may be used in the form of 
liquid, vapour, or air. We shall consider 
them under these heads in the following 
description. 
A. Simple Baths.-I. Simple Liquid 
Baths. 
1. The Cold Bath.-By a cold bath is 
meant the immersion of the body in water 
below the temperature of 70° Fh. Anything 
below 50° is considered a very cold bath. 
The first effect of the bath is a sensation of 
cold amounting almost to shivering, with 
slight gasping for breath. If the bath is con- 
tinued for more than two or three minutes, 
the temperature of the skin is diminished; 
and if it is protracted, the blood and the sub- 
jacent tissues lose a little heat, but this does 
not generally occur till after quitting the 
bath. If the cold is intense and prolonged, 
there is a certain degree of numbness of 
the skin; while the pulse becomes small, and 140 
BATHS 
may fall from ten to twenty beats in the 
minute. After a short time (the colder the 
water the shorter), reaction takes place, 
bringing redness to the skin and increase of 
temperature, with a certain amount of ex- 
citement ; but if the bath be continued, the 
depression returns. The immediate action 
of the cold bath is to cause the capillaries to 
contract and repel the blood from the sur- 
face, while by its operation on the peripheral 
extremities of the nerves, it acts upon the 
central nervous system. In its more remote 
effects, the cold bath accelerates the trans- 
mutation of tissues, augmenting the excretion 
of carbonic acid and of urea from the system, 
and, as a consequence, increasing the appetite. 
The body is usually immersed at once in 
cold water, but the shock of this may be 
diminished by first using tepid water, and 
then gradually adding cold to it. 
The effect of a cold bath depends much on 
its duration. Brief immersion, that is for 
three or four minutes, makes both the de- 
pressing and the exciting action less; a 
longer duration, say of ten to fifteen minutes, 
increases both actions; but if the bath be 
very protracted, the continued abstraction of 
heat produces depression only. The effects 
of a cold bath are less intense if the bather 
is able to keep himself in motion, and es- 
pecially if he swims. 
2. The Warm Bath.-A warm bath of 9G° 
to 104° Fh. produces no shock to the system; 
it causes a moderately increased flow of the 
circulating fluids to the surface, augmenting 
the frequency of the pulse; and scarcely 
affects the respiration. There is not the 
depression or the excitement of a cold bath. 
It rather retards the transmutation of tissues. 
With a hot or very hot bath-from 104° to 
114°, the central nervous and circulatory 
systems are more affected. The frequency 
of the pulse increases greatly. The respira- 
tion becomes anxious and quickened. The 
skin is in a hyperaemic condition, and a free 
perspiration breaks out. 
3. The Tepid Bath.-Tepid baths of the 
temperature of 85° to 95° Fh., are intermediate 
between cold and warm. Their effects seem 
to be confined to the peripheral extremities 
of the nerves, and they do not excite the 
nervous centres or the circulatory system. 
Neither the pulse nor the excretions and 
secretions are affected. As no heat is con- 
fined in the system or taken from it, there 
is no reaction, and the body temperature is 
unaltered. 
It need scarcely be said that drying and 
rubbing after a bath materially assist its 
action on the skin; or that, according to 
circumstances, it may be convenient to 
order a whole bath, a hip-bath, or a slipper- 
bath. The foot-bath is a very useful and 
convenient one, • especially when some 
stimulant substance is added to the simple 
water. Wet packing and the various pro- 
cesses of hydropathy, and those powerful 
agents hot and cold affusion, whether as 
shower-baths or as douches, are described in 
the article on Hydrctherapeutics. 
The duration of a bath must depend on a 
variety of circumstances-for instance, on the 
age and constitution of the patient, on the 
nature of his malady, and on the tempera- 
ture of the bath. It may vary from a few 
minutes to many hours. A very hot or a 
very cold bath can be supported for a much 
shorter time than a tepid one. 
Action and Uses.- Cold baths are in- 
dicated for the strong, for youth, and for 
manhood; warm baths for the delicate, for 
women, for early childhood, and for old age. 
Tepid baths are suitable for almost all con- 
stitutions, sexes, and ages. Cold baths may, 
in a general way, be considered tonic and 
bracing; they are useful when judiciously 
employed in many nervous affections, as in 
chorea and hysteria, and they are the best of 
all for general hygienic purposes. Of late 
years they have been specially employed in 
the treatment of fever (see Temperature). 
The great value of warm baths, besides 
their hygienic employment, as better deter- 
gents than cold ones, is in soothing and 
reducing excitement; in relieving spasms, 
such as colic and retention of urine; in the 
convulsions of children, combined with the 
affusion of cold water on the head; in cases 
of gout and rheumatism; and generally when 
action on the skin is desired. Where pro- 
longed immersion is wanted, tepid baths are 
indicated, as in calming many chronic 
nervous disturbances, and in many cuta- 
neous affections. 
As to contra-indications, all baths, and 
especially prolonged and even tepid baths, are 
not suited for the asthenic. Both hot and 
cold baths are to be avoided where there is a 
weak, fatty heart, or any tendency to apoplexy. 
No one should ever enter a cold bath when 
exhausted, and such baths are also contra- 
indicated when there is a tendency to con- 
gestion of internal organs. Under such 
circumstances a warm bath is usually both 
safer and more refreshing. The too long 
and too frequent use of hot baths is debili- 
tating. 
II. The Simple Vapour Bath.-A 
vapour bath is one in which the skin is 
exposed to the action of hot water presented 
in the form of vapour. The vapour bath 
may be taken in a box with the head included 
or not; or in the more common form of the 
Turkish or Russian baths, where a large 
room is filled with vapour, and where there- 
fore the vapour is inhaled; or by vapour 
obtained from a small and suitably constructed 
apparatus, which vapour may be diffused over 
the whole body or directed to a particular 
part. A very simple apparatus for the vapour 
bath may be prepared by placing under a 
chair a shallow earthenware or metallic pan, BATHS 
141 
containing boiling water to the depth of 
three or four inches, and from which abundant 
vapour can be obtained by placing in it one 
or two red-hot bricks. The patient sitting on 
the chair, surrounded by blankets and other 
suitable covering, will receive the full benefit 
of a vapour bath. Vapour baths produce 
profuse perspiration, and act in cleansing the 
sain much as hot-water baths do, only more 
powerfully. Vapour being a slow conductor, 
does not act so fast on the body as water. 
Vapour baths can be borne hotter than warm- 
water baths, but their use cannot be con- 
tinued so long, as vapour interferes with 
radiation of heat from the body. In such 
baths a heat of more than 122° Fh. is not 
borne comfortably. The vapour bath, though 
falling considerably short in temperature of 
the air bath, raises the heat of the blood some- 
what more. The great virtue of these baths 
lies in their sweat-producing properties. The 
average loss of perspiration by the use of a 
Russian bath has been set down at from § lb. 
to 3 lbs. In the Russian bath a slight degree 
of stimulation of the skin is caused by switch- 
ing it with twigs of birch, and the alternation 
of depression and excitement of the cold bath 
is obtained by placing the patient, when in a 
state of profuse perspiration, under a douche 
of cold water. 
III. The Simple Hot-Air Bath.- 
There are two forms in which the hot-air 
bath is administered: according as the patient 
does or does not breathe the heated air. The 
action of the former closely resembles that of 
a vapour bath, but differs from it in not 
impeding the respiration, as the latter does 
by depositing moisture in the bronchial tubes. 
The lungs, instead of requiring to heat up the 
inspired air, are subjected to a temperature 
above their own. Hot-air baths favour the 
highest degree of perspiration, while the 
moisture of vapour baths somewhat retards 
it. If they are very hot, they raise the tem- 
perature of the body by several degrees. 
As the arrangements for vapour and hot- 
air baths are practically the same (except 
that in the latter it is attempted to exclude 
all vapour from the calidarium or suda- 
torium, the hottest room), the following 
description of an ordinary hot-air bath, the 
arrangements of which are closely copied 
from the Romans, will answer for both. 
The patient, after unclothing, first goes into 
the tepidarium, which has a temperature of 
113° to 117° Fh., in which he remains until 
the perspiration bursts forth, which happens in 
from twenty-five to forty minutes. He next 
proceeds to the hottest room or calidarium 
(in which the air is heated by hot-air pipes 
which are inserted in the walls), of a tempera- 
ture of 133° to 140° Fh., and remains there 
until the perspiration runs down his skin, in 
twelve to eighteen minutes. An attendant 
then rubs off the perspiration with a woollen 
glove, and kneads all the muscles for four or 
five minutes. The patient next betakes him- 
self to the lavacrum, where he has water 
poured over him of the temperature of 81° to 
86° Fh.; next, the whole body is soaped over, 
the suds are rubbed off, and the patient goes 
to the frigidarium, where he lays himself on 
a couch and waits till his skin is completely 
dry. This may occupy twenty-five to thirty 
minutes, when the patient dresses and leaves 
the bath greatly refreshed. 
Such is a brief account of these baths, the 
revived use of which is at present so general. 
The arrangements vary in detail. For 
ordinary purposes it is easy to furnish either 
vapour or hot-air baths. A great variety of 
apparatus have been invented for this pur- 
pose, which resolve themselves into this, that 
the patient should lie in bed or on a seat, 
and have the bedclothes or other covering 
secured from contact with him by the em- 
ployment of a framework or cradle. Beneath 
this hot air or vapour is introduced, either 
directly or indirectly, from a suitable ap- 
paratus. 
The Sand Bath.-We may here mention 
baths of sand, which are a very old remedy. 
Of late years establishments for supplying 
them have sprung up in various towns. 
They are a convenient way of applying dry 
heat either locally or generally, and are 
employed in chronic rheumatism. Bags 
filled with heated sand (or salt) are useful in 
hospital and in domestic practice. 
Uses.-Both hot-air and vapour baths are 
indicated when increased action of the skin 
is desired. They are used most for the cure 
of catarrhs, of neuralgic and rheumatic pains, 
and sciatica. They have also been much 
employed for reducing obesity. They are 
useful for general hygienic purposes, but are 
apt to be given too indiscriminately. Hot-air 
and vapour baths are often locally applied 
with great advantage to a hand, or leg, or 
arm, in rheumatism or thickened joints. 
B. Composite, Medicated, or Artificial 
Baths.-A great variety of substances have 
been used in baths at different periods. We 
must confine ourselves to such as are at 
present in use and appear to be of real value, 
omitting even some that are employed, such 
as baths of iodine, of iodide of potassium, of 
iron, of fermented grapes, and of whey. 
I. Composite Liquid. Baths. 
1. The Sea-Water Bath. - The average 
amount of salts in sea-water may be set down 
at 3 per cent.; this may therefore be con- 
sidered a suitable strength for ordinary salt 
baths. The quantity commonly used in 
London hospitals is about 9 lbs. of salt to 30 
gallons of water. Some use bay salt, others 
Tidman's. Owing to the high price of sea-salt 
in inland continental places, various natural 
salts, some of them containing a compara- 
tively small amount of chloride of sodium, 
have been suggested as substitutes; and also, 
for economy's sake, 22 to 25 gallons have 142 
BATHS 
been set down as a minimum amount of 
water for the bath of an adult. The value of 
these substitutes can only be determined by 
observing the degree in which they stimulate 
the skin. Apparently it does not matter 
much what particular salt is employed to 
produce the stimulation. A salt bath can of 
course be increased to any strength by the 
addition of salt, or of the mother lye as it is 
termed. 
The chief uses of salt-water baths are as 
tonic remedies, especially for the young, 
when there is any tendency to scrofula or 
chlorosis; also in convalescence from many 
diseases. 
2. Alkaline Baths.-Alkaline baths may 
be made by adding G ounces of crystallised 
carbonate of sodium, or 3 ounces of carbonate 
of potassium, to 25 or 30 gallons of water. 
Alkaline baths are of use in a great variety 
of cutaneous affections. 
3. The Corrosive Sublimate Bath.-Baths 
of corrosive sublimate are occasionally em- 
ployed. They are commonly made by adding 
3 drachms of corrosive sublimate and 1 
drachm of hydrochloric acid to 30 gallons of 
water. They are employed in some skin- 
affections, and in secondary syphilis. 
4. Sulphuret of Potassium Bath.-Baths 
of sulphuret of potassium are made by dis- 
solving from 4 to 8 ounces of that salt in 25 
to 30 gallons of water. A little diluted sul- 
phuric acid is sometimes added. These 
baths have long been extensively employed 
in the treatment of cases of skin-disease 
in which the sulphur they contain is indi- 
cated. 
5. The {Nitro-Muriatic Acid Bath.-The 
nitric or rather nitro-muriatic acid bath is 
made by adding nitro-muriatic acid to water. 
The ordinary proportion is one ounce of acid 
to one gallon of water. The discolouring 
action on clothing makes a full bath of this 
kind inconvenient for domestic use, and it is 
best to take it in a bathing establishment. 
For the ordinary purposes of a foot-bath at 
home the old directions of Dr. Helenus Scott, 
who introduced the use of the acid, are suf- 
ficient. The vessel must of course be of wood 
or earthenware. Dr. Scott added four to six 
ounces of the acid to three gallons of water. 
This made a rather strong foot-bath. The 
patient was to keep his feet immersed for 
thirty minutes; and the bath was to be re- 
peated every other day for two or three weeks. 
The axillae, the groin, and the region of'the 
liver were to be sponged with the acid solu- 
tion. The bath causes slight tingling of the 
skin and a taste in the mouth, and is believed 
occasionally to produce salivation. This bath 
has been used very extensively in India and 
in England in liver affections. There is dif- 
ference of opinion as to its value; many have 
great confidence in it. 
G. The Bran Bath.-The bran bath is 
made by boiling four pounds of bran in one 
gallon of water, straining, and adding the 
liquor to a quantity of water sufficient for 
a bath. Such a bath is usefid in allaying 
irritability of the skin, and also in diminishing 
the stimulating effect of other baths. 
7. The Fucus Bath.-This is made by 
adding a decoction of sea-weed, or the sea- 
weed chopped up, to an ordinary bath; it will 
become more or less gelatinous if enough be 
added. Such baths go popularly by the name 
of Ozone Baths; and they contain a certain 
amount of chloride of sodium and a minute 
proportion of iodine. They are useful in the 
same cases as sea-baths. 
8. The Mustard Bath. - An extremely 
useful stimulating bath is the well-known 
mustard bath, which is made by adding a 
handful or two of mustard to the ordinary 
hot-bath. The pediluvium is its most useful 
form. 
9. Pine Baths.-Baths of the balsam of 
pine-leaves may be prepared extempore by 
making decoctions of the fresh leaflets at 
certain seasons ; but the usual way is to add 
about one pound of the extract, which is 
prepared from the leaves, and is everywhere 
for sale-at least in Germany. The extract 
dissolves in the bath, which is then ready for 
use; but of late it has been usual to add a 
small amount of an essence which is also 
prepared from the leaflets. It floats to the 
surface of the water, and attaches itself to 
the person on leaving the bath, and its aroma 
is grateful. Of course the quantity of the 
extract to be employed depends on its 
strength. These favourite baths are now 
more and more largely employed at all 
bathing establishments in every corner of 
Europe. They are slightly stimulant, and 
are much used in hysterical, rheumatic, and 
gouty affections, and also as an adjunct to 
the internal use of mineral waters. 
10. Baths of Conium, Lavender, de.- 
Aromatic or sedative baths are prepared by 
adding a decoction of lavender, hyssop, or 
conium to an ordinary bath. 
It is scarcely necessary to add that, as a 
rule, all composite liquid baths should be of 
a temperature a little above the tepid; and 
that their strength, and the time that the 
patient is to remain in them, must be deter- 
mined by the special circumstances of the 
case. 
II. Composite Vapour Baths. - 
Vapour baths impregnated with fir balsam 
are popular, and are considered to be more 
powerful in their operation than pine baths. 
The vapour which rises in making the decoc- 
tion of pine leaves is conveyed to a box in 
which the patient is enclosed. 
Aromatic vapour baths may be given by 
making the steam of hot water pass through 
bunches of fresh aromatics {conium, lavender, 
&c.) before reaching the box in which the 
patient is placed. Such baths may be usefid 
m hysteria. BATHS 
BERIBERI 
143 
III. Composite Air Baths. 
1. Sulphurous Acid Bath.-A valuable 
mode of applying sulphur in the form of a 
bath is by using its fumes-in other words, sul- 
phurous anhydride. The patient is seated on a 
cane-bottomed chair, and his body is encircled 
with a cradle, over which oil-cloth is thrown, 
the head remaining uncovered. Sulphur is 
placed on a metallic plate, to the lower surface 
of which the flame of a lamp is applied, when 
sulphurous acid is disengaged. This bath is 
less used in cutaneous affections than formerly. 
2. The Mercurial and Calomel Baths.- 
Very similar is the mode of applying the fumes 
of mercury. Under the chair are placed a 
copper bath containing water, and a metallic 
plate on which are put from 60 to 180 grains 
of the bisulphuret or of the grey or red oxide 
of mercury. Spirit-lamps are lighted under 
the bath and under the plate. The patient 
thus experiences the effects both of aqueous 
and of mercurial vapour. At the end of five 
or ten minutes perspiration commences, 
which becomes excessive in ten minutes or 
a quarter of an hour. The lamps are then 
to be extinguished, and when the patient 
becomes moderately cool he is to be rubbed 
dry. He should then drink some warm liquid 
and remain quiet for a time. This has often 
been a favourite mode of treating secondary 
syphilis with some practitioners. Calomel, 
in quantities of from 20 to 30 grains, is ad- 
ministered in a similar manner, under the 
name of the calomel bath. It may be given 
locally by a suitable apparatus. 
IV. Electrical Baths.-Electricity is 
an extremely useful aid in the thermal treat- 
ment of paralysis ; and Electro-Galvanic 
Baths are often connected with other bathing 
establishments, it being a very popular prac- 
tice to galvanise a patient in water-baths 
between the poles of a battery. See Elec- 
tricity. John Macpherson. 
BATHS, Natural. - See Mineral 
Waters. 
BATTAGLIA, in the province of 
Venice in Italy.-Thermal muriated saline 
waters, with sulphate of lime. See Mineral 
Waters. 
BEAUFORT WEST, in Cape 
Colony.-See Africa, South. 
BED-SORE.-Nee Ulcer; and Ulcera- 
tion. 
BELL-SOUND.- A peculiar physical 
sign associated with pneumothorax. See 
Physical Examination. 
BELL'S PARALYSIS (named after 
Sir Charles Bell).-A synonym for paralysis 
of the facial nerve. See Facial Paralysis. 
BERIBERI.-Synon.: Barbiers; Kakhe; 
and numerous other local names. 
Definition.-A disease characterised by 
anaemia, anasarca, degeneration of muscular 
tissues, effusion into the serous cavities; 
debility; numbness, pain, and paralysis of 
the extremities, especially the lower; prae- 
cordial anxiety, pain, and dyspnoea; scanty 
and high-coloured urine; and in some cases 
drowsiness or sleepiness. 
Beriberi occurs in a chronic and an acute 
form; in the latter often proving rapidly 
fatal from exhaustion, syncope, or the forma- 
tion of cardiac or pulmonary coagula. There 
are two forms, the wet (beriberia hydrops), 
in which there is a hydraemic condition of 
the blood and distension of the areolar tissues 
generally with serum, giving the body a 
bloated appearance; and the dry (beriberia 
atrophia), in which there is a notable de- 
ficiency of fluid in the vessels and in the 
areolar tissues, and early atrophy of the 
muscles. 
Etymology.-The etymology of the word 
Beriberi is obscure. Bher-bheri, a Hindi 
word, signifies a sore, a swelling. Some 
persons believe that it is derived from a 
Cingalese word beri, meaning weakness; beri- 
beri signifying great weakness. 
Geographical Distribution. - Beriberi 
prevails endemically in Ceylon; and in India, 
on the Malabar Coast, and in the Northern 
Circars, between 13° and 20° N. latitude, 
extending inland from forty to sixty miles. 
It is known in other parts of India, probably 
occasionally all over the peninsula; in Bur- 
mah, and the Malayan peninsula ; amongst 
the crews of ships trading to ports in the 
Persian Gulf, Red Sea, coast of Africa, Bay 
of Bengal, Singapore, China, Siam, and the 
islands of the Indian Archipelago, and in the 
Australian seas. On the West Coast and other 
parts of Africa beriberi also occurs, and is 
known as the sleeping sickness. In Europe 
pernicious ancemia resembles the same dis- 
ease. Beriberi is also met with in South 
America, and probably wherever certain con- 
ditions of food, water, soil, climate, and mode 
of life coexist. 
2Etiology.-All observations tend to show 
that beriberi occurs where causes of debility 
have for some time operated, especially in 
the climates and localities previously men- 
tioned, such as certain conditions of soil, air, 
and water; exposure to great alternations of 
temperature, especially when accompanied 
by wet, fatigue, mental and physical depres- 
sion ; food deficient in quantity and quality 
or variety; previous exhausting diseases; 
malaria, and other undefined atmospheric 
and telluric influences-all, in fact, that 
tends to depress the vital energies, impoverish 
the blood, and starve the nerve-centres. As 
regards a specific origin of the disease, 
Ogata and de Lacerda claim to have found 
bacilli in the blood in five out of seven cases 
of the disease, and to have cultivated them. 
They are said to be similar to, but somewhat 
smaller than those of, anthrax ; and inocula- 
tion of mice, rats, and monkeys is said to 144 
BERIBERI 
have been followed by symptoms character- 
istic of beriberi. It would be premature, in 
the present state of the investigation, to 
regard their causal relations as established. 
The symptoms, it is said, seldom begin to 
appear within ten months or a year after first 
exposure to the exciting causes. Beriberi has 
been ascribed by Ranking to disease of the 
kidney, but there is no evidence to prove that 
it is due to this cause, or indeed to structural 
changes of any of the viscera. Morehead 
refers it rather to a scorbutic origin, and in 
some respects it does resemble scurvy; it 
may, probably, also, be a consequence of 
the cachexia that so often results from long 
residence in a malarious climate, especially 
when that has been accompanied by exposure, 
privation, and excessive exhaustion of the 
vital powers. In such, the most complete 
anaunia, with debility, may occur indepen- 
dently of the existence of organic visceral 
disease, though naturally the symptoms will 
be intensified where such disease is present. 
An important contribution to our knowledge 
of beriberi has recently (January 1890) been 
made by Surgeon Thomas of the Indian 
Medical Service. He says that, in a very 
large number of cases he met with, the 
proximate cause was the presence of anky- 
lostoma duodenale in the intestinal canal, 
and that the severity of the disease was 
in proportion to the number of parasites 
present. He refers to the discovery by 
Ogata, of Tokio, of a specific bacterium, and 
to the statement of Drs. Pekelharing and 
Winkler of Utrecht, that the cause of beriberi 
is a micrococcus, so that it is an infectious 
disease. 
Anatomical Characters.-Serous fluid is 
effused generally-in the areolar tissue, in 
the lungs, brain, heart, and abdominal vis- 
cera. The cavities are, like the tissues, 
soaked with watery effusion. The tissues are 
soft and degenerate. Muscular fibre is fatty, 
especially that of the heart, which is often 
enlarged and dilated. The kidneys are 
enlarged, anaemic, and softened. 
Pathology.-The discovery, by the late Dr. 
T. Lewis, in India, of the embryo of a nema- 
tode worm in the blood of persons suffering 
from chyluria (see Chyluria), lymphorrhoea, 
and elephantiasis, of which diseases it appears 
to be, to some extent, the cause, suggests 
the inquiry whether a similar hematozoon 
may not also be in some way concerned in 
inducing beriberi. Fonsagrives and Leroy 
de Mericourt describe beriberi as general 
dropsy with a rapid course, weakness and 
loss of sensibility in the lower limbs, but no 
albuminuria. Dropsy commences as anasarca, 
and extends to the serous cavities. Though 
hepatic, splenic, or renal complications may 
exist, and intensify the severity and hasten 
the progress of the general symptoms, they 
are not essential concomitants of the disease, 
but appear to originate in a spanaemic state 
of the blood, and to be kept up by its pro. 
gressive imperfect elaboration. The resulting 
partial starvation of the cerebro-spinal nerve- 
centres, and the serous effusion into and 
amongst them, sufficiently account for the 
paralysis which, in severe cases, characterises 
this disease.1 
Symptoms.-Beriberi presents itself under 
a chronic and an acute aspect, rarely, it is 
said, occurring in either form until after 
an exposure of some months to the exciting 
causes. The general symptoms may be said 
to be those of anaemia and anasarca. CEdema 
pervades the limbs and body generally, ac- 
companied with numbness, pain, heaviness, 
and loss of power, amounting in some cases 
to paralysis. Along with these symptoms 
there occur praecordial anxiety, dyspnoea, 
irregularity and palpitation of the heart, 
pain at the ensiform cartilage, anaemic mur- 
murs, debility, and a small quick pulse, 
which at the outset may be rather hard and 
full, accompanied by dryness and heat of 
skin. The appetite is at first not impaired 
1 Since the present article was written, 
certain very recent advances in neuro-patho- 
logy have made it possible to speak more 
decidedly on the relation of the nervous sys- 
tem to beriberi. The elaborate researches of 
Baelz and Scheube in Japan, and of Pekel- 
haring and Winkler in Java, go far to elu- 
cidate this matter. In the light of these 
researches it may be said that, whatever 
the exciting and predisposing causes may be, 
the brunt of the disease falls in the first in- 
stance, and mainly, on the peripheral nerve- 
fibres. In beriberi the peripheral nerves are 
invariably found in a state of well-marked 
degeneration; and the farther from the cord 
the more pronounced the degeneration. That 
the neuritis is of a peripheral character is 
proved by the absence of degenerative or 
other changes in the brain, cord, and anterior 
nerve-roots; and also by the arrest, for the 
most part, of the degenerative changes at the 
intervertebral ganglia, which shows that the 
degeneration is an ascending not a descend- 
ing one. Pekelharing and Winkler have also 
shown that the electrical signs of nerve-de- 
generation can be elicited in cases of impend- 
ing beriberi during the premonitory stage. 
Thus beriberi may be defined as a specific 
endemo-epidemic, multiple peripheral neu- 
ritis ; and classed with the neurites associated 
with lead, alcohol, diphtheria, &c., which it 
so closely resembles. In this way the patho 
gnomonic combination of symptoms may re- 
ceive a satisfactory explanation: implication 
of the spinal nerves causes the paresis and 
anaesthesia; implication of the vaso-motor 
nerves causes the oedema; and involvement of 
the vagus, the cardiac plexus, and the phrenic 
accounts for the laryngeal symptoms, the 
palpitations, and the breathlessness.-Editor. 145 
Later there is coldness of the extremities; 
torpor of the bowels; scanty, high-coloured 
urine, of sp. gr. 1020 to 1040, but no albu- 
minuria as a rule. According to Horton 
and others, excessive drowsiness and stupor 
attend some stages of certain cases of the 
disease; also pale, flabby tongue, and blanched 
mucous membranes ; occasionally haemor- 
rhage from the stomach and bowels; with 
petechial eruptions; an anxious look; a puffy, 
swollen, and sometimes livid face; and a 
peculiar tottering gait. Death results rapidly 
in some of the acute cases, with symptoms 
of effusion into the thoracic and abdominal 
cavities, or within the skull, by exhaustion, 
syncope, or the formation of coagula, either 
in the systemic or in the pulmonic circula- 
tion. Beriberi frequently assumes a slight and 
modified form, indicated by anaemia, numb- 
ness, and a certain amount of pain in the limbs; 
an anxious expression; disordered bowels; 
scanty urine; cold skin; a low, feeble, and 
irregular pulse; praecordial pain or uneasi- 
ness, with palpitation; nervous depression; 
an unsteady, almost tottering gait; and a puffy 
face and neck. Dr. Paul says : ' I have met 
with a numerous class of cases that are not 
so serious (as the acute) or so often fatal, 
where the chief symptom complained of was 
burning of the feet.' Malcolmson describes 
this remarkable condition in connexion with 
beriberi, to which, he says, it is allied-it is 
found to affect the soles of the feet and 
calves of the legs, the back, and occasionally 
the muscles of the legs. It occurs in recent 
and slight examples of beriberi, and was 
originally observed in the troops after the first 
Burmese war-sometimes in men who had 
not had beriberi. On the whole, Malcolmson 
thinks it is neither rheumatism nor beriberi, 
and may accompany or follow other diseases, 
as an indication of nervous debility. 
In the acute forms of beriberi the symp- 
toms are very severe and often rapid; and 
the mortality would indicate it to be second 
only to cholera in fatality. The chief symp- 
toms are:-Rapid general anaemia and dropsy 
of the cavities; scanty, almost suppressed 
urine; constipation ; weak, irregular pulse ; 
intense praecordial pain; hurried, irregular, 
and painful breathing; occasional vomiting 
-sometimes of blood; swelling of the limbs, 
with numbness, pain, and paralysis, accom- 
panied by a feeble, tottering gait; and all the 
symptoms of pleuritic and pericardial effu- 
sion ; failing heart; and death either from 
syncope, or perhaps almost suddenly from 
embolism-in the most acute cases within 
a few days. In this acute form the affection 
is very fatal, but in the milder and more 
chronic form recovery is frequent. Acute 
symptoms often supervene in those who have 
suffered from the milder disease, or in those 
who are exhausted and anaemic from other 
causes. 
Thomas prefers, to the usual classification 
BERIBERI 
of beriberi into the wet, dry, and the mixed, 
the following: acute, sub-acute, and chronic. 
The symptoms of the acute form are py- 
rexia, rapid anaemia, and anasarca ; dyspnoea; 
dulness on percussion; cough and expectora- 
tion ; scanty urine; effusion into cavities, 
pleural and pericardial; peripheral paralysis 
well-marked, and great nervous depression. 
The sub-acute form is characterised by 
epigastric pain, loss of power in lower ex- 
tremities, wasting of muscles, loss of irri- 
tability, loss of patellar tendon reflex; the 
face is puffy and swollen; the lower limbs 
are cedematous; there is tremor of lips and 
hands; decubitus on back and right side; 
dyspnoea, vomiting, and jaundice are present; 
haemic murmurs are heard over the heart; 
the apex-beat is indistinct, without signs of 
hypertrophy or dilatation. Mental debility 
is marked. 
In chronic beriberi there is no rise of tem- 
perature ; the face is puffy, swollen, and 
livid ; there is tenderness of the adductors of 
the thigh and the gastrocnemius; anaemia, 
palpitation, and anorexia; the pulse is quick 
and small; aortic murmurs may be heard; 
oedema is present in the lower limbs with 
induration, pain, and numbness. The gait is 
tottering; the heart is dilated or hyper- 
trophied. 
Treatment.-Attention to diet, suitable 
clothing, and protection against vicissitudes 
of temperature, wet, and cold, are the best 
preventive measures against beriberi. Bad 
hygiene and exhausting habits of life tend to 
promote the development of the constitutional 
condition in which the disease commences. 
When beriberi is established, these precau- 
tions are still necessary, and attention must 
be paid to the symptoms as they occur. 
Diuretics and diaphoretics relieve the oedema 
and dropsical effusions. Tonics and stimu- 
lants give vigour to the weakened muscular 
fibre; while appropriate remedies and diet 
may improve the condition of the blood. 
Acetate of potassium, digitalis, and squill, 
and occasionally calomel, are said to favour 
the removal of the fluid. It is needless to say 
that the physiological action of mercury is to 
be avoided. Salines, hot-air baths, diapho- 
retics, and turpentine may at various stages 
be found useful.. The object being to remove 
the fluid and strengthen the muscular fibre, 
quinine, iron, and other tonics are an im- 
portant element in the treatment. No reme- 
dies, however, will be of much avail unless 
the patient be placed in favourable hygienic 
conditions. Malcolmson speaks highly of two 
remedies-treah farooh, and oleum nigrum, 
which are considered to be very effective in 
the treatment of the disease, especially in 
relieving the dyspnoea and oedema, which 
proved very fatal until these drugs were in- 
troduced. The composition of the treah is 
apparently generally unknown-it seems to 
be diuretic and stimulating, and probably 146 
BERIBERI 
BILE, DISORDERS OF 
not aperient unless combined with rhubarb, 
in doses of four to fifteen grains. The oleum 
nigrum is a stimulant and diaphoretic, given 
thrice daily, and has been found by Indian 
physicians to be very beneficial in some cases 
of beriberi. Sir William Aitken says that 
turpentine is a useful remedy. Ergotin, iron, 
and belladonna with zinc in the form of a pill, 
accompanied with sea-bathing, were useful in 
this disease as seen at Bahia. Nux vomica 
has often been found serviceable in the later 
stages of certain cases, as might be expected; 
and opium may be needed to allay pain and 
irritability. Hepatic and splenic complica- 
tions need their appropriate remedies. Ob- 
viously the chief indications are to regulate 
the functions of the abdominal viscera; to 
promote removal of the oedema ; to increase 
the action of the skin; and to give tone and 
vigour to the muscular fibre. By such mea- 
sures can we alone hope to deal successfully 
with this profound form of cachexia. 
Thomas believes that the first indication 
of treatment is the expulsion of the parasites, 
for which purpose he recommends frequently 
repeated small doses of calomel, with the 
administration of thymol to destroy the 
entozoa; the use of purgatives, also, such as 
jalap, elaterium; subsequently tonics-iron, 
quinine, and strychnine. For internal effu- 
sion of serum paracentesis may be performed. 
In some cases pericardial effusion has been 
beneficially treated by removal of the fluid by 
puncture with a small trocar and cannula. 
Change of climate is of great importance, 
as well as careful attention to diet and other 
measures for maintaining or restoring the 
general health. Joseph Fayrer. 
BETHESDA SPRINGS, in Wauke- 
sha County, Wisconsin, U.S.A.-Calca- 
reous waters. See Mineral Waters. 
BEX, in Switzerland.-Strong mu- 
riated saline waters, with some iodide and 
bromide of magnesium. See Mineral 
Waters. 
BIARRITZ, in France, on the Bay of 
Biscay.-A fashionable seaside resort. The 
climate is considered to be bracing. See 
Climate, Treatment of Disease by. 
BILE, Disorders of. - Disorders of 
the bile held a large place in the medicine of 
antiquity, with the exception of the theories 
of Van Helmont and Paracelsus; the latter 
looking upon the bile as the balsam of life, 
and therefore incapable of begetting disease ; 
the former regarding it as a mere excre- 
mentitious fluid, and therefore equally incap- 
able of begetting disease. Disorders of the 
bile have, nevertheless, held their own quite 
into our time. It is common enough to 
hear persons speak of a ' bilious attack,' or 
' being troubled with the bile,' expressions the 
survivals of the humoral pathology. The 
liver was formerly credited with most of the 
dyspeptic disorders of the stomach. But, as 
Sir Thomas Watson says, it is an organ often 
blamed most gratuitously and unjustly, but 
no educated or scientific physician would now 
think of attributing a gastric catarrh, or con- 
stipation, to an ' attack of the bile,' or to a 
' sluggish liver.' 1 
Physicians have arranged disorders affect- 
ing the bile under three heads-(1) diminished 
secretion of bile ; (2) increased secretion of 
bile; and (3) secretion of morbid or altered 
bile. This division may very well be 
accepted as a convenient basis for the 
further discussion of biliary disorders, but it 
is nothing more than an hypothesis. It is 
likely enough that the bile, in certain 
diseases, changes its character as regards 
both its amount and constituent parts; but 
it camiot be denied that the means by which 
physicians are able to ascertain these 
changes can scarcely be said to exist in 
ordinary cases. A common saying is that 
the patient must be making plenty of bile 
because the stools are high in colour. No 
reasoning can be more fallacious. The colour 
of the stools may be high if the faeces be 
quickly swept through the intestinal canal, 
because there has been no time for the bile- 
pigment to be absorbed into the blood. Or 
the faeces may be pale if they lie long in the 
bowel and the colouring matter is absorbed. 
So that the colour of the stools is no sure sign 
of the poverty or abundance of the secretion 
of bile. In cases of pale-coloured faeces pur- 
gatives often do good, not because they have 
any special tendency to increase the flow of 
bile, but because they hurry the faeces out of 
the intestine, and thus give no time for the 
absorption of the bile, which, if it lay long 
in the bowel, would be absorbed, carried to 
the liver, and again excreted into the gall- 
ducts-the vicious circle of Schiff. 
Nor is the analysis of the bile found after 
death in the gall-bladder of much value. 
Frerichs announced the presence of albumen 
in the bile in cases of congestion of the 
liver; but it is now generally thought that 
this appearance is due solely to a post- 
mortem transudation. Ritter also has 
described a colourless bile in which all the 
constituents of bile are present except the 
pigments. Most of his analyses were made 
on bile taken from the gall-bladder after 
death; but if the cystic duct be obstructed 
for any time, it is well known that the bile 
contained in the gall-bladder may become 
colourless without any real secretion of 
colourless bile having taken place in the first 
instance. It is impossible to be certain that 
the changes, which are found in the bile 
taken from the gall-bladder after death, have 
taken place during life. 
The only source of what may be called 
knowledge of the disorders of the bile is 
1 The opinion of this eminent physician is never- 
theless open to question.-Editor. BILE, DISORDERS OF 
BLACK VOMIT 
147 
observation of men or animals in whom 
biliary fistulae have been formed either by 
disease or by art. Unfortunately, the 
majority of such observations have been 
physiological or pharmacological; and but 
few are recorded of the changes which 
the bile undergoes in disease. Altogether 
contradictory experiments are recorded of 
the influence of the nerves and of the 
diabetic puncture of the fourth ventricle 
upon the secretion of bile. It is an 
admirable field for further research, but it 
will be seen that our present knowledge very 
closely approaches to complete ignorance. 
It is disputed still whether the presence of 
bile in the stomach puts an end to the process 
of digestion. By many it is thought that the 
bile-acids throw down the albumen of the food, 
and with the albumen the pepsin. It is well 
known that in some disorders there is an 
inverted action of the duodenum, and bile is 
poured into the stomach, as in long-continued 
vomiting, for instance ; thus the dispute has a 
practical bearing. The best treatment of this 
state would seem to be by saline purgatives. 
Bile may also be taken up into the blood, 
and when this occurs, j aundice results. See 
Chol.emia ; and Jaundice. 
J. Wickham Legg. Stephen Mackenzie. 
BILHARZIA.-The name given (by 
the late Dr. Cobbold) to a genus of flukes, 
discovered by Dr. Bilharz, of Cairo. See 
Entozoa. 
BILIARY CALCULUS.-See Gall- 
STONES. 
BILIARY FISTULA. - There are 
two kinds of biliary fistula :-one, in which 
a communication exists between the gall- 
bladder and the surface of the body; the 
other, in which there is a communication 
between the gall-bladder and other internal 
organs. Neither kind is common, but the 
first is less rare than the other. 
In the first variety a tumour forms, some- 
times in the place of the gall-bladder, at 
other times near the umbilicus, in the linea 
alba or to the left of this line, or in the 
groin. The tumour, if opened spontaneously 
or by the surgeon, discharges a quantity of 
pus, bile, and gall-stones. If the cystic duct 
be obliterated, no bile need escape. A 
suppuration of the gall-bladder, caused by 
the presence of gall-stones, is the common 
cause of these fistulae. The prognosis is 
good. The diagnosis, before the tumour 
opens, is very difficult. In a case which 
came under the notice of one of the writers, 
it was mistaken for an abscess of the liver. 
In the second kind of biliary fistula, the 
gall-bladder may communicate with the 
duodenum or colon; with an abscess of the 
liver; with the portal or other abdominal 
vein, though it must be owned that cases of 
this kind seem somewhat dubious; or with 
the urinary bladder, or at least with some 
part of the urinary tract. Gall-stones are 
in nearly every case the cause of the 
fistulous opening. 
J. Wickham Legg. Stephen Mackenzie. 
BILIER, in Bohemia.-Cold acidu- 
lated alkaline waters. See Mineral Waters. 
BILIOUS.-This term is used with 
much vagueness, and in popular language is 
often employed very incorrectly, though the 
general notion is to associate it with condi- 
tions in which an excessive formation of bile 
is supposed to occur. The chief uses of the 
word are as follows :-In the first place it is 
employed to designate a peculiar tempera- 
ment-the bilious temperament. Again, 
individuals are often said, to be bilious when 
they present a sallow or more or less yel- 
lowish tint of skin, but especially if they are 
distinctly jaundiced. Bilious vomiting and 
diarrhoea signify respectively the discharge 
of a quantity of bile, mixed with vomited 
matters or with loose stools. Certain 
febrile diseases, attended with yellowness of 
the skin, are sometimes designated bilious 
fevers; and under like circumstances pneu- 
monia has been described as bilious pneu- 
monia. Lastly, one of the most frequent 
applications of the term is to certain so- 
called bilious attacks or biliousness, which, 
however, are commonly merely attacks of 
acute dyspepsia or of migraine. The most 
prominent symptoms of a supposed bilious 
attack are anorexia, furred tongue, a bitter 
taste, sickness, constipation, and headache, 
with a feeling of marked depression and 
general malaise. Such attacks are most 
effectually prevented by careful regulation of 
diet, and the avoidance of exposure to cold, 
fatigue, and undue mental exertion or 
anxiety; when they come on, abstinence from 
food is desirable, with rest in the recumbent 
posture, and perfect quiet. Cholagogue ape- 
rients and saline effervescents may be given, 
alcoholic stimulants being avoided as far as 
possible. Frederick T. Roberts. 
BIRTH PALSIES.-See Paralysis. 
BITTER ALMONDS, Poisoning 
by.-See Prussic Acid, Poisoning by. 
BLACK VOMIT. - Vomited matters 
may be more or less black in different 
diseases, but the peculiar black vomit is that 
which occurs in yellow fever (see Yellow 
Fever). The rejected matters are acid in 
reaction, and a sediment is deposited of co- 
agulated albumen and disintegrated blood- 
corpuscles. Ammonia is also present. The 
black colour of the vomit has been attributed 
by some writers to altered bile, but there can 
be no doubt that it is due to its admixture 
with blood which has undergone certain 
changes. 148 
BLADDER, DISEASES OF 
BLADDER, Diseases of.-Synon.: Fr. 
Maladies de la Vessie-, Ger. Blasenkrank- 
heiten. 
hours, gradually diminishing in force, and 
leaving no ill-effects behind. In less than 
twenty-four hours no trace of the symptoms 
remained. 
In the third form of cystitis, which is the 
most common, and of which that arising by 
extension from gonorrhoea may be taken as 
the type, the usual symptoms are undue fre- 
quency of micturition; a necessity to perform 
the act immediately the want has declared 
itself, a condition conveniently expressed by 
the single word ' urgency '; a desire to pass 
more, accompanied by pain, when all the 
urine has been voided; and some dull aching 
over the pubes; together with a general febrile 
state of the system, often very slight, but cor- 
responding for the most part with the degree 
of local inflammation. The urine itself 
is cloudy, and deposits some light mucus on 
standing, but it is not otherwise apparently 
altered. Under the microscope abundance 
of epithelium is visible, as well as some pus- 
cells ; and if the affection is severe, a few blood- 
corpuscles are also present. It may be re- 
marked here that the presence of a few pus- 
cells in the urine-a fact to which so many 
practitioners attribute considerableimportance 
-by no means necessarily deserves to be so 
regarded. The very slightest attack either 
of this or of the preceding form of cystitis is 
certain to be attended by the formation of some 
quantity, however small, of fully-developed 
pus-cells. 
Very rarely a false membrane may be pro- 
duced on the surface of the mucous membrane 
of the bladder, and may be thrown off almost 
entire, leading to the belief that the inner 
coat has itself been removed or, as it has been 
termed, separated by ' exfoliation.' In women 
this membrane has been voided per urethram 
in a condition for examination; in men this 
cannot occur, because the urethra is too small 
to admit of it. Now and then examples of 
the former have been shown at the Patho- 
logical Society of London; and one of the 
latter, discovered on operation, may be seen 
in the museum of the Royal College of Sur- 
geons, London. See Casts. 
Treatment.-In the first form of cystitis, 
the removal of the exciting cause, if possible, 
is the chief indication. 
The treatment of the second form should 
consist of very hot bidets or hip-baths, the 
former being sometimes preferable as capable 
of being used at higher temperatures than 
the latter ; together with large doses of the 
tincture of henbane, say a drachm, with 10 or 
15 drops of liquor opii (Bat.) every four hours 
while pain is severe; 20 minims of liquor 
potassae may be given either simultaneously 
or altematelyfin water or in any bland diluent. 
The treatment of a wTell-marked case of the 
third class consists in absolute rest in the re- 
cumbent posture, mild diet, abstinence from 
all alcoholic stimulants, gentle laxative action 
of the bowels, and the administration of small 
The bladder may be the seat of the 
following morbid conditions : - Inflamma- 
tion, acute or chronic; Abscess; Neuralgia; 
Atrophy or Hypertrophy; Mechanical Dis- 
tension, with chronic engorgement and re- 
tention of urine, commonly, but erroneously, 
termed ' Paralysis ' ; Sacculation ; Displace- 
ments, such as hernia in the male, or, very 
rarely, inversion and protrusion in the female; 
Tumours or Growths of various kinds, from 
simple Mucous Polypi to Epithelioma, Sar- 
coma, and Carcinoma; Tubercular Disease; 
Ulceration, either simple or malignant; and 
Vesico-vaginal or Vesico-intestinal Fistula. 
The bladder may also be the subject of true 
paralysis, partial or complete, as the result 
of injury to the brain or spinal cord, or 
following disease of those organs. 
Only a brief statement respecting the most 
important of this class of affections need be pre- 
sented here, in order to facilitate an acquain- 
tance with their diagnosis, since the treat- 
ment of almost all of them belongs to the 
province of the surgeon, and so far only as it 
consists of medicinal remedies will the sub- 
ject be considered. 
1. Acute Inflammation-Acute Cys- 
titis.-The mucous lining of the bladder is 
the part affected by inflammation; and al- 
though, after long and severe attacks, some 
morbid action occurs by extension to the 
muscular coat, or even to the peritoneal 
covering, these structures are very rarely 
affected. An acute inflammation of a very 
severe kind occurs from injuries ; from the 
presence of instruments, foreign bodies, or 
calculi; and from unrelieved retention of 
urine. A less severe, somewhat evanescent, 
but very painful form of cystitis arises from 
irritants taken internally, as cantharides. A 
still less severe but often troublesome form 
originates by extension from gonorrhoea. 
In the first class of cases there are not only 
severe local symptoms referable to the 
bladder, but the general system may be 
gravely affected. 
In the second class, of which cantharides- 
poisoning is the type, the phenomena of very 
frequent, painful, and spasmodic attempts to 
eject small quantities of urine, which is often 
bloody, occur within a very short time after 
absorption of the poison. A common blister 
is said to produce the affection in some per- 
sons. In two cases-the only two the writer 
has seen-it has followed the application of a 
blister to a surface already partially denuded 
of the scarf skin. In one of these a blister 
was applied to a knee which had been fre- 
quently painted with tincture of iodine, and 
was still slightly sore. In three hours after 
the application the patient was attacked with 
exceedingly painful efforts to micturate, which 
were at times intense. The attack lasted six BLADDER, DISEASES OF 
149 
doses of alkali. The writer prefers liquor 
potassae, frequently repeated, to all others; 
and this may be combined with henbane, or, 
if micturition is very frequent and painful, 
with opium or morphine, or with belladonna in 
small doses. Hot hip-baths or bidets, followed 
by hot linseed-meal poultices or fomentations, 
give great relief. The patient may drink 
freely of decoction of triticum repens, linseed- 
tea, barley-water, or similar demulcents. 
Relief rapidly follows, but care is requisite to 
avoid relapse, which easily occurs if exercise 
be taken too soon, if injections for the gonor- 
rhcea be resumed too readily, or if alcoholic 
stimulants be indulged in. 
2. Chronic Inflammation-Chronic 
Cystitis.- Chronic inflammation of the 
bladder is separated from the acute form by 
very distinct characters. It is mostly the 
result of retained urine from stricture or en- 
larged prostate; but it may arise from the 
presence of calculi, or of growths in the 
bladder; from over-distension, or atony of 
its coats; from paralysis after injury or disease 
affecting a nervous centre; from disease of 
neighbouring organs; and sometimes from 
altered urine: it is also met with in certain 
affections of the kidney. Sometimes this 
condition is marked by the presence of a 
large quantity of viscous mucus, often called 
' catarrh '; but more commonly this symptom 
is absent, and the mine contains merely 
ordinary mucus or muco-pus, rendering the 
secretion more or less cloudy and opaque. 
Perhaps there are some cases in which the 
inflammation is mainly due to the existence 
of gout. 
Symptoms. - The symptoms of chronic 
cystitis are increased frequency of micturi- 
tion and pain, but the latter is by no means 
necessarily present. The urine is always 
cloudy, and contains some pus-cells. There 
is often, but not always, some supra-pubic 
uneasiness. The general health does not 
suffer unless the affection is prolonged or 
severe. If important causes, as the presence 
of stricture, calculus, &c., occasion the chronic 
cystitis, their specific symptoms will pre- 
dominate. It is not common to find chronic 
cystitis as an idiopathic disease, although 
undoubtedly it occasionally is so; so that 
the writer has always regarded it as a useful 
maxim, ' When chronic cystitis is declared 
to be idiopathic, we may be sure that we 
have only not yet discovered the real cause.' 
As a general rule we may suspect that there 
is inability to empty the bladder, or calculus, 
stricture, or organic disease of some kind in 
some part of the urinary tract, when the 
group of symptoms are present which we 
denote by the term ' chronic cystitis.' Re- 
specting the well-known glairy mucus, which 
is deposited so abundantly from the urine 
in some cases, in elderly people almost in- 
variably, it should be said that it appears 
only in those whose urine is abnormally re- 
tainecl, through atony of the vesical walls, 
or in consequence of enlarged prostate, or as 
the result of sacculation of the bladder, and 
that medicine has little or no effect upon it. 
Treatment. - The regular and habitual 
use of the catheter, and perhaps also injec- 
tions into the bladder, form the essential 
mechanical treatment of chronic cystitis in 
the cases just mentioned. In the few cases 
in which chronic cystitis is present and no 
organic cause, such as those named above, 
can be discovered-and also as adjuncts to 
mechanical treatment when these causes 
do exist-certain medicinal agents are un- 
doubtedly useful: these are buchu, triticum 
repens, uva ursi, alchemilla arvensis, pareira, 
and the alkalis-potash and soda. Buchu 
is more useful in subacute and recent chronic 
cystitis than in cases already of long dura- 
tion. The patient should take not less than 
ten ounces of the infusion daily. After this, 
in similar cases, the decoction of triticum 
repens (made by boiling two to four ounces 
of the prepared underground stem in water to 
make a pint and a-half of decoction, of which 
six ounces are taken three or four times 
in the twenty-four hours) is highly useful. 
For more chronic cases, where the urine 
is alkaline and deposits much mucus, and 
perhaps the triple phosphates also, alchemilla, 
uva ursi, and pareira may be very valu- 
able. The alchemilla is administered in 
infusion, one ounce of the herb in one pint of 
boiling water, of which the dose is four to six 
ounces three times daily; the others to be 
made according to the directions of the 
Pharmacopoeia, but taken in quantities at 
least two or three times as great as those there 
suggested. These may be taken alone or com- 
bined with potash, which in moderate quan- 
tities diminishes the natural acidity of the 
urine before it enters the bladder; the mucous 
membrane of which, although accustomed to 
that condition in health, is perhaps some- 
times, when inflamed, irritated by urine of 
even the ordinary acidity. Whether this be 
so or not, there is no doubt that alkalis do 
frequently tranquillise an irritable bladder. 
They are often given in the form of Vichy 
water, Vais water, or that of Evian-all strong 
solutions of soda; but on many grounds the 
salts of potash are preferable. On the other 
hand, the mineral acids have been largely 
administered in cases where the urine is 
alkaline; although there is no reason to 
believe that the acid has any direct action 
through the kidneys, or that it is eliminated 
by those organs. Alkalinity of the urine in 
chronic cystitis is almost always due to in- 
ability of the bladder to empty itself, and the 
remedy wanted is not medicine but a cathe- 
ter, at all events to ascertain whether this be 
the cause or not. A very small quantity of 
urine retained in the bladder, say one or two 
ounces, after every act of micturition, suffices 
in some cases to maintain an alkaline and 150 
BLADDER, DISEASES OF 
otherwise unhealthy state of the secretion; 
while it is equally true that some patients 
may habitually, and during long periods of 
time do, fail to empty the bladder, always 
leaving behind from half a pint to a pint, 
without the urine losing its acidity. Of course 
other signs, and notably great frequency of 
micturition, are present when such is the 
case. 
3. Neuralgia.-It is impossible to deny 
that the bladder may be subject, like other 
parts of the body, to symptoms which are 
described as neuralgia, although the occur- 
rence is an extremely rare one. All the 
writer can say is, that he has occasionally 
met with cases in which he has not been 
able to account, by the existence of any lesion, 
for pain and frequency in micturition, or for 
difficulty in performing that act, and where 
these symptoms have been more or less 
periodic in their appearance. In such in- 
stances he has given quinine, and has oc- 
casionally found great relief to follow a few 
doses; more frequently this has not been the 
case. But now and then the value of the 
drug has been so marked as to corroborate a 
belief in the existence of vesical neuralgia. 
It must be repeated, however, that examples 
of such phenomena are extremely rare. The 
writer has also employed arsenic on the 
same ground. It is invariably necessary to 
investigate the general health, as well as the 
habits and diet of the patient. This, perhaps, 
may be the place for stating that in all 
chronic and slight deviations from natural 
and healthy function in the urinary organs, 
it is essentially necessary to inquire into the 
state of the digestive organs, and, if possible, 
to correct by diet, and by medicine when ne- 
cessary, any imperfect action on their part. 
Constipation alone, when habitual, may pro- 
duce considerable irritability of the bladder, 
a slight affection of the organ already exist- 
ing; so also may the unnecessary use of pur- 
gatives. A gentle, easy, and daily action of 
the bowels, a healthy condition of the primary 
digestion, the absence of flatulence and dis- 
tension after food, should be ensured as far 
as possible in all patients complaining of 
frequent, difficult, or uneasy micturition; and 
many such may be completely cured of so- 
called urinary affections by strict attention 
to these matters. The writer's strong con- 
victions relative to this fact, grounded on in- 
numerable experiences of its value as an aid 
in practice, led him, upwards of twenty years 
ago, to ascertain the great value, for such 
patients, of the natural aperient waters of 
Germany and Hungary, now so extensively 
used ; and he now more than ever insists on 
the use of a mild and laxative regimen and 
careful diet in their management. 
4. Where obstruction to the outflow of 
urine exists (stricture of the urethra, most 
forms of enlarged prostate, other tumours, 
&c.), the muscular walls of the bladder be- 
come the seat of Hypertrophy, which is a 
condition of compensation, therefore, and not 
of disease in or by itself. But such changes 
in the interlacing muscular fibres existing, 
Sacculation readily occurs, by protrusion 
of the lining membrane between the bands 
so produced. On the other hand, most com- 
monly when the prostate is much enlarged, 
the bladder becomes gradually distended, its 
coats become expanded, thinned, and weak- 
ened, and a certain degree of Atrophy takes 
place. The power of the organ to expel urine 
is lost or diminished; and micturition being 
a function of a simply mechanical nature, the 
circumstances of the case demand only a 
mechanical remedy, viz. the catheter. No 
medicine can restore power and exercise of 
function under these circumstances. But 
atrophy and loss of power may occur from 
complete or partial loss of nervous influence 
over the bladder, as in those who are the 
subjects of paralytic states commencing in 
the spinal cord or brain. When the paralytic 
state follows an accident causing injury to a 
nervous centre, the nature of the case is 
obvious enough. But sometimes the onset 
and progress of chronic disease in these organs 
are very slow and insidious; the urinary 
troubles, as manifested by slowness or diffi- 
culty in passing urine, or by urine clouded 
through inability of the bladder to empty it- 
self, may be the earliest signs of the nervous 
lesion. On the other hand, impaired gait, 
and other evidences of central mischief, may 
be (and mostly are) earlier phenomena, the 
derangement in the urinary function appear- 
ing at a later stage. For such patients, the 
habitual use of the catheter is often necessary 
(always of course when unable to empty the 
bladder by the natural efforts); while such 
constitutional treatment as is indicated by 
the cerebral or cerebro-spinal lesion present 
will comprehend that which the bladder de- 
mands. It is therefore unnecessary to allude 
further to that subject in this article. The 
same remark also applies to those few ex- 
amples of Tubercular disease of the 
urinary organs, which is always a local ex- 
pression of a general constitutional state suffi- 
ciently considered under its proper head in 
this work. All other treatment of this malady 
is local and surgical. 
5. Tumours.--Tumours of the bladder 
have received much attention during the last 
few years, and the classification here offered 
is founded to a great extent on the writer's 
own experience, which has been considerable. 
Besides examining in consultation not a few 
cases, as well as taking the supervision of 
others in which, for varying reasons, no 
surgical procedure was admissible, he has 
operated for the removal of vesical tumour 
on upwards of forty patients. From these, 
from a study of the numerous preparations 
in the London museums, and from the 
growing experience of others, the following BLADDER, DISEASES OF 
151 
varieties may be enumerated and classified, 
commencing with the most simple. 
(1) Mucous Polypus.-Mucous polypus is 
not to be confounded with prostatic out- 
growths of the same form, these being inad- 
missible in any scheme comprising vesical 
tumours. It resembles polypus of the nasal 
cavity, but is more compact and solid in 
structure. Hitherto this product has been 
found in young children only. 
(2) Papillomatous Tumours.-These appear 
in two forms. The essential character of each 
is that it closely resembles the natural papillae 
occurring in certain parts of the digestive 
canal; the structure consisting of a promi- 
nence of simple membrane supported by a 
little connective tissue, but containing a large 
arterial twig as a central axis, the outer sur- 
face of the membrane being closely covered 
by a layer of cylindrical epithelium, or less 
commonly by an ovate or rounded variety. 
Formerly these growths were termed 'villous,' 
to which it was not unusual to add the word 
'cancer,' although the implied allegation was 
entirely without warrant. When slender, 
long, and floating in the bladder, a papillo- 
matous growth is termed 'fimbriated'; when 
more fibrous tissue is present and the growth 
is more solid, ' fibro-papilloma ' appears 
to be the more appropriate term. These 
growths form very slowly at first, but when 
developed give rise to repeated attacks of 
haemorrhage, which in time becomes con- 
tinuous and copious, thus terminating life. 
They are the most commonly met with of 
all vesical growths, and their symptoms have 
been often mistaken for those of renal disease. 
Microscopic examination of the urine will 
sooner or later (especially if the bladder is 
washed out with water and the debris scruti- 
nised) detect specimens of the growth which 
are quite characteristic. Moreover, on care- 
ful inquiry it may be ascertained that the 
bleeding is found occasionally, sometimes 
frequently, to appear in a manner which can 
rarely or never be met with in renal haemor- 
rhages. The patient commences an act of 
micturition with clear or almost bloodless 
urine, and at the end of the act, bright florid 
blood is mixed with the stream or appears 
alone at the close. This fact determined, the 
bleeding is without doubt vesical, and if little 
pain is complained of, as a rule the bleeding 
is certainly not due to a sarcomatous or carci- 
nomatous growth, and is therefore probably a 
sign of papilloma. 
The writer knows no styptics that bene- 
ficially affect haemorrhage from this source, 
although he has seen all the known remedies 
abundantly tried. Preparations of iron, es- 
pecially the perchloride, have the best claim 
perhaps to be employed. Treatment by local 
injections is apt to provoke rather than check 
the flow of blood. 
(3) Simple Myomatous Tumours.-These 
are not common, and are not accompanied 
by any characteristic signs of their presence. 
Nothing farther remains to be said of them 
here in relation to diagnosis. 
(4) Tumours made up of Fibrous Tissue. 
This kind of vesical tumour consists chiefly 
of fibrous tissue, more oi' less associated with 
small nuclei interspersed; sometimes the 
nuclei are in large quantity, a fact which 
leads to a graver estimate of their character. 
Both these and the preceding kind of 
tumour involve the deep structures of the 
organ, and cannot be removed entirely by 
operative procedures; on the other hand, the 
simpler forms of papilloma, especially when 
growing from a pedicle, may be completely 
removed, and often do not return. 
(5) Epithelioma.-The nature and charac- 
ters of epithelioma of the bladder are the 
same as those of this growth in other parts 
of the body. This and the two following will 
be considered together. 
(6) Scirrhus.-' Cancer,' properly so called, 
not occurring until after the middle term of 
life has been reached, is occasionally met 
with in the bladder. 
(7) Round- and Spindle-celled Sarcomata. 
These were formerly known as ' encepha- 
loid ' disease. They are most commonly met 
with in children; although occasionally in 
the adult also. 
Diagnosis. - The diagnosis of malignant 
disease of the bladder is not difficult. Exa- 
mination of the rectum furnishes valuable 
information. Scirrhous growth is very hard, 
irregular in form, and thus unlike any simple 
prostatic enlargement occurring in elderly 
men. The sarcomata are full and rounded 
in form, more elastic to the touch than ' pro- 
static enlargement,' and far more rapid in 
their rate of increase. Epithelioma, slow 
and restricted in its growth, may exist some 
years before presenting a tumour sufficiently 
dense to be recognised by palpation or sound- 
ing, In malignant disease pain is soon a 
more or less constant symptom, and some 
haemorrhage is liable to appear, increasing 
at a later date ; contrasting with papilloma, 
which latter is rarely recognisable by the 
rectum, commences with haemorrhage, and 
is rarely painful. The progress of epithelioma 
is slow, and without any very distinctive cha- 
racters. In all these three forms of recurring 
growth, microscopic observation may cor- 
roborate a diagnosis based on the symptoms, 
but cannot by itself establish one. 
Treatment.-In relation to surgical treat- 
ment of the malignant diseases of the bladder, 
nothing can be said in behalf of operative 
measures for their removal. It is always 
impossible to extirpate the disease, which 
largely involves the organ itself, and rapidly 
reappears after the attempt has been made, 
although large masses may have been taken 
away, and an apparently almost empty cavity 
has been left as the result of the procedure. 
The palliative treatment for all patients 152 
BLADDER, DISEASES OF 
BLOOD, ABSTRACTION OF 
thus affected consists in the avoidance of 
habits, occupations, and any amount of ex- 
ercise found, by the experience of each indi- 
vidual case, to produce serious increase of 
haemorrhage. The maintenance of the diges- 
tive power, and healthy activity of the func- 
tions which support life, are as far as possible 
to be ensured. Lastly, all means should be 
adopted, especially towards the closing stage 
of a case which is certainly destined to be 
fatal, to alleviate suffering, which is usually 
severe and prolonged, unless dealt with un- 
flinchingly, as it ought to be, in such painful 
circumstances. Ample use should be made 
of morphine, usually most effective by sub- 
cutaneous injection, so that, although unable 
in any way to check the progress of the 
malady, we may at least mitigate the most 
terrible accompaniment of its distressing and 
inevitable course. 
With almost all affections of the bladder, 
simple or malignant, ulcerative or associated 
with fistula, cystitis to some extent and in 
some form co-exists. It is this which gives 
rise to the presence of an undue quantity of 
mucus in th e urine; it is often the source of 
pus, sometimes of blood in small quantity. 
Thus, in all the above-mentioned diseases, 
some degree of cystitis appears sooner or 
later. Henry Thompson. 
BLADDER-WORMS.-A general term 
embracing various parasitic entozoa, having 
the character of cysts or vesicles. See 
Entozoa. 
BLANKENBERGHE, in Belgium. 
A sea-bathing resort. See Climate, Treat- 
ment of Disease by. 
BLEB.-A large vesicle or bulla, contain- 
ing, for the most part, a serous fluid, as in 
pemphigus, erysipelas, or burns and scalds. 
See Blister. 
BLENORRH(EA, BLENORRHA- 
GIA (pXewa, phlegm; and pew, I flow. 
S^ewa, phlegm; and p^ywpi, I burst out).- 
These terms are most correctly used to 
express excessive flow of mucus from any 
mucous surface. By means of an affix, the 
locality or nature of the discharge is ex- 
pressed : e.g. blenorrhoea oculi, nasalis, 
urethralis. More commonly, however, and 
less accurately, blenorrhoea is employed as 
synonymous with gonorrhoea in the male or 
female. 
BLEPHARITIS (S^ec^apov, an eyelid).- 
Inflammation of the eyelids. See Eye and 
its Appendages, Diseases of. 
BLEPHAROSPASM (3Xe</>apop, an 
eyelid; and aTraapa, a spasm).-Spasmodic 
movement or contraction of the eyelids. 
See Eye and its Appendages, Diseases of. 
BLINDNESS.-Loss of sight. See 
Amaurosis; and Vision, Disorders of. 
BLISTER.-Synon. : Bleb ; Blain ; Fr. 
Bulla; Bulle\ Ger. Blase. 
Definition.-A vesicle of the skin, caused 
by the separation of the horny cuticle from 
the rete mucosum by the transudation of 
serous lymph beneath the former. 
tEtiology.-Blisters may be idiopathic, as 
in pemphigus; or symptomatic, as in ery- 
sipelas. They are met with under the in- 
fluence of any cause which depresses the 
vitality of the integument, as in some forms 
of prurigo, in chilblain, and in carbuncle; in 
scalds and burns; and as an effect of powerful 
irritants, such as cantharides or the aniline 
salts. 
Description.-A blister ranges in size from 
that of a pea to a turkey's egg; it is more or 
less convex according to the amount of exu- 
dation ; and conforms in colour with that 
of its contents, being sometimes yellow or 
amber-coloured and transparent, like serum, 
sometimes opalescent from the presence of 
pus, and sometimes red or purple from ad- 
mixture with blood. The fluid of a blister, 
generally limpid and free, is sometimes held 
in the meshes of a delicate network, resulting 
from the stretching of the connecting cells 
of the rete mucosum and horny epidermis. 
This is. peculiarly the case in blisters de- 
veloped under the influence of acute inflam- 
mation, and especially in dermatitis anilina. 
Blisters may be dispersed, or aggregated, or 
even single, as in pemphigus or pompholyx 
solitarius. 
Treatment.-Blisters when idiopathic are 
essentially asthenic in their nature, and 
call for corroborant therapeutical treatment. 
Locally they should be punctured so as to 
admit of the gradual escape of their contents, 
and then dusted over with some absorbent 
powder, such as oxide of zinc, fuller's earth, 
or cinchona. Erasmus Wilson. 
BLISTERING.-A therapeutic measure, 
which consists in the artificial production of 
blisters on the skin. See Counter-irrita- 
tion. 
BLOEMFONTEIN, in the Orange 
Free State.-See Africa, South. 
BLOOD, Abstraction of. - Synon. : 
Bleeding; Blood-letting; Fr. La Saign^c; 
Ger. Der Aderlass. 
Definition.-The withdrawal of blood 
from the body, either (a) from the general 
circulation, by arteriotomy or phlebotomy; 
or (6) locally, by leeches, scarifications, or 
wet-cupping. 
It is to the first two of these methods of 
abstracting blood that the term ' bleeding,' 
or ' blood-letting,' has by common usage been 
restricted. 
The topical abstraction of blood by means 
of leeches, scarifications, and cupping, though 
often valuable, is of secondary importance. BLOOD, ABSTRACTION OF 
153 
The present article will, therefore, chiefly be 
devoted to general bleeding. 
General Bleeding.- This art, practised 
for centuries more or less universally, has of 
late years in this country fallen into dis- 
favour. Much discussion has been raised 
as to the grounds for so great a difference. 
It has been attributed-(1) to the type of 
disease having undergone a change; (2) to 
mere fashion or caprice; (3) to a better 
knowledge of the nature of disease, teaching 
us that its processes were of a lowering or 
depressing character, which were to be over- 
come by the more general use of drugs 
which control the circulation, as well as of 
stimulants and support. It is probable that 
several causes have contributed to the un- 
doubted change which has taken place. The 
year 1830 and subsequent years were marked 
by the epidemic visitation of cholera and 
of influenza. These diseases were charac- 
terised by extreme depression.1 If anti- 
phlogistic measures were adopted, they 
proved failures, and taught the physician 
that blood-letting was not the universal 
panacea it was supposed to be. By degrees 
it ceased to be practised as it used to be. 
A new generation which knew not the past 
has sprung up; and, as in all reactionary 
movements, the practice has become at length 
as limited as it formerly was universal. It 
is almost certain that in either extreme there 
is an evil, and that we may have recourse in 
certain cases to abstraction of blood with 
some degree of that success which formerly 
led to its extensive use, if not its abuse. It 
will be well to consider the subject at some 
little length, and under the following heads:- 
1. The effects of moderate losses of blood 
on the healthy economy. 
2. The value of bleeding as a remedy in 
disease, together with the indications for its 
employment in various affections. 
3. The method of performing the operations 
of opening an artery -arteriotomy; and open- 
ing a vein-phlebotomy. 
1. Effects.-We have first, then, to con- 
sider the effects of moderate losses of blood 
upon the healthy economy. Upon this point 
we have abundant evidence, for the custom 
of regularly bleeding healthy people had 
reached such a point during the earlier part 
of this century, that in country districts it 
became a habit for adults to be bled as 
regularly as they went to market. No better 
testimony regarding the effects of this prac- 
tice could be adduced than that of Sir James 
Paget, who, when referring to these custo- 
mary venesections, says : ' I can regard those 
as a series of venesections fairly performed 
for the determination of what is the influence 
of the removal of blood up to the point of 
syncope upon a comparatively healthy person. 
I think I can say surely that not one of these 
persons suffered harm.' To this might be 
added other and abundant testimony to the 
harmlessness of moderate venesection on the 
healthy economy. 
2. Indications and Uses.-Concluding, 
then, that the , abstraction of a limited quan- 
tity of blood has no deleterious effect upon 
the healthy organism, we will next describe 
the general indications for the use of bleed- 
ing in disease, and briefly refer to the various 
affections in which it may most suitably be 
employed. 
Broadly stated, it may be said that bleed- 
ing is indicated when there is evidence of 
marked over-distension either of the arterial 
or of the venous system. In either case the 
result will be cardiac distension-in the for- 
mer case of the left, and in the latter of the 
right chambers of the heart. In such condi- 
tions general bleeding restores the lost equi- 
librium of the vascular system, and relieves 
the heart and the other parts concerned in 
the circulation of the blood. 
The arterial system may be in a state of 
augmented tension from two causes: (1) 
contraction of the arteries (the smaller 
vessels) themselves, with a diminished 
amount of blood in the arterial system ; and 
(2) engorgement or distension of the arteries 
from spasm of the arterioles: both may be 
regarded as vaso-constrictive neuroses. In 
the first case there may be engorgement of 
the venous system and embarrassment of the 
right heart, calling for abstraction of blood by 
venesection; or visceral fluxion, the skin being 
pale : in the second case, relative emptiness of 
the veins with overfulness of the larger arteries, 
calling for blood-letting by arteriotomy. 
In the former condition there would be, 
in bedside language, a small hard or wiry 
pulse, and in the latter a full and hard or 
bounding pulse. In the former the surface 
of the body may present one of the two fol- 
lowing conditions : either the skin is injected 
and perhaps dusky, and this appears to be 
the case ordinarily; or it is pale and cool, 
the blood having receded inwards, chiefly 
to the abdominal viscera. The second con- 
dition obtains and is well seen in cases of 
uraemic asthma, when the arterial system is 
turgid almost to bursting, while the veins 
are comparatively empty. ' Hardness ' of 
the pulse is usually said to be an indication 
for bleeding, and in certain associations it is 
so; but it is necessary to discriminate care- 
fully between the ' hardness ' due to ' tension ' 
of the sound artery arising from (a) exces- 
sive contraction (the small, hard, wiry pulse), 
and (6) overfulness (the full, bounding pulse) 
on the one hand; and that due to arterial 
degeneration with more or less hard deposit 
in the walls of the vessels, on the other. In 
doubtful cases inquiry should be made into 
1 This state of depression was especially remark- 
able during the influenza epidemic of 1890, even in 
cases in which the ordinary symptoms of the disease 
were not severe; so too was the persistency of its 
effects.-Editor. 154 
BLOOD, ABSTRACTION OF 
the state of the brachial artery at the bend 
of the elbow. This can readily be done by 
flexing the limb, when, if calcareous dege- 
neration have taken place, the vessel will be 
thrown into serpentine folds, visible, except 
in fat people, to the eye, and cord-like and 
rigid to the touch. The temporal artery is a 
less safe guide, but neither it nor an arcus 
senilis should be overlooked in this connexion. 
A visible and tortuous pulse in a young per- 
son may indicate aortic regurgitant disease : 
the age of the patient must therefore be 
taken into consideration. 
Dilatation of the arterioles would permit of 
the rapid passage of arterial blood into the 
veins : under such circumstances, therefore, 
we should expect the blood issuing from a cut 
vein to present a more florid appearance than 
under ordinary conditions. Bleeding here 
should be undertaken with considerable 
circumspection, and not be pushed very far, 
for collapse out of proportion to the amount 
of blood abstracted might ensue. On the 
other hand, when there is spasm of the 
arterioles, and the abstraction of blood is 
deemed advisable, it would be well to resort 
to arteriotomy rather than venesection. The 
best guide here would be the sphygmograph, 
but, as this instrument may not be always 
available, the full, hard, bounding pulse must 
be relied on when found in association with 
corroborative symptoms. 
Whatever leads to over-engorgement of 
either side of the heart may render bleeding 
necessary. If the left side of the heart be 
over-full arteriotomy is indicated ; if the right, 
venesection. The object of the withdrawal 
of blood from the general circulation is the 
direct relief of the overburdened heart. 
Whether the right or left chambers be 
taxed, the immediate effect is the same ; they 
are over-distended, and cannot exercise full 
power upon their contents. It is with the 
embarrassed heart as with other hollow 
muscular organs-the bladder and uterus. 
Over-distension paralyses them by removing 
the ' point d'appui ' essential for the initiation 
of muscular contraction ; the energy may 
be there, but it cannot be exercised. It is 
obvious that the amount of blood which it is 
necessary to withdraw, in order to free the 
embarrassed organ, must vary considerably 
in different cases ; but it may be safely laid 
down as a rule that it need rarely exceed a 
few ounces. Excess in this respect is the evil 
which formerly existed. 
On this subject we may refer to the 
eminently practical remarks of the late Sir 
Thomas Watson, who says : ' I hold it, then, 
to be certain, that for some special morbid 
conditions, which inflammation may or may 
not accompany, general blood-letting, and 
especially venesection, is a potent and life- 
preserving remedy; that there are many exi- 
gencies for which it is not only safe to employ, 
but unsafe and unpardonable to withhold it.' 
He also gives the following judicious ad- 
vice :- 
' Always it is necessary to consider the age, 
the sex, the general temperament and con- 
dition of the sick person, when we are turn- 
ing over in our minds the expediency of 
abstracting blood. The very young, the old, 
the feeble, the cachectic, do not bear well the 
loss of much blood. This consideration is 
not to deter you from bleeding such persons 
topically when they are attacked by dangerous 
inflammation, but it especially enforces, in 
regard to them, the golden rule that no more 
blood should be abstracted than seems abso- 
lutely requisite to control the disease.' 
The following are some of the affections 
in which blood-letting would seem to be 
more or less indicated:- 
Pneumonia.-Blood-letting in pneumonia, 
as in many other inflammations, is most 
useful in the early stages. It is indicated in 
healthy patients suffering from uncomplicated 
acute sthenic pneumonia, if they happen to be 
seen early enough. It relieves pain, abates 
fever, and if it does not arrest the disease, it 
certainly appears to lessen its duration. It 
may also be called for when there is severe 
pain and evidence of cardiac embarrassment. 
It did good, and will still do good, in cases of 
pneumonia attended by embarrassment of 
the circulation, and that in truth is the indica- 
tion for bleeding in this disease. 
Apoplexy.-The same may be said with 
reference to cerebral apoplexy. The old 
belief in the importance of ' letting blood ' in 
cases of apoplexy was, if possible, stronger 
than in cases of pneumonia. But here again 
more accurate clinical and more extended 
pathological knowledge has taught us to 
look upon ' apoplexy ' very differently to our 
forefathers. Recognising the escape of blood 
from the bursting of a brittle artery as a 
common cause of ' apoplectic fits,' we see the 
futility of venesection when the ' stroke ' or 
' fit ' is due to a lesion of this kind. Nor 
will bleeding unstop an artery when it is 
plugged by an embolus, or carry nutriment 
to the region thus bereft of vital fluid. On the 
other hand we have learnt to recognise the 
value of bleeding in another class of cases of 
so-called ' apoplexy '-those which are unac- 
companied by effusion of blood or lesion of the 
nervous tissue, but depend on rapidly occur- 
ring compression of the nervous centres from 
sudden or unequal increase in the volume of 
any portion of the cranial contents; or in cer- 
tain cases of eclampsia from the circulation 
of blood poisoned by un eliminated urinary 
excreta. In cases of this description, when 
the right heart and venous system are 
engorged, phlebotomy acts beneficially: the 
stertor ceases, the purple face resumes its 
natural hue, the clouded intelligence becomes 
clear, and the impending danger is for the 
time averted. This has not cured the patient, 
however; it has only ' obviated the tendency BLOOD, ABSTRACTION OF 
155 
to death: ' it has saved the patient's life, 
though he may ultimately die of the disease 
which afflicts him. Where we meet with 
evidence of cerebral congestion, accompanied 
by fulness of the veins, a dusky countenance, 
and a slow full pulse, bleeding may most use- 
fully be resorted to. In a word, although 
bleeding will not remove the effused blood 
in cases of cerebral haemorrhage, it may some- 
times be usefully employed to prevent further 
escape, when the heart is acting too forcibly ; 
but it is altogether forbidden when that organ 
is enfeebled. The pulse at both wrists should 
be attentively examined before bleeding, in 
cases of cerebral haemorrhage, for as a rule it 
is larger on the paralysed than on the sound 
side. See Brain, Hyperaemia of. 
Eclampsia. - Indiscriminate bleeding in 
eclamptic seizures would be a grievous error. 
It would not relieve, but rather would pro- 
bably intensify, convulsions of reflex origin, 
as in certain cases of puerperal convulsions. 
On the other hand, cases of puerperal con- 
vulsions accompanied by great turgescence 
of the vascular system, whether venous (as 
is commonly the case) or arterial, would be 
immensely benefited by the withdrawal of 
blood from the general current, either by 
venesection or by arteriotomy, according to 
the indication. This treatment may serve 
to stop the convulsions, and though that may 
be far from curing the disease, it may, never- 
theless, be of the utmost value, for in the 
first place the fits themselves may kill by 
their violence or frequent repetition ; whilst, 
secondly, time may be gained for the employ- 
ment of other measures calculated to relieve 
the oppressed system, as, for example, purg- 
ing by hydragogue cathartics, vapour baths, 
cupping the loins, &c. This gain may be 
immense; for bleeding may avert impending 
dissolution. Moreover, permanent good may 
ensue, inasmuch as bleeding reduces tem- 
perature, and in the eclampsia of pregnancy 
the temperature is usually high. In this it 
contrasts with pure uraemic convulsions, in 
which there is lowering of temperature. 
Venous Engorgement. -Engorgement of 
the venous system arising from chronic dis- 
ease, such as pulmonary emphysema or heart- 
disease, does not call for bleeding, unless the 
condition be acutely intensified by some 
intercurrent mischief, such as acute bron- 
chitis ; for, as the derangement is slowly 
produced, the organs and structures involved 
learn to accommodate themselves more or 
less to the altered conditions. It is only 
when vascular engorgement suddenly occurs 
in apparently healthy subjects, or, as just 
stated, there is acute intensification of a 
chronic condition, that bleeding is required. 
Thus, in cases where mediastinal tumours 
impede the return of blood from the head 
and upper portion of the body, the condition 
is ordinarily of such comparatively slow pro- 
duction, that bleeding is seldom urgently 
called for; and, moreover, it would be of but 
small service, for the obstruction is irreme- 
diable. 
The lividity of the face which accompanies 
all fits should not be confounded with the 
duskiness due to engorgement of the venous 
system generally. 
Uramia.-In pure uraemia bleeding is use- 
ful; the kidneys being especially in default. For 
venesection answers a double purpose, by not 
only relieving the engorged right heart and 
venous system, but by removing from the body 
a certain amount of poisoned blood-blood 
that is charged with urinary excreta. Doubt- 
less, it does good in both ways, but the former 
is, quoad the fits, the more important because 
more immediate mode of its action. The 
second effect, that of ridding the body of 
damaged blood, is obviously available for us 
when we have to deal with uraemia, occur- 
ring in the non-pregnant; and when coma 
is deepening, the heart labouring, and the 
vascular system turgid, no remedy is so swift 
and sure as the lancet. 
Plethora.-Blood-letting may be ca1led for 
in cases of general plethora, whether sthenic 
or asthenic. In the former condition the 
vascular system generally seems to be over- 
full, though the excess is most marked in the 
arterial system. Arteriotomy, however, is 
seldom called for, though it might at first 
sight seem indicated, since venesection usually 
answers every purpose. 
In asthenic plethora, on the other hand, 
the venous system only is overfilled; the 
right side of the heart is distended and its ac- 
tion is laboured. Here venesection is some- 
times called for, but it should be carefully 
employed. It is seldom necessary to with- 
draw more than from 6 to 10 ounces of blood, 
and often a smaller quantity will suffice. 
Peritonitis.-The relief obtained by bleed- 
ing in acute peritonitis rendered venesection 
a famous remedy in this affection in former 
times. And there can be no doubt about its 
efficacy in relieving the pain of peritonitis, as 
of inflammation of other serous membranes. 
It may be used when the patient is young 
and strong, and in that stage of the disease 
which is accompanied by a small, hard, and 
wiry pulse-the pulse of a contracted artery, 
of augmented tension from contraction, not 
from overfulness. It is worse than useless 
in the later stages of the disease, when ady- 
namia has set in. But valuable as bleeding 
may be in certain cases of peritonitis, it rarely 
happens that it is admissible, for in the great 
majority of cases inflammation of the peri- 
toneum is secondary to other diseases, such as 
tuberculosis or disease of the kidneys. Where 
peritonitis arises after delivery it is commonly 
of septicaemic origin, and it is seldom indeed 
that bleeding is of any avail under such 
conditions. So that, practically, bleeding is 
not a remedy which we can often employ in 
peritonitis. A very high temperature cannot 156 
BLOOD, ABSTRACTION OF 
alone be held to be indicative of its use, for 
it so happens that such pyrexia is, as a rule, 
present only in septicamhc cases. Some 
cases of peritonitis, even fatal ones, run their 
course without any marked elevation of 
temperature : or indeed without showing any 
definite symptoms. Probably venesection is 
most serviceable in traumatic peritonitis, or 
it may be, when the inflammation is local- 
ised, though in that case leeches are more 
suitable. 
Pleurisy.-When pleurisy attacks a young 
and robust patient, and is accompanied by 
severe pain, great relief follows blood-letting. 
The blood should be taken from a vein, and 
plena rivo. But when, as so often happens, 
pleurisy is, like peritonitis, secondary to 
damaged blood-conditions - e.g. Bright's 
disease - bleeding is often inadmissible. 
When, as in pleuro-pneumonic cases, pleurisy 
complicates pneumonia, bleeding may pos- 
sibly be called for, if there be great pain 
and oppression of the chest; but it should be 
most circumspectly used. Local blood-letting 
is much to be preferred if bleeding be thought 
necessary; for general bleeding is usually 
incompatible with the strength of the patient. 
Ercemic Asthma.-In the affection known 
as uraemic asthma, in which there is spasm 
of the systemic arterioles, with intense tur- 
gidity of the arterial system and engorgement 
of the left heart, bleeding, in the form of 
arteriotomy, appears to be clearly indicated, 
though probably the use of nitrite of amyl or 
of nitroglycerine may render it less necessary. 
Spasmodic Bronchial Asthma. - Pure 
asthma is doubtless often a nervous malady, 
and bleeding is not a remedy which should 
ordinarily be employed for its relief. It is 
only admissible when spasm of the pul- 
monary vessels, or obstruction to the flow of 
blood through them from bronchiole-spasm, 
leads to rapid engorgement of the right heart 
and venous system. This is the exact con- 
verse of uraemic asthma; but the effect in 
both is impediment to the aeration of the 
blood. Here the abstraction of a few ounces 
of blood from a vein may give immense and 
very prompt relief. 
Emphysema.-Bleeding may be used in the 
so-called ' asthmatic attacks ' to which em- 
physematous people are chronically prone. 
Here venesection may be imperatively de- 
manded when an acute attack of bronchitis 
has, by adding to the already difficult passage 
of blood through the lungs, excited rapid en- 
gorgement of the dilated heart and previously 
turgid venous system. 
Puerperal Diseases.-Formerly bleeding 
was much employed in midwifery practice, 
and especially in inflammatory affections 
after delivery. We now recognise that for 
the most part post-partum affections arise 
from septic mischief, and are of an adynamic 
type. It is but seldom that we are called 
upon to bleed in these cases. Nevertheless, 
now and again, venesection may be called 
for. 
Disorders of Menstruation.-Bleeding is 
a most valuable remedy in certain menstrual 
disorders, and especially in the plethora of 
women at the change of life. Many women 
suffer distressingly from general vascular 
disturbance at this period. The flushings, 
headaches, giddiness, feeling of oppression, 
and other vaso-motor phenomena from which 
they suffer, in association with the cessation 
of the catamenial flow, are immensely re- 
lieved by an occasional venesection. No 
other measure will so quickly and so effec- 
tually relieve these symptoms. Some robust, 
plethoric young women with amenorrhoea re- 
quire periodical bleeding. One of the writers 
has known the abstraction of a few ounces 
of blood speedily followed by the occur- 
rence of the menses, in cases of what may 
be called congestive amenorrhoea of many 
months' or even years' duration. It may be 
well to state in this connexion that in certain 
pulmonary, intracranial, and other visceral 
lesions, danger may arise from the augmented 
arterial tension which for a few days precedes 
the flow, and that the abstraction of blood 
may avert haemorrhage into the damaged 
organs. 
After Operations.-Bleeding is less fre- 
quently called for in surgical than in medical 
practice. It is indicated mainly in the after- 
treatment of cases which present engorge- 
ment of the right heart and venous system, 
as in some cases of ovariotomy and other 
operations involving the abdominal or 
thoracic cavities. A turgid venous system, 
with a small hard pulse, and a labouring 
heart-a condition which is often associated 
with scantiness, amounting almost to sup- 
pression, of urine-indicates blood-letting 
after operations of the kind above referred 
to. 
Shock.-In certain cases of shock the ab- 
straction of a limited amount of blood may 
be required. This point will be found dis- 
cussed elsewhere. See Shock. 
Fever.-That bleeding will lower the tem- 
perature of fevered patients has been known 
from the earliest times. It is, however, not 
a remedy to be resorted to for that purpose 
alone, for, as the most pronounced hyper- 
pyrexia occurs chiefly in association with 
conditions leading to great depression, blood- 
letting is under such circumstances as useless 
as it is dangerous. 
Insolation.-There are few disorders in 
which blood-letting is more successful, when 
rightly employed, than in sunstroke. It is 
seldom necessary to take more than a few 
ounces of blood; and excess should be par- 
ticularly guarded against, for fear of subse- 
quent collapse. The insensible patient with 
turgid veins, a tight pulse, and a labouring 
heart, will gain immense and prompt relief 
from venesection. The extreme pulmonary BLOOD, ABSTRACTION OF 
157 
congestion and over-distension of the right 
heart so often found post mortem might 
probably be prevented by the timely abstrac- 
tion of a little blood from the venous system. 
Bleeding is not to be thought of in the 
syncopal form. 
3. Methods of Bleeding.-The following 
are the methods of performing the operations 
of arteriotomy and phlebotomy. 
Arteriotomy.-This operation is best per- 
formed on the temporal artery. The vessel 
should be partially cut through by a simple 
transverse incision, and when a sufficient 
quantity of blood has been obtained it may 
then be completely severed, so that, retraction 
of both ends taking place, the haemorrhage 
may be arrested. • A compress of dry lint 
should then be applied, and a tight roller- 
bandage applied over it. 
Venesection.-The median basilic vein is 
the one usually selected for the operation on 
account of its being most readily found. The 
brachial artery lies immediately beneath it, 
and care must be taken to avoid wounding 
the latter vessel. The median cephalic vein 
is preferable, but is not so easily found. A 
vein on the dorsum of the foot or other part 
of the body may be chosen, but, as a rule, 
it is not desirable to open the jugular vein, 
especially on account of the danger of the 
entrance of air, and other risks. 
The steps in the operation on the arm are 
as follows:-First, the limb is to be firmly 
bound above the elbow by a broad tape or 
fillet. This should be applied with sufficient 
tightness to compress, and prevent the return 
of blood by, the veins, but not so as to inter- 
cept the current in the artery, and to ex- 
tinguish the pulse. An oblique slit is then 
to be made in the vessel by means of a 
small lancet, care being taken not to cut 
too deeply. The spirting blood should be 
caught in a vessel and measured. 
When sufficient blood has been withdrawn, 
the operator should firmly place a thumb or 
a finger on the aperture, and then, on re- 
moving compression, place upon the wound 
a dossil of dry lint, antiseptic dressing, 
styptic-colloid, or such-like, over which a 
roller-bandage should be twined a few times 
like a figure of 8, the cross being over the 
wound. 
Local Bleeding.-The object of local 
bleeding is the relief of congested vessels, 
and especially those of inflamed parts. Ar- 
teries convey more blood to, and veins con- 
vey more away from, inflamed parts; so 
that local bleeding may give great relief 
and initiate resolution, since absorption does 
not fully commence until inflammation has 
ceased. 
Methods of Local Bleeding. - Blood 
may be abstracted topically by leeches, by 
scarifications, or by wet-cupping. 
1. Leeching.-An average leech will ab- 
stract nearly half an ounce of blood. Leeches 
are extremely useful in a great variety of 
affections, since a pretty definite amount of 
blood can be withdrawn from the affected or 
adjacent parts, or from more distant parts, 
through intimacy of the vascular connexion, 
as in diseases of the eye and ear, and in 
hepatic diseases, accompanied by obstruction 
to the flow of blood through the portal sys- 
tem, when the application of leeches to the 
anus is most valuable. 
Care should be taken not to apply leeches 
to parts over which sufficient compression 
cannot be made so as to control the bleed- 
ing, should any difficulty arise in arresting it 
otherwise. Thus, leeches should not be ap- 
plied over the trachea, especially in children, 
in whom the error of applying them over the 
episternal notch is sometimes made. For 
the same reason the fontanelles should be 
avoided. 
The skin of the part where the leeches are 
to be applied should first be washed; and 
when they do not bite readily, the part may 
be wetted with a little milk or sugar and milk. 
A slight prick of a needle, sufficient to draw 
a speck of blood, will often cause them to 
bite when refractory. 
Should the bleeding continue too long after 
the leeches fall off, pressure or styptics may 
be applied. If it is desired to encourage 
bleeding, fomentations of hot water or lin- 
seed poultices are serviceable. 
In applying leeches to the cervix uteri, the 
precaution of closing the os by a plug of 
wool should not be neglected. When they 
are applied within the mouth, a leech-glass 
should be used. 
2. Scarifying.-Scarifications consist in 
small cuts of a depth not exceeding the eighth 
of an inch, or less, into the tissue whence it is 
desired to take blood. This mode of topical 
bleeding is mainly applied to the cervix uteri, 
to the tongue in acute glossitis, and to the 
palpebral conjunctiva in certain kinds of 
conjunctivitis; in the last case only slight 
incisions are permissible. Deeper punctures 
are made by some practitioners into the tis- 
sue of the cervix uteri, but these are punc- 
tures and not mere scarifications. 
3. Wet-Cupping.-Cupping and the use 
of the scarificator, constituting wet-cupping, 
is an important method of topical blood- 
abstraction; and as a considerable amount 
of blood can thus be withdrawn, the general 
circulation may be affected. It is ordinarily 
employed, however, for its local effects. 
The method of its performance is as fol- 
lows :-Cupping-glasses being first put on for 
a brief time, as for dry-cupping {see Cupping 
-Dry-Cupping'), the operator applies to the 
part selected a spring scarificator so adjusted 
as to cut only to the required depth-about 
an eighth of an inch or less. The cupping- 
glasses are then re-applied, and the desired 
number of ounces of blood abstracted. If the 
glasses be too tightly attached the blood will 158 
BLOOD, ABSTRACTION OF 
BLOOD, MORBID CONDITIONS OF 
not flow readily, and unnecessary pain may 
be caused. After their removal adhesive 
plaster, or dry lint and a bandage, should be 
applied to the part. 
Cupping is extremely useful over the loins 
in renal ischaemia; on the temple or behind 
the ears in certain cerebral disorders ; down 
the spinal column in inflammation of the 
spinal cord or meninges; and on the chest 
in certain pulmonary and cardiac affections. 
Alfred Wiltshire. Richard Quain. 
BLOOD-DISEASE.-The term blood- 
disease was used by the humoral pathologists 
as synonymous with dyscrasis or anomalous 
crasis of the blood, and expressed the idea 
that the blood was the seat ' almost without 
exception ' of all general diseases. And, 
further, since purely local disease was con- 
sidered to be exceptional, the vast majority 
of diseases were referred to dyscrases, and 
were classed under the head of blood-diseases. 
The condition of the blood was considered 
by the humoralists to depend upon the crasis, 
that is the mixture, of its constituents ; and 
prominent among its constituents were 
reckoned the blastemata, or germinal sub- 
stances of the different tissues, which exuded 
through the capillary walls in the process- 
of nutrition. When the blood-crasis was 
disordered or diseased, a dyscrasis was said 
to exist; and dyscrases were held to be in 
the majority of cases primary, though it was 
allowed that local anomalies of nutrition 
might and did occasionally occur, and give 
rise to secondary dyscrases. A blood-disease 
or dyscrasis being established, all morbid 
changes throughout the body were believed 
to be but local manifestations of the same. 
For the purpose, therefore, of a rational 
classification of disease, a previous classifica- 
tion had to be made of the dyscrases. The 
principal blood-crases were said to be :- 
1. The fibrin-crasis ; including the simple 
fibrin-crasis, the croupous crasis, and the 
tubercle-crisis as varieties. The local expres- 
sion of the fibrin erases was inflammation in 
some form. 
2. The venous crasis, in which fibrin was 
deficient. This included a vast number of 
special erases, lying at the foundation of the 
most diverse diseases-e.g. plethora, heart- 
disease, the acute exanthemata, rickets, albu- 
minous urine, cholera, acute tuberculosis, 
lardaceous disease, cancer, acute convulsive 
diseases, metallic poisoning, &c. 
3. The serous crasis; associated with 
anaemia. 
4. The putrid or septic crasis. 
5. Anomalous erases; such as those of 
syphilis, gout, &c. 
The theory of dyscrases may be said to 
have declined since the appearance of Vir- 
chow's Cellular Pathology. Virchow showed 
that the blood is, in every relation, not an 
independent but a dependent fluid, and that 
the sources from which it is sustained and 
restored, and the exciting causes of the 
changes that it may suffer, lie without it, 
not within it. Substances may enter the 
blood and affect the corpuscles injuriously ; 
the blood may act as a medium in conveying 
to the organs noxious substances that have 
reached it from various sources ; or its ele- 
ments may be imperfectly restored. But 
never is any ' dyscrasis ' permanent, unless 
new influences arise and act upon the blood 
through some channel or through some 
organ. 
At the present time, whilst it cannot be 
said that humoralism is professed by many 
pathologists, the notion of blood-disease, as 
generally entertained forty years ago, still 
clings to our nomenclature, and pervades some 
of our pathological doctrines. Diseases that 
affect the whole economy-syphilis, tubercu- 
losis, gout, and cancer-are frequently de- 
scribed as 'constitutional,'or 'blood-diseases,' 
and'this whether their general manifestations 
are secondary to local disease, as in syphilis 
and cancer, or are referable to inheritance. 
While the morbid conditions of the blood are 
real and numerous, ' blood diseases,' so called, 
are but abstractions, and, as such, a fruitful 
source of confusion and useless discussion. 
It is desirable that the term blood-disease 
should be abandoned, and that the expression 
morbid, conditions of the blood should be ap- 
plied to those pathological states of the vital 
fluid which can be distinctly demonstrated 
by physical, chemical, or histological exami- 
nation. J. Mitchell Bruce. 
BLOOD, Morbid Conditions of.- 
The characters, composition, and functions 
of the blood in health are sufficiently fami- 
liar, and are fully described in text-books. 
But certain facts connected with the physio- 
logy of this fluid have a special bearing 
upon its pathology, and must be briefly con- 
sidered before its morbid states can be profit- 
ably discussed. 
A. Physiology of the Blood.-The red 
corpuscles of the blood consist of two 
portions-a colourless, sponge-like matrix ; 
and a coloured substance of complex com- 
position, which occupies the interstices ot 
the former and accurately fills them. The 
matrix is regarded as possessing chiefly 
physical properties ; whilst its contents con- 
stitute the active part of the corpuscle, and 
consist of haemoglobin. The source of the 
red corpuscles is of the greatest pathological 
importance. In the embryo the blood and 
blood-vessels are developed from the same 
elements, and thus the two structures in their 
physiological aspect are essentially insepar- 
able. In fully-developed blood the source of 
the red corpuscle is obscure ; but there can 
be no reasonable doubt that it originates in 
the spleen and the medulla of bones; and 
that light is of the greatest importance in the BLOOD, MORBID CONDITIONS OF 
159 
formation of haemoglobin. With respect to 
the properties and function of the red cor- 
puscle, it is to be noted that the ultimate 
elements of haemoglobin are carbon, nitrogen, 
hydrogen, oxygen, sulphur, and iron-the last 
closely associated with the colouring matter. 
Haemoglobin is soluble in water, forming a 
lake-coloured liquid from which fine crystals 
may be obtained, and which may be variously 
decomposed, giving rise to other ' blood 
crystals.' Most important of all its proper- 
ties, haemoglobin combines with certain gases 
to form definite chemical compounds: with 
O to form oxyhaemoglobin ; with CO to form 
carbonic-oxide-haemoglobin ; and with NO to 
form nitric-oxide-haemoglobin. These com- 
pounds are more or less unstable, especially 
the oxyhaemoglobin, which is broken up even 
under very feeble influences to oxygen and 
reduced haemoglobin. Alternate oxygenation 
of haemoglobin and deoxygenation of oxyhae- 
moglobin are constantly going on within the 
red corpuscles of the circulating blood; and 
the two changes, occurring in the pulmonary 
and systemic capillaries respectively, consti- 
tute the first great function of the blood-its 
oxygenating or respiratory function. The 
volume of oxygen in arterial blood is 20 
per cent.; in venous blood 8 to 12 per cent. 
It must be clearly understood that disorders 
connected with the red corpuscles or respi- 
ratory elements of the body, whether in 
amount, composition, or circulation, directly 
affect the oxidation-processes only. Besides 
its origin and its function, there is a third 
relation of the red corpuscle to the organism 
-namely, the disposal of its products. These 
are eliminated by the ordinary channels; the 
salts, which are chiefly salts of potassium, 
being excreted by the kidneys, and the coloured 
material furnishing the pigments of the bile 
and urine. 
The white or colourless corpuscles of the 
blood, also called leucocytes, are chiefly 
derived from the corpuscles of the lymph, 
and the cells of the lymphatic glands and 
allied organs, which they closely resemble. 
By escaping through the walls of the blood- 
vessels, they become identical with the 
wrandering-cells of tissues and with pus- 
corpuscles,-from which they are indistin- 
guishable except by locality. Some authorities 
regard them as phagocytes, attacking, and if 
possible destroying, pathological organisms in 
the blood and tissues. They may also influ- 
ence the plasma by continually ingesting and 
egesting certain of its constituents. It might, 
therefore, be expected that morbid states of 
the leucocytes would be associated with dis- 
orders of the lymphatic structures, connec- 
tive tissues, blood-plasma, and blood-vessels; 
and this will presently be shown to be the 
case. The proportion of white corpuscles in 
the blood is subject to physiological increase, 
without becoming excessive-e.g. after meals, 
during periods of growth and development, 
and in menstruation and pregnancy. Thia 
state is called physiological leucocytosis 
(Virchow), and signifies lymph-glandular ex- 
citement. The chemical products of the leu- 
cocytes contain a large proportion of potas- 
sium and phosphoric acid. 
The blood-plates, -platelets, or -tablets 
(hematoblastes of Hayem), minute bodies to 
be seen in blood, both within the vessels and 
after it has been drawn, are of obscure 
nature, origin, and function. Possibly they 
play some part in coagulation. 
Plasma.-The physiological relations of 
the plasma to the organism are extremely 
complex ; and disturbance of these relations 
furnishes many of the symptoms of disorder 
of the blood. Its mature function is essen- 
tially one of nutrition : it supplies the 
tissues with oxidisable material for develop- 
ment, growth, support, secretion, and the 
liberation of force. The source of the plasma 
is equally extensive. It derives its principal 
constituents from the alimentary canal 
through the absorbent glands and liver ; 
while other important albuminous substances 
are being constantly supplied from the tissues 
generally, through the lymphatic system. 
Lastly, the products of the plasma, such as 
carbonic acid, urea, and water, are discharged 
by the regular excretory channels. Thus the 
condition of the plasma is found to be most 
intimately associated with that of the organs 
and tissues generally, whether as regards its 
origin, its mature function, or its products ; 
and it is affected by disorder or disease of every 
organ, whether alimentary, sanguifacient, 
dynamic, or excretory, and of every tissue. 
Coagulation of the Blood: Fibrin.-Under 
certain circumstances, especially after re- 
moval from the body, the blood coagulates, 
and a proteid substance, fibrin, separates 
more or less completely from the other con- 
stituents. This change is now believed to be 
due to the interaction of two fibrin-factors 
contained in the plasma, namely, a ferment 
-fibrin-ferment, and fibrinogen; and along 
with these there must be present some 
neutral salt. The amount of fibrin produced 
varies not only with the amount of these 
bodies, but with the amount of salts, with 
the degree of alkalinity and of heat, and 
with other influences; and these variations 
are subject to no law at present known. 
The rapidity of the process depends upon 
(1) the amount of ferment ; (2) its in- 
creased activity by moderate elevation of 
temperature; and (3) agitation of the blood 
and the increased number of points of con- 
tact (so-called ' catalytic ' action) -by the 
presence of red corpuscles, haemoglobin, char- 
coal, &c. It thus appears that the expres- 
sions ' amount of fibrin ' and ' rapidity of 
coagulation,' however important as facts, do 
not afford any definite indication of the state 
of the blood, as was formerly believed. Three 
essential factors, and a large number of 160 
BLOOD, MORBID CONDITIONS OF 
accidental influences, share in the process; 
they may do so in very various proportions 
and degrees; they do not vary together ; the 
amount of fibrin is not in proportion to any 
one of them; and after coagulation is com- 
plete, portions of all the factors probably re- 
main uncombined. The part played by the 
red corpuscles in coagulation is a double one 
-(1) the corpuscles, ' as points of contact,' 
greatly increase the rapidity of coagulation; 
and (2) they supply oxygen, which appears 
to be indispensable to the process. The 
leucocytes probably produce the ferment; but 
it is doubtful whether it exists in the intact 
blood-cells. The blood-plates may also share 
in the process. 
B. Pathology of the Blood.-The mor- 
bid states of the blood will now be considered 
in the following order:-1. Changes in quan- 
tity, and the effects of such changes upon 
the composition of the vital fluid. 2. Morbid 
conditions of the red corpuscles. 3. Changes 
in colour. 4. Melanaemia. 5. Morbid states 
of the white corpuscles. 6. The pathology 
of the blood-plasma; and of the process of 
coagulation. 7. The presence of foreign 
materials in the blood, including poisons 
and infective substances. 8. Organisms. 
1. Changes in Quantity of the Blood. 
Alterations in the total amount of blood in 
the body are perhaps never simple, but 
always associated with alterations in quality. 
(a) Polycemia, or excess of blood in the body 
generally, may be the result of excessive 
ingestion of the elements of blood; of the 
accumulation of the same by the suppression 
of habitual haemorrhages or fluxes; of the 
loss or obsoleteness of a part of the body, 
such as a limb or a lung; or of insufficient 
exercise. It cannot be said, however, that 
polyaemia has ever been demonstrated by 
exact investigation, inasmuch as the total 
amount of blood in the body is still uncer- 
tain, and the physiological limits in this re- 
spect are very wide. Polyaemia is believed 
to be present in plethora, along with relative 
excess of the solids, particularly the red cor- 
puscles. 
(b) Oligcemia, or deficiency of the total 
amount of blood, is, on the contrary, an 
exceedingly frequent change, and constitutes 
the simplest form of anaemia. It is, how 
ever, probably never pure, inasmuch as 
alterations in quality appear to be insepa- 
rably associated with it; and the terms 
hydrcemia and sp ancemia have accordingly 
been used as synonymous with the preceding. 
The manner in which diminution in quantity 
gives rise to alteration in quality must be 
considered here. 
When haemorrhage occurs to any amount, 
and the whole quantity of blood in the ves- 
sels is reduced, the pressure falls, and ab- 
sorption of the parenchymatous plasma 
rapidly follows, by which, along with vaso- 
motor stimulation, the physical relations are 
restored. If the loss of blood has been 
moderate, the only change in its composition 
may be considered to be oligocythcemia, or 
diminution of the red corpuscles, which 
alone of all the constituents of the blood 
cannot be rapidly restored. If the haemor- 
rhage has been more serious, the fluid ab- 
sorbed into the circulation from the tissues, 
from the suppressed secretions, and from the 
alimentary canal, consists of water in ever- 
increasing excess, which carries with it an 
amount of salts equal to one-ninth the loss 
in albuminous substances. The morbid state 
of the blood is now beyond oligocythaemia; 
there is deficiency of albuminous consti- 
tuents, or hypalbuminosis, and the condition 
correctly called oligcemia vera or ancemia is 
the result. The total quantity of blood pro- 
bably remains for some time below the nor- 
mal. A similar impairment of the quantity, 
and therewith of the quality of the blood, 
may be slowly developed by repeated small 
haemorrhages, or by any cause whatever that 
impoverishes the blood, whether of the nature 
of waste or of want. The condition which 
results closely resembles that just described 
in the acute form-oligaemia with oligocy- 
thaemia and hypalbuminosis; the same is also 
known clinically as anaemia. See Anemia. 
As a therapeutic measure, oligaemia may 
be desirable. It may be induced either 
(1) by direct abstraction of blood, or (2) by 
gradual impoverishment of the blood, and 
reduction of the intra-vascular pressure. See 
Blood, Abstraction of; and Aortic Aneu- 
rysm ; Treatment. 
2. Morbid. Conditions of the Red 
Corpuscles.-The pathology of the red 
corpuscles is still imperfectly understood. 
The following comprise the most important 
changes connected with them so far as they 
are known. 
(a) Polycythcemia : plethora polycythce- 
mica.-Increase in number of the red cor- 
puscles is never considerable, being generally 
transitory and within physiological limits- 
for example, in the newly-born, and after 
meals. It has already been mentioned as 
associated with polyaemia in plethora. In 
the algid stage of cholera the red corpuscles 
are relatively in excess. 
(b) Oligocythcemia.-Diminution in num- 
ber of the red corpuscles is, on the other 
hand, of very frequent occurrence and great 
pathological importance. Microscopically the 
number of red corpuscles in a given visible 
area of blood is diminished; and chemically 
the amount of haemoglobin in a given volume 
of blood may fall from fifteen even as low as 
five per cent, (see H.emacytometer). The 
principal circumstances under which oligocy- 
thaemia occurs are-(1) in anaemia, or diminu- 
tion in the amount of blood as a whole, from 
any cause, whether rapid or protracted, espe- 
cially as the result of fever, the red corpus- 
cles suffering early, seriously, and persistently, BLOOD, MORBID CONDITIONS OF 
161 
as compared with the other constituents; 
(2) in leukaemia-the development of the red 
corpuscles being interrupted; (3) in hypalbu- 
minosis, where the red corpuscles, like other 
elements, suffer from want of albuminous 
material; (4) in chlorosis, from imperfect 
growth; and (5) in pernicious anaemia, from 
excessive destruction (haemolysis). 
(c) Oligochromeemia.- Deficiency of the 
red corpuscles in haemoglobin has been de- 
scribed by this name. It is a morbid condi- 
tion of much interest, inasmuch as it is one 
of the essential alterations of the blood in 
chlorosis. When the individual red corpuscle 
contains less haemoglobin than normal, it is 
said to present a pale appearance to the eye. 
A more trustworthy method of determining 
the richness of the red corpuscles in haemo- 
globin, is by means of the haemoglobinometer 
(see H^moglobinometer). Or we may com- 
pare the amount of haemoglobin in a given 
weight of blood with the number of red cor- 
puscles in a given microscopical area. When 
the former is small in proportion to the 
latter, the defect must lie in the individual 
corpuscle ; and this may be so great that the 
proportion of haemoglobin falls, as in some 
cases of chlorosis, to twenty-five per cent, of 
the normal. See Chlorosis. 
(d) Aglobulism.-The effects of the two con- 
ditions of blood just described, namely, oligo- 
cythaemia and oligochromaemia, may be dis- 
cussed together under the head of aglobulism, 
or deficiency of the blood in haemoglobin. 
Want of this, the oxygenating substance of the 
organism, gives rise to symptoms at once ex- 
tremely various amongst themselves, and of 
serious import. Every vital process, whether 
developmental, plastic, secretory, dynamic, or 
nutritive, is absolutely dependent on a free 
and immediate supply of oxygen. All of 
these processes, therefore, will suffer in aglo- 
bulism. The respiratory and circulatory 
movements are accelerated. The complex 
processes of alimentation and secretion are 
performed imperfectly, and the results are 
dyspepsia, constipation, and disordered san- 
guification-which intensify the abnormal 
blood-state. Muscular contraction is feeble, 
and cannot be sustained. Psychical force is 
weak; and dulness, sleepiness, pains, and 
other symptoms indicate imperfect oxidation 
within the nervous system. Bodily growth 
and development-of the sexual organs, for 
example-remain incomplete, and puberty is 
deferred. Nutrition everywhere suffers, the 
materials being insufficiently oxidised; and 
substances ' intermediate ' to albumin on the 
one hand, and carbonic acid, water, and urea 
on the other hand, are formed, especially 
oils. Thus the organs and the connective 
tissues become loaded with fat and enlarged, 
instead of suffering atrophy, as they do when 
the blood-plasma is deficient. Finally the 
excretions are disturbed, and the subject of 
aglobulism presents derangement of the 
colouring matters of the bile and urine, which 
are derived from haemoglobin. See Anaemia, 
Pernicious. 
Histological changes.-Alterations in the 
size, outline, and consistence of the red cor- 
puscle have been frequently recorded, but such 
accounts are incomplete, and no entirely suc- 
cessful attempt has yet been made to connect 
any of these changes with morbid processes 
in the tissues. In severe fevers, such as 
typhus, and in some rapid malignant dis- 
eases, the red corpuscles appear peculiarly 
soft, their outline being less resistant and 
sharp, and the bodies running together into 
irregular heaps, instead of into rouleaux with 
well-defined lines of contact between the 
elements. In another class of cases the cor- 
puscles appear small and crenated or like the 
' thorn-apple.' Macrocythcemia and micro- 
cythcemia have also been described as tem- 
porary and variable conditions, in which the 
red corpuscles are abnormally large and ab- 
normally small respectively. These changes, 
as well as alterations in form, the corpuscles 
being oval, tailed, pear-shaped, or irregular 
(poikilocytes), or provided with excess of 
haemoglobin, occur in pernicious anaemia 
(see fig. 3, page 61). Transitional cells 
between the white and the red corpuscle 
are unusually numerous in some cases of 
leukaemia. 
3. Changes in colour.-The colour of 
the blood is chiefly due to the red corpuscles, 
and alterations from the normal in this direc- 
tion will be best considered in this place, 
although the white corpuscles and the plasma 
may also affect the colour, as will be pre- 
sently shown. 
(a) The chief determining cause of the colour 
of the blood is the chemical condition of the 
haemoglobin. When this is united with 
oxygen, in the arteries, the blood is scarlet; 
as deoxidation advances, this colour passes 
into a purple, and finally becomes black or 
venous. The dark colour is directly due to 
absence of oxygen. The purest example of 
this change is seen in asphyxia, where oxygen 
is excluded from the blood; but it also occurs 
as the result of the action of certain injurious 
influences upon the corpuscle itself, such as 
extreme heat, or poisoning by phosphorus, 
prussic acid, and other toxic agents. If the 
change proceed no farther, the scarlet colour 
may still be restored by oxidation. This 
blackness of the blood is generally associated 
with imperfect coagulation or even a state of 
fluidity. See Fibrin, page 164. 
(6) Paleness of the blood is observed in 
oligsemia and oligocythsemia, and is due to 
deficiency of the haemoglobin. 
(c) The blood may not only be pale, but pre- 
sent streaks somewhat resembling pus, even 
as it flows from the living vessels, as in leu- 
kaemia. The same blood will settle on stand- 
ing into three layers-of plasma superiorly, 
loosely coagulated or not; of white corpuscles 162 
BLOOD, MORBID CONDITIONS OF 
in the middle-a puriform layer ; and of red 
corpuscles at the bottom. 
(d) The milky appearance of chylous blood 
will be presently described under the head 
of Blood-Plasma. 
(e) Lake-coloured blood. - A remarkable 
change of the blood, in which it becomes lake- 
coloured or transparent, is frequently ob- 
served as a more advanced stage of that just 
described under (a); but it may occur under 
other circumstances than deoxidation, and is 
of grave significance, inasmuch as it indicates 
complete and hopeless destruction of the red 
corpuscles. Lake-coloured blood is no longer 
opaque, but transparent; the haemoglobin 
has left the corpuscles and is dissolved in 
the plasma. The change can be effected 
experimentally by the addition to blood of 
water, chloroform, the bile-acids, or other 
solvents; and it is probable that some of 
the cases of rapid death after enormous 
draughts of water, and the destruction of red 
corpuscles which is believed to occur in jaun- 
dice, may be accounted for in this way. But 
the most important cause of ' solution ' of the 
red corpuscles is complete deoxidation of the 
haemoglobin, which is followed by its diffusion 
in the plasma. Thus drawn blood is rendered 
lake-coloured by the addition of sulphide of 
ammonium, phosphorus, phosphoric acid, or 
iron-filings ; and the same effect is produced 
by the intravenous injection of salts of the 
bile-acids. This being so, it might be ex- 
pected that blood would assume the lake 
appearance when exposed to the prolonged 
action of the causes that render it black; and 
recent observations seem to indicate that 
such is the case. In a number of diseases 
which are attended with an accumulation of 
oxidisable substances in the circulation, the 
blood has been described as ' fluid,' ' claret '- 
or ' cherry-coloured,' ' clear,' and ' staining 
the tissues,'-but apparently without more 
exact observations on the colour of the living 
plasma. Such morbid states are high fevers 
(hyperpyrexia), insolation, and poisoning by 
malaria, phosphorus, and perhaps other 
agents. The effect of some of these influ- 
ences is obviously to produce an excessive 
amount of oxidisable material in the blood, 
while the others may lead to the same result 
by reducing the oxygenating capacity of the 
corpuscles. Persons dying under such cir- 
cumstances present great lividity, from the 
black or venous condition of their blood; 
death occurs with symptoms indicative of 
want of oxygen, as if so much of the haemo- 
globin had been diffused through the plasma ; 
and post mortem the vessels are found 
stained with the solution, the tissues are 
soaked with fluid lake-coloured blood, and de- 
composition is early and rapid. The ' fluidity ' 
of such blood, or absence of clot in it, will be 
presently accounted for under Fibrin. That 
a similar solution or destruction of the red 
corpuscle may occur in all cases of fever, 
only in a much less degree, is supported by 
several facts : (1) the increased discharge of 
potassium-salts in fever; (2) a similar in- 
crease of the colouring matter of the urine; 
and (3) the anaemia that is found at the ter- 
mination of the process. 
(/) Other alterations in colour may occur 
in the blood. The blood is cherry-red after 
poisoning by carbonic oxide, and remains so 
after exposure. It is chocolate-coloured after 
poisoning by the nitrites, such as nitrite of 
amyl, giving the spectrum of methaemoglobin 
-a more stable compound than haemoglobin; 
and other hues have been recorded. 
4. Mel anaemia.-In relation with the 
pigment-bearing element of the blood there 
may be mentioned a morbid condition which 
has been described under the name of mel- 
anaemia. In this disease the blood presents 
black and brown pigment-particles and flakes, 
free or contained in cells of various shapes. 
These bodies arise from the disintegration of 
the red corpuscles; and are partly absorbed 
by the leucocytes, partly deposited in the 
spleen, liver, brain, and bone-marrow. Mel- 
anaemia is especially associated with two 
other states, namely, malaria, and an en- 
larged deeply-pigmented condition of the 
spleen; and one view of its origin is that the 
red corpuscles are destroyed in the spleen 
by the fever, and that the pigment-par- 
ticles thus produced find their way from the 
spleen into the blood. They are then de- 
posited in the liver and other organs, and 
give rise to symptoms of visceral disturbance 
during life, and to the peculiar slaty or grey 
discolouration that is found post mortem. 
It has been said that in melanotic cancer 
pigmented cells have been found in the living 
blood. 
5. Morbid Conditions of the White 
Corpuscles.-The white corpuscles of the 
blood may undergo certain morbid changes 
both in number and appearance. 
(a) The most remarkable of these is increase 
in number, which may rise from the normal 
(1 to 350 red) until the white corpuscles be- 
come even the more numerous. This condi- 
tion is known as leucocythcemia or leukcemia 
(see Leukemia). Short of this, however, the 
proportion of white corpuscles in the blood 
may be appreciably increased, and to this 
minor condition the name of leucocytosis 
has been applied. Leucocytosis, according 
to Virchow, accompanies, almost unexcep- 
tionally, every case of lymphatic excitement, 
such as inflammation, and tubercular, scrofu- 
lous, or cancerous enlargement or swelling 
of the glands and allied structures-Peyer's 
glands, the solitary follicles, the spleen, and 
the tonsils. Leucocytosis is distinguished 
from leukaemia by its very moderate degree ; 
by its evanescent course ; by the absence of 
deficiency of the red corpuscles ; and by the 
accompanying symptoms. Leucocytosis may 
be appreciated even by the naked eye in the BLOOD, MORBID CONDITIONS OF 
163 
clot of drawn blood, by the presence of an 
irregular ' lymphatic layer ' - crusta lym~ 
vhatica, consisting of collections of white 
corpuscles between the red clot and the 
buffy coat, which so frequently occurs along 
with it. 
(6) A diminution in the number of white 
corpuscles occurs in chlorosis ; and, it is said, 
in malaria, especially during the paroxysm of j 
fever. 
(c) With regard to the structure of the 
individual white corpuscles, the proportion of । 
uninuclear or young cells, and the multinu* 
clear or aged cells, may be disturbed both in 
leucocytosis and leukaemia ; while corpuscles j 
may be found containing granules of various b 
kinds, especially pigment-particles, bacteria, I 
micrococci, and other structures. 
6. Morbid Conditions of the Blood- 
plasma.-(1) Water.-The limits of the 
physiological variations jn the amount of 
water in the blood are very wide. 
(a) Diminution of water in the blood is ! 
observed in various degrees. It is moderate ■ 
and transitory as the result of stimulation of 
the kidneys, skin, or bowels, for the normal 
proportion is speedily restored by absorption. 
This condition is also found after severe 
purgation, sweating, diarrhoea, or dysentery ; 
and its production is the rationale of several 
of the methods adopted for the relief of I 
dropsy. If the drain of water continue, or if i 
the supply fail, the anhydric condition of ; 
blood increases, so that the fluid appears ■ 
black, thick, and tarry. Such is the state of 
the blood in the algid stage of cholera ; the 
specific gravity of the blood rising from | 
1055° as high as 1080°, with a comparative 
excess of salts, albumen, and urea. The chief 
symptoms of great deficiency of water in | 
the blood are intense thirst; a shrivelled, 
•shrunken aspect of the body generally; cold- 
ness and lividity of the extremities; muscu- 
lar pains ; and suppression of the excretions- 
phenomena directly referable to loss of 
water, retardation of the circulation, and 
interference with the function of the red 
corpuscles. 
(6) Excess.- Hydrcemia.-Reference has 
been already made under the head of oligae- 
mia to the anaemia or hydraemia that follows 
it. Excess of water in the blood (plethora 
serosa s. aquosd) is perhaps never absolute, 
and the change may therefore be regarded 
with equal accuracy and greater convenience 
as deficiency of solids. 
(2) Albuminous Constituents.-On re- 
viewing what has already been said under 
the head of Coagulation and Fibrin, the 
reader will observe that ' amount of fibrin,' 
and other expressions connected with the 
albuminous constituents, must be regarded 
at present as comparatively meaningless, in 
the light of our knowledge of the process of 
coagulation. Inasmuch, therefore, as little 
value can now be attached to the analyses of 
fibrin that have been made in different 
diseases, it follows that the estimates of the 
albuminous substances left after coagulation 
-that is, of the albumins of the serum, 
must also be rejected. But the total amount 
of albumins in the blood may be easily 
ascertained ; and this is subject to extensive 
variations. The balance between the albumi- 
nous substances which enter the blood from 
the alimentary tract and the lymphatic 
system, on the one hand, and the products of 
their transformation by the tissues, on the 
other hand, is represented by the albumins of 
the blood. These will increase accordingly 
when the supply is excessive, or the con- 
sumption small ; and will decrease under the 
reverse circumstances. 
(a) Plethora hyperalbuminosa is the name 
given to excess of albumins in the plasma. 
The amount has been found notably increased 
when the activity of the tissues is abnormally 
heightened, as, for example, in inflammatory 
diseases (acute rheumatism, tonsillitis, pneu- 
monia, and pleurisy), and fibrinogen, which 
is the product of this increased activity, is 
poured abundantly into the blood. The 
amount of albuminous fluid produced in an 
inflamed part, whether it appear as a catarrh, 
an infiltration, an exudation, or an effusion, 
is very great, and may be enormous ; and, 
under favourable circumstances, this and 
much that cannot be so easily appreciated 
are carried into the blood, the lymphatic 
structures swelling en route. Albuminous 
plethora, as a result of diminished oxidation, 
probably does not exist ; for the effect of an 
insufficient supply of oxygen to the albumins 
(from want of exercise or over-feeding) is 
not the accumulation of these in the blood, 
but the formation of ' lower ' products, such 
as uric acid and its allies, and the deposit of 
fat. Relative hyperalbuminosis is a neces- 
sary but transient effect of cholera and other 
severe watery fluxes. 
(6) Oligcemia hypalbuminosa, or deficiency 
of albumins in the blood, occurs under exactly 
opposite circumstances from the preceding,- 
whether the ingestion of albumins from the 
alimentary tract and the tissues be compara- 
tively small, or the consumption excessive. 
Inanition, therefore, on the one hand, and its 
multitude of causes, are associated with such 
poverty of blood ; and so, on the other hand, 
are loss of blood, profuse discharges of albu- 
minous fluids, morbid growths, and other 
sources of waste, as well as excessive 
demands of growth and development. The 
albumins of the plasma may fall under these 
circumstances from 80 to 37 parts in 1,000. 
Such hypalbuminosis is, however, never 
simple : the blood cannot be deficient in 
albuminous substances and otherwise normal, 
for, as we have already shown, loss of albu- 
men is always followed by absorption of 
water and salts from the tissues in definite 
proportions, and anaemia is the result. The 164 
BLOOD, MORBID CONDITIONS OF 
red corpuscles suffer at the same time, for 
their nutrition speedily fails in hypalbumi- 
nosis, and aglobulism ensues. Hypalbumi- 
nosis is a serious disorder of the blood. The 
relations of these conditions to each other 
and to oligaemia are even more complicated 
clinically than they are pathologically ; and 
in this relation the whole of them are most 
conveniently discussed under the comprehen- 
sive head of anaemia. See Anemia. 
(3) Clot ; Fibrin.-However uncertain as 
a measure of any particular constituent in 
the blood, the amount of clot or fibrin 
demands a brief notice as a matter of 
fact. 
(a) Abundant clot has been considered as 
indicating an excess of fibrin in the blood or 
hyperinosis, the proportion being stated to 
rise as high as 1*0 instead of 0'2 per cent. 
Acute rheumatism, erysipelas, croupous 
pneumonia, and pleurisy are the diseases in 
which hyperinosis is most marked ; but it 
also occurs in pregnancy. The two principal 
conditions of its occurrence appear to be- 
(1) increased activity of the tissues, including 
inflammation ; and (2) free and abundant 
communication of these tissues with the 
blood through the lymphatic system. 
(&) Deficiency, looseness, or absence ofclot; 
' Fluid blood.'-A small loose clot is fre- 
quently observed, as for example in typhoid 
states, or in chronic wasting diseases attended 
with loss of blood ; and has been described as 
indicating hypinosis or deficiency of fibrin. 
When the condition is extreme, the clot may 
be absolutely wanting, as in certain cases of 
anaemia. The blood then separates on stand- 
ing into three layers-an upper, consisting of 
clear liquid ; a middle, puriform, of white 
corpuscles ; and a lower, red, of red cor- 
puscles. In another and larger group of 
cases, non-coagulating or fluid blood is at the 
same time of an intensely dark or even lake 
colour, and is commonly described as ' black.' 
The circumstances under which this con- 
dition of blood occurs, and the cause of the 
remarkable colour, have been already noticed; 
and it remains to account only for the fluidity. 
The profound alteration of the red corpuscles, 
the want of oxygen, the interference with the 
production of the ferment, and the changes in 
the fibrinogen-one and all combine to pre- 
vent coagulation. 
(c) Buffy coat.-Another phenomenon con- 
nected with coagulation, from which erro- 
neous and even dangerous conclusions have 
been drawn, is the so-called buffy coat. The 
process of coagulation is generally sufficiently 
slow to allow of the gravitation of some of 
the red corpuscles from the surface of the 
blood ; and the corresponding part of the 
clot is accordingly paler. When the pale 
layer is unusually large it is known as the 
buffy coat or crusta phlogistica : it may be 
seen in the blood in pregnancy, inflammatory 
fevers, hydraemia, and oligocythaeinia. When 
these cases are analysed, it is found that the 
conditions favourable to the formation of the 
huffy coat are probably all more or less 
connected with the red corpuscles, namely- 
(1) increased specific gravity of the red cor- 
puscles, as in oligocythemia and hydremia- 
allowing more rapid sinking ; (2) interference 
with the catalytic action of the hemoglobin, 
which is so powerful in determining the 
rapidity of coagulation, as in fevers and 
oligocythemia ; and (3) want of oxygen, 
corresponding to the amount and condition 
of the hemoglobin, as in the same diseases. 
One and all of these states render the pro- 
cess of coagulation slow compared with the 
descent of the red corpuscles ; and the buffy 
coat is the result. It thus appears that the 
buffy coat is no indication whatever of excess 
of fibrin-generators, or of the opposite ; and 
that it is found under the most diverse con- 
ditions of blood. 
(4) Salts.-The amount of positive know- 
ledge concerning morbid alterations of the 
salts of the blood is but small. It is to be 
observed that the salts of the plasma have 
chiefly sodium for their base in the form of 
chlorides, whilst potassium salts and phos- 
phates mostly reside in the corpuscles. 
(a) Diminution.-In febrile diseases there 
is an increased discharge of compounds of 
both bases, but at different periods; the 
potassium salts appearing in excess in the 
excretions until the crisis is past, and the 
sodium salts during defervescence. At both 
periods, it may be considered certain that 
the blood is the chief source of the salts ex- 
creted; and that it is accordingly deficient 
in these constituents. 
(6) Excess.-On the other hand, the salts of 
the plasma are relatively in excess in hyp- 
albuminosis, replacing, in the proportion al- 
ready stated, the lost albumins. The effect, 
on the salts of the blood of such drains as 
occur in cholera has been variously stated; 
some authorities declaring that it is an in- 
crease, others a diminution. 
(c) Reaction.-The alkalinity of the blood 
is said to be diminished in gout, cholera, and 
osteomalacia. 
(5) Fats.-The normal increase of fats in 
the plasma that occurs after meals may be 
exaggerated by a diet rich in oil, and, it is 
said, in the subjects of diabetes, in chronic 
drunkards, and in persons disposed to obesity 
-lipcemia. When this increase is so great 
that the serum presents a milky appearance 
the blood has been called chylous. A cream- 
like scum forms on the surface of the serum; 
and the milky appearance is found micro- 
scopically to be due to the presence of fine 
granules and oil-globules. A marked in- 
crease of fatty matters in the blood has been 
said to occur in some cases of chyluria. 
Fat may also appear in the blood as a foreign 
body, by the escape of marrow into the 
circulation in fracture of bones-and that BLOOD, MORBID CONDITIONS OF 
BOILS 
165 
in such quantity as to cause fatal capillary 
embolism. See Embolism. 
(6) Carbonic Acid Gas, which exists in 
arterial blood in the proportion of 39 per cent., 
and in venous blood of 52 to 58 per cent., 
by volume, may accumulate within the cir- 
culation either by increased formation or by 
retention. Although associated with asphyxia, 
this increase of carbonic acid gas is probably 
not the chief cause either of the symptoms of 
that condition, or of the dark colour of the 
blood that accompanies it. See Asphyxia. 
(7) Other Constituents.-Amongst the 
most important of the other constituents of 
the blood, the following are to be noticed :- 
(a) Urea, which exists in normal blood to 
the amount of 1'8 parts in 10,000, may in- 
crease in uraemia by two or three times. 
There is still much uncertainty, however, on 
this subject (see Uremia). Disease of the 
urinary organs, which interferes with the 
elimination of urea and allied products from 
the blood, is the usual cause of uraemia; but 
excessive tissue-change, as in fever and in- 
ordinate muscular exercise, has also the same 
effect. 
(6) Uric acid, found in normal blood in 
minute traces, is increased (as quadrurate of 
soda) in all cases of gout, and may amount, 
according to Sir Alfred Garrod, even to 0T75 
parts in 10,000. Its presence is easily de- 
monstrated by the thread-experiment (see 
Gout). Uric acid is also increased in leu- 
kaemia and chlorosis-perhaps from the im- 
perfect oxidation associated with the condi- 
tion of the red corpuscles. 
(c) Leucin, tyrosin, hippuric acid, sarcin, 
and other allied complex compounds, have 
been frequently found in the blood in small 
quantities, and the same may be said of 
oxalic and lactic acids, and of acetone. 
. (d) Bile.-Certain of the constituents of 
the bile may occur in the plasma. The most 
obvious of these is the bile-pigment-bili- 
rubin-which either by direct formation in 
the blood from the haemoglobin, or more fre- 
quently by absorption from the liver, ac- 
cumulates within the circulation, and gives 
rise to the colour of the tissues in jaundice. 
The bile-acids-glycocholic and taurocholic 
acids-are also, under certain circumstances, 
absorbed into the blood, where they may be 
detected with difficulty. They have a de- 
structive effect upon the red corpuscles, and 
act further as a powerful poison to the 
tissues, possibly causing the severe symptoms 
which may occur in hepatogenous jaundice. 
Cholesterin is credited by some pathologists 
with being the cause of the same symptoms, 
and it has been found in the blood in in- 
creased proportion in some cases of severe 
jaundice. See Chol®mia ; and Jaundice. 
(e) Sugar.-The sugar of the blood is in- 
creased in diabetes, in some cases reaching 
0-3 to 0'5 per cent.-melitcemia; also after 
chloroform-inhalation, and the administration 
of amyl nitrite, chloral hydrate, and certain 
other drugs. 
7. Extraneous Matters in the Blood. 
Besides its normal constituents and their 
products, the blood may occasionally contain 
certain matters entirely foreign to it, such 
as the numerous poisons which act either 
directly upon the corpuscles, or specifically 
upon the organism. These, entering the cir- 
culation before they exert their specific effect, 
are in many instances readily discovered by 
analysis. The acid compounds of hydrogen 
with sulphur, phosphorus, arsenic, and anti- 
mony, respectively, act as blood-poisons by 
depriving the oxyhaemoglobin of its oxygen ; 
while carbonic oxide and nitric oxide uni.e 
with the haemoglobin, and expel the oxygen 
from the corpuscles. It is a matter of specu- 
lation whether other so-called poisons, the 
nature of which is still obscure, do not enter 
the blood and there exert their primary 
effect, such as the contagium of acute specific 
fevers and other infectious disorders. Similar 
infective matters, produced in the tissues of 
the body itself, are believed to be absorbed 
in septicaemia, pyaemia, and other allied dis- 
eases, and numerous observations support 
the further belief that the presence of micro- 
organisms is intimately associated therewith. 
A somewhat similar infection may occur in 
malignant disease, the juices being mixed 
with the blood-plasma, but in some instances 
the process may be different, namely, by 
means of cells. We cannot expect to detect 
these cells readily in the blood in transitu. 
The same remark applies to embola, of what- 
ever nature, and to blood-crystals. 
8. Organisms.-The blood may contain 
a variety of vegetable and animal organisms, 
either foreign or peculiar to itself; the latter 
being called hcematozoa. See Hjematozoa ; 
Chyluria ; and Filaria Sanguinis-hominis ; 
also Micro-organisms ; Malaria ; Relaps- 
ing Fever ; Spirillum ; and Zyme. 
J. Mitchell Bruce. 
BLOOD, Transfusion of.-See Trans- 
fusion. 
BLOOD-WORMS.-This term is of 
general application. It refers to all kinds of 
entozoa living in the blood. See Entozoa. 
BLUE DISEASE. - Synon. : Morbus 
Cceruleus.-A condition in which the most 
prominent symptom is a peculiar discoloura- 
tion of the skin and mucous membranes, due 
to the circulation of dark blood in the vessels. 
See Cyanosis ; and Heart, Malformations of. 
BOILS.-Synon.: Furuncles; Fr.Furon- 
cles; Ger. Furunkeln. 
Definition.-Gangrenous inflammation of 
the skin, forming small painful swellings, and 
ending by expulsion of the necrosed centre or 
' core.' The inflammation begins in the glan- 
dular structure, hence involving not only the 
skin, but also the cellular tissue immediately 166 
BOILS 
beneath. The sebaceous glands are most 
commonly the seat of boils, but occasionally 
the Meibomian glands (stye), the cerumin- 
ous glands, and the sweat-glands of the 
armpit are affected; or, more rarely still, the 
glands of the lips, vulva, or anus. 
^Etiology.-General predisposing causes. 
The general predisposing causes of boils 
are:-the male sex ; youth and after middle 
life ; a stout habit of body; seasons of spring 
and autumn; a diet too full of flesh, or 
one suddenly changed, such as that adopted 
during training for rowing, or in various 
forms of the so-called ' water cure.' To 
these must be added the vitiation of the 
blood during exhausting fevers and in certain 
cases of saccharine urine, or that induced 
by handling dissecting-room material; and 
by dirty occupations-for example, chimney- 
sweeping or rag-picking. Lastly, boils are 
sometimes epidemic. 
Local predisposing causes.-The parts of 
the skin most exposed to dirt or chafing-the 
hands and face, the neck and back, the but- 
tocks and knees-are favourite sites for boils; 
but they may form on any part except the 
palms and soles. Blisters, poultices, and 
stimulating liniments occasionally cause them. 
Determining causes. - Following these 
predisposing causes is the specific contagion 
of a parasitic microbe, which, by developing 
in a gland-cell, or hair-bulb, causes limited 
necrosis (the slough) of the tissue in which 
it grows. This microbe is the staphylococcus 
pyogenes, which can always be detected in 
the discharge of a boil; and boils have been 
produced by inoculation of this micrococcus, 
artificially cultivated from the tissues of acute 
necrosis of bones to free it from other possible 
contagia. 
Symptoms.-Boils appear either singly, in 
succession, or several at once, forming then 
an eruption on the skin. The solitary boil 
begins with itching; soon a reddish pimple 
forms at the itchy point; sometimes the 
pimple is tipped with a minute vesicle, in 
the centre of which a hair may generally 
be detected. The pimple grows larger and 
harder, the red area increases and grows 
darker, and pain begins, stinging at first, 
then throbbing. In about five days the sum- 
mit breaks, pus oozes forth, the pain abates, 
and the hardness diminishes. A day or 
two later the core, a shred of sphacelated 
cellular tissue, escapes. The boil then sub-, 
sides and healing rapidly takes place; the 
scar is depressed, and for some time has a 
violet colour. Occasionally the inflammation 
affects chiefly the cellular tissue beneath the 
skin ; the mass is then softer, more round and 
clearly circumscribed, and fluctuates like an 
abscess-this variety forms in the armpit. 
Rarely, the central slough extends rapidly 
beneath the surface, and communicates with 
the surface by several small apertures (re- 
Bembling carbuncle). In other cases the 
swelling is more diffuse ; no core appears at 
the surface, but a hard, very painful, pimple 
is formed, which is long in subsiding (blind 
boil). The furuncular eruption, consisting of 
groups of small boils, forms successive crops, 
and thus the disease may continue a long 
time. Boils are generally limited to a small 
region, but this is not always the case ; and 
the greater part, even the whole, of the body 
may be attacked. 
The constitutional disturbance is usually 
nil or slight when the boil is due to local 
irritation, though it may suffice to render 
nervous, irritable persons unfit for work. 
When the boils are in exhausted persons, 
the general symptoms are severe and de- 
note great depression. Prostration, agitation, 
stupor, low delirium, dry brown tongue, 
sordes, vomiting, and diarrhoea set in, and 
the case often ends fatally : or recovery is very 
slow, accompanied by much suppuration. 
Septic absorption and pyaemia very rarely 
take place. 
Carbuncular Boil of the Face.-There is 
a rare and generally fatal form of boil, the 
determining cause of which is still uncertain. 
Doubtless it is due to inoculation with a 
specific contagium not yet determined. It is 
met with only on the head and neck, notably 
on the lip. Mild and trifling at first, like an 
ordinary boil, it rapidly extends by inflam- 
mation of the cellular tissue and veins or 
lymphatics, and causes poisoning of the blood. 
The earliest sign of this fatal change is the 
occurrence of violent and repeated shivers. 
The boil becomes a boggy swelling of blackish- 
violet colour ; the surrounding tissues become 
hard and brawny; suppuration ceases; 
sloughing occurs; the complexion grows 
earthy ; the features, if the boil is on the 
face, become everted; the skin round the 
eyes in some cases is puffed out, and the eyes 
themselves project from the sockets ; anxiety 
and laboured, gasping breathing set in ; and 
a violent constricting pain in the head, chest, 
or belly is frequently experienced. Delirium 
and coma usually supervene, but sometimes 
consciousness and terrible suffering remain to 
the last. The duration from the first shiver 
to the end is about four days, though death 
may supervene in half that time. The veins 
of the face first inflame, and the phlebitis 
extends by the veins of the orbit to the sinuses 
in the skull, to the diploe, &c.; hence ab- 
scesses form in the eyelid, the forehead, the 
meninges, or the brain, and occasionally in 
distant viscera. 
Diagnosis.-A boil is distinguished by 
the central cavity and slough-characters 
peculiar to it. The boil of the face accom- 
panied with phlebitis has been confounded 
in this country with the ' malignant pustule ' 
of Continental surgeons. The former is still 
a boil with a central core. The ' pustule 
maligne ' is said to have invariably a large 
vesicle surrounding a brownish eschar, with BOILS 
BONE, DISEASES OF 
167 
a ring of smaller vesicles round the larger 
one,-a condition never met with in boils. 
Prognosis.-When due to local causes, 
the prognosis is good, unless the patient be 
exhausted by old age or fever; under such 
circumstances the extensive sloughing and 
suppuration often lead to a fatal issue. 
Treatment. - General. - First remove 
predisposing causes, and invigorate the 
patient by change of air, outdoor exercise, 
vapour and Turkish baths. The sanitary 
state of the patient's dwelling must be tested, 
as sewer gas may cause boils. The diet 
should be moderate and mixed. Alcohol, 
unless the patient is greatly debilitated, 
should be given in very moderate quantity, 
and the form of fermented liquor most ha- 
bitual to the patient is best; much alcohol 
taken before the core has loosened increases 
the pain and throbbing. Occasionally a 
saline purge should be given. Of empirical 
remedies, yeast (a tablespoonful thrice daily) 
is said to put an end to the repetition of 
boils. Quinine and perchloride of iron are 
also used. Quinine should be given to an 
adult in five-grain doses every six hours, till 
singing in the ears and headache begin; it 
should then be gradually lowered for three or 
four days to three or four grains per diem, and 
finally left off. In obstinate cases the waters 
of Vichy, Bareges, or Harrogate are believed 
to remove the disposition to boils. In diabetes 
omission of sugar-forming food and the free 
administration of alkalis and opium are the 
most effectual remedies. For the exhausting 
boil of the face, large doses of brandy method- 
ically prescribed, whether with or without 
quinine, are required, and copious nourish- 
ment by beef-tea, with peptonised foods in 
frequent doses. 
Local.-When signalled by itching, a boil 
may be stopped by plucking out the hair of 
the inflamed follicle, and in a long succession 
many boils may thus be prevented. When 
the areola has formed, if the pain be slight a 
drop of caustic solution applied to the.centre 
will sometimes check the progress of the boil. 
A better plan at this stage is to cover the 
boil with a galbanum and opium plaster 
(Erasmus Wilson's) spread on leather. Under 
this treatment pain at once ceases, the in- 
flammation gradually subsides, and the sepa- 
ration of the core proceeds painlessly; when 
the boil discharges, a hole should be cut in 
the centre of the plaster, for the escape of 
the products. When the pain is stinging, 
and the areola wide, with restlessness and 
headache, warm poultices are most soothing 
-those of starch cause pustulation less than 
linseed-meal poultices. Mixing lard with a 
linseed poultice, or sprinkling it with the 
dilute solution of acetate of lead, has a simi- 
lar effect. Extract of belladonna and glycerine 
in equal parts should be freely spread over 
the boil before the poultices are applied. 
Sponging with hot water also greatly allevi- 
ates the pain of boils, and may be continued 
for hours together. Poultices hasten the 
expulsion of the slough, but should be dis- 
continued as soon as the hardness changes 
to doughiness, as they tend to excite fresh 
crops of boils in the skin near the first boil. 
If the slough is large, the surface may be 
dressed with lint spread with Peruvian balsam 
or dusted with iodoform, and the boil care- 
fully protected by means of pads and com- 
presses of carbolised tow. Poultices are now 
altogether abandoned by many surgeons; 
moist heat being applied by means of layers 
of boracic lint wrung out of hot water and 
covered with oiled silk. 
Incisions are now much less employed 
than formerly. They increase rather than 
lessen the loss of tissue in ordinary boils, and 
do not shorten the duration of the inflam- 
mation. They give relief to pain, however, 
and check the spread of diffused boils. Inci- 
sions are therefore useful to relieve tension 
when severe. When made, incisions should 
be free, crucial, or even star-like, and carried 
beyond the boil. In the rapidly extending 
boil of the face simple incisions are of little 
avail; the free use of the actual cautery may 
be beneficial if employed at an early period ; 
or if the boil be seen early, free excision of 
the boil and the healthy tissue around it may 
be made. Otherwise, quinine in large doses 
and local soothing applications give most 
relief. See Pustule, Malignant. 
Berkeley Hill. 
BONE, Diseases of.-Synon. : Fr. Ma- 
ladies des Os ; Ger. Knochenkrankheiten.- 
Under this head are included:-Acute and 
Chronic Inflammations of bone and its mem- 
branes, with the consequences thereof, such as 
Necrosis, Caries, and Abscess; New Growths, 
which arise both within and upon the bone; 
Malformations ; and certain disorders of 
nutrition, namely, Hypertrophy and Atrophy. 
Viewed in another aspect, bone diseases 
may be divided into two principal groups, 
which somewhat overlap one another, namely, 
(a) those which are distinctly inflammatory 
in type; and (6) those of diathetic origin. 
Bone-tissue should be regarded as being 
similar to other connective tissues; but some 
diseases affecting it are rendered obscure by 
its structure, while others are materially 
modified in their progress, by reason mostly 
of its meshes being filled with lime-salts. 
1. Inflammation.-As a matter of clinical 
convenience, it is usual to consider separately 
inflammations of the periosteum, of the bone 
proper, and of the medulla; but it should not 
be forgotten that these structures are through- 
out continuous and interdependent, and that 
disease is rarely exclusively confined to any 
one of them : it may originate or be chiefly 
developed in one, but it cannot long exist 
without involving the others to a greater or 
less degree. Whilst inflammation of bone is 168 
BONE, DISEASES OF 
essentially the same as inflammation else- 
where, its characters are modified by the 
tissue in which it takes place, accordingly as 
it affects the periosteum, the compact or the 
cancellated tissue. The bones are most fre- 
quently affected by disease during the period 
of active growth, when the development is 
proceeding and the blood-supply abundant. 
The periosteum is especially vascular at this 
period; and as the bone derives its chief 
supply of blood through it, it powerfully reacts 
when inflamed upon the bone, and inflam- 
matory changes taking place in the perios- 
teum are very seldom limited to this mem- 
brane. Inflammation of the bone is very 
painful, from the unyielding nature of the 
tissue ; and, when the inflammation has been 
sufficiently intense, the vitality of the bone 
is destroyed, and the dead portion is subse- 
quently separated with some difficulty. So 
also in bone-disease dependent upon some 
general cause, such as syphilis, the charac- 
ters of the disease may be modified or ob- 
scured by the mechanical conditions which 
obtain. 
A. Periostitis.-Inflammation of the in- 
vesting membrane of bone.-By periosteum 
is usually meant the thin fibrous envelope 
of the bone in which the vessels for the 
supply of blood subdivide. But between 
it and the bone is a layer of osteogenetic 
cells like the cambium-layer of a growing 
plant, and immediately external is a layer of 
cellular tissue, continuous with that of the 
adjacent parts; these are integral portions of 
the periosteum, and take an active share in 
all its diseased processes. Periostitis may be 
either acute or chronic. 
(a) Acute Periostitis; Osteoperiostitis; 
Acute Periosteal Abscess; Acute Necrosis. 
This is a formidable, but fortunately com- 
paratively rare, disease, at least in the adult. 
It attacks the long bones almost exclusively, 
usually those of delicate children or young 
adults, in whom active bone-growth is still 
going on, and the periosteum is highly vas- 
cular. Acute periostitis probably never occurs 
without coincident inflammation of bone, and 
it is by far the most common cause of necrosis. 
It will be best to regard it as an acute osteitis 
and periostitis combined, and to call it osteo- 
periostitis, just as we call inflammation of 
the bone and of the endosteum osteomyelitis. 
The extent to which the bone and the perios- 
teum are in the first instance respectively in- 
volved is always difficult, and sometimes im- 
possible, to determine-it may be inferred from 
the extent of the necrosis. There are two ways 
in which the disease may begin-either in 
the fibrous investing sheath of the bone and 
the cellular layers beneath and superficial to 
it, from whence it spreads inwards to the 
cortical bone-substance, or even to the me- 
dulla ; or in the bone-tissue-the inflamma- 
tion spreading outwards to the periosteum. 
It is impossible in the living subject to dis- 
tinguish acute osteomyelitis and osteoperios- 
titis arising from idiopathic causes. The dis- 
ease is usually attributed to an injury, often 
slight, or to exposure to extremes of cold or 
heat. Frequently no cause is assignable. The 
disease is in most cases associated with the 
development of a pathogenic micro-organism, 
the pus teeming with micrococci. 
Pathology.-Rapid exudation takes place 
in the layers of the periosteum, and between 
it and the bone; also in the Haversian spaces 
and canals of the bone, often to such an extent 
as to obstruct the circulation, and probably to 
cause by pressure the severe pain complained 
of at the outset. The exudation beneath the 
fibrous layer of periosteum is copious, and 
soon becomes purulent; the periosteum is 
detached; the vascular supply of the bone 
is cut off; and necrosis results. Occasionally 
the disease originates at the epiphysial junc- 
tion, commonly between the diaphysis and 
the epiphysial cartilage, less frequently in 
the layer of cartilage itself. The extent of 
the necrosis depends upon the extent to which 
the periosteum is engaged, while the thick- 
ness of the dead bone depends mainly on the 
depth to which the inflammation in the os- 
seous tissue extends, sometimes the entire 
shaft perishing from one extremity to the 
other. Usually the diseased action is arrested 
at the epiphysial junction; but in other cases 
the extremity of the bone and the adjacent 
joint become involved. Large accumulations 
of pus, swarming with micrococci, are often 
rapidly formed in these cases, the pus escap- 
ing through openings in the fibrous envelope 
into the circumjacent cellular tissue, and 
finding its way to the surface. The shafts 
of the tibia and femur are the parts most 
frequently affected; the disease occurs more 
rarely in the bones of the upper extremities 
and other parts of the skeleton. 
Symptoms.-One of the earliest symptoms 
of acute periostitis is sudden and severe pain 
in the affected bone, which is soon followed 
by rigor and intense fever. The temperature 
mount's quickly to 104° or 105° F. There 
is sweating, rapid feeble pulse, and delirium, 
aggravated at night. On the second or third 
day deep-seated swelling may be felt, some- 
what obscurely at first; and the limb is 
swollen, hot, tense, and tender. An obscure 
sense of fluctuation may be distinguished at 
an early period; but when fluctuation becomes 
distinct very extensive damage will usually 
have taken place. After an interval varying 
from three to five days, the inflammation 
approaches the surface, the skin becomes 
cedematous, pits on pressure, and finally red- 
dens and inflames. The length of interval 
depends on the thickness of muscles and soft 
parts covering the affected bone. Other things 
being alike in respect of pain and amount of 
fever, the longer the delay in the appearance 
of external swelling, the greater the proba- 
bilitv that the bone is the first and chief BONE, DISEASES OF 
169 
tissue engaged, the inflammation having 
reached the periosteum secondarily; while 
the early appearance of swelling and fluctua- 
tion externally suggests that the inflamma- 
tion is chiefly periosteal. Blood-poisoning, 
either septicaemic or pyaemic, is a common 
consequence of acute inflammation of bone 
and periosteum. 
Diagnosis.-This disease may be obscure 
at the commencement, and its nature over- 
looked. It has often been mistaken for acute 
rheumatism, on account of the swollen joints; 
for phlegmonous erysipelas; for acute cellu- 
litis, or for typhoid fever. The only malady 
with which acute periostitis need be con- 
founded is an idiopathic inflammation of the 
deep-seated cellular tissue in a limb. This 
disease is rare. When we observe the chain 
of symptoms above described in a young 
person, we may safely assume the presence 
of an acute osteoperiostitis. 
Course and Terminations.-The disease 
almost invariably terminates in suppuration 
and necrosis ; resolution happens rarely, but 
necrosis is not inevitable, even after suppur- 
ation. In a fe casesw, especially in young 
children, if the matter be speedily evacuated, 
the abscess collapses, the periosteum reunites 
with the bone, and no necrosis takes place. 
This result is unfortunately quite exceptional. 
As the separation of the periosteum cuts off 
the vascular supply from the bone, unless in- 
cisions be very speedily made to permit the 
escape of inflammatory products, more or less 
extensive necrosis is the inevitable result. 
If not evacuated, the pus confined beneath 
the periosteum will presently escape through 
one or more openings into the intermuscular 
spaces, and in this way» reach the surface. 
In favourable cases, after evacuation of the 
matter, the acute symptoms subside; new 
bone is formed from the deeper layers of the 
periosteum; and the dead part, finally in- 
vested with a sheath of new bone, becomes a 
sequestrum. 
Prognosis.-This must be founded on the 
extent of the necrosis; whether blood-poison- 
ing has taken place; and whether the adjacent 
joints are implicated in the disease. Cure can- 
not take place until the dead bone is cast off 
or removed, and this is often long delayed. 
The usefulness of a limb may be permanently 
impaired by the disease, or it may require 
amputation, or the patient may lose his life 
from the exhaustion of the discharge or some 
intercurrent malady. On the other hand, the 
use of the limb, and the health of the patient, 
may become completely re-established. 
Treatment.-Early and energetic treat- 
ment is of the greatest importance, as it 
affords the best prospect of averting the 
disastrous consequences of acute periostitis, 
but in hospital practice the cases are rarely 
seen sufficiently early. In the first stage the 
limb should be elevated, and cold compresses 
applied. As soon as the nature of the affec- 
tion is suspected free incisions down to the 
bone, so as to divide the periosteum, are in- 
dicated, even before there is clear evidence 
that pus is formed. They relieve pain and 
tension; and, by permitting the timely 
escape of pus as soon as it does form, the 
amount of periosteal separation, and conse- 
quently of necrosis, is limited. It is the 
more important to make an early incision, 
because evidence of fluctuation is at first by 
no means easy to make out; and an incision 
down to the bone should be made in the 
centre of the inflamed area in all cases of 
doubt. Antiseptic precautions should always 
be taken. Sometimes the abscess-cavity does 
not readily collapse, owing to its walls being 
stiff and infiltrated, and its contents may 
become septic, thus greatly increasing the 
patient's risks. If there be synovial effusion 
into a neighbouring joint, it should be kept 
at rest by means of a splint or a fixed ban- 
dage. As the acute symptoms subside, the 
abscess-cavity contracts, one or more sinuses 
remain, and the dead bone begins to sepa- 
rate. See Necrosis, page 174. 
Where an epiphysis is engaged in the 
disease the case is more urgent; the fever 
runs higher, the suppuration is greater, and 
the degree of joint-implication more intense, 
proceeding in extreme cases to suppurative 
inflammation and destruction of the articu- 
lation. When the joint becomes tense and 
swollen, the fluid may be drawn off with a 
trocar and cannula, or an incision may be 
made into it. The affected limb should always 
be supported on a splint. (Edema of the limb 
often indicates a deep-seated phlebitis, the 
precursor of septic poisoning. Under these 
circumstances, amputation is often the only 
resource. It is imperative to amputate 
where there is extensive bone-destruction, 
and the symptoms indicate commencing 
pyaemia; or where, with the death of a 
large portion of the shaft, one or both of 
the neighbouring joints may have become 
gravely implicated, and great suffering and 
loss of strength forbid us to temporise. It 
is precisely in these cases, however, where 
the diaphysis has become necrosed up to the 
epiphysial junction, that good results are 
attainable by the immediate extraction of 
the dead bone. The part of the shaft which 
joins the epiphysis becomes rapidly detached 
and loose, and may be readily separated and 
removed, while the portion beyond the limit 
of the necrosis in the other direction can be 
divided with a chain saw. It is difficult, 
however, in the early stage to diagnose the 
extent of the necrosis. Where the joints 
both above and below are involved, ampu- 
tation is usually necessary. 
A periostitis of a very acute form, almost 
invariably suppurating, and accompanied 
by necrosis, is very common in the fingers, 
where it chiefly affects the ungual phalanges. 
The pain is very great, but may be relieved 170 
BONE, DISEASES OF 
by an early and free incision down to the 
bone, which, nevertheless, does not usually 
avert either suppuration or necrosis. 
(&) Chronic periostitis.-This disease is 
usually due to some diathetic cause, but may 
result from injury, or from some continuous 
pressure or source of irritation. It is most 
frequent on the superficial parts of the skele- 
ton, as the tibia, clavicle, skull, and ribs, but 
may affect any bone ; and it is often observed 
at the origin or insertion of muscles. When 
the disease arises from a general cause, such 
as syphilis, many parts of the skeleton are 
affected; when from a local one, usually 
only one. 
Symptoms.- Chronic periostitis often takes 
the form of what is called a node-a tender, 
more or less painful, rounded or oval swell- 
ing ; at first tense and hard, afterwards softer 
or even fluctuating. The pain is more severe 
at the outset, from the tension of the parts 
involved, and is generally worse at night. 
Subsequently the swelling becomes indolent, 
and painless, unless it be pressed upon; 
and the effused matter may become organised 
first into fibrous tissue and then into bone. 
Nodes are due to a localised inflammation. 
The cambium-layer of the periosteum and 
its external layer proliferate and become 
filled with leucocytes, thus forming a well- 
marked projection on the bone, which may 
undergo resolution, suppurate, or ossify, 
according to circumstances. 
Prognosis.-In chronic periostitis this is 
usually favourable. Under the influence of 
early and suitable treatment, the inflamma- 
tory products are completely absorbed, and 
the bone resumes its natural shape. If the 
chronic inflammation of the periosteum be 
permitted to proceed unchecked, a deposit 
of new osseous lamellae usually takes place 
on the surface of the affected bone, giving 
rise to permanent thickenings, or even to 
osteophytic growths. These are composed of 
light porous bone, with a rough surface. The 
skeleton of a syphilitic subject will often 
present numerous thickenings of this nature. 
On making a section of the bone, it is easy 
to see that the new bone is superimposed 
upon the old, and is formed by the perios- 
teum. 
Treatment.-When due to a local cause, 
the swelling will often spontaneously subside 
with removal of the cause and rest to the part; 
but in obstinate cases iodide of potassium 
internally, and iodine ointment or blistering 
externally, may be required. If the subject 
be unhealthy, or if the original injury be con- 
siderable, suppuration may take place, when 
the treatment will be that of an inflamma- 
tory abscess. Syphilitic nodes, which are a 
very common expression of chronic perios- 
titis, yield rapidly to the influence of iodide 
of potassium; and this in some cases may 
usefully be combined with a mercurial course. 
Blistering or friction externally is hurtful in 
such cases. Syphilitic nodes are not at first 
prone to suppuration, and even when they 
become soft and fluctuating, and the skin 
reddens over them, they should not be mis- 
taken for abscesses, as they do not require 
incision, and will readily be absorbed under 
suitable treatment. 
(c) Periostitis after typhoid fever.-A 
peculiar form of chronic periostitis is occa- 
sionally observed as a sequel of typhoid 
fever. It occurs during convalescence, and 
without general symptoms. It takes the 
form of hot, painful, and tender nodes, fre- 
quently symmetrical, and often placed on the 
tibia; the disease is also found on the ribs 
and other bones. It may be associated wrth 
necrosis, but if so the extent of the dead bone 
is small in proportion to the inflamed area 
of periosteum. The general health is not 
seriously affected by the periostitis, and the 
disease is amenable to treatment by iodide 
of potassium, combined with iodide of iron. 
(B) Osteitis.-Osteitis is an inflammation 
chiefly affecting the bone-substance. It may 
be either acute or chronic. 
(a) Acute osteitis is neither clinically nor 
pathologically to be distinguished from acute 
osteomyelitis or endosteitis. See (C) Osteo- 
myelitis. p. 171. 
(6) Chronic osteitis is a disease beginning 
in the bone, in which from first to last the 
chief changes occur, the periosteum being 
secondarily engaged. This affection may re- 
sult from injury, or be excited by exposure 
to cold; but it often depends on constitu- 
tional predisposition, such as the syphilitic, 
the strumous, the gouty, or the rheumatic 
diathesis, the first being the most frequent 
cause. It may occur in any part of the 
skeleton ; the chief changes, when produced 
by syphilis, occur in the shafts of the long 
bones. They consist mainly of hypertrophy, 
and the bone is ultimately increased in thick- 
ness, in length, and generally in density : its 
interior is often transformed into sclerosed 
bone-tissue, and the medullary cavity is ob- 
literated. Another form, associated with the 
strumous diathesis, is generally seated in the 
joint-ends of the long bones, and in the 
spongy bones. It is prone to end in suppura- 
tion, accompanied by either caries or necrosis, 
or may terminate in the condition known as 
osteoporosis or rarefying osteitis. The gouty 
and rheumatic forms are associated with 
evidence of the presence of either of these 
diatheses. 
Pathology. - Increased vascularity first 
takes place, the Haversian canals enlarge, 
the canaliculi disappear, the cancelli enlarge 
to contain the inflammatory products, and 
the earthy matter diminishes. Hence the 
inflamed bone softens, and, if macerated at 
this stage, will be found comparatively light 
and porous. "When the inflammation affects 
the superficial laminae of the bone, the peri- 
osteum becomes thick and vascular; if the BONE, DISEASES OF 
171 
deeper parts are involved, similar changes 
will occur in the endosteum. The porous 
condition of the bone may become permanent, 
when the condition is called osteoporosis, the 
result of so-called rarefying osteitis; or the 
granulations become transformed into new 
bone, and the cancellated structure is filled 
with osseous deposit, so that the whole of 
the inflamed area becomes very dense, and is 
then said to be sclerosed; or the inflamma- 
tory process may terminate in suppuration, 
followed by caries or necrosis; or an abscess 
may form in the interior of the bone, and be 
either diffused or circumscribed. 
Symptoms.-These are insidious, very ob- 
scure at the outset, and may be mistaken for 
those of chronic rheumatism, or mere perios- 
titis. They consist chiefly in aching, gnaw- 
ing pain in the affected bone, with charac- 
teristic remissions and nocturnal exacerba- 
tions. The bone is tender on pressure, and 
feels increased in bulk at first, from the in- 
filtration of the immediately surrounding soft 
tissues; subsequently the bone itself en- 
larges. There is often increase of heat in the 
limb. The progress is chronic. If unchecked 
by treatment, chronic osteitis may give rise 
to considerable deformity. 
Treatment.-Treatment should be directed 
to the cause of the disease. If this be syphilis, 
antisyphilitic treatment will be followed by 
good results; even in chronic bone-inflam- 
mation not dependent on syphilis, iodide of 
potassium is often of great service. Local 
counter-irritation may also be employed. 
Often the cause cannot be made out, and if 
iodide of potassium fail in producing an effect 
we must fall back on general treatment. In 
the early subacute stage, Test, with elevation 
of the affected part, is very desirable. Warm 
fomentations, followed by iced compresses, 
relieve the suffering. If there be much pain 
and tension, leeches should be applied. 
Puncturing the tissues down to the inflamed 
bone, with a tenotomy-knife or fine bistoury, 
relieves the tense periosteum, and allows 
extravasation beneath it to escape, so that 
the pain promptly abates. 
(c) Osteitis deformans.-A peculiar form 
of chronic inflammation of bone has been de- 
scribed by Sir James Paget under this title, 
from the changes it produces, both in the 
form and density of the affected bones. It is 
a chronic osteitis of the most extensive kind. 
The compact tissue is chiefly affected, be- 
coming thickened, soft, spongy, and vascular ; 
the Haversian canals are enlarged, and con- 
tain granulation material. It begins after 
middle age, and may continue for an indefinite 
time without influence upon the general health 
--a feature which distinguishes it clinically 
from other bone-inflammations. It is usually 
symmetrical, and affects chiefly the long bones 
of the lower extremity and the skull. At first 
the bones enlarge and. soften, from excessive 
production of imperfectly developed granula- 
tion-tissue and increased blood-supply ; and, 
yielding to the weight of the body, they be- 
come curved and misshapen. The femur, for 
example, shows a marked anterior curvature, 
and its neck becomes horizontal; the spine 
becomes curved; the skull is enormously 
thickened. The limbs, however, although 
deformed, remain strong and fitted to sup- 
port the body. In its early period, and 
sometimes throughout its course, the disease 
is attended with pains in the affected bones, 
which vary much in severity, and are not 
especially nocturnal or periodic. It is not 
attended by fever, nor associated with any 
constitutional disease. It differs from the 
chronic osteitis dependent on simple inflam- 
mation of bone, or that produced by gout or 
syphilis, in affecting the whole length of the 
bone; whilst hyperostosis and osteoporosis 
dependent on these latter causes rarely affect 
the entire bone. No treatment appears to 
produce any effect upon this disease. 
(C) Osteomyelitis.-This is an inflam- 
mation chiefly affecting the endosteum and 
interior of the bone. Like osteitis, it may be 
either acute or chronic. 
(a) Acute osteomyelitis or endosteiiis is a 
suppurative inflammation of the medulla and 
bone, which is very frequently associated 
with septic poisoning and necrosis. We 
must remember that the medulla of a long 
bone is very vascular ; it consists of fat and 
numerous white corpuscles contained in a 
delicate connective tissue. Near the cortical 
part of the bone the connective tissue as- 
sumes a very vascular membranous form, 
which has been called the endosteum. The 
disease nearly always arises in connexion 
with bone-injury, and most frequently hap- 
pens after amputation, or gunshot fracture, 
in which the cancellated structure is in- 
jured ; a severe contusion of the bone, an 
injury to the periosteum, or exposure to 
sudden extremes of heat and cold, is capable, 
under some circumstances, of producing the 
disease. 
Symptoms.-The symptoms are obscure, 
more especially if there be no opportunity of 
inspecting the affected bone, as the changes 
in the bone are often masked by inflamma- 
tion of the superficial parts. They usually 
make their appearance from five to ten days 
after the injury to the bone ; in some cases 
much earlier. The pain may not be exces- 
sive ; there is fever and probably rigor. If 
there be a wound, the secretion from it 
diminishes in quantity, and becomes less 
healthy ; the medulla protrudes from the 
central cavity ; the parts soon become sur- 
rounded by putrescent fluid ; and the symp- 
toms resemble those of more or less intense 
septicaemia. The periosteum generally, but 
not always, separates from the bone. In 
young persons the disease is sometimes 
arrested at the epiphysis ; but in the adult 
the whole length of the bone is liable to be 172 
BONE, DISEASES OF 
affected. The risk of septic poisoning is 
infinitely greater in osteomyelitis than in 
osteoperiostitis. Thrombosis of the bone- 
veins is especially prone to happen, and by 
the breaking down of the clot septic emboli 
are carried into the circulation, and deposited 
in the liver, lungs, and elsewhere. In this 
disease, too, fatty embolism often takes place 
-a condition associated with a very acute 
and fatal form of blood-poisoning. The pro- 
gnosis is generally bad. It may be impossible 
at first to distinguish acute osteomyelitis 
from acute osteoperiostitis, arising from 
non-traumatic causes. In military hospitals, 
in war time, acute osteomyelitis is often 
epidemic, and probably of septic origin. 
Treatment.-Where the symptoms lead 
us to suspect osteomyelitis, although the 
medullary cavity of the bone may not have 
been exposed, it will be desirable to trephine 
the bone, and if suppuration in its interior 
be discovered, it becomes necessary to ampu- 
tate as soon as the nature of the disease is 
recognised, and this affords the best chance 
of saving the patient's life. The chief diffi- 
culty consists in arriving at a correct dia- 
gnosis, and deciding when it becomes neces- 
sary to interfere. This may best be done by 
observing the general progress of the case ; 
and locally by the introduction of a probe 
into the medullary cavity when this is 
exposed. Should it reach healthy bleeding 
medulla near the surface we may temporise, 
if the constitutional symptoms admit of this ; 
but it is rare for the disease once commenced 
to be limited-it has an extreme tendency 
to become diffused. Experience shows that 
nothing short of amputation at the next joint, 
or even above it, is sufficient to arrest the 
consequences of the malady ; and to be suc- 
cessful this must be done before the systemic 
poisoning has become marked. Amputation 
in the continuity of the affected bone is worse 
than useless. 
(b) Chronic osteomyelitis is an obscure 
affection, not to be distinguished, either 
clinically or pathologically, from chronic 
osteitis. It may terminate in sclerosis, or 
in the formation of an abscess. See Chronic 
Osteitis, p. 170. 
2. Abscess.-This is a term usually 
applied to a limited suppuration in the bone, 
unattended by necrosis. Young adults are 
most prone to the disease, or boys about the 
age of puberty ; it is very rare in women. 
It is the result of a chronic inflammation of 
bone, which may be associated with some 
injury. This affection is most frequently 
met with in the upper and lower extremities 
of the tibia, just external to the epiphysial 
cartilage, less frequently in the ends of the 
femur, only occasionally in other bones, and 
very seldom in the compact tissue anywhere. 
Symptoms.-A circumscribed, slightly ele- 
vated, very tender and painful swelling may 
be discovered on the surface of the bone. 
This is due to a local periostitis with new bone- 
deposit. In old-standing cases the bone is 
often half an inch or an inch longer than its 
fellow, by reason of the chronic hypera;mia 
and consequent increase of activity of growth 
at the epiphysis. The skin and superficial 
parts are unchanged at first, or there may be 
but trifling subcutaneous oedema. There is 
often slight local increase of temperature. 
The pain, aggravated on deep pressure at 
the central point, is often intolerable. It is 
intermittent at first, but generally worse at 
night. After a time it becomes continuous, 
and deprives the patient of all rest, owing to 
its severity. The abscess may persist with 
little change for months or years. The 
symptoms generally resemble those of 
osteitis, from which at the outset it is diffi- 
cult to distinguish this affection. When the 
abscess tends to reach the periosteal surface, 
the soft parts become engaged, and there will 
be slight redness and oedema of the skin. 
More rarely the pus makes its way into the 
adjacent articulation, in which it sets up 
destructive inflammation ; but usually the 
joints are free from implication. The sub- 
jects of the disorder have often suffered from 
antecedent bone-disease. Evidence of this 
should be looked for, as giving a clue to the 
diagnosis. 
Treatment.-Spontaneous cure cannot 
occur: even if the abscess discharge itself, 
a permanent fistula will usually remain. It 
is necessary to lay the abscess-cavity freely 
open. A crucial incision must be made 
through the soft parts, down to the bone, at 
the most tender and prominent point, and a 
disc of bone removed by the bone-trephine- 
an instrument without a shoulder, about 
half-an-inch in diameter. The sudden loss 
of resistance indicates the piercing of the 
abscess-cavity. The layer of granulation- 
tissue lining its interior should not be inter- 
fered with, but the cavity simply washed out. 
The pus is often foul, and greenish in colour. 
The wound should be dressed antiseptically ; 
granulations presently fill it, which are sub- 
sequently transformed into a fibrous cicatrix. 
Immediate and permanent relief follows the 
operation. If the abscess is missed, the tre- 
phine may be re-applied, or drill punctures 
made in the most likely directions in the 
adjacent bone, in order to discover the pus. 
Sometimes an error of diagnosis is com- 
mitted, and the symptoms are found to arise 
from chronic osteitis, without suppuration. 
The operation, nevertheless, affords relief in 
these cases also. Where there is doubt, a 
preliminary course of iodide of potassium 
will often resolve it. 
3. Caries.-Caries is a form of chronic 
inflammation resulting in osteoporosis and 
suppuration, with gradual disintegration of 
bone, which has been likened to the process of 
ulceration in the soft tissues. It is generally 
found in the spongy bones, in any part of the BONE, DISEASES OF 
173 
skeleton, the vertebrae and tarsus being the 
parts most commonly affected. There are two 
forms of the disease : the one, simple caries, 
resembleing an indolent ulcer of the soft parts, 
is most common in the flat or short bones, 
but is sometimes met with in the compact 
tissue of long bones ; the other, fungating 
caries, is often met with in the articular ends 
of the long bones, and usually terminates in 
joint-disorganisation. It has been called 
subarticular caries ; and is part of the 
disorder known as tumor albus, a form of 
tuberculous disease (see Joints, Diseases of). 
The non-articular form of simple caries often 
originates in a localised periostitis, and is 
frequently due either to syphilis or struma 
-the latter is most frequent in young per- 
sons, the former in adults 
Pathology.-In caries the bone gradually 
disintegrates as the result of a chronic in- 
flammation of its cancellated tissue. The 
trabecul® become invaded with leucocytes; 
the Haversian canals, lacunae, and canaliculi 
enlarge from the same cause; and granula- 
tions form, which prove, on an exposed sur- 
face, the source of purulent discharge, just 
in a granulating surface of the soft parts. 
The process is, however, interfered with and 
delayed by the act of getting rid of the osseous 
structure, between the trabeculae of which 
the cells remain shut up until the bone-tissue 
finally breaks down, and comes away in the 
discharges, being often distinguished in the 
form of gritty particles. Until this process 
is completed the dead bone is soaked in pus, 
which often becomes putrid, and until it is 
got rid of a healthy granulation-surface is 
impossible. Caries is frequent in scrofulous 
subjects, and is then due to a deposit of 
tubercle in the cancellated tissue. Syphilis 
is a frequent cause of caries, the bone being 
infiltrated by gummatous material. Fun- 
gating caries occurs in the epiphyses of the 
long bones; the fungating granulation-tissue 
perforates the cartilages and invades the 
synovial membrane. The cancelli are rapidly 
filled up, and the granulations, on reaching 
the joint-surface, form fungating projections. 
Exposed to pressure, the softened bone-tissue 
yields and wastes away. In some joints, 
especially the shoulder, this may take place 
without the occurrence of suppuration-a 
condition known as ' dry caries.' More fre- 
quently purulent disintegration of the granu- 
lation-tissue occurs, and the disease presents 
the form of ordinary suppurating caries, or 
ulceration of bone. In other cases the in- 
flammatory products undergo fatty degenera- 
tion and caseate, and portions of the bone 
necrose-' necrotic caries,' which occurs in 
connexion with both syphilis and tubercle. 
When recovery takes place, the granula- 
tion-tissue is in part absorbed, and partly 
transformed into fibrous material and new 
bone. A carious bone is soft and porous; 
the cancelli are thinned or destroyed, the 
spaces enlarged, and portions of necrosed bone 
are often found in the midst-a condition 
also known as necrotic caries. On section, 
a pink, gelatinous granulation-material is 
seen, often caseating towards the centre. In 
dry caries the granulation-tissue is pink and 
gelatinous throughout. An abscess-cavity 
may form in the interior, with portions ot 
necrosed cancellous bone in its midst. The 
cause of this chronic inflammation of bone 
is usually the deposit of tubercle in the can- 
cellous tissue. Nodules of tubercle are to be 
found in the granulation-tissue which has in- 
vaded the bone, as well as in the surrounding 
soft parts, containing in their centre a giant- 
cell with branching processes, surrounded by 
lymphoid corpuscles. The spinal bones are 
most frequently affected; next, the expanded 
extremities of the long bones in the lower 
limb and the bones of the foot; lastly, those 
of the upper extremity. 
Symptoms.-Caries is very chronic in its 
progress, and often causes extensive damage 
to the bone, involving the destruction of a 
joint, or loss of a limb. It is almost always 
associated with an impaired condition of 
general health. The adjacent soft parts are 
involved in the inflammation ; abscesses form 
in them, generally connected with the diseased 
bone ; these burst or are opened; and sinuses 
lined with gelatiniform granulations, and dis- 
charging a thin pus, persist for an indefinite 
time. On examination with the probe the 
surface of the bone is felt bare, rough, and 
much softened; and outside the area of 
carious bone periosteal deposits of newly- 
formed osseous tissue are often found. The 
diagnosis and prognosis depend upon the age, 
constitutional condition, and clinical history 
of the patient, as much as on the local signs. 
Treatment.-This must be directed to re- 
lieve the constitutional taint, as well as the 
local disease. Merely to excise or destroy 
the diseased portion of bone is not always 
sufficient to cure the patient. Local means 
prove efficient only when the general condi- 
tion has been sufficiently ameliorated, espe- 
cially in the unhealthy chronic inflammation 
of bone frequently called strumous. Fresh 
air, good food, and tonics are, therefore, of 
great importance. If syphilis be present, an 
anti-syphilitic treatment must be pursued. 
The principle by which the local means act 
is to facilitate the formation of a healthy 
granulating surface-to transform, in fact, an 
indolent into a healing ulcer. The disinteg- 
ration of the dead and diseased trabecula; 
must be assisted. For this purpose the ap- 
plication of strong sulphuric acid diluted with 
two or three parts of water, or some other 
mineral acid, often proves useful. Partial 
gouging out of the diseased bone seldom 
succeeds, because of the injury done by the 
instrument to the adjacent bone, weakened as 
it is by inflammatory changes, and therefore 
prone to set up fresh disease. The complete BONE, DISEASES OF 
174 
evidement of the bone, leaving nothing 
but its thin outer shell, is more successful; 
but when the disease begins to invade ad- 
jacent joints, as in the tarsus, excision of the 
entire bone is best; or when several bones 
are involved, amputation of the whole part 
involved becomes necessary. In children 
operations of this kind are not so often re- 
quired ; general treatment frequently proves 
sufficient. In the early stages the actual 
cautery, applied over the most painful spot, 
is a valuable counter-irritant. When it is 
undesirable to make early incisions into 
strumous abscesses in connexion with diseased 
bone, it is right to empty them by a small 
trocar, so as to preserve the diseased area as 
long as possible from atmospheric influence, 
and meanwhile to improve the general health. 
When they require to be opened, this should 
be done under antiseptic precautions, and the 
whole of the diseased tissues must be scraped 
away with the sharp spoon. Iodoform dress- 
ing is the best. When the carious action is 
arrested, the cavity fills with healthy granu- 
lations, the sinuses close, the parts cicatrise, 
and the gap in the bone-tissue is filled by 
fibrous or sometimes by osseous material. 
4. Necrosis. - The complete arrest of 
nutrition in a portion of bone from any cause 
is followed by the death or necrosis of the 
bone, and by a series of inflammatory 
changes in the adjacent parts, which result 
in the complete separation of the dead from 
the living tissue. It is a common result of 
the acute inflammation of bone which is 
invariably connected with some septic or in- 
fective cause. 
^Etiology.-Necrosis is most frequently 
the result of acute bone-inflammation or 
severe injury, as after amputation, compound 
fracture, or contusion. It is especially prone 
to happen in the compact tissue, but it also 
occurs in the spongy structure, as the joint- 
ends of the long bones, or the tarsus and 
carpus, where it is usually associated with 
more chronic forms of inflammation, and is 
more limited, as in necrotic caries. The 
peculiar nature of the blood-supply to bone, 
and the facility with which it may be inter- 
fered with or arrested under the pressure of 
inflammatory exudation, go far to explain 
the frequency of necrosis as a result of 
bone-inflammation. Acute suppurative osteo- 
periostitis or osteomyelitis rarely terminates 
without necrosis. Whether the dead bone 
will be in the superficial or the deep lamellae, 
or include the whole thickness, depends 
on the seat of the inflammation, and on 
the extent to which the periosteum and 
endosteum are respectively implicated. The 
long-continued action of crude phosphorus, 
as observed in match-makers, and also of 
mercury, may induce necrosis. Syphilis is a 
frequent cause of necrosis, through its ten- 
dency to produce chronic osteoperiostitis, the 
sclerosed bone thus originated being after- 
wards prone to necrose. It is not an un- 
common sequel during convalescence from 
some eruptive and continued fevers. After 
scarlatina, osteoperiostitis, followed by ne- 
crosis, is by no means rare, although affec- 
tions of the joints are more common. It is 
probable that many cases of necrosis occur- 
ring in childhood are connected with an 
antecedent attack of scarlet fever. The 
nasal bones may necrose as the result of 
severe coryza, the vertebrae after pharyn- 
gitis, or the petrous portion of the temporal 
bone as a consequence of otitis. Arterial 
thrombosis and embolism are occasional 
sequelae of typhus, and may produce a local 
gangrene, not only of the soft parts, but of 
bone. This is, however, more frequent in 
connexion with typhoid fever. In endocar- 
ditis the nutrient artery of a bone has been 
observed to be obliterated by an embolus, 
thus producing necrosis. 
Pathology.-After the death of a portion 
of bone, the living tissue, in immediate con- 
tact with the dead, becomes inflamed. The 
Haversian canals and canaliculi become dis- 
tended with migratory cells ; the leucocytes 
multiply, and by degrees consume the hard 
substance of the bone; the trabeculae are 
absorbed or eaten away ; loops of capillaries 
form from the pre-existing vessels : a granu- 
lating surface, in fact, is formed in the layer 
of living bone, surrounding or in contact 
with the dead, in a manner precisely similar 
to what takes place in the soft parts when a 
slough is being detached. The periosteum 
separates from the bone, and becomes thick 
and vascular,while the osseous surface beneath 
is smooth and white, like macerated bone. 
In cases of syphilitic necrosis, as well as in 
that resulting from phosphorus, the surface 
is rough from antecedent periosteal deposit, 
and in the former the interior may also be 
sclerosed. How the osseous trabeculae are dis- 
solved or disintegrated at the surface of sepa- 
ration, so as to loosen the dead bone, is not 
certain. Probably the granulation-tissue that 
forms from the living bone possesses amoeboid 
properties, and thus disposes of the calcareous 
particles. The pus that is formed has a 
mechanical influence, while according to one 
theory lactic acid is produced, which trans- 
forms the insoluble into soluble salts of lime. 
"While this loosening process is going on, 
new bone, formed chiefly from the perios- 
teum, which becomes thick and vascular, is 
being deposited, constantly becoming thicker, 
and with one or more openings in it for the 
escape of pus, called cloaca?, so that even- 
tually the dead portion becomes completely 
invaginated, and is named, from its position, 
a sequestrum. This sequestration of the 
dead bone is not invariable. For instance, in 
the spongy bones, the bones of the skull, and 
the upper jaw, or where from any cause the 
periosteum has been destroyed, no sheath of 
new bone will be formed. Necrosis very BONE, DISEASES OF 
175 
rarely takes place without suppuration ; when 
this does happen the nature of the case is 
very obscure. It has been aptly called ' quiet ' 
necrosis. Occasionally nearly the whole 
shaft of a long bone has been found necrosed, 
and after an interval of months, or even 
years, no suppuration may have taken place. 
Such forms of necrosis are usually central 
and limited in extent. They may very closely 
simulate malignant disease, and often cannot 
be relieved or even recognised save after 
amputation. A chronic osteitis, followed by 
hypertrophy and sclerosis of the bone, is the 
most common antecedent condition of this 
form of necrosis. 
Treatment.-The changes already de- 
scribed, which separate the dead bone from 
the living, do not cause its expulsion from 
the body. On the contrary, they shut it up, 
like a kernel within its shell, and nothing so 
imperatively demands surgical interference 
as the presence of necrosed bone. It acts as 
a foreign body, is a constant source of risk to 
the patient, and should be removed as soon 
as practicable. Its continued presence ex- 
cites the periosteum to further formation 
of bone, so that the invaginating sheath 
becomes of great thickness in old-standing 
cases. The period at which an operation is 
usually undertaken is when the sequestrum 
has become loose, and the time required for 
this purpose varies with the extent of the 
necrosis. In the actively growing bones of 
the young, especially when the sequestrum 
involves the epiphysial junction, the process 
of separation is accomplished more quickly 
than in the adult. Roughly estimated, a 
period of from three to six months might be 
named as that within which loosening of the 
sequestrum usually occurs. Beyond the 
latter term an effort to extract the dead bone 
should not be delayed, even if it cannot be 
felt to be loose. Among other risks involved 
by delay may be that of amyloid degenera- 
tion of the viscera, principally the liver, 
kidneys, and spleen? which are subject to 
this change as the consequence of long-con- 
tinued discharge from bone-disease. In order 
to remove a sequestrum, a director should 
first be introduced through a cloaca as a 
guide, and the soft parts sufficiently divided. 
An adequately large opening must now be 
made in the encasing sheath of new bone 
with the chisel, trephine, small saw, or 
cutting-forceps, and the dead bone extracted, 
either in one or several pieces, as may be the 
more convenient. The operation may prove 
difficult on account of great thickness of the 
soft parts or of the sequestral envelope, or 
because the sequestrum itself is extensive. 
After the removal of the dead bone the cavity 
fills with granulations, which subsequently 
ossify, and the soft parts cicatrise. When 
the loss of bone-substance is very large the 
reparative process has been much facilitated 
by the implantation of small pieces of freshly 
killed rabbit's bone. Finally the sequestral 
envelope of new bone is partly absorbed, 
partly consolidated, just as the redundant 
callus is after fracture, and the bone tends 
more or less to resume its normal size and 
shape. 
5. Tubercle.-An examination of some 
cases of chronic bone-disease in scrofulous 
subjects seems to prove their connexion with 
the formation of tubercle in the bone. The 
cancellated tissue in the joint-ends of the 
long bones, and cancellated bone generally, are 
chiefly affected. Miliary tubercles, precisely 
similar to those found in other parts, are 
formed in the soft structure of the medulla. 
These may become confluent, and tend to 
caseate or undergo a fatty degeneration. The 
caseous mass only differs from a similarly 
produced mass elsewhere by reason of the 
necrosed bony framework which retains it. 
"When macerated, the bone shows a rounded 
cavity, from which the tubercle has been 
discharged. The external appearances are 
those of fungating caries ; but microscopical 
examination discloses multitudes of round 
cells like lymph-corpuscles, with protoplas- 
mic matter, filling up the interspaces, and 
enclosing one or two giant-cells. The cells 
are found surrounding the soft, grey, non-vas- 
cular patches, which are often seen on section 
of an inflamed cancellated bone in strumous 
individuals, and this central part may be 
the subject of calcareous, fatty, or suppura- 
tive changes. The bone when so affected 
undergoes osteoporotic changes, and is never 
sclerosed ; hence these are not simply cases 
of chronic inflammation. 
Treatment.-In cases of this kind general 
tonic treatment becomes of the greatest 
importance. Rest must be given to the 
affected part, and exercise to the body 
generally, combined with fresh air both day 
and night, and simple nourishing food. 
When the bone is extensively diseased, it 
must either be excised, or the part ampu- 
tated. The presence of the tuberculous dia- 
thesis does not forbid an operation, the local 
source of irritation and drain upon the 
system being thus removed, and a healthy 
traumatic surface substituted for one infil- 
trated with inflammatory products. The 
removal of the local disorder often proves a 
comfort to the patient ; increases his chance 
of regaining health and strength ; and 
diminishes the liability to dissemination. 
6. New Growths.-The bones are liable 
to be the seat of most of the tumours found 
elsewhere in the body. The most important, 
and the most frequently occurring, are the 
sarcomata. 
(a) Myeloid Sarcoma.-Some forms are 
peculiar to bone, as, for instance, the myeloid 
sarcoma, so called from the many large nu- 
cleated corpuscles contained in it, analogous 
to those found in foetal marrow ; it is of 
endosteal origin, causing an expansion of the 176 
BONE, DISEASES OF 
bone in which it grows. It is most common 
in the inferior maxillary bone, and near the 
epiphysial ends of the long bones. It is 
generally observed in young persons; requires 
removal; and extirpation, if complete, is not, 
as a rule, followed by a return of the disease. 
(6) Periosteal or Fasciculated Sar- 
coma.-This tumour, springing from the 
periosteum of a long bone, such as the femur, 
is not uncommon. The shaft of the bone 
may be seen on section passing through the 
centre of the tumour. Numerous bands of 
fibrous tissue, often ossified, radiate from the 
periosteum through the growth, like an out- 
spread fan. The cells are spindle-shaped or 
round in form, of various sizes and in different 
proportions. This form of sarcoma is malig- 
nant. The best treatment is amputation of the 
limb at the joint above, which does not, how- 
ever, ensure against recurrence of the disease. 
Carcinoma.-This does not occur as a 
primary growth in bones. 
(c) Exostosis.-This is a bony outgrowth 
developed on any part of the skeleton. It is 
difficult to distinguish cartilaginous from 
osseous outgrowths. The two structures are 
often mixed, and a tumour originally car- 
tilaginous is often transformed into bone. 
Cartilaginous outgrowths, called Ecchon- 
droses, are met with on the costal carti- 
lages of old persons, also on the interver- 
tebral discs, near the synchondroses, and 
arise also from the articular cartilages in 
osteoarthritis. Cartilaginous tumours, grow- 
ing either from the periosteum or the medulla, 
have their favourite seat upon the phalan- 
ges ; they are usually multiple, and from the 
deformity and inconvenience they produce 
often demand either enucleation of the 
tumour, or, in extreme cases, amputation of 
the finger. Chondromata also arise from 
the scapula and the shafts of the long bones, 
when they often become mixed with sarco- 
matous tissue. The more special forms of 
exostosis are of two kinds, the spongy and 
the ivory-like. Spongy exostosis is often 
developed near the articular ends of the 
long bones, where it forms a nodulated 
outgrowth of cancellated bone of variable 
size, encrusted with a thin layer of cartilage, 
by means of which it grows, and having 
generally a bursa superimposed. This kind 
of exostosis is often met with near an epi- 
physial cartilage, and ceases to grow when 
the bone is fully developed. This fact, as 
well as the proximity of the neighbouring 
joint, renders surgical interference often un- 
necessary, and it may be hazardous. Another 
form of spongy exostosis, sometimes called 
osteophyte, depends on a local excessive 
periosteal growth of bone. At first this out- 
growth is porous, and but slightly connected 
with the bone on which it is developed. 
Afterwards it may become dense and hard 
from interstitial deposit, or it may always 
remain spongy. Such exostoses often depend 
on some local exciting cause, such as a blow; 
or they may be found at the insertion or 
origin of a muscle, as in the so-called rider's 
bone, at the origin of the adductor longus 
muscle, or the exostosis frequently found at 
the insertion of the adductor magnus, or the 
' exercise bone ' of the German soldier. They 
may be regarded as morbid exaggerations of 
the normal tuberosities of the skeleton. Ivory 
exostosis, so called from its dense, eburnated 
character, is more rare. It is found on the 
flat bones, and especially the cranium. It 
varies much in size, and may be peduncu- 
lated or sessile. Hereditary influence ap- 
pears to exist in some cases, in others a 
predisposition to chronic periostitis, but there 
may be no apparent cause. The development 
is slow and painless. 
Treatment.-Interference is seldom re- 
quired in the spongy exostoses, except on 
account of pain or loss of function. When 
pedunculated, they can be broken off or 
divided subcutaneously; and although they 
may reunite, it will probably be in a more 
convenient and painless relation to adjacent 
parts. Otherwise they should be excised. 
Except on account of deformity, or of 
pressing on important structures, an ivory 
exostosis should not be meddled with. It 
can often, however, when necessary, be enu- 
cleated ; or where only a partial removal is 
possible, the low vitality of the tumour often 
leads to necrosis and subsequent exfoliation 
of the remainder. Spontaneous necrosis also 
occasionally occurs. 
(d) Osteo-aneurysm. - Certain sarco- 
mata and myeloid tumours, when very vas- 
cular, pulsate, and have been mistaken for 
aneurysm. There are, however, undoubted 
cases of aneurysmal tumours dilating the 
bone, which have been cured by ligature of 
the main vessel of the limb. When the 
tumour is small it may be excised, or the 
actual cautery applied. Sometimes amputa- 
tion is required. The causes and pathology 
of the disease are obscure. It is probably 
in some cases of a naevoid nature. 
(e) Bone-cysts.-These are tumours dis- 
tending and thinning the bone, and filled with 
serum or bloody fluid. In some rare cases they 
contain hydatids. The origin of bone-cysts 
is obscure; some originate in the dentigerous 
cavities of the maxillae, in which bone-cysts 
are most frequent, but they are sometimes 
found elsewhere. A very slow, painless in- 
crease in size takes place. The bone becomes 
gradually very thin, and often affords on 
pressure a peculiar and characteristic parch- 
ment-like crackling. In obscure cases an ex- 
ploratory puncture should be made. 
Treatment.-This consists in freely laying 
open the cyst-cavity, and providing for sub- 
sequent drainage. The cavity gradually con- 
tracts and becomes obliterated. 
(/) Hydatids.-The formation of echino- 
coccus-cysts is exceedingly rare in bone, BONE. DISEASES OF 
BOURBOULE, LA 
177 
compaied with other parts of the body. The 
causes are unknown, and the symptoms very 
obscure, resembling those of an ordinary 
cyst. A cavity is formed, usually in the 
spongy extremities of the long bones, to con- 
tain the mother cyst. But it is also found 
in the medullary canal. The affection is 
grave. Serious inflammation often follows 
interference with these entozoa. It is some- 
times difficult to remove the whole disease; 
and unless this be effectually done, a relapse 
will occur ; while in such parts as the pelvis 
art is unavailing. The cavity should, if pos- 
sible, be freely laid open, and all the cysts 
carefully removed or destroyed. The actual 
cautery may be sometimes employed with 
advantage, or the surface of the adjacent bone 
removed, as it may be invaded by the cysts. 
An exploratory puncture can alone resolve 
the diagnosis, by finding the hooks of the 
acephalocyst in the fluid. 
g. Actinomycosis.-This disease arises 
from the transmission to man of a vegetable 
parasite formed in the calf (see Actinomy- 
cosis). Its development in bone mainly 
occurs in the jaws (generally the lower), 
in which it causes great swelling. The jaw 
is distended by a mass of material chiefly 
inflammatory-consisting of a fibrous basis 
which is riddled with tracts occupied by 
the fungus. When suppuration occurs, the 
abscess-cavity presents the appearance of 
meshwork. The mode of infection may be 
either through the respiratory or digestive 
tracts, or by the socket of a diseased tooth. 
7. Malformations.-These consist in 
any departure from the normal type of the 
skeleton, by reason of excess, deficiency, or 
irregularity, either congenital or acquired. 
It is not necessary to more than allude to 
the facts that the skeleton is often defective 
in parts; that senile changes occur, especially 
in certain bones; and that supplementary 
bones and processes are met with. Various 
deformities occur in bones from fractures, 
both intra-uterine and subsequent to birth, 
and from curvatures due to rickets or soften- 
ing. Treatment of curvature consists in 
gradual straightening by splints or other 
apparatus, or immediate straightening under 
chloroform, methods which, in the soft grow- 
ing bones of the young, prove successful in 
abating many deformities. The curvatures of 
adult bones do not yield in this way. When 
there is loss or impairment of function from 
deformity, the bone may be safely divided 
subcutaneously with the chisel or saw, and 
the limb straightened-often with admirable 
results. Forcible fracture is a clumsy and 
somewhat dangerous method, as the force 
employed cannot be regulated. 
8. Hypertrophy.-Hypertrophy means 
an excessive growth of bone-tissue, increasing 
the bulk of the bone, the added bone com- 
pletely reproducing the normal structure. 
Apart from inflammation hypertrophy is rare; 
but in museums specimens of excessive 
growth are met with, especially of the bones 
of the face and skull. The causes of this rare 
condition are unknown, and no treatment 
appears available. See Acromegaly. 
9. Atrophy.-This disease consists in a 
diminution of the size or compactness of a 
bone. It may be the result of inflammatory 
changes, of senile degeneration, of disuse of a 
limb, of continuous pressure, or of an injury 
-such as a fracture-followed by non-union. 
The bone-tissue gradually wastes away, the 
cortical portion often becoming a thin parch- 
ment-like layer of bone, filled with soft 
medulla. This has been called excentric 
atrophy. The external appearance and size 
of the bone remain unchanged. Concentric 
atrophy, where the size of the bone diminishes 
in all its dimensions, may occur in bones 
which have been disused for lengthened 
periods, as from paralysis of a limb, disease 
of a joint, the bone in a stump, or un-united 
fracture. Spontaneous fractures, or fractures 
due to trifling causes, are very common under 
these circumstances. The term fragilitas 
ossium has been applied to this condition of 
bone-tissue, which also frequently occurs in 
cases of cancerous cachexia. 
10. Softening.-This change occurs in 
rickets and mollifies ossium. See Rickets ; 
and Mollities Ossium. 
William Mac Cormac. 
BORBORYG-MI (J3opftopvfa, I grumble). 
Rumbling sounds produced in the abdomen 
by the movements of gas within the bowels 
or stomach. See Flatulence. x 
BORDIGHERA, in Italy, on the 
Riviera.-A suitable winter residence for 
patients suffering from some forms of chest- 
disease. The climate is warm and dry. 
See Climate, Treatment of Disease by. 
BORMIO, in Italy.-Thermal waters. 
See Mineral Waters. 
BOTHRIOCEPHALUS (B60pu>v, a 
pit; and KfcpaXrj, the head).-A genus of 
cestode entozoa, characterised by the posses- 
sion of two pits or depressions, one on either 
side of the head, in place of the four sucking 
discs usually present in tape-worms. See 
Entozoa. 
BOTS.-A term employed to designate 
the larvse of certain dipterous insects called 
gadflies. They infest man more rarely than 
animals. See Entozoa. 
BOULIMIA.-See Bulimia. 
BOURBONNE - LES - BAINS, in 
France. - Common salt waters. See 
Mineral Waters. 
BOURBOULE, LA, in France.- 
Thermal alkaline and arsenical waters. See 
Mineral Waters. 178 
BOURNEMOUTH, in Hampshire.- 
Regarded as a suitable winter residence for 
patients suffering from certain forms of 
chest-disease. The climate is mild and 
slightly humid. See Climate, Treatment of 
Disease by. 
BOWELS, Diseases of.-See Intes- 
tines, Diseases of. 
BRAIDISM. - Synon.: Hypnotism.- 
Braidism is the name which, after its 
inventor, James Braid, has been applied to 
a therapeutic method destined to utilise the 
undoubted powers of mind over body for 
the cure of various diseases. In essence it 
consists of a species of Mesmerism, the 
patient being reduced to a partial or 
complete trance-like condition, by being 
made to look fixedly for a few seconds at a 
bright object held by the operator at ' about 
eight to fifteen inches above the eyes, at such 
a distance above the forehead as may be 
necessary to produce the greatest possible 
strain upon the eyes and eyelids, and enable 
the patient to maintain a steady fixed stare 
at the object.' The patient must be made 
to understand that he is to keep his eyes 
steadily fixed on this object, and his mind 
riveted upon the image of it. After so short 
a time as ten or fifteen seconds some 
patients may be intensely affected; and if 
so, it will be found, on gently elevating the 
arms and legs, that the patient has a dis- 
position to retain them in the situation in 
which they have been placed. 1 If this is 
not the case,' Mr. Braid writes, ' in a soft 
tone of voice desire him to retain the limbs 
in the extended position, and thus the pulse 
will speedily become greatly accelerated, and 
his limbs in process of time will become 
quite rigid and involuntarily fixed.' By 
slightly prolonging this process a condition 
of profound ' nervous sleep ' may be induced, 
in which operations may be performed as 
easily and in as painless a manner as if the 
patient had been under the influence of 
chloroform. All this has been abundantly 
proved by Esdaile and others, who per- 
formed numerous operations upon Hindoos, 
with absence of all pain, whilst they were in 
the hypnotic state. In his attempts to cure 
morbid conditions, however, Braid only 
rarely proceeded so far as to induce actual 
unconsciousness. Whilst in a semi-cataleptic 
condition the patient's attention is strongly 
directed to the morbid part, and some very 
marvellous instances of relief are recorded 
by him, said to have been effected under the 
influence of this faculty only, without the 
aid of imagination, since some of the patients 
operated upon were quite incredulous as to 
any good being likely to result. In a recent 
work on ' The Influence of the Mind upon 
the Body,' Dr. Daniel H. Tuke remarks: 
' Braidism possesses this great advantage, 
that while the Imagination, Faith or 
BOURNEMOUTH 
Expectation of the patient may be benefici- 
ally appealed to, this is not essential; th a 
mere concentration of the attention having 
a remarkable influence, when skilfully 
directed, in exciting the action of some parts, 
and lowering that of others. The short 
period of time required, also, compares 
favourably with that consumed in some 
other forms of mental therapeutics. . . . 
The great principle which appears to be 
involved in all is the remarkable influence 
which the mind exerts upon any organ or 
tissue to which the Attention is directed, to 
the exclusion of other ideas, the mind 
gradually passing into a state in which, at 
the desire of the operator, portions of the 
nervous system can be exalted in a remark- 
able degree, and others proportionately 
depressed; and thus the vascularity, inner- 
vation. and function of an organ or tissue 
can be regulated and modified according to 
the locality and nature of the disorder.' 
Braidism is a method very difficult of 
adoption in ordinary practice, and which, 
however legitimate may be its foundations, 
would, unless the greatest care and vigilance 
were exercised, be apt to descend perilously 
near to the level of quackery. If, however, 
only a small part of the results attributed to 
Braidism would follow the systematic adop- 
tion of this method for the alleviation of 
many diseases, it is one which should com- 
mend itself to the earnest attention of in- 
quirers, who may be able to place the practice 
upon a broader and firmer foundation than 
that on which it rests. But unfortunately 
the method has of late fallen somewhat into 
disrepute. This has been due to two causes. 
First, because of the facility with which it 
may be practised by non-medical persons, 
and the difficulty often experienced, even by 
medical men, in rousing persons from the 
state thus induced. And, secondly, because, 
even when practised by medical men, dis- 
agreeable consequences are apt to follow with 
some patients: fits may be induced, or the 
patient's moral and emotional control may 
be for a long time greatly impaired. In con- 
sequence of such results, a Government order 
has been issued in France, forbidding sur- 
geons in the army and navy to have recourse 
to this method of treatment. Unquestion- 
ably, however, the labours of many French 
physicians have done much of late years to 
render definite and precise our knowledge 
of the various phases of hypnotism, of the 
modes in which they are inter-related, as well 
as concerning the best means of inducing or 
terminating this or that particular phasis. A 
revival of the practice has recently taken place 
in this country-sometimes in the highly 
objectionable form of public exhibitions. See 
Mesmerism.1 H. Charlton Bastian. 
BRAIDISM 
1 See also Mesmerism, Spiritualism, &c., His- 
torically and Scientifically Considered. By W. B. 
Carpenter, C.B., M.D., LL.D., F.R.S. 1877. BRAIN, DISEASES OF 
179 
BRAIN, Dissases of. - General 
Observations.-The range of unnatural 
phenomena which manifest themselves as 
the result of disturbed actions of the brain, 
whether from functional perturbations or 
structural disease, is wide and varied. This 
result is due: (1) to the fact that the brain, 
though spoken of as a single organ, is really 
a congeries of many distinct but functionally 
related parts; (2) to the fact that this con- 
geries of parts is continuous with the spinal 
cord and intimately related to a scattered 
network of ganglia-entering into the for- 
mation of the nervous system of organic life; 
and (3) to the fact that these several centres 
within and without the cranium are brought 
into connexion, through the intervention of 
nerves, with all other structures in the body, 
whether entering into the composition of the 
organs of relation, or into that of the visceral 
system. 
The action of particular parts of the brain 
may be stimulated, depressed, or suppressed, 
and either of such altered modes of activity 
may entail a stimulation, depression, or sup- 
pression in the functions of one, two, or 
more distant parts of the nervous system. 
The first class of effects are spoken of as 
direct, and the second as indirect symptoms. 
It is often extremely difficult, if not im- 
possible, for us to say which of the symptoms 
presented by a patient suffering from organic 
disease of the brain should be ranged under 
the one head and which under the other. 
Our ability to make such distinctions is at 
present hindered by our still incomplete 
knowledge concerning the anatomical details 
of the brain, the proper functions of its 
several parts, and the precise modes in which 
they co-operate with each other. 
The effects of a shock, whether produced 
by injury or disease, falling on such an 
extensive assemblage of sensitive and 
mutually related organs are, as may be well 
imagined, subject to much variation; and 
as a matter of fact it happens that in 
different cases of cerebral haemorrhage, 
the symptoms produced are dependent 
upon three factors, viz., the situation, 
the extent, and the suddenness of the 
lesion. Except in so far as the nature of 
the lesion tends to entail variations in one 
or other of the above-mentioned respects, it 
is not of much significance from a clinical 
point of view (i.e. it does not lead to much 
difference in the sets of symptoms produced) 
whether we have to do with a case of 
haemorrhage into, or with a case of softening 
of the brain. Thus the ' locality ' and extent 
of the lesion, in the case of a local disease of 
the brain, has always to be inquired into as 
a problem altogether apart from that of the 
nature of the pathological change in the 
part affected. In other words, the problem 
of diagnosis in brain-disease is twofold: it 
must have reference to the region affected 
(regional diagnosis) and to the pathological 
cause (pathological diagnosis). The causes 
interfering with the progress of our know- 
ledge in the former direction are both 
numerous and baffling, so that, until the last 
few years, comparatively little progress had 
been made. 
Symptoms.-The most frequent effects or 
symptoms of functional or structural brain 
disease may be thus classified 
1. Perverted Sensation and Percep- 
tion.-The special senses of smell, sight, 
hearing, touch (fifth nerve), or taste may be 
interfered with by diseases of their respective 
nerves or primary ganglia within the cranium. 
Owing to the decussation of the optic nerves, 
disease of the optic tract gives rise (most 
frequently) to an affection of the sight of 
the opposite eye. The sense of taste is sub- 
served by two nerves proceeding to the same 
nucleus. Thus, the glosso-pharyngeal has 
to do with this special sensation in the back 
part of the tongue, the palate, and fauces; 
whilst the taste-nerves for the front part of 
the tongue, though they pass from these parts 
with the lingual branch of the fifth, leave it 
by the chorda tympani and then proceed to 
the brain as the nerve of Wrisberg, which 
terminates in the nucleus of the glosso- 
pharyngeal. Disease of the intracranial por- 
tion of the fifth nerve thus does not affect the 
sense of taste, though it impairs the common 
sensibility of the tongue. 
Disease of the primary ganglia of these 
nerves, whether they are separate (first and 
fifth) or lodged in the brain-substance at its 
point of connexion with the nerve, will 
produce decided impairment of the several 
special senses. But disease of portions 
of the brain above these regions on one side 
only, even though very extensive, often exists 
without seeming to disturb the exercise of 
the special senses on either side. This, 
doubtless, depends in part upon the com- 
paratively wide distribution of the several 
sets of sensory fibres within the hemispheres, 
and in part upon the liability of unilateral 
sensory defects to escape observation. There 
is, however, one limited region in each cere- 
bral hemisphere where the several sensory 
paths are brought into close relations with 
one another, before they diverge to different 
parts of the cerebral cortex. This region is 
the posterior third of the hinder segment of 
the internal capsule, and it is now well 
known that lesions which involve it give rise 
to a complete hemianeesthesia of the oppo- 
site side of the body, in which the special 
senses as well as the common sensibility of 
the one half of the body are affected. Some- 
times this result seems to be due to functional 
disorders, and at other times it is a con- 
sequence of structural disease. Hemianaes- 
thesia varies widely in its degree of com- 
pleteness, and also in its duration or per- 
sistence, and that is the case where it is of 180 
BRAIN, DISEASES OF 
functional origin as much as where it is due 
to actual organic disease. 
There may, however, be illusions, halluci- 
nations, or delusions, in connexion with one 
or other of the special senses, in many func- 
tional and structural diseases of the brain, 
where the morbid condition is situated in 
parts higher up than the primary ganglia, or 
where there is a functional exaltation of the 
ganglia themselves. This latter functional ex- 
altation seems sometimes to be favoured by 
morbid states of some of the viscera - especi- 
ally of the stomach, or of the uterus and 
ovaries. 
Still, modern clinical as well as experimen- 
tal evidence has done something towards 
revealing the paths and special cortical 
termini connected with different modes of 
sensibility. The experimental observations 
of Ferrier point to the convolutions about 
the tip of the temporal lobe as the seats of 
the senses of smell and taste. The same 
observer locates the cortical terminus of the 
sense of hearing in the upper temporal con- 
volution. The more recent experiments of 
Schafer and Sanger-Brown seem, however, to 
negative this conclusion, and to leave its site 
altogether uncertain. 
In regard to the visual sense, both experi- 
ment and clinical observation now point to 
the occipital lobe (and more especially to its 
inner aspect) as the region most concerned 
with this endowment. But the relation is a 
peculiar one. Extensive disease of the inner 
part of the right occipital lobe, for instance, 
would not give rise to more or less complete 
blindness of the opposite eye only-it would 
produce rather a left-sided hemianopsia. 
Similarly, the right halves of the visual fields 
are represented in the left occipital lobe, so 
that destruction of it would give rise to right- 
sided hemianopsia. 
The cortical centre for touch and common 
sensibility is now, since the experiments of 
Horsley and Schafer, believed to be the hip- 
pocampal convolution and the gyrus forni- 
catus, that is the region of the brain named 
by Broca the ' falciform lobe.' Under the 
term ' common sensibility ' are included dif- 
ferent modes of sensibility; thus it comprises, 
in addition to touch, the appreciation of dif- 
ferences of pressure and of temperature, and 
of painful impressions. Ferrier and some 
others would also include the impressions 
of the ' muscular sense ' under this head of 
' common sensibility ' and would refer them to 
the same cortical terminus. This, however, 
is a position which the writer contests. He 
believes, with Hitzig and others, that Ferrier's 
so-called 'motor centres' are in reality mus- 
cular-sense centres, and that no real motor 
centres exist in the cerebral cortex (Brain, 
April, 1887). Others again, like Seguin, 
without questioning Ferrier's general doctrine 
as to the existence of motor centres in the 
cerebral cortex, think there is evidence to 
show that ' muscular sense ' impressions are 
reg'stered in the cortex apart from those of 
common sensibility, and that their special 
terminus is to be found in the inferior 
parietal lobule. This subject, therefore, al 
though very important, is at present in a very 
unsettled condition. See Kintesthesis. 
Besides diminutions of sensibility, we often 
have to do with perversions of sensibility- 
that is, with disagreeable sensations of numb- 
ness, tingling, or actual neuralgic pains in 
parts. The seat of the two former may be 
widely distributed, though neuralgia from 
intracranial disease is principally limited to 
some part of the territory of the fifth nerve. 
2. Perverted Emotion and Ideation. 
These manifestations vary, from the mere 
increased tendency to emotional displays 
seen in hysterical persons, or in persons 
suffering from hemiplegia associated with 
emotional weakness, to those more complex 
aberrations met with in the various forms of 
delirium and insanity. See Insanity. 
3. Perversions of Consciousness.- 
Under this head maybe included the compara- 
tively rare states known as somnambulism, 
ecstasy, catalepsy, and lethargy; as well as 
the common conditions of drowsiness, stupor, 
and coma. The former may be said in 
almost all cases to be associated with func- 
tional rather than with structural disease of 
the brain ; at least, this is most in accordance 
with our present knowledge. Drowsiness, 
stupor, and coma are, however, among the 
commonest results of organic disease of the 
brain (see Consciousness, Disorders of), 
though they are also common conditions in 
blood-poisoning-whether arising from fevers, 
uraemia, or alcohol, poisonous doses of opium, 
or other narcotic or narcotico-irritant drugs. 
4. Perversions of Motility.-These 
manifest themselves in many forms, which, 
however distinct they may appear to be, are, 
nevertheless, closely linked to each other. 
Tremors may be general or local, and in 
the latter case they may be most marked in 
the tongue and facial muscles-principally 
those about the corners of the mouth or the 
orbicularis palpebrarum. General tremors 
may arise from debility, over-exertion, 'ner- 
vousness,' old age; or they may be due 
to alcoholic or mercurial poisoning, or to 
degenerative disease about the pons and 
medulla, and other regions of the brain. 
Twitchings may be characteristic of a 
highly nervous habit of body, and are es- 
pecially frequent in some epileptics in the 
interval between their fits, either in some of 
the facial muscles or in those of the neck 
or limbs. They may also occur in acute 
febrile affections, in which the functions ot 
the cerebrum are involved, as shown by co- 
existing delirium, &c., and also in the course 
of many organic diseases of the brain. In 
chorea the irregular movements of different 
parts of the body are often of this nature ; BRAIN, DISEASES OF 
181 
they may affect both sides of the body, or 
only one (hemichorea). 
Spasms of a continuous or ' tonic ' char- 
acter are encountered in various diseases of 
the nervous system, such as laryngismus 
stridulus, trismus, hydrophobia, tetanus, 
hysteria, and some forms of hemiplegia and 
paraplegia. Such tonic spasms produce a 
muscular rigidity which has to be distin- 
guished from that due to chronic changes in 
joints and tendons, such as are apt to occur 
in limbs long paralysed. 
Clonic Spasms or Convulsions may be 
either unilateral or general, and may be in- 
duced by the most varied causes. When 
well-marked they are mostly attended by 
loss of consciousness, as in epilepsy and the 
majority of epileptiform attacks. They are 
often limited in their distribution, rather 
than general, whether the convulsions be of 
unilateral or bilateral type. 
Co-ordinated Spasms, or movements of a 
struggling type, are met with in many epilep- 
tiform and hysterical paroxysms. Spasms 
of this type may be also limited to particular 
groups of muscles, as in the conjugated de- 
viation of the eyes and neck occurring in 
hemiplegia, in wry-neck, in writer's cramp, 
and other allied affections. 
Paralysis may be local and limited in 
seat to some of the ocular muscles, the mus- 
cles of mastication, the facial muscles, those 
of the tongue, or to parts supplied by the spinal 
accessory and pneumogastric nerves, in those 
cases in which there is merely an implication 
of the intracranial portion of one or more of 
the motor-cranial nerves about the base of 
the brain. In other cases it may take an 
incomplete or a complete hemiplegic type, 
when the lesions are limited to one half of 
the brain, and involve directly or indirectly 
certain regions thereof. Beginning at the 
surface, these regions include the so-called 
' excito-motor ' area, comprising the convolu- 
tions bordering the fissure of Rolando and 
the contiguous inner surface of the hemi- 
sphere, from which a fan-like distribution of 
white fibres converges to what is known as 
the ' internal capsule,' whence these efferent 
fibres are continued through the peduncle 
and pons to the bulb. Lesions at the part 
of the surface mentioned, or directly or 
indirectly involving any part of the tract 
of fibres issuing therefrom, give rise to 
a more or less complete hemiplegic form 
of paralysis. Whether these portions of 
the cortex contain motor centres, or cen- 
tres which register ' muscular sense ' im- 
pressions, is a matter of interpretation 
which is at present involved in doubt. What 
seems certain is that these are the last por- 
tions of the cortex called into activity in the 
execution of movements, and that from them 
issue the fibres which convey motor incita- 
tions to centres throughout the bulb and 
spinal cord (sec Kin^sthesis). In other 
cases, where a large lesion exists in the pons 
Varolii, or where the functions of both cere- 
bral hemispheres, or their peduncles, are 
gravely interfered with, the paralysis may be 
general, involving both sides of the body. In 
some of these cases, and espe dally with right- 
sided paralysis, various difficulties exist in 
giving expression to thoughts by means of 
speech or writing (see Aphasia). Deficient 
action of the will (induced by lowered activity 
in one or other of the cortical sensory centres, 
though without obvious structural change) 
may cause a temporary paralysis in hysteria 
and allied states. 
Defective Co-ordination of muscular acts 
is met with, as in stammering and in some 
hemiplegic defects of speech; also in the 
body generally in some cases of cerebellar 
disease, producing a peculiar and unsteady 
gait (titubation) closely resembling that which 
may be met with in alcoholic intoxication. 
Similar motor disturbances may be induced 
by vertigo of well-marked degree. Vomiting, 
again, is a reflex motor act due to impaired 
co-ordination, which occurs in many forms 
of brain-disease. More rarely the sphincter 
ani and the sphincter vesicse become re- 
laxed, or the bladder may be paralysed. But 
incontinence of faeces or of urine, or inability 
to void the urine, is comparatively rarely 
met with as a result of brain-disease, except 
in the comatose state, in patients who are 
more or less demented, or in those in whom 
lesions exist in both hemispheres of the brain. 
5. Nutritive or Trophic Changes.- 
With lesions in the ' motor tract ' of the brain, 
in or below the Rolandic area, a band of de- 
generation occupies a part of the internal cap- 
sule, crus cerebri, pons, and medulla on the 
same side, and (below the decussation of the 
pyramids) the opposite lateral column of the 
spinal cord. This is one of the most impor- 
tant of the trophic changes occasioned by 
brain-disease, because the degeneration in 
the lateral column of the cord is apt to spread 
to the contiguous grey matter, and thus give 
rise to some secondary trophic changes not 
infrequently met with in paralysed limbs. 
Trophic changes in other organs (occasioned 
by some severe lesions in the brain) appear as 
low inflammations and congestions-for ex- 
ample, of the lungs, or as haemorrhages into 
these organs; also as haemorrhages beneath 
the pleura or endocardium, or even into the 
substance of the suprarenal capsules or 
kidneys. 
Again, we may have acute sloughing of 
the integument in the gluteal region on the 
paralysed side, dropsy of paralysed limbs, in- 
flammations of joints and of the main nerves 
of paralysed limbs, and, though more rarely, 
marked atrophy of paralysed muscles. Re- 
tardation or arrest of growth is also apt to 
occur in paralysed limbs, when we have to do 
with infants or young children suffering from 
severe organic brain-disease. 182 
BRAIN, DISEASES OF 
Blanching of the hair, or altered pigmen- 
tation of the skin, also occurs not infre- 
quently in connexion with brain-disease or 
violent mental emotions; whilst in the in- 
sane the nutrition of bones, and of the pinna 
of the ear, is apt to be interfered with. 
6. Perverted Visceral Actions.-Ex- 
alted activity of the uterus, bladder, intes- 
tine, stomach, or heart may be occasioned 
by functional brain-disturbance more es- 
pecially ; whilst related brain-conditions 
may give rise to depressed or exalted ac- 
tivity of the liver or kidneys. With other 
functionally disturbed or emotional brain- 
states there may be a lowered functional 
activity of the salivary glands, of the heart, 
of the respiratory organs, of the organs of 
deglutition, of the organs of digestion, or of 
the sexual organs. These are only to be 
taken as mere indications of the kinds of 
modification that may be produced in 'vis- 
ceral activity by brain-disease. Much doubt- 
less remains to be learned in this direction. 
It seems fitting here also to mention those 
contractions and dilatations of vessels which 
are apt to take place in different parts of the 
surface of the body, or in internal organs, 
from stimulation or the reverse of vaso- 
motor nerves, occasioned either by direct 
or indirect influence exerted upon the princi- 
pal vaso-motor centres in the region of the 
medulla. These contractions or dilatations 
produce correlated alterations in the tem- 
perature, sensibility, and functional activity 
of the parts or organs affected. The tem- 
perature of paralysed parts, as well as the 
general body temperature, is subject to great 
variations in the apoplectic state, and these 
are now beginning to be studied more atten- 
tively. They are capable of yielding dia- 
gnostic indications of great value. 
General Remarks.-Some general remarks 
on the subject of structural and functional 
diseases of the nervous system, showing how 
intimately these two classes of disease are 
related to one another, will be found in the 
article Nervous System. Most of what is 
said there is applicable to diseases of the 
brain in particular; here, however, it is 
necessary to call attention to certain points 
specially related to brain-disease. 
When paralysis occurs from brain-disease 
affecting one cerebral hemisphere, in the 
great majority of cases it is situated on the 
opposite side of the body, owing to the fact 
that the fibres conveying the volitional im- 
pulses to the muscles decussate in the medulla 
oblongata. It is true that many cases are on 
record in which the paralysis either has, or 
has been said to have been present on the 
same side as the brain-lesion. A certain 
number of these cases are probably due to 
errors either in the clinical or in the post- 
mortem records of the case. Others, how- 
ever, may be due to the fact that in the 
individuals in question the customary decus- 
sation, above referred to, did not exist. The 
characters of the various forms of paralysis 
due to brain-disease are briefly set forth in 
the article on Paralysis. 
Lesions of the left hemisphere, much more 
frequently than those of the right, are asso- 
ciated with aphasic defects of speech ; whilst, 
according to Brown-Sequard, lesions of the 
right hemisphere are more frequently and 
rapidly fatal than otherwise similar lesions 
of the left hemisphere. They are also said 
to be more apt to be associated with acute 
sloughing of the skin on the paralysed side. 
Convulsions at the onset, and subsequent 
tonic spasms of the paralysed limbs, are also 
said by the same authority to be more fre- 
quently associated with left- than with right- 
sided paralysis. These statements, however, 
stand in need of confirmation. 
Congenital atrophy of one hemisphere, or 
an atrophy or severe lesion occurring in 
early infancy, is mostly associated with an 
arrest of growth and development in the 
limbs on the opposite or paralysed side of 
the body, or with a more or less spastic con- 
dition of the limbs (' birth palsies '). 
Very little is positively known concerning the 
diseases of the cerebellum. Of its functional 
affections we may be said to know absolutely 
nothing. That is, of the various functional dis- 
eases of the nervous system with whose clini- 
cal characters we are familiar, we are unable 
to name even one which we can positively 
say is a functional disease of the cerebellum. 
Whatever the precise mode of activity of the 
cerebellum may be, there is a general con- 
sensus of opinion that it is principally, if 
not exclusively, concerned with motility, 
and that it has more especially to do with 
the higher co-ordination of muscular acts. 
Atrophy of one hemisphere of the cerebrum 
is followed by atrophy of the opposite half of 
the cerebellum, so that there is a strong pre- 
sumption that the functional relationship of 
either half of the cerebellum is with muscles 
on the same side of the body. Clinically we 
know that disease of the cerebellum is not 
infrequently associated with more or less 
marked paralysis on the opposite side of the 
body ; but this effect is now generally attri- 
buted to the pressure which structural dis- 
eases of the cerebellum are apt to occasion 
on the pons and medulla of the same side. 
^Etiology.-The principal modes of cau- 
sation of diseases of the brain, functional 
as well as structural, may be thus summa- 
rised :- 
1. Defective nutrition operates by modi- 
fying the proper constitution of nerve-tissues 
as well as the constitution of the blood, and 
thereby interfering with the normal functional 
relations of the several parts of the brain. 
Anaemia, chlorosis, syphilis, ague, and all 
lowered states of health, howsoever induced, 
and whether acquired or inherited, become 
predisposing or actual causes of brain -disease. BRAIN, DISEASES OF 
BRAIN, ABSCESS OF 
183 
To these states, favourable to the manifesta- 
tion of brain-disease, should be added the 
various acute specific diseases, uraemia, me- 
tallic poisoning, poisoning by the narcotic 
and narcotico-irritant poisons generally, and 
also by the occasional qualities of certain 
articles of food, such as mackerel, mussels, 
mushrooms, &c. 
2. Emotional shocks cause cerebral dis- 
order, especially in children; whilst prolonged 
overwork, particularly when combined with 
worry and anxiety, with sexual excesses, or 
with protracted lactation, is apt to induce it 
in those who are older. Religious excitement, 
again, in combination with lowered states of 
health, not infrequently leads to insanity. 
3. Physiological crises, such as the period 
of the first dentition, the period of puberty, 
pregnancy, and the climacteric period, all 
favour the manifestations of various nervous 
diseases. 
4. Visceral diseases or surface-irritations 
(especially in children or in persons having a 
very sensitive and mobile nervous system) 
may give rise to varied nervous diseases. 
Thus we may have convulsions or delirium in 
children from the presence of worms or other 
irritants in the intestines; or convulsions in 
adults during the passage of a renal calculus. 
Again, we may have the phenomena classed 
as hysteria, or we may have nymphomania, 
in consequence of certain states of the sexual 
organs. Cases of paralysis are said also to 
have a reflex origin occasionally, though this 
must be a very rare event. With much 
greater frequency we find surface-irritations 
of various kinds leading, as in Dr. Brown- 
Sequard's guinea-pigs, to epileptiform attacks. 
5. Structural lesions of the brain itself 
give rise to a very large proportion of its 
diseases. The various kinds of change will 
be found enumerated under another heading 
(see Nervous System, Diseases of). Haemor- 
rhage, softening, and tumours are the most 
common, and, therefore, the most important 
of these morbid conditions. 
6. Brain-disease may be determined by 
the action of heat (insolatio), especially when 
combined with fatigue and deficient aeration 
of blood. A somewhat similar brain-affec- 
tion, however, is occasionally developed in 
the course of rheumatic fever or in that of 
one of the specific fevers, especially typhoid 
or typhus, when the temperature of the body 
rapidly rises to a lethal extent (109°-lll° F.). 
7. Conctissions (whether from blows or 
falls) may give rise to brain-disease, even 
where no traumatic injuries or lacerations of 
the brain seem to have been produced. 
Treatment.- The treatment of brain- 
disease will be discussed under the articles 
Nervous System, Diseases of; Paralysis; 
and Convulsions; and in those on the several 
special diseases which will now be described 
in alphabetical order. 
H. Charlton Bastian. 
BRAIN, Abscess of. - This term is 
applicable whenever a circumscribed collec- 
tion of pus is formed in any part of the 
cerebral mass. 
^Etiology and Pathology.-Amongst the 
most frequent causes of cerebral abscess are 
severe injuries to the skull, disease of the 
temporal bone in connexion with the ear, 
ligature or obstruction of a main artery, and 
pyaemia. Under the three first-named con- 
ditions the abscess is usually solitary, but 
from pyaemia multiple abscesses often result. 
For practical purposes we may perhaps 
conveniently discard the latter-since the 
symptoms will usually be those of general 
encephalitis-and confine ourselves to those 
cases in which single, large-sized collections 
of pus are met with. With this limitation, 
abscess in the brain is by no means of frequent 
occurrence. 
The best marked, and also the more 
common examples of large cerebral abscess 
are met with in connexion with compound 
fractures of the skull, and by far the most 
definite symptom which denotes them is 
the formation of a fungus cerebri. Unless 
in a compound fracture the brain be directly 
injured and the dura mater torn, it is very 
rare indeed for any suppuration in its sub- 
stance to occur. It is not to be denied, how- 
ever, that now and then, after severe con- 
cussion or laceration without external wound, 
abscess may follow. In such cases we may 
conjecture that usually some slight laceration 
or extravasation occurred in the first instance, 
which constituted a focus for the inflamma- 
tion. Abscess after simple concussion with- 
out lesion is probably a most rare event. 
In the article Brain, Inflammation of, we 
shall have to define Encephalitis as a diffuse 
change of a large part of the cerebral mass, 
perhaps of a whole hemisphere, attended by 
the infiltration of cells and fluid. It is obvious 
that the term abscess in the brain is ap- 
plicable to one of the results of encephalitis, 
But it seems clinically probable that the two 
classes of cases are for the most part distinct, 
and that diffuse encephalitis has but little 
tendency to result in abscess, and that abscess 
is rarely preceded by a stage of encephalitis. 
Both are usually the consequences of local 
injury to the brain, or of extension from local 
disease of its coverings; but whilst encepha- 
litis probably resembles the erysipelatous 
type of inflammatory action, in localised 
abscess this tendency is not present. Having 
distinguished brain-abscess from encephalitis, 
we must next say a word as to the risk of 
confusing it with intra-cranial but extra- 
cerebral collections of pus. Encysted col- 
lections of matter may be met with either 
between the dura mater and bone, or within 
the arachnoid cavity; and perhaps it ought 
to be added, though with some hesitation, 
beneath the arachnoid, in the pia mater. Not 
infrequently inflammation of the membranes 184 
BRAIN, ABSCESS OF 
precedes and attends the formation of an 
intra-cerebral abscess, and in these cases 
the symptoms will be mixed. In dealing with 
published cases it is also necessary to be on 
our guard as to certain errors which have 
crept in-cases of meningeal abscess being 
spoken of as bram-abscess. Sir Prescott 
Hewett has expressed his opinion that the 
celebrated case of de la Peyronie's was an 
example only of extra-cerebral abscess. It 
is absolutely necessary to make these re- 
strictions, if we would judge correctly as to 
the symptoms which attend local collections 
of matter in the brain, and the usual termina- 
tions of such cases. 
The contents of a cerebral abscess usually 
consist to some extent of broken-up cerebral 
tissue, and in some cases there are but very 
few pus-cells. Especially is this likely to 
occur when the so-called abscess follows on 
ligature of the carotid or occlusion of a cere- 
bral artery. In these cases, it is, in the first 
instance at least, the result of a process of 
softening rather than of true suppuration. 
Symptoms.-The symptoms of local sup- 
puration in the brain will vary with the 
stage, the size of the collection, its precise 
situation, and above all, with the presence 
or otherwise of a fistula of relief. In many 
of the cases which come under surgical care 
a fistula exists from a very early period, 
though not infrequently it is liable to occlu- 
sion. Under the latter conditions the symp- 
toms of a closed and an open cerebral abscess 
may be alternately studied in the same case. 
It will usually be observed that when the 
exit is closed, and the abscess fills, the patient 
complains more or less of headache, becomes 
heavy and drowsy, and experiences twitchings 
or spasms in the opposite side of the face and 
limbs, with some tendency to hemiplegia. 
Of this group the tendency to spasms is pro- 
bably by far the most significant. The head- 
ache may be but trifling, and the patient 
may even be well enough to leave his bed, 
when the occurrence of spasm followed by 
paresis alone gives warning of what is going 
on. Temperatures are in such cases very 
misleading. Persistent elevation is a symp- 
tom to be attended to, but its absence is no 
safe ground for negative conclusions. The 
cases now alluded to are chiefly those in 
which abscess results from compound 
fracture of the skull with laceration of the 
brain-substance. In these the abscess often 
gives way spontaneously, and a fistula forms, 
around the orifice of which a mass of pouting 
brain-granulations, known as fungus cerebri, 
usually forms. In these cases the canal of 
communication may be very tortuous, and 
the liability to blocking considerable. Now 
and then the same result may be met with 
after syphilitic disease of the skull and 
meninges. The writer had some years ago 
a man under his care in whom he had opened 
a cerebral abscess beneath a hole in one 
parietal bone. The patient was able to walk 
about, and ailed but little so long as the 
fistula was freely open; but spasms of the 
face, or even convulsions of the limbs (on 
the opposite side), always followed its occlu- 
sion. The softening gradually extended, and 
he at length died in consequence, perhaps, 
of the impossibility of making a counter- 
opening in a depending situation. Unless 
the abscess be in the anterior lobe, there 
will almost invariably be present some degree 
of hemiplegia, but this will of course vary 
with the size of the collection and the extent 
of destruction of tissue. The formation of 
an abscess after injury is sometimes very 
insidious, the symptoms being very slight. 
The cases in which violent headache and 
pain, vomiting, delirium, and dry tongue, 
are said to have been present in the early 
stages are, it may be suspected, usually in- 
stances of suppuration between the bone and 
dura mater. These symptoms occur especially 
when brain-abscess follows disease of the 
internal ear, and in these there nearly always 
is the complication of inflammation around 
the petrous bone. Such symptoms are very 
rarely present in traumatic abscesses, which 
often develop very quietly until they attain 
a considerable size. It is probable that 
some degree of rigor, attended with rise of 
temperature, usually occurs in the beginning 
of cerebral abscess, but no very precise data 
are extant on these points. 
* If a large abscess be permitted to develop 
without relief, the symptoms of compression 
will in time ensue: first spasm, then hemi- 
plegia, then hebetude and coma, preceded 
possibly by violent convulsions. There are 
cases, however, in which the tendency to in- 
crease ceases, and the abscess may pass into 
a quiescent state and remain for indefinite 
periods without symptoms. 
Diagnosis.-The diagnosis between cere- 
bral abscess and meningeal abscess is exceed- 
ingly difficult, and often a guess is all that 
can be made. The almost invariable occur- 
rence of spasm or convulsions in the former, 
and their frequent absence with the greater 
degree of pain and headache in the latter, are 
the most reliable signs. Sometimes-as, for 
instance, when trephining has been practised, 
and no inflammatory products are found be- 
tween the bone and dura mater or under the 
latter-the diagnosis may be helped by this 
negative knowledge. In such cases, if hemi- 
plegia. preceded by spasm, have been gra- 
dually developed, the surgeon will be well 
justified in making an incision or puncture 
into the hemisphere. Optic neuritis may 
equally be present in both, and its presence 
or absence will scarcely help the diagnosis. 
Prognosis.-In addition to the danger of 
death by compression, there is the risk that 
the abscess may break into the ventricles 
or into the subarachnoid space. Some cases 
are on record in which spontaneous openings BRAIN, ABSCESS OF 
BRAIN, ANAEMIA OF 
185 
into the nose or into the ear occurred, and 
profuse discharge followed, the patient in 
the end recovering. It may be doubted 
whether these were not instances of menin- 
geal abscess. 
Treatment.-It is needless to say that if 
abscess be diagnosed with any degree of con- 
fidence an opening is essential, and the case 
must pass into the hands of the surgeon. 
There is little or no room for medical treat- 
ment. Of late years operations with the 
trephine for the relief of cerebral abscess 
have been attended with very encouraging 
success. For the prevention of abscess, in 
all cases in which injuries likely to produce 
it have occurred, the utmost precautions 
should be enforced. Mercury in small doses, 
frequently repeated, should be given from the 
first; the injured region should be covered 
with lint soaked in a strong spirit-of-wine 
lotion, frequently re-wetted ; purgatives 
should be administered; and the patient 
should be kept very quiet until long after the 
healing of the wound. 
Jonathan Hutchinson. 
BRAIN, Anaemia of.-Definition.- 
A condition in which the blood contained 
within the brain, and especially within 
the capillaries of the brain, is deficient in 
quantity, or defective in nutritive quality, or 
both. 
The blood within the brain is contained in 
arteries, capillaries, and veins. The func- 
tional condition of the brain depends on the 
quantity and quality of the blood circulating 
in its capillaries, and it is to these that the 
special symptoms are related. Deficiency in 
the quantity contained in the arteries or 
veins can scarcely occur without the condi- 
tion being shared by the capillary circulation. 
Defect in the quality of the blood supplied 
to the brain is always of gradual occurrence, 
and affects the whole brain ; deficiency in 
quantity of blood may affect the whole brain 
or part only, and it may be sudden or gradual 
in its production. 
^Etiology.- General cerebral ancemiam&y 
be due to the following causes :-(1) It may 
be a part of systemic anaemia-defect in 
quantity or quality of the whole blood, and 
from causes which are considered elsewhere. 
This is often seen in cases of haemorrhage, 
of exhausting discharges, or of defective 
blood-nutrition, as in chlorosis. (2) The 
supply of blood to the brain may be deficient, 
the quantity of blood in the body being 
normal. The cerebral anaemia is then part 
of a cephalic anaemia. In consequence of 
posture in relation to gravitation the supply 
of blood to the head is that which is especially 
interfered with by any diminished movement 
of the blood. At the same time the closure 
of the cavity in which the brain is situated, 
and the unreadiness of the cerebro-spinal 
fluid to undergo rapid change of distribution, 
preserve the blood in the head from the 
extremely rapid diminution to which it would 
probably otherwise be liable-possibly, in- 
deed, to a degree incompatible with life. 
Cephalic anaemia may be due to cardiac 
weakness, or to causes acting through the 
nervous system on the heart, as in swooning. 
In systemic anaemia, the lessened cardiac 
power increases the cerebral deficiency. 
Whatever lessens the amount of blood dis- 
charged from the heart at each systole, such 
as aortic or mitral disease, may be a cause of 
cerebral anaemia. Pressure on the vessels 
conveying the blood to the head, as by an 
aortic aneurysm, has a similar effect. Un-' 
equal distribution of the systemic blood is 
another cause. The intestinal vessels, if 
dilated, are capable of containing a large 
part of the blood of the body, and the effect 
of their engorgement is often seen after 
paracentesis abdominis. One theory of shock 
ascribes its mechanism to vaso-motor dilata- 
tion of these vessels, and consequent anaemia 
of the rest of the system. Severe diarrhoea 
or dysentery is an occasional cause of symp- 
toms of a very pronounced and prolonged 
character. (3) The capacity of the cerebral 
vessels may be diminished by pressure on 
the brain, exerted by effusions of fluid (hydro- 
cephalus), of blood (in cerebral and meningeal 
haemorrhage), or by growths within the skull. 
(4) General contraction of the arteries of the 
brain is a rare cause, probably confined to 
some toxic states, such as that of Bright's 
disease, in which such contraction can be 
seen in the retina. 
Partial cerebral ancemia is due to local 
obstruction to the passage of the blood through 
an artery. To be permanently efficient 
such obstruction must be situated beyond 
the circle of Willis. Ligature of one carotid 
causes immediate symptoms of cerebral 
anaemia, but permanent symptoms are not 
frequent. Pressure on, or disease of, one 
carotid, for the same reason, rarely gives rise 
to symptoms. Obstruction in certain arteries 
of the brain may cause local anaemia, sudden 
or gradual, temporary of permanent, accord- 
ing to its cause. Such obstruction may be 
due to narrowing of the calibre of the vessel 
by atheromatous changes in its wall, or by 
spasm of its muscular coat, or may be due to 
actual occlusion by embolism or thrombosis. 
The pressure-effects of an intruding substance 
within the skull (tumour, or clot) act most 
intensely in one region of the brain, and may 
influence it only. Arterial spasm is per- 
haps an occasional cause of local anaemia. 
Extensively as it has been invoked as a 
mechanism to explain symptoms, its occur- 
rence has not yet received any definite proof. 
It is obvious that of these causes some act 
suddenly, others gradually, and the symptoms 
produced will differ accordingly. 
Anatomical Characters.-The principal 
anatomical character of cerebral anaemia is 186 
BRAIN, ANAEMIA OF 
pallor of the brain, observable chiefly in the 
paler tint of the cortical substance, and the 
diminished number of red spots in the white 
centre. The pallor may be partial or general. 
The membranes are usually pale, but in some 
cases of partial anaemia they are hyperaemic. 
Effusion of serum in the meshes of the pia 
mater and between the convolutions may be 
found in general anaemia. 
Symptoms.-The symptoms of this condi- 
tion vary according as the anaemia is sud- 
denly or slowly produced, and as it is general 
or partial. 
(1) In sudden general anaemia of the brain 
the sufferer feels drowsy ; the special senses 
are dulled; noises in the ears and vertigo are 
complained of; the pupils are at first con- 
tracted ; sight may fail; muscular power is 
weakened; respiration is sighing; the skin 
is pale, cold, and moist; nausea is common; 
and headache is rare. If the anaemia is more 
intense, consciousness is lost; there is univer- 
sal paralysis; and general convulsions may 
occur, epileptiform in character, these being 
especially frequent in sudden extensive losses 
of blood in strong subjects. The pupils dilate, 
and the coma may deepen to death. The 
loss of sight may persist, in cases which 
recover, but retinal changes are then found. 
(2) When general anaemia of the brain is 
slowly produced, the state of the cerebral 
functions is usually that of ' irritable weak- 
ness.' Their action is imperfect in degree, 
and excited with undue facility. There is 
mental dulness and drowsiness; sometimes, 
however, insomnia is troublesome. Delirium 
is common in severe cases, and is conspicuous 
in some forms of imperfect blood-nutrition, 
as in the so-called 'inanition delirium.' 
Headache, usually general, is a common 
symptom. Sensory hyperaesthesiae, tinnitus, 
muscae volitantes, and vertigo are frequent. 
Convulsions are rare, but muscular power is 
generally deficient. All these phenomena 
are more marked in the erect than in the 
recumbent posture, especially when the erect 
posture is suddenly assumed. It has been 
remarked that somia anaemic persons can 
think well only when lying down. In young 
children, after exhausting discharges, as 
diarrhoea, symptoms referable to cerebral 
anaemia are common, namely, somnolence 
and pallor, with depressed fontanelle and 
contracted pupils. The somnolence may 
deepen to coma with insensitive conjunctiva, 
and the coma increase to death. Such 
symptoms have been called hydrocephaloid, 
from some resemblance to those of acute 
hydrocephalus. 
(3) Partial cerebral anaemia causes, if 
complete, loss of function in the affected 
area; and if it be permanent, as in obstruc- 
tion of a vessel beyond the circle of Willis, 
necrosis of the cerebral tissue results (see 
Brain, Softening of). If incomplete and 
sudden, there is temporary arrest of function. 
Ligature of one carotid, for instance, causes 
transient weakness and numbness in the 
opposite half of the body. There may be at 
first an over-action of grey matter, causing, 
in certain regions, unilateral convulsions. 
The return of the blood-supply, as when a 
plug shifts its position or is broken up, may 
not immediately be followed by restoration 
of function, which may be put in abeyance 
for some time by the effect of the sudden 
influence. The loss of memory is occasionally 
of a remarkable character, involving only 
the power of retaining new impressions. If 
slowly developed, as in atheroma of arteries, 
pain and vertigo are common, with recurring 
local symptoms, such as numbness, tingling, 
and weakness. 
In all cases of long-continued cerebral 
anaemia, prolonged damage to the nutrition 
of the brain may result. In the child the 
development of the brain may be arrested; 
in the adult, loss of memory and of general 
mental power indicate the deterioration of 
structure. These may last for many months, 
but commonly pass away at last. 
Pathology.-The symptoms are, as already 
stated, dependent mainly on the defective 
quantity and quality of the blood circulating 
in the brain. Some influence may probably 
be ascribed to the diminution in the blood- 
pressure to which the nerve-elements are 
ordinarily exposed (Burrows). Nothnagel 
has pointed out that the symptoms indicate 
an early affection of the respiratory centre in 
the medulla, and of the cortical grey matter. 
The convulsions in acute anaemia have been 
ascribed to irritation of the medulla or of 
the pons Varolii, but our present knowledge 
suggests that they are due to the altered 
function of the motor region of the cortex. 
Diagnosis.-The diagnosis is not difficult. 
It rests on the recognition, in a given case, 
of the cause of cerebral anaemia; and on 
the exclusion of graver maladies, as organic 
cerebral disease. With the latter, it should 
be remembered, anaemia of the brain, local 
or general, often co-exists. Some symptoms 
of hyperaemia of the brain closely resemble 
those of anaemia. A common pathological 
state of imperfect blood-renewal probably 
exists in both conditions. 
Prognosis.-The extent to which the cause 
of the anaemia is amenable to treatment, and 
is of transient character, must influence the 
prognosis. As a rule this is favourable when 
there is no organic disease of heart, vessels, 
or brain. In the so-called ' pernicious an- 
aemia,' the prognosis is, of course, unfavour- 
able. Hydrocephaloid symptoms in infants, 
if met by prompt and suitable treatment, 
are usually recovered from. 
Treatment.-The treatment necessarily 
varies in the several forms of the affection, 
but it is in the main causal. The beneficial 
effect of the recumbent posture in affording im- 
mediate relief to the symptoms, and obviating BRAIN, ANAEMIA OF 
BRAIN, ATROPHY OF 
187 
permanent damage to the cerebral nutrition, 
must be always remembered. In acute 
anaemia from loss of blood, the head must 
be kept continuously low, stimulants freely 
administered, and as a penultimate resort 
bandages applied to the limbs from below 
upwards may increase the proportionate 
supply of blood to the brain. If this fails 
transfusion must be had recourse to. In 
chronic anaemia sudden change of posture 
should be carefully avoided, and ferruginous 
tonics are needed. More important than any 
other element is physical rest, permitting 
more of the scanty amount of oxygen that 
can be conveyed by the blood to be used for 
the nutrition of the protoplasm, i.e. tissues 
on which the vital functions depend. In 
spasm of the cerebral vessels nitrite of amyl 
or nitroglycerine should be employed ; and a 
course of the latter, in a small dose two or 
three times a day, lessens any liability to 
irregular contraction that may exist. In the 
cerebral anaemia of syncope, the recumbent 
posture, stimulants to the skin, cold water, 
faradisation, sinapisms, and ammonia to the 
nasal mucous membrane, assist the recovery 
of cardiac action and the return of con- 
sciousness. In all cases, carefully regulated 
food and stimulants are needed; beef-tea 
should be given in small quantities at frequent 
intervals. The group of symptoms called 
hydrocephaloid requires similar treatment. 
W. R. Gowers. 
BRAIN, Aneurysm of.-See Brain, 
Vessels of, Diseases of. 
BRAIN, Atrophy of.-Atrophy of the 
brain may be congenital, due to arrest of 
development in very early foetal life ; or the 
constituents of the brain may have been 
perfectly developed, and may subsequently 
disappear from one of several causes. This 
morbid state is regarded as primary when 
there has been no pre-existing disease of the 
brain or its membranes; secondary, either 
when there has been such pre-existing disease, 
and the atrophy has occurred from absorption 
of the part broken down by inflammation, 
softening, haemorrhage, &c., when atrophy 
of some special cerebral organ follows upon 
destruction of the particular nerve that 
arises from it; or when localised atrophy has 
taken place in a very gradual manner from 
pressure of a tumour; of ventricular effusion, 
&c. To take these forms in order :- 
1. Congenital Atrophy.-This is usually 
associated with weakness of intellect, even to 
the extent of idiocy. There is atrophy of 
the body opposite to the side of the cerebral 
lesion, and this atrophy involves all struc- 
tures, even the bones. Paralyses of various 
intensity supervene, often with contraction 
of the paralysed parts ; there being no par- 
ticular sensitiveness of the special senses, 
possibly because of the mental hebetude. 
Epileptic attacks are common; vitality is 
low; and the patient easily succumbs to 
other diseases. 
2. Primary atrophy.-In this variety there 
is general diminution both of volume and of 
weight, affecting most usually the cerebral 
hemispheres, and that in pretty equal degree. 
It is most common as a condition of old age 
-senile marasmus, atrophia cerebri senilis. 
It sometimes in earlier life follows exhausting 
diseases ; and may also be caused by deficient 
or impure blood-supply to the brain. In 
close connexion with this mode of causation 
it is seen after repeated attacks of intoxica- 
t'on, especially after dehnum tremens. In 
this last condition the cerebral atrophy may 
be acute and rapid. 
3. Secondary atrophy. - This may be 
general or partial. When general, the con- 
volutions have a shrunken appearance, and 
there is always an increase of the subarach- 
noid fluid. This condition follows various 
lesions of the brain, especially of the convex 
surface, such as haemorrhage of the convexity, 
encephalitis, or more accurately that form 
of encephalitis which attacks only the grey 
matter, or perhaps only one layer of the grey 
matter, as in some mental diseases. When the 
atrophy is partial, there are found depres- 
sions in an otherwise normal hemisphere, at 
which point a localised haemorrhage or patch 
of softening, inflammatory or depending on 
thrombosis or embolism of vessels, has been 
absorbed, leaving only a cavity of greater or 
less extent, filled with fluid and sometimes 
lined with a thin membrane. A certain 
portion also of the brain may become atro- 
phied by the gi adual pressure of a tumour or 
any foreign body. Even the little sieve-like 
depressions seen in various situations after 
constantly repeated congestion of vessels may 
be the result of atrophy from compression by 
the distended vessels. Functional inactivity 
and atrophy of the optic nerves have led to a 
similar abnormality of the corpora quad- 
rigemina, and of the higher centres of the 
perception of vision. 
Anatomical Characters.-The atrophied 
brain, or portion of brain, will vary in appear- 
ance on minute examination, according as 
the lesion has, or has not, been preceded by 
inflammation. When the atrophy is primary 
and due to gradual interference with the blood- 
supply, there is seen a shrunken condition of 
the nerve-tissue, especially of the calibre of 
the nerve-tubes. The cells are smaller than 
usual and pigmented; the arteries are de- 
creased in size or themselves diseased. If 
the lesion has had an inflammatory origin, 
the process in order of sequence is, first, 
inflammation, then softening with fatty de- 
generation, then partial absorption, and so 
atrophy; the appearances differing according 
to the stage of the lesion. Traces of fatty 
degeneration of all the tissues - vessels, 
nerve-tubes, and cells - may be found, with 
the neuroglia either wanting or sclerosed. 188 
Dr. Rudolph Arndt has lately thrown doubt 
on the possibility of determining atrophy of 
the ganglionic bodies or nerve-tubes by their 
size. The size of these bodies varies so 
greatly, within the limits of health, that he 
considers this test a very uncertain one. 
Almost the only trustworthy sign of atrophy, 
in his opinion, is the appearance in the sub- 
stance of the ganglionic bodies and in the 
medullary sheath of nerve-bundles, of black 
shining globules, somewhat fatty-looking. 
In process of time these globules increase in 
number, and at last the whole of the bodies 
appear permeated by them. These globules 
are not fatty: they are certainly more or less 
pigmental. Exactly similar bodies are found 
in post-mortem examinations, and are a sign 
of simple decomposition. The duration of this 
condition, irrespective of pre-existing lesions, 
is protracted. 
Symptoms.-The symptoms of atrophy of 
the brain necessarily vary according to the 
seat, extent, and aetiology of the lesion. 
Primary atrophy of the cerebral hemispheres 
and the first form of secondary atrophy will 
most usually induce imbecility, or some lesser 
degree of mental insufficiency, loss of memory, 
slowness of thought, and other mental dis- 
eases. Headache, giddiness, delirium, and 
stupor are seldom met with. Interference 
with speech is more common. Affections of 
sight, and of the motor condition of the eye, 
do not depend on general atrophy of the 
brain ; they own a more local cause. 
Convulsions, paralysis, stiffness of muscles, 
or contractions are often met with in con- 
nexion with this general lesion, as well as 
various irregularities of locomotion; but it 
must be remembered that general atrophy of 
the brain is not seldom associated with atro- 
phic or sclerotic lesions of the spinal cord, 
and, even where this is not so, several of the 
morbid phenomena, and particularly convul- 
sions and paralysis, may derive their origin, 
not from the atrophy, but from the condition 
pre-existent to the atrophy, such as haemor- 
rhage of the convexity, meningitis, or peri- 
encephalitis. 
In secondary atrophy of a more limited 
extent, the symptoms. are apt to be more 
strictly localised, such as partial loss of 
power in a single limb, slight imperfec- 
tions of speech, or strabismus ; but here 
again the positive diagnosis of atrophy is 
hindered by the complication of pre-existent 
disease, the local congestions, haemorrhages, 
softenings, tumours, or other conditions of 
which the atrophy is only the sequence. 
Still less characteristic are the phenomena 
attending general or partial atrophy of 
the cerebellum, the pons, and the medulla 
oblongata. 
Treatment.-Treatment is useless as to 
the atrophy of the brain : it must be directed 
to supporting the powers of the patient. 
E. Long Fox. 
BRAIN, ATROPHY OF 
BRAIN, Carcinoma of. See Brain, 
Tumours of. 
BRAIN, Compression of.-The brain 
is compressed in the pathological sense when- 
ever its structure is so squeezed that its 
functions are in any degree interfered with. 
This squeezing may be effected either by the 
effusion of blood within the skull, the growth 
of a tumour, the accumulation of pus or 
serum, or lastly by the depression of some 
large portion of the bony parietes. The 
general belief that depressed fractures are 
frequently the cause of compression is proba- 
bly quite a mistake. In such cases the frag- 
ment displaced is rarely of sufficient size to 
cause serious compression of the contents of 
the skull, and the symptoms usually supposed 
to indicate that state are really due in most 
cases to laceration and contusion, or to sub- 
sequent inflammation. This point is of great 
importance in practice, for upon its recog- 
nition depends much of the validity of the 
reasoning by which the operation of primary 
trephining in compound fractures is defended 
or condemned. It also offers a most serious 
fallacy as regards the interpretation of the 
symptoms due to compression. 
By far the best examples of uncomplicated 
compression of brain are supplied to us by 
the not very infrequent cases in wffiich a 
middle meningeal artery is injured, and a 
large blood-clot is effused between the dura 
mater and bone. It is from observation of 
cases of this kind that the assertion is jus- 
tified, that a very considerable intrusion into 
the skull may be permitted without the pro- 
duction of any symptoms. No doubt the 
suddenness or otherwise has much to do 
with the results, but there seems good reason 
to believe that, as a rule, the brain will easily 
accommodate itself to quantities not exceed- 
ing an ounce or two, and that usually as 
large a quantity as four or five ounces is 
required to cause death. It is very rarely 
indeed that a depression of bone in the least 
approaches such an extent of intrusion as 
this, and the majority of such cases are, as 
regards the amount of possible squeezing, quite 
trivial. The manner in which the accommo- 
dation is effected is by the removal of the 
fluid contents of the skull-first the subarach- 
noid fluid, and secondly the blood. Of the 
blood-vessels the veins and venous sinuses 
are probably emptied first, and lastly the ar- 
teries and capillaries. A brain in a state of 
strong compression is an exsanguined brain. 
In this respect, the brain in the last stage of 
compression differs very much from that in 
cases of insensibility from concussion or con- 
tusion. It by no means follows that because 
the brain is pale, the face should be pale 
also; but it is perhaps usually the case that 
extreme compression so much enfeebles the 
heart's action that the pulse is weak or 
flickering, the respiration shallow and irregu- 
• BRAIN, COMPRESSION OF BRAIN, COMPRESSION OF 
189 
lar, and the skin pale and cold. That ster- 
torous breathing, a laboured pulse, and a 
suffused and dusky countenance are (as 
according to the classical description) symp- 
toms of compression, is probably for the 
majority of cases a mistake. Such a group 
much more frequently denotes laceration, 
contusion, or central extravasation. Nor is 
it true that hemiplegia, excepting of the 
most transitory kind, is often due to com- 
pression. A qlot of blood poured out over 
one hemisphere may, if rapidly effused, pro- 
duce for a while weakness of the opposite 
limbs, but the brain-mass is soft enough to 
allow of considerable yielding, and in the 
course of a few hours the effects of the displace- 
ment will have become general, and not local. 
In a case recorded by the writer in which a 
post-mortem examination, some weeks later, 
proved the presence of a large blood-clot, 
there had been partial hemiplegia without 
unconsciousness at first, but on the next day 
all trace of it had disappeared, and it never 
returned. In many of the cases of bleeding 
between the dura mater and bone, from the 
meningeal artery, the haemorrhage takes 
place on several different occasions, with, it 
may be, intervals of a day or two, much as 
is often observed in wounds of arteries, such 
as the palmar arch. Thus the observer is 
able to appreciate the symptoms caused 
by different degrees of compression, and 
further proof is afforded that, if the intruded 
quantity be but moderate, the brain bears 
it without obvious inconvenience. Often 
at the autopsy it is quite easy to distinguish 
clots of very different dates, and to feel sure 
that the original one was of considerable 
size. It is clear then that in speaking of the 
symptoms of compression we must allow for 
differences in amount of the compressing sub- 
stance, and also for differences in the rapidity 
or suddenness of its application. 
(When compression is produced suddenly, 
as by a large fragment of bone driven down, 
the case is almost invariably complicated by 
contusion. If paralysis or even insensibility 
be present, it is usually impossible to say to 
which lesion they are really due. We may, 
however, hold it almost certain, from what 
we know of other cases, that the effects 
in such would be a temporary hemiplegia, 
with symptoms of shock, if the depres- 
sion were but moderate; and insensibility, 
probably soon followed by death, if the de- 
pression were very great. The cases in 
which depression of bone has alone been 
sufficient to produce long-continued com- 
pression with insensibility are possibly some- 
what apocryphal. It is possible that com- 
pression under such circumstances might be 
attended by stertor and laboured pulse, but 
it is possible also that the pulse might be 
extremely feeble, the countenance pale, and 
inspiratory efforts weak and irregular. 
The depression of bone is perhaps the only 
condition which can be supposed capable of 
producing compression suddenly. When 
blood is poured out from a ruptured artery, 
the symptoms comp on rather gradually. 
The patient complains perhaps of headache, 
and then becomes more or less confused 
in manner, his gait is unsteady, and the 
limbs on the side opposite to the injury show 
special weakness. Vomiting may occur 
and the weakened limbs may twitch, and 
unless, as is often the case, the intracranial 
bleeding stops, these symptoms are soon lost 
in a state of complete insensibility, with pale 
face, feeble pulse, and symptoms of shock. 
Convulsions may now occur, and death often 
supervenes very quickly. In such a case the 
whole course of the symptoms may occupy 
less than an hour. The surgeon ought, of 
course, to trephine and let out the blood, and 
he must be prompt, or his patient may die 
during his preparations. More commonly 
this rapid termination occurs unexpectedly 
after one or more previous attacks of tem- 
porary head-symptoms, and the patient may 
have appeared quite well in the intervals. 
In cases in which the symptoms progress 
without interruption, their rapidity, no doubt, 
depends upon the size of the vessel ruptured. 
Certain special symptoms will also depend 
upon the precise position taken up by the 
clot which may chance to press upon special 
nerve-trunks as well as upon the brain-mass. 
In ordinary cases the clot is beneath the 
squamous bone and the lower part of the 
parietal, and passes downwards into the 
sphenoidal fossa. In the latter region it may 
press upon the nerves going to the sphenoidal 
fissure; and it is of importance for the 
surgeon to know that dilatation of the pupil 
on the affected side is often produced. This 
important symptom is probably due to pressure 
upon the third nerve. 
There is yet another class of compression- 
cases in which that condition is produced by 
the slow accumulation of the products of 
inflammation within the skull. Much will 
depend, as regards special symptoms, upon 
the position of the abscess, either within or 
without the brain. If in the substance of the 
brain, it must more or less disorganise its 
structure, and thus cause symptoms due to 
laceration as well as compression. Under 
such conditions some degree of hemiplegia, 
with, probably, preceding spasms of limbs, 
can scarcely fail to be present. Now and 
then cases occur in which an irregular sinus 
leads into an abscess-cavity in the brain, and 
this sinus being sometimes free and some- 
times blocked, the surgeon has repeated 
opportunity of estimating the effects of filling 
of the cavity. In such cases, headache, 
stupor, unilateral twitching of limbs, partial 
hemiplegia, with perhaps vomiting, and, it 
may be, general convulsions, are the symp- 
toms to be expected. The position of the 
abscess as regards different regions of the 190 
BRAIN, COMPRESSION OF 
BRAIN, CONCUSSION OF 
brain is also of much importance, but its 
discussion cannot be entered upon in any 
detail here, and it obviously concerns rather 
disorganisation of structure than simple com- 
pression. 
When a large accumulation of pus takes 
place between the bone and dura mater, the 
symptoms produced are much the same as 
those caused by blood-clot. We must make, 
however, much allowance for the fact that 
these cases are almost always attended by 
meningitis, and thus the symptoms of com- 
pression are masked by those due to inflam- 
mation. Chronic abscess under the bone 
without arachnitis may occur now and then 
in syphilitic and other disease of the cranial 
bones, but such cases are very rare. They 
will differ from those of haemorrhage in that 
the symptoms are always produced very 
slowly. The writer once had the opportunity 
of watching such a case, in which the patient 
died of compression, very gradually produced 
by an increasing collection of pus between 
the bone and dura mater, and without any 
complication. The chief symptom was con- 
stant wearing headache, which prevented 
sleep. The man was pale and feeble, but 
not paralysed in any part, excepting that 
both eyelids drooped. He was rational, but 
spoke slowly, as if in a state of partial stupor. 
During the last two or three days of life he 
had convulsions; and finally, for twenty-four 
hours, he was in a state of increasing insen- 
sibility. 
Diagnosis.-It will be seen from what has 
been said above that the diagnosis of com- 
pression by symptoms is exceedingly difficult, 
and that the utmost use must in each case be 
made of the history of the case. In those of 
blood-compression after injury to a menin- 
geal artery, there is almost always the fact 
that the patient between the date of the 
injury and the supervention of symptoms 
had an interval during which there appeared 
to be little or nothing the matter. This 
history is, if the symptoms have developed 
rapidly and without the signs of inflammation, 
by itself conclusive for diagnosis. Under 
such conditions trephining ought to be at 
once resorted to, or possibly it might be yet 
better practice to first tie the carotid artery. 
The diagnosis of abscess in the brain-sub- 
stance has already been discussed, and that 
of inflammatory collections from meningitis 
will be examined in its proper place. See 
Meninges, Cerebral, Inflammation of, 
Simple Traumatic. 
Treatment.-The treatment of compres- 
sion of the brain is almost wholly surgical, and 
consists in the use of the trephine and knife to 
elevate depressed bone, or evacuate collections 
of blood or pus. Jonathan Hutchinson. 
BRAIN, Concussion of.-We class 
under the head ' Concussion of Brain ' all 
symptoms which result simply from the 
shaking, more or less violently, of the con- 
tents of the skull. It will be obvious, how- 
ever, that most cases of severe shake of the 
brain are likely to be complicated by visible 
lesions. The skull may be broken and the 
brain may be contused, lacerated, or ecchy- 
mosed. It is highly probable, however, that 
well-marked and even serious symptoms may 
be produced by shaking only, and without 
the existence of any lesion discoverable either 
by the unaided eye or the microscope. We 
must further clearly understand that this 
element of concussion (i.e. the results of 
shake independent of lesion) enters into 
almost every case of injury to the head. 
Whatever be the other lesions, it is usually 
the fact that the brain has been more or less 
severely shaken. Thus it may easily happen 
in cases in which conspicuous lesions are 
present, such as fracture of the base or local 
contusion, that still the results of the shake 
are the most important. It might be con- 
venient if we were in the habit of speaking 
of most cases of severe injury to the head as 
Concussion plus other, lesions, with the en- 
deavour to assign to each added complication 
its proper share in the general result. These 
explanations are necessary before we put the 
question-Can concussion alone cause death? 
Although it is highly probable that we ought 
to reply with a very confident affirmation, 
and to assert that it is not uncommon for 
concussion to be the chief cause of the fatal 
event, yet it is very difficult to prove it, since 
the cases are extremely rare in which severe 
concussion is produced without some attend- 
ing lesion. The symptoms caused by con- 
cussion of the brain may be studied in very 
numerous cases of very various degrees of 
severity, which yet recover perfectly. From 
what is observed in these, we may infer as 
to the part which concussion takes in com- 
plicated cases many of which prove fatal. 
The results of concussion may be divided 
into three stages. The first stage is that of 
collapse; the second, that of reaction, or of 
vaso-motor paresis, or, if named from its 
most prominent symptom, the sleepy stage ; 
the third is that of conva lescence, or recovery. 
The symptoms of the first stage, or stage of 
collapse, vary with the severity of the case; 
but if at all well-marked, consist in feebleness 
of pulse, pallor of skin, coldness of extremi- 
ties, and dilatation of pupils. They may 
approach a condition which threatens imme- 
diate death. There is no stertor, for the re- 
spiration is too feebly performed. Although 
the collapse may be very great, the insensi- 
bility is rarely quite complete. It is of great 
importance, in this stage, to establish the 
negative as regards all forms of paralysis. 
If any non-symmetrical symptoms are pre- 
sent, the case is more than mere concussion. 
During this stage nothing should be done, 
except placing the patient in a condition of 
comfort, and preventing the cooling of the BRAIN, CONCUSSION OF 
BRAIN, HAEMORRHAGE INTO 
191 
body. Stimulants, unless the collapse is 
extreme, should be avoided. 
After the collapse has lasted some little time 
(half-an-hour to two, three, or more hours), it 
begins to pass off. The patient moans, mani- 
fests discomfort, turns on his side, and draws 
his knees up. Very often at this period sick- 
ness occurs, and it is almost invariable if the 
patient's stomach was full at the time of the 
accident. Consciousness is now usually re- 
stored, and, by rousing, the patient may be 
induced to speak, and will tell his name, &c. 
Gradually, during a period of some hours, 
the case slides on into the sleepy stage. The 
pulse is now relaxed and full, the skin is 
warm or even hot, the face may be some- 
what flushed, and the pupils are contracted. 
The patient is overpowered with sleepiness, 
and can only be awakened with difficulty. 
It is, however, always within possibility to 
awaken him, and he usually rouses himself 
to the calls of nature. Very commonly the 
pulse is irregular, especially if the patient 
be young. At this stage again care must be 
taken to ascertain whether there are any 
non-symmetrical symptoms-any weakness 
of a limb, of one side of the face, or of any 
single eye-muscle. If the patient passes his 
urine or feces in bed, or if there is long-con- 
tinued retention of urine, it is very probable 
that there is more than mere concussion- 
namely, laceration or contusion. The sleepy 
stage may last for a day or for a week, and 
it is in severe cases so well-marked that the 
patient's eyelids may be held open, and 
the pupils examined, without awaking him. 
During this stage the measures of treatment 
called for are spare diet, purgation, cold to 
the head, and quiet. 
When the sleepy stage passes off, the patient 
is left weary, torpid, unfit for mental effort, 
and often with distressing headache. These are 
the symptoms of the convalescing stage, and 
they may last more or less for a considerable 
time. The patient should still be kept carefully 
quiet, no stimulants should be allowed, and 
purgatives should occasionally be used. Some 
of the symptoms present during the stage of 
convalescence may persist so long that they 
may rank rather as sequelae. Thus there 
may be for years nervousness, inaptitude for 
business, liability to headache, and peculiar 
susceptibility to the influence of stimulants. 
As a rule, however, even after very severe 
concussion, no such ill-results are left, but 
the patient regains, after a time, perfect cere- 
bral health. This remark must, however, 
not be held to apply to concussion when 
received in railway accidents; for in these 
cases there is a prospect of pecuniary com- 
pensation, and the sequela? are often severe, 
prolonged, and very peculiar. 
Jonathan Hutchinson. 
BRAIN, Congestion of.-See Brain, 
Hyperaemia of. 
BRAIN, Hesmorrhageinto.-Synon. : 
Cerebral Apoplexy; Fr. Hemorrhage cere- 
brate inter stitielle ; Ger. Hirnschlag. 
Definition.-Escape of blood, by rupture 
of a vessel, into the substance or cavities of 
the brain. Haemorrhage into the meninges is 
separately described. 
Cerebral haemorrhage is commonly due to 
the rupture of an artery, very rarely to the rup- 
ture of a vein. Occasionally, minute extrava- 
sations are caused by rupture of capillaries, 
and may constitute, by their number, an in- 
filtration of the cerebral tissue with blood. 
This is seen in cases of venous thrombosis. 
Haemorrhage from arteries or veins may also 
be due to their laceration by injury. 
AEtiology. *- Arterial haemorrhage is 
usually due to the coincidence of weakened 
vascular wall and increased pressure within 
the vessel. The causes of these states may 
be regarded as the conditions predisposing 
to cerebral haemorrhage. Hereditary influence 
is sometimes distinctly seen, as a tendency to 
vascular degeneration, or to conditions which, 
as renal disease, produce such degeneration. 
Similarity of vascular distribution may also 
be inherited, and may determine the locality 
of strain, and, therefore, first of degeneration, 
and ultimately of rupture. Cerebral haemor- 
rhage is most frequent after fifty years of 
age, but occurs at any age, though rare during 
the first half of life. It is nearly twice as 
common in men as in women. It is said to 
be more frequent in temperate than in 
tropical climates, in winter than in summer, 
and at high than at low elevations. Certain 
acquired conditions act as predisposing 
causes. Chronic Bright's disease leads to 
early and extreme degeneration of vessels, as 
well as directly to hypertrophy of the heart 
and increased blood-pressure ; hence it pre- 
disposes powerfully to cerebral haemorrhage. 
In purpura and scurvy, cerebral haemorrhage 
occasionally occurs, and also in pernicious 
anaemia and leukaemia. In the latter it is 
a not uncommon cause of death. In these 
blood-states the mechanism is doubtless im- 
paired nutrition of the walls of the smaller 
vessels, which permits them to be bulged and 
thinned by a blood-pressure that may even 
be below the normal. The state of vascular 
repletion known as ' plethora ' was formerly 
thought to be a frequent cause of cerebral 
haemorrhage. It probably does aid other 
causes, but rarely co-exists with the more 
efficient, and so takes a subordinate position. 
Chronic alcoholism and opium-eating are 
said to promote vascular degeneration. 
Among other remote causes must. be 
reckoned heart-disease and syphilis, both of 
which commonly act by causing an aneur- 
ysm larger than those that are the special 
mechanism of haemorrhage. Nevertheless, 
such aneurysms often escape even the most 
careful search. Each of these causes, so 
different in nature, acts by altering the wall 192 
BRAIN, HEMORRHAGE INTO 
of the vessel-the one by a process of growth, 
the other by inflammation excited by imper- 
fect obstruction with a plug from an inflamed 
cardiac valve. 
The proximate causes of cerebral haemor- 
rhage are the weakened state of the wall of 
the vessel, and commonly some increase of 
blood-pressure. The vessel-wall is weakened 
by degeneration, and is often imperfectly 
supported in an atrophied brain. The in- 
crease of pressure within the vessels may 
be permanent, as in peripheral obstruction, 
with or without hypertrophy of the heart; or 
temporary, as in excited action of the heart, 
or impeded circulation through the lungs 
during effort. These causes are considered 
more fully in the article on Brain, Vessels 
of, Diseases of. 
Haemorrhage from a vein is rare, except as 
the result of laceration by direct injury, or of 
ulceration invading the vein from without. 
Varicose veins in the pia mater may some- 
times rupture (Andral). 
Considerable capillary haemorrhage is 
usually due to the venous obstruction already 
mentioned. It may also result from cephalic 
congestion due to any cause, from capillary 
embolism, and from the blood-states which 
cause larger vessels to give way. In all these 
blood-states similar extravasations are often 
seen in the retina from the same immediate 
cause. 
Anatomical Characters.-In intra-cere- 
bral haemorrhage, the blood is extravasated 
into the substance or into the ventricles of the 
brain-into the ventricles usually by rupture 
of a previous extravasation within the cerebral 
substance. In the latter situation the blood 
occupies a cavity formed by laceration of the 
brain-tissue ; rarely, when very minute and 
' capillary,' by merely separating the fibres. 
In size, an extravasation varies from that of 
a pea or even smaller, up to that of the fist. 
The blood is found clotted, and reddish-black 
in colour; fragments of brain-tissue are 
mingled with it. The cavity containing it is 
often very irregular in shape; its walls are 
uneven, present projecting shreds of lacerated 
brain-substance, and are blood-stained and 
softened-at first by imbibition of serum, 
and later by inflammation. Many small 
extravasations are often seen in the neigh- 
bourhood of a larger clot. Usually there is 
only one large extravasation; sometimes, 
however, there are two or three. The 
extravasated blood exercises pressure: the 
convoluti3ns are flattened; the falx is bulged 
to the opposite side (Hughlings Jackson, 
Hutchinson); and the rest of the hemisphere 
is angemic. The effused blood may tear its 
way into the lateral ventricle; it then speedily 
distends both lateral ventricles and the third 
and fourth ventricles, and escapes by the 
openings at the lower extremity of the fourth 
ventricle, central and lateral, into the sub- 
arachnoid space. Or the blood may escape 
to the surface, infiltrate the pia mater, and 
tear its way into the subarachnoid cavity, 
often by a very small opening. It is rarely 
that the artery from which the blood has 
escaped can be detected. Occasionally the 
extravasation can be traced to the rupture of 
an aneurysm of some size. In other cases 
miliary aneurysms may be found on many 
vessels. The larger arteries commonly 
present atheromatous changes, but these are 
only associated by being the result of some 
of the causes, and especially of age. 
After a time the extravasated blood under- 
goes changes. The clot shrinks and gradu- 
ally becomes, first chocolate, then brown, and 
ultimately a reddish-yellow; and it then 
contains chiefly fat-globules, pigment and 
other granules, and haematoidin crystals. 
The rapidity with which it undergoes this 
change is doubtful, and certainly varies. It 
is said that the distinctive blood-colour has 
disappeared as early as the twentieth day. 
Meanwhile the walls of the cavity undergo 
changes. The inflammation, in rare cases 
excessive and purulent, is usually conserva- 
tive, and leads to the formation of connective 
tissue. A firm wall is thus developed, the 
inner surface of which becomes smooth by 
the softening and removal of the loose frag- 
ments of brain-substance ; by this means a 
cyst is formed. It is said that connective 
tissue may extend across its cavity, and that 
in rare cases, the fluid being absorbed, the 
cyst-walls may unite, and a cicatrix result. 
Such cicatrices are, however, much more fre- 
quently due to softening than to haemorrhage. 
Haemorrhage may occur in any part of the 
brain, but is more frequent in some situa- 
tions than in others. The most frequent seat 
is the corpus striatum and the region just 
outside it: nearly half the intra-cerebral 
haemorrhages are in this situation. Other 
primary seats, in the order of frequency, are 
the centrum ovale, the cortex, the pons and 
peduncles, the cerebellum, the optic thalamus 
(often affected by an extension of the haemor- 
rhage from the corpus striatum), the posterior 
portion and the anterior portion of the 
hemisphere. The frequency of haemorrhage 
in the cerebrum is twenty times greater than 
into the cerebellum. The frequent extrava- 
sation into and outside the corpus striatum, 
is explained by the vascular supply. As the 
rupture is often near the edge of the lenti- 
cular nucleus the blood tears up the white 
substance ; and this makes the frequency 
of haemorrhage into the centrum ovale diffi- 
cult to ascertain. See Brain, Vessels of, 
Diseases of. 
Traumatic haemorrhage occurs into and 
from a lacerated portion of brain, and is 
most frequently found on the surface, occu- 
pying mainly the middle of the convex por- 
tion of each convolution', and some other 
regions much exposed to injury, as the sur- 
face of the temporo-sphenoidal lobe, and the BRAIN, HEMORRHAGE INTO 
193 
under surface of the frontal lobe. Ventri- 
cular haemorrhage sometimes results from 
traumatic rupture of a small vein on the 
surface of the corpus striatum (Prescott 
Hewett). 
Soft tumours (especially gliomata) are 
sometimes the seat of haemorrhage. The dis- 
tinction from simple haemorrhage (sometimes 
difficult) rests on their position being com- 
monly one in which cerebral haemorrhage is 
rare ; and on some gelatinous-looking tumour- 
substance being found, into which haemor- 
rhage has not occurred, and which has 
characteristic microscopic features. 
Other organs may be healthy, or present 
the changes which have been mentioned as 
predisposing causes; the lungs are usually 
secondarily congested, often intensely. 
Symptoms.-The occurrence of cerebral 
haemorrhage is indicated by cerebral symp- 
toms of two classes, the one general and 
more or less transient, the other local and 
more or less permanent. In addition to 
these there are sometimes premonitory 
symptoms; and commonly general symp- 
toms, manifested by pulse, temperature, &c., 
which are secondary to the brain-lesion. 
Premonitory symptoms, somewhat rare, 
are those of altered cerebral function due to 
local vascular disease, headache, vertiginous 
feelings, local weakness or numbness, slight 
mental changes, and slight affection of speech 
(see Brain, Vessels of, Diseases of; and 
Brain, Anaemia of). But the disease causing 
them is commonly distinct from that causing 
the haemorrhage. The miliary aneurysms 
cause no symptoms, and hence it is only in 
the case of aneurysm of larger vessels that 
there are true premonitory symptoms. 
Hence they are less frequent than in cases 
of softening. 
The onset of haemorrhage is usually ac- 
companied with apoplexy, i.e. loss of con- 
sciousness and of power of motion and of 
sensation, often with relaxation of the sphinc- 
ters and loss of reflex action (see Apoplexy, 
Cerebral). These symptoms are profound 
and lasting according to the size of the 
haemorrhage and its position; being espe- 
cially marked in large and double effusions, 
in intra-ventricular haemorrhage, and in 
haemorrhage into the pons. In a case of 
moderate severity they last only a few hours, 
and gradually pass away. In severer cases 
they may deepen until death occurs from 
failure of respiratory power. Death is rarely 
very speedy, life being usually prolonged for 
some hours even in the most rapidly fatal 
cases. In rare instances of haemorrhage 
into the medulla, and also in meningeal 
haemorrhage, death has occurred in five 
minutes, probably in each case from the 
rapid interference with the respiratory 
centre. 
The temperature is at first lowered one or 
two degrees; the pulse becomes less frequent; 
and the respiration slow. The Cheyne-Stokes 
respiratory rhythm often precedes death. 
After a few hours the temperature rises to 
the normal and in mild cases stops there, 
but in graver cases it rises above the normal 
two or three degrees. In some very grave 
cases the initial fall or subsequent rise may 
be extreme and go on until death occurs, 
sometimes reaching 90° in the one case, and 
107° or 108° in the other (Bourneville). The 
urine is at first abundant, of low specific 
gravity, and acid in reaction. 
In slight cases of cerebral haemorrhage 
there may be no loss of consciousness. 
Vomiting in such cases is not infrequent. 
In other rare cases of large haemorrhage, 
especially between the external capsule of 
the corpus striatum and the island of Beil 
(Broadbent), the loss of consciousness comes 
on gradually, after other symptoms, as of 
shock, for example, have lasted for an hour 
or two. These cases have been termed 
ingravescent. 
Local symptoms, often permanent, and 
always of longer duration than the loss of 
consciousness, are present in all cases of cir- 
cumscribed cerebral haemorrhage, except in 
the rare instances in which, by its central 
position in the pons and medulla, it causes 
directly bilateral effects only, which are 
added to and intensify the general symptoms 
caused indirectly. In a unilateral cerebral 
lesion, the direct symptoms are unilateral 
loss of power of voluntary movement and 
often of sensation, accompanied sometimes 
with convulsion or rigidity. These local 
symptoms may commence a few minutes or 
longer before the loss of consciousness. They 
coexist with the apoplectic condition, and 
may often be recognised, even during coma, 
by the flaccidity of the paralysed limbs, 
which fall more helplessly than those of the 
opposite side; by inequality of the mouth 
and of the pupils ; by conjugate deviation of 
the head and 'eyes towards the side of the 
brain injured; by convulsive movements; 
and, as the apoplexy clears, by the detection 
of unilateral defect of sensibility. The coma 
passing away, these signs become more dis- 
tinct, and all the symptoms of hemiplegia 
remain, varying in intensity and extent ac- 
cording to the position of the lesion. The 
apoplectic state may recur after its disappear- 
ance-a grave symptom, usually indicating 
that a fresh haemorrhage has occurred in the 
same or the other side of the brain, or more 
frequently that the blood has escaped into 
the ventricles. In the former case the uni- 
lateral symptoms, conjugate deviation of the 
head and eyes, &c., are increased on the 
same, or transferred to the opposite side; in 
the latter the unilateral symptoms disappear, 
and general powerlessness and deep coma 
supervene, with stertor, relaxation of the 
sphincters, lowered temperature, and im- 
peded respiration. Death always ensues. 194 
BRAIN, HEMORRHAGE INTO 
Convulsion may be a conspicuous symptom 
at the onset or subsequently. It is usually 
unilateral in its course or commencement, 
beginning on the side paralysed, rarely affect- 
ing only the non-paralysed side. In cases in 
which the blood escapes slowly, convulsions 
may occur on one side, and in the course of 
an hour or two may cease, the side at the 
same time becoming powerless. This is due 
to the motor structures, commonly those of 
the cortex, being at first irritated by the 
haemorrhage, and afterwards interrupted or 
compressed so as to be incapable of function. 
Where convulsion is not met with, muscular 
twitching or rigidity may occur. General or 
widely-spread rigidity or twitching points to 
a bilateral lesion ; if with coma, to ventri- 
cular haemorrhage. 
After a day or two symptoms of irritation 
about the cerebral lesion come on, such as 
headache, delirium, and rigidity in the 
paralysed limbs. During this period the 
temperature rises above the normal, and 
the pulse becomes quick. On their subsidence 
these symptoms, if the lesion is slight, may 
be scarcely recognisable, and a stationary 
period ensues, at the end of which recovery 
of power over the paralysed limbs begins. 
In slight cases power may be recovered very 
speedily. Its return depends upon the struc- 
tural recovery of slightly damaged tissue, and 
on other parts taking on an increased func- 
tion in compensation for that which is 
destroyed. The electric irritability of the 
muscles exhibits little change. Sometimes, 
however, when there is great irritation at 
the lesion propagated downwards to the cord, 
a marked initial increase in the irritability 
may precede a considerable depression, 
coincident with rapid wasting. Recovery 
of power is rarely complete except in those 
cases in which the area of damage is very 
small; and when the damage is large and 
affects an important motor region, there may 
be no recovery, loss of power persisting, 
commonly with more or less ' late rigidity ' 
in the paralysed limbs. Slight permanent 
mental change often remains, and as the 
motor power is recovered, ataxic and other 
disorders of movement may supervene in the 
limbs which were paralysed, although much 
less commonly than after softening. 
Diagnosis. - The diagnosis of cerebral 
haemorrhage rests on the symptoms of a 
localised cerebral lesion occurring suddenly. 
The conditions from which it has most 
commonly to be distinguished are-conges- 
tion of the brain; softening of the brain, 
embolic and thrombic; and sometimes 
tumour. For the distinction from it of other 
causes of apoplectic loss of consciousness, 
uraemia, post-epileptic coma, &c. see Apoplexy, 
Cerebral. 
From congestion the chief distinction 
of the cerebral haemorrhage lies in the 
transient nature of the loss of conscious- 
ness, and in the slightness and general 
character of the symptoms which charac- 
terise the former. Congestion generally, 
haemorrhage only sometimes, comes on 
during effort; and the absence of history of 
effort is in favour of the latter. Similarly, 
the premonitory symptoms which are usually 
present in congestion are generally absent in 
haemorrhage. The loss of motor power, and 
the symptoms of cerebral shock, are much 
greater in haemorrhage than in congestion. 
It must be remembered that the two states 
frequently coexist. From softening conse- 
quent on embolism cerebral haemorrhage has 
also to be distinguished. The subjects of the 
latter are usually of an earlier age than those 
of haemorrhage; their vessels are healthy, 
but they have organic heart-disease, which 
is often grave. There may be evidence of 
embolism elsewhere, in spleen, kidney, or 
retina. Loss of consciousness is often absent 
in embolism, and the paralysis often comes 
on deliberately, and is almost -always brief 
in duration. Deep apoplectic coma should 
always lead to a suspicion that haemorrhage 
is the lesion, and this especially in cases of 
young persons with heart disease. It is 
important not to let the presence of heart- 
disease exclude the idea of haemorrhage, 
because it is in such cases that the most 
severe forms of haemorrhage are met with, 
when there is an aneurysm, due to embolism, 
and this has ruptured. From softening due 
to thrombosis the distinction is often difficult. 
Age, and the state of the vessels, no longer 
serve as guides. The presence of chronic 
Bright's disease is slightly in favour of 
haemorrhage ; atheroma, the cause of soften- 
ing in late life, being also induced by it, but 
only to a slight extent. Excitement at the 
time of the onset suggests haemorrhage; de- 
pression, physical or mental, suggests soften- 
ing. The occurrence of previous hemiplegic 
attacks points to softening. In the attack, loss 
of consciousness is much more considerable, 
in proportion to the subsequent paralysis, 
in haemorrhage than in softening. But the 
distinction on this ground is often very 
difficult, since loss of consciousness may be 
absent in slight haemorrhage, and consider- 
able in an extensive softening. A deliberate 
onset is in favour of softening; and so are 
much mental change, and early rigidity. A 
definite fall of temperature is generally caused 
by rupture of a vessel, and so also is a rise 
within twelve hours. Paralysis of sudden 
onset, in cases of tumour, may be ascribed 
to hemorrhage, to which it is indeed some- 
times, but not always, due. Usually, enquiry 
elicits a history of gradual, long-continued 
symptoms; intense headache and optic 
neuritis are strongly suggestive of a tumour 
into which a haemorrhage may have occurred. 
Haemorrhage into the substance of the 
brain is distinguished from meningeal 
hcemorrhage by the pain and mental excite- BRAIN, HAEMORRHAGE INTO 
195 
ment being less conspicuous, convulsion 
rarer, and by the presence of symptoms of 
a local lesion. Hcemorrhage into the ventri- 
cles, which resembles meningeal haemorrhage 
in the generality of its symptoms, is usually 
distinguished by succeeding the symptoms of 
a circumscribed lesion. 
Prognosis.-During the attack itself the 
prognosis in haemorrhage into the brain must 
be guided by the intensity of the symptoms, 
and by the place of the lesion, as far as that 
can be ascertained. Death is probable if the 
coma is profound, or has not begun to lessen 
at the end of twenty-four hours, and if the 
early depression, or the subsequent rise of 
temperature and pulse-rate, is great. Most 
cases are hopeless in which there is marked in- 
terference with respiration-even hiccough is 
a cause of anxiety. When the symptoms indi- 
cate ventricular haemorrhage, or haemorrhage 
into the pons, there is little chance of survival. 
In meningeal haemorrhage with coma the 
prognosis is exceedingly grave. Conscious- 
ness being recovered, and the danger of 
immediate death over, the freedom from 
much secondary pyrexia, from lung-conges- 
tion, and from bedsores, is a favourable 
indication. The chance of recovery from 
the paralysis is estimated by evidence of 
position of the lesion, and by any indications 
of improvement. Early contraction of the 
flexors is unfavourable. The danger of re- 
currence is in proportion to the.extent of 
vascular disease, and the existence of irre- 
movable causes of increased arterial tension. 
Hence the prognosis is rendered unfavourable 
by advanced age, or chronic renal disease, and 
by the evidence of general premature decay. 
Treatment.-During the attach.-Rest 
is the most important. The patient should 
remain, as far as possible, where he is seized ; 
stillness must be secured; and all effort is to 
be avoided. The posture should be recum- 
bent, with the head raised, and flexion of 
the neck should be avoided. Any cause of 
passive cerebral congestion, such as a tight 
collar, must be looked for and removed. 
Venesection was formerly almost always 
employed in such cases-certainly too univer- 
sally, but is now quite discarded-perhaps 
too absolutely. Loss of blood lessens the 
force of the heart and vascular tension; it 
thus hastens the cessation of external bleed- 
ing. Doubtless it acts in the same way in 
internal haemorrhage. It may be used with 
probable advantage if the arterial tension is 
great (that is, if the pulse is incompressible), 
the heart acting strongly, and there is reason 
to believe that the intracranial haemorrhage 
is increasing. A small quantity of blood 
should be taken rapidly. In ventricular 
haemorrhage, venesection is probably power- 
less for good. When this is the case, it may 
not be equally incapable of doing harm in 
other ways too obvious to be pointed out. 
Fashion should neither determine treatment 
nor be forgotten as influencing the estimate 
formed by the friends of a sufferer. Venesec- 
tion should not be employed where there is 
any evidence of failing heart-power. Its in- 
dications are drawn as much from the state of 
the patient, as from the fact of haemorrhage. 
Bright's disease is no contra-indication. 
If bleeding is not employed, the object to 
be aimed at by other measures must be to 
lower the arterial pressure within the skull, 
by keeping down the heart's action, by re- 
ducing the volume of the blood, and by 
diverting the blood as far as possible from the 
brain, by relaxing the systemic vessels, while 
endeavouring to obtain contraction of the 
cerebral vessels. "Warmth may be applied 
to the limbs, aided by sinapisms. Dry-cup- 
ping to the surface, and purgatives, as croton 
oil or calomel, will divert the blood to the 
surface, or to the capacious intestinal vessels. 
Drugs which would cause contraction of the 
vessels are to be avoided, since their influence 
being on the smallest vessels and universal, 
their tendency is to increase arterial tension 
and haemorrhage. To this, however, digitalis 
is an exception, since its action seems to be 
chiefly on arteries larger than those that 
burst. Diuretics are of great value, and their 
administration should never be neglected. 
Contraction of encephalic vessels may be 
furthered by cold to the head or sinapisms 
to the neck, according as the head is hotter 
or colder than normal. The heart should be 
allowed to fall a little below the normal in 
force, but failure of power must be warded 
off by stimulants given with great care. 
Convulsion is more effectually checked by 
cold than by bromides; the latter may be 
given if the convulsion recurs. 
After the attach.-During the stage of 
irritation, rest must be maintained, and all 
sources of annoyance must be avoided. The 
bowels should be kept gently open by laxa- 
tives or by injections. Stimulants must be 
avoided, and the diet should be light. Pain 
may be relieved by cold to 'the head, a blister 
to the neck, or by Indian hemp, bromide of 
potassium, or a small dose of hyoscine. 
During reparation the diet must be 
nutritious, but carefully regulated; and 
constipation of the bowels must be avoided. 
Rubbing of the limbs, and their gentle 
exercise, will aid their recovery; and after 
the symptoms of irritation have passed, 
faradisation will improve muscular nutrition, 
and is especially indicated where rapid loss 
of irritability indicates probable wasting. 
Nervine tonics probably aid a little the 
recovery of slightly damaged structures : 
quinine and strychnine, or very small doses 
of phosphorus if there is no kidney-disease. 
In anaemia the syrup of the phosphate of 
iron is good. Warmth, change of scene, 
and cheerful mental surroundings are useful 
adjuncts, especially in the later stages of 
recovery. W. R. Gowers. 196 
BRAIN, HYPERAEMIA OF 
BRAIN, Hypergemia of. - Synon. : 
Congestion of the Brain. 
Definition.-Increase in the quantity of 
blood within the capillaries of the brain, other 
than that which is merely the early stage of 
inflammation. 
Since neither the arteries nor the veins 
of the brain-substance can be over-distended 
with blood without capillary hyperaemia, and 
since it is to capillary hyperaemia that the 
functional disturbance of the brain is related, 
this may be justly taken as the essential 
pathological element in cerebral congestion. 
The congestion may be active, when the 
capillaries contain, in consequence of arterial 
distension or dilatation, an increased amount 
of oxygenated blood passing rapidly through 
them; or it may be passive, when, from 
venous obstruction, the increased blood in' 
the capillaries is slowly moving, and is be- 
coming, or is in great part already, venous. 
' Congestion of the brain ' is often alleged 
because no other explanation of symptoms 
occurs to the mind of the practitioner, al- 
though there may be no real evidence of 
such a state. Like ' congestion of the liver,' 
it is often adopted merely because it is a 
convenient refuge for a destitute diagnosis, 
and pleases the patient as an explanation 
which both satisfies and gratifies him. But 
it should never be assumed on purely nega- 
tive evidence. Some descriptions of it have 
been written entirely from cases of hypo- 
chondriacal dysaesthesia. 
^Etiology.- (A) Active congestion of the 
brain may be general or partial. Of the 
general form the remote causes are as fol- 
lows :-Men are said to be more liable to it 
than women. Age increases its frequency, 
chiefly from the greater frequency of its 
causes; yet children, from the sensitiveness 
of their vaso-motor system, occasionally 
suffer from active cerebral congestion. Here- 
dity has only an indirect influence. The 
plethoric condition, with its tendency to 
general-overfilling-of the vessels, is a power- 
ful predisponent. The immediate .causes of 
excessive flow through the arteries of the 
brain may be thus stated : (1) Increase in 
the blood-pressure-either general, from ex- 
cessive action of the heart (as in extreme 
hypertrophy or functional overaction); or 
partial, from an obstruction elsewhere, throw- 
ing an undue proportion of the pressure upon 
the cerebral vessels. This is seen in con- 
traction of the aorta beyond the origin of the 
vessels to the head, and in sudden contrac- 
tion of a large number of the systemic 
arterioles, as those of the surface, in exposure 
to cold and in ague. In some states, as 
Bright's disease, its influence on organs is 
partially counteracted by the contraction of 
the smaller arterioles. It results similarly 
from all cardiac excitement, whether due to 
mental or physical causes. (2) Active arterial 
dilatation of vaso-motor origin may be excited 
by prolonged mental work, severe emotion, 
insolation, digestive disturbances, or from 
the presence in the blood of various poisons, 
such as alcohol, and amyl-nitrite or nitro- 
glycerine. In these cases the vaso-motor 
disturbance may precede and cause, or may 
succeed and result from, the overaction ot 
the brain-tissue, which is intensified by it. 
It occurs in the second stage of many 
attacks of migraine. This cause may be 
conjoined with excited action of the heart, as 
in exophthalmic goitre. In acute alcoholic 
poisoning the cerebral congestion is, as 
Niemeyer suggested, secondary to the dis- 
turbance of brain-tissue, although the simul- 
taneous flushing of the face makes this 
doubtful; in chronic alcoholism the conges- 
tion may be primary. In pyrexia the head- 
ache and delirium have been thought to be 
due to congestion, but more likely result from 
the blood-state. (3) Lessened atmospheric 
pressure may cause congestion of the brain, 
as in the ' Zenith ' balloon-catastrophe ; and 
it probably occurs when divers pass from the 
increased to normal pressure. (4) Gravita- 
tion in the recumbent posture may alone 
cause cerebral hyperaemia, or may powerfully 
aid other causes in producing it. 
Partial active congestion of brain-tissue 
occurs chiefly from disease of the arteries, 
which perverts the local distribution of the 
blood-pressure; in organic brain-diseases, 
as tumour, haemorrhage, &c.; after blows 
on the head; and probably also from local 
overaction of special centres. It may also 
be due to a slight degree and transient dura- 
tion of the activity of the causes of local 
inflammation. 
(B) Passive congestion of the brain, when 
general, is the result of impeded return of 
blood from the head. It is intense in death 
from all forms of suffocation or by hanging. 
It may be due to pressure on the veins in the 
neck, as by tumours or tight collars; pressure 
on the innominate veins by tumours or aneur- 
ysm ; or obstruction to the circulation from 
violent respiratory efforts, as exertion, cough, 
or blowing wind-instruments. It may be 
caused by impediments within the circulation, 
such as tricuspid insufficiency and its causes 
in the lungs, or even by disease on the left 
side of the heart. The recumbent posture 
assists all these influences. 
Partial passive congestion may occur from 
pressure on a cerebral vein, from local venous 
thrombosis, or from pressure by a growth on 
one of the cerebral sinuses. 
Anatomical Appearances.-The capilla- 
ries are not visible to the naked eye even when 
over-distended, but with the microscope they 
are seen to be dilated, often to twice their 
normal calibre. Their distension is indicated 
by a deeper and reddish tint of the grey sub- 
stance ; and the fulness of the small arteries 
and veins shows itself in an increase, often 
very great, in the number and size of the red BRAIN, HYPEREMIA OF 
197 
points visible on section of the white matter. 
In active congestion the arteries are said to 
be distinctly larger than normal, and their 
perivascular spaces lessened in size; the 
minute vessels of the meninges are distended. 
Indeed in all forms of general congestion, 
the state of the vessels is generally more 
distinct in the pia mater than in the sub- 
stance of the brain. Even in those, how- 
ever, it is chiefly the congestion that would 
pass on to inflammation, or is really its first 
stage, that leaves distinct traces. In pas- 
sive congestion the veins and sinuses are 
gorged with blood. It must be remembered, 
however, that such engorgement of the veins 
occurs in all cases of death from interference 
with the passage of the blood through the 
thorax, and that the vessels of the most 
dependent portion are always fullest. The 
state of the cerebral veins must therefore be 
carefully compared with that of the veins of 
other organs. Active congestion may some- 
times leave no visible traces. After a time 
blood-pigment collects outside the vessels 
(Bastian), and serous effusion into the mem- 
branes and ventricles may be found in all 
forms. After a long-continued congestion, 
the vessels may be permanently distended; 
degenerative changes, consequent perhaps 
on the effusion of serum, may lead to the 
appearance of wide spaces around them ; 
and the whole brain may have undergone 
distinct wasting. It must, however, be 
pointed out that the absence or paucity of 
post-mortem evidence is equally true of the 
skin, and does not establish the absence of 
congestion during life. 
Symptoms. - It is probable that many 
symptoms have been erroneously ascribed 
to cerebral congestion; some because hyper- 
semia, due to the mode of death, was found 
post mortem; others because an assumed 
congestion was the readiest explanation. 
The symptoms commonly referred to cere- 
bral congestion may be grouped in two 
classes-those of excitement, and those of 
depression. Either of these may exist alone; 
those of excitement may precede those of 
depression; or they may partially co-exist. 
They may be slight or severe; acute or 
chronic. In all cases they are increased by 
the recumbent posture or depressing the 
head, by expiration, coughs, and effort; and 
they are usually aggravated by constipation, 
and by indulgence in alcohol. 
J. General.-In general cerebral hyperae- 
mia, among the symptoms of excitement may 
be mentioned mental irritability; headache- 
slight or violent, with feelings of fulness or 
throbbing in the head, and vertiginous or 
other unpleasant sensations; increased or 
perverted functions of the organs of special 
sense, such as flashes of light and noises in 
the ears; contraction of the pupils; sleep- 
lessness ; restlessness, startings, twitchings 
or slight actual convulsions; and mental 
excitement. The pulse is quick. There may 
he vomiting. The face varies, participating 
in the congestions of circulatory origin, and 
in some of vaso-motor disturbance, such as 
that which may occur during digestion. In 
other forms of supposed congestion of vaso- 
motor mechanism, as in those which result 
from excessive brain-work, the face may be 
pale, but the nature of these cases is doubtful. 
Among the symptoms of depressed brain- 
function, are dulness of the special senses; 
motor weakness; mental indifference and 
slowness; somnolence, especially after meals; 
dilatation of the pupils; and infrequency of 
the heart's action. Consciousness may be 
lost suddenly, and the loss, it is commonly 
believed, may deepen into coma, but this is 
seldom absolute. As a rule there is no fever, 
but in children the temperature may be 
raised a degree or so. 
In the chronic forms of cerebral conges- 
tion, these symptoms, variously grouped and 
moderate in degree, continue for days, weeks, 
or months. Their course is marked by great 
variability. Durand-Fardel has pointed out 
that in these cases there is often much viscid 
secretion of the conjunctiva. 
In the more acute forms of cerebral con- 
gestion, the symptoms of muscular spasm, of 
mental disturbance, or of loss of conscious- 
ness, may be so predominant as to give a 
special character to the attack:- 
a. In the convulsive form pain or uneasi- 
ness in the head commonly precedes the mus- 
cular spasm. The latter is usually deliberate 
in onset. It is said sometimes to be unilateral 
at first, and afterwards general, but more 
frequently it is general throughout. Tonic 
may precede clonic spasm, and the attack 
resemble an epileptic fit, or clonic spasm 
only may be present, or slight general tonic 
spasm. Consciousness may or may not be 
lost; if lost it is for a very short space of 
time. 
b. The delirious form is seen under two 
aspects-(1) in old age, after emotional ex- 
citement ; in this the wandering is slight, 
and often related distinctly to the recumbent 
posture, or to a low position of the head; 
(2) a much more violent delirium, which is 
apparently related to cerebral congestion, is 
seen sometimes after mental work or emo- 
tional excitement, or after alcoholic poisoning. 
It often resembles and may end in mania, 
but there is no pyrexia. Occasionally death 
results. 
c. The apoplectic form is marked by sudden 
loss of consciousness, occurring commonly 
during effort. The unconsciousness usually 
lasts only a few minutes, and incomplete 
general weakness remains for a day or two. 
In rare cases the loss of consciousness 
deepens into coma, with stertorous breath- 
ing and relaxed sphincters, and death may 
occur from the extension of the cerebral 
depression to the respiratory centres. 198 
BRAIN, HYPERAEMIA OF 
d. Vertiginous sensations sometimes give 
a character to an attack. 
In children congestion of the brain is said 
to be a rare but occasional cause of convul- 
sion or delirium. Headache and contracted 
pupils make up a group of symptoms resem- 
bling meningitis, but fever is rarely present, 
and if it exists it is slight, and the symptoms 
usually come on suddenly and pass away in 
a day or two. Death, however, sometimes 
occurs soon after the onset of the attack, 
especially in the convulsive form. Periodical 
attacks of this character may change to those 
of migraine in later life. 
2. Partial.-Partial hyperaemia leads to lo- 
calised symptoms of excitement or depression 
of function. Local convulsion or paralysis 
may result. Headache is often intense and 
localised. If nothing more than congestion 
is present, the symptoms usually soon pass 
off. 
Pathology.-The possibility of the varia- 
tions in the quantity of blood within the brain 
has been denied on the ground that the 
cerebro-spinal circulation is carried on within 
a closed cavity. But the statement is untrue 
in the sense that is relevant to the problem 
at issue, since the communication of the 
venous sinuses of the skull, and especially of 
the venous plexuses of the spinal canal within 
the exterior, with external vessels, is free, and 
affords a ready mechanism by which the 
amount of blood, even in the distant cerebral 
vessels, may be varied by the displacement 
of the cerebro-spinal fluid. This, it will be 
remembered, can pass into the perivascular 
spaces, and can readily yield to increased 
intravascular pressure, and thus make room 
for an increase in the quantity of blood within 
the arteries or veins. 
The detailed pathology of cerebral con- 
gestion is, however, still obscure, since we 
know little of the relative part played by 
the blood-vessels and the nerve-elements 
in determining the form which disturb- 
ance of function shall take. An excessive 
supply of arterial blood is, in all organs, 
attended with functional activity, and it is 
easy to understand that active congestion 
should result in symptoms of excitement. 
Subsequent depression of function has been 
accounted for by inferring compression of 
brain-tissue by effused serum. The reaction 
of exhaustion may contribute. In passive 
congestion the nerve-tissue is imperfectly 
supplied with oxygenated blood, and com- 
pressed by distended vessels, and its 
functions are impaired by the presence of 
effete products. Hence the predominance of 
symptoms of depression over those of irrita- 
tion. 
Diagnosis.-The diagnosis rests on the 
discovery of circulatory and other causes of 
cerebral congestion; on the circumstances of 
posture, effort, &c., under which the symp- 
toms came on; on the existence of concomi- 
taut congestion in other parts supplied by 
the carotids, as the face (by no means invari- 
able) ; on the general character of the cerebral 
symptoms; on their speedy disappearance; 
and on the absence, in the adult at any rate, 
of elevation of temperature. The diagnosis 
of the special forms of cerebral congestion 
from the diseases which they most resemble 
is considered under the head of those dis- 
eases. It may, however, be mentioned that, 
on the one hand, persistent focal symptoms 
exclude mere congestion, and that, on the 
other hand, the condition is likely to cause 
an error in cases in which the various cepha- 
lic sensations of pressure, fulness, heat, &c., 
which seem to the hypochondriacal sufferer 
suggestive of congestion, are generally 
pseudo-neuralgic in nature. It is in these 
cases that it is within the power of the doctor 
to do great harm by increasing the appre- 
hensions of the patient, by encouraging the 
erroneous opinion and so increasing the 
influence of attention in augmenting the 
distress. 
Prognosis.-The prognosis is generally 
immediately favourable; but in a severe 
attack of any form, death may occur. The 
apoplectic form is most dangerous, the con- 
vulsive least so. Degenerated vessels increase 
the immediate risk to life. After many at- 
tacks, permanent nutritional changes in the 
bram often supervene. 
Treatment.-The most important ele- 
ments in the treatment of cerebral congestion 
are posture, removal of blood, purgation, 
cold to the head, and warm and stimulating 
applications to the surface. Whatever be the 
cause, it is important to raise the patient's 
head, so that gravitation may impede the 
flow and aid the return of the blood. By 
this means alone, insomnia from hyperaemia 
may often be prevented. The removal of 
blood is useful in extreme forms of conges- 
tion, either active or passive, especially in 
those forms of active congestion in which the 
face participates. Venesection or leeching 
may be employed, according to the severity 
of the attack; in active congestion the blood 
which is taken should be removed quickly. 
The relief which in such cases follows an 
epistaxis illustrates the value of this method 
of treatment; and we may take a lesson from 
nature and, in some cases, apply a leech 
behind the ear, where there are communica- 
tions between the circulation inside and out- 
side the cranium. It is not advisable in 
those cases in which, from overaction of 
brain-tissue, or from cold to the surface, 
dilatation of the cerebral vessels results while 
the surface remains pale. In all forms of 
congestion, purgation is useful. It removes 
from the blood some of its serum, and it 
affords immediate relief to the cerebral 
circulation, by causing an afflux of blood to 
the capacious intestinal vessels. In plethoric 
states, diuresis is also most useful, and has BRAIN, HYPEREMIA OF 
BRAIN, HYPERTROPHY OF 
199 
succeeded where venesection and purgation 
failed. Cold to the head is of most value 
in reflex or secondary dilatation of the cere- 
bral vessels, as after mental work, insola- 
tion, fatigue, and in some toxaemic states. 
In the same class of cases, stimulation of 
the peripheral nerves by sinapisms, blisters, 
&c , applied to the neck, will not only draw 
blood to the surface, but also, by reflex influ- 
ence, assist in obtaining arterial contraction. 
Hot applications to the limbs act in a similar 
manner, causing local afflux of blood and thus 
lessening the tendency to encephalic engorge- 
ment. Recourse may also be had to mechani- 
cal appliances for increasing the quantity of 
blood in the limbs. This element in treat- 
ment is most useful in active congestion. 
Alcohol and opium must be avoided in all 
forms of active congestion, but in passive 
congestion they may be of service. Bromide 
of potassium is useful in those cases in which 
the congestion is produced by vaso-motor 
mechanism, excited either by stimulation of 
brain-tissue or of distant nerves. In passive 
congestion from heart-disease the treatment 
is that of the cardiac condition, digitalis, 
strophanthus, and diuretics being of especial 
service. All persons liable to congestion of 
the brain should live regularly, avoid hot 
rooms, and attend carefully to the stomach 
and bowels, relieving the latter by frequent 
moderate purgation. W. R. Gowers. 
BRAIN, Hypertrophy of. - Hyper- 
trophy of brain is a misnomer. True hyper- 
trophy would consist of increase in number 
or in size of the nerve-cells, nerve-tubes, con- 
nective stroma, and supplying vessels; and 
there might be expected, as a result of this 
condition, some manifestation of a higher 
intellectual development. Such a condition 
is never found. A so-called hypertrophied 
brain is one that is larger and heavier than 
normal. On removing the skull-cap, the 
encephalon seems to expand, so as to render 
it difficult to affix the bone-covering in its 
place; the membranes are dry; the sulci 
have nearly disappeared, and the whole organ 
appears pale and bloodless. On section there 
is a sensation of toughness, though less in 
degree than in a case of general sclerosis. 
There is no sign of pressure upon the orbital 
plates, such as is met with in chronic hydro- 
cephalus. The lesion affects only the cerebral 
hemispheres, especially on the convex surface, 
and perhaps the posterior lobes in particular. 
The base of the brain and the cerebellum are 
unaffected except by pressure. 
On minute examination, the nerve-cells and 
nerve-fibres, far from being found augmented 
m number or in size, may even be compressed 
and diminished; and there is often also some 
interference with the normal calibre of the 
vessels. Gintrac, however, records a case in 
which the calibre of the nerve-tubes was 
almost double that of the normal. What in- 
crease there is affects the white matter of the 
brain, and this structure is very pale and 
of an elastic consistence. The real and sole 
lesion is hyperplasia of the connective tissue. 
It differs from sclerosis in affecting the cere- 
bral hemispheres more universally than is 
the case with sclerosis; and also that in 
sclerosis there is not only increase of the 
connective tissue, but subsequent retraction, 
and, as a frequent consequence of this, an 
absolute destruction more or less of the nerve- 
elements of the organ. When the disease is 
far advanced it may possibly cause absorption 
of the inner table of the skull, and thus pro- 
duce a roughness or thinning of the bone, or, 
in extreme cases, even perforation. The 
sinuses are generally distended with blood. 
Hypertrophy of smaller portions of the brain 
is rare: still various cases are on record in 
which, under the name of neuromata of the 
nervous centres, white or grey matter has 
been found in certain parts of the brain over 
and above the normal constituents of this 
organ. Hyperplasia of the pineal gland is 
closely allied to glioma. It should be dis 
tinguished from encysted dropsy of that 
organ. 
In most cases of so-called hypertrophy of 
a small part of the brain the lesion is an 
infiltrating growth. 
^Etiology.-Hypertrophy of the brain has 
been said to be sometimes secondary, and 
caused by the irritation of morbid growths. 
This, however, is rare. It is generally 
primary, and may be a disease of intra- 
uterine life; but it is generally developed 
after birth, especially in rickety children. 
Some forms of encephalocele, without hydro- 
cephalus, seem to be due to the growth of 
compact masses of cerebral substance in ex- 
cess of what is normal. The conditions for 
the production of this morbid state are in- 
fancy ; bad diet; repeated congestion of the 
cerebral vessels, such as might be induced 
by frequent cough; and perhaps lead- 
poisoning. 
Symptoms. - The symptoms of so-called 
general hypertrophy vary according as the 
sutures are closed or not. If, from insuf- 
ficient occlusion of the sutures, the head ex- 
pands in proportion to the increase in size 
of the encephalon, the symptoms may be 
very slight. Children thus affected show no 
intellectual hebetude. In them, as long as 
the abnormality is uncomplicated with local 
inflammation of membranes or with haemor- 
rhages, there may be no headache, no affec- 
tion of sight, no sensory or motor paralysis, 
and no convulsions. Convulsions, however, 
are common in cases in which the occlusion 
of the sutures has prevented expansion of 
the head proportionate to the internal in- 
crease of tissue. In such cases also there is 
generally more or less motor paralysis, often 
some anaesthesia of the limbs, headache, 
vomiting, and mental hebetude-symptoms. 200 
BRAIN, HYPERTROPHY OF 
BRAIN, LACERATION OF 
in fact, either of marked interference with 
the intra-cranial circulation, or of irritation 
from inflammatory complications. The pro- 
gnosis is always bad, but in rachitic cases the 
course may be chronic. 
Treatment. - All treatment seems to be 
ineffective in diminishing cerebral hyper- 
trophy. E. Long Fox. 
BRAIN, Inflammation of.-Synon.: 
Encephalitis.-Encephalitis is a term which 
ought perhaps to be strictly limited to inflam- 
matory changes in the brain-substance itself, 
to the exclusion of all forms of meningitis. 
It may be either diffuse or local, but for our 
present purpose we have chiefly to do with 
the diffuse form. Local encephalitis will 
generally result in abscess (see Brain, Abscess 
of), and will usually be met with, if we put 
aside the results of injuries, in association 
either with disease of the ear, with tubercular 
growths, or with pysemic deposits. 
It may perhaps be doubted whether the 
occurrence of diffuse inflammation of the 
brain-substance as an acute disease has as 
yet been proved, excepting as a result of 
wounds. Even as a traumatic lesion, its 
special features have by no means been ac- 
curately studied. It is, however, highly pro- 
bable that, after penetrating wounds of the 
brain, its substance may inflame, just as the 
cellular tissue of a limb may, the inflamma- 
tory processes beginning at the site of the 
wound and rapidly spreading through a large 
part of the hemisphere. It is probably in 
the perivascular spaces that the process 
chiefly spreads, and it is in these that the 
microscope will detect the most abundant 
results. Such a condition of diffuse encepha- 
litis may exist without there being any visible 
changes in the brain. It may perhaps be a 
little softened or a little congested, but very 
probably there is nothing about which the 
most experienced pathologist could feel certain 
until the microscope is resorted to. 
Symptoms.-It is not possible in the present 
state of our knowledge to speak with any cer- 
tainty of the symptoms of diffuse encephalitis. 
They will vary, of course, with the region af- 
fected ; and disturbance of function, followed 
by more or less complete loss, will be the 
most frequent occurrence. 
Treatment.-When the symptoms of en- 
cephalitis are once recognised, it will usually 
be too late for treatment, and measures of 
prevention are those of chief importance. 
The early use of mercury, beginning in an- 
ticipation of symptoms, rather than waiting 
for them, is probably the most important; and 
next to it come cold to the head, purgatives, 
and counter irritation. 
Jonathan Hutchinson. 
BRAIN, Laceration of.-In the more 
strict sense of the word, the brain is but little 
liable to laceration from injury. Yet, in 
connexion with injuries, such as penetrating 
wounds of the skull, fractures with great 
depression of bone, and even with violent 
concussions, the brain-substance is not 
infrequently, to some extent, torn. In so 
soft a structure, however, and under the 
influence of modes of violence which are 
usually rather of the nature of blows than of 
anything likely to cause stretching, we rarely 
meet with results comparable to laceration 
of any of the firmer textures of the body. 
Whenever the brain is ' lacerated ' it is also 
contused, and the contusion often extends 
widely around the rent, and is by far the 
more important lesion. In the peripheral 
parts of the brain-mass this is especially true, 
and it is of little practical use to speak of 
lacerations excepting as complications of very 
severe contusions. In the central parts, the 
crura especially, we meet now and then with 
a laceration properly so called, and it is not 
very infrequent to find the trunks of single 
nerves torn across. The consideration of 
those forms of laceration which are produced 
by the effusion of blood from ruptured vessels 
of size sufficient to supply a stream forcible 
enough to break up the surrounding substance, 
will be found in the articles Apoplexy, 
Cerebral ; and Brain, Haemorrhage into. 
In the case of injuries to the head from 
falls or blows without perforation, certain 
definite parts are prone to suffer from contu- 
sion and laceration. Usually some slight evi- 
dence of injury is found immediately beneath 
the part of the skull upon which the blow was 
received, but by far the chief bruising will 
be at the opposite point. If the occiput be 
struck, the anterior lobes will be contused; 
and if one parietal eminence, the opposite 
sphenoidal lobe. This law, however, is 
greatly modified by the differing conditions 
under which different parts of the brain-mass 
are placed as regards their surroundings. In 
the posterior half of the skull the brain-mass 
is bulky, and between its hinder lobes and 
the cerebellum is a strong flexible membrane, 
well calculated to break vibrations gradually, 
and thus to prevent contusion. Nor are there 
in these regions any strongly marked bony 
ridges against which the brain might be 
dashed. These conditions are reversed as 
regards the anterior lobes and the middle 
lobes, and the consequence is that, whilst 
severe contusions are often seen in the latter, 
they are much more rare in the cerebellum 
and posterior two-thirds of the brain-mass. 
In cases of compound fracture, with tearing 
of the dura mater, and deep depression of 
bone, the brain-substance may, of course, be 
injured at any part; but even in respect to 
this kind of violence the hinder regions of 
the skull are specially protected. 
Symptoms.-We know enough of surface- 
laceration of the brain in parts other than the 
anterior and middle lobes, to be able to assert 
that, unless the lesion extend very widely or BRAIN, LACERATION OF 
BRAIN, MALFORMATIONS OF 
201 
deeply, it does not reveal itself by any special 
symptoms. If very extensive, weakness of 
the opposite limbs and side of the face is 
usually observed. Injury to the anterior 
lobes, unless extensive, cannot be diagnosed, 
but it may be guessed at in a few cases 
where the sense of smell is lost in one or both 
nostrils; for it is very common for the ol- 
factory bulbs to be damaged at the same 
time. If the anterior lobes are severely 
lacerated, the symptoms will be those of very 
severe concussion, w'ith the difference that 
insensibility is more nearly complete, and that 
it increases instead of diminishing as the days 
pass on. When a sphenoidal lobe is contused 
there is usually, according to the writer's 
observation, incomplete hemiplegia of the 
opposite side, involving sensation as well as 
motion, and the face as well as the limbs. 
From these symptoms the patient may, in 
the course of months, wholly recover. It is 
usually the apex of the sphenoidal lobe which 
is lacerated, but if the lesion extends higher, 
and if it occurs on the left side, aphasia may 
be present. 
In connexion with recent research (Dr. 
Hughlings Jackson, Dr. Ferrier, and others) 
as to localised functions, we are now able 
to diagnose with considerable accuracy the 
precise regions injured. 
Treatment and Prognosis.-In the treat- 
ment and prognosis of lacerations and contu- 
sions of the surface of the brain, much depends 
upon whether or not the case is complicated 
by compound fracture and the admission of 
air. If air have been admitted there is risk 
of meningitis or encephalitis, denoted in 
either case by the occurrence, within a few 
days of the injury, of hemiplegia of the 
opposite side. To prevent this must be the 
object of treatment. The scalp should be 
shaved, the wound closed with sutures as far 
as practicable, and lint wetted in a spirit-and- 
lead lotion should be laid over the part and 
systematically re-wetted every hour. If the 
case be treated in hospital it may be well, 
in addition to this, to wash the wound with 
the lotion before closing it, or to dress with 
Lister's antiseptic precautions. In cases of 
laceration without access of air, death may 
ensue from diffuse softening around the part. 
If this happens the case will probably end 
within a week or ten days. It is probable 
that many cases of fractured base with more 
or less severe laceration of brain recover; 
in some with permanent paralysis, but in 
others without. It must be added that many 
of the cases in which death occurs within 
a few hours or a day or two after fracture 
of the base are attended by laceration. 
In these the symptoms are often difficult 
to distinguish from those of compression. 
Profound insensibility, a bloated face, ster- 
torous breathing, and a full pulse, are often 
present; but they may be substituted by 
pallor and a feeble pulse in connexion with 
great depression of the heart's action. If any 
deviation from symmetry as regards the 
paralysis of the limbs can be proved, it is in 
favour of laceration and against compression, 
but the differential diagnosis is a matter of 
extreme difficulty. 
Laceration of Cranial Nerves.- 
Lacerations of single nerves within the 
cranial cavity are not by any means un- 
common. This occurrence is to be suspected 
whenever the parts supplied by a cranial 
nerve are completely paralysed, without 
accompanying symptoms indicative of severe 
lesion of the brain-mass. Cases of laceration 
of the brain itself may be complicated by 
laceration of nerve-trunks, and thus the 
symptoms may become difficult to interpret 
with confidence. 
Of single cranial nerves the olfactory 
bulbs are the most liable to suffer from 
contusion ; and the third, fourth, and sixth 
nerve-trunks are those most frequently torn 
through. Jonathan Hutchinson. 
BRAIN, Malformations of.-The mal- 
formations of the cranium and its contents 
may be divided into two series:-A. Those 
which are scarcely compatible with life; and 
B. Those in which life is possible, although 
the intellectual power may be more or less 
modified from a healthy condition. 
A. The first series will include at least 
seven forms, in all of which life is so rare 
that it is impossible to speak of more than 
the pathological anatomy. 
1. Dicephalia-in which two heads are 
found upon a single body, or upon two bodies 
pretty extensively connected. In the first 
variety, one head may be attached to the 
vault of the palate of the other, or may be 
united to the convexity of the skull. In the 
second variety the heads may sometimes 
spring from a single neck. This dicephalous 
condition is frequently accompanied by mal- 
formation affecting the spinal column and 
spinal nerves, as well as by some incomplete- 
ness in the development of the brain. 
2. Monocephalia-the union of two heads 
into one, on two separate bodies. The two 
cranial cavities are united into one. Dis- 
section of the dura mater points to this 
membrane having been formed out of two, 
and in like manner the cranial contents are 
either double, or appear to be single from the 
union of double organs. 
3. Acephalia - the complete absence of 
head. An acephalous monster is usually a 
twin; and when this is not the case, it is 
associated with the morbid condition of the 
uterus of the mother known by the name 
of uterine hydatids. 
4. Paracephalia - the head not entirely 
wanting, but deprived of most of the cranium 
and of the face. A monster of this kind is 
generally a twin. 
5. Anencephalia.-The absolute meaning 202 
BRAIN, MALFORMATIONS OF 
of this term would be the absence of all 
cranial contents, but it is made to include 
certain varieties, differing according to the 
amount of the encephalon developed. The 
aspect of the head, resembling that of a frog, 
the considerable projection of the eyes, the 
flattening of the forehead, and the absence of 
the cranial vault, are the chief characteristics 
of this abnormality. 
In the first degree, there is absence of cere- 
brum, cerebellum, mesocephale, and spinal 
cord. In cases of this kind the cranial vault is 
generally absent, and the bones at the base of 
the skull are convex and thickened. 
In the second degree, the cerebrum, cere- 
bellum, and mesocephale are absent, but a 
portion of the spinal cord is found. This 
portion of cord is most usually the lower 
part. 
In the third degree, the spinal cord is 
pretty complete, but there is still an absence of 
the cerebrum, cerebellum, and mesocephale. 
A few cases have been recorded of the 
fourth degree, in which no cerebrum or 
cerebellum is found, but a normal spinal 
cord, and a pretty complete mesocephale. 
In the fifth degree, the cerebrum alone is 
entirely or almost entirely absent, whilst the 
rest of the nervous centres are present, 
though not always in a perfectly complete 
condition. The seat of the absent cerebrum 
is often filled by fluid. 
Lastly, one case has been recorded in 
which the cerebrum was present, whilst the 
cerebellum, mesocephale, and spinal cord 
were wanting. 
Anencephalia, like the other previously 
mentioned malformations, is due to arrest of 
development, such arrest depending either on 
physical injuries to the uterus at a very early 
period of pregnancy, or to some mental shock 
experienced by the mother during the first- 
two months after conception. It differs from 
acephalia, not only by the partial formation 
of the head, but by the presence of the heart, 
and other thoracic organs. The ganglia of the 
sympathetic are usually well-developed. 
6. Pseudencephalia.-In this malformation 
there is anencephalia plus a very consider- 
able thickening of the meninges, which take 
the place and often imitate the aspect of the 
brain. Its varieties exactly correspond to 
those of anencephalia. The tumour formed 
by the development of the membranes is of 
variable size and position. It may be frontal, 
fronto-parietal, or occipital. The real seat 
of the lesion is the pia mater. The abnor- 
mality consists in extreme hypertrophy of 
this structure, with complete arrest in the 
development of the encephalon, or of some 
portion of it. Several observers have recog- 
nised certain vesicles in the interior of the 
membranous tumour, and these have been 
supposed to be cerebral cells in process of 
development. It is more in accordance with 
observation to believe with Gintrac that they 
are connected with the development of the 
choroid plexus. 
7. Cyclocephalia.-In this monstrosity 
there is an approximation or actual fusion of 
two eyes in a common orbit. It is connected 
with certain abnormalities in the brain, that 
militate against viability, or at least pro- 
longation of life. The brain itself is generally 
more or less deficient, especially in its anterior 
and centra] portions, and in some cases the 
nose and mouth are very ill-developed. 
B. The second series of cases owe their 
abnormal conditions to injury arising in the 
course of foetal life : and some forms at least 
may be due to lesion occurring at a later 
period than in the first series. 
8. Atelencephalia-incompleteness of brain 
or of membranes-is the chief of these 
forms. This incompleteness manifests itself 
in seven varieties, according to the part of the 
encephalon injured by the lesion. 
In the first variety, the dura mater is 
somewhat deficient, being altogether absent 
in certain situations at the base of the brain. 
The falx cerebri may be wanting; or from 
incomplete development it may seem per- 
forated with holes ; or the tentorium cerebelli 
may be absent There are no symptoms 
which allow a positive diagnosis cf any of 
these lesions during life. 
In the second variety, there is general 
incompleteness of the brain, or imperfection 
of several portions of it at one and the same 
time. Whilst the cranial vault is thrown 
back, and the lower jaw is short, the base of 
the skull is large, the cerebral convolutions 
almost absent, and the cerebellum large. The 
head is almost always small, and it may 
present various irregular forms. This co- 
incides with certain internal lesions, partial 
or general atrophy with consequent serous 
effusion under the membranes, inflammatory 
conditions, or thickening of the cranial bones 
and of the meninges. The incompleteness of 
the brain varies exceedingly, from a condition 
in which the whole Drain is atrophied, to 
spots of deficiency, sucn as the absence of a 
single convolution, of the septum, or cf the 
pineal gland. The symptoms will necessarily 
vary much according to the amount of cerebral 
incompleteness. Where this is general, affect- 
ing in some degree all the convolutions, the 
intellectual powers, as in the microcephalous 
Aztecs, will be very slightly developed, and 
their language of the very simplest form. 
With the brain still more imperfect, there is 
generally complete idiocy, or a condition 
closely allied to it. The special senses are 
dulled, particularly sight and hearing. Speech 
is in abeyance, or is limited to monosyllables. 
There are various motor phenomena, such as 
muscular debility, hemiplegia, paraplegia, 
contraction, convulsion, loss of power over 
sphincters, dysphagia, vomiting, or feebleness 
of respiration. 
The third variety includes incompleteness BRAIN, MALFORMATIONS OF 
203 
of the central parts of the brain. The corpus 
callosum, the septum, the fornix, the corpora 
striata, and the cornua ammonis may be 
imperfectly developed. The cerebral hemi- 
spheres may thus be in some sort fused 
together, and the shape of the ventricles 
altered. The symptoms differ from those of 
the preceding variety, in that the special 
senses are seldom involved; and that, 
although complete idiocy may accompany 
these lesions, it is more usual for the brain to 
be found capable of some slight intelligence, 
though unequal to the conception of abstract 
ideas. 
In the fourth variety, the lateral portions 
of the brain are incomplete. This lesion 
generally occupies one side of the brain, 
leaving the other hemisphere intact. Several 
points in the hemisphere may be affected, or 
the whole of a single lobe. Most usually 
there is a depression occupying the seat of 
one or more convolutions. Such a lesion 
occasionally attacks the whole hemisphere, 
giving it the appearance of a large pouch 
filled with fluid. Sometimes also the neigh- 
bouring ventricle communicates with it; or 
there may be much ventricular effusion, 
with imperfect development of the corpus 
striatum, the optic thalamus, the cornua 
ammonis, the mammillary tubercle, the crus 
cerebri, and the optic and olfactory nerves of 
one side. In a considerable proportion of 
patients so affected, the lesion is accompanied 
by idiocy, and possibly the inability to speak 
is connected with this mental condition. 
Some few patients, however, possessed with 
some intelligence, have yet been unable to 
speak ; this has been the case even when the 
lesion has existed on the right side. Deaf- 
ness is rare ; feebleness of sight, various forms 
of strabismus, and nystagmus common. 
Very frequently there is hemiplegia of the 
side opposite to the lesion, and certain other 
affections of the limbs-emaciation, incom- 
plete development, contraction, various de- 
formities of the hands, &c. Sensation even 
in the paralysed limbs is normal; convulsions 
are not uncommon. 
In the fifth variety, there is incomplete- 
ness of the anterior portion of the brain. 
Here both the anterior lobes are affected 
together. This condition may be associated 
with some deficiency of the corpus callosum, 
fornix, and corpora striata. Idiocy is not 
uncommon ; mutism is the rule, but in some 
patients not idiotic a few words have been 
possible. Other phenomena - amaurosis, 
strabismus, and various motor abnormalities 
-have occurred so irregularly in these pa- 
tients that it is probable they were symptoms 
not so much of this lesion as of certain further 
complications. 
Incompleteness of the cerebellum forms 
the sixth variety. This is sometimes asso- 
ciated with a similar condition of one side of 
the brain. Usually one lateral lobe only is 
affected. General hydrocephalus is an occa- 
sional complication, and a collection of fluid 
under the tentorium cerebelli is very com- 
mon. The symptoms are very negative. In 
general terms it may be said that there is no 
loss of muscular co-ordination, and no loss 
of sexual power. 
In the seventh variety, there is incomplete- 
ness of the mesocephale and medulla ob- 
longata. This is not carried very far. Certain 
modifications in form and volume are alone 
compatible with the preservation of life. It 
is not a common lesion, and has generally 
been associated with idiocy. 
9. Congenital hydrocephalus.-One variety 
of this congenital effusion of fluid is rare, 
viz. when the fluid is outside the dura mater, 
between this membrane and the pericranium, 
and the cranial bones are found floating in 
the midst of the fluid. 
The second variety is that in which the 
fluid lies outside the brain. The writer 
believes that serous effusion in this position 
is not the cause of the atrophy, flattening, or 
induration of the subjacent cerebral organs, 
but the effect: that where fluid is found in 
this situation it is only the consequence of 
some one of the lesions already mentioned 
notably atrophy of brain from whatever 
cause, and of atelencephalia. This view is, 
however, opposed to that of some authors. 
The third variety is congenital hydro- 
cephalus of the ventricles. In some such 
cases the increase in the size of the head 
occurs before birth; in others, not until after. 
The head increases rapidly in size in the first 
four weeks after birth. The sutures are 
widely separated, the cranial bones very thin, 
the integuments of the head injected, and 
the hair deficient. The muscles are badly 
developed, locomotion is imperfect, the in- 
tellect is generally obtuse, but the special 
senses are not particularly affected, unless it 
be that sight is deficient. 
10. Synencephalia is merely a matter of 
pathological interest. The head of the foetus 
is sometimes found adherent to the mem- 
branes or to the placenta, as a consequence 
of intra-uterme inflammation. At the point 
of adhesion the place of the cranial bone is 
taken by a thin vascular membrane. This 
condition is sometimes accompanied by, and 
indeed perhaps causes, encephalocele. 
11. Exencephalia.-Here a large portion 
of the brain is situated outside the cavity of 
the cranium. Practically it includes all the 
other malformations of the brain that are 
yet to be spoken of. Thus, if only a limited 
portion of the brain finds its way outside the 
skull by an abnormal opening, the displace- 
ment is known by the name of encephalocele, 
or hernia cerebri", if this hernia coincide 
with a hydrocephalic condition of the 
ventricles, it is called hydrencephalocele; 
and if the hernia is composed not of the 
brain, but of the membranes, distended with 204 
BRAIN, MALFORMATIONS OF 
BRAIN, (EDEMA OF 
fluid it may be, the lesion is called menin- 
gocele or kydromeningocele. Exencephalia 
proper may be subdivided into frontal, 
sincipital, and occipital, according to the 
direction taken by the extruded brain. 
In encephalocele only a portion of the 
brain, more or less limited, is found outside 
the skull. The exit takes place most fre- 
quently at the occipital, and next in the 
frontal region ; but the temporal and parietal 
regions are occasionally the seat of this lesion. 
The symptoms may be very negative. En- 
cephalocele, unless pressed upon externally, 
is not often attended by convulsions or 
paralysis, by intellectual feebleness, or by 
difficulty of speech. This latter symptom 
is sometimes found when the hernia includes 
the cerebellum. Neither is this lesion in- 
compatible with the prolongation of life. 
The chief diagnostic difficulty is the possi- 
bility of the tumour being cephalhematoma, 
but this is frequently situated over the 
parietal bones, an unusual position for 
encephalocele: and external pressure of the 
former tumour causes none of the cerebral 
phenomena - stupor, dilatation of pupils, 
paralysis, convulsion, so constantly seen 
from compression of an encephalocele. 
E. Long Fox. 
BRAIN, Malignant Diseases of.- 
See Brain, Tumours and New Growths of. 
BRAIN, Membranes or Meninges of, 
Diseases of.-See Meninges, Diseases of. 
BRAIN, Morbid Growths of.-See 
Brain, Tumours and New Growths of. 
BRAIN, CEdema of.-Definition.- 
Infiltration of the brain and pia mater with 
serum. 
.Etiology and Pathology.-In chronic 
maladies attended with general oedema, es- 
pecially Bright's disease, there is an increased 
amount of fluid around the brain-in the 
meshes of the pia mater and between the 
convolutions-and also in the ventricles. 
Occasionally the cerebral substance is infil- 
trated ; but this is uncommon, and it probably 
occurs only when there is some change in 
the cerebral structure. The perivascular 
canals normally afford a ready means of 
escape for effused serum, and in Bright's 
disease, at least, the substance of the brain 
is often remarkably firm, so as to present a 
contrast to the condition of other organs. 
But apart from any general disease, all spaces 
that result from a diminution in the volume 
of the structures within the skull, are filled 
by serum. Thus in senile atrophy of the 
brain, the space between the shrunken con- 
volutions is occupied by serum, and the 
ventricles contain an excess of fluid. The 
brain-tissue may also appear to contain more 
fluid than usual, in consequence of the 
presence of serum in the enlarged perivas- 
cular canals. Such effusion is also met with 
in those forms of insanity in which there 
are degenerative changes in the brain with 
a diminution in its volume. It is seen also 
in cases of rapid course, in which functional 
excitement is attended with some vascular 
disturbance. Conditions of hyperaemia and 
inflammation are attended with effusion of 
serum in the brain, as in other organs, and it 
is in cases of inflammation that the greatest 
amount of oedema is met with, but this con- 
dition is not included in the common use of 
the name. In passive congestion, however, 
such as results from heart-disease, enough 
serum may escape from the distended vessels 
to give rise to a condition of oedema; but it is 
probable that when the excess is more than 
trifling, room is made for it by wasting of the 
nerve-elements, the result of the continued 
pressure to which they are exposed. 
When the degree of oedema is considerable, 
the cerebral substance may be enlarged, 
the convolutions being flattened; and the 
tissue is lessened in consistence owing to the 
infiltration of the cerebral tissue by the liquid, 
and the separation by it of the nerve-elements. 
A microscopical section shows empty round 
and oval spaces between the cells and fibres, 
limited by delicate tracts of the separated 
neuroglial tissue. The same softening is 
seen in the neighbourhood of effusions of 
fluid into the ventricles; the brain-tissue, 
for a depth of some lines from the ependyma, 
being softened to a pulpy consistence. Post- 
mortem imbibition always increases the 
apparent amount of the oedema and the 
degree of the softening, because the nerve- 
elements quickly begin break up after 
death. In simple ced^^^BBissue remains 
pale, and the even 
paler than usuar' 
Symptoms.-Little is 
toms of oedema of the brain. The patKo- 
logical state is usually secondary to some 
other condition, the symptoms of which mask 
any that the oedema itself might possibly 
cause. General oedema seems attended by 
slow diminution of mental power and motor 
force, which may be in part due to the 
patient's state, but has many other possible 
causes. The effusion of serum in cases of con- 
gestion, and consequent pressure on the nerve- 
elements, has been considered as the cause of 
the symptoms of depression common in that 
condition. Cases occasionally occur in which 
effusion of serum into the ventricles and the 
pia mater is the only post-mortem condition 
to be found after an apoplectiform seizure, 
and such cases are often spoken of as in- 
stances of serous apoplexy. In so far as 
the effusion of serum is sometimes possibly 
related to the apoplectic attack, it can be 
merely as the consequence of a cerebral 
congestion which has left no recognisable 
post-mortem hyperaemia. In point of fact 
we know nothing of symptoms that can be 
ascribed to the oedema itself, and it is not BRAIN, (EDEMA OF 
BRAIN, SOFTENING OF 
205 
easy to conceive a mechanism by which 
symptoms can result from it, so far as we 
are acquainted with its intimate pathology. 
Treatment.-The treatment of cerebral 
oedema is usually secondary to the condition, 
commonly conspicuous enough, which is its 
cause-Bright's disease, passive cerebral 
congestion, &c. If oedema be suspected 
where no causal indication for treatment 
exists, purgatives and diuretics, with iron if 
there be debility, are the remedies most likely 
to be of service. But where a diagnosis is 
speculative, treatment necessarily lacks a 
confident basis. 
The effusion of fluid into the ventricles is 
described under Hydrocephalus. 
W. B. Gowers. 
BRAIN, Sclerosis of. - See Spinal 
Cord, Special Diseases of: Multiple Sclerosis. 
BRAIN, Softening of.-Definition.- 
A pathological state of brain-tissue, attended 
with diminished consistence; usually local; 
and indicated, during life, by mental, motor, 
and sensory symptoms, which vary according 
to the seat of the lesion. It is produced rapidly 
in the vast majority of cases, and is then 
usually dependent on vascular obstruction. 
Very rarely it is chronic in development, and 
the nature of the actual process is not 
known. The following description applies 
to the acute form. 
^Etiology.-Acute softening of the brain, 
occurring duringdife, and not due to trau- 
matic cause^ift'l'SWable to one of two condi- 
tions, inflammation or vascular obstruction. 
Most i eases weref^mierly thought to be due 
to inflammat^^fc^s now known that 
very softening 
deaa^^&^Tn anotj^WlWjcl^^ee Brain, In- 
vascular obstruction, 
whrch is the usual cause of softening, may be 
arterial or, rarely, capillary. Venous obstruc- 
tion also causes softening, but the loss of 
consistence does not involve the whole of the 
tissue of the part, and enough remains to 
permit an ultimate restoration of firm tissue 
and even the production of induration. The 
arterial obstruction may be due to a coagulum 
formed in situ (thrombosis), or to a plug of 
fibrin conveyed to the spot by the blood- 
current (embolism). The chief predisposing 
and exciting causes of softening of the brain 
will therefore be the causes of these conditions 
{see Brain, Vessels of, Diseases oi). The com- 
mon concomitant conditions are-in throm- 
bosis, vascular disease ; in embolism, valvular 
disease of the heart; and as predisposing con- 
ditions we usually find-in cases of throm- 
bosis, advanced age, Bright's disease, chronic 
alcoholism, gout, or syphilis;-in cases of em- 
bolism, acute rheumatism, chorea, or scarlet 
fever. Senile vascular degeneration is the 
most common cause of softening, and hence 
the disease is met with most frequently in 
the old. In rare cases, thrombosis occurs 
without disease of the vessels, from a state 
of the blood alone. It is probable that this 
is sometimes a cause of hemiplegia coming 
on a few days after child-birth, when there 
seems to be a physiological increase in the 
coagulability of the blood. Embolism, due 
to valvular disease of the heart, and throm- 
bosis due to syphilitic disease, are the most 
frequent causes of acute local softening in the 
young and middle-aged. All these aetiological 
conditions are considered in more detail in 
the article on Diseases of the Vessels of the 
Brain. 
Anatomical Characters.-The character- 
istic feature of cerebral softening is diminished 
consistence. This may, however, arise from 
either ante-mortem or post-mortem changes. 
In each case the diminished consistence de- 
pends on the breaking-up of the material, of 
which the nerve-elements are composed, into 
globules and granules, and the separation of 
these by an increased quantity of fluid. Thus 
the continuous structures of which the brain 
consists are broken up into disconnected 
fragments, and the consistence of the tissue 
is accordingly diminished. In post-mortem 
softening there is nothing more. The globules 
of myelin are often large, and the separating 
fluid abundant. The softened tissue has the 
tint of the normal cerebral substance. The 
process is the result of the imbibition of fluid 
from some collection of serum, in the 
ventricles or elsewhere, and occurs in the 
greatest degree in the immediate vicinity of 
this. In ante-mortem softening there are, 
in addition, certain changes in the tissue- 
elements. The process of segmentation of 
myelin results in the formation of finer 
granules. These are in part aggregated into 
' granule-corpuscles,' round or oval masses of 
globules and granules, sometimes contained 
within a distinct cell-wall. Some of these 
bodies may arise by simple aggregation, 
others by the degeneration of connective- 
tissue cells, and some by the aggregation of 
products of nerve-degeneration within cellular 
elements of various kinds. The walls of 
vessels in the softened area also present 
fatty degeneration. No further change may 
exist, and the area affected may present 
simply a diminution of consistence, its colour 
remaining unchanged. It is then called 
white or grey softening. Very frequently, 
however, in the part thus diseased, disten- 
sion of capillaries with blood occurs, most 
considerable in the periphery, and blood is 
actually effused, chiefly by rupture of capil- 
laries, in trifling degree perhaps by migration 
of corpuscles. In proportion to the amount 
of blood mingled with the softened brain - 
tissue, the colour of the affected area is 
changed, and thus red softening is produced 
when the amount of blood is considerable. 
In the change which results from closure of a 
vein, the tissue is crammed with punctiform 
extravasations, and a purplish colour results; 206 
BRAIN, SOFTENING OF 
but, as already stated, there is not the general 
diminution of consistence that brings the alter- 
ation into the category of ' softenings.' After 
a time, the blood effused in red softening 
degenerates, its tint becomes altered to yellow 
or orange, and yellow softening is produced. 
Ultimately, it is said, the colour, if at first 
moderate, may be removed and white soften- 
ing result, but the pigment that gives rise to 
the yellow tint may remain for many years. 
Red softening is found chiefly in the grey 
substance, where the vessels are numerous, 
especially in the cortex and central ganglia. 
The tint varies; the red colour is usually 
punctiform, or mingled with yellow and 
white. If the extravasations are large and 
numerous, ' capillary apoplexy ' results. Ac- 
cording to the amount of effusion of serum 
and blood there is swelling, and the diseased 
area may project above the cut surface. In- 
flammatory changes result from the vascular 
distension, and in proportion to these, in- 
crease in the nuclei of the neuroglia is found, 
especially at the circumferential portions. 
From this cause, and from the migration of 
white corpuscles, pus-like cells appear among 
the products of degeneration in varying quan- 
tity. The vessels are dilated, and may present 
a moniliform appearance. Their perivascular 
sheaths are often distended with blood. 
Yellow softening results from red softening, 
by degenerative changes in the blood effused 
attended with a change in its pigment. It 
has a similar seat, being frequently met with 
in the convolutions, where it constitutes the 
plaques jaunes of the French. Its consist- 
ence is usually slight, its aspect granular. 
The colour depends on the presence of minute 
pigment-granules, diffused colouring matter, 
and hsematoidin crystals. 
WTiite softening has the tint of the normal 
cerebral substance. In consistence it varies: 
it may be only a little below that of the 
cerebral substance, or it may be diffluent. 
Its aspect is uniform, or white flakes are 
scattered through it. The limits are usually 
gradual. Under the microscope it presents 
the detritus of nerve-elements, a few nuclei 
from the connective tissue, granule-corpuscles, 
and, ultimately, corpora amylacea. White 
softening is chiefly found in the white sub- 
stance of the hemispheres. It occasionally 
has a gangrenous odour, and then may be 
found in the white or in the grey substance ; 
probably this form results from the obstruc- 
tion of capillaries by septic material. It is 
theoretically probable that when softening is 
white from the first, the capillaries are the 
seat of the primary obstruction. It occurs 
also in the zone of cerebral tissue in which 
meet the regions supplied by the arteries of 
the cortex and of the central ganglia. 
Ultimate changes.-White and yellow 
softening may remain for years unchanged. 
Usually the products of disintegration of 
the nerve-elements are gradually removed, so 
that a cavity remains, across which bands 
and trabeculae pass-the remains of vessels 
and other structures that have escaped total 
necrosis. Sometimes the changes in the 
elements of the neuroglia and the extrava- 
sated white corpuscles, &c., result in the 
formation of a considerable quantity of con- 
nective tissue, consisting of fine fibre-cells 
and fibres, most abundant in the margins of 
the softened area, which become firm and 
dense, whilst the trajoeculae of the connective 
tissue, crossing the cavity, are thickened in 
like manner. After a time, when the amount 
of this tissue is considerable, the fluid may 
be absorbed, and a sort of cicatrix result from 
the union, partial or complete, of the walls. 
In other cases the walls alone are thus 
altered, the solid particles are removed from 
the softened tissue, and a cyst is formed. 
The outer portion of the cyst or cicatrix may 
be limited by a zone of dilated blood-vessels, 
presenting, under the microscope, a peculiar 
and quite characteristic feature. 
Seats of softening.-There is no part of 
the brain in which softening has not been 
found, but its most frequent seats are the 
cortex, the corpus striatum, and the optic 
thalamus. In the pons Varolii and medulla 
it is also frequently found, but it is rare in the 
cerebellum. Its frequency in the medulla is 
underrated because only minute areas of 
softening are compatible with a duration of 
life sufficient to permit them to assume a 
characteristic aspect. Its occurrence, posi- 
tion, and characters depend on the distri- 
bution of the vessels. The small arteries of 
the corpus striatum and optic thalamus are 
' terminal arteries,' having only capillary 
communication with other vessels, insuffi- 
cient for a collateral circulation adequate to 
maintain the vitality of the tissue. The 
arteries to the cortex of the brain are some- 
times terminal, but soinetimes possess anas- 
tomoses by arterioles with other branches. 
Hence obstruction in the central arteries 
leads invariably to softening, while obstruc- 
tion in the superficial arteries may also cause 
softening (which involves the grey substance 
of the convolutions and some of the subjacent 
white centre to which the vessels penetrate), 
but often the anastomoses of the superficial 
vessels are so free that softening does not 
result. An obstruction of a main trunk (as 
the middle cerebral) may lead to softening 
of the central region (corpus striatum), while 
the convolutions escape ; but usually both 
suffer. For the same reason, the softening 
of the cortex is apt to be irregular in dis- 
tribution, and partial even within the region 
of the obstructed artery, a feature considered 
further in the article on Diseases of the 
Vessels of the Brain. 
Symptoms.-The prem onitory symptoms of 
softening of the brain depend upon its me- 
chanism, and are considered in greater detail 
in the articles describing its causes. In em- BRAIN, SOFTENING OF 
207 
holism other symptoms than those of cardiac 
disease are usually absent. Occasionally a 
slight attack of loss of cerebral function, due 
to a slight embolism, may precede a graver 
attack. In softening due to arterial disease, 
premonitory symptoms of local cerebral an- 
aemia are frequently present; these may exist 
for months before the onset, or only for a few 
days, or even for a few hours. There is also, 
in many cases, sufficient disease to impair the 
nutrition of many parts qf the brain, revealed 
by symptoms of wide range-mental dete- 
rioration, numbness, and pains in the limbs, 
pain in the head, or slight local weakness. 
These symptoms are of especial significance 
when associated with evidence of degener- 
ation elsewhere in the arteries; with the 
conditions-as chronic Bright's disease, alco- 
holism, and senility-in which atheroma of 
the cerebral arteries is common; or with 
constitutional syphilis. 
The symptoms of actual softening are those 
of loss of function in the damaged portion of 
the brain. Strictly, indeed, these symptoms 
are those of the anaemia that causes the soft- 
ening, and which, depriving the brain-tissue 
of the material for its functional action, arrests 
the latter with a rapidity which seems to 
suggest that other influences may co-operate 
in the arrest. The onset of the symptoms may 
be actually sudden, as in embolism, and some- 
times in thrombosis; or it may be gradual, 
as occasionally in thrombosis. In the former 
case, the symptoms of initial shock are added 
to those due to the structures involved (see 
Convolutions of the Brain and Cortex 
Cerebri, Lesions of; &c.). Hemiplegic symp- 
toms and mental disorder are the most 
common. Hemiplegia especially occurs in 
embolism, on account of the frequency with 
which the middle cerebral artery is obstructed, 
and of the important motor regions (corpus 
striatum and motor parts of the convolutions) 
to which that artery is distributed. From the 
distribution of the artery to the lower frontal 
convolutions and adjacent region, aphasia is 
frequently present when the obstruction is on 
the left side. 
When the symptoms come on suddenly, 
they often occur after some fatiguing exertion, 
or during exhaustion from any cause. If 
the area damaged be extensive, there is loss 
of consciousness, and there may be all the 
symptoms of an apoplectic seizure. The loss 
of consciousness is rarely profound, and the 
symptoms of apoplexy soon pass off. In the 
most severe cases, however, they may deepen 
to fatal coma, especially when an important 
artery is occluded in each hemisphere. Thus 
the closure of both middle cerebrals causes 
symptoms indistinguishable from those of 
ventricular haemorrhage and equally fatal 
in ultimate result. Symptoms of irritation 
commonly succeed those of apoplexy as the 
collateral hyperaemia sets in, or they may 
be marked at the onset. Convulsions, often 
unilateral, may occur and be repeated for 
days, chiefly when the softening involves the 
motor region of the cortex, and spares the 
path from it through the central ganglia. 
The patient may pass from the apoplectic 
condition into one of delirium. In the old, 
delirium may be the chief symptom of the 
onset in cases in which the softened areas 
are small, multiple, and cortical in situation. 
According as these symptoms are chiefly 
marked at the onset three varieties have 
been described, the apoplectic, convulsive, 
and delirious forms. 
Recovery from the special symptoms of the 
attack is often incomplete; permanent weak- 
ness may remain, as hemiplegia, and mental 
power is weakened, the patient passing into 
the chronic state about to be described. The 
persistent hemiplegia is often accompanied 
by rigidity, or, when the loss of power is 
incomplete, by mobile spasm, such as, in 
its most marked form, has been described as 
athetosis. When the cause is arterial de- 
generation, return or relapse is common, and 
it is almost invariable where senile arterial 
disease is widely spread. 
Chronic softening of the brain is a term 
applied to a group of symptoms, of wide range, 
indicative of failure of cerebral power. It is a 
term that has become firmly rooted in popular 
nosology, where it denotes chiefly general 
paralysis of the insane, but includes also all 
maladies attended by a similar mental failure, 
profound in degree and permanent in dura- 
tion and progressive in course. This use of 
the word is a source of considerable incon- 
venience, since it may be strictly accurate to 
deny the application of a name to that which, 
nevertheless, it perfectly connotes; and it is 
generally wiser to explain the change which 
has come over the use of the word, rather 
than to give a simple answer to the question 
in the form it commonly assumes, Is it 
softening of the brain ? The symptoms in- 
dicated by the term may supervene on more 
acute symptoms of softening, or may be 
gradual in their onset. There is mental 
dulness, defective perception, drowsiness, loss 
of memory (especially for recent events), 
often slight wandering; emotional manifes- 
tations are easily excited. Physical power 
is defective-as a rule generally, sometimes 
locally. The more delicate motor actions are 
imperfectly adjusted: articulation becomes 
indistinct, and the handwriting imperfect. 
These symptoms may progress into actual 
imbecility, or may be cut short by some 
more profound cerebral seizure, or by some 
intercurrent pulmonary affection, rendered 
grave by the deficient muscular respiratory 
power. They are met with chiefly in the old, 
and are probably due to concomitant degene- 
ration of cerebral tissue and of the arteries 
supplying it with blood-the two pathological 
elements varying in relative degree and in 
relation. Spots of softening, often widely 208 
BRAIN, SOFTENING OF 
spread, may be found, and are, indeed, the 
cause of many of the symptoms. But the 
state may also come on without any local 
softening, and without the degenerated vessels 
to which such softening is usually due. A 
similar state often follows any grave local 
lesion of the brain in advancing life. 
Progressive symptoms, focal or general, or 
both, sometimes of the character just de- 
scribed, and sometimes such as are caused 
by a cerebral tumour, have been met with in 
a few cases in which extensive local softening 
of the cerebral tissue has been found, without 
vascular disease to explain it, and without 
correspondence with arterial territories. Most 
subjects have been old, and the disease has 
not commonly been diagnosed during life. 
Recorded cases are at present too few to per- 
mit an adequate history of the disease to be 
inferred. Altogether, not only is the term one 
of loose usage, but the lesion is one of such 
varied relations, and its symptoms of such 
equivocal significance, that the subject is a 
region of cerebral pathology in which very 
much remains to be done to establish even a 
firm outline of scientific knowledge. 
Diagnosis.-The acute form of softening 
has to be distinguished from acute congestive 
apoplexy and from cerebral haemorrhage. It 
is distinguished from the former by the oc- 
currence of the symptoms indicative of local 
mischief, and by the absence of evidence of 
cephalic hyperaemia. From haemorrhage the 
diagnosis is often difficult, except during the 
first half of life, when haemorrhage is so rare 
that it should only be thought of when loss 
of consciousness is profound and prolonged. 
In softening from thrombosis, the initial apo- 
plectic symptoms may be absent, or, if present, 
slight and brief. They are more often pre- 
ceded by slight local cerebral symptoms, due 
to the vascular disease, than is the onset of 
cerebral haemorrhage. In the latter such 
symptoms are merely associated, and are not 
due to the cause of the haemorrhage, except in 
the rare cases in which there is an aneurysm 
of one of the larger intracranial arteries. In 
these, however, preceding arterial symptoms 
are often more considerable in degree and 
duration than those which precede softening. 
Most important is the indication afforded by 
the state of the heart; evidence of its hyper- 
trophy is seldom absent in cerebral haemor- 
rhage, while it is feeble and often irregular 
in the softening from atheroma, and presents 
evidence of valvular disease in embolism. 
Improvement occurs earlier than in cerebral 
haemorrhage. The temperature rises soon after 
the attack, but falls in a day or two ; in 
haemorrhage the rise occurs later (Bourne- 
ville). There is more marked mental change 
than in haemorrhage, shown at first in excite- 
ment, subsequently by depression and deterio- 
ration of power. In the cases in which the 
onset is sudden and the apoplexy profound, a 
diagnosis from haemorrhage is often impos- 
sible. In embolism the onset of the attack is 
commonly sudden, but the loss of conscious- 
ness is less profound than in haemorrhage, 
and is often absent. This is true also of soft- 
ening from syphilitic disease, in which the 
diagnosis is often aided by a history of the 
causal malady. Too much weight must not 
be laid on the absence of such a history in 
patients in whom the disease is possible, and 
especially little significance can be attached 
to the absence of a history of constitutional 
symptoms, while neither the thoroughness of 
former treatment, nor a considerable period 
of freedom from symptoms, has any value 
whatever as a contra-indication. But with 
the lapse of time, it does become unlikely that 
softening is due to this cause ; still, it is only 
after twenty years, and in the absence of any 
suspicion of a second infection, that the im- 
probability has considerable weight. Optic 
neuritis, developing after the lesion, occurs 
in rare cases of softening from embolism, and 
is practically absent in haemorrhage. In all 
cases the various indications must be com- 
pared and balanced, and their relative weight 
noted in the estimation, special caution being 
taken to allow no weight to negative facts 
in the presence of positive evidence of oppo- 
site significance. In capill ary embolism, if ex - 
tensive, a distinction from haemorrhage often 
cannot be made-the loss of consciousness is 
profound and lasting. Bilateral softening, 
such as sometimes results from disease of 
both middle cerebral arteries, may also (as 
already mentioned) cause symptoms in- 
distinguishable from those of ventricular 
haemorrhage. 
The distinction of softening from other 
cerebral diseases is described in the accounts 
of these. 
Prognosis.-The immediate and ultimate 
prognosis in an attack of softening of the 
brain depends on the degree and extent of 
the symptoms, as indicating the extent of the 
lesion; and on their character, as indicating 
the region of the brain damaged. Both the 
near and the remote prognosis is much graver 
in damage to the medulla and pons Varolii 
than when the corpus striatum or cerebral 
hemispheres are affected. Locality is of 
especial importance in regard to the progno- 
sis in softening, because it is by far the most 
frequent lesion of the medulla or pons that is 
survived. Hence the prognosis is of high 
practical importance at the onset as well as 
later on. The intensity of the coma indicates 
a greater degree of gravity than does its 
duration. Youth and general health favour 
the rapidity and the degree of recovery. 
"Where actual softening has occurred, the 
damaged tissue never regains its functional 
power. The congested periphery may re- 
cover in proportion to the integrity of the 
tissues, and to the freedom of the vessels 
from disease. The chances of a recurrence 
of softening in another situation depend on BRAIN, SOFTENING OF 
BRAIN, TUMOURS OF 
209 
the extent to which its causal condition is 
widely spread or can be removed. In vas- 
cular degeneration recurrence is almost cer- 
tain. In embolism it is rare. The prognosis 
in syphilitic disease of the vessels depends 
upon the recognition and treatment of the 
syphilitic influence so far as recurrence is con- 
cerned; but the prognosis of developed symp- 
toms is independent of the fact of this syphi- 
litic cause, or of any treatment to which the 
patient may be subjected. Treatment can 
only influence the disease of the wall of the 
vessel, and this can have no effect in restoring 
the circulation, since the vessel beyond is 
closed by clot, or in restoring the structure of 
the destroyed tissue of the brain. As a matter 
of fact, the course of hemiplegia due to this 
cause is precisely the same as that of hemi- 
plegia due to softening produced by any other 
vascular mechanism; improvement or re- 
covery is determined by the position of the 
lesion, and the extent to which the symptoms 
are not due to the actual destructive soften- 
ing, and to which they can be compensated. 
Improvement or persistence of symptoms 
may coincide with treatment, but the one is 
not due to it, nor the other the result of its 
absence. 
Treatment.-The treatment at the onset 
of cerebral softening is of great importance, 
because, although nothing can probably be 
done to undo the mischief that has occurred, 
much may be done to prevent its extension 
or increase, and in many cases it is by such 
preventable extension or increase, after the 
patient comes under treatment, that the 
degree of ultimate disability, or death itself, 
is determined. It is. essential that the atten- 
tion of the practitioner should be fixed on 
the pathological process and its mechanism; 
he should endeavour to picture to himself 
clearly what is taking place and how it is 
being brought about, and arrange his thera- 
peutic measures so as to counteract the morbid 
influences in the utmost practicable degree. 
The closure of a vessel by clot is the great 
fact of what may be termed the therapeutic 
pathology of these cases, and the measures 
to obviate the increase in this process have 
much in common in the various forms of 
softening. The variations rendered necessary 
by the differences in mechanism are con- 
sidered in the articles on the several vascu- 
lar diseases. During the acute stage the 
patient must be kept at perfect rest, with the 
head moderately raised, flexion of the neck 
being avoided. During the initial stage of 
shock, warmth by hot-water bottles, &c., 
should be applied to the extremities, to 
equalise the circulation. The bowels, if con- 
fined, should be made to act gently; but, 
unless the evidence of encephalic congestion 
be early and conspicuous, purgation should be 
avoided. The determination of blood from 
the brain to the intestines, involved in pur- 
gation, and desirable in cerebral haemorrhage, 
is to be carefully avoided in cerebral soften- 
ing. It is important also to maintain the 
circulation steady and uniform, avoiding alike 
undue quickening or slowing of the blood- 
current. Hence, digitalis is useful in all cases 
in which there is cardiac weakness or irregu- 
larity. In all senile cases, or when there is 
a gouty diathesis, nitrous ether or other 
diuretic drug is useful, and, in the latter case, 
some lithia may be added. Thus the tendency 
of the blood to clot is lessened, and the risk 
of the extension of the lesion-always a 
danger in the early stage of the affection-is 
lessened or obviated. Stimulants must be 
given or withheld according to the state of 
the heart and circulation; when there is 
doubt whether they should be given or not, it 
is better to give a small quantity in softening, 
and to withhold them in haemorrhage or if 
the diagnosis from haemorrhage is doubtful. 
After the stage of depression has passed, the 
irritation due to secondary inflammation, in- 
dicated by headache and elevation of tempera- 
ture, needs quietude, laxatives, and sometimes 
cold to the head. When convulsions are an 
early and recurrent symptom, mustard plas- 
ters to the neck and extremities, and bromide 
of potassium, are sometimes effective ; in 
the early period, cold to the head may arrest 
them. The fits that attend the actual onset 
are seldom influenced by treatment; they 
cease because the tissue is destroyed that 
is essential for their occurrence. When these 
fail, hyoscine may be given cautiously, and 
in small doses gr.). 
After the attack has passed, recovery must 
be aided by maintaining the general health in 
the best possible condition. The secretions 
should be kept free, the digestive organs in 
good order, the habits strictly regulated, and 
nervine tonics-cod-liver oil, hypophosphite 
of sodium, strychnine, quinine, and iron- 
may be given with advantage. The symp- 
toms of chronic softening, whether occurring 
after an acute attack or coming on gradually, 
should be treated in a similar manner. 
W. R. Gowers. 
BRAIN, Syphilitic Disease of. See 
Brain, Tumours and New Growths of. 
BRAIN, Tubercle of. See Brain, 
Tumours and New Growths of. 
BRAIN, Tumours and New Growths 
of.-The intimate connexion of the brain 
with its membranes makes it impossible, ex- 
cept in the most general terms, to draw any 
marked distinction between tumours of the 
cerebral substance and tumours arising from 
its envelopes. A growth pressing inwards from 
a membrane must impinge upon brain-tissue; 
a growth originating in brain-tissue must in 
many situations involve the membranes. 
Anatomical Characters. - The tissues 
from which tumours have their origin seem 
to present the best ground for a scientific 
classification of these lesions; and it is not 210 
BRAIN, TUMOURS AND NEW GROWTHS OF 
devoid of interest to mark that the absolute 
nerve-elements of the brain are never pri- 
marily the source of a morbid growth. 
Cerebral tumours, then, may be roughly 
separated into three series:- 
1. Those whose centre of origin is some one 
or other of the membranes, external to the 
brain, or dipping into the ventricles. 
2. Those which spring from the blood- 
vessels. 
3. Those which own the neuroglia as their 
starting-point. 
Dr. Gowers considers such a classification 
of small practical value, and believes it is 
more convenient to describe the various 
growths in the order of their frequency. 
Tumours, therefore, may be grouped in six 
categories:- 
(1) Diathetic: Tubercular and Syphilitic. 
(2) Sarcomatous: Glioma, Sarcoma, Myx- 
oma. (3) Carcinoma. (4) Osteo-fibroid: 
Fibroma, Osteoma, Osteo-fibroma. (5) Mis- 
cellaneous: Cholesteatoma, Lipoma, Vascular 
or Erectile Tumours, Psammoma, Neuroma. 
(6) Parasitic: Echinococcus and Cysticercus. 
Taking, however, this original subdivision, 
which is Eindfleisch's, the tumours which 
are placed in each series differ somewhat 
from his arrangement. In the first series 
five kinds of tumour are found, arising from 
the membranes or from the free surface of 
the ventricles. These are Pacchionian granu- 
lations; spindle-celled sarcoma; myxoma of 
the membranes; psammoma; and lipoma. 
The second series will include, first, aneur- 
ysms, depending upon disease of one or more 
of the arterial coats; and, secondly, such 
tumours as have their origin in the sheaths 
of the vessels, comprising carcinoma cerebri 
simplex; fungus of the dura mater; chole- 
steatoma; epithelioma myxomatodes psam- 
mosum; papilloma of the pia mater and 
vessels; papilloma myxomatodes; and tu- 
bercle. In the third series may be counted 
glioma; myxoma of the nerve-substance; 
syphilitic gumma; and fibroma. Included 
under none of those headings, echinococci 
and cysticerci cellulosae must be mentioned, 
as they affect the brain. 
Each of the growths enumerated will now 
be briefly described. 
1. Pacchionian granulations.-These are 
granulations of the arachnoid, sometimes 
met with in childhood, very constantly from 
middle age onwards, and scarcely recognised 
as morbid lesions. Their aetiology is un- 
known. They do not give rise to any symp- 
toms. They are chiefly situated along the 
superior longitudinal sinus, which in rare 
cases is perforated by them. They form 
groups of papillae, consisting of striped con- 
nective tissue, poor in cells, and proceeding 
directly from a thin but a continually re- 
newed layer of sub-epithelial germinal tissue. 
2. Sarcoma.-1This sometimes has its origin 
in the nervous tissue itself, but more fre- 
quently arises from the dura mater, especially 
at the base of the skull. From their situa- 
tion sarcomata are especially apt to interfere 
with one or more of the cerebral nerves. 
They may attain the size of a pigeon's or 
even of a hen's egg. 
When sarcoma attacks the dura mater it 
originates from its internal side. The most 
usual situation is the membrane about the 
sella turcica and the pars petrosa. It forms 
a depression in the brain, while the bone 
becomes atrophied behind it. The growth- 
is composed of fusiform cells, with tolerably 
numerous and sometimes dilated vessels. 
Sarcomatous growths are not freely developed 
above the surface, but rather in the depths of 
the tissue ; they distend the cerebral convo- 
lutions, form deep depressions on the surface, 
and even penetrate far into the brain. They 
occur under two forms-hard sarcoma with 
compact fibrous fundamental tissue and small 
cells, often called fibrous tumour; and soft 
sarcoma, with a loose scanty intercellular 
substance, and numerous cells of compara- 
tively large size. The cells are mostly fusi- 
form, but sometimes round and multinuclear, 
and the two latter may be surrounded by the 
former. Sarcoma in this situation is generally 
single. It may attain the size of a nut or 
even of an apple, and is frequently haemor- 
rhagic. 
In the cerebral tissue itself the hard sar- 
coma attains a great degree of density: it is 
sometimes fibrous, at other times cartilagi- 
nous, of a dense homogeneous structure, 
whitish or bluish-white, with a yellow tinge 
here and there, and with very few vessels. 
It is distinguished from the brain that sur- 
rounds it by a very vascular zone. It can 
be easily separated from the parenchyma, 
and may thus be recognised after death from 
simple sclerosis and hard glioma of the brain. 
The softer form-fibro-cellular sarcoma-is 
generally either a myxo- or a glio-sarcoma: 
but pure fuso-cellular sarcoma is met with. 
The tumour is a clear grey, almost like the 
grey matter of the corpus striatum. It is 
often vascular, with a reddish tinge. These 
sarcomata are often almost spherical, and 
easily detached from the surrounding brain- 
substance. Others, however, seem to be con- 
tinuous with the neighbouring substance, and 
to be little more than simple hypertrophies 
of the cerebral tissue. Especially is this the 
case in tumours of the corpus striatum and 
optic thalamus. The cells of cerebral sar- 
coma are frequently the seat of fatty degene- 
ration, and the whole tumour may be haemor- 
rhagic. Its most frequent situations in the 
brain are the ganglia at the base. 
3. Myxoma.-Myxoma of the membranes 
is rare, and generally has its origin from the 
convexity of the brain, being connected with 
the inner surface of the dura mater. It is a 
small growth, soft, fragile, having a gelatinous 
aspect. Myxomata are frequently met with in the 
cerebral hemispheres, and then take their 
origin from the neuroglia. Such growths are 
probably malignant, the proofs of their malig- 
nancy being that they are often multiple 
locally; that they frequently recur when re- 
moved from a peripheral nerve; and that they 
not seldom affect internal organs. Myxoma 
possibly includes all that has been called 
colloid cancer. When this lesion affects the 
cerebral hemispheres it may be of large size. 
The mucus is a constituent part of the tissue; 
it is not a product of secretion, as in mucous 
cysts. It is most commonly a mucoid form 
of glioma. 
4. Psarhmoma.-Psammomata have been 
met with in the brain, spinal membranes, spi- 
nal cord, and nerves; they are not uncommon 
in the choroid plexus, but are most usually 
found in the pineal gland. There are two kinds 
of these growths. In the first, the sand oc- 
cupies the interior of the meshes of the con- 
nective tissue in very varied forms, as compact 
cylinders, as pear-shaped masses, as spines, 
or as globes, surrounded by connective tissue, 
and connected by it with the other parts of 
the tumour. In the second form, the sand lies 
without cohesion in the parts and between 
them, so that the different grains of sand 
may be easily isolated. In this latter form, 
the psammoma is composed most generally 
of round elliptical corpuscles, and sometimes 
also of large complex conglomerations. These 
little tumours have usually a concentric ar- 
rangement internally. 
5. Lipoma.-This is a rare tumour in the 
brain. It may be connected with the inner 
surface of the dura mater, or with the epen- 
dyma of the ventricles. The fatty matter is 
contained in cells, and the cells are surrounded 
by an organised membrane. Lipoma is usually 
single, seldom multiple ; of irregular shape ; 
and varies in size from a small nut to a hen's 
egg. Small pieces of carbonate of lime have 
been found in these tumours. 
6. Aneurysms.-The larger cerebral aneur- 
ysms have been observed from early times. 
More recently Liouville has called special 
attention to the subject of miliary aneurysms, 
and has shown that they are common ; that 
they are multiple ; that they frequently give 
way in the brain or in the pia mater; 
and that they often co-exist with aneurysms 
of the larger vessels in other parts of the 
body. Aneurysm of the middle meningeal, 
of the internal carotid within the cavernous 
sinus and at its exit from it, of the anterior 
cerebral, of the anterior communicating, of 
the arteries of the corpus callosum, of the 
middle cerebral, of the posterior communi- 
cating, of the vertebral, of the basilar, of the 
posterior cerebral, and of the arteries supply- 
ing the cerebellum, are all met with not in- 
frequently. The middle cerebral and the 
basilar, however, are the vessels most usually 
affected with this lesion. 
BRAIN, TUMOURS AND NEW GROWTHS OF 
The minute miliary aneurysms have been 
observed in the pia mater, at the surface of 
the convolutions or in their substance, in the 
optic thalami, the pons, the corpora striata, 
cerebellum, crura cerebri, and medulla 
oblongata; more rarely in the centrum 
ovale. A large one was found by Dr. Bastian 
in the lenticular nucleus. These miliary 
aneurysms may be visible to the naked eye. 
The smallest are seen under the microscope 
as ampullae of the vessels, containing coagu- 
lated blood or granules of haematoidin. The 
arterial walls have generally undergone some 
form of degeneration. The vessel, dilated at 
some parts, is constricted at others. The 
lesion may be a consequence of atheroma 
of the vessel, but far more commonly it 
is the result of arterio-sclerosis of the inner 
coat of the vessels, either at the seat or in 
the immediate neighbourhood of the aneur- 
ysm. Embolism is a frequent cause. See 
Brain, Vessels of, Diseases of. 
7. Carcinoma cerebri simplex.-Cancer, 
excluding from this term sarcoma and glioma, 
may originate in the cranial bones, the dura 
mater, the pia mater, the cerebrum, the 
cerebellum, the pons, and the medulla 
oblongata. The medulla oblongata, the fornix, 
and the corpora quadrigemina are the regions 
least often affected, whereas the cerebral 
hemispheres are the most favourite localities. 
All forms of cancer are met with, in all cases 
having their origin in the coats of the vessels. 
Epithelial cancer has been generally believed 
to have its starting point in the peripheral 
layer of the arachnoid, the tissue that lines 
the under surface of the dura mater. En- 
cephaloid cancer is, however, the most com- 
mon form met with in the brain. 
8. Fungus of the dura mater can scarcely 
be separated from the preceding form. It 
arises from the outer surface of the dura 
mater, penetrates with the vessel from which 
it springs into the compact tissue, destroys 
the vitreous table, and spreads out in the 
diploe: in its progress it may penetrate the 
external table and lift up the integuments of 
the cranium. The internal table invariably 
Buffers more than the external. Sometimes 
there is coincident passage of the tumour in- 
wards, and the subjacent membranes become 
glued to the dura mater and to the cerebral 
substance. There may result simply the 
depression of surface consequent upon pres- 
sure from above, but more commonly cell- 
growth similar to that of the original tumour 
takes place, first from the vessels of the pia 
mater, and afterwards from the vessels of the 
cerebral convolutions. 
9. Closely allied to the epithelial cancer 
that has its origin in the dura mater is the 
cholesteatoma, which is generally situated at 
the base of the brain. Rindfleisch considers 
it a squamous epithelioma, whose cellular 
cylinders are wholly converted into a mass 
of pearly nodules with a silky lustre. It is 
211 212 
BRAIN, TUMOURS AND NEW GROWTHS OF 
covered by the arachnoid, and springs either 
from the vessels of the pia mater, or more 
rarely from the perivascular sheath of the 
vessels in the substance of the brain. 
10. Last of the cancers is a tumour that 
has been found in the third ventricle-epi- 
thelioma myxomatodes psammosum-con- 
sisting of globes and cylinders of epithelial 
cells, embedded in a very bulky stroma of 
mucous tissue. 
11. Springing also from the vessels, two 
forms of papilloma are met with-papilloma 
of the pia mater and vessels ; and papilloma 
myxomatodes. The former is composed of 
a number of branching papillae, each of 
which contains a blood-vessel with a small 
amount of connective tissue, and a double 
coat of epithelium, of which the outer layer 
is columnar. In the latter, which is probably 
a mere variety of the former, the structure 
of the tumour is the same, but the columnar 
cells secrete a vast amount of viscid mucus. 
12. Tubercle springs from the middle tunic 
of the small arteries of the pia mater, or of 
the nerve-substance. It rarely attacks the 
membranes in the form of tumour, rarely 
also the white matter of the brain, but prefers, 
as its principal seat, the grey matter of the 
convolutions and of the deeper parts. 
Tubercle of the dura mater is, however, 
sometimes met with, and it may induce 
obliteration of sinuses. The cerebellum 
is a frequent seat of tubercle, which exists 
here in the form of superficial granulations. 
The pons also is frequently affected with 
tubercle, both in the form of small tumours 
of its substance, and as polypous tubercles 
of the fourth ventricle. Tubercle is separated 
from the surrounding cerebral substance by 
a very delicate reddish envelope. 
Tubercular tumours of the cerebral sub- 
stance are often multiple, and not infrequently 
large ; they are of very slow growth; persist 
long in the caseous state ; and may be found 
cretified. Sometimes there is cerebral soften- 
ing around them. Virchow states that the 
increase of tubercles takes place by appo- 
sition or juxtaposition, and that the apposition 
takes place not by layers primarily caseous, 
but by zones of new grey proliferation, usually 
in the form of miliary tubercle. A very 
delicate layer of connective tissue of new 
formation, a species of encysting false mem- 
brane, represents the mother-tissue for the 
subsequent generation of young tubercles. 
13. Glioma, called by Billroth granulated 
sarcoma, or round-celled sarcoma, is practi- 
cally a local hyperplasic development of the 
neuroglia. It may appear in three forms, 
either as soft glioma, rich in cells-the 
most common kind ; as hard glioma, fibrous, 
and, if the vessels are much developed, 
telangiectasic ; or thirdly, as a myxoglioma, 
a complex tumour, in which part of the 
tumour takes the appearance of mucous 
tissue. The nature of the tumour is partly 
determined by the nature of the tissue from 
which it springs; thus glioma of the brain 
is generally, but not always, soft, glioma of 
the ependyma hard. The soft gliomata are 
closely allied to myxomata. The intercellular 
substance is found in moderate quantity. In 
the more mucous gliomata the network is 
regular and large, and the tissue has little 
cohesion. If the meshes are larger still, and 
the mucous element abundant, this variety 
passes into a myxoma. If there be a con- 
s'derable increase of cells, whilst the trabeculae 
become narrower, we get a medullary glioma, 
which may be transformed into a medullary 
sarcoma if the cells continue to grow and 
multiply. These transitions are not un- 
common even in the same tumour, especially 
in the posterior lobes of the brain. If the 
vessels are developed in great abundance we 
get haemorrhages and a kind of fungus haema- 
todes. Hard glioma is closely allied to fibroma, 
with which indeed it may be combined to 
form a fibro-glioma. In hard glioma the 
fibres are not arranged in a network, but in 
parallel lines, like felt. The nervous ele- 
ments, naturally contained in the neuroglia, 
are absent in these tumours. The walls of 
the vessels are frequently thickened. 
The glioma of the ependyma is of little 
importance; it is seen as fine granulations on 
the surface of the lateral ventricles in chronic 
hydrocephalus; on the floor of the fourth 
ventricle it may grow to the size of a cherry. 
In the cerebral substance, gliomata may 
attain the size of a fist, or even of a child's 
head; and they are often mistaken for cancers 
or sarcomata of the brain. Hard glioma 
may be distinguished from sclerosis, in that 
sclerosis encloses the normal nerve-elements. 
In glioma, too, there is great proliferation of 
neuroglia cells. There is no distinct limit 
between glioma and the surrounding brain- 
substance, but the tumour on section shows 
greater vascularity, greater consistence, and 
a more transparent constitution, as well as 
often a bluish-white appearance compared 
with the white brain-matter. The demar- 
cation in grey matter is imperceptible to 
the naked eye, especially if the glioma be soft. 
Soft glioma is generally single ; hard is often 
multiple. The membranes may adhere, but 
form no part of the tumour. 
Virchow thinks that glioma is not malig- 
nant ; that hard glioma has an inflammatory 
origin; and that the soft variety is set up by 
local causes, such as injury. Gintrac, on the 
other hand, unites gliomata and sarcomata 
under the head of cancers. 
Soft glioma is most frequently situated in 
the posterior lobes, less often in the upper and 
lateral parts of the cerebral hemispheres. It 
may be congenital. It gives rise to compli- 
cations - namely, first, great congestion, 
causing cerebral compression, irritation, 
pain, excitement, or apoplexy; and, secondly, 
hydrocephalus of the ventricles, which in BRAIN, TUMOURS AND NEW GROWTHS OF 
213 
protracted cases is seldom absent. The latter 
occurs most rapidly in glioma of the optic 
thalami, or of the posterior lobe, compressing 
the choroid veins, the ven® Galeni, or the 
transverse sinus. 
14. Myxoma of the nerve-substance.-This 
is not common in the brain. It owns the 
same origin as glioma, having the neuroglia 
as its starting-point. 
15. Syphilitic gumma.-Gummy tumours 
of the brain are generally found at the cir- 
cumference, and especially at the base of the 
brain. Their origin is either from the mem- 
branes, from the vessels, or from the neuroglia 
of the cerebral substance. They have infec- 
tive properties, or at any rate they are 
multiple, and may be met with at the same 
time affecting the dura mater, the pia mater, 
the brain, nerves, and cranial bones. They 
are often accompanied by inflammatory 
phenomena, a point which distinguishes them 
from large tubercles. Gumma is not the 
usual form in which syphilis attacks the dura 
mater on its external surface. It may, how- 
ever, affect the arachnoid surface of the dura 
mater. In this situation the gummata may 
vary in size from a hemp-seed to a nut. 
They may be found just above the convexity 
of the hemispheres, or at the anterior part 
of the base of the brain, especially about the 
sella turcica, or on the tentorium cerebelli. 
They have been met with in the falx cerebri. 
The inflammatory condition around these 
tumours often unites them to the pia mater, 
and the subjacent portion of brain is fre- 
quently softened, either by the inflammation, 
or by arterial obliteration. 
When the pia mater is united to the dura 
mater, gummata very small in size may form 
m the former membrane. The subjacent 
brain may be softened or sclerosed. Much 
larger gummata, however-from the size of a 
nut to that of a hen's egg-originate from the 
pia mater, and are most usually situated in 
the region between the optic chiasma and 
the pons, or on the crura cerebelli. On the 
convex surface they are much smaller. Gum- 
mata of the cerebral substance occur in 
situations most subject to traumatic in- 
fluences. The chief seats are the cerebral 
hemispheres, the large ganglia, especially the 
optic thalami, and next in frequency the 
pons, and crura cerebri and cerebelli. The 
tumours attain to a good size, but are not so 
large as those of the pia mater. They may 
be multiple, but often exist singly. See 
Brain, Vessels of, Diseases of. 
16. Fibroma.- True fibromata, distinct 
from hard gliomata and sarcomata, probably 
do not exist in the brain or its membranes. 
Fibromata are essentially composed of con- 
nective tissue. Such increase in this tissue 
is sclerosis, and its arrangement is too in- 
definite, its amount too small, to be considered 
a tumour. Rindfleisch is probably wrong in 
stating that there are solitary tubercles of 
the brain which deserve rather to be called 
fibroid tumours ; although it may be true 
that in some cheesy nodules of the nervous 
centres the growth of fibres and the conden- 
sation predominate enormously over the 
corpuscular structure. Practically, however, 
both enchondromata and osteomata are 
fibrous tumours. An enchondroma is a 
heterologous tumour not developed from a 
pre-existing cartilage, but produced by a 
change in the type of formation by proceeding 
from a non-cartilaginous matrix. Although 
osteoid enchondromata may be malignant, 
yet true osteomata are not so. These tumours 
may attack the cerebral dura mater, and on 
the convexity are multiple. If the tumour 
attack the falx cerebri it is solitary. Its 
starting-point is the internal surface of the 
dura mater. It is distinguished from exos- 
tosis of bone by having a fibrous layer 
between it and the bone. It may set up 
irritative pachymeningitis. Such tumours 
are also found small in connexion with the 
cerebral arachnoid, as simple united patches 
or pointed prolongations. Their favourite 
seat is the convex surface of the anterior 
lobes. The nervous centres are very rarely 
the seat of these tumours. Their matrix is 
formed by connective tissue, not cartilage, 
the product of irritation of the neuroglia, 
and so a consequence of circumscribed en- 
cephalitis. 
17. Hydatids are rare within the skull, 
but are met with occasionally in all parts of 
the brain, between the membranes, in the 
ventricles, and lying free at the base of the 
brain. They are more common in children 
than in adults. The brain may suffer from 
pressure either in the way of softening from 
interference with the vessels, or from sclerosis. 
Cysticerci are also met with in various 
parts of the brain or its membranes. They 
may be surrounded by connective-tissue cap- 
sules ; or may lie free, arranged in a racemose 
form. They may be single, or may attack 
the same individual in several hundred places 
at once. 
Symptoms.-Even in tumours of consider- 
able size all symptoms may be latent. The 
more tolerant portion of the brain will in- 
clude the hemispheres and the white com- 
missural regions, whilst the mesocephale, the 
optic thalami, and the corpora striata are 
amongst the least tolerant portions. It is 
not unusual, moreover, to meet with decided 
intermissions, especially in the early period 
of the disease; such intermissions depending 
on temporary lesions in the immediate neigh- 
bourhood of the tumour. 
Even with these intermissions the diagnosis 
of the presence or position of the cerebral 
tumours would be comparatively easy, if the 
symptoms invariably depended upon direct 
excitation. Many of the phenomena pass 
the limits of the immediate sphere of the 
tumour, and are the results of reflex action. 214 
BRAIN, TUMOURS AND NEW GROWTHS OF 
Sometimes also the symptoms due to direct 
and reflex excitation may coincide, and this 
is particularly the case in tumours of the 
base. The main difficulties lie in the possible 
latency of all symptoms; in their intermis- 
sion ; in the distinction and combination of 
direct and reflex excitation; and in the re- 
missions following physical or psychical 
excitement. 
Symptoms, then, may depend on direct or 
reflex excitation, and consist of exaltation 
of functional activity, such as contractions, 
partial or general convulsions, hyperaesthesia, 
and hyperideation. Others are produced by 
secondary lesions in the neighbourhood of 
the tumour - congestion, haemorrhage, in- 
flammation, &c.-and these may include not 
only all in the previous division, but tempo- 
rary or persistent paralysis, fever, and other 
phenomena. Then there may be symptoms 
of direct compression, definite paralyses, and 
gradual enfeeblement of the sensorial and 
intellectual faculties. 
Taking some of the more common con- 
ditions in order, and viewing them as de- 
pendent on direct or reflex irritation, the 
most frequent certainly is headache; and 
except in tumour of the cerebellum, when 
the headache is almost invariably occipital, 
there is no symptom less useful in determining 
the position of the lesion. It is less frequently 
due to direct excitation than to reflex. The 
pain is very severe, indeed, more so than in 
any other disease, excepting, perhaps, men- 
ingitis ; it persists through the whole malady; 
and is increased by vibration of all kinds, 
light, sound, or movement of the head. It 
may be confined to a single spot, or be diffused 
over the whole head. Connected with head- 
ache in many cases, and often equally the 
effects of radiated influence, are tinnitus 
aurium, morbid acuteness of hearing, or 
painful sensitiveness to sound; disturbances 
of vision, diplopia, muse® volitantes, and 
strabismus, which may be transient; formica- 
tion, and sometimes hyperaesthesiae of greater 
or less extent. In some cases there is an 
agitated condition of the intellectual faculties, 
and even delirium. Disturbances of sight 
are very common. The retinal lesions will 
be subsequently described. It is a remark- 
able fact, as bearing upon the decussating 
arrangement of the optic nerves, that the 
affections of sight usually implicate both eyes, 
even where the tumour has involved only one 
optic nerve, and is not situated near the optic 
chiasma or the corpora quadrigemina. Hear- 
ing is far' less often affected than vision. 
Generally a slight diminution only of this 
function is observed; and, in the rare cases 
in which complete deafness is met with, it is 
unilateral. Taste and smell are seldom in- 
terfered with. When these special senses are 
morbidly affected, the tumour will probably 
be situated in the uncus gyri hippocampi (the 
hippocampal lobule) or its immediate vicinity. 
The symptoms of compression may be in» 
eluded in the expression 'lowering of function,' 
comprising apathy, feebleness of memory, 
want of attention, confusion, and a general 
enfeeblement of ideas. These conditions are 
often accompanied or preceded by certain dif- 
fused symptoms, such as vertigo. 
Vertigo is the first symptom in many 
cases : it is felt especially when the patient 
is in the upright position. It often produces 
uncertainty of gait, even where the tumour 
is not in the cerebellum. Strange sensations 
in the head are also complained of, a feeling 
of liquid in the head, or of a mobile body; 
or the sensation may be that of a solid body 
filling the head, or pressing upon some 
portion of it. 
These phenomena often coincide with evi- 
dences of irritation of the mesocephale, 
whether due to direct compression or to 
radiated irritation of the medulla oblongata. 
Chief amongst these symptoms is vomiting. 
It is not accompanied by nausea or other 
manifestations of dyspepsia, and it will occur 
when the stomach is empty. It can fre- 
quently be checked only by keeping the 
patient in a recumbent position. Constipation 
also is often obstinate. 
Epileptiform convulsion has an important 
bearing on the diagnosis of these lesions. 
Very frequently convulsion is preceded by 
many of the phenomena already touched 
upon, such as headache or vertigo. Fre- 
quently, however, convulsion precedes all 
other morbid phenomena, and the patient 
may be in perfect health in the intervals of 
the attacks. Given, therefore, convulsion as 
the one factor in forming an opinion, it is 
necessary to consider the liability of the 
patient to convulsive attacks from causes 
other than tumours; to realise whether the 
family history shows any suspicion of epi- 
lepsy ; and to eliminate from the case the 
possibility of saturnine, alcoholic, and uraemic 
poisoning. If this is done, and especially 
if we find early convulsion associated with 
headache and with vomiting, this symptom 
will prove an important aid in the diagnosis 
of tumour. 
The phenomena depending on the presence 
of tumour itself may be associated with 
others due to complications, such as oedema, 
congestion, encephalitis, or meningitis of the 
surrounding parts. A high temperature, for 
instance, will point to inflammation either of 
the nervous substance or of the meninges 
near the lesion; and meningeal inflamma- 
tion seems to be accompanied by the 
highest temperature. Syphilitic gumma, 
however, may coincide with syphilitic 
meningitis on some other portion of the 
encephalon not directly connected with the 
immediate surroundings of the tumour. 
Passing for the moment the subject of 
definite paralyses with the remark that the 
sphincters are seldom affected, even in cases BRAIN, TUMOURS AND NEW GROWTHS OF 
215 
in which the paralysis takes a paraplegic 
form, it may be mentioned that a want of 
equilibrium seems to be a not unusual 
evidence of the presence of tumour in the 
cerebellum. Aphasia may not only be due 
to the special localisation of tumour in 
Broca's region of the left anterior lobe, but 
also to the presence of this lesion in any 
part of the tract (corpus striatum, optic 
thalamus, or crus cerebri) which unites this 
portion of the hemisphere to the medulla 
oblongata, the highway by which the centre 
for the production of articulate speech is 
connected with the co-ordinating centre for 
this function, or to tumour affecting those 
centres lesion of which is associated with 
word-blindness, or word-deafness. Anaes- 
thesia of the skin is seldom met with 
as a symptom of cerebral tumour. When 
present it is found only in the limbs affected 
with motor paralysis, and is scarcely ever 
complete. 
Symptoms of special localities. - It 
remains to take special regions of the 
encephalon separately, and to endeavour to 
differentiate the position of the tumour by 
the symptoms attending its presence. 
Tumour in the medulla oblongata will be 
accompanied by various disturbances of 
sensibility, especially headache, and some- 
times by convulsions. The pressure of a 
tumour is seldom limited to the medulla 
oblongata, and the symptoms therefore are 
complex. In several of the cases recorded there 
has not only been amaurosis and deafness 
of one side, but interference with taste and 
smell. Aneurysm of the basilar artery has 
been known to cause temporary albuminuria 
and convulsions coincident with each other. 
Tumour of the fourth ventricle may 
manifest itself by the presence of sugar or 
inosite in the urine. Tumour here, as in 
the medulla oblongata, frequently destroys 
life quickly, before there has been time, so 
to speak, for much local lesion to be set up. 
Vomiting is a frequent symptom. 
Tumour of the crura cerebelli and of the 
corpora quadrig emina cannot be diagnosed 
by any peculiar symptoms. In one case, in 
which the corpora quadrigemina seemed 
wholly transformed into a tuberculous mass, 
the sight remained good, but there was 
double ptosis. 
In tumour of the cerebellum there is 
little disturbance of sensibility, except 
occipital headache. There are various dis- 
turbances of motility, especially convulsions 
and irregularity of locomotion, but no true 
paralysis. Amblyopia, amaurosis, and con- 
vergent strabismus are common. There is 
no interference with the psychical functions, 
or with speech, as a general rule. Vomiting 
is very common. In 76 cases collected by 
Ladame, there was no abnormality in the 
genital functions, except in 4 instances. 
In tumours of the pons, the disturbances 
of sensibility are general or partial anaes- 
thesia, and in some cases more or less head- 
ache. Hemiplegia, of unequal degree on the 
two sides, and other forms of paralysis are 
observed, but no convulsion. Various and 
manifold disturbances of the special senses ; 
phenomena of depression of mind; frequent 
alteration of speech; and early disorders in 
swallowing, occur. 
Tumours of the crura cerebri follow the 
example of the same lesion in the pons with 
reference to disturbances of sensibility. 
Equilateral hemiplegia opposite to the lesion 
is met with, and paralysis of the oculo-motor 
nerve on the same side as the tumour, often 
gradually extending itself to both oculo- 
motors. 
Tumours of the pituitary gland are ac- 
companied by intense frontal headache ; by 
no definite disturbances of sensation or of 
motion ; by double amblyopia or amaurosis, 
unequally developed; and by no loss of 
speech. 
Tumours of the middle cavities of the 
cranium seem to affect mainly the third and 
the fifth nerves, anaesthesia or pains in the face 
and ptosis being the prominent symptoms, 
with some interference with the free action of 
the other muscles of the eyeball supplied by 
the third. In one case, in which a scirrhous 
tumour of the left side was situated on the 
inner surface of the sphenoid bone, extend-, 
ing laterally to the internal auditory meatus 
and backwards to the pons, not only were the 
third and fifth nerves paralysed, but colour- 
blindness supervened some time before 
death. 
In tumours of the corpora striata and 
optic thalami, headache is less frequent than 
in other regions. Hemiplegia and con- 
vulsions are frequent, the former especially 
so. Hardly any disturbance of the special 
senses is observed. Intelligence and speech 
are frequently disordered. 
In tumour of the corpus callosum, there is 
frequently some mental aberration, and 
often convulsions; but not rarely a total 
absence of morbid symptoms. 
In tumour of the middle cerebral lobes, 
headache is frequently a prominent symptom, 
but otherwise the sensory disorder is mainly 
anaesthetic. Hemiplegia is common, as is 
also convulsion of an epileptiform character. 
These convulsive attacks are not rarely 
unilateral, and sometimes affect at first one 
limb only. In fact the position of a tumour 
towards the anterior portion of the middle 
lobe may be determined by symptoms with 
tolerable accuracy. Various disturbances of 
sight and of hearing are met with; as well 
as various psychical abnormalities, ranging 
from mere confusion of ideas to absolute 
imbecility. 
In tumour of the anterior lobes there is 
general headache, seldom of the frontal region 
particularly. No other sensory disturbance 216 
BRAIN, TUMOURS AND NEW GROWTHS OF 
occurs. Sight and smell are frequently 
affected, speech seldom. Hemiplegia, convul- 
sions, and psychical disturbance will occur, 
much as in tumours of the middle lobes. 
In tumour of the posterior lobes, there is 
general headache, seldom localised in the oc- 
ciput; no other sensory disturbance. Slightly 
marked hemiplegia occurs, and convulsive 
attacks are very frequent. There is no dis- 
turbance of the organs of special sense. The 
mental faculties are greatly altered, par- 
ticularly in the tendency to depression. 
All three lobes may be affected with 
tumour coincidently, and the headache is 
then very intense; the epileptiform convul- 
sions exceed the paralytic phenomena; the 
organs of special sense are little affected; and 
there are various mental disturbances. 
In tumour of the convexity, the headache 
is generally limited either to the frontal 
regions, to one side of the head, or to the 
occiput. There is neither anaesthesia nor 
paralysis, but intense convulsions occur. The 
special senses are not disturbed. The mental 
condition is one of irritation, evidenced by 
delirium and excitement. 
Lastly, very various regions of the brain 
may be simultaneously the seat of tumour, 
and the morbid phenomena will be necessarily 
complex. 
Retinal changes.- It has seemed more 
convenient to speak of retinal changes de- 
pendent on cerebral tumour separate from 
the other symptoms. Great variations in 
the lesion occur-according to the position 
of the tumour; its direct interference with 
the optic centres; its complication with 
meningitis; and its pressure on the optic 
nerves and chiasma. 
Taking choked disc, optic neuritis, and 
atrophy of the optic nerve as the three chief 
lesions, cerebral tumour may very frequently 
induce choked disc, by interfering with the 
venous ebb from the eye; optic neuritis, if 
meningitis is associated with the tumour; 
optic atrophy, by pressure of the tumour on 
the optic nerve, or by this pressure of the 
tumour or of hydrocephalus secondarily in- 
duced by it on the optic centres or tracts, or 
by softening around the tumour, such soften- 
ing implicating the optic centres, or, lastly, 
by the propagation of sclerosis. Any tumour 
situated far back in the encephalon may 
interfere with the venous flow through the 
venae Galeni, and so produce hydrocephalus 
of the ventricles, and the retinal effects of 
hydrocephalus. 
There are no retinal changes from tumour 
in the corpus callosum, nor, as a rule, from 
tumour in the optic thalami. Tumours of 
the cerebral hemispheres all influence the 
optic nerve, if they interfere with the base 
of the brain. 
Tumours of the cerebellum may cause pres- 
sure on the lateral sinuses, the straight sinus, 
the venae Galeni, or the torcular Herophili: 
pressure in any of these situations may pro- 
duce choked disc. Or the tumour may affect 
the corpora quadrigemina; or softening 
around it may spread to these organs, and 
atrophy of the optic nerve be the result. 
A fortiori, tumour of the corpora quadri- 
gemina themselves will lead to atrophy of 
nerve. 
Tumour of the crura cerebelli causes 
hydrocephalus, and its effects on the retina. 
In a similar way tumours springing from 
the bone or the membranes at the base of 
the brain may produce choked disc or 
atrophy, according to the position of the 
pressure, optic neuritis by complications 
with meningitis, or neuro-retinitis by irrita- 
tion of the connective elements of the nerves 
(see Ophthalmoscope in Medicine). Hemi- 
anopsia bitemporalis fugax has been shown 
by Oppenheim to be a valuable diagnostic 
symptom of syphilitic disease in the base of 
the skull. 
Course.-The clinical course of cerebral 
tumours is intermittent and paroxysmal. In 
many cases, such as those of glioma, it is 
very slow. Two groups of phenomena may 
complicate its ordinary course, namely, those 
associated with meningitis and apoplexy. 
Symptoms of Special Tumours.-Aneurys- 
mal tumours may sometimes be distinguished 
by the sense of throbbing in the head; by 
the patient being of adult age or young; by 
his being attacked in the midst of perfect 
health; by vomiting being rare, apoplexy 
frequent, paralysis of cranial nerves early and 
unilateral; and by absence of mental pheno- 
mena. Aneurysm situated in the cavernous 
sinus produces exophthalmos. See Brain, 
Vessels of, Diseases of. 
The symptoms of echinococci differ very 
little from those of other slow tumours: 
headache, dizziness, vomiting, syncope, and 
epileptiform attacks are most frequent. Dis- 
turbances of the motor and sensory functions, 
and also of the mind itself, are sometimes 
met with, and vary according to the situation 
of the lesion. The prognosis is unfavourable; 
the diagnosis impossible, unless echinococci 
exist at the same time in the liver. 
Cysticerci manifest their presence in the 
brain by epileptic attacks, which augment 
in number and severity ; the health of the 
patient between the fits is at first good, then 
apathy and torpor supervene; hemiplegia is 
rare, and never early; cranial nerve paralyses 
are exceptional; the symptoms are diffuse 
and bilateral, owing to the position of the 
parasite in the grey convolutions, and in 
many spots at a time. The age of the patient 
is above forty. Perhaps there may be evidence 
of the presence of cysticerci elsewhere. 
Syphilitic tumours coincide with actual or 
previous syphilis. The headache attending 
this form of tumour is generally intensified 
at night. 
In tubercle of the brain there is often a BRAIN, TUMOURS OF 
BRAIN, VESSELS OF 
217 
tuberculous family history, or the presence 
of tubercle elsewhere in the body. It seldom 
compresses cranial nerves. Its clinical evo- 
lution is often by paroxysms, and grave cases 
are combined with tuberculous arachnitis and 
hydrocephalus of the ventricles. Tubercle 
in the cortical substance of the brain and 
cerebellum may, however, be attended by no 
special symptoms. 
In cancer also there is frequently a family 
history of this malady; and the cancerous 
cachexia may be present. Cancer seldom 
exists elsew'here when it is cerebral. This 
growth is much less often accompanied by 
symptoms due to congestion and haemorrhage 
than glioma or sarcoma, being less vascular. 
Prognosis. - The prognosis of cerebral 
tumour is always bad, except in syphilitic 
gumma, and perhaps aneurysm. 
Treatment.-In syphilitic gumma and in 
aneurysm large doses of iodide of potassium 
may be used with more or less success. This 
remedy is also useful in dispersing the results 
of the meningitis which so often accompanies 
tumour of the base. Beyond this there is 
little to be done, except in the endeavour to 
relieve pain and to support the strength of 
the patient. In a few instances cerebral 
tumours have been successfully removed by 
operation. E. Long Fox. 
BRAIN, Ventricles of, Diseases of. 
See Ventricles of Brain, Diseases of. 
BRAIN, Vessels of, Diseases of. 
1. Aneurysm.-The larger arteries of 
the brain, and their minute branches in the 
cerebral substance, are both liable to aneur- 
ysmal dilatation. 
(a) Aneurysm of the larger cerebral arte- 
ries is more common than that of vessels of 
a similar size elsewhere. The large vessels 
of the base, or their primary branches, may 
be affected. The basilar and middle cerebral 
arteries are those most frequently diseased, 
aneurysms of these two vessels constituting 
more than half the cases. Next in frequency 
is the internal carotid. The vertebral, ante- 
rior and posterior cerebrals, anterior and pos- 
terior communicating, and anterior cerebellar 
arteries are occasionally, but less frequently, 
affected. In one or two recorded cases the 
aneurysm has been situated in the interior 
of the pons Varolii or cerebellum. The dis- 
ease is rather more frequent on the left 
side, but this is chiefly due to the greater 
proclivity of the left middle cerebral com- 
pared with the right, a fact which is ex- 
plained by the aetiology. There may be more 
than one aneurysm, situated on different 
arteries, or on different branches of the same 
artery. The aneurysm is usually sacculated, 
rarely dissecting. Its size usually varies from 
that of a pea to that of a nut, but aneurysms 
have been met with as large as a hen's egg. 
When the size is considerable the brain- 
tissue is pressed upon and softened, as by 
any other kind of tumour. 
^Etiology and Pathology.-These aneur- 
ysms are rather more common in men than 
in women, after actual childhood, and are 
far more frequent before the ordinary dege- 
nerative period than aneurysms elsewhere. 
Nearly half the recorded instances have oc- 
curred between ten and forty years of age, and 
about one-sixth between ten and twenty. The 
change in the arterial wall resembles that 
giving rise to aneurysm elsewhere-a fibroid 
degeneration, with loss of muscular and elas- 
tic tissue. Distensible tissue, which yields 
permanently before the blood-pressure, is 
substituted for the resilient elements of the 
wall, w'hich, normally, bring back the vessel 
to its previous size after each diastole. The 
alteration is occasionally part of a widely- 
spread arterial change, but more frequently 
is local. It is then due to some local pro- 
cess, usually one of three kinds : (1) syphi- 
litic disease, which has altered the wall, but 
has not obliterated or greatly reduced the 
lumen of the vessel; (2) injury-a blow 
or fall on the head, which probably acts 
by causing a local arteritis, whilst exten- 
sive traces of old inflammation are sbme- 
times found in the neighbourhood of the 
aneurysm in such cases; (3) embolism, 
imperfect occlusion of the vessel by a plug, 
from a valve affected with active endocar- 
ditis. Dr. Church first pointed out the asso- 
ciation in young persons of cerebral aneurysm 
with valvular disease of the heart; and. so 
many facts have been published which sup- 
port the opinion, that the relation must be 
regarded as beyond question. It is an occa- 
sional cause of aneurysm in other situations. 
There is often evidence of inflammatory and 
degenerative changes (thickening, calcifica- 
tion) in the arterial wall after embolic occlu- 
sion, especially when the plug comes from 
an inflamed endocardium. It then seems to 
have the power of exciting a considerable 
degree of inflammation in the tissue with 
which it is in contact, and the elements of the 
w'all of the artery may be altered as by trau- 
matic arteritis. If the obstruction is incom- 
plete, the altered wall may yield to the 
blood-pressure. This cause explains the 
greater frequency of aneurysm in the left 
than in the right middle cerebral, and also 
the fact that those who suffer from cerebral 
haemorrhage frequently have valvular disease 
of the heart, and in a still larger proportion 
in young persons. "Whatever is the cause of 
the alteration in the arterial wall, the efficient 
agent in the production of the aneurysm 
is the high blood-pressure in the cerebral 
arteries, coupled perhaps with a slighter ex- 
ternal support than is possessed by the 
vessels in other parts. 
Rupture has occurred in more than half 
of the recorded cases of cerebral aneurysm. 
The blood may escape rapidly or slowly, and 218 
BRAIN, VESSELS OF, DISEASES OF 
the haemorrhage may take place into the sub- 
arachnoid space, or into the adjacent cerebral 
substance. In the former case, meningeal 
haemorrhage is the result. Rupture into the 
cerebral substance is not uncommon. An 
aneurysm in the fissure of Sylvius may cause 
a haemorrhage into the substance of the brain, 
bursting into the lateral ventricle; and an 
aneurysm on the posterior cerebral artery 
may burst into the substance of the pons. 
Two causes may determine this rupture 
into the substance of the brain - first, 
thickening of the subarachnoid tissue adja- 
cent to the aneurysm, hindering its rup- 
ture outwards; secondly, the small size of 
the opening and consequent gradual escape 
of the blood, producing a slow disintegration 
of the brain-tissue, and thus preparing a 
channel for the effusion. In such cases only 
a small quantity of blood may have trickled 
into the ventricles or subarachnoid space. 
In rare cases a communication with a venous 
sinus forms, and constitutes an arterio-venous 
aneurysm. This has occurred between an 
aneurysm of the internal carotid and the 
cavernous sinus. 
Symptoms.-Symptoms of the existence of 
an aneurysm may be entirely absent. When 
present, they depend on the pressure which 
the tumour exerts on neighbouring parts. 
They vary widely according to its seat, and 
they are rarely by themselves distinctive. 
Mental disturbance is uncommon. Head- 
ache is a very uniform symptom. It is often 
intense, sometimes throbbing, and may be 
localised, as in the occiput in basilar aneur- 
ysm. Giddiness is not uncommon, and is 
complained of in aneurysms in all situations. 
Convulsions are not frequent except in cases 
in which the aneurysm is in the neighbour- 
hood of the motor region of the cortex, i.e. is 
on the middle cerebral or its branches. Palsy 
in some situation often occurs, and depends 
on the pressure of the tumour; the most 
common is that of the cranial nerves which 
lie adjacent to the aneurysm, as of the nerves of 
the orbit in aneurysm of the internal carotid. 
Optic neuritis is occasionally present. The 
symptoms are thus those of an intracranial 
tumour, and they suggest an aneurysm when 
they are such as to show that the tumour is 
in the position of one of the arteries liable to 
be affected ; and the probability is increased 
if one of the known causes of aneurysm can 
be traced. Aneurysms elsewhere would, of 
course, give great additional significance to 
the symptoms, but the coincidence is too 
rare, an instance being almost unique, to be 
of practical importance. In some cases a 
murmur can be heard by the patient, and in 
still rarer cases (of aneurysm of the internal 
carotid) it has been audible on auscultation. 
But such an objective murmur alone can 
not afford actual proof of the existence of an 
aneurysm, since pulsation, the chief sign of an 
accessible aneurysm, can never be perceived. 
Rupture of an intracranial aneurysm gives 
rise to symptoms which vary according as 
the blood escapes quickly or slowly. If 
quickly, the blood usually escapes into the 
meninges and causes sudden apoplexy with 
general paralysis, rapidly deepening to a fatal 
issue. If slowly, the symptoms are less sud- 
den, and unilateral paralysis or convulsion 
may occur. This is especially the case when 
the blood escapes slowly into the cerebral 
substance; the unilateral symptoms com- 
mence suddenly, and gradually increase 
during a few hours or days, with or with- 
out initial loss of consciousness, but ending 
in fatal coma. 
Treatment.-Little can be done in cases 
where intracranial aneurysm is suspected. 
Even when it is of syphilitic origin, drugs 
are powerless to alter the damaged and dilated 
vessel, since the change which has given rise 
to it is of the nature of a cicatricial transfor- 
mation of the syphilitic tissue, on which drugs 
can no longer exert the influence they possess 
over the earlier stages of the newly-formed 
growth. Hypodermic injection of ergotin 
(£-grain) has been recommended by Langen- 
beck and advocated by Bartholow. Iodide 
of potassium may also be given in the hope 
of promoting coagulation within the sac, from 
the undoubted evidence of the power it has 
to effect this in aneurysms elsewhere. Rest 
is important. All causes of increased intra- 
vascular pressure, such as effort and low posi- 
tions of the head, are to be avoided. The 
bowels should be kept regular. In rare cases 
where progressive paralysis of orbital nerves 
suggests the probability of aneurysm of the 
internal carotid, and a murmur renders the 
diagnosis certain, ligature of the common 
carotid may be, and has been, resorted to 
with success. It is, moreover, probable that 
intracranial surgery may be able to cope with 
aneurysms on some other vessels, but on this 
point experience has still to be gained. 
(6) Minute ' miliary ' aneurysms occur in 
the small arteries of the pia mater and sub- 
stance of the brain (Virchow, Charcot, and 
Bouchard). They are met with almost ex- 
clusively in the second half of life, and 
increase in frequency with age up to about 
seventy-five, the less frequency of cerebral 
haemorrhage in extreme old age making it 
probable that they are less common in very 
late life. They may involve vessels not more 
than the inch in diameter, but are most 
common on vessels a little larger than this. 
The walls suffer fibroid degeneration of the 
outer and middle coat, commencing, it is 
said, as nuclear proliferation. The muscular 
tissue of the middle coat disappears, and the 
whole wall at the spot becomes dilated into 
a sacculated aneurysm, varying in size from 
the 55 to the fjj of an inch. These dilata- 
tions have been found in all parts, but most 
frequently in the central ganglia, and next 
most frequently in the pons Varolii, the con- BRAIN, VESSELS OF, DISEASES OF 
219 
volutions, the cerebellum, the medulla oblon- 
gata, the cerebellar peduncles, and the cen- 
trum ovale (Bouchard). They are to be 
found in most cases of cerebral haemorrhage; 
and it is probable that such haemorrhage is 
usually due to their rupture. Similar minute 
aneurysms of the retinal arteries co-exist in 
rare cases. 
The rupture of a minute artery into its 
perivascular sheath distends this with blood, 
causing what has been termed a minute dis- 
secting aneurysm. Such are frequently met 
with in cases in which the vessels are ex- 
posed to extreme pressure, as in death from 
asphyxial conditions; or in the increased 
tension in collateral vessels when vascular 
obstruction has occurred. 
Symptoms.-No symptoms are known to 
be associated with the existence of these 
minute aneurysms, and this fact explains the 
absence of indications of a liability to cerebral 
haemorrhage. The symptoms of rupture are 
described under Brain, Haemorrhage into. 
2. Degeneration.-(a) Of Arteries.- 
The larger cerebral arteries are very common 
seats of the thickening of the inner coat, 
called by Virchow ' endarteritis deformans,' 
and which, when fattily degenerated, consti- 
tutes ' atheroma.' In the cerebral vessels the 
fatty change occurs quickly and frequently ; 
and opaque yellow thickenings are the result. 
Only one or two of these may be present; or 
the change may involve the whole of the 
larger vessels at the base and extend for a 
considerable distance along the chief cerebral 
branches. The distribution of the degenera- 
tion may be symmetrical. It may coexist 
with a similar change in arteries elsewhere, 
or may be isolated. Degeneration of the 
cerebral arteries is common after middle life, 
being found in seven-tenths of the subjects 
examined (Bichat). It occasionally occurs 
much earlier, especially in cases of chronic 
Bright's disease and alcoholism. The ex- 
citing cause of this disease is probably the 
strain to which the badly supported cerebral 
vessels are exposed in consequence of their 
early origin from large trunks, perhaps 
rendered more effective by the deficient sup- 
port from adjacent structures. The influence 
of strain explains the relation of atheroma to 
Bright's disease, in which the arterial tension 
is so much increased. It is not easy to ex- 
plain the occasional freedom of these vessels 
from atheroma when this is abundant else- 
where. 
The degenerated tissue occasionally softens 
and a cavity forms and opens into the vessel, 
so as to permit the formation of a dissecting 
aneurysm. More commonly it undergoes 
calcification. The result of these thickenings 
of the wall is generally to lessen the calibre 
of the vessel, sometimes to close it altogether, 
to cause local anaemia of the brain, and to 
favour the formation of a coagulum in the 
unnarrowed part beyond, with the result that 
softening occurs in the part supplied by it. 
"Where the change in the wall is slight, the new 
tissue may undergo fibroid change only, the 
wall remains thin, the artery may be dilated 
at the spot, but the tissue formed in this pro- 
cess is seldom extensible enough to permit a 
true aneurysm to result. Hence it is rare 
for arteries affected with atheroma to give 
way, and permit haemorrhage to take place ; 
the change in the wall differs from that which 
permits the extension (into an aneurysm) 
which precedes rupture. The minute arteries 
of the cerebral substance may undergo fatty 
degeneration, but they do not suffer from the 
change above described. There is not, in 
them, the formation of a new tissue that 
undergoes fatty degeneration, although their 
elastic elements may be replaced by the 
inelastic extensible tissue that permits the 
formation of an aneurysm. 
Symptoms.-Atheroma of the cerebral ves- 
sels leads to the symptoms of local anaemia 
of the brain, and is a common cause of the 
transient cerebral symptoms so frequent in 
the old. Tingling in the limbs of one side, 
and slight loss of power, may be due to this 
cause, and are frequently the precursors of 
an attack of hemiplegia from the closure of 
the vessel. It is possible also that the loss 
of memory and mental failure common in 
the old may be the result of more general 
interference with the supply of blood to the 
brain in consequence of this arterial disease, 
or of the deficient supply to certain parts sub- 
serving more general psychical functions. 
But caution should be observed in ascribing 
such senile symptoms to this mechanism; 
general symptoms are probably more fre- 
quently due to senile failure in the nutrition 
of the cells of the cortex. 
Treatment.-Tonics, cardiac stimulants, 
and substances which, as cod-liver oil, pro- 
mote the nutrition of the tissues generally, 
may be given with possible advantage. It 
is not likely, however, that any treatment can 
modify the state of the arterial wall, or that 
its tissue ever resumes, in any degree, its 
normal characters. The maintenance of the 
general nutrition in a good state may lessen 
the tendency to fatty degeneration and sub- 
sequent calcification of the tissue, and thus 
postpone or prevent the disastrous conse- 
quences of occlusion of the vessels. In this, 
however, we can only adjust our treatment 
on rational grounds, since the nature of the 
case precludes any possible evidence of bene- 
ficial result. Of especial importance is it, in 
any case in which there is reason to believe 
or to suspect the presence or future develop- 
ment of atheroma, to do all in our power to 
keep the arterial tension within normal 
limits, and to preserve the blood from the 
presence of the products of imperfect diges- 
tion and the accumulation of metabolic pro- 
ducts, which favour thrombosis. 
(6) Of Veins.-Degeneration of the walls 220 
BRAIN, VESSELS OF, DISEASES OF 
of the veins is much less frequent than de- 
generation of the arteries, perhaps on account 
of the less degree of pressure to which they 
are exposed. Disease of them is generally 
the result of inflammation communicated 
from without. Occasionally the veins of the 
pia mater may be found varicose in advanced 
life, and in one case recorded by Andral 
rupture of such a dilated vein was the cause 
of meningeal haemorrhage. 
3. Embolism. - Definition.-The ob- 
struction of arteries or capillaries of the brain 
by solid particles carried by the blood-current 
from some other part of the vascular system. 
.Etiology.-The source of the embolic par- 
ticles is almost invariably situated between 
the pulmonary capillaries and the obstructed 
vessels, i.e. in the pulmonary veins, the left 
side of the heart, or the arteries. In arterial 
embolism it is necessarily so, since no par- 
ticles large enough to obstruct even a small 
artery could pass through the capillaries of 
the lungs. In almost all cases the heart is 
the source of the plugs, a particle of fibrin 
being washed by the blood from a deposit on 
a diseased valve or in some recess (as the 
auricular appendix). Endocarditis, or chronic 
valvular disease, therefore, usually coexists 
with the embolism. Mitral stenosis is an 
especially frequent source of emboli, probably 
because the surface is commonly much 
altered, and the blood-current is in part slow 
(in diastole, allowing deposit), and in part 
very rapid (in auricular systole, detaching 
loose fibrin). Moreover the dilatation of the 
left auricle, and the imperfect degree in which 
the blood is expelled from it, frequently lead 
to a coagulum in the appendix. Disease of 
the aorta-atheroma or aneurysm-is the next 
most frequent source, and, less frequently, 
disease of the carotid or vertebral arteries, 
and coagulation in the pulmonary veins, large 
or small-the latter in some rare cases of 
inflammation and growths. 
Particles obstructing capillaries may come 
from some softened atheromatous patch or 
fibrinous deposit, from pigmentary forma- 
tions, or from deposits in ulcerative endocar- 
ditis. In the last case the obstructing material 
has a septic character, probably due to bac- 
terial organisms, and the inflammation it 
causes may be suppurative. 
Embolism occurs with equal frequency in 
both sexes, and at all periods of life, but most 
frequently between later childhood and mid- 
dle life. This is explained by the fact that 
it occurs more readily from valvular disease 
due to endocarditis, than from that which 
results from the degeneration of age, but most 
frequently when the lapse of time has led to 
secondary changes in the valves damaged, or 
during second attacks of endocarditis-in- 
flammation of valves previously diseased 
being especially prone to give rise to embo- 
lism. Hence most subjects of embolism have 
suffered or are suffeiing, from one of the 
diseases known to cause endocarditis, and 
especially from rheumatic fever. 
Anatomical Characters.-Almost any of 
the cerebral arteries may be obstructed ; but 
the vessels most prone to suffer are the 
middle cerebrals, in consequence of the more 
direct circulation into them. Next in fre- 
quency are the internal carotid and the 
anterior cerebral. Embolism is less fre- 
quent in the arteries to which the vertebrals 
convey blood, but has been met with in most 
of them; even the basilar may be obstructed 
by a clot small enough to pass through the 
vertebrals, but too large to enter the posterior 
cerebral. The cerebellar arteries are those 
least frequently affected. Obstruction of 
several vessels is sometimes found, having 
occurred at the same or different times. 
Embolism is more common on the left side, 
but the difference is not so great as is often 
stated, being not greater than as four to 
three. It is due to the more direct origin of 
the left carotid, into which a plug can there- 
fore be more easily carried than into the 
right; hence it depends on the greater fre- 
quency of the occlusion of the branches of 
the internal carotid, and especially (because 
it is the vessel most often affected) of the 
middle cerebral. The left vertebral is also 
rather more often plugged than is the right, 
but embolism of this artery is too rare mate- 
rially to influence the numerical relation 
between the vessels of the two sides in their 
liability to accident. 
The plug is usually arrested at some spot 
at which the vessel is narrowed by a branch 
being given off. Here the fragment may be 
found, usually decolourised, and commonly 
closing altogether the lumen of the vessel. 
On each side of this is a secondary clot: the 
distal extends far into the contracted branches 
of the vessel, the proximal as far as the next 
large branch. The obstruction may lead to 
inflammation of the wall of the vessel at the 
spot, especially when the plug has been car- 
ried from a place at which inflammation is 
going on. The inflammation leads to change 
of texture and degeneration, fibroid or fatty ; 
the former may permit an aneurysm to be 
formed, the latter may cause a thickened 
patch, in which calcification may occur. The 
inflammation may spread to the adjacent 
tissue, leading to induration around the spot. 
It is most intense when the plug comes from 
a valve the seat of active endocarditis, and 
may then determine a peculiar irritative 
character in the secondary inflammation, as 
is shown by the fact that optic neuritis some- 
times develops in such cases. 
The effect of embolism is to arrest the 
blood-supply to the part to which the artery 
is distributed, unless the blood can reach it 
by some other channel; the cerebral tissue, 
deprived of its circulation, undergoes necrosis 
and the necrotic softening described in an- 
other article. This result, however, is often BRAIN, VESSELS OF, DISEASES OF 
221 
prevented by the anastomoses that exist, 
and as these are very irregular in the cortex 
of the brain, both in different persons and 
in different parts of the same arterial area, 
considerable variations exist in the extent 
of softening that results from occlusion of 
the same artery. But in the central ganglia 
anastomoses are absent, and softening uni- 
formly follows. Thus embolism of the middle 
cerebral may cause softening of the corpus 
striatum, and the cortex supplied may be 
intact, softened in irregular areas, or totally 
destroyed. Capillary embolism also causes 
softening, and when the obstruction is from 
a septic source, ' metastatic abscess ' may 
result. Thus cerebral abscess results from 
suppurative disease in the thorax and other 
parts. One of the rare curiosities of patho- 
logy is the production of such abscess by the 
embolic obstruction of the vessels with frag- 
ments of oidium albicans. A plug of fibrin 
sometimes quickly breaks up, and is carried 
into the capillaries, so that the artery is per- 
vious, although the brain-tissue it supplies is 
necrosed. Necessarily, when the capillaries 
are obstructed, a collateral blood-supply is of 
no avail to prevent softening. 
For the symptoms, diagnosis, and treat- 
ment of cerebral embolism see Brain, Soften- 
ing of. 
4. Rupture. - Rupture of cerebral ar- 
teries is common and is the cause of cerebral 
haemorrhage; and rupture of capillaries is not 
infrequent. Rupture of veins is extremely 
rare, except as the result of injury. 
(a) Of Arteries.-The proximate causes of 
rupture are weakening of the arterial wall, 
and increased pressure within the vessel. 
The conditions which give rise to these two 
factors are the remote causes of rupture. 
The actual rupture is commonly due to a 
temporary sudden excess of intravascular 
pressure. 
Etiology.-The wall of the vessel is 
weakened, especially by degenerative disease 
-chronic periarteritis, or (rarely) simple 
fatty degeneration. Aneurysmal dilatation 
and thinning may have resulted from the 
chronic change. In some diseases attended 
with a tendency to extravasation (purpura, 
haemophilia, &c.) it is probable that the vas- 
cular walls undergo rapid degeneration (in 
the acquired), or are unusually thin (in the 
congenital) maladies. Defective external 
support, from atrophy of the brain, causing 
increased size of the perivascular canals, 
was formerly thought to be a potent cause, 
and is now perhaps underrated. The mobile 
perivascular fluid which surrounds the vessels 
must afford a less efficient support than 
cerebral tissue, and sudden variations in the 
size of these canals will expose the vessels to 
sudden differences in the amount of tension 
to which their walls are exposed. 
When vessels are much weakened, they 
may rupture when the extravascular pressure 
is at, or even below, the normal; very com- 
monly, however, there coexists increased 
pressure. Loss of arterial elasticity leads to 
a jerky pressure. Arterial degeneration, and 
still more constantly, arterial contraction, 
in Bright's disease, cause increased tension 
by obstruction; and the hypertrophy of the 
heart, which develops to overcome the ob- 
struction, adds materially to the pressure 
within the arteries. Hypertrophy to over- 
come an obstacle near the heart has probably 
no influence in causing rupture of cerebral 
vessels. 
The immediate cause of rupture is gene- 
rally some temporary increase of the blood- 
pressure due to effort-as in cough, straining 
at stool or vomiting; excited action of the 
heart; suddenly developed heart- or lung- 
disease obstructing the circulation; local 
obstruction to return of blood; contraction 
of the arterioles, general or local; or the 
action of gravitation in the recumbent pos- 
ture. The last two causes, acting together, 
probably determine the frequent occurrence 
of rupture during sleep. 
The conditions which produce these proxi- 
mate causes are the remote causes of rupture. 
The most efficient are those which determine 
weakening of the vascular wall, and have 
already been spoken of (see Degeneration). 
Age is an important element-rupture is 
most common after fifty, but may occur from 
local vascular disease at any age. Heredi- 
tary predisposition is effective by a tendency 
to early degeneration, and is often very con- 
spicuous ; several members of the same 
family die at the same time of life from this 
cause. Position of degeneration is probably 
largely influenced by the distribution of the 
vessels; and the latter may be hereditary, as 
the retina sometimes strikingly shows us: 
the same distribution of the retinal artery 
may be seen in parent and child. So, too, 
correspondence in the way in which the 
cerebral arteries of the two sides divide and 
are distributed may be observed to coincide 
with a close correspondence in the position 
of spots of visible degeneration, and doubtless 
also determines a like symmetry in the in- 
visible degeneration of these aneurysms; 
hence rupture sometimes occurs at the same 
place in each hemisphere. Sex tells probably 
by exposure to the greater pressure entailed 
by muscular effort (men suffer from rupture 
twice as frequently as women). Alcoholism 
leads to early degeneration. But the most 
efficient predisponent is Bright's disease, 
which leads to great intravascular pressure, 
and weakens the cerebral vessels by causing 
degeneration. It is probable that some acute 
diathetic diseases in which rupture is com- 
mon act in a similar manner. 
Some of the cerebral arteries give way 
more frequently than others, especially the 
arteries of the corpora striata and pons 
Varolii. This seems due (1) to their origin 222 
BRAIN, VESSELS OF, DISEASES OF 
of the growth resembles that of syphilomata 
elsewhere. It begins by a nuclear prolifera- 
tion between the inner coat and the elastic 
lamina, and it attains its chief development 
in this situation, the elastic lamina being 
pushed outwards and the lumen of the vessel 
obliterated. The middle coat may ultimately 
disappear. Vessels may form in the sub- 
stance of the growth, and may subsequently 
be obliterated, leading to the irregular fatty 
degeneration so characteristic of these for- 
mations. The disease is sometimes sym- 
metrical on the arteries of the two sides. 
The growth or secondary thrombosis occlud- 
ing the vessel, softening may result in the 
area of brain-tissue supplied by it. Since the 
symptoms due to the occlusion are usually 
sudden, it is probable that the final arrest 
of the diminished blood-supply is always 
through the agency of thrombosis. As in 
other forms of arterial narrowing, when a 
certain degree of constriction is reached, the 
condition of the circulation in the vessel 
beyond must of necessity be such that clot 
forms on the altered wall, and at last the 
blood-flow suddenly ceases. The softening 
resembles in its occurrence and characters 
that which is produced by degenerative 
changes in the arteries, but is more varied 
in its seat, and it affects younger persons. 
The diminished elasticity of the diseased 
wall, when the thickening is slight, may 
permit the dilatation of the vessel into an 
aneurysm. Possibly the same result may 
follow the fatty degeneration of the new 
tissue. 
Symptoms.-No symptoms are produced 
by the arterial disease until it causes local 
anaemia or softening, the symptoms of which 
resemble those due to other causes. 
Treatment.- This is that of the later stages 
of syphilis. It must be remembered that the 
removal of arterial disease may not restore 
the damaged cerebral tissue. 
6. Thrombosis.-Thrombosis-the coa- 
gulation of the blood in situ-may occur in 
the cerebral arteries; or in the cerebral veins 
and sinuses. 
(a) In the Arteries. 
Etiology.-The causes of arterial throm- 
bosis are the following :- 
(1) An alteration in the wall of the artery, 
by which the blood comes in contact with an 
abnormal surface. The most common con- 
dition is atheroma, and hence arterial throm- 
bosis is most frequent when atheroma is most 
common-in the old. Syphilitic disease of 
the artery sometimes leads to it. Much more 
rarely it is caused by an arteritis, spon- 
taneous, or the result of adjacent inflamma- 
tion or traumatic damage. 
(2) Retardation of the blood-current. This 
may result from weakened action of the 
heart in debilitating diseases (as phthisis and 
cancer), and in extreme fatigue. It may be 
part of the effect of a convulsive fit; or it 
at right angles from vessels of very consider- 
able size (basilar and middle cerebral), and 
their consequent exposure to the full pres- 
sure within the parent trunk. (2) To their 
' terminal ' character, which precludes col- 
lateral relief when a general increase of 
intra-arterial pressure augments dispropor- 
tionately that in an artery in which it is 
normally above the average for the size of 
the vessel. One artery, which very frequently 
gives way, passes from the middle cerebral 
through the anterior perforated spot, out- 
wards between the island of Reil and the 
lenticular nucleus, the outer part of which it 
perforates, and then passes through the white 
' internal capsule,' between the lenticular and 
caudate nuclei, to ramify in the anterior part 
of the latter. The arterioles supplying the 
convolutions on the surface of the brain are 
not often ruptured, except from injury. They 
are exposed much less directly to the blood- 
pressure, and sometimes possess considerable 
anastomoses. 
Symptoms.-The consequence of rupture of 
an artery is cerebral haemorrhage, the symp- 
toms and treatment of which are described 
elsewhere (see Brain, Haemorrhage into). 
In traumatic laceration of the brain the 
arteries are torn, and often cause much 
haemorrhage. 
(6) Of Capillaries.-The minutest arteries, 
and veins, and the capillaries rarely rupture, 
except when exposed to sudden pressure by 
venous thrombosis, when the obstruction in 
the part from which the vein proceeds may 
determine numerous capillary haemorrhages 
into the cerebral substance. In general 
venous congestion, as in asphyxial states, 
such haemorrhage may occur; but a more 
frequent result is rupture of a vessel within 
its perivascular sheath, which thus becomes 
distended with blood. 
For symptoms see Brain, Haemorrhage into. 
5. Syphilitic Disease.-The arteries of 
the brain are occasionally diseased in con- 
stitutional syphilis, between the first and 
twelfth year after infection, but occasionally 
in the earlier or later stages of syphilis. The 
large arteries at the base are those commonly 
affected; very rarely a similar change in- 
vades the minute arteries of the central 
substance. Usually more than one vessel is 
affected. It is generally the result of the 
acquired, but sometimes of the congenital 
malady. The frequency of the lesion is not 
known, since it is only recognised when the 
affected artery becomes occluded or greatly 
narrowed by the change. The disease may 
occur without this consequence and probably 
does so not rarely, and is removed by treat- 
ment adopted on account of simultaneous 
manifestations in other situations. The wall 
is thickened at circumscribed areas by a 
fibro-nuclear growth, which causes a nodular 
projection on the exterior, and diminishes 
also the calibre of the vessel. The structure BRAIN, VESSELS OF, DISEASES OF 
223 
may be caused locally by the arterial diseases 
mentioned already, which lead to narrowing 
and loss of elasticity. 
(3) An increased tendency of the blood to 
coagulate. This is seen in many diseases, 
especially in marasmic states in young and 
old. (such as are caused by phthisis and 
cancer), in acute rheumatism, and in the 
puerperal condition. A slight cause then 
suffices to produce coagulation, and the weak 
heart, so common in many of these conditions, 
may cause sufficient retardation of the blood- 
current. 
(4) Lastly, thrombosis in an artery may be 
secondary to its complete or partial obstruc- 
tion by an embolus. 
Anatomical Characters.-The arteries 
occluded may be one or several, and large or 
small. Thrombosis occurs most frequently 
in the internal carotid, middle cerebral, verte- 
bral, and basilar arteries, or their branches. 
It is not uncommon for a clot to form in a 
branch that comes off at a diseased spot, 
while the main artery continues pervious. 
The orifice of the branch is narrowed so 
that enough blood does not enter to main- 
tain the circulation in the part beyond. 
The vascular wall may present any of the 
local causal conditions already mentioned, 
or it may be healthy. After a time thicken- 
ing from secondary arteritis occurs. Within 
the vessel is a coagulum which usually fills 
its interior, and is adherent to the wall. 
It may not fill the vessel, either because 
originally imperfect, or because the clot has 
shrunk. A recent quickly-formed coagulum 
is red, but after a time it becomes pale and 
yellow. A slowly-formed coagulum is pale, 
and may be laminated. A secondary clot 
usually forms far into the contracted distal 
branches, and on the proximal side as far 
as the nearest large branch. Ultimately 
the clot may, rarely, soften, the channel 
being sometimes re-established. More com- 
monly it undergoes calcification, or, with 
the artery, contracts and becomes atrophied. 
The brain-tissue, in which the artery was 
distributed, may be at first anaemic, but 
quickly becomes congested. It ultimately 
undergoes softening-red, yellow, or white, 
according to the amount of vascular disten- 
sion. If the collateral circulation is free, it 
may remain unsoftened. 
Symptoms.-Where chronic arterial disease 
is the cause of thrombosis, it may be preceded 
by the symptoms of local cerebral anaemia 
(see Brain, Anaemia of). The thrombosis 
itself leads to the symptoms of loss of func- 
tion in the part to which the artery passed. 
The onset of these symptoms is slow or sud- 
den, according to the rapidity with which 
the coagulum forms; and their degree de- 
pends on the size of the vessel occluded, its 
position, and its relation to other vessels 
which may supply blood to the area in- 
volved. Thrombosis of a small vessel in the 
cerebral substance usually leads to transient 
brain-disturbance, headache, vertigo, ting- 
ling, and temporary weakness in the limbs, 
which soon pass away if a collateral circula- 
tion is established ; more slowly, if softening 
ensues, by compensatory action elsewhere. 
The occlusion of a large vessel causes com- 
monly more marked symptoms. Complete 
hemiplegia is frequent, and its onset may be 
marked by loss of consciousness. See Brain, 
Softening of. 
Diagnosis.-The diagnosis rests on a com- 
bination of the symptoms of local cerebral 
disease with the causal condition-vascular 
mischief (indicated by probable age, degener- 
ation elsewhere, or syphilis), and with con- 
ditions leading to relaxation of the blood- 
current, or increased coagulability of the 
blood. The diagnosis is rendered more pro- 
bable by the symptoms if slight being tran- 
sient, if severe being of gradual onset, and, 
whether slight or severe, being preceded by 
the premonitory indications of local cerebral 
anaemia. 
The prognosis and treatment of throm- 
bosis in arteries are considered under its 
consequence, Brain, Softening of. 
(6) In Cerebral Veins and Sinuses. 
./Etiology.-Thrombosis in sinuses may 
be primary, and due to changes in the con- 
stitution or the circulation of the blood; or 
secondary, and due to local causes inducing 
coagulation directly at the spot affected. 
Secondary thrombosis is the more common. 
The same conditions of retarded circulation 
and altered blood-state which permit coagu- 
lation in arteries, favour it also in veins, and 
it is often seen in such conditions as phthisis 
and cancer, and especially in marasmic states 
in children. Hence the primary form is most 
common in children, but the secondary form 
occurs with nearly equal frequency through 
'life. Local retardation of the circulation 
from narrowing of the sinus, or compression 
of the jugular vein, occasionally assists. The 
blood-current in the front part of the longi- 
tudinal sinus is one of extreme sluggishness, 
on account of the physical conditions of the 
circulation. Local change causing coagula- 
tion is usually the extension to the sinus of 
adjacent inflammation, or of a clot produced 
in a tributary vein by such inflammation. 
Caries of the bones of the skull, especially of 
the temporal bone, and meningitis are com- 
mon causes. Lastly, injuries of the skull 
involving the sinuses sometimes cause co- 
agulation in them. 
Anatomical Characters.- Of primary 
thrombosis the superior longitudinal sinus 
is the most common seat, and thence the 
clot spreads into the veins on either side, and 
often also into the lateral sinuses. When 
secondary, the thrombosis occurs in the sinus 
nearest to the local mischief; in disease of 
the petrous bone, the lateral sinus is usually 
involved. The sinus is distended by firm 224 
clot, commonly (not invariably) adherent, 
sometimes in concentric layers. The walls 
of the vessel are healthy when the throm- 
bosis is primary or secondary by extension of 
clot, but thickened and brittle when invaded 
directly by adjacent inflammation. After a 
time the clot may soften and break down. 
The consequence of venous thrombosis is 
local arrest of the blood-current, the tribu- 
tary veins and capillaries becoming enor- 
mously distended with blood and rupturing, 
and the cerebral substance being crammed 
with minute capillary extravasations which 
often coalesce. The condition is frequently 
seen in the convolutions. Blood is also 
effused into the meshes of the pia mater, 
and into the subarachnoid space. Into the 
looser tissues and into the ventricles serum 
may escape. Thrombosis of the veins of 
Galen is one cause of ventricular effusion. 
Ultimately the brain-tissue, the seat of the 
ischaemic congestion, undergoes softening, 
first red, and then yellow or white. Occa- 
sionally the softening of the clot leads to 
pyaemia. 
Symptoms.-The symptoms vary in their 
character. Sometimes they are at first those 
of mental excitement, namely, intense head- 
ache and muscular spasm, shown as con- 
tractions in the limbs, or as convulsion, 
often beginning locally, according to the 
position of the congestion. These symp- 
toms, after one or several days, are suc- 
ceeded by those of depression; with coma, 
and dilatation of pupils. In other cases the 
coma may come on suddenly, and the stage 
of excitement, above described, may be absent 
or little marked. Now and then hemiplegia 
slowly comes on, without initial loss of con- 
sciousness, and develops to a complete de- 
gree in the course of a few hours or a few 
days. Convulsions, when they occur, often 
continue till death. When the superior 
longitudinal sinus is plugged, epistaxis, 
oedema of the forehead, and exophthalmos 
have sometimes been observed. When the 
lateral sinus is obstructed, there may be 
painful oedema behind the ear, and the 
jugular vein on that side has been noticed 
to be less full than on the other. 
Diagnosis.-The diagnosis rests on the 
occurrence of severe cerebral symptoms in 
association with a causal condition, consti- 
tutional or local. 
Prognosis.-This is always serious, death 
being, in most cases, speedy. 
Treatment.-The indications for treat- 
ment are mostly causal. In primary throm- 
bosis stimulants and nutritious diet are 
necessary, and tonics if they can be taken. 
The patient should lie with the head and 
shoulders a little elevated, and care be taken 
that the neck is not bent, and that there is no 
constriction of it by tight clothes. In second- 
ary thrombosis, occurring in robust indi- 
viduals, leeching or cupping is recommended; 
BRAIN, VESSELS OF 
purgatives should be given; and in the less 
severe cases a blister may be applied to the 
neck, and the utmost care taken to afford 
free exit for pent-up inflammatory products. 
Pain and convulsion are relieved most effec- 
tually by cold to the head. 
W. R. Gowers. 
BRAIN FEVER.-A name popularly 
applied to any kind of febrile state in which 
symptoms of cerebral excitement are promi- 
nent ; as well as to cases of inflammatory 
disease of the brain or its membranes. 
BREAK-BONE FEVER. -A syno- 
nym for dengue. See Dengue. 
BREAST, Diseases of.-Synon. : Fr. 
Maladies de la Mamelle; Ger. Brustdriisen- 
krankheiten. This subject will be treated 
under the following divisions :- 
I. Diseases before puberty, in both sexes. 
II. Diseases about the age of the establish- 
ment of puberty ; and after that period, in 
the female.-(A) in the active state of the 
gland; (B) in the passive state. III. Dis- 
eases affecting the rudimentary organ in the 
male. IV. Diseases of the nipple. 
The diseases of an organ composed essen- 
tially of glandular structures have here to be 
described. The mammary gland is classed 
with those termed racemose; but it differs 
from every other organ in the body of a 
similar class, inasmuch as it only arrives at 
maturity when its function is to be subser- 
vient to the nourishment of the offspring. In 
its perfection it appears, normally, only in 
the female sex, and even then it does not 
become developed until the internal organs 
of generation are capable of performing their 
functions. 
Hence, to describe systematically the dis- 
eases of the breast, it is requisite to treat of 
them not only in reference to sex, but also in 
relation to the different periods of life at 
which certain diseases appear. Briefly then, 
from a histological point of view, they occur : 
(a) in the rudimentary state of the gland; 
(6) in its mature state; (c) when it has 
become a secreting organ; (d) during a state 
of degeneration. 
I. In the rudimentary period of the gland 
the tissues composing it are rarely liable to 
morbid derangement. Usually, soon after 
birth, especially in male infants, the rudi- 
mentary nipple and the skin of the region 
within the zone of the areola become slightly 
elevated and of a pink hue. In some infants 
a secretion, slightly milk-like, oozes from the 
ducts. In this state, the injudicious rubbing 
practised by the attendant excites inflamma- 
tion, which, if not arrested by desistance 
from that pernicious interference, may ad- 
vance to suppuration. When that happens, 
the abscess must be incised and treated on 
ordinary principles. 
II. About that age, in both sexes, when 
the development of the generative organs 
BREAST, DISEASES OF BREAST, DISEASES OF 
225 
advances with greater rapidity to maturity 
than in early life, the breast-gland enlarges, 
and may be painful, thus causing anxiety to 
the individual. Development usually takes 
place symmetrically in the female ; but, when 
the gland of the one side takes precedence 
of that of the other, the circumstance need 
only be regarded as a departure from the 
ordinary rule, for no trouble will result, and 
in due time both will attain their normal 
proportions. In the male, pain or uneasiness 
sometimes occurs for a few days about this 
period, very often excited by the pressure of 
the dress. The removal of this cause is suffi- 
cient to arrest further mischief. 
In the female the development of the breast 
having reached maturity, the gland becomes 
associated by sympathetic influences com- 
municated through nervous stimuli with the 
functions of the pelvic generative organs. 
This physiological fact should always be re- 
membered when investigating the nature of 
the morbid affections of this organ. 
From a clinical point of view, it is essential 
to examine the diseases of the breast under 
the two states before mentioned, namely-(A) 
whilst the gland is undergoing metamorphosis 
into a secreting organ, and during lactation; 
(B) as a mature gland, but passive as regards 
its function. 
Glancing at the various morbid states of 
the body of the gland as a whole, they may 
be divided, primarily, into two groups :-the 
functional derangements; and the structural 
or histological diseases. 
We will now proceed to discuss these affec- 
tions, as they are presented at the different 
periods mentioned above. 
A. After conception the breasts soon begin 
to enlarge, and minute pisiform indurations 
may be felt at their borders and surface. 
Occasionally, but very rarely, this normal 
increase in bulk is attended with considerable 
pain and irritation extending throughout the 
nervous relations of the gland. The pain is 
referred to the back, neck, inside of arms, 
shoulders, and side of thorax-over, in fact, 
the area of distribution of the branches of 
those intercostal nerves which send filaments 
to the breasts. It affords a good example of 
reflected irritation. This state usually occurs 
after the first conception, and in women of 
excitable, nervous temperament. Attention 
to ordinary hygienic measures during the 
progress of the metamorphosis of the organ 
into a secreting gland, with its accomplish- 
ment, affords relief to the pain. In large, 
lax, pendulous breasts, the separate lobes of 
which each is composed may excite appre- 
hension of the existence of a tumour. But 
tumours composed of new tissue are so ex- 
tremely rarely developed during pregnancy, 
that the greatest caution must be exercised 
in the diagnosis of their nature. 
Agalactia.-Very rarely, no change what- 
ever in the breasts accompanies pregnancy, 
under which circumstances there is an absence 
of the secretion of milk after parturition. 
Inflammation of the Breast.-Synon. : 
Mastitis. 
Etiology.-Before lactation, acute inflam- 
mation of the brea sts is very uncommon. After 
lactation, on the contrary, it is very frequent. 
This morbid state is often the result of care- 
lessness or ignorance on the part of the nurse. 
The slightest unusual fulness or ' knottiness ' 
discovered after the infant has been sucking, 
and when the ducts and their terminal secret- 
ing vesicles should be empty, requires imme- 
diate attention. Congestion of a lobule or 
lobe with milk produces the nodule, and the 
cause of the impediment to its escape should 
be sought for. The state of the nipple is 
generally the origin of the difficulty. Either 
the orifice of a duct may be obstructed by 
epithelium, or a superficial ulceration exists 
around it. The morbid or defective states 
of the nipple are the most fruitful causes of 
inflammation and its results in the breast. 
Prophylactic measures should always be in- 
stituted when there is reason to fear that a 
defective development of the nipple will 
interfere with the free flow of the milk. 
Even with some mothers it would be ad- 
visable to resign the duty of suckling, rather 
than subject themselves to the almost certain 
misery arising from persistent and ineffectual 
attempts to do so. inflammation, generally 
passing on to suppuration and abscess, either 
within the body of the breast or on its sur- 
face, is most frequent in primiparae, and 
within the first month after parturition. 
Symptoms.-First, hardness is felt, ' a knot,' 
in some part of the substance of the organ ; 
this enlarges, and may attain to considerable 
dimensions before causing pain or even un- 
easiness. N ext, pain is felt during suckling; 
this increases each time the infant sucks, and 
' the draught ' is produced. The integuments 
then become pink, and afterwards red, tense, 
shining; more or less of the breast feeling 
very inelastic, firm, prominent, and heavy. 
Pain is now often very severe, and great 
constitutional disturbance is excited. In the 
centre of the redness the skin becomes of a 
purplish tint; around this it is cedematous; 
and with the finger, at the centre of the purple 
zone, a slight depression and softening spot 
can be detected. An abscess now exists, and 
fluctuation is more or less marked in pro- 
portion to the quantity of pus. At the purple 
centre the cuticle has probably by this time 
separated from the cutis; and a vesicle con- 
taining serum, either yellow or slightly tinged 
with blood, indicates that ulceration of the 
cutis is proceeding, and that the pus will soon 
escape. The above is a brief description of 
the objective signs indicating the morbid 
processes noticeable in all cases of local in- 
flammation advancing to and terminating in 
suppuration and abscess. It is not possible 
to state with any degree of exactness the 226 
BREAST, DISEASES OF 
period of time required for the accomplish- 
ment of these definite changes. It varies 
according to so many local and constitutional 
circumstances, that it would be idle to attempt 
to predict any certain definite period or stage 
for each phase. It will be more useful to 
describe the treatment by which the progress 
of the disease may be arrested or limited, and 
its painful course mitigated. 
Treatment.-Great attention should al- 
ways be given to the nipple of primipar®. 
In many women, this important division of 
the gland is very small and undeveloped, 
perhaps only on one side, so that the infant, 
especially if not very strong, has great diffi- 
culty in obtaining sufficient milk to appease 
the appetite, and its efforts cause pain in the 
part. This circumstance induces the mother 
to prefer suckling most with that breast the 
nipple of which is perfect, and the infant soon 
appreciates the advantage of that side. Con- 
sequently the gland-tissue of that breast 
having the imperfect nipple becomes con- 
gested. Every time the infant sucks it 
becomes worse, more and more pain and 
irritation are excited, the orifices of one or 
more of the ducts in the nipple become 
blocked, and perhaps the infant refuses to 
suck the breast. But the gland becomes 
more and more distended, the nipple deeply 
buried, until at last suckling is impracticable. 
Probably none of these increasing troubles 
have been stated to the attendant surgeon; 
and, when he is consulted, he finds the breast 
to be in the state above described. The 
perfect development of the nipple should be 
always a subject of anxious solicitude on the 
part of the obstetric practitioner. If this 
organ be imperfect, precautions should be 
taken to prevent the gland itself from be- 
coming congested, and if the infant cannot 
draw the milk sufficiently, some mechanical 
means should be employed to effect this 
object. The nipple itself should be examined. 
If its end be more than usually coated with 
secretion, or the openings of the ducts seem 
to be obstructed with an excess of epithe- 
lium, attempts may be made to remove it. 
If abrasions, ulcers, ' cracks or chaps,' are 
visible between the rug®, a soothing appli- 
cation, or a weak solution of carbolic acid, 
should be used. Ablution with warm water, 
or the contact of a little moist cotton covered 
with gutta-percha tissue, is preferable to the 
dressing ; or, if there be much secretion 
from the glands on the nipple, after cleansing 
its surface, some dry powder is beneficial, 
such as carbonate of magnesium, oxide of 
zinc, or starch powder. 
When actual congestion of the gland-tissue 
exists, mechanical means should be used to 
reduce it. Supporting the gland with strips 
of plaster and a bandage is sometimes very 
useful. When inflammation is excited, local 
applications of warmth and moisture are 
indicated, and the constitutional condition of 
the sufferer demands special attention. The 
application of glycerine of belladonna and a 
suitable support of the breast are also of 
great service. When suppuration has taken 
place, its relation to the adjacent parts and 
the exact size of the abscess when formed 
should be carefully ascertained. There is 
great diversity in the progress, duration, and 
sufferings of the patient, depending upon the 
locality of the pus. It may be situated 
over the body of the gland, within it, or 
beneath it. 
When overlying or superficial to the body of 
the breast, the course of the disease is rapid. 
In those cases the constitutional disturbance 
is usually trifling. 
Both the local and constitutional symptoms 
are much more severe when inflammation 
affects the body of the gland, and pus collects 
between its lobes. The progress of the disease 
is tedious, pointing of the pus is slow, and the 
exact spot at which it may reach the surface 
is for a long time doubtful. In the majority 
of cases it makes its way between the ducts, 
and reaches the surface near the areola or 
within its area; usually to the sternal side 
of the nipple, where the gland-tissue is 
thinnest. In either case, as soon as the' 
presence of pus is ascertained, it should be 
evacuated, by means of a short incision 
radiating from the nipple. This must be 
kept open by as large a drainage-tube as the 
incision will admit, and the strictest antiseptic 
treatment should be employed. The omission 
of the latter is very likely to lead to burrowing 
of pus and the development of troublesome 
sinuses. 
When the abscess forms beneath the breast 
the local appearances are quite characteristic. 
The gland itself seems little involved, but it 
is pushed prominently forwards and seems to 
rest upon a cushion of fluid. To the touch 
the elasticity of the swelling is very striking, 
and, without producing additional pain, a 
slight bulging of the walls of the abscess may 
sometimes be produced at the periphery of 
the gland when, with the palm of the hand 
and outspread fingers, compression is made 
from the front backwards against the thorax. 
The patient should be recumbent. The pus 
in these cases often points somewhere around 
the borders of the body of the gland, and must 
be evacuated at the earliest possible date. 
During the time occupied in the formation 
of a mammary abscess and its local treat- 
ment, the constitutional powers of the patient 
must be well supported, and the general 
health maintained by every means. 
The sequelce of suppuration in an organ 
composed of so much connective tissue, and 
endowed with its peculiar function, some- 
times cause great trouble; they are, however, 
much less frequently met with now than 
before the introduction of the antiseptic 
treatment. They are protracted induration, 
sinuses, and fistul®, through which last the BREAST, DISEASES OF 
227 
milk persistently escapes. Induration of the 
whole or part of the breast subsides when 
lactation ceases, and the organ in due time 
resumes its healthy state. Sinuses and 
fistulae may require incisions, but the ordinary 
methodsfor their cure should be adopted before 
having recourse to a treatment often involving 
much subsequent deformity. 
At the time for weaning the infant inflam- 
mation rarely occurs. Considerable milk- 
congestion of the secreting structure may 
sometimes produce irritation and incon- 
venience, to be relieved by mechanically 
drawing the milk in just sufficient quantity 
only to diminish the fulness. 
G-alactocele.-An accumulation of milk, 
to which the above term is given, forms a 
tumour in the connective tissue of the organ, 
and results from the bursting of a lactiferous 
tube. The swelling always appears first 
during lactation. It may vary in size from 
time to time; sometimes enlarging rapidly 
as suckling goes on. Two varieties are met 
with. In the one form there is a single 
swelling near the nipple, quite superficial, 
and quickly recognisable by its objective signs. 
In the other there may be several swellings 
distinguishable in the substance of the gland, 
as well as on its surface, all of comparatively 
small size, very firm and globular. In the 
same gland they vary very much in size, and 
in the degree of resistance they offer to 
manipulation. The discrimination between 
these tumours and others in the breast is 
easy, if the surgeon is able to ascertain with 
exactness that the swelling appeared some- 
what suddenly during suckling, and that 
its size varied conformably with that func- 
tion. 
In cases of long standing, the contents of 
the cyst become solid in proportion to the 
quantity of the fluid constituents of the milk 
absorbed, and the cyst-wall itself is very often 
rigid and even may become gritty. 
Treatment.-The treatment of this malady 
consists in cutting into the cyst, removing its 
contents, and drainage. 
B. The diseases affecting the mature gland, 
in its passive state, from the age of puberty 
to that period of life when the catamenia 
cease, may be grouped as follows:-the 
functional affections, or those which are 
characterised by changes in the secreting 
portion of the gland, accompanied by more 
or less induration, inconvenience, and pain; 
the structural, or those diseases characterised 
by some new-growth, which is altogether a 
superaddition to the organ, and-growing 
within its sphere of nutrition-often re- 
sembles, more or less, the gland-structure in 
composition; and others the minute elements 
of which are nucleated cells of various shapes, 
definitely and diversely arranged. 
In this state of the breast inflammation 
rarely occurs. Nevertheless, both the acute 
and chronic varieties of that morbid process 
terminating in abscess are met with, and 
careful discrimination is necessary to avoid 
mistaking such diseases for new-growths, 
especially in patients above forty years old ; 
for the amount of matter in a chronic abscess 
is often small, while the surrounding inflam- 
mation is often great and not infrequently 
an enlargement of the axillary glands, and 
some retraction of the nipple, make the 
diagnosis from cancer very difficult. The 
history of the case, tactile examination, and 
the variations occurring during the progress 
of the affection, commonly suffice for the 
detection of such cases. The treatment should 
be the same as for abscess in general. 
Functional Derangements. - The 
functional derangements of the breast in its 
passive state demand special attention. They 
are characterised by a peculiar activity of its 
secreting portion, which undergoes structural 
changes of a specific kind. "When the tissues 
composing a mature but perfectly passive 
gland are examined with the microscope, the 
caecal terminations of the ducts are found to be 
small, and little else than fibre-tissue is seen. 
Here and there caeci may be detected contain- 
ing minute aggregations of epithelium. But 
when, under some sympathetic excitement, 
with derangement of the functions of the 
pelvic generative organs, the secreting cells 
of the gland become active and are distended 
with epithelium, they induce more or less 
enlargement of the breast. This condition 
of things is called chronic lobular mastitis, 
and should perhaps more properly be included 
amongst the inflammatory diseases of the 
organ. But of such affections there is this 
important fact to be noticed. The whole 
breast need not be necessarily involved. On 
the contrary, one lobe only may be excited, 
and when this occurs the existence of a 
tumour is declared. When, after excision, 
such enlarged lobes are carefully examined 
with the microscope, normal gland-tissue is 
seen, the caecal ends of the ducts are readily 
recognised, and their immediate association 
with the excretory ducts may be observed. 
The former are gorged with epithelium; and 
true gland-tissue, less its peculiar secretion, 
has been developed. 
Symptoms.-Associated with this state of 
the tissues of the breast, the patient com- 
plains of pain, both locally and spread over 
a very wide area. To express as briefly as 
possible the superficial regions affected and 
over which pain is felt, the reader must be 
reminded of the distribution of the descending 
cutaneous branches of the cervical plexus, 
and of the lateral and anterior cutaneous 
branches of the second, third, fourth, and 
fifth intercostal nerves. From these, special 
filaments are distributed to the breast; and 
to the site of exit of one or more of them 
at the intercostal foramina, the source of the 
pain is referred by the patient. The skin of 
the neck, shoulder, side of thorax, and inside 228 
BREAST, DISEASES OF 
of arm receives filaments from the same 
source. Hence an explanation of the widely- 
diffused pain. 
It is of the first importance to discriminate 
between this state of the gland-tissue and 
substantial new-growths, especially because 
the latter cannot be removed by natural 
processes, whilst the former most probably 
will be. The objective signs are the follow- 
ing : to the touch the excited gland-tissue is 
nodular, irregular over its surface, much 
identified and mingled with the body of the 
organ. If the whole breast be large and 
relaxed, the tips of the fingers may be 
insinuated between the borders of the indu- 
rated lobe and the lobes not affected. If 
the entire body of the gland be morbidly 
firm, it feels like a disc-shaped mass lying 
on the thorax, under the borders of which the 
fingers can be pressed. Occasionally, at one 
or more spots along the periphery of the 
gland irregular nodules are perceptible, pro- 
jecting into the connective tissue around 
them. When one lobe is affected, the shape 
of the induration may be detected correspond- 
ing with that of a lobe, namely, broad at the 
periphery and gradually narrowing towards 
the areola. Pain as a subjective indication 
is of great assistance in forming a diagnosis 
of these cases; but the source and course of 
the pain must be carefully traced. Generally 
manipulation of the induration produces 
increased pain; occasionally touching the 
induration, even however gently, is intoler- 
able, and persistence in or repetition of the 
act is strongly opposed by the sufferer. Light 
pressure should be made over the points of 
exit of both the anterior and lateral branches 
of the intercostal nerves, when the pain ex- 
cited thereby will correspond with the nerve- 
filaments of the affected lobe. Pressure 
along the upper dorsal spinous processes 
usually excites pain also. The morbid affec- 
tions above described occur in single women, 
married but sterile females, and young widows, 
at ages between twenty years and forty. More 
or less disturbance of the catamenia co-exists, 
either in relation to the frequency or quantity 
of the discharge. The patient complains of 
languor and inability for bodily or mental 
exertion; and she is desponding and often 
alarmed for the possible consequences of the 
affection suggested by sympathising friends. 
She is irritable, restless at night, loses appe- 
tite for food, as well as all desire for social 
enjoyments, and becomes highly susceptible 
and emotional. 
Diagnosis.-An exact diagnosis of these 
histological changes may be made if the 
manipulator examines the organ methodi- 
cally. He should, first, gently grasp the 
induration between the thumb and fingers, 
when it will be distinctly appreciable. 
Afterwards, placing the palmar surface of 
the fingers over the surface of the breast and 
gently pressing backwards against the thorax, 
the induration cannot be detected. Should 
there still remain any doubt on the subject, 
let the patient recline on her opposite side on 
a sofa, and in this posture, if there exists a 
substantial new-growth, the integument is 
usually elevated by it. 
Treatment.-The treatment of these cases 
consists in attention to the general health. 
Every hygienic direction should be enjoined, 
and such medicines administered as conduce 
to its improvement. Local soothing appli- 
cations are usually futile, and, except in those 
cases of extreme pain, are not advisable; but 
strapping with belladonna plaster may give 
relief, and will serve to support the breast 
and to prevent manipulation of the part, and 
the consequent frequent recurrence of the 
patient's thoughts to it. Should the gland 
be heavy and pendulous, a suspensory band- 
age, as thin as possible, may be adjusted. 
New Formations.-We shall next de- 
scribe the diseases of the mature gland 
arising from the development of new for- 
mations-either of tissues constituting new- 
growths ; or of conditions causing collections 
of fluid of distinct and specific kinds. All 
of these may be thus arranged in three 
groups:-first, the fluid tumours ; second, 
the solid; and, third, those composed of both 
solid and fluid. 
A. Cysts. - The fluid tumours, com- 
monly termed cystic, consist of a mem- 
branous sac with its contents. Now, calling 
to mind the histological divisions of the 
breast, and dwelling on the structural differ- 
ences between its parts, the secreting appa- 
ratus and the excretory, there is little diffi- 
culty in assigning to the cysts their true 
histological affinities. Thus there are cysts 
associated with the secreting apparatus ; 
others with the excretory, the ducts ; and 
some due to the extravasation of the secretion 
of the gland, the milk, into the connective 
tissue. Effusions of blood also give rise to the 
development of cysts, either independently 
of other diseases or associated with them. 
Another variety of cyst is produced by the 
development of entozoa, notably of echino- 
coccus hominis; and it must not be forgotten 
that cysts as well as abscesses may be 
developed in connexion with various kinds 
of tumours. An ordinary examination of 
the fluid derived from these cysts at once 
establishes the fact that heat and the admix- 
ture of nitric acid produce coagulation in that 
abstracted from some of them, whilst that 
from other cysts remains unaffected by the 
treatment. The cysts are thus divisible by 
the nature of their contents into two distinctly 
defined groups:- 
a. Those containing fluid without the ad- 
mixture of any coagulable element. 
6. Those enclosing fluid which does contain 
coagulable material. Other characteristics 
of these two fluids are not less conspicuous. 
From an objective point of view all cystic BREAST, DISEASES OF 
229 
tumours of this gland may be classed m two 
groups, thus :-first, those associated with 
its ducts, the evidence of which is afforded 
by the escape of fluid at the nipple; and 
secondly, those not connected with the ducts 
by any such evidence. 
The following tabular arrangement will 
place before the reader, at a glance, all the 
varieties of cysts met with in the breast. 
I. Cysts associated with the ducts, com- 
municating and connected with them. 
1. Containing milk. 
2. Enclosing growths; with serum, 
coagulable and often tinged with 
blood 
a. Adenoid growths. 
b. Granulation cell-growths. 
c. Cancer. 
II. Cysts not connected with the ducts. 
1. Surrounding effused blood. 
2. Enclosing milk. 
mined, are developed in the breast, and are 
probably associated immediately with the 
secreting part of the gland. For the sake of 
identification the writer would designate them 
mucous cysts. The contained fluid is not 
coagulable by either heat or acid. Its colour 
is brown, more or less inclining to a greenish 
hue, and is probably really that of altered 
milk ; it is opalescent, of variable specific 
gravity-about 1020, rather greasy when 
rubbed between the fingers, and exhibits an 
alkaline reaction. When sufficient quantity 
is collected in a test-tube and allowed to cool, 
in a few hours the lowermost stratum of the 
fluid becomes clearer than the upper. The 
uppermost always remains opalescent. If a 
little of this last be examined with a micro- 
scope, oil-globules are seen, together with the 
bodies called colostrum cells. The greasy 
nature of the fluid can be detected by smearing 
a drop of it on a piece of glass. 
The development of these cysts is not very 
common. We may here remark that they 
seem to have escaped the observation of 
surgeons, as no special notice of them occurs 
in the most recent monographs. Yet they 
are so distinctly separated from all the other 
cysts which are formed in the breast, in 
respect of the composition of their fluid con- 
tents, their progress, and their prognosis, that 
they constitute a marked, distinct, and iso- 
lated class. We meet with them in the 
breasts of single women, in married but 
sterile females, and in widows between forty 
and fifty years of age. Usually they are 
accidentally discovered in any quarter of the 
gland when about an inch in diameter. Their 
shape is globular or ovoid ; to the touch elas- 
ticity is the main feature, and if sufficiently 
large and superficial, fluctuation may be 
detected. In some instances the tips of the 
fingers may be insinuated into a sort of furrow 
around them. Pain is rarely complained of. 
The treatment consists in emptying the cyst 
with a trocar and cannula. After this the 
fluid does not again form. These cysts 
usually appear singly and in one breast only, 
but the writer has seen a patient in whom 
they were multiple and on both sides. 
4. Cysts containing blood-hcematomata- 
are very rarely formed in the breast, except 
in association with some new-growth from 
which blood, or more often bloody serum, 
oozes. They may, however, occasionally occur 
independently of any new-growth. 
5. True entozoa-cysts are developed in the 
breast. They are certainly rare, and cannot 
be distinguished from other cysts until in- 
cised. Extirpation by excision is the speediest 
means of effecting a cure. 
6. Sebaceous cysts are occasionally met 
with in this region. 
B. Solid Tumours.-We have next to 
describe the solid tumours. These are es- 
sentially new-growths of tissue superadded 
to the normal gland. Generally, therefore, a 
3. Simple cysts. 
4. Entozoon cysts. 
Fluid not co- 
agulable. 
5. Investing growths with serum co- 
agulable, tinged with blood and 
containing cholesterine:- 
a. Adenoid growths. 
b. Granulation cell-growths. 
c. Cancer. 
1. We have already described, under the 
name galactocele, a tumour observed during 
suckling and composed of milk. But the 
surgeon is occasionally consulted about a 
swelling which, at first sight, would seem to 
have no reference to that function. Never- 
theless the milk, or all that remains of that 
secretion, constitutes its entire bulk. If exact 
inquiry be made, the patient states that a 
tumour has existed, unaccompanied by pain, 
from the period of the last weaning, perhaps 
not having been observed until the gland 
ceased to secrete, and that its size slowly 
diminished until a certain period, since which 
it has remained of unvarying bulk. This 
decrease is due to the absorption of the serum 
of the milk, whilst the solid parts remain. 
The cyst should be incised, the contents re- 
moved, and the wound should be drained. 
Cysts containing the solid parts of the milk 
are sometimes associated with perfectly new 
growths of the glandular type. 
2. True sero-cysts-that is to say, collec- 
tions of serum circumscribed by a fibrous 
membrane- are frequently met with, and are 
most commonly associated with adenoid, 
granulation, and cancerous growths. They 
occur in the breasts of middle-aged women. 
The fluid which these cysts contain is some- 
times quite clear, and of a yellow tint; at other 
times it is tinged with blood-colouring matter, 
and is turbid. It always contains some con- 
stituent coagulable by heat and the admixture 
of nitric acid. These are the exudation-cysts 
of the mammary gland. 
3. Other cysts containing a fluid like 
serum, until its composition is carefully exa- 230 
BREAST, DISEASES OF 
characteristic feature of the existence of such 
growths is an increased bulk of the affected 
organ; another, the firmness or resistance 
to pressure with the fingers when contrasted 
with the group of tumours before described. 
The solid tumours have long been classed in 
regard to their local and constitutional effects, 
and their results on the life of the individual 
affected with them, into two groups-the 
innocent or harmless; and the malignant or 
life-destroying. 
1. Adenoma.-In the first class are placed 
the growths more or less closely resembling 
in their tissues those composing the glandular 
structure of the breast. Various terms have 
been assigned to these tumours, namely, 
Chronic Mammary Tumours, Pancreatic Sar- 
coma, Tumeur adenoide, Corps fibreux, Hy- 
pertrophic partielle, Mammary Glandular 
Tumour, Fibroma, Adenocele. Their com- 
position is chiefly fibrous tissue ; the cseci or 
acini of secreting structures, with more or 
less distinctly marked traces of ducts, being 
interspersed throughout the mass. See Tu- 
mours : Adenoma. 
Adenomata are developed in the breasts of 
young, unmarried women from the age of 
puberty upwards; rarely after thirty, but 
very commonly before that age. They may 
be intraglandular, occupying the substance 
or body of the gland, and having the normal 
gland-tissue investing them. In other in- 
stances they seem to be attached by a kind 
of pedicle either to its surface or margin. In 
every instance they are placed within the 
fascial investment of the organ. When at- 
tached, as just described, their remarkable 
mobility, slight lobulation of surface, and 
firmness, coupled with the youth of the 
patient, are sufficient indications of the 
harmlessness of their nature. Usually they 
occur singly and in one breast; they may be 
multiple and in both breasts. The only means 
by which they can be removed is excision. 
However large the tumour, its removal should 
be always attempted without cutting away any 
portion of the normal breast. In most cases 
this can be done, especially if the patient be 
youthful and the growth of medium size, 
even should it be developed in the body of 
the gland and extend through it to the 
pectoral muscle. After thirty-five years of 
age it is expedient to remove the breast as 
well. For these tumours, especially those 
which may be called soft adenoids, approach 
very closely to the cancers (see Tumours). 
A section shows a solid, uniform surface, 
divided into lobes and lobules by fibrous septa, 
sometimes slightly broken up by fissures or 
clefts in which there appears a little clear 
tenacious fluid. The growth is often very 
succulent, at other times only moist; its hue 
may be greyish, yellow, or almost white. 
Its vascularity is scarcely perceptible. The 
prognosis of these cases is invariably favour- 
able. 
2. Fatty tumour.- Lipomata or masses 
of adipose tissue are developed in the breast, 
or rather in relation with it, to speak with 
accuracy. They are characterised by the 
usual indications, and require no special 
mention. 
3. Navus.-It may be questioned whether 
naevus, or a growth of true trabecular vas- 
cular fibre-tissue, is ever developed in the 
substance of the breast, that is to say, in the 
gland-tissue, although the integument around 
the mammilla may certainly be so affected 
in early life before the development of the 
gland, and a subcutaneous naevus may exist 
at the site of the future organ. 
4. Sarcoma.-Under this heading, as well 
as that formerly employed of ' fibroplastic 
tumour,' we include a group of new-growths 
composed of more or less well developed 
sarcoma tissue, in which are interspersed 
somewhat modified acini and ducts of the 
gland. They are developed in women of 
middle age, increase rapidly, and after ex- 
cision are liable to grow again. They 
usually require complete removal of the 
breast. 
5. Colloid.-Colloid growths are occasion- 
ally met with in the breast. They are true 
cancers which have undergone the usual 
colloid degeneration; and they must be 
treated on the same lines. They appear in 
middle life, and are not distinguishable 
from other solid tumours until after ex- 
cision. 
6. Carcinoma. - Carcinoma, commonly 
called cancer, is developed in the breast in 
two distinct forms. The first, and most 
common, is that variety which is due to in- 
filtration of the normal tissues of the gland 
by the elementary cells of cancer. It consti- 
tutes the scirrhous variety. The second is 
that kind which is produced by the develop- 
ment of a mass of soft, medullary or en- 
cephaloid cancer-growth. Both varieties are 
met with in women after forty years of age, 
but the first much the most frequently. 
Previously to that age the disease is rare; 
from forty to fifty it is most commonly seen; 
and it becomes relatively less frequent as 
age advances. A larger number of married 
women are affected by it than single, and 
prolific women who have suckled their 
children are quite as prone to the disease 
as the sterile or those who have not 
suckled. For the histological structure see 
Cancer. 
Symptoms.-Scirrhous cancer commences 
in any region of the mammary gland, al- 
though most frequently perhaps in the axil- 
lary segment. A small, firm nodule is 
usually accidentally discovered, without the 
attention of the patient having been attracted 
to it by pain. Rarely, the whole organ is 
simultaneously infiltrated, but most fre- 
quently one lobe only is affected. The in- 
filtration is often central in the body of the BREAST, DISEASES OF 
BREATH, THE 
231 
gland, especially when the organ is atrophied, 
and the reverse occurs when the extreme 
edge of a lobe is affected at its periphery. 
The infiltration may steadily increase until 
the whole breast forms a rigid, solid mass; 
but most frequently the larger part of the 
organ remains unaffected. The disease gives 
rise by its contraction to much deformity of 
the region, to dimpling, corrugation, and 
irregularities of the otherwise rotund integu- 
mental surface. The nipple, just in propor- 
tion to the effect of the growth upon the 
ducts, becomes retracted or drawn towards 
the tumour. Such are the ordinary objective 
signs of infiltrating cancer in its early stage. 
The progress made by the disease is subject 
to very remarkable variations in different 
individuals, and the stage above described 
may be long delayed. In some cases many 
months or even years may elapse before the 
growth assumes any grave importance. 
Sooner or later, however, the integument 
over the growth becomes adherent to it, 
infiltrated, and red, and advances towards 
ulceration. An ulcer now forms, the edges 
of which are everted, ragged, and attached 
to the growth beneath. A hole extending into 
the tumour becomes deeper and deeper; 
ichorous discharges, more or less profuse, 
continue without much pain; and the patient 
becomes at last worn-out, or succumbs to 
the ravages of a cancerous growth in a vital 
organ. 
The encephaloid variety commences in a 
small, circumscribed, globular nodule in the 
body of the gland; grows rapidly; separates 
the lobes of the organ; extends equally in 
all directions; and becomes adherent to the 
skin, which commonly sloughs and allows of 
a protruding, fungating mass. 
In both varieties the axillary lymphatic 
glands sooner or later become involved in 
the disease, which may also spread to those in 
the neck and within the thorax. 
Treatment.-Local applications exert little 
if any influence on the growth of cancer. The 
vital powers of the patient should be sup- 
ported. as much as possible by hygienic 
measures, and especially by ferruginous 
tonics. The removal of the primary growth 
before the contamination of the lymphatic 
system is of great importance; and the 
methodical removal of the axillary glands is 
to be strongly recommended. If the case 
have advanced too far for operative inter- 
ference, and an open sore have formed, 
suitable antiseptic remedies must be em- 
ployed. 
C. Mixed Tumours.-To the group of 
mixed tumours belong:-1. Those composed 
of cysts, intracystic growths, and solid inter- 
spersed masses of new tissue. 2. Granulation 
cysts-cysts with growths attached to their 
walls, the elementary tissues of which re- 
semble those of ordinary granulation-growths 
-whence the term applied to them. 3. Cysts, 
so called, often formed upon the surface of 
cancers, in consequence of the slow exudation 
of serum from the growth itself. 
1. Tumours of the first class belong patho- 
logically to the group of adenoid formations, 
and although they differ so remarkably in 
their external objective appearances, they are, 
when unalloyed with other growths, perfectly 
harmless. The sero-cystic disease of Brodie, 
and the proliferous cysts of Paget belong to 
this class. 
2. The granulation-cystic growths consti- 
tute a class of themselves. It is only of late 
years that attention has been attracted to 
them. They are rarely met with, and when 
pure are unattended by untoward circum- 
stances. 
8. To the third class belongs a group of 
cases thoroughly cancerous in their nature, 
and differing only from the ordinary forms 
of that disease by the accidental formation 
of cysts. See Tumours. 
III. Diseases of the Male Breast.- 
The male has sometimes a well-developed 
mammary gland, and the part is subject to 
the same diseases as the female. But the 
simple enlargement of the organ is harmless, 
and should not be interfered with. At the 
age of puberty the mammary region often 
becomes painful, owing in part to the pres- 
sure of the dress upon the mammilla and the 
rudimentary organ. Inflammation followed 
by suppuration has been observed at this 
time. 
IV. Diseases of the Nipple.-A defec- 
tive formation of the nipple is of grave im- 
portance, and when it exists measures should 
be adopted to assist its elongation. This is 
to be done by using an exhausting-glass, such 
as those employed to empty the gland of 
milk. 
Inflammation and its effects produce much 
suffering, and at the period of suckling fre- 
quently excite deep-seated mischief. The 
small ulcers, called ' cracks,' ' chaps,' &c., 
which form between the rugae on the apex 
and sides of the nipple, may be cured with 
an application of water-dressing, or by pow- 
dering the part with carbonate of magnesium 
or oxide of zinc, or with a weak solution of 
carbolic acid. Sir James Paget has described 
a chronic eczema of the nipple which may 
assume a malignant character. 
Pendulous cutaneous growths occur on 
the nipple, and should be excised. 
Cystic follicular tumours are sometimes 
seen within the zone of the areola. See 
Nipple, Diseases of. 
John Birkett. 
BREATH, The.-The expired air, or 
what is familiarly termed the breath, is im- 
portant both from an setiological and a 
clinical point of view, and the object of the 
present article is to present a brief summary 
of the main facts relating to this subject, 232 
BREATH, THE 
with which, for practical purposes, it is 
necessary to be acquainted. 
1. The setiological relations of the ex- 
pired air will be more appropriately discussed 
in detail under the general subject of setio- 
logy (see Disease, Causes of), but a few of the 
more striking examples of the manner in 
which it affects the health may be given 
here. It is well known that the expired air, 
if re-breathed by the same individual with- 
out having been purified by a proper admix- 
ture with atmospheric air, will produce 
serious effects upon the economy, and will 
ultimately lead to death by asphyxia. Again, 
the breath of a number of persons collected 
together in an ill-ventilated place may prove 
injurious to such individuals; the impure 
atmosphere thus generated tends to lower 
the general health, to retard the development 
of the young, to increase the virulence of 
infectious diseases, and to predispose to pul- 
monary affections. Indeed, some writers 
regard re-breathed air as one of the most 
prominent causes of pulmonary phthisis. 
Further, undoubtedly the expired air is a 
most important channel by which the poison 
of certain infective diseases-for example, 
that of measles, scarlatina, or diphtheria-is 
conveyed from one individual to another. It 
has been affirmed that phthisis can be trans- 
mitted directly in this manner, but adequate 
proof of this statement is entirely wanting. 
2. From a clinical point of view, the 
breath may afford useful information in 
diagnosis; or it may present characters 
giving important indications for prognosis 
and treatment. It might be requisite in 
different cases to submit the expired air to 
a more or less systematic examination, and 
the following outline will serve to suggest the 
particulars to which attention should be 
directed in this examination, and to point out 
the practical uses which it may serve. 
a. The breath has been made use of to 
distinguish between real and apparent 
death. For this purpose a delicate feather 
or a light is held before the mouth or nos- 
trils, and it is noted whether either of these 
is disturbed; or a cold mirror is placed 
before the mouth, when, if breathing is going 
on, its surface will be clouded by the mois- 
ture condensed upon it. These tests are, 
however, not considered very reliable. 
b. The temperature of the expired air may 
be important to notice. In some conditions 
it becomes exceedingly cold, and this may 
be readily perceptible to the hand, the breath 
having a chill feel, or it may be visible in 
consequence of the moisture in the expired 
air being condensed, even when the sur- 
rounding atmosphere is warm. The pheno- 
menon is observed, for instance, in the col- 
lapse-stage of cholera. On the other hand, 
the temperature of the breath may be raised 
more or less, as in febrile diseases. 
c. Chemical examination of the breath 
may prove of service, and it is probable that 
this might afford useful information, if it 
were resorted to more frequently than is the 
custom at present. In the first place, this 
examination may be employed to determine 
the proportion of carbonic acid present. In 
certain affections, as during an attack of 
asthma, or in cases of extensive bronchitis, 
the amount of carbonic acid in the expired 
air is more or less increased; in others, 
such as in the collapse-stage of cholera, this 
constituent may be very deficient. Again, 
chemical examination of the breath may 
reveal the presence of a poison in the system, 
introduced from without, for example, hydro- 
cyanic acid. It has also been employed to 
show the existence of deleterious products 
generated within the body, especially in 
cases of renal disease. It is affirmed that 
ammonia may be detected in the breath in 
some cases of this kind, by holding a glass 
rod dipped in hydrochloric acid before the 
mouth, the ammonia being a product of the 
decomposition of urea. 
d. Microscopical examination of the ex- 
pired air has been attempted, but at present 
no results of practical value have been ob- 
tained, although it has been affirmed that 
tubercle-bacilli have been found in it in cases 
of pulmonary phthisis. 
e. The odour of the breath is the most im- 
portant character demanding attention from 
a practical point of view. It is easily recog- 
nised, and the practitioner should always be 
on the alert to notice the smell of the breath 
of a patient, as this often affords material 
aid in diagnosis, and may even reveal certain 
morbid conditions which otherwise are liable 
to be entirely overlooked. Besides, patients 
not uncommonly seek advice on account of 
' foulness of breath,' as a symptom for which 
they require special treatment. The follow- 
ing summary will indicate the principal cir- 
cumstances under which this clinical pheno- 
menon may prove of service in diagnosis, 
and in the course of the remarks it will be 
pointed out in what conditions the breath is 
particularly offensive. At the outset it must 
be observed that in some individuals the 
breath seems to have naturally a more or 
less disagreeable odour, which cannot be 
referred to any particular cause, and this 
amounts occasionally to extreme foulness. 
In females this may only be noticed at cer- 
tain periods, and in some instances it seems 
to pass off in course of time. Again, it must 
be borne in mind that the breath is frequently 
unpleasant, either temporarily or constantly, 
owing to persons eating certain articles of 
food, or indulging in certain habits, such as 
excessive smoking, or chewing tobacco. 
(i.) The odour of the expired air may aid 
in recognising poisons in the system. The 
smell of prussic acid or laudanum, for in- 
stance, may be revealed when either of these 
is present in the stomach. Alcohol, however, BREATH, THE 
BRIGHT'S DISEASE 
233 
chiefly demands attention in this relation- 
ship. In cases of acute alcoholic poisoning, 
the odour of the alcohol or of its products is 
at once apparent; and in persons who are 
found in a state of unconsciousness, the cause 
of which is not known, the smell of the 
breath is made use of as one of the diagnostic 
signs of drunkenness, though it must be taken 
with great caution. It is in the chronic forms 
of alcoholism that the breath gives the most 
valuable information. In very marked cases 
of chronic alcoholism it has an intensely foul 
odour, which is quite characteristic; but it 
gives extremely important indications in less 
confirmed cases, where the other symptoms 
of alcoholism are not so apparent; and es- 
pecially does it enable us to detect dram- 
drinkers, and to explain the symptoms of 
which they so frequently complain. These 
persons, if their habits are inquired into, 
generally give themselves an excellent cha- 
racter for temperance, and seem entirely to 
forget that those with whom they come into 
contact are endowed with the sense of smell. 
Again, the breath may reveal the presence 
of certain metallic poisons in the system, of 
which mercury is the most important ex- 
ample, but lead may also affect its odour. 
The expired air presents the odour of ammo- 
nia in exceptional instances of uraemia, due 
to the exhalation of carbonate of ammonium, 
derived from the decomposition of urea. In 
cases of diabetes, and especially diabetic 
coma, the breath may have a sweetish, frag- 
rant, or ethereal odour, attributed to acetone. 
(ii.) The breath has a peculiar, or more or 
less disagreeable odour, in connexion with 
several diseases. That which is associated 
with the febrile condition is well known. In 
various disorders of the digestive organs the 
breath is often very offensive, but it is not 
practicable to refer any particular odour to 
particular diseases of either of these organs ; 
it may, however, be affirmed that an un- 
pleasant smell is frequently associated with 
habitual constipation. In cases of stercora- 
ceous vomiting the breath may have a dis- 
tinctly fecal odour. In this relation it may 
be mentioned that in some cases of phthisis 
the writer has noticed a sickly smell of the 
breath which is quite characteristic, and 
which seems to depend upon the state of the 
stomach. In cases of cerebral disease also, 
the breath often becomes exceedingly offen- 
sive, on account of the condition of the ali- 
mentary canal. Local morbid conditions 
about the mouth, throat, or nasal cavities 
constitute a most important class of affec- 
tions which influence the odour of the breath; 
in many cases it becomes extremely foul, and 
maybe quite peculiar in its characters. Among 
these conditions should be specially men- 
tioned want of cleanliness of the mouth and 
teeth ; decayed teeth; diseased bone in the 
mouth or nose; ulceration or gangrene about 
the mouth, especially cancrum oris, and gan- 
grenous ulceration along the gums; suppu- 
ration, ulceration, or gangrene in the throat, 
either of local origin, or associated with 
syphilis, scarlatina, diphtheria, or other 
general diseases; ulceration of the nasal 
mucous membrane, and chronic ozaena ; and 
malignant disease. The smell of the breath 
is of special value in drawing attention to 
some of these conditions, for they may exist 
without giving rise to any local symptoms 
whatever, and the patient may be quite un- 
conscious that there is anything wrong. 
Several striking illustrations of this state- 
ment have come under the writer's observa- 
tion. Again, certain conditions of the respi- 
ratory organs are liable to affect the odour 
of the expired air, and may render it unbear- 
ably foetid. Among these may be mentioned 
sloughing ulceration about the larynx, pul- 
monary gangrene in any form, and the de- 
composition of retained morbid products in 
dilated bronchial tubes or in certain cavities. 
Here, again, the smell of the expired air may 
reveal what otherwise is liable to be entirely 
overlooked, and especially when the patient 
coughs, so as to expel some of the retained 
air out of the lungs. Lastly, the breath may 
have a peculiar odour in some special dis- 
eases, such as pyaemia and its allies. 
Treatment.-It is only intended here to 
offer a few remarks as to the treatment of 
foulness of breath. The first great indication 
is, of course, to seek out the cause of this 
symptom, and endeavour to remove or re- 
medy this, by which in a large proportion 
of cases a cure may be readily effected. The 
habits should be duly regulated; the mouth 
and teeth properly cleansed ; the alimentary 
canal maintained in good order; and any 
special affection requiring treatment attended 
to. When unpleasant breath depends on the 
stomach, it may often be improved by taking 
charcoal powder or biscuits, at the same time 
remedies being employed suitable for the par- 
ticular affection present, and calculated to 
promote the functions of the alimentary canal, 
the bowels being also kept freely open. When 
the bad smell depends on local causes, it may 
be diminished by the use of antiseptic mouth- 
washes, gargles, sprays, or nasal douches, of 
Condy's fluid, carbolic acid, or creasote. Anti- 
septic inhalations are indicated in fuetor from 
the air-tubes. Frederick T. Roberts. 
BRIDES-LES-BAINS, in Savoy.- 
Thermal alkaline saline waters. See Mineral 
Waters. 
BRIGHT'S DISEASE.-Synon. : Fr. 
Maladie de Bright', Ger. Die Bright'sche 
Kranhheit. 
The term Bright's Disease is now re- 
cognised as generic, and as including several 
diseases of the kidney. Many writers re- 
cognise at least three varieties,1 each of 
1 Dr. Quain was the first to describe three forms 
of Bright's disease : first, the granular or atrophied 234 
BRIGHT'S DISEASE 
which involves chiefly one of the individual 
structural elements of the organ, and only 
secondarily, or in a minor degree, affects the 
others. There are thus morbid processes 
affecting mainly the uriniferous tubules, the 
fibrous stroma, and the blood-vessels, par- 
ticularly those of the Malpighian tufts. That 
which originates in the tubules is always 
inflammatory in its character, although the 
inflammation may be acute or chronic, and 
may to a greater or less extent affect the 
stroma; that which is proper to the stroma 
is an extremely chronic process, supposed by 
many to be inflammatory, but as it appears 
to others, rather of an hypertrophic charac- 
ter; that which commences in the vessels 
consists in a peculiar degenerative change, 
the so-called waxy, lardaceous, albuminoid, 
or amyloid degeneration. In the following 
article are described :- 
I. The inflammatory affection, affecting 
the tubules, or the stroma, or both. 
II. The cirrhotic or gouty affection, origi- 
nating in the fibrous stroma. 
III. The waxy or amyloid affection, origi- 
nating in the vessels. 
Definitions.-I. Inflammatory Bright's 
disease is an acute or chronic affection of the 
kidney; caused by exposure to cold, and by 
scarlatinal and other blood-poisons; consist- 
ing in inflammation of the elements, passing 
through various stages of transformation, 
viz. inflammatory enlargement, fatty de- 
generation, and atrophy; characterised in 
the earlier stages by diminution of urine, 
albuminuria, frequently luematuria, tube- 
casts, and dropsy ; in the later stages by the 
same symptoms, in a more or less marked 
degree, with secondary changes in the heart, 
blood-vessels, and other organs; terminating 
frequently in recovery in the early stage, 
rarely in the later, often in death by dropsy, 
uraemia, or intercurrent affections. 
II. Cirrhotic Bright's disease is a chronic 
affection of the kidney, caused generally by 
the abuse of alcohol, sometimes by the 
poison of gout, occasionally by plumbism, 
and by unknown conditions; consisting in 
increase of the fibrous stroma, with thicken- 
ing of the capsule, and ultimate atrophy of 
the organ; characterised by a very insidious 
commencement, by the absence of the early 
symptoms of either of the other forms, by 
albuminuria, at first slight or only occasion- 
ally present, afterwards more pronounced, 
and by the ultimate appearance of enlarge- 
ment of the heart, tension of pulse, sclerosis 
of arteries, polyuria, albuminuric retinitis, 
oedema of the lungs, and uraemia; resulting 
ultimately in death, from uraemia, oedema 
of the lungs, or other intercurrent affections. 
III. Waxy Bright's disease is a chronic 
affection of the kidney, caused by phthisis, 
syphilis, caries, suppuration, and other ex- 
kidney ; second, the enlarged, amyloid kidney; and 
third, the fatty kidney.-Lancet, November, 1845, 
hausting conditions; consisting in waxy or 
amyloid degeneration of the Malpighian 
bodies, small arteries, and sometimes the 
basement membrane, with, in many cases, 
transudation into the tubules; passing 
through various stages of transformation, 
viz. simple degeneration, enlargement from 
transudation, and atrophy; characterised 
by a large flow of albuminous urine of low 
specific gravity, and absence of dropsy; often 
attended by evidences of waxy disease of 
other organs, particularly the liver, spleen, 
and intestinal canal; resulting probably in 
some cases in recovery, usually in death by 
exhaustion, uraemia, or co-existing affections 
of the kidneys and other organs. 
^Etiology.-I. Of the inflammatory form. 
Cold is the commonest cause in the adult. 
It acts especially on those who have been 
exposed to its influence whilst perspiring. 
It frequently contributes towards the pro- 
duction of the disease in persons otherwise 
predisposed. Various blood-diseases, while 
they induce temporary albuminuria along 
with their more ordinary symptoms, have 
renal inflammation as a common sequela. 
Among these scarlatina occupies the first 
place, diphtheria stands next in order, fol- 
lowed by erysipelas, measles, pyaemia, typhus, 
ague, acute rheumatism, and pneumonia. 
Many of these maladies being most common 
in childhood, it follows that in the earlier 
years of life they are the chief causes of 
inflammatory Bright's disease. Pregnancy, 
heart-disease, gout, and malaria contribute 
towards its production in some cases; and 
the undue use of cantharides, turpentine, or 
alcohol may also be reckoned as causes. 
II. Of the cirrhotic form. The com- 
monest cause is the abuse of alcohol, par- 
ticularly in the form of ardent spirits. After 
this, though at a long interval, rank gout and 
lead-poisoning. Congestion from cardiac 
disease is also by many authorities, but 
erroneously, held to be a cause (see Kid- 
neys, Congestion of). As experience shows 
that the disease is often met with in people 
who have neither indulged in alcohol, been 
exposed to lead, nor suffered from gout, it is 
obvious that other efficient, though as yet 
undiscovered, causes must exist. Some au- 
thorities believe that true cirrhosis is also 
frequently a result of acute interstitial in- 
flammation, and that this process is thus 
referable to cold, scarlatina, and other causes. 
III. Of the waxy form. Constitutional 
syphilis, phthisis, prolonged suppuration, 
caries or necrosis of bone, and other exhaust- 
ing diseases, such as cancer and chronic 
rheumatism, induce this degeneration. There 
is at present no satisfactory evidence as to 
the precise connexion between these in- 
fluences and the morbid process. 
Anatomical Characters.-I. Of the in- 
flammatory form. When a case of this 
kind is prolonged, the renal disease passes BRIGHT'S DISEASE 
235 
through several conditions, which, for con- 
venience of description, may be divided into 
three stages, (a) Stage of active inflamma- 
tion. In this stage the kidney is enlarged; 
its capsule strips off readily; its surface 
appears more or less red, sometimes of a 
deep purple colour; and occasionally extra- 
vasations of blood are present in its sub- 
stance. On section the cortical substance is 
found to be relatively increased in bulk. Its 
vessels, as well as those of the cones, are 
congested. The structure appears somewhat 
coarser than natural, while the convoluted 
tubules often present a swollen, opaque ap- 
pearance, and occasionally contain blood. 
On mieroscopic examination the congestion 
of the vessels becomes very apparent, and 
the tubules are found to be dark and opaque, 
their lumen being frequently occluded. The 
individual epithelial cells are granular, and 
in a state of cloudy swelling. In some cases 
almost all the tubules appear affected, in 
others comparatively few. The enlargement 
of the organ is in part due to congestion, in 
part to exudation into the tubules. As the 
exudation increases the congestion becomes 
less marked, so that in the later period of 
this stage the kidney appears paler and more 
opaque. Unless recovery or death takes 
place, this condition passes into (6) The 
second stage, that of fatty transformation. 
In this stage the organ is still enlarged. Its 
capsule strips off readily; the surface often 
presents stellate veins, and its colour is 
mottled. At this time extravasations are 
very rarely observed, but there are alternat- 
ing patches of yellowish opaque sebaceous- 
looking material, mingled with more natural 
structure. On section the cortical substance 
is seen to be relatively increased. There is 
no congestion of the vessels, and the Mal- 
pighian bodies are not prominent. The con- 
voluted tubules are in many parts occupied 
by the sebum-like material, and sometimes 
the straight tubules present the same appear- 
ance. On microscopic examination the 
tubules alone are found affected. Many of 
them present under low powers a black 
appearance, due to fatty degeneration of the 
contents of the tubules. It is in the cells 
alone that this change occurs, and not, so far 
as the writer has seen, in the free exudation 
which binds the cells together. Many of the 
tubules are completely blocked up by this 
material; and sometimes in making the sec- 
tion of the recent kidney there is such an 
amount of oil set free that it permeates the 
whole structure of the organ, and is liable to 
produce the impression that the fatty de- 
generation is universal. This condition may 
be developed within a week or two of the 
commencement of the inflammation, and it 
may continue for years. During the whole 
course of the second stage it must be under- 
stood that inflammatory action is going on, 
although much less acutely than at first, and 
less widely diffused. The disease is some- 
times recovered from, but, more commonly, 
it persists; and if the patient survive long 
enough, it passes into (c) The third stage, 
that of atrophy. The organ is then re- 
duced to or even below the natural size. 
Its capsule strips off with little difficulty, 
and without tearing the surface. The sur- 
face is uneven; it rarely appears coarsely 
granular, as in the cirrhotic form, but rather 
presents a series of depressions, which give 
it an uneven or finely granular character. 
Its colour is very similar to that described 
as occurring in the second stage, but there is 
less of the sebaceous-looking material. On 
section the cortical substance is found rela- 
tively diminished. The Malpighian bodies 
are not prominent. The tissue feels more 
dense, and many of the tubules are occupied 
by sebaceous-looking material. The blood- 
vessels, and particularly the small arteries, 
are sclerosed : the intima and the adventitia 
are frequently, the middle coat almost in- 
variably, thickened. The fibrous stroma is 
relatively increased, especially towards the 
surface of the organ, and the tubules may 
be traced in different stages of atrophy. On 
close inspection that atrophy is found to 
result not so much from shrinking of the 
fibrous stroma as from molecular absorption 
of the contents of the tubules. 
Besides the typical form of the inflamma- 
tory affection just described, a very common 
variety is the form of post-scarlatinal in- 
flammation first accurately described by 
Klebs, to which he has given the name 
glomerulo-nephritis, because the glomeruli 
are especially affected. In this condition an 
accumulation of round cells (leucocytes) takes 
place in the glomeruli and neighbouring 
connective tissue, while blood is frequently 
extravasated within the glomeruli between 
the tufts of vessels and the capsule, as well 
as into the tubules. In the tubules also more 
or less inflammatory action manifests itself 
in the epithelium, and the corresponding 
structures of the Malpighian bodies suffer 
in a greater degree. At times the accumula- 
tion and swelling of these structures is suffi- 
cient to compress the vascular tuft. This 
disease also may be described as passing 
through three stages-in the first of which 
there is some enlargement with minute extra- 
vasations and the microscopic changes above 
described; in the second, where a fatty 
transformation has occurred in the epithe- 
lium and the fibrous tissues show thickening; 
in the third there is more or less atrophy, 
with shrinking of tubules or morbid increase 
of the fibrous stroma. 
The anatomical changes met with in other 
organs are described along with the com- 
plications. 
II. Of the cirrhotic form. The course of 
this affection is very chronic. It consists 
essentially in an increased growth of the 236 
BRIGHT'S DISEASE 
fibrous stroma, with secondary changes in 
the tubules and vessels. In an early stage 
the organ may be found of fully the natural 
size. The capsule strips off less readily than 
in health. The surface is somewhat uneven, 
and may present cysts. On section the cor- 
tical substance is relatively enlarged, and this 
is due merely to an increase of the stroma, 
not to any change in the vessels or in the 
tubules. But it is in the more advanced 
stages that the disease is commonly seen. 
Then the organ is reduced in bulk, it may be 
slightly, it may be to one-fourth of its normal 
size. Its capsule cannot be peeled off with- 
out tearing the gland. The surface is uneven 
and granular, and often of a reddish colour. 
On section the cortical substance is found 
relatively diminished, its structure being 
dense and fibrous. The small arteries are 
thickened and very prominent, all their coats, 
but especially the middle, being increased in 
volume. Many of the tubules are atrophied, 
but the epithelium of such as are not involved 
is for the most part natural. Cysts are 
numerous, and are found in connexion with 
the tubules, the Malpighian bodies, and the 
cells. 
There are two points worthy of being 
specially kept in view by those who desire to 
attain to clear conceptions of Bright's disease 
-viz. (1) That its different forms are very 
frequently combined-in particular that the 
inflammatory affection is found associated 
sometimes with the waxy disease, sometimes 
with the cirrhotic ; but that the descriptions 
here given are derived from pure examples 
of each process; and (2) that atrophy results 
in all the forms if the disease lasts long 
enough; that is, that a small, uneven-surfaced 
kidney may result from either the inflam- 
matory disease of the tubules, or the waxy 
disease of the vessels, as well as from the 
increased growth and subsequent contraction 
of the fibrous stroma in the cirrhotic form. 
III. Of the waxy or amyloid form. This 
chronic morbid process may also, for con- 
venience of description, be divided into three 
stages. Of these the first is (a) The stage 
of degeneration proper, in which the organ 
presents an almost normal appearance. The 
size is natural; the capsule strips off readily; 
and the colour is not altered. On section all 
appears normal, excepting that the Malpi- 
ghian tufts, without being congested, are pro- 
minent, and in certain lights may be seen, 
even by the naked eye, to present the dim 
translucency characteristic of waxy degenera- 
tion. On applying a little aqueous solution 
of iodine, the Malpighian tufts and the small 
arteries assume a peculiar mahogany hue. 
On examination with the microscope, the 
stroma and tubules are found to be healthy, 
the vascular structures being alone affected. 
The affection is often first seen and is most 
distinct in the middle coat of the arteries, 
the swollen transverse fibres taking on the 
colour, and producing what has been described 
as the ipecacuanha-root appearance. How 
long this condition may last without the 
tubules becoming affected it is impossible at 
present to say, for it has only been met with 
in patients who had died of one or other of 
the causal complications while the renal 
malady was still in an early stage. Sooner 
or later it passes, however, into the condition 
most commonly met with-(b) the second 
stage, that of degeneration with secondary 
changes in the tubules. In this condition 
the organ is enlarged. Its capsule strips off 
readily, the surface is smooth and pale, 
presenting, in pure examples, little or no 
mottling. On section the cortical substance 
appears relatively increased, and looks much 
paler than the cones. The structure usually 
is denser than natural. The vessels appear 
prominent, and the Malpighian tufts resemble 
minute grains of boiled sago. On the addition 
of iodine the degenerated parts become 
characteristically coloured, and stand out 
prominently from the tubular tissue, which 
does not exhibit the characteristic reaction. 
On microscopic examination the vessels are 
found altered as in the earlier stage, but the 
change is more advanced. The stroma is 
normal, but many of the tubules are altered. 
Some are blocked up by a dimly translucent, 
wax-like material, which however does not 
assume the mahogany colour on the addition 
of iodine. The epithelium in many of the 
tubules presents a finely granular appearance, 
and occasionally is somewhat fatty, but the 
epithelium and the basement membrane very 
rarely present the characteristic reaction. 
This change in the tubules is thus secondary 
to the degeneration proper, which is confined 
to the vessels; and these secondary changes 
consist in some alteration of the nutrition of 
the epithelium, with exudation or transu- 
dation of coagulable material into the lumen 
of the tubes. This condition may last for 
years, but should the patient live long enough 
it passes into (c) the third stage, that of 
atrophy. The organ is then below the nor- 
mal size; the capsule strips off readily; the 
surface presents an uneven granular appear- 
ance, and is pale. On section the cortical 
substance is found relatively diminished. Its 
small arteries are prominent and thickened; 
its Malpighian bodies are very conspicuous, 
and are grouped together in consequence of 
the atrophy of the intervening structure. The 
stroma is relatively increased, and many of 
the tubules are destroyed, while of those 
which remain not a few present the characters 
above described as being met with in the 
second stage. The organ may, in extreme 
cases, be diminished to less than half its 
natural size. 
Symptoms.-1. Of the inflammatory form. 
The leading clinical features of this variety, 
in addition to the albuminuria which exists 
in all the forms of Bright's disease, are dimi- BRIGHT'S DISEASE 
237 
nution in the quantity of urine, and the pre- 
sence of dropsy. 
The onset of the disease may be sudden 
or gradual. Sometimes it is the diminution 
and alteration of the urine that attracts 
attention, sometimes the dropsy, sometimes 
the gastric derangement and general uneasi- 
ness ; but whichever symptom may appear 
first, the others usually speedily follow. The 
urine is generally diminished in quantity, 
often somewhat opaque, and smoky or even 
bloody. It contains much albumin and 
numerous tube-casts. The casts are granular, 
being composed mostly of epithelium in a 
state of cloudy swelling; sometimes bloody; 
frequently hyaline or fibrinous. The urea is 
diminished, it may be, to one-half, one-fourth, 
or even a less proportion of the natural 
amount. This leads to a corresponding re- 
duction of the specific gravity, unless there be 
a compensatory diminution of water, or in- 
crease of albumin. The dropsy is generally 
distinct in the face, and swelling of the eye- 
lids is well-marked in the morning. Towards 
evening, if the patient be out of bed, the legs 
are chiefly affected. The scrotum and penis 
are often swollen, and sometimes the abdo- 
men is also dropsical. There is little quicken- 
ing of pulse or elevation of temperature, but 
a good deal of general uneasiness is ex- 
perienced, with debility and pain in the loins; 
and dyspeptic symptoms are often present, 
due to gastric catarrh. Such is the usual 
condition at the commencement of the disease, 
and during the period which has been already 
described as the first stage. But sometimes 
at this stage a much more serious condition 
is developed-namely, suppression of urine, 
followed by coma or convulsions leading to a 
fatal result; or dropsy may increase to such 
an extent as of itself to cause death. Or, again, 
without or even with the most unfavourable 
symptoms, under appropriate treatment the 
kidneys may begin to act more freely, the 
urine increasing in amount and improving 
in characters, with consequent gradual dis- 
appearance of the dropsy, and restoration of 
health. Or, as often happens, the general 
condition improves, but a chronic albuminuria 
remains, and the disease passes into the 
second stage. The urine is then no longer 
bloody; the quantity is greater, though still 
below the normal; the specific gravity is low; 
there is albumin, along with tube-casts, fatty, 
hyaline, or mixed, partly fatty and partly 
hyaline. The urea is below the normal 
standard. The dropsy may continue, and 
may even gradually increase, or it may pass 
off and only appear when the patient is 
fatigued, or when he has caught cold. The 
general symptoms remain unchanged, except 
that anaemia comes on, and the patient's 
debility steadily increases. This course of 
events may pass on to a fatal result; or there 
may be complete, or, as is more common, 
merely partial recovery. In this condition 
the patient may linger for many months, 
occasionally suffering exacerbations, and he 
may succumb to one of them, or to one of 
the numerous complications to be presently 
described. If the patient passes into the 
third stage, he appears prematurely old. His 
urine is of natural amount or even somewhat 
increased in quantity, but of low specific 
gravity. It contains albumin and a few casts, 
mostly hyaline, with scattered fatty cells im- 
bedded in them. The urea is still diminished. 
There is dropsy of the feet and ankles in the 
evenings, and slight exposure brings on more 
general attacks. The face is pale and pasty, 
and the eyelids are often oedematous. The 
pulse becomes hard and tense; the arteries 
gradually become thickened from sclerosis 
and atheroma; while the apex-beat of the 
heart passes downwards and to the left side, 
owing to hypertrophy, particularly of the 
left ventricle. In this condition a fatal result 
may be induced by an acute exacerbation 
with general dropsy; by chronic, or, more 
rarely, acute uraemia; or by intercurrent 
attacks of inflammatory or other affections 
of various organs. 
Glomerulo-nephritis is perhaps attended 
with a greater tendency to haematuria, and 
less tendency to dropsy, than other forms of 
acute nephritis, but the clinical features are 
not as yet capable of being definitely marked 
off from those of other maladies. Dr. George 
Johnson has drawn attention to a peculiar 
kind of cast, containing numerous leucocytes 
which characterise this particular lesion. 
2. Of the cirrhotic disease. The onset of 
this affection is extremely insidious, and it 
may exist for a long time without distinctly 
manifesting itself by symptoms. Its exist- 
ence may be suspected when a patient 
suffers from renal inadequacy in respect 
that the urea-discharge falls below the 
normal standard, and albumin occasionally 
appears in the urine, but one is not entitled 
to establish a diagnosis upon such grounds 
alone. The condition is often discovered 
only when dyspepsia, uraemic convulsions, 
or blindness from retinitis leads the patient 
to consult a medical man. The earliest 
symptoms are occasional slight albuminuria, 
and frequent calls to micturition during the 
night, the urine however not being excessive, 
its specific gravity being low, and the urea 
somewhat diminished. But when the disease 
has existed for some time the complexion 
becomes altered ; the eye assumes a peculiar 
appearance, from oedema of the conjunctiva; 
the patient is subject to dyspeptic attacks; 
the heart becomes hypertrophied, and the 
vessels sclerosed and degenerated; while 
there is little or no dropsy. When the dis- 
ease is advanced, these changes in the cir- 
culatory organs are well-marked, and the 
cachectic condition becomes distinct. The 
occurrence of various complications, such 
as severe gastric catarrh, diarrhoea, anaemia. 238 
BRIGHT'S DISEASE 
dyspnoea, bronchitis, oedema of the lungs, 
headache, uraemia, and the characteristic 
retinal affection, render the diagnosis easy. 
Frequently towards the end there is an in- 
creased flow of urine, of low specific gravity. 
This is in some cases a very prominent 
symptom. The disease is never recovered 
from, and the fatal result occurs from urae- 
mia ; from some inflammatory complication, 
such as pleurisy, pericarditis, bronchitis, or 
pneumonia ; or from some result of degener- 
ative change, as haemorrhage from a mucous 
surface or into the brain. 
3. Of the waxy disease. The onset of 
this affection is gradual and insidious. A 
patient who has suffered from phthisis, sy- 
philis, or other wasting malady passes an 
excessive quantity of urine, and finds himself 
obliged to rise several times during the night 
for micturition. The urine is pale, of low 
specific gravity, containing at first no albu- 
min, subsequently only a trace, ultimately 
a considerable amount. The urea is little, 
if at all, diminished; the tube-casts are ex- 
tremely few, and mostly hyaline. There is 
no dropsy, but evidence pf concomitant waxy 
affections of other organs is frequently af- 
forded. The liver is enlarged, its margin 
being easily felt and sharply-defined. The 
spleen is also increased in size. The blood 
is slightly altered, the white corpuscles 
being somewhat increased, and the red 
being rather flabby and ill-defined. These 
conditions gradually become more distinct, 
and the strength of the patient diminishes, 
partly from the disease of the kidneys and 
other organs, partly from the wasting dis- 
eases which have induced the degenerative 
changes. A case of the kind has been known 
to go on for nearly ten years, during which 
time the urine continued of the characters 
just described, and dropsy never appeared. 
At length the vital powers of the patient be- 
came depressed, head symptoms gradually 
supervened, and death ensued. It is not 
often that such an uncomplicated case is 
met with. More commonly the exhausting 
disease which led to the degeneration causes 
death before the waxy change has gone so 
far. Sometimes also intercurrent complica- 
tions induce the fatal result. Clinical obser- 
vation renders it probable that the kidneys, 
as well as the liver and spleen, may recover 
from their degeneration, in cases in which 
the causal malady has been got rid of. 
Complications.-(<i) Complications con- 
nected with the Alimentary System. 
Gastric affections are met with in all the 
forms of Bright's disease. Catarrh of the 
stomach-acute, sub-acute, and chronic-is 
common to them all, and is characterised by 
an unusual tendency to nausea and vomit- 
ing. It is especially frequent during the 
first stage and in acute exacerbations of 
the inflammatory form, and is often a chief 
source of suffering during the most advanced 
stages. It is not uncommon during the 
whole course of the waxy form, but is most 
usually met with in the cirrhotic variety. 
So close indeed is the relationship between 
them, that in the management of cases of 
cirrhosis regard should constantly be had to 
the state of the stomach, and in no case of 
chronic gastric catarrh should the physician 
neglect to inquire into the state of the urine. 
This affection, when complicating the early 
stage of the inflammatory form, often owes 
its origin to the same cause as the kidney- 
affection itself. When complicating the later 
stages of the inflammatory, and any of the 
stages of the cirrhotic disease, the catarrh 
is probably a result of efforts at elimination 
of materials retained in the blood by the 
failure of the action of the kidneys. 'When 
occurring in the waxy form, it is frequently 
due in part to the existence of waxy degener- 
ation of the vessels of the gastric mucous 
membrane. In the waxy disease we some- 
times find blood mingled with the vomited 
matters, just as we find haemorrhage in 
other organs when this degeneration exists. 
Catarrh of the intestine also occasionally 
occurs, sometimes producing an exhausting 
diarrhoea, especially in advanced inflamma- 
tory and cirrhotic cases; but it is along with 
the waxy disease that intestinal symptoms 
are most common. These are due to waxy 
degeneration, and consequent ulceration; or 
to ordinary tubercular disease of the intes- 
tine. Both of these affections induce diar- 
rhoea, but there is evidence that not only 
may it thus occur, but that blood may also be 
discharged, although there be no ulceration 
recognisable by the naked eye. 
Hepatic affections.-Functional derange- 
ments of the liver occur in the course of all 
the forms of Bright's disease. The chief 
organic changes are fatty degeneration, waxy 
degeneration, cirrhosis, and syphilitic affec- 
tions. The first-named is not specially re- 
lated to any of the forms. The waxy de- 
generation and the syphilitic affections are 
of course commonly met with as accompani- 
ments of the waxy disease; whilst cirrhosis 
is occasionally associated with the cirrhotic 
kidney, and sometimes with the other forms. 
Ascites is often seen as a manifestation of 
general dropsy in the inflammatory form of 
Bright's disease; and sometimes this is a 
prominent symptom in mixed forms, when 
waxy disease of the liver is associated with 
a waxy and slightly inflammatory condition 
of the kidneys. 
Peritonitis, like inflammation of the other 
serous membranes-one of the most impor- 
tant classes of the complications of Bright's 
disease, is occasionally the cause of death in 
all the three forms. It may result from 
local affections, or from the state of the 
blood; and may be acute, severe, and there- 
fore obvious, or so insidious as scarcely to 
attract attention. BRIGHT'S DISEASE 
239 
(3) Complications connected with 
the Blood, or with the Lymphatic- 
and Blood-glands. 
The spleen is usually unaffected in cases of 
inflammatory Bright's disease, except such as 
prove fatal in the earliest stage, and in which 
the spleen is affected in common with the kid- 
ney. In the waxy and cirrhotic forms corre- 
sponding lesions are frequent in this organ. 
The lymphatic glands are rarely altered 
excepting in the waxy form, in which they 
are sometimes the seat of the waxy de- 
generation, sometimes of tubercular disease, 
or of strumous inflammation. 
The blood itself is altered in its chemical 
composition. In the inflammatory form its 
density is diminished, the corpuscles and 
albumen being deficient, while the water is 
correspondingly increased. The quantity of 
urea is above the normal. In long-standing 
cases of waxy disease similar changes are 
found; and not infrequently there is a slight 
numerical increase of the white corpuscles, 
and flabbiness of the red blood-discs when 
the spleen is affected. In the cirrhotic form 
like alterations also occur. 
Hcemorrhage is apt to occur in advanced 
stages, especially of the cirrhotic form. It 
may take place from the kidneys, or from 
the mucous membranes, particularly that of 
the nostrils. In the inflammatory affection 
haematuria is common in the early stage ; in 
the waxy variety this symptom occasionally 
occurs, but rarely to a serious extent. 
(y) Complications affecting the Cir- 
culatory System. 
Hypertrophy of the heart is almost always 
present in cases of advanced cirrhotic disease, 
and also in the advanced stages of the inflam- 
matory affection. One may trace in patients 
the gradual development of this hypertrophy, 
advancing pari passu with the progress of 
the renal affection. It is comparatively rare 
in the waxy form. Hydropericardium is 
met with in some cases, as a manifestation 
of general dropsy. Pericarditis occurs as 
an intercurrent affection in all the forms, but 
especially the inflammatory and the cirrhotic. 
It is apt to be overlooked, owing to the 
absence of local pain, or from the pain being 
referred to the abdomen. Endocarditis is 
also frequently associated with the various 
forms of Bright's disease. 
The arteries are sclerosed and athero- 
matous in the advanced stages of the inflam- 
matory and in the cirrhotic, and to a less 
extent in the corresponding stage of the waxy 
disease. In that affection the small vessels 
in other parts are frequently the seat of waxy 
degeneration. Thickening of the arteries 
occurs constantly in the more advanced stages 
of the inflammatory and cirrhotic diseases, 
and is due in great part to hypertrophy of 
their middle coat, in lesser degree to sclerosis 
of the tunica intima, the tunica adventitia, and 
perhaps the perivascular lymphatic sheath. 
The pulse becomes tense and sustained in 
chronic cases, partly from the hypertrophy of 
the heart, partly from the changes in the 
capillaries and smaller arteries. 
(3) Complications connected with, 
the Respiratory System. 
Acute bronchitis is common, especially in 
the advanced stages of Bright's disease, and 
tends to pass into the chronic state. Bron- 
chitis may originate also as a sub-acute or 
chronic affection. (Edema of the lungs is 
very common in advanced stages, and fre- 
quently occurs as a manifestation of general 
dropsy in the early, as well as in the later, 
stages of Bright's disease. It may be very 
suddenly developed in cirrhotic cases, and 
may rapidly prove fatal. Pneumonia occurs 
sometimes as a cause of inflammatory Bright's 
disease, sometimes as a consequence of ex- 
posure to cold during the course of chronic 
cases. Ph thisis in its various forms is found 
causally associated with these renal affec- 
tions-frequently with the waxy, more rarely 
with the inflammatory form. It usually 
proves fatal w'hile the renal malady is yet 
in its early stage. Hydrothorax, acute or 
chronic, is often seen in dropsical cases. 
Pleurisy occasionally occurs with all the 
forms of Bright's disease, and may be due to 
the state of the blood; or, as seems more 
likely, to increased susceptibility to inflam- 
matory changes, which results from the 
lowered vitality of the organism. Dyspnoea 
is frequently met with in the inflammatory 
and cirrhotic forms of the disease, and may be 
independent of any local lesion, being pro- 
bably a result of uraemic poisoning. (E dema 
glottidis is apt to occur in inflammatory 
cases, when even a slight laryngitis has from 
any cause been brought on. 
(«) Complications affecting the Skin 
and Subcutaneous Tissues. 
Dropsy, in the form of anasarca, is almost 
constantly present in the early stage, and 
during exacerbations of the inflammatory 
form. It can scarcely be said to occur in 
uncomplicated waxy and cirrhotic cases. 
Eczema is occasionally troublesome in 
chronic cases. Erysipelas is met with now 
and then, always constituting a serious 
addition to the other malady. 
(Q Complications affecting the 
Urinary Organs. 
The chief of these is scrofulous disease of 
the kidney, and more rarely of the bladder 
and prostate. They occasionally occur along 
with the waxy affection. 
if) Complications affecting the Re- 
productive System. 
By far the most important complication 
is pregnancy, which may coexist with any of 
the forms of renal disease. Most frequently 
it is the inflammatory variety that causes 
danger, and in it dropsy is a prominent symp- 
tom, and uraemic convulsions and coma may 
at any time occur. But in many cases of 240 
BRIGHT'S DISEASE 
this kind the term of utero-gestation is com- 
pleted without the occurrence of ursemia, and 
often when uraemia does occur the patient 
comes safely through the ordeal, the delivery 
being effected, and the nervous symptoms 
passing off. Cirrhosis may coexist with preg- 
nancy, and a woman may have successive 
satisfactory confinements during the con- 
tinuance of this renal disease. It is rarer to 
find pregnancy in women suffering from waxy 
disease, but it may occasionally occur. 
Sometimes also there may be strumous 
disease of the uterus, complicating waxy 
degeneration of the kidney. Strumous or 
syphilitic disease of the testicle may be 
similarly associated. 
(d) Complications affecting the Ner- 
vous System and Special Senses. 
Urcemic blindness may occur, which is 
sudden and usually temporary, being un- 
accompanied by any lesion recognisable by 
the ophthalmoscope. It is generally met with 
in advanced cirrhotic and inflammatory cases. 
Retinitis albuminurica is a peculiar and 
characteristic inflammation of the connective 
tissue of the retina, leading to the formation 
of white patches and lines, with fatty de- 
generation. With it are also frequently 
associated minute haemorrhages into the sub- 
stance of the retina. This occurs by far the 
most frequently in cirrhosis. It is often also 
seen in the advanced stages of the inflamma- 
tory form, and is rarely recovered from except 
in the case of pregnant women, in whom it 
seems apt to occur as a passing condition. 
Urcemia includes a group of the most 
striking symptoms of Bright's disease. It 
may occur at the commencement of the 
acute inflammatory affection, or in its later 
stages, or in the chronic forms. The con- 
dition is, however, rare in the purely waxy 
disease, but common in the cirrhotic. There 
are several types of uraemia, of which the 
most important are :-(a) Sudden acute 
convulsions, followed by coma and death; 
(&) Gradually advancing torpor, passing at 
last into coma. The clinical features of 
these and minor varieties are described, and 
the hypotheses as to their origin discussed, in 
the article Uremia. 
Headache is frequently complained of by 
patients suffering from Bright's disease. 
Apoplexy from haemorrhage into the sub- 
stance of the brain is common in the later 
stages of the inflammatory and cirrhotic dis- 
eases. It is due partly to the degenerated state 
of the vessels, and partly to the increased 
pressure resulting from cardiac hypertrophy. 
(i) Complications affecting the Loco- 
motory System. 
Of these the only ones of importance are 
diseases of bones and joints, which may 
occur as causal or concomitant complications 
in waxy cases; and gouty affections, which 
have been already mentioned in comiexion 
with the cirrhotic disease. 
Diagnosis.-(a) Of Bright's Disease 
from other affections.-From f unctional 
albuminuriathe organic diseases of the kidney 
are to be distinguished by comparison of the 
clinical history of the respective conditions. 
The writer has sought to distinguish four 
forms of functional albuminuria:-I. Parox- 
ysmal albuminuria, a condition often asso- 
ciated with paroxysmal hsemoglobinuria, the 
discharge of albumen sometimes preceding, 
sometimes following, and sometimes re- 
placing the haemoglobin discharge. The 
attack comes on occasionally, is marked by 
very distinct albuminuria, and by the pre- 
sence of numerous tube-casts, and often oxa- 
lates, but the symptoms very rapidly again 
disappear, and are not attended by dropsy. 
II. Dietetic albuminuria, in which the 
albumen appears only after the ingestion of 
food, of some particular meal or some special 
article of diet. III. Albuminuria from ex- 
ertion, in which the discharge of albumen 
follows muscular effort of a more or less 
severe kind. In these two varieties (both 
of which stand related to Pavy's 'cyclical 
albuminuria ' and the ' albuminuria of adol- 
escence ') a comparison of the secretion 
passed at different times of the day and 
night, enables one to mark the functional off 
from the organic diseases, for at one time 
there is no albumen, or almost none; at 
another it is abundant; and one soon learns 
to make out in the functional cases the pre- 
cise conditions which induce its appearance. 
Other urinary conditions which characterise 
the functional cases are the normal discharge 
of urea, the absence of casts, and the occa- 
sional occurrence of phosphaturia, of oxalates, 
of urates or uric acid, of sugar or other chemical 
abnormalities. Much weight is also to be 
attached to the absence of the characteristic 
general features of Bright's disease. IV. 
Simple persistent albuminuria, in which 
patients continue to discharge albumen with 
the urine for long periods without giving 
evidence of organic disease. This is much 
more difficult to distinguish. The diagnosis 
depends mainly upon evidence excluding 
Bright's disease, such as the complete, or 
almost complete, absence of tube-casts, the 
discharge of a normal or even excessive 
proportion of urea, the absence of the com- 
plications of Bright's disease, particularly of 
the various causal, concomitant, and conse- 
quent complications which are so generally 
associated with it. Thus, for example, if 
a patient has albuminuria for months, but 
secretes abundance of urea, does not become 
anaemic, has no increased tension of pulse 
nor hypertrophy of heart, no tendency to 
dropsy, or to retinal changes, or any other of 
the well-known complications, we may con- 
clude that he is suffering from functional 
disease. But diagnosis and prognosis must 
always be cautiously expressed in cases of 
this kind. From passive congestion of the BRIGHT'S DISEASE 
241 
kidneys due to cardiac disease these maladies 
are distinguished by the general condition of 
the patient; the absence of cardiac disease, 
and of congestion in other organs; and the 
characters of the urine. In heart-affections 
the urine is generally scanty, high-coloured, 
not of low specific gravity. It may contain 
albumin, and deposits urates, but rarely 
blood, renal epithelium, or tube-casts. Hya- 
line casts may be present, but never in any 
large quantity. The presence of epithelial and 
fatty casts, or marked diminution of the 
amount of urea in any case, proves at least 
the co-existence of actual inflammation of 
the kidney. From paroxysmal hcemoglo- 
binuria, Bright's disease is distinguished by 
the abrupt commencement and brief duration 
of this malady; by the marked nervous 
symptoms, with gastric catarrh, and some- 
times slight j aimdice; and by the absence 
of dropsy. In haemoglobinuria also the con- 
dition of the urine is very distinctive; the 
dark-red -colour being due, not to blood- 
corpuscles, but to granular pigment, the de- 
posit consisting mostly of this material and 
of tube-casts. Hcematuria, with tendency 
to suppression of urine, is distinguished from 
Bright's disease by the small proportion of 
epithelial tube-casts, and in some cases by the 
complete absence of casts. There may be a 
question whether the case is one of haema- 
turia or of commencing acute inflammatory 
Bright's disease ; or, again, whether it is one 
of a chronic affection, cirrhotic or cystic, in 
which haemorrhage has come on. The cases in 
which Bright's disease simulates haematuria 
are generally the sequelae of scarlatina or 
diphtheria; and, therefore, even when these 
diseases have been overlooked, the presence 
of desquamation or of paralysis may afford a 
clue; but the peculiar reddish-brown deposit, 
rich in cells and in epithelial tube-casts, 
which occurs in Bright's disease, makes the 
case clearer even when, as often happens, 
there is no dropsy. Again, when the question 
is between simple haematuria and haematuria 
with cirrhosis or cystic disease, the evidence 
afforded by the tube-casts is not important, 
but the hypertrophy of the heart, the thicken- 
ing of the arteries, the character of the pulse, 
the albuminuric retinitis, the low specific 
gravity of the urine and the small amount of 
urea which it contains, as well as the ten- 
dency to haemorrhage from other sources, 
afford evidence of the presence of the chronic 
organic disease. 
Slight pyelitis, with or without renal cal- 
culus or gravel, may simulate Bright's dis- 
ease ; but the history of pain, the presence of 
mucus and pus-corpuscles in the urine, of oxa- 
late of lime or uric acid, with the full pro- 
portion of urea, and the absence of tube-casts, 
or their presence only in small quantities, 
indicate the nature of the case. 
(3) Of the different forms of Bright's 
disease from each other.-The discrimi- 
nation presents in simple cases little or no 
difficulty. The points to be attended to are 
the history of the patient; the amount and 
characters of the urine; the presence or 
absence of dropsy; and the nature of the 
complications. The previous occurrence of 
exanthematic affections, of chronic wasting 
disease, or of intemperance, gout, or plum- 
bism, would afford some obvious indications. 
The mode of origin and progress of the 
malady is very important. Thus a case com- 
mencing acutely with dropsy and diminution 
of urine is inflammatory; one of less acute 
character, with polyuria, is waxy ; and one 
commencing insidiously, with no marked 
symptom until perhaps convulsions or dim- 
ness of vision appeared, would be an exam- 
ple of cirrhosis. The leading symptoms of 
the inflammatory variety are diminution of 
urine ; an abundance of albumin and of epi- 
thelial tube-casts, with diminution of urea; 
and marked dropsy. Other indications may 
be gathered from the complications of each 
form of Bright's disease. It must be remem- 
bered that mixed forms frequently occur, and 
that in these careful inquiry and patient in- 
vestigation are essential to the establishing 
of a correct diagnosis. Of the waxy kidney, 
the prominent features are early and persis- 
tent polyuria; waxy degeneration of other 
organs: and absence of dropsy. In the cir- 
rhotic form the insidious commencement; the 
gradual development of vascular and cardiac 
changes; with in the later stages, in many 
cases, polyuria, are the most important 
phenomena. 
Prognosis.-The prognosis, though always 
grave, varies in the different forms of Bright's 
disease. In the inflammatory affection it is 
least unfavourable, although this affection is 
the most immediately dangerous. During 
its first stage we may always hope for com- 
plete recovery, especially in cases of post- 
scarlatinal origin. Of forty-one successive 
cases treated by the writer in the Royal 
Infirmary, Edinburgh, twenty-two recovered 
entirely, while twelve died, and seven passed 
into the second stage. If this be the pro- 
portion in hospital cases, which are generally 
sent there on account of their severity, and 
are rarely sent in the earliest stages of the 
disease, it is obvious that the proportion of 
recoveries must be much larger in private 
practice. When the disease reaches the 
second stage, the prognosis is more grave, 
complete recovery being rare, and death 
sometimes taking place from sudden or 
gradual increase of the symptoms, or from 
intercurrent affections. But even in this 
condition complete recovery may be brought 
about, and in many cases the patient goes on 
for long periods, presenting few symptoms 
fitted to attract attention. In the third stage 
the prognosis is entirely unfavourable, the. 
system becoming steadily more deteriorated, 
and death occurring, either from the direct 242 
BRIGHT'S DISEASE 
efiects of the disease, or from complications. 
Still, even such cases often go for long 
periods, if placed under favourable hygienic 
and therapeutic conditions. 
In the cirrhotic form the prognosis is 
very unfavourable, but the progress of the 
disease is so slow that it is often unadvisable 
to say anything about it to the patient, as 
the fatal result may be long deferred. It 
must, however, be kept in view that the 
disease is commonly far advanced before its 
existence is made out. 
In the waxy form the prognosis must 
almost always be unfavourable, although the 
malady is never rapidly fatal. On the con- 
trary, its course is always chronic, in some 
cases extending over five or even ten years. 
The fatal result is due to complications more 
frequently than to the disease itself. Re- 
covery probably sometimes takes place, but 
only when the cause of the degeneration is 
removed, and the general surroundings of 
the patient are favourable. It is certain that 
the liver and spleen may to a large extent 
recover from waxy disease, and recovery has 
been witnessed in cases which presented all 
the symptoms pointing to implication of the 
kidneys. 
Among the symptoms and complications 
which are fitted to cause special alarm when 
they occur in connexion with any of the 
forms of Bright's disease, we must recognise 
suppression or great diminution of urine, es- 
pecially if accompanied by nervous phenomena 
or general dropsy; urnemia, more particularly 
its chronic form; and acute inflammations 
and haemorrhages. Retinitis albuminurica is 
always a very serious symptom, except when 
it occurs in pregnant women. 
Treatment. - (1) Of the inflammatory 
form. The objects to be kept in view are to 
arrest the inflammatory action; to remove the 
inflammatory products from the kidneys ; to 
supply the deficiency induced by the drain 
upon the system; arid to obviate the dele- 
terious effects upon the system generally 
of the accumulation of effete materials. One 
remedy or plan of treatment may meet more 
than one of these indications. The most 
useful means of subduing the inflammatory 
action, or at least the congestion which at- 
tends it, are local blood-letting by means of 
leeches or wet cups; dry-cupping; and the 
application of hot fomentations, poultices, 
and counter-irritants. Blood-letting is only 
serviceable in the early stage of the disease, 
or when severe exacerbations with suppres- 
sion of urine occur. Poultices or hot fomen- 
tations are of use in the same circumstances. 
Counter-irritation is helpful in the more 
chronic conditions. Iodine and croton oil 
inunction are the best fitted for its induction, 
while cantharides must be avoided on account 
of its tendency to irritate the kidneys. 
The removal of the inflammatory products 
which block up the uriniferous tubules is of 
the utmost importance, and is in the great 
majority of cases best effected by means of 
diuretics. Water and diluent drinks are the 
safest, and are sometimes found sufficient. 
The medicinal diuretics must be non-irrita- 
ting, and the best of all is digitalis, which 
may be given safely even when the mine is 
bloody. It may be administered in the form 
of infusion, tincture, or made up into a pill. 
Of the infusion from a drachm to an ounce, 
of the tincture from five to thirty minims, of 
the powder from half-a-grain to two grains, 
should be given three times a day. The in- 
fusion or the tincture may be combined with 
spirit of nitrous ether, with acetate of potas- 
sium, or with tincture of perchloride of iron. 
Its action is often favoured by the addition of 
squill and carbonate of ammonium. Other 
diuretics, such as caffeine or strophanthus, 
occasionally act better than digitalis. Some- 
times it happens that diuretics do not suit 
the case, the urine becoming diminished and 
more bloody under their use; and in other 
cases the symptoms become so urgent that 
death might take place before there would be 
time for diuretics to act. In either of these 
conditions relief must be obtained by the 
bowels or skin. The bowels are best acted 
upon by means of from twenty grains to a 
drachm of the compound jalap powder, or 
one-twentieth to half-a-grain of elaterium. 
The action of the skin may be excited by the 
use of acetate of ammonia or antimony ; but 
pilocarpine, hot air, vapour-baths, and the wet 
pack are the most efficient agents. Through- 
out the whole course of the disease constipa- 
tion should be avoided, and the action of the 
skin encouraged. When the disease has be- 
come less acute, and certainly when dropsy 
persists during the second stage, other diu- 
retics are of the utmost value, particularly the 
acid tartrate of potassium, the oil of juniper, 
and the decoction of broom. Iron must be 
assiduously administered, to make up for the 
waste of the materials of the blood. Gallic 
acid, ergot, hydrochlorate of rosanilin, and 
belladonna have all been praised as tending 
to diminish the discharge of albumin resulting 
from a persistent chronic inflammation of the 
tubules. The treatment of special symptoms 
and complications will be considered after 
indicating the general management of the 
other varieties of Bright's disease. 
The diet during the earliest stages should 
be easily assimilable, and not too rich in 
nitrogenous elements. Milk is, as a rule, well 
borne. Some practitioners laud skimmed 
milk as an unfailing remedy in the disease. 
It is a good diuretic, and, when it suits the 
stomach, a good article of diet, but possesses 
no other therapeutical virtue. In the more 
chronic stages the food should be of a more 
nourishing kind, and a moderate allowance 
of stimulants may be needed. 
(2) In the cirrhotic form it is probable 
that no remedy we at present possess can BRIGHT'S DISEASE 
BROMISM 
influence the pathological process, although 
arsenic and alkaline remedies, and particu- 
larly iodide of potassium, enjoy a certain 
reputation. It is the duty of the skilful 
physician to ward off or minimise the results 
of the morbid process. It is obviously of 
great importance to avoid the causes of the 
disease. Lead-poisoning should be avoided; 
the gouty tendency kept in check; and the 
free use of alcohol forbidden. 
(3) In the treatment of the waxy form, 
the most important indication is to seek to 
remove the cause of the degeneration, if still 
existing. If there be disease of bone or 
chronic abscess it must, if possible, be cured ; 
constitutional syphilis must be combated by 
appropriate remedies. The tincture of per- 
chloride of iron, quinine, mix 'vomica, and 
combinations of these in the form of phos- 
phates, are useful. The patient must also 
have good food, and should lead an easy life. 
(4) In the management of the combined 
forms of Bright's disease these plans of treat- 
ment must be conjoined according to cir- 
cumstances, but, on the whole, treatment is 
much less successful than in the simple cases. 
In the combined waxy and inflammatory 
affection, for instance, it is not uncommon 
for dropsy to persist, although the diuretics 
bring the urine up to or above the natural 
standard. 
(5) With regard to the special symptoms 
and complications of Bright's disease, the 
gastric catarrh is often benefited by the use 
of bismuth, soda, and rhubarb ; the sickness 
and vomiting are best relieved by counter- 
irritation over the stomach, and by giving 
ice, milk, and hydrocyanic acid internally. 
These symptoms are, however, often very 
intractable. Diarrhoea must sometimes be 
let alone; at other times it must be treated 
by means of astringents or sedatives, either 
administered by the mouth or as enema or 
suppository. Ascites must be treated as a 
manifestation of dropsy, and occasionally the 
abdomen requires tapping. Peritonitis must 
be combated by hot fomentations and opium, 
but the latter requires great care in its ad- 
ministration. All through the disease in all 
its forms haematic tonics are demanded ; iron 
in some form should be constantly adminis- 
tered. For haemorrhages the pemitrate of 
iron, local astringents, ergot and ergotin, 
gallic acid, or acetate of lead must be tried 
in various combinations. The best results 
have followed the use of ergotin in 3- to 
5-grain doses injected subcutaneously. The 
irritating effects sometimes observed after 
the subcutaneous injection of ergotin may 
often be obviated by boiling the solution, or by 
the addition of a minute quantity of salicylic 
acid. Hydropericardium and pericarditis 
must be treated in the usual way. In the 
latter the writer has repeatedly seen much 
benefit follow the application of leeches, and 
during the past few years has witnessed a 
number of recoveries from this complaint. 
The vascular and cardiac symptoms are often 
relieved by the use of the nitrites, and par- 
ticularly of nitroglycerine cautiously admin- 
istered. Bronchial catarrh must be carefully 
attended to, by the avoidance of exposure to 
cold, by the application of counter-irritation 
externally, and by the internal administra- 
tion of expectorants. (Edema of the lungs 
must be treated by counter-irritants, and by 
remedies fitted to reduce the general dropsy. 
Pneumonia, phthisis, and pleurisy must be 
treated on ordinary principles. Hydrothorax 
may demand paracentesis. General dropsy 
is one of the most important complications, 
and should be combated by means of diuretics, 
purgatives, and diaphoretics ; in many cases 
the introduction of Southey's tubes or puncture 
of the oedematous parts is demanded. When 
these methods have been determined upon, 
precautions must be taken to avoid inflam- 
mation. Eczema and erysipelas, when they 
occur, should be dealt with according to 
ordinary principles. Headache is relieved 
in different cases by iron, by hot or cold 
applications to the head, by quinine, or by 
inhalation of a few drops of nitrite of amyl. 
When uraemia occurs in acute inflammatory 
conditions, or with suppression of urine, dry- 
cupping or wet-cupping over the renal regions 
should be tried, along with free purgation 
and hot-air baths and, especially in puerperal 
cases, general blood-letting. But, above all, 
reliance must be placed in the use of pilo- 
carpine. Generally it is best to inject it sub- 
cutaneously, and thereby produce diaphoresis. 
Bromide of potassium should be given in 
drachm doses, and if convulsions be severe, 
the patient must be kept under the influence 
of chloroform. In the more chronic and 
gradually advancing form of uraemia, counter- 
irritation at the back of the neck and over 
the scalp sometimes appears to be useful. 
But treatment is not so often of advantage 
in this as in the other form. In the eye- 
affections, iodide of potassium enjoys some 
reputation. Haemorrhagic apoplexy demands 
no special discussion in this article. 
T. Grainger Stewart. 
BRINKENAU, in Bavaria.-Chaly- 
beate waters. See Mineral Waters. 
BROMIDROSIS (3pwgor, a stench; and 
tbpms, sweat).-A term for fetid perspiration. 
See Perspiration, Disorders of. 
BROMISM.-Definition.-Bromism is 
the term applied to the morbid effects pro- 
duced by the administration of the salts of 
bromine under certain circumstances. 
Description.-The effect of the salts of 
bromine, when administered in medicinal 
doses, is to reduce nervous activity; and 
thus, with a certain amount of anaesthetic 
influence, to promote rest and sleep. When 
such doses have been long continued, or in 
243 BROMISM 
244 
certain idiosyncrasies, or when excessive 
doses are administered, results are produced 
which constitute a state of disease, and to 
this condition the term ' bromism ' is applied. 
These results are manifested on the brain 
and spinal cord; on the skin; on the mucous 
membranes and glandular structures; and 
on the organs .of circulation and respiration. 
1. On the Brain and Spinal Cord.-When 
the therapeutic action intended to be obtained 
from the use of a salt of bromine is exceeded, 
the quiet or sleep becomes more pronounced, 
and there is more or less constant somno- 
lence; the memory becomes impaired, words 
being forgotten or misplaced, whilst written 
and spoken language is confused, the tongue 
is tremulous, and speech is difficult. The gait 
becomes feeble and staggering, with inability 
to control movement, and somewhat re- 
sembles the condition observed in locomotor 
ataxy. The special senses-sight, hearing, 
taste, and touch-are impaired. Reflex ex- 
citability is diminished. This impairment 
is especially observed in the fauces, where 
touching does not as usual cause sickness ; 
indeed it may occasionally be present to such 
a degree as to lead to difficulty in swallowing. 
Sexual feelings are diminished or altogether 
suppressed. The general aspect of a case of 
well-marked bromism much resembles one 
of senile imbecility. 
2. On the Skin.-A very frequent result of 
the internal use of the bromides is a follicular 
eruption of the skin, closely resembling acne. 
It is generally situated on the face, chest, 
and shoulders. When the use of the drug is 
persisted in, the acne becomes aggravated, 
and boils appear. A more rare form of skin- 
disease similarly caused has been described 
by Dr. Cholmeley, Mr. Hutchinson. M. Voisin, 
and others. This disease appears as vesicles, 
which become aggregated into clusters or 
patches. They proceed to suppuration, and 
are soon followed by scabbing, their base 
being slightly raised, hard, sometimes ulcer- 
ated, and surrounded by a red areola. In a 
later stage the eruption presents the appear- 
ance of dusky red stains. It has been ob- 
served more especially on the limbs and 
head. Eruptions having more or less the 
characters of erythema and of eczema have 
also been described as following the use of 
these agents. 
3. On the Mucous Membranes and Glan- 
dular Structures.-Dryness of the mouth 
and tongue is often experienced in bromism ; 
but in some cases there is said to be an in- 
creased flow of saliva. Nausea, flatulence, 
eructations having a saline taste, heat and 
fulness at the epigastrium, and occasionally 
gastric catarrh and diarrhoea, have been 
observed; it is said that acute enteritis and 
even a typhoid condition have occurred. 
4. On the Organs of Circulation and 
Respiration.-The salts of bromine are said 
to produce contraction of the capillaries. 
The skin may present a peculiar dusky hue 
or pallor, and the extremities are cold. The 
action of the heart is rendered slower and 
weaker; and may even cease altogether, 
under the continued operation of these drugs. 
The action on the respiratory organs is simi- 
lar to that upon the heart. It has been 
observed that bromine-recognised by its 
peculiar odour in the expired air-is elimi- 
nated from the respiratory mucous mem- 
brane. Bronchial catarrh occurs, and in- 
stances are recorded in which pneumonia is 
said to have followed and proved fatal. 
It must be remembered that, although it 
has been thought desirable to discuss sepa- 
rately here the effects of the bromides on the 
several systems, these effects are combined 
in various degrees. In some cases the affec- 
tion of the skin is alone noticeable; in others, 
that of the nervous system; while in a third 
class there is produced a combination more 
or less of all the phenomena, constituting 
what may be called a cachexia. In such cases 
we find loss of flesh and strength, of colour 
and mental power; paralysis of the muscles ; 
loss of reflex and general sensibility and of 
the functions of the special senses ; complete 
apathy and general prostration, the coun- 
tenance having a semi-idiotic expression ; 
coldness of the extremities; and gradual 
failure of the heart's action. 
Pathology.-The condition just described 
is but the extreme effect of the ordinary 
physiological action of the salts of bromine. 
This condition may be due either to idiosyn- 
crasy-that is, to undue susceptibility on the 
part of the individual-or to the administra- 
tion of large quantities of the drug, either 
in medicinal doses for a long period, or in 
excessive doses administered within a short 
time. The individual susceptibility may 
depend upon the want of capability to 
eliminate the drug; on the general state 
of health; or on the presence of a disease 
which resists its action. Under these cir- 
cumstances, as well as in the presence of 
certain modifying influences, such as the 
action of other remedial agents simultane- 
ously administered, it is difficult to fix upon 
the amount of a bromine salt capable of pro- 
ducing morbid symptoms in any given indi- 
vidual. The writer has seen a nightly dose 
of ten grains of bromide of potassium, con- 
tinued for some weeks, produce marked 
somnolence during the day, and impairment 
of memory; whilst it has required the enor- 
mous doses of 200 or 300 grains a day, which 
seem to be administered on the Continent, to 
produce the extreme effects above described. 
The rapidity with which these effects are 
produced, constituting the acute and chronic 
forms of bromism, will depend on the amount 
and frequency of the dose, and on the sus- 
ceptibility of the individual. The effect of a 
sudden considerable increase in the dose has 
been observed by the writer in a case which BROMISM 
BRONCHI, DISEASES OF 
245 
first directed his attention to the subject of 
bromism in 1872. This case he saw in 
consultation with Mr. Alfred Burton. Half- 
drachm doses of bromide of potassium had 
been taken twice a day for several weeks, 
when by mistake the quantity of the drug 
was doubled; then, after three days, symp- 
toms closely resembling senile imbecility 
were rapidly developed. 
Diagnosis.-Recognising the value of the 
bromides,1 and the frequency with which they 
are used, it is extremely important that the 
peculiar results which they are capable of 
producing should be borne in mind; for if 
they are not recognised in time, and if the 
use of the drugs be persisted in, disastrous 
effects, which might otherwise be avoided, 
will follow. Without going into details of 
diagnosis, it will probably be sufficient to 
point out the necessity for remembering that 
the symptoms which have been described 
above can be produced by the use of bromides; 
and that when such a combination of symp- 
toms does occur during their use, it is highly 
probable, in the absence of disease capable of 
accounting for them, that the symptoms have 
originated from the operation of these agents. 
'Treatment.-This consists in stopping the 
use of the drug, and hastening its elimination 
by promoting the action of the kidneys and 
other excreting organs. It is found that 
arsenic in combination with these salts acts 
in some measure as a preventive of the 
eruptions. 
The above description refers more espe- 
cially to the effects of bromide of potassium ; 
but like effects are produced by other salts of 
bromine, though to what extent by each has 
not been so clearly ascertained. 
Richard Quain. 
BRONCHI, Diseases of.-Synon. : Fr. 
Maladies des Branches; Ger. Bronchien- 
Krankheiten.-The diseases of the bronchi 
will be discussed in the following order:- 
1. Acute inflammation; 2. Chronic inflam- 
mation ; 3. Plastic inflammation; 4. Di- 
latation ; 5. Narrowing or obstruction; 
6. Cancer. 
1. Acute Inflammation-Acute Bron- 
chitis-Acute Bronchial Catarrh. 
Definition.-An acute inflammation or 
congestion, general or partial, of the bron- 
chial tubes. 
^Etiology.-The causes of acute bronchitis 
may be classed as (a) predisposing, and (6) 
exciting. 
(a) Predisposing causes.-Of these age is 
one of the most important. The disease is 
indeed confined to no period of life, but is 
most frequently met with in the young and the 
1 It is of interest to record here that the use of 
bromide of potassium in this country dates from 
May 1857, when its value in the treatment of 
hysteria was mentioned by Sir Charles Locock 
at a meeting of the Royal Medical and Chirurgical 
Society, of which he was then President. 
old; and in these subjects it assumes its most 
serious characters. The imperfect develop- 
ment of the infant, and the diminished 
vitality of the aged, seem to render them 
especially liable to attacks of bronchitis, and 
to make the disease exceptionally fatal in 
them. Sex appears to have no influence as 
a predisposing cause. The habits of life have 
an important influence in the causation of 
bronchitis. The practice of living in heated 
rooms, especially where gas is largely con- 
sumed, and of breathing the vitiated atmo- 
sphere produced by the assemblage of large 
numbers of persons in apartments, is un- 
doubtedly a fertile predisposing, as well as 
exciting, cause of the complaint; so also is 
the practice of keeping children too much 
within doors on the one hand, or, on the 
other, of exposing them to inclement weather 
when insufficiently clad. Temperament can 
scarcely be considered a predisposing cause, 
but the state of the general health exercises 
a powerful influence. A weakly constitution, 
or one weakened by overwork, improper 
food, &c., predisposes to bronchitis; whilst 
such affections as Bright's disease, gout, and 
diseases of the heart, alike favour its occur- 
rence. Again, certain occupations are favour- 
able to the development of bronchitis. Inde- 
pendently of the fact that living or working 
in heated and confined rooms predisposes to 
the disease, such occupations as lead to the 
inhalation of irritating particles, as those of 
steel, cotton, &c., give rise to it. The climate 
most favourable to the production of bron- 
chitis is probably that which is at the same 
time both cold and damp, and where sudden 
variations of temperature occur. The seasons 
of the year in which it prevails most are 
the late autumn, the winter, and the early 
spring. 
(&) Exciting causes.-Although undoubt- 
edly cold directly applied to the surface of 
the body is in a large number of cases the 
exciting cause of bronchial inflammation, 
still the transition from cold to heat-passing 
from a cold atmosphere to a heated one-is an 
important factor of the disease. There can be 
little doubt that bronchitis is often produced 
directly by the effects of heated and vitiated 
air on the bronchial membrane, and on the 
system at large ; and that, in the latter in- 
stance, the affection is merely a local mani- 
festation of a general influence. Bronchitis 
may also be caused by the direct action of 
irritants contained in the air-as irritant 
vapours, minute particles of steel, cotton, or 
ipecacuanha, and the emanations (pollen) 
from flowering plants. Again, morbid con- 
ditions of the blood, the result of specific 
febrile affections, act as exciting causes of 
the disease ; as do also the poison of syphilis, 
and the altered condition of the blood pro- 
duced by gout. Bronchitis, moreover, must 
be regarded as a constant accompaniment of 
influenza. 246 
BRONCHI DISEASES OF 
Anatomical Characters.- The mucous 
membrane is mainly affected in acute bron- 
chitis, but morbid changes may be produced 
in the deeper structures. The mucous mem- 
brane is red-the redness being arborescent, 
streaked, or mottled, but not usually spread 
uniformly over a large surface. The injected 
condition of the membrane does not, as a 
rule, extend into the finer bronchial tubes, 
but in some cases where there have been 
frequent attacks of inflammation, these tubes 
have a red appearance. The membrane is 
sometimes thickened and soft, but ulceration 
is very rare. The tubes are generally found 
more or less filled with secretion, either frothy 
mucus, muco-pus, or even actual pus. Some- 
times the secretion is very abundant, filling 
all the tubes. Fibrinous masses are oc- 
casionally met with, which may form casts 
of the tubes. Collapse of portions of lung- 
substance-lobulettes or whole lobules of 
the lungs-is not infrequently found, as are 
also patches of lobular pneumonia. The 
venous system and the right side of the 
heart are overloaded, and the blood is dark. 
In many cases fibrinous deposits are found 
in the cavities and great vessels of the 
heart. 
In speaking of the pathology of bronchitis, 
it is necessary to refer to the distribution of 
the bronchial blood-vessels. The bronchial 
arteries when they have fairly entered the 
lungs have no accompanying veins. The so- 
called bronchial veins are some small vessels 
which return the blood supplied to the struc- 
tures about the roots of the lungs. The 
blood which is supplied to the bronchial 
tubes, when they have commenced their 
divisions, passes into radicles of pulmonary 
veins, and is returned directly to the left side 
of the heart. The question whether there is 
a communication between the bronchial 
arteries and the pulmonary artery, is still 
sub judice. If such communication exist, it 
is only slight. The blood of the bronchial 
arteries, after supplying the mucous mem- 
brane and other structures of the tubes, 
passes, either wholly or in a very large part, 
to the left side of the heart, not having 
circulated through the aerating portion of the 
lungs. The circumstances of this anatomical 
arrangement are most important in a prac- 
tical point of view. Anything which em- 
barrasses the circulation on the left side of 
the heart-such as mitral regurgitation- 
must necessarily cause a very loaded con- 
dition of the bronchial vessels; and all 
physicians are familiar with the form of 
bronchitis which is so common in these 
cardiac affections. The congested mucous 
membrane, and the profuse bronchial secre- 
tion, are the result of the direct impediment 
to its circulation which the blood meets with, 
from passing at once into vessels which go 
straight to the left side of the heart. The 
relief often afforded in this form of bronchitis 
by the exhibition of digitalis, is explained by 
the circumstance above referred to. 
Symptoms.-The symptoms of acute bron- 
chitis vary according as the larger or smaller 
tubes are affected. The disease attacks first, 
the larger and medium-sized tubes; and, 
secondly, the smaller ones. To this latter 
form of the affection the name of capillary 
bronchitis has been given. 
1. Acute bronchitis of the larger tubes. 
The attack is usually ushered in by symp- 
toms of catarrh-sneezing, lachrymation, a 
sense of fulness about the nose and eyes, 
with frontal headache; the throat becomes 
dry and sore, and then increased secretion 
sets in; the follicles at the back of the 
pharynx become enlarged; the upper part 
of the larynx is often involved, there being 
slight hoarseness; and the affection gradually 
creeps down into the bronchial tubes. The 
disease is not ushered in by decided rigors, 
but chills and sometimes shiverings are ex- 
perienced; the pulse is not much affected, 
but its frequency is increased in some cases; 
there is a general sense of malaise, as well 
as a want of energy. When the disease has 
set in fully certain local symptoms are found. 
More or less pain is felt behind and above 
the sternum ; the sensation is increased by a 
deep inspiration ; the pain shoots at times 
over the chest in the direction of the 
larger bronchial tubes; and there is a tickling 
or unpleasant irritation felt behind the ster- 
num, which gives rise to a cough. Dyspnoea 
is not a marked feature of this form of bron- 
chitis ; it exists, however, sometimes; and 
in the most severe cases a sense of oppression, 
weight, and tightness about the chest is ex- 
perienced. Cough is one of the earliest and 
most prominent symptoms; it is at first dry, 
and there is usually at this period some 
hoarseness. The cough is paroxysmal, and 
often very violent; it becomes attended with 
expectoration as the disease progresses. 
This varies at different stages of the affection; 
at first watery and frothy, and almost trans- 
parent, it becomes, as the disease progresses, 
more consistent, viscid, and opaque, passing 
through the stages of mucus to muco- 
pus and pus; it is sometimes distinctly 
nummulated. Small streaks of blood are 
occasionally seen mixed with the sputa. 
Examined under the microscope the sputa 
are found in the early stages of the disease 
to contain epithelial cells from the mucous 
membrane; and, later, many of the so-called 
exudation-corpuscles, molecular and granular 
matter, pus-cells, and occasionally blood-discs. 
In the milder cases of this form of bron- 
chitis there is but little general disturbance ; 
and even in the more severe cases the febrile 
reaction is not usually very great. The 
pulse rises a little, but does not become very 
frequent; the temperature rarely becomes 
high; there is in many cases but little inter- 
ference with the appetite. A general feeling BRONCHI, DISEASES OF 
247 
of depression, which in some cases is very 
marked, is usually experienced. 
2. Acute bronchitis of the smaller tubes - 
Capillary bronchitis. This is a very for- 
midable disease. It attacks the finer bron- 
chial tubes, and probably extends to their 
smallest ramifications. Its symptoms are 
very grave. Some of the worst cases of 
capillary bronchitis are met with in con- 
nexion with emphysema of the lungs. It 
may be an extension of inflammation from 
the larger tubes; or the capillary tubes may 
be attacked simultaneously with the larger 
ones, or alone. The early symptoms are 
more severe than those of ordinary bronchitis, 
and rigors are more common. Dyspnoea is 
marked; it may vary from mere rapid 
respiration to constant or paroxysmal ortho- 
pnoea. The respirations may rise to fifty in 
a minute. Cough is almost continuous, at 
times becoming very violent and most dis- 
tressing. Expectoration is attended with 
difficulty. The sputa soon become very 
abundant, and rapidly assume a purulent 
character; or they are very viscid and ropy. 
The general symptoms are very severe. 
The fever is high-the temperature reaching 
to 103° Fahr, and upwards ; and the pulse is 
frequent, rising to 120 or 140. The tempera- 
ture rarely attains the height which charac- 
terises acute tuberculosis or pneumonia. 
There are often profuse perspirations, and in 
some cases excessive debility is felt. If the 
disease progresses unfavourably, symptoms 
of very imperfect aeration of the blood come 
on. The face becomes turgid and bloated, 
the lips and ears get livid, the veins are dis- 
tended, the temperature falls, cold clammy 
perspirations break out, the pulse becomes 
very small and rapid, delirium supervenes, 
the respiration is shallow and catching, and 
the patient dies of asphyxia, and from the 
presence of fibrinous clots in the heart and 
great blood-vessels. 
Physical Signs.-The physical signs of 
both forms of acute bronchitis may be re- 
ferred to together. Inspection reveals little 
of practical value in simple bronchitis. The 
chest-form is not altered. In severe cases 
the abdominal movements are in excess. 
The costal movements are frequently those 
of elevation rather than expansion. In ex- 
treme cases the lower end of the sternum 
and the connected cartilages sink with in- 
spiration ; while the expiration-movements 
are slow, laboured, and inefficient. If the 
hand is applied to the chest, rhonchal fre- 
mitus may be often felt, sometimes over a 
large area. The percussion-sound may be 
somewhat exaggerated from over-distension 
of the lungs, especially in children; not ap- 
preciably altered; or deficient in resonance, 
owing to the accumulation of secretion at 
the bases of the lungs, to oedema or conges- 
tion (as in typhoid fever), or to pulmonary 
collapse. In young children a sound re- 
sembling the cracked-pot sound may be oc- 
casionally produced, variable in site. The 
sounds heard in auscultation vary according 
to the stage of the disease. The breath- 
sounds are loud when the tubes are free; 
when the latter are plugged by secretion, 
they often become feeble or even totally sup- 
pressed, from closure of a tube leading to a 
portion of the lung. The adventitious sounds 
of bronchitis include the various rhonchi, 
dry or moist: the dry rhonchi are heard in 
the early stages of the disease for the most 
part, but when once secretion has set in, the 
moist rhonchi or rales are more or less ex- 
tensively heard, depending for their character 
on the size of the tubes which are the seat of 
inflammation. Thus they are called mucous 
when produced in the large tubes, sub-mucous 
and sub-crepitant when produced in the 
finer ones ; the latter term being used to 
characterise the rales of capillary bronchitis. 
When the large bronchial tubes are filled 
with a secretion which is not viscid, the 
sounds may have a rattling character. The 
various rhonchi may be heard over different 
parts of the lungs at the same time, according 
to the seat and stage of the bronchitis. In 
capillary bronchitis sub-crepitant rales, ac- 
companying inspiration and expiration, are 
abundantly heard towards the bases of 
both lungs especially. As a rule there is 
no displacement of organs in bronchitis, 
but the diaphragm is sometimes depressed 
from great distension of the lungs, and 
the heart is occasionally displaced towards 
the right. 
Diagnosis.-The diagnosis of acute bron- 
chitis, except in a few instances, presents 
no great difficulty. In the early stages of 
whooping-cough it is impossible to decide 
whether the case is one of simple bronchitis 
or not, but subsequently the paroxysmal 
character of the cough settles the point. In 
some cases of bronchitis occurring in children 
the breathing may resemble that of croup; 
but here the presence of catarrh, the wheez- 
ing nature of the respiration, the absence of 
much fever, the characters of the sputa- 
obtained by wiping the back of the tongue 
-and their freedom from membranous 
shreds, and the physical examination of the 
chest indicating the presence of rhonchi, will 
be sufficient to establish a diagnosis. From 
laryngitis the discrimination is not difficult. 
Pneumonia may generally be easily dia- 
gnosed from capillary bronchitis, with which 
form it can perhaps be alone confounded. 
Capillary bronchitis is not ushered in, as 
pneumonia usually is, by a well-marked and 
prolonged rigor; the general febrile distur- 
bance is less, and the temperature not so 
high; moreover the absence of dulness on 
percussion, and of increased vocal resonance 
and fremitus will aid in the differentiation. 
From lobular pneumonia in children the 
diagnosis is not always easy. In this 248 
BRONCHI, DISEASES OF 
disease there is often no dulness to be per- 
ceived on percussion; whilst, on the other 
hand, dulness may exist in bronchitis from 
pulmonary collapse. 
The diagnosis of capillary bronchitis from 
acute phthisis often presents difficulties. The 
main points to be relied on, independently of 
the family history, which may aid, are that 
in capillary bronchitis the fever is less and 
the temperature lower; signs of asphyxia 
soon come on; and there is free expectora- 
tion of muco-purulent matter, from which 
the tubercle-bacilli are absent. In one form 
of acute phthisis there is evidence of pneu- 
monic consolidation, followed by signs of the 
formation of cavities. In the miliary tuber- 
cular form there are in many cases scarcely 
any physical signs except rales, most marked 
at the apices of the lungs. Here, however, 
the diagnosis may be aided by the examina- 
tion of the sputa under the microscope, which 
may reveal the presence of tubercle-bacilli. 
Prognosis, Duration, Terminations, and 
Mortality.-The prognosis in an ordinary 
case of bronchitis is favourable, but when 
the disease occurs in the very young or the 
aged the prognosis should always be guarded. 
In the milder forms the affection may last 
only a few days, or two or three weeks. 
Severe cases are more protracted. The 
disease may terminate in perfect recovery, 
in death, or by passing into the chronic form. 
It may be the starting-point of emphysema 
of the lungs, or of certain forms of phthisis. 
The mortality is much influenced: (1) by 
age, being greatest in the very young and the 
very old ; (2) by the previous state of health, 
which, if lowered by any circumstances, will 
render recovery more doubtful; (8) by the 
extent of the inflammation, especially when 
the disease is of the capillary form; (4) by 
the existence or non-existence of any organic 
disease of the heart, lungs, or kidneys; (5) by 
the disease being epidemic in connexion with 
influenza or otherwise; and, lastly, by the 
time the case has come under treatment, 
whether early or late. 
Treatment.-In the treatment of bron- 
chitis regard must be had to the constitu- 
tional condition of the patient. Care must 
be taken to ascertain "whether the disease is 
secondary to some organic affection, or the 
result of mechanical irritation, or of the 
presence of gout or rheumatism in the 
system, or of influenza; or whether it arises 
idiopathically. The treatment of the disease 
as a primary affection will be considered first. 
In an ordinary case of acute bronchitis it 
is very desirable to keep the patient con- 
fined to his room, and, if the case is at all 
severe, to his bed. The temperature of the 
apartment should be maintained at from 60° 
to 65° Fahr. A higher temperature than 
this is generally not favourable to the pro- 
gress of the case. In the early stages of the 
attack it is well to allow the air of the room 
to be more or less saturated with steam. A 
free action of the skin should be promoted ; 
and for this purpose warm drinks, with or 
without some form of alcohol or some diapho- 
retic medicine, may be given; or a hot-air 
bath may be used in bed. Great relief is often 
experienced from the application of a large 
mustard or mustard and linseed-meal poul- 
tice to the chest; and it is well, if mustard 
is applied first, to apply immediately after- 
wards a large hot linseed-meal poultice, to 
be renewed every few hours. This constant 
application of warmth and moisture to the 
chest is often productive of very great relief 
to the symptoms. 
Cases of acute bronchitis do not require 
venesection, nor is the application of leeches 
often, even if ever, called for. Severe coun- 
ter-irritation is moreover to be prohibited. 
It is generally desirable to act on the bowels, 
and a mercurial, followed by a saline purga- 
tive, will often be of great service. In the 
old and debilitated, as also in the young, 
all lowering treatment must, however, be 
avoided. In the early stages of the affec- 
tion, before secretion has commenced, and 
when the mucous membrane is dry and the 
cough hard, diaphoretics with ipecacuanha 
may often be given with advantage; but as 
soon as secretion is fairly established, car- 
bonate of ammonium, spirit of chloroform, 
ether, cascarilla, senega, or such-like drugs 
should be administered. Indeed in ahnost 
every stage of bronchitis carbonate of am- 
monium is one of the most valuable remedies 
we possess. Care should be exercised, es- 
pecially with the aged, that nothing should 
be given which will so nauseate as to prevent 
food being taken. In the exhibition of medi- 
cines to alleviate the cough, regard must be 
had to the condition of the patient and the 
stage of the disease. Opium in all its forms 
should be given with caution, especially in 
the young and old. It no doubt often suc- 
ceeds in checking cough, but in doing so it 
also checks expectoration, and causes an ac- 
cumulation in the bronchial tubes, which 
sometimes becomes very dangerous to life. 
Chloral hydrate in small doses is often of great 
use for relieving cough, and it may be com- 
bined with oxymel of squill. It has also a 
good effect in allaying spasm of the tubes, if 
this exist. In some cases of bronchitis the 
question of procuring sleep becomes an im- 
portant one. Opium in its various forms is 
generally inadmissible, in consequence of its 
tendency to increase the condition of as- 
phyxia ; but chloral hydrate may be given 
with safety, and the recovery of a patient 
may sometimes be dated from the sleep 
which this agent procures. 
In reference to the exhibition of alcoholic 
stimulants, except in the early stages, and in 
certain cases dependent on a gouty or rheu- 
matic condition, they should usually be given 
in smaller or larger quantities. They increase BRONCHI, DISEASES OF 
249 
expectorating power, and ward off the ten- 
dency to asphyxia. In the old they are 
especially called for, and, together with 
carbonate of ammonium, should form the 
main therapeutic agents to be relied on. In 
the treatment of capillary bronchitis, am- 
monia and alcoholic stimulants should be 
exhibited from the commencement, and the 
quantity must depend on the symptoms of 
each case. There is one source of danger in 
capillary bronchitis which should always be 
borne in mind, viz. the formation of fibrinous 
clots in the heart and great blood-vessels. 
These deposits become the proximate cause 
of death in many cases, and they are especi- 
ally liable to form when there is emphysema 
of the lungs. Their presence may often be 
diagnosed during life from the respiration 
becoming very rapid, shallow, and laboured ; 
from the pulse being quick, weak, and small, 
although the heart may at the same time 
be felt beating vigorously; from the voice 
becoming feeble, and the mental faculties 
seriously impaired. After death a large 
portion of the cavities of the heart may be 
found occupied by these deposits, the calibre 
of the pulmonary artery and the aorta being 
also materially diminished by them. 
In many cases of bronchitis, when the 
acute symptoms have passed off but the 
secretion continues profuse, as well as in 
those cases called bronchorrhcea, the exhi- 
bition of iron is often of great service. It 
seems to give tone to the relaxed capillaries 
of the mucous membrane, and to diminish 
the secretion. It may be given in combina- 
tion with carbonate of ammonium, in the 
form of the ammonio-citrate ; or the tincture 
of the perchloride with ether or spirit of 
chloroform may be employed, or the ethereal 
tincture of the acetate (Ph. Ger.), which is a 
very valuable preparation in some cases. 
Inhalations are useful for allaying cough 
in the earlier stages of the affection, or for 
the relief of spasm. In some cases of severe 
bronchitis where asphyxia has been threat- 
ened, recovery has followed the exhibition of 
large doses-half an ounce-of oil of turpen- 
tine. In this dose, however, it sometimes pro- 
duces alarming symptoms, and it is perhaps 
better to exhibit it in smaller quantities 
tentatively. An emetic may be serviceable, 
especially in children, if the tubes are much 
loaded. Children suffering from severe 
attacks of bronchitis should not be allowed 
to sleep long, for fear of dangerous accumula- 
tion in the tubes, and care should be taken 
that the secretions do not collect about the 
back of the mouth. 
Patients should not be kept on a low diet 
even at the beginning of an attack, and as the 
disease progresses the quantity of food allowed 
may be increased according to the appetite. 
In the treatment of gouty bronchitis, or 
bronchitis associated with a tendency to 
the formation of uric acid in the system, 
colchicum and the alkalis must be given, 
and the general measures used which are 
applicable to the constitutional condition. 
If bronchitis depend on a gouty state, it will 
not yield to the ordinary treatment, but when 
its cause is recognised and the appropriate 
remedies are administered, the symptoms 
usually soon begin to improve. 
In the cases of bronchitis which are con- 
nected with heart disease, and especially 
with mitral regurgitation, digitalis is often of 
great value. By steadying the action of the 
heart it relieves the overloaded pulmonary 
veins, and thus directly diminishes the con- 
gestion of the mucous membrane, as men- 
tioned in the paragraph relating to the 
pathology of the disease. 
It is impossible in the scope of this article 
to refer specially to the treatment of bronchitic 
attacks arising from the various kinds of 
mechanical irritation. There is, however, 
one form of bronchitis which may be men- 
tioned, viz. that connected with hay-fever, 
arising either from the inhalation of pollen, 
or caused by some peculiar atmospheric 
influence acting on a peculiar nervous 
system. It is very difficult of cure. In the 
writer's experience no remedies seem to have 
any particular influence over it, and it is 
usually only to be relieved by removing the 
patient from the exciting cause of the affec- 
tion. In the treatment of bronchitis depend- 
ing on constitutional syphilis, the appropriate 
measures for that affection must be resorted to. 
2. Chronic Inflammation - Chronic 
Bronchitis - Chronic Bronchial Ca- 
tarrh. 
Definition.-A chronic inflammation or 
congestion, more or less extensive, of the 
bronchial tubes. 
^Etiology.-Chronic bronchitis very fre- 
quently results from repeated attacks of the 
acute disease, but it may be chronic from the 
beginning. Emphysema of the lungs, dilated 
bronchi, and phthisis are causes of the com- 
plaint ; as are also various forms of heart- 
disease, and some blood-affections, such as 
gout. The inhalation of irritating particles 
gives rise to chronic bronchitis; and it is also 
met with in connexion with chronic alcohol- 
ism. It is most common amongst the old. 
Anatomical Characters.-The bronchial 
mucous membrane is discoloured, being of a 
dull-red tint, greyish, or brownish. The dis- 
coloration is usually partial, but sometimes 
general. There is swelling and increased 
firmness of the mucous membrane, and the 
sub-mucous tissue in old-standing cases 
becomes infiltrated and indurated. The 
fibrous and muscular tissues are hyper- 
trophied ; the cartilages in the larger tubes 
are sometimes calcareous; and there is 
generally more or less emphysema of the 
lungs. 
Symptoms. - The symptoms of chronic 
bronchitis vary greatly in different cases. 250 
BRONCHI, DISEASES OF 
They resemble in kind those of the acute 
affection. There is cough, expectoration, 
pain, soreness or uneasiness Behind the 
sternum, with more or less dyspnoea. The 
constitutional symptoms may Be very slight, 
scarcely any effect on the general health 
being apparent: or the y may Be very severe. 
Three forms of chronic bronchitis are recog- 
nised clinically:-1. That which includes the 
ordinary cases of the disease, varying much 
in severity: 2. That characterised by excessive 
secretion - bronchorrhoea ; 3. That form 
which is called dry catarrh. 
1. In the first form of chronic bronchitis 
the cough is at first slight, perhaps only 
occurring during the winter, being altogether 
absent in the summer. After a time the 
at tacks become more frequent, and at last 
the patient is never free from the affection, 
which is aggravated at times. The cough in 
such cases is more or less severe, but usually 
most so in the morning. It is often 
paroxysmal, and sometimes very violent. 
The expectoration, in some cases being 
scanty, viscid, and difficult to discharge, is 
in others, especially old-standing cases, 
copious and easy. The sputa vary much 
both in appearance and quantity. They may 
be yellowish-white, muco-purulent matter, 
or more decidedly purulent, of a greenish- 
yellow or bright or dark green colour; they 
are but little aerated, sometimes not at all, 
so that they sink in water; at times they 
are nummulated and quite opaque. In some 
cases the expectoration is foetid, constituting 
the form of the disease denominated ' foetid 
bronchitis,' the odoui resulting either from 
sloughs of minute portions of the mucous 
membrane, or from chemical changes taking 
place in the sputa. Occasionally streaks of 
blood are met with. Microscopically the 
sputa are found to consist of epithelium, 
pus-cells, and granular matter, with at times 
blood-corpuscles. 
The constitution does not suffer much in 
mild attacks, but when chronic bronchitis is 
permanent and general, the system at large 
sympathises more or less severely: the appe- 
tite fails, sleep is disturbed by the cough, 
emaciation sets in and sometimes becomes 
marked, but it does not proceed beyond a 
certain point, unlike that of phthisis, which 
is usually progressive. In all cases of chronic 
bronchitis there is great risk of an acute 
attack coming on, especially amongst the 
aged. These attacks are very dangerous, in 
consequence of the rapid extension of the 
disease throughout the lungs, and its as- 
phyxiating character. 
2. The second class of cases is characterised 
by excessive secretion from the bronchial 
tubes-bronchorrhoea. This form is often 
met with in the old and feeble, and especially 
in cases of valvular disease of the heart. 
The cough is paroxysmal, and attended with 
the expectoration of a large quantity of thin 
watery glairy fluid, or of thick ropy gluey 
matter, like white of egg. The quantity ex- 
pectorated is sometimes very large. This 
form of bronchitis may cause death somewhat 
suddenly by asphyxia. During the paroxysms 
of cough there is dyspnoea, but at other times 
it is absent, except when heart-disease exists. 
The constitution suffers little, and the flux 
seems sometimes to be beneficial in cases of 
obstructive cardiac disease. 
3. The third variety, or catarrhe sec, is 
characterised by very troublesome cough, 
oppression of breathing, tightness of the 
chest, and sometimes severe dyspnoea. Ex- 
pectoration is either absent or very scanty, 
the sputa consisting of small masses of tough, 
viscid, semi-transparent mucus. There is 
usually no febrile disturbance. The disease 
is met with in gouty people, and is often 
associated with emphysema of the lungs. 
Pathologically it seems to consist in a con- 
gested condition of the bronchial tubes. 
Physical Signs.-Inspection reveals no- 
thing abnormal in the form or size of the 
chest, unless emphysema of the lungs is 
present. The expansion in long-standing 
cases is usually deficient; the chest being 
raised more than in health. Expiration is 
often prolonged. Rhonchal fremitus may be 
felt more or less, depending on the state of 
the bronchial tubes. There is often increased 
resonance, from the presence of emphysema. 
The breath-sounds are more or less changed: 
they may be harsh and loud, and the expiration 
is prolonged in cases that have existed for a 
considerable period. The rhonchi vary : they 
are dry, coarse, moist, or bubbling according 
to the condition and contents of the tubes. 
Vocal resonance varies: it may be broncho- 
phonic, normal, or deficient. 
Diagnosis.-There is usually but little 
difficulty in the diagnosis of chronic bron- 
chitis. The affection is most likely to be 
confounded with phthisis, but the character 
and degree of the wasting, and the absence 
of increased temperature, of haemoptysis, of 
tubercle-bacilli from the sputa, and of the 
physical signs of consolidation, will generally 
enable the practitioner to decide in favour 
of the less serious disease. The main diffi- 
culty lies in the diagnosis of cases where the 
bronchi are dilated; this will be referred to 
hereafter. 
Prognosis. - Although in itself not a 
dangerous malady, chronic bronchitis be- 
comes so in consequence of the liability 
which exists to the occurrence of acute 
symptoms; when once established in middle 
or advanced age it is almost incurable. The 
complaint is further serious from its tendency 
to produce emphysema and dilatation of the 
bronchi. Per se it can scarcely ever be said 
to kill. 
Treatment.-No case of chronic bronchitis 
can be successfully treated without due re- 
gard to the constitutional condition of the BRONCHI, DISEASES OF 
251 
patient. In some cases it is impossible to 
cure the disease, and all efforts should be 
directed towards preventing its extension; 
alleviating the symptoms to which it gives 
rise; and warding off acute attacks. Atten- 
tion must be especially paid to the state of 
the heart and kidneys ; the duration of the 
affection; the age of the patient; the cha- 
racters of the expectoration ; the state of the 
lungs, as to the existence of emphysema or 
other morbid conditions; and the presence 
of gout or rheumatism. Speaking generally, 
chronic bronchitis must be treated by the use 
of a generous diet, with more or less stimu- 
lants; by the exhibition of expectorants and 
tonics; and by the avoidance of all depress- 
ing measures. The function of the liver 
must be looked to; and the administration of 
a few doses of blue pill with a saline aperient 
often gives great relief, and alters the cha- 
racter of the bronchial secretion. If gout, or 
a tendency to the formation of uric acid, is 
present, colchicum with alkalis and other 
remedies for gout, such as a course of Fried- 
richshall or Hunyadi or Carlsbad waters, will 
prove of great service. If cardiac disease 
exist, whether in the form of valvular incom- 
petence, or of weak, flabby, or dilated heart, 
digitalis combined with iron frequently pro- 
duces marked benefit. 
In the treatment of ordinary cases of 
chronic bronchitis, not dependent on any 
organic disease or constitutional condition, 
the patient's general health has to be looked 
to. The affection has a tendency to lower 
the health and to dimmish strength, and 
therefore the various tonics may often be 
given with great benefit. Of these the most 
useful are quinine, the preparations of iron, 
and those of zinc. Cod-liver oil is also very 
valuable in some cases where there is much 
wasting. The cases of bronchitis marked by 
excessive secretion are generally best treated 
by tonics; whilst those where the secretion 
is slight-cases of ' dry catarrh '-being often 
associated with a gouty condition of the 
system, are more amenable to the use of 
colchicum, the alkalis, iodide of potassium, 
and mineral waters. 
In what may be called the symptomatic 
treatment of the affection, the various expec- 
torants are useful-carbonate of ammonium, 
ipecacuanha, squill, cascarilla, senega, chloro- 
form, &c., and these may often be beneficially 
combined with some form of tonic. In 
many cases of chronic bronchitis the expec- 
torating power is diminished, and stimulat- 
ing expectorants are of great service. Much 
caution must be exercised in the administra- 
tion of opiates and other narcotics or seda- 
tives. When, however, the mucous mem- 
brane is very irritable, and when there is but 
little secretion, with a troublesome cough, 
these remedies are indicated. Opium is of 
great value, and chloral hydrate is also very 
useful, as well as, in some cases, henbane 
and hydrocyanic acid, or, whenever spasm is 
present, stramonium, lobelia, the ethers, and 
cannabis indica. Inhalations are sometimes 
very beneficial, as of the vapour of warm 
water, iodine, creasote, and other substances. 
The inhalation of creasote is especially valu- 
able if the expectoration is foetid. 
Counter-irritation is one of the most im- 
portant means we possess of relieving chronic 
bronchitis. The irritation should not be ex- 
cessive, but should be long-continued. The 
application of iodine over a large surface of 
the chest, so as to keep up a constant slight 
inflammation of the skin, is perhaps the best 
that can be used; but other irritants may 
be tried, such as sinapisms, or the various 
stimulating liniments. 
The general management of the patient 
is most important. A mild climate should, 
if possible, be chosen in the winter. The 
patient should live as far as possible in an at- 
mosphere which is mild and dry. Although 
some cases are benefited by a moist and 
warm atmosphere, the majority of cases of 
chronic bronchitis do better in a drier one. 
The skin must be carefully looked to, its 
action should be well maintained, and warm 
clothing always worn. A moderate amount 
of some alcoholic stimulant is generally 
desirable ; and the food should be nutritious 
and of easy digestion. Relief will often be 
found from wearing a respirator. 
8. Plastic Bronchitis.-This is a rare 
form of disease, and of its particular causes 
nothing is known. It is perhaps connected 
with some peculiar diathesis. The late Sir 
John Rose Cormack suggested that it may 
be a variety of diphtheria. It may occur in 
either sex, and at any period of life, but is 
most frequent in those who are of a stru- 
mous or phthisical constitution. It has been 
known, however, to attack persons of appa- 
rently healthy frame, and in the enjoyment 
of robust health. 
Anatomical Characters.-Plastic bron- 
chitis is anatomically characterised by the 
formation of concretions in the bronchial 
tubes. These concretions consist of fibrinous 
exudation from the mucous membrane; 
they form casts of the tubes, and are ex- 
pectorated. These casts are either solid or 
hollow, and on examination are always found 
to consist of concentric laminae. They are, 
for the most part, poured out into the finer 
bronchial tubes, sometimes, however, into 
the larger ones, but never into the trachea. 
The casts are of a whitish colour, but they 
are often stained with blood. Microscopic- 
ally they consist of an amorphous or fibrillar 
material, with exudation-corpuscles, granular 
matter, and oil-globules. 
Symptoms.-This disease is essentially 
chronic, but it has been met with as an 
acute affection in children. At the times 
when the casts of the tubes are expelled, exa- 
cerbations occur, the patient being attacked 252 
BRONCHI, DISEASES OF 
with pain and a sense of constriction across 
the chest, dyspnoea, and an irritating cough. 
After a time, varying from some hours to a 
few days, the dyspnoea becomes very urgent, 
and the cough very severe; then, after a 
paroxysm of coughing, it is found that the 
patient has expectorated some solid mate- 
rial, either with or without blood, usually 
intermixed with ordinary bronchitic sputa. 
The dyspnoea and cough now subside, to 
recur after an interval of a few hours or 
longer. This disease may last for weeks, 
months, or even years, marked from time to 
time by severe accessions, and relieved by 
the expulsion of further concretions. The 
matter expelled is often in small masses, 
but at times casts of bronchial tubes with 
several ramifications are expectorated. The 
disease may recur at intervals for many years; 
the general health in such cases does not seem 
to suffer, the breathing during the intervals 
being unaffected. There is, in some in- 
stances, an absence of febrile symptoms 
during the attack, whilst in others the fever 
is more marked. With the general symptoms 
are combined the physical signs. These are 
somewhat peculiar. The bronchial tubes 
being obstructed, portions of lung are de- 
prived of air; the breath-sounds are there- 
fore faint or absent. There may be dulness 
more or less complete on percussion, from 
collapse of the lung-substance, or, as occurs 
in some cases, from localised pneumonia. 
Asphyxia may be threatened if a large tube 
is blocked up. 
Diagnosis.-The diagnosis of this affec- 
tion turns on the peculiarity of the expec- 
torated matters. Doubtless the disease may 
be mistaken for ordinary bronchitis or pneu- 
monia; but when once the fibrinous casts 
of the tubes are observed in the sputa, the 
nature of the case becomes clear. 
Prognosis, Duration, Terminations, and 
Mortality.-The prognosis, if the disease is 
uncomplicated, is favourable ; but there is a 
great liability to recurrence. The complaint 
may last for many years, and may ter- 
minate in complete recovery. A fatal result 
generally depends on the presence of some 
other organic disease, such as phthisis or 
pneumonia. 
Treatment.-But little can be advanced 
as to the value of any special treatment for 
this affection. Iodide of potassium is said to 
have been employed with success. The chief 
object should be to maintain the general 
health by hygienic measures, and the 
exhibition of tonics, such as iron, quinine, 
and cod-liver oil, especially if there be any 
tubercular taint. During the exacerbations 
the administration of ammonia and the use 
of inhalations should be resorted to, and the 
general principles on which ordinary bron- 
chitis is treated should be carried out. 
4. Dilatation-Bronchiectasis.-This 
is a rare disease, which arises as a secondary 
affection. It is often associated with serious 
pulmonary mischief, and is at times difficult 
of diagnosis. There are two forms of bronchi- 
ectasis, namely, general or uniform dilata- 
tion; and saccular or ampullary dilatation. 
(1) The general or uniform bronchiectasis 
consists in a cylindrical dilatation of one or 
more of the tubes throughout a considerable 
portion of their extent. The tubes are evenly 
widened for the most part, and the dilatations 
end abruptly. 
(2) The saccular form of bronchiectasis 
consists of a globular dilatation of a tube at 
one point, or at several points. The dilata- 
tions vary in size, being from half an inch to 
an inch or more in diameter. On the tracheal 
side they usually communicate with a slightly 
enlarged bronchial tube, whilst on the peri- 
pheral side the continuity of the tube is 
almost or entirely lost from narrowing or 
actual obliteration. Sometimes the cavities 
communicate with one another. 
The two forms of bronchiectasis often 
coexist. 
The walls of the dilatations undergo 
changes in the course of the disease. The 
mucous membrane becomes granular, swollen, 
and congested; while at a later stage it 
presents a velvety or villous appearance, and 
in some cases there is even ulceration with 
superficial necrosis. The muscular and 
elastic coats become atrophied, and, coinci- 
dently with this, dilatation increases. At 
times the wasting of these coats is partial; 
some portion of the walls retaining their 
natural volume, and forming bands or ridges 
elevated above the surrounding membrane. 
The dilated tubes occasionally present an 
appearance of hypertrophy; the walls are 
thickened, but the thickening depends on 
changes which have taken place in the 
mucous membrane. The cartilages resist 
the destructive metamorphoses longer than 
the other structures, but they sometimes 
partake of them. The contents of the tubes 
may be either muco-pus, or pus; and casts 
of the minute bronchi are met with. At 
times the contents are very foetid. Crystals 
of margarin are occasionally found, and 
sometimes fragments of pulmonary tissue. 
It is said that the contents may become 
calcareous. 
Dilatation of the bronchi may be un- 
attended with any change in the surrounding 
lung-tissue, but, generally speaking, conden- 
sation of the latter takes place, as the result 
either of pressure or of chronic pneumonia. 
In some instances the tissue forms an abscess, 
in the centre of which the walls of the 
bronchus are found, whilst in others the 
walls of the bronchi and the surrounding 
tissue are destroyed by gangrenous inflam- 
mation. It is generally not difficult to 
distinguish between a phthisical cavity and a 
dilated bronchus. The latter is not charac- 
terised by the broken irregular surface which BRONCHI, DISEASES OF 
253 
usually exists in the former; its shape is 
generally more regular; and it is usually 
continuous with bronchial tubes. The sur- 
rounding lung-tissue has no tubercular 
infiltration. 
The mechanism of bronchiectasis has oc- 
cupied much attention. It is probable that 
the elastic and muscular fibres lose their 
elasticity and contractility as the result of 
chronic inflammation, and thus yield to the 
distending influence of coughing. When 
once a dilatation is produced, accumulation 
of the secretions takes place, which tends 
further to increase the dilatation. 
Symptoms.-The symptoms of bronchiecta- 
sis are those of chronic bronchitis aggravated 
in some important respects. The cough is 
frequent and paroxysmal. The expectoration 
is very abundant, very purulent, and, when 
the disease has lasted some time, very foetid. 
The breath also becomes foetid. Haemoptysis 
is occasionally met with, even to a consider- 
able extent. There is more wasting than in 
ordinary bronchitis, and the blood is more 
imperfectly aerated. Night-sweats are not 
uncommon. In fact, the general symptoms 
approach those of phthisis. The digestive 
functions are usually not much impaired. 
Physical Signs.-The movement of ex- 
pansion is diminished in bronchiectasis, while 
that of expiration is prolonged. Over the 
affected portions of the lung there may be 
slight retraction. Vocal fremitus is increased, 
and rhonchal fremitus is sometimes well 
marked. The percussion note is altered. If 
a dilated tube is surrounded by condensed 
lung-tissue, or is full of secretion, there is 
dulness on percussion; but if it is situated 
near the surface and empty, some degree of 
tubular resonance may exist. Cracked-pot 
sound may be, at times, elicited. The respira- 
tory sounds are harsh, or loudly bronchial 
with a more or less blowing character, and 
they may be distinctly cavernous. Vocal 
resonance is often greatly increased. The 
pulse becomes rapid in the later stages. The 
temperature rarely if ever reaches the height 
that it does in phthisis with cavities, and 
the daily oscillations are not so marked. 
Diagnosis.-The main difficulty as regards 
diagnosis is in the differentiation of certain 
cases of phthisis with cavities from bronchi- 
ectasis with large globular dilatations. The 
points to be relied on are that in the latter 
disease the morbid physical signs are usually 
met with at the middle and lower parts of 
the lungs, whilst in ordinary phthisis they 
are found at the apex ; that the temperature 
differs in the two affections as mentioned 
above; that emaciation and night-sweats 
are not so marked in bronchiectasis; and 
that, if cases are watched, there is usually 
observed a progressive advance of symptoms 
in phthisis, whilst in bronchiectasis the 
symptoms may remain stationary. In 
phthisis signs of consolidation precede those 
of cavities, whilst they follow them in bron- 
chiectasis, and in the latter disease tubercle- 
bacilli are absent from the sputa. Bronchial 
dilatations and tuberculous cavities have 
been found in the same lung. The fcetor of 
the breath and sputa in bronchiect: sis may 
cause a suspicion that gangrene of tne lung 
is present; but the general symptoms will 
usually enable the practitioner to differentiate 
between the two affections. 
Prognosis.-Bronchial dilatation is prob- 
ably never cured. It may last for years. 
Treatment.-The treatment of bronchiec- 
tasis must be that of chronic bronchitis with 
the use of such measures as are applicable 
to wasting diseases in general. The fcetor of 
the breath is best relieved by the inhalation 
of creasote, or some other antiseptic. The 
disease has, in some cases, been treated 
successfully by incision and drainage. 
5. Narrowing or Obstruction.-Nar- 
rowing or obstruction of the bronchial tubes 
is by no means uncommon, and may depend 
on intrinsic or extrinsic causes. Complete 
obliteration of a tube is sometimes found in 
connexion with bronchiectasis, immediately 
beyond a globular dilatation. 
JEtiology.-The intrinsic causes of ob- 
struction are a thickening of the mucous 
membrane resulting from bronchitis; the 
retention of viscid secretions ; the exudation 
of plastic material into the interior of the 
tubes; and the deposition therein of tubercle 
or cancer. 
Amongst the principal extrinsic causes 
are the pressure of adjacent tuberculous or 
cancerous deposits ; the contraction of plastic 
matter exuded into the tissues surrounding 
the tubes ; solid formations in the pleura; 
enlarged bronchial glands; and aneurysmal 
and other thoracic tumours. 
Obstruction is most frequently met with in 
the smaller tubes, but the pressure of thoracic 
tumours not infrequently causes obstruction, 
or even obliteration of a main bronchus, 
which occasionally-as in the case of aneur- 
ysms-becomes perforated. 
Symptoms.-If a large bronchial tube be- 
come suddenly and greatly obstructed, dys- 
pnoea of an urgent character sets in, and 
death from asphyxia may speedily result, 
unless the obstruction be removed. When 
the obstruction is on a smaller scale, being 
confined to the smaller tubes, or when a large 
tube suffers only from slow, gradually in- 
creasing obstruction, the symptoms are by 
no means urgent for a time, and slight 
dyspnoea, sometimes accompanied by stridor, 
is the most marked feature. 
Physical Signs.-Complete obstruction of 
a bronchial tube invariably leads to collapse 
of the portions of the lung to which the tube 
is distributed, and thus an entire lung may 
collapse if its main bronchus be obliterated. 
Where partial collapse is produced, em- 
physema of the neighbouring lung-tissue 254 
commonly follows, and if one lung become 
collapsed, the opposite lung becomes enlarged 
and emphysematous. The existence of col- 
lapsed lung gives rise to dulness on percussion 
over the affected part, unless this be situated 
away from the chest-walls, or masked by the 
presence of emphysema. Further, obstruc- 
tion of the bronchi causes a weakness or 
deficiency of the respiratory sounds, with a 
prolonged expiratory murmur, attended at 
times with sonorous and sibilant rhonchi. 
Over the collapsed portion of the lung, or 
over portions of the lung supplied by a tube 
which has become completely obstructed, 
the breath-sounds are absent. Deficiency or 
absence of vocal vibration is another physical 
sign of obstructed bronchial tubes. 
Treatment.-The treatment of obstruction 
of the bronchi must depend on the nature of 
its cause. The chief interest of the affection 
arises from the means of diagnosis of thoracic 
tumours which it may afford. 
6. Cancer. - Cancer of the bronchial 
tubes occurring independently of cancer in 
the lungs, or mediastina, is probably never 
seen; but cancerous matter has been found 
in the tubes: (1) in cases where the lungs 
have been infiltrated with a similar deposit; 
(2) where a cancerous tumour connected 
with the root of a lung has perforated a 
tube; and (3) in some cases of cancerous 
disease of the lung, a tumour of a similar 
nature being found connected with the 
mucous membrane of a tube. (4) Cancerous 
matter has also been found in transitu in a 
tube, having been detached from a cancerous 
mass. A. T. H. "Waters. 
BRONCHIAL GLANDS, Diseases 
of. - Synon. : Fr. Adenopathie Tracheo- 
bronchique ; Ger. Krarikheiten der Bron- 
chialdriisen. 
Definition.-Disease of those lymphatic 
glands which are situated at the bifurcation 
of the trachea, between the right and left 
bronchus, or upon these tubes and their 
primary divisions. 
General Description.-A short reference 
to the anatomical relation of these glands in 
connexion with their pathological and clinical 
history will be useful. Taking the bifurca- 
tion of the trachea as a starting-point, we 
find a group of glands in the space between 
the right and left bronchus. They are from 
ten to fifteen in number, and they vary in 
size from that of a small pea to that of an 
almond. The glands towards the right 
bronchus are larger than those towards the 
left. Glands are also situated upon the 
tubes; they are few in number and small. 
The vascular supply of the glands, which is 
free, is derived from the bronchial arteries, 
and the blood is returned to the bronchial 
veins. Afferent lymphatics reach the glands 
from the lungs, from the pleura, from the 
neck and other neighbouring parts. Besides 
BRONCHI, DISEASES OF 
these groups of comparatively large glands, 
numerous minute lymphatic glands are found 
in connexion with the primary divisions of the 
bronchi, chiefly at the back of these tubes, 
at their bifurcations, and at those of the 
pulmonary artery. The central group of 
glands is in relation in front with the 
pericardium, the arch of the aorta, and the 
pulmonary artery; behind with the pul- 
monary plexus of nerves, the oesophagus, the 
aorta, the vena azygos, &c. The ganglia on 
the upper, anterior, and posterior surfaces 
of the right bronchus are four or five in 
number and smaller than those of the central 
group. Their situation brings them into 
relation with the arch of the aorta, the 
innominate and subclavian arteries, with 
the brachio-cephalic vein, and with the 
vena azygos, the pneumogastric nerve, and 
its recurrent branch. The ganglia on the 
left bronchus are still smaller than those of 
the right side. Their position gives them 
relations with the arch of the aorta, the 
origin of the left carotid and subclavian 
arteries, the left branch of the pulmonary 
artery, with the large veins, with the left 
pneumogastric nerve, and especially with its 
recurrent branch. Lastly it should be stated, 
as a guide in clinical examination, that the 
bifurcation of the trachea takes place at the 
back in front of the body of the fifth dorsal 
vertebra, or between the fourth and fifth, and 
in front behind the lower end of the first 
bone of the sternum. The glands, except 
when diseased, are proportionately larger in 
children than in adult or aged persons. 
Knowing that these glands, in common with 
other lymphatic glands, are liable to such 
diseases as enlargement, abscess, morbid 
deposits, growths, and other textural changes, 
and bearing in mind, as just mentioned, 
their relations to surrounding organs, we 
can readily see how important is the study of 
their diseased conditions. Not only is their 
study important in reference to the diseased 
glands themselves, but also by reason of their 
modifying or masking the symptoms of 
disease in other organs, as the results of 
pressure which, when enlarged, they cause 
on nerves, air-passages, blood-vessels, &c. 
Throughout English and foreign medical 
literature numerous cases will be found 
described, in which there existed, more or 
less conspicuously, striking disease of the 
bronchial glands, little notice, however, being 
taken of less marked, though far more 
numerous, examples of disease. It is only 
within a comparatively recent time that the 
subject has received special attention and 
been discussed as a disease per se. 
MM. Rilliet and Barthez, in their well- 
known Traits des Maladies des Enfant s, 
have described the disease in infants, and 
Dr. West, in his work on The Diseases of 
Infancy and Childhood, has fully and clearly 
described-under the head of Bronchial 
BRONCHIAL GLANDS BRONCHIAL GLANDS, DISEASES OF 
255 
Phthisis-the tubercular diseases of these 
glands in young subjects. It is, however, to 
the late M. Noel Gueneau de Mussy, follow- 
ing up and widely extending the investigations 
of his predecessors, that we are especially 
indebted for our knowledge of the effects of 
these lesions, and to his pupil M. Barety, 
who has published an exhaustive memoir 
upon them, under the title L' Adenopathie 
Tracheo-bronchique. The subject of dis- 
ease of the bronchial glands has attracted the 
present writer's notice since (or even before) 
the year 1853, and the notes of more than 
sixty cases which have fallen under his ob- 
servation will form the basis of some of the 
conclusions to be subsequently stated in this 
article. 
Morbid Anatomy and Pathology.-The 
bronchial glands participate in the diseases 
which affect lymphatic glands generally, and 
which will be found described in a sub- 
sequent article (see Lymphatic System, 
Diseases of). In this place it will suffice 
to enumerate the principal morbid changes 
to which they are liable, and the effects 
which these changes produce. 
a. The bronchial glands are liable to con- 
gestion with enlargement, as are glands in 
other situations. Hypertrophy will be the re- 
sult of this last condition becoming chronic. 
The glands in this situation become after 
childhood almost invariably studded with 
black deposits, the quantity of which may be 
so considerable as to constitute melanoma. 
b. These glands are liable to acute and 
chronic inflammation. Acute inflammation 
in this situation, terminating in abscess, is 
rare, but several cases of the kind have been 
recorded. A case of acute inflammation of 
these glands associated with double hydro- 
thorax will be found described by the writer's 
friend the late Dr. Moxon in the Transac- 
tions of the Pathological Society, vol. xix. 
p. 572. Chronic inflammation of the glands 
is by no means uncommon. It may lead to 
permanent enlargement, to contraction and 
induration of the glandular textures, with the 
presence of calcareous particles, or to chronic 
abscess. The contents of the abscess may 
be more or less completely absorbed, leaving 
a partially filled sac or cyst, containing thick 
pus, or cheesy or calcareous matter. But 
these glands, when inflamed and enlarged, 
may form adhesions with surrounding parts, 
and the contents of an abscess, if it exist, 
may be discharged, by an ulcerative pro- 
cess, into the substance of a lung, into the 
mediastinum, into the trachea or oesophagus, 
or even into a blood-vessel. General emphy- 
sema has occurred in some cases; whilst 
the emptied sac has assumed in some in- 
stances the character of a cavity connected 
with the lungs. When the matter is dis- 
charged into the air-passages, purulent ex- 
pectoration is the result. Two or three 
examples of the kind were noticed amongst 
the writer's cases, and the possibility of 
their being mistaken for the discharge from 
a cavity in the lungs, or an empyema, was 
remarked upon at the time. The abscess 
may discharge by a sinus in the neck or 
into the mediastinum. A remarkable instance 
of this kind is recorded in the case of the 
late much-lamented Dr. Fuller. A chronic 
abscess of the bronchial glands had opened 
into the posterior mediastinum. This led to 
pyaemia, to the formation of abscesses in the 
brain, and to the loss of a valuable life. 
Cases of great pathological interest illustrative 
of these points will be found recorded in 
the Pathological Transactions-in vol. xxv., 
p. 29, by Dr. Coupland ; in vol. xxx., p. 254, 
by Dr. Barlow; in vol. xxxv., by Mr. Makins. 
In vol. xxxvi. Dr. Percy Kidd records two 
remarkable cases, in one of which sudden 
death was caused by the impaction of a 
caseous gland in the trachea, and a second 
case in which death resulted from profuse 
haemorrhage caused by bronchial ulceration 
perforating the pulmonary artery, due to the 
pressure of a calcareous gland. In the same 
volume is recorded a case of suppurating 
bronchial gland by Mr. John Poland. Dr. Gee 
has recorded several cases of interest in vol. 
xiii. of The Bartholomew's Hospital lieports. 
The pressure of enlarged glands may cause 
dysphagia ; and a series of cases illustrative 
of this point collected by Korne will be found 
noticed in the Medical Chronicle, vol. iii. 
p. 112. The pressure of enlarged glands on 
the pneumogastric nerve may have marked 
effects on the heart's action, causing great 
rapidity of the pulse or the contrary. See a 
Memoir by Dr. Marklen, Bulletin des Hopi- 
taux de Paris, tome iii., annee 1887. 
c. These glands are liable to suffer espe- 
cially from tuberculous or scrofulous dis- 
ease, from various forms of malignant dis- 
ease, and in secondary or tertiary syphilis. 
Of the latter form of disease, some striking 
examples have fallen under the notice of 
the writer, in which symptoms closely 
resembling phthisis existed, but which 
yielded to treatment directed to the specific 
disease. 
Aetiology.-The causes which give rise 
to disease of the lymphatic glands being dis- 
cussed in another article, reference will here 
be made only to the special circumstances 
which influence the particular glands; and 
thus it will be sufficient merely to allude, 
amongst predisposing causes, to hereditary 
predisposition, to general impairment of 
health, and the like. With regard to the 
influence of age and sex, reference has al- 
ready been made to the works of Rilliet and 
Barthez, of Dr. West, and of other authors 
who described the frequency of the disease 
in childhood. The writer's observations made 
on young persons and adults show that 
of 58 cases (of whom 21 were males and 
36 females-in one case the sex was not 256 
BRONCHIAL GLANDS, DISEASES OF 
recorded) 2 were under 10 years of age, 9 were 
between 10 and 20 years of age, 18 were be- 
tween 20 and 30, and 26 were over 30 years 
of age. In three cases the age was not 
stated. If these observations justify any 
inference, it is that females are more liable 
to disease of the bronchial glands than 
males, and that the disease occurs with in- 
creasing frequency after the age of puberty. 
Amongst the exciting causes of disease in the 
glands we leave to be considered elsewhere 
those general conditions which give rise to 
disease in the lymphatic glands generally, 
such as scrofula, tubercle, malignant disease, 
&c., and pass on to the consideration of the 
more immediately local exciting causes. Cold 
leads frequently to congestion and enlarge- 
ment of the bronchial glands. But it is to 
local irritation or inflammatory disease in 
organs or tissues with which these glands 
have a connexion that the source of disease 
may be frequently traced. As we find the sub- 
maxillary glands or cervical lymphatic glands 
enlarged from irritation or disease in the 
mouth or throat, or the axillary glands or 
inguinal glands enlarged from irritation or 
inflammation about the hands or feet, so we 
may find the bronchial glands enlarged tem- 
porarily or permanently from inflammatory 
disease in parts the lymphatics of which 
pass to these glands. They have also been 
observed to be enlarged in the course of or 
after certain acute specific diseases, such as 
scarlet fever, measles, and typhoid fever. In 
whooping-cough this enlargement has been so 
frequently observed by the late M. Gueneau 
de Mussy, that he believed this disease to 
be an exanthem of the bronchial mucous 
membrane, and that this local condition 
leads to enlargement of the glands, which, 
again, by pressure on the pneumogastric and 
recurrent nerves, gives rise to some of the 
special phenomena, such as crowing cough, 
and even to the vomiting so frequently ob- 
served in this disease. It is right to remark 
here that the late Dr. Hugh Ley speaks in- 
terrogatively, in his work on Laryngismus 
stridulus, of enlarged bronchial glands being 
capable of producing a cough like that of 
pertussis, and he further alludes to some 
cases of whooping-cough in which the glands 
by the side of the trachea were enlarged. 
He asks, ' May it not be that an enlarge- 
ment of these glands from a specific animal 
poison, similar to that of the parotid gland 
in mumps, is after all the cause of whooping- 
cough?' (Note, p. 440.) The same author 
gives several striking illustrations of dis- 
eased bronchial glands pressing upon the 
pneumogastric and other nerves producing 
marked results. The black deposit so often 
found in the glands is the result of the 
absorption of carbonaceous or pigmentary 
matter from the lungs. 
Symptoms.- The symptoms which have 
been recorded by the writer as more or less 
characteristic of the presence of enlargement 
of the bronchial glands are as follows :- 
1. Cough, which is noted as being a pro- 
minent symptom in 39 cases. In 21 of these 
cases it was stated to have been the most 
troublesome of the symptoms present. In 
6 cases it was described as harsh and laryn- 
geal ; in 4 cases spasmodic, resembling 
whooping-cough. In other cases, 5 in num- 
ber, it was characterised as short and hack- 
ing, constant, incessant, and in one case the 
sound resembled that made by the peculiar 
cough of a sheep. 
2. Pain is, in regard to the frequency of 
its occurrence, the next symptom recorded. 
It was mentioned as being present in 22 
cases. The seat of pain was almost con- 
stantly referred to the situation of the fourth 
and fifth dorsal vertebrae, at one or both 
sides of the spinal column. The pain was 
mentioned in a few cases as existing only in 
front, beneath and at one or both sides of 
the upper end of the sternum and below 
the clavicles. The feeling was described in 
some cases (5) as of distressing tightness, 
and in one case as a ' spasm.' Tenderness 
on pressure over the seat of pain was very 
frequently observed. The persistence of the 
pain was very varied. 
3. Difficulty of breathing was a notice- 
able symptom in several cases. In 13 it was 
recorded as being specially so; in 4 it had 
all the characters of spasmodic asthma, oc- 
curring at intervals and especially during 
the night. 
4. Difficulty of swallowing was noticed in 
10 cases; in one of these the difficulty was 
remarked especially in swallowing liquids. 
5. Hcemoptysis was present in 10 cases. 
The amount of blood varied in these cases 
from marked streaks to copious expectora- 
tion, lasting two or three days. Nc case was 
recorded as presenting this symptom except 
on tolerably clear proof that it depended on 
bronchial gland enlargement, and on no 
other cause 
6. Congestion and puffiness of the face 
have been mentioned as present in 3 cases. 
7. Expectoration of mucus, such as results 
from bronchial catarrh, was frequently pre- 
sent. Copious expectoration of pus was 
present in 3 cases. In each it resembled 
the contents of an ordinary glandular abscess, 
but mixed with air. In one of these the 
discharge was intermittent. The frequent 
occurrence of cough without any expectora- 
tion was remarked in many cases. Cal- 
careous particles are mentioned also as 
having been expectorated. 
8. Loss of voice (4 cases) and hoarseness 
(2 cases) are recorded as striking symptoms. 
9. Vomiting is mentioned as having been 
present twice. 
10. Lastly, the posit ion assumed with least 
discomfort by the patient when in bed was 
noticed in 41 cases. Of these 23 rested on BRONCHIAL GLANDS, DISEASES OF 
257 
that side on w'hich the glands were mentioned 
as being chiefly if not wholly affected. In 
15 cases an opposite condition was noticed. 
In 2 cases the most comfortable position was 
lying on the back. One patient, unable to 
lie down, sat when in bed, and stooped for- 
ward. One patient, a little boy, could only 
rest on his face and knees. This case was 
further remarkable in reference to the clear- 
ness with which the disease was recognised, 
and the successful result of subsequent treat- 
ment. 
It might be mentioned here incidentally 
that the glands of the right side were noticed 
as being chiefly affected in 28 cases, and of 
the left in 22 cases, in 4 both sides seemed 
equally affected, and in 4 no record was 
made. The general or constitutional symp- 
toms connected with the malady under no- 
tice need not be discussed here. They are 
in nowise peculiar, and will be found treated 
of elsewhere. The symptoms described above 
have special reference to the bronchial glands. 
The cough and its peculiar characteristics 
are, no doubt, in a great measure dependent 
on pressure or on irritation communicated to 
the pneumogastric nerves and their branches. 
So likewise pain and difficulty of breathing, 
in a great degree, through direct pressure on 
the air-passages, may also cause or aggravate 
these symptoms. Aphonia especially seems 
to have relation to the condition of the re- 
current nerves. In one of the cases, which 
the writer saw with Mr. Lennox Browne, 
paralysis of the left chorda vocalis existed. 
The diagnosis of glandular disease was clear, 
a conclusion confirmed by the results of treat- 
ment. Vomiting is mentioned in two cases. 
M. de Mussy wrote that this is a more frequent 
result when the left pneumogastric nerve is 
pressed upon. He saw a connexion between 
the troublesome vomiting which occurs in 
some cases of tubercular disease of the lungs 
and like pressure upon nerves. The puffiness 
of the face and eyes noticed in these cases 
is due to pressure on the venous trunks, a 
condition which also accounts not only for 
some cases of haemoptysis, but for bleeding 
from the nose, occasionally present. Copious 
and sometimes persistent haemoptysis (pro- 
fuse, as in the instance previously men- 
tioned) has been traced to the perforation of 
a vessel by ulceration in connexion with 
disease of the glands. 
Physical Signs.-The physical signsnoticed 
in the 58 cases referred to were : 1. Dulness. 
This was present in 47 cases. It was found 
between the margin of the scapula and the 
spinal column at one or both sides, on a level 
with the fourth and fifth dorsal vertebrae. It 
varied in degree, and was more readily mani- 
fested when the muscles of the back were 
strained by folding the arms across the chest, 
and was often strikingly distinct when one 
side was contrasted with the other. Dulness 
was present in front in 8 cases (whether coinci- 
dentally with dulness at the back or not is not 
clearly stated), beneath the top of the sternum, 
and at each side below the sterno-clavicular 
junction. The dulness here was best elicited 
by the patient expiring deeply and holding 
the head backwards whilst percussion was 
being made. 
2. Flattening of the affected side in front 
was mentioned in 3 cases. Diminished mo- 
bility of the affected side, chiefly indepen- 
dent of flattening, was recorded in 4 cases. 
Prominence in front was not recorded in any 
case, though, no doubt, it may occur. 
3. The respiratory sounds were variously 
modified. Marked tubular breathing was 
recorded as being present over the seat of 
disease in 14 cases. In 10 the expiratory 
murmur was described as being very loud, 
various modifications of the inspiratory mur- 
mur being found at the same time. Feeble- 
ness of the respiratory murmur as a whole 
was noticed in 14 cases. In some this de- 
ficiency extended over the whole lung; in 
others it existed over the upper or lower 
portion of a lung, behind or in front. The 
observations made on the voice by the writer 
were few, but M. de Mussy and M. Lere- 
boullet speak of a peculiar and increased re- 
verberation of both the voice and the cough. 
Dr. Eustace Smith has described in the cases 
of children a venous hum, heard at the root 
of the neck when the head is thrown back, 
caused by the pressure of the enlarged glands 
on the venous trunks. 
Diagnosis.-In the present article those 
cases are not kept in view in which the 
bronchial glands, becoming the seat of con- 
stitutional disease in association with other 
glands in the neighbourhood, constitute large 
and manifest tumours-such will be found 
described under another head (see Medias- 
tinum, Diseases of). Nor is it intended to 
give prominent consideration to the state of 
the glands when they enlarge in acute disease 
-where the state of the glands plays a 
secondary part. The writer has been anxious 
to describe and to assist in recognising the 
presence of a condition in which the disease 
of the bronchial glands constitutes to some 
extent a disease per se, or gives rise to 
complications which it is important to dis- 
criminate. He believes the symptoms and 
signs above described will suffice for the 
purpose, always remembering that in the 
present and in all similar instances it is 
necessary to take means for excluding in 
our investigations diseases which may pro- 
duce like phenomena. Thus we may find 
cough, pain, tenderness on pressure, and 
aphonia in a case of hysteria without any 
evident structural disease. On the other hand, 
a small tumour-say, a small aneurysm- 
may produce all the signs of pressure which 
are above given as the signs of bronchial 
gland-enlargement. It is the duty of the 
physician to recognise these differences and 258 
BRONCHIAL GLANDS 
BUBO, VENEREAL 
distinctions, to trace them to their origin, 
and thus establish as far as may be a know- 
ledge of the nature of the disease under 
investigation. 
Prognosis.-Prognosis will, as in like in- 
stances, so entirely depend on the nature of 
the disease, on its amount and its condition, 
on its relation to and effects on surrounding 
organs and textures, that each case must be 
regarded independently. It would be fin- 
possible to discuss the subject fully here-all 
that can be said is that the simple enlarge- 
ments, or those resulting from specific dis- 
eases, generally yield to treatment, and within 
a reasonable period. 
Treatment.-In several cases of morbid 
gland-enlargement, treatment has proved 
very effective. These cases would seem to 
be those of simple chronic enlargement. 
Many such cases have yielded to the use of 
iodide of iron in the form of pills or syrup, 
and to the external application between the 
shoulders of a solution of iodine, composed 
of equal parts of the tincture and the lini- 
ment of iodine. The same treatment has 
likewise proved very effective in cases in 
which a syphilitic origin for the disease 
could be traced. Symptoms such as cough, 
difficulty of breathing, pain, and loss of 
flesh and strength, &c., will all require 
more or less suitable treatment. The cough 
and difficulty of breathing may in some 
cases be relieved by simple expectorants or 
antispasmodics. A useful application when 
pain is a prominent symptom, is an embro- 
cation composed of equal parts of chloroform, 
belladonna liniment, laudanum, and spirit 
of camphor. A couple of drachms of this 
composition sprinkled on the surface of im- 
permeable piline, and applied over the painful 
part for a few minutes, often affords relief. 
Hypodermic injection of morphine may be 
required when pain is very severe. Under 
all circumstances it is necessary to improve 
the general health by wholesome diet, pure 
air, and the other conditions which will 
promote good digestion and a free elimi- 
nation by the excreting organs. 
Richard Quain. 
BRONCHOCELE (Spoy^os, the throat; 
and Kq'Xr), a tumour).-A synonym for goitre. 
See Goitre. 
BRONCHOPHONY (Spoy^os, the 
throat; and (ftavr), the voice).-The resonance 
of the voice, as normally heard on auscultation 
over those parts of the chest which corre- 
spond with the main bronchi, and, in certain 
morbid conditions, beyond these situations. 
See Physical Examination. 
BRONCHO-PNEUMONIA. -A sy- 
nonym for catarrhal pneumonia. See Lungs, 
Inflammation of. 
BRONZED SKIN.-A peculiar dis- 
coloration of the skin, frequently associated 
with Addison's disease. See Addison's 
Disease. 
BROW-AGUE.-A synonym for frontal 
neuralgia, or tic-douloureux. See Malaria ; 
Neuralgia ; and Tic-Douloureux. 
BRUIT (bruit, Fr. a noise).-A word 
used to designate various abnormal sounds 
heard on auscultation, in connexion with the 
heart or vascular system. See Physical 
Examination. 
BUBO (SovS^v, the groin). - Synon. : 
Apostemainguinis; dragoncelus", Fr. bubon-, 
Ger. Leistenbeule.-An inflammatory swell- 
ing of a lymphatic gland in any part of the 
body, whether caused by irritation or absorp- 
tion, as in venereal disease; or referable to 
some constitutional affection, such as the 
plague. See Bubo, Venereal ; and Plague. 
BUBO, VENEREAL.-Definition.- 
An affection mentioned in the most ancient 
medical writings, but not properly distin- 
guished in its several varieties until the pre- 
sent century. The term bubo is almost exclu- 
sively confined to swelling of the glands of 
the groin consequent on venereal irritation 
of the genitals, and will be so employed here. 
Varieties.-Buboes are divided into :- 
1. Simple bubo, known also as sympathetic 
bubo, due to inflammation of a gland through 
ordinary irritation from an inflamed surface. 
2. Specific bubo, the chancrous or virulent 
bubo, or an abscess inoculated with the pus 
of a chancre. 3. The indolent enlargement 
of the lymphatic glands accompanying the 
development of the initial sore of syphilis 
is, by some, called syphilitic bubo, though its 
formation is not due to active inflammation, 
and is quite distinct from the two forms just 
mentioned. 
The glands first affected in the sympathetic 
and in specific bubo are always those in most 
direct communication with the sore. Further, 
according to Bicord, when chancrous matter 
has reached a gland through the absorbent 
ducts, it never passes beyond that gland into 
another more remote in the series. On the 
other hand, the effect of syphilitic absorption 
is general, and affects the glands of the group 
which are remote as completely as it does 
those which are nearest to the inlet of the 
poison. 
Buboes occur most frequently on the side 
of the body occupied by the source of irrita- 
tion ; still they form not rarely on both sides, 
and sometimes only on the side opposite to 
the position of the exciting sore. When bubo 
forms in both groins, there is usually a sore 
on each side or one at the mesial line. The 
crossing of the irritant is due to anastomosis 
or interlacing of the lymphatic ducts at the 
mesial line. And when the glandular affec- 
tion forms on the side opposite to the sore, 
there is want of communication with the 
glands of the groin on that side. Bubo, in BUBO, VENEREAL 
259 
eluding simple and virulent, occurs in about 
thirty per cent, of chancres ; how often with 
urethritis and other lesser venereal affections 
is not known. 
1. Simple Bubo.-Adenitis. 
JStiology.-This variety may be caused 
by mechanical irritation of the surface, such 
as erosions or fissures irritated by dirt or by 
caustic applications; by urethritis, balano- 
posthitis, or by a chancre when that acts 
only as a simple local irritant. Simple bubo 
is also often excited by herpes, erysipelas, 
boils, or other non-venereal irritants of the 
genitals. Lastly, though nearly all buboes 
can be traced to a lesion of the part where 
their absorbents arise, there are occasionally 
some observed for which such origin cannot 
be found. Some are caused by excessive 
sexual intercourse or excitement; they are 
met with generally among young lads and 
girls. Such are analogous to the inflamma- 
tion of the inguinal glands which sometimes 
follows excessive straining of the muscles in 
long walks or rides. But it is also believed 
by one or two authorities that chancrous 
poison in rare instances has been absorbed 
along the lymphatic ducts without producing 
a sore on the surface. This may be, though 
extremely rarely, an actual occurrence. It 
has received the names of idiopathic bubo 
and bubon d'emblee. 
Symptoms.-There are two forms of simple 
bubo:-1. Slight swelling and tenderness of 
one or more glands, ending in a few days 
by resolution. This occurs most frequently 
in urethritis, balano-posthitis, or simple 
chafings. In genuine chancre the next 
and more serious form is most frequent. 
2. Swelling, commonly of one, seldom of 
several glands; brawny thickening of the sur- 
rounding tissues; redness of the integuments; 
great tenderness and pain, especially when 
walking. In a few days this condition ter- 
minates either by abscess, the most frequent 
culmination, by gradual subsidence to the 
normal state, or by chronic induration of one 
or more glands. When the bubo suppurates, 
the matter, instead of pointing at once, may 
burrow in various directions among the 
layers of cellular tissue before it breaks 
through the skin. The pus of this form of 
bubo is always the ordinary pus of inflam- 
mation. 
Some cases may terminate by gradual 
conversion into chronic fistulae ; or the glands 
may degenerate by tuberculisation with suc- 
cessive formations of abscesses around the 
tuberculous glands, with undermining of the 
skin. 
Prognosis.-This form of bubo is seldom 
dangerous, but always serious when it causes 
tuberculisation of the glands and burrowing; 
it is then often very tedious and exhausting 
to the patient. 
2. Specific Bubo.-Virulent bubo. This 
is in reality an enormous chancre, identical 
in all but size with the sore whence it was 
inoculated. This form is never a consequence 
of gonorrhoea or of constitutional syphilis, 
but only of the local sore. It may be gene- 
rated in two ways. 1. By touching the sur- 
face of a simple open bubo with chancrous 
pus. 2. By the absorption of chancrous pus 
along the lymphatic ducts leading from the 
chancre to the gland most directly connected 
with the sore. Two pathological facts prove 
the reality of this mode of origin. First, it 
has been observed that occasionally small 
circumscribed abscesses will form in the 
course of the lymphatic ducts before they 
reach the gland. When these little abscesses 
are opened they present the peculiar cha- 
racters of the chancre. Secondly, when an 
efferent duct has brought chancrous pus into 
a gland, the abscess around the gland retains 
the ordinary phlegmonous character until the 
necrosing action going on in the infected 
gland lays open its interior, then contamina- 
tion of the abscess takes place, and in a few 
days the abscess-cavity assumes the aspect 
of a huge chancre. 
The conditions which assist or hinder the 
conveyance of chancrous pus along the lym- 
phatic vessels are wholly unknown. 
The proportional frequency of virulent 
bubo to the number of chancresis not known. 
It is far less frequent than simple bubo. It 
is said that women are less prone to it than 
men. 
When not accidentally inoculated, virulent 
buboes are almost wholly confined to the 
groin, and originate in the gland which lies 
commonly in the centre of the group over 
the great blood-vessels. Occasionally, when 
the chancre is on the finger, a gland of the 
epitrochlear or axillary groups develops into 
virulent bubo. Hiibbenet, of Kiew, experi- 
mentally inoculated a soft chancre on the 
cheek, which was followed by virulent bubo 
of the gland in front of the tragus of the 
ear. This bubo is generally unilateral; 
rarely are both sides of the body affected; 
in such cases the chancre is at the mesial 
line, or there are two chancres. Still more 
rarely the bubo forms at the side of the 
body opposite to that of the chancre. The 
time for appearance is generally in the first 
or second week of the existence of the 
chancre; but it may occur at any time while 
the chancre is spreading. 
Symptoms. - At first the symptoms of 
specific bubo are those of acute abscess form- 
ing rapidly round a single gland. Thus far 
they differ nowise from those of simple 
bubo. When the contagious pus reaches the 
abscess accidentally from without, or from 
within the gland by ulceration or incision of 
its capsule, the simple suppurating cavity 
becomes a spreading ulcer, which rapidly 
makes itself widely open by destruction of 
the integuments. The skin, thin as tissue- 
paper, gives way at several points, and lets 260 
BUBO, VENEREAL 
out a large amount of matter, which is thin, 
yellowish-grey or yellowish-red, with shreds 
of a chocolate colour floating in it. When 
perforated, the skin breaks rapidly away 
until the cavity is widely exposed. 
The further progress varies. In the least 
severe variety the edges of the skin ulcerate 
irregularly for a short distance, then thicken 
and begin to granulate; the floor of the 
ulcer loses its unevenness and rises up to the 
level of the skin; and cicatrisation follows. 
But commonly a much greater destruction 
of tissue is effected. The skin is eaten away 
into wide gaps ; the floor burrows under the 
skin in long channels, or dives deeply among 
the great vessels. In other cases the ulcera- 
tion produces a large shallow sore. The 
contagious condition of these buboes often 
continues for weeks or months, so that con- 
secutive inoculation of the skin is not infre- 
quent. The characters of the fully formed 
virulent bubo are those of the chancre. The 
surface is greyish-brown, dug-out, ' worm- 
eaten '; the borders at some parts are 
thickened, everted, and pared away, at others 
sharply eroded or undermined and curled in. 
The matter is thin, shreddy, plentiful, red- 
dish in colour, and inoculable. Again like 
the chancre, the virulent bubo passes through 
periods of extension, stagnation, and repair. 
The virulent, as well as the simple bubo, 
is liable to erysipelas and inflammatory 
sloughing. 
The duration of virulent bubo for the 
reason stated is wholly indefinite-in a few 
cases ending in a week, in many cases lasting 
for months. 
Diagnosis.-The virulent bubo has in its 
early stage no distinguishing mark from the 
simple acute bubo. After it has become in- 
oculated with the contagious matter it is dis- 
tinguished from every other affection by the 
characters already described. The earliest 
signs of virulence are two : the matter which 
escapes when the bubo is lanced is thin and 
shreddy, and the edges of the cut become 
in a day or two eroded and partly covered 
by adherent sloughs. Subsequently other 
characters develop and remove all doubt. 
Nevertheless, in some cases the signs of 
virulence are so feebly marked throughout 
that the diagnosis remains uncertain. This 
difficulty may be increased by the primary 
sore having healed before the suppuration of 
the bubo, or by its being hidden in some 
unusual position (urethra, anus). 
Prognosis.-This is not always grave. 
Virulent buboes often reach cicatrisation in a 
few weeks, and meanwhile cause no serious 
inconvenience. On the other hand, they are 
prone to inflammation; or if the patient have 
suffered from syphilis some years previously, 
the form of tertiary disease known as phage- 
daena may attack the ulcers, and thereby 
permanently cripple the patient, or even 
destroy life. 
3. Syphilitic Bubo.-Indolent multiple 
bubo; pleiade ganglionnaire.-This enlarge- 
ment of the group of lymphatic glands in 
nearest connexion with the initial sore is the 
constant, or at least almost constant, symptom 
of early syphilitic infection. In this it differs 
much from the bubo of chancre or gonorrhoea, 
in which affections the bubo is more often 
wanting than present. Four conditions have 
been noted to exist in patients in whom the 
enlargement of the glands could not be 
detected, namely :-1. Phagedaena of the 
sore. 2. Obesity ; in such persons the lym- 
phatic system as a rule is small. 3. Second 
infection ; i.e. a primary sore on a patient 
who has had constitutional disease before. 
4. Scantiness of the induration of the primary 
sore, the sore itself being ill-developed. But 
these exceptions are most rare. Fournier 
gives five instances only of absence of indo- 
lent multiple bubo in 265 cases of hard sore, 
accompanied by well-marked general syphilis; 
or 2 per cent. In 176 similar cases noted by 
the writer, three had no apparent inguinal 
enlargement. One of the patients was a 
very fat man, and in another the initial sore 
was only slightly hardened. 
The seat of this bubo is, in the great 
majority of cases, the groin, whither, besides 
the lymphatic ducts of the external genitals, 
those of the anus, perinaeum, buttocks, and 
lower part of the abdomen are directed. But 
the glands of other regions-epitrochlear, 
axillary, sub-maxillary, buccal, cervical, and 
nuchal-are all occasionally found primarily 
enlarged when the syphilitic poison enters 
the body through the regions whence their 
absorbent ducts are derived. 
In the groin the bubo is generally double, 
that is, the glands are enlarged in both groins, 
those on the side of the sore being most 
affected. In a few cases only the glands 
situated on the same side of the body as 
that of the sore enlarge, and in rare examples 
only those of the side opposite to that of the 
sore. This enlargement affects the group 
widely, for when the deeply-placed glands 
can be examined they are found to be simi- 
larly enlarged along the iliac vessels and 
lumbar vertebrae. 
The enlargement of the glands is first per- 
ceived about eleven days after the induration 
of the sore, though probably the affection 
commences at the end of the incubation of 
the poison. In extremely rare instances 
enlargement is delayed until the third or 
fourth week after the induration of the sore. 
Symptoms.-The distinguishing marks of 
this bubo are swelling, not inflammatory, 
and rarely surpassing an almond or a hazel 
nut in size ; gristly hardness ; ready isolation 
and mobility ; insensibility to pressure ; 
natural hue and condition of the overlying 
skin ; and absence of fulness of the cellular 
tissue. 
The gland in most direct communication BUBO, VENEREAL 
261 
with the sore is most enlarged; in rare 
exceptions only a single gland is enlarged. 
Copious enlargement of the glands does not 
always attend copious induration of the sore, 
nor is scanty induration of the sore always 
accompanied by small swelling of the glands, 
though commonly this is the case. So also, 
though absence of tenderness is the rule, the 
glands may be slightly painful if pressed. 
Again, though the glands remain distinct 
in most cases, they have been known to 
coalesce into a single mass, which becomes 
fixed to the fascia. In many patients the 
dorsal lymphatic vessel of the penis becomes 
indurated sufficiently to be easily distin- 
guished under the skin. 
This bubo reaches full development in one 
or two weeks, and remains without apparent 
change for several weeks, or even for two or 
three months. Then it begins to diminish 
slowly, but is generally still evident in the 
fifth or sixth month after infection, and now 
and then even for years afterwards. In rare 
cases the enlargement vanishes in two or 
three weeks. The long duration of enlarge- 
ment renders this bubo a valuable sign of 
constitutional syphilis when the primary sore 
has disappeared. Again, the conspicuous 
enlargement of a group of glands may in- 
dicate the place of entry of the syphilitic 
poison when that is hidden. 
Terminations.-In most cases the glands 
revert to their natural state. Sometimes they 
degenerate into masses of fibrous tissue. Now 
and then suppuration takes place, not from 
the syphilitic change, but from ordinary irri- 
tation, and then it produces a simple phleg- 
monous abscess. A further change is apt to 
occur in tuberculous persons. The glands 
enlarge still more, grow soft, and coalesce; 
presently matter forms in the thickened cellu- 
lar tissue around the glands, and the further 
progress becomes that of tubercle. 
Diagnosis.-This is generally easily drawn 
from the character of the swelling, aided by 
the presence of other syphilitic signs (hard 
sore, rash on the skin, &c.). This bubo may 
be confounded with chronic inflammatory 
enlargement, but in such cases the history 
and attendant symptoms remove doubt. 
Prognosis.-Apart from its connexion with 
syphilis, the prognosis is good. The only 
untoward termination is tuberculous degene- 
ration. • 
Treatment.-1. Simple acute bubo, from 
whatever cause it may arise, demands the 
treatment of acute abscess. In the early 
stages, antiphlogistics, rest in bed, the con- 
stant application of a cream made of equal 
parts of extract of belladonna and glycerine, 
warm poultices, fomentations, and baths, 
sometimes even leeches, are requisite. Cau- 
tion must be observed in applying leeches 
if chancre be present, lest the bites be 
converted by inoculation into chancres. 
The leeches should be applied at the cir- 
cumference of the swelling, so that they 
may be removed as far as possible from 
the centre where pointing is most probable. 
If suppuration arrive more speedily than 
was expected, and the bubo prove a virulent 
one, it is best to open it freely and trust to 
antiseptics, such as iodoform, to prevent the 
inoculation of the bites. 
When active congestion has ceased and 
matter has not formed, the subsidence of the 
glands may be aided by pressure with a pad 
and spica bandage. Stimulating ointments 
and plasters, iodine, and similar preparations 
are of doubtful service, and may possibly re- 
kindle the inflammation. When pus has 
formed, it should be let out by a vertical 
incision at once. The proper drainage of the 
cavity should be ensured by making the in- 
cision long in. usually), and by placing a 
bit of drainage-tube between the edges of the 
incision during the first twenty-four hours. 
Early evacuation checks the undermining 
of the skin and prevents burrowing. When 
matter forms at several points, a small in- 
cision should be made at each fluctuating 
point. When free exit has been given to the 
pus, the groins should be dressed with boracic 
lint soaked in hot water ; and when swelling 
is gone, the surfaces may be covered with 
boric acid ointment and overlaid by a thick 
compress and spica bandage; which, slackly 
applied at first, may be tightened as the 
swelling subsides. 
2. The chancrous bubo, not being dis- 
tinguishable from ordinary sympathetic bubo 
during the inflammatory swelling and conse- 
quent suppuration, requires the same treat- 
ment-sedatives and an early single incision. 
By early incision the cavity of the abscess, 
subsequently the chancrous ulcer, is kept as 
small as possible; by a single incision the 
number of chancres is restricted. Occasion- 
ally, but only when the abscess has already 
undermined the skin, more than one incision 
is necessary. Caustics have no advantage 
over the knife for opening the abscess, while 
they make a larger gap. When the abscess 
has been opened and the chancrous nature is 
suspected, a free cut should be made, and 
the cavity should be well cleared at the time 
by injections-of one part of carbolic acid to 
sixty of water, for example, or of 5-10 grains 
to the ounce of nitrate of silver, or of tar- 
tarated iron, or of some other astringent and 
disinfectant, and the interior well dusted with 
iodoform. The injection may be repeated 
three times in the first twenty-four hours; 
and constant drainage maintained by a 
drainage-tube and a compress of Lister's 
antiseptic gauze or boracic lint. Should these 
precautions fail to prevent the conversion of 
the abscess into a chancre, it must then be 
dressed as a chancre. It must be sedulously 
washed by injection twice daily, dried by 
careful mopping with bits of cotton-wool, and 
well dusted and packed with iodoform in 262 
BUBO, VENEREAL 
powder; the whole cavity being loosely filled 
with pellets of cotton-wool, and compressed 
gently with a layer of boracic lint and a 
bandage. Should this fail, as it sometimes 
will, caustic may be applied. The caustics 
most suitable are the strongest and most 
penetrating, such as Vienna paste, acid 
nitrate of mercury, Ricord's paste (powdered 
charcoal and the strongest oil of vitriol). To 
apply the caustic thoroughly the patient 
should be anaesthetised. If the least part of 
the surface is left undestroyed, that will re- 
inoculate the whole. Before cauterising, it 
is well to scrape the surface thoroughly with 
Volkmann's sharp spoon. Complete cauter- 
isation is practically very difficult to accom- 
plish, hence caustics should be reserved for 
the cases where iodoform, which is painless, 
fails. Overlapping bands of skin should 
be divided, that the dressing may be fairly 
applied. 
Phagedcena.-"When the ulceration by its 
obstinacy deserves this title, plan after plan 
of treatment must be tried till the destruc- 
tion of tissue is arrested-caustics being re- 
served for the last. To the local treatment of 
phagedtena that for syphilis should be added. 
The patient should be brought under the in- 
fluence of mercury as quickly as possible, 
by giving two or even three grains of blue 
pill thrice daily, or by the injection into the 
thick muscles of the trunk of some suitable 
mercurial solution, such as that of Raggaz- 
zoni (bichloride of mercury, 1 part; iodide of 
sodium, 1 part; distilled water, 64 parts: 
8 minims being a dose). When the patient's 
general health is good, the ulceration seldom 
fails to yield to iodoform, applied thoroughly 
in the manner directed. While the nocturnal 
gnawing pain continues, the patient should 
be narcotised with opium or other narcotic. 
The cessation of pain is a signal that the 
eroding action has stopped. When iodoform 
alone is insufficient, the continuous warm 
hip-bath must be employed. By it pain is 
at once arrested and healing soon set in 
motion. As continual immersion in a bath 
becomes extremely irksome in many cases, 
the ulceration may be arrested by keeping 
the patient in water for sixteen hours every 
day, and allowing the night to be passed in 
bed-in this interval the wound should be 
carefully packed with iodoform. When the 
ulceration is stopped, the bath may be dis- 
continued and iodoform alone used. If the 
water-bath fail (and such a result has not yet 
happened during a considerable employment 
of this method at the Male Lock Hospital), 
caustics may then be used. 
The strength of the patient, generally much 
exhausted, should be restored by tonics, good 
diet, stimulants, and other general means. 
3. The syphilitic bubo usually causes no 
trouble, and gets well during the course of 
treatment which is carried out for the cure of 
the general disease. If tenderness or aching 
occur, rest and a few warm baths are sufficient. 
If suppuration takes place the abscess must 
be incised and poulticed. The tuberculous 
degeneration is best met by remedies against 
the diathesis-iodide of ammonium or of 
iron, cod-hver oil, nutritious food, sea-air, and 
other tonics. Mercury, in -grain doses of 
the bichloride, combined with the iodide of 
sodium or with solution of perchloride of iron, 
may be added to the treatment. Locally, 
the abscesses and sinuses must be emptied 
as fast as they form and cleared by dissect- 
ing the diseased glands away and scraping 
their sites with the sharp spoon. 
Abortive treatment of bubo.-This once 
favourite method of treating buboes has fallen 
into disuse as the varieties of bubo harve been 
better understood. The chronically enlarged 
glands of syphilis have little or no tendency 
to suppurate, but subside spontaneously if let 
alone. Others only suppurate when freely 
irritated, hence the best abortive treatment 
is to guard against the increase of irritation, 
and assuage that which exists by antiphlo- 
gistics. In the bubo virulent by absorption 
suppuration is inevitable. Thus, the sympa- 
thetic bubo is the only one which can be 
acted on by abortive treatment. To anti- 
phlogistics may be added counter-irritants, 
but these are uncertain in their effect. Those 
least open to objection are vesicants, and 
the form most beneficial is repeated ' flying ' 
blisters. By this means a series of small 
blisters are produced round about, not over 
the swelling. Any other plan is most un- 
certain-painting the part with tincture of 
iodine, or other mild irritant, is simply waste 
of time. 
Compression is of great value for reducing 
indolent enlargement, or for removing the 
boggy condition of the groin where several 
abscesses have formed, with more or less 
undermining of the skin. It is useless for 
syphilitic bubo and mischievous for the viru- 
lent bubo. The simplest and most effectual 
method of applying compression is by a gra- 
duated compress of lint kept firmly in place 
by a spica bandage of calico, or of elastic 
tape. For abscesses, careful packing may be 
added to the compress. Each focus of pus 
must be laid open, and bridges or tunnels 
cut across, so that narrow strips of lint soaked 
in liquor plumbi subacetatis and lightly 
pressed between the fingers, to drive out the 
dripping excess of fluid, may be laid into the 
hollows and under overhanging borders of 
skin. The strips must be renewed every day 
at first, and the cavities well cleared by 
syringing with water. In a few days, when 
the discharge is very small, the strips may 
be left for three or four days unchanged. 
The first application is painful, but very soon 
an insensible crust is formed over the ulcer- 
ating surface, and fresh applications cause no 
discomfort. As soon as healthy granulations 
are formed the plugging should be laid aside. BUBO, VENEREAL 
BURSAE MUCOSAE 
263 
If the glands do not shrink in size after 
a fair trial of the methods already described, 
the patient should be anaesthetised, the 
glands scraped away by the sharp spoon, 
and the wound well spread with iodoform. 
Berkeley Hill. 
BULB.-A synonym for the globe of the 
aye, and also for the medulla oblongata. Its 
adjective, bulbar, is commonly restricted in 
application to the latter, and has for a con- 
siderable time been commonly thus employed, 
as in the terms 4 bulbar symptoms,' 4 bulbar 
nerves,' and the like. This use of the adjec- 
tive has led to a more extensive employment 
of 4 bulb ' for the medulla oblongata, because 
the term 4 medulla ' is also applied to the 
spinal cord, the 'medulla spinalis,' as well 
as in its general sense of 4 marrow.' 
BULBAR PARALYSIS.-A synonym 
for labio-glosso-laryngeal paralysis; derived 
from the pathological relation of the disease 
with the bulb or medulla oblongata. See 
LABIO - Gqo SSO-LARYNGEAL PARALYSIS. 
BULIMIA (&ov, a prefix signifying 
excess; and \ip.os, hunger).- Excessive or 
voracious appetite. See Appetite, Dis- 
orders of. 
BULLA (bulla, a bubble).-See Blister. 
BURGHERSDORP, in Cape Colony. 
See Africa, South. 
BURNS.-The morbid local effects pro- 
duced by the direct application of excessive 
dry heat. See Heat, Effects of Severe or 
Extreme. 
BURSAS MUCOSAS, Diseases of.- 
Bursae mucosae are spaces in the connective 
tissue lubricated with a small amount of 
serous fluid, and situated at points exposed 
to repeated pressure or friction. Structurally 
they are composed of a layer of condensed 
cellular tissue, fusing externally with the 
areolar tissue of the part, and lined inter- 
nally with an imperfect layer of flattened 
endothelial cells, similar to those found in 
the pleura or peritoneum. Some bursae, as 
that over the patella, that under the deltoid, 
those about the great trochanter, and many 
others, are constantly present; but new bursae, 
equally perfect in their structure, may form 
at any part exposed to abnormal pressure 
and friction, as over the outer malleolus of a 
tailor, under an old corn, or over the head of 
the metacarpal bone of the great toe (bunion'). 
Like the great serous cavities, bursae are in 
direct communication with the lymphatics, 
and inflammatory products are consequently 
absorbed from them with great readiness, 
often giving rise locally to a diffuse inflamma- 
tion of the surrounding cellular tissue, closely 
resembling phlegmonous erysipelas in appear- 
ance, and always accompanied by high fever. 
Bursae are liable to four kinds of disease :- 
1. Acute inflammation and suppura- 
tion-Acute bursitis.-This is usually the 
result of some more or less violent mechanical 
injury. It may occur in any bursa, but is 
most common in the bursa patellae, those 
about the hip and over the olecranon, and in 
the small false bursa formed beneath an old 
corn, or in a bunion. The symptoms are 
those of acute inflammation generally, but 
the redness and swelling often extend a 
remarkable distance up and down the limb. 
Thus, a drop of pus beneath a corn may 
cause oedema and redness to the knee. The 
febrile disturbance is usually proportionately 
severe. About the trochanter the abscess 
may assume a chronic form. 
Treatment.-Hot fomentations, and the 
application of glycerine and extract of bella- 
donna (equal parts), may be of use. It is 
very important that pus shall be let out early, 
or it may burrow extensively, especially about 
the knee. Antiseptic treatment will be found 
especially useful in the treatment of sup- 
purating bursae. 
2. Cnronic Bursitis-Dropsy of the 
bursa.-This consists of an accumulation of 
serous fluid distending a bursa more or less 
tensely. The wall becomes somewhat thick- 
ened and opaque, but is otherwise unchanged. 
The fluid is clear, straw-coloured, and al- 
buininous in character.- The cause of the 
disease is usually repeated slight mechanical 
injury, but in some cases it may be due to 
some of those obscure conditions spoken of as 
4 rheumatism.' The symptoms are merely 
those of a collection of fluid in the situation 
of the bursa, perhaps accompanied by a feeling 
of weakness in the neighbouring joint. There 
is no pain or tenderness. The commonest 
form of this disease is the so-called 4 house- 
maid's knee,' but it is not infrequent in the 
bursa of the popliteal space. 
Treatment.-Avoidance of the mechanical 
injury, whatever it may be, which has caused 
tjie disease, is most important. The swelling 
may be painted with tincture of iodine twice 
a day for some weeks, or a series of small 
blisters applied over it. If this fails, an in- 
cision may be made into the swelling under 
antiseptic precautions, and a small drainage- 
tube introduced for a week or ten days. But 
before either of these means is adopted, care 
must be- taken to ascertain that the bursa 
does not communicate with the neighbouring 
joint. In the ham it is safer as a rule not to 
operate, except by means of the aspirator. 
3. Chronic enlargement of the bursa, 
with fibroid thickening of its walls.- 
This affection is most common in the bursa 
patellae, but may occur in that situated over 
the tuberosity of the ischium. The bursa 
becomes converted into a dense fibroid mass 
of almost cartilaginous hardness. On section 
it is found to be composed of concentric layers 
of dense fibroid tissue. There is usually a 
small central cavity containing a little fluid. 
The cause of this change, as of simple dropsy, 264 
BURSE MUCOSA 
CECUM, DISEASES OF 
is repeated mechanical injury of a slight 
nature. In some cases it seems to be con- 
nected with syphilis. The only treatment is 
removal by the knife. 
4. Chronic enlargement of the bursa, 
with the presence in it of the so-called 
melon-seed bodies.-In this form of dis- 
ease, in addition to some thickening of the 
wall and accumulation of fluid in the bursa, 
small oval, flattish, smooth bodies of a white 
colour are found floating freely in its interior. 
These are similar in nature to those found in 
some forms of ganglion {see Ganglion). This 
condition is recognised by the peculiar soft 
crackling feeling perceived on palpation, com- 
bined with the ordinary symptoms of an 
enlarged bursa. 
Treatment.-The affected bursa may be 
dissected out; or it may be laid open, 
emptied, and drained. The closure of the 
cavity may be insured by the application of 
pure carbolic acid, so as to destroy the lining 
membrane. Marcus Beck. 
BUXTON, in Derbyshire.-Simple 
thermal waters. See Mineral Waters. 
BUZIAS, in Hungary.-Strong mu- 
riated chalybeate springs. See Mineral 
Waters. 
o 
CACHEXIA (kokos, bad; and e$ts, a 
habit or constitution of body).-Synon.: Fr. 
Cachexie; Ger. Kachexie. 
Definition.-A chronic state of ill-health 
associated with impoverished or depraved 
blood, arising from malnutrition, persistent 
loss of blood-elements, or the presence of a 
morbific agent. 
In such diseases as tabes mesenterica, 
lymphadenoma, and the like, the patients be- 
come cachectic from direct depravation of the 
blood, in consequence of disease of organs 
which are importantly concerned in its 
nutrition and elaboration. In other diseases 
persistent loss of blood-elements arising 
from chronic suppuration or from repeated 
haemorrhages (especially observed in some 
uterine conditions) induces a cachexia which 
is well described by the term secondary 
ancemia. Again, certain poisons introduced 
from without, and nurtured within the body, 
may produce marked cachexia. The 
syphilitic and malarial poisons are good 
examples of the first kind. Of cachexiae 
produced by the presence of morbific 
agents which have been generated within the 
body we may instance those arising from 
defective elimination, as the uraemic and 
gouty cachexiae from inadequate functional 
activity of the kidneys and liver. In the 
latter connexion it should be noted that, as 
has been hinted by Sir James Paget in 
reference to cancer, the malignant cachexia 
may arise from blood-contamination with 
the waste products yielded by the morbid 
growth in the process of its nutrition; such 
a growth not only abstracting material from 
the blood for its nutrition, but also con- 
tributing effete material to it. 
It must be farther observed that in the 
opinion of some pathologists the term 
cachexia implies much more than the 
secondary anaemia consequent upon the 
ravages of a given local or general disease 
upon the system. It rather signifies the 
morbid constitution which is the disease, 
and which may precede its local manifesta- 
tion. Thus we may have the cancerous 
cachexia, culminating in scirrhus of the 
breast, the tubercular cachexia in pulmonary 
tuberculosis, and the like. It is thus 
evident that with many observers the terms 
cachexia and constitutional disease have the 
same significance. 
R. Douglas Powell. 
CACOPLASTIC (xa/cdf, bad; andirAda-crto, 
I mould or form).-A term applied to pro- 
ducts of inflammation which are more or 
less incapable of organisation. 
CADAVERIC (cadaver, a dead body).- 
This word signifies ' belonging to the dead 
body '; and it is applied to the aspect, colour, 
odour, and other phenomena resembling 
those of death, which are sometimes observed 
in the living subject. 
C^CUM, Diseases of.-Synon. : Fr. 
Maladies du Ccecum ; Ger. Blinddarm- 
krankheiten.- The structural peculiarities 
and anatomical relations of the caecum are 
specially favourable to the occurrence of 
the diseases to which this part of the large 
intestine is most liable, viz. (1) accumula- 
tion of solids (faeces, foreign bodies, &c.); (2) 
ulcerative inflammation, typhlitis, &c.; and 
(3) dilatation, contraction, and perforation. 
1. Accumulations.-Hardened faeces, 
biliary and intestinal concretions, foreign 
bodies, stones of fruit, balls of worms, and 
also gases resulting from decomposition, 
are apt to collect in the caecum, and cause 
varying degrees of local disturbance. Some- 
times, as in elderly patients of torpid habit, 
the caecum is found loaded with faeces, with- 
out inducing pain or other signs of inflam- 
mation. The right iliac region may be full 
and hard, and in it may be felt a well-defined, 
almost painless, doughy uneven mass, of the 
shape of the caecum. As a rule, however, CJECUM, DISEASES OF 
CALCULI 
265 
sooner or later the accumulation leads to one 
or more of the following results:- 
(a) Obstruction of the bowels. This may 
be partial, as in the various degrees of con- 
stipation, or complete. "When complete, it 
may even prove fatal-e.g. from perforation 
or rupture, without the caecum or peritoneum 
exhibiting signs of inflammation. On the 
other hand, general peritonitis supervening, 
obstruction in the caecum may be quickly 
obscured ; still, however, the chief pain and 
tenderness may be found in the right iliac 
region. (6) Pressure on adjacent nerves, 
vessels, or other structures, producing numb- 
ness and oedema of the right leg, retraction 
of the right testicle and other symptoms, 
(c) Inflammation and Ulceration: stercoral 
ulcer, caecitis, typhlitis, peritonitis. 
It is of clinical importance to bear in mind 
that the caecum, when overloaded or en- 
larged, may occupy an unusual position, e.g. 
a site between the right and left iliac regions, 
or may descend somewhat into the pelvis 
and press on the urinary bladder. 
Tympanitic distension of the caecum is 
generally associated with some faecal accu- 
mulation or obstruction in the colon or other 
part of the large intestine. See Faeces, Re- 
tention of; and Flatulence. 
2. Inflammation.- Synon. : Caecitis.- 
Until recent years inflammation of the walls 
of the caecum has been designated by the term, 
Typhlitis; but this is no longer applicable, 
for it has been shown that the symptoms of 
what is clinically recognised as typhlitis do 
not depend on inflammation of the caecum, 
but on inflammation of the peritoneum in- 
vesting the caecum and vermiform appendix 
(see Typhlitis). The mucous membrane 
of the caecum is liable to catarrhal inflam- 
mation, from the lodgment of faeces, indi- 
gestible matters, and foreign bodies; but the 
symptoms induced by it are, as a rule, ill- 
defined, and generally resemble those of colitis 
(see Colon, Diseases of). It may, however, 
lead to ulceration, which may ultimately in- 
volve the outer wall of the caecum and the 
peritoneum, and thus induce typhlitis. 
3. Dilatation, Contraction, and Per- 
foration.-The caecum may be (1) dilated, 
from accumulation within it of solids and 
gases, or from obstruction in the colon; 
(2) contracted, from growths (polypi, cystic 
tumour, cancer, &c.), or cicatrisation of ulcers 
(tubercular, dysenteric); or (3) perforated, 
from ulceration (stercoral, enteric, tubercular, 
cancerous, dysenteric), from tearing of the 
wall by over-distension, or from a typhlitic 
abscess (originating in the appendix vermi- 
formis) opening into it. 
George Oliver. 
CALCAREOUS DEGENERATION. 
A form of degeneration characterised by the 
deposit in the tissues of earthy salts, especially 
those of lime. See Degeneration. 
CALCULI (calx, chalk).-Definition. 
The term calculus is now applied to any 
kind of concretion formed in the ducts or 
passages of glandular organs ; though older 
writers limited its employment to the desig- 
nation of concretions met with in the kidneys 
and urinary bladder. 
Varieties.-The following is a concise 
summary of the principal calculous concre- 
tions met with in the human body, given 
in their alphabetical order. 
1. Biliary Calculi.-Biliary calculi vary 
considerably in size, number, form, and com- 
position. In size they range from minute 
grains about the size of a pin's head to a mass 
as large as a hen's egg. The smaller they are, 
generally, the larger is their number. Their 
form is very various. "When solitary they are 
usually round or oval; when numerous they 
are generally more or less irregular in shape, 
their surfaces being flattened and faceted 
from compression. The colour is usually a 
blackish-green or brown, less frequently 
yellow or greyish-white. In consistence, 
some are soft like wax; others hard, dry, 
and friable. On section they will be found 
to differ widely-some being granular, and 
made up of sub-morphous particles without 
any apparent nucleus; others crystalline, 
the glistening white crystals (cholesterin) 
radiating from a central nucleus, which is 
frequently found to consist of inspissated bile. 
Biliary calculi consist of two kinds, (a) Those 
of the one group are formed of cholesterin and 
bile-pigments, mixed with a variable propor- 
tion of insoluble organic matter, fatty matter, 
stearate of lime, and traces of the earthy 
phosphates. To separate the cholesterin, 
finely powder the gall-stone and thoroughly 
exhaust with ether; the ethereal solution on 
evaporation yields amorphous cholesterin. 
To obtain it in the crystalline form, it must 
be redissolved in boiling alcohol, which on 
cooling deposits it in characteristic, glisten- 
ing, rhombic plates. The pigmentary matters 
can be obtained by exhausting the residue 
of the crushed gall-stone, from which the 
cholesterin has been removed, successively 
with water, alcohol, and dilute hydrochloric 
acid. The dried residue is then boiled with 
pure chloroform for some time, and the 
chloroform extract is distilled to near dry- 
ness, and several volumes of alcohol are 
added, which throws down bilirubin. Bili- 
rubin thus obtained is an orange-red powder, 
insoluble in water and ether, slightly soluble 
in alcohol, but very freely soluble in chloro- 
form. On passing a current of air through 
an alkaline solution of bilirubin the solution 
acquires a green colour-biliverdin. Accord- 
ing to Stadeler, biliverdin is formed from 
bilirubin by the addition of one atom of 
water in the presence of oxygen. A brown 
pigment, bilifuscin, can also be obtained by 
acting on bilirubin with strong sulphuric acid. 
(&) Calculi of the other group are composed 266 
CALCULI 
solely of one substance: such are the small 
white pearly calculi, frequently passed by 
young children and very old persons, and 
which consist entirely of cholesterin ; small 
black masses like dried tar which consist of 
pigment; and brownish, irregular fragments 
which are formed solely of stearate of lime. 
2. Intestinal Calculi.-Intestinal cal- 
culi are rare in man and carnivorous animals, 
but are not uncommon in herbivorous 
animals. They consist almost entirely of 
ammonio - magnesium phosphate, calcium 
phosphate, and calcium carbonate, deposited 
round a nucleus, generally a fragment of 
some indigestible material of the food, such 
as stones of fruit, husks of grain, or portions 
of bone. There is a kind of intestinal cal- 
culus occasionally met with among Scottish 
and Lancashire people, who use oatmeal 
largely as food, which is chiefly composed 
of the hairs and fragments of the envelopes 
of the oat, encrusted with calcium phosphate 
and carbonate. Magnesium carbonate when 
taken habitually and in bulk is apt to accu- 
mulate in the bowels and concrete there; 
there is now less risk of that danger since 
the fluid forms of magnesia have come into 
such general use. 
3 Pancreatic Calculi.-Calculi in con- 
nexion with the pancreas are the rarest of 
all glandular concretions. When found they 
are generally numerous, being met with in 
the main dudt, the accessory duct, and even 
in the smaller radicles. The size varies 
greatly, the largest that has come under the 
writer's observation being quite one inch in 
length. They are generally oval in shape, and 
their surface has frequently a worm-eaten 
appearance, of whitish colour, which when 
rubbed acquires an enamel-like lustre. When 
broken, the fracture often presents a white, 
glistening, porcelain appearance. One cal- 
culus analysed by the writer gave a percent- 
age composition of organic matter 24, fixed 
inorganic salts 76. The bulk of the fixed 
inorganic salts consisted of calcium carbonate, 
calcium phosphate being present in much 
smaller proportion. 
4. Prostatic Calculi.-Prostatic calculi 
consist essentially of calcium phosphate and 
calcium carbonate, though incidentally traces 
of uric acid, calcium oxalate, and ammonio- 
magnesium phosphate may be found. They 
occur in three forms, namely (a) small, rough 
concretions, from the size of a pin's head to a 
hazel-nut; (6) irregular masses with porce- 
lainous appearance; and (c) large regular con- 
cretions. The quantity of earthy matter that 
may be deposited in the prostate gland is 
often enormous. When the calculi are of the 
small variety, fifty or sixty may be present, 
and a gland, may feel like a bag of nuts. 
The Hunterian Museum contains a specimen 
showing the enormous size these concretions 
may attain. See Prostate, Diseases of. 
5. Salivary Calculi.-These are gener- 
ally rough externally, irregular in shape, and 
are usually found near the orifice of the duct, 
which they obstruct. The nucleus frequently 
consists of some foreign body which has 
accidentally found its way into the duct, as 
a splinter of wood or a fragment of bone. 
Their chief component is calcium carbonate, 
of which they contain more than any other 
kind of concretion, and traces of earthy 
phosphates. 
6. Urinary Calculi.-Urinary calculi 
vary considerably in size, form, colour, and 
general appearance, according to their com- 
position. The constituents that form these 
stones are uric acid, urates, cystin, xanthin, 
calcium oxalate, calcium phosphate, magne- 
sium phosphate, ammonio-magnesium phos- 
phate, calcium carbonate, and also concre- 
tions of blood and fatty substances (urostea- 
lith). Any of the above-named substances, 
combined with a varying proportion of organic 
matter, may constitute the sole ingredient of 
a calculus; more commonly, however, two 
or more are associated together. To fully 
ascertain the composition of the mass of the 
calculus it must be sawn across, and if made 
up of different layers, a portion of each layer 
must be analysed. See the articles on the 
several kinds of urinary calculi; and Urine, 
Morbid Conditions of. 
Pathology.-The manner in which these 
concretions are formed, especially renal and 
urinary calculi, has long been a matter of 
speculation with physicians, some regarding 
them as of purely local origin, others en- 
deavouring to show that they are the result 
of some peculiar diathesis, wherein uric 
acid, the phosphates, &c., are formed in the 
body so profusely, and are eliminated in such 
quantities as to be precipitated in the pas- 
sages. The researches of Ord and Carter 
have thrown much light on this obscure 
subject. They have shown that the particles 
constituting the bulk of the calculus are not 
mere accretions, formed in the urinary 
passages by a process of chemical precipita- 
tion, in the presence of blood, mucus, &c.; 
but consist of structures, designated as ' sub- 
morphous '-granules, spheroids, laminae, &c. 
-and which require considerable time for 
their formation. They have shown that this 
modification of form, i.e. the change from 
the crystalline to the submorphous type, can 
be artificially produced by allowing two 
saline solutions to intermix slowly through 
a colloid medium; as gum, albumen, &c.; 
the more slowly the mixture is effected and. 
the denser the colloid, the more perfect is 
the change to the submorphous condition. 
On the other hand, if the colloid medium is 
attenuated, and the admixture rapid, the 
crystalline form is more or less retained. 
The nature of this colloid medium has not 
been clearly made out. The fact that calculus 
rarely accompanies Bright's disease shows 
that the ordinary effusion of blood or albumen CALCULI 
CANCER 
267 
into the renal tubules does not furnish the 
necessary medium. Indeed, if simple effu- 
sion of fibrin, or increased secretion of mucus, 
furnished the colloid, calculus, instead of 
being comparatively a rare disease, would be 
extremely common. Some authors have re- 
garded the ' entangling mucus ' as the pro- 
duct of a specific catarrh. Thus Meckel 
speaks of a stone-forming catarrh (steinbilden- 
(Lender Katarrh); and the late Dr. Owen 
Rees pointed out that among the evils 
attendant upon gout is ' a tendency of 
mucous membranes to secrete a viscid mucus, 
which modifies the ordinary crystalline 
character of uric acid, causing it to appear 
in agglutinated masses, which adhere to the 
sides of the urinary passages.' In specula- 
tions as to the origin of stone, too little 
attention has as yet been paid to the condi- 
tion of the renal cells. These cells normally 
eliminate the urinary constituents ; and it is 
not difficult to imagine that under certain 
conditions of vital impairment these sub- 
stances may be retained and deposited, 
instead of being eliminated, the cell itself 
furnishing the colloid medium. The objec- 
tion urged against this view is that recent 
observers have discovered no satisfactory 
pigns of cell-structure in the matrix of calculi; 
but this objection can hardly be considered 
fatal, since the accretion of particles w'ithin 
the cell would gradually destroy the cell-struc- 
ture. Professor Quekett, however, figured 
(Med. Times, vol. xxiv. p. 552, 1851) crystals 
of calcium oxalate and triple phosphate 
contained in cells taken from human tubuli 
uriniferi; and though his observations have 
not been confirmed by others, still the 
accuracy of his work has never been ques- 
tioned, and it may be when the tubuli 
uriniferi of persons dying of calculous affec- 
tions come to be more frequently examined 
by pathologists, cells containing calculous con- 
stituents at an early stage of deposition may 
be observed-that is, before the cell-wall is 
destroyed. It is a remarkable fact that 
calculous deposit commencing in the kidney 
tubules is rarely met with in the convoluted 
portion of the tubule, but invariably occurs 
at the apices of the mammillary processes, 
the extremities of the ducti papillares. Now 
less blood circulates through this portion of 
the kidney than through any other part of it, 
and moreover in the ducti papillares the 
basement membrane (tunica propria) dis- 
appears and the wall consists of epithelium 
alone. May not these anatomical differences 
render the cells of this part of the tubule 
more liable to calculous deposit-in short, to 
undergo calculous degeneration ? 
C. H. Ralfe. 
CALIPERS.-An instrument employed 
for measuring diameters, used more especi- 
ally in clinical medicine for measuring the 
diameters of the chest. See Physical Ex- 
amination. 
CALVITIES (calvus, bald).-Synon. : 
Alopecia calva.-A synonym for baldness. 
See Baldness. 
CANARIES, The, in North-east 
Atlantic Ocean ; Teneriffe.-Mean tem- 
perature in winter, 64° to 85°. Warmer, 
drier, but more variable, than Madeira. East 
winds from Africa. See Climate, Treatment 
of Disease by. 
CANCER (cancer, a crab).- Synon.: 
Carcinoma; Fr. Cancer; Ger. Krebs. 
Definition.-The word cancer is without 
histological meaning. We find it and its 
synonym carcinoma used as long ago as the 
time of Hippocrates, and the latter term was 
then, as is the former at the present day by 
the vulgar, applied to any new-growth of a 
malignant character. The name originated 
in the large ramifying veins and puckered 
furrows which spread from a cicatrising 
cancer that is involving the skin. When the 
broad distinction between the epithelial and 
connective-tissue type of tumours was 
established by Virchow and others, it was 
decided to retain the word cancer as the 
name for the more malignant or epithelial 
growths ; while the equally meaningless but 
less formidable word sarcoma has been, from 
this time, confined to those tumours which 
have connective tissue for their type. See 
Tumours. 
In this sense of the word the cancers 
form a class which is, on the whole, easily 
distinguished by definite microscopical and 
clinical characters ; but at two points, at 
least, the difference from simpler growths is 
almost imperceptible. First, as a matter 
of accident, one sarcoma (the alveolar) re- 
sembles a cancer so closely in microscopical 
structure, that it is impossible to distinguish 
between them without reference to clinical 
facts; and, in the second place, as cancers 
are essentially depraved modifications of 
epithelial, epidermic, or glandular structures, 
they may be found to differ so slightly in 
histological characters from simple hyper- 
trophies, that the fact of ultimate malignancy 
is often all that can decide between, say, a 
papilloma and an epithelioma, a glandular 
cancer of the rectum and a simple polypus, 
or a scirrhus of the breast and a chronic 
mammary tumour. 
Histological Structure.-Histologically, 
cancers are distinguished by consisting partly 
of cells of an obviously epithelial origin and 
partly of connective tissue. The connective 
tissue forms alveolar spaces, and may vary in 
structure from a loose fibro-cellular material 
to strong and old fibrous tissue. The 
alveolar spaces communicate with each 
other and contain the epithelial cells. These 
vary much in shape, size, and arrangement, 
but are always easily separable from the 
surrounding connective tissue, while they 268 
CANCER 
are never separated from one another by a 
stroma of any soit 
Clinical Characters.-Clinically, cancers 
are distinguished by the structures in which 
they originate; by the method of their re- 
currence and their mode of growth ; as well as 
by a few characteristics apparent to the eye 
and touch. 
Seat.-As their nature would a priori 
have rendered almost certain, cancers pro- 
bably never originate except in connexion 
with epithelial or epidermic structures-i.e. 
in skin, mucous membrane, or secreting 
glands; but as the epidermis and epithelium, 
the original upper and lower layers of the 
embryo, are widely diffused throughout the 
body, and often intimately associated with 
the descendants of the cells of the middle 
layer, it is not surprising that primary 
cancers have been described as occurring in 
organs which have their origin from con- 
nective tissue only. Such are the instances 
of primary cancer of bone and lymphatic 
glands, the possibility of the occurrence 
of which may be at present considered 
undecided. 
Recurrence.-The first recurrence is almost 
without exception in the lymphatic glands, 
which collect their supply of lymph from the 
seat of the original tumour; when this has 
occurred the process may be repeated in the 
next proximal lymphatic glands, or numerous 
distinct tumours may appear in different parts 
of the body; but if a single growth occur in 
another locality without previous glandular 
enlargement, the case may probably be looked 
upon as one of double primary development. 
A soft cancer may break into the abdominal 
cavity, where its small particles may stick 
to various parts of the peritoneum and form 
the starting-points of new-growths (dis- 
seminated cancer of the peritoneum); it is 
probable that a similar seeding may take 
place into the lungs when an ulcerated epi- 
thelioma projects into the trachea. The re- 
currence is usually of precisely the same 
structure as the original growth. 
Mode of growth.-Cancers increase in size 
by infiltration of the surrounding tissues, and 
this gives rise to the very important clinical 
facts that they are not enclosed by a capsule 
like many simpler growths, and that they 
have a great tendency to implicate the skin 
and cause ulceration. 
Naked-eye appearances.-The contraction 
of the connective tissue forming the alveoli 
in its advance towards fibrous tissue gives 
rise to puckering of the surrounding skin; 
and the looseness of the connexion between 
the epithelial and connective-tissue elements 
causes a milky juice consisting of the foTmer 
to escape on scraping a recent section. This 
characteristic was made much of by our pre- 
decessors before the word cancer had lost its 
inclusive meaning; we know now that many 
rapidly growing sarcomas yield a similar 
juice, but in less abundance than cancers; 
and thus it has come to pass that a milky 
juice is now more diagnostic of the malig- 
nancy than of the genetic origin of the 
growth. 
This completes the list of the signs by 
which cancers may be distinguished from 
other tumours. Tables have been published 
to show the relative frequency with which 
cancer attacks different organs; they are not, 
upon the whole, trustworthy, and this question 
will be best considered in discussing the sub- 
divisions of the genus. 
Classification. - The subdivisions of 
cancers are as follows:- 
Hard cancer or Scirrhus. 
Soft cancer or Encephaloid. 
Glandular 
type. 
Epithelial 
and 
Epidermic 
type. 
Lobular Epithelioma. 
Cylindrical Epithelioma. 
Colloid. 
Typical hard and soft cancers stand obviously 
at opposite ends of one series which is built 
upon the type of the secreting gland: between 
the two are an infinitude of intermediate 
stages. The two forms of epithelioma are, 
quite as evidently, monstrous growths of 
skin or mucous membrane. Colloid is pro-, 
bably the result of degeneration of any one 
of the other forms. Besides these, other 
varieties are often mentioned which do not 
justify a more complicated classification; 
amongst these are tumours, which though of 
nearly normal glandular structure are never- 
theless malignant, and those which have 
received the names melanotic, telangiectatic, 
osteocancer, &c. 
Diagnosis.-The diagnosis depends upon 
the clinical characters of the several groups. 
That of an advanced case of cancer is 
generally easy; in the early stages it is 
mostly impossible. 
Prognosis.-The prognosis is always bad, 
especially in encephaloid cancer, but least 
so in epithelioma; this suggests the much- 
debated question of the constitutional nature 
of the disease. If in its origin a cancer be 
purely local, early removal ought to effect 
a permanent cure; but if there be at the 
bottom a constitutional taint, a reprieve 
should merely be granted until a suitable 
fresh irritation arise. There is probably 
some truth on both sides. The cancerous 
cachexia is often spoken of; it depends 
chiefly, if not altogether, on the weakening 
effects of the discharge after ulceration has 
taken place; mental worry may have some 
share in causing it; but it must be remem- 
bered that cancerous patients, who, before 
they are attacked, are frequently amongst 
the most robust, often retain their health for 
a remarkably long space of time. 
Course.-The course of a cancer depends 
upon its seat, and the symptoms must ac- 
cordingly be sought amongst the articles on CANCER 
269 
diseases of special regions. If, however, life 
be not shortened as a result of interference 
with the functions of the organ attacked, 
death is caused either by marasmus-the 
result of prolonged suppuration and pain-or 
by extensive or repeated hfemorrhages. The 
rate of progress is more slow as age 
advances. 
Treatment.-The treatment of cancer in 
the early stages belongs to the surgeon, the 
practitioner giving such counsel as will im- 
prove the general health and support the 
strength. In the later stages the physician 
may be called upon to treat symptoms; 
but up to the present time all the specifics 
introduced either by regular practitioners or 
by charlatans have proved quite inefficient, 
if not actually harmful. 
We shall now discuss the varieties of 
cancer. 
I. Scirrhus.-Scirrhus, as its name im- 
plies, is amongst the hardest of tumours, if 
bony growths be excepted. Its hardness, as 
compared with soft cancer, depends upon the 
larger proportion which the alveolar stroma 
bears to the contained cells ; and this is pro- 
bably the consequence of the soil in which the 
tumours originate, and the rapidity of their 
growth, rather than of any specific difference 
between them. 
Seat. - The female breast is the most 
common seat for scirrhus, but it also occurs 
in the stomach, uterus, tongue, oesophagus, 
and the liver and other glands, and it has 
been described as primary in the prostate, 
testicle, skin, and other structures. 
Naked-eye appearances.-A section through 
the centre of a matured hard cancer of the 
breast presents to the naked eye well-marked 
and constant appearances, which, with the 
exception of such peculiarities as are due to 
the situation, will serve as a description of 
such a tumour occurring elsewhere. These 
are clearly explained by the microscopical 
arrangement, and when looked at by the 
light which it affords, fully account for all 
the clinical characters. The knife passes 
through it with a creaking noise, and the 
cut surfaces are at once hollowed in the 
centre. There is not a sharp edge to the 
growth, and the circumference is of a greyish 
or pinkish-white tint, projecting a little above 
the surrounding tissues, into which it sends 
small lobular prolongations; the hollow 
centre is very hard and of a glistening white 
colour. Scirrhus is evidently fibrous in 
structure, and receives from all quarters 
fibrous bands, which often pass far out into 
the fat of the breast or the skin, and some of 
which can nearly always be traced to the 
principal milk-ducts. Between the centre and 
the edge the greater part of the tumour 
is on the whole of a pinkish-yellow colour, 
but notably pink and soft externally, and 
yellow and hard internally. The surface 
yields a milky juice on scraping, and may 
show some of the following appearances, 
which are, however, accidental: round the 
circumference little masses of healthy fat 
may be included, though this but rarely 
happens; cysts containing grumous grey or 
red fluid may have formed by the breaking 
down of the new-growth or by haemorrhage ; 
or such a haemorrhage may have resulted in 
patches of yellow or even black pigmenta- 
tion. 
Microscopical appearances.-Without dis- 
cussing the merits of the opposing theories 
as to the origin of cancer-cells, the following 
may be taken as the undoubted microscopical 
appearances of scirrhus. The grey outer layer 
is made up of indefinite smallish round cells, 
resembling white blood-corpuscles, infiltrated 
through the tissue into which the growth is 
spreading, amongst which are scattered a few 
which have the appearance of epithelial cells. 
The next or pink layer represents full develop- 
ment and shows fibro-cellular stroma, enclos- 
ing large epithelioid cells, and containing a 
copious supply of vessels. In the third or 
yellow layer the stroma has become fibrous, 
and the cells are undergoing fatty degenera- 
tion; and in the inner white centre the 
cells are replaced by indefinite masses of 
granular debris, and the stroma consists of 
firm and old fibrous tissue. See Plate, figs. 
14, 16, and 17. 
Clinical features.-The relation of these 
appearances to the clinical peculiarities of 
scirrhus is as follows: the excessive hardness 
is explained by the great development of 
fibrous tissue; the peculiar indefiniteness 
of the edge, and the tendency to involve the 
skin and ulcerate, by the manner of growth; 
while the puckering, retraction of the nipple, 
and indirectly (from the manner in which 
cutaneous nerves are involved) the pricking 
and shooting pains, are due to the contraction 
or cicatrisation of the stroma. To the latter 
is also due a very important but not generally 
recognised diagnostic character of an early 
scirrhus, namely, that long before the skin is 
involved it is seen to be dimpled when gently 
moved to and fro over the growth. 
A scirrhus which has involved the skin 
forms a purplish-red, flattened, and shining 
tumour, covered with small veins and tender 
to the touch. The ulcer which results from 
its breaking down is ragged, with a hard base 
and hard irregular undermined edges, and a 
dirty surface covered by knobby masses of 
pseudo-granulations, which have a great 
tendency to bleed, and often slough. After 
removal it often returns in the scar. When 
occurring in the liver it is softer than else- 
where, and the name of scirrho-encephaloid 
is often given to it. See fig. 13. 
II. Eneephaloid.-Encephaloid, medul- 
lary, or soft cancer, so named from its usually 
brain-like appearance and consistence, is 
softer and grows more rapidly, and is more 
frequently observed in internal organs than 270 
CANCER 
scirrhus, often indeed forming enormous 
intra-abdominal tumours. 
Seat.-It has hitherto been observed as 
primary in the salivary and mammary glands, 
testicle, ovary, and prostate, the thyroid 
body, and in the mucous membrane of the 
nose, the liver, and the stomach. It has 
with some degree of looseness been called 
the cancer of childhood by those who consider 
scirrhus as almost peculiar to mature age. 
Naked-eye appearances.- To the naked 
eye a fresh section usually presents a convex 
surface; it is whitish, but generally mottled 
by coloured patches, the result of old or re- 
cent haemorrhages; and yields very copiously 
a milky juice on scraping. 
Microscopical appearances.-Encephaloid 
cancer differs from scirrhus only in the 
relative proportion of the two chief factors. 
The cells are more numerous and are con- 
tained in larger spaces ; they are sometimes 
small, but generally much larger than in 
scirrhus; and the stroma is delicate and 
fibro-cellular and very small in amount. 
See fig. 15. 
Its method of extension is the same as 
that of other members of the class. It is 
by far the most malignant form of cancer, 
because of its rate of growth and recurrence, 
and the rapidity with which it causes general 
cachexia. 
III. Lobular Epithelioma.-Lobular 
epithelioma; epithelial cancer, or cancroid, 
develops in connexion with skin and mucous 
membrane, and though consisting essentially 
of squamous epithelium, may start from a 
part. which is covered by the cylindrical 
variety. It occurs near the natural orifices 
of the mucous tracts-as, for example,,on the 
mouth and tongue, anus, penis, or vulva; 
but also at other parts of the skin-as on 
the scrotum (chimney-sweep's cancer) and at 
the upper end of the oesophagus. The his- 
tory of a local irritation as its origin is often 
obtainable, but more frequently nothing of 
the kind can be discovered. 
Naked-eye appearances.-The first appear- 
ance is that of a pimple, which soon breaks 
down in the centre, forming a small sore. 
When fully developed there is an irregular 
ulcer, with an extensive, hard and nodular, 
generally inflamed base and circumference; 
the edges are abrupt or undermined, and 
the floor grey or reddish, very uneven, dis- 
charging a foul pus, and with a great tendency 
to bleed. As a rule there is considerable 
pain, and the proximal lymphatic glands 
are very generally enlarged. A section to 
the naked eye shows a number of minute 
cylinders of yellowish-white colour, cut some- 
times longitudinally, sometimes transversely, 
fusing together into an indefinite mass super- 
ficially, but more or less discrete below, and 
infiltrating amongst the subjacent tissues. 
On squeezing the section little nodules like 
sebum appear on the surface. 
Microscopical appearances.-The cylinders 
or lobes of epithelioma are found to be made 
up of squamous epithelium, the cells of which 
generally exhibit in parts a crenated margin 
(Max Schultze's spine-cells). As in the skin, 
the deeper-that is the circumferential-layer 
of cells in each lobe, which are the youngest, 
are roundish or oblong, with large nuclei 
which stain readily; further in, the cells 
are larger and flatter, and in the centre are 
found the well-known globes or nests. These 
were at one time considered peculiar to epi- 
thelioma, but are now known to occur in 
warts and corns ; they consist of onion-like 
arrangements of epithelial cells, varying much 
in size and the number of concentric layers, 
and containing in the centre sometimes an 
amorphous mass, sometimes large and irre- 
gular cells. The tissues beneath and between 
the lobules are infiltrated with small cells, 
and often contain in sections what appear to 
be isolated masses of epithelium; these are, 
however, the ends of divided divergent 
lobules. Opinions differ as to the exact 
starting-point of an epithelioma, the share 
which the sweat- and other glands take in it, 
and also as to the rationale of the formation 
of the globes. See fig. 8. 
Epithelioma seems to be more local in its 
nature than other cancers-that is, a com- 
plete and early removal has not infrequently 
given the patient a long lease of life. It 
recurs, as a rule, in the lymphatic glands 
(which inflame and break down or suppurate) 
or in the scar; and generally proves fatal 
from the constitutional disturbance which 
these local manifestations give rise to. Later, 
but more rarely, it may appear in the internal 
viscera, bones, &c. 
IV. Cylindrical Epithelioma. - The 
cylindrical epithelioma-badly named ade- 
noid or glandular cancer-is specially the 
cancer of the alimentary mucous membrane, 
but may occur in the bladder and else- 
where. 
Naked-eye appearances.-To the naked 
eye it forms at first a prominent tumour in 
the interior of a viscus, which has a tendency, 
like other cancers, to ulcerate and involve 
surrounding tissues, so that the mass may 
reach an enormous size, and may even make 
its appearance through the skin. To the 
naked eye a section is generally whitish and 
has a granular appearance, which is given 
to it by the tubules of which it is made. 
It frequently causes death by obstruction 
of the bowel; but if it last sufficiently long, it 
recurs in the lymphatic glands, and then in 
the viscera and other parts of the body. It 
is not unfrequent to find recurrences in the 
liver with little if any implication of lym- 
phatic glands. The recurrence reproduces 
precisely the structure of the original 
tumour. 
Microscopical appearances. - Cylindrical 
epithelioma consists essentially of irregular CANCER. 
Fig. 7. Papilloma of Soft Palate. 
Fig. 8. Epithelioma of Lip. 
Fig. 9. Edge of Rodent Ulcer. 
Fig. 10. Simple Polypus of Rectum. 
Fig. 11. Columnar Epithelioma of 
Intestine. 
Fig. 12. Colloid of Breast. 
Fig. 13. Cancer of Liver (Scirrho- 
encephaloid). 
Fig. 14. Scirrhus infiltrating Fat. 
Fig. 15. Encephaloid Cancer. 
Fig. 16. Cicatrising Cancer. 
Fig. 17. Scirrhus of Mamma. 
Fig. 18. Adenoid of Upper 
Jaw (Benign). 
Fig. 19. Adenoid of Breast (common 
type). 
Fig. 20. Ulcerated Adenoid of 
Parotid (Malignant). 
Fig. 21. Adenoid of Breast (epi- 
thelial element in excess ). 
Fig. 22. Adenoid of Breast 
(Adeno-sarcoma). 
Drawings illustrating a Series of Tumours of the Epithelial Type. 
All drawn to the same scale ( x 87 diameters'). CANCER 
CANCRUM ORIS 
271 
tubules lined with columnar epithelium in 
one or more layers, which are the much over- 
grown crypts of Lieberkuhn, and differs in 
microscopical structure from simple papil- 
loma of the digestive tract only in the 
greater irregularity of the cells and in the 
larger proportion of connective-tissue stroma 
between the tubes. Compare figs. 10 and 11. 
V. Colloid.-Colloid, or alveolar cancer, 
named from its jelly-like appearance, has 
given rise to much discussion in reference 
to the question whether it is developed 
originally in its mature form, or whether it 
results from the degeneration of one of the 
varieties of cancer already described. The 
latter view is that most widely held, though 
it must be allowed that epithelioma seldom 
degenerates in this way, and also that the 
colloid change usually takes place pari passu 
with the growth of the tumour. 
Seat.-Colloid cancer is found most fre- 
quently in the abdominal viscera and peri- 
toneum, but may occur elsewhere, as in 
the breast. Its malignancy is great, but is 
shown chiefly by the rapidity with which it 
involves surrounding tissues; it thus forms 
primary tumours of enormous size, but as a 
secondary growth is less common; it does, 
however, occur in lymphatic glands and 
other parts. It causes death in most cases 
by interference with the functions of the 
organs attacked. 
Naked-eye appearances.-Colloid cancer 
consists to the naked eye of a mass of semi- 
transparent jelly, varying slightly in colour, 
but mostly pale yellow: this is intersected 
by delicate white fibrous bands, forming 
alveolar spaces of different sizes, visible to 
the naked eye. The consistence of the 
growth depends upon the relative proportions 
of these two constituents. 
Microscopical appearances. - The bands 
are found to be actually fibrous; the con- 
tained jelly is arranged in concentric lamin® 
between which are minute granules, and in 
the centre of which is a granular mass, 
sometimes quite indefinite, but often show- 
ing clearly that it consists of the remains 
of altered cells. These cells are seen in the 
more recent parts of the growth to be the 
subjects of colloid degeneration. The source 
of the colloid material must be considered 
still undecided; that some of it is formed by 
the cells is certain, but it is not equally clear 
whether the stroma takes any share in its 
deposition. See fig. 12. 
Conclusion.-Our knowledge of the patho- 
logy of new-growths is undergoing a process 
of evolution, not now, however, so rapid as 
in recent years. Not much therefore has 
required alteration since this article was 
written nearly ten years ago, and it is hoped 
that it will still be found fairly to represent 
the opinions most widely accepted at the 
present day. 
R. J. Godlee. 
CANCRUM ORIS (cancrum, a sore; 
and oris, of the mouth).-Synon. : Gan- 
grenous Stomatitis; Noma; Water-canker; 
Fr. Nome; Ger. Wasserkrebs. 
Definition.-A rapidly progressive gan- 
grenous ulceration of the cheek, gum, and lip. 
jEtiology.-Cancrum oris is usually seen 
in ill-fed, ill-tended children, living under the 
most faulty hygienic circumstances. It fre- 
quently ensues upon some acute depressing 
illness, especially measles (110 times in 226 
cases-Sannee). Occasionally two or three 
cases occur together in a school, suggesting 
the possibility of contagion. Lingard has 
demonstrated long threads of small bacilli in 
the spreading edge of noma in man, and in a 
similar disease of calves ; and inoculation on 
calves of a pure culture from man induced 
the disease. 
Symptoms.-Cancrum oris commences on 
the inner surface of the cheek, often near the 
angle of the mouth, or upon the gum; and 
at this stage some superficial ulceration will 
usually be found here-that is, ulcerative 
stomatitis. The disease rapidly advances. 
The cheek becomes much swollen, brawny, 
shining, and red; a livid spot appears in the 
centre, and here a spreading black slough 
forms, while the surrounding parts become 
purplish or mottled. If the patient can open 
his mouth sufficiently, the gums will be seen 
to be red and spongy, ulcerating, or destroyed; 
even the tongue may show some ulceration. 
The cheek is fined with a tough, adherent, 
greyish-yellow or soft purplish slough; the 
jaw may be laid bare, the teeth loosened, 
and portions of the alveolus necrosed. The 
breath is very foul, and the flow of saliva is 
excessive and foetid. Fever may be moderate 
or high. Pain is slight or absent, and the 
child, though lethargic, is conscious almost to 
the end. Not more than one in twenty cases 
recovers, death being generally due to septic 
broncho -pn eumonia. 
Diagnosis.-Formerly mercurial stomatitis 
sometimes ran on to gangrene in debilitated 
patients ; this inflammation was general, and 
affected the tongue markedly. N o hard line 
can be drawn between ulcerative stomatitis 
and noma. 
Treatment.-This consists in complete and 
careful excision by knife and sharp spoon of 
the diseased area, regardless of the deformity 
which must result. To parts which cannot 
be excised, nitric or pure carbolic acid should 
be freely applied. Iodoform gauze is the 
best dressing. The mouth must be frequently 
and carefully syringed and sponged out with 
an antiseptic lotion, especially before food is 
taken. As far as possible, the child should 
lie so that foul saliva, &c. may dribble from the 
mouth and not down the throat. Dr. Goodhart 
thinks that even tracheotomy might be done 
to prevent inhalation of septic material into 
the lungs. Fluid food, especially pancrea- 
tised beef-tea or milk-gruel, should be given 272 
CANCRUM ORIS 
CAPILLARIES, DISEASES OF 
regularly and frequently, by mouth, nasal 
tube, or enemata. Ammonia and bark or 
other tonics should be exhibited. 
W. Fairlie Clarke. Stanley Boyd. 
CANITIES (canus, hoary or greyhaired). 
Whiteness or greyness of the hair. See Hair, 
Diseases of. 
CANNES, in France, on the Mediter- 
ranean coast. A dry, bracing, fairly mild 
winter climate. Exposed to N.W. Abun- 
dant accommodation, both near and at some 
distance from the sea. See Climate, Treat- 
ment of Disease by. 
CANTHARIDES, Poisoning by.- 
Synon. : Fr. En-poisonnement par la 
Cantharide; Ger. Cantharidenvergiftung. 
Cantharides, the so-called Spanish Fly, 
owes its poisonous properties to the presence 
of cantharidin, a non-alkaloidal body. All 
the preparations of the drug are highly 
poisonous. 
Symptoms.-Soon after taking a poisonous 
dose of cantharides, the patient is seized with 
burning pain in the pharynx, and a sense of 
constriction in the oesophagus. The pain 
soon extends to the abdomen, and vomiting 
ensues; the abdominal pain becomes 
aggravated; and usually purging sets in. 
The stools are numerous, often scanty, 
passed with great pain and straining; they 
are at first mucous, and finally bloody. 
If carefully examined, little iridescent specks 
-portions of the elytra of the beetle-may 
be observed in the faeces and vomited 
matters. These are of course only observ- 
able when the powdered insect has been 
taken; and they frequently escape observa- 
tion. Up to this period of the case, should 
portions of the beetle not have been detected, 
there is nothing to distinguish the case from 
one of ordinary irritant poisoning; except, 
perhaps, that salivation and swelling of the 
salivary glands are usually prominent 
symptoms. The gastro-intestinal inflamma- 
tion may be so intensely and rapidly 
'developed, that death may occur from 
collapse before strangury, the diagnostic 
symptom, is set up. Generally, however, 
the course is somewhat different, genito- 
urinary irritation and inflammation setting 
in; the symptoms of which are aching pains 
in the lumbar region, frequent desire to 
micturate, with violent tenesmus of the 
bladder, till eventually a few drops of 
albuminous or bloody urine only can be 
passed, or none at all. Priapism, erotic 
excitement, and swelling of the genitals 
are of frequent, though not of constant, 
occurrence. Delirium, tetanic convulsions, 
or paraplegia, may be noted in some cases. 
Eventually the intolerable agony gives way 
to collapse, stupor, coma, and death. Abor- 
tion not infrequently occurs in pregnant 
women, the drug being formerly much used 
as an abortifacient. 
Diagnosis.-The intense strangury, the 
swelling of the genitals, and the bloody 
stools, will leave little or no doubt as to the 
nature of the case; and the presence of 
particles of the drug in the ejecta will be 
conclusive. 
Fatal dose.-Less than half a drachm of 
the powder, and an ounce of the tincture, 
have alike proved fatal. 
Treatment.-Evacuation of the stomach 
by the use of the stomach-pump, syphon-tube, 
or an emetic is the first indication in poison- 
ing by cantharides. It is best to thoroughly 
wash out the stomach. Mucilaginous drinks, 
white of egg (not the yolk), and demulcents, 
may be freely given ; but oil in any form is 
to be avoided, as tending to dissolve cantha- 
ridin. Opium by the mouth or rectum, or 
the hypodermic injection of one-third of a 
grain of morphine, is advisable. Leeches 
to the region of the bladder, warm fomenta- 
tions, and warm sitz-baths may afford 
relief. Chloral should also be given, or the 
patient kept cautiously under the influence 
of chloroform. Collapse may be met by 
ammonia and other stimulants. The hypo- 
dermic injection of a few drops of ether is 
useful. There is no known antidote for 
cantharidin. Thomas Stevenson. 
CAPE COLONY, in South Africa. 
See Africa, South. 
CAPE OF GOOD HOPE-A warm, 
generally dry climate, but very variable,' and 
liable to sudden storms. See Africa, South ; 
and Climate, Treatment of Disease by. 
CAPILLARIES, Diseases of.-Synon. : 
Fr. Maladies de Vaisseaux Capillaires; Ger. 
Krankheiten der Capillargefdssen. - The 
morbid conditions of the capillaries may be 
described in the following order:-1. Fatty 
Degeneration. 2. Calcareous Degeneration. 
3. Albuminoid Degeneration. 4. Pigmenta- 
tion. 5. Changes in Inflammation. 6. Dila- 
tation. 7. Narrowing and Obliteration. 8. 
Thrombosis. 9. Embolism. 10. Rupture. 
11. The New Formation of Capillaries. 
12. Capillaries in New-Growths and Tu- 
bercle. 13. Changes in the Perivascular 
Space and Sheath. 14. Teleangiectasis. 
1. Fatty Degeneration.-This is the 
most common disease of the capillary-wall, 
and is frequently associated with fatty de- 
generation of the surrounding tissues. The 
cause of this change in the protoplasm of the 
capillary is, as elsewhere, interference with 
nutrition, and especially with oxidation. It is 
accordingly found in morbid conditions of the 
blood; in interference with the blood-supply; 
and in lesions of the nervous system. The 
microscopical characters of the early stages 
of fatty degeneration when it affects the 
capillaries are not peculiar; in advanced 
stages the diseased vessels may present the 
appearance of opaque granular cords; and CAPILLARIES, DISEASES OF 
273 
the lymphatic sheaths of the cerebral capil- 
laries are sometimes found, under such cir- 
cumstances, filled with oil-globules and fatty 
cells. A frequent termination of the disease 
is rupture and. haemorrhage. Fatty degenera- 
tion of the capillaries occurs most frequently 
in the nervous centres, where it can be 
readily demonstrated, in the kidneys, in 
certain tumours, and in the products of in- 
farction and inflammation. 
2. Calcareous Degeneration. - This 
disease is rare in capillaries. 
3. Albuminoid Degeneration.-Albu- 
minoid degeneration affects the Malpighian 
glomeruli in the early stage of this affection 
of the kidneys. In other parts of the body 
the capillaries are less subject to albuminoid 
change than the small arteries. 
4. Pigmentation.-Pigmentary granules 
may sometimes be found in the walls of 
capillaries, but they more frequently occupy 
the perivascular space. In either situation 
pigmentation is the result of chronic conges- 
tion or inflammation, or of haemorrhage. 
5. Changes in Inflammation.-The 
changes of the capillaries of an inflamed part 
constitute an important factor of the process 
of inflammation. See Inflammation. 
6. Dilatation.-Dilatation of capillaries, 
which is one of the changes in passive venous 
congestion and inflammation, may become 
permanent if the cause persist. 
Changes in the nutrition of the capillary- 
wall, combined with disturbances of the cir- 
culation, such as increased pressure, produce 
local dilatation or Aneurysm of the vessels, 
and subsequent rupture. This is one form of 
miliary aneurysm as it occurs in the brain. 
See Brain, Vessels of, Diseases of. 
7. Narrowing and Obliteration.- 
Narrowing of capillaries may be temporary, 
as in inflammation; or permanent, from ex- 
ternal pressure, or from interference with the 
blood-supply. Narrowing may proceed to 
complete obliteration. 
8. Thrombosis.-Thrombosis rarely oc- 
curs in capillaries. See Thrombosis. 
9. Embolism.-The phenomena of ordin- 
ary embolism in a great measure affect the 
capillaries corresponding with the obstructed 
artery. But, besides this change, capillaries 
are themselves subject to embolism, or im- 
paction of particles within them. The pro- 
ducts of inflammation or degeneration, pig- 
ment-particles, oil or fat-drops from the 
marrow of fractured bones, organisms, and 
various substances artificially introduced into 
the circulation, have been discovered obstruct- 
ing the capillaries in different instances. All 
the possible results of embolism in large 
vessels may follow, according to circum- 
stances, but anastomosis being very free, they 
are comparatively insignificant functionally, 
unless the obstruction be extensive ; and in the 
case of the cerebral vessels definite symptoms 
are believed by some to result, such as 
delirium and choreic movements. See 
Chorea. 
10. Rupture.-Three circumstances spe- 
cially determine the occurrence of this lesion 
of capillaries, namely, disease of the vessel- 
wall, increase of the blood-pressure, and a 
' terminal ' distribution of the branches of the 
artery that supplies them. The most com- 
mon diseases of the wall are fatty degenera- 
tion and aneurysm. The blood-pressure rises 
within the capillaries of any part in ventri- 
cular hypertrophy, in increased tension of the 
arteries of other parts, and in venous obstruc- 
tion. When an artery is ' terminal,' that is, 
unprovided with other anastomoses than 
through its capillaries, no lateral relief can 
be afforded in sudden and excessive rises in 
the force of the circulation. For these 
several reasons, rupture of capillaries is most 
frequent when the vessel-walls have been 
weakened in the fatty degeneration of senile 
decay, in septicaemia, inflammation, purpura, 
fever, and scurvy; in chronic Bright's dis- 
ease with increased blood-pressure; and in 
such organs as the corpus striatum, retina, 
spleen, kidney, villi, and skin. Disturbances 
in the pressure of the air within the chest 
powerfully influence the occurrence of capil- 
lary-rupture in the respiratory tract. When 
a capillary-wall gives way, the blood is extra- 
vasated either on a free surface, constituting 
haemorrhage; into the substance of the 
tissues around; or along the lymphatic 
sheath of the ruptured vessel, where it gives 
rise to the appearance that has been described 
by some authorities as dissecting capillary 
aneurysm. 
11. New Formation of Capillaries. 
Capillaries grow or develop in nearly all 
forms of new-growths, whether inflamma- 
tory or otherwise. The young capillaries are 
derived either from cellular buds upon pre- 
vious capillaries, which become hollowed by 
the blood-pressure ; from anastomosing exu- 
dation cells, or connective-tissue corpuscles; 
or, in some cases, from the parallel disposition 
of exudation-cells. 
12. Capillaries in New-Growths and 
Tubercle.-The capillary-walls are believed 
to play an important part in the production of 
certain forms of new-growths. See Tumours ; 
and Tubercle. 
13. Changes in the Perivascular 
Space and Sheath.-The perivascular or 
lymphatic sheath, which probably envelops 
all capillaries, is liable to certain morbid con- 
ditions, which are chiefly secondary to changes 
in the vessel within it. Thus the space may 
become filled with blood from escape of the 
corpuscles by rupture or otherwise; with 
leucocytes in inflammation; with oil-globules 
and fatty corpuscles in degeneration of the 
wall; with pigment-particles ; or with serum 
in disturbances of the circulation. The calibre 
of the perivascular canal, which varies in- 
versely with that of the contained capillary, 274 
CAPILLARIES. DISEASES OF 
CARBONIC ACID, POISONING BY 
may thus be increased, and present uniform 
or irregular dilatation. 
Changes in the outer sheath, or wall of the 
lymphatic space, have also been observed, in- 
cluding fatty degeneration of the lining cells, 
and hyaline thickening. 
14. Teleangiectasis.-At least one form 
of vascular tumour consists of a local over- 
growth of capillaries, which are both enlarged 
and multiplied. See Tumours. 
J. Mitchell Bruce. 
CAPILLARY BRONCHITIS.-In- 
flammation involving the minute bronchial 
tubes. See Bronchi, Diseases of. 
CARBOLIC ACID, Poisoning by. 
See Poisons. 
CARBONIC ACID, Poisoning by. 
The inhalation of carbonic acid causes inju- 
rious or fatal results, according to the length 
of time and degree of concentration. Carbonic 
acid accumulates in large quantities, almost 
undiluted, in pits, cellars, wells, mines (espe- 
cially after explosions, constituting what is 
called choke-damp), volcanic grottoes, fer- 
menting vats, lime kilns, &c. A continuous 
contamination of the atmospheric air with 
carbonic acid goes on from the respiration of 
animals and the combustion of fuel. The 
generation of CO2 by a human being averages 
about 0-6 cubic foot per hour ; that of an or- 
dinary gas-burner 2* cubic feet of CO2 for 
every one of gas burnt; that of an oil lamp 
relatively more. The gradual exhaustion of 
oxygen and proportionate accumulation of car- 
bonic acid in ill-ventilated apartments is one 
of the factors of the evil results of bad venti- 
lation, but not the only one, as other animal 
exhalations contribute largely to the result. 
As a rule excess of carbonic acid means 
corresponding deficiency of oxygen in the at- 
mosphere, and the proportion cannot exceed 
10 per cent, without rapidly fatal results ensu- 
ing ; but much less than this causes injurious, 
and even fatal consequences if long inhaled; 
and less than 2 per cent, cannot be breathed 
for any length of time with impunity. 
If the amount of oxygen be not correspond- 
ingly diminished, carbonic acid if present in 
sufficient quantity in the atmosphere respired 
will still act fatally. Thus Bernard found 
that a bird died instantaneously in an atmo- 
sphere of equal parts of oxygen and carbonic 
acid; and Snow found that 20 per cent, of car- 
bonic acid in an atmosphere containing the 
normal proportion of oxygen soon proved fatal 
to small animals, and that even 12 per cent, 
might cause death after a longer interval. 
Symptoms.-Undiluted carbonic acid is not 
readily inhaled, as it tends to induce spasm 
of the glottis, but immersion in such an at- 
mosphere is rapidly fatal. It seems to act as 
a narcotic. The patient falls down prostrate 
and insensible, and death occurs almost im- 
mediately. This effect is seen occasionally 
when labourers incautiously descend an old 
well, or when miners enter a region filled with 
choke-damp. Not infrequently several fall 
victims, as one goes to see what has happened 
to the other and meets the same fate. 
When the carbonic acid is more diluted, the 
symptoms are headache, giddiness, and sense 
of oppression, followed by drowsiness, and 
singing in the ears. Ultimately a condition 
of insensibility ensues, with stertorous breath- 
ing and muscular prostration; death usually 
occurring quietly and without convulsions. 
If the excess of carbonic acid corresponds 
with deficiency of oxygen, we have in addition 
to the essentially narcotic effects of carbonic 
acid, the dyspnoea and other symptoms of 
asphyxia. See Asphyxia. 
Post-mortem Appearances. - These are 
largely those of asphyxia, namely, a general 
engorgement of the venous system. This is 
generally seen in the brain more frequently 
than in asphyxia pure and simple. The blood 
is dark and fluid. The haemoglobin is com- 
pletely reduced. Animal heat is said to be 
retained long after death, and rigidity is well- 
marked and enduring. 
Pathology.-As has been already said, car- 
bonic acid does not act merely as a negative 
asphyxiant by taking the place of oxygen, but 
has a distinctly toxic narcotic effect. Very 
frequently in cases of poisoning by carbonic 
acid there is a combination of asphyxia, essen- 
tially due to deficiency of oxygen, with the 
narcotic symptoms due to carbonic acid. 
Treatment. - 1. Prophylactic.-Caution 
should be exercised in exploring wells, mines, 
&c., where there is any likelihood of the accu- 
mulation of carbonic acid. The introduction of 
a lighted candle is a rough and ready test of 
considerable value. The mere fact of a candle 
continuing to burn in an atmosphere is no 
test of its being respirable with impunity, for 
a candle will burn in an atmosphere contain- 
ing 10 per cent, of carbonic acid if the oxygen 
is present in the normal amount, and the pre- 
sence of an amount of carbonic oxide sufficient 
to cause death will not materially affect the 
flame. If carbonic acid reaches the propor- 
tion of 16 per cent, the candle will, however, 
be extinguished. If a candle is extinguished, 
then certainly the atmosphere cannot be 
breathed, and therefore the test is of sound 
practical value. If carbonic acid is present, 
it should be expelled by creating a draught of 
some kind. Thus wells may be swept by 
some such contrivance as an inverted um- 
brella, and a stream of air or steam can be 
directed into enclosed spaces. 
2. Restorative.-Artificial respiration and 
its various accessories are needed to restore a 
person actually in a state of coma from car- 
bonic acid. This treatment, of course, is subse- 
quent to instant removal from the impure 
atmosphere. Pure oxygen should also be ad- 
ministered if at hand. See Artificial Respi- 
ration; and Resuscitation. D. Ferrier. CARBONIC OXIDE, POISONING BY 
CARBUNCLE 
275 
CARBONIC OXIDE, Poisoning by. 
Carbonic oxide is a much more dangerous 
agent than carbonic acid, and to it are due 
many of the effects sometimes ascribed to the 
latter. Pure carbonic oxide is rarely generated 
out of the chemical laboratory, but mixed 
with other gases carbonic oxide is not uncom- 
mon. This is especially the case in the fumes 
of burning charcoal. The carbonic acid of 
the burning charcoal while passing over the 
heated embers loses an atom of oxygen, or 
takes up an atom of carbon, and is converted 
into carbonic oxide, which burns with a bluish 
flame at the top. The toxic action of charcoal 
vapours is essentially dependent on the car- 
bonic oxide they contain. Usually charcoal 
fumes contain from 2 to 3 per cent, of carbonic 
oxide, to 25 of carbonic acid, along with some 
heavy carburetted hydrogen. The vapours, 
however, are still as effective after being 
passed through lime-water, which fixes the 
carbonic acid. Poisoning by charcoal vapour 
is not an uncommon form of suicide, more 
particularly abroad, and many cases have 
occurred accidentally in this country, from 
sleeping in rooms in which there was no flue 
for the escape of the fumes of burning char- 
coal, or into which there has been leakage 
from stove pipes, &c. Carbonic oxide is 
always found in the air of rooms where cast- 
iron stoves are used, from some of the carbon 
of the cast iron itself being formed into CO, 
and the iron when heated allowing a large 
quantity to pass through the metal. 
Carbonic oxide also exists in coal gas, and 
in still larger quantities (44 per cent.) in 
the new water-gas, constituting their main 
danger. It is likewise found in the emana- 
tions from brick-kilns. 
Carbonic oxide is an extremely active poison. 
Letheby found that -5 per cent, of carbonic 
oxide in the respiratory medium killed small 
birds in three minutes, and that 2 per cent, 
killed a guinea-pig in two minutes. Many 
similar experiments have been performed 
with similar results. The animals soon be- 
come insensible, and die generally without 
exhibiting convulsive phenomena beyond a 
few tremors or flutterings. 
Symptoms.-In man inhalation of carbonic 
oxide for a short time, as Sir H. Davy and 
others have proved on themselves, causes 
headache, pulsation in the temples, giddiness, 
nausea, and great prostration, tending to 
drowsiness and insensibility. Continued 
inhalation causes profound coma. Usually 
death occurs quietly, but signs of vomiting 
are frequently observed near those who have 
been poisoned by charcoal fumes. 
Post-mortem Appearances.-The specially 
characteristic appearance of death from car- 
bonic oxide is the cherry-red colour of the 
blood and internal organs. The post- 
mortem hypostasis exhibits a similar bright 
red tint. Frequently in those poisoned with 
carbonic oxide the face retains a ruddy hue. 
The red tint of the blood is due to the com- 
pound which carbonic oxide forms with 
haemoglobin. Carbonic oxide displaces the 
oxygen and forms a very stable compound 
with the haemoglobin, not readily broken up, 
and hence the oxygen-carrying power of the 
corpuscles is paralysed. 
In the spectroscope carbonic-oxide blood 
exhibits two absorption-bands very similar 
to those of ordinary blood-colouring matter 
or oxyhaemoglobin, but a difference in the 
exact breadth and position of the bands can 
be made out by means of the microspectro- 
scope, when the two are compared together. 
Carbonic-oxide-haemoglobin resists reduction 
in the usual manner, and here again differs 
from normal blood-colouring matter. Hoppe- 
Seyler gives as an additional test the action 
of caustic potash on carbonic-oxide- and 
ordinary haemoglobin respectively. With 
the latter it causes a green colour on a por- 
celain plate, while with the former the colour 
continues red. 
Pathology.-Carbonic oxide acts by para- 
lysing the blood-corpuscles, as Bernard ex- 
presses it, and rendering them unable to take 
up oxygen. Hence internal respiration is pre- 
vented, and death ensues from asphyxia. 
Treatment. - As carbonic-oxide-haemo- 
globin is a very stable compound, and offers 
a very considerable resistance to displace- 
ment by oxygen, though not absolute as was 
at one time considered, artificial respiration 
is not likely to be successful by itself. The 
best treatment is venesection and transfusion 
of fresh blood. This method of treatment 
has proved successful in one or two instances 
in which it has been employed. 
D. Ferrier. 
CARBUNCLE (carbun cuius, a small 
coal-carbo).-Synon. : Anthrax; Fr. An- 
thrax ; Ger. Karbunkel. 
Definition.-A specific local inflammation 
of the subcutaneous areolar tissue, rapidly 
leading to sloughing of the deeper and more 
central parts, followed by destruction of the 
skin; the whole of the dead tissues finally 
separating in the form of a slough. 
^Etiology.-Carbuncle is a constitutional 
affection, dependent upon conditions of 
general debility or of plethora, and often as- 
sociated with gouty or diabetic tendencies. 
It is more commonly seen in men than in 
women; is rarely met with under the age of 
twenty; and it attacks all ranks of life. 
Symptoms.-The most common seat of car- 
buncle is the back of the trunk or neck, but 
it may occasionally be found in other situa- 
tions. The affection usually begins as a 
painful, hard, slightly elevated, and ill-defined 
swelling, which gradually increases in extent 
and assumes a dusky red tint. A vesicle 
containing bloody serum soon forms over the 
most prominent part, and on rupturing dis- 
closes several small apertures in the sub- 276 
CARBUNCLE 
CARDIOGRAPH 
jacent skin, which give exit to a glutinous 
purulent discharge. This sieve-like condition 
of the undermined integument often persists 
throughout the course of the disease. Occa- 
sionally, however, owing to the destruction 
of the intervening skin, the several apertures 
merge into a single, large, ragged opening, 
and thus expose the characteristic ash-grey, 
slimy slough, which separates slowly by sup- 
puration, leaving an irregular cavity with 
deeply undermined edges. The cicatrix left 
after healing is usually uneven and may be 
permanently discoloured. 
In the early stage of the disease, while the 
inflammatory oedema is still extending, the 
patient generally complains of a burning, 
throbbing sensation in the part, which may 
become intensely painful; but on the full 
exposure of the slough, the pain diminishes, 
and in the later stages it may cease entirely. 
When the carbuncle is large, or involves 
a portion of the scalp, there is usually con- 
siderable constitutional disturbance of an 
asthenic type. Death may then occur from 
exhaustion, which is sometimes aggravated 
by free haemorrhage resulting from incisions ; 
but the most frequent cause of a fatal termi- 
nation is pyaemia. 
Diagnosis. - Carbuncle is distinguished 
from boil by the size and extent of the swell- 
ing, and by its tendency to spread ; by the 
livid tint of the skin, and the early forma- 
tion in it of more than one aperture; by the 
character of the slough, by the severity of 
the pain, and the marked constitutional dis- 
turbance ; and, finally, by the fact that car- 
buncle, unlike boil, usually occurs singly. 
Prognosis.-This will depend chiefly upon 
the age of the patient, and upon the seat and 
extent of the disease, which proves most 
dangerous to life when situated or encroach- 
ing on the scalp, especially in a person over 
fifty. The coexistence of albuminuria or 
chronic saccharine diabetes is always a grave 
complication. 
Treatment.-The constitutional treatment 
and the management of patients with car- 
buncle are best conducted on general prin- 
ciples. In ordinary cases the diet should be 
of good quality and sufficient in quantity, 
with a moderate allowance of stimulants, 
proportionate to previous habits. Should 
the patient's strength and the situation of 
the carbuncle allow him to move about, he 
need not be confined to his room, and may 
even be allowed exercise in the open air. 
In the more severe forms of the disease, 
the frequent administration of dietetic stimu- 
lants and good nourishment in an easily 
assimilable form is usually necessary. The 
bowels, if they require it, should be cleared 
out by some non-irritating aperient, and the 
patient put on a course of quinine or bark 
and the mineral acids. Opium or other 
sedatives may be required in the earlier 
stages to relieve the intense sufferings of 
some patients; while in the after-course of 
the disease, it may be sometimes needed to 
procure sleep. 
For local treatment see Boils. 
For carbuncle of the face, an affection dis- 
tinct from the Malignant Pustule described 
by Continental surgeons, see Pustule, Ma- 
lignant ; and Boils. 
William A. Meredith. 
CARCINOMA. See Cancer. 
CARDIAC DISEASES. See Heart, 
Diseases of. 
CARDIALGIA (KapSta, the heart; and 
akyos, pain).-A synonym for heartburn, 
originating in a popular impression that this 
painful sensation, which starts from the epi- 
gastrium, is connected with the heart. See 
Heartburn. 
CARDIOGRAPH, The (*apMa, the 
heart; and ypafjjco, I write).-This is an in- 
strument for registering graphically the form 
of the heart's movements. It really records 
a tracing of the cardiac impulse, the curves 
of the trace representing the changes of 
pressure exerted by the apex of the heart on 
the chest-wall. We owe the invention of 
the cardiograph to Marey, who, in his physi- 
ological researches on the circulation of the 
blood, obtained by the following means the 
form of movement of each cavity of the 
heart. He introduced into the auricles and 
ventricles of a horse, hollow sounds terminat- 
ing in elastic ampulla; filled with air. The 
air communicated through the sounds and 
elastic tubes with terminal ampullae, or* 
tympana covered with elastic membrane, 
on each of which rested a light lever. The 
movements communicated by the heart to 
the closed column of air were amplified by 
the levers and recorded by them on a 
revolving cylinder. In this way tracings 
of the forms of movement of each cavity 
were obtained, and by comparison with 
a tracing taken simultaneously of the ex- 
posed apex-movement, an explanation of 
the complex apex-tracing was rendered 
possible. The cardiograph used for clinical 
research is a modification of the above, and 
consists of a hollow cup containing a small 
spring which can be depressed by means of 
a screw so as to rest firmly on the chest-wall 
where the impulse is felt. The cup com- 
municates by means of an elastic tube with 
a tympanum covered with elastic membrane, 
carrying on its surface a lever. When 
applied to the chest the cup hermetically 
seals the air column, which transmits as 
waves the motion received by the spring to 
the lever resting on the tympanum. The 
movements are recorded by the end of the 
lever, either on the plate of a sphygmograph 
or on a revolving cylinder. 
By means of this apparatus a very perfect 
representation of the cardiac movements can CARDIOGRAPH 
CARMINATIVES 
277 
be obtained, the auricular and ventricular 
elements traced, and the duration of each 
measured. The transmission of the motion 
through an elastic medium like air has been 
objected to, as liable to modify the tracing 
by (1) the production of secondary oscilla- 
tions in the air column; and by (2) gradual 
change in the form of motion caused by the 
elasticity of the medium. Practically, how- 
ever, these objections are not valid, as is 
shown by the fact that the last of a series of 
cardiac pulsations is often an exact repro- 
duction of the first, and also by the close 
resemblance between the tracings obtained 
in this way and those registered by the 
sphygmograph, or an enlarged modification 
of it, such as Galabin's cardiograph, applied 
over the apex-beat. Pond's sphygmograph 
may also be used as a cardiograph. 
A cardiogram collected on a healthy per- 
son by the instrument described is here given. 
One cardiac revolution is 
figured. The several waves 
maybe interpreted as follows. 
The wave a, in the line of 
ascent, corresponds with the 
early part of the ventricular 
diastole. The wave b corre- 
sponds with the true auricu- 
lar systole ; from b to d the 
line marks the true impulse 
caused by the ventricular contraction, the 
rounding of the heart, and its pressure 
against the chest-wall. The wave c, at the 
summit of the curve, immediately follows 
the closure of the auriculo-ventricular valves, 
which does not always form the summit of 
the curve, but occasionally in slower cardiac 
contractions is marked by a wave below the 
summit. The waves between c and d are 
oscillations produced by the closure of the 
auriculo-ventricular valves. The length of 
the summit c to d is important; it is long 
and sustained in hypertrophy, narrow and 
pointed in dilatation. Its length is a measure 
of systolic strength. The closure of the aortic 
valves is marked by d; while e marks the 
closure of the pulmonary valves, separated 
by an interval of -05 to -09 second. If the 
pressure in the aorta falls and that in the 
pulmonary artery rises (pulmonary second 
sound accentuated), d and e approach and may 
no longer be distinct. In the above cardio- 
gram the period of ventricular contraction 
is measured by the space between the com- 
mencement of the line of ascent after the 
wave b, to the point d, which marks the 
termination of the systole; the rest of the 
curve is diastolic. The wave d is prominent 
in hypertrophy of the left ventricle. 
The clinical value of the cardiograph has 
yet to be fully established. It has hitherto 
been useful in showing the relation of prse- 
systolic murmur and thrills to the ventricular 
and auricular contractions ; in demonstrating 
modifications of the form of impulse in ad- 
herent pericardium; in recording a con- 
siderable increase in the wave a, and a sudden 
rising of the trace after a to b, as signs of 
aortic insufficiency; and in the recognition 
of the relation between reduplication of the 
heart-sounds and respiratory influences. The 
wave a is larger the more sudden the relaxa- 
tion of the ventricle, and thus it is increased 
by the influx of the blood in cases of aortic 
and mitral regurgitation. Waves following a 
usually indicate vibrations and thrill due to 
mitral stenosis, while prominence of wave b 
indicates auricular hypertrophy. 
The cardiograph is also of great value in 
registering the form of movement of pulsat- 
ing tumours and aneurysms. In its applica- 
tion, it is sufficient to hold the instrument 
firmly over the apex-beat, and to record the 
pulsations at the end of expiration, the 
breath being stopped for a brief interval. 
When the influence of respiration is to be 
observed, this precaution is of course un- 
necessary ; but it must be borne in mind 
that the movement of the chest-wall modifies 
the tracing. 
(Balthazar) Walter Foster. 
CARDITIS (sapbia, the heart).-Inflam- 
mation of the substance of the heart. See 
Heart, Inflammation of. 
CARIES (caries, rottenness). - A de- 
structive inflammatory disease of bone, ana- 
logous to ulceration of soft tissues. See Bone, 
Diseases of. 
CARLSBAD, in Bohemia. Thermal 
alkaline sulphated waters. See Mineral 
Waters. 
CARMINATIVES (carmino, I card, 
or cleanse). 
Definition.-Substances that aid the ex- 
pulsion of flatus from the stomach and in- 
testines, and relieve griping. 
Enumeration.-The principal carminative 
remedies are-the essential Aromatic Oils, 
for example, Peppermint and Cloves ; Chloro- 
form ; Charcoal; Ethers; and Camphors, and 
substances containing them. 
Uses.-The uses of carminatives are suffi- 
ciently indicated in the preceding definition. 
They are extensively administered in cases of 
flatulent dyspepsia, especially when it is as- 
sociated either with disease or disorder of 
the heart, or with a nervous or hysterical 
state of the system. A combination of 
several different carminatives is usually 
more successful than the exhibition of a 
single drug, one of the best being a mixture 
containing Spirit of Ether, Aromatic Spirit 
of Ammonia, and Tincture of Orange. Given 
along with antacids they are useful in cor- 
recting acidity, as in the favourite Soda- 
mints ; and they are frequently prescribed 
with purgatives to prevent pain-an applica- 
tion illustrated by the Compound Rhubarb 
Pill. T. Lauder Brunton. 
Fig. 23. 
Cardiogram. 278 
CARNIFICATION 
CARTILAGE, DISEASES OF 
CARNIFICATION (caro, flesh; and 
fio, I become).-A condition of the lung in 
which it resembles flesh. The term was 
formerly applied to the transformation of 
any tissue into a flesh-like substance. See 
Lungs, Collapse of. 
hyaline substance is denser and more dis- 
tinctly fibrillated than in the others. 
Summary of Diseases.-Cartilage being 
non-vascular, its inflammation is of a modi- 
fied type, and it may undergo degenerative 
changes as the result of impaired nutrition. 
In uncomplicated disease of cartilage there is 
no inflammatory exudation, and when lymph 
or pus is found in a joint, it is obvious that 
other structures have become inflamed. 
1. The ensiform and costal cartilages, with 
those of the trachea and larynx, show a 
great tendency to ossification, as the result 
of senile changes; they are also liable to 
necrosis. The articular cartilages never 
ossify, but large or small portions of them 
may perish and be detached, in consequence 
of some interference with their supply of 
nutriment from the subjacent bone. In 
pyasmic joint-effusions the cartilage softens, 
and is rubbed off the most prominent portions 
of the articular surfaces in a manner quite 
characteristic. In osteo-arthritis, one of the 
earliest of the pathological changes occurs in 
the articular cartilage. The cells proliferate, 
the primary capsules enlarge and fill with 
secondary capsules. The matrix fibrillates 
and softens, and by degrees the cartilage is 
wort off the central part of the articulation, 
exposing the bone underneath; laterally, 
where the pressure and friction are less, the 
cartilage cells proliferate and form a tuber- 
culated margin, which subsequently ossifies. 
2. The cartilages of the epiglottis, ears, 
nose, eyelids, and Eustachian tube have little 
disposition to ossify, but they are liable to 
ulceration, especially of the syphilitic variety; 
in these cases the diseased action commences 
in the skin or mucous membrane, and 
spreads to the cartilage by contiguity. 
3. The cartilage of the external ear is often 
the seat of chalk-stones in gouty persons, and 
similar deposits of urate of sodium are found 
in the articular cartilages. 
4. The epiphysial cartilage may be the 
seat of inflammatory changes, generally very 
acute, which lead to separation of the shaft 
from the epiphysis, a condition which, 
whether the result of disease or accident, is 
of great moment, inasmuch as the destruc- 
tion of this layer of cartilage checks further 
growth at this end of the bone. 
Primary epiphysitis is rare : the changes in 
the epiphysis usually spread to it from the 
extremity of the diaphysis. Syphilis, espe- 
cially of the inherited form, is the most 
common cause of this disease. Injury, par- 
ticularly in strumous children, is also a factor 
in its production. The acute form is often 
associated with general septicaemia, and is 
followed by destructive changes in the adja- 
cent joint. 
5. Cartilage is not primarily attacked by 
cancer, but it may become involved by the 
spread of a malignant tumour. The epi- 
thelial form of cancer not infrequently 
CARPHOLE GY 
CARPHOLOGY 
(jcap^os, chaff; and 
Xeya>, I collect).-The 
movements of the hands and fingers observed 
in certain delirious patients, as if they were 
searching for or gathering imaginary ob- 
jects. A familiar illustration of the act is 
' picking of the bedclothes.' See Typhoid 
Fever. 
CARTILAGE, Diseases of.-Synon.: 
Fr. Maladies du Cartilage; Ger. Knorpel- 
krankheiten.-For a due appreciation of the 
abnormal conditions to which cartilage is 
subject, a brief description of this tissue in 
its healthy state is necessary. 
The temporary cartilage, which forms the 
early skeleton, gradually undergoes conver- 
sion into bone, leaving at the joint surfaces 
a thin layer, the articular cartilage, which 
never becomes ossified. Certain other por- 
tions of the skeleton also retain their carti- 
laginous condition throughout life ; these are 
known as the permanent cartilages, and as 
examples the cartilages of the ribs, ears, and 
nose may be named. The extremities of the 
long bones, or epiphyses, remain separate 
from the shaft for a varying period after 
birth, and so long as the bone continues to 
grow, they are attached to it by a thin but 
important layer of cartilage, called the epi- 
physial cartilage. There are also the fibro- 
cartilages, in which the fibrous and carti- 
laginous elements are found in varying pro- 
portions, according as the tenacity of the one 
or the elasticity of the other material is re- 
quired. 
Cartilage is altogether destitute of nerves, 
and therefore of sensibility; and it is equally 
devoid of blood-vessels, being nourished by 
imbibition from the vessels of the neighbour- 
ing parts. All cartilages, except the articular 
and the fibro-cartilages, are covered by a 
fibrous membrane, the perichondrium, which 
is similar to, and subserves the same pur- 
poses as the periosteum. When cartilage 
has been destroyed, it may be replaced by 
fibrous tissue or by bone, but it is never re- 
produced. 
Under the microscope a section of carti- 
lage presents a transparent, structureless 
matrix, studded with nucleated cells; these 
cells are flattened and arranged parallel with 
the free surface of the cartilage, whilst more 
deeply they are elongated and grouped 
vertically. The nutrient materials are ab- 
sorbed from the neighbouring blood-vessels, 
and transmitted throughout the cartilage by 
means of these cells. In those cartilages 
where tenacity or flexibility is needed, this CARTILAGE, DISEASES OF 
CASTS 
279 
extends from the mucous or cutaneous sur- 
face, in which it originated, to the subjacent 
cartilage. 
6. The articular cartilages are liable to 
certain structural changes as the result of 
disturbed nutrition; and the fibro-cartilages 
are also subject to the same abnormal con- 
ditions. 
Ulceration, absorption, degeneration of 
cartilage, are terms used to denote a series 
of destructive changes which take place in 
the substance of articular cartilage, and lead 
to its partial or complete removal. These 
changes may originate in the cartilage itself, 
or they may be secondary to disease of the 
bone or synovial membrane; however this 
may be, the morbid action is the same, and 
consists in increased cell-development, with 
disintegration of the hyaline substance. 
According to the observations of Goodsir 
and Redfern, the cartilage-cells become en- 
larged, filled with nucleated corpuscles, and 
arranged irregularly; the distended cells 
then burst, and set free their contents upon 
the surface, or in the midst of the altered 
hyaline substance. Whilst the cell-changes 
are taking place, the matrix softens: in acute 
cases it rapidly disintegrates and is dis- 
charged ; but when the disease is more 
chronic, it splits up into fibres which remain 
attached by one end to the cartilage, and at 
the other project loosely into the interior of 
the joint, giving a villous appearance to the 
affected spot. The remains of the matrix 
and the granular contents of the cells 
together form a fibro-nucleated membrane, 
which ultimately is converted into fibrous 
tissue, and constitutes the sole medium of 
repair when a cure is effected. When this 
membrane is recent it has an indistinct 
granular appearance, from the presence of 
nuclei amongst the fibres, and according to 
Rainey these nuclei are often converted into 
fat-globules; when the membrane is of older 
date it is distinctly fibrous; and no doubt the 
several appearances which the membrane 
presents under different circumstances have 
led to the several terms fibrous, fatty, and 
granular degeneration being applied to this 
disease, in the belief that they were really 
distinct pathological conditions. 
Changes of this kind may be primary, as 
in osteo-arthritis, but they are commonly 
secondary to disease in the articular ends of 
the bones, the result of syphilis, tubercle, 
or injury. W. Mac Cormac. 
CASEOUS DEGENERATION.-A 
form of degeneration in which the pro- 
ducts present the appearance of cheese. See 
Degenerations. 
CASTS (derived from the Middle Eng- 
lish word casten, which is adapted from the 
Old Norse hasta, signifying to cast or throw). 
Synon. : Fr. Cylindres; Ger. Cylindern. 
Definition.-A term applied to moulds of 
gland-tubules and hollow viscera, thrown off 
in certain states of disease. 
Classification.-The varieties of casts met 
with may be thus grouped:- 
A.-Casts of Gland-Tubules. 
Blood-casts. 
Pus-casts. 
Hyaline casts. 
Granular casts. 
Epithelial casts. 
Fatty casts. 
I. Of the Uriniferous 
Tubules. 
II. Of the Seminal Tubules. 
III. Of the Gastric Tubules. 
IV. Of the Bile-ducts. 
V. Of the Cutaneous Glands. 
B. - Casts of Hollow Viscera and 
Passages. 
I. Of the Alimentary Canal. 
II. Of the Urinary Bladder. 
III. Of the Female Genital Pas- 
sages. 
IV. Of the Respiratory Passages. 
A.-Casts of Gland-Tubules. 
I. Of the Uriniferous Tubules.-Dr. 
F. Simon, of Berlin, is usually credited with 
having been the first to describe these bodies 
in his work on Medical Chemistry, published 
in 1842; but it appears that before then they 
had been noticed and described by Vogla in 
1837 and 1838, by Rayer in 1838, and by 
Nasse of Marburg in 1842. These observers, 
however, do not seem to have entered on the 
question of the origin, structure, or signifi- 
cance of these bodies, and for years they 
were looked upon rather as curiosities, and 
by some writers wrere wholly disregarded. 
Henle, in 1844, appears to have been 
the first to refer their origin to the co- 
agulable matter of the blood, but it was 
some time after that date before their value 
in the diagnosis and prognosis of renal dis- 
eases came to be appreciated. This result 
has been mainly effected in this country by 
the labours of Basham, Lionel Beale, George 
Johnson, William Roberts, Dickinson, and 
Grainger Stewart. 
Casts may be formed in any part of the 
kidney. They have been found in the con- 
voluted tubules even up to the Malpighian 
capsules, and also in the straight tubules. 
Various modifications in shape and contour 
probably occur in the course of their passage 
along the tubes, even to the inclusion of a 
small cast in one of larger size. 
Characters.-The urinary casts are mostly 
cylindrical in shape, frequently somewhat 
coiled and bent, and occasionally forked. 
Their length, depending very much on acci- 
dental circumstances, varies considerably. 
In sections of the kidney they may be oc- 
casionally traced for some distance in the 
tubules; but they become broken up into 
smaller pieces after leaving the gland. In 280 
CASTS 
diameter casts range between 7^^ and of 
an inch-the former being known as ' small,' 
the latter as ' large ' casts. The greater 
number are of a ' medium ' size of 7^ of 
an inch. The diameter of the casts is in 
part determined by the calibre of the tubule 
in which they are first formed, and in part 
by any subsequent additions they may receive 
in their passage outwards. Dr. Beale has 
suggested that after their formation the 
casts may probably shrink. In tubules 
that have become abnormally dilated or 
contracted, casts beyond the limits above 
mentioned may be found. 
The appearance of renal casts varies con- 
siderably, not only in different kidney- 
diseases, but also in various stages of the 
same affection. In all cases the cast consists 
of a solid cylinder of a transparent or very 
faintly granular substance, which is rarely 
fibrillated. It was formerly accepted that 
these bodies were produced by a coagulation 
of fibrin due to an escape of blood-plasma 
into the tubules, and hence they were known 
as ' exudation-cylinders '-a term still often 
employed. It is easy to understand the for- 
mation of casts in this manner, and it is cer- 
tain that such blood-casts do occur, whether 
as shreds of fibrin with abundance of blood- 
corpuscles in its meshes, or as casts consist- 
ing of little more than pure fibrin with its 
characteristic fibrillated appearance. In a 
similar manner pus-casts, so-called, may be 
produced. 
In most cases of renal disease, however, 
in which casts are found in the urine, these 
bodies usually appear as transparent and 
prevail as to the nature and source of these 
bodies ; and it is not improbable that, differ- 
ing in their composition, they may originate 
in either of the following ways :- 
(a) The coagulation of some proteid mate- 
rial, which has transuded from the blood- 
plasma into the tubules, the epithelial cells 
being unaffected, and, so far as is known, 
taking no share in the formation of the 
cast. Such may be called ' transudation 
cylinders' and masses of the coagulated 
substance are occasionally to be seen be- 
tween the epithelial cells and the membrana 
propria of the tubule. The exact nature of 
the material is unknown; as stated above, 
it is not ordinary fibrin, but is probably some 
proteid derivative which has been made to 
coagulate-perhaps, as has been suggested, 
by the acid urine, or by the gland-cells. 
(6) In contrast to the foregoing, it has been 
demonstrated that the living epithelium may, 
under certain conditions of irritation, as from 
cantharides, swell up, and, undergoing a form 
of colloid or mucoid degeneration, become 
transformed into clear transparent casts of 
the tubes, sometimes exhibiting a partial 
segmentation, indicative of their origin from 
several coalesced portions, or involving the 
remains of cells which have been only par- 
tially metamorphosed. To these the term 
'fusion cylinders ' has been applied. Or the 
cells; without being entirely converted into 
colloid matter, may appear to secrete drops 
of such material, which are moulded in the 
tubules into hyaline casts-the so-called 
* secretion cylinders.' Here, again, the actual 
nature of the cast-substance is unknown, 
though described as mucoid or colloid; and 
from the great variability in its behaviour to 
staining fluids and other reagents, it most 
probably differs much in composition. Oc- 
casionally some of the large waxy casts will 
give the characteristic reactions, with iodine 
or with methyl-violet, of lardacein; even, it 
is asserted, when the kidney itself offers no 
evidence of lardaceous change. 
Whatever may be the true explanation of 
their formation, they present themselves as 
semi-solid and somewhat viscid cylinders, 
readily entangling adjacent matter. Due to 
this property is much of the variety they 
offer; thus, should the epithelium of the 
tubules be loosened, as in nephritis, the 
Fig. 24.-Blood-Casts. 
faintly granular, tolerably uniform cylinders, 
frequently somewhat rounded at the extremi- 
ties, and often overlooked unless searched 
for with care. In them no sign^of fibrilla- 
tion is to be discerned, and they do not cor- 
Fig. 25.-Hyaline Casts. 
respond in their chemical behaviour to fibrin. 
These are the hyaline, transparent, or waxy 
casts, which may be large, small, or medium 
in diameter ; the largest and smallest casts 
met with belong to this variety. Several 
views, supported by experimental evidence, 
Fig. 26.-Epithelial Casts. 
cells will adhere to the cast which has been 
formed in the lumen of the tube, and an 
epithelial cast will be voided. Such casts 
may present but one or two cells on their CASTS 
281 
surface, or may appear as if consisting only 
of coherent epithelial cells. Should the cells 
cocytes produced by an abnormal prolifera- 
tion of the renal epithelium. 
Method of examination.- Samples of urine 
(three or four ounces) suspected to contain 
casts should be allowed to stand at least three 
hours (and longer if the urine be of very low 
specific gravity) in perfectly clean conical 
glasses, and a few drops should be removed 
from the bottom with a pipette, and covered 
in the usual way on a glass slide. They may 
be so abundant as to form a visible sediment 
in the glass. For all practical purposes a 
|-in. objective, giving with the eye-piece a 
magnifying power of about 850 diameteis. 
is sufficient. The hyaline casts are often so 
transparent as to escape any but the most 
careful observation, and then a little dilute 
staining fluid, introduced beneath the cover- 
glass, much facilitates their detection; cut- 
ting off some of the transmitted light has a 
similar effect. It is to be remembered that 
casts retain their characteristics far better in 
acid than in alkaline urine ; in the latter 
they are very apt to break up and disappear. 
As a rule there is no mistaking a renal tube- 
cast, but occasionally a transparent or granu- 
lar streak may be noticed, the nature of 
which cannot be positively stated; shreds 
of mucus, especially when mixed up with 
granular matter, are the commonest objects 
which simulate casts, and are not infrequent 
in disease of the bladder or prostate ; their 
disappearance on the application of liquor 
potassae and a little heat to the slide deter- 
mines their character. 
Clinical Significance.-Valuable as is 
the evidence of the changes in the renal 
epithelium afforded by the detection of these 
bodies in the urine, their recognition and 
comprehension is nevertheless but one of the 
means to be employed in the study of kidney 
diseases. Of themselves they afford infor- 
mation, rarely, if ever, conclusive when taken 
alone. Without doubt certain renal diseases 
may exist, and may continue throughout their 
course, either to recovery or death, without 
the occurrence of casts in the urine ; and, on 
the contrary, casts may be found entirely 
independent of renal disease. But for all 
practical purposes it may be accepted that 
when casts do occur, they generally indicate 
the existence of a disease of the kidneys which 
is possibly incurable, certainly serious. With 
our present knowledge of the conditions 
under which they are found, it would appear 
that their presence in the urine does not 
necessarily imply the existence of an inflam- 
matory state of the kidney, for they may 
accompany simple congestion, the gland sub- 
stance being intact; but doubtless in the 
majority of cases they are evidence of a 
nephritis, acute or chronic, and the subse- 
quent associated degeneration. Besides the 
value of casts in determining the existence 
of kidney-disease, they are further most im- 
portant aids in helping to distinguish what 
Fig. 27.-Fatty Casts. 
have undergone fatty degeneration, the cast 
will be pervaded with oil-globules of all sizes, 
more or less escaped from epithelial cells, 
according to the extent of the degeneration ; 
this constitutes & fatty cast. Very frequently 
the casts are finely or coarsely granular, this 
appearance being produced by the involve- 
Fig. 28.-Granular Casts. 
ment in the base-substance of granular matter 
derived from broken-down epithelial cells or 
blood-corpuscles, molecular fatty matter, 
amorphous urinary salts, or micro-organisms. 
Granular casts may exhibit a faint yellowish 
Fig. 29.-Casts enclosing crystals ; and a smaller 
cast; also of seminal tubule with spermatozoa. 
or brownish tint depending on their constitu- 
tion. In a similar way casts may be found 
containing crystals of oxalates, triple phos- 
phates, haematoidin, salts of fatty acids, &c. 
It is very commonly the case that more 
than one variety of cast occurs in the same 
urine-epithelial and hyaline, or granular and 
fatty, often co-existing. Corresponding to 
the casts in the urine, free epithelial cells, 
blood - corpuscles, fat - globules, and salts, 
amorphous or crystalline, are always found, 
and almost always albumin, though not of 
necessity is there any correspondence in the 
quantity of this substance and the number 
of casts. The epithelial cells, whether free 
or on the cast, are rarely quite normal in 
appearance. The pathological changes asso- 
ciated with their desquamation have at the 
same time altered them more or less. Not 
infrequently the cells of an epithelial cast 
present all the microscopic characters of leu- 282 
variety or stage of disease it may be, and also 
in making out the actual condition of the 
kidney, thus furnishing valuable data on 
which to form a prognosis, and to suggest a 
plan of treatment. Little is to be concluded, 
however, from one examination. This should 
be performed frequently, as in that way alone 
can the morbid progress in the kidney be 
recognised. 
From what has been said of the nature of 
casts, it should be expected that several varie- 
ties of these bodies occur at the same time in 
the urine. It is rare for any variety to exist 
singly, at least for any time. In such cases 
their significance is ascertained by careful 
study of coincident circumstances, and es- 
pecially by a frequent comparison, in order 
to determine which variety is in excess. 
The fact that casts are very abundant in 
any sample of urine is not in itself of neces- 
sity a serious sign. Thus in ' granular kid- 
ney '-one of the most serious of all renal 
affections-the casts may be, and usually are 
very few, and require careful looking for; 
whilst in the convalescence from acute neph- 
ritis they may be extremely numerous. In 
chronic nephritis, however, the number be- 
comes an important element in the con- 
sideration. 
Blood-casts are diagnostic of haemorrhage 
into the tubules, whether that be due to 
•wounds of the organ, or to intense arterial 
hyperaemia or venous congestion-causing 
escape of blood from the capillaries of the 
glomeruli. 
Pus-casts may indicate the bursting of a 
renal abscess into the tubes, and coagulation 
of the escaped pus; or a diffuse suppuration 
of the gland substance. 
Hyaline casts.-The large forms of this 
variety chiefly occur in chronic nephritis, 
and are therefore usually a grave sign. Pro- 
duced in tubules which have been denuded 
of their epithelium, or in others that have 
become dilated from contractions in the 
intertubular substance, they indicate an ad- 
vanced condition of disease. Exceptions to 
this do occur, and large hyaline casts may be 
found in acute and curable cases. 
Small hyaline casts are formed in both 
acute and chronic forms of renal disease. 
They therefore become valuable as means of 
diagnosis only in conjunction with other signs, 
such as the history of the case, the character 
of the other urinary sediments, &c. They 
are frequently seen in acute nephritis, par- 
ticularly in the later stages of the disease, 
and are then formed in tubes which have not 
been stripped of their epithelial lining. In 
simple congestion of the kidney they may be 
formed from a coagulation of tbe fibrin of the 
effused plasma. When associated with the 
large variety they usually indicate a chronic 
and advanced stage, being then found in 
tubules that have become contracted. These 
two varieties of hyaline casts are common in 
CASTS 
the lardaceous kidney, and similar casts have 
been met with in the tubules in cases of 
diphtheria. 
Granular casts.-The significance of these 
is very variable. As has been said, the 
granular casts differ much in nature, and no 
positive diagnosis can be made upon them 
alone. They may occur in conjunction with 
blood-casts where the corpuscles have broken 
down, and will then generally indicate a 
commencing recovery from an acute stage. 
A similar interpretation may sometimes be 
put on casts whose granulation is due to fat- 
molecules resulting from the degeneration of 
inflammatory products. Large, dark, and 
coarsely granular casts are more particularly 
noticed in ' granular kidney,' where indeed 
they may be the only casts found. In such 
circumstances they become a very serious 
sign. In the later stages of chronic nephritis 
the epithelial cells disintegrate and produce 
granular casts. 
Casts consisting of micro-organisms en- 
tangled in a basic substance have been met 
with in septic affections of the kidney. They 
are for the most part distinguishable from 
other ' granular casts ' by their resistance to 
such reagents as nitric acid and liquor 
potassae, which dissolve up mineral granular 
matter. 
Epithelial casts.-These are more especi- 
ally met with in the earlier stages of neph- 
ritis during active proliferation, and their 
significance much depends on the character 
of the epithelium cells, which may differ but 
slightly from the normal, or may be so 
altered as to resemble leucocytes in appear- 
ance, or they may be loaded with fat. They 
may be very abundant at first; later on, 
when the hyaline variety appears in the 
urine, becoming less numerous. 
Fatty casts.-Probably no casts are so 
general in their occurrence as the fatty. Their 
presence may be of the gravest import, or 
they may betoken commencing recovery, and 
more than any, therefore, must they be con- 
sidered in connexion with other circum- 
stances. The casts that are found in the 
later stages of acute nephritis during con- 
valescence are in part fatty. The inflamma- 
tory products undergoing this degeneration 
are those thrown off. Hyaline casts, both 
large and small, frequently present a few oil- 
globules on their surface. In certain forms 
of chronic nephritis the casts may appear 
as if made up of oil-globules only. In such 
case an advanced stage of fatty degenera- 
tion of the gland is distinctly indicated, and 
the persistence of fatty casts is generally 
taken to signify the same; though such casts 
have been known to continue in numbers 
for some weeks, and to be followed by re- 
covery. 
Casts in non-albuminous urine.-The oc- 
currence of renal tube-casts in such urine is 
now well recognised, being chiefly met with CASTS 
283 
in cases of prolonged jaundice, lithuria, oxal- 
uria, diabetes, and more rarely after very 
severe exercise. They are of the hyaline 
variety, and probably owe their origin to the 
epithelial cells rather than to the escape of 
any material from the blood, but their patho- 
genesis cannot be regarded as being under- 
stood. Their entire independence of albu- 
minuria should not be too readily assumed, 
for, apart from the fact that this condition 
may only exist to such a very slight degree 
as might be overlooked, it may be that the 
presence of albumen is intermittent, the 
casts being voided in the intervals. 
Cylindroids is a term given to certain 
spurious casts of a long, flattened, filamentous 
character which have been found in the urine 
of scarlet fever and cholera patients, also, it 
is said, more frequently in children. Whether 
they are renal in origin is very uncertain, 
and albuminuria does not always accompany 
them. 
II. Of the Seminal Tubules.-Dr. 
Beale has pointed out the occasional exist- 
ence in urine of casts containing spermatozoa 
(see fig. 29). The base-substance of these 
bodies is a viscid tenacious mucus, and they 
are usually much larger than the casts 
derived from the uriniferous tubules. They 
have not been found associated with inflam- 
matory conditions of the testicle, and do not 
correspond pathologically to the renal casts 
just described. 
III. Of the Gastric Tubules.-In in- 
flammation of the gastric mucous membrane, 
especially in scarlet fever, a desquamation of 
the epithelial coat involving the glands has 
been noticed. The casts of the follicles have 
been found in the vomit, and more abundantly 
in the contents of the stomach post mortem. 
Their length is variable, and in width they 
range from to tiAut °f an inch. The 
base-substance is described as fibrinous, and 
is covered more or less completely by altered 
epithelial cells and granular debris. 
IV. Of the Biliary Ducts.-In the 
centre of gall-stones there have been found 
long, hair-like threads, often branched, and 
generally under of an inch in diameter, 
consisting of mucus, inspissated bile, and 
epithelium, which have been regarded as 
casts of the smaller biliary tubes. 
V. Of the Cutaneous Glands.-In 
the various skin-affections which are asso- 
ciated with desquamation of the cuticle, casts 
of varying length, coming from the sweat- 
and sebaceous glands, are thrown off as part 
of the general shedding of the epidermis. 
Such bodies are hollow tubes, and bear no 
resemblance to the renal casts in nephritis. 
B.-Casts of Hollow Viscera and 
Passages. 
From time to time, more or less perfect 
casts of these organs are met with. The con- 
ditions which determine their occurrence are 
but imperfectly understood ; they are in most 
cases associated with inflammation of the 
surfaces from which they are thrown off, 
especially with those forms of inflammation 
accompanied by the formation of false mem- 
brane, croupous or diphtheritic. A mere 
catarrhal inflammation, provided the result- 
ing mucus be sufficiently viscid and coherent, 
may entangle the proliferated epithelium, and 
be detached as more or less complete casts of 
the surface. 
I. Of the Alimentary Canal.-Solid 
casts of the tonsillar crypts and branches 
consisting of inflammatory products, are oc- 
casionally expectorated in follicular tonsillitis 
and diphtheria. 
Muco-cellular casts of several inches in 
length, and more or less perfect, have been 
met with from the oesophagus, and more 
rarely pieces have been detected in vomit as 
coming from the stomach. Casts of portions 
of the gullet formed of dense masses of aphthae 
have also been described. More frequently 
seen are intestinal casts-indeed, small floc- 
culent pieces from the surface of the colon 
are far from uncommon, especially in associa- 
tion with chronic constipation. These also 
consist of viscid mucus and epithelial cells, 
matted into tough, coherent pseudo-mem- 
branes, often forming complete hollow moulds 
of the tube, large or small, and varying in 
length from a few inches to several feet; they 
have been observed to be solid cylinders of 
jelly-like mucus and embedded cells. Occa- 
sionally they retain on their surface the im- 
pression of the follicles, sacculations, and other 
inequalities of the intestinal surface. See 
Path. Soc. Trans., vols. ix. and xxiii.; Brit. 
Med. Joum. 1887, pp. 617 and 832. 
II. Of the Urinary Bladder.-A com- 
plete exfoliation of the mucous membrane of 
the bladder has been occasionally observed in 
puerperal women. It does not appear to be 
always the result of inflammation, and though 
the detachment may be complete, perfect re- 
covery may follow. In structure such bodies 
consist of epithelial cells in varying stages of 
degeneration, felted together by mucus and 
fine granular material. The surface is fre- 
quently thickly coated with urinary salts. 
The conditions giving rise to their formation 
are quite unknown, though retention of urine 
is associated with their occurrence. 
III. Of the Female Genital Passages. 
Casts of the uterus and vagina have been 
frequently noticed. The latter occur as hollow 
moulds of the canal, more or less complete, 
and consisting of layers of epithelium cohering 
by a tough mucus. They have been known 
to follow astringent injections. Partial casts 
of the vagina formed of diphtheritic mem- 
brane have also been seen. 
Uterine casts are of commoner occurrence, 
and are of various kinds. Exclusive of solid 
moulds of the cavity formed of coagulated 
blood, the states of pregnancy and menstrua- CASTS 
CATALEPSY 
284 
tion are each liable to give rise to the forma- 
tion of membranous casts of the surface, 
complete or partial, and usually accompanied 
by much pain in their extrusion (mem- 
branous dysmenorrhcea). The menstrual cast 
is rarely entire, and is usually about one and 
a-half inches long, and one-twelfth of an inch 
thick, of a translucent appearance, and con- 
sists of the decidua ordinarily shed at the 
period, but of greater consistency than normal. 
It may be that the cast passed at any one time 
is the product of a previous menstrual period. 
The cast expelled in extra-uterine pregnancy 
is much larger and thicker, appearing as a 
triangular bag with orifices at the angles cor- 
responding to the openings of the Fallopian 
tubes and cervix ; externally the bag is rough 
and shaggy, but on the inside it is smooth, 
and shows the orifices of the uterine glands. 
IV. Of the Respiratory Passages.- 
The mucous membrane of the respiratory 
tract is remarkably prone to those forms of 
inflammation which are distinguished by the 
production of considerable quantities of new 
material highly coagulable in character, to 
which the terms croupous and diphtheritic 
are applied. Of such material are the different 
forms of casts of the air-passages composed, 
the products of simple catarrhal inflammation 
never being sufficiently coherent to retain the 
shape of the surface from which they are de- 
rived. In these conditions the epithelium of 
the mucous membrane comes to be replaced 
by a layer of material derived from the meta- 
morphosed epithelial cells, with a variable 
amount of coagulated fibrin formed from the 
effused blood-plasma. Such false membrane 
appears under the microscope to be made up 
of interlacing fibres of a clear homogeneous- 
looking substance, felted together in all direc- 
tions, and containing in the meshes leucocytes, 
altered epithelial cells, blood-corpuscles, and 
a small quantity of serum. It is easy to 
understand that the extent to which the 
materials constituting this membrane infil- 
trate the deeper layers of the mucous mem- 
brane must vary considerably; yet on the 
extent of infiltration, and consequent adher- 
ence, depends in great part the distinction be- 
tween croupous and diphtheritic exudation. 
More important is the difference in the changes 
which occur in the epithelial cells in these 
two conditions. In the diphtheritic they are 
far more profoundly altered, undergoing a 
process of necrosis and fusion into a mass of 
coagulated tissue, filaments of fibrin and leu- 
cocytes infiltrating the subjacent parts. In 
the croupous state the epithelium, though de- 
generating, is far less changed, and the cells 
desquamate more freely. False membranes 
thus formed are loosened by the effusion of 
serum beneath them, and subsequently ex- 
pelled in shreds or as entire casts. 
In the larynx and trachea, the new material 
forms more or less complete layers, covering 
the vocal cords, dipping into the ventricles, 
and even blocking up the laryngeal cavity 
completely. Occasionally a cast of the whole 
length of the trachea, and part of a main 
bronchus, may be expectorated. 
When this inflammatory product originates 
in the bronchial tubes, it forms the so-called 
bronchial polypi, so characteristic of plastic 
bronchitis. It is rare foi' more than very 
limited areas of the air-passages to be so 
affected, but within these areas perfect casts 
of the entire extent from trachea to alveoli 
may be obtained. Expectorated as irregular, 
rolled-up, and twisted masses, they are cap- 
able of being shaken out in water into rami- 
fying whitish or pinky white moulds of the 
tubes, varying in length from one and a half 
to six or seven inches, and of a maximum dia- 
meter of half an inch, often with swollen ends 
corresponding to the infundibula. They are 
either hollow and membranous, or solid, and 
in the latter case frequently present indica- 
tions of being made up of concentric layers. 
Sometimes only one of these casts may be 
expectorated, especially if a large one; at 
other times they may be re-formed again and 
again, and large quantities may be coughed up 
daily. Microscopically they consist of altered 
epithelial cells, leucocytes, red corpuscles, fat- 
globules, and very rarely octahedral crystals, 
entangled in a fibrillar or granular base-sub- 
stance. Similar casts of the smallest tubes 
are exceptionally found in the expectoration 
of acute croupous pneumonia, but are com- 
monly to be found in situ on post-mortem 
examination. W. H. Allchin. 
CATALEPSY (xaraX^tr, a seizure).- 
Synon. : Fr. Catalepsie; Ger. Starrsucht. 
Definition.-A disease of the nervous, sys- 
tem, characterised by attacks of powerless- 
ness, commonly with loss of consciousness, 
and accompanied by a peculiar form of mus- 
cular rigidity, in which the limbs remain for 
a time in the position in which they are 
placed by passive movement. On account of 
the trance-like state which exists in the 
attack, the name is sometimes applied to 
simple trance, but should be restricted to the 
condition in which there is the peculiar state 
of the muscular system. The origin of the 
name is connected with the old spiritualistic 
pathology, which referred such sudden states 
to the action of an immaterial agency, and 
recognised as such only some immaterial 
agent of personal nature. 
.Etiology.-Catalepsy may occur at all 
ages between six and sixty years, and in both 
sexes, but it is incomparably more frequent 
in the female sex and in early adult life, at 
or soon after puberty. It is, in the maj ority 
of cases, associated with distinct evidence of 
hysteria. In other cases, in which no hysteri- 
cal symptoms have preceded it, the affection 
may be traced to such exciting causes as give 
rise to the hysterical paroxysm. Nervous 
exhaustion is the common predisponent; and CATALEPSY 
285 
emotional disturbance, especially religious 
excitement, or sudden alarm, or blows on 
the head and back, are frequent immediate 
causes. It occasionally appears in the course 
of mental affections, especially melancholia, 
and is said to occur as an early symptom 
of epilepsy, but it is much more likely that 
the fits thought to be epileptic were really 
hysteroid. In an imperfect form it has ap- 
peared to be due, in some cases, to paludal 
poisoning or to other toxaemic states, as 
chloroform-narcosis. In a few instances men- 
ingitis, and other organic cerebral or spinal 
diseases, have caused a cataleptoid condition; 
but these cases are too rare and diverse to 
allow of any inference from them. 
Symptoms.-Catalepsy is usually paroxys- 
mal, attacks lasting hours or days being 
separated by periods of freedom; less com- 
monly a single prolonged attack constitutes 
the whole affection. In some cases head- 
ache, giddiness, or hiccough has preceded 
the attack. The onset of the special symp- 
toms is usually sudden, commonly with loss 
of consciousness. The whole or part of the 
muscular system passes into a state of 
rigidity. The limbs remain in the position 
they occupied at the onset, as if petrified. 
The muscular rigidity is at first considerable, 
and movement is resisted ; but after a short 
time the limbs can be moved, and then re- 
main in the position in which they may be 
placed. The resistance to passive movement 
is peculiar : it is as if the limbs were made of 
wax, and hence the condition has been termed 
flexibilitas cerea. The rigidity commonly 
yields slowly to gravitation. The counte- 
nance is usually expressionless. The respi- 
ratory movements and heart's action are 
weakened. Substances placed in the back 
of the mouth are swallowed, but slowly. 
The state of sensibility varies; in profound 
conditions of catalepsy it is lost to touch, 
pain, and electricity, and no reflex move- 
ments can be induced even by touching the 
conjunctiva, a state of mental trance being 
associated. In other cases partial sensibility 
remains, and reflex phenomena may be ex- 
cited. In rare instances hyperaesthesia is 
present. In induced catalepsy there is often 
a peculiar local exaltation of reflex action, 
so that stroking the skin over a superficial 
muscle causes an increased contraction of 
it. This involves a change of posture, in 
consequence of a definite sensory impres- 
sion, and an analogous effect may be pro- 
duced through the special senses, especially 
hearing ; if a ticking watch be brought near 
the subject's ear, the posture is changed with 
a start, the head turned towards the object, 
and the eyes, if previously closed, may be 
opened, although the cataleptic condition 
continues as before. Consciousness, although 
usually lost, may remain, but it is seldom 
intact, being generally in an obscured condi- 
tion. The temperature is commonly lowered 
in a long seizure. The attack may last a 
few minutes or several hours. Recovery is 
gradual or sudden; sometimes the patient 
at first is unable to speak. A sudden respira- 
tory stimulus-such as blowing on the face- 
will often terminate an attack of induced 
catalepsy. Sometimes a strange periodicity 
may be observed in the occurrence of the 
paroxysms. In the intervals between the 
attacks, headache, giddiness, or hysterical 
manifestations may be present, or the patient 
may feel and seem perfectly well. 
Pathology.-Concerning the nature of the 
disease there has been much speculation, but 
little definite knowledge. It may probably 
be placed between epilepsy and hysteria in 
the scale of maladies, but nearer the latter 
than the former, and as regards the nature 
of its chief feature, it may be regarded as es- 
sentially one of the motor. But there is also 
distinct interference with the intellectual 
processes, and interruption of the connexion 
between the will and the motor centres. 
To say this is only to express obvious 
facts in general terms, and affords no expla- 
nation of them. A careful consideration of 
their nature may give us at least the mate- 
rial for thought on the subject. The wax-like 
rigidity is an excess of the action by which 
muscles are constantly adapted to posture, i.e. 
to the distance between their attachments, 
and yet preserve the same degree of physio- 
logical tone. This is effected by a reflex 
process, the afferent impulse for which pro- 
bably comes from the afferent muscle nerves, 
and is generated by the sum of the related 
tension and compression of the interstitial 
tissue in which these nerves begin. The 
motor cells (and therefore the muscular 
fibres) are active in inverse proportion to 
these impulses, and so the opponents of a 
passive movement relax, the muscles shorten 
that correspond to it in their action; they are 
thus adapted to posture, and, if this process 
is in excess, the cataleptic rigidity must of 
necessity ensue. But it is probable, on many 
grounds, that the afferent impulses from the 
muscles have a double action-a lower on the 
motor centres of the spinal cord, and a higher, 
through the cerebellum, on the motor centres 
of the cortex cerebri. The phenomena suggest 
that the action is similar on each; since the 
cortical cells govern the spinal cells, their 
functional states must be in related corre- 
spondence. Thus the afferent impulses that 
regulate adaptation to posture must do this 
through both cortical and spinal centres 
simultaneously. The excessive action of 
catalepsy may be in the cortical and not in 
the spinal mechanism. This would enable 
us to understand the otherwise strange fact, 
that the cataleptic state may be induced by 
influences acting on the brain, as in the 
induced catalepsy of hysteria. The motor 
cortical centres, whence the pyramidal fibres 
proceed, are probably the lowest of the centres 286 
CATALEPSY 
of the cortex ; the induction of catalepsy may 
consist simply in the inhibition of higher 
centres that act on and through them and 
normally restrain them. The over-action of 
these entails the over-action of the spinal 
centres, and the wax-like rigidity results. 
Thus, too, we can understand that conscious- 
ness should be lost or strangely changed 
during the attack, and its relation to emotion 
as a cause. So, too, it is clear that every 
forced change of posture will leave the con- 
dition of the centres essentially unchanged, 
although there will be a slightly different 
distribution of activity. Arrest the inhibition 
which prevents the higher cortical centre 
from acting on the lower, and the resumed 
control involves restraint of the over-action 
of the latter and of the spinal centre, and 
the cataleptic state is at an end. 
Diagnosis.-The peculiar rigidity of cata- 
lepsy is characteristic, invariable, and renders 
the diagnosis a simple matter. Hysteria 
with tonic spasm has been erroneously 
termed catalepsy, but is distinguished by the 
local position of the spasm, and the fact that 
it does not yield to passive force. The malady 
most likely to be confounded with catalepsy 
is tetany, since in it there are attacks of tonic 
spasm involving all the limbs. But in this 
the rigidity is fixed; it cannot be overcome, 
and the posture of the limbs changed; while 
the hands are in a characteristic posture, 
with the fingers straightened at the middle 
joints, and their points and that of the thumb 
brought together. The condition is some- 
times simulated: in true catalepsy the rigid 
limb slowly yields to the influence of gravi- 
tation, and more rapidly if a weight be 
attached to it; in the feigned form the limb 
and weight are held firm. 
Prognosis.-The prognosis is favourable 
in simple catalepsy, in proportion to the 
freedom of the intervals from affections of 
sensibility or motion. In pronounced hysteria 
and psychical affections the condition is 
often obstinate ; and, by interfering with the 
due nourishment of the system, may cause 
grave inanition. 
Treatment.-During the attack itself little 
can be done save an attempt, which may be 
repeated at intervals, to rouse consciousness 
by external stimulation. The ordinary ap- 
plications-ammonia to the nostrils, cold 
douches, &c.-often fail in the spontaneous 
form, but this does not hold true of most cases 
of induced catalepsy, in which any stimulus 
that excites a respiratory effort commonly 
arouses the patient and cuts short the at- 
tack. A pinch of snuff will, however, often 
succeed in both varieties. Another effectual 
stimulant is faradisation. It may be ap- 
plied to a limb or to the cervical spine. 
The current should be gentle at first, and 
gradually increased. Emetics are also use- 
ful in arresting an attack. Injections of 
tartar emetic into the veins have been used 
with success by Calvi, but can hardly be 
recommended. The writer has found sub- 
cutaneous injection of apomorphine, to 
1*5 of a grain, an efficient remedy for similar 
paroxysmal conditions; with the onset of 
nausea, about five minutes after the injection, 
consciousness is regained, and all spasm 
ceases. In the intervals between the attacks 
the treatment is that of hysteria. Iron, 
antispasmodics, especially valerian, aloetic 
aperients, and cold baths, are the most 
effectual measures. Firm moral treatment 
is also indispensable. Removal from home 
influences is often necessary to effect a cure. 
W. R. Gowers. 
CATAMENIA, Disorders of.-See 
Menstruation, Disorders of. 
CATAPLASM (Kara, down ; and 7rXd<r<ra>, 
I mould or smear).-A synonym for a poul- 
tice. See Poultice. 
CATARACT.- Derivation and Syn- 
onyms.-Earlier Greek : y\avnuxns (Hippoc.), 
y\avKa>pa (Aristot.) ; Later: viroyvpa and 
vnoxvais; Latin : Suffusio (Celsus); Arabic : 
elma enndzil (descended water or humour) ; 
Mediaeval Latin translators, Aqua in oculum 
descendens; Descensus Aquce ; also Cataracta 
(allied to Greek KarappaKTq^, used at first 
in the sense of an obstruction or obstacle, 
like a floodgate, a portcullis, an obscuration 
such as that of the sun by a cloud. Fr. 
Cataracte ; Ger. Staar. 
Definition.-Cataract is an opacity, partial 
or complete, of the substance of the crystal- 
line lens, or of its capsule. The former is 
called lenticular, the latter capsular. Either 
may exist separately, or the two may occur 
together, to form capsulo-lenticular. From 
a surgical point of view it is sometimes 
necessary to embrace within the definition of 
cataract some extra-capsular opacities, such 
as inflammatory deposits, or the remains of 
embryonic structures within the pupillary 
area of the anterior or of the posterior layer 
of the capsule. Such opacities are called 
false cataracts. 
Anatomy and Physiology.-The nature 
and origin of cataract can only be made in- 
telligible by reference to the anatomy, em- 
bryology, and physiology of the crystalline 
lens. 
Anatomy.-The lens consists of three parts: 
first, the substance of the lens, which is made 
up of fine, flattened fibres; second, a layer of 
endothelium lining the anterior part of the 
capsule; and, third, the capsule, which, 
as a bag, surrounds and encloses the lens- 
substance and the endothelium. The fibrous 
portion of the lens consists of a harder, cen- 
tral part, or nucleus, and a softer external 
portion, or cortex. The cortex is disposed 
around the nucleus in thin, concentric layers, 
each of which is subdivided into sectors. 
Within the sectors the fibres lie with their 
CATARACT CATARACT 
287 
ends at the edges of the sectors, and each 
sector has two of its edges towards the 
anterior, and two towards the posterior sur- 
faces of the lens. The apposition of the edges 
of the adjoining sectors leaves fine radiat- 
ing fissures, which make up the rays of the 
stella existing at the anterior as well as at 
the posterior surface of the lens. The fibres 
of the lens are softest at their ends, where 
they abut on the rays of the stellae. The 
endothelium consists of a single layer of 
nucleated and nucleolated cells, and is usually 
limited to the anterior capsule. Towards the 
margin or equator of the lens these cells 
accumulate, elongate, and become gradually 
transformed into lens-fibres. Fine channels, 
occupied by lymph and other fluids, exist 
between the endothelium and the capsule, 
and between the endothelium and the an- 
terior layers of the cortex, passing thence 
through the rays of the stellae into the sub- 
stance of the lens and between its several 
layers. The capsule, which is elastic and 
transparent, consists of two layers, a delicate 
inner one and a stronger outer one, which is 
further strengthened by prolongations of the 
suspensory ligament-the zonula of Zinn. 
Embryology.-The ancestry and mode of 
origin of the several parts of the lens deter- 
mine the peculiarities not only of the normal 
nutrition of the lens, but also of its pathological 
departures. The lens-fibres and the endothe- 
lium are descended from the external layer of 
the blastoderm-the epiblast, and are, there- 
fore, immediately related to the cuticular tis- 
sues, including the enamel of the teeth and the 
epithelium of the sense-organs, and more re- 
motely to the cerebro-spinal system. As will 
be seen later, this common origin from a primi- 
tive stock of epiblastic elements throws light 
upon many of the pathological associations 
of congenital and other cataracts. According 
to recent researches, the capsule of the lens 
seems to have a double origin, the inner layer 
being derived by a process of cuticularisation 
from the lens-substance, while the outer is the 
offspring of the mesoblastic elements from 
which the foetal capsulo-pupillary sac, the 
vitreous, choroid, and intra-ocular blood- 
vessels are derived. Hereby the capsule is 
in direct histogenic relations with the bones, 
muscles, blood-vessels, and other fibro-vas- 
cular tissues derived from the middle layer 
of the blastoderm. These relations may also 
determine pathological manifestations in the 
capsule, and through its intermedium within 
the lens-substance itself. 
Growth.-The foetal crystalline lens is 
somewhat globular in shape, and its fibres 
have an antero-posterior disposition. But 
during later intra-uterine life, and still more 
after birth, the lens alters its shape, becoming 
broader and relatively flatter. It grows by 
the apposition of lens-fibres upon the nucleus, 
chiefly about the equator. The fibres them- 
selves are derived from the endothelial cells 
lining the anterior capsule. These cells 
proliferate and gradually shift towards the 
equator, where they accumulate, and, as 
already stated, become transformed into 
fibres. The fibres bend round the equator, 
and spread out in front and behind, so as 
gradually to encase and push towards the 
centre the older underlying layers. The 
growth of the lens continues throughout life, 
and does not, in health, cease with the at- 
tainment of adult life. Priestley Smith has 
found that the volume of the lens increases 
through life at the rate of about 1'5 cubic 
mm. each year (Trans. Ophthal. Soc., vol. iii. 
p. 79). 
Nutrition.-The crystalline lens, being a 
non-vascular body, is nourished by imbibition 
from surrounding fluids, which are chiefly 
furnished by the ciliary body, though this 
source is supplemented by contributions from 
the choroid, the iris, and perhaps the retina. 
It is probable that these fluids are modified 
by their passage through the vitreous. It 
is- not known exactly how or where these 
fluids gain access to the lens-substance, but 
it is evident that they pass through the 
capsule, and that in the passage they undergo 
some alteration; for if the anterior or the pos- 
terior capsule be ruptured, the lens becomes 
opaque. The surrounding fluids then come 
into immediate contact with the fibres of the 
lens, and being unmodified by the dialytic 
properties of the capsule, or the elaborating 
influences of the endothelium, they are un- 
suited for the purposes of normal nutrition. 
In health, after the nutritive fluids have 
made their way through the capsule, they 
pass from the periphery to the centre through 
the stellate clefts and other channels which 
exist throughout the lens. In this respect 
the lens differs from other cuticular struc- 
tures, in which waste products are shed from 
the surface; while in the lens waste products 
are apparently driven inwards to the centre, 
to undergo elimination in a manner not yet 
fully understood. 
The nutritive activity of the lens, as mani- 
fested by the number of nuclei, is appa- 
rently greatest at the equator, and it is at 
this point, between the layers of the suspen- 
sory ligament, that the capsule is in most 
immediate contact with the ambient fluids. 
Many authorities believe that the nutritive 
fluids enter the lens chiefly, if not entirely, at 
this place, and that this region is the principal 
seat of cell-growth. There are, however, 
reasons for thinking that neither endosmosis 
nor cell-proliferation is most active here. In 
some diseases of the choroid or of the retina 
on the one hand, and of the iris or of the 
cornea on the other, opacities of the lens 
first manifest themselves not at the equator, 
but at the posterior or the anterior surface 
respectively, that is at that part of the lens 
which is nearest to the diseased structures, 
and which bears the brunt of the morbidly 288 
altered fluids. A typical example is the for- 
mation of posterior polar or stellar cataract 
in retinitis pigmentosa. Moreover, micro- 
scopical examinations of cataractous lenses 
often disclose proliferation and accumulation 
of yuclei behind the anterior capsule, and 
even within the posterior capsule, without 
corresponding increase at the equator. 
Beyond increasing in size, the lens does not, 
in health, undergo much change till after 
middle life. Thenceforth the fibres gradually 
assume a yellowish or brownish tint, and 
the rate of formation of new fibres diminishes. 
As age advances the fibres become drier, 
harder, and less elastic, and the capsule 
thickens. If a senile lens be ophthalmosco- 
pically examined with a strong magnifying- 
glass, semi-translucent lines, flaws, spaces, 
and vacuoles, and fine, dusty films, may 
often be discovered, even when there are no 
coarse physical opacities. These phenomena 
are due to shrinking of the lens-fibres and 
loosening of the lamellae from one another, 
with accumulation of fluid and lens-debris in 
the spaces thus formed. Still later, separation 
of the cortex may take place, both from the 
nucleus and from the capsule. The separa- 
tion from the capsule is, as Becker has shown, 
especially liable to occur at that part of the 
capsule which is most acted upon by the 
suspensory ligament during accommodation. 
Increase and extension of the changes even- 
tuate in opacity, and the occurrence of senile 
cataract. These senile changes have their 
analogues in the skin and its appendages. 
The skin of old people is wrinkled, the cuticle 
becomes dry and harsh and shrivelled, and 
the hair thin and white. 
Pathology.-A lens of good ancestry and 
of good constitution continues to be trans- 
parent so long as the conditions and processes 
of nutrition are normal; but any fault in the 
original constitution of the lens, or any defect 
in the embryonic process, or any alteration 
in its nutrition at any subsequent period, will, 
sooner or later, and in proportion to the de- 
gree of divergence from the healthy standard, 
induce opacity of some portion of the lens or 
of its capsule. 
The chief embryonic abnormalities are 
(1) inherent faults of the epiblastic cells 
which constitute the rudimentary lens. The 
fibro-cellular portions of the lens fail to 
undergo proper evolution, and either do not 
become transparent, or, if they do clear, their 
potentiality is low, and they soon retro- 
grade. The lens is often undergrown as well 
as opaque, and is not infrequently malposed. 
Sometimes the eyeball itself is small (mi- 
crophthalmia). Even if the lens do attain 
its natural proportions, the new cortical sub- 
stance is generally of inferior quality, because 
the endothelium, which furnishes the cortical 
substance, shares the same faults as the nu- 
cleus itself. Hence the whole lens is either 
opaque from the beginning (congenital cata- 
CATARACT 
ract), or becomes opaque within a few 
months or years (infantile or juvenile cata- 
ract). (2) Owing to causes which may be 
peculiar to the lens, or which may affect the 
whole of the growing organism, or which 
may operate indirectly through so-called 
maternal influences, a temporary or perma- 
nent disturbance may occur during intra- 
uterine life to thwart the development of a 
lens. If the interference be violent its effects 
may be permanent, so that the whole of the 
lens becomes opaque, even though it may 
continue to increase in bulk. If the check 
be of a temporary character, only a thin 
layer of opacity may be produced: natural 
development re-asserts itself, and transparent 
cortical fibres are produced in the ordinary 
way. The nucleus of the lens, though not 
unaltered, is usually translucent and the 
cortex transparent; but the intermediate 
layers-that is, the sub-cortical or peri- 
nuclear- are more or less opaque. This form 
of opacity is called lamellar cataract, because 
in sagittal section it is seen to be disposed in 
layers around the nucleus ; or zonular cata- 
ract, because the opaque portions, whenlooked 
at en face, are bordered by a transparent 
zone of clear cortex. It would seem that 
the layers which are opaque are either those 
which were immediately sub-capsular at the 
time when the disturbance took place, or 
those which were produced by the endo- 
thelial cells during the period of disturbance. 
On this assumption the position of the opacity 
may be regarded as indicating the time at 
which the interruption took place. The 
earlier the interference the nearer will the 
opacity be to the nucleus of the lens, and 
vice versa. In some rare cases there are two 
or more concentric layers of opacity, with 
intervening layers of clear substance, as if 
there had been several disturbances at 
different epochs, followed by intervals of 
normal growth. Lamellar cataracts may be 
found in eyes otherwise healthy, but they are 
sometimes associated with developmental de- 
fects of the eye and of the general organism, 
an almost invariable concomitant being defi- 
ciency of enamel of the permanent teeth, espe- 
cially the first molars, the incisors, and the 
canines (Hutchinson), and not infrequently 
there is a clinical history of ' fits,' or other 
evidences of a neurosis. (3) As the result 
of inflammation of the cornea, uveal tract, or 
vitreous during intra-uterine life, single or 
multiple opacities may form in the capsule 
and sub-capsular layer. These are called 
congenital capsular cataracts, and are most 
common at the anterior pole. They may, 
however, be scattered about the anterior sur- 
face, or lie about the posterior pole of the 
lens. These opacities consist of proliferation 
of the endothelium and granular disintegra- 
tion of the superficial cortical layers, similar 
to those changes which produce capsular 
and sub-capsular opacities after birth. It is, CATARACT 
289 
however, not improbable that congenital 
anterior polar cataracts may sometimes be 
due, not to inflammation, but to retarded 
separation of the involuted lens-vesicle from 
the cornea, and delayed closure of the vesicle. 
This retardation may permit of the intrusion 
of mesoblastic elements within the vesicle, and 
these would still further increase the opacity 
about the capsule. This may conceivably 
cause an axial opacity, the so-called spindle- 
shaped cataract. (4) Congenital false cata- 
racts may be due to the presence of extra- 
capsular opacities upon the anterior or the 
posterior pupillary areas. These opacities may 
be the results of inflammatory exudations, 
but more commonly they are due to an arrest 
of development in its final stage. The de- 
velopment and growth of the lens may have 
been normal up to the stage at which the 
removal of the embryonic capsulo-pupillary 
sac should have taken place, but, having 
ceased immediately before the removal was 
complete, portions of the foetal structures 
remain. When these are on the anterior 
surface, they are connected with the edge of 
the iris, or more frequently with its anterior 
surface ; when on the posterior surface of the 
lens, the remnant may be connected with a 
fine thread which is itself the remains of the 
hyaloid blood-vessels. This state of incom- 
pleteness may be designated by the Aristote- 
lian term Ateleia {Physic, viii. 9 ; De Animal. 
Gen. iii. 9). 
The alterations in nutrition which, after 
birth, lead to the formation of cataract may 
be classified as follows:- 
(1) Diminution in the quantity of the 
nutrient elements, without material altera- 
tion in their quality. This diminution may be 
due to many causes: (a) mechanical obstacles 
impeding due access of the fluids; {b) damage 
to the secretory apparatus consequent upon 
chronic atrophy of the ciliary body and 
choroid; (c) general malnutrition, cachexia, 
anaemia, cardiac, renal, or other visceral 
disease ; or {d) simple old age. 
Mere diminution of the quantity of nutri- 
tive elements operates slowly on the nutrition 
of the lens, and the opacity which results 
manifests itself in or about the nucleus-that 
is to say, the parts most remote from the 
sources of the nutrient fluids. The cortex 
seems to receive enough pabulum to keep it 
clear, but not enough to spare for the support 
of the deeper layers. 
(2) Alterations in the quality of the 
nutrient elements. These may be due to: 
(a) congestion, inflammation, or any other 
morbid state of the secretory organs of the 
nutritive fluids-namely, the ciliary body, 
iris, choroid, and retina; (S) changes in the 
vitreous or in the aqueous humour; (c) 
morbid states of the blood and tissues, as in 
many general and diathetic diseases-gout, 
glycosuria, albuminuria, &c.; {di) changes in 
the physical, chemical, or vital properties of 
the capsule or of its endothelium, in conse- 
quence of which the fluids that pass through 
the capsule are not properly prepared for 
the due nutrition of the lens; or (e) impeded 
elimination of waste products, whether from 
the lens itself or from the whole eyeball. 
Alterations in the quality of the nutrient 
elements are more or less prompt-and if the 
alteration be very great, as, say, in rupture 
of the capsule-they are very prompt in pro- 
ducing opacities. The opacities which result 
affect primarily the sub-capsular and the 
cortical layers, more particularly at the ends 
of the fibres adjoining the rays of the crystal- 
line stellae where the endosmotic processes 
are most active, and where the effect of the 
altered quality of the fluids is first apparent. 
The affected parts are those with which the 
altered fluids first come into contact, and 
which lie therefore nearest to the sources of 
the altered fluid. If the alteration be intense, 
but of brief duration, as in the case of perforat- 
ing ulcer of the cornea in purulent ophthalmia 
of children, the change may be limited to a 
circumscribed area of the capsule and sub- 
capsular layers, giving rise to an anterior 
polar cataract, or, if this opacity assume a 
conical shape, anterior pyramidal cataract. 
In alterations of less intensity, but of con- 
tinuous duration, due to chronic morbid 
states in the posterior segment of the globe, 
such as retinitis pigmentosa, slowly forming 
opacities may occur in the posterior sub- 
capsular layers of the lens, beginning at the 
pole of the lens, and extending thence in a 
radial direction along the rays of the pos- 
terior stella, giving rise to posterior polar or 
stellar cataracts. 
(3) Alterations of quantity and, quality 
combined. This co-operation obtains in 
most of the cases of cataract; diminution 
of quantity being the chief factor in some, 
alterations in quality predominating in 
others. Where the departure from the 
normal approaches most closely to mere 
diminution in quantity, the onset and pro- 
gress of the cataract is slower, and the opacity 
tends to affect at first the parts nearer the 
centre of the lens; but where the alteration 
in quality is pronounced, the onset and pro- 
gress are more rapid, and the opacity begins 
in the cortex. It will easily be understood 
that the great majority of cataracts are cor- 
tical, because there are comparatively very 
few cases, even in apparently healthy eyes, 
where the alteration in nutrition does not 
exhibit some difference in the quality of the 
nutrient elements, as well as falling off in 
quantity. 
Mobbid Anatomy.-The changes which 
take place in cataract are not the same in all 
cases. There is, for example, a great differ- 
ence between the changes which produce 
some embryonic cataracts and those which 
give rise to acquired cataracts, and between 
those which produce lenticular cataract and 290 
CATARACT 
those which give rise to capsular cataract. 
Indeed capsular opacities are often secondary 
to lenticular. Even in true lenticular cataract 
the morbid changes are many and various. 
In senile cataracts, and in most slowly form- 
ing cataracts, the opacity of the lens-fibres is 
merely an extension of physiological senile 
changes, and is usually preceded by the for- 
mation of spaces and vacuoles between the 
fibres and the lamelhe due to shrinkage and 
sclerosis, as already described. Priestley 
Smith's investigations have shown that a 
diminished rate of growth of the lens precedes 
cataract (op. cit.). According to Otto Becker 
the initial cause of senile cataract is the 
drying of the nucleus and its separation from 
the cortex, the gap between them being filled 
by a fluid which is probably derived from the 
fibres. In more rapidly forming cortical 
cataracts it may often be observed that the 
opacity begins in the sub-capsular layers and 
about the borders of the rays of the anterior 
stella. Instead of shrinkage and sclerosis, 
the fibres may swell and become softer. In 
some cases the rays of the stella are broad- 
ened, but whether they are or not, a hazy line 
may often be traced along one or both of the 
edges of the ray, in the ends of the cortical 
fibres. From the ends of the fibres the 
opacity extends along their lengths towards 
the equator, until the whole of the cortex is 
implicated. The endothelium also undergoes 
changes, giving rise to triangular patches of 
glistening opacities which may present a 
mother-of-pearl appearance. When once the 
opacifying process begins in any part of the 
lens it tends to progress till the whole of the 
lens is involved. The cataract is then said to 
be ripe or mature. 
If a ripe cataract be allowed to remain 
within the eye indefinitely, it may undergo 
further degenerative changes and become 
what is called over-ripe. In some instances 
the lens-substance shrinks and becomes hard 
and calcareous, and the capsule thickens and 
grows more opaque. In other cases the 
cortex liquefies, allowing the harder nucleus 
to move within it (Morgagnian cataract). 
In calcification of the lens the process begins 
in the external cortical layers, and it may 
ultimately affect the entire thickness of the 
lens. Calcification is more liable to occur in 
cataracts due to gross disease of the eye, and 
especially when there is an inflammatory 
exudation upon the capsule. Short of general 
calcification, minute white dots, lines, and 
patches may appear in the capsular endothe- 
lium of mature cataracts. Over-ripe cataracts 
may also become loosened, in consequence 
of softening or rupture of the suspensory 
ligament. Fluidity of the surrounding vitreous 
may likewise occur, and then on slight pro- 
vocation the loosened lens may fall into the 
vitreous. 
A peculiar form of degeneration sometimes 
occurs in the lens, producing what is called 
black cataract. This is commonly thought 
to be due to the staining of the lens by blood- 
pigments, and in some cases this may be so; 
but, according to a careful spectroscopic ex- 
amination by Dr. McMunn, no blood pig- 
ments were found, but the lens was infiltrated 
with a pigment analogous to melanin, which 
is the pigment of hair and feathers (Trans. 
Ophth. Soc. vol. ii. p. 10). 
^Etiology.-Besides the causes and con- 
ditions already described, there are other 
circumstances which may induce cataract, or 
at least predispose to it. The most important 
of these are as follows :- 
Age.-Cataracts occur more frequently in 
infancy and in old age than in early adult 
and middle life, except when due to disease 
of the eye or to injuries. Sex.-The two 
sexes are about equally affected, except in 
respect of traumatic cataract, in which males 
greatly preponderate. Heredity.-Hereditary 
influences may determine the occurrence of 
cataract in several ways. There may be the 
inheritance of actual (congenital) cataract or 
of a disposition to cataract. In either case 
the descent seems to pass more through the 
male than the female line. Occupation.- 
Certain occupations predispose to cataract, 
especially such as necessitate close applica- 
tion of the eyes to near work, or involve 
stooping positions or exposure to bright light, 
more particularly if light be combined with 
heat (as in the occupation of smiths, cooks, 
stokers, &c.), and occupations in which the eyes 
are exposed to irritating fumes and vapours. 
Uncorrected errors of refraction and accom- 
modation may favour the production of 
cataract by overstraining the accommodation, 
and by the frequent and successive changes 
which the capsule has to undergo. These 
strains not only increase the wear and tear 
of the lens, but facilitate the loosening of the 
cortex of the lens from the capsule. Hyper- 
metropia and astigmatism may predispose to 
cataract in another way. The incessant strain 
upon the ciliary muscle required to correct 
hypermetropia involves constant congestion 
of the ciliary body and the base of the iris. 
The nutritive fluids secreted during this state 
are not perfectly normal; they are in some 
measure altered in quality and will therefore 
sooner or later make their influence felt on 
the transparency of the lens. Injuries.- 
Wounds of the capsule are generally soon 
followed by opacity, which occurs more 
quickly in proportion to the size of the rent 
and the youth of the patient. Perforating 
wounds of the cornea, especially when fol- 
lowed by suppuration, may induce cataract 
even though the capsule have not been per- 
forated. Blows on the head, face, or brow, 
shocks and jars of the body, may also be 
followed by cataract, either from causing flaws 
or cracks or rents in the capsule or by rup- 
ture of the suspensory ligament. Other con- 
ditions which accompany and apparently pre- CATARACT 
291 
dispose to cataract are degenerative changes 
in the blood-vessels, especially of those of the 
head and neck and of the eye; diseases of the 
orbit, or changes in the orbital vessels; cardiac 
disease, renal disease, gout, and diabetes. It 
is probable, however, that the influence of 
diabetes in the production of cataract has been 
overrated. The number of diabetic persons 
who get cataract is comparatively small, and 
when cataract coexists with glycosuria there 
is no necessary causal relationship between 
the two. It has been stated that ergotism 
often leads to cataract (J. Meyer). 
Classification. - Cataracts have been 
classified in many ways, as (1) according to 
age-congenital, juvenile, senile; (2) to stage 
-incipient, progressive, stationary, immature, 
mature; (3) consistency-fluid, soft, hard, and 
mixed. 
All these plans possess some clinical utility, 
but they are not sufficiently comprehensive. 
Following the indications afforded by the 
consideration of the pathology and causation 
of lenticular opacities, cataracts may be 
arranged into five main groups according 
(1) as they are due to developmental abnor- 
malities-embryonic; (2) as they occur in- 
dependently of obvious disease of the eye- 
idiopathic', (3) as they are associated with ob- 
vious disease of the eye-sympathetic', (4) as 
they follow wounds or injuries of the eye 
-traumatic', and lastly (5) as they are due 
to the opacification of lens-matter remaining 
within or on the capsule at the time of opera- 
tion for the removal of cataract, or of lens- 
matter which may have grown subsequently 
and then become opaque -deuteropathic or 
subsequent (bevTfpoTraOea), I suffer later.- 
Galen, De Loc. Affect, i., iii. ed. Kuhn viii. 
31). Within one or other of these groups 
all the varieties of cataract may be arranged 
according as they implicate (1) the nucleus ; 
(2) the perinuclear region (lamellar); (3) the 
axis (spindle-shaped); (4) the cortex, anterior 
or posterior; (5) the equator; (6) the capsule, 
anterior or posterior; (7) the external surface 
of the capsule-extra-capsular-which may 
be congenital or acquired. 
Symptoms.-The chief subjective symptom 
of senile and other acquired cataracts is im- 
pairment and ' fogginess ' of sight, especially 
for distant objects. As the cataract advances, 
this dimness increases, until the appreciation 
of form and colour may be lost; but, in eyes 
otherwise healthy, the power of discerning 
light always remains, even though the lens 
be quite opaque. In ordinary daylight the 
eye may still be able to ' count fingers ' at a 
distance of six to twelve inches, or see the 
movement of, say, a hand at a distance of 
twelve to eighteen inches (hand-movement); 
and in a darkened room the eye should be 
able not only to see a lighted candle at a 
distance of ten to fifteen feet, but should be 
able also quickly to indicate its position in 
various parts of the field of vision without 
movement of the eyes or head. This would 
indicate that there is good perception of 
light, good projection, and a good field of 
vision. In the early stages of cataract, 
especially when the opacity occupies the 
pupillary area, patients may see better 
when the eyes are shaded, the pupil being 
thereby made to dilate; a bright light em- 
barrasses and distresses them. Muscae voli- 
tantes are also often seen; these may be 
due to the congestion of the ciliary body and 
choroid which may have preceded cataract, 
or they may be the results of the straining 
efforts to see through a hazy lens. Another 
common symptom is the multiplying or 
splitting of objects, especially of lights (mon- 
ophthalmic polyopia). The amount of im- 
pairment of sight is not always in proportion 
to the amount of appreciable opacity; diffused 
haziness about the nucleus or about the 
pupillary area is more hampering than well- 
defined striae or sectors with clear interspaces. 
There may be dense opacities at the equator 
with perfect acuteness of vision. An oc- 
casional early symptom of cataract is a 
change in the refraction of the eye, leading 
to what some persons describe as getting 
' the second sight.' Eyes that have required 
strong convex glasses for near work prefer 
weaker ones, or none at all; and those who 
have needed convex glasses for distance may 
find that they see better without them, or 
even with concave glasses. This is a passing 
state, though it may last for weeks and even 
for months; it is due either to the swelling 
of the lens or to some change in its refractive 
index. After a time this condition passes off 
and is followed by progressive failure of sight. 
Many children with zonular cataract are 
thought to be merely short-sighted, and often 
they are short-sighted, but the true cause of 
the defect is frequently not discovered till the 
' optician ' has failed to get good vision by 
means of spectacles. 
Diagnosis.-In all cases of failing sight, 
whether opacities are to be seen or not by 
means of direct light or by so-called focal 
or oblique illumination, the media of the eye 
should be examined with the ophthahnoscope. 
Owing to thickening of the lens-capsule, the 
pupils of old persons are sometimes grey 
instead of black, and the lenses may seem 
to be opaque when they are not really so ; 
and in glaucomatous eyes the change of 
colour which takes place in the cornea and 
in the lens not infrequently suggests cata- 
ract even when the media are translucent. 
Diagnosis of advanced cataract is easy, but 
in slighter cases careful examination of all 
parts of the lens may be needed. The aims 
of diagnosis are to recognise the presence 
of the cataract, to ascertain its seat, extent, 
consistence, and its relations or complica- 
tions, and to discriminate it from other 
morbid states which may be mistaken for 
it. Examination of the anterior part of the 292 
CATARACT 
lens, the capsule, anterior cortex, and the 
nucleus may be made with ' focal illumina- 
tion,' that is concentrating light upon the 
eye by means of a magnifying-glass. The 
equator of the lens and the posterior cortex 
require the ophthalmoscope for their exami- 
nation. Opacities which seem white or 
greyish by focal illumination appear black 
against the red ground of the fundus-reflex 
when looked at with the ophthalmoscope. 
The different parts of the lens should be 
examined methodically, beginning with the 
anterior capsule and passing through the 
thickness of the lens to the posterior capsule. 
Anterior extra-capsular opacities, whether 
inflammatory deposits or remains of the cap- 
sulo-pupillary membrane, project beyond 
the level of the capsule. The latter have 
usually attachments to the anterior surface 
of the iris (cir cuius minor'), whereby they are 
distinguished from inflammatory adhesions 
(posterior synechiae) which are connected 
with the edge and posterior surface of the 
iris. Capsular cataracts may be single or 
multiple. Anterior polar cataract occurs as 
a small circumscribed dot in and behind 
the centre of the capsule; when viewed in 
profile the dot can be seen to project slightly 
beyond the general level of the capsule; 
occasionally it projects considerably and 
is conical (pyramidal cataract). Both these 
cataracts are generally associated with 
nebula or leucoma of the cornea. Multiple 
capsular opacities may be scattered irregu- 
larly or arrayed in a circle. Cortical opacities 
assume many shapes-striae, wedges, or ir- 
regular patches. When the opacities are in 
the anterior cortex, they are convex in their 
arrangement; when in the posterior they are 
concave. Equatorial opacities may be partial 
or complete, continuous or interrupted, limited 
as a corona to the periphery, or send tapering 
offshoots towards the anterior and posterior 
cortices. Perinuclear opacities may be cir- 
cumscribed or diffused. The circumscribed 
(lamellar or zonular cataracts) are best seen 
with the ophthalmoscope when the pupil has 
been dilated by a weak solution of atropine 
or other mydriatic. Lamellar cataract appears 
as a greyish disk surrounded by a clear zone. 
If the nucleus be translucent the disk is most 
opaque at its edge; but if the nucleus be itself 
opaque, then the opacity is densest in the 
centre. The edge of the disk may be sharply 
defined, or indented or broken by centrifugal 
striae. Nuclear opacities may be dense and 
diffuse, as in some congenital cataracts, or they 
may appear as a brownish or yellowish unde- 
fined blur or cloud, as in early senile cataract. 
Posterior polar cataract can be properly seen 
only with the ophthalmoscope. It may assume 
the form of a smaller or larger dot, or of 
several dots, or of radiating streaks. The 
position of the opacity is determined partly 
by its remoteness from the pupil, and partly 
by the small excursions it makes in the 
various movements of the eye, the posterior 
pole of the lens being immediately in front of 
the centre of rotation of the globe. Posterior 
polar cataract may be congenital, but more 
commonly it is pathological and associated 
with opacities in the vitreous or with disease 
of the choroid or retina. 
Whenever practicable, it is desirable in 
all forms of cataract to examine the state of 
the optic nerve and fundus of the eye. The 
data thereby obtained may influence the pro- 
gnosis and the later treatment. When the 
cataract is mature the pupil is uniformly 
white or greyish, and the opacity comes up 
to and seems to touch the pupillary edge of 
the iris, and no reflex can be obtained by means 
of the ophthalmoscope. If the cortical layers 
are not opaque, a shadow of the iris can be 
thrown into the lens by means of oblique 
illumination, giving the appearance of a gap 
between the opacity and the edge of the iris. 
For surgical purposes it is not necessary that 
the whole of the lens-substance should be 
opaque; it is enough that the cortical layers 
be opaque, for then the connexion between 
the cortex and the capsule is broken, and 
the endothelial cells have lost their power of 
growing fresh lens-fibres. It is not always 
possible to estimate the consistency of a cata- 
ract ; but, as a rule, cataracts which begin in 
the cortex, or occur in persons under the age 
of thirty years, or are rapidly formed, are 
usually ' soft ' ; such cataracts are generally 
whiter and more opaque than harder ones, 
and the opacity is often patchy or diffused. 
Nuclear cataracts, and those which occur in 
old persons, or are of slow formation, or 
yellowish in colour, or in which the lenses are 
small and shrunken, or which have small, 
well-defined opaque striae w'ith clear inter- 
spaces, are usually ' hard.' 
The failing sight of chronic glaucoma is 
sometimes ascribed to cataract. This mis- 
take is fostered by a superficial resemblance 
between these two conditions. By the ophthal- 
moscope and by palpation, the error may 
easily be avoided. When the lens is not 
opaque in glaucoma the diagnosis is simple, 
mere absence of opacity excluding cataract; 
but when, in glaucoma, the lens is also 
opaque, the diagnosis may present some diffi- 
culty. In chronic glaucoma the characteris- 
tic symptom is increased hardness of the eye- 
ball. Usually a history of haloes seen round 
artificial light may be elicited, with perhaps 
attacks of neuralgia and redness of the eye. 
The pupils are semi-dilated and very sluggish, 
if not immobile, and the anterior chamber is 
shallow, and the sight is more impaired than 
the cataract accounts for. In advanced (ab- 
solute) glaucoma there is an entire abolition 
of the perception of light. 
Prognosis.-Cataract may be considered, 
as regards its prognosis, from two points of 
view: first, when it is immature, as to its 
probable course; and, secondly, when it is CATARACT 
293 
mature, as to the prospects of recovery of 
sight after operation. Some cataracts may 
remain stationary throughout a long life : 
such are anterior polar, anterior pyramidal, 
and zonular cataracts. Others progress 
slowly, such as posterior polar cataracts. 
Cortical cataracts, as a rule, advance more 
rapidly than nuclear ones, and soft cataracts 
more rapidly than hard. It is not possible 
in all cases to decide whether a cataract is 
likely to progress slowly or quickly. Gener- 
ally the progress is quicker the earlier the 
cataract occurs, and the closer its association 
with morbid states of the eye or with injury. 
When cataracts are sharply defined, confined 
to the equator of the lens, or present only a 
haze or blur in or about the nucleus, or when 
the cortical striae are few and fine and well- 
defined, with clear interspaces, and the eyes 
are otherwise healthy, and the sight good, 
the progress will usually be slow; but when 
the cpacities are dense, irregular, ill-defined, 
diffuse, especially where they extend far 
along the anterior or posterior cortical layers, 
with rapidly failing sight, or with sight bad 
out of all proportion to the amount of actual 
opacity, or when there is obvious irritative 
or inflammatory disease of the eye, or when 
there is grave visceral or other constitutional 
disease, such as gout, diabetes, nephritis, then 
the progress will probably be rapid. But it 
should be remembered that cataracts which 
may have been very slowly progressing may 
at any time take a sudden and rapid start 
and progress quickly. The usual course, in 
senile cataract, is from one to four years or 
more. 
As regards mature cataract, the prognosis 
in reference to operation is good in proportion 
as the eye is otherwise sound, and the general 
health good. Where there is a history of 
attacks of pain or of redness in the eye, or 
where there are signs of past disease, whether 
iritis or choroiditis or retinitis, or where there 
is a high degree of myopia, or where the iris 
is discoloured and lustreless, and sluggish or 
immobile, or where it is tremulous, or where 
the anterior chamber is much deeper than 
natural or much shallower, or where there is 
a chronic conjunctivitis, ciliary ■ blepharitis, 
or catarrh of the lacrymal sac, or where the 
tension of the eye is too high or too low, 
the prognosis is more or less unfavourable. 
Nystagmus, squint-especially divergent 
squint-are unfavourable concomitants ; and 
the prognosis is, of course, less favourable 
when it is known that there was antecedent 
disease of the fundus, or when, failing this 
knowledge, the perception of light is poor, 
and the projection bad, and the field of vision 
contracted or irregular. Where there is no 
perception of light, the prognosis is hopeless. 
Treatment.-From a medical standpoint, 
the treatment of cataract is rather preven- 
tive and palliative than operative. 
Prevention.-From a consideration of the 
causes and pathology of cataract, it is evident 
that, while some cases are beyond the reach 
of prophylactics, there are others which do fall 
within the category of preventible diseases. 
In the present state of knowledge and thera- 
peutical art, little can be done, directly, to 
prevent many of the embryonic forms of 
cataract, and those other cataracts which are 
due to simple diminution of the quantity of 
nutrition, of which pure senile cataract is the 
type. Our control over the processes of 
development and of senile decay is, at best, 
slight and limited. On the other hand, it is 
at least ideally possible to prevent the occur- 
rence of many of those cataracts which are 
due to alterations of quality of nutrition. 
By the prevention or the avoidance of those 
general and local conditions and morbid 
states which induce these qualitative altera- 
tions, or by their early and effectual treat- 
ment, secundum artem, by obedience to the 
laws of personal and public hygiene, by con- 
forming to the requirements of healthy sight, 
by the scientific correction of errors of re- 
fraction and accommodation, by adequate pro- 
tection of the eyes during those occupations 
which entail risks of phsyical, thermic, or 
chemical injuries, cataract may often be pre- 
vented, or its progress arrested, if perchance 
initial changes have already begun. For the 
prevention of cataract, as well as in its general 
treatment, the twofold origin of the lens- 
substance and its capsule should be borne in 
mind. The fibres and the endothelium of the 
lens, and the inner layer of the capsule, being 
epiblastic in origin, are in intimate relation- 
ship with the central nervous system, the 
cuticle, hair, nails, enamel of the teeth, and 
other tissues derived from the external layer 
of the blastoderm, and are, therefore, apt to 
participate in many of their pathological 
states. Similarly, by its mesoblastic origin, 
the external layer of the capsule is directly 
related to the bones, muscles, blood-vessels, 
and other fibro-vascular tissues, and is liable 
to their affections. In these affections the 
lens-fibres and the endothelium may become 
secondarily involved. Whatever promotes the 
nutrition, or averts breakdown, or arrests or 
cures disease, of one portion of these groups 
of tissue-elements, will, presumably, in some 
degree influence other portions. Hence 
general principles are capable of a particular 
application to the several parts of the lens 
and its capsule. It should, however, be 
borne in mind that though the epiblastic and 
the mesoblastic portions of the lens have 
their proper constitution and peculiar modes 
of activity, they are nourished by fluids 
chiefly, if not exclusively, furnished by the 
ciliary body and other parts of the uveal tract. 
Palliation.-If opacity of the lens exists, 
but not to an amount sufficient to materi- 
ally impair sight, it is sometimes possible, by 
general and local measures, to improve the 
special nutrition of the lens, and thereby to 294 
CATARACT 
retard the progress of the cataract. In some 
cases, where slight endothelial and cortical 
opacities occur during transitory inflamma- 
tion of the cornea, iris, or choroid, or during 
exacerbations of diabetes and other diathetic 
diseases, the opacities may gradually dis- 
appear on the resumption of normal nutrition 
after the subsidence of the inflammation or 
the melioration of the general health. But, 
except within these narrow limits, genuine 
cataractous opacities are incurable and irre- 
movable by any means known to positive 
science other than operation. Notwithstand- 
ing the advancement of medical knowledge 
and the increased resources of surgical art, 
the earliest dictum recorded in medical litera- 
ture respecting the curability of cataract still 
holds good. Nearly nineteen hundred years 
ago Celsus remarked: ' Cum [suffusio] recens 
incidit, medicamentis quoque sajpe discutitur; 
sed ubi vetustior facta est, manus curationem 
desiderat ' (De Medicina, vii. 7,13). Increased 
knowledge of the nature of cataract lessens 
rather than increases the hope and expecta- 
tion of dispersing the opacity by local applica- 
tions or internal medicaments; indeed it tends 
more and more to demonstrate the futility of 
such pretensions and attempts. 
Nevertheless the inconveniences which 
attend progressing cataract jiiay be palliated 
by alleviating local irritation, by the use of 
tinted glasses, by shading the eyes from 
bright light, by correction of optical errors, 
or by the use of stenopaeic glasses. When 
the opacity, whether congenital or acquired, is 
limited to the pupillary area of the lens, vision 
may be improved by moderate dilatation of the 
pupil, by means of weak solutions of atropine 
(gr. ~ to gr. | in an ounce of water), or 
other mydriatic. In any case, if the eyes be 
otherwise healthy, moderate use of the eyes 
may be indulged in, short of discomfort and 
fatigue. 
Operations.-The operations for the cure 
of cataract may, with some allowance made 
for differences of local conditions, be compared 
with the three procedures employed for the 
removal of vesical calculus-namely, simple 
crushing, with escape of the fragments per 
vias naturales-lithotrity; crushing with 
instant removal of the fragments by aspira- 
tion-litholapaxy; and, lastly, extraction of 
the calculus en masse-lithotomy. The corre- 
sponding operations for cataract are: First, 
discission, or keratonyxis(Ktpa$, horn [corneaj; 
vvcra-w, I prick), in which the anterior capsule 
is torn by a fine needle passed through the 
cornea. The lens-substance, being thereby 
exposed to the disintegrating action of the 
aqueous humour, gradually liquefies and is 
ultimately eliminated by the absorbent 
vessels. Secondly, discission with evacua- 
tion. The capsule is torn as in discission, 
but the lens is more freely broken up. The 
fragments are then, or within a few days, 
removed by a grooved curette through a 
narrow incision immediately within the 
corneal margin (linear extraction), or with- 
drawn by aspiration through a fine tube 
(suction). The third operation is extraction, 
in which an incision is made at or near 
the corneal margin, the capsule divided and 
the lens extruded by gentle pressure. Until 
quite recently a portion of the iris was in the 
modern operation removed (iridectomy) at 
the time of the extraction-operation, or a few 
weeks or months previously (preliminary 
iridectomy). But some surgeons now try to 
dispense with the iridectomy, or only do it 
when the cataract cannot otherwise be safely 
and efficiently removed. The first and second 
of the operations above referred to are applic- 
able to ' soft ' cataracts, while extraction is 
usually reserved for ' hard ' cataracts. Soft 
cataracts may be operated on almost at any 
time and in any stage ; but hard cataracts 
are, as a rule, not extracted until they are 
'mature,' though there are many circum- 
stances which may suggest and justify de- 
parture from this rule. An immature cataract 
may be operated on whenever both eyes are 
so affected that the patient is unable to read 
ordinary print or to follow his occupation or 
profession. 
It may here be remarked that when zonular 
cataract is slight, and does not cause appre- 
ciable impairment of sight, operation may be 
indefinitely deferred. If, on the other hand, 
the opacity is more pronounced, and the 
degree of impairment of vision is such that 
education or occupation cannot be comfort- 
ably pursued, operative interference is called 
for. The precise procedure will depend upon 
circumstances. If the cataract be small, 
dense, with defined margins and surrounded 
by a broad clear zone, a small iridectomy 
downwards and inwards (artificial pupil) 
may suffice to give useful vision; but if it be 
large, and not very opaque, or if its edges 
be ill-defined and broken by projecting striae, 
and the surrounding zone narrow and hazy, 
then discission, with or without evacuation, 
will be indicated. 
When the eye has recovered from the effects 
of the operation, spectacle-lenses are needed 
to correct the error of refraction due to the 
absence of the crystalline (aphakia chirur- 
gica'). Except in very short-sighted eyes 
convex lenses are required. The strength of 
the lens will depend upon the refraction of 
the eye, but ordinarily for distance a lens 
of about 10 dioptres (4-inch) is needed, and 
for near work about 14 D. (2^-inch). If 
astigmatism (see Vision, Defects of) be 
present, then cylindrical lenses must be added 
to the sphericals. In any case, it is deshablo 
that an eye which has been operated on 
should not be used too soon, nor, at first, for 
too long a time. 
Sometimes it happens after the removal of 
a cataract that, owing to the presence of hazy 
or opaque lens-capsule within the pupil, it is CATARACT 
CATARRHAL 
295 
not possible to obtain useful vision by the 
most accurate optical correction. It will then 
be necessary to tear through the membrane 
with one or two fine needles, and thereby 
effect a clear opening opposite the pupil. 
John Tweedy. 
CATARRH (Kara, down; and pea, I flow). 
Synon. : Coryza ; Catarrhus (Cullen) ; Cat- 
arrhus communis (Good); Rheuma-, Fr. Cat- 
arrhe; Coryza; Ger. Katarrh; Schnupfen. 
Definition.-The term catarrh is applied 
generally to inflammation or congestion of 
the mucous membranes, attended with in- 
creased secretion. Thus authors speak of 
cata/rrh of the stomach, intestines, bladder, 
de. In the present article the term is limited 
to the inflammatory affections of the upper 
part of the air-passages, resulting from cold, 
and attended by discharge from the nostrils, 
soreness of the throat, hoarseness, and cough. 
The term coryza is, however, more especially 
limited to the cases in which there is copious 
discharge from the nasal passages, while 
catarrh is applied to affections of the whole 
mucous membrane, including the fauces and 
larynx. 
Symptoms.-The attack generally com- 
mences, shortly after exposure to cold or 
more particularly to cold and damp, with a 
feeling of indisposition, sense of cold down 
the back or general chilliness, weight in the 
forehead, headache, especially frontal, and 
dryness of the nares and throat. These 
symptoms are succeeded by the discharge 
from the nostrils of a thin acrid fluid, water- 
ing of the eyes, pains in the face, soreness of 
the throat and hoarseness, with aching in all 
parts of the body, and disinclination to bodily 
and mental exertion. 
At first the affection is often confined to 
one nostril, and there is pain in the corre- 
sponding temple, eyebrow, eyeball, and side 
of the face, and lacrymation on that side; 
but it soon appears in the other nostril, and 
involves both eyes and all parts of the face ; 
and there is great sense of weight and pain 
in the forehead and eyebrows. The discharge, 
also, loses the thin character and becomes 
mucous, and is often very profuse; there is 
copious lacrymation, the throat becomes 
decidedly sore, the hoarseness is greater, and 
there is pain in speaking and sometimes 
almost entire loss of voice. There are also 
transient pains in the chest, with a sense of 
tightness and some wheezing. The appetite 
from the first is impaired, and there may be 
entire distaste of food, and sometimes sick- 
ness and vomiting; not infrequently there 
is some sense of weight in the right hypo- 
chondrium, and sallowness of the com- 
plexion ; the bowels are usually confined, 
but there may be diarrhoea. The tongue is 
generally white, the pulse may be a little 
quickened, the skin may be dry, the tempera- 
ture is raised, and the urine is scanty and 
somewhat high-coloured, and deposits a little 
sediment. The pains in the head and face 
especially affect the forehead, the eyebrows, 
the root of the nose, the eyeballs, and the 
course of the dental and other nerves ; they 
generally increase towards night, and may 
be so severe as entirely to prevent sleep. 
Not infrequently there is more or less deaf- 
ness, and usually loss of smell and taste. 
Herpetic spots often appear about the mouth, 
and the nostrils may become ulcerated from 
the discharge; the throat is more or less red 
and swollen, and often there is stiffness and 
pain of the neck, and tenderness on pressure 
over the larynx. 
After these symptoms have continued for 
two or three days they generally gradually 
subside ; but the cough may continue trouble- 
some, and the patient be able to take very 
little food, and may still feel weak for a week 
or more. In persons of delicate constitution, 
also, the weakness is often very persistent; 
and, if care be not taken, more serious in- 
flammation of the bronchial mucous mem- 
brane or of the lungs may supervene, and 
may lapse into phthisis. 
Treatment.-In the slighter forms of com- 
mon cold but little treatment is required, ex- 
cept the use of the ordinary household reme- 
dies : the feet may be placed in hot water, 
some warm diluent beverage may be taken, 
and a light diet must be had recourse to for 
a day or two. In the more serious cases 
febrifuge medicines may be given, with an 
anodyne to relieve the cough, if troublesome, 
or to procure rest at night, if the neuralgic 
pains be very severe.1 When the attack has 
continued for two or three days a more 
stimulating diet may be given, and during 
convalescence tonics and stimulants may be 
required. 
Dr. Ferrier recommends in catarrh the 
local application to the nose of the follow- 
ing powder in the form of a snuff: Hydro - 
chlorate of morphine 2 grains, subnitrate of 
bismuth 6 drachms, gum acacia in powder 
2 drachms. From one-quarter to one-half of 
this may be taken in the course of twenty- 
four hours. 
It not infrequently happens that in delicate 
persons a cold is very difficult to get rid of, 
and the slightest exposure is followed by an 
aggravation or renewal of the symptoms. 
When this is the case the most effectual 
remedy is change of air, and the patient after 
leaving home often rapidly improves, and 
soon gets well. Thomas B. Peacock. 
CATARRHAL (Kara, down; and pea, I 
flow).-Pertaining to catarrh, both in its 
pathological and clinical significations-for 
example, catarrhal products, catarrhal pneu- 
monia, catarrhal fever, catarrhal attack. 
1 From 20 to 60 minims of Spiritus Ammonias 
Aromaticus in a claret-glass of any effervescing 
water may be taken at bed-time or oftener with 
marked benefit.-Editor. 296 
CATHARTICS 
CELL 
CATHARTICS (Kodatpa, I cleanse).- 
This word is sometimes used as a synonym 
for purgatives; but in a more limited signi- 
fication it means purgatives of moderate 
activity. See Purgatives. 
CAUSES of Disease.-See Disease, 
Causes of. 
CAUSTICS (taia, I burn).-Definition. 
Substances or measures which destroy orga- 
nic tissues with which they may be brought 
in contact. 
Enumeration. - The caustic substances 
in most common use are Potash, Soda, and 
Lime ; Nitric, Hydrochloric, Sulphuric, 
Chromic, Lactic, and Glacial Acetic Acids; 
Red Oxide, Acid Nitrate, and Perchloride of 
Mercury ; Carbolic Acid ; Chloride of Zinc; 
Chloride of Antimony; and Arsenic. The 
ordinary caustic measures are the galvano- 
cautery; Paquelin's cautery ; the red-hot 
iron ; and moxae. See also Poisons. 
Uses.-Caustics are chiefly employed to 
destroy unhealthy, exuberant, or malignant 
growths; to establish issues for the purpose 
of counter-irritation (see Counter-irrita- 
tion) ; and to destroy poisons when intro- 
duced into the body by breach of the external 
surface. T. Lauder Brunton. 
CAUTERETS, in the French 
Pvrenees.-Sulphur waters. See Mineral 
Waters. 
CAVERNOUS.-A peculiar quality of 
sounds heard on auscultation of the lungs, 
indicative of the presence of a cavity. See 
Physical Examination. 
CAVITY, Pulmonary.-As the result 
of certain morbid processes which terminate 
in the destruction of portions of the pulmo- 
nary tissues, abnormal spaces or excavations 
are frequently formed in the lungs, which 
are designated cavities or vomicce. These are 
usually associated with, and are by far most 
important in that large class of cases which 
are grouped under the term Phthisis. They 
may, however, originate under other condi- 
tions, namely, as the result of abscess or 
gangreqe of the lung ; of the destruction of 
morbid growths or hydatid cysts ; of dilata- 
tion of the bronchi; or of destruction of the 
pulmonary tissue from without, in connexion 
with glandular disease, empyema, and other 
lesions. The most recent observations on 
this subject are given in the article Vomica. 
Pulmonary cavities present wide variations 
in different cases as regards their number, 
size, shape, condition of their walls, amount 
and nature of their contents, and other par- 
ticulars. Usually they begin to form in the 
upper part of one lung, but subsequently 
they are produced in other parts, frequently 
both lungs becoming more or less involved, 
and any portion may be excavated in the 
first instance. A cavity frequently goes 
through certain stages, namely, those of for- 
mation and extension ; of arrest ; and of 
healing or contraction, which may terminate 
in ultimate closure and obliteration of the 
vomica. Enlargement of cavities is effected 
either by progressive implication of their 
walls, terminating in their disorganisation 
and removal ; or by coalescence of adjacent 
spaces, the intervening lung-tissue becoming 
destroyed. During this process of destruc- 
tion some of the tissues often escape more 
or less, especially the vessels, which may not 
uncommonly be seen traversing the spaces or 
running along their walls, their channel being 
obliterated. When an excavation is arrested 
in its progress, it becomes lined by a smooth 
membrane, and a more or less purulent fluid 
is secreted within it. This cessation of active 
mischief may not take place until a whole 
lobe, or even the greater part of the lung, 
is involved, a huge cavity being formed, 
which presents no tendency to contract. In 
other instances the progress of destruction 
is stayed, the formation of purulent matter 
is checked and finally ceases, a fibroid tissue 
forms, and the space undergoes a process of 
contraction or cicatrisation, which may end 
in a complete cure, but more commonly 
merely diminishes the size of the vomica 
more or less. At a post-mortem examination 
in cases of phthisis it is common to find 
numerous cavities in the various conditions 
and stages indicated above. Occasionally a 
vomica gives way into the pleura, followed by 
pneumothorax and its consequences. 
Clinically, the existence of cavities in the 
lungs can only be ascertained positively by 
physical examination of the chest; and as a 
rule not only their presence, but their condi- 
tions, may by this means be determined with 
tolerable accuracy. The physical signs vary 
considerably in different cases, and are 
more conveniently described in other articles. 
See Phthisis ; Physical Examination ; and 
Vomica. Frederick T. Roberts. 
CELL (cella, a cell in a honeycomb; a 
closed chamber).-The term ' cell ' was for a 
long time applied in anatomy to various spaces 
in the body large enough to be recognisable by 
the naked eye; hence ' cellular ' tissue, a name 
which is still often used to designate areolar 
or connective tissue. But the word came after- 
wards to be applied by botanists in an entirely 
different sense, namely, to the hollow, bladder- 
like particles of which many of the parts of 
plants were shown by the microscope to be 
composed; and the name was extended so as 
to apply to similar particles in the animal 
body. It has since been retained and used in 
histology in that sense, although it has long 
been recognised that these particles, whether 
in plants or animals, but especially in the 
latter, do not necessarily conform to the ori- 
ginal definition of a cell, the principal factor in 
which was the presence of a definite cell-wall. CELL 
297 
Cells may be either free or fixed. Instances 
of free cells are to be found in the white cor- 
puscles or leucocytes which occur in blood, in 
lymph, and pus, and which constitute the bulk 
of lymphatic or lymphoid (adenoid) tissue. 
As instances of fixed cells may be mentioned 
the various kinds of epithelium cells; the 
fixed cells of the connective tissue, including 
cartilage and bone; the cells of nervous tissue; 
and those which constitute the several kinds 
of muscular fibres. To these may be added 
the cells of most tumours. 
All the cells in the body can be shown to 
have been ultimately derived from the ovum 
or egg-cell, which, after impregnation by and 
union with a spermatozoon or sperm-cell, 
divides at first into two, these again into two, 
and so on by a binary process of subdivision 
until a small mass of cells is ultimately pro- 
duced. As the cells continue to multiply, this 
mass presently becomes hollowed out by the 
accumulation of fluid in its interior, and is 
converted into a vesicle the wall of which is 
eventually found to show an arrangement of 
its component cells in three layers, which 
collectively form the blastoderm. The three 
layers are termed respectively, from without 
in, the epiblast, mesoblast, and hypoblast, and 
give origin in course of development to the 
different tissues and organs of the body. The 
epiblast produces the cuticle and nervous 
tissues, and the essential parts of the sense 
organs; the mesoblast the muscular and con- 
nective tissues, including the blood and blood- 
vessels ; the hypoblast forms the epithelium 
of the alimentary canal, and of the glands 
which open into it, including the epithelium 
of the pulmonary air-passages. 
Cells vary very much in size, but few are 
large enough to be visible to the naked eye. 
Every cell in the body possesses one or more 
nuclei, although in some cells, in conse- 
quence of chemical alterations, the nucleus 
may have disappeared completely. Such 
cells are, however, invariably dead, and un- 
dergo only passive changes; of the living 
cell the nucleus appears, at least in all the 
higher animals and plants, to be an essential 
part. 
The main part of the cell, in which the nu- 
cleus is embedded, is known as the cell-body 
or cell-substance. In most cells it is chiefly 
formed by a soft albuminous material, named 
protoplasm. It is upon the presence of 
this material that the so-called ' vital ' phe- 
nomena which are manifested by the cell 
obviously depend, such as the amceba-like 
movements or changes of shape which are 
exhibited by free cells such as the white 
blood-corpuscles ; the production, storage, 
and eventual expulsion from the cell of 
materials which are to take part in the 
formation of the secretions, as in the fixed 
cells of glands; and the internal changes, 
molecular or molar, which result in the wave- 
Hke transmission of impulses or movements, 
as is seen in the manifestations of activity 
which occur in muscle, nerve, and in ciliated 
cells. Most of these changes are or may be 
produced or modified by the incidence of ex- 
ternal stimuli; and the property by virtue of 
which the protoplasm responds to these or 
other (unknown) stimuli is termed its ' irrita- 
bility' or ' excitability.' 
When protoplasm is examined chemically 
in the dead state it is found to be mainly 
composed, besides water, of certain forms of 
globulin and albumin, which do not mate- 
rially differ from those which occur in fluids, 
such as egg-albumen and blood-serum, which 
exhibit none of the phenomena of life. But 
there is reason to believe that the molecular 
constitution of the protoplasm is very diffe- 
rent during life from that which is found after 
death, being in the former condition of an 
especially unstable character and undergoing 
changes with great readiness. It is indeed 
in the highest degree probable that chemical 
and physical changes are continually pro- 
ceeding during life, and that the chemical 
changes are of two antagonistic kinds, the one 
kind tending to produce a building up of fresh 
protoplasmic substance from the proteid and 
other material supplied by the blood and 
lymph, and the other kind tending to produce 
a breaking down of such substance, and a 
formation of simpler products. To these two 
hypothetical antagonistic processes which pro- 
ceed during life, the terms anabolic and kata- 
bolic have been applied, while to the whole 
of the chemical changes which go on, both in 
the individual cells and in the collective or- 
ganism, the name metabolism is given. 
The forms assumed by the cells are very 
various; thus they may be spherical, ovoidal, 
spindle-shaped, flattened or scale-like, co- 
lumnar, stellate-in short, of any conceivable 
shape. Fixed cells retain the same shape for 
an indefinite time, or undergo only passive 
alterations; free cells are frequently observed 
to alter their shape continually by the spon- 
taneous protrusion and retraction of processes 
of their protoplasm (pseudopodia). These 
spontaneous changes or amoeboid movements 
may, under certain circumstances, produce an 
actual locomotion of the cell, as is noticed to 
occur in the process of diapedesis, or passage 
of the white blood-corpuscles through the 
walls of the capillaries and venules. 
Cells may lie scattered and isolated in a 
tissue, or they may be united by their pro- 
cesses into a network, as in the connective 
tissues, or closely packed and joined edge to 
edge to form either a membranous stratum 
or a solid mass of cells, which may constitute 
the bulk of the tissue to which the cells be- 
long, as in the epithelial tissues. Or the cells 
of a tissue may undergo special development 
and structural modification, associated with 
the assumption of special properties of con- 
duction and contractility, as in the nervous 
and muscular tissues. In ciliated epithelium 298 
CELL 
the protoplasm of the cell is prolonged at the 
free border into minute hair-like projections, 
which during life execute a spontaneous lash- 
ing movement (vibratile cilia). 
In spite of the numerous researches which 
have been made of late into the structure of 
cells, very little is known regarding the struc- 
ture of the protoplasm. Until a comparatively 
recent date it was described as entirely with- 
out structure ; and in many cells, especially 
those of the free type, it is difficult to make 
out any definite appearance of structure, 
especially in the living condition. It is true 
that under the influence of certain hardening 
re-agents, such as alcohol and chromic acid, 
a reticular appearance is produced in proto- 
plasm, but the same appearance can equally 
well be produced in solutions of albumin and 
mucin under similar circumstances, so that 
the reaction in question by no means proves 
that the apparent structure is preformed; 
and it is still the opinion of some histologists 
that protoplasm is essentially structureless. 
It is certain, however, that in many fixed cells 
a network may be observed even in the living 
condition, the nodes of the network causing 
a characteristic finely granular appearance in 
the protoplasm, and most cytologists accord- 
ingly describe the living substance of a cell as 
being composed of a spongework (spongio- 
plasm reticulum), and interstitial matter or 
matrix occupying the meshes of the sponge- 
work (hyaloplasm enchylemd). Whether the 
vital phenomena exhibited by protoplasm de- 
pend upon the spongioplasm or the hyaloplasm, 
or belong to both these parts of the living 
substance, is entirely unknown. 
The protoplasm of a cell may contain other 
materials embedded in its substance, which 
may either have been formed by the proto- 
plasm from materials obtained from the blood, 
or in the case of ' free cells ' may have been 
taken bodily into the cell-protoplasm by aid 
of the amoeboid movements of which these 
cells are capable (inception of particles). These 
materials may be in the form of granules of 
albuminous, fatty, or carbohydrate nature, or 
of globules of watery fluid containing sub- 
stances in solution (vacuoles). Such non- 
protoplasmic ingredients of the cell-substance, 
when occurring within the cell as ordinary 
products of its nutrition, are collectively 
termed deuteroplasm. This term also includes 
such portions of protoplasm as may have be- 
come converted within or at the surface of 
the cell into non-living material, as when the 
external layer of protoplasm becomes trans- 
formed by physical and chemical alterations 
into a firmer and more resisting covering to 
the cell, which thus becomes invested with a 
cell-ivall. Pathological changes in cells are 
usually due to chemical transformations of 
the protoplasm, which in this case are usually 
termed degenerations, such as the fatty, 
mucous, and colloid. 
Every cell in the body possesses at least one 
nucleus, but some cells-e.g. the white blood- 
corpuscles-may have two or three nuclei; 
and others, such as the giant-cells which are 
met with in normal red marrow and in certain 
pathological formations, may contain a large 
number. The nucleus of a cell is usually 
spherical; it is situated near the centre of 
the cell, and appears to possess the function 
of presiding over the nutritive changes of the 
protoplasm, as well as that of initiating the 
division of the cell. 
Most nuclei have a well-marked reticular 
structure, which is visible even in the living 
cell unaltered by reagents. The filaments of 
the network have the property of becoming 
darkly stained by haematoxylin and many 
other staining reagents; hence the substance 
of which they are composed has been termed 
chromatin, to distinguish it from the part of 
the nucleus which remains unstained, and 
which is termed in contradistinction achro- 
matin. The filaments are aggregated at the 
surface of the nucleus into a closely reticu- 
lated membrane, which serves to limit the 
nucleus externally. The nodes of the network, 
as seen in optical sections of the nucleus, give 
the latter a coarsely granular appearance, 
especially because the substance of the fila- 
ments tends to become aggregated at the 
nodes. Besides these aggregations there are 
usually present in the nucleus one or two 
larger masses of chromatin, staining some- 
what differently from the rest, and not always 
situated at a node of the nucleus network. 
To these larger masses the term nucleoli is 
applied. In some nuclei the usual network 
is replaced by a sort of convoluted skein of 
nuclear filaments, the latter being somewhat 
thicker than usual, and exhibiting, when suffi- 
ciently magnified, a peculiar transversely stri- 
ated appearance. This condition is, however, 
usually only met with in nuclei which are 
about to undergo division. 
The division of the nucleus was formerly 
believed to occur by a simple process of fission, 
preceded by the division of the nucleolus. It 
is doubtful, however, if this simple process of 
direct division occurs regularly in any cells. 
In nearly every case of cell-division, both in 
normal tissues and in pathological forma- 
tions, the nucleus undergoes a complete series 
of changes, which are collectively known 
under the name karyokinesis or karyomi- 
tosis, and which result in the division first 
of the nucleus and ultimately of the cell 
(so-called indirect division). The changes 
which are thus undergone are as .follows :- 
The whole of the chromatin, including the 
substance of the nucleoli and the membrane 
of the nucleus, first becomes collected into 
one or more filaments, which have a convo- 
luted skein-like arrangement, the skein being 
at first closely wound, and its filament or fila- 
ments fine, but becoming gradually more 
open, and its filaments coarser. Next, it is 
found that the skein has become subdivided CELL 
CELLULITIS 
299 
into a definite number of short filaments, 
which often assume a bent, V-shaped form, 
with the apices of the V's directed towards 
the centre of the nucleus (aster phase). The 
V's then undergo an alteration in relative 
position, becoming interlocked at the equator 
of the now elongated nucleus, and having 
their apices directed towards the two poles. 
Usually at this equatorial phase of karyo- 
kinesis the filaments undergo a process of 
longitudinal cleavage, so that there are now 
twice as many as before. The resulting finer 
V-shaped filaments then begin to pass into 
two groups, which gradually tend towards 
either pole of the nucleus, assuming as they 
pass thither a radiate arrangement, with 
the apices of the V's towards the centre 
of each group. This is the dyaster phase. 
Finally, in each of the two groups, the V- 
shaped filaments unite end to end to form a 
skein, which subsequently becomes converted 
into a network, and the formation of the 
daughter-nuclei may now be regarded as com- 
plete. Around each one the corresponding 
half of the protoplasm of the cell becomes 
aggregated, so that two daughter-cells have 
become formed by division of the parent-cell. 
While these changes are going on in the 
chromatin of the nucleus, others are proceed- 
ing in the achromatin substance. Within this 
a spindle-shaped system of the finest possible 
fibrils makes its appearance, both the poles 
and the equator of the spindle corresponding 
with those of the nucleus. At each pole of 
the spindle is a spherical particle termed the 
polar particle, and from this particle other 
fine fibrils radiate into the adjacent proto- 
plasm, so that a system of achromatic fibres 
penetrates not only through every part of the 
nucleus, but throughout the greater part of 
the protoplasm of the cell as well. The fibres 
of the nuclear spindle appear to serve as 
directing lines along which the above-de- 
scribed movements of the chromatic filaments 
towards the poles of the nucleus occur, and 
the equator of the spindle determines the 
plane of separation both of the nucleus and 
of the cell.1 E. A. Schafer. 
CELLULITIS. - Definition. - Cellu- 
litis is the term applied to inflammation of 
the cellular or loose connective tissue, chiefly 
the subcutaneous areolar tissue, but also that 
interposed between muscles and viscera, or 
surrounding various organs. 
The areolar connective tissue is so univer- 
sally distributed throughout the body, that it 
is necessarily concerned in most inflamma- 
tions-no matter of what structure ; and in 
it, in fact, the chief changes generally take 
place. 
To consider completely the pathology of 
inflamed connective tissue would, be more or 
less to review the whole series of the acute 
diseases. We must limit our consideration 
to cases in which the cellular tissue is the 
chief or only tissue involved, or where changes 
in other parts are secondary to those primarily 
affecting the cellular tissue. 
Beneath the skin, over the whole surface 
of the body, lies a layer of this tissue, con- 
taining within its meshes more or less adipose 
matter. It will be convenient to consider 
the changes which occur in it when inflamed, 
as they are identical with those in cellular 
tissue elsewhere. 
Inflammation of the subcutaneous cellular 
tissue may be either diffuse or circumscribed, 
which are varieties rather in degree than in 
kind. The former is nearly always acute in 
type; the latter often, but not invariably so. 
A chronic form of cellulitis causing thicken- 
ings is observed in various regions, or it may 
be a sequel to the acute disease. The acute 
form of the disease is clinically similar to 
phlegmonous erysipelas, and is characterised 
by a spreading inflammation without ten- 
dency to arrest. 
1. Circumscribed Cellulitis.-Etio- 
logy.-Any injury to a part, whether of the 
nature of a wound or contusion; an impacted 
foreign body; or a fragment of bone, may 
cause cellulitis. Septic absorption from any 
decomposing secretion in a wound, altered 
blood, or infiltrated urine is prone to pro- 
duce marked inflammatory changes in the 
connective tissue in different parts of the 
body. The poison introduced in a dissection- 
or post-mortem wound often occasions an 
acute cellular inflammation. Frost-bite, 
burns, inflammation of viscera, arteries, veins, 
or periosteum may produce inflammation of 
the adjacent cellular tissue; thus, inflam- 
mation of the kidney may cause perinephritis; 
inflammation of the uterus may lead to pelvic 
cellulitis; or some mischief in the greater 
bowel or rectum may produce inflammation 
and abscess in the loose cellular tissue around 
them (perityphlitis or ischio-rectal abscess); 
the poison also of scarlatina causes cellulitis 
of the submucous areolar tissue of the throat; 
and angina Ludovici is the name given to 
the cellulitis of the floor of the mouth and 
neck which is often associated with symptoms 
of intense septicaemia. A sympathetic bubo 
is an irritated lymphatic glandcausing inflam- 
mation of the cellular tissue around it. 
Pathology.-Pathologically, areolar con- 
nective tissue is of the greatest importance 
in the organism, being the most frequent 
seat of inflammatory and other changes. 
It mainly consists of loosely interlaced 
bundles of fibrous tissue, with flattened con- 
nective-tissue corpuscles adherent to them, 
and leucocytes, or amoeboid corpuscles, in 
1 It is difficult to make these changes in the cell 
and cell-nucleus perfectly clear without the aid of 
illustrations. The reader who desires a more com- 
plete account of the subject is referred to Quain's 
Anatomy, 10th edition, vol. i., where also a list of 
recent articles dealing with the question will be 
found. 300 
CELLULITIS 
the areolae. The exact part played in in- 
flammation by the cellular elements is not 
quite settled. Under ordinary circumstances 
the leucocytes doubtless proliferate, and the 
fixed corpuscles probably do so also. Even 
under the influence of a slight irritation the 
flattened corpuscles in a few hours become 
globular, and present many nuclei in their 
interior-changes certainly pointing towards 
proliferation; while the very rapid, increase 
of cells which takes place points to their 
derivation from cells pre-existing in the part, 
although the immigration of leucocytes from 
the blood into the inflamed part adds con- 
siderably to their numbers. Whether the 
perversion of nutrition which forms the start- 
ing point of the disease first induces a local 
cell-proliferation, or an immigration of leu- 
cocytes, or what proportion these two pro- 
cesses bear to each other, is difficult to deter- 
mine. 
The disease consists essentially in a very ac- 
tive cell-proliferation and increase. Whether 
the cellulitis be circumscribed or diffuse, 
similar changes occur; the difference be- 
tween the varieties being that in the former 
there is formed a limiting zone of vascular 
tissue resembling granulation-material, which 
is absent when the inflammation is diffuse. 
There are otherwise no anatomical differ- 
ences. When cellular tissue inflames, the 
part swells from the sero-fibrinous exudation 
poured out from the distended capillaries; 
its meshes are filled with young round cells, 
partly by proliferation of the connective- 
tissue corpuscles, in part by the accumulation 
of migrating leucocytes; and the circulation 
is interfered with by the pressure of the effu- 
sion, complete stasis sometimes taking place. 
While the cell-increase is proceeding, the 
fibrillar intercellular substance gradually 
disappears, in part by necrosis, and in part 
by becoming liquefied; and the tissue is 
finally transformed into pus. When this 
has happened the deeper layers of the skin 
disintegrate; it becomes undermined and 
gradually thinner; necrosis in one or more 
places follows; and the pus mingled with 
shreds of dead cellular tissue escapes, the 
latter resembling nothing so much as soaked 
washleather. The pus, at first thin and 
serous, subsequently becomes laudable. There 
is always a great tendency to suppuration, 
the vitality of areolar tissue being very low; 
but resolution sometimes takes place with- 
out formation of pus. The consequences of 
cicatrisation differ, according to the tissue or 
organ involved and the extent of the disease; 
but essentially they are similar everywhere. 
A gradual contraction sets in. In external 
parts we can observe atrophic changes taking 
place, followed sometimes by deformity or 
loss of function, while in the viscera the 
condition is known as cirrhosis. The special 
tissue of an organ or of a muscle cannot be 
reproduced ; it is replaced after an injury by 
connective-tissue cicatrix. In such tissues 
as bone, tendon, and nerve, however, the 
cicatrix will usually be converted into the 
normal tissue of the part. 
Symptoms.-The amount of fever varies 
with the extent of the disease and the nature 
of the cause. When the cellulitis is quite 
limited there may be little or none, but deep- 
seated or extensive cellulitis produces con- 
siderable constitutional disturbance. Painful 
swelling of the inflamed part will first be 
observed; the skin soon becomes tense, red, 
and oedematous, although at the outset it is 
sometimes paler than normal. The redness 
is gradually lost towards the periphery of the 
swelling, and is darker, or of a bluish-red 
tint in the centre, from the obstruction to 
the exit of blood; the swelling is doughy, 
inelastic to the touch, and pits on pressure. 
The inflamed region feels hard, the indura- 
tion ceasing by no well-defined border. If 
resolution occur all these symptoms subside. 
A greater or less amount of thickening of 
the tissue may, however, persist-often for a 
lengthened period, the parts slowly return- 
ing to their normal state. In the central 
portion suppuration is, however, the rule. 
When it occurs, the pain and tension dimin- 
ish ; fluctuation is felt-obscure at first; the 
pus by degrees approaches the surface, and 
escapes spontaneously, or by an artificial 
outlet which may be provided. When the 
inflammation is more deeply placed, espe- 
cially when beneath strong fasciae, there will 
at first be no well-marked redness or swelling 
of the skin, or only a slight pinkish hue, with 
some oedema, to indicate the changes taking 
place beneath ; and fluctuation may be diffi- 
cult or impossible to make out long after 
pus has formed; but the pain and fever are 
considerable. This variety of the disease 
may also terminate in resolution-especially 
when early and appropriate treatment has 
been adopted; or in suppuration. It may 
also become chronic; or relapses may take 
place after temporary amendment. If the 
cause of irritation be a slight one, but re- 
peatedly renewed, permanent thickenings or 
atrophic changes in the tissue may result; 
or the circumscribed may be converted into 
diffuse cellulitis. A very intense irritant 
sometimes induces gangrene. The same 
event may happen if a previously diseased 
tissue be attacked, as an anasarcous limb; 
or pressure, associated with the cellulitis 
accompanying the formation of bed-sores, 
may be sufficient to cause it. 
2. Diffuse Cellulitis.-Synon. : Diffuse 
phlegmon; Pseudo-erysipelas; Diphtheria of 
the cellular tissue.-This is a severe disease, 
attended by general symptoms of a marked 
character, frequently associated with septi- 
caemia, of which it may be both a cause and 
an effect. 
Etiology.- The most frequent cause of 
diffuse cellulitis is some form of septic in- CELLULITIS 
301 
fection. In the extremities the disease may 
originate from some trifling cause, especially 
in those whose constitution is impaired by 
age, privation, or excess; in the hand and 
forearm of such persons it is especially 
common after wounds on the finger or an 
insignificant whitlow. In convalescence from 
acute febrile diseases, especially typhus or 
typhoid, a local phlegmon is sometimes 
transformed into a diffuse cellulitis. 
Symptoms.-The local symptoms of diffuse 
cellulitis resemble those of the circumscribed 
form, but are more intense : the disease is not 
limited, and it is accompanied by severe 
constitutional disturbance. 
A sudden rigor with elevation of tempera- 
ture often ushers in the attack; the rigor 
may recur at intervals, but sweating is 
unusual, and vomiting infrequent. In the 
affected region the patient experiences a 
great sense of weight and distension, with 
severe dragging pain. When the inflamma- 
tion is deep-seated the changes in the skin 
may not be well-marked, even after a con- 
siderable extent of the cellular tissue has 
perished. This peculiarity is a very dan- 
gerous one, because it leads to the nature of 
the affection being for a time overlooked 
and efficient aid postponed. When the skin 
participates, the redness is duskier in hue, 
less sharply defined, and less easily dispersed 
by the pressure of the finger than in the 
cutaneous inflammation of erysipelas, while it 
soon becomes cedematous. The affected area 
feels brawny, hard, and swollen throughout, 
and is extremely tender and painful; sleep 
is interfered with; any movement causes 
great suffering; the fever is often very high ; 
the secretions are diminished; and the appe- 
tite is lost. Rigor and sweating presently 
announce the formation of matter. The 
swelling becomes less prominent and more 
soft; the skin is mottled, thinned, and yield- 
ing in places; and the fever and pain subside. 
Convalescence may take place on the evacua- 
tion of the pus; or the rigor may be renewed, 
the fever reappear or continue, and the patient 
sink with symptoms of blood-poisoning. The 
more deeply the inflammation extends the 
more tedious is recovery, and the more liable 
is the patient to relapse. The muscles, 
tendons, and adjacent joints may become 
involved in the suppuration; or perforation 
of a dangerous character of neighbouring 
cavities or organs may take place. Suppura- 
tion consequent upon diffuse cellular inflam- 
mation will sometimes extend up the forearm 
to the elbow, undermine the skm, dissect the 
muscles, open into the finger- and wrist- 
joints, cause necrosis of tendons, and ter- 
minate in the loss of the limb by amputation, 
or perhaps in loss of life from septic poisoning. 
Should recovery ensue, the limb is often 
permanently crippled from the matting to- 
gether of muscles and tendons, the impaired 
mobility of the joints, and the adhesions that 
take place between tissues which should 
freely glide over one another. Suppuration 
is the rule, but under favourable circum- 
stances, and with early and suitable treatment, 
it may occasionally be prevented. Usually 
pus has already formed when the case comes 
under observation, and the surgeon has only 
to use his bistoury to evacuate the matterand 
thus limit the spread of the disease. 
The irregular cavities and sinuses left after 
the evacuation of the dead tissue often sup- 
purate for a long time, and this may lead to 
amyloid degeneration of the viscera. The 
thromboses which form of necessity in the 
smaller veins implicated in the inflamed area 
may break down and lead to septic embolism 
and pyaemia. The risk of this complication is 
a serious and ever-present one in these cases. 
Diagnosis.-Cellulitis has chiefly to be 
diagnosed from erysipelas. Erysipelas may 
involve the subcutaneous tissues, and cause 
inflammation and suppuration of the connec- 
tive tissue, but it always begins in the skin, 
which is more extensively affected. Inflam- 
mation of the cellular tissue begins beneath 
the skin, where the swelling and effusion 
first take place ; the skin becomes involved 
later, and usually to a less extent, while it 
may remain, at least for some time, almost 
entirely free ; the redness, too, is less bright, 
and more diffused, not presenting the distinct 
margins of erysipelas, but fading into the 
surrounding parts. In the later stages the 
two conditions are scarcely distinguishable. 
At first it may be difficult to decide whether 
the case is one of inflammation of the sub- 
cutaneous cellular tissue, of the intermuscular 
areolar tissue, or of that connected with the 
periosteum, or around a vein. The greater 
the general swelling of the limb, the more 
considerable the fever and the pain, and the 
less the redness of the skin, the more probable 
is it that the inflammation affects the more 
deeply seated structures. 
Prognosis.-The prognosis of cellulitis de- 
pends on the extent and severity of the disease 
and the constitution of the patient. 
Treatment.-The local cause should be 
removed, as far as practicable. If the wound 
be in a foul condition it should be rendered 
aseptic. Absolute rest to the inflamed parts 
is of great importance. So long as suppura- 
tion has not occurred, resolution is possible. 
Graduated pressure can rarely be tolerated. 
Blistering is not employed in the acute form, 
but may be useful in removing more chronic 
changes. Cold applications and ice may 
abate pain and inflammation, but in many 
cases warm fomentations and poultices give 
relief. In the more advanced stages, espe- 
cially when they tend to become chronic, cold 
is useless or even dangerous, from liability to 
cause gangrene in debilitated subjects. Local 
blood-letting does not prevent suppuration, 
and is usually contra-indicated by the weak 
state of the patient. When pus forms, or 302 
its presence is suspected, a sufficiently free 
outlet should be provided for it as soon as 
possible. Nothing so effectually checks the 
further spread of the disease. The incision 
should be made at the most prominent 
point. It is often better to make a num- 
ber of small incisions, from half an inch 
to an inch in length, than one long one, 
which is apt to be followed by serious bleed- 
ing, and does not so efficiently relieve the 
strangulated tissues. When suppuration is 
only suspected, incisions should nevertheless 
be practised without delay, without waiting 
for fluctuation. Pus and shreds of dead 
cellular tissue should be frequently washed 
out of the wound with an irrigator. No 
force should be used to remove portions of 
dead tissue; any dragging tends to rupture 
the small blood-vessels, and to destroy the 
remaining connexions of the skin with the 
deeper structures. Antiseptic precautions 
must be zealously carried out. 
When a joint is involved, or when the pa- 
tient is exhausted by the discharge, and the 
tissues are spoiled, amputation is often neces- 
sary. Excision may be practised if the con- 
dition of the soft parts admits of it. But these 
are points for the surgeon's consideration. 
The general treatment consists in giving 
nourishing food and stimulants, combined 
with opiates to relieve pain, and iron, 
quinine, and other tonics. 
William Mac Cormac. 
CEPHALALGIA (KF0aX>), the head; 
and aXyoy, pain).-Pain in the head. See 
Headache. 
CEPHALHEMATOMA the 
head; aqxa, blood; and oma, a formative suffix 
indicating a tumour). 
Definition.-An effusion of blood occurring 
in newly born infants, forming a tumour upon 
the head ; situated beneath the pericranium, 
upon the surface of the skull; or more rarely 
beneath the skull, between it and the dura 
mater. w 
Description.-This disease is of very 
rare occurrence, and must not be confounded 
with the caput succedaneum, which is an effu- 
sion of serum external to the pericranium, 
and of common occurrence. The blood is 
generally extravasated immediately beneath 
the pericranium, over one of the parietal 
bones, most frequently the right, but it may 
occur over the frontal or occipital. Com- 
bined with this, or arising independently, 
but of extreme rarity, may be an effusion 
beneath the cranium. The origin of cephal- 
haematoma has been attributed to a variety 
of causes, but is most probably due to the 
constriction of the margin of the os uteri 
during labour. It is generally observed 
some hours or a day after birth, as a cir- 
cumscribed swelling, slightly tense and fluc- 
tuating ; and its peculiarity consists in a 
bony circle surrounding and limiting it. 
CELLULITIS 
Diagnosis. - These tumours have been 
mistaken for hernia cerebri; but their situa- 
tion over the bone away from the fontanelles, 
the absence of pulsation, and the existence 
of fluctuation in cephalhsematoma should 
prevent this mistake. 
Prognosis.-Generally the blood becomes 
absorbed, but occasionally suppuration oc- 
curs, or the bone may become necrosed; if 
beneath the skull, serious consequences, in- 
cluding idiocy, may ensue. 
Treatment.-As a rule, cephalhematoma 
is not to be interfered with. If suppuration 
take place the pus must be evacuated. 
Clement Godson. 
CEREBELLUM, Lesions of.-The 
cerebellum is liable to the same diseases as 
the brain and nerve-centres generally, such 
as haemorrhage, abscess, various forms of de- 
generation, tumours, &c. The nature of the 
pathological condition is to be determined by 
the symptoms peculiar to each, so far as this 
is possible. Its locality in the cerebellum is 
to be diagnosticated, first, by certain symp- 
toms which are due to the cerebellar lesion 
as such, which may be termed the direct 
symptoms; and, secondly, by those symp- 
toms which depend more on the influence 
exerted by the lesion on neighbouring or sub- 
jacent centres and structures. These latter 
may be termed the indirect symptoms. 
It is by no means easy to separate these 
symptoms from each other, and to say how 
much is due to interference with the functions 
of the cerebellum, and how much to inter- 
ference with the functions of other parts. 
There are few diseases which have a purely 
local organic or functional limitation. Hence, 
in order to arrive at the symptoms peculiar 
to cerebellar lesions, it is necessary to 
exclude all pathological affections which in 
their very nature affect the whole of the 
intracranial centres, such as tumours or men- 
ingitis. The most satisfactory conclusions, 
from a pathological point of view, are to be 
drawn from cases of atrophy or degeneration 
of the cerebellum, and, from a physiological 
point of view, from the results of the experi- 
mental lesions of this organ in the lower 
animals. 
The evidence from these two sources is 
mutually supporting. 
Direct Symptoms.- The characteristic 
symptoms of cerebellar disease are disorders 
of equilibrium, shown, on attempts at loco- 
motion, in a reeling or staggering gait (titu- 
bation), and a continual tendency to stumble 
or fall over the most trifling obstacle, or on 
hurried movements. 
These symptoms may be confounded with 
locomotor ataxy, but careful observation will 
show that in cerebellar disease there is no 
true ataxy. The movements are quite co- 
ordinated with each other, and are such as 
would instinctively be made to prevent fall- 
CEREBELLUM, LESIONS OF CEREBELLUM, LESIONS OF 
303 
ing, or to preserve the equilibrium; and have 
none of the precipitate, irregular, and sprawl- 
ing character seen in ataxy. They are not 
specially intensified on closure of the eyes, 
which is such a marked feature in ataxy. 
Nor are they accompanied by any of the 
sensory affections of ataxy, whether in the 
form of pains or anaesthesia. 
There is no true motor paralysis in cere- 
bellar disease as such, and the various 
volitional movements of the limbs can be 
carried out perfectly well in the recumbent 
posture. Sensation, general and special, is 
not directly affected in cerebellar disease. 
Nystagmus and strabismus have been ob- 
served, more particularly in connexion with 
lesion of the cerebellar peduncles. Defects 
of articulation have been noticed, but it is 
very doubtful whether they should be re- 
garded as direct symptoms. 
Lesions of the cerebellum may be entirely 
latent, or not cause any very obvious symp- 
toms during life. This has been observed 
in cases of congenital atrophy, or when the 
disease has been of a slowly progressive 
character, or limited to one lobe. Affections 
of the middle lobe are specially calculated to 
induce the characteristic symptoms. 
Indirect Symptoms.-Pain in the head, 
more particularly at the back, though not 
constantly situated there, is frequently asso- 
ciated with organic disease of the cerebellum. 
Vomiting is also very frequently observed, 
perhaps more constantly than in connexion 
with diseases of other parts of the brain. 
There is, however, no reason to regard this 
as due to cerebellar disease as such. It is pro- 
bably due to indirect effects on the medulla. 
As a general rule, diseases tending to en- 
croach on the space of the posterior fossa, 
or to increase the pressure in this region, 
have a similar effect. 
Hemiplegia is not uncommon in con- 
nexion with cerebellar disease, and more par- 
ticularly in cases of tumour or haemorrhage 
in the lateral lobe of the cerebellum. The 
hemiplegia is on the side opposite the lesion. 
This does not prove that the hemiplegia is 
due to the destruction of the cerebellar lobe, 
or that the cerebellar lobes have cross rela- 
tions with the limbs. Experimental physio- 
logy and anatomical investigations tend to 
show that the cerebellar lobes are function- 
ally related to the motor tracts on the same 
side. This is also borne out by the fact that 
atrophy of the lateral lobe of the cerebellum 
follows disease and degeneration of the oppo- 
site cerebral hemisphere. The hemiplegia 
from cerebellar disease is, therefore, in all 
probability, due to compression or some 
affection of the subjacent motor tracts, which 
decussate at the pyramids. The fact that it 
occurs chiefly when the disease is limited to 
the lateral lobe is what might be expected on 
anatomical grounds. 
Affections of sensation, common and 
special, have been observed in cases of cere- 
bellar disease. Diminution of tactile sensa- 
tion on the opposite side of the body, when 
the disease is situated in the lateral lobe, is 
to be accounted for in the same way as the 
motor paralysis. As regards the special 
senses, affections of sight have been most 
frequently noted. Sight is certainly not 
abolished by destruction of the cerebellum 
in the lower animals, and when blindness 
occurs in man in connexion with diseases of 
this organ, it is due either to implication of 
the corpora quadrigemina, functionally or 
organically, or to secondary degeneration in 
the optic tracts, as the result of neuritis. 
A special feature of tumours of the cere- 
bellum, more especially of the middle lobe, 
is a tonic rigidity of the muscles of the back 
of the neck, with retraction of the head, asso- 
ciated frequently with flexion of the forearms, 
and extension of the lower extremities and 
pointing of the toes. In these cases also, 
psychical affections, more particularly mental 
hebetude or stupor, occur as the result of 
secondary dropsy of the ventricles, caused by 
pressure on the veins of Galen. The symp- 
toms then become those of hydrocephalus. 
Haemorrhage into the middle lobe of the 
cerebellum, in addition to the ordinary symp- 
toms of apoplexy, has been frequently found 
to cause vascular excitement of the genital 
organs-in the male marked priapism. This 
symptom, of which several cases were first 
reported by Serres, led this -observer to 
modify the view of Gall that the cerebellum, 
as a whole, was related to the sexual instinct, 
and to regard the middle lobe only as having 
any such function. The facts, however, are 
susceptible of a totally different interpreta- 
tion, and one more in harmony with other 
data of physiology and pathology. It has 
been found experimentally by Segalas and by 
Eckhard that irritation of the posterior sur- 
face of the medulla and pons gives rise to 
vascular excitement of the generative organs, 
and hence the symptoms in cases of haemor- 
rhage into the middle lobe are to be ascribed 
to irritation of this region. This also ex- 
plains the absence of the symptoms when 
the haemorrhage occurs into the lateral lobes. 
There is absolutely no evidence of the slightest 
value in support of Gall's hypothesis. The 
facts of clinical medicine go a considerable 
way in diametrical opposition to it, if they 
are not themselves sufficient entirely to over- 
throw it. 
Cerebellar Peduncles.-Respecting the 
effects of disease of the restiform tracts or 
inferior cerebellar peduncles we have no 
definite knowledge. 
Cases, however, are on record in which 
lesions have been found involving principally 
either the superior or middle cerebellar 
peduncles. The symptoms, in the main, 
agree with those observed by Magendie on 
section of the middle peduncle in the lower  CEREBELLUM, LESIONS OF 
CEREBRO-SPINAL FEVER 
304 
animals. The chief effect of this lesion was 
to cause an irresistible tendency to roll over 
towards the side of lesion. Together with 
this rotatory disturbance of the equilibrium, 
a peculiar distortion of the optic axes was 
observed, the eye on the side of lesion being 
directed downwards and inwards, the other 
looking upwards and outwards. 
In a case described by Curschmann 
{Deutsches Archiv f. klin. Med. xii. 356), 
along with appearances of basilar meningitis, 
which somewhat complicated the case, there 
was found a focus of softening, surrounded 
by capillary haemorrhage, in the right 
superior cerebellar peduncle. The symptoms 
observed in this case were a rotatory distor- 
tion to the right side, to which position the 
patient invariably returned when resistance 
to this movement was withdrawn. There 
was no motor paralysis, nor was there any 
distortion of the optic axes. 
A case has been put on record by Nonat 
{Comptes Eendus, 181) of apoplectic extrava- 
sation into the right middle peduncle of the 
cerebellum and right cerebellar hemisphere. 
In this case the head and trunk were twisted 
towards the right side, and the ocular symp- 
toms were also present, the eyes being im- 
movable in a position of skew deviation. 
Other cases are on record in which the 
cerebellar peduncles have been involved in 
more extensive lesions; but the symptoms, 
though not opposed to those above related, 
are incapable of differential analysis. The 
special diagnostic symptoms, therefore, of 
lesion of the cerebellar peduncles are what 
are frequently termed ' forced movements ' 
{Zwangsbewegungen), or distortions of the 
normal axis of the trunk. The exact direc- 
tion of the distortion, in consequence of lesion 
specially limited to one or other peduncle on 
the right or left side respectively, is somewhat 
doubtful, though as a rule it has been found 
towards the side of lesion. Much, however, 
will depend on whether the lesion is of an 
irritative or inflammatory, or of a destructive 
character. A lesion of an irritative nature, 
though occupying the same position as a 
destructive lesion, would exactly reverse the 
direction of the distortion of the head and 
trunk. D. Ferrier. 
CEREBRAL ABSCESS.-See Brain, 
Abscess of. 
CEREBRAL APOPLEXY. - See 
Apoplexy, Cerebral. 
CEREBRAL ARTERIES, Diseases 
of.-See Brain, Vessels of, Diseases of. 
CEREBRAL HAEMORRHAGE.- 
See Brain, Haemorrhage into. 
CEREBRITIS.-Inflammation of the 
brain-substance. See Brain, Inflammation 
of. 
CEREBRO - SPINAL FEVER. - 
Synon. : Epidemic Cerebro-spinalMeningitis; 
the Black Sickness (popular, Dublin); Fr. 
Meningite ciribrospinale epidemique; Ger. 
Cerebral-Typhus', Epidemische Meningitis. 
Definition.-An acute epidemic febrile 
disease, characterised by sudden invasion, with 
extreme nervous shock, vomiting, excessive 
pain referred to the back of the neck and 
spine, spasmodic contraction of muscles, ex- 
cessive sensibility of the skin, and frequently 
delirium; accompanied by purpuric eruptions, 
either circumscribed, raised, hard, and shotty 
to the feel, or extensive purpuric spots or 
patches, frequently accompanied by vesicular 
eruptions, usually of herpetic but sometimes 
of a pemphigoid character ; and often puru- 
lent inflammation of the eyes. Post mortem 
there are found : inflammation of the mem- 
branes of the brain and spinal cord, especi- 
ally of the arachnoid, with deposit of white, 
yellow, or greenish-yellow lymph upon the 
surface of the arachnoid, especially at the 
base of the brain and anterior portion of 
the medulla oblongata and spinal cord, and 
effusion of serum into the ventricles and 
sub-arachnoid spaces. 
^Etiology.-Age.-Cerebro-spinal fever is 
more commonly met with among children 
under ten years of age; after childhood it 
usually attacks those approaching the age of 
puberty or in early adult life; it is seldom 
met with after the age of thirty-five years, 
and is very rare after forty. 
Sex.-The disease is much more frequent 
in adult males than females-robust males 
between the ages of fifteen and thirty are its 
chief victims; but among children it seems 
to attack both sexes almost equally. 
Occupation.-It seems specially to affect 
young recruits in the army, as was the case 
in the French epidemics. In Dublin it was 
specially severe among the recruits of the 
Royal Irish Constabulary stationed in the 
police barracks in the Phoenix Park. There 
does not appear to be any other occupation 
which predisposes to cerebro-spinal fever. 
Excessive fatigue seems to increase the 
liability to the disease : it has arisen after a 
hard day's hunting, foot-racing, long walks, 
dancing, or in children exhausted from out- 
door play. 
In epidemics it occurs in isolated localities 
far apart from one another: it does not seem 
to extend from a district to adjacent districts; 
thus resembling affections connected with 
marsh miasms, and evidently requiring some 
very special local conditions to secure its 
spread. Micro-organisms similar to those 
described in pneumonia have been found in 
connexion with this disease, but no microbe 
has been discovered which can as yet be 
specifically associated with it. 
Season and Climate.-Cerebro-spinal fever 
is widely distributed in the temperate zone. 
It prevails more in cold than in hot weather; CEREBRO-SPINAL FEVER 
305 
in Ireland it has usually prevailed in winter 
and early spring. 
General Sanitary Conditions.-It seems 
to be less influenced than most other epidemic 
affections by general sanitary conditions. 
Communicability.-It is generally believed 
not to be contagious. A few doubtful cases 
of contagion have been recorded; except, 
however, where it has appeared as an epi- 
demic among recruits, there are compara- 
tively few instances of more than one case 
arising in any particular house or circum- 
scribed locality. 
Epidemic Influence.-The disease is un- 
doubtedly epidemic in its character. 
Unwholesome Food.-It has been suggested 
that cerebro-spinal fever owes its origin to 
the use of breadstuff's made from diseased 
grain, but there is no proof of such being the 
case. 
Anatomical Characters.-Cadaveric rigi- 
dity is well-marked. Large purpuric patches 
form after death, even in cases where there 
were no purpuric symptoms during life ; in 
some cases the whole body has turned black. 
On incision a large quantity of dark, tarry- 
looking blood exudes; the muscles are darker 
than usual, and in prolonged cases much 
weakened and wasted. There is increased vas- 
cularity of the scalp; the cerebral sinuses are 
much distended with dark blood; and serum 
is found in the sub-arachnoid spaces and ven- 
tricles. All the membranes of the brain may 
be more or less congested, the arachnoid being 
always extremely vascular and opaque from 
deposits of lymph-this opacity varies from 
slight milkiness to thick and dense deposits. 
The most marked intracranial lesion is the 
white-yellowish or yelkwish-green ' fibrino- 
purulent' deposit found at the base of the 
brain. This deposit varies somewhat with the 
duration of the disease : in cases which die 
early the deposit is usually slight, whitish, 
and soft; in those which live for a week 
or so it is yellowish or greenish; in pro- 
longed cases the deposit is more white and 
pure, the effused serum greater in quantity, 
and the vascular fulness less. The origins of 
the nerves seem to be buried in and com- 
pressed by the deposit. The brain-substance 
itself is more vascular than normal, but not 
otherwise altered. In the spinal cord the 
lesions are similar to those found in the brain 
and its membranes. In some cases purulent 
infiltration of the eyeball, and effusion into 
the joints have been met with. The lungs, 
liver, and spleen have been found much con- 
gested and softened in many cases. 
Symptoms.-The patient is usually attacked 
suddenly, when apparently in vigorous health, 
by faintness, vomiting of greenish matter, and 
intense pain referred especially to the back of 
the head and neck; the extremities become 
cold; the patient becomes insensible and 
sometimes convulsed; the limbs become rigid. 
On recovering from the collapse, the patient 
complains of great pains in the head, back of 
neck, and along the spine; the head is drawn 
back, so as to be almost at a right angle with 
the spine; the whole back is sometimes 
arched, as in tetanus; the muscles become 
rigid, and the skip excessively sensitive ; neu- 
ralgic pains are also complained of in all parts 
of the body. In most of the severe cases 
eruptions appear within the first twenty-four 
hours. The eruption usually appears first on 
the legs, and is frequently confined to the 
lower extremities. The spots are usually black, 
raised, about a line in breadth, and feel like 
a grain of shot under the skin. Sometimes 
these raised spots are surrounded by a dark 
purplish areola ; in most cases large purpuric 
patches of many inches in extent form on vari- 
ous parts; sometimes they coalesce and cover 
the entire body. Vesicular eruptions are also 
common; these usually have the character 
of herpes, and are most frequent on the face, 
neck, and shoulders. The herpetic eruptions 
are met with as frequently in mild as in 
severe cases. Pemphigus sometimes appears 
in the advanced stages of the disease. When 
reaction sets in, the temperature is found to 
have risen to from 100° to 103° or 104° F., 
and in some cases has reached 107° F. In 
many cases the temperature never rises, and 
the patient dies in the stage of collapse ; the 
respiration becomes of a sighing character ; 
the pulse rises to about 120, and has a peculiar 
jerking character, giving a sharp upstroke to 
a sphygmographic tracing. 
The foregoing symptoms are very variable ; 
any one, or even a considerable number of 
them, may be absent throughout the whole 
course of the case. 
Complications and Sequel®.-Complica- 
tions connected with the nervous system are 
the most often seen. Paralysis of one or more 
limbs is common, of a hemiplegic character, 
and most frequently attacking the arm. 
Deafness is not very common, but has been 
met with in several cases, sometimes be- 
coming permanent. The eye-complications 
are among the most frequent and most 
serious. The eye may be attacked with a 
low form of inflammation, terminating in 
purulent infiltration of the whole or part 
of the organ ; the cornea is more frequently 
involved than any other portion; and this 
sometimes giving way, the whole contents 
of the globe escape, causing hopeless loss of 
the eye. The sight is also often permanently 
impaired by iritis, or opacity of the cornea. 
In many cases, however, the inflammation 
completely subsides. It is remarkable that 
it is the right eye which is usually attacked, 
that both eyes are seldom affected, and 
rarely the left eye alone. Acute inflamma- 
tion of the larger joints is a frequent com- 
plication in some epidemics ; this often 
terminates in purulent intra-articular effu- 
sion. Hsemorrhages are frequent in the 
more malignant forms, and are almost 306 
CEREBRO-SPINAL FEVER 
CHALAZION 
always present in cases where the purpuric 
blotches are of large extent; these haemor- 
rhages have occurred from the nose, uterus, 
bowels, kidneys, and ears in about the fore- 
going order of frequency. Gangrene is occa- 
sionally met with, and the cases in which it 
occurs are usually fatal; although toes have 
been lost, and yet the patient has recovered. 
The purpuric patches have also sloughed 
without serious danger to the patient's life. 
Diagnosis.-Cerebro-spinal fever is liable 
to be confounded with typhus fever, on account 
of the petechial rash, but is distinguished 
from it by the eruption appearing suddenly, 
without any previous mottling of the skin. 
The nervous symptoms also distinguish it 
from typhus, although in a case of typhus 
complicated with cerebro-spinal meningitis 
the diagnosis is extremely difficult, and may 
be impossible. It is distinguished from pur- 
pura hemorrhagica by the intensity of the 
fever, and the localised nervous symptoms. 
The malignant cases are more likely to be 
mistaken for malignant scarlatina than for any 
other disease, and must be distinguished there- 
from by the rash, sore-throat, and nervous 
affections; yet in some cases the two dis- 
eases have been indistinguishable from each 
other, especially where death occurred within 
twenty-four hours and both were epidemic 
at the time. In other cases malignant small- 
pox has been mistaken for this disease. 
Prognosis, Duration, Terminations, and 
Mortality.-The prognosis, duration, &c., of 
cerebro-spinal fever depend much upon the 
form the affection assumes, and for con- 
venience we may divide it into the following 
forms:- 
1st. Cases of a very mild form, terminating 
in recovery ; the duration being usually from 
one to three weeks. 
2nd. Cases of a very severe form, setting 
in suddenly ; the symptoms being very 
violent and well-marked, accompanied by 
purpuric spots and blotches, with a tendency 
to haemorrhages, with deep collapse and 
coma; usually terminating fatally in from 
a few hours to three days. 
3rd. Cases of medium severity, where all 
the nervous symptoms set in with less 
suddenness than in the second class of 
cases, purpuric blotches not being usually 
present, and no haemorrhages. These usually 
yield to treatment, and terminate in recovery 
in from two to six weeks. 
4th. Cases which set in either in a mild 
or in a severe form, but in which, on the 
subsidence of the fever, the strength does not 
return, convalescence is retarded or arrested 
altogether, and the patient falls into a 
general atrophic condition, and usually dies, 
in from three to six months, of marasmus. 
By deciding to which of the above classes 
the case belongs, the prognosis will be to a 
great extent determined. The chief indica- 
tion of danger is the early appearance of pur- 
puric and haemorrhagic conditions. Patients 
who have for from ten days to a fortnight 
escaped serious complications usually recover. 
The mortality in cerebro-spinal fever is 
very high-probably on an average about 
GO per cent. In some of the American 
epidemics it is placed as high as 75 per cent. 
Among the Irish constabulary it reached 80 
per cent. Like other epidemic diseases, the 
mortality is highest at the commencement of 
the epidemic. It is most fatal about the age 
of twenty, and less so under fifteen years. 
Treatment.-The treatment in the early 
stage must be directed to recovering the 
patient from the collapse. This is best done 
by the application of heat, the administration 
of small quantities of stimulants or stimu- 
lating enemata, and the application of sina- 
pisms over the chest and back. In the next 
stage of the disease attention must be almost 
altogether directed to allaying the spinal 
irritation, and promoting the absorption of 
the effused matters. The extreme irritation 
will be best diminished by the use of bella- 
donna and bromide of potassium. Ergot 
has also been found useful for this pur- 
pose. The pain, which is extreme, will yield 
best to frequent and considerable doses of 
opium ; indeed, many physicians have relied 
altogether on opium as the curative agent. 
Chloral hydrate has proved beneficial, in 
conjunction with bromides, in allaying rest- 
lessness and procuring sleep. With a view 
of promoting absorption of the effused mat- 
ters, mercury and iodide of potassium have 
been chiefly relied upon. In the more 
sthenic cases calomel may be employed with 
benefit in small and repeated doses. The 
disease being usually of an asthenic type, 
mercury will seldom be well borne, and 
iodide of potassium should be preferred. 
Leeches applied to the back of the neck, 
behind the ears, or to the temples, produce 
great relief of the excessive pain in the head 
and upper part of the spine. The application 
of ice to the head and spine temporarily allays 
pain, but there is little evidence of permanent 
benefit being derived therefrom. In pro- 
longed cases blisters applied along the spine 
have been favourably spoken of. The local 
complications must be treated as they arise, 
and according to general principles applicable 
in each case. Stimulants are required in 
considerable quantity in a very large number 
of the cases which present adynamic symp- 
toms. T. W. Grimshaw. 
CEREBRUM, Diseases of. - See 
Brain, Diseases of; also Convolutions of 
the Brain, Diseases of; Corpus Striatum, 
Diseases of; tic. 
CERES, in Cape Colony. - See 
Africa, South. 
CHALAZION (ydX^a, hail).-A smali 
encysted tumour of the eyelids, colourless and 
transparent, somewhat resembling a hailstone. CHALK-STONES 
CHANGE OF LIFE 
307 
CHALK-STONES.-This name is ap- 
plied to the deposits which are formed in 
connexion with the gouty diathesis, especi- 
ally in the joints. They are thus denomi- 
nated from their appearance and physical 
characters, in which they more or less 
resemble chalk ; but in their chemical com- 
position they are entirely different, consisting 
mainly of urate of sodium. See Gout. 
CHALYBEATE WATERS (chalybs, 
steel).-Mineral waters which contain iron. 
See Mineral "Waters. 
CHANCRE (Fr. chancre). - Hard 
chancre is the initial manifestation of 
syphilis. See Syphilis. For Soft chancre, 
see Venereal Disease. 
CHANGE OF LIFE.-Synon. : Cli- 
macteric epoch; Sexual involution; Fr. Meno- 
pause ; Ger. Menstruationsende. 
Definition.-The time of life in a woman 
when the functions of the uterus and ovaries 
cease, menstruation terminating-a period 
when disease of these organs is especially 
prone to occur, and when various constitu- 
tional disturbances are almost certain to arise. 
Anatomical Characters.-Great changes 
occur in the sexual organs-the ovaries lose 
their smooth outline, and after a while be- 
come shrivelled up, occasionally only a trace 
of them remaining; the Fallopian tubes di- 
minish in size, and sometimes become ob- 
literated; the walls of the uterus atrophy, 
its cavity becomes much smaller, and the 
cervix disappears altogether. 
Symptoms.-The term ' change of life ' is 
used among women very widely to signify 
everything which affects them at this critical 
time. It is so rare for the transition from 
activity to inactivity to take place without 
some disturbance locally, or constitutionally, 
that women are apt to neglect seeking advice 
for symptoms which should demand careful 
treatment, believing as they do that it is 
natural to suffer in such ways at ' the change.' 
There is no fixed period for the climacteric 
epoch, though roughly it may be said to 
occur between the ages of forty-five and 
fifty. Certain causes are apt to determine 
the time-amongst these are parturition and 
lactation, febrile attacks, such as typhus 
or acute rheumatism, profuse haemorrhages, 
fright, &c. 
The symptoms vary much. In some 
women the change is abrupt, menstruation 
ceasing all at once after perfect regularity; 
in others, and more frequently, the change 
is prolonged, the catamenia being irregular 
for many months, and varying as to periodi- 
city and quantity. Frequently, after a long 
interval, a profuse flow with clots occurs, 
and this is very often attributed to a mis- 
carriage. This loss is frequently beneficial, 
and if it do not take place, and if relief be 
not derived from vicarious discharges, such 
as bleeding from piles, the excess of blood 
gives rise to headaches, flushes, vertigo, and 
a host of other unpleasant symptoms. The 
balance between the nervous and circula- 
tory system is upset; irritability of temper, 
hyper-sensitiveness and all sorts of fancies 
arise, or depression sometimes amounting to 
melancholia ensues. If germs of disease 
exist, the uterus is especially prone at such 
times to develop them, so that carcinoma, 
fibroid disease, and polypus frequently pre- 
sent their first symptoms at this epoch. 
The importance, therefore, of an early exa- 
mination cannot be too forcibly dwelt on, 
or the mischief of delay from considering the 
abnormal condition as typical of ' the change 
of life,' and as a natural consequence, which 
will right itself. At these times pruri- 
tus of the vulva, vascular growths at the 
orifice of the urethra, and cutaneous eruptions 
are especially likely to occur. There is a 
tendency to grow fat, and to become coarse ; 
hairs frequently appear on the face. The 
breasts often become very large and pen- 
dulous, and this, with the increase in the 
size of the abdomen from flatus, and the 
deposition of fat in its walls, together 
with the cessation of menstruation, not in- 
frequently gives rise to the supposition of 
pregnancy. To this imaginary state the 
term pseudocyesis has been applied, and it 
is often almost impossible to set aside the 
opinion of the woman regarding her sup- 
posed condition. The headaches, neuralgia, 
loss of memory and nervous symptoms 
appear to be due to disturbance in the gan- 
glionic system of nerves, with which the 
uterus and ovaries are largely supplied. If 
insanity arise, the most common form it as- 
sumes is hypochondriasis or melancholia. 
Treatment.-This must be directed to 
regulating the secretions. Generally consti- 
pation, previously troublesome, becomes ag- 
gravated.; and portal congestion frequently 
occurs. Saline purgatives are especially 
beneficial, and these may be administered 
in the form of' mineral waters, such as 
Rubinat, Hunyadi Janos, or FriedrichshaU. 
Blue pill with aloes is often very useful. The 
headaches and reflex nervous symptoms may 
be best combated by the administration of 
bromide of potassium, and this drug appears 
to act as a direct sedative to the sexual 
organs, besides diminishing the amount of 
blood determined to them. Occasionally, 
bleeding from the arm or cupping gives 
great relief. Attention must above all be 
paid to the diet. It should be plain and un- 
stimulating : beer and spirits should be pro- 
hibited, and only light wines, if any, allowed. 
Tepid baths are useful. Late hours, heated 
rooms, and excitement of all kinds should be 
avoided. If local troubles arise, they must 
be treated according to their indications ; as 
a rule, abstracting blood from the uterus 
does harm, but leeches to the anus are some- 308 
CHANGE OF LIFE 
CHELOID 
times beneficial. It is clearly impossible to 
map out any empirical line of treatment for 
a condition in which the symptoms are so 
variable. Clement Godson. 
CHAPPED NIPPLES.-See Breast, 
Diseases of; and Nipple, Diseases of. 
CHAPS.-Synon. : Rhagades.-Cracks or 
fissures of the skin occur where the integu- 
ment has become hardened by infiltration, as 
in the erythema of the hands and wrists in 
cold weather, in chronic eczema, psoriasis 
and lepra vulgaris. The treatment for chaps 
consists in protection from the atmosphere; 
careful drying after the hands have been 
washed or wetted; and the use of zinc oint- 
ment and glycerine soap. Diluted glycerine, 
vaseline, and cold cream are also popular 
remedies. Erasmus Wilson. 
CHELOID {x^^ a claw).-Synon.: Che- 
loma; Er. Chiloide (Alibert); Ger. Keloid. 
Definition.-A tumour of the skin re- 
sulting from overgrowth of connective tissue 
within the corium. 
.Etiology.-Cheloma may be idiopathic 
or accidental; the former is, however, of very 
rare occurrence; and in both cases it is 
referable to a diathesis. When of accidental 
origin it is commonly associated with a cica- 
trix, and is then developed in the midst of 
the cicatrix-tissue. This form of the tumour 
has been denominated cheloides spuria or 
traumatica, and, as such, has been seen 
scattered numerously over the chest and 
shoulders as a sequel of acne. 
The traumatic cheloid may follow a light 
as well as a severe injury of the skin, such as 
a boil, a blister, a leech-bite, or even the ir- 
ritation of a stimulating liniment; it is some- 
times met with in the scars of strumous 
abscesses or ulcers, but is most common in 
the cicatrices of burns or scalds. 
Anatomical Characters.-At its first de- 
velopment cheloma occupies the fibrous por- 
tion of the corium. As it increases in bulk, 
it pushes the vascular layer outwards and 
stretches the corpus papillare, obliterating 
the capillary network more or less com- 
pletely. In its aggregate form, when it pre- 
sents itself as a flat plate, raised for a quarter 
of an inch above the level of the adjoining 
skin and sinking to a similar extent into the 
corium, it has the appearance of being tied 
down by strong cords or roots at either end, 
and frequently overlaps the healthy skin 
along its borders. In this state it is seen 
to be composed of strong fibrous bands en- 
veloped by a smooth transparent pinkish 
layer, in which may be detected a scanty 
vascular plexus converging to venules which 
sink between the meshes of the fibrous struc- 
ture. Around the circumference of some of 
these larger flattened tumours, such as are 
commonly met with on the sternum, and 
measuring several inches in diameter, there 
will generally be observed a few scattered 
knots. These are developed in the fibrous 
sheath of the arteries at a short distance 
from the mass, and, being thus linked to the 
central growth, are subsequently drawn into 
the focus of the tumour. And the develop- 
ment of the so-called ' roots ' is explained by 
the propagation of the proliferating process 
by the coats and sheaths of the blood-vessels 
communicating with the central tumour. 
Fully-formed cheloid consists of dense white 
glistening fibrous tissue, the fibres of which 
are closely packed and arranged in more or 
less parallel bands. Occasionally bands of 
fibres are seen running obliquely, but they 
follow a definite course, and present quite a 
different appearance from the irregular mesh- 
work of fibres seen in the scar tissue. The 
cheloid grows up in the cicatricial tissue and 
pushes the latter aside, so that it can be seen 
surrounded by scar tissue. Cheloid also in- 
vades the healthy corium in the neighbour- 
hood, and in this respect differs altogether 
from hypertrophied scar. 
Description. - Cheloid has received its 
name from its habit of throwing out spurs 
from its circumference, these spurs having 
been compared to crab's claws. It originates 
in a round, oval, or oblong tubercle or knot 
in the skin, and this may be followed by a 
second in its immediate neighbourhood, or 
sometimes by a cluster of three or four. "When 
two of these knots are situated at a short dis- 
tance apart they are apt to become connected 
by a cord of the same structure as themselves, 
and to give rise to what has been called a 
cylindrical, club-shaped, or dumb-bell che- 
loid. When three or four knots are grouped 
near together they are disposed to become 
blended by growth, and produce an oval or 
square-shaped cheloid; and when the growth 
extends from these latter into the surrounding 
integument the appearance denominated radi- 
ciformis is established. Cheloma being due 
to a tendency to overgrowth or hyperplasia 
of connective tissue within the skin, it may 
appear on several parts of the integument at 
the same time, one of the most common seats 
of its development being the sternum, which 
it generally crosses transversely. It is often 
solitary ; is more commonly composed of five 
or six tumours, discrete or confluent; but 
has been met with occasionally to the number 
of fifty or sixty tubercles or more. 
Course and Prognosis. - Cheloid rarely 
gives rise to much inconvenience or attains 
any considerable magnitude. When left to 
itself, it progresses very slowly or remains 
stationary for a number of years or for life ; 
and it has been known to disappear spon- 
taneously. Its subjective symptoms are of 
no great severity, being limited to itching, 
tingling, and smarting, and more or less un- 
easiness in moving the limbs, or from pressure 
when sitting or lying in bed. It has no ten- 
dency to desquamation or ulceration. CHELOID 
CHEST, DISEASES OF THE 
309 
Treatment.-Cheloid which forms in scar 
tissue should never be removed by the knife 
or caustics, as it almost always returns quickly 
after removal. It has a tendency to undergo 
slow atrophic changes if left to itself, and 
these changes are favoured by the pressure 
of a plaster. The mercurial plaster is a very 
suitable one. 
Erasmus Wilson. Robert Liveing. 
CHELTENHAM, in Gloucester- 
shire.-Common salt waters. See Mineral 
Waters. 
CHEMOSIS a hole).-A swollen 
condition of the conjunctiva, caused by effu- 
sion into its tissue around the cornea, which 
thus appears as if placed in a hole or hollow. 
See Eye and its Appendages, Diseases of. 
CHEST, Diseases of the.-Following 
the plan adopted in the general article on the 
Abdomen, it is proposed in the first place to 
give an outline of the diseases of the chest; 
and then to indicate the principal points 
bearing on their clinical investigation. 
General Summary.-The diseases of the 
chest may be conveniently divided into cer- 
tain groups, namely 
I. Diseases of the walls of the chest, or 
extending inwards from the walls. 
II. Diseases of the respiratory apparatus 
contained within the chest-walls, namely:- 
1. Pleurae. 2. Trachea. 3. Main Bronchi. 
4. Lungs. 
III. Diseases connected with the circu- 
latory system, including:-1. Pericardium. 
2. Heart. 3. Great vessels within the chest, 
both arteries and veins. 
IV. Diseases originating in the mediastinal 
cellular tissue. 
V. Diseases of the absorbent vessels or 
glands within the chest; of the thoracic duct; 
and of the thymus gland or its remains. 
VI. Diseases of the oesophagus. 
VII. Diseases of either of the important 
nerves traversing the chest. 
VIII. Diseases of the diaphragm. 
IX. Diseases encroaching upon the thoracic 
cavity from the abdomen or from the neck. 
The particular diseases comprehended 
within most of the groups just mentioned are 
very numerous, and they will be found de- 
scribedin their respective articles. Affections 
connected with the chest constitute a large 
proportion of the cases which come under 
observation in practice. This will be readily 
understood when we remember that the 
thorax encloses organs essential to life, which 
are never at rest, and which are constantly 
more or less exposed to influences liable to 
injure them. They may be mere functional 
disorders, and to these the heart is especially 
prone ; but serious organic diseases are also 
exceedingly common, and rank very high as 
causes of death. Moreover, they may either 
come under the category of local affections, 
though even then they frequently depend 
upon some cause acting through the general 
system, such as exposure to cold or wet; or 
they arise in the course of some general 
malady. For instance, pulmonary complica- 
tions are of common occurrence in connexion 
with fevers and various other diseases; the 
heart is implicated in a large proportion of 
cases of rheumatic fever; and malignant dis- 
ease is not infrequently manifested by a local 
development of cancer in connexion with 
certain of the thoracic contents. The struc- 
tures within the chest have an important 
mutual influence upon each other; and they 
may also be affected, either directly or in- 
directly, in connexion with local diseases in- 
volving other parts of the body, such as the 
abdomen or the central nervous system. 
Clinical Investigation.-It may be con- 
fidently affirmed, that the means which we 
now possess for investigating diseases con- 
nected with the chest are so adequate and 
precise, that anyone possessing the requisite 
knowledge and skill, and who carries out the 
clinical examination properly, can, in the very 
large majority of cases, arrive at a diagnosis 
with certainty and practical accuracy. At the 
same time it must be remembered that every 
complaint referred to this region, however 
trivial it may appear to be, does require 
systematic and. thorough investigation, other- 
wise very serious mistakes are constantly 
liable to be made. Moreover, chest-cases do 
come under observation occasionally which 
are obscure, and which may call for repeated 
examination before a correct diagnosis can be 
formed; and exceptional instances occur in 
which no satisfactory conclusion can be ar- 
rived at. The previous general condition of 
the patient, the hereditary history, and the 
account given of the origin and progress of 
the illness, often afford signal aid in the dia- 
gnosis of chest-affections, and ought never to 
be overlooked. The symptoms to which these 
affections give rise are necessarily various. 
Pain or other morbid sensations are very 
commonly complained of, but only in a com- 
paratively few instances are these at all sig- 
nificant, and they can never be positively 
relied upon in making a diagnosis, while 
they are often absent in diseases of the most 
serious character. The important organs, 
namely, the lungs and heart, usually present 
more or less disturbance of their functions 
when they are affected, but grave diseases 
may exist without any such evidence. The 
different structures within the chest have a 
mutual influence upon each other, and thus 
other symptoms besides those connected with 
the part actually diseased are often apparent. 
For instance, the lungs and heart are thus 
very intimately associated; while aneurysms 
or growths often disturb these organs seriously, 
or interfere with the air-tubes, nerves, veins, 
and other structures. In consequence of 
more or less interference with the circulation, 310 
CHEST, DISEASES OF THE 
CHEST, DEFORMITIES OF 
various symptoms in parts remote from the 
chest are frequently originated ; and distant 
organs may become the seat of organic lesions 
as the result of long-continued mechanical 
congestion, a new train of symptoms being 
thus set up. The general system may be in 
this manner affected; whilst pyrexia, wast- 
ing, and other general symptoms are often 
associated with chest-diseases. Lastly, mor- 
bid conditions within the thorax may directly 
affect the abdominal organs; or may actually 
make their way through the diaphragm into 
the abdominal cavity. 
Physical examination constitutes an es- 
sential and most important part of the clinical 
investigation of the chest and its contents. 
Indeed, without such examination no certain 
and exact diagnosis can ever be made. This 
subject is fully discussed in other appropriate 
articles, and here it need only be mentioned 
that the methods of examination which are 
usually required, and which should in every 
case be practised, are:-1. Inspection. 2. 
Palpation. 3. Percussion. 4. Auscultation. 
Other modes which may be called for in- 
clude :-5. Measurement (not uncommonly). 
6. Succussion. 1. The use of special instru- 
ments, directed to the investigation of par- 
ticular organs, such as the spirometer, the 
stethometer, cardiograph, sphygmograph, as- 
pirateur, oesophageal bougie, &c. See Physi- 
cal Examination ; and the articles relating 
to the several organs. 
Frederick T. Roberts. 
CHEST, Deformities of.-Under this 
head are included all deviations in shape 
from the normal chest. 
Deviations from the shape of the typical 
thorax are appreciable by careful physical 
examination. Of the various methods em- 
ployed for this purpose, by far the most valu- 
able are inspection and palpation. Although 
in some few cases it may be important to 
determine the exact amount of deformity by 
mensuration, there are very few deviations 
in shape or size of the thorax, the degree 
of which cannot be sufficiently estimated 
for clinical purposes by the eye and hand, 
without the aid of any special instruments 
for measuring. 
Deformities of the chest may be due either 
to abnormity of the parietes, or to disease of 
internal structures. 
Description.-Deviations from the form 
or size of the typical thorax may be either 
general or local-that is, the abnormity may 
involve the whole thorax, or a part only. 
I. General Deformities.-1. General 
Diminution.-The chest may be too small- 
that is, diminished in all its diameters with- 
out being in other respects deformed. Dimi- 
nution of the thorax simultaneously and 
uniformly in its antero-posterior and lateral 
diameters is effected mechanically by an 
increase in the obliquity of the ribs. The 
smaller the chest (having regard to the 
height of the person) the more obliquely are 
the ribs arranged, and the more acute the 
angle formed between each of the true ribs 
(excepting the first) and its cartilage. The 
intercostal spaces of the true ribs are widened 
about the junction of the ribs with their 
cartilages, and at the same time the ribs 
posteriorly are approximated more closely to 
each other, the closeness of the approxima- 
tion being in proportion to the diminution in 
the size of the thorax. The vertical diameter 
of the thorax is lessened by an increase in 
the height of the arch of the diaphragm. 
The very oblique position of the false ribs, 
and the height to which the diaphragm rises 
into the chest, cause several of the false ribs 
to lie in contact with the diaphragm, and 
thus no portion of lung is under these ribs. 
They are, practically speaking, no longer 
part of the chest-walls. The costal angles 
are diminished in proportion to the diminu- 
tion of the size of the thorax-that is, to the 
obliquity of the ribs. The obliquity of the 
ribs also causes the shoulders and the sternal 
ends of the clavicles to droop, and at the 
same time to incline forwards; the upper 
part of the scapula, is carried by the shoulder 
forward, the inferior tilted backward. 
General and symmetrical diminution in 
the size of the thorax has one and only 
one cause, namely, small size of the lungs. 
Small lungs may be congenital, due to 
original conformation; or the consequence 
of atrophic degenerative changes incident 
to age. In both these cases the lungs 
are, in relation to the length of the ribs, 
disproportionately small, and, as a necessary 
consequence, the relatively too long ribs are 
arranged more obliquely than they are in a 
well-formed chest, and the diaphragm is 
pushed by the abdominal organs higher into 
the thorax. When the small size of the 
lungs is due to atrophy, the supra-clavicular 
fossae are deepened and the vertical diameter 
of the chest proportionately diminished. In 
advanced life the congenitally small lungs 
are frequently reduced still further in size by 
the supervention of atrophous emphysema. 
The congenitally small lungs with the conse- 
quently small chest is one of the characteris- 
tics of tuberculosis-that is, of that congenital 
organisation in which tubercle is likely in 
subsequent periods of life to occur. Atrophous 
emphysema is especially common in those 
who have either manifested symptoms of 
tubercle in their youth, or belong to tuber- 
cular families. It is the congenitally small 
lungs of childhood which are prone to become 
the seat of tubercle in youth, and the subjects 
of atrophous emphysema in old age. 
2. General Enlargement.-The thorax may 
be too large, increased in all its diameters, 
without being otherwise deformed. It is 
simply bigger than it should be, having 
regard to the height of the subject. CHEST, DEFORMITIES OF 
311 
When the thorax is abnormally large, the 
ribs, instead of being more obliquely situated 
than natural, as they are in the small thorax, 
are placed more horizontally than they are 
in the normal thorax. The angle formed 
between each rib and its cartilage is greater 
than in health; while the intercostal spaces, 
especially the lower, are widened, and the 
ribs less closely approximated, the arch of 
the diaphragm is lessened in depth, and a 
considerable mass of lung lies under the 
lower false ribs, between them and the dia 
phragm. The chest is increased in all its 
diameters. The shoulders are raised. The 
costal angles are greater than natural. 
Increase in the size of the whole thorax 
has but one cause, namely, increase in the 
size of the lungs. Increase in the size of the 
lungs generally, and pretty uniformly, is the 
consequence of disease, and of one disease 
only, namely, large-lunged or hypertrophous 
emphysema. When the increase in size of 
the thorax attending large-lunged or hyper- 
trophous emphysema is moderate in degree, 
this is effected by the altered position of the 
ribs; but when the lung-disease is extreme, 
then a certain amount of the enlargement is 
caused by pressure on the inside of the chest 
during the violent expiratory efforts of severe 
cough. 
3. Irregular General Deformities. - In 
the deformities above described the antero- 
posterior and the lateral diameters retain 
more or less perfectly their normal propor- 
tion-both are increased or both are dimin- 
ished ; in the former case the chest is on 
the whole more barrel-shaped than natural, 
but the deviation from the normal form is 
not considerable. If, however, the chest- 
walls are from any cause unduly soft or 
unduly rigid, then the actually or relatively 
soft portions will recede during each inspi- 
ratory act, and local deformity of the chest 
follows. The diameter of the chest at the 
part where the absolutely or relatively soft 
portion of the parietes is placed will be 
diminished. The special deformities of the 
chest which result are due, therefore, prima- 
rily to the state of the parietes, and are not, 
as those previously described, secondary to 
conditions of the lungs themselves. 
a. Diminution in the antero-posterior 
diameter of the thorax.-The antero-pos- 
terior diameter of the thorax is frequently 
less than that of the normal thorax, the 
lateral diameter being proportionately in- 
creased. The chest has an oval form-it is 
flattened from before backwards. 
The thorax flattened from before backwards 
is usually associated with small lungs, but 
the mechanical cause of the flattened form is 
the want of full resisting power in the ribs 
and considerable strength in the cartilages. 
These conditions of thorax are common in 
the subjects of tuberculosis. 
The flattening of the thorax is increased by 
all impediments to the free passage of air 
through the air-tubes. In some children suf- 
fering from even slight bronchial catarrh, the 
flattening of the chest is seen to be increased 
at each inspiration; and if the impediment 
to the entrance of the air to the pulmonary 
tissue be constant or extreme, not only is the 
flattening increased at each inspiration, but 
the sternum is also depressed, especially at 
its lower half, below the level of the costal 
cartilages, and thus the antero-posterior dia- 
meter of the thorax is still further diminished 
in the median line. 
6. Increase in the antero-posterior dia- 
meter of the thorax.-In rickets the carti- 
lages of the ribs are very firm, whilst the ribs 
themselves are softer than natural, and es- 
pecially so near to their enlarged growing 
ends-the softest part of the ribs; that is to 
say, just outside the nodule formed at the 
spot where cartilage is in the process of grow- 
ing into bone. The consequence of the ex- 
treme softness of the ribs at this part is that 
at each inspiration the weight of the atmo- 
sphere presses inwards the softest part of the 
ribs, while the sternum is borne forward by 
the firm cartilages. The result is great in- 
crease in the antero-posterior diameter of the 
thorax, and diminution of the lateral dia- 
meter at the parts corresponding to the softest 
part of the ribs. The depression of the softest 
part of each rib is increased by the want of 
resilience of the softened structures. 
A groove is thus formed in the thoracic 
walls just posterior to the rickety nodules; 
and this groove being deepened at each in- 
spiration, the part of the lung adjacent is com- 
pressed in place of being expanded during the 
inspiratory act. At the same time, in conse- 
quence of the cartilages and sternum being 
thrust forward at each inspiration, air enters 
with undue force into the lung-tissue subjacent 
to these parts. The consequence of the ex- 
cessive expansion of the anterior part of the 
lung is vesicular emphysema, and the re- 
cession during inspiration of the softened 
and imperfectly resilient and therefore deeply 
grooved part of the chest-wall leads to col- 
lapse of the subjacent pulmonary tissue; and, 
as the effect of these two conditions, the lungs, 
when the chest is opened, present a vertical 
groove corresponding to the groove in the 
chest-walls. The antero-posterior diameter 
of the thorax in rickets is still further in- 
creased by the curvation of the spine. The 
muscles are weak, the child is unable to sit 
upright, that is to say it is unable, in conse- 
quence of the weakness of its muscles, to sup- 
port the weight of the upper part of its body; 
the bones of the spine are, in common with 
the other bones of the body, softened; and 
the result of the weakness of the muscles and 
the softness of the vertebrse is the dorsal bow. 
When deformity of the chest is the result 
of undue softness of the chest-walls, the 
position of the solid organs subjacent to the 312 
CHEST, DEFORMITIES OF 
parietes is frequently perceptible to the eye. 
The liver supports the lower ribs on the right 
side, the heart supports the ribs and cartilages 
over it on the left side, and thus these organs 
cause local prominence of the chest-walls, 
without being themselves in any way ab- 
normal. 
In the so-called pigeon-breast, the antero- 
posterior diameter of the thorax is increased 
in the middle line, the lungs are small, the 
ribs and cartilages are firm, the ribs are placed 
obliquely and the chest-walls are flattened 
laterally, and the sternum as a consequence 
is thrust forwards; thus the chest in the 
pigeon-breasted has a triangular form, the 
apex of the triangle being the sternum. Im- 
pediment to the free entrance of air into the 
lower lobes of the lungs will favour the pro- 
duction of and increase the deformity. The 
chests of children who suffer from repeated 
attacks of bronchitis, but are otherwise 
healthy, are commonly the subjects of this 
deformity, while there is increased expansion 
and subsequent enlargement of the upper part 
of the chest, the lungs being more or less col- 
lapsed below and emphysematous above.1 
c. Transverse anterior constriction of the 
lower part of the thorax is the consequence 
of small size of the lungs, or of imperfect in- 
spiratory expansion, permanent or frequently 
recurring in youth. In these cases the lower 
ribs are little used in respiration, while below 
they are borne outwards or supported by the 
liver, stomach, and spleen, and thus an im- 
perfectly formed transverse depression is pro- 
duced in the front of the chest on a level with 
the base of the ensiform cartilage. 
The deviations from the type of the normal 
thorax hitherto described are bilateral, and 
more or less symmetrical. 
II. Local, Unsymmetrical, and 
Unilateral Deformities.-1. Fulness of 
the supraclavicular region. - The supra- 
clavicular region, corresponding to the por- 
tion of the thoracic cavity above the clavicle, 
may be fuller than natural. The causes of 
this local bulging are-a. Development of 
adipose and cellular tissue, b. Distension of 
the deep-seated veins, c. Large-lunged em- 
physema, in which disease there is occasion- 
ally distension of that part of the cavity of 
the thorax which lies above the level of the 
clavicle. The distension is due to pressure on 
the inside of this part of the thoracic cavity ; 
air being forced violently into the correspond- 
ing part of the lung during the powerful ex- 
piratory effort of cough. 
2. Depression of one supraclavicular fossa 
is caused by any pathological condition of the 
apex of the lung which produces diminution 
of its bulk, for example, atrophous emphy- 
sema, or chronic consolidation of the apex. 
3. Elevation of one shoulder - Occupation 
is a common cause of elevation of one shoulder; 
1 Nurses should be taught not to compress the 
chest laterally when carrying a child.-Editob. 
thus in clerks, who sit much at the desk, the 
left shoulder is permanently a little higher 
than the right, and the upper portion of the 
spine is slightly curved, the convexity being 
to the left; so in those who carry heavy 
weights on one arm, the opposite shoulder 
is elevated and the spine curved. Whatever 
necessitates an increase in the capacity of 
one side of the thorax causes elevation of the 
shoulder on the same side; thus, considerable 
dilatation of the heart, fluid in the pericar- 
dium, fluid in the pleura, aneurysm of the arch 
of the aorta or of the innominate, all lead to 
elevation of the shoulder. The shoulder is 
depressed and carried forward when, from 
any cause, the whole or upper part of one 
side of the chest is diminished in size, as 
when the apex of the lung is the seat of 
chronic pneumonia or chronic phthisis. 
4. Uniform dilatation of one side of the 
thorax is due, with one exception, to fluid or 
air in the pleura. The exception is those rare 
cases of encephaloid cancer of the lung, in 
which the formation of cancer is uniformly 
diffused through the lung-tissue, and in 
amount so great that the lung ' infiltrated ' 
with cancer very decidedly exceeds in bulk the 
healthy lung inflated with air by inspiration. 
In uniform dilatation of one side of the 
thorax, the shoulder is raised, the ribs are 
placed more horizontally than on the healthy 
side, the intercostal spaces are widened, and 
the spine is slightly curved. When the en- 
largement is moderate in amount, the in- 
crease in capacity is effected by the altered 
position of the ribs; but when the increase 
in size is very considerable, then it is due in 
part to the pressure exercised by the air, 
fluid, or cancer-loaded lung on the inner side 
of the chest-wall. 
5. Uniform contraction of one side of the 
thorax is the consequence of any pathological 
condition which leads to general and uniform 
reduction in the size of the lung, such as 
cirrhosis of the lung, infiltrated cancer of the 
lung, chronic tubercular disease of the lung, 
chronic pneumonia, or the change in the 
texture of the lung which follows long-con- 
tinued compression by fluid in the pleura. 
When the whole of one side of the thorax is 
reduced in size, the shoulder on that side is 
depressed, the ribs are placed more obliquely 
and are more closely approximated than on 
the opposite side, the intercostal spaces are 
narrowed, and the spine is curved, often con- 
siderably, the concavity of the curve being 
towards the contracted side. 
6. Lateral curvature of tne spine, instead 
of being the consequence, may be the cause 
of deformity of the thorax : the ribs are then 
approximated on the side and at the part 
where the concavity of the curvature is placed, 
while they are separated and the shoulder 
is raised on the side of the convexity. 
7. In angular curvature of the spine the 
deformity of the thorax varies with the seat CHEST, DEFORMITIES OF 
313 
and the extent of the vertebral disease; but, 
speaking generally, it may be said that in 
angular curvature of the spine the antero- 
posterior diameter of the thorax is increased 
in proportion to the amount of destruction of 
the bodies of the vertebrae, and that the ribs 
are in a corresponding degree approximated. 
8. Extreme depression of the lower part 
of the sternum is the consequence of softness 
of the cartilages of the ribs, and impediment 
to the free passage of the air to the pulmonary 
tissue. This deformity is never congenital, 
although the subjects of it often affirm it to 
be so; it may, however, commence to be 
formed directly after birth if there be a 
congenital impediment to the entrance of air 
into the lungs-for example, atelectasis. 
This deformity may be the result of direct 
pressure. In certain occupations pressure 
has to be exerted on the lower part of the 
sternum-thus, some shoemakers use a 
wooden instrument which has to be kept in 
its place by pressure against the lower part 
of the sternum. For direct pressure to pro- 
duce this deformity it must have been applied 
in early youth, while the parts are still 
flexible, and have been exerted frequently 
over a long period of time. 
9. Congenital deformities of the thorax 
are few in number and are due to arrest of 
development-for example, cleft sternum, 
and defective formation of one or more ribs 
or cartilages. 
10. Unsymmetrical diminution in size of 
a part of the thorax is produced by any 
pathological change which reduces the size 
of the subjacent part of the lung. All chronic 
inflammatory or congestive conditions of the 
apex of the lung, whether primary or the 
consequence or the concomitant of the for- 
mation of tubercle, are attended by diminution 
of the bulk of the part of the lung which is 
the seat of the lesion. Considerable loss of 
pulmonary tissue is usually accompanied by 
falling inwards of the chest-wall over the 
cavity.1 The formation of a cavity is almost 
invariably attended by chronic inflammatory 
condensation, and this increases the local 
depression of the chest-wall. In chronic 
thickening of the pleura, the chest-wall at 
the part is, by the contraction of the fibrin, 
drawn inwards, and the lung subjacent to the 
thickened pleura being condensed, the chest- 
wall is also forced in during inspiration by 
atmospheric pressure. Hence, after pleurisy 
limited in extent it is common to find per- 
manent flattening of the thoracic parietes at 
the base of the chest on the side affected. 
In cancerous infiltration of the lung, limited 
in extent, the lung-tissue is sometimes so 
much condensed that the bulk of the cancer 
and lung are less than that of the healthy 
lung, and the chest-walls as a consequence 
are flattened over the seat of disease. 
11. Unsymmetrical localised bulging.-If 
the ribs are, in relation to the size of the 
lungs, disproportionately long, and their 
cartilages soft, then one or more of the 
cartilages may be knuckled forwards; the 
cartilage, being compressed between the end 
of the rib and the sternum, bends in an angle 
outwards. Although the prominence is 
trifling, it often causes anxiety to parents 
and its subject. Local deformity of this kind 
is occasionally the result of repeated lateral 
compression of the chest-wall in the athletic 
sports of young boys, such as cricket. 
All the diseases of the chest which are ac- 
companied by general enlargement of both 
or one side of the chest, when localised, are 
attended by local bulging; thus, a common 
cause of abnormal fulness of the lower part 
of the left side of the thorax, posteriorly, is 
emphysema of the corresponding part of the 
lung; and a moderate amount of fluid in the 
pleura is attended by fulness of the lower 
part of the chest on the same side. In both 
these cases the ribs are raised into an abnor- 
mally horizontal position; the chest-walls are 
not pushed outwards, but the ribs are raised, 
and the intercostal spaces are to that extent 
widened. The ribs are put into the position 
which gives the greatest capacity to the 
thoracic cavities containing the fluid or the 
enlarged lung. Local bulging may be pro- 
duced by aneurysm of the arch of the aorta 
or of the innominate artery; by growths, 
malignant or other, within the chest; by 
chronic pleurisy with effusion circumscribed 
by dense false membrane ; by hydatids; or 
by abscess; and in all these cases the pro- 
minence is due to direct pressure on the inner 
side of the chest-wall, and to changes in the 
chest-wall itself. 
Hypertrophy and dilatation of the heart 
and fluid in the pericardium are attended by 
fulness of the praecordial region. The bulging 
from these diseases is much greater in the 
child than in the adult. In these cases a 
little of the fulness is produced by a more hori- 
zontal arrangement of the ribs; but when the 
prominence of the praecordial region is at all 
considerable, it is the result of the pressure 
exercised by the fluid or by the large and 
powerfully acting heart on the inner surface 
of the corresponding part of the chest-wall. 
At the part corresponding to the junction 
of the first and second bones of the sternum, 
opposite the cartilage of the second rib, the 
sternum projects forward. This prominence 
is called the angle of Ludovicus. Any im- 
pediment to the free entrance of air into the 
lungs may cause depression of the lower part 
of the sternum; if the ossification of the 
sternum is not complete at the junction of 
the first and second bones, undue prominence 
of this part is the result. Subsequently a 
formation of bone takes place at this spot, 
and increases the prominence. 
William Jenner. 
1 It is said that a very large air-containing cavity 
may give rise to local bulging. 314 
CHEST, EXAMINATION OF 
CHEST-WALLS 
CHEST, Examination of.-See Phy- 
sical Examination. 
CHEST-WALLS, Deformities of.- 
See Chest, Deformities of. 
CHEST-WALLS, Morbid Condi- 
tions of.-The walls of the chest may be 
the seat of various morbid conditions, and 
the affections of this portion of the frame- 
work of the body demand more attention 
than they are accustomed to receive. All 
that can be done within the limits of this 
article is to indicate their nature; to notice 
briefly such of them as are not described in 
other parts of these volumes; and to point 
out the principles of treatment. They may 
be practically considered according to the 
following arrangement:-• 
1. Superficial Affections.-Under this 
group are included morbid conditions of the 
skin and subcutaneous structures, {a) Cuta- 
neous eruptions are of common occurrence 
over the chest. Among these may be specially 
mentioned the eruptions of some of the ex- 
anthemata, herpes zoster, and chloasma. 
{b) The superficial vessels are liable to become 
enlarged under certain circumstances. This 
enlargement is usually seen in the veins over 
the front of the thorax, which may be dis- 
tended on both sides, or only on one side, or 
in some particular region. The larger divi- 
sions may alone be involved; or a more or 
less, extensive network of smaller veins is 
visible, and occasionally even the capillaries 
seem to be implicated. This condition gene- 
rally arises from some obstruction interfering 
with the circulation through one or other of 
the principal veins which, either directly or 
indirectly, receive the blood from the veins 
of the thoracic wall. Thus the superior vena 
cava, or either innominate, subclavian, or axil- 
lary may be implicated, being, for example, 
pressed upon by new-growths or enlarged 
glands, the distribution and extent of the 
venous distension varying accordingly. Oc- 
casionally one of the smaller veins is thus 
interfered with. The writer has met with 
cases in which considerable enlargement of 
the veins was visible over portions of the 
thorax, where the cause was by no means 
evident, the patients asserting that this con- 
dition had existed ever since they could re- 
member, and being regarded by them as per- 
fectly normal. Probably it has resulted from 
some local obstruction occurring during early 
life. It must be remembered that women 
who are suckling frequently present consider- 
able enlargement of the superficial veins over 
the front of the chest, which usually subsides 
when the period of lactation is at an end, but 
may become permanent after several children 
have been nursed. Again, more or less venous 
and capillary engorgement in this region may 
occasionally be observed in cases of cardiac 
or pulmonary disease. Sometimes a ring of 
enlarged veins and capillaries is seen round 
the lower part of the chest. When the venous 
distension is due to obstruction of the vena 
cava superior, the skin presents a more or 
less marked cyanotic tint; and in cases of 
general cyanosis, the chest, in common with 
other parts, may have a cyanotic appearance. 
Occasionally one or other of the small arteries 
which supply the thoracic walls is enlarged, 
and it may attain a considerable size, 
(c) Subcutaneous oedema is sometimes ob- 
served over the chest. In most instances this 
is a local condition, being the result of venous 
obstruction; but it may be a part of general 
dropsy, particularly in connexion with renal 
disease. This morbid state is evident on in- 
spection and palpation, and the affected part 
pits on pressure, {d) The thorax is one of the 
most common seats of subcutaneous emphy- 
sema, in which gas, consisting usually of air 
which has escaped from the respiratory appa- 
ratus, collects in the cellular tissue, and tra- 
vels, to a greater or less extent, over the body. 
The causes of this condition are described 
elsewhere {see Emphysema, Subcutaneous). 
Subcutaneous emphysema is attended with 
evident swelling of the part, which usually de- 
velops rapidly, and may be very great, all the 
normal anatomical outlines being obliterated. 
It has an elastic feel, and pits readily on 
pressure with the finger, but speedily rises 
again ; the peculiar minutely crepitant sensa- 
tion accompanying this condition is elicited 
on palpation andpercussion; percussion yields 
a curious, superficial, muffled, tympanitic 
sound; and. on auscultation a superficial 
small, dry, crepitant sound is heard, (e) As 
belonging to the superficial affections of the 
chest may be just mentioned diseases of the 
mammary gland or nipple, which of course 
constitute a most important class of diseases 
in females. See Breast, Diseases of. 
2. Muscular and Tendinous Affec- 
tions.-(a) The muscles of the chest or their 
tendinous attachments may be the seat of 
certain painful affections. These are of the 
nature of so-called muscular rheumatism or 
myalgia, of inflammation, or of more or less 
injury or strain ; being induced by cold, con- 
stitutional conditions such as gout, overwork, 
straining, violent coughing, fatigue from pro- 
longed sitting, and other causes. The pain- 
ful condition is usually localised, but different 
muscles are involved in different cases, some- 
times those which are superficial being affected, 
in others the deeper muscles, including the 
intercostals; or the complaint may be con- 
fined to a single muscle. Pleurodynia, dorso- 
dynia, and scapulodynia are the terms applied 
to muscular rheumatism affecting the side of 
the chest, the upper part of the back, and the 
scapular regions respectively. As the result 
of severe coughing, muscular pains are very 
common around the lower part of the chest. 
The pain is usually more or less aching in 
character, and not severe, but it may be very 
intense, especially in acute cases. WThatever CHEST-WALLS, MORBID CONDITIONS OF 
315 
brings the affected muscles into play aggra- 
vates the suffering, such as moving the arms 
or shoulders when the superficial muscles are 
affected, coughing, sneezing, and similar ac- 
tions. In some instances the pain is not felt 
when the affected structures are kept quite 
at rest. There may be local tenderness on 
pressure, or diffused pressure may give relief; 
while posture often influences the sensations 
experienced, such as whether the patient as- 
sumes the recumbent or sitting posture, or 
lies on one or other side. Fatigue generally 
increases the pain. Muscular affections con- 
nected with the chest are not necessarily ac- 
companied with any other local symptoms; 
and physical examination reveals nothing, 
except that perhaps the act of breathing is 
voluntarily restrained, on account of the pain 
thus induced, (b) The muscles of the chest 
may be affected, on the one hand, with spasm 
or cramp ; on the other, with paralysis. The 
former is attended with more or less pain, 
usually localised, which may be very severe; 
the latter is indicated by loss of power in the 
muscles involved. These disorders generally 
depend on some lesion of the central nervous 
system, but may result from local nerve- 
disease. Muscular cramp may arise from a 
sudden twist of the body, and it is usually 
supposed to be the cause of the ' stitch ' in the 
side brought on by running, but this is doubt- 
ful. In cases of hemiplegia from cerebral mis- 
chief, the muscles of the thorax on the affected 
side are often temporarily weakened, but 
they usually subsequently soon regain their 
power. When the upper part of the spinal 
cord is injured or diseased at a certain point, 
all the muscles of the chest become paralysed, 
which is a very serious matter, as respiration 
and the acts connected therewith cannot be 
carried on, except by the diaphragm, and con- 
sequently the blood is imperfectly aerated, 
secretions accumulate in the lungs, respira- 
tory paralysis follows, and the patient dies 
of apnoea, (c) Atrophy or degeneration may 
involve more or less of the thoracic muscles. 
In cases of pulmonary phthisis either the 
whole of these muscles or certain of them are 
not uncommonly wasted out of proportion to 
the general emaciation. They may also be 
implicated in progressive muscular atrophy; 
and occasionally a single muscle undergoes 
marked wasting. The writer has seen a 
striking example of this local atrophy in 
connexion with the pectoralis major, but the 
serratus magnus or other muscles may be 
implicated. The wasting is probably in most 
cases due to disease of the nerves supplying 
the affected muscles. It is quite evident on 
examination, and the movements which are 
usually performed by the involved structures 
cannot be executed properly, (d) On the 
other hand, the chest-muscles may become 
hypertrophied. This may be a natural re- 
sult of athletic exercises and training; or 
it may occur in consequence of their being 
called upon, either habitually or at intervals, 
to act excessively, as in cases of emphysema 
or asthma. In exceptional instances the con- 
dition known as pseudo-hypertrophic mus- 
cular paralysis has extended up to the chest, 
(e) The thoracic muscles not uncommonly 
present marked irritability under percussion 
or friction. This has been regarded as an 
important sign of phthisis; but the writer 
has often found it equally if not more evi- 
dent in cases where the lungs were perfectly 
healthy. (/) As the result of injury and other 
causes, some portion of the muscular struc- 
tures of the chest may be lacerated, ruptured, 
or perforated, either alone or along with other 
structures. This condition will be further 
alluded to presently. 
3. Nervous Affections.-(a) Neuralgia 
is very common in different parts of the 
chest, especially in the side, and particularly 
the left side-intercostal neuralgia. The 
pain is localised, being usually referred to a 
point where a branch of nerve becomes super- 
ficial. It is more or less constant, in some 
cases being at times very severe. It often 
precedes or follows an eruption of herpes. It 
maybe increased by deep breathing or cough- 
ing, but is not, as a rule, so much affected by 
these and similar actions as are other painful 
chest-affections. Shooting and darting sensa- 
tions often radiate from the principal point, 
and certain spots of tenderness-points dou- 
loureux-maybe recognised (see Intercostal 
Neuralgia). (6) Intercostal neuritis is oc- 
casionally met with, and this affection is 
attended with great pain, localised and radiat- 
ing, with much tenderness, the suffering being 
aggravated by whatever causes any local dis- 
turbance. It is probable that the severe pains 
experienced in some instances where the 
complaint is supposed to be muscular, are 
due to branches of nerve being inflamed. 
Severe pain often precedes or follows herpes 
zoster, and this probably depends upon actual 
nerve-changes. It may also be mentioned 
here that pains around the sides may be 
associated with disease of the spine, or of 
the spinal cord, (c) Some individuals, es- 
pecially females, exhibit a remarkable super- 
ficial tenderness or hyperaesthesia over the 
thorax or in parts of this region, especially 
the anterior and upper portions. The slightest 
touch is resented, and the most delicate per- 
cussion cannot be borne. This condition 
may exist without any actual disease, or it 
is sometimes observed in phthisical cases. 
(d) Sensation may be more or less impaired 
over the chest, or in limited portions, either in 
connexion with central or local nervous dis- 
ease, or in hysterical and neurotic persons. 
Various paraesthesiae are also frequently re- 
ferred to this region by the class of individuals 
just mentioned. 
4. Diseases of the Bones or Carti- 
lages.-The morbid conditions which may 
be referred to the bony and cartilaginous 316 
CHEST-WALLS, MORBID CONDITIONS OF 
framework of the thorax are as follows: 
(a) The chest-walls are often unduly rigid and 
firm, owing to an excessive deposit of cal- 
careous matter in the sternum and ribs, with 
ossification or petrifaction of the cartilages. 
This is a normal condition in old people, 
being one of the degenerative changes to 
which they are liable, but it also occurs not 
uncommonly in younger individuals, as the 
result of hard work, or excessive athletic 
exercises, or in connexion with certain pul- 
monary diseases. This state of rigidity in- 
terferes more or less with the respiratory 
movements, and not infrequently causes 
serious embarrassment. (&) On the other 
hand, the ribs and cartilages may be deficient 
in firmness, and consequently too yielding 
and elastic. This is observed in children and 
young persons who are ill-nourished, but 
especially in connexion with rickets, and it 
becomes a condition of great moment when 
any disease sets in which causes obstruction 
to the entrance of air into the lungs, such as 
bronchitis. The chest-walls are then liable 
to fall in more or less during the act of 
inspiration, and may become permanently 
deformed, ' pigeon-breast,'1 ' rickety,' and 
other abnormal forms being thus originated 
(see Chest, Deformities of), (c) Acute or 
chronic periostitis or perichondritis is some- 
times observed in connexion, respectively, 
with the sternum or ribs, or with the car- 
tilages. The acute affection gives rise to 
limited pain and tenderness, which may be 
accompanied with superficial redness and 
swelling, and may simulate some more seri- 
ous disease. The chronic complaint usually 
assumes the form of a node, being the result 
of syphilis. The writer has occasionally ob- 
served a small swelling at the junction of one 
of the ribs with its cartilage, painless, un- 
accompanied with redness, hut with fluctua- 
tion. (d) The bony and cartilaginous struc- 
tures themselves may be the seat of disease 
in some part of the chest, and here must be 
included the portion of the spinal column 
which limits this region posteriorly. Thus 
there may be acute inflammation, caries, 
necrosis, or so-called scrofulous disease. 
Among the more important causes which 
may originate these conditions are injury, 
syphilis, scrofula, empyema opening exter- 
nally, and thoracic tumours or aneurysms 
growing outwards. They may lead, to 
serious consequences, both local and general, 
and frequently cause more or less deformity 
of the chest. (e) Permanent thickening 
and distortion of portions of the ribs 
occur after fractures which have united 
improperly. 
5. Inflammation and Abscess.-It is 
expedient to make a separate group of those 
cases in which inflammation, resulting in the 
formation of one or more abscesses, occurs in 
some portion of the soft structures entering 
into the construction of the chest-walls. 
This may be of local origin, arising from 
injury, bone-disease, or other causes; or it 
may be due to the opening of an empyema 
into the tissues; to suppuration extending 
and burrowing from the axilla or other 
parts; or to pyaemia. If deep-seated, an ab- 
scess may be difficult to detect with certainty, 
but usually the signs of this condition be- 
come sufficiently obvious. Sinuses or fistulae 
may be left as a consequence of suppuration 
in the chest-wall, especially when pus makes 
its way outwards from within. 
6. Tumours and New-Growths.- 
These morbid conditions also demand brief 
notice. They may be connected with any of 
the structures of the chest-walls, and are of 
various kinds; among those which have come 
under the writer's notice may be mentioned 
molluscum, fatty growths, cystic tumours, 
enlarged sebaceous glands, and infiltrated 
carcinoma. Tumours may make their way 
inwards from the chest-walls, encroaching 
upon the cavity of the thorax; or, on the 
other hand, the walls may be involved by 
growths extending from within. It need 
scarcely be mentioned that mammary 
tumours constitute a distinct, and by far the 
most important group associated with the 
structures covering the chest. See Breast, 
Diseases of. 
7. Perforations and Ruptures.-The 
muscular structures of the thoracic wall may 
be more or less destroyed in some part, 
either by sudden rupture or gradually, allow- 
ing a hernial protrusion of the lung to take 
place between the ribs. As already noticed, 
empyema may make its way externally 
through the chest-wall. Aneurysms and 
tumours extending outwards from within the 
thorax frequently cause serious destruction 
of the tissues, including the bony and carti- 
laginous, as well as the soft structures. This 
destructive process is often attended with 
severe pain and suffering, and leads to grave 
mischief. Congenital clefts or more exten- 
sive deficiencies are sometimes met with in 
the sternum or other parts of the thoracic 
walls. 
8. Variations in Form and Size.- 
The chest often presents deviations from the 
normal shape and size, and these are so 
important that they demand separate con- 
sideration. See Chest, Deformities of. 
Treatment.-In many cases where the 
chest-walls are in a morbid state, they either 
do not need any special treatment, or no 
treatment can be of any avail. The chief 
circumstances under which the practitioner 
may be called upon to interfere, and the 
measures to be adopted, may be briefly in- 
dicated as follows:- 
(a) Painful affections of the chest-walls, 
depending upon conditions of the muscles or 
nerves, frequently demand local applications 
1 A condition often produced by pressure of the 
nurse's hand in holding the child.-Editor. CHEST-WALLS 
CHICKEN-POX 
317 
for their relief. Thus in different cases it 
may be requisite to employ hot fomentations, 
dry heat, or cold applications, in the form of 
wet rags frequently changed, ice, or evaporat- 
ing lotions; or to use anodyne applications 
of various kinds, such as belladonna plaster 
or liniment, opium plaster or liniment, oleate 
of morphine, tincture or liniment of aconite, 
or ointment of aconitine or of veratrine. 
Anodynes may also sometimes be added to 
fomentations with advantage. Friction is 
often of much service, and at the same 
time stimulating liniments may be employed, 
such as one containing camphor, chloroform, 
or turpentine. For ill-defined muscular pains 
about the chest, which are frequently com- 
plained of, free douching with cold water 
every morning, followed by friction with a 
rough towel, is often highly efficacious. When 
pain is localised and obstinate, much benefit 
may in many cases be derived from the appli- 
cation of a sinapism, mustard-leaf, or even a 
small blister. In other instances the use of 
the ether-spray is serviceable, repeated more 
or less frequently; or sometimes much relief 
may be obtained from applying over a pain- 
ful spot a mixture of equal parts of chloro- 
form and belladonna liniment. Galvanism 
is another agent which may be of the greatest 
service in relieving painful sensations about 
the chest, whether connected with the muscles 
or nerves. Subcutaneous injections of hot 
water, morphine, or atropine maybe demanded 
in some cases, and constitute a most valuable 
mode of treatment if pain cannot otherwise 
be assuaged. 
In the treatment of many painful affections 
of the chest-walls much assistance may be 
derived from attention to posture, especially 
in connexion with certain occupations; from 
the avoidance of undue fatigue, or of any 
violent actions which are known to influence 
this part, such as cough; and from the 
adoption of measures tending to support the 
structures, or to keep them in a state of rest. 
The writer has found great benefit in a large 
number of instances from strapping the side 
more or less extensively, in the manner ad- 
vocated by him for the treatment of pleurisy; 
and if there is any localised pain, some limited 
anodyne application, such as a piece of bella- 
donna plaster, may be placed over this spot 
under the strapping. 
(&) In many affections of the chest-walls, 
treatment directed to the general system, or 
to some special constitutional condition, is 
often of the greatest service. Thus, in the 
painful complaints already noticed, there are 
frequently marked general debility and 
anaemia; and essential benefit is derived 
from the administration of quinine, prepara- 
tions of iron, strychnine, cod-liver oil, pre- 
parations of phosphorus, and other tonic 
medicines, or such as improve nutrition. 
Some of these are also most useful when 
there is disease of bone and its consequences. 
Again, certain affections of the thoracic wall 
may be associated with rheumatism, gout, or 
syphilis, and then the particular treatment 
indicated for these several diseases is called 
for. 
(c) "When disorders of the muscles of the 
chest-walls occur, such as paralysis or spasm, 
associated with some disease of the central 
nervous system, the treatment must usually 
be directed to this disease, and but little can 
be done for the local disturbance. In some 
instances, however, electrical or other modes 
of treatment may be of some service, by in- 
fluencing the action of the muscles, but no 
definite rules can be laid down. 
(d) Local inflammation and its results in 
connexion with the thoracic walls must be 
treated as in other parts of the body, but it 
is unnecessary to discuss this subject in the 
present article. 
(e) Surgical treatment may be called for 
under certain circumstances. Of course this 
will be the case if the chest-walls are injured 
in any way. Among other conditions likely 
to demand surgical interference may be 
specially mentioned subcutaneous emphy- 
sema, abscesses, disease of the bones, and 
tumours. Frederick T. Roberts. 
CHEYNE - STOKES RESPIRA- 
TION.-A peculiar disturbance of breathing, 
first described by the late Drs. Cheyne and 
Stokes, of Dublin. See Respiration, Dis- 
orders of. 
CHICKEN-POX.-Synon. : Varicella; 
Fr. La Varicelle ; Ger. Wasserpocken. 
Definition.-An acute specific infectious 
disease, characterised by the appearance, in 
successive crops, of red spots, which in the 
course of about a week pass through the 
stages of pimple, vesicle, and scab. 
.Etiology.-The origin of this disorder is 
unknown. It is certain that it arises from 
contagion, and that childhood is its predis- 
posing cause. It occurs in children at the 
breast, and is seen with increased frequency 
up to the fourth year, at which period it at- 
tains its maximum. It is less often found 
between four and twelve, and after twelve 
it may be said to disappear, although it is 
occasionally seen in adults. 
Symptoms.-The illness commences with 
out any, or with but slightly-marked, pre- 
monitory symptoms. There is usually some 
feeling of lassitude, and the patient goes to 
bed earlier than usual. Within a few hours an 
eruption appears, generally on some part of 
the back or chest, but there are many excep- 
tions to this rule. It may commence on the 
face, neck, chest, abdomen, or extremities, or 
upon several of these parts at the same time 
The eruption consists of small, faintly papular 
rose-spots, varying in number from twenty to 
one or two hundred. These, in the course of 
eight, twelve, or, at the most, twenty-four 
hours from their appearance, change into 318 
CHICKEN-POX 
vesicles, which, at first small in size and 
clear as to their contents, become quickly 
large ; globular, or semi-ovoid, in form ; 
translucent, glistening, and opalescent in 
appearance; and surrounded with a faint 
areola. Towards the end of the second day 
of illness, the vesicles attain complete de- 
velopment, and about this time a few may 
be seen on the sides of the tongue, on 
the lips, cheek, or palate, and sometimes 
upon the mucous membrane of the genitals. 
About the third day a few of the vesicles 
may have a pustular appearance, and some- 
times a few pustules are seen; but, regarding 
the eruption as a whole, pustulation forms 
an incident rather than an essential feature 
in its progress. On the fourth day the 
vesicles begin to dry up, and by the sixth 
complete scabs are formed. These fall off 
in a few days, leaving in their place faintly 
red spots, and sometimes a few pits. A 
single crop of eruption may be said to com- 
plete itself in five or six days; and, as two 
or three crops appear on as many successive 
days, the illness will last rather more than a 
week. In the event, however, of there being 
four or five crops, it may be prolonged for 
another week, but this is unusual. With the 
appearance of the eruption, the temperature 
rises two, three, or even more degrees, and 
this rise recurs with each successive crop of 
spots. The pulse is sometimes slightly in- 
creased in frequency; the tongue is moist, 
and sometimes covered with a light fur. As 
a rule, however, there is but little constitu- 
tional disturbance, although it is occasionally 
severe. 
Pathology.-Chicken-pox is due to the 
reception of a specific poison, which after an 
incubation of about thirteen days, shows it- 
self by an eruption upon the skin. What this 
poison is, how it enters the body, and what, 
if any, changes it produces upon the internal 
organs, the present state of our knowledge 
does not enable us to say. It affects the 
same individual once only, and it is per- 
fectly distinct from modified small-pox, as 
the following considerations will show :- 
1. Chicken-pox is characterised by the rapidity 
with which it runs through its stages ; 
modified small-pox, on the contrary, is 
characterised by an interruption in the 
course of the disease at one or other of 
three points-the papular, the vesicular, or 
the pustular. 2. The chicken-pox eruption 
attains complete development by the end of 
the third day; in modified small-pox, should 
the eruption attain complete development, 
this will not occur before the ninth day, 
however much the disease may be modified. 
3. In modified small-pox the premonitory 
symptoms are usually well-marked, often quite 
as severe as in the natural disease, and these 
last forty-eight hours, after which there is an 
eruption of small hard papules on the fore- 
head, face, and wrists, followed by a fall of 
temperature. In chicken-pox the premoni- 
tories are most often wanting, and when 
present are slightly marked, and the eruption 
is followed by a rise in the temperature. It 
appears, moreover, upon any part of the body 
indiscriminately, and less frequently on the 
face than on other parts; and within a few 
hours-at the most within twenty-four-it 
has become vesicular; whereas in modified 
small-pox the vesicular stage is only reached 
forty-eight hours after the appearance of 
eruption. 4. The vesicles of chicken-pox are 
globular or ovoid in form, without any central 
depression; glistening or translucent in ap- 
pearance ; and unicellular in structure. They 
collapse on pricking; and attain their maxi- 
mum development in from twelve to eighteen 
hours. Modified and natural small-pox 
vesicles are flat and circular in form, always 
depressed in the centre, and sometimes um- 
bilicated, of an opaque dirty white colour, 
and multicellular in structure. They do not 
collapse on pricking, and attain their maxi- 
mum development at the end of the third 
day from their origin. 5. Small-pox is an 
inoculable affection; chicken-pox, according 
to reliable authority, is not. 6. When cases 
arise which all recognise to be modified small- 
pox, they are always accompanied by others 
which are more severe ; and in epidemics 
these latter gradually become more numerous 
up to a point of maximum intensity, when 
they decline and the modified forms reappear. 
In chicken-pox there is no such gradual in- 
crease in the intensity of illness, and neither 
serious nor fatal cases form part of its 
epidemics, which prevail independently of 
small-pox. 7. Small-pox and vaccinia are 
often early followed, in the same individual, 
say within two or three years, by chicken- 
pox, and vice versa. 8. Chicken-pox, vac- 
cinia, and small-pox have been known to 
follow in immediate succession in the same 
individual. 
Course and Termination. - Varicella 
always runs a favourable course. It has no 
sequel®. 
Diagnosis.-It should be borne in mind 
that a sure diagnosis cannot be made in less 
than forty-eight hours. The appearance, 
however, of a crop of vesicles, followed on 
the next day by a second crop, points almost 
certainly to chicken-pox. Attention to this, 
and to the points noted under the head of 
Pathology, ought to make the diagnosis 
easy. 
Prognosis.-This is always favourable. 
Treatment.-The patient should be con- 
fined to his room, perhaps in the more 
marked cases to his bed. His food should 
be that which is easy of digestion; and 
although no physician has recorded a fatal 
case, a child whose temperature rose to three, 
four, or six degrees above normal should be 
examined with care. 
Alex. Collie. CHIGOE 
CHILBLAIN 
319 
CHIGOE.- Description.- The Chigoe 
is a minute parasitic insect, common in 
the West Indies and northern parts of 
South America. It is also popularly known 
as the Jigger or Sandflea. Though formerly 
regarded as an acarus or mite, it is now 
generally recognised as a true flea, belonging 
to the genus Pulex (P. penetrans); but several 
entomologists have advanced solid reasons 
for separating it from the ordinary fleas. 
Thus Westwood terms it the flesh-flea, or 
Sarcopsylla penetrans, whilst Guerin formed 
the genus Dermatophilus for its reception. 
Practically, these distinctions are of little 
moment. 
The Chigoe ordinarily lives in dry and 
sandy situations, where it multiplies to a pro- 
digious extent. It attacks, however, the feet, 
chiefly underneath the nails and between the 
toes ; the impregnated females burying them- 
selves beneath the skin. Here the abdomen 
of the parasite swells to the size of a pea; 
and, unless removed by operation, gives 
rise to acute local inflammation, terminating 
in suppuration and sometimes in extensive 
ulceration, with even fatal results to the 
patient. Dogs also suffer excruciating tor- 
ment from the bites and immigration of the 
Bicho do Cachorro, which, however, Pohl 
and Kollar regard as distinct from the human 
jigger (Bicho de pe). Be that view correct 
or not, it would appear from the observations 
of Rodschild and Westwood that the larvae 
of the human chigoe are hatched in the open 
wounds or ulcers, which sometimes extend 
inwards so as to involve the bones themselves. 
In bad cases amputation of the toes and ad- 
jacent parts becomes necessary. Left to 
themselves, the larvae escape from their host, 
and probably, after- the manner of bots and 
other parasitic insects, penetrate the soil for 
the purpose of acquiring the pupal stage of 
growth. In European practice cases of jigger 
are rarely seen; nevertheless the writer has 
recorded an instance in which strong mental 
delusions followed the torture produced by 
these creatures. The patient, a middle-aged 
married lady, had suffered severely during 
her residence in the West Indies. Although 
she had got rid of the parasites, she con- 
stantly harpooned her own feet in the hope 
of destroying the young jiggers which she felt 
sure were still burrowing beneath the skin. 
Treatment.-As regards treatment, the in- 
dications are simple. The parasite should 
be removed with the utmost care. Where 
this has not been done, and where, as a con- 
sequence, open sores exist, frequent washings 
with tepid water, followed by the application 
of carbolic acid lotions (twenty or thirty grains 
to the ounce) or of ointments (one drachm 
to one ounce of benzoated lard) will be found 
most suitable. Or, again, the carbolic acid 
putty, as sold in shops, or the application of 
one part of the acid previously mixed with 
ten or twelve parts of simple olive oil, will, 
in all likelihood, be sufficient to cause the 
destruction of any larvse that might remain. 
Lastly, it seems almost needless to say 
that residents and travellers in Guiana, 
Brazil, and in the West Indies generally, 
should have their feet properly protected. 
T. S. Cobbold. 
CHILBLAIN.-Synon.: Kibe; Pernio', 
Fr. Bng elure ; Ger. Frostbeule. 
Definition.-A state of inflammation of a 
part of the skin induced by cold. 
^Etiology.-Chilblains are common in 
children and young persons, and are more 
frequent in girls than boys. They occur 
chiefly in those of a lymphatic constitution, 
and may be considered as an indication of 
debility and deficient vital power. In adult 
age they are rare, and are only met with 
when the powers of the constitution are re- 
duced. Their occurrence is influenced more 
by the strength of the individual than by 
the degree of cold, and they continue in some 
persons throughout the entire year. Their ten- 
dency is to cease with the full development 
of the system, and they reappear occasionally 
in advanced life. 
' Description.-The regions of the body 
usually affected with chilblains are the feet 
and hands, to which are sometimes added 
the ears and nose. A chilblain presents three 
stages or degrees of severity, namely, erythe- 
matous, 'bullous, and gangrenous', and it 
may be arrested at the first or second stage 
by the withdrawal of the cause. The erythe- 
matous stage is restricted to hypersemia, 
swelling, and severe burning and itching, the 
itching being increased by heat, as by that of 
the fire or that induced by exercise. The 
congested spot is circular in figure, somewhat 
tumid, brightly red at first, but later on 
roseate crimson, purple, or livid in colour. 
The second or bullous stage exhibits the 
blain or blister resulting from effusion of 
serum beneath the cuticle; the permanent 
colour of the swelling is now purple or livid; 
and the contents of the blister a limpid serum, 
generally reddened with blood-sometimes, 
indeed, the fluid of the blister may be semi- 
purulent. In the gangrenous stage the 
blister is broken, the surface of the derma is 
in a state of gangrene, and the gangrenous 
layer is subsequently removed as a slough by 
ulceration. 
Treatment.-The treatment of chilblain 
requires to be modified to suit its different 
degrees. In the first, the indication is to 
restore normal circulation by gentle friction, 
and, when the part is severely chilled, it is 
usual to rub it with snow: then some sooth- 
ing liniment may be employed ; and, finally, 
a stimulating liniment, covering the part 
afterwards with zinc ointment and cotton- 
wool, or shielding it with lead or opium 
plaster spread on washleather. The applica- 
tions most in favour for this purpose are the 320 
CHILBLAIN 
CHLOROSIS 
soap liniment with chloroform and laudanum, 
the compound camphor liniment, the tur- 
pentine liniment, and the tincture of iodine. 
In the bullous stage a similar treatment may 
be used to the erythematous portions, whilst 
the blister should be snipped and the broken 
surface pencilled with the compound tincture 
of benzoin, and afterwards dressed with 
unguentum resinae or an ointment of Peruvian 
balsam. In the third stage the erythematous 
phenomena still require attention, and the 
ulcer should be dressed with unguentum 
resinae, either alone, or in combination with 
antiseptics. 
To obviate constitutional debility, the diet 
should be nutritious and generous, and re- 
course may be had to tonic remedies, such 
as iron and quinine and good air. 
Erasmus Wilson. 
CHILL.-A subjective sensation of cold- 
ness, accompanied with shivering, and most 
frequently experienced in connexion with 
febrile or inflammatory diseases, in nervous 
individuals, and after exposure to cold and 
wet. In popular language ' taking a chill ' is 
used as synonymous with ' catching a cold,' 
as from some undue exposure. See Rigor. 
CHIN-COUGH. - A synonym for 
whooping cough. See Whooping Cough. 
CHIRAG-RA (yetp, the hand; and hypa, 
a seizure).-Gout in the hand. See Gout. 
CHLOASMA (x^oa, a green herb).- 
Synon. : Liverspot ; Fr. Ephelide; Ger. 
Leberflech. 
A pigmentary discoloration of the skin, 
of a yellowish-brown or liver-colour tint, oc- 
curring in blotches, and due to constitutional 
causes. Its synonym, ephelis gravidarum, 
indicates its occasional association with preg- 
nancy. See Pigmentary Skin Diseases. 
CHLORAL HYDRATE, Poisoning 
by.-Synon. : Fr. Empoisonnement par VHy- 
drate de Chloral ; Ger. Chloralhydratver- 
giftung. 
Poisoning by chloral hydrate is a very 
common occurrence, this medicament being 
frequently taken in fatal quantity by mis- 
adventure. There is reason to think that it 
is also largely used for suicidal purposes. 
The so-called ' chloral habit ' is a growing 
evil. A syrup containing about twenty-two 
grains of this substance per fluid drachm is 
largely and injudiciously sold in this country 
under a patent-medicine stamp. 
Anatomical Characters.-There may be 
an entire absence of any characteristic ap- 
pearances after death by hydrate of chloral; 
and at most these consist in more or less 
modified signs of asphyxia-especially a dark 
colour of the blood, and pulmonary and cere- 
bral hyperaemia. 
Symptoms.-The most striking symptoms 
of poisoning by chloral hydrate is the rapid 
supervention of quiet sleep, at' first simu- 
lating natural sleep. In this stage the patient 
can be easily roused, but he speedily drops 
off again. The pupils are contracted; the 
respirations are full, deep, and regular; the 
pulse is not much affected. This condition 
rapidly deepens into full coma. The respira- 
tions slacken; and the pulse is either weak 
and slow, or, more commonly, rapid and 
irregular. The temperature of the body is 
reduced; the muscular system is totally 
relaxed. The pupils now dilate ; and with 
feeble, thready pulse, the anaesthesia and 
paralysis gradually end in death, preceded 
by lividity and collapse. Exceptionally, in 
fatal cases, burning pain in the mouth, 
fauces, and throat, and symptoms of gastritis 
have been observed. In one case of recovery 
the patient became idiotic. The urine con- 
tains an abundance of glycuronic acid. 
Diagnosis.-The history of the case, or 
the finding of a vessel containing the 
medicine, coupled with the symptoms, will 
usually set all doubts at rest. Otherwise the 
case may be mistaken for poisoning by 
opium or other narcotic, for carbolic acid 
poisoning, or for cerebral congestion. The 
pupil is not so contracted as in opium 
poisoning; and, as the coma deepens, the 
pupils dilate instead of undergoing further 
contraction. There is an absence of the 
olive-green or black urine so commonly 
noticed in carbolic acid poisoning, of the 
peculiar odour of the breath, and of stains 
about the mouth and lips. 
Prognosis.-This wall depend upon the 
state in which the patient is found, and upon 
the length of time which has elapsed since 
the ingestion of the poison. 
Treatment.-Evacuation of the stomach 
by the aid of the stomach-pump is the first 
step in the treatment of a case of poisoning by 
chloral hydrate. Emetics, unless given early, 
usually fail to excite vomiting. The patient 
must be roused, if possible, as in opium poison- 
ing (see Opium, Poisoning by). The tempera- 
ture of the body must be kept up by warm 
applications. Stimulants may be freely 
given, and hot coffee injected into the rectum. 
Strychnine (jg gr.) has been recommended 
for use as a counter-poison, by subcutaneous 
injection; also picrotoxin. The former is a 
dangerous remedy; the latter also would not 
perhaps be a safe antidote, if given in full 
doses. Inhalations of amyl nitrite, and 
artificial respiration are advisable. 
Thomas Stevenson. 
CHLOROFORM, Use of.-See Anes- 
thetics. 
CHLOROSIS (xXwpdr, green or sallow). 
Synon. : Green-sickness; Er. La chlorose ; 
Ger. Chlorose ; Bleichsucht. 
Definition.-A variety of anaemia occur- 
ring in a peculiar diathesis or habit of 
body, which is characterised by defective CHLOROSIS 
321 
growth of the blood-corpuscles and vascular 
system. 
The subjects of this diathesis are said to 
be chlorotic. They ordinarily enjoy good 
health, unless exposed to any of the causes 
of anaemia, when they readily suffer from 
aglobulism ; and this aglobulism may proceed 
to complete anaemia. The term chlorosis is 
properly applied to the first and simpler form 
of anaemia in these subjects ; the second and 
more complex condition is designated chlor- 
ancemia; or, more commonly, ancemia. 
See Anaemia. 
^Etiology.-Chlorosis occurs most com- 
monly in young women from the age of puberty 
to twenty-one, but it may appear or reappear 
up to the thirtieth year; it is found occasion- 
ally in children and older women; it is very 
rare in men. It is believed to be more com- 
mon in the higher ranks of life. Beyond these 
predisposing causes, the origin of the disease 
lies in peculiar characters of the blood and 
blood-vessels, to be presently described, which 
are believed to be congenital, and perhaps 
hereditary. In such subjects, and under the 
preceding circumstances, any of the numer- 
ous causes of anaemia may be sufficient to ex- 
cite the appearance of chlorotic symptoms; 
but those which do so most commonly are 
bodily growth and development, the es- 
tablishment of menstruation, disturbances 
of alimentation - particularly constipation, 
and an insufficient enjoyment of air, light, 
and wholesome muscular exercise. 
Anatomical and Chemical Characters.- 
The blood in chlorosis presents one essential 
imperfection, as far as our present knowledge 
extends. The individual red corpuscle con- 
tains less than the normal amount of haemo- 
globin, the total amount of haemoglobin in 
the blood sometimes falling to less than one- 
fourth. With this defect there may be 
associated various other abnormalities. The 
total quantity of blood is below the normal, 
though there may be an excess in relation to 
the calibre of the vessels {plethora ad vasa). 
Both red and white corpuscles are sometimes 
deficient in numbers, and that proportion- 
ately. In pure chlorosis the quality of the 
liquor sanguinis is believed to be unchanged; 
but it is possible that certain complex organic 
substances exist in the blood which cannot 
be discovered by our present methods of 
examination. 
With this condition of blood there are 
associated certain remarkable abnormalities 
of the aorta and arterial system generally. 
The most striking of these is a hypoplasia 
or dwarfed condition of the aorta, represented 
by small calibre, increased elasticity, anoma- 
lous origin of the branches, and unequal 
thickness and fatty metamorphosis of the 
intima. The heart is, as a rule, small in early 
life; but full-sized or even hypertrophied at 
a later period, with traces of endocarditis. 
The blood-glands and lymphatic structures 
are not diseased. The condition of the 
ovaries and uterus has been carefully 
examined in chlorosis and found to vary 
extremely. In some cases the generative 
organs are described as ' infantile,' while in 
others they are either immoderately deve- 
loped, or perfectly normal in every respect. 
Corresponding with the aglobulism, the sub- 
cutaneous fat is abundant; and the viscera 
present various degrees of fatty metamor- 
phosis. When the cardio-vascular changes 
are marked and advanced, there may be 
extensive secondary disease throughout the 
body. 
Symptoms.-The symptoms of simple 
chlorosis are those of mild anaemia, with 
certain important differences which become 
fewer and less marked, and finally disappear, 
as chlorosis advances to the more serious 
disease. The present article will be chiefly 
devoted to a description and discussion of 
these. 
The appearance of the chlorotic girl is 
peculiar, inasmuch as the pallor of her 
complexion is accompanied by natural or 
even increased fulness, from the excess of 
subcutaneous fat. At the same time the 
colour of the skin is so remarkable as to have 
given its name to the disease, the general 
hue being a greenish-yellow. In blondes the 
transparency of the skin is increased; in 
brunettes it is diminished, and a dull 
yellowish-grey colour of skin is the result, 
which, in contrast with the greyish-blue of 
the eyelids, may appear of a sickly green. 
The patient's usual complaint is of this 
alteration of colour, menstrual disorder, de- 
bility, great breathlessness, cardiac symptoms, 
and various pains. She probably believes 
that she has heart disease ; her mother fears 
that she is consumptive. Various menstrual 
disorders are present-namely, premature 
menstruation, amenorrhcea (with respect both 
to the period and the amount), occasionally 
menorrhagia, and leucorrhoea. Breathless- 
ness on exertion is one of the most striking 
symptoms. The cardiac symptoms and the 
cardiac and vascular signs closely resemble 
those of anaemia. But there is this important 
difference in the phenomena connected with 
the heart, that in many cases of chlorosis 
they indicate enlargement, and especially 
hypertrophy of the left ventricle. The cha- 
racters of the blood already described are 
readily discovered by the use of the hsemo- 
globinometer and haemacytometer. Venous 
thrombosis may be found in the legs. The 
alimentary system is often seriously de- 
ranged, constipation being an urgent symp- 
tom. The urine is abundant, watery, and 
pale. There is no dropsy in simple, uncom- 
plicated chlorosis. Rheumatic symptoms are 
occasionally associated. Pyrexia (99°-103° F.) 
has been observed in some instances. Optic 
neuritis may occur. 
The chlorotic constitution or diathesis 322 
CHLOROSIS 
may be recognised by the following charac- 
ters, which are variously associated in dif- 
ferent cases :-Diminutive stature; imper- 
fect sexual development; a history of pecu- 
liar anaemia in childhood, of anaemia with 
menstrual irregularity at puberty, and of pre- 
vious attacks of symptoms of chlorosis; evi- 
dence of cardiac enlargement or mitral disease 
in the absence of all the ordinary causes of 
these ; the occurrence of endocarditis during 
pregnancy or post partum ; and the presence 
of any of the diseases which will be referred 
to under the head of Complications. 
Course, Duration, and Terminations.- 
The commencement of chlorosis is generally 
gradual, but may be sudden. Its ordinary 
course is towards confirmed anaemia, in which 
it may terminate, the liquor sanguinis becom- 
ing affected, and wasting and oedema being 
added to the previous symptoms, which are 
also aggravated. It is for this reason that 
pure chlorosis is a rare disease, while an- 
semia associated with the chlorotic diathesis 
is comparatively common. The duration of 
the disease is variable; it rarely declines 
until the determining circumstances have 
been removed, and the patient subjected to 
careful treatment. Chlorosis may reappear 
in the subject of the diathesis, and that more 
than once; but the probability of its return 
is small after the age of thirty, especially in 
the married woman. Death from chlorosis 
directly is excessively rare. 
Complications and Sequel®.-According 
to Virchow, serious valvular disease and 
cardiac enlargement may be traced in some 
of the worst cases of chlorosis to the associ- 
ated vascular condition; and the mitral valve 
is peculiarly liable to be attacked by endo- 
carditis in rheumatic, puerperal, or septic 
fever. Haemorrhages, gastric ulcer, and ex- 
ophthalmic goitre are believed to occur with 
comparative frequency in persons of the 
chlorotic diathesis. 
Pathology.-The deficiency of the indi- 
vidual red corpuscle in haemoglobin, and the 
deficiency of the blood in red and white 
corpuscles, indicate an imperfect growth of 
the red corpuscles and an imperfect produc- 
tion of the cellular elements of the blood. 
With this blood-state there is undoubtedly 
associated a hypoplastic or dwarfish condi- 
tion of the blood-vessels. In the embryo 
the blood and blood-vessels are developed 
from the same elements, the former making 
its appearance within the cells which produce 
the latter. It is highly probable, therefore, 
that the anomaly of blood and the anomaly 
of vessels are to be considered as together 
an expression of some congenital defect of the 
blood-vascular system, leading to imperfect 
growth both of blood and of vessels. Any 
individual possessing a blood-vascular system 
thus anomalous labours under a peculiar 
diathesis, or debility of the corpuscles and 
circulatory system, and is said to be a chlorotic 
subject, or to possess the chlorotic constitu- 
tion or diathesis. 
If the other systems of the body are full- 
sized (which is not always the case), the 
dwarfish condition of the arteries of the 
chlorotic subject and the scanty supply ol 
haemoglobin may have some difficulty in 
satisfying the ordinary demands for blood, 
and especially for oxygen. This difficulty 
of the blood-vascular system will become 
a breakdown when the processes of ali- 
mentation are deranged from which the 
blood derives the materials for its mainte- 
nance, or when the blood is w'asted by the 
excessive demands of growth, development, 
or haemorrhage. Such a result is more likely 
to happen at periods of extraordinary de- 
mand within the economy, of which the 
establishment of menstruation is the chief. 
It is in this way that exposure to the causes 
referred to is sufficient to produce the symp- 
toms of chlorosis, when they might not affect 
the blood of an ordinary (non-chlorotic) in- 
dividual. 
The symptoms of uncomplicated chlorosis 
are due to aglobulism or deficiency of oxygen 
in the system (see Blood, Morbid Conditions 
of). When chlorosis advances to complete 
anaemia, by the implication of the plasma, a 
new series of phenomena present themselves, 
prominent among which are loss of flesh and 
oedema of the extremities. 
The cardiac enlargement and valvular dis- 
ease are directly referable to the vascular 
hypoplasia, that is, to the obstruction caused 
by the narrow calibre of the aorta. The con- 
nexion between the blood-vascular condition 
and that of the generative organs is more 
complex. On the one hand, the chlorotic 
diathesis or actual chlorosis interferes with 
the development and activity of the ovaries 
and uterus; on the other hand, disorders of 
the sexual functions are occasionally exciting 
causes of aglobulism. 
A variety of suggestions have been offered 
as to the manner in which derangement of 
the alimentary processes in the bowels im- 
poverishes the blood in chlorotic subjects. 
Sir Andrew Clark maintains that w'hen the 
bowels are inadequately relieved, ptomaines 
and leucomaines are produced within the in- 
testine and absorbed into the blood, ' where 
they originate in girls of a nervous type of 
organisation those alterations of the consti- 
tution of the blood which constitute the true 
pathogeny of this anaemia.' Another sugges- 
tion is, that sulphuretted hydrogen generated 
in the bowels destroys the organic compounds 
of iron which go to form haemoglobin. Ac- 
cording to a third suggestion, substances 
containing animal gum, which are developed 
in excess within the alimentary canal of 
the girl or woman, being required for the 
after-nourishment of the embryo, act in- 
juriously on the haemoglobin molecule. Still 
another theory is, that, from a deficiency of CHLOROSIS 
CH0L2EMIA 
323 
hydrochloric acid in the system, iron enters 
the blood in forms which cannot be assimi- 
lated by the corpuscles. 
Diagnosis.-Chlorosis has chiefly to be dis- 
tinguished from symptomatic and pernicious 
anaemia. The points by which the diagnosis 
may be accomplished have been sufficiently 
indicated. Leukaemia may be readily recog- 
nised by a careful examination of the blood 
and spleen. See also Anaemia, Pernicious. 
Prognosis.-The prognosis is highly fa- 
vourable as regards life; and a speedy cure 
may be assured in uncomplicated cases sub- 
jected to careful treatment. 
Treatment.-The success of a particular 
method of treatment of simple chlorosis is 
one of the strongest arguments in favour of 
the correctness of the preceding view of the 
pathology of the disease. The condition 
being one of aglobulism, the treatment em- 
ployed will be so far simpler than that of 
anaemia, that the red corpuscles alone have 
to be restored. While the various measures 
recommended in the more serious blood-dis- 
order are therefore to be employed, if neces- 
sary, it will generally be found that iron alone 
will be sufficient to effect a cure in chlorosis, 
and that rapidly. The particular form in 
which the drug is to be presented must be 
carefully selected according to circumstances. 
These are fully set forth in the article 
Anaemia, and need not be repeated here. A 
free supply of sunlight is essential, and must 
be insisted upon ; and physiological rest of 
the blood and of the organs of circulation is 
equally necessary. 
J. Mitchell Bruce. 
CHOLJEMIA (^oA>),bile; andcu/xa,blood). 
Definition. - This term literally denotes 
that condition in which the blood contains 
some or all of the bile constituents which 
have been secreted by the hepatic cells, and 
subsequently reabsorbed, either directly by 
the capillaries or via the lymphatics. It is 
usual to include the symptoms which this 
state induces under the expression 'jaundice,' 
which is more properly only one of the mani- 
festations of the circulation of a bile-contain- 
ing blood; and hence the word cholsemia has 
come to have a more restricted application, 
corresponding to the icterus gravis of older 
writers, or even to have fallen into disuse. 
Symptoms.-The symptoms of cholsemia 
are very variable in their occurrence and 
severity. Jaundice is certainly the most con- 
stant, and is elsewhere fully treated of. The 
derangements of digestion, which depend on 
exclusion of bile from the alimentary canal, 
are scarcely to be regarded as effects of viti- 
ated blood. But the slow pulse, bitter taste 
in the mouth, pruritus, cutaneous eruptions, 
hsemorrhages, wakefulness, yellow vision, and 
certain nervous phenomena, some or all of 
which so constantly accompany jaundice, are 
obviously attributable to this cause. 
The explanation of these symptoms is not 
altogether clear, owing in great part to our 
ignorance of the intimate nature of bile- 
secretion, and of the exact share taken by 
the liver in urea-formation and other meta- 
bolic processes. In obstructive jaundice the 
bile-pigments are soon absorbed from the 
occluded biliary passages, and are obviously 
the cause of the icteric discoloration of the 
skin and tissues. Later the bile-salts are dif- 
fused into the blood-current, and doubtless 
they are responsible for the slow pulse so 
commonly found in jaundice unassociated 
with pyrexia, and also for the destruction of 
blood-corpuscles and consequent petechias 
and other haemorrhages, since these condi- 
tions are well known to follow the artificial 
injection of bile-salts into the blood. The 
bitter taste, as also the pruritus, are probably 
due to the same cause. Whether the various 
cutaneous eruptions are the expression of the 
local irritation of a bile-containing blood, or, 
as is more probable, of some trophic dis- 
turbance, determined by the toxic materials 
acting through the nervous system, cannot be 
affirmed. The most interesting and impor- 
tant symptoms of chol8emia,to which the term 
has sometimes been limited, are the nervous 
symptoms. It is well known that many cases 
of bile-retention, even of considerable severity, 
may run a prolonged course, and, except for 
the jaundice, be almost unaccompanied by 
other symptoms directly referable to the 
vitiated blood; but in some, even when the 
jaundice is but slight or even quite absent, 
nervous symptoms of a grave character super- 
vene, often with considerable suddenness. 
The general character of these manifestations 
is an increasing drowsiness, which deepens 
into coma, usually fatal. Preceding this, a 
stage of excitement, with noisy violent de- 
lirium, may occur, or sometimes convulsions 
of varying severity. There is a noticeable 
absence of headache, in the writer's ex- 
perience, offering therein a marked con- 
trast to uraemia, with which by some the 
state now described has been considered 
identical. The general condition of the pa- 
tient is that of the ' typhoid state,' with vary- 
ing degrees of coma or convulsion. With our 
present knowledge it is extremely difficult to 
suggest the cause for these symptoms: the 
prevailing view is that they are toxic, the 
poison being developed in the body as a con- 
sequence of the perverted hepatic functions. 
But whilst it may be said with certainty that 
they are not due to accumulation of choles- 
terin in the blood (cholesteraemia), as was 
formerly stated, it remains uncertain whether 
the poisonous material is actually excess of 
bile-salts, or, what is far more probable, of 
nitrogenous derivatives of proteid digestion, 
which, in the normal action of the liver, 
would be converted into bile-salts or urea. 
The close relationship existing between the 
bile-forming and urea-forming functions of 324 
CHOL^EMIA 
CHOLERA, ASIATIC 
the liver should not be forgotten; nor also 
the fact that the bile is normally one of the 
most important channels whereby toxic sub- 
stances are eliminated from the organism, 
whether these be poisons introduced from 
without or developed in the liver or other 
tissue as results of morbid metabolism. The 
suppression of the biliary secretion or its 
obstructed excretion readily explains how a 
blood-poisoning may be engendered, though 
the exact source and nature of the poison 
may not as yet be accurately known. Another 
explanation of these symptoms has been put 
forward by Cohnheim, who, comparing them 
to the delirium often seen at and after the 
crisis of acute diseases, attributed them to 
cerebral inanition, coupled with an excessive 
albuminous disintegration in the tissues. 
Treatment.-This usually resolves itself 
into removing the cause of the bile-retention; 
when this is impossible, but little can be 
done for the resulting symptoms. The itch- 
ing of the skin may sometimes be consider- 
ably allayed by alkaline baths, or by causing 
profuse sweating by pilocarpine or hot-air 
baths. It often subsides independently of 
treatment, to recur again with increased seve- 
rity, especially at night. The internal ad- 
ministration of bicarbonate of potassium, a 
method commonly adopted in jaundice from 
most causes, also relieves the pruritus. Active 
diaphoresis, with a brisk purge and blisters to 
the nape of the neck, are indicated for the 
cerebral symptoms. Very little benefit ap- 
pears to follow such remedies as the bromides 
if given for the convulsive seizures, but 
leeches to the temples are of occasional ser- 
vice if indicated. W. H. Allchin. 
CHOLAGOGUES (XoX^, bile; and fiya, 
I move).- Definition.-Substances which 
lessen the amount of bile in the blood. 
Enumeration.-The principal cholagogues 
are Mercury and its preparations-especially 
Calomel and Blue Pill; Podophyllum and 
Podophyllin; Euonymin, Iridin; Ipecacu- 
anha ; Aloes; Rhubarb; Sodium Salicylate, 
Sodium Phosphate, and Sodium Sulphate. 
Action and Uses.-The liver has a two- 
fold action-it forms bile, which is poured 
into the duodenum; and it also excretes 
the bile which has been re-absorbed from the 
duodenum and carried back to the liver by 
the portal circulation. Much bile thus cir- 
culates continually between the liver and 
duodenum, while part is carried down the 
intestine with the feces, and its place sup- 
plied by newly formed bile. When the 
quantity circulating in this way is too great 
to be completely excreted by the liver, it 
enters the general circulation and produces 
symptoms of biliousness. These are removed 
by the so-called cholagogues, which probably 
act by stimulating the duodenum, and thus 
Carrying the bile so far down the intestine 
as to interfere with re absorption. Amongst 
the beat cholagogues are the preparations of 
mercury, which, with the exception of the 
perchloride, do not increase the secreting 
power of the liver, nor augment the quantity 
of bile formed by it. Their utility is greatly 
increased by combination with a saline 
purgative, which still further clears out the 
intestine, and completely prevents any re- 
absorption of bile. Other cholagogues, such 
as podophyllin, rhubarb, and aloes, actually 
increase the secretion of bile by the liver. 
At the same time, they probably prevent its 
re-absorption, in a similar way to mercurials 
and salines. T. Lauder Brunton. 
CHOLELITHIASIS (yoXij, bile; and 
XWof, a stone).-The condition of system as- 
sociated with gall-stones. See Gall-Stones. 
CHOLERA, ASIATIC. - Synon. : 
Epidemic, Spasmodic, or Malignant Cholera; 
Fr. Cholera Asiatique ; Ger. Asiatische 
Cholera; Itai. Colera Asiatico. 
Definition.-Asiatic cholera is a specific 
disease, characterised by violent vomiting 
and purging, with rice-water evacuations, 
cramps, prostration, collapse, and tending to 
run a rapidly fatal course. It is capable of 
being communicated to persons otherwise in 
sound health, through the dejecta of patients 
suffering from the disease. These excreta are 
most commonly disseminated among a com- 
munity, and taken into the system, by means 
of drinking-water, or in fact by anything 
swallowed which contains the specific or- 
ganisms passed from cholera patients. In 
badly ventilated rooms, the atmosphere may 
become so fully charged with the exhalations 
from patients suffering from cholera as to 
poison persons employed in nursing the sick. 
In the same way, people engaged in carrying 
the bodies of those who have died from 
cholera for burial, or in washing their soiled 
linen, may contract the malady. In a dried 
condition the organisms contained in cholera 
excreta may retain their dangerous proper- 
ties for a considerable period. 
Asiatic cholera is endemic in certain parts 
of British India, where, from time to time, it 
assumes an epidemic character, and is apt 
then to spread, through the means above 
indicated, along the chief lines of human 
intercourse, and. so to extend over the world. 
History.-Since the days of Hippocrates, 
medical practitioners residing in various parts 
of Europe have described a disease which 
they called cholera. The nosology of this 
affection was hardly a matter of doubt with 
them, and it is only in modern times that 
the question has arisen, as to whether the 
cholera commonly met with among us is 
identical in its nature with Asiatic cholera. 
Doubtless, if we compare isolated cases we 
may find that the symptoms which these 
affections induce are very similar; but those 
who have lived beyond the endemic area of CHOLERA, ASIATIC 
325 
Asiatic cholera, and watched the disease 
spread from India over Europe and America, 
can scarcely mistake this malignant malady 
for simple cholera. Asiatic cholera was 
unknown in Europe before the year 1829-30, 
although it has existed in India for many 
centuries. It is true we have no accounts of 
cholera extending throughout the whole of 
Hindustan prior to the year 1817, but this 
arises from the circumstance that it was only 
at the commencement of the present century 
that the British Government began to bind 
the heterogeneous principalities of India into 
union, and thus render it possible for us to 
gather together authentic details regarding 
the disease, as it spread from one province 
to another. 
We cannot here fully consider the relations 
which unquestionably exist between the 
rapidity of the diffusion of cholera from the 
East over Europe, and the increased facilities 
of communication that have recently been 
established between India and Persia and 
Arabia, also from Hindustan to Russia and 
the shores of the Mediterranean. For 
instance, sixty years ago the passage from 
Bombay, up the Arabian and Persian 
Gulfs, could only be undertaken at certain 
seasons of the year when the winds were 
favourable, and even then the voyage was 
difficult to accomplish ; now large steamers 
run every week from Bombay to Bassorah 
and the intermediate ports along the Persian 
Gulf, and others pass with equal rapidity to 
the various towns bordering the Red Sea. 
But although we cannot enter further into 
this subject, we must, in order to appreciate 
the nature of cholera, glance at the chrono- 
logical order of some of the principal out- 
bursts of the disease, which have been dis- 
seminated from British India over the world. 
In 1817 cholera spread rapidly throughout 
Bengal, extending during the following 
year over the greater part of Hindustan, and 
from thence to Ceylon, Burmah, and China. 
The disease was communicated from Bombay 
vid the Persian Gulf in 1820-21, and travelled 
northward, but did not extend into Europe. 
During the year 1826 cholera again broke 
out over Bengal, and, passing through the 
Punjaub, it entered Cabul in 1828, and from 
thence extended to Persia, and so to Russia 
during the years 1829-30, and over the whole 
of Europe and the greater part of America. 
In 1840-41 cholera accompanied a British 
force despatched from Calcutta to China ; it 
broke out among our troops on their voyage 
to that country, and, having spread through- 
out the Chinese and Burmese empires, it 
passed in 1843-44 through Kashgar to Bok- 
hara, and so to Cabul. From Afghanistan the 
disease extended south into Scinde, and west- 
ward in 1845-46 through Persia to Russia 
and Europe, reaching America in 1848. 
In 1849 cholera was very fatal over Bengal; 
and during the season of 1851-52 it was com- 
municated through the Punjaub and Bombay 
respectively to Persia and Arabia; and in 
1853 -54 it spread vid Russia and Egypt 
with frightful virulence throughout Europe 
and America. 
During the years 1860-61-62 cholera pre- 
vailed to an alarming extent throughout 
Bengal and the Central Provinces, and in 
1864-65 in Bombay and along the shores of 
the Red Sea ; thence it passed with pilgrims 
from Mecca to Egypt, and so to Europe, and 
for the fourth time to America. It is well to 
fix our attention on the lessons to be learnt 
from a careful study of the history of these 
early epidemics of Asiatic cholera; because, 
subsequently to 1865, the rapid and com- 
plicated means of transit between India and 
Europe has rendered it difficult, if not im- 
possible, to trace the spread of the disease 
westward through the Red Sea route. 
These outbursts of. epidemic cholera were 
remarkably sudden in their advent, a con- 
siderable number of people in the affected 
locality being attacked by the disease within 
a few days after it appeared among them. 
The malady almost invariably died out from 
among the inhabitants of a country under 
its influence during the cold seasons of the 
year, to re-appear on the approach of summer. 
As a general rule, the disease was most 
deadly during the first year of the epidemic; 
it decreased in violence the second season, 
and then gradually disappeared, seldom 
prevailing in any one locality for more than 
three consecutive years. 
^Etiology.-The more we study the early 
history of Asiatic cholera, the better shall we 
understand, that every outburst of the disease 
which occurred beyond the confines of India 
might invariably be traced back through a 
series of cases to that country. The disease 
has never broken out spontaneously in any 
part of the world-no amount of filth, of bad 
food, or climatic influences has up to the 
present time induced a widespread epidemic 
of cholera : it has invariably spread from its 
endemic area over the world. The inhabi- 
tants of countries far removed from Hin- 
dustan, and having limited communication 
with that empire, such as Australia, have not 
experienced the disease; whereas states in 
proportion as they are brought into intimate 
relation with India become subject to out- 
breaks of cholera. 
Many of the earliest Anglo-Indian authors 
declared their conviction that the disease 
was contagious; others disputed this idea ; 
but all agreed that cholera, when extending 
over a country, often settled on the inhabi- 
tants of low-lying, ill-drained, and over- 
crowded localities, and that it frequently left 
unharmed people residing beyond the af- 
fected area, although they might have been 
employed in attending patients suffering from 
the disease. It remained for Dr. Snow, in 
1854, to explain this apparent mystery, and 326 
CHOLERA, ASIATIC 
to demonstrate, as he did by means of the 
Broad Street case,1 that the poison which 
causes cholera is contained in the excre- 
ments of those suffering from the disease, 
and ' that if by leakage, soakage from cess- 
pools or drains, or through reckless casting 
out of slops and wash-water, any taint, how- 
ever small, of the infective material gets 
access to wells, and other sources of drinking- 
water, it imparts to enormous volumes of 
water the power of propagating the disease ' 
(Simon). Cholera patients cannot, in fact, 
communicate the affection to others, unless 
by means of the discharges which they pass. 
Persons attending them run no risk of con- 
tracting the disease, provided they are pro- 
tected from swallowing the organic matter 
passed by the sick; but in badly ventilated 
rcoms, this material, having been dissemi- 
nated through the atmosphere, may be taken 
into the system by attendants and so poison 
them. 
Sir William Aitken observes that the evi- 
dence in favour of the communicability of 
cholera by means of water or food, con- 
taminated with cholera dejecta, has since 
1854 become almost overwhelming. A re- 
markable instance of the kind, reported by 
the late Mr. Netten Radcliffe, took place in 
East London during the year 1866 ; and 
previous to this time, the circumstances of 
a case came under the writer's notice, in 
which a small quantity of a fresh rice-water 
stool, passed by a patient suffering from 
cholera, was accidentally mixed with some 
four or five gallons of water, and the mix- 
ture exposed to the rays of the tropical 
sun for twelve hours. Early the following 
morning nineteen people each swallowed 
about an ounce of this contaminated water 
-they only partook of it once-but within 
thirty-six hours five of these nineteen persons 
were seized with cholera. In this instance 
the choleraic evacuation did not touch the 
soil: as it was passed, so was it swallowed ; 
but (and this is most important to remember) 
it had been largely diluted with impure water, 
and the mixture had been exposed to the light 
and heat of a tropical sun for twelve hours. 
Professor Pettenkofer holds, that if the 
excreta from patients suffering from cholera 
pass into the earth, they may there, under 
peculiar conditions of the soil, moisture, and 
heat, undergo changes, and, having risen as 
a miasma into the air, be absorbed, and 
act as a poison on persons predisposed to 
the disease. It appears certain that cholera 
germs cannot multiply unless exposed to 
a definite range of temperature; they also 
require moisture, containing certain chemical 
substances, for their development and growth. 
The evidence brought together by Professor 
R. Koch and G. Gaffky in their admirable 
report on cholera in Egypt, and in India, in 
1883, published in Berlin 1887, is sufficient 
to convince the writer that the germs of Asi- 
atic cholera consist of a specific bacillus. 
This micro-organism is found in the contents 
of the intestinal canal, and in the matter 
passed by persons suffering from cholera. 
We know that if such excreta gain access 
through water or food to the intestinal canal 
of persons predisposed to cholera, they may 
become affected with the disease, and so we 
conclude that the symptoms characteristic of 
Asiatic cholera are in some way dependent 
on the action of the cholera bacillus. From 
the researches of Dr. Cartwright Wood, Pro- 
fessor Hueppe, and other authorities, we 
learn that infectious organisms are capable 
of splitting up the particles of living albu- 
men at the temperature of the body, and 
that these dissociated elements may combine 
to form specific basic poisons: organisms, 
constituting a definite species, produce the 
poison of cholera, and exist at all times in 
the soil throughout the endemic area of the 
disease; but in this, its saprophytic form, the 
microbe has but feeble action on living albu- 
men ; it may, however, under certain condi- 
tions of the soil, temperature, and so on, 
become exceedingly vigorous, in fact, para- 
sitic, and then it can break up living albu- 
minoid elements into combinations possess- 
ing toxic properties. We may thus form 
some idea as to the relation that exists be- 
tween endemic and epidemic Asiatic cholera, 
and account for the manner in which the 
disease develops in certain localities, and from 
thence spreads at times over the world along 
the lines of human intercourse. As Dr. C. 
Wood remarks, it is possible that, as in the 
case of Pasteur's vaccines, the cholera mi- 
crobe, when in its saprophytic form, may pro- 
tect human beings subject to its influence from 
the more deadly action of the same organism 
when it has burst forth into parasitic growth, 
and if such be the case, may we not hope to 
discover means whereby human beings can be 
preserved from the effects of Asiatic cholera ? 
Drs. Pye-Smith and Lauder Brunton, from 
experiments made with choleraic discharges, 
are inclined to think that the outpouring 
of fluid from the glands of the intestinal 
canal in this disease, is due to paralysis 
of the mesenteric nerves in connexion with 
ganglia derived from the solar plexus. It may 
be that the poison produced by the cholera 
bacillus has some such effect; but it is a long 
step from the fact that microbes are capable 
of producing certain toxic compounds to the 
proof that Asiatic cholera depends on the influ- 
ence of this poison on the mesenteric nerves. 
Predisposing Causes.-As far back as 1869, 
in a work published by the writer on Asiatic 
cholera, the following observations occur 
(p. 420):-' With the exception of the specific 
cholera-infecting matter, I entirely ignore al) 
1 By this discovery, the result of rigid scientific 
investigation, Dr. Snow rendered an immense ser- 
vice to mankind which has not been recognised as 
fullj as it should be.-Editob. CHOLERA, ASIATIC 
327 
other causes, or combination of causes, as 
capable of producing this disease. The cir- 
cumstances under which people live may 
predispose them to the action of the or- 
ganism ; but neither air, water, nor any 
other agency can induce an attack of cholera, 
though many of them may serve as media 
by which the infecting matter is conveyed 
into the intestines.' P. 383 and p. 402:- 
' From researches I have instituted into this 
matter, there is reason to believe that the 
acids of a healthy stomach destroy the 
organic molecular matter in decomposing 
choleraic dejecta, so that when swallowed in 
a concentrated form they may be so acted on 
by the gastric juice as to have their infecting 
power destroyed; but when swallowed di- 
luted with water, a portion of the fluid pro- 
bably passes at once through the stomach, 
and reaching the alkaline contents of the 
small intestines, begins its work of destruc- 
tion upon the epithelium.' ' Persons in 
bad health, whether suffering from actual 
disease, or in the less-defined ill-health which 
results from imperfect hygienic conditions, 
are those most apt to be attacked by cholera. 
This is the case with the poor of our large 
towns, which are generally situated on allu- 
vial soil. May not this be due to the want 
of a healthy acid secretion from the walls of 
the stomach, which their more vigorous 
neighbours are blessed with ? ' Recent inves- 
tigations have added little beyond this to 
our knowledge of the predisposing causes of 
Asiatic cholera. 
Anatomical Characters.-The external 
appearances of the bodies of those who have 
died of cholera include the mottled skin, 
shrunken and livid appearance of the limbs, 
and other features hereafter described as 
characteristic of the disease during the stage 
of collapse. The temperature of the body 
rises after death, and it remains warm for 
some time. Rigor mortis sets in speedily, 
and is sometimes accompanied with muscu- 
lar contractions, which displace the limbs of 
the corpse. 
After death in the stage of collapse from 
Asiatic cholera, the only alteration to be 
discovered in the tissues and the blood is to 
be accounted for by the rapid drain of water 
into the intestinal canal which has occurred 
during life. The mucous surface of the 
stomach and small intestines is injected 
and swollen, and its epithelium is shed dur- 
ing life, and drops off from the mucous mem- 
brane in large patches within an hour and 
a half after death. Dr. Koch states that the 
cholera bacillus in many cases is found 
between the epithelium and the basement 
membrane, and also within the tubular 
glands; ' it also settles in large numbers on 
the surface of the villi of the intestines, and 
often had penetrated into their tissue, and in 
some instances had passed as far as the mus- 
cular layers of the intestine.' The epithelial 
cells lining the kidney-tubules, bladder, and 
other organs are found detached from the 
basement membrane, but they, like the blood, 
do not contain the cholera bacillus. 
Abnormalities of a specific nature, espe- 
cially with reference to the amount of blood 
contained in the right side of the heart 
and lungs, have been described by patholo- 
gists as being characteristic of Asiatic cholera; 
and in many instances after death from this 
disease, if the post-mortem examination is 
delayed for a few hours, the right side of the 
heart will be found full of blood, together 
with the pulmonary artery and its divisions, 
while the lungs are collapsed and bloodless. 
But there are numerous exceptions to this 
state of the heart and lungs, and the condition 
above described is not infrequently due to post- 
mortem changes; for if the bodies of those 
who have died of cholera be examined imme- 
diately after death, the left side of the heart 
will often be found as full of viscid blood 
as the right side. A peculiar shrunken con- 
dition of the lungs exists, depending on the 
dry and empty state of the bronchi, which 
allows the elasticity of the organs to drive the 
air out of them more completely than usual 
after the chest is opened.1 On the other 
hand, when death has occurred during reac- 
tion, the smaller tubes are often found full of 
pus, and parts of the lungs may be cedema- 
tous, or even in a state of broncho-pneu- 
monia (Fagge, The Principles and Practice 
of Medicine, p. 287). 
Symptoms.-Asiatic cholera is most deadly 
at the commencement of an epidemic, and 
then usually begins without premonitory 
symptoms. The patient feels well up to 
within a few hours of the attack, or, it may 
be, goes to bed and sleeps soundly through 
the night, and immediately on rising in the 
morning is seized with violent purging and 
vomiting. After the first outburst of the 
disease, as a rule, cholera commences with 
diarrhoea, the stools being copious and 
watery, .followed by great prostration of 
strength, with a peculiar feeling of exhaus- 
tion at the pit of the stomach; the sick 
person suffers from nausea, but seldom from 
actual vomiting or pain at the outset of the 
attack. If judiciously treated, many patients 
recover from this, the first stage of cholera ; 
but if neglected the tendency of the disease 
is to grow rapidly worse. The stools be- 
come very frequent, and resemble in appear- 
ance and consistency the water in which 
rice has been boiled. These liquid evacua- 
tions flow away from the sick person with a 
sense of relief rather than otherwise. But 
the patient now commences to vomit, first 
throwing up the contents of his stomach, and 
subsequently all the water he drinks, mixed 
with mucus and disintegrated epithelium. 
1 On this subject see the chapter on Epidemic 
Cholera in Dr. George Johnson's Medical Lectures 
and Essays.-Editob. 328 
CHOLERA, ASIATIC 
The fluid is rejected from his mouth with 
considerable force, and this adds to the in- 
creasing prostration which is one of the most 
urgent and marked features of the disease. 
The patient complains of intense thirst, and 
a burning heat at the pit of his stomach ; he 
suffers also excruciating pain from cramps 
in the muscles of the extremities; he is 
terribly restless; and his urgent cry is for 
water to quench his thirst, and that some 
one might rub his limbs, and thus relieve the 
muscular spasm. Although the temperature 
of the sick person's body falls below the 
normal standard, he complains of feeling 
hot, and throws off the bed-clothes in order 
that he may keep himself cool. The pulse 
is rapid and very weak ; the respirations are 
hurried; and the patient's voice becomes 
husky. His countenance is pinched, and 
the integument of his body feels inelastic 
and doughy, while the skin of his hands and 
feet becomes wrinkled and purplish in colour. 
The duration of this, the second stage of 
cholera, is very uncertain. It may last for 
two or three hours only, or may continue for 
twelve or fifteen hours; but so long as the 
pulse can be felt at the wrist, there are still 
good hopes of the sick person's recovery. 
The weaker the pulse becomes, the nearer 
the patient is to the third, or collapse-stage 
of cholera, from which probably not more 
than thirty-five per cent, recover. The result, 
however, depends much on the condition of 
the patient's heart. It is quite possible, 
although the cases must be rare, that a sud- 
den outpouring of fluid into the intestinal 
canal has been sufficient to cause syncope 
and death in persons suffering from weak 
heart, before the liquid contents of the 
bowels have had time to be ejected through 
the mouth or anus. 
In the third stage of the disease the 
vomiting and purging continue, although in 
a mitigated form; and the skin is covered 
with clammy perspiration, especially if the 
cramps are still severe. We now cease to 
be able to feel the pulse at the wrist, the 
lividity of the extremities and surface of the 
body increases, the patient cannot speak 
above a low whisper, his breathing is very 
rapid, his eyeballs are deeply sunk in their 
sockets, and his features are marvellously 
changed within a few hours. The urine 
is suppressed. The temperature of his body 
may fall as low as 94° F. The patient re- 
mains terribly restless, longing only for sleep, 
and that he may be supplied with water. 
His intellect is clear, but he seldom ex- 
presses any anxiety regarding worldly affairs, 
although fully conscious of the dangerous 
condition he is in; sleep, and a plentiful 
supply of drinking-water, are the sole desires 
of a person passing through the collapse-stage 
of cholera. This condition seldom lasts for 
more than twenty-four hours, and reaction 
either commences within that period, or the 
patient dies in collapse, or he passes on into 
the tepid stage, which in ninety-nine cases 
out of a hundred ends speedily in death. In 
the tepid stage of the disease the sick person's 
body feels cold to the touch, but the tempera- 
ture, as shown by the thermometer, begins 
to rise rapidly, sometimes marking 99° or 
100° F. The purging and vomiting cease; 
and the patient lies in a semi-comatose state, 
his eyes half-open, the ocular conjunctiva 
being deeply congested, the cornea hazy, and 
the pupils fixed. The pulse can be felt at the 
wrist, but the respirations are very hurried, 
suppression of urine continues, the patient's 
body is bathed in a cold clammy perspiration, 
the skin becomes of a dusky red hue, and 
death too frequently closes the scene within 
a few hours. 
On the other hand, the sick person having 
been in the collapse-stage of cholera some 
twenty-four hours (it may be a longer or 
shorter period), the temperature of his body 
may begin to rise, gradually creeping up to 
the normal standard ; the respirations dimi- 
nish in frequency; the pulse returns; the 
patient can sleep, and after some thirty-six 
hours may pass a little urine: in fact, the 
functions of animal life are slowly restored, 
and the sick person recovers his health. 
This desirable result, however, is not infre- 
quently thwarted by various complications 
which arise during the stage of reaction. Of 
these complications the following are the 
most important: suppression of urine ; gas- 
tritis and enteritis; pulmonary congestion; 
meningitis: sloughing of the cornea; ab- 
scesses over the body; the formation of 
coagula in the right side of the heart or 
pulmonary arteries: haemorrhage from the 
bowels; and roseola choleraica. 
Diagnosis.- The question of the diagnosis 
of Asiatic cholera is discussed in the article 
on Choleraic Diarrhcea. 
Prognosis.-The means of forming a pro- 
gnosis in cholera may best be gathered from 
the preceding account of the disease. Speak- 
ing generally, the prognosis depends largely 
upon the stage of the disease, and upon the 
period in the epidemic at which the case 
occurs-that is, according as the patient has 
been seized at the outbreak, at the height, or 
towards the end of an epidemic. 
Treatment.-In the first stage of Asiatic 
cholera we should endeavour to stop the 
purging, and without doubt opium is the drug 
upon which we may with the greatest con- 
fidence rely for effecting this purpose. "When 
practising in the endemic area of cholera, 
the writer was in the habit of carrying about 
pills containing one grain of opium and four 
of acetate of lead, so that, if called to see a 
patient suffering from the disease in its early 
stage, no time was lost in administering one 
of these pills suspended in water. The next 
thing done was to make a large mustard 
poultice, and apply it over the whole surface CHOLERA, ASIATIC 
329 
of the patient's abdomen. The sick person 
was ordered to remain in bed, and to be 
allowed nothing in the shape of food or 
water; but he might suck as much ice as 
he felt inclined for. 
If the patient was again purged after the 
first pill, a second was given, and a third (but 
not more) after each loose motion. It often 
happened that the first or second pill, to- 
gether with the mustard poultice, ice, and 
rest, sufficed to check the progress of the 
disease, and the patient recovered. Suppos- 
ing this treatment not to succeed, or that on 
first seeing the patient it be found that he 
has passed into the second stage of the 
disease, we should still prescribe the pill, as 
above directed, suspending it in water, because 
in the solid form it might be rejected entire, 
and under any circumstances it would take 
time to be dissolved by the fluid contained 
in the stomach; the mustard poultice also 
should be applied, and the sick person kept 
warm and in bed. Ice is invaluable in this 
stage of the disease, and unless a person has 
passed through an attack of cholera, it is 
impossible to realise the immense relief it 
affords. It should be given in small lumps, 
the sick person eating and swallowing as 
much as he chooses. He will frequently de- 
vour a pound or two of ice in the course of 
an hour, and he cannot take too much of it. 
In the treatment of cholera there can be no 
question as to the value of ice. The patient 
should be prohibited from drinking water or 
any other fluid beyond that which he gets 
from the ice. The practitioner must be firm 
on this point, turning a deaf ear to the 
entreaties of the sick man or his friends that 
he may be permitted to swallow even a small 
quantity of water; for if they once break 
through this rule, it will be impossible to 
limit the amount of liquid the patient may 
consume. If this treatment does not check 
the progress of the malady, we may prescribe 
three grains of acetate of lead and fifteen 
drops of diluted acetic acid in water every 
second hour, and fifteen drops of diluted 
sulphuric acid in water every alternate hour, 
so that the patient should take a draught, 
first of one mixture, then of the other, 
every hour. Five drops of spirit of camphor 
may be added to each dose of the medicine, 
but this drug requires care in its adminis- 
tration, and should seldom be continued 
beyond five or six doses of from five to ten 
drops each. Should the vomiting be very 
severe, in spite of the free administration of 
ice, a second mustard poultice should be 
applied over the abdomen; all medicine must 
then be omitted for an hour and a half, after 
which time a scruple of calomel may be 
sprinkled on the patient's tongue, and he 
should be made to wash it down with a little 
iced water. The cramps are best relieved by 
hand-friction, and if very severe, ease may 
from time to time be given by allowing the 
patient to inhale some ether. Hot-water 
bottles should be applied to the soles of 
the patient's feet, and also to his legs and 
abdomen. 
Should the disease have reached the col- 
lapse-stage there is but little we can do for 
the patient. Ice must still be given, and, 
if the purging is frequent, the sulphuric acid 
draught (but no opium) may be administered 
every hour; heat and friction may with ad- 
vantage be applied to the surface of the 
body; and the patient may now be permitted 
to drink iced water in moderation, provided 
it does not increase the vomiting. Wine and 
stimulants, if given by the mouth, do harm 
in this stage of cholera ; but, if the purging 
has abated, enemata of warm beef-tea and 
brandy may be administered by the rectum 
every third hour. When reaction comes on, 
we must guard against doing too much-it is 
very rare indeed to see a patient in this con- 
dition sink from exhaustion, but probably 
many lives are lost by endeavours erroneously 
made, under the idea of keeping up the 
patient's strength. Iced milk or arrowroot 
is all that should be allowed to be given by 
the mouth for some time after reaction has 
set in; but enemata such as those above- 
mentioned, administered per rectum every 
five or six hours, or nutrient suppositories, 
are often beneficial, especially if the stomach 
remains irritable. Under these circumstances 
we not infrequently find that a small quan- 
tity of solid food is digested, when soup and 
liquids are rejected. In each case, however, 
the dictates of common sense and experience 
must guide the medical practitioner in his 
treatment of the sick person through the 
convalescent stage of the disease. 
With reference to the treatment of sup- 
pression of urine after cholera, we should get 
the patient to drink about half a pint of water 
every second hour, so as to add fluid to his 
blood. Dry-cupping over the loins should be 
employed; and ten drops of the tincture 
of cantharides in water administered every 
hour, until a drachm of the drug has been 
given. It need hardly be remarked that 
suppression of urine after cholera is a most 
dangerous complication, and there is very 
little that can be done to restore the sus- 
pended functions of the kidneys. 
Preventive Treatment.-Among persons 
predisposed to its influence, the infecting 
organisms of Asiatic cholera will manifest 
their effects on the system within five days 
of having been swallowed, but the germs of 
the disease do not always engender symp- 
toms of virulent cholera. Nevertheless, in 
milder cases of the disease the evacuations 
passed by the patient may contain the 
microbes of cholera, and may therefore, under 
favourable conditions for its development, 
produce a deadly type of the malady. Conse- 
quently, the following remarks are applicable 
to instances of so-called cholerine, as well as 330 
CHOLERA, ASIATIC 
CHOLERAIC DIARRHCEA 
to the severer forms of cholera. If the 
disease has appeared within a neighbour- 
hood, a searching examination must be made 
into the condition and source of the local 
water-supply, not overlooking that of the 
milk, which is too often diluted with water 
before being sold. All surface and doubtful 
wells or reservoirs (especially those in the 
proximity of drains and cesspools) should be 
immediately closed; and it is desirable that 
the drinking-water, before being consumed, 
should be carefully boiled and filtered. All 
accumulations of house refuse and filth must 
be removed; and dirty places, both within 
and without uncleanly premises must be 
freely disinfected and cleansed. There is no 
necessity when the disease is prevalent for 
making any alteration in the usual diet; but 
in times of cholera we cannot too strongly 
insist on at once checking any tendency to 
diarrhoea, especially if it be of a watery 
nature. Many cases of incipient cholera have 
been prevented from running on into danger- 
ous disease, by the early administration of 
pills containing four grains of acetate of lead 
and one of opium, one pill to be taken after 
each loose motion, to the extent of three pills. 
If called to treat a case of Asiatic cholera, 
care should be taken that the rice-water 
stools, and the matters vomited, are dis- 
infected by means of a solution of mercury 
perchloride or some other germicide, which 
should be poured over the bottom of the 
vessel into which the evacuations are 
received from the patient; and directly the 
dejecta are passed from the sick person, a 
solution of one part of carbolic acid to 
twenty of water should be sprinkled over 
them, and they must be immediately taken 
from the patient's room, and disposed of as 
follows:-If the sewage of the locality is 
conveyed away by means of a constant 
water-supply, the disinfected cholera evacua- 
tion should be thrown at once into the sewer. 
Drains used for a purpose of this kind must, 
however, be constantly flushed with a mix- 
ture containing about an ounce of ferrous 
sulphate to a pint of water. But if the 
drainage of the place passes into a cesspool, 
the disinfected cholera stools should be 
buried in a deep hole in the ground, re- 
moved from wells, and, if possible, from 
human habitations. It is a most danger- 
ous practice, however carefully cholera stools 
have been disinfected, to allow them access 
to a cesspool. The room in which the 
patient has been treated must be freely 
disinfected, and his bedding subsequently 
burnt. If the sick person should die, the 
corpse is at once to be placed in a coffin con- 
taining a mixture of lime, charcoal, and car- 
bolic acid: in fact, the body should imme- 
diately be buried in a mixture of this kind, 
and the coffin with its contents committed to 
the grave, or, better, consumed by fire with- 
in twenty-four hours of the patient's death. 
By far the most important preventive 
measures to be adopted against cholera are 
to provide a pure supply of drinking-water, 
good drainage, ventilation, and cleanliness; 
for these means, if rightly enforced, must 
prevent the cholera germ from spreading 
among human beings. 
The Vienna Cholera Conference has de- 
cided that quarantine is inapplicable to the 
circumstances of cholera; but this subject, 
together with the duties incumbent on 
sanitary and port authorities with reference 
to the preventive treatment of the disease, 
hardly falls within the scope of this article. 
See Quarantine. C. N. Macnamara. 
CHOLERAIC DIARRHCEA. - Sy- 
non. : Cholerine; Sporadic Cholera; Fr. Cho- 
lera sporadique ; Ger. Sporadische Cholera. 
Definition.-An acute catarrhal affection 
of the mucous membrane of the stomach 
and small intestines, attended with vomiting 
and diarrhoea. The stools consist of a 
serous fluid, containing a little albumen. 
The whole system is implicated to a greater 
or less extent, through the rapid loss of water 
from the body, and its imperfect absorption 
through the intestinal canal during the active 
stages of the disease. 
Etiology.-As remarked in the preceding 
article, it is only of late years that the ques- 
tion has arisen as to whether Asiatic cholera 
and simple cholera are identical diseases; 
but it seems probable that any obscurity 
which may exist on the subject occurs from 
the impression that similar symptoms are 
necessarily produced by precisely the same 
causes. It appears reasonable, however, to 
believe that, if the infecting matter of 
Asiatic cholera, when introduced into the 
intestinal canal, induces changes such as 
we have described, decomposing animal or 
vegetable substances, under certain con- 
ditions, may excite analogous changes in the 
mucous membrane of the alimentary canal, 
the consequence being that in both diseases 
a drain of serous fluid takes place from the 
bowels, followed by symptoms of cholera. 
In the case of Asiatic cholera, however, we 
believe that the discharges have the power, 
under favouring conditions, of propagating the 
disease, whereas the evacuations in simple 
cholera are in this respect less pernicious. 
Doubtless climatic and meteorological in- 
fluences materially affect the susceptibility 
of the human subject to disease, and conse- 
quently we find that simple cholera, like the 
malignant form of the malady, is apt to 
prevail as an epidemic in moist or wet 
seasons of the year, and especially among 
people whose bodies are predisposed to pass 
into a diseased condition, from their having 
habitually breathed impure air and consumed 
unwholesome food and water, or become 
debilitated from other causes. 
In a hot and moist climate like that of CHOLERAIC DIARRHCEA 
331 
Lower Bengal, choleraic diarrhoea is an 
affection which we meet with at all seasons 
of the year, and it is especially prevalent 
among infants who are being reared on cow's 
milk, or on other kinds of food prone to 
undergo putrefaction. Among the fish-eating 
Hindoos we frequently see several members 
of the same family who have been seized 
with symptoms of choleraic diarrhoea, attri- 
butable to the patients having partaken of 
fish which was slightly tainted. In fact, there 
are few more certain sources of this form of 
diarrhoea than stale fish; and it is evident 
that, whatever the deleterious influence may 
be which food of this description contains, 
the mere fact of keeping it in boiling water 
for some time does not destroy its poisonous 
properties. 
It occasionally happens that cases of 
choleraic diarrhoea occur among people re- 
siding in malarious districts, the diarrhoea 
taking the place of the cold stage of a fit of 
ague; patients in these circumstances may 
be seized with all the symptoms of severe 
cholera, but they almost invariably recover 
from the attack. 
Symptoms. - Choleraic diarrhoea begins 
suddenly; that is, the patient, whether an 
infant or an adult, has probably up to the 
commencement of the attack been in good 
health ; there are, in fact, seldom any pre- 
monitory symptoms. A child may perhaps 
look somewhat paler than usual, and has a 
dark ring under his eyes, but beyond this 
appears to be perfectly well. Shortly after 
taking food, the infant vomits up a quantity 
of uncoagulated milk, the evacuation not 
being curdled like that from an overloaded 
stomach, the gastric secretion no longer 
having the power of coagulating the casein 
of milk. Soon after vomiting, or it may be 
before, the child commences to pass from 
the bowels an acid greenish-yellow fluid, con- 
taining flakes and often lumps of undigested 
food. The patient becomes very thirsty, is 
restless, and evidently in considerable pain, 
crying and drawing his legs up towards the 
abdomen. If these symptoms continue, the 
evacuations become colourless, resembling in 
appearance the rice-water stools of Asiatic 
cholera. The temperature of the body falls, 
the face becomes of a dusky hue, the features 
are pinched, and the eyeballs deeply sunk in 
their sockets. The fontanelles are depressed; 
the child is evidently terribly prostrated, his 
pulse can no longer be felt at the wrist, and 
his crying passes into a weak whimpering; 
he eagerly drinks water when offered him; 
and, as the exhaustion increases, convulsions 
supervene, and the child dies within a few 
days or even hours. On the other hand, the 
symptoms may abate at any stage of the 
disease, and the little patient gradually re- 
cover his health. 
In the adult the symptoms of choleraic 
diarrhoea are much the same as those above 
detailed. There are seldom any premonitory 
symptoms, and the attack begins with nausea 
and vomiting, together with a sensation of 
exhaustion referable to the pit of the sto- 
mach ; the vomiting is speedily followed, or 
it may be preceded, by purging; copious 
watery discharges are thus passed out of the 
body, and the larger and more rapid the 
evacuations the more they come to resemble 
the serum of the blood, which, in fact, drains 
into the intestinal canal and passes away 
from the stomach and bowels. The patient 
naturally complains under the circumstances 
of intense thirst. He is very restless; and at 
the commencement of the attack suffers from 
colicky pains in the abdomen, and subse- 
quently from spasms and cramps, which often 
seize the muscles of the extremities. The 
pulse becomes small and weak, the respira- 
tions are hurried, the voice feeble, and the 
countenance pale and shrunken. The urine 
is scanty or suppressed; and the temperature 
of the body falls one or two degrees below 
the normal standard. These symptoms, as 
a rule, gradually subside, the purging and 
vomiting cease, and the patient falls off to 
sleep, waking more or less exhausted in 
proportion to the severity of the attack, but 
he usually recovers his health rapidly. 
Diagnosis.-The question naturally arises, 
Are there any symptoms by which we can 
distinguish a case of choleraic diarrhoea from 
one of Asiatic cholera ? In reply it may 
be affirmed that there is no characteristic 
symptom by which these affections can be 
diagnosed from one another. But, taking all 
the circumstances of any particular case into 
consideration, it is difficult, except on paper, 
to confound the two diseases; for unless a 
patient has recently imbibed the poison which 
produces Asiatic cholera, he cannot be suffer- 
ing from that malady. Should the sick person 
reside in a neighbourhood affected by Asiatic 
cholera, we must, in forming an opinion as 
to the nature of the affection, be guided by 
the previous history of the case, the nature 
of the food consumed, and so on, and above 
all by the severity of the symptoms. Choleraic 
diarrhoea, even in the tropics, rarely passes 
on into collapse within a few hours from 
the commencement of the attack, such as is 
commonly seen in cases of Asiatic cholera ; 
and, in the early stages of the former disease, 
there is seldom that complete loss of voice 
and pulse so characteristic of the malignant 
form of this affection. An experienced medi- 
cal practitioner, placed at the bedside of a 
person suffering from Asiatic cholera, even 
in its earliest stages, feels no doubt whatever 
as to the nature of the affection, and is at 
once impressed with the grave responsibility 
of the charge which rests upon him : his 
anxiety is infinitely less when he meets with 
an instance of choleraic diarrhoea, although 
he is unable to lay down any hard and fast 
rules, by means of which he could define the 332 
CHOLERAIC DIARRHCEA 
CHOLESTERIN 
difference that exists between the symptoms 
present and those occurring in a case of 
Asiatic cholera. 
Prognosis.-Although choleraic diarrhcea 
in its more severe forms resembles mild cases 
of Asiatic cholera, it is a comparatively harm- 
less disease. Unless among young infants, 
or old and sickly people with weak hearts, 
no matter how threatening the symptoms 
may be, however great the collapse and de- 
pression of the patient may seem, a previ- 
ously healthy adult seldom dies of choleraic 
diarrhcea. 
Treatment.-In cases of simple cholera 
occurring in the child, the important point 
we must enforce in our treatment is that 
the affected part shall have rest. In prac- 
tice, however, it is often difficult to per- 
suade parents and nurses that an infant can 
exist uninjured for ten or fourteen hours on 
iced water ; nevertheless, we must insist on 
a plan of this kind being carried out. The 
little patient will eagerly swallow cold water, 
either from a bottle or spoon, and the child 
may be allowed to take as much cold water 
as he requires, and to suck ice, which may be 
wrapped up in the corner of a handkerchief 
and put into his mouth. A poultice made of 
equal parts of mustard and flour, applied over 
the abdomen, is often very useful in this 
form of disease. With reference to drugs, 
should the treatment above indicated not 
relieve the symptoms, or should the vomiting 
be very constant, from two to four grains of 
calomel may be given, and repeated if neces- 
sary in an hour's time; however, if the diar- 
rhcea is the more prominent symptom, calomel 
is not required, but a teaspoonful of castor oil 
should be administered. After the bowels 
have been cleared out, if the serous discharge 
continues, we should order astringents, in the 
form of | of a grain of acetate of lead every 
hour, or of a grain of nitrate of silver, until 
the purging subsides. Tannic acid, in com- 
bination with diluted sulphuric acid and sugar, 
is frequently a useful combination to ad- 
minister to children in cases of this descrip- 
tion. With reference to opium, much as 
we dislike prescribing it for infants, it may 
be necessary in cases of simple cholera; but 
it should hardly be given in a mixture to be 
administered from time to time by a nurse. 
Opium under these circumstances can only 
be admissible when given by the medical at- 
tendant himself, in doses of one, two, or three 
minims of laudanum in a little weak brandy 
and water, carefully watching its effects. If 
the drug causes the child to sleep for a few 
hours, it may act almost like a charm: the 
infant awakes comparatively well. But if the 
opium has no such effect, we may be tempted 
to repeat the dose, but can scarcely give it a 
third time, at any rate until some hours 
have elapsed since the administration of the 
second dose. The symptoms having subsided, 
the child's diet must be strictly attended to, 
a good healthy wet nurse as a rule being an 
urgent necessity in the case of infants. Lime- 
water may with advantage be mixed with 
the child's food. The diet must be most 
carefully ordered. See Diarrhcea. 
With reference to the treatment of adults 
suffering from choleraic diarrhoea, we must 
bear in mind that, unless among old and 
debilitated persons, the patient will, as a 
rule, recover without medicine. If there- 
fore called to prescribe for a case of this 
complaint, we may order fifteen minims of 
laudanum, or a drachm of the compound 
tincture of camphor in water, to be taken 
(supposing the patient is very sick) imme- 
diately after vomiting; half the above dose 
may be given at the expiration of one hour; 
and again after another hour, unless the 
symptoms have in the meantime subsided. 
A large mustard poultice should be applied 
over the abdomen, and the patient must be 
confined to bed, and kept on ice and iced 
water; he should not, however, be permitted 
to swallow too much liquid. If the vomit- 
ing is severe, a scruple of calomel may be 
given to an adult, or in the first instance 
an effervescing mixture with hydrocyanic 
acid may be employed to allay the sickness. 
On the other hand, should the diarrhoea be 
excessive, we may with advantage prescribe 
four grains of acetate of lead and ten drops 
of diluted acetic acid every second hour; or 
pills containing a drop of creasote, a quarter 
of a grain of nitrate of silver, a grain of 
camphor, and two grains of Dover's powder, 
to be repeated after each loose motion. 
Among old or weakly persons, and also in 
the case of infants, it is often necessary to 
administer brandy and water from time to 
time, according to the state of the patient's 
pulse. C. N. Macnamara. 
CHOLERINE.-A term applied to a 
class of cases which occur during the pre- 
valence of cholera, in which the milder 
symptoms of the disease are present. It has 
also been used to designate the poison on 
which cholera is supposed to depend. See 
Cholera, Asiatic; and Choleraic Diar- 
rhcea. 
CHOLESTEATOMA bile; and 
(yredrapa [Galen], a fatty tumour).-An en- 
cysted tumour, consisting chiefly of chole- 
sterin. See Cysts. 
CHOLESTERIN bile; and 
(rTfppds, solid. The term cholestearin, occa- 
sionally used, is derived from bile ; and 
a-reap. suet).-Synon. : Fr. Cholesterine; Ger. 
Cholesterin; Gallenfett. 
Chemical and Physical Properties.- 
Cholesterin is a monatomic alcohol, repre- 
sented by the empirical formula C.,eH44O, 
first discovered, in 1755, by Conradi in ox- 
bile, its exact composition being subsequently 
ascertained by Chevreul. It is probable that CHOLESTERIN 
CHORDEE 
333 
there are several isomeric substances included 
within the term, though one only is known 
to occur in the human body. When pure it 
occurs as white, tasteless, inodorous, glittering 
scales, which form needles when crystallised 
out from solution in chloroform, and as 
rhombic plates, often deficient at one corner, 
when derived from alcoholic and ethereal 
solutions (see Microscope in Medicine). It 
is insoluble in water, alkalis, and dilute 
acids, but readily dissolves in ether, chloro- 
form, boiling alcohol, benzol, turpentine, and 
solutions of the bile-acids, and its solu- 
tions are fevo-rotatory. It melts at 145° F. 
The crystals heated with strong sulphuric 
acid give a carmine-red colour, or with strong 
nitric acid a yellow colour ; with the former 
acid and tincture of iodine a violet which 
becomes blue green. 
Sources.-The exact physiological signifi- 
cance of cholesterin is not known, but it is 
generally regarded as a product of the meta- 
bolism of the nervous tissues, which should be • 
eliminated by the liver in the bile. It is a 
normal constituent of certain of the tissues, 
forming nearly 50 per cent, of the solids of 
the white nervous matter, and 18| per cent, 
of the solids of the grey matter, being pro- 
bably combined therein with true fatty sub- 
stances ; it is estimated to form '25 per cent, 
of the red corpuscles of the blood; '4 per 
cent, of human bile; and it occurs in minute 
quantities in the spleen, urine, milk, and 
serum, and as a constant though quantita- 
tively variable ingredient of the feces, where 
it has been erroneously supposed to be repre- 
sented by stercorin, which substance is in 
reality an impure form of cholesterin (see 
F.eces, Examination of). It is also found 
in the yolk of egg. A cholesterin is of wide- 
spread occurrence among plants (such as 
peas and maize, also in almond and olive 
oils), and may be regarded as a decomposi- 
tion-product of some of the albuminous con- 
stituents of the cells. 
Pathological Relations.-The patholo- 
gical occurrence of cholesterin is varied and 
of unknown import. It is liable to be much 
increased in quantity in the normal places of 
its occurrence; thus in association with jaun- 
dice, though apparently not always, the blood 
has been known to contain 4 or 5 per cent.; 
in the bile it may be so abundant as to form 
crystals or be deposited as gall-stones, of 
which it forms the greater portion; in the 
feces, when they are free from bile, a con- 
siderable increase of cholesterin and fats 
may be met with. In exceptional cases of 
renal disease crystals have been deposited in 
the urine. The fluid of cysts, especially 
hydatid and ovarian, seems to be more liable 
to contain cholesterin than effusions into 
serous cavities; and this fact has been con- 
sidered of some value in the diagnosis of 
ascites from ovarian dropsy. But it some- 
times occurs in considerable quantities in 
hydrocele fluids, and it has been met with 
in old pleural and peritoneal effusions, where 
it appears as glistening particles suspended 
in the fluid. In the caseous degeneration of 
pus and other inflammatory products crystals 
of this substance are sometimes formed, and 
in this way may be found in sputum and 
other excreta. 
The train of nervous and other symptoms 
which often accompanies long-continued jaun- 
dice has been attributed to the retention of 
cholesterin in the blood, and hence the term 
cholestercemia. was employed to denote this 
condition. It is certain, however, that cho- 
lesterin as such is quite inert and harmless 
to the tissues, and it is undesirable to per- 
petuate the expression. See Chol^mia. 
W. H. Allchin. 
CHORDEE (yop&y, a harpstring).- 
Definition.-Painful imperfect erection of 
the penis during gonorrhoea. 
^Etiology and Pathology.-Chordee is 
most common in the second and third weeks 
of gonorrhoea, and rarely attacks the patient 
after the third week. In exceptional cases, 
on the contrary, chordee, absent in the acute 
stage, is violently developed after the in- 
flammation has Become chronic and very 
slight. The bulbous part of the urethra is 
generally intensely inflamed when chordee 
happens; and, further, chordee is very un- 
common when the urethritis is limited to the 
anterior or posterior portions of the canal. 
The mechanism of chordee is imperfectly 
understood. Two explanations have been 
put forward:-(a) That the corpus spongio- 
sum surrounding the urethra being affected 
by inflammation through the effusion of 
lymph into its substance, proper distension 
of its spongy tissue and elongation during 
erection cannot take place. Hence it is 
drawn tight like a bowstring by the arch- 
ing of the distended corpora cavernosa. 
(6) That the inflammatory condition of the 
mucous membrane and submucous tissue at 
the bulbous part excites reflex spasm of the 
muscles surrounding that part of the corpus 
spongiosum. This prevents distension of the 
parts compressed; while the corpora caver- 
nosa, being untrammelled, continue to expand 
in the ordinary manner. The first explana- 
tion is insufficient to account for some cases 
where the inflammatory action is very slight, 
and there is no evidence that lymph has 
been effused into the erectile tissue; for 
example, after a plastic operation on the 
penis. Again, natural erection has been 
known to take place very shortly after the 
subsidence of gonorrhoeal inflammation, and, 
it is fair to suppose, before effused lymph can 
have been absorbed. The second explanation 
is unsatisfactory, because spasm of other 
muscles of the perinaeum is often absent. 
In our present imperfect knowledge of the 
purposes served by the nervi erigentes, these 334 
CHORDEE 
CHOREA 
theories must be accepted with reserve. 
Probably both methods may be active in pro- 
ducing chordee. 
The causes of chordee are indirect or 
direct. The most common indirect cause is 
urethritis or urethral congestion. Direct 
causes are the reflex irritants which usually 
produce erection during sleep, such as 
stimulating food and drink, strongly acid 
urine, great superficial warmth of the body, 
or a distended bladder. 
Symptoms.-The organ grows suddenly 
turgid and assumes a bowed or crooked form, 
causing acute pain, which is felt at the part 
and towards the perinaeum. In severe cases 
the strain causes rupture of the mucous 
membrane and spongy tissue, with haemor- 
rhage. The loss of blood is usually limited 
to a few drops, and gives relief to the pain. 
Rarely the haemorrhage is rapid and pro- 
longed. 
Treatment.-Abstinence from stimulants 
of all kinds, and late suppers; light clothing, 
and a hard mattress at night, are the best 
means of preventing chordee. Micturition 
at short intervals during the night must be 
enjoined. Of medicines the best is a sup- 
pository, at bed-time, of one grain of crude 
opium in ten grains of cacao-butter. The 
subcutaneous injection into the perinaeum of 
one-sixth grain of acetate of morphine is also 
an effectual remedy. Both these applica- 
tions should be followed by an aperient saline 
draught the next morning. A drachm of 
spirit of camphor thrown just before it is 
swallowed into an ounce of water, and taken 
on lying down at night, is also useful, and it 
may be repeated once if chordee awaken the 
patient; but it is a very uncertain remedy. 
More trustworthy are twenty or twenty-five 
grains of chloral hydrate in syrup and water 
at bed-time, and repeated in four or six 
hours if needed. Bathing the genitals and 
perinaeum with very hot water for ten 
minutes before going to bed sometimes 
proves successful. The application of a spiral 
coil of narrow india-rubber tubing round the 
penis and scrotum, through which a con- 
tinuous current of ice-cold water flows, is 
also an excellent preventive. 
To subdue an attack of chordee the best 
measures are voiding urine ; the application 
of cold to the perinaeum, by sitting on a cold 
seat, or applying an evaporating lotion or ice ; 
and the upright posture. 
Berkeley Hill. 
CHOREA (xoptia, a dance).-Synon. : 
Chorea Minor ; St. Vitus's Dance ; Fr. Danse 
de St.-Guy, Choree; Ger. Veitstanz. 
Definition.-A disease of the nervous 
system, characterised by a succession of 
irregular, clonic, involuntary movements of 
limited range, occurring in almost all parts 
of the body. 
The distinctive features of the movements 
are the entire absence of either rhythm or 
method in their recurrence; that not indi- 
vidual muscles but co-ordinate groups are 
affected; and not one or more groups only, 
but almost all the muscles in turn. There 
is not actual loss of command over the 
muscles, but voluntary movements are 
interfered with by superaddition of involun- 
tary movements. As a rule the movements 
cease during sleep. 
^Etiology.- Chorea is a disease of child- 
hood : it is most common between the ages 
of eight and twelve, very rare before six, 
and rare after sixteen. It is more than twice 
as frequent in girls as in boys, especially after 
the age of nine. It occurs more frequently 
in families in which nervous diseases are 
hereditary than in others. It is more common 
in large towns than in the country ; and far 
more frequent among the poor than among 
those in comfortable circumstances. Want 
of proper food, neglect, ill-usage, with the 
weakness and anaemia induced by these 
means, are very common antecedents, or 
chorea may follow measles or other febrile 
disease of childhood. Children well-nourished 
and with a good colour, exposed to none of 
these causes, may however suffer. An inti- 
mate association between chorea and rheu- 
matism has long been recognised. A large 
proportion of the children suffering from 
chorea are found to have had acute or 
subacute rheumatism, and some of the most 
terrible cases met with, especially after the 
age of puberty, are those in which the chorea 
comes on during or just after acute rheuma- 
tism. Whether traceable to rheumatism or 
not, there is very frequently found in chorea 
a cardiac murmur, usually mitral systolic, 
sometimes aortic. This may or may not 
disappear after recovery. In almost all the 
fatal cases of chorea which have been 
examined after death, endocarditis with 
fibrinous vegetations on the valves has been 
present. In adults, pregnancy divides with 
rheumatism the causation of this affection; 
recovery generally speedily follows delivery, 
and can rarely be brought about till this has 
taken place. Bad habits, and disorders of 
menstruation, are also undoubtedly capable 
of inducing chorea. Intestinal worms again 
have appeared to set up the disease, and 
instances are on record in which the expulsion 
of worms has been followed at once by 
cessation of the movements, but this must 
be extremely rare. Fright or some powerful 
emotion is very frequently assigned as the 
cause ; and it is seldom that parents are not 
prepared with the instance required. But, 
making allowance for this, and notwithstand- 
ing the fact that endocarditis may be present 
in cases said to have originated in fright, it 
does not seem possible to exclude fright as a 
cause of chorea. The influence of imitation 
is less certain. The disease is said to be far 
less common in negroes. CHOREA 
335 
Anatomical Characters and Pathology. 
The study of chorea, as of epilepsy and many 
other affections of the nervous system, has 
been hampered by its being regarded as a 
morbid unity. The view here maintained is 
that it is a symptom rather than a disease, 
and that the characteristic movements are 
in relation not with the nature of the morbid 
change, but with its seat. The seat of the dis- 
turbance is the corpus striatum, its character 
probably different in different cases; but 
the anatomical condition cannot amount to 
actual breach of structure, since that is 
known to give rise to hemiplegia, while it 
must obviously be of a kind to impair the 
functional vigour of the ganglia. Chorea has 
been called ' insanity of the muscles '; a 
better phrase (as the writer has said else- 
where) would be 'delirium of the sensori- 
motorganglia.' In delirium there is loss of 
control over the mental processes, with rapid 
succession of incoherent and imperfect ideas ; 
in chorea loss of control over the motor 
apparatus, with movements excessive in point 
of number and extent, but wanting in vigour 
and precision. 
In some cases of chorea nothing abnormal 
has been detected after death, but usually the 
minute methods of investigation now pursued 
yield positive results. The largest series of 
examinations published is contained in a com- 
munication to the Royal Medical and Chirur- 
gical Society, in the session of 1875-6, by Dr. 
Dickinson. He describes dilatations of the 
minute arteries as existing throughout the 
brain and cord, more especially, however, in 
the corpus striatum and optic thalamus, with 
small haemorrhages; and considers the dis- 
ease to be due to a widely spread hyperaemia 
of the nerve-centres. He did not find capil- 
lary embolisms, but does not appear to have 
drawn out the arterioles to look for them. 
The appearances he describes are very much 
those producible by impaction of microscopic 
particles of fibrin in the minute vessels. 
Capillary embolisms have been found by 
Dr. Tuckwell and other observers, predomi- 
nantly in the central ganglia, but also in the 
central convolutions and spinal cord, accom- 
panied by patches of softening and minute 
haemorrhages. In almost all fatal cases of 
chorea there is endocarditis with deposits of 
beads of lymph on the mitral or aortic valves, 
or both, whether a murmur have been audible 
during life or not. 
The post-mor tern appearances consequently 
do not indicate any localisation of the morbid 
change in the central ganglia. But it is to be 
remembered that the fatal cases are those in 
which there is not only extreme violence in 
the choreic movements, but usually also deli- 
rium and other symptoms. There are in fact 
multiple symptoms just as there are multiple 
lesions, and we are called upon to distribute 
the symptoms, and assign them to their re- 
spective sources, by such knowledge of the 
functions of the different nerve-centres as 
physiology affords us. The delirium or com- 
parative dementia is thus attributed to the 
lesions in the convolutions; the loss of speech 
to lesions in convolutions or in lower centres, 
according to its character; the impairment oi 
sensation to lesions in the thalami; the chorea 
to lesions in the corpora striata. The grounds 
upon which this last localisation-that -in 
which we are immediately concerned-is de- 
cided, are as follows. We exclude the cerebral 
hemispheres and cerebellum, rather arbitrarily 
perhaps, since there is much to be said in 
favour of their contributing to excite the 
movement, now especially that convolutional 
motor areas have been demonstrated by 
Hitzig and Ferrier. The important point to 
be made clear, however, is that chorea has 
not its seat in the cord. The arguments and 
evidences against this are : (1) that tonic and 
not clonic spasm is characteristic of persis- 
tent spinal irritation; (2) the degree of con- 
trol over the movements retained by the will; 
(3) their increase under emotion; (4) their 
cessation during sleep. To those, which were 
originally advanced by Dr. Russell Reynolds, 
may be added : (5) the diminished reflex 
action on tickling; and (6) the phenomena of 
hemichorea and its relations with hemiplegia. 
The evidence afforded by hemichorea is so 
conclusive that other considerations have 
been merely alluded to. It cannot be sup- 
posed, for example, that one lateral half of 
the entire length of pons, medulla, and cord 
can be affected without implication of the 
other half, which would be the case with 
hemichorea of spinal origin ; and still more 
conclusive is the fact that when in hemichorea 
there is impairment of sensation it is on the 
same side with the movements, and not, as 
in hemiparaplegia (due to the division of one 
half of the cord), on the opposite side to the 
motor paralysis. The parallelism between 
hemichorea and hemiplegia is so perfect as 
to suggest at once that the two affections 
represent different conditions of the same 
nerve-centres, and is made more complete by 
the very discrepancies, as they may at first 
sight appear, which have been considered to 
be objections. In hemiplegia there are cer- 
tain muscles which more or less completely 
escape paralysis : the motores oculorum, 
orbiculares palpebrarum, and other facial 
muscles, the muscles of the neck, chest, back, 
and abdomen. In hemichorea the irregular 
movements cross the median line and invade 
the opposite side in these same muscles, 
This has been explained (rightly or wrongly) 
by the hypothesis that all these muscles act- 
ing in compulsory concert with the corre- 
sponding (or other) muscles of the opposite 
side, the nerve-nuclei of the bilaterally asso- 
ciated muscles will be commissurally asso- 
ciated in the cord, so as to become in effect 
a single nucleus, and this single nucleus for 
muscles on each side of the body, being 336 
CHOREA 
connected with both corpora striata, is thrown 
into action by the sound corpus striatum 
when its fellow of the opposite side is 
damaged, as in hemiplegia, thus preventing 
paralysis; and, on the other hand, is reached 
by the irregular impulses from the corpus 
striatum affected in hemichorea, thus causing 
bilateral chorea in the parts enumerated. 
•In addition to the correspondence between 
hemichorea and hemiplegia just described, 
there are transitions from one to the other, 
and combinations of the two to be mentioned 
below, under the head of Complications. 
Hemiplegia may be succeeded by hemichorea 
(the post-hemiplegic chorea of various ob- 
servers) ; or chorea may deepen into paralysis; 
or, as in a case reported by the writer, there 
may be with chorea of the limbs on one side, 
first chorea, then paralysis (hemiplegiform), 
and then again chorea of the same side of 
the face. The conclusion is obvious, that 
hemiplegia and hemichorea in these cases 
are indicative of different degrees of damage 
in the same centre. Hemichorea and hemi- 
anaesthesia have been found very constantly 
associated with structural lesions in the white 
fibres just outside the posterior extremity of 
the thalamus, usually involving also the gan- 
glion itself at this part. 
The well-known embolic theory of chorea 
originated by Kirkes, and improved and ably 
maintained by Dr. Hughlings Jackson, at 
once finds its place here. Capillary embolism 
is of all others the condition which might be 
expected to induce the instability without 
abolition of function which exists in chorea, 
and in almost all cases a fertile source of 
fibrinous shreds is present, in the form of 
vegetations on the valves of the heart; the 
fact of embolism, again, has repeatedly been 
demonstrated. While, however, giving to 
capillary embolism a prominent place among 
the causes of chorea, it cannot be considered 
as the only cause. The clinical differences 
between ordinary chorea and the acute and 
fatal form are of themselves suggestive of a 
different pathology ; and the speedy recovery 
after delivery in the chorea of pregnancy, or 
(as in one or two cases on record) after ex- 
pulsion of intestinal worms, is inconsistent 
with the existence of embolism. What the 
precise anatomical condition is can only be 
matter of conjecture, but it will be some form 
of innutrition; irritability and debility, as 
the late Dr. C. B. Radcliffe has abundantly 
demonstrated, going together. Hyperaemia, 
with capillary blood-stasis, and capillary 
thrombosis by cohering leucocytes, have been 
suggested as causes. Prolonged arterial spasm 
from persistent reflex irritation, uterine or 
intestinal, or the more brief contraction of the 
cerebral vessels from fright, may perhaps 
lower the functional vigour of the ganglia to 
the degree required. Dr. Octavius Sturges 
has ably maintained the view that chorea is 
a purely functional affection, and that the 
movements are adequately accounted for by 
instability of nerve-cells without any struc- 
tural or vascular change recognisable even by 
the microscope, comparing it in this respect 
with epilepsy. A very important considera- 
tion is the remarkable limitation of chorea to 
the period of childhood-the period between 
infancy and puberty. This is a limitation, if 
not without parallel, certainly unequalled, 
and it points to a condition of nerve-centres 
in childhood which specially favours the oc- 
currence of the disease. This condition may 
be said with confidence to be the fact that 
childhood is the period of special activity of 
the sensori-motor ganglia. 
Symptoms.-In a slight case of chorea the 
patient, usually a child, may be perfectly quiet 
when lying down, and for a short time even 
when sitting or standing, if not conscious of 
being under observation ; but when walking, 
or while under examination, there will be 
various fidgety actions-abrupt flexion of the 
fingers, a sudden pronation of the forearm, 
or hitching up of one shoulder, or twist of 
the body, or there is shuffling of a foot on the 
floor, or, again, a jerk of the head or twitch 
of the mouth or eyes. If the patient be told 
to do anything, the movements will be mul- 
tiplied and exaggerated in the muscles em- 
ployed. A small object will be picked up 
and held, but the hand is brought down upon 
it hastily and after various irregular excur- 
sions. In a more severe case the grimaces, 
contortions, andjerkings succeed each other 
without intermission. The gait is now very 
peculiar, being slow, shuffling, and uneven; 
the steps of irregular length and unequal 
time; and the line of progress deviating. In 
the worst forms of this disease every muscle 
appears to be thrown in turn into violent 
contraction, the face is distorted this way 
and that, the eyes roll to and fro, the teeth 
are snapped or ground together, the whole 
body writhes, and the limbs are in unceasing 
motion. It is to be remarked that, even in 
extreme cases, the movements, violent as 
they may be, are in some degree circum- 
scribed ; the arms, for example, are not 
thrown up over the head, nor do the legs 
go to the full extent of their range of mo- 
tion ; the tongue is rarely bitten, though the 
lips may be. Deglutition is greatly inter- 
fered with in a severe attack, and the evacua- 
tions may be discharged involuntarily. In 
the mildest forms the diaphragm and. mus- 
cles of the chest and abdomen are affected, 
causing irregularity in respiration. The 
action of the heart may also be irregular, 
but this is probably secondary to the respira- 
tory variations in frequency and depth, and 
is not attributable to chorea of the heart. 
There is generally impairment of motor 
power, and frequently diminution of sensa- 
tion. This is most readily ascertained in 
hemichorea, that is, chorea affecting one half 
of the body only, when the sound side can be CHOREA 
337 
employed for comparison ; but in the violent 
forms of the disease, when the skin is gradu- 
ally worn through by incessant friction, there 
is often so little complaint of pain that sen- 
sibility must, it would seem, be blunted. 
Reflex sensibility is also commonly dull. 
It has already been stated that the move- 
ments cease during sleep; this is a rule to 
which exceptions are rare though not un- 
known, even in mild cases, and especially in 
hemichorea. 
Chorea is usually gradual in access, even 
in the cases which ultimately become severe; 
it is very commonly one-sided for a time, 
and occasionally throughout, when the name 
hemichorea is given. It is not, however, 
strictly unilateral in these cases, as the move- 
ments transgress the median line and affect 
the corresponding muscles of both sides of 
the body at those parts where these are bi- 
laterally associated, and where in hemiplegia 
there is immunity from the paralysis, as, for 
instance, the oculo-motor muscles, and the 
muscles of the neck, chest, and abdomen. 
Complications.-The foregoing description 
applies more or less to all cases of chorea, 
but there are often additional symptoms, and 
it will conduce to clearness if these are con- 
sidered apart and called complications. Men- 
tion has been made of impairment of motor 
power; at times this amounts to complete 
paralysis, and the relations and combinations 
of chorea and paralysis, and especially of 
hemichorea and hemiplegia, throw much 
light on the disease. Paralytic chorea has 
been described as a special variety of the 
affection, but no line of demarcation exists 
between this and the common form. Chorea 
sometimes succeeds hemiplegia in the para- 
lysed parts; more rarely chorea deepens into 
paralysis. Cases again occur in which with 
facial hemiplegia there is chorea of the limbs 
of the same side. Speech is very commonly 
more or less affected and occasionally com- 
pletely lost for a time. The difficulty is 
usually articulatory, chorea of the muscles 
of respiration, phonation, and articulation 
interfering with utterance of words; but 
there is in some cases true aphasia, and when 
this is so, there is the same tendency to the 
association of aphasia with right hemichorea 
as with right hemiplegia. The intellect may 
suffer; the face has often an idiotic expres- 
sion, usually from the muscular contortion 
or atony, but sometimes indicative of tem- 
porary imbecility. In the violent and fatal 
forms there is almost always delirium. Im- 
pairment of sensation is common, and hemi- 
anaesthesia is almost always associated with 
hemichorea. Bor Heart Complications, see 
Etiology. 
Duration, Terminations, and Prognosis. 
-The average duration of chorea is about 
two months; if prolonged beyond three 
months it may be exceedingly chronic and 
go on better and worse for one or two years. 
There is a tendency to spontaneous recovery; 
but on the other hand relapses are common. 
Chorea is rarely fatal in children; when it 
is so the case is usually acute and violent 
from a very early period of the attack, and 
it is rare for a case to rim the usual course 
for a time, and then take on a very severe 
character. After puberty, and especially when 
it supervenes on acute rheumatism, it is very 
dangerous, but less so when associated with 
menstrual disorders and pregnancy than in 
youths or men. 
Diagnosis.-It is only necessary under this 
head to warn against the mistake of con- 
founding with the movements of chorea the 
tremor or jactitation of disseminated scle- 
rosis of the nerve-centres, which, though 
most common in adults, is not unknown in 
childhood. 
Treatment.-In a large proportion of 
cases of chorea, especially such as come 
into the hospitals of London, rest and food, 
with perhaps aperients, are all that are re- 
quired for recovery. But it can scarcely be 
denied that medicinal treatment often renders 
important services, especially in cases of a 
lingering character. The causation and 
pathological condition being various, it is to 
be expected that the remedies required will 
be different, and the attempt should be made 
to adapt the treatment to the special features 
of the case, the basis of all being the en- 
deavour to improve the nutrition of the body 
generally, and of the nervous system, by 
good food, rest, and warmth. The food may 
be supplemented by cod-liver oil, and the late 
Dr. C. B. Radcliffe attached importance to the 
free administration of wine or other stimu- 
lants. Any recognised cause should be re- 
moved, such as constipation or worms; irre- 
gularities or suspension of the catamenia 
should receive attention; when there is preg- 
nancy it may perhaps be necessary to induce 
premature labour. When the chorea is ac- 
companied by rheumatoid pains and feverish- 
ness, iodide of potassium with ammonia may 
have a remarkably good effect. Iron in some 
form or other is very generally useful, but 
especially when the patient is anaemic. An- 
other remedy is sulphate of zinc, given in 
doses gradually increasing from one or two 
grains three times a day, to six, eight, or ten 
grains, till sickness is induced, when in some 
cases the disease appears to be cut short. The 
remedy which in the writer's experience has 
been found most generally useful is arsenic. 
Trousseau sometimes gave strychnine in 
gradually increasing doses till its physiolo- 
gical effects manifested themselves. On the 
other hand, conium, recommended by Dr. 
John Harley, has been extensively employed; 
the only trustworthy preparation is the Juice, 
which should be given in gradually in- 
creasing doses, beginning with a drachm 
and going up to one or two ounces if neces- 
sary, till its depressing effect on the muscles 338 
CHOREA 
CHYLURIA 
becomes evident. It has not, in the writer's 
hands, given satisfactory results. The same 
may be said of the application of ether-spray 
along the spine, which has been strongly 
recommended, except in acute cases in which 
the freezing of the skin here has in some 
cases been followed at once by sleep, and 
in a few days by alleviation of the violence of 
the chorea. Baths, warm and cold, especi- 
ally shower-baths, spinal douches, spinal ice- 
bags, gymnastics, musical gymnastics, that is, 
movements timed by music, have advocates, 
and may no doubt be useful in suitable cases. 
In the terrible cases of acute chorea the 
great indications are to procure rest for the 
poor sufferer and keep up the strength. 
Milk, eggs, beef-tea, and other forms of 
concentrated fluid nourishment, should be 
given freely, together with wine or brandy. 
Conium, hyoscyamus, bromide of potassium 
or ammonium, and chloral hydrate, have been 
tried separately or in combination, with more 
or less appearance of success; chloroform, 
again, may be administered ; chloral hydrate 
by the mouth or rectum, and hypodermic in- 
jection of morphine, with free administration 
of brandy, have, in the writer's judgment, ap- 
peared to do much good. It is in these cases 
that tartar emetic in full doses has been re- 
commended ; it is certainly tolerated in an 
astonishing degree. Restraint of the violent 
movements is often a great comfort to the 
patient; the limbs should be carefully band- 
aged with flannel and bound, the legs to- 
gether, the arms to the sides, a folded 
blanket, across the abdomen and hips, keep- 
ing down the body. If half-done it only adds 
to the suffering, but when properly carried 
out it gives a feeling of relief and favours 
sleep. W. H. Broadbent. 
CHOROIDITIS.-Inflammation of the 
choroid. See Eye and its Appendages, 
Diseases of. 
CHROMIDROSIS (ypwpa, colour; and 
ISpow, sweat).-Coloured perspiration. See 
Perspiration, Disorders of. 
CHRONIC (ypovof, time).-This word is 
applied to a disease when its progress is slow, 
and its duration prolonged. See Disease, 
Duration of. 
CHYLOUS URINE.-See Chyluria. 
CHYLURIA1 (yvAor, chyle; and ovpov, 
urine).-Synon. : Galacturia; Chylous Urine; 
Fr. Urine laiteuse; Ger. Chylurie ; Milch- 
saftiger Harnabgang. 
The affection known as chylous or chyloid 
urine has long remained a puzzle to phy- 
sicians, not only on account of the very re- 
markable character assumed by the secretion, 
but also on account of the very erratic course 
which the disease runs. Scarcely any two 
persons affected with this malady give a 
similar account of its mode of onset, of the 
duration of the attack, or of the symptoms 
and seasons of its occurrence. The writer 
has had the opportunity of studying from 
thirty to forty cases of the disease in Calcutta; 
and the variety of symptoms presented, and 
the numerous causes, of the most opposite 
character, to which the disease has been 
attributed, are very perplexing. The histories 
of the cases published by various observers 
present a like uncertainty, and Sir William 
Roberts very aptly describes the course which 
the disease runs as marked by an irregularity 
and capriciousness which baffle explanation. 
It would seem as though the one symptom 
which may be looked upon as constant is 
the condition of the urine implied by the 
designation which was applied to the disorder 
by Prout. 
Definition.-[A diseased condition, origi- 
nating in the great majority of cases in 
tropical or sub-tropical climates, which mani- 
fests itself usually by a more or less milky 
appearance of the urine, modified at times 
by an admixture of a variable proportion of a 
substance resembling blood.] 
On standing, the fluid coagulates, so as to 
present the appearance of size. A micro- 
scopic nematoid entozoon (Filaria sanguinis 
hominis nocturna) is generally found in the 
blood and urine of persons affected with the 
disease. 
[Geographical Distribution. - This is 
peculiar. The vast majority of cases are tro- 
pical or sub-tropical in their origin. Never- 
theless, from time to time, cases crop up in 
the persons of individuals who have never 
been out of the temperate zones, nor in any 
way exposed to tropical influences.1 More- 
over, the disease is not equally distributed 
over the zone in which, in a general way, it 
may be said to be endemic. In most tropical 
countries it is of more or less frequent occur- 
rence, but there are districts in these same 
countries which enjoy an immunity similar to 
that of temperate climates. The explanation 
of this apparent caprice in the distribution 
of chyluria is afforded by the peculiarity 
of the distribution of the filaria sanguinis 
hominis nocturna-its principal aetiological 
factor.] 
1 It has been deemed advisable, in view of recent 
advances in our knowledge of chyluria and allied 
subjects, to slightly alter and rearrange the late Dr. 
Lewis's articles. These advances are, in a great 
measure, the outcome of Dr. Lewis's own discoveries, 
and it is, therefore, much to be regretted that his 
premature death has deprived the Editor of his 
assistance. Those portions of the article on Chy- 
lukia which are placed within brackets are new; 
the unbracketed parts are as they stood originally, 
and nearly as they were written by Dr. Lewis. 
1 Of the four or five cases which have been re- 
corded as having originally occurred in Europe, one 
is furnished by Sir William Roberts, the patient 
never having been out of Lancashire; and another 
by Dr. Beale, in a person who had never resided out 
of Norfolk. CHYLURIA 
339 
Symptoms.-So far as is at present known, 
there are no premonitory symptoms of chy- 
luria. Sometimes the only symptom is the 
milky condition of the urine-a condition 
which usually comes on very suddenly; 
generally, however, the patient complains 
of an uneasiness, scarcely amounting to pain, 
across the loins, along the ureters, over the 
bladder, or along the course of the urethra- 
especially towards the perinaeum in the male. 
There is generally marked debility, with 
mental depression. Occasionally chylo-serous 
discharges take place from various parts of 
the body-the axilla, the surface of the ab- 
domen, the groin, and especially from the 
scrotum, in that condition of it which is 
known as elephantiasis lymphangiectodes 
(Bristowe), nsevoid elephantiasis, or varix 
lymphaticus. The disease is also sometimes 
observed associated with true elephantiasis 
of the limbs and scrotum. It occurs at all 
ages, from childhood to extreme old age, and 
in about equal proportion among the sexes- 
perhaps more frequently in the female than 
in the male. 
With regard to the urine, it presents, as 
already mentioned, a milky appearance, and 
frequently emits a strong milky or whey-like 
odour, which is made more evident by 
warmth. After standing a short time the 
fluid coagulates, so as to form a more 
or less semi-solid mass resembling blanc- 
mange. In the course of a few hours the 
clot contracts, and the urine becomes rapidly 
decomposed. In some cases the fluid pre- 
sents a pink colour, from the admixture of 
[coloured corpuscles like those of] blood. 
Commonly-at least, in India-the blood-like 
admixture, when present, is seen forming a 
shreddy adherent coagulum at the bottom of 
the vessel after it has stood for some hours. 
Not infrequently the flow of urine is sud- 
denly stopped during micturition by the 
blocking up temporarily of the urethra with 
one of the clots. The specific gravity varies 
greatly-may range in the same individual 
from 1007 to over 1020. Shaken up with 
ether, the urine loses its milky aspect; and 
when nitric acid or heat is applied, a precipi- 
tate almost invariably results. These charac- 
ters, and the fact of the coagulability of the 
fluid, indicate the presence of fat, albumen, 
and fibrin, all of which are to be considered 
as abnormal constituents. The proportion, 
however, in which they exist in different 
individuals, and even in the same individual 
at different times, varies greatly. Dr. Beale's 
analyses show, that though a specimen of 
urine may contain at one time 1-39 per cent, 
of fat, another specimen, obtained a few 
hours later, from the same person, may con- 
tain none. In the majority of cases the fatty 
element is usually scanty in the morning 
before meals, and so are the other abnormal 
elements, unless exercise have been taken, 
or the circulation otherwise accelerated. 
Under the latter circumstance, as the late 
Dr. Bence-Jones has shown, the albumen is 
increased, without, however, a correspond- 
ing increase of the fat.1 It is evident, there- 
fore, that in order to institute a comparison 
between the character of the urine and the 
character of the various nutritive fluids, for 
the purpose of ascertaining from which of 
them the abnormal constituents of the urine 
are derived, the results of analyses of the latter 
fluids at different times of the day and at dif- 
ferent stages of the disease should be taken. 
Further, as the nutritive fluids themselves 
undergo constant changes dependent on the 
quality of the nourishment supplied and the 
time which has elapsed since partaking of it, 
it is equally evident that any single analysis 
would be insufficient. An attempt has been 
made to bring together in the following table 
all of what appeared to be the most trust- 
worthy analyses of these fluids which have 
been published. In order to simplify the 
table, only the estimates of the albuminoid 
and fatty matters have been given, these being 
the most pronounced of the more readily 
estimated abnormal constituents in the 
urine:- 
Constituents 
selected. 
Urine 
in chy- 
luria. 
[Mean 
of 15 an- 
alyses.] 
Blood 
in chy- 
luria. 
[Hoppe- 
Seyler.] 
Blood 
-Nor- 
mal 
human. 
[Bec- 
querel 
and 
Bodier.] 
Chyle 
[Mean 
of 6 ana- 
lyses : 
man, 
cow, 
horse, 
ass, dog, 
cat.] 
Lymph 
-human 
[Mean 
of 4 ana- 
lyses]. 
Albuminoids 
0'54% 
3-35% 
7-00% 
7-08% 
2'96% 
Fatty mat- 
ters 
0-80% 
0'67% 
00G% 
0'92% 
0-56% 
A glance at this table illustrates the fact that 
the relative proportion of the albuminoids to 
the fatty matter in chylous urine does not 
correspond with the proportion in which 
they are found in any one of the nutritive 
fluids of the body. In normal blood, for 
example, the fatty matter is as 1 to 116 of 
the albuminoid, whereas in the urine the 
former exceeds the latter to a very consider- 
able extent. The same discrepancy, but to 
a less degree, is found to exist when the 
urine and chyle are compared-the quantity 
of albumen in the latter being more than 
seven times greater than that of fat. The 
proportion of these substances in lymph ap- 
proaches more closely to what is encountered 
in the urine-the fat being to the albumen 
as 1 to 4 very nearly. The specimen of 
chyluria-blood analysed by Hoppe-Seyler2 
approaches very closely to the average com- 
position of human lymph-the fatty matters 
being as 1 to 5 of the albuminoid, thus 
differing in this respect very considerably 
1 Phil. Trans, of Royal Soc., cxl., 1850, p. 651. 
2 Med.-chem. Untersuchungen, 1871, s. 551-56. 
Abstract by Dr. Ferrier in Journ. Chem. Soc., 
vol. ix., 1871; p. 740. 340 
CHYLURIA 
from Dr. Bence-Jones' analyses of similar 
blood, where the quantity of fat given is 
that of normal blood. On the other hand, 
the urine of the man from whom this blood 
was obtained yielded a proportion of fat 
almost identical with what Hoppe-Seyler 
obtained in the urine of the person whose 
blood he examined-the figures given by the 
former writer being 0'74 and by the latter 
0'72 per cent. The composition of the blood 
in this affection must be regarded as hitherto 
unsettled. Guibort found in a clot of it 
almost twice, and Hoppe-Seyler about eleven 
times, as much fat as is found in normal 
blood; on the other hand, Bayer, Bence- 
Jones, and Crevaux could detect no change 
in its composition. It is possible that the 
discrepancy in the results of these analyses 
and macroscopic examinations of the blood 
may be due in part to the particular moment 
when the blood was abstracted. According 
to M. Claude Bernard, ' Les urines chyleuses 
resemblent au sang d'un animal en digestion, 
ou plutot & celui des oies que 1'engraisse.'1 
Microscopical Characters of the Urine.- 
[The filaria sanguinis hominis may gene- 
rally be detected in the urine.] In making 
a search for it, it is advisable to pick out 
one of the coagulated shreds found in the 
urine, transfer it to the glass slide by means 
of a forceps or pipette, and carefully tease 
the fragment before applying the cover- 
glass. 
[A still better plan is to break up the coa- 
gulum in the urine with a glass rod as soon 
as it is formed, and then to search the sedi- 
ment which, after an hour or two, collects at 
the bottom of the vessel in the same way as 
is customary in examining for ' casts.' As 
large a slide as is practicable ought to be 
examined, and a low power employed in 
the first instance, as it often happens that 
the filariae are present, but only in very small 
numbers, and might be readily overlooked if 
a small quantity of sediment is examined or 
a high power employed.] 
[The periodicity characteristic of the filaria 
when in the blood is not observed by the 
parasite in the urine. It may be found in 
chylous urine passed during the day as well 
as in that passed during the night. In a 
certain, though small proportion, of cases the 
parasite cannot be found ; but there is every 
reason to suppose that at one time, even in 
these instances, the filaria had been present. 
Cases are on record in which, after its presence 
had been fully ascertained, the parasite dis- 
appeared from the urine while the patient 
was under observation, the chyluria persist- 
ing. In the rare instances of chyluria origin- 
ating outside the endemic area the filaria 
will, of course, not be found at any time. It 
is difficult to define the limits of this area, 
however, so that in every case of chyluria the 
parasite ought to be sought for.] 
The other leading microscopical character 
of the urine is the minutely molecular matter 
-fat in an emulsified condition-to which 
the fluid owes its opaline or milky aspect. 
There are also numerous white, lymphoid 
corpuscles, together with red corpuscles, 
numerous or the reverse according to the 
degree of sanguinolence of the urine. Casts 
of the tubular structure of the kidney- 
indicative of organic disease of these organs 
-are seldom to be seen; they were absent 
in all the cases that have come under the 
writer's observation. 
With regard to the microscopical examina- 
tion of the blood, the writer has not observed 
that the corpuscles or serum presented any 
abnormality indicative of the presence of 
fatty matter in any form-the serum has 
seemed as clear and as free from molecular 
matter as normal blood. As far as his ex- 
perience goes, the only feature worthy of 
special note in connexion with microscopical 
examination of the blood in chyluria is the 
presence of the ha?matozoon already referred 
to. [In consequence of the periodicity ob- 
served by the filaria in the blood, it is ab- 
solutely necessary that this examination be 
made during the late evening, the night, or 
the early morning; some time between 9 p.m. 
and 6 a.m. is the best. Searched for at this 
time, and as recommended elsewhere (see 
Filaria Sanguinis Hominis), the filaria is 
usually found in the blood; if it is absent 
from the urine it will not be found in the 
blood. If it is found in the blood in chyluric 
cases it will also be found in the urine; but 
it sometimes happens that, though the filaria 
is present in the urine, yet the most careful 
and prolonged examination may fail to detect 
it in the blood.] 
Anatomical Characters.-The post-mor- 
tem examinations of persons who have died 
whilst affected with chyluria also testify to 
the freedom of the kidneys from disease. 
This was the case in two autopsies con- 
ducted by Dr. McConnell in Calcutta. The 
writer had the opportunity of examining the 
kidneys of the first case, and all the organs 
of the body of the other case, but could find 
nothing in any of the organs or tissues 
suggestive of being a cause of the urinary 
derangement, except the fact that all the 
vessels - arteries as wrell as veins - con- 
tained the filaria in their minutest ramifi- 
cations. 
[But, although no evidence of disease of 
the parenchyma of the kidneys has been dis- 
covered in connexion with this disease, two 
more recent and carefully conducted post- 
mortem examinations have shown that the 
lymphatic system connected with the urinary 
tract may be seriously deranged. This is 
only what might have been expected from the 
frequency with which chyluria is associated 
with diseased conditions of the lymphatics in 
different parts of the body-notably of the 
1 Quoted by Crevaux, op. cit. CHYLURIA 
341 
scrotum and the inguinal glands. Dr. Stephen 
Mackenzie 1 and Ponfick2 have each put on 
record details of such examinations, and in 
both instances thickening and dilatation of 
the thoracic duct, and marked varicosity of 
the pelvic and other lymphatics were found. 
It can be readily understood-as pointed out 
by Sir William Roberts3-how a varicosity, 
which may have been distinct enough during 
life, would collapse after death, and be diffi- 
cult then to demonstrate and readily over- 
looked ; and it is possible that in this cir- 
cumstance lies the explanation of the negative 
results of most of the post-mortem examina- 
tions of cases of chyluria.] 
^Etiology and Pathology.-Having con- 
sidered in detail what seem to be the leading 
pathological features of chyluria, a brief re- 
ference may be made to the views which 
prevail regarding its aetiology. These may 
be comprised under three heads:-(1) Dr. 
Vandyke Carter4 advocates the view that 
a direct communication exists between the 
chyle-carrying vessels and the urinary tracts. 
(2) MM. Claude Bernard and Ch. Robin be- 
lieve that the condition of the urine is but a 
symptom of piarrhaemia-fatty blood; the 
latter condition being but the normal con- 
dition of the blood for some time after the 
partaking of food, aggravated and made per- 
manent by derangement of the digestive 
organs-notably the liver. One of these dis- 
tinguished authors (M. Robin) suggests, fur- 
ther, that this derangement is probably 
induced in the liver and elsewhere by the 
filaria sanguinis hominis.5 (3) The third 
view to be noticed is that advanced by Sir 
William Roberts. This view appears to be 
based mainly on the history of a very remark- 
able case, published by him in 1868. It was 
one in which a coagulable chylo-lymphous 
discharge escaped from open vesicles which 
had formed over the surface of the abdomen; 
the patient's urine was, moreover, chylous for 
two days. Sir William Roberts suggests that 
a condition somewhat similar to that on the 
surface of the abdomen existed in the urinary 
tract-a sort of eczema-probably on the 
front of the bladder. Post-mortem exami- 
nation did not, however, confirm this view, 
nor could anything be detected in any of the 
organs suggestive of a cause, but this authority 
infers that this was probably due ' to the fact 
that in the last few weeks of life the morbid 
process had retrograded and had consequently 
left no appreciable marks on the surface of 
the bladder.' The examination of the skin 
in the diseased part showed that the cutis 
vera and the subcutaneous tissue were 
traversed by short channels or lacunae from 
the width of a crow-quill to that of a hair. 
A careful study of this and other cases sug- 
gested to Sir William Roberts the view that 
one, at least, of the forms of chyluria may be 
due to hypertrophy of the lymphatic channels, 
and subsequent acquisition by them of gland 
properties. M. Robin's view does not suggest 
any special anatomical difficulty, but it re- 
mains to be demonstrated more conclusively 
than has hitherto been done that the blood 
in man ever contains a sufficient quantity of 
fatty matter to produce such extreme milki- 
ness by admixture with the urine as is 
observed in chyluria. Sir William Roberts' 
theory is certainly not open to these particular 
objections, as, given a certain agent to start 
the formation of these glandular tissues, there 
does not appear to be any special anatomical 
or physiological difficulty to be got over ; but 
the results of all the autopsies as yet recorded 
do not warrant the inference of the existence 
of such pathological conditions. Future ob- 
servation, however, may show that they really 
do exist. 
[Multiplied observations, made during re- 
cent years, have made it more than probable 
that Dr. Carter's view of the pathology of chy- 
luria is the correct one-namely, that some- 
where in the urinary tract there is a varicose 
condition of the lymphatics, similar to that 
found in elephantiasis lymphangiectodes, varix 
lymphaticus, or lymph-scrotum-a disease, as 
pointed out, also commonly associated with 
the filaria, and very frequently with chyluria. 
Either the mature parasite itself, or its young, 
or its prematurely expelled ova, or stenotic 
conditions of the lymphatic trunks induced 
by some of these, act as a mechanical ob- 
struction to the onward flow of the lymph, 
and thus induce a varicose condition of the 
lymphatics on the distal side of the seat of 
the obstruction. Rupture of the varicose 
vessels will then admit the lymph to the 
urine if the varicosity is anywhere in the 
urinary tract.] 
[For diagnostic purposes, as well as to 
arrive at a correct idea of the pathology of 
chyluria, it is necessary to bear in mind that 
whilst chylous urine, or its coagula, on the 
one hand, may be clear as the purest gelatine 
or, on the other hand, white like milk-in 
most cases from time to time, in others 
always-they may have a blood-like tinge, 
often of great intensity. This latter circum- 
stance is likely to lead the unwary to a dia- 
gnosis of hsematuria, and give rise to the idea 
that blood-vessels as well as lymph-vessels are 
in some way involved; all the more so as 
genuine haematuria is endemic and very pre- 
valent in many of the countries-Egypt, for 
example-in which chyluria is also endemic 
(see Entozoa; Bilharzia). Some authors, 
misled by a false idea of the pathology of 
the disease, describe these cases of red chy- 
luria under the name of haematuria, or 
haemato-chyluria, assuming, and apparently 
1 Trans. Path. Soc., 1882, vol. xxxiii. 
2 Berlin, klin. Wochen. 4 Oct., 1880. 
5 Urinary and lienal Diseases. 
4 Trans. Med. and Phys. Soc. Bombay, vol. vii. 
1861. Medico-Chzr. Trans., vol. xlv., 1862. 
5 Lemons sur les Humeurs, 2nd edit. 1874, p. 845. 342 
CHYLURIA 
CICATRISATION 
being under the impression, that genuine 
blood from the blood-vessels is the cause of 
the red colour of the chylous clots in the 
urine. It is quite possible for the same 
individual to be the subject of chyluria and 
also of hsematuria, and such a coincidence 
has been noted; but in an ordinary case of 
red-tinted chylous urine there is no reason 
to suppose, further than that suggested by the 
colour only of the urine, that the term chy- 
luria, applied to these cases, is unscientific, 
or that the characteristic pathological feature 
is derived from any set of vessels other than 
the lymphatics. In the first place, it is very 
unlikely that both sets of vessels-blood- 
vessels and lymphatics-could be similarly 
affected in the same individual and in the 
same organ; and, in the second place, it is 
well known that the contents of the thoracic 
duct, and of some of the larger lymphatics, and 
also lymph long stagnant in obstructed lym- 
phatics, acquire a red tinge from the normal 
advance of the development in them of red 
blood-corpuscles.1 Hence, undoubtedly, the 
red colour so frequently seen in the coagula 
referred to. In the same way may be ex- 
plained the absence, or gradations, of milki- 
ness occasionally encountered. If the ab- 
normal element in the urine be derived from 
vessels into which no chyle has regurgitated, 
if the vessels are filled with a chyle in which 
the fatty element is defective, either from 
peculiarities of diet or from its relation as 
regards time to the period of digestion, it 
will be less milky and more transparent and 
j eUy-like. The differences in the analyses 
of chylous urines admit of a similar expla- 
nation.] 
Of the set iologic al significance of the pre- 
sence of the filaria in the circulation there can, 
the writer thinks, scarcely be much doubt- 
more especiaUy when the number of ob- 
servations recorded within the short period 
that has elapsed since attention has been 
drawn to its existence therein, is taken into 
consideration. These suggest more than a 
fortuitous connexion; indeed, it might rather 
be said that chylo-serous effusions may be 
considered as symptomatic of the parasit- 
ism. Filariae have even been detected 
shortly before chyluria had manifested 
itself. 
[As regards those cases of chyluria appa- 
rently unassociated with the filaria, we must 
bear in mind that anything which could give 
rise to constriction or blocking of the lymph- 
channels might act in the same way as the 
filaria does as regards producing lymphatic 
varicosity and rupture. Thus pressure by 
a tumour, constriction from inflammatory 
thickening in or about the walls of the 
thoracic duct or pelvic lymphatics, or stric- 
ture foflowing ulceration of their walls, might, 
it is conceivable, bring about this state of 
varicosity leading to rupture and possibly 
to chyluria.j 
Prognosis.-Persons have been known to 
suffer off and on from this affection for from 
one to fifty years. This would suggest that 
the malady usually runs a chronic course, 
which, as a rule, it doubtless does; on the 
other hand, patients apparently in fair health 
otherwise have been known to die very un- 
expectedly from no recognised acute disorder. 
With regard to the prospect of a cure a very 
guarded opinion should be given, as the 
probability is that the complaint will return 
again and again so long as life lasts-even 
when the disease commences at a very early 
age, and often after a complete change of 
climate and avocation. 
Treatment.-This has proved extremely 
unsatisfactory in almost all the cases recorded; 
in fact it cannot be distinctly stated that the 
course of the disease has been materially 
modified, much less cured, by any known 
remedy. Iodide of potassium has been tried 
in large doses, and in some cases appears to 
have been beneficial; in others the tincture 
of the perchloride of iron has seemed to be 
more successful. A decoction of the bark 
of Rhizophora racemosa (mangrove) has a 
reputation in Guiana, just as a decoction of 
the seed of Nigella sativa (used also as a 
condiment in curries) has in India. The 
latter remedy has, however, been known to 
be powerless in mitigating the malady even 
in cases where on former occasions it had 
been resorted to with apparent success. 
Perhaps the most satisfactory results which 
have been published are those which have 
followed the administration of large doses of 
gallic acid-one or two drachms a day. 
[Large doses of benzoic acid given in gly- 
cerine have, in some hands, been followed by 
a cessation for a time of the chyluria. But 
from what we now know about the pathology 
of this disease, it is evident that rest in the 
recumbent position, with elevation of the 
pelvis, is by far the most important indica- 
tion to be attended to in the treatment.] See 
Filaria sanguinis hominis. 
Timothy Lewis. Patrick Manson. 
CICATRISATION (cicatrix, a scar). 
Cicatrisation is the process by which solutions 
of continuity in an organ or tissue are re- 
paired. These solutions of continuity may 
be due to injury, ulceration, extravasation, or 
the effusion of inflammatory products. The 
result of the process is the formation of a 
cicatrix or scar. 
Pathology.-Cicatrisation as it occurs in 
superficial parts in surgical practice may be 
selected as affording a typical illustration of 
the process. It is most frequently and 
easily observed, and it corresponds to what is 
met with in deeper tissues. 
Repair may take place either with or with- 
out the occurrence of granulation, and the 
1 Gibson., Joum. of Anat, and Physiol., vol. xx. 
1886. CICATRISATION 
CIRCULATION, DISORDERS OF 
343 
process of granulation may or may not be ac- 
companied by suppuration; the existence both 
of granulation and of suppuration depending 
on the degrees of abnormal stimulation to 
which the injured tissues are subjected. 
Healing by first intention.-In an incised 
wound favourably circumstanced as to vas- 
cularity of tissue, absence of tension, and ap- 
position of edges, epidermic continuity may 
be re-established in thirty-six to seventy- 
two hours. The lips of such a wound are 
temporarily united by a thin layer of lymph 
and white corpuscles of the blood, and 
perhaps soon afterwards by cells proliferated 
from connective-tissue corpuscles. These 
cells become spindle - shaped, and are 
ultimately converted into ordinary connec- 
tive-tissue corpuscles, whilst offsets from 
the neighbouring capillaries re-establish 
the circulation throughout the new tissue. 
Coincidently with these changes the surface 
becomes covered with epithelium. The re- 
sulting scar at first appears as a red line, 
which subsequently becomes white from the 
disappearance of many of its blood-vessels. 
Healing by scabbing. -When an open 
wound heals by scabbing, the epidermis 
spreads over the tissues without the inter- 
vention of the process of granulation, owing 
to the protection afforded them by the crust 
of blood and lymph which has formed upon 
the wound. 
Recent antiseptic surgery has shown that 
even large hollow wounds filled with blood- 
clot, such as are caused, say, by operation for 
ununited fracture of the femur, may cicatrise 
completely without suppuration or granula- 
tion, if protected from the stimulation of the 
antiseptic used. In these cases the white 
corpuscles of the clot become organised 
directly into fibro-plastic cells and connective- 
tissue corpuscles, and the new epidermis 
will probably be formed beneath a thin upper 
layer of the clot. 
Healing by granulation.-If a recent 
wound, too large for scabbing, be simply left 
exposed to the air, or treated with water 
dressing, or with an ordinary antiseptic, 
there will be a discharge at first of serum 
tinged with blood, then of pale serum, and 
afterwards of cloudy yellowish serum, replaced 
in about three days by fully-formed pus. By 
this time the wound will be studded over 
with little bright red elevations, termed 
granulations, which ultimately cover the 
whole surface. Granulation-tissue consists of 
nucleated cells, amongst which pass vascular 
loops with thin walls. After an interval the 
edges of the skin are seen to be on a level 
with the granulating surface, and as it were 
continuous with it. Perhaps already the 
wound is much smaller, owing to the shrink- 
ing of the granulations as their cells assume 
the spindle-cell type. Then, extending from 
the cutaneous margin there may be observed 
a narrow red line, brighter than the rest of 
the granulating surface, owing to the presence 
of a layer of transparent epidermis. Next 
day this zone will be bluish, from the 
growing opacity of the epidermic cells, and 
there will be a fresh red line corresponding 
with the newest epithelium. A day later the 
outer layer will have become so opaque as to 
be whitish, and the second to be bluish ; and 
there will again be a fresh inner red line, 
which will gradually advance until the scar 
is complete. The new epidermis quickly 
separates into a horny and a mucous layer. 
See also Skin Grafting. 
The healing of an evacuated abscess-cavity 
depends partly upon the contraction, and 
partly upon the coalescence of the granu- 
lations of which its pyogenic membrane 
consists. This contraction is an essential 
part of the cicatrising process, and often 
causes deformities and secondary effects by 
pressure exerted on vessels and nerves. 
Many cases of disease of joints (caries, 
&c.), and the behaviour of abscesses treated 
antiseptically and with adequate drainage, 
may be referred to as instances of the exist- 
ence of non-suppurating granulations. 
John Bishop. B. J. Godlee. 
CINCHONISM.-A condition induced 
by the administration of quinine, the chief 
active principle of cinchona. See Quinism. 
CINCLISIS I move often). 
This word signifies agitation or motion, and 
was formerly applied to involuntary winking 
or movements of the eyelids ; and also to the 
movements of the chest in dyspnoea. 
CIRCULATION, Disorders of.- 
Abnormal excess and deficiency of blood are 
known as hypercemia and ancemia respec- 
tively. Each of these may be general or 
local. We also recognise as a disorder of 
circulation stagnation or local cyanosis. 
I. Hypersemia. - General hyperaemia 
signifies excess of blood in the body, and 
is also called plethora. Local hypereemia 
means excess of blood in a part. Such ex- 
cess may be caused either by superabundant 
supply, or by deficient removal of blood 
through the agency of the blood-vessels. 
Dilatation of the arteries, however produced, 
causes more copious afflux of blood, which 
fills the capillaries and veins in a correspond- 
ing degree, so that there is excess of blood in 
all the vessels of the part. This condition is 
called arterial or active hypercemia, active 
congestion, or determination of blood. If, 
on the other hand, blood is imperfectly re- 
moved by the veins, these vessels, as well as 
the capillaries, become gorged, and the con- 
dition called venous or passive hypercemia, 
or venous congestion, results. It is doubtful 
whether there can be capillary hypercemia, 
except as the result of one of these condi- 
tions. 344 
CIRCULATION, DISORDERS OF 
A. Arterial or Active Hypercemia.-An 
excessive amount of blood can be conveyed 
by the arteries only under two conditions:- 
(1) Enlargement of these vessels by relaxa- 
tion of their muscular walls; (2) Increased 
pressure within them, from obstruction of 
collateral channels with which they com- 
municate, i.e. collateral hyperaemia. 
(1) Relaxation of the muscular walls may 
be caused directly by violence or by warmth, 
as is illustrated in the redness of the skin 
produced by a blow, by heat, or by the re- 
action after intense cold. Sudden withdrawal 
of pressure has the same effect, as is some- 
times seen on evacuating a hydrocele or 
fluid-collection in a serous cavity. Dry-cup- 
ping produces similar but more complex re- 
sults, the veins being acted upon as much as 
the arteries. Relaxation of the muscle-fibres 
is produced also indirectly through the vaso- 
motor nerves. If these are paralysed, re- 
laxation of the fibres occurs, and the arteries 
dilate. Experimental section of the cervical 
sympathetic in animals shows this most 
clearly; but the same result follows less con- 
stantly if other nerves containing vaso-motor 
fibres are divided or injured, such as the 
mixed nerves of the limbs, or branches of the 
trigeminus. Wounds of the brachial plexus 
have been found to cause hyperaemia of the 
fingers (glossy fingers of Paget). When the 
section is complete, hyperaemia is only tran- 
sitory, and is soon followed by a return to the 
normal condition, or even by undue anaemia, 
which is permanent. In irritative lesions, 
on the other hand, such as gunshot wounds, 
hyperaemia continues as long as the irritation. 
In such cases it is possible that the lesion is 
not paralytic, but depends upon stimulation 
of the actively dilating vaso-motor fibres 
which physiologists have now shown to exist 
in many parts of the body, since stimulation 
of these produces the same result as paralysis 
of the inhibitory fibres. Hyperaemia often 
accompanies neuralgia, both depending upon 
some morbid condition of the nerve. The 
starting point of the neurosis in all these cases 
may be, and often is, in the central nervous 
system, and hence chronic diseases of the 
spinal cord or brain are often accompanied 
by general paralytic hyperaemia-that is, 
flushing, or by congestion of special parts. 
The same result may come from reflex 
nervous action, set up by disturbances of the 
digestive organs, the organs of generation, or 
of other parts. 
(2) Collateral hyperaemia is a consequence 
of the rise of pressure produced by the block- 
ing-up of arterial channels in the adjoining 
parts. It is usually effected by the enlarge- 
ment of existing vessels, and the conversion 
of small, almost capillary, vessels into pul- 
sating arteries. It occurs not only in the 
familiar instances of surgical ligature, and 
the sudden blocking of an artery by a plug 
(see Embolism), but in the gradual obstruc- 
tion which accompanies atrophic and sclerotic 
processes. When the chief afferent blood- 
channels to an organ become obstructed, its 
peripheral parts are very liable to become 
hypersemic, a principle which when applied 
to such cases as cirrhosis of the liver, granular 
kidney, and sclerosis of the brain, will be 
found fruitful in practical deductions. 
Signs and Results.-The colour of parts 
in a state of active hyperaemia is, during life, 
bright red, the arteries, large and small, being 
visibly injected, while the capillaries, filled 
with arterial blood, produce a diffuse red 
colour. In experimental hyperaemia the 
blood may remain bright red even in the 
veins. The temperature of external parts 
becomes elevated, though not above that of 
internal parts. Sometimes there is obvious 
pulsation or throbbing. There may be swell- 
ing, which is due to simple enlargement of 
the vessels, not to exudation of fluid, since 
this does not occur from arterial hyperaemia 
alone. The nerves, both those of common 
sensation and those of special sense, are more 
excitable than they are normally. There is 
usually a subjective sensation of warmth, and 
there may be pain or itching. 
Arterial hyperaemia may last for a long 
time without producing any change whatever 
in the part affected, but may, under condi- 
tions little understood, give rise to hyper- 
trophy, which sometimes, though rarely, re- 
sults from section of the cervical sympathetic. 
Transitory but repeated hyperaemic condi- 
tions more regularly produce this result, as 
is seen in hypertrophy from pressure; in 
thickening of the skull from excessive expo- 
sure of the head to the sun; in hypertrophy 
of the skin of the face and its glands from fre- 
quently recurring hyperasmia (acne rosacea). 
This kind of hyperaemia constantly precedes 
inflammation, but can hardly be said to pro- 
duce it. It does, however, render the tissues 
more vulnerable, bringing them into a condi- 
tion in which a slight cause will set up inflam- 
mation. Unless the vessels are unsound, 
simple arterial hyperaemia does not lead to 
haemorrhage. 
B. Passive Hyperczmia or Venous Con- 
gestion.-This may be due to-(1) Feeble 
circulation ; or (2) Obstruction in the veins. 
(1) Blood may be imperfectly removed 
from a part, owing to the imperfect action of 
the forces which normally maintain the flow 
of blood in the veins. These are, besides the 
action of the heart, the pressure of muscles 
(combined with the arrangement of the valves 
in the veins), and the movement of the thorax 
in inspiration. If these are deficient, the 
venous current will be everywhere delayed, 
but notably in those parts where it has to 
overcome the action of gravity. In the erect 
posture this will be the case in the lower 
limbs; and hence venous congestion is com- 
mon in the legs, ankles, and feet. In decum- 
bent patients, for analogous reasons, the CIRCULATION, DISORDERS OF 
345 
nates, sacrum, shoulder-blades, and the bases 
of the lungs behind become the seat of what 
is called hypostatic congestion. Very general 
obstruction, such as results from imperfec- 
tion of the heart itself, may lead to the con- 
dition called cyanosis, which is essentially 
venous congestion, and to similar congestion 
of the lungs, liver, kidneys, and other internal 
organs, with very serious results. 
(2) Obstruction of the veins is rarely pro- 
duced by a morbid condition of the walls of 
these vessels, but may result from coagula- 
tion of blood within them. Another cause is 
external pressure, such as that of tumours, of 
the gravid uterus, or of the intestinal con- 
tents, as in the case of the haemorrhoidal 
veins. Finally, indurative changes in the 
solid viscera lead to venous obstruction, as is 
seen in cirrhosis of the liver, which produces 
congestion of the whole portal system. 
Signs and Results.-The colour of parts 
in a state of passive hyperaemia is bluish 
rather than red, the veins, large and small, 
being injected with venous blood, and the 
capillaries, in which the blood is also venous, 
producing a uniform purple colour. If the 
congestion is extreme, collateral venous 
channels are likely to be established, which 
are sometimes the only evident sign of in- 
ternal venous obstruction. The surface is 
usually cooler rather than hotter when com- 
pared with corresponding parts, of the body ; 
and there is no unusual nervous sensibility 
or sense of throbbing. Swelling very fre- 
quently occurs, and depends on actual serous 
effusion from the vessels, so that the parts 
are often anasarcous, pitting on pressure; 
while in cavities there is an accumulation of 
fluid. 
Venous congestion produces more impor- 
tant and permanent results than arterial. In 
experimental venous obstruction, besides en- 
gorgement of the vessels, two nearly constant 
phenomena are seen-copious transudation 
of serum, and passage of a number of red 
blood-discs through the walls of the capil- 
laries and smaller veins. Few or no white 
corpuscles emigrate, and the arterial circu- 
lation is unaltered. The absence or occur- 
rence of dropsy depends upon the adequacy 
or inadequacy of the lymphatics to carry off 
the superfluous serum. In ordinary patho- 
logical venous congestion all these changes 
are seen to some extent; extravasation of 
red blood-discs being shown by the pigmen- 
tation of parts in chronic congestion, though 
this is not evident in the acute condition. 
Chronic venous congestion increases the 
hardness and density of organs, a change 
which may, in the first instance, result 
from simple cedema, but in the end is 
due to fibroid change (see Degeneration). 
Such organs are at first enlarged, but ulti- 
mately diminish in size, and suffer fatty 
atrophy, not only through the general law of 
fibroid change, but because venous blood is 
inadequate to the proper nutrition of tissues. 
These changes are seen in the liver and kid- 
neys in cases of obstructive heart-disease. 
External parts, as the skin of the lower part 
of the leg, show by a tendency to ulceration 
that they are imperfectly nourished, and are 
also liable to become inflamed from slight 
causes (varicose eczema). 
Post-mortem Characters.-The appear- 
ance of hyperaemic parts after death is not 
necessarily the same as during life. The 
colour of the blood does not enable us to 
say whether the hyperaemia was arterial or 
venous. All blood contained in the body 
after death, excluded from the air, is dark or 
venous, but becomes florid when exposed to 
the air, unless it have previously undergone 
some post-mortem change, or some morbid 
alteration during life. This change may be 
watched in the lungs when the chest is 
opened, especially in the case of children 
whose lungs have little local colour. The 
only important point after death is the ful- 
ness of the three kinds of vessels. Arteries 
are usually empty, unless diseased; the larger 
veins almost always full. If the smaller 
veins and arteries are conspicuously and 
brightly injected, the part may be described 
simply as congested; a uniform colour in- 
dicates fulness of the capillaries, which may 
be confirmed by the microscope. Uncom- 
plicated arterial hyperaemia leaves no trace 
after death; the appearance of it is produced 
by inflammation. Simple venous hyperaemia 
can only be recognised as such after death-by 
comparison, that is, with the same part under 
normal conditions. Chronic venous conges- 
tion is indicated by many of the same charac- 
ters as during life. Care should be taken not 
to mistake for arterial hyperaemia mere stain- 
ing with blood-pigment of the walls of the 
vessels; nor for venous congestion mere 
post-mortem hypostasis, or the settling down 
of the blood, if fluid, after death. 
II. Anaemia.-General anaemia is a mor- 
bid condition in which there is a deficiency 
of blood, or, more correctly, a deficiency of 
the red corpuscles of the blood, throughout 
the whole body. It is also called oligcemia, or 
oligocythcemia (see Anaemia). Local anaemia, 
with which we are here concerned, signifies 
deficiency of blood in a part. It may be 
complete or partial. Complete local anaemia 
can only occur when the blood-supply of a 
part is totally cut off by obstruction of its 
arteries. The conditions and consequences 
of such obstruction are discussed elsewhere 
(see Embolism). Partial anaemia or ischcemia 
may be produced by direct pressure, or else 
by arterial obstruction, permanent or tran- 
sitory. Permanent anaemia of many parts 
results from gradual obstruction of arteries 
by atheromatous change; or, still more strik- 
ingly, by a form of endarteritis (endarteritis 
obliterans) generally due to syphilis; or, 
again, from deposition of fibrin on the diseased 346 
CIRCULATION, DISORDERS OF 
vascular wall. Temporary anaemia results 
from spasmodic contraction of the annular 
fibre-cells in the muscular coat of the artery. 
Such a contraction may be produced experi- 
mentally by direct electrical stimulation, or 
by stimulation of the sympathetic branches 
distributed to the vessel; and in pathological 
conditions we find such contraction occur- 
ring in consequence of some derangement 
of the nerve-centres, or from reflex irritation, 
or even, as it would seem, idiopathically. 
Neuralgia and migraine are often accompanied 
or caused by spasm of the arteries, and 
epilepsy has, with less certainty, been attri- 
buted to the same cause. In these cases it 
is possible, as is held by some authorities, 
that anaemia of the nerve-tissue is the cause 
of the disturbed innervation. Hysterical 
blindness, and probably other hysterical 
affections, may be explained in the same 
way. Partial anaemia may, as shown else- 
where, lead to local cyanosis, with the 
appearance of venous hypersemia. Total 
anaemia necessarily causes necrosis of the 
part; and even partial anaemia produces 
characteristic changes. 
Signs and Results.-An anaemic part is 
pale, its temperature in the case of external 
parts is diminished, and there is weakened 
or arrested arterial pulsation. A permanent 
condition of partial anaemia produces de- 
generation, ending in atrophy of the affected 
part. The wasting of the skin, and possibly 
that of the kidneys in old age, is due to this 
cause. Transitory anaemia causes necessarily 
a cessation of functional activity in the part, 
as is obvious in the nerve-centres and the 
muscles; but does not, so far as we know, 
produce any permanent change. Compres- 
sion or obstruction of the abdominal aorta 
produces symptoms of temporary paraplegia, 
from anaemia of the lower part of the spinal 
cord. 
III. Local Cyanosis.-It must not be 
supposed that a venous condition of the blood 
in a part, with consequent purple colour, low 
temperature, and deficient vitality, is neces- 
sarily due to venous engorgement. It may 
be due, as is obvious in external parts, to 
mere stagnation in the capillaries. When 
blood is stagnant, or nearly so, it becomes 
venous, having given up its oxygen to the 
tissues; and the part shows the characters 
of venous congestion. This is seen in the 
familiar instance of the effects of external 
cold on the extremities. A similar condition, 
which may be called local cyanosis, some- 
times occurs independently of, or only 
assisted by, the action of cold, in certain 
parts, such as the extremities of the fingers 
and toes, the tips of the ears and the nose. 
It is possible that similar conditions of in- 
ternal parts may occur. A part affected with 
local cyanosis may undergo partial necrosis 
or inflammation, as in the case of frost-bite 
or chilblain. 
Some persons, especially when young, 
have a constitutional proclivity to this con- 
dition, especially in cold weather, and have 
been described as having a ' chilblain circula- 
tion '; but it is not necessarily associated 
with chilblains, properly so-called. In other 
cases the cyanosis is preceded by, or alter- 
nates with, a condition of anaemia in the 
part, and is evidently due to a functional 
disturbance of circulation, more or less 
transient. In its extreme form, when occur- 
ring suddenly, and affecting deeper parts as 
well as the skin, and leading to necrosis, 
this constitutes Raynaud's disease. The con- 
dition is nearly always symmetrical, affecting 
corresponding parts on both sides of the body. 
^Etiology.-The constitutional or habitual 
form of local cyanosis is generally associated 
with malnutrition and sluggish circulation; 
but it does not appear that mere weakness 
of the heart is sufficient to produce it, or is 
more than a contributory factor. The fault 
of circulation appears to lie in the arteries, 
and to consist either in habitual spasm, or 
possibly in want of tone. Imperfect nutrition 
of the walls of the capillaries may also, by 
retarding the flow, assist in producing stag- 
nation. In the more transient forms there 
would seem to be spasm of the smaller 
arteries, causing anaemia, on which capillary 
stagnation supervenes. The slighter forms 
occur chiefly in women, accompanying hys- 
teria or menstrual disturbances, or at the 
climacteric period. Such persons present an 
alternation of ' dead fingers ' with cyanotic 
circulation. The severe form known as Ray- 
naud's disease is attributable to more com- 
plete and sudden spasm of arteries, deep as 
well as superficial. In both these forms 
there must be some antecedent derangement 
of the vaso-motor nerves, dependent probably 
upon deeper-lying disturbances of the nervous 
system, probably central, which cannot here 
be discussed. 
Consequences.-The slighter form may 
cause no material change, or may lead to 
the same series of changes as seen in chil- 
blains, namely, necrosis of epidermis, with 
formation of imperfect bullae, and inflam- 
mation, ending possibly in ulceration. It is 
difficult to draw the line between these 
changes and those produced in healthy per- 
sons by frost-bite. In Raynaud's disease 
complete necrosis, causing symmetrical gan- 
grene of deeper parts, may result. 
Treatment.-Young persons, with a ten- 
dency to local cyanosis, should be well fed, 
warmly clothed, and encouraged to take 
vigorous exercise for short periods. Cod- 
liver oil is the most useful drug; but iron 
or arsenic may also have their place. When 
the condition is paroxysmal, rather than 
constant, large doses of sulphate of quinine 
(5 gr. twice or thrice daily) are sometimes 
extremely useful. In the spasmodic anaemia, 
followed by cyanosis, of hysterical women, or CIRCULATION, DISORDERS OF 
CIRRHOSIS 
347 
at the climacteric period, arsenic has ap- 
peared to the writer to be by far the most 
useful medicine. See Raynaud's Disease. 
J. F. Payne. 
CIRRHOSIS (icippos, yellow).-Synon. : 
Sclerosis; Fibroid Substitution; Fibroid 
Degeneration; Chronic Interstitial Inflam- 
mation ; Fr. Cirrhose; Ger. Cirrhose. 
Definition.-The term ' cirrhosis,' which 
was originally invented to describe a par- 
ticular state of the liver, has now acquired 
a more extended meaning, and is applied 
to similar morbid processes affecting other 
organs, though the name itself, derived as it 
is from the yellow colour of the liver in this 
disease, ceases to be properly applicable. Cir- 
rhosis may be regarded as a chronic non- 
suppurative inflammation affecting the in- 
terstitial, connective, and supporting tissues 
of the different organs, and not those by 
which the proper physiological function is 
performed. 
Anatomical Characters. - The process 
begins, after a more or less protracted hy- 
peraemia, by the appearance in the inter- 
stitial tissues, between the proper functional 
elements, of small lymphoid corpuscles or 
leucocytes, which are arranged in lines or 
tracts interpenetrating the affected organ. 
These corpuscles crowd the tunica adventitia 
of the small vessels, the lymph-spaces, and 
the cavities in which the connective-tissue 
corpuscles lie; and when present in con- 
siderable amount appear to the naked eye as 
narrow lines of a slightly translucent greyish 
material. This condition was formerly termed 
cellular hyperplasia of the connective tissue, 
and the corpuscles themselves were supposed 
to originate from proliferation of the connec- 
tive-tissue corpuscles. More recent researches 
have, however, rendered it probable that in 
inflammation the connective-tissue corpuscles 
remain passive and take no part in the forma- 
tion of new cells. The early stage of cirrhosis 
is perhaps therefore more correctly described 
as cellular infiltration of the connective tis- 
sue, the cells themselves being white blood- 
globules which have emigrated from the 
vessels, and their descendants. The amount 
of this cellular exudation varies very much 
in different organs in the different forms of 
the disease. In many cases of cirrhosis of 
the liver, and in the fibroid induration of the 
left ventricle of the heart, and of the pylorus, 
it is very considerable, and causes much 
increase in the bulk of the affected organ. 
In other instances, as in some forms of 
granular kidney, it may be extremely small, 
and the indurated fibrous tissue consists in 
great part of the withered remains of the 
vessels, ducts, &c. of the organ. 
The later stages of the process consist in 
the conversion of these tracts, which may be 
looked upon as closely analogous to ordinary 
granulation-tissue, into fibrous tissue. A 
more or less fibrillated intercellular substance 
appears ; the corpuscles diminish in number; 
the remaining ones become in part elongated 
and oat-shaped, and some may pass into true 
spindle-cells, or become stellate : in cirrhosis 
of the lung tracts of true spindle-cell tissue 
are often met with. In the liver, where 
much of this new tissue is often formed, 
numerous blood-vessels become developed in 
it; they are devoid of distinct walls, and con- 
sist merely of channels lined by endothelium. 
The fibrous tissue which is the final result of 
the whole process closely resembles ordinary 
cicatricial tissue; it is usually tough, dense, 
and imperfectly fibrillated, with a strong 
tendency to contract. Sometimes, especially 
in the suprarenal capsules, and less frequently 
in the liver, portions of it consist of a reticu- 
lated connective tissue. 
The effect of this series of changes on the 
proper physiological tissue of the organ is to 
cause its atrophy. This is partly due to the 
direct pressure of the new-growth, when it is 
formed in large quantities, but chiefly to the 
constriction of the contracting fibrous tissue 
and the consequent obliteration of the blood- 
vessels ; for even where, as in the liver, new 
vessels are developed, the original vessels of 
the organ become obliterated. The atrophy 
of the proper tissue of the organs appears to 
take place by a gradual process of granular 
and fatty degeneration, followed by absorption. 
Pathology.-If we now proceed to inquire 
into the nature and causes of these forms of 
chronic interstitial inflammation, the question 
arises whether this irritative hyperplasia of the 
connective tissue is primary, or whether it is 
the result of some preceding change in the 
parenchyma of the affected organ. 
In the analogous condition of sclerosis of 
the central nervous system it can hardly be 
doubted but that the latter is the case ; so 
also in cirrhosis of the lung, the interstitial 
changes in most cases are preceded by inflam- 
mation of the lining membrane of the bron- 
chial tubes and air-cells. In other organs, as 
the liver and kidney, the interstitial change 
is usually considered to be primary, but this 
cannot be looked upon as certain. 
The cause of cirrhosis seems always to be 
some form of protracted irritation of a low 
degree of intensity producing a chronic 
hyperaemia, functional or mechanical. As 
examples of this may be mentioned cirrhosis 
of the liver, which results from the congestion 
produced by spirit-drinking ; sclerosis of the 
grey matter of the cerebral convolutions after 
protracted maniacal excitement; cirrhosis of 
the lung, the result of prolonged inhalation 
of irritating dust in the various forms of 
grinders' and miners' phthisis ; the cirrhotic 
thickening of the pylorus in chronic catarrh 
of the stomach; and cirrhotic affections of 
the lungs and heart extending to these organs 
in chronic inflammation of their serous cover- 
ings. A mere passive congestion, however, 348 
CIRRHOSIS 
CIVIL INCAPACITY 
if long-continued, may cause a simple hyper- 
trophy or overgrowth of the interstitial con- 
nective tissue, and more or less induration 
in consequence. Still, it does not appear 
to have the same tendency to excite active 
proliferation and the formation of the con- 
tracting fibrous tissue characteristic of true 
cirrhosis. The exception to this rule is that 
we usually meet with a slight degree of the 
cirrhotic change in cases of ' nutmeg ' atrophy 
of the liver, due to prolonged passive conges- 
tion of the hepatic venous system. 
Chronic tuberculosis of the lungs often 
gives rise to extensive interstitial fibrous in- 
duration, the so-called fibroid phthisis. Vis- 
ceral syphilis also may produce changes 
which can hardly be distinguished from other 
forms of cirrhosis. Even the typical gum- 
mata originate in and are surrounded by 
tracts of cirrhotic induration; and in other 
cases, where true gummata are not formed, 
the only difference between syphilis and true 
cirrhosis is that in the former there is a 
greater accumulation of the new-growth at 
particular points, and a less general diffusion 
of it through the affected organ. Lastly, in 
some cases, as in the cirrhotic liver of 
hereditary syphilis, the two conditions cannot 
be distinguished. W. Cayley. 
CIRRHOSIS OF LIVER, LUNG, 
&c.- See Liver, Lung, &c., Diseases of. 
CIVIL INCAPACITY. - A chief 
cause of civil incapacity is mental weakness 
or disease, and it is one of the duties of the 
physician to aid in determining the existence 
and nature of such conditions. There is a 
kind of incapacity which is implied in the 
restriction of a person's liberty when he is 
placed under care in an asylum or other 
special place for treatment. The necessary 
information regarding this will be found in 
the article, Lunacy, Laws of. But the ques- 
tion of incapacity is more directly raised 
when it is proposed that a person should be 
declared unfit to exercise his civil rights, to 
require the shield of the law to prevent his 
being imposed on, and to obtain special pro- 
tection for his property. Medical evidence 
must be taken if it becomes necessary for a 
Commission of Lunacy to be issued by order 
of the Lord Chancellor. This is a proceed- 
ing which ought not to be adopted if it can 
properly be avoided. But until a person 
has been found lunatic by inquisition he is, 
though placed in an asylum under regular 
certificates, not debarred from exercising his 
rights in the disposal of his property. The 
acts of any person either in or out of an 
asylum may, however, be declared invalid if 
it can be shown that at the time they were 
performed the person laboured under such 
form of insanity as rendered him incapable 
of performing them rationally and without 
harmful consequences. On this principle any 
person may be found to have been incapable 
of contracting marriage, of executing a deed, 
contracting a debt, making a will, or giving 
credible evidence. The principle, it must be 
carefully noted, is not that the mere existence 
of insanity in the person performing them 
invalidates such actions, but that if the in- 
sanity has materially affected the character 
and quality of the actions they may be there- 
by invalidated. This is one of the most 
important principles that a medical jurist 
has to keep in mind, as it is not an infrequent 
mistake to suppose that a person is neces- 
sarily incapacitated from the performance of 
every civil act the moment he can be proved 
to labour under any condition to which the 
term insanity may be applied. Perhaps the 
case in which the validity of a civil act is 
most easily endangered by the existence of 
any form of insanity is the contract of 
marriage. This proceeding is supposed to 
so affect the whole relations of life, that 
almost any form of unsoundness of mind 
may be sufficient to interfere with that in- 
telligent and deliberate consideration which 
is essential to the giving of rational consent. 
The different kinds of mental disease will 
be found described elsewhere (see Insanity), 
and it is necessary that the practitioner, 
when dealing with medico-legal questions, 
should be fully acquainted with them. But 
it is chiefly important that he should dis- 
tinguish the two following classes: (1) dis- 
eased perversion of the mental faculties; 
and (2) weakness or enfeeblement of these 
faculties, resulting either from defective de- 
velopment, disease, or decay. The first class 
includes all kinds of insanity which are the 
result of active disease. These would include 
the simple forms of delirium, mania, melan- 
cholia, and monomania; as well as the 
similar primary conditions which are found 
in general paralysis, and other diseases which 
present maniacal, melancholic, or mono- 
maniacal symptoms. It is in this class that 
the special knowledge of the physician can 
be most successfully applied in aiding the 
administration of justice. In order to estab- 
lish the incapacity of a person said to labour 
under any of these forms of disease, it must 
be necessary that an experienced physician 
should not only be able to detect their cha- 
racteristic symptoms, but also to show that 
the performance of the duties or the exercise 
of the rights under consideration would be 
modified or obstructed by the existence of 
such disease. The second class includes con- 
genital imbecility, and all the forms of what 
is called chronic dementia-all those en- 
feeblements of mind which are sometimes 
the remaining effects of acute disease, some- 
times the concomitants of chronic disease, 
and sometimes only the mental phase of 
senile decay. Here, again, the information 
which may be communicated by the phy- 
sician must be of great importance. But in 
estimating the extent to which a condition CIVIL INCAPACITY 
349 
of mere mental weakness will disable a 
person from the performance of a certain 
class of actions, there so much special medi- 
cal knowledge is not required as is necessary 
in the consideration of more active disease. 
Marriage.-As has been already stated, the 
mere existence of any form of insanity in one 
of the parties may render a contract of mar- 
riage void. In one case which terminated in 
this manner, a man who had been insane, and 
when in that state had voluntarily contracted 
marriage, instituted the suit himself. 
Civil Contracts.-These may be held bind- 
ing although made by lunatics. If the person 
with whom a contract is made had no know- 
ledge that the person contracting was insane, 
and if no attempt was made to take undue 
advantage of him, the contract would be held 
good. 
Wills.-.A person is considered to be of a 
disposing mind-that is, capable of making a 
valid will-if he knows the nature of the act 
which he is performing, and is fully aware 
of its consequences. It is in regard to the 
making of wills that the law has carried 
out most thoroughly the principle, that the 
validity of an act ought to be maintained in 
cases of insanity, unless at the time the act 
is performed the state of mind of the agent 
can be shown to render him unfit to perform 
that particular act in a rational manner. 
Persons have made valid wills while inmates 
of lunatic asylums. And one will was held to 
be good though the testator had committed 
suicide within three days after its execution. 
The existence of delusion which has been re- 
garded by lawyers as of such importance in 
cases of alleged insanity does not invalidate 
a will; for it has been declared to be ' com- 
patible with the retention of the general 
powers of the faculties of the mind,' and to 
be ' insufficient to overthrow the will, unless 
it was calculated to influence the testator in 
making it.' On the other hand, a will may 
be invalidated on account of the existence of 
mental states which would not be regarded 
as insanity from either a legal or medical 
point of view. Drowsiness and stupor re- 
sulting from erysipelas or fever, extreme 
weakness from cholera or other disease, and 
failure of memory in old age, have been suf- 
ficient to render wills void. It frequently 
happens that a medical man is called on to 
be witness to a will. On such an occasion 
it is his duty to satisfy himself as to the tes- 
tamentary capacity of the testator. His sub- 
sequent evidence in regard to this, will, in 
case of dispute, be of almost decisive in- 
fluence, if he has taken proper means of 
forming an opinion. In all cases, therefore, 
where there may be a possibility of doubt, it 
is well to require the testator to show that, 
without extraneous aid, and without referring 
to the document itself, he remembers and 
understands all the provisions of the deed 
Evidence of the Insane.-Lunacy was, till 
a recent date, regarded by the law as in- 
capacitating a patient from giving evidence 
in court. But according to the much more 
extended signification which the term lunacy 
has received, it now includes states of mind 
which are looked on as compatible with testi- 
monial capacity. Where the judge is satis- 
fied that the lunatic understands the obliga- 
tion of an oath, and can give a rational 
account of such things as happen before his 
eyes, the evidence maybe admitted. But the 
weight to be attached to such evidence will 
still depend on the extent to which it fulfils 
the conditions commonly required to con- 
stitute credibility. It has been held, how- 
ever, that when a person has suffered from 
an attack of insanity between the occur- 
rence of the transaction and the time he 
tenders his testimony, his evidence cannot be 
admitted. 
Management of Property.-Where persons 
are supposed to be unable, from unsoundness 
of mind, to undertake the management of 
their own property, it may be necessary that 
they should be placed under the protection of 
the Court of Chancery ; but this proceeding 
is not usually had recourse to unless there is 
urgent necessity, or a strong probability that 
the person's incapacity will be permanent. It 
is consequently resorted to chiefly in chronic 
or congenital cases where there is no room 
for doubt as to the mental condition of the 
individual; and in cases of recent insanity, 
where it is necessary to have recourse to an 
asylum for the protection of the individual, it 
may also be necessary to obtain protection 
for his property by the aid of the Court of 
Chancery. In giving evidence or framing a 
statement in such a case, it is important, if 
incapacity is to be proved, to show that the 
individual has been found, when placed in 
circumstances requiring such capacity, unable 
to perform the acts which the management 
of property necessitates. In cases of active 
insanity it is especially required to show, not 
merely that there is delusion or other symp- 
toms of insanity, but that the insanity is of 
such a nature as specially to disable the per- 
son from duly performing the duties which 
would be required of him. Difficulties most 
frequently occur in cases of imbecility and 
dementia; but the verdicts in such cases, 
when disputed, will generally be found to rest 
rather upon the impression produced by evi- 
dence of the actual behaviour of the individual, 
than upon the mere medical view of his 
mental condition. The most effectual aid 
that the medical witness can render in such 
cases, is to show whether there are or are not 
such peculiarities in the conduct of the per- 
son under inquisition as are known to be 
characteristic of imbeciles or demented per- 
sons. In undisputed cases, where the duty 
of the medical man consists merely in making 
an affidavit, there is no special difficulty to be 
encountered. Brevity, scrupulous accuracy, 350 
CIVIL INCAPACITY 
CLIMATE 
and attention to the fact that such unsound- 
ness of mind as involves incompetency to 
manage property must be established, are 
the most important requirements. A person 
found by the court to be incapable is placed 
under the control of a ' committee of the 
person,' and the property under a ' committee 
of the estate.' In Scotland, proceeding by 
petition to the Court of Session, or, in the 
case of small estates, to a sheriff, for the 
appointment of a curator bonis, takes the 
place of the English inquisition. The chief 
peculiarities of the Scotch process are that 
it is cheaper, more easily effected and more 
easily annulled, and that it does not affect the 
person of the lunatic. The functions of the 
curator correspond to those of the committee 
of the estate in the English court. The 
Scotch procedure for the appointment of a 
guardian of the person was virtually in des- 
uetude until the passing of a recent statute 
(31 & 32 Viet., c. 100). Under this Act a 
brieve for the cognition of an alleged lunatic 
is issued from Chancery, and tried before a 
judge of the Court of Session and a special 
jury. The procedure is similar to that of 
jury trials in other civil causes in Scotland, 
and both medical and other evidence must be 
produced. If the person so cognosced be 
found ' furious, fatuous, or labouring under 
such unsoundness of mind as to render him 
incapable of managing his affairs,' his person 
is placed under the guardianship of the 
nearest male relative found competent. 
Drunkenness.-This condition is not held 
to deprive a man of civil capacity unless it 
has at the time rendered the individual un- 
conscious of what he was doing. 
John Sibbald. 
CLAP.-A popular name for gonorrhoea. 
See Gonorrhoea. 
CLAREMONT, in Cape Colony.- 
See Africa, South. 
CLAVUS HYSTERICUS (clavus, a 
nail).-An acute pain, often associated with 
hysteria, but occurring also in other condi- 
tions, which is felt in a localised point in the 
head, and is compared by the sufferer to the 
sensation that might be produced by a nail 
being driven into the part. See Hysteria. 
CLIMACTERIC (K\inaKrf]p, a step of a 
ladder).-This word, which properly signifies 
' by degrees,' was originally employed to 
indicate certain epochs or periods in the life 
of an individual, which were looked upon as 
critical, and at which the body was supposed 
to have undergone a complete change, so 
that it had become entirely renewed in its 
structural elements. The years in which 
these epochs terminated were called climac- 
teric years-anni climacterici-and their 
number was variously estimated. Thus, 
some only recognised three climacterics; 
the Greek physiologists held that there were 
five, ending at the seventh year, the twenty- 
first (7 x 3), the forty-ninth (7 x 7), the sixty- 
third (7 x 9), and the eighty-first (9x9); 
others made them multiples of seven or nine, 
or multiples of seven by an odd number. 
Most regarded the sixty-third year as the 
grand climacteric, but the Greeks recognised 
two grand climacterics, terminating respec- 
tively at the sixty-third and eighty-first 
years, and this special denomination was 
given because there was little, if any, pro- 
spect of life being extended beyond these 
periods. At the present day the word ' cli- 
macteric ' has lost much of its original mean- 
ing, and is generally applied to certain times 
of life, without any reference to numbers of 
years, at which marked physiological or 
developmental changes occur, such as the 
period of puberty, or that of the cessation of 
menstruation. 
A particular climacteric disease has been 
described, which is said to occur either about 
or subsequent to the sixty-third year or grand 
climacteric, and supposed to be distinct from 
the natural decay and degeneration which 
takes place in advanced life, inasmuch as 
recovery often ensues. It is stated that the 
complaint comes on suddenly, but advances 
insidiously, the symptoms being at first loss 
of flesh and weakness, followed by loss of 
appetite and dyspeptic symptoms with a 
white tongue, which are regarded as sympa- 
thetic, sleeplessness or disturbed and unre- 
freshing sleep, constipation, pains in the head 
and chest, a frequent pulse, swelling of the 
legs, and an emaciated or bloated appearance 
of the face. The urine does not present any 
abnormal characters, and most of the viscera 
seem to perform their functions properly. 
Whether there is any independent disease 
deserving this special denomination is, in the 
writer's opinion, extremely doubtful. 
Frederick T. Roberts. 
CLIMATE.-Formerly the word climate 
(from the Greek word kKIvv, I incline) was 
a term of astronomical or mathematical geo- 
graphy, which implied a portion or zone of 
the earth's surface comprised between two. 
lines parallel to the equator, and measured by 
the length of time during which the sun there 
appears during the summer solstice, that is, 
by the sun's inclination. The space between 
the equator and the pole was divided into 
half-hour climates, in which the length of 
each day increased by half an hour; and also 
into monthly climates. This unequal division 
of each hemisphere is now replaced by a 
division of the interval between the equator 
and the poles into ninety degrees, which con- 
stitute what are called degrees of latitude, 
and the word ' climate ' has received a more 
extended application. 
By climate is now understood those con- 
ditions of heat, moisture, atmosphere, wind, 
soil, and electricity, which impress certain CLIMATE 
351 
conditions, uniform even when apparently 
irregular, on given portions of the earth's 
surface, and which modify, also in a uniform 
manner, vegetable and animal life. 
Classification.-Climate, when thus in- 
terpreted, is still principally dependent on 
astronomical facts, on the sun's position or 
inclination with regard to the earth, and on 
the amount of heat it supplies to different 
portions of the surface of the latter. Climate 
may be studied generally and locally. The 
division of the earth's climates is necessarily 
arbitrary, and many different classifications 
have been proposed. The most simple is 
that which recognises three principal kinds 
of climate, each susceptible of subdivision, 
viz.: warm climates from the equator to 35° 
lat.; temperate climates from 35° to 50° or 
55° lat.; cold climates from 50° or 55° to the 
pole. As subdivisions we may recognise 
equatorial, tropical, sub-tropical, sub-polar, 
and polar climates; and also insular and 
maritime or moist climates, and continental 
and mountain or dry climates. 
1. Warm Climates.-Warm climates, 
extending from the equator to 35° lat., that 
is, 12£° beyond the tropics, comprise nearly 
all Africa and its islands, South Asia, most 
of the islands of Polynesia, and the portions 
of North and South America comprised be- 
tween California and the north of the La 
Plata territory. In the equatorial regions the 
medium temperature for the year is from 80° 
to 84° F., the min. being 54°, the max. 118°. 
Near the equator the annual mean tempera- 
ture decreases slowly as we recede from it, 
the decrease not amounting to more than 
2° F. for the first 10° lat. The difference of 
temperature during the day is slight, but much 
greater during the night, owing to radiation. 
The general variations of the barometer are 
slight, but the periodical or diurnal variations 
are very marked. It ascends and descends 
regularly twice in the twenty-four hours. It 
ascends from 4.13 a.m. to 9.23 a.m., and 
descends until 4.8 p.m., ascending again until 
10.23. Electrical phenomena are very de- 
cided. The rainfall is variable, but 40 inches 
may be given as a mean. It is generally 
supposed that heat is greatest at the equator, 
and diminishes as we recede from it; but 
both observation and astronomical induction 
lead to the conclusion that not only the 
maximum of temperature in warm climates 
is attained at or near the tropics, but also 
the highest annual mean. The countries in 
which the highest degree of heat is known 
to be attained are near the tropic of Cancer, 
as, for instance, the banks of the Senegal, 
the Tehama of Arabia, and Mehran in Balu- 
chistan. Moreover, the snow-line, or the 
line of perpetual snow, is higher at the tro- 
pics than at the equator. In the Bolivian 
Andes, near the tropic, it is 17,000 feet, 
whereas in the Ecuador Andes, on the 
equator, it is only 16,000 feet. These facts 
are partly explained by the unequal progress 
of the sun after the equinox in its course 
towards the tropic. In the first month it 
passes through 12° of latitude, in the second 
month through 8°. At the end of the second 
month, therefore, it is 20° from the equator, 
and there remain only 3|° to be traversed in 
the third month. The sun receding from 
the tropic at the same rate at all places 
between 20° and 23^° of latitude, the solar 
rays during two months fall at noon either 
perpendicularly or at an angle which deviates 
from a right only by 3|° at most. 
Another cause which tends to diminish 
heat in the regions near the equator is the 
prevalence of rain. For about five degrees 
north and south of the equator, in the region 
of the equatorial calms, there are few con- 
secutive days in the year without rain. The 
principal cause both of the calms and of the 
rains has been attributed to the meeting in 
the upper atmospheric regions of the trade 
winds, north and south. They neutralise 
each other, and precipitate the vapour they 
hold in solution. 
Regions that lie between 5° and 10° of 
latitude have usually two rainy and two dry 
seasons. The greater rainy season occurs 
when the sun in its passage to the nearest 
tropic passes over the zenith, lasting from 
three to four months. The lesser rainy sea- 
son occurs when the sun on its return from 
the nearest tropic approaches the parallel of 
the place. The rains then only last from six 
weeks to two months, and are much less 
abundant and continual. Countries more 
than 10° or 12° from the equator have only 
one rainy and one dry season; the first 
begins when the sun approaches the nearest 
tropic, and ends some time after, when in its 
course from the tropic it has passed the 
parallel of the place. It lasts from four to 
six months. Local conditions may modify 
the course of the dry and wet seasons, as is 
the case in India, where the dry and rainy 
seasons depend principally on the monsoons. 
The amount of rain that falls in a short time 
within the tropics is very great, much more 
so than in more northern regions, but these 
heavy rains do not last continuously, as is 
supposed. Days of continued rain, even in 
the rainy season, are rarer than in the north. 
Still, heavy rains are apt to cause great 
inundations, and to cover large extents of 
low or level country with water, producing 
swamps and marshes, very injurious to 
health. 
In the vicinity of the tropics there is a 
belt, extending over several degrees of lati- 
tude, where it seldom rains. This rainless 
tract is precisely the region which has been 
already mentioned as that of greatest heat. 
These belts of rainless regions, extending 
around the globe on each side of the equator, 
may be said to separate the countries which 
lie on each side of the equator from the 352 
CLIMATE 
temperate zones. Thus in Africa the rains 
cease on the southern border of the desert 
of Sahara at about 1G° N., and begin again at 
28° N. On the banks of the Nile the rain 
ceases about 18° or 19°, to begin again between 
28° and 29°. The Tehama, or low coast of 
Arabia, is all but rainless. This rainless 
tract crosses Asia as far as China, where there 
is no rainless region, owing, probably, to the 
fact that all parts of China between 22° and 
30° N. lat. are traversed by high mountain 
chains. 
The influence of warm climates impresses 
certain peculiarities on the people who in- 
habit them. They are the abode of the 
Ethiopian and Mongolian races of mankind, 
and appear to have impressed the same 
characteristics, in a minor degree, on the 
Caucasian races that inhabit them : a dark 
complexion and black hair. The inhabitants 
of these countries are indolent and apathetic. 
The functions of the skin and liver are pe- 
culiarly active, a circumstance which exposes 
them to severe disease of these organs. The 
digestive functions are sluggish, and the 
nervous system is alternately excited and 
depressed. Remittent and intermittent fevers, 
dysentery and yellow fever, are common. 
During the dry season disease tends to as- 
sume the ataxic, during the rainy season the 
adynamic form. Pulmonary consumption is 
frequently met with in the towns, in contra- 
diction to received opinions. 
2. Temperate Climates.-Temperate 
climates may be said to occupy the zones 
of the earth's surface comprised between 35° 
and 50° or 55° lat. They comprise Southern 
and Central Europe, with its islands; the 
parts of Asia which extend between the Black 
Sea and the Mediterranean on the west, and 
Japan on the east; the greater part of North 
America; a part of Chili and La Plata and 
Patagonia in South America. The mean 
temperature may be stated at from G0° to 50°. 
The climates in which the mean temperature 
is from 60° to 68° are often spoken of as 
temperate, but in reality they approximate 
closely to warm climates. The four seasons, 
winter, spring, summer, and autumn, are 
well-marked, but are very variable both as 
to barometrical and thermometrical con- 
ditions. The mean temperature in the cen- 
tral regions is, for winter 38°, for spring 51°, 
for summer G8°, and for autumn 53°. The 
regions which are near the south and north 
limits of the northern temperate zone ap- 
proximate to the meteorological characters 
of the warm and cold climates respectively. 
The periods of the year when storms, rain, 
and general versatility of meteorological phe- 
nomena are principally observed correspond 
with the vernal and autumnal equinoxes. 
The influence of a temperate climate on 
the human organisation is salutary, extremes 
of heat and cold being both trying. Thus 
the healthiest climates of the world's surface 
are found in this zone. Intense heat, or even 
moderate heat if persistent, throws a physio- 
logical strain on the liver, skin, and digestive 
system, and renders mankind prone to severe 
and fatal diseases of these organs. Intense 
cold throws a physiological strain on the 
lungs and kidneys, and exposes them also to 
severe and fatal disease. The healthiest 
temperate climates are those in which the 
winter is not very cold and the summer is 
not very warm, and in which, consequently, 
there is no great or continued strain on any 
one class of organs. The diseases of tem- 
perate regions are those that are the best 
known, as their study and description con- 
stitute the foundation of pathological science, 
ancient and modern. 
The climate which, perhaps, the best de- 
serves the appellation of temperate is that 
of the Mediterranean basin. The winters are 
not severe on any part of its north shores, 
and the summers are not intensely hot on 
its south shores ; at least the heat falls short 
of that of the tropics. There are many con- 
ditions of physical geography which conduce 
to this result. The north shores are pro- 
tected from north winds by the ranges of 
high mountains of Southern Europe which 
skirt them, and the south shores are in close 
proximity to the hot, rainless'tract of Northern 
Africa-the desert of Sahara, which favour- 
ably modifies winter temperature. Moreover, 
the Mediterranean is a warm sea, but few 
cold rivers of considerable size flowing into 
it from the north, a fact which increases the 
temperature on its shores and islands. 
3. Cold Climates.-Cold climates com- 
prise the regions which extend from 50° to 55° 
lat. to the poles. They may be subdivided 
into cold, with a mean of from 50° to 40°; 
very cold, with a mean of from 40° to 32°; 
glacial, with a mean below the freezing-point. 
In the austral hemisphere the zone contains 
but little known land, although the existence 
of an antarctic continent is suspected; in the 
northern hemisphere it comprises, in Europe, 
the north of Scotland, Denmark, Sweden, 
Norway, Iceland, Finland, Lapland, Northern 
Russia, Spitzbergen, Nova Zembla; Northern 
Asia, and some of its large plains below 50° 
lat., Siberia, and Kamtchatka; in America, 
Canada, including some regions below 50°, 
the northern lands and islands of Hudson's 
and Baffin's Bays, and Greenland. In this 
zone the decrease of the mean temperature 
is much more rapid as we recede from the 
equator, than it is in th 6 tropical regions. 
Thus from the equator to 20° lat. the varia- 
tion of the mean temperature is not more 
than 7° or 8°, whereas the variation between 
55° and 75° lat. amounts to from 22° to 27°. 
The coldest region of the globe is not, it 
would appear, at or near the pole, but at 
about 80° lat., or 10° from the pole, north of 
Behring's Straits: the cold of the glacial 
climates has been exaggerated. At the lati- CLIMATE 
353 
tudes of from 70° to 78°, the extreme limit 
of human habitation, the mean annual tem- 
perature is between 19° and 17°, i.e. 13° tc 
15° below the freezing-point. I he extreme 
of cold registered, however, reaches a hundred 
degrees or more below the freezing-point. 
Owing to astronomical conditions there is 
great disproportion between the length of 
the nights and of the days at different 
seasons of the year. In the more northern 
regions, for several months in the winter the 
sun never appears above the horizon, and in 
the summer for several months the sun never 
disappears below it. Spring, during which 
the extreme cold is mitigated, lasts but a 
very short time, and is succeeded by summer, 
which is in its full strength in June and July. 
Temperature rises rapidly from 35° to 55° 
and 60°. In some northern localities it rises 
to 86° or 90°. Under the influence of the 
prolonged or persistent days, and of the in- 
creased temperature, the vegetation peculiar 
to each locality passes through all its phases 
with extreme rapidity. Towards the end of 
July rain and fog reappear, and are followed 
by snow and intense cold, the highest ex- 
pression of which is in January and February. 
The barometrical changes are the reverse of 
what obtains in the tropics. Above 60° lat. 
the diurnal or periodical changes are scarcely 
perceptible, whereas general or occasional 
variations become more marked as we ap- 
proach the pole. Electrical phenomena be- 
come less marked, and above 68° lat. they 
are scarcely perceptible, with the exception 
of the aurora borealis. The winds which 
predominate are the N.E. and S.W., and 
they change rapidly from one point of the 
horizon to the other, and thus frequently 
occasion tempests which extend over con- 
siderable areas. The quantity of rain that 
falls in cold climates is much less than in 
the tropical and temperate, with some ex- 
ceptions. Between 60° and 90° lat. it only 
amounts to a few inches, and falls princi- 
pally in the form of snow. 
The influence of cold climates is shown on 
the inhabitants of these countries, who vary 
much in stature, and possess a vigorous con- 
stitution, a sanguineous temperament, great 
muscular development, active digestive func- 
tions, and sluggish nervous powers. Not- 
withstanding the severity of the climate, they 
generally succeed in preserving health, and live 
to old age, presenting few diseases referable 
to climatic influences. They are, however, 
subject to ophthalmia and amaurosis, owing 
to the reflexion of light from the snow in the 
polar regions, and to scrofula and scurvy, 
the result of a poor and incomplete dietary. 
Agues and intermittent fevers from marsh 
influences are rare, and not severe, and dis- 
appear entirely as we approach the pole. 
Continued fevers are met with, but seldom if 
ever epidemically. 
4. Insular Climates.-Insular climates 
present important peculiarities. The tem- 
perature of the sea is more equable than that 
of the land. Owing to the action of currents, 
and to the circulation of its waters under the 
influence of heat, its superficial temperature 
is warmer in winter and cooler in summer 
-more equable-than that of the land. It 
has thus a tendency to warm in winter and 
to cool in summer the island which it sur- 
rounds. Moreover, there is constantly watery 
vapour arising from the sea, which extends 
to island atmospheres, veils the sky more or 
less, shields the surface from the ardour of 
the sun in summer, and prevents great radia- 
tion both in summer and in winter. Thus 
it is that the climate of all islands is more 
equable than that of continents. This fact is 
more especially recognisable in the climate 
of the British Isles, which is also modified- 
rendered warmer and moister-by the waters 
of the Gulf Stream impinging on their 
shores. The warm Gulf Stream, commenc- 
ing in the tropics, in the Gulf of Mexico, 
passes northwards along the shores of N orth 
America, crosses the Atlantic to the south of 
Newfoundland, and strikes the shores of the 
British Islands, of Norway up to Cape North, 
of Holland, and of France; every where raising 
temperature and the annual mean. 
5. Maritime Climates.-Maritime cli- 
mates participate in these influences: tem- 
perature is more equable, warmer in winter 
and cooler in summer, on the shores of seas 
and oceans than it is inland. Owing to this 
cause most of the winter sanitaria have 
been chosen in islands or on the coasts of 
oceans and seas : such as Hastings, Ventnor, 
Bournemouth, Torquay, Funchal, Malaga, 
Cannes, Nice, Mentone, Naples, Salerno, and 
Algiers. 
6. Continental Climates.-Continental 
climates exhibit conditions the reverse of 
those which obtain in maritime climates. 
The tendency is to cold winters and warm 
summers, owing principally to the absence 
of the equalising influence on temperature 
of large masses of water. A very short dis- 
tance from the sea is sufficient to establish 
this difference. Thus the central parts of 
France are very much warmer in summer 
and colder in winter than the coasts of Nor- 
mandy and Brittany. But it is when we 
reach the centre of continents - Rqssia, 
Central Asia, Central America-that the 
difference is the most marked. 
7. Mountain Climates.-As we rise 
above the level of the sea, we meet with twTo 
important meteorological conditions. The 
air becomes more and more rarefied, and the 
heat diminishes, independently of the more 
or less obliquity of the sun's rays. The 
higher we rise above the sea-level the more 
the air is rarefied, and the more the degree 
of heat due to the solar rays diminishes. 
We arrive at last, even at the tropics or the 
equator, at a height, variable according to 354 
CLIMATE 
latitude, where the sun's heat is insufficient 
to melt the snow. This is termed the snow- 
line. Mountains attract clouds and watery 
vapour, and the coolness of their atmosphere 
causes the precipitation of the vapour in the 
form of rain or snow. Thus, mountains, 
mountain-ranges, and the glaciers they con- 
tain, are the principal cause and origin of 
rivers. 
The influence of mountain climates, not- 
withstanding the clouds, fogs, and rain which 
characterise them, is proverbially a healthy 
one, owing to the purity of the air, the 
shelters found in the valleys, and, perhaps, 
to the sparseness of population. They have 
of late been much recommended for phthisis. 
The conditions above mentioned, together 
with sunshine to a limited extent, are quite 
sufficient to account for the rarity of phthisis 
amongst their inhabitants, and for the im- 
provement of the phthisical who resort to 
them. 
Soil modifies climate considerably. Wet 
and marshy soils are cold, engendering fog 
and mist. Sandy, dry, well-drained soils are 
comparatively warm. All sandy plains are 
warm in summer and cold in winter. 
Such are the features which characterise 
the climates of the terrestrial globe, gener- 
ally. Each locality, however, each moun- 
tain, plain, and valley, each city, village, and 
house has a climate of its own, modified by 
all the meteorological elements which we 
have successively considered. To discover 
what each climate is, we must study care- 
fully the meteorological conditions and in- 
fluences which we have rapidly surveyed in 
their application to it. 
Isothermal Climates.-Owing to the un- 
equal influence of the different elements 
that constitute climate, the annual mean 
temperature of regions occupying the same 
latitude on the earth's surface is very vari- 
able. Hence the above name has been given 
to the regions in which the annual mean is 
the same. The study of a map on which the 
isothermal lines are marked is an instructive 
illustration of the facts above described. 
Thus it will be seen at a glance that the 
limit of constantly frozen ground in the 
central plains of Asia and in the northern 
plains of America is below 54°, which is the 
latitude of York ! 
The General Influence of Climate.- 
The vegetable and animal worlds, including 
man himself, have been modified in essential 
characters by climatic conditions. The study 
of its influence on their vitality and organi- 
sation opens out a wide field to the observer. 
This study leads to the conclusion that geo- 
logical periods of time have been necessary 
to impress on terrestrial life, be it vegetable 
or animal, the characteristics observed now 
or formerly in the climates of different regions 
of the earth. The current of modern research 
is strongly directed to the elucidation of the 
influence of climate on life during such geo- 
logical periods. The investigations of Darwin 
and his followers may be named as the most 
remarkable and important illustration of this 
fact. We may also mention the researches 
of modern philologists, which have proved, 
by the study of languages and their roots, 
that most of the nations of modern Europe 
have descended from the same Aryan parents 
as the inhabitants of the Indian peninsula. 
Climate, in the course of time, has so modi- 
fied them as apparently to produce different 
races. For such a change to take place geo- 
logical lapses of time are certainly required. 
Our earliest records, dating back several 
thousand years, show these races, such as 
they are now, quite as distinct. In these 
days the Aryan races of Europe cannot rear 
their children in the climate of India, where 
their Hindoo relatives thrive and propagate 
their species. In Palestine and Egypt the 
biblical records, those of the Pharaohs, and 
those of Nineveh and Babylon, show these 
regions to have been inhabited, several 
thousand years ago, by nations and tribes 
presenting precisely the same race charac- 
teristics as those that now inhabit them. 
During the historical period, the races of 
Europe have in vain endeavoured to colon- 
ise the valley of the Nile ; for they have not 
been able to propagate their species, and have 
died away, leaving the valley of the Nile to 
its ancient inhabitants. Their children can- 
not withstand the heat of summer. On the 
north-eastern shore of Africa, the Algeria of 
the present, history presents the same record. 
The Romans and the Visigoths occupied its 
plains for centuries, continually recruiting 
their colonies from the mother-countries; 
and yet, except in the mountains, all trace 
of their presence has disappeared. They 
could not rear their children so as to occupy 
the land of the Arabs. What lengthened 
periods of time must have elapsed to so pro- 
foundly modify races deriving their origin 
from a common parentage, that they can no 
longer live and propagate their species in the 
same climates! 
Therapeutical Applications.-The thera- 
peutical application of many of the above 
facts is contained in the facts themselves. 
Reasoning suffices to deduce the therapeu- 
tical law, and experience proves the correct- 
ness of the deduction. Only a very brief 
summary can here be given. See also 
Climate, Treatment of Disease by. 
Firstly, it is clear that if a local climate 
produces injurious effects on the health of its 
inhabitants, or of visitors, the latter should 
leave it, and the regular inhabitants, who 
cannot leave it, should endeavour by every 
possible means to modify the pernicious 
climatic influence to which they are exposed, 
and to partially escape from its action. This 
rule may be illustrated by the influence of 
confined mountain valleys in producing CLIMATE 
355 
goitre, and of marshy districts in producing 
intermittent fevers. The principle applies 
to all local climates which exercise a per- 
nicious influence of any kind on the human 
organisation. When possible the climate 
should be abandoned; if that is impossible, 
its pernicious influence must be combated by 
every possible hygienic and therapeutical 
means. 
The injurious effects which extreme cli- 
mates exercise on the human economy- 
warm climates on the abdominal and cere- 
bral organs, cold climates on the thoracic- 
point to change of residence as an important 
therapeutical agent, the value of which is 
only beginning to be understood. Our naval 
and military surgeons have done much to 
clear up this branch of therapeutics, as re- 
gards the diseases of tropical regions. Thus 
chronic affections of the liver and intestines, 
incurable, n a warm climate, often become 
quite curable if the patient is transferred to 
a temperate region or to a mountain eleva- 
tion in the tropics, which reproduces a tem- 
perate climate. 
Inversely, persons suffering from diseases 
of the respiratory organs, so common in 
damp temperate climates like those of France, 
England, and Holland, find relief by migrat- 
ing, especially during winter, to warmer 
regions of the earth's surface, w'here they 
escape from the influences which have proved 
so detrimental to them. Thence the yearly 
increasing exodus of persons suffering from 
chronic laryngitis and bronchitis, from bron- 
chial asthma and from phthisis, from the 
north of Europe to the south. 
The increased facilities of locomotion, by 
rail and by steam, have thus opened out, as 
it were, a new and important branch of 
therapeutics, that of the application of cli- 
mate to the treatment of disease. 
J. Henry Bennet. 
CLIMATE, ^Etiology of.-See Dis- 
ease, Causes of. 
CLIMATE, The Treatment of Dis- 
ease by.-Though we can scarcely say with 
accuracy that change of climate is a specific 
for disease, yet much can be effected by it 
in relieving symptoms, and in assisting the 
recuperative powers of the organism by thus 
improving the general health. The diseases 
in which change of climate has been found 
of value will be enumerated below, with a 
short notice of various climates. Here we 
may notice the rationale of the benefit to be 
derived from such change. 
Change of climate, we must premise, is 
only a relative term. It does not necessarily 
involve the idea of removal to a great dis- 
tance from the patient's home. A few miles' 
journey from the town to the country, from 
inland to the seashore, from the plain to the 
mountain, often suffices to produce marked 
results. One use of climate being to expose 
the organism to the effects of contrast, the 
element of distance comes in most when we 
wish to make the contrast greater; for in- 
stance, in ordering change from a cold to a 
warm climate or vice versa. 
The therapeutic elements of most import- 
ance in any climate are: (1) pure air, free from 
dust and organic particles, or excessive 
damp; (2) abundance of sunshine, without 
excessive heat, so that much time can be 
spent in the open air; (3) a temperature 
without extremes, so that the body is not 
exposed to the risk of great variations of heat 
and cold-equability; (4) absence of violent, 
very cold, or very hot winds, at any rate of 
long duration (in this is involved the element 
of local shelter). 
These four elements should be present in 
each of the subdivisions of climates which 
a therapeutic classification renders neces- 
sary, namely, climates of : (1) the seashore ; 
(2) mountains ; (3) inland wooded districts; 
and (4) the open sea. 
The epithets ' moist ' and ' dry,' which are 
applied to climates, are merely relative, and 
depend on local peculiarities of rainfall, soil, 
&c., as well as to some extent on season; and 
the essential differences between the climate 
of the seashore, the woodland, and the 
mountain remain everywhere the same. We 
shall say a few words about each of these, 
with the indications for their use. The 
climate of the open sea will be referred to in 
speaking of sea voyages. 
1. Climate of the Seashore.- The 
special peculiarities of this variety of climate 
are that the air is saturated with moisture, 
except when dry land winds prevail; it is 
dense, and, as a rule, therefore, bulk for bulk, 
contains more oxygen than air of any higher 
level; its density is liable to great and 
frequent but regular variations, which in- 
crease the activity of the circulatory and 
respiratory organs, and thus favour their 
functional activity; it is more equable; and, 
lastly, it contains saline particles in suspen- 
sion. 
According to Beneke, sea air cools the 
body relatively more quickly than mountain 
air, and thus hastens more the processes of 
tissue-change. Hence, the seaside should be 
ordered where we wish for a highly stimulat- 
ing effect, as in persons of scrofulous ten- 
dency, in chronic succeeding acute diseases, 
or in the later stages of convalescence from 
the latter, in convalescence from surgical 
operations, or in some surgical diseases 
where we wish to accelerate tissue-change, 
without exertion on the patient's part. On 
account of the equability of the climate, some 
patients who cannot bear great changes of 
temperature do well at the seaside. Persons 
suffering from overstrain, mental or bodily, 
with a fair digestive power, and not liable 
to nervous irritability, may also be sent 
there. 356 
CLIMATE, THE TREATMENT OF DISEASE BY 
2. Mountain Climates. - Mountain 
climates are distinguished from seaside 
climates by the lower density of their at- 
mosphere ; their lower and less equable tem- 
perature ; by less humidity, though, owing 
to local winds, mist and cloud often form; 
and by relatively lower night-temperatures 
in clear weather, owing to the dryness of the 
air, and consequent great radiation. They 
are cooler also than the inland climates of 
level districts, and this coolness tends to 
some extent to diminish the rarefaction and 
increase the density of their air. 
The general action of mountain air is to 
produce a freer circulation of the blood and 
greater vascularity of the lungs, owing to 
deeper and more frequent inspirations and 
greater ease of bodily movement. Owing to 
the cooling of the body by the lowered tem- 
perature more food is required, the appetite 
improves, and the body becomes better 
nourished and gains weight. 
The intensity of the effect is, broadly 
speaking, directly as the height. The term 
' mountain climate ' is applied in medical 
parlance to elevations in Europe of from 
1,500 to 6,000 feet, though in South America 
patients have been sent as high as 10,000 
feet, or higher. 
Mountain climates are indicated: (1) in 
cases of hereditary tendency to phthisis in 
young persons with narrow, shallow chests, 
who are growing too fast; also in young 
scrofulous patients. (2) In chronic phthisis 
and pneumonia; remembering, however, that 
phthisis occurs at all elevations. The cool- 
ness of the mountain air in the height of 
summer is an important element in phthisical 
cases, which always suffer from great heat. 
(3) As a tonic and restorative in persons 
suffering from over-work in business or 
literary pursuits, and who have no real or- 
ganic disease. (4) Generally to complete the 
convalescence from acute diseases of indi- 
viduals not past middle life, with a fair 
amount of muscular power and bodily activity. 
(5) As a prophylactic against hay-fever, 
cholera, and other infectious diseases. Moun- 
tain climates are not advisable in cases of 
chronic bronchitis, heart-disease, emphysema, 
Bright's disease, chronic rheumatism, haemo- 
ptysis, nor for aged persons. 
3. Climate of Inland Wooded Dis- 
tricts.-The climate of wooded districts 
(elevations above 1,500 feet are not here 
referred to) is peculiar in several respects. 
It has a temperature lower than that of the 
surrounding country-on the average 3° F.- 
during the hours of daylight; the tempera- 
ture is also more equable. The relative 
humidity is higher (9'3 per cent.) in summer 
than in the less wooded country, and hence 
there is greater liability to rain and mist. 
It also affords greater protection and shelter 
against winds than other climates. 
The general effect of woodland climates, as 
may be deduced from the above, is sedative 
and tonic. They may be advised in chronic 
bronchitis, emphysema, heart-disease, and in 
hypochondriasis, hysteria, and other nervous 
affections where tranquillity and subdued 
light are of importance ; also in the earlier 
stages of convalescence from acute disease 
when sea or mountain air is too stimulating. 
In bronchitis pine-woods should be selected, 
and in heart-cases level walks are essential, 
unless exercise be deliberately ordered for 
certain kinds of cardiac disease in the form 
of graduated hill-climbing. 
4. Ocean Climates: Sea Voyages.- 
Voyages have been much recommended in 
the treatment of phthisis in its early stages, 
with a view to enable the invalid to spend 
much time in an exceedingly pure and fairly 
equable atmosphere, and to secure a sufficient 
amount of bodily movement without great 
fatigue. 
The drawbacks to the sea ought to be pro- 
vided against as far as possible, although 
certain of them from their very nature must 
be endured. The principal of them are the 
impossibility of escape from bad weather, 
and the confinement, perhaps, to ill-ventilated 
cabins, when such occurs; the absence of 
sufficient light and air below decks, the latter 
being felt very much at night; want of variety 
in the diet after a certain time, and in many 
instances of fresh food, milk, &c.; monotony 
in society and occupations; and, lastly, the 
inconveniences arising from crowding of the 
maindeck with hen-coops, sheep-pens, &c., 
and in steamers from the smoke of the 
engines, and the smell and vibration of the 
machinery. 
The routes generally recommended to in- 
valids are chiefly: (1) to Australia, 90 days in 
a sailing vessel, 45 in a steamer; (2) to the 
Cape of Good Hope, 20 days; (3) to the West 
Indies, J7 days; and (4) to the United States 
or Canada (in summer), 6 to 7 days. Short 
cruises in the Mediterranean, or to the lati- 
tudes of the Canaries and Azores, are suitable 
for certain cases where expense is no object. 
Of routes (3) and (4) we may say that they 
are too short for the full benefit of the sea to 
be obtained, as improvement does not gene- 
rally begin for a week or two after sea-sick- 
ness has subsided, and the patient can remain 
comfortably on deck. Route (2) does not 
allow him to get the bracing effect of high 
South latitudes. Hence where a long sea 
voyage is indicated, route (1) is decidedly the 
best. England is quitted in the beginning of 
October, Australia (Sydney or Melbourne), or 
New Zealand (Wellington), is reached early 
in January, and the return voyage is begun 
not later than the end of February. 
Patients should not remain in the coast- 
towns of Australia in summer on account of 
the heat and the dust. They should go to the 
table-land of New South Wales, or to the 
Darling Downs in Queensland, or else they CLIMATE, THE TREATMENT OF DISEASE BY 
357 
should cruise from port to port, or cross to 
New Zealand or Tasmania. 
In returning, the route round Cape Horn 
should be avoided, on account of the great risk 
of the climate of the South Pacific Ocean, and 
the chance of encountering icebergs, fogs, and 
unfavourable winds. Either the patient 
should come back round the Cape of Good 
Hope; or, if his strength permit, he may 
cross to California, travel overland to New 
York and thence by steamer; or, lastly, he 
may come by the Red Sea, Suez Canal, and 
Mediterranean. 
The invalid must expect about 20 wet days 
on the voyage out. The temperatures met 
with range from 40° to 80° F., the coldest 
and most uncertain weather occurring in the 
North Atlantic and South Pacific Oceans. 
Choice of Vessel.-The following considera- 
tions may be useful in deciding between 
steam and sailing vessels :- 
For a steamer there is the greater certainty 
in predicting the length of the voyage, and 
the calms of the tropics are sooner passed. 
Against steamers there is the nuisance of 
steam and smoke on deck ; much space is 
taken up by the engines, stokers' rooms, &c., 
and hence other parts of the ship are more 
crowded; the bilge water is tainted with the 
engine grease; there is the wearying grind of 
the screw by day and by night; while more 
seas are shipped, because a steamer can run 
against a head-wind. 
For sailing vessels there arc the advantages 
of more room, light, and air in the cabins, and 
the absence of the above-mentioned dis- 
agreeable conditions. 
Against them there is the longer and more 
uncertain duration of the voyage, the neces- 
sity of shaping their course by the prevailing 
winds, and the possibility by route No. 1 of 
being becalmed at the equator for days or 
weeks, in a humid atmosphere of 80°-85° F. 
The vessel selected should not be under 
1,000 tons, and her age, class of passengers, 
the character, temper, and standing of her 
captain, as well as the reputation of the 
owners, and the size of her cabins, should be 
carefully ascertained. Of course it is a sine 
qua non that she should carry a duly quali- 
fied surgeon. 
The cabin for the outward voyage to Aus- 
tralia should be on the port side, so as to get 
the breeze in hot weather, and vice versa in 
returning. 
The cabin outfit should include a spring 
mattress, with hair (not wool) mattress over, 
a folding easy chair, chest of drawers, carpet, 
curtains, and sponge bath (Faber). Clothes 
of various degrees of thickness are essential, 
both for body and head, and a waterproof 
suit is necessary for bad weather. 
Plenty of linen must be taken, as washing 
is difficult on board, and there should be a 
supply of preserved milk, meat or essence of 
meat, fruit, and light wines. 
The indications for a sea voyage are here- 
ditary tendency to phthisis, or the presence of 
actual but uncomplicated disease in a very 
early stage, in persons not past middle life, 
with a fair digestion, absence of severe 
pyrexia, and general health not much im- 
paired. Patients with a tendency to haemo- 
ptysis should not be sent, nor should those of 
a desponding disposition, who would thus be 
likely to suffer by the long absence from 
home, or from fears of their personal safety. 
Of course a tendency to protracted sea-sick- 
ness is a distinct contra-indication. 
The invalid should be careful not to over- 
tax his digestion too much; he should take 
regular daily exercise on deck to the extent 
of his strength, have some definite occupation 
to beguile the time, and, if possible, be accom- 
panied by a personal friend (Faber). 
Choice of a Climate-General Hints.-It 
is a good plan, if possible, to order a patient 
a climate with that mean temperature and 
relative humidity which he is known to 
tolerate well (Sigmund). The patient's dis- 
position must be considered, and a lively or 
a quiet place chosen according to his tem- 
perament. We should not send a poor man 
to a place beyond his means, otherwise he has 
to grudge himself many comforts, and loses 
much, if not all, the benefit of the change. 
In sending patients to the South of Europe 
this rule is too often neglected. 
The special indications for the climates of 
particular places can only be understood by 
studying their local aspect. Generally speak- 
ing, as far as Great Britain is concerned, the 
climate of the east coast is colder and drier 
than that of the west and south coasts. In 
Europe the north and west coasts are moister 
and cooler than the shores of the Mediter- 
ranean. As to season, mountain climates 
include some very important winter stations; 
woodland climates are almost exclusively indi- 
cated from May to the middle of July. Certain 
parts of the sea-coast are adapted for invalids 
at all seasons of the year; but as a rule the 
northern coasts of Europe and the eastern or 
south-eastern coasts of Great Britain are best 
suited for summer, and the south, west, and 
south-western for winter residence. The 
Mediterranean coast is only to be recom- 
mended from mid-October to the middle or 
end of May, and Egypt should be quitted not 
later than April. A word may be added as 
to the advantages of wintering in the South 
of Europe. It is incontestable that the in- 
valid gets a milder winter, a longer autumn, 
and an earlier spring. Although there is no 
place where some days of bad weather do not 
occur, or where uninterrupted calms are met 
with, yet the number of rainy days is fewer, 
there is more sun, little or no fog, and, except 
in the neighbourhood of the Pyrenees, little or 
no snow or ice. The scenery is picturesque 
and attractive, and the invalid is able to spend 
much time in the open air, and to sit out of 358 
CLIMATE, THE TREATMENT OF DISEASE BY 
doors on many days, even in mid-winter. 
The drawbacks to the South are the risk of 
chills, owing to the difference between sun 
and shade temperatures, especially at first, 
when persons are unaccustomed to the 
climate, and fail to take sufficient care ; the 
occasional occurrence of high winds, especially 
in spring; the more limited accommodation, 
owing to the expense of rooms and living; 
and the absence of many so-called 'home 
comforts.' 
Those who visit the South must remember 
that the curative value of the climate consists 
in its allowing much time to be spent in the 
open air, and in its milder temperature and 
drier air, which protect the respiratory organs 
from fresh inflammatory attacks. A south 
room and warm clothing of the texture 
usually worn in England in autumn are 
essential, and a coat or wrap should always 
be carried out of doors in mid-winter to put 
on in passing from sun to shade. The invalid 
should strictly avoid the hot atmosphere of 
gaslit salons at night. 
Patients with acute diseases of the respira- 
tory organs should not be sent to the South; 
and high fever, excessive weakness, or the 
necessity of remaining in bed, are also contra- 
indications, owing to the fatigue and risks of 
the journey and the need of home comforts. 
Cases of mental disease with excitement, 
where rest and protection of the mind and 
body are of primary importance, should like- 
wise not be sent. 
In the convalescence from acute diseases 
occurring in autumn, where a cold northern 
winter would prevent open-air exercise, and 
probably set up fresh exacerbations, southern 
winter climates are of great value. 
In ordering change of climate the accom- 
modation, food and water supply, soil and 
drainage of the locality chosen, should be care- 
fully considered, especially if the distance be 
a long one. The best climate may be un- 
available for the invalid, owing to defects in 
one or more of these particulars. 
Lastly, the patient's own feelings should 
be carefully consulted before he is sent far 
away from home. In some cases all the 
benefits of climate are counteracted by ' home- 
sickness.' Ccelum non animum mutant qui 
trans mare currunt. 
Enumeration of Climates.-We shall 
now enumerate various climates and regions 
suitable for the treatment of cases that can 
be thus benefited. 
1. Of the Nervous System.-In neu- 
ralgia:-Arcachon (for the calm, sedative, yet 
tonic atmosphere of the pine-woods), Cannes 
(the districts away from the sea), Upper 
Egypt (Cairo, Luxor, Helwan), Hastings, 
Hyeres, the Engadine, the Bernese Oberland, 
Pau, Pisa, Rome, the Salzkammergut (Ischl, 
Aussee, Berchtesgaden). Some of the above 
climates will also be found suitable to cases 
of hemicrania and sciatica. 
In hysteria, hypochondriasis, spinal irri- 
tation, and in some cases of protracted 
chorea :- Cannes, Ischl, Aussee, Meran, 
Mentone, Montpellier, Morocco (Tangiers), 
Nice, Naples, the Bernese Oberland (Grindel- 
wald, Miirren), Palermo, Pau, Seville, Spezia, 
and Valencia; the effect produced being 
chiefly due to diversion of the attention by 
the change of scene, although the bracing 
influence exerted on the system at large must 
be taken into account. 
In chronic softening of the brain and spinal 
cord, in paralysis of cerebral origin, and in 
some cases of locomotor ataxy, the South of 
France may be advantageously ordered in 
winter, and Alpine climates of moderate 
height in summer. As a rule hot climates, or 
those where the sun has considerable power, 
are contra-indicated where there is a tendency 
to apoplexy or hyperaemia of the brain. 
Temperate and bracing climates are, as a 
rule, to be recommended in nervous diseases, 
to restore the general tone of the system. 
The immediate neighbourhood of the sea 
not infrequently causes nervous excitement, 
neuralgia, and sleeplessness. 
2. Of the Respiratory and Circula- 
tory Systems.-In chronic bronchitis, em- 
physema, bronchial and spasmodic asthma, 
as well as in chronic pharyngeal and laryn- 
geal catarrh and laryngeal ulceration, the 
following climates may be recommended :- 
Africa (South), Algiers, Australia, the Azores, 
Bordighera, Bournemouth, the Canaries, 
Upper Egypt, Glengariff, Hastings, Hyeres, 
Lisbon, Madeira, Malaga, Mentone, Meran, 
Montreux, Nervi, Nice, Palermo, Pau, Pen- 
zance, Pisa, Queenstown, Rome, San Remo, 
Santa Barbara, St. Leonards, Torquay, and 
Ventnor. 
Change of climate is of great value in con- 
valescence from the acute, and as a prophy- 
lactic and curative measure in the chronic 
forms of bronchitis; but we must remember 
that where there is copious expectoration a 
dry climate is indicated, while in the irrita- 
tive forms with scanty sputa (bronchitis 
sicca) a moderately moist mild climate is 
generally suitable. In emphysema we should 
choose a mild and not too dry climate, if 
possible in the neighbourhood of pine-woods, 
such as Arcachon on the west coast of 
France, or Bournemouth. In spasmodic 
asthma the choice of climate must be partly 
a matter of personal experience. 
In the early active, and in the quiescent 
forms of the later stages of phthisis, as well 
as in chronic pleurisy, and in convalescence 
from pneumonia, the following (chiefly winter) 
health resorts and climates have been favour- 
ably spoken of, and many of them will be 
found described in this work under their own 
or associated headings :-Africa (South), 
Algiers, Australia, Bordighera, Bournemouth, 
Canaries, Cannes, Colorado Springs, Denver, 
Davos. Upper Egypt, Upper Engadine, South CLIMATE 
COAL GAS, POISONING BY 
359 
of France, Falmouth, Hastings, Hyferes, 
Queenstown, Ischl (in summer), Madeira, 
Malaga, Mentone, Natal, Nervi, Nice, the 
Oberland (in summer), Palermo, Pau, Pisa, 
St. Paul's in Minnesota, San Remo, Santa 
Fe, Sicily, Spezia, Torquay, and the Under- 
cliff (Isle of Wight). 
In chronic endocarditis, pericarditis, and 
in heart-disease generally, a rather bracing 
climate, without extremes and of the character 
suited to chronic bronchitis, is usually indi- 
cated. Here both the tonic effects of climatic 
change, and the prevention of pulmonary 
complications, and fresh rheumatic attacks, 
must be taken into account. Mountain re- 
sorts of moderate height, well-protected from 
sudden changes of temperature, may be pre- 
scribed in summer. 
In the neuroses of the heart, including 
(1) angina pectoris, (2) palpitation associated 
with chlorosis, hysteria, or hypochondriasis, 
and (3) exophthalmic goitre, moderately 
bracing climates are indicated. In angina 
pectoris long journeys involving fatigue or 
exertion must be rigorously forbidden, as 
must also sightseeing or exciting amusements. 
3. Of the Abdominal Organs.-In 
the various forms of chronic dyspepsia and 
intestinal catarrh, in chronic hepatic disease, 
in chronic dysentery (after removal from a 
malarial district or tropical climate), in dia- 
betes, and in chronic endometritis, pelvic 
cellulitis, and other diseases of the uterus and 
its surroundings, the following climates may 
be selected from :-Cannes, the Engadine, 
Hastings, Hyferes, Lisbon, Malta, Mentone, 
Montpellier, Morocco, Naples, Nice, the Nile, 
the Bernese Oberland, Pontresina, the Pyre- 
nees (in summer), Queenstown, Schwalbach, 
Seville, Spezia, St. Moritz, Valencia, and 
Ventnor. 
In convalescence from acute nephritis, and 
in all forms of chronic Bright's disease, but 
especially catarrhal nephritis, warm dry 
climates are indicated. Among the best are 
Upper Egypt, the Riviera, the Cape of Good 
Hope (inland), Bombay; and, in England, 
Brighton, Folkestone, Hastings, and Ventnor. 
In renal calculus, removal from particular 
districts in which stone is known to be preva- 
lent may possibly be of use in some cases. 
4. Of the System at large.-Change of 
climate is here nearly always indicated:- 
(1) In convalescence from typhus and 
typhoid fevers, scarlet fever (at the end of the 
desquamative stage), measles, diphtheria, and 
acute rheumatism; also in the third stage of 
protracted whooping-cough. 
(2) As a prophylactic against all infectious 
diseases, and especially cholera, yellow fever, 
hay fever, influenza, and malaria; also against 
rheumatism and phthisis by withdrawal from 
damp districts, and goitre and cretinism by 
removal from the ensemble of conditions to 
which the latter are due. 
(3) In rickets, scrofula, chlorosis, general 
anaemia, and functional debility. Here, 
where a pure air and a bracing sunny atmo- 
sphere are the chief indications, the climates 
enumerated in section 1 are suitable; as are 
also Algiers, Biarritz (in autumn), the Cape 
of Good Hope, Ischl, Malaga, Rome, Sicily, 
St. Moritz ; and, in Great Britain, a number 
of inland and seaside places (Malvern, Scar- 
borough, &c.) which it is unnecessary to 
mention. 
Edward I. Sparks. M. Charteris. 
CLINICAL (kAIvy, a bed).-This word 
literally signifies ' of or belonging to a bed '; 
but it has been especially applied to the 
practical study and teaching of disease at the 
bedside; and has more recently been extended 
to all that relates to the practical study of 
disease in the living subject generally. 
CLONIC (*Xdvos, tumultuous movement). 
This word is applied to spasmodic movements 
which are of short duration, and alternate 
with periods of relaxation. See Convulsions ; 
and Spasm. 
CLONUS (kXovos, tumultuous movement). 
The term now applied to the movement of 
a portion of a limb by striking or forcibly 
stretching one of its tendons. See Spinal 
Cord, Diseases of; § 5. Spinal Reflexes. 
CLOT.-A clot* or coagulum, is the pro- 
duct of the formation of fibrin (see Blood, 
Morbid Conditions of). Coagulation of the 
blood within the blood-vessels is described 
under Thrombosis ; the coagulation of extra- 
vasated blood under Hemorrhage, and Brain, 
Haemorrhage into; and the coagulation of 
inflammatory exudations under Inflamma- 
tion. 
CLOTHING.-See Disease, Causes of; 
and Health, Personal. 
COAGULUM (coagulo, I curdle).-See 
Clot. 
COAL GAS, Poisoning by.-Coal gas, 
so largely employed for illuminating purposes, 
is a compound containing--in addition to 
olefiant gas and analogous hydrocarbons, on 
which the luminosity principally depends- 
certain so-called diluents, which burn with 
a non-luminous flame, namely, hydrogen, 
marsh-gas, and carbonic oxide, along with 
what are termed impurities, of which the chief 
are carbonic acid, sulphuretted hydrogen, and 
bisulphide of carbon. On these impurities the 
characteristic odour mainly depends. This 
odour, which is perceptible even to the extent 
of 1 in 10,000, is a valuable safeguard against 
accidents from escape of gas. The recently 
introduced water gas, made by decomposing 
aqueous vapour over burning coke, while it 
is more dangerous-only 1 per cent, being 
necessary to produce a fatal result-has not 
even this safeguard, for it is quite odourless. 360 
COAL GAS, POISONING BY 
A mixture of coal gas with the air inhaled 
exerts a deleterious effect on the system, and 
proves fatal when it reaches a certain per- 
centage. In addition to the danger from 
inhalation, fatal accidents frequently occur 
from the explosive nature of the compound 
which is formed when the gas reaches the 
proportion of 1 to 10 of the atmosphere. 
Much less than this, however (a non-explo- 
sive mixture, therefore), proves fatal if long 
inhaled. 
It is difficult to determine the exact propor- 
tion of the gas present in atmospheres in 
which fatal accidents have occurred, but we 
derive important information on this point 
from experiments on animals. Many such 
have been made. M. Tourdes, who has care- 
fully investigated the subject, finds that pure 
gas is almost instantaneously fatal; |th kills 
rabbits in five minutes, and dogs in twelve 
minutes; ^th kills rabbits in from ten to 
fifteen minutes; g^th still proves fatal after 
a longer period ; and evident signs of distress 
are caused in rabbits by an atmosphere con- 
taining only -^th of the gas. Dr. Taylor 
(Edin. Med. Journ., July 1874) has estimated 
the proportion of gas existing in a room in 
which a fatal case occurred at three per cent. 
Sources of Poisoning.-Poisoning by coal 
gas is only known of as an accident. Occa- 
sionally suddenly fatal consequences ensue 
among workmen from exposure to a sudden 
rush of undiluted gas from gasometers and 
mains. More commonly slowly fatal cases 
result from the gas tap in a bedroom being 
left open carelessly, from accidental extinction 
of the light, or from leakage of gas-pipes in a 
house or at a distance. The gas gains access 
to the house in the latter case through cellars, 
walls, and more especially by means of drains 
and sewer-pipes, most commonly during 
■winter and severe frosts, presumably from 
the ground surface being frozen and prevent- 
ing escape into the streets. After passing 
underground, coal gas loses its odour, which 
is such a safeguard, most of the carburetted 
hydrogen and marsh gas is absorbed, and 
the amount of carbonic oxide is increased. 
Symptoms.-Gas, even when in compara- 
tively small proportion and just sufficient to 
cause an unpleasant odour, acts deleteriously 
if long breathed, and gives rise to headache 
and general depression of health. A very 
slight escape of coal gas-just sufficient to 
produce a close smell, not like that of gas, and 
therefore not recognisable as such-will cause 
relaxed or ulcerated throat, probably from 
the irritation of the sulphur compounds. 
In severe and fatal cases the symptoms 
which have been noted are headache ; nausea 
or vomiting ; vertigo ; and loss of conscious- 
ness, passing into deep coma and muscular 
prostration, which resembles the apoplectic 
state, the individual lying insensible and in- 
capable of being roused, with livid features, 
stertorous breathing, and froth at the mouth. 
Death usually occurs quietly, in this state of 
coma, but occasionally with convulsions. 
The state of the pupils does not seem to be 
constant, though they are generally dilated 
before death. 
In Dr. Taylor's case (sup. cit.') the teeth 
were firmly clenched, and the eyes were in a 
constant state of lateral oscillation. 
Fatal Period.-The fatal period of poison- 
ing by coal gas is extremely variable, and a 
remittent character of the symptoms some- 
times gives rise to fallacious hopes of re- 
covery in cases which ultimately prove fatal. 
Diagnosis.-The smell of gas in the clothes, 
breath, and perspiration, which continues for 
a considerable time after removal from the 
polluted atmosphere, is the best indication of 
the cause of the coma. 
Anatomical Characters.-The smell of 
gas is often very marked. M. Tourdes found 
the blood as a rule dark, but in some re- 
cent cases it has been noted as being of a 
bright red colour. Other signs are : a bright 
coloration of the pulmonary tissue; froth in 
the air-passages; congestion of the mucous 
membrane at the base of the tongue, the 
mucous membrane of the trachea being in 
some cases a bright rose colour; engorgement 
of the cerebral and spinal venous system; 
and rose-coloured patches on the thighs. 
Mode of Action.-It is obviously impos- 
sible to differentiate between the effects of 
the various constituents of coal gas, but we 
have good reason for believing that the most 
active agent is the carbonic oxide, which 
exists in the proportion of from five per cent. 
(English gas) to twenty-five per cent. The 
active agent is the same in water gas, winch 
contains forty-four per cent, of carbonic oxide. 
The symptoms in the main agree with 
those caused by carbonic oxide (see Carbonic 
Oxide, Poisoning by), and the effects, there- 
fore, would be chiefly due to the action of 
the carbonic oxide on haemoglobin. The 
blood of one patient after sixty hours gave 
the spectrum of CO-haemoglobin, and Grehaut 
calculates that 100 c.c. of l^lood from an ani- 
mal poisoned with gas give 20 c.c. of CO. 
Treatment.-Instant removal from the 
polluted atmosphere is the first thing to be 
attended to. Attempts must then be made 
to cause oxygenation of the blood, by artificial 
respiration and excitation of the respiratory 
centres, by reflex stimulation of the face, chest, 
&c. Pure oxygen gas may be administered. 
As, however, the compound which carbonic 
oxide makes with the blood colouring-matter 
is a very stable one, and not easily broken up 
by the introduction of atmospheric air or 
oxygen, it not infrequently happens that 
these measures prove of no avail. In such 
cases it would be highly advisable to perform 
venesection, and then transfuse fresh blood, 
a plan of treatment which has been found 
successful in poisoning by carbonic oxide. 
D. Ferrier. COARCTATION 
COLD, EFFECTS OF 
361 
COARCTATION (coarcto, I straiten). 
A pressing together, narrowing, or stricture 
of any hollow tube, such as the aorta, intes- 
tine, or urethra. 
COCCYGODYNIA the cuckoo; 
and oSvvt], pain).-Synon. : Fr. Coccygodynie; 
Ger. Steissbeinschmerz. 
Description.-This name has been given 
to a peculiarly severe and obstinate neuralgic 
pain in the neighbourhood of the coccyx, 
incited by such actions as defaecation, walk- 
ing, sitting down, or rising from a recumbent 
position. It may arise from injury, such as 
fracture or luxation or horse exercise; or it 
may be the result of inflammatory affections 
of the sacro-coccygeal joint or of the peri- 
coccygeal fibrous structures. Coccygodinia 
is also a concomitant symptom of many rectal, 
vulval, vaginal, and uterine disorders, being 
excited whenever any of the muscles which 
have their insertion in or near to the coccyx 
are brought into play. It not infrequently 
is a sequela to a difficult instrumental par- 
turition, or may be a neurosal condition 
associated with gout or rheumatism. 
Treatment.-In cases where the affection 
is primary, recourse must be had to rest in 
the lateral posture, anodyne suppositories of 
extract of belladonna and opium, and to the 
careful regulation of the bowels. If the pain 
be very severe, a local hypodermic injection 
of morphine may have to be administered. 
To be successful in our treatment we must, 
however, always endeavour to differentiate 
by means of a carefully conducted systematic 
examination the cause or causes which may 
be at work, and to attend to the proper in- 
dications. Tenotomy and excision of the 
coccyx have not proved to be uniformly suc- 
cessful, and should therefore only be had re- 
course to in specially selected cases. Attention 
must be paid particularly to the nervous 
system, and the general nutritive processes 
improved by the administration of arsenic, 
quinine, and iron. John Harold. 
COLD, A.-A popular name for Catarrh. 
See Catarrh. 
COLD, ^Etiology of.-See Disease, 
Causes of. 
COLD, Effects of Severe or Ex- 
treme.-Introductory.-The general effect 
of exposure to severe or extreme cold is to 
lower, even to extinction, all vital activity. 
The blood-vessels, especially the smaller 
arteries and capillaries, after a brief period 
of congestion, become contracted, the latter 
to such an extent as no longer to permit the 
passage of the red corpuscles; the normal 
condition, composition, and structural in- 
tegrity of the various tissues are more or 
less impaired, or altogether destroyed; the 
red corpuscles become first crenated and 
later disorganised and broken up, the watery 
elements of the blood thicken, and when 
frozen become more or less separated from 
the saline and other constituents ; and those 
processes of chemical and physiological 
change which are essential to every mani- 
festation of life, being only possible within 
certain very narrow limits of temperature, 
are hindered or absolutely prevented. 
The more special effects vary in degree 
and kind:-1st, with the degree of cold, the 
duration of the exposure, and the medium or 
manner of application; 2nd, with the part, 
and extent of surface exposed ; and, 3rd, with 
the general constitution and physiological 
condition of the sufferer. 
Moderate cold, acting during a short time, 
or even severe cold during a still shorter 
time, followed by the glow of speedy reaction, 
exercises a tonic and stimulating influence. 
If, however, the cold is very severe, or the ex- 
posure too long, the glow of reaction does not 
occur, but a sense of depression is experienced, 
from which, at best, recovery takes place but 
slowly. Continued exposure to such a degree 
of cold as is yet not incompatible with the 
maintenance of life, nevertheless keeps at low 
ebb activity of nutrition and function alike. 
Extreme cold and long exposure lead to con- 
gelation and consolidation of the various 
tissues of the body. After complete congela- 
tion of the body recovery is impossible. 
Dry cold is much less readily injurious in 
its influence than cold associated with wet. 
The better conductor of heat the medium is, 
the more speedily and completely does it 
reduce the temperature of the part with 
which it is in contact. Immersion in water 
cools more rapidly than exposure to air of the 
same temperature; and contact with wool, 
wood, or metal, of the same degree of cold- 
ness, excites in each case a different sensa- 
tion, and leads to a different result, or to 
similar result but with very different rapidity. 
Constant renewal of the medium in contact 
hastens the cooling effect; and a continuous 
draught of only moderately cold air may do 
more to chill than temporary exposure to an 
intensely cold but still atmosphere. If some 
external part, and a comparatively small ex- 
tent of surface only, be acted upon, the effect 
may be simply local, and the general dis- 
turbance of the system scarcely appreciable. 
But if the whole body, or a considerable 
extent of surface, or any important internal 
organs be acted upon, a proportionately 
serious general effect is produced. 
The young (infants especially) and the aged 
alike ill sustain exposure to cold, and are most 
liable to suffer, not only from its direct effects, 
but also from the various maladies to which 
it gives rise. The feeble, ill-nourished, and 
broken in health, especially the subjects of 
organic disease, or of degeneration due to 
habitual intemperance, readily succumb, or 
only slowly and imperfectly recover. Among 
the healthy and otherwise vigorous, hunger, 
fatigue, sleep, anxiety of mind, fear, and 362 
COLD, EFFECTS OF SEVERE OR EXTREME 
mental depression of whatever kind, lower- 
too often even to fatal issue-the power of 
resistance to the deadly influence of cold. 
Local Effects.-For local effects of ex- 
posure to cold, see Chilblain ; Frost-bite ; 
and Gangrene. 
General Effects.-The general effects 
and symptoms produced by exposure to 
severe or extreme cold vary in different 
cases. Temporary exposure produces, first, 
a sense of coldness or chilliness, associated 
with paleness and corrugation of the skin 
(the so-called cutis anserind), then shivering 
and tingling sensations, followed by numb- 
ness and diminution of muscular activity 
and power. Healthy reaction restores more 
or less quickly the normal condition. Pro- 
longed exposure to extreme cold gives rise 
to a series of symptoms, graphically de- 
scribed by Beaupre somewhat as follows:- 
Reaction has a limit, and a moment arrives 
when the powers are exhausted. Shiverings, 
puckerings, paleness and coldness of the skin, 
livid spots, muscular flutterings, are symp- 
toms of the shock given to the vital forces; 
syncope approaches; the stiff muscles con- 
tract irregularly; the body bends and shrinks; 
the limbs are half-bent; lassitude and lan- 
guor invite to repose ; a feeling of weight and 
numbness retards the steps ; the knees bend; 
the sufferer sinks down or falls; the propen- 
sity to sleep becomes irresistible ; everything 
grows strange; the senses are confused ; the 
mind grows dull, the ideas incoherent, and 
the speech stammering or raving; respira- 
tion, at first interrupted, becomes slow; the 
heart's action is feeble, quick, hard, irregular, 
and sometimes painful, and the pulse progres- 
sively smaller ; the pupils dilate ; the brain 
becomes stupefied; and finally deep coma 
indicates the approach of inevitable death. 
Other and somewhat different effects and 
symptoms, attributable to differences of cir- 
cumstances and condition, have been from 
time to time observed. Distressing and 
almost intolerable thirst, with loss of appe- 
tite for food, is often experienced; and the 
attempt to obtain relief, by sucking snow or 
ice, only adds to the suffering. Somnolence 
is by no means so constant an effect as is com- 
monly supposed-at any rate, in the earlier 
stages, and less extreme cases. On the other 
hand, inability to sleep has proved a'common 
cause of suffering and consequent loss of 
strength. The manifestations of brain dis- 
turbance due to exposure to cold, varying as 
they do from dulness, incoherence, wander- 
ing, and thickness of speech, to even raving 
delirium, are especially worthy of note, inas- 
much as they resemble, and are liable to be 
mistaken for, the effects of alcoholic intoxica- 
tion. 
Death from the direct and immediate 
effects of cold is rare in the British Islands; 
but it is estimated that in the Russian Em- 
pire, on an average, G94 deaths occur annually 
from this cause. The length of time during 
which exposure can be sustained varies 
greatly with the condition of the individual 
and with surrounding circumstances, as well 
as with the degree of cold. Under ordinary 
circumstances, an hour's exposure to intense 
cold, without due protection against the loss 
of natural heat, often suffices to determine a 
fatal result. At the same time, well-authen- 
ticated cases are on record, in which persons 
buried, for days even, in snow, have never- 
theless survived and ultimately recovered 
with little permanent damage. 
Mode of Death.-The immediate cause or 
mode of death occurring directly from expo- 
sure to cold seems in some cases to be prin- 
cipally shock; in some, syncope; in some, 
apoplexy; in others, asphyxia; and in others, 
again, coma. In most cases it is probable 
that these several conditions, with others less 
readily specified, combine to produce the fatal 
result. 
Anatomical Characters.-The appear- 
ances presented on post-mortem examination 
are somewhat differently described and esti- 
mated by different observers; but none of 
them are absolutely pathognomonic, and some 
are as likely to be produced by exposure of 
the body after death as during the process of 
extinction of life. Among the more note- 
worthy are the following:-strong cadaveric 
rigidity ; paleness or waxy whiteness of skin, 
with patches of more or less bright redness 
about the face, neck, and limbs, especially 
on exposed or prominent parts ; a contracted 
and shrunken condition of the male genital 
organs; comparative bloodlessness of super- 
ficial and external parts; accumulation of 
blood in and about the thoracic and ab- 
dominal viscera; great distension of all the 
cavities of the heart, with more or less clotted 
and often bright-coloured blood; the blood in 
other parts also sometimes of brighter colour 
than usually seen on post-mortem inspection; 
hypersemia and congestion of the lungs; 
hyperaemia of the brain, overfulness of the 
sinuses, and excess of serous fluid in the 
ventricles, and at the base, in some cases; in 
others, comparative bloodlessness of the sur- 
face of the brain, and no distension of the 
sinuses; excessive fulness of the urinary 
bladder ; and, lastly, separation of the cranial 
bones along the coronal and sagittal sutures. 
The lines of reddish or brownish staining 
along the course of the superficial blood- 
vessels, relied on by some as pathognomonic, 
are certainly not so, inasmuch as they depend 
upon exosmosis of the blood colouring-matter 
set free by disruption of the corpuscles, which 
may be effected by freezing after death, as 
well as before. 
' Treatment.-The treatment of sufferers 
from the effects of cold consists in the restora- 
tion of warmth, and the rekindling of those 
processes by which the natural heat of the 
body is maintained. But this must be done COLD, EFFECTS OF 
COLD, THERAPEUTICS OF 
363 
gradually, and with great care. As in the 
treatment of a frost-bitten part, so in the treat- 
ment of the body generally-all sudden or 
rapid elevation of temperature must be 
avoided. The sufferer, divested of the cloth- 
ing previously worn, and wrapped in blankets, 
should be placed in the recumbent position 
in a room, the air of which is dry, still, and 
cold, but capable of being gradually warmed. 
Gentle but continuous friction should be 
made over the trunk and limbs, care being 
taken that rigid or frozen parts be not 
damaged by rough manipulation. At first, 
ice or ice-cold water may be used; afterwards 
dry rubbing with flannel or with the hands is 
better ; later still some stimulating liniment 
may be employed. Some recommend im- 
mersion of the body in a bath of cold-at 
first ice-cold-water, the temperature of 
which can be gradually raised. This method 
would seem easy and advantageous, if means 
are at command. When the sufferer can 
swallow, warm, gently stimulating drinks- 
as tea, coffee, aromatic infusions, beef-tea, or 
soup-may be given, at first without, but 
later with some wine or spirit. Alcohol, 
though useless or inj urious if taken to fortify 
against cold, is useful and beneficial when 
judiciously administered as a restorative after 
exposure. In all cases of insensibility, and 
even apparent death from cold, every effort 
must be made to restore animation ; and the 
attempt must be persevered in for a con- 
siderable time before being given up as hope- 
less. It is often difficult, sometimes impos- 
sible, to judge whether life is absolutely 
extinct or not. And while, on the one hand, 
it is important that the temperature be not 
raised too quickly, lest reaction should be too 
strong or dangerously irregular; on the other 
hand, it is equally if not more important that 
the needful measures be adopted without 
delay, and carried out not too slowly, lest the 
chance of revival should be lost. In the less 
severe cases, restoration of warmth may be 
comparatively quickly accomplished. The 
state of the bladder should always be ex- 
amined, and relief afforded, if needful, by aid 
of the catheter. Attention to the general 
health is often requisite for long after re- 
covery from the more immediate effects of 
exposure has taken place. Rest, good nourish- 
ment, and tonics are indicated. 
Cold as a Cause of Disease.-As a 
predisposing and exciting cause of disease, 
cold proves, in the British Islands, year by 
year, more fatal in its effects probably than 
any other single condition or influence. Any 
considerable fall in the thermometer below 
the average standard during the colder months 
of the year is constantly followed by a corre- 
sponding rise in the death-rate, and an increase 
in still greater proportion in the amount and 
extent of sickness and suffering. The Reports 
of the Registrar-General clearly prove this, 
so far as the death-rate is concerned. A 
striking instance may be quoted. In the 
week ending December 19, 1863, in the Lon- 
don district, 1,291 deaths were registered. 
Severe frost set in, and in the week ending 
January 9, 1864, the number rose to 1,798. 
The week following, ending January 16, no 
fewer than 2,427 deaths were registered. This 
enormous increase could be attributed to no 
other cause than the effects of the severe cold 
which prevailed. The Registrar-General also 
shows that after the age of from twenty to 
forty the mortality from cold increases in 
something like a definite ratio with increasing 
years. 
General depression of the vital powers, 
congestion and functional' derangement of 
various internal organs-the lungs, liver, and 
kidneys-catarrhal and other forms of in- 
flammation of the mucous membranes, especi- 
ally of the respiratory tract, but also of the 
intestinal canal and bladder, paralysis from 
central or peripheral lesion, together with 
rheumatism, chilblain, frost-bite, and gan- 
grene, constitute the list of maladies most 
commonly caused and fostered by exposure to 
the influence of cold. 
Arthur E. Durham. 
COLD, Therapeutics of.-The thera- 
peutic uses of cold are various and extensive. 
Cold may be applied as moist cold, by means 
of wet compresses and cold lotions or baths; 
and it may also be used as dry cold in the 
form of ice enclosed in a receptacle of metal 
or india-rubber, or as a current of iced water 
circulating through a soft metal coil, as in 
Leiter's tubes. The flat coil of tube can be 
pressed to fit any part of the body. Each 
of these methods has its special advantages 
and adaptations. Furthermore, cold may be 
made use of by the mouth, and by injection 
into the mucous canals of the body. 
General Principles.-The general effects 
of cold, however applied, are to lower tem- 
perature, to diminish sensibility and fluidity, 
to contract the tissues and vessels, and so to 
reduce the volume of parts. The cold bath 
and cold sponging alike have the effect of 
lowering the temperature of the body. The 
fall of temperature sometimes is but tran- 
sient, reaction setting in and heat of surface 
returning, when the body is withdrawn from 
the cooling medium. At other times the 
temperature continues to fall after the indi- 
vidual is removed from the bath. If the 
action of the cold bath be prolonged, then a 
thermometer, introduced within the rectum, 
shows a great depression of temperature, and 
much pain is experienced, similar to the 
severe pain which is felt in the hand and 
arm when the former is held for some time 
in water at a temperature of 41° F., and 
which soon compels the withdrawal of the 
hand from the vessel. Cold baths and their 
uses are treated of in another article (see 
Baths), but attention may here be drawn to 364 
COLD, THERAPEUTICS OF 
the practice of cold sponging over the surface as 
an efficacious means of lowering preternatural 
heat and relieving acridity and dryness of the 
skin during fever. The addition of enough 
solution of potassium permanganate to give 
a slight purple tinge to the water, makes it 
especially refreshing to the patient. Reduc- 
tion of hyperpyrexia by means of cold is now 
a well-established therapeutic method. See 
Fever ; and Temperature. 
Methods of Application and Uses.- 
There are several methods of applying cold 
therapeutically:- 
1. Cold Affusion and Wet Packing. 
In the practice of cold affusion, introduced by 
Dr. Currie, in 1797, the patient is unclothed, 
seated in a tub, and four or five gallons of 
cold water thrown over him. Thus, Dr. 
Currie said, a commencing fever might be 
' extinguished.' In cases where the skin was 
burning hot and dry, it was observed that 
after the cold affusion temperature fell, per- 
spiration broke out, and the patient usually 
dropped into a refreshing sleep. If the 
body-heat did not exceed 98'4° F., or if the 
patient was damp and chilly, with or without 
delirium, the cold affusion was regarded as 
dangerous and by all means to be avoided. 
Drs. Strauss and Hirtz speak most highly of 
the marvellous effect of cold affusion in cases 
of collapse during fever. This kind of 
collapse appears due to a paralysis of the 
nervous centres : the heart's action fails, as 
does also the respiration ; but while the sur- 
face of the body is cold, the temperature, 
taken in the rectum, still remains abnormally 
high. The affusion is applied by pouring a 
pitcherful of water, at a temperature of, 
or a little above, 10° C. (50° F.), over the 
patient seated in a bath or on a waterproof 
cloth. The patient, plunged in stupor, is 
suddenly roused by the shock; he draws a 
long breath; the respiration becomes fuller; 
the cardiac ataxy ceases, and the pulse, 
which, traced by the sphygmograph during 
the collapse, presented a scarcely broken 
horizontal line, now regains its normal line of 
ascension; heat of surface returns, and the 
temperature in the rectum falls. The action 
of the cold affusion, as thus applied, is to excite 
immediate and energetic reflex action. 
In many nervous affections, such as 
maniacal delirium, chorea, and hysteria, cold 
douches, shower baths, and affusions are 
valuable as restorative and curative agents. 
In the convulsions of robust children, a 
stream of cold water directed over the head 
from a height of two or three feet often has 
a speedily beneficial effect. Cold affusion 
has been tried in tetanus, but it has in some 
instances killed the patient (Elliotson). 
Other cases in which cold affusions are of 
service are those where respiration fails, and 
it is necessary to appeal powerfully to the 
reflex excitability of the nervous centres. To 
resuscitate those who are in danger of death 
from a narcotic such as chloroform or opium, 
slapping the patient severely with a cold wet 
towel is an efficient method. In sunstroke, 
cold affusion over the head and neck may 
be resorted to, provided the skin be not 
cold and clammy, and the patient in a 
syncopal state. In conditions of nervous 
spasm-of the larynx, for example-cold 
douches over the neck may prove useful. 
Cold affusion to the feet was much com- 
mended by Cullen as a mgans of promoting 
action of the bowels in cases of obstinate 
constipation. Spasmodic retention of urine 
has been relieved by a cold douche over 
the perineum and thighs (Currie); and Mr. 
Erichsen mentions the case of an old man 
who found his power of micturition increased 
by sitting on the cold marble top of his 
commode. In cases of extreme debility, with 
damp, cool skin, low muttering delirium, and 
very feeble pulse, cold affusions are dangerous. 
In some cases of fever, where for any 
cause a cold bath is objectionable, the patient 
may be wrapped in a w'et sheet and then 
covered with a few blankets. The sheet as 
it becomes heated may be changed for one 
fresh and cold, or very cold water may be 
squeezed from a sponge over the sheet as 
the patient lies rolled up in it on a water- 
proof cloth. Allowing fragments of ice slowly 
to melt on the sheet which covers the patient 
is, in the author's experience, a successful 
way of treating the hyperpyrexia of acute 
rheumatism. In scarlet fever of malignant 
type, where the rash does not readily appear, 
this form of cooling pack has been found most 
valuable. The late Dr. Hillier and Dr. Gee 
have both added their testimony to its utility. 
In Dr. Gee's cases the patient remained 
packed in the wet sheet for one hour and was 
then removed to bed. The cases best suited 
for treatment by the wet pack are those where 
the skin is very dry and hot, and the patient 
exceedingly restless and delirious. 
2. Cold Compresses, Ice-Bags, Irri- 
gations, Lotions, and Injections.-Cold 
may be continuously applied with a view to 
abating undue heat of a part of the body. 
Iced-water rags or compresses may be placed 
over an inflamed throat, or on the head in 
inflammation of the brain. A narrow bladder 
of ice laid over each carotid artery in the 
neck is an excellent wTay of cooling the blood 
as it flows to the brain. In acute pneumonia 
Niemeyer lias commended strongly the use 
of cloths dipped in cold water, well wrung, 
and then applied so as to cover the chest, 
and especially the affected side. These com- 
presses are repeated every five minutes. 
Pain and dyspnoea are much relieved; some- 
times the temperature falls an entire degree; 
and if the cold appliances do not arrest the 
actual attack of pneumonia, they may shorten 
its duration and promote convalescence. 
The necessity of so often having to change 
the compress, and thus disturb the patient, COLD, THERAPEUTICS OF 
365 
is a great objection to this mode of applying 
cold. Dr. Lees, in the Lancet, Nov. 2, 1889, 
records several instances of arrest of the 
pyrexial process in pneumonia by means of 
a bag of ice applied over the inflamed lung. 
The development of broncho-pneumonia in 
children may be cut short by the ice-bag. A 
frozen compress over the caecum is useful to 
stay peristalsis and check haemorrhage in 
typhoid fever. 
A powerful sedative and antiphlogistic 
effect of cold can be obtained by irrigation ; 
i.e. allowing cold water to fall drop by drop 
on a cloth, so as to keep it continually wet 
with fresh supplies of water. This may be 
done by suspending over the part to be irri- 
gated a bottle of water, in which a few pieces 
of ice may be put; one end of a skein of 
cotton, well wetted, is then allowed to hang 
in the water, while the other end is brought 
over the side of the bottle. This, acting as 
a syphon, causes a continual dropping upon 
the part to be irrigated. In injuries of joints, 
where it is of much consequence to check 
inflammation, this process, which abstracts 
heat gradually and without disturbance of 
the part, is most valuable. Irrigation of the 
shaven scalp in cases of meningitis is a very 
powerful cooling and sedative appliance, 
requiring care and watchfulness. A cap of 
india-rubber or coil of tubing over the head 
and back of neck, so arranged that a current 
of cooled water may flow continuously 
through it, will act as a general reducer of 
temperature. "Where pounded ice is applied 
to the head in a bladder, this should be 
suspended by a string from the bedstead, so 
that the head of the patient may not have 
to sustain the weight of the bag and its con- 
tents. Five ounces of sal ammoniac and 
five ounces of nitre in a pint of water will 
form a frigorific mixture, which can be 
applied in a bladder when ice is not at hand. 
The ice-bag. and cold-water compresses re- 
newed every three minutes, have been used 
as an appliance to strangulated hernia, and 
to prolapsed rectum, to reduce the volume 
of the part and so facilitate reduction. Care 
must be taken that the cold application be 
not continued so long as to cause gangrene. 
Cold wet compresses should not be applied 
over dry bandages, with which wounded or 
broken parts are secured. Several cases are 
recorded where a hand or arm has become 
gangrenous, in consequence of having been 
bound up with dry bandages, and then 
treated with cold-water compresses. The 
dry bandages, as they become wet, contract 
tightly on the limb and stop the circulation. 
A mixture made of spirit of wine and 
water, or of eau de Cologne and water, is 
a simple form of cooling lotion. The spirit 
evaporates and so carries off heat from the 
surface. 1 fl. cz. of rectified spirit to 15 of 
water makes a good spirit lotion, and the ad- 
dition of 4 drachms of nitrate of potassium, or 
chloride of ammonium, will add to its cooling 
and sedative effect. 4 drachms of the chlo- 
ride of ammonium with half a fluid ounce of 
diluted acetic acid, and the same quantity of 
rectified spirit, in 15 fl. oz. of camphor water, 
is another form for a very serviceable lotion. 
These lotions, applied by means of a piece of 
soft rag or lint over the skin, act as refriger- 
ants, cooling the head when it is hot or pain- 
ful ; reducing heat and arterial excitement in 
tumours or contusions; and tending in the 
latter to promote the absorption of effused 
blood. A lotion of 1 part alcohol and 3 parts 
camphor water, at a temperature of 75° to 
85° F., was highly praised by Scudamore in 
cases of gout. Cold, water, and cold lotions 
of vinegar and water, are familiar means for 
stopping haemorrhage. 
In cases of severe uterine haemorrhage, 
injections of ice-cold water into the vagina, 
or into the rectum, frequently succeed in 
checking the bleeding. If the cold injection 
fail, hot water (110°-120° F.) may be tried in 
its place. In cases of bleeding internal piles, 
an injection of cold water, after the action of 
the bowels, braces the parts and constringes 
the bleeding vessels. Iced water has been 
used as antipyretic enemata. 
3. Dry Cold. Uses of Ice.-Heat 
may be continuously abstracted from an 
inflamed part in a safe way, and without 
undue risk, by applying dry cold by means of 
a waterproof bag of vulcanised india-rubber 
filled with ice, snow, or a freezing mixture 
made of equal parts of salt, nitrate of potas- 
sium, and chloride of ammonium. Moisture 
from the air will condense on the exterior of 
the cold bag, but a piece of lint interposed 
will protect the skin from damp. The india- 
rubber is a bad conductor, and too great 
abstraction of heat need not be feared. The 
walls of an animal bladder conduct heat 
much better than the india-rubber, and it is 
necessary to watch carefully over the 
application of ice-bladders, for when con- 
tinuously applied they have been known to 
cause severe frost-bite of the part. If, 
when cold is being applied, the patient 
persists in complaining of severe pain, it is 
right to examine carefully and see how the 
part is affected by the cold. Professor 
Esmarch, in cases of fracture, and in various 
forms of traumatic inflammation, his ap- 
plied ice for periods of twenty or thirty days 
with the best results. In cases of com- 
mencing disease of the vertebrae this surgeon 
has used cold water placed in a tin vessel, so 
made as to adapt itself to the part to be 
treated. Minor cases of bruise with inflam- 
mation may be treated by cold employed in 
the form of a common bottle filled with cold 
water and kept pressed against the part. 
After operations upon the eye, the extraction 
of cataract for example, a small ice-bag is 
very useful in relieving pain and keeping down 
inflammation. For the same purpose an ice- 366 
COLD, THERAPEUTICS OF 
COLIC, INTESTINAL 
bag is sometimes applied to the chest after the 
operation of paracentesis. 
Ice-bags placed along the course of the 
spine have been found effectual remedies in 
many forms of nervous disorder. In cases 
of epilepsy, where the circulation is sluggish, 
the hands and feet being always clammy 
and cold, an india-rubber bag of ice applied 
along the spine has been found to restore 
warmth, at the same time relieving headache 
and symptoms of incipient paralysis. Cold 
to the spine is asserted by Dr. Chapman to 
lessen the excito-motor power of the cord. 
In the severe pain of an inflamed ovary or 
testicle ice in a bag may often be employed 
beneficially as an anodyne. The long- 
continued application of bags of ice to the 
chest, for the arrest of haemorrhage from 
the lungs, has been observed by Sir Richard 
Quain and others to be very apt to cause 
bronchitis. 
Lumps of ice swallowed are invaluable in 
arresting haemorrhage from the throat and 
stomach. In tonsillitis and diphtheria this 
same treatment tends to reduce inflamma- 
tion and cool the throat of the patient. 
Obstinate vomiting can often be checked by 
swallowing fragments of ice. 
4. Cold as an Anaesthetic. - Dr. 
James Arnott, in 1849, brought forward the 
use of a freezing mixture of ice and salt as a 
means of producing local anaesthesia, by 
freezing the part to which the mixture was 
applied either in a bag or in a metallic 
spoon. For small superficial operations this 
method of anaesthesia by congelation answers 
very well. The part becomes white and har- 
dened to the cut of the surgeon's knife, there 
is very little haemorrhage, and the wound 
made usually heals well by primary adhesion. 
Subsequently Dr. Richardson indicated a 
very convenient way of inducing local 
anaesthesia, by the volatilisation of ether in 
the form of spray, by means of the hand- 
ball spray atomiser. Ether sprayed on the 
bulb of a thermometer, held about an inch 
from the jet, brought down the mercury to 
within 10° of zero F. When the jet was 
turned on to the skin, a marked degree of 
local anaesthesia was produced, but not 
enough for surgical purposes. By driving 
over the ether under atmospheric pressure, 
instead of trusting simply to capillary action 
-or to suction, as in Siegle's apparatus-one 
may bring the thermometer to 4° below zero 
within thirty seconds. By the use of this 
apparatus, at any season or temperature, the 
surgeon can produce cold even 6° below 
zero; and by directing the spray upon 
a half-inch test-tube containing water, he 
can produce a column of ice in two minutes. 
For local anaesthesia by cold, the ether spray 
answers well. Such operations as the 
removal of small tumours, opening abscesses, 
and inserting sutures may be painlessly per- 
formed. John C. Thorowgo.od. 
COLIC (ko>Xov, the large intestine). - 
Originally colic signified a painful affection 
due to spasm of the bowel, but, though still 
retaining this application, it has now come to 
be further associated with other complaints 
which are attended with severe pain of a 
spasmodic character, a qualifying adjective 
indicating the nature and seat of each par- 
ticular form. Thus renal colic is applied 
to the group of symptoms due to the passage 
of a stone from the kidney to the bladder; 
hepatic colic to those accompanying the 
escape of a gall-stone. See Colic, Intestinal. 
COLIC, INTESTINAL.-Synon. : Fr. 
Colique ; Ger. Die Kolik. 
Definition.-Painful and irregular con- 
traction of the muscular fibres of the in- 
testines, without fever. 
^Etiology.-Predisposing causes.-These 
include the nervous (as hysteria and hypochon- 
driasis) , lymphatic, and bilious temperaments; 
sedentary occupations; the female sex; and 
the period of youth or adult age. Exciting 
causes.-These maybe grouped as follows :- 
1. Irritation-from lodgment of gas due to 
fermentation of undigested food, and decom- 
position of faeces long retained within the 
large intestine; from faeces, or intestinal 
concretions, undigested or partly digested 
food, such as pork, shell-fish, salt meats, 
unripe fruit, or septic game; from cold 
drinks or ices; from excessive or morbid 
secretions, especially bile ; from gall-stones ; 
or from worms-a bundle of round-worms 
or coiled up tape-worms. 2. Morbid states 
of the bowel, including obstruction from 
intussusception, twisting, strangulation, &c.; 
ulceration (typhoid, tubercular, dysenteric); 
inflammation (enteritis, typhlitis, &c.) 3. Re- 
flex nervous disturbance, due to anxiety, 
fright, anger, or other emotional disorder; to 
disease of the ovaries or uterus; to calculus 
(hepatic or renal); to dentition ; or to ex- 
posure, especially of the feet and abdomen, 
to cold. 4. Blood-poisoning, as from lead, 
copper, gout, rheumatism. 
Symptoms.-The characteristic or essential 
symptom of intestinal colic is pain in the 
abdomen, without febrile disturbance. It 
usually begins, and is most severe, in the 
umbilical region, then spreads to other parts, 
or to the whole abdomen, and is apt to travel 
from one part to another. It is almost always 
relieved by firm pressure, and by expulsion 
of flatus; and is paroxysmal in character, re- 
mitting, or exacerbating, or completely sub- 
siding at intervals. The suffering is usually 
severe, often agonising, and to relieve it the 
patient bends forwards, pressing the abdomen 
firmly with his hands or against some hard 
surface, or rolls about. As a rule the abdo- 
men is distended by flatus; in lead-colic it 
is, however, firmly retracted towards the 
spine, and the movements of the inflated 
intestines affected by spasmodic contraction, COLIC, INTESTINAL 
COLLAPSE 
367 
producing loud borborygmi, may frequently 
be seen and may be felt by the hand applied 
to the abdomen. The muscles of the abdo- 
minal wall and the bladder usually participate 
in the internal spasm : the abdomen becomes 
rigid or knotted, and the recti muscles be- 
come contracted into round balls, while fre- 
quently the navel is retracted; micturition 
is frequent or suppressed. Usually there is 
constipation, and the pain disappears when 
the bowels are freely relieved; sometimes, 
however, it persists for a time. Constipation 
stands in a twofold relation to colic, either 
as cause or as effect of the spasm. 
The countenance expresses great suffering, 
anxiety, and depression, and the features 
may be pinched. The surface of the body is 
cold, especially the feet, and the pale skin is 
covered by a cold perspiration. The pulse is 
commonly of normal frequency, or is infre- 
quent and feeble. 
The symptoms vary somewhat with the 
cause. When due to irritating ingesta, the 
prominent symptoms are vomiting and diar- 
rhoea, sometimes ending in catarrhal dysen- 
tery. In children the legs are drawn up upon 
the abdomen; the bowels are often at first 
confined; and the evacuations are greenish, 
offensive, and very acid, afterwards becoming 
loose. 
In nervous and hypochondriacal subjects, 
and especially females, severe pain in the 
intestines, resembling that of spasmodic colic, 
is apt to occur (see Enteralgia). Flatulence 
plays a varying part in different cases; it is 
often a prominent symptom, and the form 
of colic thus characterised has been termed 
Colica flatulenta. 
Vomiting is generally in proportion to the 
severity of spasm and the degree of intes- 
tinal obstruction. 
Duration.-The duration of the attack 
varies greatly, from a few minutes to several 
days. The spasm usually ceases abruptly, leav- 
ing a feeling of soreness in the abdomen, while 
there is enjoyable relief from suffering. Colic, 
when violent or intractable, may terminate 
in enteritis, in peritonitis, and-especially 
with children-in intussusception. 
Diagnosis.-A pain moving from place to 
place, relieved by firm pressure and un- 
attended by fever, separates cblic from other 
affections, more particularly from those due 
to inflammation, in which pain is always 
aggravated by pressure. 
Distension with spasm of the stomach may 
be distinguished from a similar condition of 
the colon, by the pain occupying a higher 
position in the abdomen (at or around the 
ensiform cartilage instead of-as in colic- 
the umbilical or hypochondriac regions), and 
by the percussion note elicited being deeper- 
toned and more prolonged than that which 
is produced by a distended colon. Besides, in 
colic the spasmodic contraction of the colon, 
producing borborygmi, may be traced by the 
hand, or may be even seen, and there is 
tenesmus. 
It should be borne in mind that enteritis or 
peritonitis may follow colic, when the pulse 
may become frequent, hard, and small, or 
frequent and soft, the temperature increased, 
and the seat of inflammation becomes tender. 
Prognosis.-Colic almost always £nds in 
recovery, preceded by free evacuation of the 
bowels. Unfavourable signs are those arising 
from inflammation or intestinal obstruction. 
Treatment.-In the first place the aetio- 
logical indications should be met. The irri- 
tating contents of the bowels should be 
dislodged by purgatives combined with se- 
datives, such as calomel (five or eight grains) 
or rhubarb (twenty grains), with opium (one 
grain), followed by repeated doses of some 
saline aperient, such as sulphate of magne- 
sium or potassium, with tincture of belladonna, 
henbane or opium, and spirit of chloroform, 
until free action of the bowels is obtained. 
A suppository containing half a grain each 
of hydrochlorate of morphine and extract of 
belladonna, or a subcutaneous injection of 
morphine, may secure immediate relief from 
pain before aperients have time to act. 
Large warm enemata often relieve quickly. 
Other suitable measures are-the warm bath, 
friction with warm oil or stimulating lini- 
ments, hot-water fomentations, steamed flan- 
nels, mustard or turpentine stupes, flannel 
bags containing hot chamomile flowers or 
heated sand, the stomach-warmer filled with 
hot water, and large linseed and mustard 
poultices. The diet should be liquid. 
In the prophylactic treatment the diet 
should be strictly regulated; lodgment of ir- 
ritating solids and gases within the bowels 
should be prevented (see Constipation ; 
Flatulence ; and Stools) ; and the abdomen 
and feet should be kept warm by a flannel 
roller or belt and thick woollen stockings, or 
by a foot warmer. George Oliver. 
COLLAPSE.-Definition.- Col!apse is 
a condition of nervous prostration. When 
it is extreme, the vital nervous functions 
are in a state of partial, sometimes nearly 
complete, abeyance. It may terminate in 
death, or be followed by gradual reaction and 
complete recovery. 
Collapse and shock have usually been 
classed together, but it is not accurate to do 
so. It is true that the ganglionic centres of 
the medulla oblongata are more or less pro- 
foundly involved in both, and that the two con- 
ditions possess many symptoms in common, 
dependent upon the derangement of function 
of one or more of these centres. Some con- 
fusion is attributable to the fact that shock 
is a term applied not only to a state or mor- 
bid condition, but to the cause which most 
frequently produces that condition-a violent 
impression or ' shock ' to the nervous centres 
(see Shock). Collapse arises from many 368 
COLLAPSE 
COLLIQUATIVE 
different causes, shock being one, of which 
collapse may be regarded as a final and 
extreme degree, and into which it often im- 
perceptibly passes. Collapse may occur under 
conditions where there has been no antece- 
dent state of shock. Collapse presupposes 
previous nervous exhaustion, while shock 
may instantly appear in a healthy individual. 
^Etiology.-Any severe injury, especially 
if attended by profuse and sudden haemor- 
rhage, may terminate in collapse, such, for 
instance, as the rupture of one of the 
abdominal viscera, a penetrating wound of 
the chest or abdomen, or a wound of the 
heart or of a large artery. Extensive burns 
or scalds frequently give rise to typical 
collapse; and severe and prolonged pain is 
capable of causing it. Rupture of the heart 
or of an internal aneurysm, if the patient do 
not immediately die, causes extreme collapse. 
Certain poisons, as tobacco and arsenic, will 
also produce this condition. It is an advanced 
stage of some diseases, as, for instance, of 
Asiatic cholera; severe drastic purgation also, 
or prolonged vomiting, from whatever cause, 
may occasion it. The pernicious malarious 
fevers and yellow fever often end in col- 
lapse. In acute yellow atrophy of the liver 
symptoms of severe nervous disturbance, 
resulting in a species of collapse, sometimes 
suddenly supervene. Pyaemia, septicremia, 
prolonged narcosis, frequently terminate in 
collapse. 
Symptoms.-The severity of collapse de- 
pends on the nature of the cause, and on the 
age and physical and mental vigour of the 
individual. It may vary from a moderate to 
an extreme degree. A moderate amount is 
seen in the course of fevers and some other 
diseases, but this neither modifies the pro- 
gress of the malady nor attracts the notice of 
the patient, causing chiefly peripheral cold- 
ness. From this trifling amount collapse 
may pass to the most intense form, where 
the patient scarcely differs in outward 
semblance from a dead body. A superficial 
inspection will fail to detect the existence of 
the functions of respiration and circulation. 
Vitality may be said to have reached its 
minimum. In well-marked collapse from 
severe injury or loss of blood, the pulse at 
the wrist may be almost or wholly imper- 
ceptible ; the heart's action scarcely audible, 
or very rapid, fluttering, and irregular ; the 
surface of the body, the face especially, is 
deadly pale and cold, and the skin moist 
with clammy sweat; the respirations are very 
feeble, slow, and irregular, accompanied by 
sighing or gasping inspirations at intervals; 
the expression and character of the face are 
lost; the features are sunken and relaxed; 
the eyes are dull, glassy, staring, or languidly 
rolling about, and the conjunctivae perhaps 
insensible to the touch; the nostrils are 
dilated; the sensibility of the whole body is 
diminished; and the muscular debility is 
extreme. The patient lies on his back, 
without a trace of voluntary effort. If a 
limb is lifted it falls back again as if dead. 
Yet the consciousness and senses may in 
many cases be almost unimpaired; if roused 
by repeated questions, the sufferer will with 
visible effort make a coherent though, pro- 
bably, inadequate reply. 
If relief be not given, the respirations may 
become slower and slower till each one 
appears the last, when a sudden sigh shows 
that life is still present; finally the pulse and 
heart's action become more and more faint, 
and death results from pure asthenia. A 
condition closely resembling traumatic col- 
lapse is often witnessed in the last stage of 
cholera, when in an extreme degree the 
patient almost resembles a corpse save for the 
convulsive movements induced from time to 
time by the painful cramps. The surface is 
pale or bluish and covered with profuse sweat, 
but is at the same time cold to the touch. 
The hands and extremities are icy cold; the 
tongue is cold, and so also is the breath, 
which is gasping and paroxysmal; no pulse 
can be felt at the wrist; the eyes and 
features are sunken; the mind is apathetic, 
but nevertheless the consciousness may be 
perfect, and the patient able to respond to 
questions with a strong voice. Severe purg- 
ing and tobacco-poisoning produce a condition 
very like that described as traumatic collapse. 
Some cases of malignant fever terminate in 
collapse, which is characterised by extreme 
anxiety, by pallor or lividity of the face and 
surface, coldness of the skin, sweating, and a 
small, frequent, and irregular pulse. 
A decrease of animal heat, especially in 
the external parts, is characteristic of col- 
lapse. The temperature of the internal organs 
varies; and there may be collapse with high 
internal temperature. This occurs in cholera, 
intense fevers, and some forms of septicaemia; 
or the converse may obtain, as is frequently 
witnessed in the collapse of dissolution. 
Collapse from loss of blood differs from 
syncope, although the latter may be described 
as an acute and transient form of collapse. 
In syncope the prominent symptom is loss 
of consciousness, which in collapse may be 
almost or quite perfect. 
For the Pathology and Treatment of 
collapse, see Shock. 
William Mac Cormac. 
COLLAPSE, Pulmonary.-A condi- 
tion in which the lung is simply more or less 
devoid of air. See Lung, Collapse of. 
COLLIQUATIVE (colliqueo, I melt). 
A term which originated in the belief that in 
certain conditions the solid parts of the body 
melted away, and -(Vere carried off as liquid 
discharges. The word is now generally 
applied to the copious sweats and diarrhoea 
which occur in certain wasting diseases, 
such as phthisis. COLLOID 
COLON, DISEASES OF 
369 
COLLOID (xdXXa, glue; and eiW, like). 
A peculiar morbid product resembling in its 
characters glue or jelly, and found associated 
with cancer and other forms of new-growth. 
See Cancer ; and Degeneration. 
COLON, Diseases of. - Synon. : Fr. 
Maladies du Colon; Ger. Dickdarmkrank- 
heiten.-The colon participates to a varying 
extent in the lesions and derangements of 
dysentery, typhoid fever, enteritis, peritonitis, 
and other affections. The special disorders 
to which it is most liable are intimately con- 
nected with its anatomical and physiological 
peculiarities. The colon is a distensible 
membranous tube, of large capacity, with 
chiefly solid contents, which are propelled 
slowly onwards by the muscular contractions 
of the walls. The moving force and the 
resistance offered to it are often too finely 
balanced, so that whenever the energy of the 
former is somewhat reduced, an accumulation 
of excretory products is apt to be determined. 
Hence arise retention of faeces and gases, 
constipation, and consecutive evils, such as 
colic, colo-enteritis, or ulceration of the colon. 
I. Atony and. Dilatation.-Definition. 
Loss of contractility of the walls of the 
colon, leading to accumulations, dilatation, 
and other sequelae. 
JStiology.-The causes of torpor or atony 
of the colon are mainly those of consti- 
pation- sedentary, indolent, and luxurious 
habits, over-stimulation of the bowels by 
coarse foods, purgatives, and enemata, a slug- 
gish and lymphatic temperament, old age, and 
general debility or exhaustion, as after a 
long and tedious illness (see Constipation). 
Whenever the walls of the colon are dis- 
tended by solid or gaseous accumulations, 
the contractile power is apt to be enfeebled, 
leading to further retention, loss of tone, and 
dilatation. 
Atony of the colon is an important element 
in the pathogeny of constipation. The colon 
is apt to become greatly dilated throughout, 
or mainly so in certain portions, such as the 
caecum and sigmoid flexure, behind some 
cause of obstruction - stricture, misplace- 
ment, elongated meso-colon, lodgment of 
faeces, &c.; but instances of even excessive 
dilatation are recorded without the post-mor- 
tem discovery of a mechanical cause. When, 
however, dilatation results from obstruction, 
there will be found hypertrophy of the mus- 
cular coat of the bowel. Tympanitic dis- 
tension of the colon from paralysis of the 
sympathetic occurs in peritonitis and in 
certain fevers, such as typhoid. 
Symptoms.-Torpor of the colon may be 
indicated only by constipation. There are 
usually the ordinary signs of retention of 
flatus or feces. In hysteria, and in inflam- 
mation of the bowels or peritoneum, flatus 
is apt to accumulate rapidly, and to pro- 
duce great distension of the colon. Faeces 
may collect and form large tumours in any 
part of the large intestines, but especially in 
the caecum and sigmoid flexure. See Stools. 
Faecal and gaseous accumulations in the 
colon resulting from atony may produce the 
following effects, directly or remotely con- 
nected with them:- 
(a) Local.-1. Colic. 2. Inflammation of 
the walls of the colon, or of the mucous and 
submucous coats, and ulceration. 3. Distur- 
bances from pressure. Thus flatulent disten- 
sion and faecal accumulation encroaching on 
the cavity of the thorax, and impeding the 
descent of the diaphragm, may cause feeble 
respiration, dyspnoea or short and rapid respi- 
ration, palpitation and irregular action of the 
heart or upward displacement of this organ, 
with remote effects arising from a disturbed 
circulation in the brain, such as giddiness and 
headache. On the other hand, a distended 
caecum or sigmoid flexure, pressing on veins 
and nerves, may induce oedema, numbness, 
and cramps of the right or left lower extremity. 
4. Retarded digestion, derangement of the 
stomach and liver, and intestinal obstruction. 
(&) General.-The absorption of excremen- 
titious matters may lead to widespread gene- 
ral effects, indicated by a sallow, earthy, or 
dirty complexion, lassitude, debility, offensive 
breath, loaded urine, and other symptoms. 
Chlorosis has been attributed to this cause. 
Treatment.-Atony of the colon is usually 
a chronic disorder demanding prolonged 
treatment. The hygienic and dietetic rules 
laid down in the article Constipation require 
in most cases to be supplemented by medi- 
cines. The most satisfactory results follow a 
course of tonics combined with aperients, such 
as iron, quinine, strychnine, and belladonna, 
with aloes, colocynth, or rhubarb. The pur- 
gative should be adjusted to each case, so as 
to secure no more and no less than a regular 
and efficient evacuation; and while the loaded 
colon continues to be thus relieved, the dose 
should be very gradually reduced. This 
tonic-aperient course may be greatly aided 
by local stimulation of the colon, as by mas- 
sage, electricity, and cold-water compresses 
or abdominal douches (see Constipation). 
The abdomen should be supported by a belt 
or roller. Bretonneau and Trousseau strongly 
advised a course of belladonna, giving gr. 4 
of the extract, or of the powdered leaf, as a 
pill in the early morning-the stomach 
being empty; then two such pills, if in four 
or five days the bowels do not respond ; and 
increasing the dose, but not beyond that 
contained in four or five pills in twenty-four 
hours. A teaspoonful of castor oil may be 
given twice a week to aid this course of treat- 
ment. Flatulent distension of the colon in 
the elderly, and in females at the climac- 
teric period, is often greatly relieved by the 
prolonged use of a pill containing the com- 
pound asafcetida pill and extract of nux 
vomica, after meals. 370 
COLON, DISEASES OF 
COLORADO SPRINGS 
In excessive gaseous dilatation of the colon 
(as in volvulus of the sigmoid flexure), pro- 
ducing much distress from dyspnoea, pain, 
and vomiting, puncture by a fine trochar or 
aspirator-needle has been successfully re- 
sorted to as a palliative measure. 
II. Stricture. - Stricture of the colon 
may occur in any part, but is most common 
in the sigmoid flexure and descending colon. 
It is limited to adults. It more commonly 
arises from cancer than from the cicatrising 
of an ulcer (simple stenosis). In non-can- 
cerous stricture a history of dysentery is im- 
portant-though a long interval (even years) 
may have elapsed since the attack. The stric- 
ture declares itself by setting up symptoms of 
intestinal obstruction-there being at vary- 
ing intervals attacks of paroxysmal, shifting, 
colicky pain across the navel, with constipa- 
tion (or constipation alternating with diar- 
rhoea) aggravated by purgatives, becoming 
more and more frequent and associated with 
vomiting-when, as a rule, the difficulty ceases 
to be intermittent. Large faecal masses may 
often be felt above the site of obstruction. 
In stenosis of the sigmoid flexure there is 
sometimes tenesmus, and the motions are 
flattened ; the stricture can be reached 
when the whole hand is introduced into the 
rectum. The motions are not, as a rule, 
altered in shape when the stricture is situate 
in the higher part of the colon. The site of 
obstruction may sometimes be determined 
by auscultating the abdomen while water is 
being gently and intermittently injected into 
the rectum-the observer failing to hear the 
stream above the stricture. The duration of 
the cancerous as well as of the simple forms 
averages from five to six months. 
Treatment.-The treatment of stricture of 
the colon is further referred to in the article 
on Intestinal Obstruction. 
III. Inflammation. - Synon.: Colitis; 
Colonitis ; Colo-enteritis; Fr. Oolite; Ger. 
Entziindung der Schlcimhaut des Kolons. 
An inflammation, leading to ulceration of 
the mucous membrane and submucous con- 
nective tissue of the colon, producing lesions 
indistinguishable from those of dysentery, 
has been.pointed out by Copland and Parkes. 
Colitis is said to be a non-specific local affec- 
tion, commencing in the submucous tissue, 
and subsequently attacking the mucous 
membrane with its glandular structures-the 
primary seat of dysenteric inflammation. As 
in dysentery, the inflammation induces gan- 
grenous destruction and ulceration of the 
mucous membrane and underlying cellular 
tissue. 
A catarrhal form of colitis is apt to occur 
in measles. ' It often happens that the 
morbillous catarrh of the intestines exhausts 
itself by attacking the large intestine, pro- 
ducing that special form of colitis character- 
ised by tenesmus and glairy bloody stools.'1 
Inflammatory diarrhcea, particularly in chil- 
dren, often terminates similarly. 
Colitis arising from retained excreta may 
involve the entire wall of a circumscribed por- 
tion of the colon, commonly the ascending 
colon and sigmoid flexure, or may be con- 
fined to the mucous and submucous tissues. 
In faecal retention the mucous follicles of the 
colon may become obstructed, and the dis- 
tension resulting therefrom may lead to 
inflammation and ulceration. Irritation of 
the mucous lining of the colon from the 
lodgment of faeces may extend to the lym- 
phatic vessels and glands. The glandular 
enlargement cannot, however, as a rule, be 
recognised during life. In colitis there are 
usually colicky pains, intestinal distension, 
and diarrhcea alternating with constipation; 
and the stools are often coated with masses 
of mucus. 
Treatment.-The treatment of colitis con- 
sists in the local application of fomentations, 
poultices, opium enemata, or morphine sup- 
positories ; and in the use of gentle laxatives, 
such as castor oil, combined with sedatives, 
such as opium, belladonna, or henbane. The 
catarrhal form generally terminates in spon- 
taneous recovery. Trousseau advised the 
use of albuminous injections, or of injections 
containing about half an ounce of water and 
nitrate of silver-from f to H grains; or 
sulphate of copper or sulphate of zinc -from 
3| to 4^ grains. The diet must be very care- 
fully ordered. 
IV. Displacements.-The parts of the 
colon most liable to displacement are the 
transverse colon and sigmoid flexure. The 
former may descend as low as the pubes; 
the latter may occupy any position be- 
tween the left iliac region and the right 
side of the abdomen. Usually the meso- 
colon is elongated ; there is adhesion between 
the displaced part and the new site; and, 
the longitudinal bands being elongated, the 
loculi are obliterated. Displacements are 
most apt to occur in those who have long 
suffered from constipation, retention of faeces, 
chronic dysentery, hernia, or from encysted 
or other tumours. They may lead to com- 
plete obstruction, and cannot usually be 
recognised with certainty during life. 
V. Diverticula.-A loculus of the colon 
from repeated accumulation may become so 
distended as to form a lateral appendix. 
Such a diverticulum when loaded with faeces 
may be felt through the abdominal wall as a 
distinct tumour, which may collapse when 
pressed between the fingers. 
George Oliver. 
COLORADO SPRINGS, in Colo- 
rado, U.S.A.-A clear, cold, and very 
bracing climate, with great dryness and 
diathermancy of the atmosphere ; 6,028 feet 
above the sea. No snow in any quantity, and 
consequently no snow-melting season. Dry 
1 Trousseau, Clinique Medicale. COLORADO SPRINGS 
COMEDONES 
371 
and dusty winds in spring. Camping out at 
nearly all seasons tolerably safe. A high-alti- 
tude station, useful in asthenia and in chronic 
phthisis, especially with limited lesions and 
no pyrexia. The name of4 springs ' is added 
from the proximity of Colorado City to Mani- 
tou Springs, six miles distant. See Climate, 
Treatment of Disease by. 
COLOUR-BLINDNESS-A defect of 
vision, the subject of which is unable to 
distinguish certain colours. See Vision, 
Disorders of. 
COMA (Ka>na, deep sleep).-A condition 
of profound insensibility. See Conscious- 
ness, Disorders of. 
COMA-VIGIL (natgo, deep sleep; and 
vigil, wakeful). 
Definition.-A symptom, or set of symp- 
toms, where continuous sleeplessness is asso- 
ciated with partial unconsciousness. 
Coma-vigil occurs towards the end of dis- 
eases in which the nervous system is involved 
either directly or indirectly, especially where 
sleeplessness has been a symptom in the 
earlier part of the disease. Thus it frequently 
appears towards the end of an attack of 
typhus or of delirium tremens, when these 
are about to terminate fatally. 
Symptoms.-The patient lies quiet with his 
eyes half-closed, inattentive to everything 
around, but not absolutely unconscious. If 
the eyelids are touched, they are closed, and 
perhaps the head is slowly turned away. 
The eyes have a dull, half-glazed look, and 
slowly follow any moving object near them. 
The pupils are neither much dilated nor con- 
tracted, and they move under the influence 
of light, but very sluggishly. The mouth is 
generally somewhat open and dry, as are also 
the lips. The power of swallowing is much 
impaired : if a small quantity of fluid be put 
into the mouth, an effort is made after a short 
time to swallow it, and this effort is for a time 
successful; but after the symptoms have been 
present for some time, the effort is so feeble 
that no result follows. The patient lies 
mostly on the back; if turned on the side, he 
either remains as placed, or often slowly 
turns to the former position. The limbs are 
occasionally moved a little; and if the hand 
or arm be raised, a slight resistance is offered. 
If the bladder or the rectum be emptied, 
there is slight consciousness of the act, as if 
a feeling of discomfort preceded it. The pulse 
is quick and weak. The respirations are 
weak, but otherwise normal. The symptoms 
continue unbroken throughout, nothing like 
natural sleep occurring. 
Pathology.-As being little more than a 
symptom, coma-vigil has strictly speaking 
no pathology. It seems to coincide with the 
gradual suspension through exhaustion of the 
functions of the nervous centres ; the cerebral 
hemispheres being nearly if not quite inac- 
tive, while the action of the rest of the centres 
is kept up weakly but continuously, till the 
little remaining nervous power is exhausted, 
when death ensues. It differs from coma 
inasmuch as in the latter the medulla oblon- 
gata is the only centre left active, the func- 
tions of the rest being entirely suspended. 
It differs from concussion, inasmuch as the 
symptoms of the latter attending the tem- 
porary unconsciousness are more those of 
irritation than of pure suspension of function. 
Diagnosis. - Coma-vigil is distinguished 
from coma by the presence of a certain 
amount of consciousness, by the quick pulse, 
and by the absence of stertorous breathing. 
It is distinguished from concussion of the 
brain by the pupil not being contracted, by 
the history of the case, and by the absence of 
coldness of the skin, and of any sign of shock. 
Prognosis.-Theprognosis isunfavourable: 
coma-vigil is almost invariably a fatal symp- 
tom. It may last from a few hours to three 
or four days ; from twenty-four to forty-eight 
hours being the most common duration. It 
may deepen into actual coma; but more 
usually the symptoms change but little, save 
that the pulse becomes quicker and weaker, 
and the respiration more feeble, and death by 
asthenia then results. 
Treatment.-Coma-vigil does not call for 
treatment directly itself, but is an urgent in- 
dication for nutritive and stimulant measures 
calculated to relieve the primary disease. 
R. Beveridge. John Banks. 
COMEDONES (comedo, a glutton).- 
Synon. : Grubs.-This is the name applied 
to the little cylinders of sebaceous and epi- 
thelial substance which are apt to accumu- 
late in the follicles of the skin, and to appear 
on the surface as small round black spots. 
When squeezed out they have the appear- 
ance of minute maggots or grubs with black 
heads, and thence have derived their name. 
They may occur in all parts of the body 
where sebaceous follicles exist, but are most 
common on the face, the nose, the neck and 
shoulders, the breast, and within the concha 
of the ears, in the latter situation often at- 
taining a considerable size. The accumula- 
tion of this substance is due to want of 
expulsory power of the skin, and to the slight 
impediment which is afforded by the aper- 
ture of the follicle to its exit. When squeezed 
out, a comedo is found to vary in colour, in 
figure, and in density, according to the 
period of its detention. When recent, the 
comedones are soft and white, and modelled 
into an exact cylinder by compression through 
the mouth of the follicle. If impacted 
for a considerable time, they acquire the 
yellow tint, the transparency and hardness 
of horn; they assume a bulbous figure from 
the dilatation of the follicle below the con- 
stricted orifice of the epidermis ; and by their 
bulk they sometimes stretch the hair-follicle 
so far as to obliterate it completely. Besides 372 
COMEDONES 
CONCRETION 
their usual composition of sebaceous sub- 
stance and epithelial cells, they frequently 
contain lanuginous hairs, and not rarely the 
entozoon folliculorum in its different phases 
of development (see Acarus). When they 
raise the pore into a minute pimple they have 
a similitude to acne punctata, and might be 
mistaken for that affection; whilst the black 
spot on the summit of conical acne is due to 
a comedo. 
Treatment.-Comedones are most fre- 
quently met with in young persons in whom 
the powers of the constitution are not yet es- 
tablished, and who are benefited by generous 
diet and tonic treatment. Locally, soap and 
water with plentiful friction and ablution 
will be found of great service; and, as an 
astringent, a lotion of perchloride of mercury 
in emulsion of bitter almonds (two grains to 
an ounce) and spirits of wine ; or a lotion of 
carbolic acid. Erasmus Wilson. 
COMPLICATION (con, with; and^Zico, 
I fold).-It is difficult to give a strict defini- 
tion of what ought to be included under the 
term complication; but the word signifies the 
occurrence during the course of a disease of 
some other affection, or of some symptom or 
group of symptoms not usually observed, by 
which its progress is therefore ' complicated,' 
and not uncommonly more or less seriously 
modified. The difficulty lies in determining 
what should be looked upon as essentially 
part of the original disease, and what as a 
mere accidental occurrence. For instance, 
many regard the cardiac affections which so 
often arise during the progress of acute rheu- 
matism as a part of the complaint, others 
as complications. The same remark applies 
to the relationship of renal disease to scarla- 
tina, as well as to numerous other cases. 
Complications arise in different ways. 
They may, as just indicated, be considered as 
developments of the original morbid condi- 
tion, resulting from the same cause and being 
more or less allied; or they are independent 
and accidental, of which an illustration is 
to be found in the association of ague with 
scurvy or dysentery, or in the co-existence of 
two or more of the exanthemata. The most 
important class of complications, however, 
are those which follow the primary disease as 
more or less direct consequences. These may 
further be induced in various ways. Thus, 
for example, in febrile diseases secondary 
lesions are liable to arise as a result of 
changes in the blood; a mechanical act, such 
as cough, may lead to complications in the 
course of phthisis and other pulmonary affec- 
tions ; cardiac diseases frequently bring about 
consecutive changes in other organs, by in- 
ducing obstruction of the venous circulation; 
or emboli may originate under certain con- 
ditions and produce their usual consequences. 
It is of great practical importance to be ac- 
quainted with the complications which are 
liable to be met with in various diseases, 
and especially in those which are of an acute 
nature, in order that measures may be taken 
for their prevention, and that they may be 
recognised and treated at the earliest possible 
period, if they should occur. 
Frederick T. Roberts. 
COMPOUND GRANULAR COR- 
PUSCLES.-Formerly these microscopic 
objects were regarded as of inflammatory 
origin, and as affording positive evidence 
of the occurrence of inflammation. Hence 
they were termed 'compound inflammation 
globules ' (Gluge). Almost all pathologists 
now, however, recognise the fact that they 
are not products of an inflammatory process, 
but result either from the degeneration of 
pre-existing cells, in which protein and fatty 
granules accumulate, or, perhaps, from the 
aggregation of granules originally distinct, 
which are present in abundance in degene- 
rating tissues. They may even be formed 
out of the cells of morbid products, such as 
cancer. These compound granular corpus- 
cles derive their name from the fact that 
they consist of a large number of minute 
granules aggregated together, and they 
either present a delicate cell-wall, or this 
cannot be detected. Occasionally there is an 
appearance of a nucleus in the centre. See 
Cell. Frederick T. Roberts. 
COMPRESS.-A compress is made of 
folds of lint or other material, and is used 
for the purpose of producing pressure, or as 
a pad by which hot or cold water or medi- 
cinal agents may be applied to the surface. 
In the latter case the compress may be 
rendered waterproof by being covered with 
a piece of gutta-percha tissue or mackintosh- 
cloth. See Hydropathy. 
COMPRESSIBLE.-A term implying 
comparatively slight resistance, and applied 
specially to the pulse when it yields readily 
under the finger. See Pulse, The. 
COMPRESSION of the Brain.-See 
Brain, Compression of. 
COMPRESSION of the Lung.-See 
Lungs, Compression of. 
CONCRETION (con, together; and 
cresco, I grow).-Synon. : Calculus; Fr. Con- 
cretion ; Calcul; Ger. Concrement. 
Definition.-An unorganised body,formed 
either in one of the natural cavities or canals, 
or in the substance of an organ, by the deposit 
of certain solid constituents of the fluids of 
the part. In the widest sense of the term, 
concretions comprehend calculi. 
Enumeration and Classification.-The 
following classified list includes the principal 
varieties of concretions:- 
1. In glandular structures: lacrymal, 
salivary, pancreatic, prostatic, seminal, uri- 
nary, hepatic, sebaceous, and mammary. CONCRETION 
CONDYLOMA 
373 
2. In the circulatory system : cardiac, and 
venous (phleboliths). 
3. In closed sacs : peritoneal, and articular. 
4. In culs-de-sac: bronchial, pulmonary, 
nasal, tonsillar, laryngeal, gastric, intestinal, 
praeputial, uterine, and vaginal. 
5. In the substance of tissues and new 
formations, especially in the nervous system : 
corpora amylacea. 
6. Various: such as the concretions on the 
teeth known as ' tartar.' 
General Characters and Number.-Con- 
cretions are generally firm or even of stony 
hardness ; but they may be soft and friable. 
Their colour varies from white to black 
through shades of yellow and red. Concre- 
tions occur either singly or in groups; and 
their shape and size, as well as the charac- 
ters of their surface, vary considerably with 
their number: single concretions are more 
frequently larger, rounded, and less smooth 
than multiple specimens, which often pre- 
sent facets and polished surfaces. Many 
concretions are composed of concentric 
laminae. 
Composition.-The chief constituents of 
concretions are inorganic, that is, mineral 
salts, in a basis of organic matter. The bulk 
of the salts are carbonate and phosphate of 
calcium and magnesium, with smaller quan- 
tities of alkaline compounds. The organic 
basis is composed of albuminous substances, 
mucus, cholesterin, and colouring matters. 
Mode of Formation.-Concretions are 
generally derived from the solid constituents 
of vital fluids, whether physiological or 
pathological. In most instances the fluids 
are delayed in the natural passages by some 
abnormal obstruction or dilatation ; and under 
such circumstances a chronic inflammatory 
condition of the walls contributes greatly to 
the probability of mineral deposit. Most 
frequently-as in the formation of the sali- 
vary and biliary concretions-the fluid por- 
tions of the secretion escape by the natural 
outlet or are absorbed, while the solid con- 
stituents are deposited; the particles being 
either agglomerated around a nucleus, or 
deposited in centripetal layers upon the 
surface of the cavity. In other instances- 
intracardiac, peritoneal, and articular-a nu- 
cleus is furnished by a particle of fibrin, 
blood-clot, or growth, on which fresh deposits 
take place, while calcification proceeds in the 
interior. In a third series, examples of which 
are found in the alimentary canal, the basis 
of the concretion consists of foreign or indi- 
gestible matter, such as hair, a gall-stone, 
inspissated faeces, and masses of magnesium 
or iron salts. See Calculi. 
Effects and Symptoms.-The functions 
of a part occupied by a concretion are gene- 
rally more or less impaired; the neighbouring 
tissues frequently atrophy; and inflammation 
and ulceration are common results, ending 
probably in the escape of the body. The 
concretion may be passed along a duct, and 
this process is generally attended with great 
pain; but concretions may remain where 
formed without causing symptoms. Occa- 
sionally they are spontaneously disintegrated 
or dissolved. 
_ Treatment.-The treatment of concre- 
tions will be found discussed under the heads 
of the diseases of the organs where they re- 
spectively occur. 
J. Mitchell Bruce. 
CONCUSSION (concutio, I shake to- 
gether).-This term is used to indicate a con- 
dition induced by a more or less violent 
shaking or physical commotion of the general 
system, or of some particular organ, whereby 
serious symptoms may be induced, but no 
definite lesion can be detected to account for 
them. The nerve-centres are the parts most 
liable to be thus affected, concussion of the 
brain or spinal cord being of considerable 
moment, giving rise to more or less complete 
abolition of their functions, though this effect 
is usually only temporary (see Brain, Con- 
cussion of; and Spinal Cord, Diseases of). 
General concussion of the body is highly im- 
portant at the present day, in connexion with 
railway accidents, after which persons seem 
to be uninjured, or only to be slightly shaken, 
but subsequently more or less grave symp- 
toms, associated with the nervous system, set 
in. See Railway Accidents, Results of. 
Frederick T. Roberts. 
CONCUSSION OF BRAIN, SPINE, 
&c.-See Brain, Concussion of; and Spinal 
Cord, Diseases of. 
CONDYLOMA (KovbvXa>p.a, a knob).- 
Synon. : Fr. Condylome; Ger. Feiywarze. 
This vague term has been used to de- 
scribe at least two different things-namely, 
(a) papillomata, or warty growths in the 
neighbourhood of the anus and. genital organs; 
and (&) the syphilitic lesions called mucous 
patches or mucous tubercles. Of these the 
former only will be dealt with here. The 
latter are described under Mucous Patch. 
Description. - Condylomata are com- 
monly found in connexion with the constant 
moisture and irritation due to acrid secre- 
tions, whether natural or morbid, especially 
the discharges of venereal affections. The 
growths occur most frequently and attain the 
greatest size in dirty persons, in whom also 
they are most liable to become inflamed, ul- 
cerated, and fissured. The enormous masses 
sometimes seen in pregnant women are often 
called ' cauliflower ' growths. 
Treatment.-Frequent washing, followed 
by the free application of some absorbent 
powder, such as oxide of zinc, is essential. 
When the growths are very large, or fail to 
disappear under caustics, removal by scissors, 
knife, or cautery will be necessary. 
Arthur Cooper. 374 
CONFLUENT 
CONSCIOUSNESS, DISORDERS OF 
CONFLUENT (confluo, I run together). 
Applied chiefly to a variety of small-pox and 
other exanthemata, in which the eruption 
runs together or coalesces. 
CONGENITAL (con, together; and 
genitus, begotten).-Existing at birth: a term 
generally applied to diseases such as con- 
genital syphilis, or malformations such as of 
the heart, and congenital clubfoot. 
CONGESTION (congero, I accumulate). 
Overfulness of vessels, caused by accumula- 
tion of their contents: generally applied to 
blood-vessels. See Circulation, Disorders of. 
CONIUM, Poisoning by. - Synon. : 
Fr. Empoisonnement par la Cigue; Ger. 
Schierlingsver gif tung.-All parts of the 
hemlock plant (Conium maculatum; Greek, 
Kcoretov) are poisonous. Both the leaves and 
fruit are used in medicine. Its toxic properties 
were known in ancient times ; the plant was 
used for the destruction of criminals by the 
ancient Greeks, and there is no doubt that 
Socrates was poisoned by it. Death from 
conium in this country has perhaps always 
been the result of misadventure or suicide; 
but on the Continent the active principle of 
the plant, conine, an alkaloid, has been ad- 
ministered for the purpose of wilful homicide, 
death resulting from a dose of 10 to 15 drops. 
Anatomical Characters. - The signs of 
asphyxia, engorgement of lungs and of the 
right heart, and a general venous condition 
of the blood, appear to be constant after 
death from conium. There is nothing else 
specially noticeable. 
Symptoms.-Preparations of conium, as well 
as the alkaloid, or mixture of alkaloids, known 
as conine, when taken in toxic doses, produce 
excessive muscular weakness, beginning in 
the lower limbs, and extending gradually up- 
wards, with giddiness and disordered vision. 
These symptoms are in some cases preceded 
by nausea and vomiting, with dryness or 
burning pain in the mouth and fauces. There 
is a desire to remain quiet, and a peculiar 
heaviness or drooping of the eyelids, the 
patient lying with his eyes shut. This, and 
the impairment of vision, appear to be due 
to paralysis of the ocular muscles. The 
pupils may be natural, but later they become 
dilated. The pulse is slow till death is ac- 
tually impending. The paralysis progresses 
gradually upwards, till eventually heart and 
respiration are affected, more especially the 
former. Convulsions and impairment of 
the mental faculties-hitherto intact-now 
set in; finally sensation is impaired, and 
death ensues from asphyxia. 
Diagnosis.-The paralysis of motion, pro- 
gressing gradually upwards, with sensation 
long unimpaired, and the peculiar drooping 
of the eyelids, are perhaps diagnostic of the 
nature of the poison. 
Prognosis. - As no antidote is known 
which counteracts the effects of conine, the 
prognosis must always be a guarded one, 
and will depend entirely upon the general 
condition of the patient. 
Treatment.-The stomach must be emp- 
tied by the stomach-pump or syphon-tube, 
and well washed out. Emetics may also be 
used to evacuate the stomach. Tannin and 
other astringents must be freely administered, 
to precipitate the active alkaloid, and prevent 
its absorption. Castor oil, administered by 
the mouth or rectum, may aid the removal 
of the alkaloid when it has been rendered 
insoluble by tannin. Strong coffee, brandy, 
ammonia, and stimulants generally are ser- 
viceable, as may also be the hypodermic 
injection of ether. Hypodermic injections of 
l-40th grain of sulphate of atropine are very 
promising, especially in the later stages; 
atropine acting as a respiratory and cardiac 
stimulant. Artificial respiration, and stimu- 
lation of the respiratory and cardiac functions 
by the use of electricity, ought not to be 
neglected when these are affected. 
Thomas Stevenson. 
CONJUNCTIVITIS. - Inflammation 
of the conjunctiva. See Eye and its Appen- 
dages, Diseases of. 
CONSCIOUSNESS, Disorders of.- 
The disorders of consciousness are so nume- 
rous as to make it desirable briefly to consider 
them in one article, with a view to their 
classification and the better comprehension 
of their mutual relations. We shall, there- 
fore, here group and arrange the varied mor- 
bid conscious states, not aiming to produce 
a strictly scientific classification so much as 
one which will be practically useful. 
1. Exaltation.-Under this head may 
be ranged certain states of consciousness 
more or less distinctly bordering upon the 
unnatural, to be met with in persons under 
the influence of ' mental excitement ' from 
various causes, as from sudden good news, or 
generally pleasant surroundmgs ; also from 
a slight degree of poisoning by alcohol, 
opium, hashisch, or other drugs ; or from an 
early stage of some forms of insanity, or of 
delirium. In this state of mental exaltation 
the individual's powers of perception, appre- 
hension, recollection, thought, emotion, and 
volition, would seem to be all more or less 
intensified, just as in that of hebetude or 
dementia they are diminished, and conscious- 
ness is proportionately dwarfed. 
2. Perversions.-Many of the various 
defects here to be referred to are very partial 
in the extent to which they implicate con- 
sciousness, though others are general. In 
what is known as an illusion some object 
of sense is not correctly perceived ; or, in 
other words, some sensorial impression is 
quite wrongly interpreted-as when a feverish 
or a maniacal patient, looking at some inani- 
mate object, declares that it is a cat or a dog CONSCIOUSNESS, DISORDERS OF 
375 
about to fly at him, or, hearing even the 
slightest noise in any part of his room, inter- 
prets it to be the voice of some friend or 
imagined enemy. In the case of an halluci- 
nation, however, forms are declared to be 
seen, or voices heard (by a patient suffering 
from delirium tremens, for instance), where 
no appreciable external realities could have 
started the notion. And in these cases, it is 
not that the patient sees or hears without 
believing; he implicitly believes that the 
visions or voices, which have been conjured 
up subjectively by the mere disordered work- 
ing of his own brain, have a real existence 
in the outside world. It is necessary to 
make this distinction, because it is by no 
means uncommon, in regard to the olfactory 
sense (especially in some epileptics), for 
odours or smells to be perceived which the 
patient soon comes to know are purely sub- 
jective or devoid of any external correlative. 
Hallucinations and illusions, moreover, 
though occasionally existing alone, are quite 
commonly associated with a very important 
and more general derangement of conscious- 
ness, namely, deUrium. This is a symp- 
tom very common in many fevers, in cer- 
tain low states of the system, after severe 
frights, in inflammatory or other lesions of 
the brain and its membranes, as a result 
of some narcotico-irritant poison, or occa- 
sionally in a person who is recovering from 
an epileptic attack, or from the stupor sequen- 
tial to a series of convulsive attacks. The 
state itself varies much in intensity. Three 
fairly distinct types exist. In (a) low or 
muttering delirium the patient lies still and 
more or, less heedless of what is occurring 
around ; or, if heeding at all, the impressions 
which he receives give rise to erroneous per- 
ceptions (illusions), which are woven into the 
incoherent fabric of his rambling thought. 
In (6) delirium tremens the patient is more 
restless; tremors of the limbs and of the 
muscles of the face are often easily induced; 
hallucinations of sight and hearing are 
common; and the character of the delirium 
reveals that the patient is, to an unusual 
extent, possessed by fears, terrors, and other 
emotions of a depressing type. In (c) wild 
or raving delirium we have to do with a 
much more active state. The patient raves 
loudly and incoherently, more in regard to 
his fleeting dream-like thoughts than in con- 
nexion with external impressions, of which 
he is more or less heedless. He is often 
violent in demeanour, and difficult to be 
restrained, persons in this state being capable 
of great and prolonged muscular exertion. 
The bodily activity accompanying this form 
of delirium is, in fact, just as characteristic 
as the great intensity of the mental processes. 
It is met with occasionally in some fevers, 
but more commonly in meningitis and in 
acute mania. 
In its early stages delirium is principally 
noticed during the transition-period between 
waking and sleeping-at times, that is, when 
the nervous system most needs the re- 
invigorating influence of sleep. It is in these 
cases, too, that beef-tea or stimulants may 
for a time dispel all traces of the wandering 
thought. Whilst illusions and hallucinations 
enter largely into the mental activity of a de- 
lirious patient, delusions also are generally 
well-marked components. That is to say, 
the person becomes for a time possessed by 
an idea, notion, or fancy, for which there is 
no real warranty, though he believes and 
wishes to act as though it were true. 
Somewhat allied to delirium in nature, 
though much lower in intensity as a mental 
process, is that incoherence of thought which 
is met with in many chronic maniacs, or in 
non-febrile patients suffering from various 
organic brain-diseases. In its slighter de- 
grees this incoherence displays itself as mere 
' rambling ' talk; the patient has not suf- 
ficient brain-power to follow up the main 
subject of thought, and is frequently diverted 
into collateral channels. This, which is a 
natural state with some persons, may be 
distinctly indicative of disease in others 
whose mental power has previously been 
of a more vigorous type. At times the inco- 
herence is seen to be governed principally 
by mere verbal suggestion, the patient being 
led away from point to point in new di- 
rections, owing to the associations of some 
word which has been used becoming for the 
time dominant. This state is often well seen 
in the sub-acute exacerbations of chronic 
mania, though it may occur also where mul- 
tiple softenings or indurations of the brain 
exist. At other times the incoherence is 
more absolute-wayward transitions from 
subject to subject, connected by no discover- 
able bond, rapidly following one another. 
The result in such a case is a mere unmean- 
ing jumble of words, interspersed here and 
there with brief propositions having a limited 
significance of their own, though often wholly 
unrelated to that which precedes or follows. 
Hypochondriasis is a perverted state of 
consciousness, having some resemblance to 
that of illusion, but in which some internal 
or visceral state becomes the starting-point 
of impressions (possibly not actually pain- 
ful) which, when magnified and perverted as 
they are in the mind of the patient, fill him 
with false and gloomy apprehensions of 
various kinds. This perversion of conscious- 
ness is more generalised than that which 
exists in the case of illusion; and also, in- 
stead of being a more or less temporary defect, 
it is one that may last for weeks, months, or 
even years. The state of mind of an hysterical 
patient is often not altogether different from 
that of the hypochondriac. 
3. Partial Loss.-Defects of this order 
are numerous and may exist in great variety. 
They may implicate almost equally nearly all 376 
CONSCIOUSNESS, DISORDERS OF 
the varieties of conscious mental activity, 
or some more than others. They may be 
either congenital, or acquired during the life 
of the individual. 
In idiocy we may have from birth defect 
in the power of concentrating the attention, 
a defective power of apprehension and of 
thinking, and a defective volition, shown 
alike by an inability to guide or control 
thought, and by a deficient vigour of bodily 
movement. Again, as a result of epilepsy, 
of organic brain-disease, or of injuries to the 
head, the patient may gradually lapse into 
such a condition from one of health, so as to 
become, as it is termed, ' demented.' Whilst 
this state of dementia may supervene at any 
age, it is much more common as a conse- 
quence of the brain-diseases frequent in 
advanced life. There is, moreover, a form 
known as senile dementia, in which without 
any typical disease, but as a consequence of 
impaired tissue-vitality and diffused degenera- 
tive changes throughout the nervous system, 
the mental faculties undergo a more marked 
degradation than is usually met with in old 
age. This condition in its minor degrees 
goes by the name of hebetude. In all such 
states or grades of idiocy and dementia, 
we meet with an undue tendency to sleep 
in the daytime as a result of the listless 
and languid mental condition. This is but 
another sign of the general lowering of con- 
scious vigour. 
Here we must include, also, a peculiar 
group of conditions, having some alliance with 
one another, and which are all characterised 
by loss of consciousness to some extent, 
either partial in range or general. They are- 
reverie, somnambulism, ecstasy, coma-vigil, 
catalepsy, hypnotism, and trance. They are 
merely enumerated here, but are defined or 
described in their several places. In the 
last of these conditions the loss of con- 
sciousness, in the ordinary acceptation of the 
term (namely, loss of perceptive power}, is so 
absolute, that some may think it ought rather 
to be included in the next section. Loss of 
perceptive power, however, would not seem 
to be absolutely synonymous with loss of 
consciousness. There is good reason to be- 
lieve, for instance, that where the influence 
of chloroform and other anaesthetics is not 
pushed to the fullest extent, a condition of 
ancesthesia intermediate between slight and 
profound is produced, in which, whilst there 
is absolutely no consciousness for external 
impressions, so that pain is altogether unfelt, 
there is still a certain amount of cerebral 
activity-as evidenced by rambling and 
indistinct speech on subjects altogether apart 
from what the surgeon may be doing. There 
is mental activity clearly, though the nature 
of this, as revealed by the patient's speech, 
may preclude the notion that pain is at the 
time being felt. Sensorial consciousness is 
blotted out, whilst a kind of ideational con- 
scionsness remains. We have an approxima- 
tion to such a condition, also, in the case of 
sleep when dreams are rife. But here sen- 
sorial consciousness is not completely in 
abeyance. Again, in certain rare and anoma- 
lous epileptiform attacks we may find the 
patients, after the first paroxysms, bereft of 
some senses, though not of others. They 
may hear what is said by those around them, 
though they continue for a time quite unable 
to see or speak. 
4. Complete Loss.-In very profound 
sleep (sopor), in that prolonged form of it 
in which the person, if he can be mo- 
mentarily roused, drops off again imme- 
diately (lethargy), and also in profound 
ancesthesia, there is complete loss of con- 
sciousness. The terms sopor and lethargy 
are now rarely used, and authors are not even 
agreed as to the precise state which would be 
designated by the latter word. It is some- 
times regarded as a synonym for ' trance.' 
In syncope we have insensibility resulting 
from a cutting off of the proper supply of 
blood to the brain; whilst in asphyxia we 
have a like result following upon an inter- 
ference with respiration, and a consequent 
engorgement with impure blood. 
A condition of narcosis or profound in- 
sensibility may result from opium or other 
drugs and poisons, amongst which alcohol is 
to be included as one of the most common 
producers of such a state. It may also be due 
to the deficient elimination of waste products 
by the kidneys, when ' uraemic coma ' is 
produced ; or to the abnormal production of 
chemical compounds in the system, which lead 
on to blood-poisoning, as in ' diabetic coma,' 
and in the final stages of septic poisoning. 
Complete loss of consciousness exists for 
some time during the ordinary form of 
epileptic fit, or during an attack of convul- 
sions ; though in other epileptiform fits, not 
infrequently met with-having some of the 
characters of hysterical convulsions-there 
seems to be a loss of sensorial consciousness 
only (loss of perception), whilst a certain 
amount of ideational consciousness remains. 
In apoplexy also there may be for hours or 
days a more or less profound loss of con- 
sciousness. In the less profound attacks, as 
well as after an epileptic fit or an attack of 
convulsions, the loss of consciousness is not 
complete, and we have a condition now 
commonly known as stupor. This state is 
also frequent as a result of concussion or 
other injuries of the brain, and it occasionally 
follows a severe fit of hysterical convulsions. 
It may last for hours, days, or even weeks in 
some cases. In it the patient lies with his 
eyes closed, taking no heed of what is passing 
around, though he may show obvious signs 
of feeling when touched or pinched, and may 
be capable of being momentarily roused, so 
as to give a short monosyllabic answer if 
slightly shaken or spoken to in a loud voice. CONSCIOUSNESS, DISORDERS OF 
CONSTIPATION 
377 
On these occasions, signs of impatience are 
often shown. Though such a patient will not 
ask for food, he will often drink freely when it 
is offered. He will of his own accord, when 
his bladder is full, sometimes get out of bed, 
find the chamber-pot, use it, and return to 
bed without saying a word-and then speedily 
relapse into his previous state of stupor. 
When the insensibility is more profound, 
both urine and feces are passed incontinently. 
The state just spoken of is referred to in 
this section because it is so intimately allied 
to and connected by all sorts of transition 
conditions with another, known as coma, in 
which the loss of consciousness is more 
complete and absolute. There are different 
degrees of stupor and there are different 
degrees of coma; the former is commonly 
spoken of as slight or deep, whilst a comatose 
condition, coma, and profound coma (the 
latter being what the older writers termed 
earns) are the phrases ordinarily used to 
denote the increasing insensibility of the 
graver state, which is more especially 
characteristic of the apoplectic condition. 
Coma may result from long-continued ex- 
posure to cold, from sunstroke, from poisons 
of various kinds, from erysipelas of the head 
and face, from inflammations of the meninges, 
multiple embolisms, the effects of hyper- 
pyrexia, or from cerebral haemorrhage. The 
most common cause of very profound coma 
is cerebral haemorrhage (apoplexy). In this 
condition the breathing is often loud and 
stertorous, and consciousness is entirely 
obliterated, so that there is an utter absence 
of reflex movements when a limb is pinched 
or when the conjunctiva is touched. The 
patient in the deeper forms of coma often 
cannot be roused at all, even for a moment; 
and if this state does not terminate in one 
way or another before the expiration of 
twenty-four hours, or if it does not gradually 
pass into one of mere stupor, a fatal result 
may be considered imminent. 
H. Charlton Bastian. 
CONSTIPATION (con, together ; and 
stipo, I cram).-Definition.-Slow passage 
of the feces from the caecum to the anus, 
leading to infrequent or incomplete alvine 
evacuation, and to retention of feces. 
^Etiology.-The causes of constipation 
may be local-an impediment to the onward 
movement of the feces in the large intestine 
or from the rectum ; or general-pertaining 
to habits, diet, and other conditions. 
Local.-The local causes of constipation 
include: (a) Lesions inducing narrowing of 
some part of the large intestine, as from 
cicatrising of an ulcer or displacement of the 
bowel, (b) Collections of scybala, intestinal 
concretions, &c., in the caecum, sigmoid 
flexure, or rectum. Faeces are more especially 
apt to collect when too solid or when defi- 
cient in bile, (c) Pressure on the rectum, by 
uterine fibroids or ovarian tumours, uterine 
displacements, the gravid uterus, or an 
enlarged prostate, (d) Defecation thwarted, 
as when the expiratory abdominal muscles 
are enfeebled, as in pregnancy-especially 
when repeated or after twins, obesity, old 
age, or in some painful affection of the abdo- 
men, such as rheumatism of the abdominal 
walls and diaphragm, chronic dysentery, 
piles, fissure, or the evacuation of a hard 
mass of feces, (e) Feeble contraction of the 
intestinal muscular fibres, as in distension of 
the large intestine or a portion of it by gas, 
feces, or lumbrici, inflammatory affections 
(chronic intestinal catarrh, chronic perito- 
nitis), lead-poisoning, senile atrophy, or in 
delicate females with lax muscular fibre (see 
Colon, Diseases of). (/) Pain in the pelvic 
viscera, and probably elsewhere, may induce 
paralysis of the sympathetic nerves supplied 
to the intestinal walls; thus may be explained 
obstinate constipation in painful uterine and 
ovarian diseases, which cannot be accounted 
for by pressure on the bowels or otherwise. 
General.-The general causes of consti- 
pation are: (a) Sluggishness of function- 
lymphatic temperament, hereditary influ- 
ence, anaemia, especially with amenorrhcea; 
or, on the other hand, disposition to great 
activity of the muscular and nervous system. 
(6) Certain habits, such as sedentariness; 
railway travelling-long journeys ; too great 
muscular activity; mental application, es- 
pecially when excessive or prolonged; the 
continued and apparently necessary use of 
aperients or enemata after the relief of tem- 
porary constipation-falling under the tyranny 
of aperients; habitual disregard of defeca- 
tion, or hurry in the act; prolonged hours of 
sleep ; the excessive or even moderate use of 
alcohol, tea, tobacco, or opiates, (c) Dietetic 
errors : the diet too nutritious-leaving little 
intestinal residue, or poor and insufficient; 
improper feeding, especially in infants and 
children; and the use of indigestible sub- 
stances, such as cheese, nuts, or uncooked 
vegetables. 
Constipation is frequently a prominent 
symptom in diseases of the stomach ; of the 
liver ; of the heart, inducing congestion of the 
portal system; and of the nervous system: as 
well as in connexion with diabetes, excessive 
perspiration, prolonged lactation, and morbid 
discharges. 
The causes of constipation are such as 
evidently induce one or both of the following 
conditions, namely, (1) dryness and hardness 
of the contents of the large intestine from de- 
ficient secretion, or too active absorption of 
fluid from the intestinal tract; and (2) im- 
paired contraction of the muscular fibres of 
the large intestine. 
Description.-In constipation the evacua- 
tions are infrequent, solid, deficient in quan- 
tity, and sometimes unusually offensive; they 
often consist of dry, hard, dark or clay- 378 
CONSTIPATION 
coloured masses or scybala. Defecation is 
generally difficult or even painful. As a 
rule the depth of colour, and the scybalous 
character of the motions, are in proportion 
to the duration of the lodgment of feces in the 
large intestine. Infrequency of defecation 
regarded alone is an untrustworthy sign of 
constipation, or of constipation demanding 
medicinal or other treatment, inasmuch as 
it often depends on individual peculiarity. 
Good health may be consistent with depar- 
tures from the ordinary rule-a daily evacua- 
tion ; not infrequently there is no relief from 
the bowels for several days or even for a 
week, and yet without inconvenience, so long 
as the infrequent defecation is habitual, or 
can be ascribed to idiosyncrasy. 
The disturbances of function usually asso- 
ciated with constipation may be local, or may 
extend to distant parts. 
The immediate or local effects are such as 
may arise from retention of feces signs of 
fecal collections in the caecum, colon, sigmoid 
flexure, or rectum ; irritation of portions of 
the intestine, indicated by colic, inflamma- 
tion, dilatation, ulceration, and perforation 
of the intestines, followed by peritonitis; 
intestinal obstruction-a portion of the bowel 
loaded and distended with feces being no 
longer capable of peristaltic movement; 
pressure of fecal accumulations on the intra- 
pelvic vessels and nerves, inducing menor- 
rhagia, uterine catarrh, seminal emissions, 
varicocele, hsemorrhoids, cold feet, neuralgia, 
numbness and even oedema of the legs (see 
Faeces, Retention of). Constipation fre- 
quently exerts a pernicious influence on 
primary digestion, indicated by foul tongue, 
foetid breath, anorexia, acidity, flatulence, 
biliary disturbance-even jaundice, and urine 
loaded with lithates. 
The remote or general effects of constipa- 
tion are lassitude of body and mind; head- 
ache, flushing, heat of head, and vertigo; 
palpitation; anaemia, and wasting. Head- 
ache and nausea depending on retention of 
feces may be either pretty frequent without 
loaded tongue ; or may recur with vomiting 
and much coating of tongue every three or 
more weeks-these periodical attacks re- 
sembling migraine, but always cleared up by 
an aperient. 
Treatment.-Constipation depending on 
individual peculiarity is rarely relieved per- 
manently by treatment. The bowels, having 
acquired from early life the habit of infre- 
quent evacuation, may be stimulated for a 
time, and are then apt to become more slug- 
gish than before. In all cases the habit of 
the patient in this respect from childhood 
should first be determined, either as a caution 
against active or prolonged treatment, which 
may prove injurious, or as a guide to the 
adjustment of directions and remedies- 
affording as it does a limit which should not 
be overstepped. A healthy daily discharge 
of faeces should not fall far short of five 
ounces, and should form a coherent cylindri- 
cal-shaped mass of five or six inches in 
length, which should float; and it is an 
essential condition of healthy and efficient 
defaecation that the colon should always be 
moderately full of retained faeces. The prac- 
titioner should bear in mind that many per- 
sons acquire the erroneous belief that they are 
not discharging a sufficiency of faeces, and in 
consequence betake themselves to aperients, 
which daily remove the normal residuum of 
faeces that should exist in the colon-healthy 
peristalsis and defaecation being thus out of 
question. This apparent constipation can 
only be met by completely suspending the use 
of aperients. 
1. ./Etiological, hygienic, and dietetic 
treatment. - In treating constipation the 
causes should be met. Local causes, such 
as those inducing contraction of or pressure 
on some part of the large intestine, or feeble 
or ineffectual contraction of the intestinal 
muscular fibres or of the expiratory muscles, 
should first be eliminated. When defaecation 
is obstructed by the sphincter ani either 
remaining firmly contracted, or failing to re- 
lax sufficiently, it may be effectually relieved 
by forcibly dilating the anus under ether. 
Habits disposing to constipation should also 
be corrected. Persons who are much pre- 
occupied or careless are apt either to disregard 
the call to stool, or to perform the act of 
defaecation hurriedly, incompletely, and at 
irregular intervals. Such persons should be 
strictly enjoined to direct their attention, 
expectancy, and will to the attainment of 
complete and regular evacuation. The sen- 
sibility of the nerves of the rectum becomes 
blunted by the constant contact of faeces, 
and the promptings of nature at last cease. 
Hence the periodical removal of collections 
in the lower part of the large intestine is 
an essential element of the treatment. This 
is best secured if possible by well-timed 
and well - directed and sustained natural 
efforts. The patient should be told to 
attempt defaecation every day after break- 
fast, and to persevere in this habit even 
though the result be occasionally or fre- 
quently unsuccessful, and in order to develop 
his solicitation into the daily habit of eva- 
cuation he should continue to practise it 
always at the same hour, and should dis- 
regard any prompting that may arise at 
other times. While straining to relieve the 
bowels, he may facilitate evacuation by press- 
ing firmly the fingers in front and on each 
side of the coccyx, thus supporting the levator 
ani during contraction, reducing the concavity 
of the rectal pouch, and causing the mass of 
faeces to glide forwards through the sphincter, 
which should be smeared with vaseline; or 
he may attain the same end by alternately 
contracting or relaxing the anal sphincter. 
Failing to obtain relief on the second day, CONSTIPATION 
379 
a small cold-water enema should be used to 
prevent further accumulation of faeces in the 
rectum, and to restore tone and sensibility to 
the blunted nerves. The enema should never 
be larger than is required to dislodge the 
motion from the pouch of the rectum, nor 
should it be warm ; at first it may, however, 
be tepid, but should afterwards be cold. When 
evacuation is obstructed by the lower part of 
the faecal mass becoming dry, relief may 
be obtained from a small emollient enema 
administered on rising (such as infusion of 
linseed, glycerine in small quantities, solution 
of white of eggs, olive oil alone or in oatmeal 
gruel) and allow'ed to remain until after 
breakfast; or by the use of suppositories at 
bedtime, consisting of cacao-butter, or honey 
hardenedby heat,either alone or combined with 
extract of belladonna. The clothing should 
not constrict the abdomen or waist, and should 
be warm-especially about the feet and legs. 
Sedentary habits should be broken into. 
Exercise on foot or on horseback, or on a 
cycle, is especially to be commended, and 
carriage exercise to be avoided. While study- 
ing or reading, the patient should walk about, 
and stand rather than sit at the desk. Gym- 
nastics and out-of-door games (such as lawn- 
tennis, cricket, football, golf) are useful when 
a limited time only can be devoted to exercise. 
Excessive and exhausting exertion should be 
avoided. It is generally advisable to recom- 
mend early rising and cold bathing, followed 
by brisk general towelling in the morning. 
In different cases one or other of the follow- 
ing may be found serviceable: a shower or 
sponge bath containing vinegar or bay-salt, or 
consisting of sea-water, or a cold sitz-bath; 
douches directed to the abdomen; a cold-water 
compress applied to the abdomen during the 
day or night, or for three or four hours in the 
morning; friction or kneading, or slapping 
with the half-closed fist in the course of the 
colon every morning, and when at stool; an 
abdominal belt (flannel or elastic)-especially 
if the abdomen be pendulous. 
Diet.-The diet should be varied, should 
not consist too exclusively of animal food, but 
should contain a good proportion of fresh 
vegetables, and especially green vegetables 
(cabbage, lettuce, spinach). Fresh and ripe 
fruit (such as grapes, apples, and oranges) 
should also find a prominent place, and are 
most effective when taken in the early morn- 
ing, or at breakfast. When fruit induces 
acidity a tumblerful of alkaline (Vichy or 
Vais) water should be taken at the same time. 
Oils and fats are generally serviceable when 
they do not disturb the digestion, such as the 
addition of a dessert-spoonful of olive oil to 
green vegetables or to potatoes. A tea-spoon- 
ful of glycerine with each meal is often helpful. 
The diet should not be too dry. As to bever- 
ages, much must be left to individual ex- 
perience : sometimes coffee, or beer, or cider 
answers best. A tumblerful of cold water 
should be taken night and morning on awak- 
ing ; sometimes carbonic-acid water in the 
early morning is found preferable to plain 
water. Coarse articles of food-such as bran- 
or wheatmeal bread, oatmeal porridge, &c.- 
are often commended, and now and then 
they do favour the continuance of more effi- 
cient evacuation; more frequently, however, 
they fail-especially after a time-and they 
then aggravate the evil by further adding to 
the undue collection of residue in the large 
bowel, and are apt to set up catarrhal irrita- 
tion. Acidity and other symptoms of dys- 
pepsia contra-indicate the use of these indi- 
gestible foods. Honey or treacle with bread, 
gingerbread, and Spanish or Portugal onions, 
plainly boiled, may be found useful in certain 
cases. Dujardin-Beaumetz recommends in- 
fusion of linseed (a little water let stand on a 
dessert-spoonful of linseed for an hour) imme- 
diately before a meal.1 As a rule, eggs, milk, 
cheese, farinacea, astringent wines, and tea 
increase constipation ; and besides these 
articles it is best to avoid pickles, salted 
meats, nuts, and pastry in any form. 
2. Treatment by massage and electricity. 
Many observers in recent years have 
reported the complete cure of constipation 
by a course of massage alone. The manipu- 
lations consist of kneading (petrissage), strok- 
ing (effleurage), and slapping (tapotement), 
each having its special effect: the first loosen- 
ing impacted faecal masses, the second favour- 
ing their passage along the bowel, and the 
third improving peristaltic action. In some 
instances the forms of massage best adapted 
to the case should be applied to the whole of 
the large bowel from the caecum onwards; in 
others it should be addressed specially to 
certain portions, as the caecum, transverse 
colon, or sigmoid flexure. Sometimes all the 
manipulations, in varying proportions and 
degrees, are required in succession, or only 
one or two kinds-for instance, in atony of 
the bowel depending on sedentary habits, 
gentle and then deep stroking should give 
place to strong slapping with the half-closed 
hand; and in cases marked by flabbiness of 
the abdominal muscles, the recti should be 
forcibly separated by the thumbs and fingers, 
and then strong transverse strokings from 
the median line should be made, and the 
patient should take deep inspirations to 
strengthen the diaphragm. Each case should 
therefore be treated with discrimination, and 
a routine method should be avoided. The 
massage should be applied for from twenty to 
thirty minutes every or every other morning, 
and should be continued without interruption 
for from five to eight weeks.2 Electricity, 
1 L'Hygiene Alimentaire. 
2 A rude form of massage has been suggested in 
the form of a cannon-ball, or other similar round 
metallic body, weighing 8 or 4 lbs., to be rolled up 
and down the uncovered abdomen for from five to 
ten minutes daily at the same hour, the patient being 
recumbent. 380 
CONSTIPATION 
either alone or with massage, has also proved 
successful in certain cases ; a mild galvanic 
(continuous) current being applied by insert- 
ing the negative pole well within the sphincter 
ani and drawing the positive pole along the 
colon, and the faradic (interrupted) current 
being passed through the abdominal muscles. 
3. Medicinal treatment.-Should the fore- 
going directions fail ro establish the habit of 
a regular action of the bowels-either daily 
or on alternate days, they may be supple- 
mented by the prescription of medicinal 
agents, to compass the twofold aim of (1) 
relieving the large bowel of the excess of 
faeces and'gases which, by over-distending 
it, opposes peristalsis, and (2) toning its 
walls. To this end care should be taken to 
so adjust the dose (for it varies considerably 
in different cases) as to secure if possible 
efficient assistance to the discharge of faeces, 
without going so far as to clear away or to 
considerably reduce the normal residuum 
which should always exist in the colon. If, 
therefore, any prescribed dose has exceeded 
this limit it should be reduced, and should 
not be given next day, but after the lapse of 
a day or two. Repeated purging exhausts 
torpid bowels, and perpetuates constipation. 
Nor should the bowels be pushed to more 
frequent relief than has been habitual with 
the patient from early life. If the evacuations 
habitually contain scybala, and faeces are gene- 
rally found, on examination, in the rectum, 
the injection of a tea-spoonful of glycerine, or 
the insertion of a glycerine suppository, twenty 
minutes or so before the time of the desired 
evacuation, may alone suffice, or may enable 
a smaller dose of medicine to deal effectually 
with the difficulty. If gentle assistance only 
is required, and if griping and other signs of 
irritation are readily set up by the ordinary 
aperients, one or other of the following may 
be tried:-a tea-spoonful of castor oil alone, 
or with an equal part of glycerine, beaten 
together and then added to a table-spoonful 
or two of milk, or with olive oil or almond 
oil, at bedtime or in the early morning; the 
official sulphur lozenges (suggested by Sir 
Alfred Garrod) or tabloids at bedtime; rhu- 
barb and dried carbonate of sodium (gr. ij. or 
iij. of each), or a small piece of rhubarb-root 
before the midday meal; pills of dried ox-gall 
and soap. Or, if a more- decided laxative is 
necessary, a preference may be given to the 
compound liquorice powder, or confection of 
senna (with or without confection of sulphur 
or the compound sulphur tabloids), or the in- 
fusion of a few senna-pods in half a tumbler 
of water let stand over night, or extract of 
cascara sagrada. During late years cascara 
sagrada has acquired a high position as a 
tonic aperient, and is prescribed either in the 
form of solid extract (as in tabloids or pills, 
alone or variously combined), or in that of 
the liquid extract-the dose of the latter 
varying from ll[v. to iqxxx. alone or asso- 
ciated with tincture of nux vomica, of bella- 
donna, or of podophyllum, in a tea-spoonful 
of glycerine, or along with euonymin in cap- 
sules. Combinations on the lines of the 
favourite formula of Sir Andrew Clark also 
meet the indications well in the majority of 
cases (aloin, extract of nux vomica, extract 
of belladonna, sulphate of iron, powdered 
myrrh, powdered soap, of each half a grain; 
and, if the feces are dry and hard and there is 
no special weakness of the heart, add powdered 
ipecacuanha half a grain). Some prefer a pill 
of Socotrine aloes with henbane and sulphate 
of iron and quinine. In a well-organised 
course of medicinal treatment the form of 
the aperient should be varied every now and 
then, and the dose very gradually reduced 
until at last it is almost withdrawn, while 
the intestinal tonics (belladonna, nux vomica, 
and iron) should be continued. The time 
when the dose should be taken is important, 
for it will vary-be it before lunch, or dinner, 
or at bedtime-with the slowness or quick- 
ness of the response of the bowels to the 
attainment of relief after breakfast. Bre- 
tonneau's treatment by belladonna, greatly 
prized by Trousseau, is described in the 
article Colon, Diseases of. 
In anaemic cases a firm and prolonged 
course of iron should be aided by aloes, nux 
vomica, and arsenic. In haemorrhoidal com- 
plications aloes should, as a rule, be avoided, 
and laxative electuaries should be prescribed; 
in some cases, however, it gives tone without 
irritating the rectum. In obstinate cases 
colocynth-either alone or variously combined 
-is most useful; such as the tincture of the 
Prussian Pharmacopoeia, iqv. or more on sugar 
or in extract of liquorice (to disguise the bitter- 
ness) three or four times a day, or 10 to 20 
minims an hour before breakfast; or the 
extract or compound pill with small doses of 
croton oil, or with gamboge, elaterium, or 
other combinations. A full dose of opium 
may liberate the bowels after the failure of 
the strongest purgatives, and constipation 
depending on inhibition of the sympathetic 
nerve from pain will be relieved by opium 
with belladonna. "When constipation is asso- 
ciated with a deficient flow of bile, cholagogues 
(such as an occasional mercurial, euonymin, 
or podophyllin) should be prescribed with the 
other remedies; and dried ox-bile in capsules 
or pills, and nitric acid or nitro-hydrochloric 
acid often prove useful. Sometimes enemata 
answer better than purgatives; then, when 
frequently required, they should be small 
in quantity, and at first tepid, afterwards 
cold; for occasional use, for the purpose of 
clearing away feces loading the large bowel, 
they should be large (from two to six pints) 
and warm (see Recks, Detention of). The 
frequent use of large warm injections perpe- 
tuates constipation. Purgative waters, such as 
the Rubinat, Friedrichshall, Pullna, Hunyadi 
Janos, or Carlsbad, given in warm water CONSTIPATION 
CONTAGION 
381 
in the.early morning or over night, are often 
valuable adjuncts to other treatment. A 
combination of the sulphates of iron, mag- 
nesium, and sodium with strychnine and 
belladonna, after food twice a day, is often 
efficacious ; especially in the constipation of 
children; and in children under two years 
of age carbonate of magnesium (gr. v. to xx.) 
in milk is preferable to other aperients. 
George Oliver. 
CONSTITUTION.-Synon. : Diathe- 
sis ; Habit; Conformation of Body; Fr. Con- 
stitution ; Ger. Leibesbeschaffenheit. 
The constitution may be sound or unsound. 
A sound constitution may be defined as the 
harmonious development and maintenance of 
the tissues and organs of which the body is 
made up. It originates with the union of a 
healthy sperm and germ cell, continues with 
the growth of the product under the most 
favourable conditions to adult life, and be- 
comes gradually enfeebled with advancing 
age by the process of natural decay. 
The constitution may be unsound in con- 
sequence of deficient vitality. This deficient 
vitality may be general, as is sometimes ob- 
served in the children of parents one or both 
of whom are in advanced life, or whose vitality 
on one side or the other has been reduced by 
excesses, such as alcoholic or venereal. Ex- 
hausted vitality from prolonged disease, e.g. 
phthisis or tertiary syphilis, affecting either 
parent, may determine the death of the off- 
spring at an early period, from mere failure 
of nutrition, or may cause it to succumb to 
acute disease not necessarily associated with 
any inherited tendency of a special kind. The 
deficient vitality may be restricted to certain 
tissues or organs, namely, those concerned in 
the nervous, vascular, respiratory, or digestive 
systems. Thus amongst the most strikingly 
hereditary of diseases are those of degeneracy, 
such as emphysema, structural heart-diseases, 
atheroma of vessels, and certain kidney- 
diseases. Bightly interpreted, these diseases 
are of the nature of premature senility, at- 
tacking certain tissues or organs-as it may 
be seen to attack the hair or the cornea-from 
some inherent defect in their vitality. 
The constitution may, in the second place, 
be unsound from some definite inherited form 
of disease. Although the constitution of an 
individual begins with his life, it is neverthe- 
less the resultant of the constitutional pecu- 
liarities of many antecedents. This being so, 
tendencies to disease may date far back in 
the pedigree, to be called forth from time to 
time by favouring circumstances. We need, 
however, practically only go back a few gene- 
rations in inquiring for those diseases which 
are well recognised as being hereditary. 
These form one section of the group of con- 
stitutional diseases. - Congenital syphilis, 
gout, scrofula, tuberculosis, cancer, asthma, 
and certain neuroses, are all diseases which 
are apt to appear at certain periods of the 
life of the offspring, in consequence of some 
specific inherent defect of blood or tissue 
derived from his progenitors. 
The constitution may, thirdly, become 
unsound at any period subsequent to birth. 
(a) This may be due to the surrounding con- 
ditions of life being evil. Deficient or impure 
air, insufficient or improper food, defective 
sunlight, over-work, intemperance, &c., may 
injure the constitution, and give rise to 
diseases whose constitutional nature is some- 
times strikingly shown in the tendency of 
some of them to become hereditary. Bickets, 
phthisis, and scrofula are examples. (&) The 
introduction of certain poisons into the system 
affects the constitution profoundly, and in 
some cases permanently, after the more ob- 
vious effects of the poisons have passed away. 
All the acute specific zymotic diseases, includ- 
ing vaccinia, would come under this category. 
They render the organism, for a long period 
or for life, proof against subsequent attacks 
of the same disease. Only in certain cases, 
however, can the soundness of the constitution 
be said to be impaired by such diseases, and 
then it is usually through the occurrence of 
sequelae. B. Douglas Powell. 
CONSTITUTIONAL DISEASES. 
These may be regarded as diseases generated 
from within, in the course of the wear and 
tear, nutrition and waste, of the body, in 
consequence of inherent or acquired weakness 
in its construction. 
The applicability of the term 'constitu- 
tional ' to disease is sufficiently explained in 
the preceding article on Constitution. The 
term may, however, be associated with a 
group of so-called ' general ' diseases, in op- 
position to that which includes ' zymotic ' or 
' specific ' diseases, which are generated by 
the introduction of some definite poison from 
without. 
In our present state of knowledge, how- 
ever, no very rigid lines can be drawn to 
separate local, general, constitutional, and 
specific diseases from one another. See 
Disease, Causes of. 
B. Douglas Powell. 
CONSTRICTION (constringo, I bind 
together).-A narrowing, to a limited extent, 
of a canal or hollow organ, due either to a 
textural change in its walls, or to the pressure 
of a band surrounding it. 
CONSUMPTION (consumo, I waste).- 
A term for any wasting disease, but generally 
applied to pulmonary phthisis. See Phthisis. 
CONTAGION.-The word contagion is 
applied in pathology to the property and pro- 
cess by which, in certain sorts of disease, the 
affected body or part causes a disease like its 
own to arise in other bodies or other parts; 
and the Latin word contagium is conveniently 382 
CONTAGION 
used to denote in each such case the specific 
material, shown or presumed, in which the 
infective power ultimately resides. See Zyme ; 
and Zymosis. 
The property of contagiousness belongs 
to a very large number of the diseases which 
affect the human body. And in more than 
this direct way the property is of great in- 
terest to mankind. Contagiousness of disease 
is a fact not only for man, but apparently 
for all living nature; and the influence of 
contagion in spreading destructive diseases 
among domestic animals, and among those 
parts of the vegetable kingdom which con- 
tribute to the nourishment of man, is such as 
to make it of immense social importance that 
the laws of contagion should be well studied 
and understood. Further, just as contagion 
in the case of living bodies and their parts 
spreads disease from one to another, so, to 
an immense extent, in the case of certain 
matters which, though of organic origin, are 
not living, it spreads various processes of 
decay. The so-called ' fermentations ' which 
yield alcohol and vinegar, as well as that in 
which putrefaction consists, are contagious 
affections of the respective matters in which 
they occur: every cheesemonger knows that 
moulds of different kinds spread by inocula- 
tion, each in its own kind, from cheese to 
cheese; and if the Greek proverb ' grape 
mellows to grape ' is true of the living fruit, 
the apple-loft gives analogous experiences of 
contagion among the fruit which is garnered. 
The rationale of the word ' contagion ' as 
now used, is that the property is understood 
to attach itself essentially to a material 
contact', not necessarily that, when infection 
is spread from individual to individual, the 
contact of the individuals must have been 
immediate; but that in all cases there must 
have been such passage of material from the 
one to the other, as was in itself at least 
a mediate contact between them. And 
similarly, in those very instructive illustra- 
tions of the process of contagion which are 
furnished within the limits of a single 
diseased body by the propagations of disease 
from part to part of it, we can in general 
easily see that infection advances from part 
to part, either in proportion as part touches 
part, or in proportion as the one receives 
from the other the outflow of lymph or blood 
or secretion. 
The various specific matters which effect 
contagion in the living body, the respective 
' contagia ' of the given diseases, seem all to 
have in common this one characteristic: that 
in appropriate media (among which must 
evidently be counted any living bodily 
texture or fluid which they can infect) they 
show themselves capable of self-multiplica- 
tion ; and it is in virtue of this property that, 
although at the moment of their entering the 
body they in general do not attract notice, 
either as objects of sense or as causes of 
bodily change, they gradually get to be re- 
cognisable in both of these respects. Now, 
the faculty of self-multiplication is eminently 
one of the characters which we call vital; 
and when it is said that all contagia are self- 
multiplying things, this is at least very 
strongly to suggest that perhaps all contagia 
are things endowed with life. 
In order to any general consideration of 
the question thus suggested, contagia may 
conveniently (even if but provisionally) be 
distinguished as of two main classes, differ- 
ing, or at present seeming to differ, from 
each other in their mode of action on the 
organisms which they infect: one class, 
namely, that of Parasites', and the other 
class, that of the true or Metabolic Con- 
tagia. Of this separation, so far as present 
knowledge seems to justify it, the assumed 
grounds are: that each true Contagium, in 
proportion as it multiplies in the body, trans- 
forms, in a way which is specific to itself, 
and is different from the ways of other con- 
tagia, the bodily material with which it has 
contact; while, on the contrary, the Parasite, 
however much it may grow or multiply 
in the body, produces no qualitative effects 
specific to itself, but only such effects as 
are of common kind to it and all other para- 
sites-indications, namely, of its mechani- 
cal intrusiveness in the parts which it 
occupies, and sometimes of the drain which 
it makes on its host's general nutritive re- 
sources. 
A.-Of Parasites, in relation to processes 
of contagion, little needs be said, in the 
present article. When an organism or part 
of it is, in greater or less amount, inhabited 
by other organisms, animal or vegetable, 
which subsist on it, or its food or refuse, 
it of course may be a centre of infection to 
other (if susceptible) bodies or parts, to which 
it can transmit live parasites or their germs 
or seeds: for, when this transmission takes 
place, growth and self-multiplication, as in 
a colony, are the natural results which have 
to be expected; and in proportion as these 
occur, the newly-infected body or part 
gradually gets to suffer, like the old, from 
those particular derangements which make 
the type of parasitic disease. Some parasitic 
diseases, especially some of those of the skin, 
spread actively by direct contagion in ordinary 
intercourse; as, for instance, scabies by the 
migration of its acari, and porrigo (among 
children) by the spores of its microphyte; 
and the spreading of such diseases where 
they exist may of course be to any extent 
facilitated by aggregation of persons and un- 
cleanliness of personal habits. There are 
cases in which parasitic disease spreads from 
animal to animal only in proportion as the 
one feeds on the other, and eats it with para- 
sites still living in it; or in proportion as live 
parasite-eggs or larvae, discharged from the 
body of one animal, get conveyed with food CONTAGION 
383 
(especially on raw herbage and in water) 
into the bowels of another. Considerable 
epidemics of trichiniasis in the human 
subject have been traced, chiefly in Germany, 
to infection from the pig; in cases where 
pork, abounding with trichinae, has been 
eaten, as sausage-meat or otherwise, in a 
raw or imperfectly-cooked state: and in 
Iceland the very great sufferings of the 
human subject and the cattle from echino- 
coccus have been traced to the influence 
of the dogs in spreading contagion from the 
slaughter-house, where they eat hydatidised 
offal, to the kitchen-gardens and water- 
sources and pastures, where they discharge 
tape-worm eggs from their bowels. See 
Porrigo ; Scabies ; Entozoa. 
The diseased states which consist in 
being colonised by parasites are diseases 
of indefinite duration, tending in some cases 
to indefinite increase. In cases where the 
disease consists in the presence of swarms of 
blood-sucking or otherwise exhausting animal 
parasites, symptoms of the blood-drain will 
of course gradually arise; but otherwise the 
parasite, whether animal or vegetable, oper- 
ates only as a mechanical presence. Skin 
and mucous membrane will be irritated in 
their superficial layers, and in some cases 
more deeply, by the animal or vegetable 
parasites which breed on or in them, just as 
they might be by dead mechanical irritants : 
solid organs having cystic entozoa in them 
will in like manner show evidence of irrita- 
tion by encapsulating the colonists; and the 
surrounding tissue will of course suffer com- 
pression and displacement in proportion as 
the colonisation (e.g. in case of echinococcus) 
is compact and massive. In the case of 
trichiniasis-but, in our ordinary experience, 
in no other-the multiplication of the para- 
sites, the burrowing of their young, and the 
general diffusion of these in the body, are 
processes of such extreme activity that, if 
the quantity of contagium taken into the 
stomach has been large, the innumerable 
local irritations suffice to make a very acute 
fever' but even in this extreme case, the 
merely irritative type, though exaggerated, 
is essentially preserved. 
As different sorts of animals are notoriously 
liable to different sorts of parasites, so, even 
among animals of one sort-as, for instance, in 
the human kind-the liability of different 
bodies to receive particular parasite-infec- 
tions, does not seem to be quite equal for all. 
Especially, the vegetable parasites seem to 
have their affinities determined or modified 
by the general state of health of the re- 
cipient ; and there are cases in which it looks 
as if there ran in particular family-lines 
(perhaps with some slight chemical idiosyn- 
crasy) a special liability to particular intes- 
tinal worms. There, however, is no reason 
to believe that in regard of the more im- 
portant animal parasites, as particularly of 
trichina and the taeniadte, the susceptibility 
of individuals to attacks is other than univer- 
sal and practically equal. 
B.-The true or metabolic contagia (to 
which the rest of the present article will 
exclusively refer)-the contagia which, in 
their respective and specific ways, operate 
transformingly on the live bodily material 
which they affect, are perhaps the most 
important of all the incidental physical in- 
fluences which concern mankind. Whether 
they may all, at some time hereafter, admit 
of being named, like the parasitic contagia, 
in terms of biological classification, is a ques- 
tion which needs not in the first instance be 
raised; for meanwhile the identity of each 
separate true contagium is settled in experi- 
mental and clinical observation by the uni- 
formity of the operation of each on any given 
animal body which it affects. Each of the 
diseases propagates itself in its own form in 
as exact identity as if it were a species in 
zoology or botany; and in each such repeti- 
tion of the disease there is a multiplication- 
always a large, and sometimes an inconceiv- 
ably immense multiplication-of material 
which has the same infective-property. Evi- 
dences innumerable to that effect are under 
daily clinical observation in this climate in 
instances of smallpox, measles, scarlatina, 
whooping-cough, enteric fever, mumps, ty- 
phus, syphilis, cowpox, diphtheria, erysipelas, 
hospital gangrene, purulent ophthalmia and 
gonorrhoea, venereal soft-chancre and phage- 
daena, &c.; for, barring fallacies, no man 
ever sees any one of those diseases produced 
by the contagium of any other of them; and 
any man who has before him a case of any 
of them can see that, however minute may 
have been the quantity of contagium by 
which the disease was started, the patient's 
diseased body (part or whole) yields for the 
time an indefinitely large supply of the speci- 
fic agent. It is more or less habitual to some 
of the diseases that the infectedness of the 
patient is first made known to the observer 
by such general pyrexia as tells of change 
already far advanced in the circulating mass 
of blood; and it is only after this has shown 
itself, that other symptoms, adding them- 
selves to the fever, complete the more or less 
complex type which establishes the identity 
of the disease. But in many of the diseases 
it may be the case (either naturally or as the 
result of experimental infection) that the 
first, and in some diseases the main or even 
the only, effects of the contagion are local 
changes, passing where we can from the 
first observe them; and the broad facts ot 
metabolic infection, as regards waste of bodily 
material with concurrent increase of conta- 
gium, are, in many such cases, among our 
most familiar experiences. Most instructive, 
too, are the facts of contagion which are to 
be learnt in the study of tubercle : the con- 
tagium, introducible either by tubercular and 384 
CONTAGION 
certain septic inoculations through the skin, 
or internally by the infective action of the 
milk or diseased organs of tubercular animals 
if taken as food; and the contagium, when 
introduced, gradually spreading as it multi- 
plies, and as lymph and blood carry it from 
the first infection-spot to other organs which 
now will repeat the process. And similarly 
in cancer (though the primary disease is at 
present of unknown origin and cannot be 
created by experiment) the repetition of the 
primary disease in secondary and tertiary 
propagations in the body of the sufferer is 
one of the most striking of all evidences of 
contagion; because of the great number of 
structural types which pass under the name 
of cancer, and the fidelity with which each 
of them is reproduced in the organ to which 
the contagion extends. A further fact of 
contagion, deserving notice in the present 
context, is the local spread of certain of these 
processes by continuity of tissue; as, for in- 
stance, in the continuous extension of phage- 
daena or hospital-gangrene from any centre 
of first inoculation, or of tubercular softening 
or cancer at the place where it begins: a 
mode of extension which indicates succes- 
sive infective actions of matter on matter 
in spheres of ever-widening circumference;1 
and the like of which, but in rudimentary 
degree, may be traced in the areola of any 
acute inflammation. 
In the physiology of the metabolic contagia 
no facts are more characteristic or more im- 
portant than those which show the relative- 
ness of particular contagia to particular 
receptivities of body.-First, and in intimate 
connexion, as would seem, with a chemical 
electiveness of action which will presently be 
imputed to contagia, there is the preference 
which some particular contagia (however in- 
troduced into the system) show for particular 
organs of the body; so that by the exercise 
of this preference, there is given to each of 
the diseases its own set of clinical and ana- 
tomical characters. Compare, as instances in 
this point of view, the respective local affini- 
ties of smallpox, enteric fever, mumps, 
syphilis, hydrophobia, &c.-Secondly, it may 
be noted that, in regard to some of the con- 
tagia, different persons, and particularly per- 
sons of different family-stocks, show original 
differences of susceptibility; original, namely, 
as distinguished from others, hereafter to be 
mentioned, which are acquired; so that, for 
instance, the severity with which scarlatina 
or diphtheria will strike in particular families 
contrasts with a comparative mildness of the 
same disease in other families, or perhaps 
even with cases of apparently complete per- 
sonal immunity under exposure to the par- 
ticular danger: and recent researches have 
seemed to suggest as possible that, in the 
very wide differences of degree with which 
tubercular disease prevails in different 
families, an essential condition may be, that 
the families have widely different degrees of 
original predisposition towards some of the 
septic contagia.-Thirdly, there is the ex- 
tremely suggestive fact with regard to many 
of our best-known febrilising contagia, that 
they run a course of definite duration, and 
that in this course, provided the patient do 
not die, all present, perhaps all future, sus- 
ceptibility to the particular contagium is 
utterly exhausted from the patient', so that 
re-introduction of the same contagium will 
no more renew that patient's disease than 
yeast will excite a new alcoholic fermentation 
in any previously well-fermented bread or 
wine. The inference from this fact seems un- 
avoidable, that each such contagium operates 
with a chemical distinctiveness of elective 
affinity on some special ingredient or ingre- 
dients of the body; and that exhausting this 
particular material in febrile process, which 
necessarily ends when the exhaustion is com- 
plete, is the bodily change which the con- 
tagium 'specifically' performs.-Of not all 
metabolic contagia, however, can it be said 
that their operation runs so definite and self- 
completing a course. For, first, there are 
particular acute infections which, as a rule, 
kill ; either (as appears to be the case in 
splenic fever when affecting man) because of 
the extreme magnitude of the transforming 
process which the contagium sets up, or else 
(as appears to be the case in hydrophobia) 
because the elective incidence of the con- 
tagium is on an organ indispensable to life ; 
so that in such cases there is in fact hardly 
such an event as passing alive through the 
whole process of the disease. And, secondly, 
there are the contagious dyscrasies which 
are clearly characterised by their tendency 
to indefinite duration: syphilis, which oftener 
than not relapses in successive outbreaks, and 
often as years pass invades the body more 
and more deeply, and may after all never 
during life be ended ; and tubercle and 
cancer, which, with almost invariable per- 
sistence, will in general steadily advance 
month by month to infect more and more 
of the body till the process eventuates in 
death. 
The transmission of various contagious 
diseases in communities is of course greatly 
influenced, both in detail and in aggregate, 
by such differences of individual receptivity 
as were mentioned in the last section. 
Notably, as regards communities through 
which particular acute infections have had 
full run, fresh sparks of the contagium may 
find little or no fuel on which to act; and 
much new diffusion of the disease may not 
again be possible, till immigration, or births, 
or lapse of time operating in other ways, 
shall have reconstituted a susceptible popu- 
lation. And, given the susceptible population, 
1 Compare Tennyson's 
' little pitted speck in garnered fruit, 
Which, rotting inward, slowly moulders all.' CONTAGION 
385 
circumstances of time and place are infinitely 
various (especially as regards quantity and 
quickness of personal or quasi-personal inter- 
course) in determining how far this popula- 
tion shall have particular contagia thrown in 
its way. 
Also there are conditions, not primarily of 
a personal kind, which operate on a very large 
scale in determining the spread of some of the 
metabolic infections: giving to them respec- 
tively at certain times, in ways not hitherto 
understood, a special increment of spreading - 
power, and in some instances also special 
malignity: and thus enabling them respec- 
tively from time to time to come into com- 
parative prominence in national life, and 
perhaps at once or successively in many 
different countries, in the form of so-called 
epidemics. Thus, it is matter of familiar 
knowledge that the fevers which are most 
habitual to this country-scarlatina, measles, 
smallpox, enteric fever-are of nothing like 
uniform prevalence ; that scarlatina, for in- 
stance, will be three times as fatal in one 
year as in another, and that smallpox is liable 
to even greater exacerbations: and it is known 
that temporary differences of this kind are 
not exclusively local; that, for instance (to 
quote a late official report), ' the epidemic of 
smallpox which began in England towards 
the close of 1870 and terminated in the second 
quarter of 1873 was part of a general epidemic 
outbreak of that disease, of worldwide diffu- 
sion, marked wherever it occurred by an in- 
tensity and malignity unequalled by any pre- 
vious epidemic of the disease within living 
memory.' The wider the survey which we 
take of epidemiology, the more certain it 
becomes to us, that, outside the conditions 
which are independently personal or local, 
there are cosmical conditions which have to 
be considered. Doubtless there are great epi- 
demiological facts-such, for instance, as the 
first spreading of smallpox to America, or in 
our own times the increasing frequency of 
Asiatic cholera in Europe, which may be 
ascribed to novel conditions of international 
intercourse ; but there are others, equally 
great, to which apparently no such explanation 
can be applied. Eor what reason it is that 
cholera every few years has its definite fit of 
extension in India,-or why diphtheria, which 
scarcely had a place in history till it overran 
Europe in the 16th century, and which since 
then had been rarely spoken of, began again 
some twenty-odd years ago to be compara- 
tively important in England,-or why the 
plague of the Levant has for the last two 
centuries been so unfamiliar to us,-or why 
the yellow fever of the Mississippi has in 
particular years raged furiously in parts of 
Europe,-or why our black-death of the 14th 
century, though apparently still surviving in 
India, has never but that once been in Europe, 
■-or whither has gone our sweating-sick- 
ness of three centuries ago,-or whence have 
come the modern epidemics of cerebro-spinal 
meningitis: these, and many like questions, 
which cannot at present be answered, seem 
to be evidence enough that, in the making of 
epidemics, contagion and personal suscepti- 
bility may be factors in a partly conditional 
sense. Influences which are called ' atmo- 
spheric '-the various direct and indirect in- 
fluences which attach to the normal succes- 
sion and occasional abnormality of seasons, 
in respect of the insolation of our planet, and 
of the temperature and humidity of air and 
earth-are in general far too vaguely regarded 
as elements of interest in the present ques- 
tion, but are possible factors which no epide- 
miologist should omit from scientific con- 
sideration. For any definite knowledge which 
exists on the relation of particular conditions 
of season to the prevalence of particular 
epidemics, the reader is referred to the article 
Epidemics, and to articles on the respective 
diseases. 
In the passage of the metabolic contagia 
from person to person various agencies may 
be instrumental,-bedding or clothing or 
towels which have been used by the sick, 
dirty hands, dirty instruments or other 
utensils, the washerwoman's basket, foul 
water-supply, stinking house-drains, con- 
taminated milk or other food, the common 
atmosphere, &c.; but differences of that sort 
are only differences as to the means by which 
such communication is established with a 
diseased body as brings its products into 
relation with healthy persons; and the dis- 
engagement of infectious products from the 
bodies of the sick is pathologically the one 
influential fact. As regards the products 
which ought to be deemed infectious, the 
specially-diseased surfaces and organs of the 
patient, and the discharges and exhalations 
which they respectively yield, must always 
be regarded with chief suspicion; but sus- 
picion, however much it may insist on them, 
must never disregard other sources of danger. 
Of some of the metabolic contagia we prac- 
tically know, and of many of the others we 
may by analogy feel sure, that, when a given 
body is possessed by one of them, no product 
of that body can be warranted as safe not to 
convey the infection. Presumption against 
every part and product of the diseased body 
is by everyone readily admitted where there 
are vehement general symptoms of disease : 
but it is important to know that not only in 
such febrile states, but even in states of chronic 
dyscrasy, and even at times when the dyscrasy 
may be giving no strong outward sign, the 
infected body may be variously infective. 
Thus, in regard to constitutional syphilis, it 
is certain that the mere utero-catarrhal dis- 
charge of the syphilitic woman, or the sperm 
of the syphilitic man, or the vaccine lymph 
of the syphilitic infant, may possibly contain 
the syphilitic contagium in full vigour, even 
at moments when the patient, who thus 386 
CONTAGION 
shows himself infective, has not on his own 
person any prominent outward activity of 
syphilis. Similarly, in regard to tubercular 
disease, experiment has proved beyond ques- 
tion that the milk of animals suffering from 
tubercle will, if taken as food by other 
animals, infect them through the intestinal 
mucous membrane: and there are indepen- 
dent reasons for believing that the tubercular 
contagium (like the syphilitic) will at times 
during the dyscrasy be contained in the 
seminal fluid, and that men, tubercular per- 
haps only in some degree which is not im- 
mediately important to themselves, may by 
that secretion convey fatal infection to women 
with whom they have conjugal relations.1 
Regarding many of the metabolic contagia, 
conclusive evidence exists that, when they 
are in operation in pregnant women, the 
fietus will in general be infected by them ; 
and this though the diseases (e.g. smallpox, 
cholera, syphilis) be of the most different 
pathological types : but with regard to preg- 
nant animals affected with splenic fever it is 
noticeable that Brauell, in his extensive re- 
searches, found the blood of the foetus not to 
be infective. 
In general, each contagium has its own 
favourite way or ways of entering the 
body ; and these preferences are not only of 
speculative interest, as attaching to varieties 
of nature and natural habits among the con- 
tagia, but are of obvious practical importance 
as measures of the widely different degrees 
in which the different contagia are qualified 
to spread in communities. Thus, inoculation 
at broken surfaces of skin or mucous mem- 
brane has long been known as the ordinary 
mode by which the infections of syphilis, 
hydrophobia, splenic fever, cowpox, and farcy 
or glanders, get admission to the body; and 
our best knowledge of some other infectious 
diseases (notably of tubercle) has been de- 
rived from inoculations intentionally made 
with their contagia for purposes of study. 
While probably all infections which tend to 
be of general action on the body can be 
brought into action in that way, and while 
some infections are not known to pass by any 
other mode of transmission, there are many 
infections which spread freely from subject 
to subject by atmospheric and dietetic com- 
munication ; and the meaning of these pre- 
ferences is hitherto not fully known. It seems 
that some contagia are so acted upon by air 
and water, that they seldom or never reach 
the body in an effective state by those com- 
mon means of communication,-some hardly, 
if at all, by water, and some not by air except 
with very close intercourse; and further, that, 
of contagia which reach the body in an effec- 
tive state, some require, while others do not 
require, that an abnormal breach of surface 
shall give them special opportunity for taking 
hold. In some of the cases where a disease 
can be propagated in both ways,-i.e. cer- 
tainly in smallpox, and apparently also in 
bovine pleuro-pneumonia, the artificially 
inoculated disease tends to be much milder 
than the disease otherwise contracted; but 
pathologically it is difficult to conceive any 
essential difference between those different 
modes of contagion. It may be presumed 
that, in the modes which are not by true 
inoculation, acts which are comparable to 
inoculation take place on internal surfaces ; 
that, for instance, when particles of scarlatina- 
contagium are caught in the tonsils, or inhaled 
into the bronchi, or swallowed into the 
stomach, they begin by penetrating the tex- 
ture of the mucous membrane, and by thus 
effecting as real an inoculation, with regard 
to the blood, as that which art or accident 
provides in other cases through the punctured 
skin. That previous abnormal breach of sur- 
face by artificial puncture or otherwise is not 
necessary to allow the infection of mucous 
surfaces is illustrated in ophthalmia and 
gonorrhoea; where apparently no other con- 
dition has to be fulfilled than that a particle 
of the blenorrhagic contagium shall be de- 
posited on the natural surface of the mucous 
membrane. It deserves notice that, while 
a considerable number of the worst diseases 
of the domestic animals admit of being com- 
municated to man by artificial inoculation, 
atmospheric communication seems to be very 
inapt, if not absolutely unable, to infect man 
with any one of them; and in this con- 
nexion it may be of interest to remember 
that syphilis, one of the most familiar of 
human infections, but hitherto not traced 
to any brute ancestry, differs from our other 
current infections in requiring inoculation to 
transmit it. 
When any metabolic contagium enters the 
animal body, it requires an interval of time, 
and in most cases a considerable interval, 
before its morbific effects can become mani- 
fest even to skilled observation. The period 
of latency or so-called incubation varies 
greatly in different cases. In hydrophobia 
it is very rarely less than of one month, is 
certainly often of several months, and is said 
to be sometimes of years. In syphilis the 
inoculated spot remains generally for at least 
a fortnight, and may remain even as much 
as five weeks, without any ostensible change; 
and the roseola of the general infection will 
not be seen till some weeks later, when gene- 
rally at least three months will have elapsed 
since the first inoculation. In the acute 
eruptive fevers, when their contagium is 
transmitted by air, the first changes which 
ensue on infection are not external, and we 
cannot be sure what early internal changes 
may take place; but in smallpox, the fever 
(which is the first overt sign) does not attract 
notice till about the twelfth day after infec- 
tion, nor the eruption till two days later; and 
in measles the incubation-time, though per- 
1 See Dr. Weber, in Clin. Soc. Trans., 1874. CONTAGION 
387 
haps less uniform, seems to be little (if any) 
shorter than that of smallpox. The septic 
contagia and the contagium of splenic fever 
seem to be of particularly quick operation; 
but even the most virulent septic contagium, 
when without admixtures which tend to 
complicate its action, will not begin sensibly 
to derange the infected animal till at least 
several hours after it has been inoculated. 
As regards the contagia last referred to, it is 
conceivable that the self-multiplication of the 
contagium in the form in which it proves 
fatal to life is a process which goes on con- 
tinuously and uniformly from the moment of 
inoculation to the moment of death, and that 
the moment when signs of general derange- 
ment become manifest is the moment when 
this uniformly-advancing process has accu- 
mulated in the system a certain quantity of 
result:-but it does not seem easy to apply 
this explanation to the diseases of long in- 
cubatory period; and we can hardly conjec- 
ture what may be the latent processes-for 
instance of smallpox, during the first ten or 
more days after contagium has been received. 
It is not yet possible to say, in any universal 
sense, with regard to the metabolic contagia, 
what is the essential constitution of'conta- 
gious matter,' or what the intimate nature 
of the ' transforming power ' which the par- 
ticle of such matter exercises on the particles 
which it infects.-As regards the question 
of the force, chemists, when they refer in 
general terms to the various acts which they 
designate acts of fermentation, allege that 
certain processes of change in certain sorts of 
organic matter induce characteristic changes 
in certain other sorts of organic matter, not 
by the common chemical way of double de- 
composition with reciprocally new combina- 
tions, but (so to speak) as a mere by-play or 
collateral vibration-effect of the chemical force 
which is in movement; and though language 
can hardly be more vague than this for any 
scientific purpose, it expresses clearly enough 
the conviction of experts that a certain great 
force in nature lies beyond their power even 
of definite nomenclature, much more of exact 
identification and measurement. In that most 
interesting, but most difficult and hitherto 
almost uninvestigated, branch of chemical 
dynamics, we are supposed to have our 
nearest clue to the scientific problems of the 
present subject-matter. It may be conceded 
that the 1 contact-influences ' which are 
dimly recognised as causing the fermentatory 
changes of dead organic matter have apparent 
analogues in many of the morbid influences 
of contagion : for the changes which chemists 
call ' fermentatory ' are all catalytic or dis- 
integrative of the organic compounds which 
they affect; and when living protoplasm is 
brought by contagion into processes of charac- 
teristic decay, the analogy seems sufficiently 
close to justify the word zymotic in the naming 
of the nature of the process. But it must not 
be forgotten that, among immediate effects of 
contagion in the living body, are cases wherein 
the process (so far as we can yet see) is pri- 
marily not catalytic or <Zis-integrative, but, 
on the contrary, anaplastic or con-structive. 
Thus, when tubercle gives rise to tubercle, 
whether by secondary or tertiary infection in 
a single diseased body, or by infection from 
the sick to the healthy, each new tubercle 
which the contagion brings into being is a 
growth-product of the texture which bears 
it. And similarly, when the innumerable 
varieties of cancerous tumour propagate them- 
selves by contagion, each after its special 
type, in the bodies of the respective sufferers, 
it is growth, not disintegration, which we first 
see. It would seem that in those cases of 
anaplastic ' contact-influence ' something far 
beyond the analogy of chemical fermentations 
must be involved; and, m view of some of 
them, the physiologist has to bethink himself 
of the analogy of that ' contact-influence ' 
which becomes the mainspring of all normal 
growth and development, when the ovum 
receives spermatic impregnation.-As regards 
the ultimate organic constitution of the 
several metabolic contagia-(each of them of 
course abstracted from accidental admixtures, 
and seen or conceived in the smallest and 
simplest units of quantity and quality in 
which its specific force can be embodied)- 
modern research seems more and more tend- 
ing to show that the true unit of each meta- 
bolic contagium must either be, or must 
essentially include, a specific living organism, 
able to multiply its hind. For with regard to 
those other contagia (as we may properly call 
them) which spread fermentatory processes 
in common external nature, and of which it 
is as clear as of the morbific contagia that 
they multiply themselves in proportion as 
they act, it seems to be established beyond 
reasonable doubt that the ' self-multiplication ' 
of each of them as it acts is the self-multipli- 
cation of a specific microphyte; and that, 
directly or indirectly, the microphyte's self- 
multiplying life is the force which originates 
the fermentation.1 This being the case in 
regard of those fermentations (and the more 
intimate nature of the process needs not just 
1 In regard of some of these common-world fer- 
ments, it seems pretty certain that their charac- 
teristic microphytes operate mediately-that is to 
say, by means of special zymotic matters which they 
respectively produce, and which when produced can 
be mechanically separated from them: but whether 
this be true of all the same class of agencies does 
not hitherto seem fully settled. So far as it may 
prove to be true for them, that the microphyte is 
not itself the ferment, but is the producer and 
evolver of the ferment, the case of these ferments 
would be in parallelism with that of the chylopoietic 
and other functional ferments which more highly 
organised creatures produce for the purposes of 
their own economy. In the latter case the distinc- 
tion between the ferment-yielding live bodies (say 
certain gastric cells) and their not-live product (say 
pepsin) is already familiar. 388 
CONTAGION 
here be discussed), it seems probable that the 
same is in substance true of the specific mor- 
bid changes which extrinsic contagia produce 
in the materials of the living body-probable, 
namely, that low, self-multiplying organic 
forms, specific in each case for the particular 
disease which is in question, are essential to 
each morbid poison; that the increase of each 
contagium as it acts is the characteristic self- 
multi plication of a living thing; and that 
this (however obscure may yet remain its 
mode of operation) is the essential originator 
of change in the affected materials of the dis- 
eased body. The fact that low organic forms 
of the sorts now spoken of have often, or 
generally, been seen in the morbid products 
and tissues of persons with zymotic disease, 
would not by itself be a proof, or nearly a 
proof, that the forms are causative of the 
morbid change : for obviously they might be 
mere attendants on the necrosis and decom- 
position of bodily material, availing them- 
selves of the process (just as certain insects 
would) to feed and multiply: and in many of 
the cases in which micrococci have been seen 
in morbid material, no direct proof could be 
given that the meaning of their presence was 
more than that. There are, however, some 
cases in which this proof has been completely 
established; and though such cases are at 
present but few, the significance of each of 
them in aid of the interpretation of other 
cases is of the highest importance. The re- 
searches of successive able observers in regard 
of the splenic fever of farm-stock, and those 
of Dr. Klein in regard of the ' pneumo- 
enteritis ' (as he names it) of swine, have 
shown that in each of these cases the micro- 
phyte which attends the disease is botanically 
specific ; that it and its progeny can be con- 
ducted through a series of artificial cultiva- 
tions apart from the animal body; and that 
germs thus remotely descended from a first 
contagium will, if living animals be inocu- 
lated with them, breed in these animals the 
specific disease. It is equally well known 
that the organisms (spirilla) which are found 
multiplying in the blood during the accesses 
of relapsing fever are botanically specific: 
but in regard to this disease, experimental 
proof has not hitherto been given that the 
spirilla, if separately inoculated, will infect 
with relapsing fever. Studies as complete as 
those which have been made in splenic fever 
and pneumo-enteritis will no doubt sooner or 
later be made in regard to many other of the 
diseases, but their progress will necessarily 
be slow; partly because the objects which 
have to be scrutinised, and to which specific 
characters have to be assigned, are so ex- 
tremely minute, and often so similar among 
themselves, that none but very skilled and 
very patient microscopical observers are com- 
petent to pronounce on them; and partly 
again because the conditions of the case are 
such as to limit very closely the field within 
which the essential experimental observations 
can be made. Meanwhile, however, the two 
diseases, regarding which the larger know- 
ledge has been obtained, must be regarded as 
highly suggestive in regard of other diseases 
of the same pathological group, and particu- 
larly as giving importance to fragments of 
evidence (not by themselves conclusive) which 
have been gathered of late years in studies of 
some of these other diseases. Eminently this 
is true of the large family of the septic infec- 
tions-including, on the one hand, erysipelas 
and pyaemia with its congeners, and having, 
on the other hand, tuberculosis intimately 
associated with it; and almost equally it is 
true of enteric fever and cholera and diph- 
theria, and of the smallpox of man and beast. 
Thus, though it would be at least premature 
to say of these diseases that they certainly 
have as their contagia microphytes respec- 
tively specific to them, it seems at present 
not too much to say that probably such will 
be found the case; and if as much may not 
yet be said of many other diseases which are 
due to metabolic contagia, it must be remem- 
bered that the right lines of study relating to 
contagia in this point of view have not till 
within very recent times been opened. See 
Postscript, 1. 
Of the natural history of the contagia, 
considered independently of the part which 
they play in the living body, there are hitherto 
only the beginnings of knowledge. The abso- 
lutely first origin of contagia may perhaps 
not be more within reach of scientific research 
than the absolutely first origin of dog or cat; 
but their nearer antecedents-the states out 
of which they come when first about to act 
on the living body, and generally the varia- 
tions which they and the common ferment® 
exhibit under natural and artificial changes 
of circumstance, are within easy reach of 
investigation; and those humbler studies are 
likely to give very useful results. For some 
of our cases we seem to have an instructive 
analogy in the facts which Professor Mosier 
has put together in explanation of the blue- 
milk contagium of dairies-facts showing that 
the omnipresent penicillium glaucum, if its 
spores happen to alight in particular (morbid) 
sorts of milk, will operate distinctively on 
their casein as an anilin-making ferment, 
rendering the milk blue and poisonous, and 
imparting to each drop of it the power to 
infect with a like zymosis any normal milk 
to which it may be added.1 In our own more 
special field, pathologists have already learnt 
that certain of the so-called ' morbid poisons ' 
-the contagia of erysipelas, pyaemia, and 
tuberculosis, are intimately related to the 
common ferment or ferments of putrefac- 
tion ; and that the most vehement of these 
contagia can be developed by the artificial 
culture of successive transmissions in the 
living body from the comparatively mild 
1 Virch. Arch., vol. xliii. CONTAGION 
389 
contagium of any common inflammatory 
process.1 
Two other directions suggest themselves as 
likely to lead to fields of useful observation 
and experiment. On the one hand, in com- 
parative pathology, and with the tracing of 
contagion from animal to animal, there is the 
possibility that at last some lower and rela- 
tively worthless order of animals may be 
found the starting-ground of fatal infections 
for higher orders ; and this, perhaps, by con- 
tagia which in their former relations are of 
mere inflammatory significance. On the 
other hand, in geographical pathology, and 
with the tracing of contagion from place to 
place, local centres of contagium-origination 
may possibly be found, in which the contagium, 
before it enters the animal body, will show 
itself an independent microphyte of the earth, 
first operating on the animal body as the 
essential force in a local malaria. Some of 
the worst pestilences known to the human 
race-yellow fever, cholera, perhaps plague, 
and also some of the diseases of cattle, have 
in their history facts which suggest that sort 
of interpretation: the supposition, namely, 
that certain microphytes are capable of thriv- 
ing equally (though perhaps in different forms) 
either without or within the animal body; now 
fructifying in soil or water of appropriate 
quality, and now the self-multiplying con- 
tagium of a bodily disease. In regard to our 
own common ague-poison there seems every 
reason to suspect that its relation to soil is 
that of a microphyte; and though we know 
ague only as practically a non-contagious 
disease, we do not know that any little trans- 
fusion of blood from sick to healthy would 
not show it to be (in that way) communicable 
from person to person. See Postscript, 2. 
It needs hardly be said that exact scientific 
knowledge of the contagia, and of their re- 
spective modes of operation, is of supreme 
importance to the prevention of disease. 
With even such knowledge of them as already 
exists, diseases which have in past times been 
most murderous of mankind and the domestic 
animals can, if the knowledge be duly applied, 
be kept comparatively, or absolutely, in sub- 
jection; and the fact that at the present time 
fully a fifth part of the annual mortality of 
the population of England is due to epidemics 
of contagious disease is only because of the 
very imperfect application hitherto made of 
that knowledge. In the present article it 
is not necessary to state in detail the practice 
which ought to be adopted in the various 
different cases of infectious disease; but 
briefly it may be said that one principle is 
at the root of all such practice, whatever the 
disease to which it relates. This principle, 
which of course becomes more and more 
important in proportion as the infection is 
dangerous, and as the persons whom it would 
endanger are many, is the principle of 
thoroughly effective separation between the 
sick and the healthy: a separation which, so 
far as the nature of the disease requires, 
must regard not only the personal presence 
of the sick, but equally all the various ways, 
direct and indirect, by which infective matters 
from that presence may pass into operation 
on others. Especially as regards the diseases 
which make serious epidemics, the principle 
of isolation is not carried into effect unless 
due care be taken to thoroughly disinfect in 
detail all infective discharges from the sick, 
and all clothing and bedding and towels and 
like things which such discharges may have 
imbued, and finally, as regards certain con- 
tagia, the rooms in which the cases have 
been treated; and in order to secure these 
objects, it is essential in all grave cases to 
make such nursing-arrangements and such 
arrangements of the sick-room (whether 
private or in hospital) that no retention or 
dissemination of infectious matters will escape 
notice. It is likewise essential that all who 
attend on the sick should be careful not to 
carry contagion to other persons; as they may 
but too easily do, particularly in scarlatina 
and in certain traumatic and puerperal infec- 
tions, if they omit to take special precautions 
against the danger. See articles Quarantine ; 
Disinfection ; and Public Health ; and 
those on the special diseases. See also 
Postscript, 3. 
The social conditions through which, in 
our own country at the present time, the more 
fatal infectious diseases are enabled to acquire 
epidemic diffusion are chiefly such as the fol- 
lowing:-that persons first sick in families 
and districts, instead of being isolated from 
the healthy, and treated with special regard 
to their powers of spreading infection, are 
often left to take their chance in all such 
respects; so that, especially in poor neigh- 
bourhoods, where houses are often in several 
holdings, and where always there is much 
intermingling of population, a first case, if 
not at once removed to a special establish- 
ment, will almost of necessity give occasion 
to many other cases to follow;-that persons 
with infectious disease, especially in cases of 
slight or incipient attack, and of incomplete 
recovery, mingle freely with others in work- 
places and amusement-places of common 
resort, and, if children, especially in day- 
schools ; and that such persons travel freely 
with other persons from place to place in 
public conveyances;-that often, on occasions 
when boarding-schools have infectious disease 
getting the ascendant in them, the schools 
are broken up for the time, and scholars, 
1 See particularly Professor Sanderson's papers 
in successive yearly volumes of Reports ~of the 
Medical Officer of the Privy Council from 1868 
to 1877. It concerns the second fact mentioned in 
the text to remember that apparently every ' com- 
mon inflammatory process ' includes more or less of 
textural changes which are necrotic and of septic 
tendency. See Holmes's System of Surgery, first 
edition, article ' Inflammation.' 390 
CONTAGION 
incubating or perhaps beginning to show in- 
fection, are sent away to their respective, per- 
haps distant, homes;-that keepers of lodging- 
houses often receive lodgers into rooms and 
beds which have recently been occupied by 
persons with infectious disease and have not 
been disinfected;-that persons in various 
branches of business relating to dress (male 
and female) and to furniture, if they happen 
to have infectious disease, such as scarlatina 
or smallpox, on their premises, probably often 
spread infection to their customers by pre- 
vious carelessness as to the articles which 
they send home to them; and that laundries 
further illustrate this sort of danger by care- 
lessness in regard to infected things which 
they receive to wash ;-that purveyors of 
certain sorts of food, if they happen to have 
infectious disease on their premises, by care- 
lessness spread infection to their customers; 
-that streams and wells with sewage and 
other filth escaping into them are most dan- 
gerous means of infection, especially as re- 
gards enteric fever and cholera ;- and that 
great purveyors of public water-supplies, so 
far as they use insufficient precautions to 
ensure the freedom of their water from such 
risks of infectious pollution, represent in this 
respect an enormous public danger;-that 
ill-conditioned sewers and house-drains, and 
cesspools receiving infectious matters, greatly 
contribute to disseminate contagia, often into 
houses in the same system of drainage, and 
often by leakage into wells. Of the dangers 
here enumerated, there is perhaps none 
against which the law of England does not 
purport in some degree to provide. At pre- 
sent, however, they all are, to an immense 
extent, left in uncontrolled operation; partly 
because the law is inadequate, and partly 
because local administrators of the law often 
give little care to the matter; but chiefly 
because that strong influence of national 
opinion which controls both law and ad- 
ministration cannot really be effective until 
the time when right knowledge of the subject 
shall be generally distributed among the 
people, and when the masses whom epidemics 
affect shall appreciate their own great interest 
in preventing them. 
Whenever that time shall come, probably 
the public good will be seen to require, with 
regard to every serious infectious disease 
which is apt to become epidemic, that the 
principles which ought to be accepted in a 
really practical sense, and to be embodied in 
effective law, are somewhat as follows:- 
(1) that each case of disease is a public dan- 
ger, against which the public, as represented 
by its local sanitary authorities, is entitled to 
be warned by proper information; (2) that 
every man who in his own person, or in that 
of anyone under his charge, is the subject of 
such disease, or is in control of circumstances 
relating to it, is, in common duty towards his 
neighbours, bound to take every care which 
he can against the spreading of the infection; 
that so far as he would not of his own accord 
do this duty, his neighbours ought to have 
ample and ready means of compelling him; 
and that he should be responsible for giving 
to the local sanitary authority proper notifi- 
cation of his case, in order that the authority 
may, as far as needful, satisfy itself as to the 
sufficiency of his precautions; (3) that so far 
as he may from ignorance not understand 
the scope of his precautionary duties, or may 
from poverty or other circumstances be un- 
able to fulfil them, the common interest is to 
give him liberally out of the common stock 
such guidance and such effectual help as may 
be wanting; (4) that so far as he is volun- 
tarily in default of his duty, he should not 
only be punishable by penalty as for an act 
of nuisance, but should be liable to pay pecu- 
niary damages for whatever harm he occasions 
to others; (5) that all who are in attendance 
on any case of infectious disease should be 
similarly bound to use every proper care and 
precaution not to carry the infection to any 
other person; (6) that the various commercial 
undertakings which in certain contingencies 
may be specially instrumental in the spread- 
ing of infection-water-companies, dairies, 
laundries, boarding-schools and day-schools, 
lodging-houses, inns, &c., should respectively 
be subject to special rule and visitation in 
regard of the special dangers which they may 
occasion; and that the persons in authority 
in them should be held to strict account for 
whatever injury may be caused through 
neglect of rule ; (7) finally, that every local 
sanitary authority should always have at 
command, for the use of its district, such 
hospital accommodation for the sick, such 
means for their conveyance, such mortuary, 
such disinfection-establishment, and generally 
such planned arrangements and skilled ser- 
vice, as may, in case of need, suffice for all 
probable requirements of the district. See 
Postscript, 4. 
Persons who are imperfectly acquainted 
with the scientific and social facts relating to 
the present subject-matter, or who have never 
seriously considered them, may think it would 
be over-sanguine to expect any general recog- 
nition of principles so peremptory as the above 
may at first appear to them; but, if so think- 
ing, they would perhaps have under-estimated 
the rapidity with which knowledge is now 
increasing as to the common interests and 
mutual duties of mankind in respect of dan- 
gerous infectious disease. In the year 1865, 
when the so-called cattle-plague or steppe- 
murrain was imported afresh, as a long-for- 
gotten disease, into this country, and was 
found to affect very large pecuniary interests, 
primarily of the chief landowners of the 
United Kingdom, and secondarily of other 
classes, an immensely valuable stimulus was 
given to the education of the country, and 
especially of its Legislature, in regard to CONTAGION 
CONTINUED FEVERS 
391 
the preventibility of the infectious diseases. 
And the remarkable zeal and ability which 
from that time onward have been shown, in 
providing adequate laws and admirable ad- 
ministrative arrangements against the diffu- 
sion of steppe-murrain and other infectious 
diseases of Farm-Stock, are not likely to be 
found permanently absent in relation to the 
interests of Human Life, when once the true 
bearings of the subject shall have got to be 
popularly understood. John Simon. 
CONTINUED FEVERS. - Charac- 
ters.-Under the name of Continued Fevers 
is included a group of diseases which have 
the following characters in common :- 
1. They are attended with pyrexia, or a 
febrile condition sustained for a more or less 
definite period of considerable duration, with- 
out intermission or very decided remission, 
and not due to any local inflammation. 
That is, the fever is essential, and not merely 
symptomatic. The distinguishing feature of 
pyrexia is unnatural elevation of the tem- 
perature of the body; but there are other 
symptoms scarcely less constant-increased 
frequency of the pulse, thirst, loss of appetite, 
furred tongue, headache, chilliness, and-if 
the temperature is high-various manifesta- 
tions of disturbance of the nervous system. 
2. They are clearly due to the introduction 
into the body of & poison from zvithout, and 
this poison is reproduced in the system, so 
that continued fevers are communicable 
directly or indirectly from the sufferer to 
others. This statement would not apply to 
simple continued fever so called ; but simple 
continued fever, when not a mild or abortive 
attack of one or other of the specific fevers, 
has scarcely anything in common with them. 
3. The continued fevers rarely affect the 
same individual twice. An attack is pro- 
tective against subsequent attacks of the 
same fever. This is much less manifest in 
relapsing than in typhus and enteric fever. 
4. The continued fevers have a more or 
less definite duration. A certain time inter- 
venes between the exposure to the poison and 
the onset of the disease, which is called the 
period of incubation; and the disease is 
divisible into the stages of invasion, domi- 
nance, and decline. 
5. In two out of three continued fevers 
there is a characteristic cutaneous eruption. 
Enumeration.-The continued fevers are 
typhus, enteric, and relapsing fever. Com- 
mon continued fever, or febricula, often asso- 
ciated with them for the sake of convenience, 
resembles them only as consisting in pyrexia 
not traceable to any known local inflamma- 
tion. It does not conform to the character- 
istics enumerated, and cannot be brought 
within any definition which applies to the 
true fevers. 
Diagnosis.-The continued fevers have to 
be distinguished from the intermittent and 
remittent fevers on the one hand, and from 
the eruptive fevers and some other diseases 
on the other. 
1. From intermittent and remittent fevers 
they are distinguished clinically by the com- 
paratively sustained high temperature; but 
were this all, the continuous character some- 
times assumed by intermittents and the remit- 
tent type occasionally seen in enteric fever- 
especially in children-wouldbringthem close 
together. The essential distinction is that 
indicated under the second head, and is 
Postscript.-In revising, for the reprint of 
the Dictionary of Medicine, the above article, 
written in 1878, the writer has been able to 
leave the original text almost entirely with- 
out change, but has to add the following few 
remarks referring to steps of later progress. 
1. First, with regard to the exact science of 
Contagion, knowledge of microphyte-life as the 
power of the metabolic contagia has during 
the past twelve years advanced considerably 
both in extent and in minute accuracy, and 
is rapidly tending to consolidate itself into 
general law. Work of especial value in that 
line has been done by Dr. Klein in respect of 
scarlatina and diphtheria, and also of the 
foot-and-mouth disease of farm-stock. 
2. And with regard to the question of cases 
in which perhaps the microphytes of given 
diseases, before infecting the human body, 
may have multiplied in soils or waters of 
appropriate quality, an extremely interesting 
line of research has been opened by Dr. 
Ballard in his study of the setiological re- 
lations of summer diarrhoea. 
3. With regard to the proper action of 
Local Authorities against the spreading of dan- 
gerous contagions in their districts, it has to be 
noticed that, in 1889, an important step towards 
supplying the first requisite for such action 
was represented by the passing of an Act for 
the compulsory local Notification of cases of 
Infectious Disease (52 & 53 Viet., cap. 72). 
4. Within the last few years, by the admir- 
able studies of Mr. Power and Dr. Klein, it 
has been made almost certain that scarlatina 
and diphtheria are diseases common to man 
with at least some of the animals which are 
most intimately in his service: both of them 
appearing to be capable of affecting bovine 
animals, and to be communicable by means 
of cows' milk, while diphtheria appears also 
to be a disease which spreads among cats: 
and, with this extremely important addition 
to knowledge which previously existed, the 
consequence is now strongly suggesting itself 
that systems of law and administration in- 
tended to guard human society against dan- 
gerous infections of disease, must extend to 
the provision of adequate means for observing 
and controlling the infectious diseases of 
domestic and farm-yard animals, and for 
securing that the public health shall not be 
jeopardised through the negligent or wilful 
distribution of infected milk. J. S. 392 
CONTINUED FEVERS 
CONVALESCENCE 
mainly aetiological. Both kinds of fever are 
due to a poison received from without; but 
while in continued fevers the source of the 
poison is for the most part a previous case of 
fever of the same kind, and the poison is 
generated anew in the subject of the disease, 
remittents and intermittents are of malarious 
origin, and the poison is never reproduced 
in the system, and therefore never communi- 
cated by the sufferer. 
The formation of the specific contagium of 
continued fevers within the system during 
the disease is of course the cause of their 
spread by contagion. The mode of this 
spread is different for the different fevers. 
Typhus and relapsing fever are directly con- 
tagious in an eminent degree; the poison is 
contained in the emanations from the skin or 
lungs, and is capable of entering the blood of 
healthy persons by being breathed or swal- 
lowed; it may also be carried by fomites. 
Enteric fever, if directly contagious at all, is 
very slightly so ; the contagium is apparently 
not given off in the breath or perspiration, 
but chiefly or exclusively from the bowels, 
and the disease is spread mainly by the con- 
tamination of drinking-water, or, more rarely, 
by sewer gases or by the emanations from 
typhoid excreta, especially after long residence 
in sewers. 
2. The distinctions between the continued 
and the eruptive fevers remain to be pointed 
out. They are of a very slight character. 
All the characters given of the continued 
fevers, including the occurrence of a cuta- 
neous eruption, are common to them and 
the eruptive fevers. The differences are as 
follows:- 
(d) The liability to the eruptive fevers is 
almost universal in the absence of protection 
by a previous attack, and is little affected by 
the state of health of the individual, while the 
liability to continued fever is very variable 
in different persons, and even races, and is 
greatly influenced by external conditions. 
There is no parallel in the eruptive fevers 
to the predisposition to typhus and relapsing 
fever generated by overcrowding and famine. 
(b) The protective influence of a previous 
attack is more marked in the eruptive fevers, 
though not to such a degree as would con- 
stitute an important distinction. Instances 
of small-pox alter a previous attack, or after 
vaccination, and second attacks of measles 
and scarlet fever, are not very uncommon. 
(c) While in the eruptive fevers the specific 
poison is considered to be invariably derived 
from a previous case, this cannot be said with 
the same confidence with regard to the con- 
tinued fevers. It is true that, in by far the 
largest proportion of attacks of typhus, en- 
teric, and relapsing fevers, the source of the 
poison can be traced, and that as the ex- 
perience and trained skill brought to bear on 
the search increase, the fewer are the examples 
in which it fails ; but it cannot yet be said | 
definitely that these fevers are not generated 
anew under certain conditions. The con- 
stancy with which typhus and relapsing fever 
follow in the track of overcrowding and 
starvation is suggestive of spontaneous origin; 
but in this country typhus is never so com- 
pletely extinct that foci of infection are want- 
ing, and epidemics of relapsing fever may 
be imported. Enteric fever, again, appears 
from time to time under circumstances which 
appear to exclude the possibility of the poison 
having been derived from a previous case, 
though in most instances of epidemic pre- 
valence of the disease, there is conclusive 
evidence of specific, and not merely general, 
contamination of the air or water. It is not, 
however, necessary to enter upon this con- 
troversy here, or to do more than allude to 
the question whether or not their contagia 
are of the nature of organic germs. See 
Contagion ; and Zyme. 
The fevers will be fully described under 
their respective names. 
William H. Broadbent. 
CONTRACTION, Muscular (con- 
traho, I draw together).-A term applied to 
the action or to the shortening of a muscle 
from any cause, whether in health or in 
disease. See Spasm. 
CONTRA-INDICATION.-Any cir- 
cumstance which forbids the employment of 
therapeutic measures otherwise indicated. 
CONTRE-COUP (Fr.), Counter-stroke. 
An injury of a part opposite to but distant 
from that to which force is applied, as by a 
fall or direct blow. Contre-coup is chiefly 
observed in injuries of the skull. 
CONTUSION (contundo, I bruise).-A 
bruise or injury of the soft parts without 
breach of surface. 
CONVALESCENCE (con, with; and 
valesco, I grow well).-The period of con- 
valescence signifies that period during which a 
patient is progressing towards recovery, and 
is returning to a state of health after having 
suffered from an illness. When the health 
has been completely restored, convalescence 
is said to be established, and the patient is 
regarded as convalescent. The word is used 
most commonly in association with fevers, 
inflammatory diseases, and other acute affec- 
tions. Convalescence may be ushered in by 
a crisis, and become speedily established; or 
it may be very slow and protracted in its 
progress, which is also often interrupted by 
relapses, complications, or sequels. Patients 
frequently require careful watching and 
judicious treatment while becoming convales- 
cent, as they are apt to retard or even prevent 
their recovery, and to lay the foundation for 
permanent disease, by neglect of due precau- 
tions, especially as regards their diet. Much CONVALESCENCE 
CONVOLUTIONS OF THE BRAIN 
393 
injury is not uncommonly inflicted by the 
injudicious administration of medicines, and 
the employment of other means which are 
supposed to hasten convalescence ; but, on 
the other hand, it can undoubtedly often be 
promoted by suitable measures. 
Frederick T. Roberts. 
CONVOLUTIONS OF THE BRAIN 
and CORTEX CEREBRI, Lesions of. 
The pathology of the cortex cerebri is still 
comparatively in its infancy. The older re- 
cords and observations, made while the idea 
was still prevalent that the convolutions of 
the brain had no definite dispositions and re- 
lations, and that the various parts of the 
hemispheres were functionally equivalent, are 
not sufficiently exact to be made the basis of 
trustworthy clinical and physiological conclu- 
sions. Recent anatomical investigation into 
the topography and homologies of the cerebral 
convolutions, and the experimental researches 
of Hitzig, the writer, and others in reference 
to the results of electrical irritation of the 
brain, have directed greater attention to ac- 
curate topographical descriptions of the lesions 
of the cortex in connexion with observed 
clinical symptoms. Up to a comparatively 
recent date physicians and physiologists 
generally held by the views of Flourens, 
based on experimental investigation of the 
brains of the lower classes of animals. Ac- 
cording to Flourens the hemispheres were 
concerned purely with intelligence-a faculty 
one and indivisible; and each part of the 
hemisphere possessed the functions of the 
whole, so that, if part were destroyed, func- 
tional compensation might be effected by the 
parts which remained. These views seemed 
satisfactorily to explain the cases, not uncom- 
mon, in which, notwithstanding the existence 
of extensive lesions in the hemispheres, no 
symptoms were observed during life. The 
frequent association of aphasia with a limited 
lesion of the cortex cerebri, vaguely indicated 
by Bouillaud and Dax, and definitely fixed 
by Broca at the posterior extremity of the 
third left frontal convolution, was a step 
towards localisation of function in the brain, 
which, however, met with much opposition 
and counter-facts. The clinical and patholo- 
gical observations of Hughlings Jackson in 
reference to the causation of limited and uni- 
lateral epileptiform convulsions were an im- 
portant contribution to the physiology and 
pathology of the cortex. These convulsions 
he attributed to irritative or discharging 
lesions of the grey matter in the neighbour- 
hood of the corpus striatum in the opposite 
hemisphere. 
Physiological experiment has demonstrated 
the correctness of the views advanced by 
Hughlings Jackson, and shown that, not only 
can movements be excited by electrical irri- 
tation of certain regions of the cortex, but also 
that definite combinations of muscular move- 
ments uniformly result from stimulation of 
certain specialised areas within this region. 
Physiological experiment is, as to precision 
in its results, considerably in advance of 
clinical observation, and, from the nature of 
the two methods, this is what might be ex- 
pected. 
The investigation of diseases of the brain 
is surrounded by special difficulties. Though, 
as shown by physiological experiment, the 
brain is capable of being mapped out into 
different regions possessing different func- 
tions, yet the brain acts as a whole, and it is 
not always easy to analyse the facts of 
disease, and to distinguish with certainty 
between the effects directly dependent on the 
locality of the brain, and those due to the in- 
direct influence exerted on the functions of 
neighbouring regions and on the brain as a 
whole. 
That the brain is diseased in insanity, 
functionally or organically, is a fact now uni- 
versally admitted; but it is also true that the 
lesions which cause objective symptoms in 
the domain of motion and sensation need not 
cause mental derangement, and also that 
lesions which cause mental derangement 
need not manifest themselves in any dis- 
coverable disorders of sensation or motion. 
In fact, for purposes of ideation we have 
practically two brains; for, though motion 
and sensation will be paralysed on the oppo- 
site side by destruction of one hemisphere, 
yet intelligence and thought are possible 
through the hemisphere which remains. 
Various forms of lesion have been found in 
the brains of the insane, including morbid 
conditions as to vascularity, degeneration of 
the blood-vessels, and degeneration of the 
nerve-cells, neuroglia, and membranes; but no 
constant relation has as yet been established 
between any one form of degeneration and any 
one form of mental alienation, or between the 
latter and any localised lesion. Nor has it 
been clearly established whether the forms 
of degeneration found in the brains of the 
chronically insane are the result or the cause 
of the mental disorders. An exception, how- 
ever, is to be made in favour of general 
paralysis of the insane, where there seems to 
be a definite connexion between the anatomi- 
cal lesion and the symptoms manifested. In 
this disease we find as a constant, if not the 
only factor, a form of chronic encephalitis, 
affecting chiefly the cortical regions which 
physiological experiment has shown to be the 
motor zone of the hemispheres. This lesion 
is associated with progressive motor paralysis, 
varied with intercurrent epileptiform and 
apoplectiform seizures, and with mental 
symptoms characterised generally by exalted 
ideas and delusions as to wealth, power, and 
grandeur. The motor symptoms are readily 
accounted for by the locality and character 
of the cerebral lesion, but the relation be- 
tween this and the mental symptoms is a 394 
CONVOLUTIONS OF THE BRAIN, LESIONS OF 
subject which psychological analysis has yet 
to elucidate. 
The objective symptoms of cortical lesions 
depend on their locality, and on whether they 
exercise an irritative or destructive influence 
on the parts they invade. From the locali- 
sation point of view alone the intimate nature 
of the morbid process is unimportant, except 
same fissure. The centre for the arm is 
situated below that of the leg, and partly in 
front of it, and occupies the middle third, or 
rather two-fourths of the central convolu- 
tions (3, 4, 5, 6, 7, a, b, c, d, figs. 30 and 31). 
Fig. 30.-Side view of the Left Hemisphere of the 
Monkey. The areas have the same signification as 
in the next figure. 
in so far as its irritative or destructive 
character is concerned. Lesions, such as 
tumours, which from their very nature exer- 
cise important indirect effects on the ence- 
phalon as a whole, apart from their effects on 
the regions which they directly invade, can 
rarely be exactly localised, owing to the diffi- 
culty of separating the direct and indirect 
symptoms from each other and referring each 
to its exact cause. Also no rigid conclusions 
as regards localisation can be drawn from 
morbid affections of the hemispheres which 
extend over a large area, such as the various 
forms of meningitis and meningo-encepha- 
litis. In all these cases the nature of the 
affection must be diagnosed from its own 
general and special characters; its position 
and extent in the brain being arrived at 
approximately from a consideration of the 
effects of accurately circumscribed lesions, as 
determined by careful clinical and pathologi- 
cal observation and physiological experiment. 
The brain may be considered as divided 
into a motor and a sensory zone. 
Motor Zone.-The motor zone includes 
the convolutions bounding the fissure of 
Rclando, viz. the ascending frontal (pre- 
central), the ascending parietal (post-central), 
and postero-parietal lobule, the base of the 
three frontal convolutions, and the internal 
or mesial aspect of the same convolutions, or 
marginal gyrus. In this zone are differen- 
tiated centres for the movements of the 
trunk, limbs, head, and eyes, and those of 
the mouth, tongue, larynx, and correlated 
muscles. The centres of the lower limb are 
situated at the upper extremity of the cen- 
tral convolutions and in the paracentral 
lobule or posterior part of the marginal con- 
volution (numerals 1 and 2, figs. 30 and 31). 
The centres for the foot and toes are more 
especially posterior to the upper end of the 
fissure of Rolando; those of the thigh and 
leg anterior to the upper extremity of the 
Fig. 31.-Side view of the Left Hemisphere in 
Man, with the areas of- the cerebral convolutions. 
The effects of stimulation of each area, as ascertained 
by experiments on the brain of the monkey, are sub- 
joined. 
1, 2 (at the upper extremity of the fissure of 
Rolando). Movements of the foot and leg. 
8, 4. Complex movements of the opposite leg and 
arm, and of the trunk, as in swimming. 
a, b, C, d. Ascending parietal convolution. Indi- 
vidual and combined movements of the fingers and 
wrist of the opposite hand. 
5. Posterior extremity of the superior frontal con- 
volution. Extension forward of the opposite arm and 
hand. 
6. Upper part of ascending frontal convolution. 
Supination and flexion of the opposite forearm. 
7. Median portion of ascending frontal convolu- 
tion. Retraction and elevation of the opposite angle 
of the mouth. 
8. Lower part of the ascending frontal convolution. 
Elevation of ala nasi and upper lip, with depression 
of lower lip. 
9 and 10. Inferior extremity of ascending frontal 
convolution (Broca's convolution). Movements of 
the mouth, tongue and larynx. Action bilateral. 
11. Between the inferior extremities of the ascend- 
ing frontal and the ascending parietal convolutions. 
Retraction of the opposite angle of the mouth; and 
the head turned slightly to one side. 
12. Posterior portions of superior and middle 
frontal convolutions. Eyes opened widely; pupils 
dilated; head and eyes turned towards opposite side. 
13 and 13'. Supra-marginal lobule, angular gyrus, 
and occipital lobe. Eyes moved towards the oppo 
site side, with an upward (13) or a downward (13') 
deviation. The pupils generally contracted. (Centre 
of vision.) 
14. Infra-marginal (superior temporo-sphenoidal) 
convolution. Pricking of opposite ear; head and eyes 
turned to opposite side; pupils largely dilated. 
(Centre of hearing.) 
In this area may be differentiated centres for 
the upper arm (protraction), (5, figs. 30 and 
31), and retraction (4, figs. 30 and 31); move- 
ments of the forearm, viz. flexion, supination, 
&c. (6, figs. 30 and 31); and those of the wrist, 
fingers, and thumb (a, b, c, d, 30 and 31). CONVOLUTIONS OF THE BRAIN, LESIONS OF 
395 
The proximal movements of the upper ex- 
tremity are represented most in the upper 
part of this area ; the distal movements, that 
is those of the finger and thumb, most at the 
lower part. Below the arm area, and occu- 
pying the lower third of the central convolu- 
tions, is the centre for the movements of the 
face, mouth, and tongue and larynx, &c. (7, 8, 
9, 10, 11). The upper facial movements are 
centralised more particularly in front of 7, 8 
(figs. 30 and 31), and those of the platysma 
behind the fissure of Rolando (11, figs. 30 and 
31). The movements of the mouth, tongue, 
and larynx are represented more particularly 
at the lower part of this area (9, 10, figs. 30 
and 31). The centres for the adduction of the 
vocal cords are situated more particularly at 
the lower portion of the ascending frontal 
convolution, immediately posterior to the 
precentral sulcus. The centres for the lateral 
movements of the head and eyes are situated 
at the base of the frontal convolutions (figs. 
30 and 31). The areas or centres for the 
head and eyes, arm and leg, extend over the 
margin of the hemisphere into the mesial 
aspect or marginal convolution. In this con- 
volution, posterior to the centres for the head 
and eyes, and arm, are centralised the move- 
ments of the trunk, and, behind these, those 
of the leg. The prefrontal area, that is to 
say the region in advance of the anterior ex- 
tremity of the precentral sulcus, though ana- 
tomically related to the motor tracts of the 
internal capsule, is a so-called non-excitable 
area-that is to say, it gives no outward 
response to electrical stimulation like the 
centres above described. 
Irritative lesions of the motor zone proper, 
such as may be induced by syphilitic lesions, 
tumours, spicula-of bone, depressed fractures, 
thickening of the membranes, &c., cause con- 
vulsions, which may remain limited to one 
limb, or one group of muscles, without loss of 
consciousness, or affect the whole of the oppo- 
site side with loss of consciousness, or become 
more or less bilateral with all the symptoms 
usually observed in so-called idiopathic epi- 
lepsy. 
If the convulsive phenomena begin always 
in the same way, and if they frequently re- 
main localised in one limb or one group of 
muscles, and especially if paralytic symptoms 
manifest themselves, the exact position of the 
lesion in the opposite hemisphere may be 
accurately diagnosed. 
Destructive lesions of the motor zone cause 
general or limited paralysis of voluntary 
motion in the opposite side of the body, ac- 
cording as the lesion affects the whole of the 
motor zone, or. is limited to special centres 
within this area. The causes of destructive 
lesions of the cortex may be various-hsemor- 
rhage, laceration by wounds, &c. One of the 
most common causes is embolism or throm- 
bosis of the arteries supplying the cortical 
motor area. These are derived from the 
Sylvian artery of the middle cerebral. The 
cortical branches may be occluded without 
interfering with the circulation in the corpus 
striatum, which is supplied by special 
branches, as shown by the researches of 
Duret and Heubner. 
When the motor zone is affected by a general 
destructive lesion, complete hemiplegia of the 
opposite side results, in all respects like that 
resulting from destructive lesion of the corpus 
striatum and anterior portion of the internal 
capsule. In this form of paralysis the loss of 
motion is most marked in those movements 
which are most independent; hence the arm 
is more paralysed than the leg or face, and 
the hand more paralysed than the shoulder 
movements of the arm. This has been ac- 
counted for by the fact, that the centres for 
bilateral movements are intimately associated 
in the lower ganglia: hence the stimulus 
from one hemisphere can to a certain extent 
call forth the action of the conjoint motor 
nuclei. The electrical contractility and nutri- 
tion of the muscles is not affected by paralysis 
of cerebral origin. The nutrition of the 
muscles may, however, suffer from disuse, 
and frequently paralyses of cortical origin 
are followed after a time by rigidity and 
contracture, with descending sclerosis of 
the pyramidal tracts of the crura, pons, and 
lateral tracts of the spinal cord. In some 
cases the descending degeneration invades 
the anterior cornua of the spinal cord, and 
atrophy of the paralysed muscles ensues. 
Occasionally from limited lesions of the cor- 
tical motor area complete hemiplegia may 
occur on the opposite side, for the time at 
least. This is to be explained by the fact that 
sudden establishment of a destructive lesion 
may cause such commotion or perturbation 
of the centres in general, that their functions 
are for the time suspended. But in such 
cases those centres which have been only 
functionally suspended again resume their 
functions, and the paralysis disappears except 
of those movements the centres of which 
have been permanently damaged. 
Limited lesions of the motor zone cause 
paralysis of those movements the centres of 
which the lesion invades. The result is not 
complete hemiplegia, but a monoplegia or 
dissociated paralysis. Hence, from a cortical 
lesion we may get a paralysis of the arm, or 
of the arm and face, or of the leg and arm, or 
of the face alone, or of the lateral movements 
of the head and eyes. If the leg is specially 
paralysed, the lesion is in the upper third of 
the central convolution; if the arm, in the 
middle third of the central convolution ; if 
the face, in the lower third of the central 
convolution, and we may more precisely 
localise the lesion in the upper or lower half 
of these respectively, according as the proxi- 
mal or distal movements are more particularly 
affected. The lesion which, while circum- 
scribed at first, causes a monoplegia, may 396 
CONVOLUTIONS OF THE BRAIN, LESIONS OF 
advance to other centres, and after a time 
produce general hemiplegia of the opposite 
side. Hemiplegia so resulting is a succession 
of monoplegias, and is a sure indication of 
cortical disease. It is to be noted that de- 
structive lesion of the mouth-centre (Broca's 
region) on one side does not cause paralysis 
of articulation or phonation, owing to the fact 
that each centre has a more or less complete 
bilateral influence over the movements of the 
mouth and tongue and larynx. Destructive 
lesion of this centre in the left hemisphere 
generally gives rise to aphasia without para- 
lysis of articulation (see Aphasia). In bi- 
lateral lesions there is both aphasia and 
paralysis of articulation (see Dr. Barlow's 
case, Brit. Med. Journ. 1877, vol. ii. p. 103). 
Limited cortical motor lesions are frequently 
associated with transitory rigidity of the op- 
posite side of the body ; and occasionally also 
with unilateral convulsions, owing to the 
morbid process inducing irritation of the 
neighbouring centres. 
Unilateral destruction of the oculo-motor 
area causes a temporary conjugate deviation 
of the head and eyes to the side of lesion, a 
condition which is frequently seen in the 
early stages of hemiplegia, and it is due to 
the unantagonised action of the centre in 
the sound hemisphere. But the effects of 
unilateral destruction of this centre are not 
permanent, hence lesion of this region may 
appear entirely latent. Lesions of the pre- 
frontal region cannot with certainty be dia- 
gnosed. Not infrequently they give rise to an 
irritable dementia; but it is difficult to dis- 
tinguish this from the general symptoms of 
other forms of cerebral disease, such as tumour, 
abscess, and the like. 
Subcortical lesions of the motor zone cause 
symptoms not readily, if at all, distinguish- 
able from lesions of the cortex itself. They are 
perhaps less frequently quite limited, owing 
to the close relation of the various tracts con- 
verging towards the internal capsule, though 
occasionally they have the character of dif- 
ferentiated monoplegiae. Theoretically, ac- 
cording to the results of experiment, irritative 
lesions of the medullary fibres should produce 
only tonic, and not clonic, epileptiform spasms 
of the related muscular groups; but, practi- 
cally, this is not a reliable test, inasmuch as 
these lesions are apt to cause also cortical irri- 
tation and clonic convulsions of the usual type. 
In the majority of instances of paralysis 
from disease of the cortex sensation has been 
unimpaired ; but, on the other hand, a num- 
ber of cases have been put on record in which, 
with lesions of various kinds (including tu- 
mours) implicating the motor zone, there has 
been paralysis, not only of motion, but also 
of sensation in a greater or less degree. But, 
whereas paralysis of motion is invariably 
caused by truly destructive lesions of the 
motor area, anaesthesia is onlv of occasional 
occurrence in connexion with apparently 
similar lesions. There is no relation between 
the extent, degree, or duration of the motor 
paralysis and the impairment of sensation; 
for there may be the most complete paralysis 
of motion with perfect sensibility in all its 
forms, cutaneous as well as muscular; and 
the motor paralysis may remain when the 
anaesthesia, if any, has entirely disappeared. 
The centres of common and tactile sensi- 
bility have been shown by the writer's ex- 
periments, and those of Horsley and Schafer, 
to be situated in the falciform or limbic lobe, 
and many of the recorded cases of anaesthesia 
in connexion with lesions affecting the motor 
zone can be shown to have directly impli- 
cated either this lobe or the sensory tracts of 
the internal capsule, and we may legitimately 
assume, even if we cannot demonstrate, a 
similar direct or indirect implication of these 
regions in the case of others. The slight de- 
gree of anaesthesia affecting the fingers more 
particularly which has been most frequently 
noted in connexion with cortical motor para- 
lysis, is, in the writer's opinion, to be regarded 
as the beginning or the remnant of a general 
hemianaesthesia, due to direct or indirect im- 
plication of the sensory tracts. 
Sensory Zone.-Experiments on mon- 
keys and other animals, by the complemental 
methods of excitation and destruction, have 
shown that in the regions behind and below 
the motor zone there are differentiated cen- 
tres for the senses of sight, hearing, common 
and tactile sensibihty, smell, and taste. 
The experiments of the writer indicate that 
the visual centre is situated in the angular 
gyrus and occipital lobe, or occipito-angular 
region; though those of Munk and Schafer 
would limit this centre to the occipital lobe. 
Unilateral lesion of the angular gyrus, or 
occipital lobe, may remain latent; but if it is 
such as to cause extensive destruction of the 
medullary fibres of this region, homonymous 
hemianopia towards the opposite side is the 
result. This is particularly frequent in 
connexion with lesions invading the mesial 
aspect (cuneus) of the occipital lobe. De- 
structive lesions of the angular gyrus of the 
left hemisphere commonly cause word-blind- 
ness, and allied defects in visual ideation. 
Hemianopia may be caused also by lesion of 
the optic tract, or of the corpora geniculata. 
Uncomplicated hemianopia from cerebral 
lesion is comparatively rare. Usually it is 
associated with some degree of hemianaes- 
thesia, owing to implication of the adjacent 
sensory tracts, or, it may be, with a greater 
or less degree of hemiplegia. In cerebral 
hemianopia, a pencil of light thrown on the 
anaesthetic side causes contraction of the 
pupils ; whereas, if the lesion is in the optic 
tract no reaction occurs (Wilbrand's test). 
Irritative lesions of the angular gyrus not 
infrequently give rise to subjective ocular 
spectra, or visual hallucinations. 
The auditory centre is situated mainly, CONVOLUTIONS OF THE BRAIN 
CONVULSIONS 
397 
if not exclusively, in the superior temporal 
gyrus. Owing to the bilateral relations of 
each centre, unilateral lesion may cause no ap- 
preciable symptoms. If, however, the lesion 
is in the superior temporal gyrus of the left 
hemisphere, word-deafness is usually met 
with. This does not occur in connexion with 
lesion of any other part of the temporal lobe, 
provided that the superior temporal gyrus is 
intact. Deafness from cerebral disease is 
very rare. In order that this should occur, 
it is necessary that the superior temporal 
gyrus should be destroyed on both sides. 
There are only two cases on record of such 
a bilateral lesion; one reported by Shaw (Ar- 
chives of Medicine, February, 1882), and an- 
other by Wernicke and Friedlander (Fortsch. 
d. Med., March, 1883). In both cases total 
deafness was observed. In monkeys, how- 
ever, complete destruction of this region on 
both sides does not entirely abolish sensitive- 
ness to sonorous vibrations (Croonian Lec- 
tures on Cerebral Localisation, Ferrier, 
1890). There are several cases on record 
of irritative lesions of this region causing 
subjective auditory sensations, or epilepsy 
ushered in by an auditory aura (ibid). 
The centre of tactile and common sensi- 
bility is situated in the falciform or limbic 
lobe, as above mentioned (gyrus fornicatus 
and gyrus hippocampi). This conclusion is 
founded almost entirely on the results of ex- 
periments on monkeys. Pathological evidence 
in favour of the localisation of the tactile 
centre in this region is as yet scanty. 
Experiments on monkeys indicate that the 
centres of smell and taste are situated in close 
relation to each other at the lower extremity 
of the temporal lobe, or region of the hippo- 
campal lobule (see Croonian Lectures, sup. 
tit.) 
The anatomical relations of the olfactory 
tract, as well as the results of electrical stimu- 
lation, indicate that the olfactory centre is 
chiefly in relation with the nostril on the 
same side, and cases have been reported in 
which smell has been affected cn the same 
side as the cerebral lesion. But the facts of 
cerebral hemianaesthesia, functional and or- 
ganic, indicate that some at least of the olfac- 
tory tracts pass into the opposite hemisphere 
by way of the internal capsule. It was sup- 
posed by Meynert that the olfactory tracts 
decussate in the anterior commissure, but this 
is opposed by the anatomical and experi- 
mental investigations of von Gudden and 
Ganser. There are several cases on record 
of subjective olfactory sensation in connexion 
with tumours and other irritative lesions im- 
plicating the region of the uncinate gyrus in 
man (Jackson and Beevor, Brain, October, 
1889). The exact position of the centres of 
taste has not been determined either by ex- 
perimental research or by clinical observation, 
but the evidence is in favour of their being 
situated in close relation to those of smell. 
Treatment.-The principles of localisation 
above indicated, combined with those of an- 
tiseptic surgery, have in recent years been in 
several instances successfully applied to the 
treatment of certain forms of cerebral disease 
otherwise hopeless (' Cerebral Localisation in 
its Practical Relations,' Ferrier, Brain, 1889; 
and ibid., Mills). These include traumatic 
cysts and extravasations, the position of which 
has been determined by the symptoms, as 
well as cases of tumour and abscess, the 
last more particularly in connexion with 
disease of the middle ear. Excisions of ir- 
ritable portions of the cortex have also been 
undertaken for the cure of focal epilepsy ; in 
some instances with benefit, though in others 
without material improvement. 
Up to the month of December, 1889, 
eighteen cases of cerebral tumour had been 
operated upon. Of these, seven were suc- 
cessfully removed. Of the remaining eleven 
cases (including three cases of tumour of the 
cerebellum, and five of unremovable tumours, 
two of them operated on in extremis) nine 
have died from various causes, including 
septic inflammation, cerebral oedema, or shock. 
This gives a mortality of fifty per cent. Con- 
trasted with the latest statistics of trephining 
for all causes, or of the mortality from the 
major operations in surgery, we have reason 
to regard the surgical treatment of cerebral 
tumour as having achieved an encouraging 
measure of success, and probably greater suc- 
cesses may be attained in future when the 
conditions of successful operation and after- 
treatment have become better known. In the 
absence of definite indications as to the cha- 
racter of the tumour, and as to whether it is 
situated on, in, or beneath the cortex, tre- 
phining is, in the writer's opinion, justifiable 
as a diagnostic measure ; for if the tumour 
should, after all, not be removable, the risks of 
the operation itself are less than the evil of 
allowing a case to perish which the autopsy 
might prove to be one which could have been 
dealt with successfully. 
D. Ferrier. 
CONVULSIONS.-Synon. : Eclampsia; 
Fr. Convulsions; Ger. Krampfen. 
Definition.-This term is commonly given 
to more or less general, purposeless muscular 
contractions, occurring simultaneously and 
successively for a variable time-constituting 
a ' fit ' of this or that kind. It is also, how- 
ever, applied at times to certain more localised 
purposeless contractions, though these would 
be more appropriately (and are in the ma- 
jority of cases) termed spasms. The latter, 
like convulsions, are of two kinds, tonic and 
clonic. 
Classifications.-Convulsions have been 
variously classified by different authors ac- 
cording to the different points of view from 
which they have been regarded. From the 
point of view of their causation, it was the 398 
CONVULSIONS 
custom of older writers to recognise both a 
clinical and a physiological division into 
classes. From the former standpoint there 
was the division into (1) primary or essential; 
(2) sympathetic; and (3) symptomatic: whilst 
from the physiological point of view convul- 
sions were divided into (1) centric ; and (2) 
excentrie. These classifications are altogether 
arbitrary and superficial, and will not stand 
the test of a critical examination-though 
the first of them is to a certain extent useful. 
Again, looking to the distribution of the 
convulsions, or to the parts involved, the 
classification that has been adopted by various 
writers may be summarised as follows :- 
(1) external convulsions-a, general; b, uni- 
lateral ; c, partial; (2) internal convulsions. 
These various terms need little explanation, 
though before referring to a more recent and 
more strictly scientific classification something 
requires to be said in regard to them. 
Convulsions are termed primary or essen- 
tial when they occur either without assignable 
cause, from mental or moral perturbations, 
or as a result of some local irritation. They 
are called sympathetic when the convulsions 
declare themselves as a prelude to, or in the 
course of, any of the specific fevers, as a con- 
sequence of acute pulmonary or renal affec- 
tions, or in association with disordered states 
or structural diseases of any of the organs of 
the body other than those of the nervous 
system; while the name symptomatic has 
been applied to the convulsions which occur 
as a result of injury or structural disease of 
the nervous system itself. The unilateral 
convulsions which affect one half of the body 
only, as well as other more partial convul- 
sions, are almost entirely confined to this 
latter group, though general convulsions of 
the symptomatic type are perhaps just as 
frequently met with. The so-called internal 
convulsions constitute an ill-defined group, 
the members of which are scarcely worthy of 
the name of convulsions at all. They are 
rather tonic or clonic spasms of particular 
parts. The best-known member of this group 
is laryngismus stridulus; but another ex- 
ample is a spasmodic and frequently re- 
curring hiccup. Some authors would also 
include angina pectoris. 
Convulsions, either tonic or clonic, or both, 
enter into or form the semeiological basis of 
six principal diseases having separate places 
in our nosology. These are eclampsia, 
epilepsy, tetanus, laryngismus stridulus, 
hydrophobia, and chorea. All but the first 
of these conditions vzill be considered in 
their respective places, so that eclampsia 
alone remains. But eclampsia and convul- 
sions are convertible terms, meaning almost 
absolutely the same thing. The former 
term, indeed, is useless except for the mere 
purpose of literary precision. In epilepsy 
and in eclampsia we have equally to do 
with convulsions, which are now admitted 
by almost all modern writers to be, so far as 
the form of the attack is concerned, indis- 
tinguishable from one another. The former 
name, however, is given to convulsions which 
have a known tendency to recur at variable 
intervals; whilst the latter has been com- 
monly applied to convulsions which are 
either solitary or, if not exactly so, which 
occur as a closely successive cluster or group, 
more or less distinctly sympathetic with some 
general or local bodily condition. Seeing 
that there is, in a very large number of 
cases, almost nothing in the nature of the 
attack itself to enable a medical man, called 
to a patient in convulsions for the first time, 
to say whether he has to do with an attack 
which will be repeated or not, it is easy to 
understand that eclampsia is a word more 
frequently to be seen in books than to be 
heard at the bedside. In books we may read 
of eclampsia neonatorum, the eclampsia of 
parturient women, and urajmic eclampsia; 
though the more common clinical equiva- 
lents are infantile convulsions, puerperal 
convulsions, and uraemic convulsions. The 
distinction between epilepsy and eclampsia 
is, therefore, one which is to a very great 
extent purely artificial, from the point of 
view of the convulsions themselves. 
Convulsions have a frequent though less 
constant relationship also with many other 
affections, such as general paralysis of the 
insane, tubercular meningitis, chronic hydro- 
cephalus, hemiplegia, and hysteria. 
The more recent classification of convul- 
sions, previously referred to, is that of Dr. 
Hughlings Jackson {Brit. Med. Joum., vol. i. 
1890). This is an attempt in the right 
direction-an attempt, that is, to identify the 
intimate cause of the phenomena, and to 
range convulsions into different classes 
according to the different portions of the 
brain which are the seats of the initial 
morbid processes in this or that form of 
the disease. He recognises three kinds of 
convulsion ; each kind including several 
varieties; and these varieties again compre- 
hending ' fits ' of many different degrees of 
severity. The first kind or class corresponds 
with epilepsy proper, and these attacks are 
dependent, as he thinks, upon discharges of 
nerve-elements occurring in some portion of 
the cortex of the prefrontal lobe; the second 
kind or class comprises what are known as 
epileptiform attacks (epileptic hemiplegia 
or Jacksonian epilepsy), due to discharges 
commencing in this or that portion of the 
cortex of the so-called 'motor area ' (Rolandic 
region) of the cortex; whilst the third kind 
or class comprises what he terms ' ponto- 
bulbar fits,' being due, as he thinks, to initial 
discharges of nerve-elements occurring in 
some part of the pons, the bulb, or (much 
more rarely) the spinal cord. 
The aim of this classification is essentially 
scientific, but even its main divisions are CONVULSIONS 
399 
based to a very large extent not so much 
upon well-ascertained facts as upon hypo- 
thesis and speculation. This is especially the 
case, as Dr. Hughlings Jackson admits, in 
regard to the convulsions belonging to the 
first and third classes; though the pathology 
of the second class-to a very large extent as 
the result of his labours - stands upon a much 
firmer basis of actual knowledge. Some 
kinds of eclampsia would fall into the first 
class, whilst many others would belong 
rather to the third class. It is difficult to 
say into which category well-developed 
hystero-epileptic attacks should be placed. 
It must not be lost sight of, moreover, that 
the conceptions which have inspired this 
classification are eminently hypothetical and 
speculative, however ably and consistently 
they may have been worked out; so that our 
notions as to the mode of production of fits, 
and as to the natural groups into which they 
are to be ranged, should still be regarded as 
being in a very rudimentary stage. 
^Etiology.-The causes of convulsions are 
oftentimes more than usually complex, con- 
stituting a web of conditions partly made up 
(a) of predisposing, partly (b) of exciting, and 
partly (c) of proximate elements. It is often 
the fashion to pick out some one of the most 
prominent or easily recognisable of these 
factors, and speak of it as ' the cause ' of the 
attack. It must never be forgotten, however, 
that this so-called cause, in any given case, 
may be able to act as such only when in 
conjunction with certain other more obscure, 
though perhaps not less potent, co-operating 
conditions. 
The question of the causation of convul- 
sions resolves itself into a strictly clinical and 
a strictly physiological department. It is one 
thing for the medical man to ascertain what 
are the particular individual states, conditions 
of life, and occurrences, physical or moral, 
which have contributed to induce an attack of 
convulsions. It is quite a different problem 
when he endeavours to unravel, by physio- 
logico-anatomical data, the actual mode of 
production of the convulsions. For the pre- 
sent this is a point of view which concerns 
us less than the more strictly clinical side of 
the inquiry. 
Predisposing causes.- One of the most 
important of these is the existence of an 
unduly excitable nervous system-one in 
which there is an exaltation of the tendency 
to produce reflex movements. This is a state 
of things which is often more marked in 
women than in men, and is also notably pro- 
minent in young children of both sexes. It 
is, moreover, much exaggerated in some chil- 
dren of nervous habit, who, besides being un- 
duly emotional or excitable, are very prone to 
start or tremble at the least noise, and are 
subject to muscular twitchings in various 
parts of the body. With increasing age, and 
more especially in the male sex, we find the 
sensorial and emotional nerve-centres becom- 
ing less excitable. 
In persons possessing a nervous system of 
this type there is a lack of proper balance or 
equilibrium between the functional activities 
of some of its parts; and there seems to be an 
undue tendency to errors of nutrition whereby 
the matter of its nerve-cells becomes from 
time to time highly unstable and prone to 
undergo ' discharges ' of a morbid character. 
The predisposing groundwork being of this 
nature, how is it caused or to be accounted 
for ? (1) It may be inherited from parents, 
or from grandparents, who may themselves 
have possessed a nervous system of this type, 
and may have been subject to fits or other 
well-marked disease of the nervous system. 
But though not inherited in the strict sense 
of the term, it may (2) be connate : the patient 
may always (i.e. from birth) have possessed a 
nervous system of this type, as an accompani- 
ment of the mere low vitality which is often 
seen in children born from parents who are 
weak or aged and debilitated. (3) At other 
times the nervous system may have acquired 
such predisposing characters some time dur- 
ing the life of the individual (especially during 
childhood or adolescence) owing to the action 
of various sets of conditions, such as-(a) the 
cachexia which occasionally follows measles, 
pertussis, &c.; (6) insufficient or improper 
food; (c) chronic diarrhoea ; (d) haemorrhages 
or exhausting discharges. 
If we turn now to the various exciting 
causes, we find these powerfully influenced 
by the periods of age, which we may con- 
veniently, though artificially, mark off from 
one another. 
Infancy (from birth to end of 2nd year).- 
In certain cases convulsive attacks are con- 
genital ; and here perhaps the most frequent 
exciting cause is a meningeal effusion of 
blood which irritates the surface of the brain 
-the extravasation having been occasioned 
during parturition. These congenital attacks 
are most frequently associated either with more 
or less marked hemiplegia, or with a subse- 
quent partial or distinct condition of amentia 
or idiocy. Such unfortunate infants may 
continue quite unable to stand or even sit 
up; they remain unable to speak, and, as 
in a case seen by the writer, the child may 
be quite blind. Meningeal or superficial 
haemorrhages may also occur in young 
infants, under the strain produced by violent 
fits of coughing; and in some of these cases 
snch effusion maybe followed by convulsions. 
Fits in infancy may also follow falls or blows 
upon the head. 
In infancy, again, convulsions may usher 
in or supervene in almost any acute disease, 
this being especially the case in the exanthe- 
mata ; in pneumonia or bronchitis ; and also 
in tubercular meningitis. 
But, still more frequently, convulsions in 
infancy are excited by mere peripheral irrita- 400 
CONVULSIONS 
tions, as during the process of teething, from 
an overloaded stomach, or from indigestible 
food. Diarrhoea and worms also take their 
place as more or less frequent excitants of con- 
vulsive paroxysms in infants, though worms 
only begin to appear towards the end of this 
period. But though irritations in the field 
of distribution of the fifth and pneuraogastric 
nerves are especially potent in exciting con- 
vulsions, irritations of other parts of the body 
may also lead to similar results, whether 
they are occasioned by the injudicious dis- 
position of pins, by tight strings wounding 
or irritating the skin of the body, or by any 
other means. The more distinctly that predis- 
posing conditions exist, the more frequently 
will any or all of these exciting causes give 
rise to an attack of convulsions. 
Lastly, an infant which has taken the 
breast of a woman who has shortly before 
been much perturbed by violent anger, grief, 
or any other strong emotion, may thereafter, 
if predisposed, be seized with convulsions- 
probably owing to the milk of the nurse 
having been so altered in quality as to have led 
to gastric trouble and irritation in the infant. 
Childhood (from the 2nd to the 13th year). 
Most of those exciting causes which are in- 
fluential during the previous period continue 
to be occasionally operative in this-especi- 
ally during the first half of it. Meningeal 
haemorrhages are now rarer, though they 
may still occur during violent paroxysms of 
coughing, and also from falls or blows upon 
the head. The latter causes of haemorrhage 
may, however, act in producing fits in other 
ways, e.g. by concussion, shock, &c., and 
they now come to be more frequently opera- 
tive. The exanthemata are still apt to be 
preceded or associated with convulsive at- 
t icks; and irritations, especially from teeth- 
ing or irritants (undigested food or worms) 
in the intestinal canal, are also occasionally 
prone to be followed by such a sequence. 
During this period another cause comes 
into operation with great frequency, and this 
is fright. The first fit either follows the fright 
more or less immediately, or it may not take 
place for days, or perhaps for weeks. During 
the interval, however, the health and mental 
condition of the child is generally obviously 
disturbed. Proper treatment at this stage 
may prevent the occurrence of fits. Scrofulous 
or other tumours in the brain sometimes help 
to determine convulsions in children. 
Adolescence (from the 13th to the 20th 
year).-Fright or other sudden emotions, 
falls upon or blows about the head, still 
appear as frequent excitors of convulsive 
attacks which recur (epilepsy) at this period 
of life, though meningeal htemorrhages, acute 
diseases, and peripheral irritations are much 
less frequently operative than at earlier 
periods, since the special irritability of the 
nervous system characteristic of childhood 
decidedly abates during these years. 
Other and new causes, however, come into 
play at this epoch. The establishment of 
puberty is a kind of crisis during which, in- 
dependently of all other causes, convulsions 
or fits may be initiated in those whose 
nervous systems are at all predisposed towards 
such an occurrence. This is more especially 
so in the case of the female, partly because 
of the existence of a rather more frequent 
predisposition in persons of this sex, and 
partly because of extra excitations in associa- 
tion with the establishment of the catamenia. 
Ovarian or uterine irritation, or irregularity 
of the functions of these organs at this period, 
may occasion fits which may take an hysteri- 
cal type. Masturbation may also be added 
as an occasional provocative of epilepsy at 
this critical period of life, though the writer 
is inclined to think too much stress is often 
laid upon this as a cause. This mode of causa- 
tion occurs more frequently with the male sex. 
Excessive study and mental application, as 
well as worry or anxiety, must also undoubt- 
edly be enumerated among the causes of 
epilepsy at this period of life. 
Neither must we forget the possible exist- 
ence of aneurysms of the cerebral arteries, 
or of morbid growths in connexion with some 
portion of the brain or its meninges. This 
latter cause also figures in earlier periods of 
life-more especially in those children who 
are of a scrofulous type. And in some of 
such cases the new-growth may lead to the 
supervention of chronic hydrocephalus, and 
thus render the occurrence of convulsions 
even still more likely. 
Early adult years).- Fits 
originate much less frequently during this 
period of life than in adolescence or child- 
hood. They are, however, apt to supervene, 
more especially when the general health is 
lowered, under the influence of various ex- 
citing causes. Grief and mental worry (par- 
ticularly when combined with long-continued 
bad sleep), and the labours or cares of busi- 
ness, are then apt to induce them. 
Blows or falls upon the head may still be 
followed by attacks of this kind, though per- 
haps with less frequency than in the earlier 
periods of life. 
Syphilitic indurations or growths from the 
meninges may now occur ; and other attacks 
(often of one-sided convulsion) may be deter- 
mined by various pathological changes or 
accidents taking place in regions of the 
brain where more severe lesions would give 
rise to hemiplegia. The primary change in 
these cases may be minute haemorrhages into 
the brain-substance, or minute and slight 
softenings produced by blocking of small 
vessels (embolism or thrombosis). With 
lesions of this kind hemiplegia and convul- 
sions are often more or less associated. 
Occasionally the cause may be a non-syphi- 
litic tumour, occupying the side or base of 
the brain. CONVULSIONS 
401 
Puerperal convulsions in the female, and 
uraemic convulsions in both sexes, are most 
frequently met with during this period. Dur- 
ing pregnancy the excitability of the nervous 
system is often greatly increased, and in the 
production of puerperal convulsions some 
amount of uraemia also intervenes not infre- 
quently. Intemperate habits, carried to ex- 
cess, frequently produce fits, and so also may 
venereal excesses. 
After middle age (40 years and onwards). 
The excitability of the nervous system dimi- 
nishes, so that epileptic attacks commence 
with much less frequency at this period. At 
the climacteric this excitability is temporarily 
increased, and fits again become more fre- 
quent, under slight exciting causes. 
Although fits are only very rarely liable to 
be induced by the sequelae of haemorrhages 
or of occlusions of cerebral vessels, yet these 
events now grow more common as age ad- 
vances, and are therefore to an almost cor- 
responding extent more liable to figure as 
causes of convulsive attacks. An attack of 
haemorrhage or of softening may be ushered 
in by epileptiform convulsions (especially 
when the lesion occurs in certain parts of 
the brain), and in some cases such attacks 
may thereafter recur at irregular intervals. 
Exposure to great heat, or sunstroke, may 
also at this period, or earlier, act as the ex- 
citing cause of convulsions. 
Mental overwork, worry, fright, and such- 
like influences, are much less likely to ope- 
rate in persons over 40 than in earlier life ; 
and the same is to be said of blows or inju- 
ries of the head, short of the most severe, 
causing actual lesions of the brain. But the 
malnutrition and degeneration induced by 
intemperate habits may predispose to symp- 
toms of this kind; and so also may blood- 
poisoning from renal disease, which is often 
present. 
Various organic diseases of the brain, 
whether principally characterised by dege- 
nerations with a process of more or less 
general atrophy, or with localised overgrowth 
of connective tissue, are also not infrequently 
productive of convulsions, either in persons 
of middle or of advanced age. A well-marked 
instance of the former of these associations 
is to be met with in general paralysis of the 
insane. Cysticerci on the surface of the brain 
have also been the cause of most obstinately 
recurring convulsions. 
Lastly, it should always be borne in mind 
that convulsions are sometimes the result of 
the action of poisons of various kinds upon 
persons of any age. Occasionally such poi- 
soning may be brought about by articles 
of diet, such as mussels or fish in certain 
states, or poisonous mushrooms; whilst at 
other times it results from some of the well- 
known narcotico-irritant poisons, taken either 
inadvertently or purposely. 
Anatomical Characters.-These may be 
said, so far as our present knowledge goes, 
to be absent. It is true that general or par- 
tial congestion of the brain may frequently 
be encountered in those who die during an 
attack of convulsions. But this congestion 
is to be regarded as a result rather than as 
a cause of the fit. The convulsions are due 
to mere molecular changes in the brain, in- 
appreciable to, or at all events xmappreciated 
as yet by, the most skilled microscopists. 
When fits occur in association with actual 
organic growths or o.ther lesions of the cere- 
bral cortex or elsewhere, some of the nerve- 
cells contiguous to such lesions may have 
their nutrition so altered as to form occa- 
sional starting-points for nervous discharges, 
which descent! so as to upset the equili- 
brium of certain unstable or highly charged 
motor centres (ponto-cerebellar) in such ways 
as to determine the convulsive phenomena. 
But a similar disturbance cf nervous equi- 
librium with discharge of motor energy, im- 
mediately productive of convulsive pheno- 
mena, may result, in another case, from 
abnormal visceral impressions (induced, it 
may be, by indigestible matters in the intes- 
tine, or by an acute disease of the lungs), or 
from some surface-irritation. In accordance 
with this point of view, such organic growths 
or other lesions as may be found, in the brains 
of epileptic patients need receive no further 
mention here. Those who may be inclined 
to think otherwise, should bear in mind the 
fact that convulsive attacks are easily pro- 
duced in animals from whom the cerebral 
hemispheres have been removed. It should 
always be borne in mind, however, that there 
is one region in particular of the cerebral 
cortex, viz. the so-called Rolandic area (com- 
prising the convolutions which bound the 
fissure of Rolando), the irritation of which 
by new-growths or other organic lesions is 
specially prone to give rise to unilateral con- 
vulsions, whose characteristics are in many 
respects extremely well-defined (' Jacksonian 
epilepsy '). 
Symptoms. - The varied nature of the 
causes makes it impossible to say anything 
of moderate compass concerning the pre- 
monitory signs or symptoms which may 
precede an outbreak of convulsions. These 
must necessarily vary immensely in different 
cases. Some of the characters of the pre- 
disposing state have been already alluded to. 
The onset is, however, often abrupt, and 
without any distinct premonitory symptoms. 
With regard to the actual characters of the 
attack, it will be sufficient to say here that 
they also vary extremely in different cases; 
arid as, notwithstanding this great variability, 
it is impossible in any individual case to tell, 
from the nature of a first convulsive fit, 
whether it will form a more or less isolated 
attack, or whether it will constitute one of a 
subsequently recurring series, the reader 
may, for this part of the subject, be referred 402 
CONVULSIONS 
to the description of the different forms of the 
attack given under Epilepsy. All that is 
there said concerning the actual phenomena 
and mechanism of the attacks, holds good 
for occasional convulsions as well as for those 
which are habitual. In each well-marked 
attack we have to do with (1) a more or less 
distinct stage of tonic spasm, followed (2) 
by one of clonic spasms, and (3) suc- 
ceeded by a state of stupor. One or other of 
such stages is, however, not infrequently 
more or less abortive. Convulsive attacks 
may, at times, so rapidly follow one another 
as to be merged into one long series or status 
convulsivus, differing in no respect from the 
analogous status epilepticus. 
Complications and Sequels.-The com- 
plications of convulsions are most various, 
seeing that in different cases we may have to 
do with irritated gums, repletion, diarrhoea, 
worms, or an acute specific disease; whilst 
in other cases the causal complicating con- 
ditions may be general debility and sleep- 
lessness, mental anxiety, puberty, or the 
climacteric period. Again, in other cases, 
either pneumonia, renal disease, pregnancy, 
ovaritis, or some organic brain-disease may 
be the accompanying condition. 
The nature of the sequel® will depend 
principally upon the frequency of the attacks, 
and the duration of the period during which 
the patient has been subject to the recurrence 
of them, so that for this part of the subject 
the reader may refer to the article Epilepsy. 
Diagnosis.-There is very little difficulty 
in regard to the diagnosis of convulsions. 
The differential characters of laryngismus 
stridulus are given elsewhere, and the 
absence of any real distinction between a 
fit of eclampsia and a fit of epilepsy has 
already been insisted upon. Neither of these 
affections can be easily confounded with 
certain forms of chorea, which occasionally 
present themselves in adults, with move- 
ments not unlike those of ordinary7 convul- 
sions. The more continuous nature of the 
movements, and the fact that consciousness 
is not impaired, suffice to distinguish all 
forms of chorea. The spasms of tetanus 
and hydrophobia are also easily distinguish- 
able from an ordinary attack of convulsions. 
The characteristics of hysterical convul- 
sions are pointed out in the article Hysteria. 
The real difficulties from the point of view 
of diagnosis have reference to the cause of 
the attack. To arrive at a decision in regard, 
to this is often very difficult, and occasionally 
impossible-at all events when a patient first 
comes under observation. At other times, 
however, the indications are so plain that 
there can be little or no difficulty. It is a 
question which should always be considered 
with the utmost care, since on the correct- 
ness of our conclusions in regard to this point 
the efficacy of the particular line of treatment 
which we adopt must necessarily depend. 
Nothing is more to be deprecated than hasty 
jumping at conclusions, from mere routine 
and superficial considerations. The condition 
of the patient must be carefully examined, 
and the nurse, attendants, or relatives must 
be closely questioned in order that we may 
learn as much as possible as to the previous 
state of health of the patient, and more 
especially as to the time and events which 
immediately preceded the first outbreak 
of an attack of convulsions. Examination 
and inquiries combined may convince us 
that the convulsions are (1) of the primary 
or idiopathic variety, immediately occasioned 
perhaps by fright, anxiety, overwork, over- 
much or indigestible food, &c.; or we may 
come to the conclusion that the convulsions 
are (2) of the sympathetic order, dependent 
upon pregnancy, renal disease, the onset of an 
acute specific fever or of pneumonia, or due 
to the existence of whooping-cough, scarlet 
fever, &c. Or, in the absence of reasons for 
placing them in either of these categories, 
we may be forced to conclude that they are 
(3) symptomatic of some organic brain- 
disease, the nature of which must then 
be determined as nearly as possible, judging 
from the age of the patient, the mode of 
onset of the attacks, his present state and 
associated conditions. 
In any case we may have to inquire more 
closely as to the hereditary tendencies, or ac- 
quired predisposing causes, which sometimes 
reduce the nervous system to such a degree 
of excitability, or disturbed equilibrium of 
certain parts, as to lead to an attack of con- 
vulsions without the aid of any obvious ex- 
citing cause. In infants or very young chil- 
dren such a condition of the nervous system 
may display itself by great restlessness and 
startings at night, by the child's sleeping 
with half-open eyes, by drawing in of the 
thumbs across the palms, by twitchings of 
the limbs, of the angles of the mouth, or of 
the facial muscles generally. In older chil- 
dren and in young adults the signs which 
most easily mark a similar below-par con- 
dition of the nervous system are twitching 
of the muscles about the angle of the mouth, 
and of the tongue (the former being specially 
well seen when the latter organ is tremu- 
lously protruded for inspection), associated 
with debility, anorexia, partial insomnia, and 
general nervousness. In nervous girls fits 
are induced by very slight causes about the 
time when the catamenia become first estab- 
lished. The indications for treatment must 
in fact vary immensely in any five or six 
consecutive cases of convulsions to w'hich the 
practitioner may be summoned. 
Prognosis.-The possibilities under this 
head are at least six in number in regard to 
any case of convulsions :-(1) The patient 
may recover after having a single fit or a 
batch of them within a few hours or days, 
and may never have another attack. (2) The CONVULSIONS 
403 
patient may recover, and though he or she 
may not have fits habitually thereafter, they 
may recur at prolonged intervals, whenever 
predisposing circumstances chance to be 
strong or are supplemented by an exciting 
cause of unusual potency. Thus convulsions 
during teething may cease, and may not re- 
cur till the constitution has been lowered by 
some illness years after, or when the nervous 
system has been rendered more irritable, as 
at the time when the catamenia are about 
to commence, especially if then some slight 
fright should also come into operation as an 
exciting cause. (3) The patient may recover, 
though he subsequently continues to have 
fits either at irregular or regular intervals; 
he becomes, in short, a confirmed epileptic. 
(4) The convulsions may come to be followed 
by temporary delirium or a more or less 
marked maniacal condition, recurring after 
all or some seizures. (5) The patient may 
recover from the convulsive attack and may 
or may not have another fit, though he may 
remain hemiplegic. (6) The patient may die 
during the attack or almost immediately 
afterwards-(a) from the effects of it, or (&) by 
reason of some organic lesion by which the 
fit itself has been determined. 
Recoveries are fortunately the rule, but 
death, especially in infants, is by no means 
uncommon. We possess no accurate data to 
enable us to assign the numerical proportion 
of these terminations to one another or to the 
other above-mentioned sequences. 
Treatment.-During the convulsion itself, 
whether we have to do with an infant or an 
adult, we must see that all clothes are 
thoroughly loose about the neck and chest, 
and the patient should be placed in the supine 
position with the head slightly raised. Be- 
yond seeing that the patient does not knock 
or injure himself, owing to the violence of 
his movements, these should not be much 
restrained; although efforts should always be 
made to prevent the tongue being bitten, by 
slipping the most suitable thing at hand be- 
tween the molar teeth on one side, when the 
age of the patient or the character of the fit 
renders it likely that this event might other- 
wise occur. Beyond such simple measures 
as these, the less we do during the actual con- 
tinuance of the fit the better it will probably 
be for the patient. We know of no rational 
or successful means of cutting short an 
ordinary attack of convulsions, and in the 
face of such an attack we should be cautious 
how we interfere lest evil may be done. 
Where we have to do with a succession of 
attacks quickly following one another, and 
which have already lasted some time, the 
injection into the rectum of chloral hydrate, 
with or without bromide of potassium, in 
suitable doses may be beneficial; or the 
careful administration of chloroform may be 
tried, as it is found very serviceable in many 
cases when a status convulsivus occurs in 
children or in adults-though it would noi 
be desirable to have recourse to it in infants. 
Under similar circumstances, for the latter 
the warm bath may be substituted, and 
sometimes seems to do good. Antipyrin and 
antifebrin have also occasionally been given 
with benefit in cases where fits are succeed- 
ing one another rapidly, and such drugs are 
especially indicated in those cases where the 
temperature in the rectum rises rapidly to 
103° F., or upwards. 
On the cessation of the convulsion or 
convulsions, or during the intervals, the 
treatment to be adopted to prevent their 
recurrence must necessarily vary immensely 
according to the age of the patient, and 
according to the predisposing and exciting 
causes which appear to have been operative 
in inducing the attack. 
An overloaded stomach will call for the 
speedy administration of an emetic ; or where 
indigestible food has already passed into the 
intestine, an enema or brisk purgative should 
be given. Diarrhoea must be checked, or 
anthelmintics administered when worms are 
suspected. Gums may be lanced if they 
seem really to need it. In many of these 
cases an acquired or hereditary predisposition 
will have to be combated by the careful regu- 
lation of the diet, so that nutritious and easily 
digested food is to be given in place of their 
opposites, and at the same time the most 
suitable nervine tonics and antispasmodics. 
For general usefulness in such cases no 
remedies can compare with the bromides of 
potassium, sodium, and ammonium. The 
former salt seems to be the most potent of 
the three; though if the bromide of sodium 
will check the fits, it is often more desirable 
to give it than the potassium salt. On the 
other hand, where the circulation is weak, or 
mental depression is apt to be induced, it is 
often best to administer bromide of ammo- 
nium. Sometimes the best results may be 
obtained by giving two of these salts in com- 
bination; at other times by administering 
moderate doses of chloral hydrate in com- 
bination with one or other of them. As part 
of the specific influence which these drugs 
exercise over nerve-tissue, they fortunately 
establish a tendency to quieter and sounder 
sleep, of which such patients often stand 
much in need. Ten-grain doses three times 
a day should be given at the commencement 
to youths or adults, and afterwards slightly 
increased if necessary. Or a larger dose 
may be given once a day, either in the 
morning or at night, or night and morning, 
according to the indications in each case. 
Very large doses of these drugs are rarely 
beneficial, and may do harm (see Bromism). 
Their action often seems to be favoured and 
harmful symptoms warded off by combining 
with the bromides suitable doses of liquor 
arsenicalis and tincture of digitalis or of con- 
vallaria. Quinine or belladonna are other 404 
remedies which may also often be given 
simultaneously with great advantage. For 
young children or infants, the dose of the 
bromide must, of course, vary with their age. 
Valerianate of zinc and oxide of zinc are 
mostly remedies of altogether less power, 
though these and other drugs may be tried 
where bromides appear to fail. Occasionally, 
too, good results may follow from the adminis- 
tration of borax in doses of fifteen or twenty 
grains three times a day,freely diluted and com- 
bined with liquor arsenicalis, where bromides 
only seem to aggravate the patient's condition, 
or, at least, to be powerless for good. 
General treatment of this kind is applicable 
to a large proportion of cases also in which 
in debilitated or ' nervous ' patients fits have 
been brought on by fright, worry, or anxiety, 
or by no assignable cause. Wherever the fits 
have recurred frequently, and a sort of habit 
has thus been established, such treatment 
has to be continued over long periods (one to 
three years or more), with suitable modifica- 
tions, in order to stamp out the tendency to 
recurrence and thus effect a cure. In all such 
cases fatigue of mind and body is always to 
be avoided; a quiet and regular life, free 
from excitement, must be led ; and in those 
instances in which over-attention to business 
or over-study has been in part operative in 
bringing on the fits, absolute rest must form 
an essential part of the treatment. In girls 
or young women in whom fits occur at the 
time of the establishment of the catamenia, 
or where they recur in association with an 
irregular menstrual function, the general 
health often requires our most careful at- 
tention, in addition to such measures as are 
above indicated. 
The convulsions that belong to the class 
known as sympathetic have to be carefully 
considered in relation to the malady of which 
they are the forerunners or associates. When 
convulsions precede an attack of scarlet fever 
or of small-pox they usually subside of them- 
selves as the disease develops. They are, 
however, of much more significance when 
occurring during the course or towards the 
close of one of these maladies, or during an 
attack of whooping-cough or of croup. Our 
indications for treatment must then be derived 
in the main from the general state of the 
patient, and this is also eminently the case 
where we have to do with uraemic convulsions. 
The treatment of symptomatic convulsions, 
dependent upon actual organic brain-disease, 
must also necessarily be subordinated to that 
appropriate for the affection itself upon which 
such symptoms depend. No drug will be 
found more generally useful, however, than 
bromide of potassium in ten- to fifteen-grain 
doses for an adult (administered three times 
a day), in checking or diminishing the repe- 
tition of convulsions in these cases. Often 
here also the action of the bromide seems 
to be favoured by combining it with liquor 
CONVULSIONS 
arsenicalis and with moderate doses of digi- 
talis, the latter being indicated especially in 
those cases in which there is great general 
nervousness in association with a disordered 
cardiac rhythm. Where sounder sleep is 
necessary, chloral hydrate, alone or in com- 
bination with bromide of potassium, should 
be given at bedtime. Sulphonal often has 
the desired effect. Tinctures of sumbul or 
of henbane are at times useful adjuvants. 
Where we have to do with tumours of the 
brain, and especially with syphilitic growths 
in the meninges, much better results are to 
be hoped for from large and increasing doses 
of iodide of potassium (that is, x to xxx grains 
or more, three times a day), either alone or 
in combination with small doses of bichloride 
of mercury. With such drugs we should 
combine the administration of nutritious 
food, and attention to the improvement of 
the general health in every way that may be 
possible. Occasionally, both in these cases 
and in non-specific cortical growths and 
thickenings of the dura mater, the operation 
of trephining has been had recourse to with 
great benefit to the patient. In some instances 
a cortical growth, or a portion of cicatricial 
tissue or of thickened dura mater, has been 
excised, with the effect not only of curing 
previous pain and tenderness, but also of 
curing or greatly diminishing the frequency 
of epileptiform attacks to which such patients 
have been subject. The cases for which this 
treatment is suitable constitute, however, 
only a comparatively small percentage; and 
much judgment and knowledge are needed 
for the selection of those in which such sur- 
gical treatment is likely to prove beneficial. 
See Brain, Diseases of; Epilepsy ; and 
Spinal Cord, Diseases of. 
H. Charlton Bastian. 
CO-ORDINATION.- This term is used 
in reference to muscular movements princi- 
pally. Certain parts of the nervous system 
have more especially to do with the calling 
into activity, and therefore with combining, the 
contractions of different muscles, both simul- 
taneously and in succession, in the precise 
order in which they occur in the several motor 
acts of which they are capable. The nervous 
arrangements upon which these actions de- 
pend have come into being, both in the race 
and in the individual, by processes of organic 
growth and development pari passu with the 
possibility of executing these several move- 
ments. It would be wrong to expect, there- 
fore, that an isolated organ should exist solely 
for co-ordinating muscular movements. The 
execution of the most habitual of these must 
depend, to a large extent, upon the activity of 
the ordinary motor (and related sensory) 
tracts of the spinal cord and brain. The 
extent or precise mode in which the cere- 
bellum intervenes in certain higher forms 
of co-ordination is still involved in much 
CO-ORDINATION CO-ORDINATION 
COPPER, POISONING BY 
405 
obscurity. That it has some share in such 
functions may be regarded as certain, though 
it probably intervenes far less than some 
would have us believe, who regard the cere- 
bellum as the organ for the co-ordination of 
muscular movements. 
Many nervous affections exist in which the 
co-ordination of muscular movements is more 
or less impaired. One of the most familiar 
of these is locomotor ataxy, a disease depen- 
dent upon a morbid process in the posterior 
columns of the cord. Sclerosis of the antero- 
lateral columns of the cord also not infre- 
quently disturbs the execution of muscular 
movements, especially those of the upper ex- 
tremities. Chorea gives rise to very similar 
uncertainties in the execution of muscular 
acts. Spasms of all kinds, in short, tend to 
interfere with the harmony of the muscular 
movements in the course of which they inter- 
vene. Stammering is an affection of this 
kind, implicating some of the muscles of arti- 
culation; and certain disturbed cardiac actions 
characterised by disordered rhythm can only 
be regarded as belonging to the same category. 
The above-mentioned are common instances 
of impaired co-ordination of muscular move- 
ments dependent upon structural or func- 
tional changes in parts of the nervous system 
other than the cerebellum. Certain diseases 
of this organ, however, are known to give 
rise to a distinct form of inco-ordination. It 
is characterised by a reeling, unsteady gait in 
walking, with legs straggling, and mostly 
wide apart, to which the term ' titubation ' is 
commonly applied. Other kinds of inco-ordi- 
nation may hereafter be proved to depend 
upon diseases of the cerebellum. Its morbid 
conditions are still very imperfectly recog- 
nised, and this is especially true in regard to 
its merely functional perturbations. 
Certain inco-ordinations in speech and 
writing are common. Instances are to be 
found in that use of wrong words or misappli- 
cation of terms which we meet with in aphasic 
and amnesic persons; also in the substitution 
of wrong words in the act of writing, or of 
wrong letters in the writing of words, when 
such substitution is mechanical and uninten- 
tional-and when it is wholly distinct, there- 
fore, from mere inability to spell. These defects 
are inco-ordinations of a complex kind, de- 
pendent upon the perverted action of higher 
cerebral centres, in the same way that inco- 
herent speech generally is dependent upon 
incoherent thought. There is reason to be- 
lieve, indeed, that the same kind of ultimate 
defective nervous action which leads to inco- 
ordinations of movements when certain motor 
regions of the nervous system are affected, 
may, on the other hand, give rise to perverted 
perceptions (illusions') or to perverted thought 
(incoherence) when the disturbed nervous ac- 
tion occurs in other and in higher parts of the 
central nervous system. 
H. Charlton Bastian. 
COPHOSIS (k^6s, deaf).-Deafness. 
See Hearing, Disorders of. 
COPPER, Poisoning by.-Synon. : 
Fr. Empoisonnement par le Cuivre; Ger. 
Kupfervergiftung.-Metallic copper may be 
regarded as innocuous when swallowed, and 
the recent researches of Hirt show that those 
who are engaged in the metallurgy and 
manufacture of copper utensils are not speci- 
ally liable to any diseases which can be 
attributed to copper as such. It is, indeed, 
stated that workers in copper enjoy an im- 
munity from cholera, a conclusion which is 
based on very insufficient premisses. It is 
contradicted by the occurrence of cholera 
among coppersmiths in Breslau in 1866, and 
by certain other cases of a like nature re- 
ported by Hirt. That the disease is seldom 
found among workers in copper is true, but 
that the copper has anything to do with this 
result is not proved. 
Though pure copper may be regarded as 
innocuous, it is otherwise with alloys of 
copper, more particularly those with zinc and 
tin, known under the names of brass and 
bronze respectively, and with compounds of 
copper with lead or arsenic. In these the 
injurious agent would appear to be the alloy, 
and not the copper itself. An affection of a 
febrile character, and known as ' brass- 
founder's ague,' occasionally occurs on fus- 
ing days, and it is attributable to the zinc 
fumes which are generated by the melting 
process. 
The salts of copper, on the other hand, are 
capable of causing injurious and fatal results. 
The more important salts, from a medico- 
legal point of view, are the sulphate, blue 
vitriol, or bluestone ; the acetates (basic and 
neutral) constituting artificial verdigris ; and 
the carbonate or natural verdigris. The 
manufacture of verdigris is carried on to a 
large extent in the South of France. Plates 
of copper are acted on by the skins of grapes, 
which are allowed to undergo the acetous 
fermentation. Those engaged in this in- 
dustry on the whole enjoy good health, and it 
is only rarely that symptoms can be directly 
traced to the work; and then only when 
through sheer carelessness and uncleanliness 
quantities of the salt have been ingested^ 
It is even said that dogs eat the refuse 
grape-skins without appearing to suffer 
from poisonous symptoms. On the other 
hand, symptoms of poisoning of a family 
have recently been recorded where they 
had eaten haricot beans, grown, as is the 
custom, between the vines, which latter had 
been watered with a solution of sulphate of 
copper (Raynaud, Bull. Gen. de Therap., 
1888). 
1. Acute poisoning by copper.- 
Symptoms.-The salts of copper, when taken 
in sufficient quantity, cause symptoms of 
acute poisoning, frequently terminating fatally. 406 
COPPER, POISONING BY 
CORN 
Twelve to fifteen grains of the acetate have 
been sufficient to kill a dog within an hour. 
The fatal dose in man is not quite deter- 
mined ; but doses above the usual emetic 
dose of the sulphate (ten to fifteen grains) 
have caused serious symptoms, and death has 
resulted within four hours after swallowing 
some pieces of the sulphate. Starr (Med. 
liecord, May 1882) records a case of death 
in four days from one ounce of the sulphate. 
Half an ounce would probably cause a fatal 
result. The symptoms are essentially those of 
irritant poisoning, namely, styptic or coppery 
taste, constriction of the fauces, epigastric 
pain, violent vomiting and purging, followed 
by collapse and death, usually with tetanic 
or convulsive symptoms. That which cha- 
racterises copper-poisoning more especially, 
as compared with other irritants, is the fre- 
quent occurrence of jaundice. Hsemoglobin- 
uria with albuminuria has also been observed 
(Starr's case). In dogs copper usually causes 
death with symptoms of paralysis of the 
hinder extremities, proceeding like a form of 
ascending paralysis, in addition to the usual 
irritant symptoms. It is said also to have a 
paralysing action on the heart. Such effects 
have only followed, at least constantly, intro- 
duction into the veins; when taken by the 
stomach most of it seems to be stepped by 
the liver, or in the case of some of the salts 
(i.e. acetate) may be reduced by the sugar of 
the food (Roger, Revue de Medecine, 1887, 
No. 11). 
2. Chronic poisoning by copper.- 
It is generally stated that the long-continued 
introduction of copper into the system in 
small doses gives rise to a form of chronic 
poisoning known under the name of ' copper 
colic.' 
Symptoms.-The symptoms are essentially 
those of gastro-intestinal irritation, with 
nausea or sickness and diarrhoea. They have 
none of the characters of colic in the sense 
in which the term is usually employed. 
The hair and the cutaneous secretions of 
workers in copper and brass are sometimes 
found of a green colour, and a line is some- 
times found at the margin of the gums 
and teeth, variously described by authors- 
Corrigan calling it purple, while Clapton 
calls it green. 
Though symptoms of gastro-intestinal irri- 
tation, as above described, have been found 
among workers in copper, the question is 
whether they are in reality due to the copper, 
or merely symptoms of a not uncommon 
affection showing themselves among copper- 
workers. That copper does gain access into 
the system, and may be detected in the urine 
during life, and found in the bones after death, 
without the individual showing any manifest 
symptoms during life, seems pretty well 
established. But though we may regard it 
as certain that symptoms of copper-poisoning 
are more rarely found than those of lead- 
poisoning among those who have to deal with 
these metals, yet it would be a very un- 
warrantable conclusion, and contrary to all 
that we know of the action of poisons, to 
assert that a substance which is undoubtedly 
poisonous can be taken freely into the system 
with impunity. This is a point of considerable 
interest in reference to the accidental or 
wilful adulteration of articles of food with 
copper salts. Many cases are on record of 
severe symptoms resulting from the use of 
copper utensils in cooking, or more frequently 
from the storage of water or articles of food 
in copper vessels, especially if the food con- 
tains oil-which, on turning rancid, dissolves 
the copper-or vegetable acids, or even large 
quantities of ordinary salt. 
Copper salts are also employed intention- 
ally to impart a green, fresh colour to pickles 
and. preserved vegetables, such as peas. It 
is asserted that the quantity of copper neces- 
sary to produce this effect is infinitesimal, and 
that no poisonous effects can be proved to 
have resulted even from long-continued 
employment of these vegetables as articles 
of food. This is strongly maintained by 
M. Galippe, who has tried them on himself 
and family. Assuming the impossibility of 
proving the injurious effects of copper-tinted 
vegetables, the question comes to be princi- 
pally a social and economic one, as to the 
propriety or legality of adulteration of food 
at all, and especially with a substance un- 
doubtedly poisonous. Copper is said by 
Odling and Dupre to be a natural constituent 
of the human body. They have found it 
in the blood, tissues, viscera, and in many 
animal products, such as cheese, eggs, and 
also in many vegetables. It takes the place 
of iron in the blood colouring-matter of some 
invertebrates (cray-fish), and is found as a 
constituent of the colouring-matter of the 
feathers of the turaco (plantain-eater). 
Diagnosis.-The greenish or bluish colour 
of the vomited matters, which turn bright blue 
on the addition of ammonia, renders the 
diagnosis comparatively easy. 
Treatment.-In acute cases the stomach 
should be evacuated by encouraging vomiting, 
or by the stomach-pump. Albumen in some 
form, as milk or white-of-egg, should be 
given, in order to precipitate the copper. 
Iron filings may be given for a similar 
purpose. 
In chronic poisoning the cause should be 
discovered and removed, or the individual 
removed from the cause. D. Ferrier. 
CORN.-Synon.: Clavus; Fr. Clou; Cor; 
Ger. Leichdorn; die Huhnera/uge. 
Definition.-A corn is a thickening of 
the epidermis, caused by undue pressure and 
friction, as by boots, shoes, or implements 
of occupation. It is usually situated on a 
prominence, such as that of a joint, where 
the skin is subjected to double pressure CORN 
CORONARY ARTERIES 
407 
and is therefore unable to yield, or between 
the toes. Corns are most common on the 
feet. 
Description.-A corn usually begins as a 
general and uniform thickening of the epi- 
dermis, which is termed a callosity {tyloma, 
tylosis, Schwielen). Callosities may occur 
on any part of the integument. Thus they 
may occupy the prominence of a joint, or 
spread over the heel or the metatarsal cushion 
of the foot from pressure in walking, or 
occupy the metacarpal prominences of the 
hand, as in boatmen. 
The callosity is composed of laminated 
epidermis; is thickest in the centre, becom- 
ing thin towards the circumference; and is 
more or less hard and condensed, smooth 
and hornlike in appearance, and yellowish 
in colour. When the irritation which gives 
rise to a callosity is prolonged, effusion is apt 
to take place beneath it, and it is raised like 
a blister, the effused fluid being sometimes 
serous and sometimes sero-purulent. When- 
ever this happens, the subsequent separation 
of the hbrny layer results in spontaneous 
cure. 
When the pressure giving rise to a cal- 
losity, instead of being diffused, is concen- 
trated on a central point, the epidermis cor- 
responding with that point increases in 
thickness, by its under surface, and forms a 
conical prominence; further pressure in- 
creases the length and breadth of the cone, 
and in this way a corn is established. Con- 
tinued irritation enlarges the corn by hyper- 
plasia of epidermic cells, and its pressure 
produces absorption of the derma, sometimes 
extending to the bone itself. Not infre- 
quently effusions of serum or blood take 
place beneath the conical prominence; and, 
in rare instances, a bursa is found between 
the corium and the joint. 
At a late stage of its growth the corn has 
the appearance of a central core-technically, 
the eye of the corn-surrounded by a collar 
of smooth epidermis in the state of callosity. 
The core is a lamellated ovoid mass, corre- 
sponding in external figure with the cup by 
which it is produced; and consisting in sub- 
stance of vertical cup-shaped lamellae closely 
packed one within the other. In an old 
corn the shape of the entire core is conical, 
the point resting on the sensitive skin, and 
the signification of the term clou or nail 
thus applied by the French is made mani- 
fest. The substance of the corn resembles 
horn both in colour and density, but between 
the toes, where moisture is generally present, 
it remains white and soft, like soddened 
cuticle, and is thence named soft corn. 
Effusion at its base is more common in the 
soft than in the hard corn. 
Treatment.-The treatment of a corn is 
to remove its causes, namely, pressure and 
friction; but when this is impracticable, to 
equalise pressure, by which the corn will 
revert to the state of callosity. The second 
indication is best effected by some simple 
unirritating application, such as the soap- or 
lead-plaster spread on washleather. As a 
preliminary to this application, as much of 
the hard epidermis as possible should be 
removed by soaking and scraping, and the 
core turned out with a blunt-pointed instru- 
ment. The soft corn may be removed as the 
hard one, or by snipping with scissors. When 
there is inflammation about the corn, it 
should be treated by water-dressing. Chronic 
corns are much benefited by an application 
composed of Salicylic Acid, 30 parts; Ex- 
tract of Indian Hemp, 5 parts; Flexile Col- 
lodion, 240 parts. 
Erasmus Wilson. 
CORNEITIS. - Inflammation of the 
cornea. See Eye and its Appendages, 
Diseases of. 
CORNUAL {cornu, a horn).-Relating 
to the cornua or horns of grey matter 
of the spinal cord, e.g. cornual myelitis. 
See Spinal Cord, Diseases of. 
CORONARY ARTERIES, Diseases 
of.-Synon.: Yr. Maladies des Ar teres Coro- 
naires; Ger. Krankheiten der Kranzarte- 
rien.-The diseases of the coronary arteries 
may be classified as follows: {a) atheroma 
and calcification; (5) aneurysm; (c) occlusion 
of the orifice ; (d) thrombosis and embolism; 
and (e) syphilitic disease. 
a. Atheroma ; Calcification. - Athe- 
roma and calcification of the coronary arteries 
are frequent, but by no means constant, 
sequelae of similar changes in the root of the 
aorta. The disease may be general, affecting 
both vessels equally or unequally; or it may 
be limited to one of them, or even to a 
primary branch of either; and may lead to 
fatty degeneration or fibroid change of the 
corresponding substance of the heart. The 
experiments of Mr. Erichsen and M. Schiff 
have proved that the nutrition of the heart 
in health depends upon a free coronary cir- 
culation, and pathology has confirmed this 
conclusion. Sir Richard Quain found the 
coronary arteries diseased or obstructed in 
13 out of 33 cases of fatty degeneration of 
the heart, and in one of these cases, the 
trunks of both vessels being healthy, a cal- 
cified coronary branch led to the only por- 
tion of the heart exhibiting fatty change. Of 
55 cases of fatty degeneration of the heart 
collated from the Transactions of the Patho- 
logical Society of London, 21 exhibited athe- 
romatous or calcific change of the coronary 
arteries. In 10 of these death occurred by 
rupture of the left ventricle, in 1 by rupture 
of the right ventricle, and in 2 by rupture 
of the septum ventriculorum, the coronary 
branch leading to the seat of rupture having 
been, in every instance, in a more advanced 
state of disease than the other portions of 408 
CORONARY ARTERIES 
CORPORA QUADRIGEMINA 
the vessel. From the foregoing statistics it 
would appear, that whilst fatty degeneration 
of the heart may exist independently of 
disease of the coronary arteries, the latter 
condition may be regarded as an immediate 
cause of fatty change in the heart, in the 
proportion of about 38 per cent, of all cases. 
Hitter points out (Virchow's Archiv, vol. 
Ixxxix. 1882) that fibroid disease of the heart 
is frequently associated with sclerotic changes 
in the coronary arteries, the fibroid patches 
corresponding to the site of the changes in 
the arteries. Fibroid disease may also be 
produced as a result of embolism of the 
coronary vessels. 
Symptoms and Signs.-There are none 
which are peculiar to this disease; those 
which exist being due to the consecutive 
changes in the substance of the heart. The 
doctrine formerly held, that calcification of 
the coronary arteries was the cause of angina 
pectoris, is no longer tenable, though fatal 
cases of angina are more frequently asso- 
ciated with disease of these vessels than 
with any other lesion. It is probable, how- 
ever, that the affection of the coronary 
arteries producec angina only by disturbance 
of the functions of the cardiac nerves and 
ganglia. See Angina Pectoris. 
b. Aneurysm.-Aneurysm of the coron- 
ary arteries is of rare occurrence. It is 
usually preceded by atheromatous or calcific 
changes in the coats of the vessels, and may, 
therefore, be regarded as a disease of middle 
or advanced age. Dr. Gee has, however, 
published an example of coronary aneurysm 
in which the patient was a boy of only seven 
years. 
Symptoms and Signs.-There is no posi- 
tive indication of coronary aneurysm during 
life. When the termination is fatal, as it 
usually is, death occurs by haemorrhage into 
the pericardium from rupture of the sac. 
c. Occlusion.-Occlusion of the orifices 
of the coronary arteries has been met with 
only in connexion with calcific changes in 
the root of the aorta, a partially detached 
calcareous plate overlying the orifice of either 
vessel (both are rarely affected), and partially 
or completely shutting off the circulation. 
There are no symptoms distinct from those 
of the principal disease. 
d. Thrombosis and Embolism. - 
Thrombosis of the coronary arteries is a 
frequent result of disease in the coats of 
these vessels; and owing to their small size, 
complete blocking and arrest of circulation 
through them are the ordinary consequences 
of this accident. Embolism of the coronary 
arteries has been observed in cases of endo- 
carditis especially involving the mitral valve. 
The heart-substance, depending upon the 
occluded vessel for its vascular supply, 
quickly undergoes the atrophic changes of 
fatty or fibroid degeneration; or appearances 
like those found in infarction in other viscera 
are produced. Special symptoms are en- 
tirely wanting. 
Disease or obstruction of the coronary 
arteries, with the ordinary consequences- 
fatty degeneration of the heart, and anemia 
with white softening of the brain-are con- 
ditions usually found in cases of perman- 
ently slow pulse. 
e. Syphilis.-Syphilitic disease of the 
coronary arteries has been recorded in a 
number of instances, but its identification 
depended entirely upon the history and the 
concomitant symptoms, the deposit being 
histologically indistinguishable from ordinary 
atheroma. 
Thomas Hayden. C. J. Nixon. 
CORPORA AMYLACEA (corpus, a 
body; and amylum, starch).-These minute 
bodies, which were first described in this 
country by Sir Richard Quain and Dr. Hughes 
Bennett in the 2nd and 3rd vols. of the 
Transactions of the Pathological Society of 
London, were thus named by Virchow. They 
are generally visible only with the ^id of the 
microscope, but sometimes are large enough 
to be seen with the naked eye, and now and 
then attain some size. Usually they are 
round or oval, and present a concentric, 
laminated arrangement, which is made more 
apparent by the action of acetic acid. They 
often have a yellowish tinge. In appearance 
corpora amylacea somewhat resemble starch- 
gran ules, and they are tinged brown or bluish 
by the action of iodine upon them. These 
bodies were formerly supposed to be com- 
posed of starch, and hence their name. This 
is not the case, however, and their actual 
chemical composition is not clearly known; 
it probably differs in different structures. 
Bodies resembling corpora amylacea in ap- 
pearance and arrangement have been found 
in various parts, but they have attracted 
most attention in connexion with the nerve- 
centres, being particularly observed when 
these are the seat of atrophy or degeneration; 
they are especially seen in the choroid plexus. 
Frederick T. Roberts. 
CORPORA QUADRIGEMINA, 
Lesions of.-The facts of comparative 
anatomy and experimental physiology tend 
to show that the corpora quadrigemina (cor- 
pora bigemina or optic lobes of the lower 
vertebrates), though related to the optic tracts, 
do not correspond in their development to 
the eyes or oculo-motor apparatus, and ap- 
pear to be largely concerned in those func- 
tions, such as equilibration and locomotor 
co-ordination, which are independent of the 
cerebral hemispheres. 
The facts of human pathology, though not 
opposed to these data, cannot be made the 
basis of very precise conclusions as to the 
diagnostic indications of disease of these 
ganglia, as it is exceedingly rare to find 
disease such as local softening limited to CORPORA QUADRIGEMINA 
CORPUS STRIATUM 
409 
this region anatomically or functionally, and 
haemorrhage is unknown. 
The corpora quadrigemina are, however, 
not infrequently involved in lesions which 
invade neighbouring parts, such as menin- 
gitis-simple and tubercular, tumours, especi- 
ally of the pineal gland and the middle lobe 
of the cerebellum, &c. 
It is stated by experimenters on the lower 
animals (pigeons, &c.) that when the anterior 
tubercles, which are more especially con- 
nected with the optic tracts, are destroyed, 
vision is abolished, and that if the lesion is 
unilateral, the blindness occurs on the side 
opposite the lesion. 
It is questionable whether such results 
occur in man, apart from indirect implication 
of the optic tracts (neuritis). Dr. Bastian, 
however, has recorded a case of total blind- 
ness, in which the cause proved to be soften- 
ing limited to the anterior tubercles of the 
corpora quadrigemina (Paralysis from Brain 
Disease, p. 115). 
It has been found experimentally in ani- 
mals, and also in man, that atrophy of the 
opposite tubercle ensues when the eye has 
been destroyed. Irido-motor action is also 
paralysed by destruction of the corpora quad- 
rigemina, a result which, however, is stated 
not to occur unless the injury is more than 
superficial and implicating the oculo-motor 
nuclei. 
Disturbances of equilibration and co-ordi- 
nation also result from lesion of the corpora 
quadrigemina. These are attributed to im- 
plication of the subjacent tracts, and, ac- 
cording to Lussana and Lemoigne, more 
particularly to lesion of the subjacent superior 
cerebellar peduncle. For his own part, the 
writer thinks that all attempts at differentia- 
tion are pure hypotheses, and from the nature 
of the question must remain so. But, from 
whatever cause, there is no doubt that the 
disturbances alluded to do occur. 
Irritation of the corpora quadrigemina on 
one side causes dilatation of the pupil and a 
hemiopisthotonos of the opposite side, which 
becomes general if the irritation is prolonged 
or bilateral, the head being retracted and the 
legs extended, trismus also being very marked. 
According to Lussana and Lemoigne uni- 
lateral lesion of the corpora quadrigemina 
causes an incurvation of the trunk and gyra- 
tion to the side of the lesion. This would agree 
with the effects of irritation, being naturally 
a reversal of the phenomena. Tumours 
implicating the corpora quadrigemina are 
generally associated with a reeling gait, which 
is an early symptom, and also frequently 
with symptoms of ophthalmoplegia from 
implication of the oculo-motor nuclei. The 
affection of the ocular muscles is unequal, 
according to the degree in which the respec- 
tive nuclei may be affected by the lesion 
(Nothnagel). In a case reported by Dr. Duffin 
(Trans. Clin. Soc. of London, vol. ix.), which 
the writer had an opportunity of investigating, 
of tumour of the pineal gland, which, besides 
passing forward into the third ventricle, 
pushed underneath the aqueduct of Sylvius, 
stretching and causing atrophy of the corpora 
quadrigemina, the symptoms, in addition to 
those of cerebral tumour-namely, violent 
occipital headache and double optic neuritis- 
were double vision followed by loss of sight, 
vertigo, specially marked when the eyes were 
open, staggering gait, and tendency to re- 
traction of the head and rigidity of the dorsal 
muscles. The pupils were large and sluggish. 
These symptoms, to a certain extent, re- 
semble those caused by tumour in the middle 
lobe of the cerebellum, and it is a question 
how far these latter may be due to mechani- 
cal irritation of these ganglia. But we may 
infer that such a combination of symptoms 
as the above points to lesion of the corpora 
quadrigemina, or of the middle lobe of the 
cerebellum, though we cannot be certain of 
the absolute limitation of the lesion. 
Naturally the same secondary affection 
of the functions of the cerebral hemispheres 
occurs from tumours situated in this region, 
as in tumours of the middle cerebellar 
lobe. 
Pressure on the veins of Galen leads to 
dropsy of the cerebral ventricles, and its con- 
sequences on the cerebral circulation and 
functions. D. Ferrier. 
CORPULENCE (corpus, a body).-An 
undue accumulation of fat in the body. 
See Obesity. 
CORPUSCLE (corpusculum, a little 
body).-In physiology and pathology this 
word is generally used as synonymous with 
cell. See Cell. 
CORPUS STRIATUM, Lesions of. 
The corpus striatum of English anatomy 
and pathology comprises various structures 
which have received special names-namely, 
the nucleus caudatus, or intra-ventricular 
nucleus, which is exposed to view by laying 
open the lateral ventricle; the nucleus len- 
ticularis, or extra-ventricular nucleus, con- 
sisting of three divisions, and subjacent to 
the convolutions of the island of Beil ; 
together with the anterior division of the 
internal capsule, or peduncular expansion, 
which connects the cortex and crus cerebri. 
This differentiation is necessary, as the 
effects of lesion of the corpus striatum will 
differ according to whether the grey matter 
alone, or the internal capsule, is involved. 
Physiological experiment has not suc- 
ceeded in defining the respective functions of 
the ganglionic masses of the corpus striatum. 
The experiments of Aronsohn and Sachs, 
Ott, Hale White, and others seem to show 
that lesions of these ganglia in animals cause 
a rise of several degrees in body temperature 
from increased heat-production. 410 
CORPUS STRIATUM 
The corpus striatum is especially liable to 
lesion from embolism or rupture of its blood- 
vessels. These are furnished principally by 
the middle cerebral artery, which in the first 
part of its course sends off numerous straight 
twigs, which sink into the anterior perforated 
space, and supply this ganglion and the ad- 
jacent part of the optic thalamus. Owing to 
their position, and direction as regards the 
main current, they are easily ruptured or 
blocked up, and owing to their being of the 
nature of ' end arteries,' and almost destitute 
of anastomoses with other cerebral arteries, 
embolism rapidly leads to softening of the 
regions which they nourish. 
Symptoms.-The symptoms of lesion of the 
corpus striatum may be divided into three 
groups or stages. 
First stage.-This includes certain symp- 
toms which are more or less transient, and 
depend chiefly on the suddenness of the 
lesion and functional disturbance of other 
parts. 
To the latter belong the symptoms usually 
accompanying an apoplecticseizure (apoplexy), 
as also the loss or diminution of sensation on 
the opposite side of the body, which some- 
times occurs in consequence of pressure on, 
or functional interference with, the sensory 
tracts of the internal capsule by effusion into 
the corpus striatum. The symptoms due to 
the suddenness of the lesion of the corpus 
striatum, as such, are complete paralysis of 
every voluntary movement on the opposite 
side of the body, occasionally varied by con- 
vulsive spasms of the paralysed side, and 
conjugate deviation of the head and eyes 
towards the sound side. This latter symptom 
is due to the centres for the head and eyes 
of the opposite hemisphere suddenly losing 
their antagonists. The temperature of the 
paralysed side is, as a rule, higher than that 
of the sound side. The total paralysis and 
flaccidity of the opposite side of the body, 
and conjugate deviation of the head and 
eyes, are transient symptoms, lasting from a 
few hours to a day or two. 
Second stage.-This stage includes those 
symptoms which continue for a variable 
period, after those depending on the sudden- 
ness and disturbing effect of the lesion have 
passed off. They constitute the common 
type of hemiplegia or paralysis of voluntary 
motion on the side opposite the lesion. The 
face, arm, and leg, and to a certain extent 
the thoracic and abdominal muscles on the 
one side of the body, are affected. The 
paralysis does not affect all these parts 
equally. As a general rule it may be stated 
that those movements are most affected 
which are most independent of those of the 
opposite side, and which are most complexand 
delicate. Hence the movements of the hand 
and arm are more affected than those of the 
face or leg, owing to the fact that these are 
more commonly exercised in associated or 
alternating action with those of the other 
side. The facial paralysis is most marked 
in the lower facial region. The orbicularis 
palpebrarum is more or less paretic, but 
never paralysed to the extent which occurs 
in Bell's or true facial paralysis, depending 
on lesion of the portio dura. The angle of 
the mouth on the paralysed side hangs lower, 
and the tongue deviates slightly to the 
paralysed side. The weakness of the facial 
muscles is best brought out when the patient 
smiles or tries to whistle. The face then 
becomes drawn to the sound side. While 
some volitional control may have been 
acquired over the leg, the hand and arm 
remain perfectly motionless. 
In the process of recovery, the leg recovers 
before the arm, and as a rule the recovery 
proceeds from the proximal to the distal end 
of the limb, the shoulder and hip movements 
being regained before those of the hand or 
foot. The flexors regain their power before 
the extensors. 
The sensibility of the paralysed parts is 
unimpaired. The superficial reflexes are 
diminished, the deep (tendon) reflexes in- 
creased. 
The faradic contractility of the muscles is 
unimpaired; occasionally it is increased rather 
than diminished. 
The muscles do not undergo atrophy except 
by disuse. 
The temperature of the paralysed limbs, 
which at first is usually increased, is generally 
found to be lower than that of the sound side, 
to the extent of a degree, more or less. 
Recovery may take place from all the 
symptoms of this stage, within a period vary- 
ing from weeks to months, or the patient 
may pass into the third stage. 
Third stage.-The special symptoms of 
this stage are the occurrence of what is termed 
' late rigidity ' in the paralysed limbs, a condi- 
tion of evil import. This rigidity shows itself 
most frequently in the arm, but it is common 
enough in both limbs. The rigidity affects 
the flexors more particularly, and causes the 
limb to assume a position in which the flexors 
predominate. It is variable in degree, and at 
first is capable of being overcome. At first, 
also, it is remittent, tending to give way when 
the patient abstains from volitional efforts or 
from excitement, and seems almost gone on 
waking from sleep or when the patient yawns 
or stretches himself. Gradually it assumes a 
more intense form, and the limb becomes 
permanently fixed and rigid. 
After death, this condition is found to coin- 
cide with descending sclerosis of the motor 
tracts of the brain and spinal cord. The de- 
generation proceeds from the seat of lesion 
downwards through the crus, pons, and pyra- 
mid of the same side, and then across to the 
posterior part of the lateral column of the 
spinal cord on the paralysed side. Frequently, 
also, a similar track of degeneration is found CORPUS STRIATUM 
CORRELATION 
411 
on the inner aspect of the anterior column of 
the spinal cord, and occasionally also in the 
lateral column on the same side as the brain- 
lesion (Charcot, Turek, &c.) 
Even during the rigid stage, there is, as a 
rule, no trophic degeneration of the muscles 
or annihilation of faradic contractility, though 
the muscles waste from disuse unless arti- 
ficially stimulated. But in some rare in- 
stances, as Charcot has shown, the secondary 
degeneration invades the anterior cornua of 
the spinal cord, in which case amyotrophy 
or trophic degeneration of the muscles en- 
sues. 
There is no recovery from this condition. 
Variations and complications. - Though 
general hemiplegia of the opposite side, with- 
out affection of sensation, is the type of dis- 
ease of the corpus striatum, certain variations 
and complications have been observed, some 
of which still require elucidation. 
When sensation is permanently affected 
along with voluntary motion, we have reason 
to regard the lesion as not confined to the 
corpus striatum, but as implicating also the 
posterior part of the internal capsule and the 
thalamus, an occurrence by no means rare. 
When the lesion affects only the grey matter 
of the nucleus caudatus, the hemiplegia is, as 
a rule, comparatively slight and transitory. 
Similar affection of the nucleus lenticularis 
is said to produce more marked paralysis than 
that caused by affection of the nucleus cau- 
datus, but also not of a permanent kind. 
When, however, the lesion causes rupture of 
the anterior two-thirds of the internal cap- 
sule, the hemiplegia is most marked and most 
enduring. It is this lesion only which gives 
rise to secondary degeneration of the motor 
tracts and permanent rigidity. 
Cases are on record in which lesions of the 
corpus striatum have given rise, not to general 
hemiplegia of the opposite side, but to mono- 
plegia, such as paralysis of the face or of one 
or other limb. But these monoplegias are 
without doubt due to limited lesions of the 
internal capsule, which, as the researches of 
Franck and Pitres and of Beevor and Horsley 
have demonstrated, contains the motor tracts 
corresponding to the differentiated centres of 
the cortex. 
Cases are also on record of paralysis occur- 
ring on the same side of the body as the lesion. 
The real existence and explanation of such 
exceptional occurrences are still sub judice, 
and though various explanations maybe sug- 
gested, it is well to wait for further instances, 
carefully investigated by accurate modern 
methods, before pronouncing definitely on the 
question. D. Ferrier. 
CORRELATION.-This term is used 
in medicine almost exclusively in reference to 
the aetiology of disease, and in this relation 
principally in regard to the zymotic diseases. 
The term ' correlation of the physical forces ' 
may be taken as implying that the several 
forces are capable of being converted into or 
of giving place to one another when they are 
permitted to act under certain conditions, and 
that they are all related to a common cause. 
It is very much the same idea that is implied 
by the term ' Correlation of the Zymotic Dis- 
eases,' a subject which has been discussed in 
a separate work by A. Wolff. 
It is contended that the several contagious 
diseases of a general type (the exanthemata) 
do not, necessarily and in all cases, reproduce 
their like; but that occasionally, the conta- 
gious particles thrown off from the same sick 
person suffering from one of the diseases (e.g. 
scarlatina) may suffice to engender one or more 
different kinds of disease, according to the 
mode in which this matter operates-that is, 
according as it may be swallowed, taken into 
the system through the pulmonary surface, or 
through some other mucous membrane or skin- 
abrasion. These diseases are said to be cor- 
related, therefore, on account of this assumed 
relation to a common cause-a specific con- 
tagium. According to this notion the seat of 
primary action and the constitutional condi- 
tion of the patient are factors which largely 
influence the form of disease that ultimately 
manifests itself as a result of the contact of 
any given contagium. This view has at pre- 
sent scarcely passed beyond the stage of an 
ingenious speculation-though it is one which 
is by no means unworthy of further attention, 
opposed though it may be to many current 
doctrines as to the specific and unalterable 
nature of contagia. 
Of late years, moreover, evidence in support 
of some such doctrine has been strengthen- 
ing. Thus, to take one example, it has now 
been shown (see Dowdeswell's Report in 
Brit Med. Journ., July 19, 1884) that two 
very distinct forms of septicaemia exist of an 
extremely contagious character, which may 
take their origin from common putrefactive 
material introduced into different parts of 
the body. The one, known as 'Davaine's 
septicaemia,' may be set up by introducing 
two or three drops of putrid blood beneath 
the skin of an animal; whilst a totally 
different form of the disease, known as 
' Pasteur's septicaemia,' may be induced by 
introducing a similar quantity of the same 
putrid blood into the peritoneal cavity of 
another individual of the same kind of 
animal. The late Professor Hueter, indeed, 
held, as a result of experimental observations, 
that the contagia of many diseases are de- 
rivable from common septic organisms and 
their alkaloids, by virtue of alterations taking 
place under particular conditions in the pro- 
cess of putrefaction, by which means the 
common organisms take on ' specific modes 
of activity.' Instances of such conversion, as 
well as of the interchangeable morphological 
characters of bacilli and micrococci associated 
with different contagious processes, are cited 412 
CORRELATION 
COUGH 
by him and also by Professor Fokker of 
Groningen. See Trans. Intern. Med. Cong. 
1881, vol. i. pp. 329-334. 
Diseases may be said to be correlated also 
when they are severally related to the same 
cause acting with different degrees of in- 
tensity. Thus it is held by some epidemiolo- 
gists that the plague is only a malignant form 
of typhus; that yellow fever is due to a more 
intense form or action of the same poison as 
suffices at other times to engender intermit- 
tent or remittent fever; and that summer 
diarrhoea, cholerine, and cholera are also but 
different manifestations of one common though 
variable cause. 
Similarly it is held by many surgeons that 
ordinary surgical fever, pyaemia, and septicae- 
mia are correlated effects, due to the action 
of the same poison in different degrees of in- 
tensity. They maintain that the appearance 
of one or other of these morbid states after a 
surgical operation is dependent in part upon 
differences in the constitutional condition of 
their patients, and, moreover, that these forms 
of disease are further linked to one another 
by numerous intermediate states. This point 
of view has been both strengthened and ex- 
tended by some of the experimental researches 
of Dr. Burdon Sanderson. He found that the 
subcutaneous injection of different portions of 
the same inflammatory product, executed at 
the same time, would often produce quite dif- 
ferent effects upon different animals of the 
same species. In the one a typical septicaemia 
proved rapidly fatal, in another a slower py- 
aemic process was established, whilst in a third 
animal the still more chronic process of so- 
called tuberculosis was set up. Here again 
we seem to get out of the region of specu- 
lation into that of fact. See Trans. Path. 
Soc. of London, 1872, pp. 303-308. 
The term ' correlation ' is only applicable to 
communicable diseases, otherwise its leading 
signification, namely, convertibility, could not 
be fulfilled. Hence it is that, though very 
many diseases may arise from the operation 
upon different individuals of some common 
cause (such as exposure to cold), the maladies 
which may result from such a cause no one 
would think of speaking of as correlated. 
H. Charlton Bastian. 
CORROSIVE SUBLIMATE, Poi- 
soning by.- See Mercury, Diseases arising 
from. 
CORYZA ^opv^a, a running from the 
head).-A synonym for nasal catarrh. See 
Catarrh. 
COUGH.-Synon. : Tussis; Fr. Toux; 
Ger. Husten. 
Description.-The act of coughing con- 
sists in one or more abrupt forcible ex- 
pirations, preceded by contraction of the 
glottis. First a deep inspiration is taken, 
the glottis is closed for a moment, and then 
it is opened by the pressure of the air forced 
out by the combined action of the thoracic 
and abdominal expiratory muscles. With 
the air thus suddenly expelled, any foreign 
matter that may be in the larynx or bronchi 
is driven into the pharynx or the mouth. 
Etiology.-The immediate cause of cough 
is the presence of an irritant, mechanical or 
sympathetic, affecting the surface of the air- 
tubes or the nerves that supply them, and it 
is the object of the cough to remove this 
source of irritation. 
The sensibility of the respiratory surfaces 
is greatest at its commencement-the glottis' 
being an ever-watchful janitor. It may be 
increased by congestion or inflammation, or 
by the continued act of coughing. Even the 
mere inhalation of cool or dry air may, in 
asthma or bronchial congestion, be sufficient 
to excite cough. The result of the irritation 
is to increase the natural secretion, and to 
alter its characters. See Expectoration. 
Cough may be due to numerous reflex 
causes, such as gastric irritation, ear-disorder, 
aneurysmal, glandular or other pressure on the 
vagus, recurrent, or sympathetic nerves. The 
act may also be caused by a long uvula or 
enlarged tonsil; a granular state of the 
pharyngeal or laryngeal mucous membrane ; 
polypi or other foreign bodies in the larynx, 
trachea, or even in the external auditory 
meatus; various affections of the bronchial 
tubes-for example, undue dryness, hyper- 
semia, alteration in the quality or quantity 
of the bronchial secretion, or inflammatory 
affections ; inflammation of the lung or 
pleura ; or tubercle, cancer, or other growths 
in or near the lung. 
Diagnosis.-Cough is not a disease to be 
treated, but a symptom to be traced to its 
source. An inspection of the pharynx and 
larynx, and a physical examination of the 
chest, will generally suffice to detect the 
cause. 
The character of the cough is often quite 
pathognomonic-e.g. the ' whoop ' of whoop- 
ing cough ; the ' bark ' of hysteria; the 
catching, painful cough of pleurisy; the 
slight ' hack ' of early phthisis, and the 
equally distinctive cough of advanced phthi- 
sis with laryngeal ulceration; the tearing 
cough of empyema threatening bronchial 
fistula; the loud clanging cough due to 
pressure on the trachea or laryngeal nerves; 
the spasmodic, suffocative cough of asthma. 
The ' tightness ' or ' looseness ' of cough, 
indicating the absence or presence of secre- 
tion, is a valuable guide in diagnosis and 
treatment. 
The absence of cough is no proof of the 
absence of serious lesion ; thus, while the 
presence of a few granulations in the lung 
is often productive of incessant and uncon- 
trollable cough, long-continued destructive 
disease may exist without it. 
Treatment. - Before prescribing for a 413 
cough it is of course essential to ascertain its 
cause ; and the simplest and most innocuous 
remedies should be first used. The routine 
treatment of cough by sedatives is highly 
injurious. The secretions which ought to 
be removed are thus locked up, and the 
irritation, which would have been transient, 
becomes established. 
If the tonsils are found much enlarged, or 
the uvula pendulous and irritating the epi- 
glottis, caustics or the guillotine will remove 
the evil. If a granular state of the pharyn- 
geal membrane exists, dependent on torpid or 
engorged abdominal viscera, gout, or hepatic 
obstruction, it may be treated by local as- 
tringents and general deobstruents. 
A lax or congested state of the laryngeal 
membrane, due to overwork of voice, or the 
undue direction of attention to the vocal 
apparatus (clergyman's sore-throat), is best 
treated, according to the writer's experience, 
by the local application of a solution of zinc 
sulphate-ten grains to an ounce of water, 
or of iodine dissolved in spirit and olive oil. 
Undue dryness, simple hyperaemia, or hyper- 
aesthesia of the respiratory mucous tract, may 
often be relieved by the act of sipping and 
slowly swallowing cold water, or the decoc- 
tion of Iceland moss, fruit lozenges, gum 
arabic, liquorice, or linseed tea. Sucking 
ice or inhaling steam is very often all that is 
needed. In the early stage of catarrhal sore- 
throat, chlorate of potassium in crystal, or in 
the form of lozenge, used in moderation, 
should not be neglected. The use of glycerine 
of tannin, or nitrate of silver dissolved in 
glycerine (half a drachm to one ounce), is of 
more service in relaxed throat than alum or 
tannin gargle; indeed, the free use of well- 
selected lozenges has rendered the employ- 
ment of gargles well-nigh obsolete. The 
former can be constantly, the latter but 
seldom applied. 
Medicinal treatment.-If it is desired to 
increase the fluidity of the secretion, squill 
or ipecacuanha may be used, or, better still, 
tartar emetic in small doses, which is best 
given in effervescence with carbonate of 
ammonium and citric acid. It must not be 
forgotten that syrups and nauseating ex- 
pectorants are apt to do harm by enfeebling 
or disturbing digestion. Tincture of aconite, 
in three-drop doses, is often of value in allay- 
ing irritable cough, especially when fever is 
present. Gelsemium is a more recent remedy 
for the same purpose. Of the direct sedatives, 
morphine is the most valuable ; it proves of 
service in very small doses, ~ gr. in a 
lozenge being often adequate. Conium, with 
or without morphine, suits some persons; 
hydrocyanic acid still more ; and Indian 
hemp is also of value. The bromides, in 
combination with chloral, have gained great 
repute; the latter should be given with 
caution. The power of the bromide of am- 
monium in allaying spasmodic cough is re- 
COUGH 
markable. An emetic of ipecacuanha, sul- 
phate of zinc, or mustard may be useful in 
relieving cough, by expelling secretion when 
this has accumulated in large quantity. If 
cough causes vomiting, food should be taken 
in small quantities, fluids should be limited, 
and a little capsicum or spiced brandy 'stays 
the stomach.' 
External applications. - The use of 
counter-irritants must not be neglected. In 
the inflammatory stage of bronchitis, for 
instance, linseed and mustard poultices, and, 
in the later stages, iodine, are of great use ; 
and in some cases the application of a small 
blister or vesicating fluid is a remedy not 
to be forgotten. 
Inhalations.-Infusion of hop as an in- 
halation is a useful calmative; iodine is 
indicated in relaxed conditions in strumous 
subjects. Chloroform (10 to 15 minims) 
mixed with eau de Cologne, and inhaled 
from a handkerchief, is useful in other cases. 
By means of the spray-inhaler, many non- 
volatile preparations may be applied to the 
respiratory passages. A solution of car- 
bonate of sodium is very useful in liquefying 
tenacious secretion. Tannic acid, alum, 
perchloride of iron, and nitrate of silver, are 
all valuable. Of sedatives, henbane, conium, 
camphor; and of antiseptics, sulphurous and 
carbolic acids, are serviceable as inhalants. 
The vapour of tincture of iodine, 15 drops 
to 2 ounces of water, in the steam draught 
inhaler, is often useful. In chronic granular 
disease of the pharyngeal and laryngeal 
mucous membranes, the sulphurous waters 
of Aix-la-Chapelle, Aix-les-Bains, and St. 
Saveur in the Pyrenees, when inhaled in an 
atomised state, are of distinct service. 
Patients may be taught how to cough 
as follows : Try to suppress the inclination, 
until the secretion that causes the cough is 
within reach, then take a deep and deliberate 
inspiration, and the accumulated phlegm is 
removed at a single effort. By inhaling 
steam from a hot sponge or a basin of boiling 
water on first waking from sleep, the inspis- 
sated secretion, which is apt to be difficult to 
move, may be easily loosened and expelled. 
An ipecacuanha lozenge may serve a similar 
purpose. E. Symes Thompson. 
COUNTER - INDICATION. - See 
Contra-indication. 
COUNTER-IRRITANTS.-Synon. : 
Fr. Contre-stimulants ; Ger. Gegenreiz- 
mittel. 
Definition.-The term ' counter-irritation ' 
implies any irritation artificially established 
with a view to diminish, counteract, or re- 
move certain morbid processes which may 
be going on in a more or less remote part 
of the system. The substances employed in 
establishing this state are called counter- 
irritants, and may be classified as follows, 
COUNTER-IRRITANTS 414 
COUNTER-IRRITANTS 
according to the degree of their action:- 
1. Rubefacients. 2. Epispastics, vesicants, 
or blistering agents. 3. Pustulants. 
Although some therapeutists have of late 
been disposed to question the value of counter- 
irritants, on the theoretical ground of inability 
to explain their mode of action, yet there 
is not wanting evidence, both from clinical 
observation and physiological experiment, 
that irritation in one part of the body may 
affect the functions and nutrition of other 
parts. That stimulation of the vessels of the 
surface can influence decidedly the circula- 
tion of deeper parts has been demonstrated 
by Dr. Brown-Sequard; for he found that 
irritation of the skin of the back, over the 
kidneys, caused a contraction of the arteries 
supplying those organs. Ziilzer found that 
when cantharides collodion was painted over 
the back of a rabbit for fourteen days the 
vessels underneath the skin were congested, 
whilst the deeper parts, including the lungs, 
were pale and anaemic. From these experi- 
ments we can understand how a blister may 
relieve a sudden internal congestion in the 
lungs or brain, and how it may act in re- 
storing tone to dilated and paralysed capil- 
laries. 
Revulsion and derivation are both 
examples of counter-irritation. In the first, 
the induced morbid action is set up in a part 
remote from the primary disease, as when 
mustard poultices are applied to the feet in 
an attack of apoplexy; in the second, deriva- 
tive action is set up in the neighbourhood of 
the primary malady, as when a blister is 
placed on the back of the neck for the relief 
of cerebral disorder. 
1. Rubefacients. - Action.-These re- 
medies, applied to the skin, produce local 
warmth and redness from increased flow of 
blood in the cutaneous vessels. The local 
hyperaemia thus induced subsides gradually 
on ceasing to employ the rubefacient; but 
sometimes, when the action of this has been 
prolonged, the epidermis may peel off, and 
more or less local soreness remain. Rube- 
facients are usually quick in action; their 
local after-effects are trifling; and they may, 
therefore, be applied without injury over a 
large extent of surface. 
Enumeration and Application.-Exam- 
ples of rubefacients are found in Ammoniacal 
liniments or embrocations; Mustard plasters 
and the Compound Liniment; Volatile Oil 
of Mustard; Oils of Turpentine and Caju- 
put; and Iodine. Hot water is at times 
applied on a sponge or flannel to produce 
a speedy counter - irritant and derivative 
effect in relieving sudden internal congestion 
and spasm, as in the early stage of croup, 
laryngitis, and laryngismus stridulus. The 
Cataplasma Sinapis, or mustard poultice, is 
a useful and rapidly acting rubefacient in 
inflammation, spasm, and neuralgic pain. 
Sir Alfred Garrod recommends a very useful 
sinapism, made by mixing 10 minims of 
volatile oil of mustard with 1 oz. of spirit of 
camphor, and sprinkling this on impermeable 
piline. Rigollot's mustard leaves, or the 
Chart® Sinapis (B.P.), applied to the skin, 
produce a speedy rubefaction of the surface. 
Linimentum Sinapis Compositum is also a 
very active rubefacient. Vinegar should not 
be added to mustard poultices; but by mixing 
some oil of turpentine or a little powdered 
capsicum in a mustard poultice, its rapidity 
of action as a stimulant and rubefacient can 
be greatly increased. Where, on the other 
hand, a gentle stimulation with warmth and 
moisture on the surface are desired, as in some 
cases of pneumonia, a linseed-meal poultice 
may be used with its surface sprinkled lightly 
over with mustard meal. Generally twenty 
minutes is as long as an ordinary mustard 
poultice can be safely borne on the skin. In 
persons who have a very delicate skin, a 
layer or two of muslin should be placed 
between the mustard application and the 
surface of the body. In applying mustard 
poultices to those who are unconscious of pain, 
caution is necessary, for it has happened that 
the poultice being left on for a long time has 
produced dangerous ulceration and sloughing 
of the surface. A. mustard foot-bath is at 
times employed with a view to a revulsive 
and counter-irritant effect. To prepare a 
mustard bath, two tablespoonfuls or more of 
mustard should be tied in a cloth and agitated 
well with cold water; then hot water may 
be added to make the bath. It is found by 
experiment that cold water extracts the active 
principle or volatile oil of mustard far better 
than very hot water does. 
Uses.-Rubefacients are used in chronic 
inflammation and irritation of the mucous 
surfaces, as in bronchitis, and irritation about 
the air-passages. Troublesome cough, in 
cases of phthisis, is often relieved by apply- 
ing tincture of iodine, or acetic acid and tur- 
pentine liniment, to the chest. Rubefacients 
are of service in removing lingering irritation 
about a joint, their use also tending to pro- 
mote the absorption of chronic thickening or 
effusion in the joint; but friction with a 
rubefacient liniment over a joint must not 
be employed till all active inflammatory 
action has entirely ceased. Various degrees 
of persistent counter-irritation may be main- 
tained by applying, after the skin has been 
well cleansed with soap and water, the Em- 
plastrum Picis or Emplastrum Calefaciens 
of the Pharmacopoeia. A mustard plaster 
applied to the nape of the neck has proved 
useful in cases of irritable brain with sleep- 
lessness. The same application made to the 
foot or great toe is a valuable revulsive where 
gout attacks more important organs. A 
mustard plaster has the advantage over a 
blister in rapidity of rubefacient action; and, 
from the sharp pain caused, the mustard 
plaster is preferable when it is a matter of COUNTER-IRRITANTS 
415 
moment to rouse one who is in a state of 
lethargy or torpor from narcotic poisoning 
by opium, or alcohol, or from coma in the 
course of a fever. Where we wish to exercise 
a prolonged action over chronic inflammation 
in an organ, we should use a blister rather 
than a sinapism. 
2. Vesicants, Epispastics, or Blis- 
tering Agents.-Action.-A blister acts 
primarily as a rubefacient and powerful 
stimulant to the cutaneous vessels. The 
papillae of the skin become reddened and 
raised; minute vesicles soon appear on the 
elevations; and these, gradually coalescing, 
form a bleb, or large vesicle, between the 
true skin and epidermis, containing an 
albumino-fibrinous fluid. 
Enumeration and Application. - The 
agent most commonly employed for blister- 
ing purposes is the Cantharis or Spanish 
fly; but there are others that have been 
used for a similar object. Glacial Acetic 
Acid applied to the skin produces intense 
redness and pain, with rapid vesication, but 
its action may extend too deeply as a caustic, 
and cause a troublesome sore. Liquor Am- 
monise dropped on a piece of lint, applied to 
the skin, and covered with a watch-glass, 
very soon causes redness and rapid vesica- 
tion in most persons. This is a good way of 
raising a blister when it is desired to apply 
powdered morphine endermically to relieve 
severe pain. The Liquor Epispasticus of 
the Pharmacopoeia, applied with a brush, 
soon raises a blister on the surface. Blistering 
Collodion is used for a similar purpose, but is 
slower in action. 
The application of blisters should not be 
made directly over an inflamed part. There 
is some evidence to show that a strong 
stimulus applied very near an inflamed 
organ may increase the paralytic dilatation 
of its capillaries, and so add to the disease. 
Blisters should not be applied where the 
skin is loose, nor over any prominence of 
bone, nor to the breast during pregnancy. 
It should moreover be borne in mind that 
the cantharidine of a blister may be absorbed 
by the skin, and act on the kidneys, produc- 
ing strangury and bloody urine. This acci- 
dent may be obviated by sprinkling powdered 
camphor over the blister before placing it on 
the skin, or a thin piece of silver paper may 
be interposed. In persons of feeble vitality, 
a blister left on for too long a time has been 
known to induce dangerous sloughing. 
When vesication is specially desired, there 
is no need to leave the blister on for twelve 
hours or more, for it may be removed at the 
end of six or eight hours, and a warm linseed 
poultice applied. If the blister be opened, 
which is best done by pricking the most de- 
pendent part with a disinfected needle, sweet 
oil and cotton-wool is the best dressing. The 
practice of maintaining a blister as a running 
sore or exutoire, by applying irritating oint- 
ments, is not often resorted to now. The 
process causes great pain and exhaustion of 
the system, and is one rather of depletion 
than of counter-irritation. In the case of 
children, blisters should be used with caution, 
being kept on for about one hour or till the 
skin is well reddened, when they should be 
replaced by a poultice. It is well not to open 
the blister, as the effused serum forms the 
best dressing covered with cotton-wool. By 
following this plan the child is saved much 
worry and pain. 
Uses.-In its primary effect a blister acts 
as a local stimulant, but when it remains on 
long enough to produce extensive vesication 
and discharge of serum, it acts as a depletive 
and depressing agent. This primary and 
secondary action of blisters has been much 
insisted on by the late Dr. Graves of Dublin, 
who found great benefit in cases of fever 
with apathy and prostration from the appli- 
cation of flying blisters to various parts of 
the surface. Thus a blister over the prae- 
cordial region, kept on for about one hour, 
and then removed, was observed to rouse 
and stimulate a flagging heart. In other 
cases the flying blister might be placed at 
the chest or back, or else behind the head on 
the neck. Care should be taken not to leave 
the blister on long enough to cause actual 
vesication, and the size of the blister should 
be fairly large. 
Vesication by a blister is of service in 
many brain-affections attended with conges- 
tion and tendency to serous effusion, such as 
in the chronic forms of hydrocephalus, and 
non-tubercular meningitis. In hysterical 
paralysis narrow strips of blister placed com- 
pletely round the affected limb have proved 
curative. A strip round the throat may cure 
nervous aphonia. A strip of blister one inch 
wide may possibly sometimes stay the spread 
of erysipelas along a surface. In cases of 
pleuritic or pericarditic effusion the repeated 
application of blisters to the chest-wall is of 
manifest advantage. In effusions into joints 
(hydrarthrosis) blisters aid absorption; and 
it has seemed to the writer that absorbent 
remedies, such as iodide of potassium, often 
begin to do good as soon as a blister appears 
to have once set the absorptive process in 
action. In the joint-affections of acute rheu- 
matism, ' the blister treatment ' has attracted 
notice. Armlets and wristlets of blister- 
plaster are applied close to the inflamed 
joints during the fever, and the serous dis- 
charge from the blister is kept up by means 
of linseed-meal poultices. 
In the obstinate acid vomiting of gouty 
patients, a blister over the epigastrium often 
gives relief. Some forms of neuralgia, as for 
example pleurodynia, may yield to a blister 
over the seat of the pain. At times obstinate 
pleurodynia, or mastodynia, can be relieved 
by flying blisters applied in the vertebral 
groove on the affected side, where a tender 416 
COUNTER-IRRITANTS 
CRAMP 
spot can often be detected on pressure. Blis- 
ters should be avoided in cases of renal and 
vesical inflammation, as the absorption of 
the cantharidine may increase the mischief. 
Counter-irritation by heat.-The skin 
can be rapidly blistered by applying a ham- 
mer-' Corrigan's hammer '-a small flat 
iron heated in a spirit-lamp or boiling water. 
The skin is tapped for a few seconds with 
the hammer, just to induce redness of the 
part In some forms of rheumatism, neu- 
ralgia and spinal weakness, this practice has 
been followed by satisfactory results. Vesi- 
cation of the skin by the ferrum candens, 
or hot iron, has been used in chronic joint- 
disease. 
Moxas.-Moxas were used for the purpose 
of causing severe counter-irritation. Euro- 
pean moxas were made either with cotton- 
wool soaked in solution of nitrate of potas- 
sium, or of the pith of the sunflower, which 
naturally contains this salt. A wet rag was 
placed on the skin; in the centre of this 
was a hole in which the lighted moxa was 
placed, which gradually burned down to the 
skin and produced an eschar, which in due 
time separated by suppuration. In spinal 
affections, and in some forms of paralysis of 
the sensory and motor nerves, moxas are 
said to have done good; but their applica- 
tion is very painful, and now they are seldom 
employed. 
3. Pustulants.-Action.-The agents be- 
longing to this class of counter-irritants pro- 
duce a pustular eruption on the part to which 
they are applied, and their use is not recom- 
mended. 
Enumeration and Application.-Among 
pustulants may be placed Croton Oil, Tar- 
tarated Antimony, and strong solution of 
Nitrate of Silver. When croton oil is applied 
to the skin, it acts as an intense irritant, pro- 
ducing an eruption which is at first papular, 
but very soon becomes pustular. The oil is 
best employed in the form of the Linimen- 
tum Crotonis of the Pharmacopoeia. Tartar- 
ated Antimony in the form of the Ointment, 
or in hot aqueous solution, is a powerful 
counter-irritant, producing pustules which 
resemble those of variola. When applied 
thus it may, by becoming absorbed, induce 
symptoms of gastro-enteritis. It should not 
be applied to parts usually uncovered, as 
the pustules leave marks behind them; and 
under all circumstances the remedy, being a 
painful one, must be used with caution. 
Strong solution of nitrate of silver will pro- 
duce pustulation, but it is seldom employed 
for this purpose. 
Issues.-Issues have long been used as 
counter-irritants. An issue is formed by 
placing on the skin a piece of adhesive 
plaster, in a hole in the centre of which a 
fragment of caustic potash is inserted. The 
caustic causes an eschar, and when this has 
come away, an issue-pea is placed in the 
cavity left by the eschar; this pea acts as a 
foreign body, and keeps up suppuration. 
One drachm of pus may be discharged daily 
by an issue ; more than this is too great a 
drain on the system. An issue requires to 
be dressed daily, and when it has been long 
open and running it must not be healed too 
suddenly. Issues over the spine have been 
found useful in chronic spinal disease; and 
in some chronic brain-affections, with hyper- 
semia and congestive tendency, an issue in 
the back of the neck or in the arm is of ser- 
vice, but is not now much used. 
Setons.-A seton is made by passing a 
narrow-bladed knife under a fold of skin and 
then carrying a few silk threads through the 
incision by means of a probe or long needle. 
The threads remaining in the wound prevent 
it from healing, and maintain a free purulent 
discharge. Setons are used for the same 
purposes as issues, and they have proved 
useful in certain intractable forms of head- 
ache-the seton being inserted in the skin 
of the neck. Setons have been used in cases 
of cystic bronchocele with thickened walls; 
and, as counter-irritants, in chronic inflam- 
mation of the bladder and uterus ; in chronic 
skin-diseases of an obstinate character; in 
inflammations of the eye, with ulceration of 
the cornea; and in the early stages of pul- 
monary phthisis. 
In acute affections issues and setons are 
never employed, and they should not be 
placed over any part where there is much 
movement, as a troublesome sore may be 
the result. It is necessary to bear in mind 
that issues, setons, and pustulants are, like 
blisters, when kept on long enough to induce 
serous discharge, of the nature of evacuants. 
They carry off nutrient material from the 
blood, and therefore are more or less de- 
pressing and exhausting to the system, and 
their repeated or protracted employment will 
tend to induce the irritative fever of debility. 
John C. Thorowgood. 
COUP DE SOLEIL (Fr.).-A synonym 
for sunstroke. See Sunstroke. 
COW-POX.-See Vaccinia. 
COXALGIA (coxa, the hip; and aXyor, 
pain).-Pain in the hip-joint. See Joints, 
Diseases of. 
CRACKED-METAL or CRACKED- 
POT SOUND.-Synon.: Fr. Bruit de pot 
fete.-A peculiar sound elicited by percussion, 
and resembling that emitted on striking a 
broken jar or a metallic vessel. See Physical 
Examination. 
CRADOCK, in. Cape Colony.-See 
Africa, South. 
CRAMP.-Synon. : Fr. Crampe ; Ger. 
Krampf.-This name is applied to certain 
painful varieties of tonic spasm. In its most 
familiar form it affects the calves of the legs, CRAMP 
CRETINISM 
417 
coming on principally at night, on the occasion 
of some slight movement of these parts. The 
affected muscles, mostly on one side, contract 
with such energy as to give rise to a board- 
like rigidity, together with sensations of an 
agonising character. The attack rarely lasts 
more than a minute or two, though it may 
more or less speedily recur. It is perhaps 
best cut short by a vigorous but steady volun- 
tary contraction of the opposing extensor 
muscles of the foot. Where it is more obsti- 
nate than usual, firm pressure around the 
thigh or upon the great sciatic nerve some- 
times gives relief. Cramp is often associated 
with some irritation of the stomach or of the 
intestines, especially in children or delicate 
nervous persons. In this way it is produced 
not infrequently when arsenic in medicinal 
doses has been continued for some time, and 
is beginning to exert some slightly poisonous 
effect upon the system. In a more general 
form it often occurs, to a marked extent, in 
cholera. Localised, painful, cramp-like con- 
tractions of muscles may also be due to 
irritation of anterior root-fibres, either in 
their intra-medullary or extra-medullary 
course. Other forms of painful spasm are 
by no means common, if we except colic. See 
Spasm ; and Thomsen's Disease. 
H. Charlton Bastian. 
CRANIOTABES {cranium, the skull; 
and tabes, thinning).-A morbid condition of 
the cranium m children, consisting in spots 
of local thinning of the occipital, parietal, 
and (rarely) the frontal bones, as well as in 
general abnormal flexibility of the osseous 
tissue. See Skull, Diseases of. 
CREPITANT {crepito, I make a noise). 
When applied to a body, this word signifies 
that it is capable of yielding the sensation or 
sound of crepitation. It is also associated 
with a rale, to indicate a peculiar character 
which it possesses. See Physical Examina- 
tion. 
CREPITATION {crepito, I make a 
noise).-A sensation or sound of crackling. 
It may be observed in morbid states of the 
bones, joints, or subcutaneous tissue; but the 
term is more frequently applied to a physical 
sign connected with the lungs. See Physical 
Examination. 
CRETINISM {cretin, Swiss patois for 
chretien, a Christian).-Synon. : Lat. Cre- 
tinismus ; Fr. Cretinisme ; Ger. Cretinismus. 
Definition.-A condition of idiocy arising 
from endemic causes, associated with im- 
perfect development and deformity of the 
whole body, varying however in degree. 
This condition of physical and mental 
degeneracy is not limited to any nationality. 
It obtains in the great mountain-chains of 
Europe, Asia, and America. In Europe it 
is met with in the valleys of Switzerland, 
Savoy, and Piedmont; and it abounds in the 
neighbourhood of Salzburg, Styria, and the 
Tyrol. It is less frequently met with in the 
Pyrenees and in the valleys of the Auvergne 
in France. Even in England it has been 
met with in various parts, among others in 
the dales between Lancashire and Yorkshire. 
Although more frequently met with in valleys, 
it is not unknown on plains which are subject 
to inundations. 
^Etiology.-The conditions for the deve- 
lopment of cretinism are hereditary predis- 
position ; the action of deteriorating influences 
on the parents, such as unwholesome dwell- 
ings and non-nutritious diet; and accidental 
causes operating on the infant during the 
period when its physical and intellectual 
life are developing. The last-named causes 
are atmospheric and possibly geological 
conditions, peculiar to special localities. 
Humidity of the soil and air in valleys where 
there is little interchange of the atmosphere, 
and the existence of magnesian limestone in 
the soil, are probably the most potent factors. 
Cretinism is not met with as an endemic 
disease on elevated plateaux, nor in cold 
countries where sudden changes of tempera- 
ture are uncommon. Goitre is a frequent 
accompaniment of cretinism, and would ap- 
pear to be developed under the same con- 
ditions. The cases of cretinism met with in 
England present features which are indicative 
of a scrofulous origin. There is a condition 
of idiocy associated with arrest of growth and 
development at the period of first dentition, 
not infrequently met with in England, which 
has been termed sporadic cretinism. Some 
of these cases have been traced to alcoholism 
on the part of the progenitors, and are usually 
associated with an absence or atrophy of the 
thyroid body, and with the development of 
loose fatty tumours in the supra-clavicular 
spaces. They remain permanent children, 
both physically and mentally. They have a 
strong sense of the ridiculous, and are fond 
of exciting ridicule in others by their gro- 
tesque facial expressions. There is reason 
to believe that children become cretinoid 
when taken to reside, at the period of their 
early development, in localities where the 
disease is markedly endemic. There are 
numerous well-attested instances of healthy 
women living during their pregnancy in 
cretinic districts bringing forth cretinoid 
children, who, removing from such localities, 
propagate healthy children. By far, how- 
ever, the greater number of cretins arrive at 
their helpless condition by successive steps 
of degeneracy in their ancestors. It has been 
thought that cretinism is due to premature 
ossification of the cranial sutures, especially 
of the spheno-basilar suture; and that this 
is caused by drinking water largely charged 
with lime. It is impossible, however, to 
regard this premature ossification, when it 418 
CRETINISM 
CRIME, IRRESPONSIBILITY FOR 
does occur, as other than one of the out- 
comes of the malady, not its cause. More- 
over, there are numerous examples where 
the synostosis is deferred instead of being 
premature. 
Anatomical Characters. - Pathological 
anatomy shows that the bones of the cranial 
vault are thickened and without diploe. The 
basilar groove is generally wanting. The 
foramina for the passage of arteries and 
nerves are somewhat smaller than natural. 
The occipital fosste are flatter than usual, as 
if the flattening had resulted from a com- 
pression of the cranium from above down- 
wards. Every variety of deformity of the 
cranium is met with of the brachycephalic 
type. The brain is usually small, unsym- 
metrical, pale, and infiltrated with serum. 
Premature synostosis is occasionally met 
with at the spheno-basilar suture, and with 
it a rectangular form of the base of the skull; 
this, however, cannot be regarded as a con- 
stant condition. 
Description.-The degrees of cretinism 
are numerous. A residence in one of the 
valleys where this affection exists, enables 
one to trace the various steps of degeneracy, 
commencing with those who are taking part 
in the industrial life of the valley, down to 
the helpless individuals who are leading only 
a vegetative existence. 
The typical cretin presents a very marked 
physical conformation. He is stunted in 
growth, rarely reaching five feet in height. 
His skin is of a tawny yellowish hue, thick- 
ened and wrinkled ; and looks as if too large 
for the body. There is also a great increase 
of subcutaneous areolar tissue. His tongue, 
large and thick, with hypertrophied papillae, 
always displays lessened power of co-ordina- 
tion ; and often hangs from the mouth. The 
mouth is partly open, margined by thick 
fissured lips, and with the saliva running 
over the chin. The face is large ; the lower 
jaw is drooping, and its angle obtuse. The 
eyes are often affected by strabismus, ob- 
liquely placed, and small; and the lids are 
commonly puffy. The belly is pendulous 
from the laxness of the skin. The lower 
limbs are generally short and deformed, and 
the gait is waddling. The head is deformed, 
the forehead retreating, the top flat, and the 
occipital region ill-developed. The cranium 
is brachycephalic. The nose is broad and 
flattened. Puberty is often delayed to the 
twentieth year. The mammae in the female 
are large and pendulous; the same remark 
applies to the genitals in the male. The 
intellectual faculties are imperfectly de- 
veloped. The cretin is often unable to 
speak, and his hearing is frequently defec- 
tive. The affection is usually associated 
with more or less enlargement of the thy- 
roid gland. His viability is low, few living 
beyond thirty years of age. The sexual 
functions are abnormal; masturbation is 
frequent; and the subjects of cretinism are 
often impotent. 
Diagnosis.-The diagnosis of cretinism 
may be made in childhood, from the slow- 
ness of the development of the body, the 
stupid expression, the postponement in the 
evolution of the teeth, and of the ossification 
of the fontanelles and sutures, the tawny 
yellow colour of the skin, the thick and 
goitrous neck, the slavering, and the delay of 
speech and of walking. 
Treatment.-This consists in removing 
the child as early as possible from the cir- 
cumstances which have produced the disease. 
He should be taken to a locality where the 
soil is dry and porous, and should have fre- 
quent baths with friction to the surface of 
the body. The diet should be of the most 
nutritious kind-a diet into which animal 
food largely enters. The administration of 
cod-liver oil and of the lacto-phosphates of 
lime and iron is indicated. Early education 
should be commenced as to habits of clean- 
liness, followed by systematic physical exer- 
cise of the various muscles. All intellectual 
advancement must be sought for through the 
improvement in every way of his physical 
condition. The lower animal life may thus 
be supplemented, if earnest efforts are used, 
by increased capacity for rational enjoyment, 
and a more or less useful existence. 
J. Langdon-Down. 
CRIME, IRRESPONSIBILITY 
FOR.-Historical Summary.-A medical 
opinion as to the condition of an accused 
person is often necessary in order to deter- 
mine whether he or she can be held account- 
able for criminal acts. Such an opinion 
generally depends on the presence or absence 
of insanity, or on the connexion which may 
be traced between this mental condition and 
the act in question. In the article on legal 
insanity it is explained that it is only within 
a comparatively recent period that insanity 
has been admitted as an excuse for crime, 
except in those comparatively rare cases in 
which, as Justice Tracey expressedit in 1723, 
a person does not know what he is doing, 'no 
more than an infant, a brute, or a wild beast ' 
(see Insanity, Legal). This view fairly re- 
presents the stateofpublic andof legal opinion 
until the later years of the eighteenth century. 
The subsequent enlightenment of the public 
mind did not receive juristic expression until 
the trial of Hadfield in 1800, when Erskine 
first enunciated the doctrine, that ' delusion 
where there is no frenzy or raving madness 
is the true character' of such insanity as im- 
plies irresponsibility. The most important 
case in the history of this question was that 
of Bellingham, who was executed in 1812 for 
shooting Mr. Spencer Perceval. In this case 
Lord Chief Justice Mansfield said, that if a 
person labouring under mental derangement 
were capable in other respects of distinguish- ing right from wrong, ' he could not be excused 
for any act of atrocity which he might com- 
mit.' ' It must be proved beyond all doubt,' 
he added, 'that at the time he committed the 
atrocious act he did not consider that murder 
was a crime against the laws of God and 
nature.' The trial of MacNaughton in 1843 
for the murder of Mr. Drummond led to the 
most authoritative statement of the law 
which has ever been obtained in this country. 
MacNaughton was acquitted on Chief Justice 
Tindal's direction that the point for the jury 
to consider was whether 'at the time the act 
was committed' the accused 'had that com- 
petent use of his understanding as that he 
knew that he was doing by the very act itself 
a wicked and wrong thing.' The general 
application of this doctrine would have greatly 
enlarged the area of irresponsibility, and its 
enunciation at that time produced consider- 
able surprise and even consternation. The 
matter was indeed regarded as so urgent that 
the House of Lords immediately ordered a 
series of questions to be laid before the fifteen 
judges with the view of settling the state of 
the law. In the answers to these questions 
it was in substance laid down that, to entitle 
an accused party to acquittal on the ground 
of insanity, it is necessary that he be either of 
diseased mind, and at the time he committed 
the act not conscious of right or wrong; or, 
that he be under some delusion which made 
him regard the act as right. But this state- 
ment has been far from effecting a final settle- 
ment of the question. 
Most writers on medical jurisprudence have 
insisted that the real criterion of responsibility 
is the freedom of the will, or the power of the 
individual to control his actions. This has 
been more or less advocated by Esquirol, 
Marc, Ray, Pagan, Jamieson, Mittermaier, 
and von Krafft-Ebing. Esquirol dwells 
strongly on the importance of the freedom of 
the will. Ray includes it in the comprehen- 
sive statement which has received the ap- 
proval of so many medical jurists. ' Liberty 
of will and action,' he says, 'is absolutely 
essential to criminal responsibility, unless 
the constraint upon either is the natural and 
well-known result of immoral or illegal con- 
duct. Culpability supposes not only a clear 
perception of the consequences of criminal 
acts, but the liberty, unembarrassed by disease 
of the active powers which nature has given 
us, of pursuing that course which is the result 
of the free choice of the intellectual faculties.' 
Pagan observes that the ' loss of control over 
our actions, which insanity implies, is that 
which renders the acts which are committed 
during its continuance undeserving of punish- 
ment.' Jamieson puts the question: 'Had 
the lunatic at the time of committing the 
deed a knowledge that it was criminal, and 
such a control over his actions as ought, if it 
existed, to have hindered him from commit- 
ting it ? ' Dr. Taylor says : ' The power which 
CRIME, IRRESPONSIBILITY FOR 
is most manifestly deficient in the insane is 
generally the controlling power of the will '; 
and he expresses the opinion that ' we have 
here a fair criterion on which responsibility 
or irresponsibility may be tested.' Dr. Buck- 
nill's view is substantially the same. ' Re- 
sponsibility,' he says, ' depends upon power, 
not upon knowledge, still less upon feeling. 
A man is responsible to do that which he can 
do, not that which he feels or knows it right 
to do. If a man is reduced under thraldom 
to passion by disease of the brain he loses 
moral freedom and responsibility, although 
his knowledge of right and wrong may re- 
main intact.' The latest German code puts 
responsibility upon the same basis. ' An act 
is not punishable,' according to it, 'when the 
person at the time of doing it was in a state 
of unconsciousness; or of disease of the 
mind, whereby free volition was prevented.' 
Mittermaier and von Krafft-Ebing sanction 
the attempt to render the meaning of ' free 
volition ' more definite by describing it as 
made up of libertas judicii and libertas 
consilii-freedom of judgment and freedom 
of choice. Casper somewhat obscurely defines 
criminal responsibility as ' the psychological 
possibility of the efficacy of the penal code.' 
Mr. Balfour Browne, a recent writer, gives as 
the best definition ' a knowledge that certain 
acts are permitted by law, and that cer- 
tain acts are contrary to law, and, combined 
with this knowledge, the power to appreciate 
and be moved by the ordinary motives which 
influence the actions of mankind.' Dr. Guy 
thinks that every person who is insane must 
be regarded as wholly irresponsible, and that 
the law of England ought to be assimilated 
to that of France in the declaration that: ' Il 
n'y a ni crime ni delit lorsque le prevenu 
etait en etat de demence au temps de Faction.' 
Mr. Warren, on the other hand, suggests 
that a person should not be held irresponsible 
unless he were as ' unconscious of his act as 
a baby.' Dr. Maudsley and others hold that 
the determination of responsibility in cases 
W'here insanity is alleged depends on whether 
a connexion can or cannot be traced between 
existing disease and the act. 
Insanity has been pleaded as an excuse for 
acts of theft; but such cases are rare, and 
never occur except where the social position 
of the accused adds importance to the de- 
cision. Indeed it may almost be said that 
the plea is never raised except in order to 
avoid, capital punishment. Hence it is, that 
in the discussions which have arisen the 
question has been intimately associated with 
the law of murder and homicide. A special 
inquiry into the state of this law by a Com- 
mittee of the House of Commons1 has conse- 
quently given occasion to the enunciation of 
important views as to the legal relations of 
419 
1 Report of Select Committee of the House of 
Commons on the Homicide Law Amendment Bill, 
July 21, 1874. 420 
CRIME, IRRESPONSIBILITY FOR 
insanity and responsibility. Evidence was 
furnished to the Committee by Lord Chief 
Justice Cockburn, Baron Bramwell, Mr. 
Justice Blackburn, and Sir James Fitz-James 
Stephen. The immediate object of the Com- 
mittee was to examine a bill drawn by Sir 
James Stephen for the codification of the law 
of homicide. In the clause of the bill which 
deals with the relations of disease and re- 
sponsibility, homicide is stated to be ' not 
criminal if the person by whom it is com- 
mitted is at the time when he commits it 
prevented by any disease affecting his mind- 
(a) from knowing the nature of the act done 
by him, (b) from knowing that it is forbidden 
by law, (c) from knowing that it is morally 
wrong, or (d) from controlling his own con- 
duct.' But it is stated to be ' criminal, al- 
though the mind of the person committing it 
is affected by disease, if such disease does not 
in fact produce one of the effects aforesaid in 
reference to the act by which death is caused, 
or if the inability to control his conduct is 
not produced exclusively by such disease.' 
It was, however, proposed in the bill that, 
' if a person is proved to have been labouring 
under any insane delusion at the time when 
he committed the homicide, it shall be pre- 
sumed, unless the contrary appears or is 
proved, that he did not possess the degree 
of knowledge or self-control hereinbefore 
specified.' That is to say, where delusion 
exists, the burden of proving moral capacity 
would be shifted, the prosecutor having to 
prove its existence, instead of the accused 
having to prove its absence. The opinions 
elicited during the inquiry showed that the law 
is regarded by legal authorities as' being at 
present too uncertain in its operation, and as 
failing to recognise some of the most im- 
portant elements in the question. The diver- 
gent character of the recommendations which 
were made showed, however, that legal 
opinion is much divided, not only as to the 
proper relations of insanity and crime, but 
also as to the essential elements of responsi- 
bility. In the meantime, therefore, the state- 
ments of the fifteen judges after the Mac- 
Naughton case remain the chief exposition of 
the English law where insanity is pleaded in 
excuse for crime. 
Present State of the Question.-It is 
necessary, in order to justly appreciate the 
present aspect of the subject, thus to trace 
its more recent history, and it might be use- 
ful to present an estimate of the compara- 
tive value of the several tests or criteria 
which have been proposed for the determina- 
tion of cases in which insanity has been 
alleged. These criteria may be broadly sum- 
marised in the following six propositions. 
According to one view a person should be 
held irresponsible for an act if at the time 
of committing it (1) he laboured under in- 
sanity of any kind or degree; according to 
another, if (2) he laboured under delusion; 
or (3) if he was ignorant of right and wrong; 
or (4) had not power to appreciate and be 
moved by ordinary motives; or (5) had lost 
the controlling power of the will; or (6) if 
the act is traceable to, or its nature has been 
determined by mental disease affecting the 
agent. The last of these views is the only 
one to which fatal objection may not be 
raised, both on the theoretical and practical 
sides. The others are all too vague to be of 
much advantage; and they rather tend to 
introduce new difficulties than to remove 
those already existing. The proposition 
therefore which seems to approach nearest 
to a solution of the difficulty is that irrespon- 
sibility must be admitted whenever the act 
is traceable to, or its nature is determined 
by mental disease affecting the agent. It 
will of course be understood that under such 
a rule the term ' mental disease ' must be 
held to include both congenital and acquired 
disorders; arrest of development being as 
much a morbid condition as functional or 
structural change. This view of the subject 
may not be ultimately accepted in the pre- 
cise terms of the proposition here given; but 
the principle on which it rests seems to 
afford the only safe basis upon which we can 
go. As has already been shown, it has not 
hitherto been regarded in this light by the 
majority of the judges; but there have been 
indications of late years that judicial views 
are tending in that direction. The late Lord 
Wensleydale and others have given sanction 
to the principle in their judicial statements. 
And the late Lord Justice-General of Scot- 
land (Inglis) gave definite expression to it in 
one case (Brown, Sept. 1866). He told the 
jury that the main question was 'whether 
the prisoner was in such a state of insanity 
at the time, as not to be responsible for the 
act which he had committed ; ' and in order 
to constitute such insanity he said that ' it 
must be clearly made out that at the time of 
committing the act the prisoner was labouring 
under mental disease in the proper sense of 
the term, and that that mental disease was 
the cause of the act.' In America the doc- 
trine has been frequently acknowledged, but 
never more fully and tersely than by Judge 
Doe, of New Hampshire (State v. Pike), who 
comprehensively defined the medical rela- 
tions of both criminal irresponsibility and 
civil incapacity, when he stated that a ' pro- 
duct of mental disease is neither a contract, 
a will, nor a crime.' One important point 
is to prevent persons from being punished 
for actions which are the direct outcome of 
pathological processes. But it is of equal 
importance to avoid the adoption of a prin- 
ciple which would make the existence of 
slight mental irregularities incompatible 
with responsibility. There does not appear 
to be any danger of this in acting on the 
principle which is here enunciated. For it 
lies in the very nature of the cases in which CRIME, IRRESPONSIBILITY FOR 
CRISIS 
421 
the doctrine could be applied, that the con- 
dition to which it is proposed that irrespon- 
sibility should be attached must be one which 
is known to exhibit itself in acts of serious and 
even criminal character. If the trained ob- 
server of disease is able to recognise in an act- 
which is ordinarily followed by severe punish- 
ment-a direct result or a characteristic 
feature of a morbid process, of the existence 
of which there may otherwise be sufficient 
proof, the question of responsibility cannot 
present any serious difficulty. It may admit 
of doubt whether a person is responsible for 
not controlling his actions, or for not knowing 
right from wrong, or even in some cases for 
the harbouring of a delusion. But once let 
it be proved that an act is the natural result 
of a disease under which a person is known 
to labour, and the question must be prac- 
tically removed from the field of discussion. 
Before, however, the principle can be ac- 
cepted as fully satisfactory, it is necessary 
to inquire whether its application would 
permit insane persons to be held responsible 
who ought not to be so considered. In other 
words, are there states of insanity in which 
a person is irresponsible for acts to which he 
has not been predisposed or impelled by the 
insanity? It is perhaps impossible to give 
such an answer to this question as would be 
both definite and complete ; but for practical 
purposes we think it may be answered in 
the negative. Where the insanity is of such 
a nature that it does not modify the whole 
conduct, we believe it will be found in 
practice necessary to admit the existence 
of responsibility for acts where there is no 
demonstrable connexion between them and 
the mental disease. The insane persons who 
on this principle might be held responsible, 
would be found solely among those whose 
irresponsibility could only be admitted after 
very searching inquiry, and whose insanity 
was of that kind and degree which has often 
been declared by medical writers to be con- 
sistent with responsibility. It is not to be 
supposed that under this rule difficulties 
would cease. It would often be hard to 
show in cases of actual disease that there 
was good reason for believing in its existence, 
or that it was really contributory to the act 
committed. This, however, would not result 
from any defect in the principle, but from 
that imperfection of our knowledge which 
renders the perfect application of any prin- 
ciple impossible. Let the task of the medical 
witness be limited to the demonstration of 
facts indicative of disease and its conse- 
quences, and he will at least be acting quite 
within his special province, and might expect 
that reasonable weight would be attached to 
his opinion. And if juries were instructed 
that the law does not hold a person respon- 
sible for acts committed under the influence 
of disease, it is scarcely conceivable that any 
one would be found guilty where good cause 
had been shown even for the reasonable 
supposition of such an influence. Whatever 
may be the view ultimately adopted, it would 
seem to be in every way desirable that the 
attention of the medical expert should be con- 
fined to the elucidation of the medical facts, 
and that he should not be required to deal with 
questions which are legal and abstract, and 
in no way specially medical. The condition 
known as diminished responsibility has not 
been alluded to in this article. It is only 
indirectly recognised by British law, and 
therefore, though much is to be said in favour 
of its recognition, it is unnecessary to deal 
with the subject here. John Sibbald. 
CRISIS (Kptats, a decision, a turn).- 
Synon. : Fr. Crise ; Ger. Krise.-Crisis is a 
term applied to the rapid defervescence of 
an acute febrile disease. It has wandered 
somewhat from its original meaning, which 
was 'judgment '-primarily an operation in 
the mind of the observer, but reflected upon 
the phenomena observed. The converse 
term, employed to designate a gradual sub- 
sidence of fever, is lysis. 
Crisis formed at one time the basis of an 
important medical doctrine. Certain days 
from the onset of the disease on which the 
crisis commonly occurred were considered to 
be propitious. The seventh day was especi- 
ally favourable, while the sixth was the most 
unfavourable; speaking generally, the odd 
numbers or the multiples of 7 were propi- 
tious, and the even numbers and such odd 
numbers as stood near multiples of 7, such as 
19, were unpropitious. The preparation also 
for a crisis was indicated, and the critical 
day foretold, by remissions perceptible some 
days previously. The whole morbid process 
of fever was represented as a process of 
elaboration by which a materies morbi was 
prepared for expulsion, and an essential 
feature of the crisis was a critical evacuation, 
by means of which this was eliminated. 
The doctrine of crisis and even of critical 
dayswas not pure imagination or superstition, 
but was founded originally on careful observa- 
tion. In times when nothing was known of 
the organic lesions which give rise to fever, 
and in countries where a large proportion of 
the diseases were of a malarious origin, it 
would afford data for prognosis and conduce 
to appropriate treatment; and at the present 
day in hot climates a crisis is anxiously 
looked for in febrile attacks on a given day, 
and, as is well known, a critical fall of tem- 
perature and improvement in the general 
symptoms precede in pneumonia improve- 
ment in the physical signs. 
In order to constitute a true crisis the de- 
fervescence should occupy less than forty- 
eight hours, and it often takes place in a 
much shorter time. The fall of temperature 
should be accompanied by a corresponding 
reduction in the frequency of the pulse, and 422 
CRISIS 
CROUP 
should coincide with a feeling of relief and 
a return of strength; the skin will be warm 
and soft, the tongue moist, and there will be 
indications of reviving appetite; there may 
or may not be a critical evacuation, but the 
secretions will become more natural in amount 
and character. 
This favourable mode of termination of an 
acute febrile disease is more common than is 
usually supposed. The circumstances under 
which it is most likely to occur are when the 
attack begins abruptly and the temperature 
rises rapidly, the natural course of the disease 
being short and not attended with organic 
lesion s, such as will of themselves keep up lever. 
After twenty-one days, termination by crisis 
is not to be expected. The more marked the 
onset-as, for example, by a definite rigor- 
the more rapid the rise of temperature, and 
the greater the height to which it reaches, 
the greater the probability of an early criti- 
cal termination. 
Occurrence.-The diseases in which the 
conditions favouring a crisis are realised, and 
in which this mode of termination is observed, 
belong to various classes. 
Among the specific fevers, eruptive and 
continued, it occurs frequently in variola, but 
in severe cases it is interfered with by the 
febrile disturbance excited by the eruption. 
In measles it is very common. In scarlet- 
fever a true crisis is seen only in mild cases, 
though the onset of this disease is peculiarly 
abrupt. The mode of termination of typhus 
is essentially critical, but as a rule the crisis 
is not sharp. Relapsing fever affords the 
best examples of crisis, which is moreover 
attended by a critical evacuation in the form 
of profuse perspiration, the temperature 
sometimes falling 10° F. in as many hours, 
and the patient passing from a state of ex- 
treme suffering and oppression to almost 
perfect ease and comfort. In enteric fever 
lysis is the mode of termination. 
Remittent fevers often present crises, which 
may be true and curative, or false and illusive; 
and the sun fever and common continued 
fever of hot climates, and tropical diseases 
generally, have a tendency to fever running 
high very early and breaking abruptly at a 
critical period. 
In this country feverish colds, attacking 
the throat or taking the form of influenza or 
catarrh, often terminate critically in three or 
four days. Erysipelas may so end, but at a 
later and less definite period. The sharp 
febrile attacks which sometimes occur after 
childbirth often exhibit a very decided crisis. 
In pneumonia the natural termination is by 
a well-marked crisis, which may take place 
as early as the fifth day, or be deferred to the 
ninth, after which a critical termination is 
not to be expected, and the suspicion may be 
entertained that the case is not one of frank 
pneumonia, the prognosis becoming grave. 
As has been already stated, the general im- 
provement precedes the indication by phy. 
sical signs of resolution in the inflamed lung. 
Pleurisy is said also to terminate critically, 
but it is not in the same definite way as 
pneumonia. 
The critical evacuations which entered into 
the original notion of a crisis are really a 
common attendant. The most common is a 
profuse warm perspiration, which may occur 
whatever the disease may be. Occasionally 
the evacuation is a copious flow of urine, or it 
may take the form of diarrhoea. Epistaxis or 
haemorrhoidal flux is a more rare and doubt- 
ful critical evacuation. A common critical 
phenomenon is a prolonged, sound, and re- 
freshing sleep. 
The question whether or not a favourable 
crisis affects the odd rather than the even 
days has been a frequent subject of dispute, 
and it still remains undecided. It is not, 
however, of any importance; but another 
point handed down with the doctrine is 
worthy of attention, namely, that indications 
of an approaching crisis are often given two 
or three days beforehand in slight remissions 
of fever. By the presence or absence of such 
remissions at a certain period of the attack, 
or by a continuous rise of temperature where 
a remission might be expected, important 
prognostic information may be afforded and 
indications for treatment obtained. 
Therapeutic Indications. - The main 
therapeutic deduction from a study of crisis 
as a termination of acute disease is, that we 
should not hastily interfere with the reactions 
by which the system adjusts itself to altered 
conditions or meets the incidence of the 
causes of such disease, but contribute to their 
completion. We do not assume the existence 
of a vis medicatrix tending invariably to the 
restoration of health ; but we must recognise 
the power inherent in a living organism to 
respond by internal changes to external in- 
fluences, and to regain the balance when this 
has been disturbed. In this process a certain 
cycle of changes must be gone through, and 
the great opportunity for treatment of an 
active kind, should any be required, arises 
when the course, direction, and probable 
duration of these changes are known, and 
when agencies can be brought to bear at a 
given moment, which will contribute to 
bring about the appropriate critical evacua- 
tion or a critical sleep, through which a re- 
turn to a normal condition would naturally 
be effected. William H. Broadbent. 
CRITICAL.-Having relation to a crisis. 
See Crisis. 
CROUP (Scotch, croup or roup, hoarse- 
ness).-Synon. : Cynanche trachealis; Fr. 
Croup; Ger. Croup. 
Definition.-An acute febrile affection, 
occurring in childhood, accompanied by in- 
flammatory swelling of the mucous mem- brane of the larynx, and in some rare cases 
by the formation of a fibrinous false mem- 
brane. 
.Etiology and Pathology.-The symp- 
toms of the most usual form of croup, as 
described below, are due to an acute catarrh 
of the laryngeal mucous membrane. The 
condition is, in fact, a simple catarrhal laryn- 
gitis, and is not accompanied by the forma- 
tion of any false membrane. The mucous 
membrane swells by reason of the conges- 
tion of its blood-vessels, and the pouring out 
of inflammatory exudation into its tissue. 
Mucus, too, is prone to accumulate on its sur- 
face. These conditions are precisely the same 
as occur in the ordinary catarrhal laryngitis of 
adults. But in the child the glottis is much 
narrower than in adults, and the swelling of 
the mucous membrane from inflammation is 
greater, and more rapid in reaching its 
height. Moreover, the larynx is in children 
more irritable, and therefore its muscles are 
more easily excited to spasm. Thus when a 
simple catarrhal laryngitis makes its appear- 
ance in a child, it is very shortly followed by 
laryngeal stenosis, partly from the swelling 
of the mucous membrane, partly from accu- 
mulation of mucus, and partly too from 
spasm of the laryngeal intrinsic muscles. 
The condition described is most often due to 
exposure to cold and damp, especially at a 
time when the body is heated. It is caused 
also by scalds of the larynx, when unduly 
hot fluids are drunk by accident, by wounds, 
by the irritation of noxious gases, and by 
the presence of foreign bodies in the larynx. 
It is more common in male than in female 
children, and is usually met with between 
the ages of two and nine years. 
But there also exists an inflammation of 
the larynx which is accompanied by the 
formation of a false membrane, and it is in 
respect to this condition that so much dis- 
cussion has arisen, and even now doubt 
exists in the minds of some observers. It is, 
of course, well known that in diphtheria the 
characteristic membrane may spread from 
the pharynx, its usual site, into the larynx, 
and in doing so may produce all the symp- 
toms of so-called croup, in addition to those 
due to the diphtheria proper. But much of 
the confusion which existed as to the patho- 
logical entity of croup resulted from the 
non-recognition of those cases of diphtheria 
in which the local lesion had its primary seat 
in the larynx. Pathological observations, 
however, have now placed it beyond doubt, 
that such cases really exist. Death may 
occur entirely from the laryngeal stenosis 
so produced, as in all other and simple 
obstructions of the larynx. But the diph- 
theritic nature of the affection is obvious 
from the other possible terminations of such 
cases, and from the general symptoms pre- 
sent at the height of the affection. Thus 
death may also be due to the heart-failure, 
CROUP 
or to the general blood-poisoning, character- 
istic of diphtheria. Again, in the acute stages 
of such a disorder, symptoms may appear, 
such as great asthenia, excessively frequent 
pulse, haemorrhages from various parts, 
albuminuria, and a formation of diphtheritic 
membrane on sores far removed from the 
larynx, which symptoms, while inconsistent 
with a diagnosis of non-specific membranous 
inflammation of the larynx, are frequent 
associations of diphtheria when it occurs in 
its ordinary form. Moreover, when, in fortu- 
nate cases, the acute symptoms have passed 
away, after an interval the characteristic 
paralyses of diphtheria may show them- 
selves. The facts of contagion are also of 
importance, for from such cases of membra- 
nous laryngitis, other cases may arise, in 
which the diphtheritic membrane appears 
first in the pharynx, and the disease runs its 
ordinary and unmistakable course. The 
teachings of bacteriology are perhaps, as yet, 
not sufficiently definite, in reference to this 
point, for them to be accepted as absolute 
proof. It may, however, be noticed that 
Leffler's diphtheria-bacillus (not merely the 
micrococci which may be found in any 
decaying membrane) has been demonstrated 
equally well in those cases of diphtheria 
which presumably began in the larynx, as in 
those where the membrane was limited to 
the pharynx. Thus it must now be admitted 
that the local lesions of diphtheria may be 
limited to the larynx; and, in the opinion of 
the writer, under this category must be 
placed by much the larger number of cases 
formerly styled 'membranous croup.' The 
description of diphtheria of the larynx will 
be found in the article Diphtheria. 
There remains still a certain proportion of 
cases of membranous laryngitis which are 
not due to the action of the diphtheritic 
poison. Some of these are produced as 
secondary complications by the poisons of 
other specific fevers, and amongst these are 
to be mentioned scarlet-fever, small-pox, 
measles, enteric fever, and whooping-cough. 
Yet this question is before us, whether a 
membranous laryngitis may occur without 
the action of any specific poison. The older 
writers assumed that this occurred in a large 
number of instances, and the prevalence of 
this view led to the report by a Committee 
of the Royal Medical and Chirurgical Society 
in 1879, upon the Relations of Membranous 
Croup to Diphtheria. That by far the larger 
number of cases of membranous laryngitis 
are, in the opinion of the writer, due to diph- 
theria has already been stated above. But 
the evidence is also indisputable that the 
affection may occasionally arise from other 
and simple sources. Thus, the late Dr. 
Hilton Fagge1 recorded, amongst others, 
cases where both the fauces and air-passases 
were covered with false membrane, from a 
423 
1 Guy's Hospital Reports, 1877, p 345. 424 
CROUP 
scald of the throat by boiling water, and again 
from burns of the fauces; where a foreign 
body in the bronchus had caused mem- 
branous laryngitis ; where a similar appear- 
ance followed a cut throat, other diseases of 
the pharynx or larynx not diphtheritic, and 
pneumonia. 
Mr. R. W. Parker,1 too, has recorded a case 
where false membranes formed in the larynx 
after a scald. The Committee mentioned 
above, reported that cases had fallen under 
their notice, where ' membranous affection of 
the larynx and trachea had shortly followed 
exposure to cold, but their knowledge of the 
individual cases was not sufficient to exclude 
the possible intervention or co-existence of 
other causes.' General pathology would not 
negative the view that an inflammation, usu- 
ally simple, might occasionally become mem- 
branous. As is mentioned under Diphtheria 
in respect to the true diphtheritic membrane, 
an important factor in its production is the 
occurrence of coagulative necrosis of the 
epithelial cells, a condition which may arise 
from the intense action of an irritant usually 
productive only of catarrhal inflammation. 
We have a formation of false membrane, 
analogous to that of the assumed mem- 
branous and non-diphtheritic croup in the 
affection known as plastic bronchitis, in the 
intestine in dysentery, in the mouth in 
syphilitic and sometimes in simple stoma- 
titis, and on various mucous surfaces in 
septic disorders. Further, membranous in- 
flammation has actually been produced 
experimentally by the injection of acrid 
irritants into the larynx of animals. A 
priori, therefore, there seems no reason why 
a membranous laryngitis should not occur 
without the intervention of a specific poison. 
Practically, however, it must be concluded, 
from the evidence at our disposal, that such 
cases are exceedingly rare, and that false 
membranes do not form in the laryngitis 
which forms the basis of what is met with as 
the simple non-diphtheritic croup of children. 
It must here be stated, that in modern times 
the late Dr. Hilton Fagge held an opposite 
view, though he with great care and fairness 
considered the arguments against the posi- 
tion he maintained. He believed not only 
that, in many cases of croup which recovered, 
false membrane had formed without being 
detected, but also that a non-specific mem- 
branous croup might spread from the larynx 
to the pharynx and fauces, causing fresh 
deposits of false membrane on those parts, 
which most other observers would assume to 
be characteristic of diphtheria. He suggested 
that the term ' Croup ' should be applied 
only to cases of membranous and non-diph- 
theritic laryngitis, while those where no 
membrane was formed should be known as 
' Spurious Croup.' 
In former accounts of the pathology of 
croup, differences are described between the 
croupal and the diphtheritic false membranes. 
There are, indeed, differences between the 
false membranes found on the laryngeal and 
pharyngeal mucous membranes respectively; 
but these are due merely to the differences 
in structure of the mucous membrane at- 
tacked. The false membrane is in both 
cases essentially the same in structure and 
in its mode of formation. What is said 
of the diphtheritic membrane will apply to 
the membrane rarely found in croup, so that 
no detailed description of the latter need be 
given here. See Diphtheria. 
Symptoms.-In accordance with the view 
expressed above, little will be said under this 
heading about cases other than those of non- 
membranous, or as the late Dr. Hilton Fagge 
styled it, ' spurious ' croup. The child affected 
by this disorder may suffer from general catar- 
rhal symptoms for a time, varying from a few 
hours to two or three days. More commonly 
before the actual attack he appears quite well 
at bed-time, though very often it may after- 
wards be ascertained that some time during 
the day he has been exposed to cold or damp, 
or has sustained a chill. In a few hours, 
however, he wakes suddenly, as if frightened, 
breathing hurriedly with loud, hoarse, in- 
spiratory laryngeal stertor. He coughs fre- 
quently, making a harsh, metallic noise, but 
at first removing no mucus from the larynx. 
He cries, and perhaps speaks, in a shrill, 
cracked tone, which soon gives place to a 
mere whistling sound. The character of the 
breathing, voice, and cough gave rise to the 
Scotch vernacular name for the disease, 
' croup,' which was adopted by Dr. Home in 
1765, when describing the affection, and 
which is now employed by most nations as a 
scientific term. The child is very restless, 
tosses his body and limbs about incessantly, 
clutches at his throat as if to remove the ob- 
struction there, and seizes any surrounding 
objects with his hands. The face is at first 
flushed, the eyes bright, and the expression 
exceedingly alarmed and anxious. Soon, 
however, the flush becomes dusky, and 
gradually pallor supervenes, while the whole 
body is covered with a cold sweat. The feet, 
and sometimes the hands, not infrequently 
assume the position found in tetany, and in 
extreme cases general convulsions may occur. 
The pulse is frequent and feeble, the tem- 
perature is slightly raised. The difficulty 
with which air enters the chest is obvious 
from an observation of the patient's position 
and respiratory movements. The head is 
thrown backwards, the chin held out pro- 
minently, and this position is accentuated at 
each inspiration by a contraction of the 
sterno-mastoid muscles. All the extraordi- 
nary muscles concerned in chest-expansion 
are brought into play, and the nostrils dilate 
at each breath. Yet, in spite of the extra 
force employed, the thorax is not filled with 
1 Clinical Transactions, 1875, p. 144. CROUP 
CROWING CONVULSION 
425 
air. During inspiration the supra-clavicular 
fossae, the lower ribs, the epigastrium, and 
even the lower portion of the sternum are 
depressed. The yielding of the chest-wall is, 
as might be expected, more pronounced in 
rickety children, and in such subjects the 
whole of the ribs may be seen to give way at 
the sides as each breath is drawn. If the 
chest and larynx be auscultated, at first 
nothing is heard but laryngeal sibilus ; after- 
wards rattling noises are perceived in the 
larynx, due to the presence of mucus, while 
in the chest rhonchi may be discovered. 
The cough, which was at first dry, as the 
attack continues displaces small pellets of 
thick, tough mucus; sometimes threads of 
this substance are expectorated, and have 
been mistaken for false membrane. 
Usually, after a time varying from half an 
hour to two or three hours, the difficulty in 
respiration subsides, and the child falls asleep 
again, but not quite free from symptoms indi- 
cative of his ailment. His face is somewhat 
flushed, and there is some degree of pyrexia. 
The restlessness does not quite disappear even 
in sleep. The hands and feet frequently re- 
tain their tetanoid position. The breathing 
is still husky and somewhat hurried, and an 
occasional slight cough has the clanging 
character noticed during the paroxysm; 
during the next day, or for the next two or 
three days, the breathing is hurried and some- 
what stertorous, and the attack may return 
during the next and even succeeding nights. 
For some time after recovery is apparently 
complete, any slight cough is prone to assume 
a ' croupy ' character, just as after an attack 
of whooping-cough the characteristic whoop 
may at times recur. After one attack, too, 
or series of attacks, the child may again and 
again suffer from repetitions of the disorder, 
even for several years. 
As has been stated, this non-diphtheritic 
membranous laryngitis is not always idio- 
pathic. In such cases the signs of laryngeal 
stenosis are added to those of the original 
disease or inj ury. It is convenient, therefore, 
to discuss them in the article on Diphtheria, 
where they will be found in the section upon 
Diphtheria of the Larynx. 
Prognosis.--The prognosis of non-mem- 
branous croup is almost invariably favourable 
in so far as the actual attack is concerned. 
In spite of the apparent severity of the 
symptoms, they nearly always subside natur- 
ally. The friends of the patient should, 
however, be warned of the probability that 
the attack will be repeated at times for some 
years after its first appearance. Membran- 
ous croup, on the other hand, is a much 
more serious matter. At any moment .the 
false membranes may accumulate or curl up 
in the larynx, and entirely close the glottis. 
Nor is the danger merely that of the laryn- 
geal affection. The laryngitis occurs in only 
severe cases of the specific fevers, and the 
blood-poisoning of the original disorder, just 
as in diphtheria, is usually a most fatal 
condition. 
Treatment.-As soon as the attack of non- 
membranous croup has commenced, the child 
should be placed in a warm bath, to which 
preferably a little mustard has been added. 
Sponges, wrung out of water as hot as can be 
borne, should be applied over the larynx, and 
renewed as often as they become cold; or a 
mustard-leaf may be applied here. An 
emetic, too, is useful. This may be admin- 
istered in the form of ipecacuanha wine, in 
doses of one teaspoonful every ten minutes 
until vomiting comes on. Sir William Jenner 
recommends that afterwards a dose of calomel 
and jalap should be given. It is well, too, to 
place the child in a tent-bed, under the cover 
of which the nozzle of a steam-kettle is 
introduced. 
Prophylactic treatment is of importance, 
when the disease has once shown itself. In 
cold weather the child should be wrapped 
up warmly, and protected from chills and 
draughts. At the same time, the larynx may 
be, as it were, accustomed to cold, by being 
sponged once or twice a day with cold water. 
General tonics, too, are of use in warding off 
future attacks. 
The treatment of membranous croup is 
practically the same as that of laryngeal 
diphtheria. See Diphtheria. 
Robert Maguire. 
CROUP, FALSE.-A term commonly 
applied to laryngismus stridulus. See 
Larynx, Diseases of. 
CROUPOUS, CROUPY (Scotch, croup, 
hoarseness).-These terms were originally 
employed with reference to the peculiar crow- 
ing or stridulous character of the respiration, 
cough, and voice in certain affections of the 
larynx, and signified ' belonging to croup ' in 
its clinical relations ; for example, ' croupy 
cough,' 'croupy symptoms.' When morbid 
anatomy demonstrated the occurrence of a 
fibrinous exudation or false membrane upon 
the affected surface in a special form of croup, 
the word ' croupous ' was used also to desig- 
nate this false membrane; thus ' croupous 
exudation ' and ' croupous membranes.' The 
application of the term was afterwards further 
extended; and it is now employed to indicate 
the process that leads to a fibrinous exudation 
in any situation whatever; such as ' croupous 
inflammation' and 'croupous pneumonia.' 
Thus the words ' croupous ' and ' croupy,' 
which were originally associated with peculiar 
sounds, have come in a remarkable manner 
to express certain physical, chemical, and 
microscopical characters in the products of 
inflammation. See Croup ; Diphtheria ; 
and Inflammation. 
CROWING CONVULSION. - A 
popular synonym for laryngismus stridulus. 
See Larynx, Diseases of. 426 
CRURA CEREBRI 
CUPPING 
CRURA CEREBRI, Lesions of.-In 
the crura cerebri lie the paths of communica- 
tion between the cerebral hemispheres and 
the periphery. The motor or pyramidal tracts 
lie in the foot or ventral portion of the crus, 
which is separated from the dorsal portion, 
or tegmentum, by the locus niger. The pyra- 
midal tracts of the internal capsule constitute 
only the middle third of the foot of the crus ; 
the inner third connects the prefrontal lobe 
with the grey matter of the pons, and, in- 
directly perhaps, with the opposite cerebellar 
hemisphere (Flechsig); the outer third, which 
has been supposed by Meynert to constitute 
the sensory path, would appear, from the re- 
searches of Flechsig and others, to connect 
the occipito-temporal regions of the hemi- 
sphere with the grey matter of the pons, and 
probably with the cerebellum. The sensory 
tracts, in all probability, run in the tegmentum 
or dorsal division of the crus cerebri. The 
fibres of the third nerve pass through the 
internal, or mesial, aspect of the crus on 
their way to the oculo-motor nuclei in the 
floor of the aqueduct of Sylvius. 
From the anatomical and functional rela- 
tions of the crus cerebri, lesions of this region, 
such as may arise from haemorrhage, pressure, 
&c., are apt to cause paralysis of motion and 
sensation on the opposite side of the body, as 
well as oculo-motor paralysis on the same 
side as the lesion. The degree of implication 
of the sensory and motor tracts and fibres 
of the third nerve varies in individual in- 
stances ; but an alternate paralysis, in which 
there is some degree of oculo-motor paralysis 
on the one side and paralysis of the limbs 
on the other, is diagnostic of lesion of the 
crus. A typical instance of this form of 
paralysis has been recorded by Weber (Med.- 
Chir. Trans. 1863). In this case there was 
oculo-motor paralysis on the side of lesion 
and complete paralysis of voluntary motion, 
with partial paralysis of sensation on the 
opposite side of the body. A similar case 
has been recorded by Rosenthal (Med.Jahrb., 
1870). In this case there was, progressively, 
ptosis on the left side, right hemiplegia, anaes- 
thesia and analgesia. The right third nerve 
became implicated later. After death a cyst 
was found in the left crus cerebri, together 
with a tumour of the size of a bean occupy- 
ing the interpeduncular space, and compress- 
ing the right third nerve. In paralysis from 
lesion of the crus cerebri, there is, as a rule, 
also well-marked vaso-motor paralysis, and 
the temperature of the paralysed side may 
be two or three degrees above that of the 
other. 
D. Ferrier. 
CRUSTA LACTEA (crusta, a crust; 
and lactea, milk-like).-Milk-crust: a syno- 
nym for eczema pustulosum of the face and 
head, met with in infants at the breast. See 
Eczema. 
CRUVEILHIER'S PARALYSIS.- 
A synonym for progressive muscular atrophy. 
See Progressive Muscular Atrophy. 
CUPPING.-Synon. : Fr. Action de ven- 
touser; Ger. Schropfen. 
This is a mode of treatment sometimes 
employed to relieve congestion or inflamma- 
tion of internal parts by drawing blood to the 
surface of the body. When the blood thus 
attracted to the superficial parts is actually 
abstracted from the body by means of in- 
cisions, the operation is called we^-cupping; 
and this has been described in the article 
Blood, Abstraction of. We shall here de- 
scribe <Zr?/-cupping, in which no scarifications 
are made, the blood being simply drawn 
towards the surface by atmospheric exhaus- 
tion, and hyperaemia of the subcutaneous 
parts or organs thereby relieved. 
Formerly cupping was extensively prac- 
tised, but of late years it has fallen into dis- 
use. In some respects it serves the purpose 
of counter-irritants, but has a more power- 
ful effect than these; rapid and marked 
results being sometimes produced upon the 
circulation of inflamed or congested tissues. 
Modes of Application.-Dry cupping is 
performed as follows: The flame of a spirit- 
lamp, being allowed to burn for an instant in 
the dome of a cupping-glass, is quickly with- 
drawn, and the cup is then rapidly and evenly 
applied to the skin over the affected part. 
The heat expands the air contained in the 
glass cupola, and, owing to the contraction 
which ensues on cooling, the skin is forcibly 
sucked up into the cup. It is well first to 
sponge the skin of the selected spot with hot 
water, so as to render it more supple and 
vascular. Slightly moistening the rim of the 
cupping-glass helps to increase the degree of 
exhaustion. 
An excellent modification of cupping, which 
has been demonstrated to the writer by Sir 
Richard Quain, is practised in the following 
way : Instead of allowing the cup to remain 
stationary after its application to the skin, as 
is usual, the operator dexterously slides it to 
and fro along the surface. When the opera- 
tion is to be thus performed the amount of 
surface drawn into the glass must not be con- 
siderable. In this way a large tract of skin 
may be quickly rendered hyperaemic without 
effusion of blood into its meshes, as happens 
when the cups are stationary. 
Precautions.-Cupping-glasses should be 
applied where the skin is thick and cushiony, 
as over the loins, nape of the neck, pectoral 
region of the chest, &c., and not where bony 
prominences, or other irregularities, are likely 
to interfere with complete exhaustion. The 
edges of the glasses must not be so hot as 
to burn the skin. 
Uses.-Cupping may be advantageously 
employed in cases of sthenic cerebral conges- 
tion, the cups being applied to the nape of the CUPPING 
CYSTOSCOPE 
neck ; in hyperaemia of the spinal cord; and 
in inflammation or congestion of the lungs, 
kidneys, or other viscera. In renal ischaemia 
it is eminently serviceable. This may be 
owing to the fact that the blood-supply of the 
skin of the loins is in intimate relation with 
that of the kidneys; the vascular supply to 
those organs being thus directly and imme- 
diately influenced. Alfred Wiltshire. 
CUTIS, Diseases of.-See Skin, Dis- 
eases of. 
CUTIS ANSERINA (cutis, the skin; 
and anser, a goose).-A state of roughness of 
the skin, resembling that of a goose when 
plucked, produced by prominence of the pores 
or follicles. It is due to contraction of the 
muscular structure of the corium, and is 
commonly occasioned by cold. 
CYANIDES, Poisoning by. - See 
Antidote ; and Prussic Acid, Poisoning by. 
CYANOSIS (<vave6s, blue).-This, which 
is really not a disease, is the peculiar blue 
or more or less livid colour of the surface 
of the body, especially in certain parts, which 
is observed in several affections that interfere 
with the circulation and oxygenation of the 
blood. The condition is most commonly 
associated with certain forms of congenital 
malformation of the heart, and reaches its 
highest development in them, for which con- 
sequently cyanosis is not uncommonly used 
as a synonym. Lesser degrees of similar 
discoloration are, however, not infrequently 
noticed in cases of cardiac disease developed 
after birth, and they may also accompany 
pulmonary affections which materially ob- 
struct the circulation. A cyanotic appearance 
is also one of the obvious effects resulting 
from all modes of suffocation, and it is ob- 
served in the collapse-stage of cholera. The 
upper half of the body may become extremely 
cyanotic as the result of obstruction of the 
superior vena cava. For the pathology of 
cyanosis, see Heart, Malformations of. 
CYNANCHE (kvo>v, a dog; and dyyw, 
I strangle).-Synon. : Er. Angine ; Ger. 
Brdune. 
This word is used to express an inflam- 
matory condition of the throat, or contiguous 
parts, in which difficulty of breathing or of 
swallowing exists, accompanied by a sense or 
feeling of choking. The term is used synony- 
mously, more frequently on the Continent 
than in England, with angina; an affix, in- 
dicative of the seat or nature of the affection, 
being employed as a designation for each of 
the several forms or varieties of disease 
affecting the throat or adjacent parts. Such, 
for example, are the terms cynanche laryngea, 
or croup; cynanche maligna, or malignant 
sore-throat; cynanche parotidea, or mumps; 
cynanche pharyngea, or inflammation of the 
pharynx; and cynanche tonsillaris, or quinsy. 
See those several diseases. 
CYRTOMETER (Kvpros, curved; and 
perpov, a measure).- An instrument for 
measuring the absolute and relative dimen- 
sions and movements of the chest-wall. 
See Physical Examination. 
CYSTICERCUS.-See Entozoa. 
CYSTINE or CYSTIC OXIDE 
(kvotis, the bladder).-A peculiar substance, 
occurring either in solution or in the form 
of small crystals in the urine, or as calculi 
in connexion with the urinary apparatus. 
See Urine, Morbid Conditions of; and 
Calculi. 
CYSTITIS (kwtis, the bladder).-In- 
flammation of the bladder. See Bladder, 
Diseases of. 
CYSTOSCOPE (Kvans, the bladder; 
and aKo-rreco, I inspect). 
Definition.-An instrument designed for 
inspecting the interior surface of the urinary 
bladder. 
Introduction.-Progress in the improve- 
ment of the means for inspecting the interior 
of hollow organs was slow from the begin- 
nings of Bozzini (1807), Segalas (1826), 
Avery (1846), and Desormeaux (1853 and 
1865), and of others by whose apparatus 
light outside the body was thrown through 
an inspecting tube on to the surface of the 
bladder. Among the many workers in 
endoscopy, Avery and Griinfeld (1874) were 
conspicuous for their originality and fertility 
of resource. Avery devised the means of 
reflecting light in sufficient amount to illu- 
minate the urethra, and his apparatus was 
modified by Desormeaux and others, but 
greatly improved by Griinfeld. That surgeon 
described many conditions of the interior of 
the bladder in health and disease when seen 
during life. Dittel and Nitze, in 1876-1879, 
fixed an electric glow-lamp to the beak of an 
instrument, and thus carried the source of 
light into the bladder itself, and so obtained 
a great intensity of illumination. Nitze, by 
suitable optical contrivances, brought into 
view nearly all the surface of the bladder. 
Previously, when fight reflected from without 
was employed by Griinfeld and others, only 
a small part of the wall of the bladder-that 
in immediate contact with the tube-could 
be seen. 
Nitze has arranged the lamp differently 
in a second instrument, to obtain a view of 
that small portion of the bladder which the 
ordinary cystoscope may miss. 
Apparatus.- Leiter's forms of Nitze's 
instrument are the most useful for internal 
inspection. The apparatus is contained in 
two tubes, one of which slides in the other. 
The outer one has the form of an ordinary 
coude catheter, the angle of junction of the beak 
with the stem being 130 degrees. The electric 
427 428 
CYSTOSCOPE 
current for supplying the lamp passes in 
through the tube itself, and back by an 
insulated wire carried in a groove inside the 
outer tube. The stem just above the angle of 
the bend is cut away at one side where a 
right-angled prism is cemented into it. This 
prism has its hypothenuse silvered, so that 
rays passing through the exposed face of the 
prism may be reflected into the inner tube. 
The inner tube is straight, about eight inches 
long, and slides in the outer tube. It carries 
four lenses: one, at the end farthest from 
the observer, is a hemispherical lens, the flat 
face of which, on pushing the tube in, goes 
quite close to that face of the prism which is 
at right angles to the axis of the instrument. 
Near to this hemispherical lens is another of 
very short focal length. The two lenses, 
receiving rays reflected at the hypothenuse 
of the prism, form a small image of objects 
situated opposite the prism, within a field of, 
say, 45 degrees diameter. This image is very 
near to the inner surface of the second lens. At 
the middle of the inner tube is a third lens of 
focal length somewhat less than one fourth 
of the length of the tube. This lens takes up 
the little image from the first and second 
lenses, and forms of it another image of 
nearly the same size not far from the end of 
the tube near the eye of the observer. Lastly, 
there is a short-focussed lens at the eyepiece 
for viewing the image formed by the third 
lens. For convenience we may call this 
inner tube and four lenses " the telescope." 
Besides the telescope and the insulated 
wire, recent instruments contain two small 
tubes-one for conveying an inflowing stream 
of some sterilised or antiseptic fluid, to dis- 
tend the bladder, and keep its contents clear 
during inspection; the other for allowing 
the injected fluid to escape after circulating 
in the bladder, carrying with it any blood or 
muco-pus not evacuated before the cysto- 
scope was introduced. By a Higginson's 
air-pump, acting on a reservoir, the stream 
is maintained constantly, and the bladder- 
walls are firmly distended-a very important 
condition for satisfactory inspection. This 
modification for irrigating during inspec- 
tion was brought into notice by the present 
writer. 
With the cystoscope above described the 
observer, on looking down the telescope, ob- 
tains a view of that portion of the illuminated 
surface which is situated within about 25 
degrees of a perpendicular to the exposed face 
of the prism, provided the bladder be fairly 
distended with fluid. The w'hole surface of 
the bladder may be examined, in most cases, 
by pushing the prism farther into the bladder, 
or by drawing it back, or by turning the in- 
strument on the axis of the stem, or by tilting 
the stem. But it is obvious that the parts of 
the surface near where the instrument enters, 
and in the region opposite to it, are difficult 
to bring into view in a satisfactory manner. 
Nitze has accordingly some different forms of 
cystoscope adapted specially for those cases, 
the principal one of which has the window 
placed in the beak opposite the outer side of 
the bend, and the light at the farther or pos- 
terior end of the beak. By this arrangement 
the light is thrown directly upon the floor of 
the bladder, and so passes through the window 
to the telescope. This form of cystoscope 
illuminates the area between the uvula and 
the mouths of the ureters, and often reveals 
changes there not detected with the ordinary 
form. 
In interpreting the significance of the 
images obtained, account must be taken of 
the varying distance and obliquity of different 
parts of the surface. This will evidently be 
a matter of difficulty, to be overcome by 
practice, especially by practice on a model 
of the bladder, in which the various natural 
landmarks are represented in bold exaggerated 
figures. 
Application.-In the use of the cystoscope 
little can be seen if the cavity be not dis- 
tended or if the contents of the bladder be 
turbid. "When about six or eight ounces of 
fluid are injected, the surface of the bladder 
is fairly smooth, reddish or yellow, and race- 
mose blood-vessels collecting into trunks 
towards the base of the viscus are very dis- 
tinct. If the walls be tightly expanded the 
surface may seem glistening white, like 
mother-of-pearl. On the floor, the trigone 
is dull red., granular, and somewhat pro- 
minent. Near the ends of the ridge at the 
base of the trigone are placed in two little 
eminences the openings of the ureters. If 
the urine coming from a kidney be turbid 
with pus or other matter, a jet of this turbid 
fluid can often be seen issuing from the 
eminence and so discovering the orifice of the 
ureter. Similarly, if there be ulcers on the 
mucous membrane, or a papillomatous tumour, 
a jet of blood can be seen occasionally to dart 
through the clear fluid, which speedily renders 
it a luminous red fog, through which nothing 
definite can be descried. In such cases the 
apparatus for maintaining a constant flow of 
ice-cold boracic solution through the bladder 
is of great service, as the opaque fluid is 
displaced through the outlet tube, and trans- 
parency is restored; and an artificially chilled 
solution represses haemorrhage during in- 
spection. If the contents of the bladder be 
allowed to escape during examination, the 
view becomes dark, or so indistinct as to 
prevent recognition of any known object, and 
then there is danger of the lamp growing hot 
and injuring the wall of the bladder in con- 
tact with it. Hence, whenever the view 
ceases to be luminous, the electric current 
should be at once cut off and the bladder 
refilled. The various changes effected in the 
appearance of the bladder by disease are 
described in the article Bladder, Diseases of. 
Berkeley Hill. CYSTS 
429 
CYSTS.-Definition.-The word 1 cyst ' 
(kvo-tis, the urinary bladder) is used in patho- 
logy without strict scientific accuracy for a 
closed cavity containing fluid or soft matter ; 
which cavity will have, from the nature of its 
contents, a spherical or spheroidal shape. 
The objects thus defined differ much among 
themselves, and are associated together rather 
from convenience that on account of any real 
pathological similarity. 
Classification.-Cysts may be classified 
according to their structure, as simple or 
compound; according to their contents, as 
serous, mucous, fatty, &c.; or according to 
their mode of origin. The latter, though not 
free from objection, is the basis of description 
which will be here adopted. Cysts may 
originate: (1) from dilatation of previously 
existing closed cavities; (2) from retention 
of the products of secretion of a secreting 
gland; (3) as a part of new-growth-, (4) by 
a vice of development. These kinds are dis- 
tinct structures with a wall lined by epithe- 
lium. But the name is often given, less 
accurately, to spaces containing fluid which 
result from softening of solid tissue, whether 
in a new-growth or in an inflammatory pro- 
duct. Cystic parasites have also been con- 
founded with cysts properly so called. 
1. Cysts from Dilatation. - Spaces, 
normal or newly formed, in connective tissue 
may, by irritation and consequent excessive 
exudation, be converted into cysts; or the 
same result may happen from the confluence 
of several such spaces. In proportion as the 
wall becomes smooth, and the shape uniform, 
they may be called cysts. Bursae, whether 
normal or pathological, are cysts. Ganglion 
in the sheath of tendon is clearly a patholo- 
gical cyst. To these and like structures the 
name hygroma cysticum has been given. 
They all contain clear serous fluid, and are 
lined by an endothelium. Encysted hydro- 
cele may also be called a cyst. One class of 
ovarian cysts comes under this head, those, 
namely, which are due to simple dropsy of 
the Graafian vesicle. Tubo-ovarian dropsy 
has the same explanation; and cysts of the 
broad ligament are enlargements of normal 
structures which are left as relics of the de- 
velopment of the ovary. The thyroid gland 
seems, from its structure, containing as it 
does so many closed follicles, particularly 
disposed to this kind of cyst-formation, and 
this is doubtless the explanation of broncho- 
cele. The cause of such an enlargement of 
closed follicles is very obscure, but appears 
to be immediately due to increased pro- 
duction of the material normally filling the 
space. 
2. Cysts from Retention.-Cystic for- 
mations may result from the obstruction of 
the natural outlet of a secreting organ, and 
the consequent retention of secretion. It is 
necessary that the walls of the secreting 
cavity should admit of enlargement, and that 
the tension should not become so great as to 
check secretion. 
All secreting glands present instances of 
such cysts. The sebaceous glands of the skin 
are particularly liable to obstruction of their 
ducts, and in this way are formed sebaceous 
cysts, the contents of which are sometimes 
epithelium and the products of normal secre- 
tion, sometimes abnormal products. The 
same term has, with less propriety, been 
applied to the sebaceous productions called 
milium and comedo. See Follicles, Dis- 
eases of. 
The glands or mucous surfaces are liable 
to similar obstructions, and mucous cysts 
result, such as are sometimes seen in the 
mouth. Larger cysts in the mouth (ranula) 
result from the obstruction of the ducts of 
the salivary glands, or are perhaps connected 
with an abnormal production of gland-sub- 
stance. The stomach very frequently, other 
parts of the intestinal canal more rarely, 
show similar cysts, which, when they project 
and become complicated in structure, are 
called polypi. They are occasionally seen 
on the larynx and trachea. In no part are 
mucous cysts more frequent than in the 
uterus, where, indeed, similar formations, the 
ovula Nabothi, must be regarded as normal. 
The varieties here met with have, as Virchow 
has pointed out, a close analogy with the 
various forms of retention-cysts in the 
skin. 
In the mamma, cysts may result from the 
cutting off of portions of the gland-follicles, 
but the cysts contained in mammary tumours 
are not always formed in this way, some 
being part of new-growths. In the testicle 
obstruction and cutting off of seminiferous 
tubes may lead to small cysts, but these are 
more often connected with new-growths. 
The curious cysts known as spermatoceles, 
containing spermatozoa, appear to arise from 
a similar distension of detached portions of 
testicle-substance, which, by an error of 
development, have failed to become connected 
with the excretory ducts. The testicle is also 
liable to a general cystic degeneration, 
usually called cysto-sarcoma. Cysts of the 
kidney are of various kinds, but many, no 
doubt, both large and small, result from the 
dilatation of uriniferous tubules and capsules 
of glomeruli when their outlet is obstructed, 
as occurs in the cirrhotic form of Bright's 
disease. The origin of the very numerous 
microscopic cysts has been much disputed. 
The writer inclines to the belief that they 
arise from moniliform contraction of the urini- 
ferous tubes, especially such as contain the 
hyaline cylinders, known as fibrinous casts. 
Another form of cystic disease of the kidney 
is developmental. In this the whole of the 
organ is converted into a mass of cysts, and 
is usually much enlarged. This condition 
may be congenital, and the organ may be 
so large as to obstruct parturition. It is 430 
CYSTS 
attributed by Virchow to inflammation of the 
calyces during intra-uterine life. 
To guard against a common error of 
language, it should be pointed out that the 
condition of the kidney which results from 
the obstruction of the ureter, or of the 
urinary passages lower down, though some- 
times called cystic dilatation of the kidney, is 
not properly a case of cyst-formation, and is 
better called hydronephrosis. 
3. Cysts from New-Growth. - In 
many forms of new-growth cysts are pro- 
duced, but not always in the same way. Oc- 
casionally, as in myxoma and enchondroma, 
softening of portions of new-growth already 
formed produces spaces containing fluid, 
which are sometimes, though hardly correctly, 
called cysts. In many sarcomata, the pro- 
duction of new tissue goes hand in hand with 
that of cysts, and is sometimes effected, as in 
glandular organs, by the formation of new 
follicular structures without an outlet, some- 
times by new-growth into the dilated cavities. 
Polypoid or pedunculated growths on a free 
surface may sometimes, by the fusion of 
their extremities, enclose spaces which 
become converted into cysts. We do not 
often find cysts forming by themselves a 
new-growth of so definite a character as 
to deserve a separate name. When they do 
so, they may be called cystoma. 
4. Cystoma or Cystic Tumour.- 
Cysts are met with in the ovary which come 
under the definition just given, namely, so- 
called compound' multilocular cysts, which 
constitute the well-known formidable cystic 
disease of the ovary, and sometimes produce 
tumours of immense size. In these the origin- 
ally simple primary cyst appears to become 
complicated by the formation in its walls of 
secondary cysts, which may encroach upon 
or project into the primary. Again there 
may be papillary growths starting from the 
inner wall of the primary cyst, which either 
fill it up, or by fusion enclose spaces, which 
become secondary cysts. Very complicated 
structures thus result. The contents may 
vary in consistence and colour, from clear, 
pale, albuminous liquid to gelatinous matter, 
and may be stained through haemorrhage, or 
purulent through inflammation. The origin 
of these structures, which have no precise 
parallel in other parts of the body, is 
extremely obscure. It is not even certain 
whether the primary cysts commence, as 
might seem prima facie highly probable, in 
the Graafian follicles ; but they are plainly 
due to an error of development, possibly 
beginning in early intra-uterine life, and are 
not set up by any external causes. The pre- 
sence of a tubular gland-tissue, such as is 
found in the rudimentary, but not in the 
perfect ovary, confirms this view, by throw- 
ing cyst-formation back into an early stage 
in the development of the organ. 
In another, but rarer, form of cystic 
disease of the ovary, equally due to an error 
of development, and sometimes congenital, 
the whole organ is found converted into a 
mass of small cysts, with no striking in- 
equality of size. This variety resembles one 
form of cystic disease in the testicle and 
kidney. 
Dermoid cysts are those of which the 
wall is composed of skin or mucous mem- 
brane, and generally lined by a layer of 
flat cells resembling epidermis. The wall 
may be complicated with connective tissue, 
forming papillae resembling those of true 
skin, and may contain hairs, sebaceous 
glands-either in connexion with them or 
unattached-and sudoriparous glands. The 
accumulation of fatty matter within the 
cysts is doubtless the result of the continuous 
activity of the sebaceous glands, the products 
of which cannot escape. Large masses of 
hair may also be found, from continuous 
growth, and there are often numerous 
detached epidermic scales. Distinctly 
formed mammary glands, with nipples, are 
sometimes found. Such a cyst has only the 
characters of a portion of skin, which might 
be imagined inverted and included by the 
growth of the surrounding parts in an early 
stage of development-an explanation which 
applies only to those situated in certain 
parts of the integument where a junction 
has normally taken place-e.g. along the 
lines of the branchial fissures in the neck, in 
the anterior middle line of the body, &c. 
These simple dermoid cysts are some- 
times complicated by containing teeth, it may 
be in very large numbers (dentigerous cysts); 
but since teeth may also be regarded as cuta- 
neous products, the cyst may still have 
originated in the skin. This explanation 
no longer holds, however, when masses of 
bone are found, sometimes serving for the 
attachment of teeth, sometimes separate ; as 
well as other tissues, e.g. nervous tissue and 
striated muscle. Cysts with this variety of 
contents have been called proliferative. 
Dermoid, dentigerous, and proliferative cysts 
appear to be always congenital structures, 
but may show further growth and develop- 
ment in after-life. At least two-thirds of the 
known cases have occurred in the ovaries. 
Next to these organs, the testicles are the 
most frequent seat, but these cysts have been 
also found in other parts of the body-cavity, 
in the mediastinum, lung, and even within 
the skull. The origin of these growths 
is extremely obscure ; but it is desirable to 
reject entirely the hypothesis that a mixed 
tumour of this kind can be the remains of 
an undeveloped foetus included in the perfect 
individual; a hypothesis rendered improbable 
by the extreme irregularity of the tissues 
produced, the teeth, for instance, sometimes 
numbering one hundred or more. It would 
rather appear as if, in some instances, a 
portion of embryonic epithelial tissue had CYSTS 
DEATH, MODES OF 
431 
become misplaced at an early period of 
development. In other cases, these cysts 
originate in obsolete canals, representing 
rudimentary structures ; such as the central 
canal of the nervous system, the post-anal 
gut, the branchial clefts, the vitello-intestinal 
duct, and others.1 
Several parasitic animals infesting the 
human body may appear in an encysted 
form, and may resemble in appearance true 
pathological cysts. The commonest-the 
larval form of Tania echinococcus, or hyda- 
tid cyst--is known by its laminated wall, 
and by containing a fluid which is not albu- 
minous, but holds in solution sodium chloride. 
Cysticercus celluloses has a transparent wall 
and clear contents. The other encysted 
parasites are either very small, as Trichina 
spiralis, or unimportant. 
Contents of Cysts.-The serous cysts and 
hygromata contain an albuminous fluid like 
that of serous cavities, which may hold 
enough fibrinogenous material to coagulate 
spontaneously. Leucocytes may also be 
present. If inflammation be set up, the 
proportion of albumin and of leucocytes 
becomes greatly increased. In the fluid of 
mucous cysts mucin is contained ; in that of 
colloid cysts, little-known substances which 
are allied to gelatin. Sebaceous cysts con- 
tain neutral fats-sometimes hard, sometimes 
fluid, and cholesterin. Both mucous and 
sebaceous products may harden into concre- 
tions, and even become calcareous. In renal 
cysts urea has been found ; in biliary cysts, 
bile-pigment ; and in general the products of 
special secretion may be found in cases of 
retention, at least in early stages; but if 
retention last too long, special secretion may 
cease. Various exceptional contents have 
been already enumerated. 
Treatment.-The treatment of cysts is 
referred to under the head of Tumours. 
J. F. Payne. 
D 
DACTYLITIS (MktvKos, a finger).-A 
term meaning inflammation of the finger. It 
is applied to syphilis and struma of the 
part, as in the terms dactylitis syphilitica 
and dactylitis strumosa. 
DANDRIFF, or Dandruff (from Celtic 
fen, skin ; and drwg, foul).- Scurf of the head 
(see Hair, Diseases of). Dandriff is met with 
in pityriasis, chronic eczema, and psoriasis of 
the scalp. 
DANDY FEVER. - A synonym for 
Dengue. See Dengue. 
DARTRE (Fr.)-This term is the French 
equivalent of the word tetter, and is applied 
to a variety of cutaneous diseases, without 
strict limitation. 
DAVOS-PLATZ, in North Enga- 
dine, Switzerland, an Alpine valley at an 
altitude of 5,177 feet. Well sheltered; atmo- 
sphere still and cold. A winter health resort, 
particularly for cases of phthisis. See 
Climate, Treatment of Disease by; and 
Phthisis. 
DAY - BLINDNESS.-A disorder of 
vision, characterised by the patient being 
unable to see in the daylight; called also 
hemeralopia. See Hemeralopia ; and Vision, 
Disorders of. 
DEAFNESS.-Loss of the sense of hear- 
ing. See Ear, Diseases of; and Hearing, 
Disorders of. 
DEATH, Modes of.-The proximate 
causes of death, whether resulting from 
natural decay, disease, or violence, may be 
reduced in ultimate analysis to two, namely, 
first, cessation of the circulation; and, second, 
cessation of respiration. On the continu- 
ance of these functions, and particularly of 
the former (if specialisation is possible where 
all are essential), life of the body as a whole, 
or of the individual tissues and organs, de- 
pends. These functions may cease from 
causes directly operating on their mechanism, 
but they may also be brought to a standstill 
by causes operating indirectly through the 
nerve-centres which regulate them. Hence 
it is usual, in accordance with Bichat's classi- 
fication, to describe this as a third mode of 
death ; so that we speak of death beginning 
at the heart, death beginning at the lungs, 
and death beginning at the head. This 
classification is convenient; for though death 
beginning at the head is, in reality, death 
from failure of the respiration or circulation, 
or of both, through paralysis of the vital nerve- 
centres, yet the affection of the nervous sys- 
tem is the primary fact, and the phenomena 
are sufficiently distinct and characteristic to 
require separate consideration. It must, 
however, always be borne in mind that, owing 
to the interdependence of all the vital func- 
tions, there is no such sharp line of demarca- 
tion, in reality, as we, for convenience sake, 
make in theory between the various modes 
of death. The failure of the circulation, 
however, seems the ultimate factor in the 
1 Dermoid Tumours. Bland Sutton, 1889. 432 
DEATH, MODES OF 
extinction of life, as cases are sometimes met 
with (of cerebral origin-tumour, &c.) in which 
respiration ceases and the pulse continues for 
some comparatively prolonged time, and, 
indeed, if artificial respiration be resorted to, 
the heart will continue beating for a long 
period (an hour or more), the reverse condi- 
tion not being observed. The suddenness of 
the death is also in direct ratio with the 
rapidity of interference with the heart's action. 
In pure asphyxia it is comparatively slow 
as compared with that from heart disease or 
stoppage, and, indeed, ends fatally only by 
producing that result. 
I. Death from failure of the Cir- 
culation.-This may be (1) sudden, as in 
syncope and shock', or (2) gradual, as in 
asthenia. 
(1) Sudden failure of the Circulation.- 
As the circulation of the blood depends on 
the difference in the pressure in the arteries 
and veins, the circulation will be brought to 
a standstill by any cause which annihilates, 
or very greatly lowers, this differential pres- 
sure. The cause may be in the heart, or in 
the vessels, or in both. 
(a) In the heart. As the action of the heart 
is the chief factor in the maintenance of arte- 
rial tension, any organic or structural disease 
of the heart, rendering it incapable of propel- 
ling its contents into the arterial system, will 
naturally result in cessation of the circulation, 
and death. Under this general head are to 
be classed all diseases of the heart and its 
annexes. 
But, apart from structural disease, the 
heart may suddenly be made to cease through 
nervous influence. The heart may be 
inhibited, or be made to cease finally and 
for ever, either by central causes, such as 
violent emotion, or a blow on the head, and 
probably in this way in the sudden death 
often observed in cases of cerebral abscess 
and tumour; or by reflex inhibition, as in the 
case of a violent blow on the epigastrium, 
or sudden irritation of the sensory nerves 
of the stomach, as in corrosive poisoning, 
and even in the ingestion of a large draught 
of cold water when the system is over- 
heated. 
Death from sudden cessation of the heart's 
action is death from syncope. Momentary 
cessation of the heart's action is transient 
syncope or fainting. There is sudden loss of 
consciousness, due mainly to the cessation of 
pressure in, and anaemia of, the cerebral 
centres. 
(b) In the vessels. Rapid fall of the blood- 
pressure, and cessation of the circulation, 
will naturally be brought about by rupture 
of the vessels, either from injury or disease, 
causing death by haemorrhage ; or by occlu- 
sion of the pulmonary artery, which seems 
a commoner cause of sudden death than 
is usually believed. But, besides actual 
rupture of the vessels, the vascular area may 
in certain conditions become so enlarged or 
dilated, that we may practically have death 
from haemorrhage without any loss of blood 
externally. This is what we observe in death 
from shock or collapse. In certain condi- 
tions, such as that resulting from blows on 
the abdomen, the vascular area of the abdo- 
men and viscera may become so dilated as 
practically to retain almost the entire volume 
of blood in the body. Hence, even though 
the heart may be acting, yet the circulation 
throughout the body generally, and especially 
in the extremities and superficially, is prac- 
tically nil. The individual may, however, 
retain his consciousness, and thus he differs 
from a patient in a state of syncope. But 
very frequently, in cases of blows on the ab- 
domen, there is not merely reflex dilatation 
of the abdominal vessels, but also reflex in- 
hibition, for a time at least, of the heart, so 
that we have syncope and shock co-existing. 
The symptoms of syncope may pass off, leav- 
ing those of shock still remaining. Shock, 
like syncope, may be either transient or 
fatal. 
(2) Gradual failure of the Circulation.- 
This constitutes death from asthenia. This 
is the natural termination of life, and it is 
also the mode of death after wasting and 
exhausting diseases, cold, starvation, &c. 
The vital powers fade gradually, while con- 
sciousness may be retained up to the last 
moment. 
II. Death, from failure of the Respira- 
tion.-The various ways in which the func- 
tion of respiration may be interrupted, and 
the phenomena consequent thereon, have 
been described under the head of Asphyxia, 
to which article reference may be made. 
III. Death from paralysis of the 
vital nerve-centres-Coma.-As already 
remarked, death beginning at the head ends 
by paralysing respiration and circulation. 
The nerve-centres situated above the medulla 
and pons are not essential to life, except in so 
far as animal life is concerned, and the 
possibility of adaptation to surroundings. 
Diseases of the brain, however, are liable to 
prove fatal by indirect action on the medulla 
and pons through pressure, extension of 
inflammation, and the like. Certain poisons 
also, W'hether introduced from without-such 
as opium and narcotics generally-or aris- 
ing within, owing to the non-elimination of 
waste products, as in uraemia, affect the nerve- 
centres, both cerebral and spinal, and not 
only produce unconsciousness or coma, but 
also paralyse the respiratory and cardiac 
centres. 
In death arising in this manner, the indivi- 
dual lies unconscious, reflex action becomes 
abolished, and the breathing becomes ster- 
torous and ultimately ceases, death occurring 
quietly or in convulsions. In death from 
coma, in addition to the usual phenomena 
of asphyxia, there is, as a rule, more or less DEATH, MODES OF 
DEATH, SIGNS OF 
433 
marked congestion of the cerebral and spinal 
centres. 
Management of the Eying.-In whichever 
of the three ways death may commence, the 
management of the dying calls for careful 
attention on the part of the medical atten- 
dant ; and requires to be specially discussed. 
See Euthanasia. D. Ferrier. 
DEATH, Signs of.-It is not always 
easy to determine when the spark of life has 
become finally extinguished. From the fear 
of being buried alive, which prevails more 
abroad than in this country, some infallible 
criterion of death, capable of being applied 
by unskilled persons, has been considered a 
desideratum, and valuable prizes have been 
offered for such a discovery. The conditions 
most resembling actual death are syncope, 
asphyxia, and trance, particularly the last. 
We cannot, however, say that any infallible 
criterion applicable by the vulgar has been 
discovered, and we do not rely exclusively 
on any one sign, but combine several. 
The most reliable sign of death is proof of 
cessation of the heart's action. This, how- 
ever, is not to be inferred from mere pulse- 
lessness, for the heart may still be beating, 
and resuscitation may be possible, when no 
pulse is to be felt in the arteries by ordinary 
manipulation. The use of the stethoscope is 
necessary, implying, of course, technical 
skill. Though, according to Rayer, the heart 
cannot cease to beat for more than seven 
seconds without death, yet, considering the 
very slow and feeble action of the heart (8 to 
10 beats per minute) in hybernating animals, 
which normally have a pulse of 80 to 90 per 
minute, it is well to regard a similar condi- 
tion as possible in man, and to spend in 
doubtful cases some minutes, up to half an 
hour, in auscultation. The so-called cases of 
life continuing notwithstanding cessation of 
the circulation, as that of Colonel Townsend, 
or of the Indian Fakirs, are to be set down 
as altogether apocryphal, and not scientifi- 
cally investigated. 
To enable unskilled persons to determine 
whether the circulation continues or not, 
Magnus recommends the application of a 
tight ligature on a finger or toe. If the cir- 
culation has quite ceased, no change in 
colour is produced; but if circulation con- 
tinues, however feebly, the extremity, in 
course of a longer or shorter period, assumes 
a livid tint from strangulation of the venous 
flow, while a ring of arterial anaemia is ob- 
servable at the point ligatured. 
Cessation of the heart's action, if abso- 
lutely established, renders other indications 
unnecessary. As accessories they are use- 
ful, but the following signs are none of them 
individually conclusive, taken alone. The 
first is cessation of respiration. Respira- 
tion may not be very obvious, and yet it 
may be going on. The popular methods, of 
holding a cold mirror before the mouth and 
nostrils, and looking for indications of mois- 
ture ; placing a flock of cotton wool on the 
lips to ascertain whether air-currents exist; 
and placing a cup of water on the chest, and 
observing whether the reflection on its sur- 
face moves or remains still, are all well 
adapted for the purpose in view. 
With the cessation of the circulation and 
vital turgor, the skin becomes ashy pale, 
there is an absence of the pink colour in 
transparent parts when examined under the 
influence of a strong light (Richardson), and 
the tissues lose their elasticity. The eyeball 
becomes less tense, and the cornea becomes 
opaque. The pupils cease to react to light; 
and there is no vital reaction on the applica- 
tion of irritants to the skin. Though the 
body is dead as a whole, certain parts may 
continue to retain their independent vitality 
after somatic death. This is seen in the 
muscles, which may retain their electrical 
contractility from two to three hours after 
death. The existence of electrical contract- 
ility of the muscles in a body supposed to 
be dead indicates life, or death within the 
previous two or three hours, according to 
M. Rosenthal. 
The subsequent changes which occur in 
the dead body not only indicate the fact of 
death, but aid in fixing the probable period 
at which death occurred. These are the 
following:- 
(1) The cooling of the body.-The body 
after death, except under certain special cir- 
cumstances, as in fatal cases of cholera and 
yellow fever, ceases to be a source of heat- 
production, and therefore is to be looked 
upon as an inert mass possessed of a higher 
temperature than the average medium, which 
parts with its heat according to certain 
physical laws. The superficial coldness of 
collapse, which is due to cessation of the 
peripheral circulation, must not be mistaken 
for the cadaveric coldness, for there is still 
an amount of internal heat which has to be 
parted with; and the body, cold to the touch 
before death, may after death rise in tem- 
perature, as the internal heat radiates. It is 
impossible to describe here in detail all the 
circumstances which modify the rate of cool- 
ing of the body; but it may be said in general 
that all circumstances which favour radia- 
tion, convection, and conduction of heat in 
inorganic bodies are equally applicable here, 
while the opposite conditions retard. There- 
fore a thick coating of adipose tissue, cloth- 
ing, &c., retard cooling. The observations of 
Goodhart (Guy's Hosp. Rep. 1870) and 
Burman (Edin. Med. Journ. 1880) show that 
under ordinary circumstances we may as- 
sume the temperature in the axilla at the 
time of death to be the normal 98'4 F. Cool- 
ing occurs at the rate of T6° F. per hour. 
The rate of cooling is greater (2-4°) during 
the first few hours. Taking the difference 434 
DEATH. SIGNS OF 
between the axillary temperature in any 
given case and the normal, and dividing it 
by 1*6, would give the number of hours that 
have elapsed since death. 
(2) Hypostasis. - After death the blood 
gravitates to the most dependent parts, both 
externally and internally, giving rise to livid 
discolorations, termed hypostases. These 
are liable to be confounded with ecchymoses 
or extravasations externally, and with the 
results of congestion and inflammation in 
the internal viscera. They differ from ecchy- 
moses in the fact that the blood is not extra- 
vasated into the tissues, but still contained 
in the vessels, as may be shown by an inci- 
sion into the skin. So long as the blood 
remains fluid, these discolorations may be 
caused to disappear if the position of the 
body be reversed; they will again form in 
the parts which are now the most dependent. 
They usually occur in from eight to ten 
hours after death. 
(3) Rigor mortis.-After death the mus- 
cles become stiff, giving rise to rigor mortis 
or cadaveric rigidity. It is due to coagula- 
tion of the muscle-plasma. This rigidity 
attacks the muscles usually in a certain defi- 
nite order, beginning in the muscles of the 
neck and face, and gradually extending from 
above downwards. It gives way to putre- 
faction and the attendant solution of the 
coagulated plasma, in the same order; so 
that, while the upper parts of the body may 
be flaccid, the legs may be found rigid. It 
can only be overcome by tearing the tissues, 
and if overcome it does not return. In this 
it differs from cataleptic rigidity. A certain 
amount of mobility is still observable at the 
joints. In this it is unlike the stiffness of 
freezing, in which all the parts are equally 
rigid, and crackle if bent. 
The period of the occurrence of rigidity, 
and the length of its endurance, are extremely 
variable, so that no definite practical rules 
can be laid down. It may be said generally, 
however, that the greater the store of muscular 
energy at the time of death, the longer it is 
before rigidity sets in, and the longer it lasts. 
On the contrary, the greater the exhaustion, 
the sooner rigidity sets in, and the sooner it 
disappears. Hence rigidity is longer in ap- 
pearing in subjects dying suddenly in full 
muscular vigour, than in those dying from 
exhaustion. As a rule, a period of relaxation 
intervenes between death and the occurrence 
of rigidity, but in certain cases the last mus- 
cular contraction seems to pass directly into 
the rigidity of death. This is seen more par- 
ticularly in death during great nervous ex- 
citement, as in soldiers on the field of battle, 
or in suicides. The same is said to occur 
also in death from strychnine-poisoning and 
in death by lightning, in which the tetanic 
spasm passes into rigidity. 
Rigidity may therefore occur immediately 
on death or within a few hours. It has never 
been observed to be delayed beyond a day 
after death. It may last from so short a time 
as scarcely to be perceptible, up to a week or 
more. 
(4) Putrefaction.-After death the tissues 
undergo changes in colour, consistence, &c., 
by which they are ultimately resolved into 
their simple elements, included under the 
general term putrefaction. Putrefaction, 
however, may occur locally during life, and 
general septic changes may occur to some 
extent before death. The term, however, is 
not generally applied until the changes are 
clearly perceptible in alteration of colour, 
consistence, and smell. The first external 
sign is a greenish discoloration of the abdo- 
men. Internally the raucous membrane of 
the larynx and trachea is the first to exhibit 
change in colour and consistence. The less 
compact tissues putrefy first, the fibrous tis- 
sues resist longer, and-in the female body- 
the compact tissue of the uterus resists 
longest of all. In process of time, however, 
the soft tissues become entirely disintegrated, 
and the skeleton is exposed and gradually 
falls to pieces. 
The rate of putrefaction is very variable, 
depending partly on the state of the body it- 
self, but mainly on external conditions as to 
temperature, moisture, and exposure. A com- 
bination of high temperature, moisture, and 
free exposure supplies the most favourable 
conditions for rapid putrefaction. A high 
temperature alone, without moisture, tends to 
dry the tissues, and thus to produce mummi- 
fication, instead of colliquative putrefaction. 
Moisture alone, as when a body lies in water 
or moist earth, tends to produce a saponifica- 
tion of the tissues, more particularly the fatty, 
with the formation of a substance termed 
adipocere (see Adipocere), The course of 
putrefaction can be stopped by antiseptics, as 
in embalming, and in certain cases of poison- 
ing, as with arsenic, as also by freezing. 
Putrefaction is more rapid in air than in 
water, and least rapid in earth. Under 
ordinary circumstances and average tempera- 
tures, signs of putrefaction are clearly visible 
on the third day after death, commencing 
with the green hue of the abdomen. Many 
months elapse before the soft tissues become 
entirely disintegrated. The uterus has been 
found fit for judicial examination as long as 
nine months after death, where no antiseptics 
had been employed. When such has been 
the case, however, there is practically no 
limit to the period of preservation-witness 
the Egyptian mummies, embalmed thousands 
of years ago. 
There is still much to be learnt respecting 
putrefaction, and it is unsafe to lay down 
dogmatic rules as to how far putrefactive 
changes shall have advanced at a given time, 
for even under apparently similar conditions 
the most extraordinary divergences have been 
recorded. D. Ferrier. DEBILITY {debilis, feeble).-Synon. : 
Feebleness; Weakness; Asthenia; Fr. Fai- 
blesse; Ger. Schwache. 
Definition.-The body or any of its organs 
is said to be in a state of debility when its 
vital functions are discharged with less than 
the normal vigour, and when the amount 
of activity which it displays and of work 
which it can accomplish is diminished. The 
term ' debility ' is also employedin a somewhat 
different sense in the case of constitutional 
weakness of an organ, to convey the notion 
of vulnerability or predisposition to disease. 
In this acceptation, 'pulmonary debility,' for 
example, signifies a peculiarly delicate ' build ' 
of the lungs, which renders them more than 
ordinarily liable to succumb to the causes of 
disease. 
/Etiology.-Debility is frequently consti- 
tutional and inherited; but it is more often 
developed after birth. It is most commonly 
due to impaired nutrition, whether this be pro- 
longed and moderate, as in defective hygiene 
or chronic illness, or, on the other hand, rapid 
and extreme, as in acute disease. Such 
failure of nutrition, when local, may arise 
from the blood being deficient in quality 
or quantity, or possibly from some inter- 
ference with the nervous supply. Another 
frequent cause of debility is the abuse of the 
affected organ. Over-use of a part leads to 
fatigue, and if frequently repeated to exhaus- 
tion, the chief feature of which is extreme 
debility, as in cases of sustained and mental 
exertion, or of repeated strain of the heart. 
On the contrary, an organ may become feeble 
from want of exercise Paralysed muscles 
furnish the best examples of this condition, 
but the same may be seen in all organs after 
unnatural rest. Debility is more Hable to 
occur at certain ages, such as the periods 
of active growth and development, and in 
connexion with the menopause; and it is 
one of the manifestations of advanced life. 
Symptoms.-The natural ability of the 
organs to perform their functions varies ex- 
tremely with sex, age, previous exercise, and 
many other circumstances. Debility, or the 
loss of this functional power, is therefore fre- 
quently ill-defined; and, when unquestionably 
present, may vary greatly in different cases, 
from a condition in which fatigue comes on 
only somewhat earlier than usual, as in 
muscular debility, to a state in which the 
slightest exertion may exhaust the whole of 
the vital energy, and the functional life of the 
part may cease-as is seen in the cardiac 
asthenia of acute fevers, and scarcely less 
markedly in certain chronic diseases, such 
as idiopathic anaemia and Addison's disease. 
Debility may be general, affecting the whole 
body; or local, individual organs only being 
involved. Speaking broadly, the symptoms 
of debility of an organ may be said to be 
chiefly two. These are, first, increased irri- 
tability, or an unnatural readiness of the part 
DEBILITY 
to respond to stimulation; and, secondly, a 
tendency to untimely exhaustion. The 
phenomena of irritability and exhaustion 
naturally vary with the organ involved. The 
symptoms of muscular asthenia are few and 
simple; those of digestive feebleness are more 
complex; and in debility of the nervous sys- 
tem the whole of the mental processes, as 
well as the functions of organic life, may be 
involved. For a specific account of the 
phenomena of each of these cases, and of 
debility of other parts, the reader is referred 
to the articles upon diseases of the several 
organs. 
Diagnosis.-Debility pure and simple is, 
as a rule, easily distinguished from disease by 
the absence of all evidence of organic altera- 
tion, and especially of physical signs of ana- 
tomical change. It is more difficult to separate 
debility from disorder or derangement, but 
careful observation will generally determine 
in the case of pure debility that the functions 
are normally discharged as long as the de- 
mands made upon them are not excessive. 
Prognosis.-Debility due to acute disease 
may, in the absence of complications, be 
expected to disappear during convalescence. 
If the cause have been more chronic, and be 
less easily removed, recovery will certainly 
be more slow and less satisfactory. The 
prognosis of inherited constitutional debility, 
as regards its disappearance, is nearly always 
unfavourable. 
Treatment.-Debility must be treated ac- 
cording to its cause. If nutrition have failed, 
it must be restored as far as possible; and 
until this can be done, stimulants and suitable 
tonics are indicated-especially in the case of 
acute disease. Best is of the first importance 
in most instances; and frequently it is alone 
sufficient to restore the vital force. In a few 
cases, however, the opposite line of treatment 
must be followed, as in muscular debility 
from want of exercise or in some forms of 
paralysis. Where the vital activity is low 
from constitutional defect, age, or sex, the 
condition may not be remediable; and the 
treatment of such cases is chiefly prophylactic. 
The principal indication then is to secure 
the subject of debility against exposure to 
damaging influences. 
J. Mitchell Bruce. 
DECLINE {decIino, I decline).-A popu- 
lar name for any wasting disease; especially 
associated with pulmonary consumption. The 
word is also applied to the period in the 
course of a disease when the symptoms are 
abating; and likewise to the time of life 
when the physical and mental powers are 
failing. 
DECUBITUS {de, down; and cumbo, I 
lie).-The lying posture. Decubitus is also 
the German name for bed-sore. See Pos- 
ture. 
DECUBITUS 
435 436 
DEFECATION, DISORDERS OF 
DEFECATION, INVOLUNTARY 
DEFECATION, Disorders of.-Or. ' 
the descent of the faeces, which accumulate 
in the sigmoid flexure of the colon, into the 
rectum, the associated movements necessary 
for their expulsion are excited. These move- 
ments are chiefly involuntary, though influ- 
enced and controlled by the will. 
Etiology.- Some of the more impor- 
tant difficulties interfering with the actions 
of defaecation arise from disorders in the 
nervous system, by which the movements 
are excited and directed. In injuries and 
diseases of the brain or cord, the controlling 
action of volition, especially its influence over 
the sphincters, is annihilated, whilst the 
excito-motor movements depending on the 
spinal cord continue. In these cases the 
actions of defaecation take place only when 
the need of expulsion arises, without any 
power of the patient to induce or restrain 
them. In injuries destroying the lower part 
of the spinal cord, the faeces escape involun- 
tarily in varying quantities and at all times. 
Serious troubles in defecation may also 
arise from excessive as well as from weak- 
ened action of the muscles concerned in this 
function. The sphincter may be irritable or 
subject to spasm, and resist too forcibly the 
expulsive actions of defecation (see Anus, 
Diseases of). Or the muscular fibres of the 
rectum may lose their tone, and be defective 
in power and incapable of properly extruding 
the feces. Patients thus situated are often 
obliged, when at stool, to use the finger to 
dislodge masses retained in the weakened 
bowel. An atonic condition of the rectum 
usually arises from over-distension. It may 
be produced as the result of accumulations, or 
by too free and frequent use of enemata, the 
quantity injected being so large as to dilate 
the bowel and impair the power of its mus- 
cular coat. This atonic state of the bowel is 
itself apt to give rise to fecal accumulation. 
The present article will deal with deficient 
defecation associated with such accumula- 
tion. The opposite condition is described in 
the next article. See Defecation, Involun- 
tary. 
Faecal Accumulation.-Pathology.- 
Cases of this kind are not uncommon, yet 
the nature of the affection is liable to be 
overlooked. The rectum may become gradu- 
ally dilated and blocked up by a collection of 
hard dry feces, which the patient has not the 
power to expel, being unable from loss of 
tone in the distended bowel to overcome the 
resistance of the sphincter to the passage of 
so great a body. Some indurated lumps from 
the sacs of the colon, on reaching the rectum, 
perhaps coalesce so as to form a large mass; 
or a quantity accumulated in the sigmoid 
flexure, on descending into the lower bowel, 
becomes impacted there. In several instances 
a foreign body has been found in the centre 
of the mass. The persons most subject to 
these troubles are those enfeebled by age or 
disease, especially women. They may also 
occur in infants who have been operated 
on for imperforate anus, when the artificial 
aperture contracts, or is left too small for 
the free passage of the faeces. In these cases 
the distension of the bowel is sometimes ex- 
cessive, and its expulsive functions are seri- 
ously impaired and weakened. 
Symptoms.-Such a collection gives rise to 
considerable distress, producing constipation, 
a sensation of weight and fulness in the 
rectum, tenesmus, and forcing pains which 
women liken to those of labour. In cases of 
some duration, where the hardened faeces do 
not quite obstruct the passage, they excite 
irritation and a mucous discharge, which, 
mixing with recent faeculent matter passing 
over the lump, causes the case to be mistaken 
for diarrhoea. 
Treatment.-Injections have no effect in 
softening the indurated mass : they act only 
on the surface, and return immediately, 
there being no room for their lodgment in 
the bowel. The practitioner on passing his 
finger finds the rectum blocked up with a 
large lump, which feels almost as hard as 
a stone. In such cases the only mode of 
giving relief is by mechanical interference. 
The mass requires to be broken up and 
scooped out-an operation which may re- 
quire the use of a cocaine suppository, or the 
administration of an anaesthetic. After the 
breaking up and extraction of the larger por- 
tions, injections of soap and water will be 
sufficient for the removal of the remainder. 
T. B. Curling. Frederick Treves. 
DEFECATION, Involuntary. - 
Under normal circumstances the faeces are 
retained within the rectum by the closure of 
the sphincter ani. When defaecation takes 
place, the sphincter is relaxed; and there is 
increased peristalsis of the lower bowel and 
pressure on the intestines, from forcible con- 
traction of the expiratory muscles with the 
glottis closed. The nerve-governance of these 
three associated phases of the act is different 
in each case. The contraction of the ab- 
dominal muscles is mainly due to an effort 
of the will. The activity of the colon and 
rectum is reflex, from irritation of the accu- 
mulated faeces. Lastly, the relaxation of the 
sphincter depends on the inhibition of the 
tonic centre in the lumbar enlargement of the 
spinal cord; such inhibition being brought 
about either in a reflex manner from the rec- 
tum or directly from the cerebral centres. It 
is obvious that the relaxation of the sphincter 
is the most important stage in the act, for 
until that takes place no discharge can occur. 
Up to a certain point the increased peristalsis 
and pressure on the bowels may be resisted 
by a voluntarily increased contraction of the 
sphincter, but at a certain stage the inhibiting 
influence is exerted, and relaxation results. 
Since this influence is only in part under the DEFECATION, INVOLUNTARY 
DEGENERATION 
437 
control of the will, it would follow that the 
chief causes of the involuntary discharge of 
the feces are to be found in those conditions 
which diminish the normal tonicity of the 
sphincter. At the same time, any circum- 
stances which may increase the pressure of 
the abdominal muscles, or the activity of the 
bowels, much beyond what ordinarily occurs, 
may lead to an involuntary discharge. 
JEtiology.-The causes of involuntary 
discharge of feces may be discussed in the 
following order:- 
1. Violent contraction of the expiratory 
muscles. This cause of involuntary defeca- 
tion is such as may be induced by strych- 
nine-poisoning. It is of rare occurrence in 
tetanus. 
2. Increased peristaltic action of the in- 
testines. Increased peristalsis is chiefly de- 
pendent on causes of irritation situate in the 
bowels themselves, such as inflammation or 
ulceration of the walls; irritating contents; 
or worms. Extreme fluidity of the feces is 
frequently sufficient to induce their partially 
involuntary discharge, and is noticeable in 
the looseness sometimes associated with 
accumulation of feces in the lower bowel, 
and the diarrhoea of infants and children. 
3. Abnormal relaxation of the sphincter 
ani. As already said, the previously mentioned 
causes are powerless to produce the discharge 
of the feces until the sphincter yields ; and 
how far the sphincter may relax as a result 
of their efforts, or independent of them, is not 
easy to determine. The nervous influence 
emanating from the lumbar centre which 
normally determines the tonic state of the 
sphincter may be inhibited by various 
causes:- 
a. Beflexly. Reflex inhibition of the 
sphincter ani may arise from such causes 
as worms, fissure of the anus, or calculus 
vesicas. It is quite true that the immediate 
result of irritating the sphincter is to deter- 
mine in a reflex manner an increase of its 
contraction, as may be experienced in intro- 
ducing instruments into the rectum ; but it 
would also seem that at a certain point the 
irritation may lead to an arrest of the tonic 
influence, and so allow the sphincter to yield, 
and this is particularly the case with affections 
of the bladder. 
S. From cerebral disease. That certain 
emotional conditions may lead to involuntary 
defecation is well known, and that a similar 
result follows some diseases of the cerebral 
centres is not an uncommon event. The 
paralysis of the sphincter which occurs under 
these circumstances is brought about by in- 
hibiting the normal tonic stimulus discharged 
from the lumbar centres. Involuntary evacu- 
ations frequently occur in epileptic fits; in 
states of profound coma induced by apoplexy, 
or by opium- and other forms of poisoning ; 
and in death by hanging or suffocation. Its 
occurrence can scarcely be regarded as in- 
cheating lesion of any one part of the cere- 
bral centres, but rather as a result of general 
brain-states. It constitutes a troublesome 
complication in such chronic forms of brain- 
disease as general softening, paralysis of the 
insane, &c. 
y. From disease of'the spinal cord. The 
relaxation of the sphincter may of course be 
produced by disease or injury of the lumbar 
enlargement of the spinal cord. Inasmuch 
as it is from the cells of this region that the 
normal tonic influence is understood to issue, 
destruction of the nervous tissues can readily 
be understood to prevent the origination 
of such stimulus to contraction. Certain 
lesions also above the lumbar enlargement 
may lead to involuntary passing of faeces 
by interfering with the cerebral control 
! of the sphincter. It is noticeable that dif- 
: fused changes in the substance of the cord, 
| such as acute or chronic myelitis, intra-spinal 
\ haemorrhage, and compression, are far more 
: frequently accompanied by paralysis of the 
sphincter than are the scleroses of a ' sys- 
temic ' or ' columnar ' character-e.g. anterior 
polio-myelitis, lateral sclerosis, progressive 
muscular atrophy, or inflammatory affections 
of the spinal meninges. 
8. From local lesion. The control over 
the sphincter may be lost from injury to the 
muscle itself. This occurs in laceration of the 
perinaeum, involving the lower end of the 
bowel; sometimes it is the result of surgical 
operation, such as deep division of the sphinc- 
ter in connexion with fistula. 
Treatment.-No direct treatment of in- 
continence of faeces is of avail, beyond re- 
moval, when possible, of the cause. This may 
be done with success when the involuntary 
discharge depends on the presence of some 
local irritant, such as worms or faecal impac- 
tion. As a distressing complication of cer- 
tain diseases of the nerve-centres, which are 
too frequently incurable, little remains to be 
done for it beyond adopting such measures 
as will permit of the escape of the discharge 
with every regard to cleanliness. 
W. H. Allchin. 
DEFERVESCENCE {de, down; and 
fervesco, I grow hot).-The decline of fever, 
characterised by a fall of temperature and 
of pulse, and by other phenomena. See 
Fever. 
DEFORMITIES.-See Malformations. 
DEFORMITIES OF THE CHEST. 
See Chest, Deformities of. 
DEGENERATION (degener, unlike 
one's race ; out of kind).-Synon. : Fr. JDe- 
generescence; Ger. Entartung. 
Definition. - The word ' degeneration,' 
meaning etymologically change or deteriora- 
tion of kind, is used in pathology for any pro- 
cess by which a tissue or substance becomes 438 
DEGENERATION 
replaced by some other, regarded as less 
highly organised, less complex in composi- 
tion, of inferior physiological rank, or less 
suited for the performance of its original 
functions. While some change for the worse 
is thus the essence of degeneration, there is 
great variety in the mode by which this 
change is effected. It may be by direct 
chemical metamorphosis, as of albuminous 
into fatty material; by infiltration of the 
tissues with some new material, as in albu- 
minoid degeneration; by deposition of some 
foreign substance, such as lime salts, in the 
tissues; or even by substitution of a newly 
formed tissue, inferior to the original in 
organisation or in functional efficiency, as 
in what is called fibroid degeneration. The 
degenerative process may be in certain cir- 
cumstances any one of the above processes. 
Degeneration is very closely connected with 
atrophy, since on the one hand it is often 
caused by imperfect nourishment, and on 
the other hand may be a stage in progressive 
wasting; so that it may be difficult to draw 
the line between the two. 
Summary.-The following kinds of degene- 
ration may be recognised : albuminoid,fatty, 
mucoid or colloid, parenchymatous, calca- 
reous,pigmentary, and. fibroid, with possibly 
one or two minor varieties of less moment. 
The two first-mentioned are described else- 
where. See Albuminoid Disease ; and Fatty 
Degeneration. 
1. Mucoid: Colloid.-This kind of de- 
generation is in one sense a physiological 
process, since it is probably by a partial 
transformation of the protoplasm of epithelial 
cells into mucin that the secretion of mucus 
is effected. 
Mucoid degeneration and colloid degenera- 
tion are sometimes distinguished. We are 
unable to recognise any difference except in 
situation, and this distinction is better ex- 
pressed in other words. The process consists 
in the transformation of portions (usually 
albuminous) of the tissues into a semi-trans- 
parent homogeneous material, varying in con- 
sistency from fluid to a gelatinous solid, and 
consisting of altered albuminates with vari- 
able proportions of mucin, a substance allied to 
albumin, but differing in its entire insolubility 
in acetic acid and its solubility in alkalis. 
All masses of gelatinous appearance have not 
this composition, since the colloid material 
which fills some ovarian cysts, that of renal 
cysts, and probably that found in some other 
cases, is said to contain no mucin. The 
thyroid gland when enlarged and cystic, as 
in one form of bronchocele, is a striking in- 
stance of colloid degeneration. The enlarged 
cystic vesicles become filled with colloid 
material, which plainly results from a trans- 
formation of the epithelial elements, and 
possibly also of some albuminous exudation 
in the original vesicles. Small masses of 
colloid material first appear in the cells, 
which become confluent into homogeneous 
masses. In colloid cancer a similar process 
appears to take place, but it is rather syn- 
chronous with, than subsequent to, the 
growth of the tumour. The alveolar spaces, 
which in other forms of cancer are filled with 
cells, here contain colloid material resulting 
from the metamorphosis of cells; and every 
transitional stage, from the epithelioid cancer- 
cell to a homogeneous translucent mass, may 
often be met with. The stroma is unaffected, 
and remains fibrous. The gelatinous mate- 
rial of colloid cancer is stated to contain 
more mucin than that of the enlarged thy- 
roid. It is instructive to notice that this 
form of cancer usually occurs or commences 
in parts where epithelium is present, which 
undergoes the mucous transformation and 
secretes mucus, as in the stomach and in- 
testines. When colloid or mucoid transfor- 
mation affects tissues of the connective tissue 
group, it is the intercellular substance which 
appears to be chiefly affected. This change 
is seen in the mucoid softening of cartilage 
which sometimes occurs in old age, where 
the chondrin undergoes chemical change, 
and the intercellular substance softens into 
a diffluent or liquid substance containing 
mucin. The so-called mucous tissue, which 
forms the umbilical cord and the vitreous 
body of the eye, as well as certain foetal 
structures, consists essentially of a reticu- 
lated connective tissue with mucous inter- 
cellular substance, and the same tissue forms 
the new-growth called myxoma, which may 
therefore be regarded as formed by mucous 
transformation of connective tissue. Its cells 
are quite unaffected by this change, being 
either fixed stellate connective-tissue cells, 
or migratory lymphoid corpuscles. This 
view explains how portions of other tumours, 
as sarcoma, enchondroma, and lipoma, are 
often found to have undergone myxomatous 
degeneration. All these mucoid or colloid 
substances contain mucin with albuminates. 
2. Parenchymatous.-Synon.: Granular 
Degeneration; Cloudy Swelling.-This is a 
peculiar change met with in some epithelial 
structures, especially liver and kidney cells, 
and muscular tissue, occurring only in the 
course of some infective febrile diseases, 
especially typhus, enteric fever, scarlatina, 
diphtheria, and pyaemia. The histological 
elements are found after death to have lost 
their transparency, and to be filled with 
minute granules, so that the general appear- 
ance is not unlike that of fatty degeneration. 
The naked-eye appearance of the organs is 
also not dissimilar: they are pale, dull, and 
opaque-looking. This change has been thought 
to be the precursor of fatty change; but, 
whether this be so or not. it is at once dis- 
tinguished by the solubility of the granules 
in acetic acid, and their insolubility in ether. 
The cause of this degeneration has been 
asserted to be simply high temperature; still it is not found in all febrile diseases. It has 
also been regarded as a post-mortem change, 
which is possible, but still this implies some 
abnormality in the tissues during life. 
Another change which occurs in febrile 
diseases is ivaxy or vitreous degeneration of 
the voluntary muscles. They are found after 
death with little or no striation, and the 
myosin irregularly coagulated in lumps. 
That this is a change occurring after death 
there can be no doubt; while it is equally 
clear that this abnormal coagulation shows 
some abnormality of composition to have 
existed during life. 
3. Calcareous.-Calcareous degeneration 
consists in the deposition of calcareous par- 
ticles in the elements of a tissue, or in some 
inflammatory products previously formed. 
It is more appropriately called calcareous 
infiltration or deposit. When the normal 
tissues are thus infiltrated, there is not of 
necessity any other alteration in the tissues 
themselves, though the process generally in- 
dicates retardation of the circulation or arrest 
of tissue-metamorphosis. In the case of in- 
flammatory products, new-growths, and para- 
sites, as well as in other cases, the calcareous 
deposit follows on partial necrosis or local 
death. It is, therefore, if not a degeneration, 
the consequence or accompaniment of de- 
generation. See Deposits. 
4. Pigmentary.-Pigmentary degenera- 
tion is a name which has been given to the 
changes produced in a tissue or organ by the 
deposition or formation of pigment. It is 
very doubtful whether this should always be 
described as a degeneration, since the change 
does not necessarily diminish the vital ac- 
tivity of the part, lower its physiological rank, 
or involve a simpler chemical or anatomical 
composition. Pigmented tumours do not 
show less vitality than others, nor is exces- 
sive pigmentation of the skin, or any organ 
where pigment normally occurs, necessarily 
an accompaniment of degeneration. The 
colouring matter in this case is the normal 
pigment called melanin. An entirely differ- 
ent kind of pigmentary change is that which 
depends upon the extravasation and breaking 
up of red blood-discs, the haemoglobin of 
which becomes converted into a simpler form 
of pigment, such as haematoidin or some other. 
The pigmentation of the spleen and liver from 
intermittent fever, and that which is the con- 
sequence of chronic venous congestion, are of 
this kind; and are often the accompaniment 
of fibroid induration, thus forming part of a 
degenerative process. Pigmentation in gene- 
ral must not, therefore, be identified with pig- 
mentary degeneration. 
5. Fibroid.,-Fibroid degeneration is the 
name given to a process frequently met 
with, in which the original tissue becomes 
replaced by a form of connective tissue. It 
is also called fibroid substitution or fibroid 
change. In the early stages of this process 
DEGENERATION 
we find the tissues penetrated with numerous 
cells of the lymphoid type, which become 
slowly organised into connective tissue-at 
first of the cytogenous form, and rarely very 
vascular. The infiltrated lymphoid cells are 
probably chiefly derived from the blood- 
vessels ; but some may be, as theory teaches, 
the descendants of tissue-cells. The process 
is an essentially chronic interstitial inflam- 
mation (see Inflammation). Since the final 
result of the process is that tissue of less 
physiological value is substituted for the 
original, the process may be described in 
general terms as a degeneration, though it is 
not an actual metamorphosis of tissue. It 
finally leads to induration, contraction, and 
partial atrophy. J. F. Payne. 
DEGLUTITION, Disorders of.- 
Synon. : Disturbances of Swallowing; Fr. 
Troubles de la Deglutition; Ger. Stdrun- 
gen des Schluckens. 
Before describing the disorders of deglu- 
tition or swallowing, it is necessary to state 
briefly in what this physiological act consists, 
and how the process is performed. 
Physiology of Deglutition.-The act of 
deglutition is commonly divided into three 
stages. The first is a voluntary effort, ac- 
complished by means of the tongue and the 
muscles of the cheeks and mouth, as far 
back as the anterior arch of the fauces. The 
second stage is an involuntary act, though 
certain voluntary muscles are engaged in 
effecting it. It is accomplished by the action 
of those muscles the duty of which is to 
retract the tongue, to raise the larynx and 
close the glottis, to lift the soft palate, to con- 
tract the fauces and bring the tonsils in con- 
tact with the bolus of food, to close the pos- 
terior nares, and to raise and contract the 
pharynx. Then the food passes into the 
oesophagus or gullet, when the third stage is 
entered upon; and as the morsel passes into 
this tube, a progressive undulatory or peri- 
staltic movement of the gullet is produced, by 
which the bolus is propelled into the stomach. 
Definition.-Any condition which inter- 
feres with the perfect integrity of this phy- 
siological process constitutes a disorder of 
deglutition. The general term which is 
applied to this condition is Dysphagia or 
deglutitio impedita, as it is sometimes 
termed. But, in actual fact, such conditions 
will be found to be dependent for the most 
part on some other morbid state of the struc- 
tures immediately concerned in the act of 
swallowing, or of those in close proximity to 
them. Yet, although dysphagia must, as a 
rule, be regarded merely as a symptom of 
some more or less serious disorder, still it 
may be convenient and useful to examine 
the subject somewhat more in detail than 
can be done in the consideration of those 
affections in which it frequently plays so 
prominent a part. 
DEGLUTITION, DISORDERS OF 
439 440 
DEGLUTITION, DISORDERS OF 
DELHI SORE OR BOIL 
^Etiology.-All affections of the throat 
modify in some way the power of swallow- 
ing, and render the act of deglutition painful 
and difficult. Thus:-1. We meet with it 
as one of the symptoms in acute catarrh of 
the pharynx, in tonsillitis, and in ulceration 
of the throat. 2. Similarly, diseases of the 
larynx may give rise to disorders of degluti- 
tion ; such as laryngitis, inflammation of 
the perichondrium, and laryngeal polypi. 
3. Specific diseases-for example, phthisis, 
syphilis,cancer, scarlatina, measles, and croup 
-are another fertile cause of difficulty of 
swallowing, owing to their affecting the throat 
in various ways. 4. So also are nervous 
affections - for instance, post - diphtheritic 
paralysis, hysterical disorders, general para- 
lysis of the insane, progressive muscular 
atrophy, and glosso-pharyngeal paralysis. 
5. Affections of the salivary glands, such 
as parotitis, may interfere with deglutition. 
6. (Esophageal disorders, whether functional, 
or causing organic obstruction, are important 
causes of dysphagia. 7. Difficulty of degluti- 
tion may result from pressure upon some part 
of the passage, as by an aneurysm of the 
thoracic aorta, a solid tumour, whether 
malignant or benign, or a retro-pharyngeal 
abscess. 8. It may be set up by the character 
of substances swallowed-e.g. when these are 
irritant, corrosive, or very hot articles. All 
these causes, though in different degree, offer 
some impediment to the act of deglutition. 
Symptoms.-Although difficulty in the act 
of swallowing is the essential symptom in 
many and various affections, yet this differs 
greatly in degree, as well as in the attendant 
phenomena, according to the pathological con- 
dition of the parts involved. Thus, when 
irritation of any kind is met with in any 
part of the track through which the bolus of 
food has to pass, then the act of deglutition 
is attended merely with more or less pain, 
which in such cases constitutes the sole diffi- 
culty in the process. When, however, the 
calibre of this portion of the alimentary canal 
is reduced by disease affecting its own struc- 
ture, or when it is encroached upon by mor- 
bid growths or other disease in its immediate 
vicinity, a mechanical impediment is set up, 
which necessitates a certain amount of volun- 
tary effort to accomplish the act. This supple- 
mentary aid is usually sufficient to propel the 
bolus onwards; and deglutition, though slower 
than in health, and usually attended with 
pain, may be successfully performed. It oc- 
casionally happens, however, that the obstruc- 
tion is so great as to prevent the passage of 
at least the larger portion of the food down- 
wards, and regurgitation takes place through 
the mouth or nostrils. 
A similar result is brought about when 
paralysis affects any portion of the muscular 
structures concerned in the act of swallowing, 
but obviously in a different manner. For 
example, in post-diphtheritic paralysis, in 
consequence of the implication of the soft 
palate and neighbouring structures in this 
loss of power, the food, instead of passing 
into the gullet, returns through the posterior 
nares. 
The dysphagia occasionally observed in 
hysterical persons, and which appears to par- 
take of the nature of spasm, differs essentially 
from those forms already described, in the 
fact that it is not a constant phenomenon, 
and that it is but one manifestation of the 
neurotic temperament. 
Treatment.-This will manifestly depend 
upon the recognition of the cause which 
gives rise to the impediment in swallowing. 
Cases of simple catarrh of the mucous mem- 
brane of the throat, and those produced by 
the action of irritant substances generally, 
yield, after a short interval, to the use of 
bland articles of diet and demulcents, such 
as olive oil, milk, linseed tea, &c. It must, 
however, be borne in mind that permanent 
stricture of the oesophagus may be the result 
of causes such as those last mentioned. Of 
course, when abscess is the cause of the dys- 
phagia, the evacuation of its contents will 
give immediate relief. In that form of dys- 
phagia dependent upon diminution of the 
calibre of the oesophagus, the question of its 
treatment by the use of bougies or stomach- 
tubes should be considered. See (Esophagus 
Diseases of. 
The dysphagia dependent upon specific dis- 
orders of the larynx, such as that occasioned 
by phthisis, syphilis, or cancer, may often 
be greatly mitigated by the use of warm 
medicated sprays containing sedative drugs, 
such as bromide of ammonium, opium, or 
chlorine water ; a 15 or 20 per cent, solution 
of menthol in liquid vaseline or olive oil, in- 
jected into the larynx and pharynx; also a 4 
per cent, solution of cocaine, &c. In cases ac- 
knowledging a nervous origin, the treatment 
must bear reference to the general nervous 
disorder of which the dysphagia is but a 
symptom. Thus, hysterical dysphagia may 
be speedily removed by the application of 
galvanism in the neighbourhood of the oeso- 
phagus. Post-diphtheritic dysphagia usually 
disappears as the health of the patient im- 
proves, and is to be treated by the adminis- 
tration of nervine tonics, such as strychnine, 
iron, and quinine. 
The food should be of semi-solid consistence, 
concentrated, and small in bulk - e.g. iced milk, 
cream-ice, jellies, switched egg, or the un- 
broken raw egg, custard, and oysters. 
C. Muirhead. 
DELHI SORE OR BOIL.-Synon. : 
Aleppo Evil; Mycosis Cutis Chronica (V. 
Carter); Lupus Endemicus (Lewis and Cun- 
ningham) ; Oriental Sore (Fox). Fr. Bouton 
d'Alep; Ger. Beule von Alep. 
Definition.-An indurated, indolent, and 
very intractable sore; papular in the early, DELHI SORE OR BOIL 
441 
encrusted or fungating in the advanced stages; I 
spreading by ulceration of skin; single or 
multiple; and often occupying extensive sur- ' 
faces of the exposed parts of the body, such 
as the face, neck, and extremities. It is 
capable, if inoculated, of reproducing the 
disease; and it also affects dogs and horses. 
Geographical Distribution.-This disease 
occurs in India, especially the North-west Pro- 
vinces, Punjab, Cabul and Scinde, Persia, 
Arabia, Crete, the Sahara of Africa, perhaps 
China, and doubtless wherever certain pecu- 
liar conditions of soil and hot climate coexist; 
for example, an epidemic lately (1889) pre- 
vailed in Greece. Though called Delhi boil, 
it is neither a furunculus, nor is it peculiar 
to that city. The Scinde boil, the sores of 
Roorkie, Moultan, Lahore, Meerut, other 
crowded Indian cities, and Aden, are pro- 
bably only varieties, if not identical. The 
same may be said of the Bouton d'Alep of 
Biskra, Bussorah, Baghdad, and Crete. Slight 
differences may exist, but essentially they are 
the same disease. The Yeman and Cochin 
China sores are probably varieties, as are 
other indolent indurated and intractable 
sores occurring in persons of impaired health, 
residing in hot and malarious climates, who 
use certain waters, and in whom there is 
neither syphilitic nor strumous taint. 
./Etiology and Pathology.-Drs. Fleming 
and Smith, V. Carter, and Lewis and Cun- 
ningham give the best account of the disease. 
Though called a local disease, it is probable 
that the state of the health has much to do 
with its production, certain conditions of 
climate, soil, and especially of drinking-water 
being also concerned. Furunculi of a severe 
and painful though different character are pre- 
valent in hot climates at certain seasons of the 
year, in enervating and malarious climates 
like India, especially after the rains, i.e. to- 
wards the termination of the most exhausting 
season, when the vital powers have been de- 
pressed during the preceding months, and the 
functions of the liver and spleen are impaired. 
The blood, imperfectly elaborated, and not 
freed from excrementitious matter, is then in 
a condition in which it not only ministers im- 
perfectly to nutrition, but is prone to fibrinous 
coagulations, which cause capillary embolism, 
giving rise to local starvation and death of 
minute portions of areolar tissue in or under 
the integument. These result in suppuration, 
which is set up for the purpose of getting rid 
of the dead fragment or core. An analogous, 
though perhaps not precisely similar, patho- 
logical condition may be concerned in the 
causation of the Delhi sore, and is not incom- 
patible with an otherwise fairly good condition 
of the general health. Water, soil, food, bites 
or stings of insects, parasitic micro-organisms, 
insanitary conditions, such as exist in crowded 
native cities, have all been charged with caus- 
ing the disease. Improved hygiene, planting 
of trees, and change of water, food, and locality, 
have all been credited with benefit in the 
treatment of it. The facts that this peculiar 
form of sore manifests itself under similar 
climatic conditions in other parts of the world, 
which, it is to be noted, are generally those of 
the more arid regions, and that it occurs most 
frequently at the most exhausting season, 
seem to point to a constitutional state as a 
predisposing cause. 
The disease is not confined to human 
beings. In Delhi it has been observed that 
dogs are very liable to be affected, especially 
in the nose, and this, from the position of 
the sore, has been adduced as strong evidence 
in favour of the theory that it is due to the 
presence of a parasitic organism which finds 
its way there from the water. In some dis- 
tricts other animals are affected; and it 
seems probable that the indolent, indurated, 
and intractable sore that horses are liable to 
in India, called Bursattie (Rain Sore), is of 
the same character. Further investigation 
into the causation and pathology of Delhi 
boil is needed, especially with reference to 
the action of drinking-water, and the nature 
of the structures that form the essential con- 
stituents of the disease. 
Anatomical Characters.-When the Delhi 
sore is cut into, yellowish points are seen, 
consisting of minute cellular growths, which 
have been described by Dr. Smith as the ova 
of a parasite (Distoma), and by others as of 
vegetable origin, but are probably the result 
of cell-growth, connected with the hair- and 
gland-follicles, perhaps an abnormal develop- 
ment of connective-tissue corpuscles, or an 
imperfect form of granulation. After ulcera- 
tion has disintegrated the surface, mycelium 
or other low forms of organism may be pre- 
sent ; but it is a question if these be the 
essential cause, and not rather an accident of 
the disease, introduced from without. Dr. V. 
Carter refers Delhi boil to a parasitic organ- 
ism, consisting of spheroids and mycelium, 
which occupies the distended lymphatic ves- 
sels in and around the sore, arranged in open 
and angular meshes, the free ends giving off 
conidia which multiply and reproduce. Pale, 
round or stellate granulation-cells are found; 
and numerous bright orange-tinted particles, 
arranged as spherical or ovoid groups dissemi- 
nated throughout the tissues of the tumour. 
These, it is considered, are the fructification- 
stage of the fungus. Lewis and Cunningham 
described lymphoid nucleated cells, the pro- 
ducts of a condition which they considered as 
identical with that of lupus, and which they 
ascribed to the action of the chemical con- 
stituents of certain hard waters; but in a 
more recent paper, dated 1885, Dr. Cunning- 
ham observed, in a specimen of Delhi 
boil which had not yet ulcerated, certain 
microscopic bodies, probably zoocysts or 
sporocysts of some monoclinic origin, which 
he believes to have been connected with the 
causation of the disease for more than one 442 
DELHI SORE OR BOIL 
DEMENTIA 
reason, the chief being their presence in 
greater numbers where the greatest morbid 
changes had taken place, and in the water in 
certain localities where the disease occurs. 
Symptoms.-Delhi sore commences as a 
small pink and reddish papule, like a mos- 
quito-bite, which gradually extends, generally 
around a hair-follicle as its centre. This is 
elevated, and after a time desquamates. 
There is itching and a stinging sense of pain; 
on pressure it is somewhat boggy. The pro- 
gress of the disease is slow, often occupying 
several weeks, during which time it assumes 
a semi-transparent appearance, with blood- 
vessels ramifying near the surface. A vesicle 
then rises, bursts, and gives exit to an ichor 
which forms a crust; under this, suppuration 
and ulceration take place and advance until, 
by the coalescence of several papules and de- 
struction of skin, an indurated sore is formed, 
which is either crusted over or fungates. The 
sore gradually invades the surrounding parts, 
and, destroying the integument, may give rise, 
especially on the face, to deformity from cica- 
tricial contraction; and, from the irritation 
and the pain it causes, may, when the num- 
ber and extent of the sores are large, seriously 
compromise the health. An ordinary boil or 
abrasion may assume these specific charac- 
ters. The disease is regarded as contagious, 
and apparently may be produced by inocula- 
tion of the specific cell-matter, though not by 
the pus which forms on the surface. 
Treatment.-Preventive.-Cleanliness of 
person, clothing, and habitation, good food, 
the use of pure drinking-water, and careful 
attention to the sanitary condition of the 
locality-avoiding overcrowding and contact 
with the disease in men or animals,-are the 
best means of preventing Delhi sore. 
Curative.-The most effective measures of 
a curative kind are-change of locality when 
practicable ; in some cases early destruction 
of the sore by the potential or actual cautery; 
the application of metallic astringents, iodine, 
or carbolic acid lotion; pressure; attention to 
the state of the health, and any ailment that 
may be present; tonics and nutritive diet, 
and especially wholesome drinking-water; 
and change to another climate. 
In the advanced conditions of the disease 
similar measures are indicated. The sore, 
if too extensive to be destroyed, should be 
dressed with stimulating and astringent ap- 
plications. Soothing measures are indicated 
if there is pain. Black wash, sulphate and 
sulpho-carbolate of zinc, copper, Gurjun oil, 
and lime-water, with change of climate and 
the use of tonics, will generally prove efficient. 
Joseph Fayrer. 
DELIRIUM (deliro,! rave).-A derange- 
ment of consciousness, characterised by in- 
coherence of thought, and evidenced by 
various expressions and actions. See Con- 
sciousness, Disorders of. 
DELIRIUM TREMENS (delirium 
tremens, trembling delirium).-A form of 
acute alcoholism, chiefly characterised by 
delirium and tremors. See Alcoholism. 
DELUSION (deludo, I deceive).-An 
unfounded belief in regard to some fact or 
occurrence which almost invariably concerns 
the patient, and of the falsity of which he can- 
not be persuaded, either by the evidence of his 
senses, by his own knowledge and experience, 
or by the declarations of others. Such de- 
lusions, when distinguished from merely 
erroneous judgments upon complicated or 
abstract questions, generally indicate in- 
sanity. See Consciousness, Disorders of; 
and Insanity. 
DEMENTIA (de, without; and mens, a 
mind).-Synon. : Fr. Demence; Ger. Bliid- 
sinn. 
Definition.-A mental weakness, or a de- 
ficiency rather than an aberration of intellect, 
depending for the most part on some antece- 
dent brain-disorder, such as apoplexy or epi- 
lepsy ; or being the sequel and termination 
of various forms of insanity. It may also 
be congenital, deserving rather the name of 
idiocy ; or it may be due to senile decay. 
1. Acute Primary Dementia.-There 
is a form of insanity known as primary or 
acute dementia, which comes on rapidly with- 
out any preceding disorder, is accompanied 
by the most profound vacuity and abeyance 
of all the mental faculties, yet yields to treat- 
ment and disappears, leaving the patients 
sane. 
Aetiology.-The patients are young per- 
sons, boys and girls,-more frequently girls. 
The complaint is seldom seen in any case 
beyond the age of 30, and chiefly in those 
under 20. It seems to be a collapse of all 
mental power, due to great physical weakness 
and deficient nerve-force. Owing to imper- 
fect development, to bad food and living, 
or to the patients having outgrown their 
strength, the mental condition becomes so 
weakened that, with or without some moral 
cause, as a fright or a scolding or something 
apparently more trivial, or after some illness 
slight or severe, they suddenly or gradually 
present that condition which is now to be 
described. If the immediate exciting cause 
is some mental shock or fright, the symp- 
toms may come on rapidly. If they are due 
to ill-health or some protracted exhausting 
occupation, the access may be gradual; and 
if they are set down to sulkiness, temper, or 
idleness, the measures adopted for the correc- 
tion of the latter may quickly indicate the 
real state of things. 
Symptoms. - Nothing can appear more 
hopeless than the appearance many of these 
patients present. The face is vacant, with 
a fatuous grin, and often the saliva dribbles 
continuously. The sufferer sits motionless 
and lost, or automatically wags the head. DEMENTIA 
443 
snaps the jaws, or moves the limbs for hours 
together, unconscious of fatigue. Or if a limb 
is placed in any position, it is retained there 
for a time in a way that no effort of will could 
accomplish. There may be a repetition of 
some word or sentence, but all conversation 
is abolished, and the patient has to be fed, 
washed, and tended like a baby. 
The physical condition of these patients 
is peculiar, and corresponds closely to the 
mental. The heart's action and the circula- 
tion are so reduced in strength that the blood 
in the extremities is stagnant. Hands and 
feet are blue with cold even in the heat of 
summer. In cold weather they are covered 
with chilblains, and great care must be taken, 
otherwise these will give rise to obstinate 
sores. The tongue is pale and flabby. The 
pupils are dilated. There is no rapid ema- 
ciation, for the waste here is not great; 
neither is sleep absent, as in mania, but it is 
irregular and uncertain. 
Pathology.-The external physical mani- 
festations sufficiently indicate the condition 
of the brain in these patients. It is the very 
opposite of that in acute sthenic delirious 
mania. In the latter there is an excessive 
discharge of nervous force, a hypersemic 
state of brain, and rapid brain-circulation; 
the whole leading in a short time to death 
by exhaustion, if relief does not come. In 
acute dementia we see the very opposite. 
The brain-action is reduced to the lowest 
point, and the circulation is stagnant, as in 
the extremities, giving rise to passive con- 
gestion and oedema. 
Course, Terminations, and Prognosis.- 
In acute dementia there is no sudden ex- 
haustion; but death, if it occur, is caused, 
not by the brain-disease, but by a general 
failure of the bodily strength, or by some 
low form of lung-disease-phthisis, pneu- 
monia, or gangrene. Death, however, in 
this disorder, is the exception. When taken 
in time and properly treated, the majority of 
these seemingly hopeless cases recover, and 
recover perfectly. 
Treatment.-The treatment of acute de- 
mentia may be carried out in a family, or 
even at home, if means are ample, and if the 
necessary measures are strictly enforced. But 
it may be necessary to feed the patient by 
force, and that for a considerable time, and 
relations do not always care to enforce this 
to the extent required. Abundant nutrition 
is imperatively demanded in order to restore 
the force that is so greatly in default; and un- 
less abundant nutrition is administered, there 
will be no recovery, but the patient will die, 
or sink into permanent dementia. There is 
not, as a rule, violent resistance to food, but 
it may be kept in the mouth without being 
swallowed, and care must be taken in feed- 
ing, even if a stomach-tube be not necessary. 
Food should be given frequently, and so a 
habit of taking it engendered. Stimulants- 
wine and brandy-will be necessary, espe- 
cially in the early stages. Equally necessary 
is warmth; an amount of heat is required 
which to those in health would be oppres- 
sive, for the greatest heat of summer fails 
to warm the hands and feet. Warm clothing 
must be provided, and the circulation aided 
by a short sharp shower-bath, cold or tepid, 
and plenty of friction afterwards. Exercise 
is useful for the same purpose, but this is to 
be taken under proper supervision, for it must 
not be fatiguing, and due regard ought to be 
had to the debilitated state of the individual. 
In addition to the stimulus of the shower- 
bath, that of electricity is of great use in 
acute dementia. Here, and in certain cases 
of melancholia, marked benefit follows the 
application of the continuous current. Of drugs 
the most useful appear to be steel and qui- 
nine. The former, in this as in almost every 
form of insanity, is a most valuable tonic: 
the choice of the particular preparation 
should depend upon the state of the patient 
at the time. 
2. Chronic Primary Dementia. - 
Dementia, however, may be primary, yet 
may not be that just described. It may 
come on gradually or suddenly, without 
previous mental affection, but is in such 
cases connected almost invariably with dis- 
ease of the brain. Its first and most promi- 
nent symptom is loss of memory. In con- 
nexion with apoplectic or epileptic attacks, 
or after years of drinking, the memory is 
found defective. This loss may appear quite 
suddenly, or may be noticed to come on gradu- 
ally, being at first so slight as to cause little 
alarm. It may vary at different times. If 
a patient is kept from alcohol, the memory 
may gain strength ; and if epileptic attacks 
are reduced in frequency, the same thing 
may happen. The prognosis in all such cases 
is unfavourable, for loss of memory points to 
decided deterioration of brain. Apart from 
loss of memory, symptoms of dementia or 
weakness of mind are occasionally found as 
the first indication of mental unsoundness, 
following a fright or shock or some severe 
illness. If they assume the form of acute 
dementia, we may have hopes that they will 
pass away; but if with little disturbance of 
the bodily health the mind becomes weaker 
and weaker, the hopes of recovery are small. 
3. Secondary Dementia.-Of dementia 
which is the sequel of prior mental disorder, 
such as mania and melancholia, little need 
be said. It varies in degree, but it is not 
in our power to remove it. It may be in our 
power, however, to ameliorate in a great de- 
gree the condition of such patients when, as 
is frequently the case, they are found in a 
very neglected state. Their friends think 
that nothing can be done or need be done, 
and they are allowed to lie in bed, often in 
a filthy condition, or roam about and get 
into mischief for want of care and skilled 444 
DEMENTIA 
DENGUE 
attendance. Many demented'patients have far 
more mind than is generally imagined by the 
uninitiated, and can be taught to be cleanly, 
to take their meals in an orderly fashion, and 
to keep themselves tolerably neat. They are 
susceptible of amusement, and open to reward 
for good behaviour. The vital powers of de- 
mented patients are low, and they suffer much 
from cold. In winter their minds, like their 
bodies, are enfeebled, and with warm weather 
they recover somewhat of their energy. There 
is a tendency in many of these patients, espe- 
cially women, to become very fat, and in this 
condition they are subject to bronchitis, and 
may succumb to acute attacks of this dis- 
order. They require warmth and good diet, 
for it is difficult to make them take sufficient 
exercise. 
Females, in the writer's experience, are 
more prone to drift into dementia than males. 
The latter present various types of chronic 
mania, with well-marked delusions; but, 
among private patients at any rate, there 
are fewer of the hopelessly demented than 
among the female inmates of private asy- 
lums. One cause of this may be that the 
mortality amongst males is greater, and thus 
fewer are left to reach the demented stage. 
G. F. Blandford. 
DEMODEX fat; and 8i]$, a 
worm).-See Acarus. 
DEMULCENTS (demulceo, I stroke 
softly). 
Definition. - Substances which soften, 
protect, and soothe mucous membranes. 
They are generally of a mucilaginous charac- 
ter. When applied to the skin they are termed 
emollients. 
Enumeration.-The demulcents in ordi- 
nary use are: Linseed-tea, Gum, Starch, 
Bread, Honey, Figs; Linseed, Almond, and 
Olive Oil; Glycerine, White-of-Egg, Gela- 
tine, and Isinglass. 
Action.-The chief action of demulcents 
is a mechanical one, in forming a smooth, 
soft coating for an inflamed mucous mem- 
brane, and thus protecting it from external 
irritation. T. Lauder Brunton. 
DEN GUE.-Synon. : Dandy Fever (West 
Indies); Three-day Fever; Break-bone Fever; 
Fr. and Ger. Deng lie. 
Definition.-An eruptive fever, considered 
by many to be infectious; commencing sud- 
denly; and characterised by severe pain in 
the head and eyeballs, swelling and pain in 
the muscles and joints-prone to shift sud- 
denly from joint to joint, catarrhal symp- 
toms, sore-throat, congested conjunctivae, and 
affection of the submaxillary glands. The 
disease may remit, and is liable to relapse. 
Natural History and Geographical Dis- 
tribution.-Dengue occurs epidemically and 
sporadically in India, Burmah, Persia, Egypt 
and other parts of Africa, North and South 
America, and the West Indies. Epidemic 
visitations of dengue, extending over wide 
tracts of country, occur at considerable inter- 
vals, and probably depend on certain unknown 
atmospheric and cosmic conditions that favour 
its development. 
^Etiology.-Dengue attacks persons of all 
ages, from infancy to extreme old age. Its 
infectious character has been deduced from 
the apparent transmission of the disease from 
person to person. 
Symptoms.-The symptoms characteristic 
of dengue are the presence of severe continuous 
arthritic and muscular pains; great debility 
and prostration; the occurrence of an initial 
and a terminal rubeoloid or scarlet rash; fever, 
which is subject to remissions and relapses ; 
the possibility that convalescence may be 
tedious and painful, and complicated by the 
continuance of general cachexia, pain and 
swelling of joints, enlargement of glands, 
orchitis, weakness of eyes, deafness, visceral 
disease (such as diarrhoea or dysentery of a 
chronic and intractable character, and hepatic 
derangement), boils, carbuncles, and perhaps 
insanity. In the female, uterine haemorrhage 
and miscarriage may occur. 
The invasion of dengue is usually sudden, 
the patient feeling well up to the period of 
attack. The earliest symptom is severe pain 
in some joint, probably of a finger, which 
rapidly extends to all the other joints and 
bones ; and this pain during the progress oi 
the disease often passes from one joint to 
the other by a sort of metastasis. Sometimes 
there is a period of preliminary malaise, of one 
or more days' duration, marked by anorexia, 
a sense of weariness and languor, giddiness, 
nausea, chilliness or rigor, severe pain in the 
head or in the eyeballs, and pains in the 
body, limbs, and joints-notably of the fingers 
and toes. The attack is often, however, 
strikingly sudden, as was frequently seen in 
the late Calcutta epidemic, commencing with 
violent pains and swelling of the joints, or 
severe pains in the head, eyeballs, neck, and 
back. In some epidemics certain phenomena 
are more prominently marked than others. 
The eruption commences on the third day. 
The fever is accompanied by redness of the 
face, which is puffy and swollen; sore-throat; 
congested conjunctivae; and a general red- 
ness, like the scarlatinal rash, extending over 
the whole body. The tongue is red at the tip 
and edges, and loaded with white fur, through 
which the red papillae protrude. The pulse is 
rapid, ranging from 100 to 120, or even 140; 
respiration is hurried; and the temperature 
rises to 103° or even 105° F. These symptoms 
mark the occurrence of the initial fever and 
rash, and endure for a period varying from 
twenty-four to forty-eight hours. After this 
the rash disappears; the fever subsides; and 
the remission lasts for a period of two, three, 
or four days. A recurrence of febrile symp- 
toms then takes place, accompanied by a DENGUE 
445 
second or terminal rash. This differs in 
character from the first, resembling a rube- 
oloid or even an urticarial eruption, often 
showing itself first on the palms of the hands, 
and in some cases resulting in profuse desqua- 
mation of the cuticle, which, however, may 
sometimes be so slight as to be barely percep- 
tible. These symptoms gradually subside, 
leaving the patient weak, exhausted, and often 
still tortured by swelling and pain of the 
joints, especially the smaller ones, which may 
continue in this state for weeks, making con- 
valescence tedious and painful. Or there 
may be repeated relapses, prolonging the 
suffering and protracting recovery. 
Varieties.-The symptoms vary in dif- 
ferent cases, as to the character of the rash, 
the temperature, and the muscular or osseous 
pains. 
The rash not only varies considerably in 
colour, character, and duration, but it is some- 
times almost absent; in other cases it is 
attended with so much hyperaemia and action 
of the skin that excessive desquamation re- 
sults. This hyperaemia also sometimes ex- 
presses itself by haemorrhage from the mouth, 
nose, bowels, and uterus. 
The fever is sometimes accompanied by 
delirium, or in children by convulsions ; in 
the latter, indeed, these occasionally initiate 
the disease. 
Dengue occasionally assumes a malignant 
form, where the amount of poison received 
has been overwhelmingly large. Dr. Charles 
says: ' Drowsiness may have passed into 
coma ; the temperature verges on the hyper- 
pyrexic; the heart fails, and the lungs are 
cedematous; while the whole surface is highly 
cyanotic. These cases have been popularly 
termed " black fever," and are justly much 
dreaded.' Happily they are rare. Again, 
there are very mild forms of the disease, in 
which the patients are scarcely ill, and where 
it is not easy to decide as to their exact 
nature : ' A trifling sore-throat and slight 
malaise may be all you can lay hold of till the 
terminal rash appears to show you what you 
have had to deal with; and even this may not 
be seen.' 
Course, Duration, and Complications.- 
The period of incubation of dengue is pro- 
bably from five to six days; it may be a day 
or two more or less in some cases. 
In simple and uncomplicated cases the 
average period for the duration of the disease 
may be taken as about eight days ; but it is 
frequently prolonged over weeks, and recovery 
is slow and painful; the constitution often 
being so much shattered that complete re- 
storation to strength and vigour does not 
occur for months. It is rarely fatal. Re- 
lapses are liable to be frequent, and the 
patient may suffer more than even a second 
or a third relapse before recovery. 
Some of the segueice already mentioned 
may remain to torture the patient and retard 
his recovery. Albumen is occasionally pre- 
sent in the urine; but it is not, as in scar- 
latina, especially in the cases of children, a 
frequent or dangerous result of the disease. 
Diagnosis.-The distinction betwixt scar- 
latina and dengue is well marked; though 
during the outset there is considerable re- 
semblance between the two diseases. There 
is a high temperature at first in both, but it 
is more quickly attained, and is transient in 
dengue; in scarlatina it endures for several 
days, whilst in dengue the fastigium gives a 
temperature of 103°, or even up to 105° or 
107°, and, this being attained, it rapidly 
declines. It is exceptional to find a tempera- 
ture above 102° maintained in dengue. In 
scarlatina the period of decline extends over 
several days, and is marked by slight exacer- 
bations in the evening. In dengue it occupies 
a few hours, and the temperature may even 
fall below the normal. The severe muscular 
and arthritic pains of dengue do not occur in 
scarlatina; and the pulse in the latter is 
much more rapid during the early stages 
than in the former. 
Prognosis.-An attack of dengue does not 
confer absolute protection from a recurrence 
of the disease, though it does so to a great 
extent. 
Treatment.-This is a specific fever, and 
has to run a certain course. The treatment 
is simple, and if judiciously directed miti- 
gates the sufferings, and materially aids re- 
covery. 
Neither emetics nor active purgatives are 
necessary. They do no good, but increase 
the weakness and aggravate the suffering by 
the muscular movements necessarily induced. 
Moderate action of the bowels is advisable, a 
warm carminative aperient, or an occasional 
dose of calomel, rhubarb, or colocynth being 
administered, especially if the bowels remain 
.confined, to which there does not appear to 
be any peculiar tendency, though the evacua- 
tions may be dark and often slimy, and con- 
fined at the outset. Salines, such as the 
acetate of ammonium, or citrate of potassium, 
with nitric ether, combined with aconite, are 
good during the pyrexia. In cases of very 
high temperature (105° to 107°) Dr. Charles 
suggests cold sponging as beneficial ; he 
recommends it when 1052 is reached. The 
danger to life of such a high temperature 
during the intense heat of the hot months in 
India is great; and it is then that cold spong- 
ing or the cold bath is indicated. 
Belladonna seems to confer great relief in 
this disease. Ten to fifteen drops of the tincture 
may be given ; and two or three such doses, at 
intervals of an hour, will sometimes produce 
excellent effects, and afford much relief. The 
extract may be given if preferred, in doses of 
one-third of a grain ; or the juice in similar 
doses to those of the tincture. For the pains and 
nocturnal restlessness, morphine or Dover's 
powder may be given. Liniments containing 446 
DENGUE 
DENTITION, DISORDERS OF 
opium, belladonna, and chloroform are ser- 
viceable as external applications to the spine, 
back, and joints. 
Tonics, and a carefully-regulated nutritious 
diet, are also indicated, and depletive measures 
must be avoided. The tonics should be of the 
bitter vegetable kind, such as gentian and 
calumba; with these may be combined a 
small quantity of quinine, with a mineral 
acid; or, in some cases, the dilute phosphoric 
acid, combined with nux vomica or small 
doses of strychnine. 
Quinine is given more for its tonic than for 
its antiperiodic effects; though, where there 
is a tendency to relapses, the judicious ad- 
ministration of five- or even ten-grain doses 
may be beneficial in arresting them and re- 
ducing temperature. Bromide of potassium 
is recommended by some authorities, and 
especially when convulsions occur in children. 
Alkalis, colchicum, and other remedies in 
use in rheumatism have been found to have 
little, if any, effect in relieving the pains of 
dengue. 
As to wines, claret is probably the best, but 
others may be given. 
For the irritation of the skin, which is 
sometimes very troublesome, the application 
of camphorated oil and the use of warm baths 
have been suggested. 
As in so many other diseases, especially 
those that occur to Europeans in tropical 
climates, complete restoration to health is 
likely to be expedited and promoted by change 
of air; and if the cachexia be severe after a 
prolonged attack of dengue, return to the 
patient's native climate for a season is 
desirable. Joseph Fayrer. 
DENTITION, Disorders of.-Synon. : 
Teething; Fr. Troubles de la Dentition-, Ger. 
Zahnung. 
General Remarks.-The period of cutting 
the teeth has been always recognised as a 
critical time, during which the health of young 
children is especially liable to become dis- 
turbed ; and it has been a common practice 
amongst mothers to attribute every illness 
occurring in early life, from the irritation of 
scabies to the distortions of rickets, to the 
same baneful influence. The evolution of 
the milk-teeth is no doubt attended with 
some irritation, especially as at this period 
the follicular apparatus of the intestines is 
undergoing considerable development; and we 
know that, on account of the impressibility 
of the nervous system in young children, any 
irritation is apt to be followed by general 
disturbance. It is no doubt also the case 
that local functional derangements are fre- 
quent at this period, but it is often unfair to 
attribute these directly to the irritation of an 
advancing tooth. One of the most common 
direct results of teething is pyrexia, which 
may be intense; and a feverish child is 
particularly susceptible to impressions of cold, 
and to the irritation of unsuitable food. 
Catarrhal attacks coining on at this time 
need not be therefore the immediate result 
of the condition of the gum. It is at least 
admissible to attribute them to the ordinary 
causes of such derangements, acting upon a 
body rendered for the time particularly 
susceptible to injurious influences. This view 
is supported by the fact that diarrhoea, which 
is a very common complication of dentition, 
is especially frequent during the warmer 
months, when the temperature is apt to 
undergo rapid variations, while the dress of 
the child remains unchanged; and is far less 
common during the winter, when the tem- 
perature is more uniform, and the child is 
more carefully guarded against the cold. 
As a rule, the first milk-tooth appears in 
the seventh month after birth; but dentition 
may begin at an earlier period. It is not 
rare for an infant to cut a tooth at the age of 
four months; and occasionally at the time of 
birth one tooth is found to be already through 
the gum. In cases where the ordinary time 
of teething is anticipated, a pause generally 
ensues after the appearance of one or two 
teeth, and further dentition is delayed until 
the usual age. Constitutional conditions 
influence the time of teething. Thus tuber- 
culous and syphilitic children cut their teeth 
early, while in rickety children the teeth are 
very slow to appear. 
In the majority of cases the teeth pierce 
the gum in the following order: lower 
central incisors, upper central incisors, upper 
lateral incisors, lower lateral incisors, first 
molars, canines, back molars. A child of 
twelve months old should have eight teeth 
and be cutting his first molars; and the whole 
number (twenty) should be through the gums 
soon after the end of the second year. The 
order given above is frequently departed 
from. The incisors, in particular, are often 
cut irregularly, and it is not rare for the 
molars also to appear out of their proper 
order. A double tooth will often be seen to 
precede the lateral incisors, and may indeed 
in exceptional cases be the first tooth to 
appear through the gum. The canines seldom 
or never precede the first molars. 
Some infants suffer more than others from 
the cutting of a tooth, and it is not always 
in cases where the eruption of the teeth has 
been delayed that dentition, when it occurs, 
is attended with special inconvenience. On 
the contrary, in severe rickets, where the 
delay is great, the teeth are often cut with 
remarkable ease. 
The second dentition begins at about the 
sixth year. The permanent teeth are cut 
with more regularity than is the case with 
the earlier crop. The first to be seen are 
usually four molars, which appear behind the 
last of the temporary teeth. Next come the 
central incisors at about the eighth year; 
the lateral incisors at about the ninth; the DENTITION, DISORDERS OF 
447 
first and second bicuspids, in the place of the 
temporary molars, at the tenth and eleventh ; 
the canines between the twelfth and thir- 
teenth ; and the second molars at about the 
time of puberty. The last four permanent 
molars are cut later. 
Symptoms.-The phenomena which may be 
looked upon as natural to the first dentition 
are salivation; swelling of the gum, which 
becomes more and more tense, hot, and 
painful; slight general pyrexia, with flushing 
of one or both cheeks ; irritability of temper; 
and some degree of restlessness at night. 
These all subside when the point of the 
tooth appears through the gum. The com- 
plications not necessarily attendant upon the 
process are high fever; inflammation of the 
mouth and aphthae; vomiting (gastric cat- 
arrh) ; diarrhoea (intestinal catarrh); cough 
(pulmonary catarrh); otitis, with purulent 
discharge from the auditory meatus; various 
eruptions of the skin, with, sometimes, swell- 
ing, and even suppuration of lymphatic 
glands; and certain troubles of the nervous 
system, such as convulsions, squinting, &c. 
The peculiarity of the pyrexia of dentition 
is its irregular character. It is often higher 
in the morning than at night, and varies in 
intensity in a remarkable manner from day 
to day. A temperature of 104° F. at 8 a.m. 
is not at all uncommon in a teething infant; 
indeed such an amount of fever in the morn- 
ing should alone lead us to inspect the mouth, 
as few diseases are marked by so much 
pyrexia at that hour of the day. It is impor- 
tant in practice to bear in mind this simple 
cause of elevation of temperature, for any 
disease in a child is apt to be complicated by 
teething, and much needless anxiety may be 
occasioned by overlooking the condition of 
the gum. We must not, however, in every 
case where the gums are swollen and tense, 
rush to the conclusion that they are the sole 
cause of the symptoms, for the most serious 
cerebral disease may co-exist with the erup- 
tion of a tooth. Thus, to take an example: 
if we find cerebral symptoms to supervene 
in the course of dentition, we must most 
narrowly scrutinise their character, before 
passing them over as merely harmless indica- 
tions of the general disturbance. Headache, 
delirium, vertigo, startings, twitchings, and 
convulsive attacks, may merely indicate 
functional disturbance of the brain, such as is 
common to many disorders, and these pheno- 
mena are not necessarily symptomatic of 
cerebral disease; but if the bowels become 
obstinately confined, the pulse slow and 
irregular, and the respiration unequal and 
sighing; and if in addition there be photo- 
phobia, with sullenness and tendency to 
drowsiness, we may conclude that something 
more than mere functional derangement is 
present, and that there is every reason to 
suspect the existence of tubercular menin- 
gitis. 
In the case of the second dentition there 
may also be digestive derangement. During 
this period the child is subject to gastro-in- 
testinal catarrhs, which give rise to looseness 
of the bowels. He is often irritable in the 
day and restless at night. Night terrors are 
common, and he may wake up from his sleep 
screaming with fright at some horrible dream. 
Besides the discomfort due to fermentation of 
food and acidity, considerable loss of flesh 
may be the consequence of digestive derange- 
ment if long continued. 
Treatment.-The treatment of the com- 
plications which occur during dentition must 
be conducted upon ordinary principles. 
Aphthae of the mouth are readily cured by 
the administration of rhubarb and soda, and 
the application to the mouth of a solution of 
chlorate of potassi um or borax (ten grains to th e 
ounce) in water, and sweetened with glycerine. 
Perfect cleanliness is necessary, and the 
child's mouth should be washed out each time 
after taking food with a piece of soft rag dipped 
in warm water. 
Vomiting is best checked by clearing out 
the stomach with an emetic of ipecacuanha 
wine, giving a tea-spoonful every ten minutes 
until sickness is produced. Afterwards, a few 
grains of bicarbonate of sodium may be given 
with one drop of liquor arsenicalis in a tea- 
spoonful of water three times a day. Diar- 
rhoea should be treated on the same principle: 
first a dose of castor oil to remove irritating 
products from the bowels; then a mixture 
containing chalk and catechu, or oxide of zinc 
(one grain to the dose). If afterwards the 
motions continue large, pasty-looking, and 
offensive, and are passed too frequently in the 
day, one drop of tincture of opium may be 
added to the mixture, as there is usually in 
such cases too rapid peristaltic action of the 
intestines. In the case of either of these 
derangements (vomiting or diarrhoea), it is of 
great importance to keep the body warm, and 
this is most effectually done by applying a 
broad flannel bandage to the abdomen. The 
diet also should be temporarily modified, 
reducing the quantity of farinaceous matter 
that is being taken, on account of the ten- 
dency to acid fermentation of food which is 
set up by such a condition of the alimentary 
canal. 
Looseness of the bowels during dentition 
has been looked upon by some writers as a 
natural method of relief to the system, and 
fears have been entertained of grave troubles 
which might ensue if the looseness were too 
suddenly arrested. Such fears are, however, 
quite groundless. A catarrhal condition of 
the bowels should be cured as quickly as pos- 
sible, especially during dentition, for at this 
time the susceptibility to chills is heightened, 
and the danger of severe diarrhoea being set 
up correspondingly great. In some cases of 
teething, where the lungs as well as the 
bowels are the seat of catarrh, and there is 448 
DENTITION, DISORDERS OF 
DEODORANTS 
a risk of bronchitis, Trousseau recommends 
that the intestinal derangement should not 
be suddenly put an end to; but even in these 
cases a dose of castor-oil may be safely given, 
to remove irritating matters from the canal, 
for, according to the writer's experience, any 
irritation of the bowels is apt rather to 
increase than to diminish pulmonary mis- 
chief. 
The favourite remedy for all disorders oc- 
curring at the time of dentition is lancing 
the gums, but the practice is one which ought 
not to be pursued indiscriminately. Unless 
the gum be actually swollen and tense, in- 
cising it has no object whatever, for to cut 
the top of the gum can have no influence in 
promoting the development of the tooth be- 
low. If, however, there be very much inflam- 
mation and swelling, and the child seem to 
be in pain, relief may be obtained by lancing, 
but in this case the object is merely to re- 
lieve tension. Excitement of the nervous 
system dependent upon the condition of the 
mouth can perhaps be allayed by the same 
means; but in the case of convulsions 
more benefit is to be gained by the use of 
warm baths, cold applications to the head, 
and the gentle action of a mild alterative 
aperient. 
In the second dentition, care should be 
taken to keep the child's feet warm and 
his body properly protected from cold. At- 
tacks of indigestion and diarrhoea must be 
treated by suitable remedies, and attention 
should be paid to the diet, limiting the quan- 
tity of starches and sweets allowed, on ac- 
count of the tendency to fermentation and 
acidity. Night terrors, which are merely 
attacks of nightmare, can be cured at once in 
children by a mild aperient to clear away 
undigested food from the bowels, and by a 
careful diet. Sweets, starches, and fruit 
should be forbidden; and the child must be 
fed on meat, fish, poultry, milk, butter, cooked 
green vegetables, eggs, stale bread, and any 
kind of non-fermentable food suited to his 
age. Eustace Smith. 
DENVER, in Colorado. - Situated 
5,200 feet above the sea, on a plain backed 
by the Rocky Mountains. A dry, cold, clear, 
and bracing climate. Diathermancy con- 
siderable. Temperature : mean daily range, 
24° F., showing great variation ; mean tem- 
perature, 49°. Rainfall, 15 inches. A valuable 
high-altitude station for phthisical patients. 
Railway communication and accommoda- 
tion excellent. For invalids the suburbs of 
Denver are preferable to the city itself. 
DEOBSTRUENT (de, from; and ob- 
struo, I obstruct).-A measure which re- 
moves obstructions, such as an aperient; 
or which opens the natural passages or 
pores of the body. See Purgatives ; and 
Diaphoretics. 
DEODORANTS (de, from; and odoro, 
I cause to smell). 
Definition. - The term * deodorant;' al- 
though it has a more extended signification, 
is generally used to signify a substance that 
destroys offensive odours. 
General Principles.-Odorous bodies are 
essentially volatile, and those which are 
offensive frequently contain sulphur in some 
state of combination. Deodorants usually 
produce the effect for which they are used 
by causing a chemical change in bodies to 
which they are applied ; but sometimes their 
action consists in absorbing and condensing 
odorous substances, and thus destroying or 
counteracting their volatility. Substances 
which, like charcoal, possess this latter pro- 
perty may, however, indirectly produce 
chemical changes by bringing the odorous 
substances into contact with oxygen in a 
condensed and active condition. 
Deodorants may be classed as volatile and 
non-vola tile. 
1. Volatile Deodorants. - These all 
consist of substances the action of which is im- 
mediately and exclusively chemical. Being 
intended to act on bodies which are them- 
selves volatile, they admit of more generally 
useful application than those which are not 
volatile. 
Enumeration. - Chlorine and its lower 
oxides, Sulphurous Acid, Nitrous Acid and 
other oxides of Nitrogen, Ozone, and Peroxide 
of Hydrogen, are the most important mem- 
bers of this class. 
Application.-In the selection and use of 
volatile deodorants, it is necessary to distin- 
guish between bodies which possess the power 
of destroying or removing a noxious smell, 
and those which merely cover one smell by 
another. Carbolic acid, for instance, which 
is a valuable disinfectant, is of little use as a 
deodorant, although its powerful odour may 
render other weaker but more objectionable 
odours imperceptible or indistinguishable. 
On the other hand, the so-called chloride 
of lime (chlorinated lime of the Pharma- 
copoeia), while it possesses a strong and 
characteristic smell itself, is capable of de- 
stroying other noxious odours, and is an 
excellent deodorant. 
The chemical action by which noxious 
odours are destroyed is principally one of 
oxidation, and therefore the agents forming 
this class of deodorants are generally oxidis- 
ing agents. Ozone, or active oxygen, is the 
natural deodorant contained in the atmo- 
sphere, which no doubt largely contributes to 
the destruction of noxious vapours in the air. 
Volatile oils, which emanate from the flowers 
and other parts of plants, in contact with 
atmospheric oxygen produce peroxide of 
hydrogen, and this as an oxidising agent pos- 
sesses deodorising as well as disinfecting 
properties. The moderate and judicious use 
of perfumes may thus produce a beneficial DEODORANTS 
DEPILATORIES 
449 
effect, although their undue employment, by 
hiding rather than removing what is objec- 
tionable, may be injurious to health, and can- 
not be recommended. The preparation called 
' Sanitas ' is principally a solution of peroxide 
of hydrogen. 
2. Non-volatile Deodorants. - Enu- 
meration.-Among this class of deodorants 
are included Charcoal, Earth, Lime, Oxide 
of Iron, Sulphate of Iron, Chloride of Zinc, 
Nitrate of Lead, and Permanganate of Potas- 
sium. 
Application. - Although very efficient 
when brought into contact with the class 
of odorous substances referred to as noxious 
gases, these deodorants are less generally 
useful than they would otherwise be on ac- 
count of their non-volatile character. Char- 
coal owes much of its efficacy as a deodorant 
to the surface-attraction and power of con- 
densation which it possesses, by virtue of 
which it brings noxious gases, such as sulphu- 
retted hydrogen, into contact with oxygen in 
a condensed and active state, so that they 
are burnt up and resolved into innocuous 
compounds, or compounds less noxious than 
those from which they are produced. Earth 
and oxide of iron, which, like charcoal, are 
used in the solid and dry, or nearly dry, state, 
absorb and combine with, or promote the 
combination of, noxious gases, producing in- 
nocuous products. Lime may be used either 
dry or in the state of milk of lime. The 
other substances named are used in the form 
of solution in water. Where large quantities 
of decomposing animal or vegetable matter 
are required to be deodorised, dry lime or 
solution of sulphate of iron (green vitriol) 
may be economically and advantageously 
used. T. Redwood. 
DEPILATORIES (depilis, without 
hair).-Synon. : Psidothron', Rusma. 
Definition.- Depilatories are measures 
used for the destruction of superfluous hairs. 
Hypertrichosis.-The patients who pre- 
sent themselves for treatment by depilation 
are, of course, almost always women. In 
the immense majority of cases the dis- 
figuring hairs are on the upper lip, chin, 
neck, or in front of the ears, the annoy- 
ance and mental depression caused by them 
being often so extreme as to justify any 
procedure likely to give permanent relief, 
provided it is rationally employed and its 
limitations are properly understood. It must 
be carefully borne in mind, however, that in 
a certain number of cases hypertrichosis is 
only temporary, dependent perhaps on preg- 
nancy or menstrual disorders, or associated 
with acne and other sebaceous affections; 
and that in these circumstances it may dis- 
appear spontaneously, or as the result of 
treatment directed to these associated condi- 
tions. As a rule, the disfigurement is first 
noticed at about the age of eighteen, and is 
progressive till twenty-five or thirty, after 
which it remains permanent till the meno- 
pause, when it frequently becomes aggra- 
vated. 
Enumeration.- Various caustic applica- 
tions are occasionally used as depilatories. 
Sir Erasmus Wilson recommended the fol- 
lowing:-Quicklime (three parts), sulphide 
of sodium or of barium (one part), diluted 
with starch (four parts). The powder, mixed 
with water to the consistence of a thin paste, 
is laid on the affected part by means of an 
ivory paper-knife, and allowed to remain for 
from five to fifteen minutes. It must then 
be carefully scraped off, when the hair, 
shrivelled and burnt, comes away with it. 
The skin must then be washed with water, 
dried, and anointed with cold-cream. 
Although the immediate result of this 
method is sometimes satisfactory, a trouble- 
some degree of dermatitis is generally occa- 
sioned by it. The hairs, too, always return, 
their roots not being destroyed, but only 
stimulated by the treatment; and the subse- 
quent growth is invariably stronger, darker, 
and more disfiguring than the original, while 
considerable scarring too frequently results. 
Many women keep the disfigurement due 
to hypertrichosis in abeyance hy habitually 
extracting the hairs with forceps. There are 
many obvious objections to the procedure, 
but in some cases, where no other treatment 
is applicable, it answers fairly well; as its 
result, however, the growth becomes darker, 
stronger, and more bristly. In a certain 
number of cases good cosmetic results are 
obtained by bleaching the hair with a satu- 
rated solution of peroxide of hydrogen. 
Depilation by Electrolysis.-The only 
efficacious and permanent method of destroy- 
ing superfluous hair is by electrolysis. First 
practised by Michel, of St. Louis, U.S., in 
1879, subsequently by Hardaway, G. H. Fox, 
and other American dermatologists, it has 
of late years been introduced to the continent 
of Europe and to this country, where, how- 
ever, owing to its indiscriminate employ- 
ment, too often by unscientific persons, the 
treatment appears likely to fall into un- 
merited discredit. 
Indications. - Generally speaking, the 
cases in which electrolysis is most applicable 
are those where-(1) the growth is limited 
in extent, and stationary, not progressive; 
(2) the hairs are strong and dark; (3) the 
amount of downy undergrowth is slight; 
(4) the patient stands pain well, is sufficiently 
intelligent to understand the bearings and 
restrictions of the process, and is in a position 
to submit to its necessarily protracted dura- 
tion. There is little doubt that downy hairs 
in the regions operated upon sometimes 
become dark and strong with, undue rapidity 
as the result of electrolysis; but it is also 
more than probable that, independently of it, 
these hairs would ultimately, although more 450 
DEPILATORIES 
DEPLETION 
slowly, become sources of disfigurement. 
The writer is of opinion that cases in which 
the growth is most abundant upon or con- 
fined to the upper lip-and, unfortunately, 
they form a considerable proportion of those 
who present themselves for treatment-are, 
as a rule, unsatisfactory, owing to the large 
number of hair-follicles there present, the 
extreme sensitiveness of the part, the small 
number of hairs which can be extracted at 
a sitting (seldom exceeding twelve to fifteen), 
and the amount of inflammatory oedema set 
up in the lax tissue. 
Apparatus.-The necessary apparatus for 
depilation by electrolysis comprises-(1) a 
reliable constant-current battery of from ten 
to twenty cells, the nature of the elements 
being a matter of indifference; (2) an abso- 
lute dead-beat galvanometer, graduated in 
milliamperes, and preferably incorporated 
with the battery; (3) long, light, pliable rheo- 
phores; (4) a suitable needle-holder, con- 
nected with the negative pole of the battery, 
many forms of which are now made (those 
which have the current-interrupting appa- 
ratus in the handle are clumsy and incon- 
venient) ; (5) a fine needle made of steel or 
platinum, or of gold or platinum tipped with 
iridium-(the writer, after giving all these a 
fair trial, has reverted to the finest steel 
sewing-needles - Abel Morrall's 12's, the 
only disadvantage of which is their brittle- 
ness) ; (6) a carbon or brass cylinder covered 
with chamois-leather, constituting the posi- 
tive electrode, and connected with the positive 
pole of the battery. A steady hand and 
good vision are indispensable on the part 
of the operator, all suggested arrangements 
of magnifying-glasses being unsatisfactory. 
The best of such is a watchmaker's glass 
mounted on a spectacle-frame. 
Method.-The patient being placed in a 
good light, and preferably in the recumbent 
posture, the needle is introduced into the 
hair-follicle for a distance of to | of an 
inch or more, the follicle being, as it were, 
catheterised. The experienced touch is even 
able to distinguish when the bottom of the 
follicle is reached, by a slight increase in 
the resistance encountered. The current is 
closed by the patient firmly grasping the 
positive electrode, previously well soaked in 
warm water, and a sharp pain is experienced 
at the moment of closure, which persists, 
but in a modified form, throughout the de- 
struction of the hair. The hair may then be 
seized with forceps, held in the left hand; 
and, when destroyed, it comes away without 
appreciable traction. The current is then 
broken by the patient relaxing the grasp of 
the positive electrode, and the needle is 
withdrawn. Whilst the current passes, a 
little froth, evidence of the electrolytic ac- 
tion, wells up by the side of the hair, and an 
urticarial wheal forms. This soon subsides, 
leaving a pink, hardish papule, which lasts a 
few days; whilst occasionally a minute scab 
forms, which may take about a week to 
separate. In either case a tiny white de- 
pressed scar is left, but it is usually practi- 
cally imperceptible after a short time. Oc- 
casionally, however,-especially in persons of 
dark complexion-the scars are rather deeply 
pigmented, and the resulting disfigurement 
disappears but slowly. A current of five 
milliamperes employed for half a minute is 
sufficient to destroy the strongest hairs, if the 
follicle is accurately struck; and from six to 
ten cells are usually sufficient to generate 
this current strength. Weaker currents are 
effectual in destroying finer hairs, but it is 
strongly inadvisable to attempt to destroy 
lanugo. The amount of pain experienced 
varies within very wide limits; it is seldom 
so intolerable as to contra-indicate the opera- 
tion. In some cases ointments containing 
10 20 per cent, of cocaine, rubbed in for 
ten minutes beforehand, diminish it sensibly. 
The number of hairs extracted at a sitting 
ought never to exceed fifty, and an interval 
of several days ought always to be observed 
between the destruction of hairs close to- 
gether. A few recurrences necessarily take 
place, their number being in inverse ratio to 
the expertness with which the operation has 
been performed. They are easily recognis- 
able, and are generally most abundant 
beneath the chin and on the neck, where it 
is difficult to determine the precise direction 
of the hair-follicles. 
It is impossible here to dwell upon all the 
details of the procedure, the success of which 
mainly depends upon skill, patience, and ex- 
perience. J. J. Pringle. 
DEPLETION (depleo, I empty out). 
Synon.: Fr. Depletion', L'Action de vider', 
Ger. Entleerung. 
Definition.-By the term ' depletion ' is 
understood: (a) the unloading, or rendering 
less full, of that which is over-burdened or 
over-full, for example, portions of the turgid 
vascular system-as the portal vessels; or 
(6) excessive evacuation, causing exhaustion 
-as in choleraic or other severe diarrhoea. 
Uses.-Depletion, local or general, as a 
therapeutic agent, may be practised in a 
variety of affections, such as cerebral con- 
gestion, venous turgescence, engorgement 
of the portal system, pulmonary congestion, 
renal ischaemia, aneurysm, or general ple- 
thora. 
Methods.-The agencies whereby deple- 
tion may be produced are blood-letting, 
general or local; purging; vomiting; sweat- 
ing ; and abstinence from food and drink. 
1. General Blood-letting.-There is no 
more powerful or prompt depleting agent 
than general blood-letting by venesection or 
arteriotomy. Indeed, the chief indications 
for bleeding are to be found where it serves 
a depleting purpose-e.g. in engorgement of DEPLETION 
the right heart and venous system as a result 
of disease of the heart itself, or from disease 
of the lungs or from impaired respiratory 
movement; also in visceral congestion and 
arterial turgescence (see Blood, Abstraction 
of). It is seldom, however, that abstraction 
of blood needs to be carried to such an extent 
as to exert a marked depleting effect on the 
w'hole system ; it is required, rather, for the 
relief of limited vaso-motor disturbances. 
2. Local Bleeding.-Bleeding by means 
of leeches, scarification, or cupping, may serve 
a very valuable depleting purpose in limited 
congestions, as in those of the pericardium, 
pleura, peritoneum, lungs, eyes, kidneys, 
tongue, uterus, and haemorrhoidal vessels. 
3. Purgation. - For general depleting 
purposes free purging by means of hydra- 
gogue cathartics is a most efficacious agent. 
When it is required to give relief to turgid 
vessels without abstracting blood in cerebral, 
cardiac, and hepatic congestions, nothing 
depletes so readily, efficiently, and safely as 
watery purges. The best purgatives are 
elaterin, jalap, senna, scammony, sulphate of 
magnesium or sodium, tartarated soda, acid 
tartrate of potassium, croton oil, and gam- 
boge ; to which list may be added mercury, 
antimony, and resin of podophyllin. The 
great advantage of hydragogue purges is that 
they deplete by removing serum from the 
blood-vessels without the loss of red cor- 
puscles. Depletion by means of such purges 
is of cardinal service in cerebral congestion. 
In congestion of the intestinal tract arising 
from hepatic, cardiac, or pulmonary disease, 
a mercurial followed in a few hours by a 
saline purge is of great service. Antimony 
has been mentioned in the above list be- 
cause of its usefulness in combination with 
sulphate of magnesium and other saline 
purges. As it also acts as a powerful circu- 
latory depressant, we should remember that 
it can be only employed when such action is 
permissible. 
4. Vomiting.-Antimony, when used as 
an emetic, has a powerfully depressant, as 
well as evacuant or depletory effect; but de- 
pression and depletion are not synonymous. 
The lowering effects of free purging are pro- 
nounced, and, ordinarily, sufficient. Emetics 
may act as depletants by evacuating the 
contents of, or producing a flux from, the 
stomach and intestine; but when used with 
this object their depressant action is always 
to be borne in mind. 
5. Sweating.-Sweating is a less effectual 
method of depletion, but if freely induced 
may, as in cases of renal disease, serve a 
good purpose in lowering arterial tension 
and assisting the elimination of retained 
materials. The usual modes of exciting dia- 
phoresis are active exercise, the hot air (or 
Turkish) bath, the vapour bath, wet packing, 
nitrate of pilocarpine (jaborandi), antimony, 
Dover's powder, and spiritus aetheris nitrosi, 
or a judicious combination of these measures. 
Copious draughts of hot liquids often aid the 
action of diaphoretic remedies. The evacuant 
action of sweating and purging may be ad- 
vantageously combined when speedy deple- 
tion is desired. The combination is valuable 
in certain dropsies. See Dropsy. 
6. Abstinence.-General depletion may 
be produced by abstinence from food and 
drink, and this method is sometimes em- 
ployed in the treatment of aneurysm. 
Alfred Wiltshire. John Harold. 
DEPOSITS.-The term ' deposit ' had at 
one time a much wider extension in pathology 
than it has now. In accordance with the 
doctrine of morbid erases or dyscrasice, it 
was customary to regard cancers and all new- 
growths, the products of tubercular and 
scrofulous diseases, as well as those of the 
specific fevers and ordinary inflammation - 
in fact, almost every kind of morbid product 
in the body-as ' deposited ' from the blood 
in. consequence of some alteration in its 
composition (see Blood-disease). In many 
of these cases the term deposit is still often 
used, even though an entirely different view 
may be taken of the processes leading to 
these morbid changes. The name remains, 
though the idea has departed; and this is also 
true of other morbid products called ' deposits.' 
The term secondary deposits was formerly 
used for what are now' called pyaemic or secon ■ 
dary abscesses, from a belief that pus was re- 
moved from the original seat of disease, and 
deposited in distant parts. The term athero- 
matous deposit is due to Rokitansky, who 
described this change as due to the deposition 
upon the arterial wall of material precipitated 
from the blood. In both these cases the term 
seems now misleading. Again, several pro- 
cesses which we now call degenerations or 
infiltrations were formerly spoken of as de- 
posits ; for example, lardaceous, fatty, and 
pigmentary deposits ; and although these 
processes may now be better described by 
another name, it cannot be doubted that in 
some of them an extraneous substance is 
actually deposited in the tissues. The term 
fibrinous deposits was also used for the 
masses now known as infarctions or blocks 
(as for example in the spleen or kidneys), 
where the appearance of a mass of extrane- 
ous material is produced by the degeneration 
as a mass of tissue, mixed with products of 
haemorrhage, inflammation, and exudation. 
In quite another sense the various substances 
precipitated from urine are spoken of as 
urinary deposits, with which we are not here 
concerned. 
When these exceptions are made, the 
present use of the word deposit is a limited 
one, but is appropriate in those cases where 
something different from the elements of the 
tissue, and especially if it be an inorganic 
material, is found in their substance, and 
DEPOSITS 
451 452 
DEPOSITS 
DERIVATIVES 
when it may reasonably be supposed that this 
material has been brought to the tissues by 
the circulating fluid and there deposited. 
The term is clearly inappropriate when the 
foreign matter is formed by some chemical 
change in the substance of the tissue-ele- 
ments; but between such cases and those 
just mentioned it is very difficult to draw the 
line. We shall speak, in the sense just de- 
fined, of calcareous, metallic, and pigmentary 
deposits. 
1. Calcareous Deposits.-All calcifica- 
tion of the tissues of the body, whether nor- 
mal or degenerated, of inflammatory products, 
of new-growths, or of any other morbid pro- 
ducts, appears to depend upon the deposition 
of lime-salts in the form of granules, this 
deposition taking place either within the sub- 
stance of the elements, or more rarely in the 
intercellular substance, or, possibly, some- 
times in the interstices of the tissue. Cal- 
careous deposit takes place towards the close 
of life in several parts of the body, as in the 
walls of arteries, in cartilages and tendons, 
in the valves of the heart, and the crystalline 
lens of the eye; though in most of these 
cases, if not in all, some other pathological 
change precedes the deposition of lime. Still 
more frequently this change occurs in masses 
of dead or degenerated materials, as, for 
instance, in organs which have partially or 
wholly lost their vitality, in new-growths 
which have reached the stage of retrogressive 
change, in old blood-clots, or in products of 
bygone inflammation. A wasted eyeball 
always becomes partly calcified (sometimes 
ossified); tumours, such as myoma and 
fibroma, are especially subject to calcifica- 
tion ; venous clots which remain long undis- 
turbed, as in the deep veins of the pelvis, 
undergo the same change, and become phle- 
bolites. Old inflammatory products, as pus 
and lymph, seem to become necessarily cal- 
cified if they are not absorbed; so do especi- 
ally the products of chronic degenerative in- 
flammations which have become necrotic, as 
seen in scrofulous lymphatic glands, and in 
tubercular masses in the lungs. A similar 
explanation applies to calcareous deposit in 
the walls of arteries, where the lime is 
generally deposited in new products which 
result from chronic arteritis or the athero- 
matous process, though lime may also be de- 
posited in the muscular walls independently 
of atheroma. Necrotic masses resulting from 
embolic infarction are frequently calcified. 
Parasites of all kinds, occurring in solid 
organs, are liable to become surrounded by 
a calcified wall; a change frequently seen in 
hydatid cysts. 
From all this it appears that calcareous 
deposit rarely occurs in normal healthy 
tissues, but is common in such parts as are 
dead or of deficient vitality. Its deposition 
must be attributed to some chemical reaction 
between the tissues thus altered and the lime- 
salts in the blood; and it is possible that the 
presence of an excessive quantity of lime-salts 
in the blood sometimes favours the change, 
since deposition of lime in one part sometimes 
coincides with removal of it from another 
part. In senile decay the wasting of bones 
goes on simultaneously with the calcifying 
processes just mentioned, and in some rare 
cases rapid absorption of bone from special 
disease has appeared to be the determining 
cause of its deposit elsewhere by a sort of 
calcareous metastasis. 
2. Metallic Deposits.-Other minerals 
besides lime-salts are rarely found deposited 
in the tissues, although in cases of chronic 
metallic poisoning, compounds of lead, silver, 
and copper may be found thus deposited. 
Zinc and mercury are less clearly traced, but 
probably follow the same law. The state of 
chemical combination in which the metals 
occur is not positively known, but appears to 
be some combination with albumen. 
3. Pigmentary Deposits.-Pigmenta- 
tion as a process is discussed in the article 
Degeneration, and has been shown to de- 
pend very frequently upon the occurrence of 
hfemorrhage and transformation of the ex- 
travasated blood. But physiological pigment, 
or melanin, is deposited in many parts of 
the body, both normally and pathologically, 
quite independently of haemorrhage. Nor- 
mally this is seen in the skin, the choroid 
coat of the eye, kc.: pathologically in the 
same situations, but in excessive quantity; 
and also in abnormal situations, as on the 
mucous membrane of the mouth. The ar- 
rangement of the pigment is in every case the 
same, forming minute black granules in the 
protoplasm of the cells around the nucleus. 
Its deposition and removal are regulated by 
causes as yet very imperfectly known, but 
are probably in some way dependent upon 
the nervous system. 
The deposit of such substances as fat, lar- 
daceous material, colloid, &c., is not a simple 
process, but depends either upon chemical 
metamorphosis of the cell, or on general 
pathological changes, which are dealt with in 
other parts of this work. 
J. F. Payne. 
DERBYSHIRE NECK.-A synonym 
for goitre, which is thus called from the pre- 
valence of the disease in that county. See 
Goitre. 
DERIVATIVES (derivo, I drain). 
Definition.-Medical appliances or reme- 
dies which lessen a morbid process, such as 
inflammation, in one part of the body, by 
producing a flow of blood or lymph to 
another part. 
Enumeration.-Derivatives include Local 
Bleeding, Cupping, Leeches, Blisters, Sina- 
pisms, and Setons. 
Action.-The name ' derivative ' was ap- 
plied in ancient times under the belief that DERIVATIVES 
DEVELOPMENT, ARREST OF 
453 
diseases were caused by morbid humours, 
which might be drawn away from the part 
which they were affecting. It is now used 
chiefly to signify the diminution of blood in 
an inflamed part, by increased circulation in 
some other vascular district, either adjoining 
or remote from it. 
T. Lauder Brunton. 
DEEMATALGIA (8eppa, the skin; and 
aXyos, pain).-Pain and aching in the skin. 
See Neuralgia. 
DERMATITIS (8eppn, the skin).-In- 
flammation of the skin: a term applicable to 
every variety of inflammation of the integu- 
ment, but especially to an acute inflammation 
attended with exfoliation of the cuticle and 
copious desquamation - for example, der- 
matitis exfoliativa, the pityriasis rubra of 
Devergie. 
DERMATOLYSIS (feppa, the skin; and 
hvais, a loosening).-Looseness or relaxation 
of the skin. See Molluscum. 
DESQUAMATION (de, signifying 
separation; and squama, a scale).-The pro- 
cess of separation or shedding of the epithe- 
lium of any surface. It is of most importance 
in connexion with the skin in scarlatina, 
where the epidermis usually desquamates 
extensively. 
DESQUAMATIVE NEPHRITIS.- 
A synonym for certain forms of Bright's dis- 
ease, applied on account of their being cha- 
racterised by shedding of the epithelium 
lining the tubules. See Bright's Disease. 
DETERGENTS (detergo, I cleanse). 
Definition. - Substances which cleanse 
the skin. 
Enumeration.-The principal detergents 
are-Water, Soap, Alkalis, Ox-gall, Milk, 
Vinegar, Alcohol, Charcoal, Sand, Oatmeal, 
Sawdust, Pumice-stone, Oil, and Borax. 
Uses. - Detergents are used to remove 
either extraneous dirt adherent to the skin, 
or. epidermal scales which have accumu- 
lated upon it and interfere with its function. 
The chief detergent is warm water, but its 
action is greatly aided by such substances 
as soap, alkalis, borax, or vinegar, which act 
chemically in the removal of dirt or epider- 
mis ; or by such substances as oatmeal, saw- 
dust, charcoal, pumice-stone, and sand, which 
act mechanically. Oil, or alcohol in the form 
of eau de Cologne, removes the resinous 
deposit left on the skin by plasters. Where 
the skin is tender, as in the case of the scalp, 
and where at the same time the detergent 
employed cannot very readily be removed, 
borax with elderflower water may be found 
preferable to the more irritating soaps as a 
means of removing scurf. 
T. Lauder Brunton. 
DETERMINATION OF BLOOD.- 
Increased flow of blood to a part or organ: 
synonymous with active hyper cemia or active 
congestion. See Circulation, Disorders of. 
DEVELOPMENT, Arrest of.-The 
causes of arrest of' development are in most 
cases still very doubtful, and for the most 
important theories and observations on the 
subject the reader is referred to the article 
on Malformations. Such arrests may take 
place at any stage in the development of the 
embryo and of its organs; but only the most 
important of them, and the mode in which 
some typical examples are brought about, 
will be mentioned here. 
Varieties.-Those which occur very early 
in foetal life are complex and, for the most 
part, incompatible with viability; whilst 
those which occur later often affect only one 
organ or a set of organs, and in some cases 
form no barrier to a prolonged existence. 
Not only must the foetus be considered, but 
als^ the placenta and membranes in which 
it is enclosed in utero ; for diseases of these 
lead to many forms of monstrosity, either by 
interference with the nutrition and respira- 
tion of the embryo, as in the case of many 
so-called ' true moles '; or the normal 
changes may be checked by adhesions 
between them and the foetus. Persistence 
of the umbilical vesicle is excessively rare, 
but a patent vitelline duct is not uncommon, 
and explains many of the diverticula in con- 
nexion with the small intestines. A want 
of closure of the visceral laminae is the 
source of many deformities, from a simple 
fissure in the sternum, or a ventral hernia, 
to a complete anterior cleft, with the thoracic 
and abdominal viscera lying bare out of the 
body-cavity. In other cases the skin and 
muscles only may cover the viscera, or the 
muscles may not be developed. The thorax 
is closed before the abdomen, so that ectopia 
of the abdominal is more common than of 
the thoracic viscera. The abdomen, how- 
ever, is sometimes closed in whilst the 
thorax remains open, and varying degrees 
of ectopfa cordis result; but this is rarely 
complete. Epispadias and hypospadias to 
varying extents are further examples of im- 
perfect fusion of the ventral laminae. These 
may or may not be attended with displace- 
ment or deficiency of the urinary and genital 
organs. Similarly, from an incomplete fusion 
of the vertebral laminae, the various forms of 
spina bifida occur; and these are generally 
accompanied with an excess of fluid in the 
spinal canal, or hydrorachis. 
The arrests in the development of the 
cerebro-spinal centres and of the organs of 
special sense are very numerous. The whole 
brain may be wanting, or the medulla ob- 
longata may be developed and the remain- 
ing portions missing, or any part of it 
may be absent or quite rudimentary. From 454 
DEVELOPMENT, ARREST OF 
DIABETES MELLITUS 
incomplete fusion of the bones of the skull 
hernia cerebri or encephalocele occurs, and 
this is generally complicated with hydro- 
cephalus, though the latter is frequently found 
as an independent and solitary affection. 
Coloboma and deficiency of the olfactory, 
optic, or auditory nerves are well-known 
examples of arrested development of the 
organs of special sense. The special mal- 
formations of the heart and vascular system, 
the digestive, respiratory, and urino-genital 
systems, will be found described under the 
various organs; but reference must here be 
made to congenital fissures leading into the 
pharynx (persistent branchial clefts), to the 
various fissures of the face and palate, to per- 
sistent cloacae, to the numerous forms of 
hermaphroditism, and to imperforate anus, 
as all coming under this head. Varying de- 
grees of ill-developed extremities are common, 
from a diminution of number in the fingers 
or toes, or their coalescence, to a complete 
absence of one or all the limbs. Finally, 
ducts, vessels, and openings-such as the 
urachus, ductus arteriosus, umbilical vessels, 
and foramen ovale-which normally close 
soon after birth, may remain patent through- 
out life. John Curnow. 
DEVONSHIRE COLIC.-A synonym 
for lead colic, which has arisen from the fre- 
quency of lead-poisoning in that county, sup- 
posed to be due to the contamination of cider 
with lead. See Lead, Poisoning by. 
DIABETES INSIPIDUS (8ta^aPat, I 
walk with the legs apart; 8iaSf]rr]s, a thing 
with outstretched legs, a pair of compasses, 
a siphon-whence the idea of free flow is 
derived; insipidus, tasteless).-Synon.: Poly- 
uria; Bx.Diabete insipide', Diab etenon sucre', 
Ger. Polyurie. A synonym for polyuria. 
See Polyuria. 
DIABETES MELLITUS ; 
and geXt, honey).-Synon.: Glycosuria; Fr. 
Diabete; Ger. Harnzuckerruhr. 
Definition.-The term Diabetes, meaning 
an excessive flow of something, has been ap- 
plied to the pathological condition fndicated 
by an excessive flow of urine. It has, more- 
over, been almost wholly limited to the kind 
of malady characterised by the presence of a 
notable quantity of sugar in the urine-a con- 
dition more strictly described by the term 
Diabetes Mellitus. Another condition is some- 
times seen where no sugar is to be found in 
the urine, which is, however, excessive in 
quantity. This is designated Diabetes In- 
sipidus, or (better) Polyuria. 
Diabetes is a malady more or less chronic, 
characterised by the persistent presence of a 
notable quantity of sugar in the urine, which 
is in most cases markedly abundant. It is 
accompanied by thirst, hunger, and bodily 
wasting. If unrelieved, it invariably tends to 
death. The ordinary form of diabetes is thus 
to be distinguished from certain other condi- 
tions, where, for instance, a small, or hardly 
perceptible trace of sugar may be detected in 
the urine; or where, yet again, considerable 
quantities of this substance may be detected 
occasionally, and for a short time only. To 
this abnormal condition the term glycosuria, 
which is often also employed to describe aiti- 
ficial diabetes, best applies. 
General Considerations.-Three impor- 
tant facts lie at the bottom of our knowledge 
of the pathology of diabetes. These are:- 
I. That grape sugar is found in the healthy 
human body. 
II. That glycogen, a substance closely allied 
in chemical composition to grape sugar, is also 
found in the healthy human body. 
III. That both of these may be formed in 
the healthy human body. 
Beyond these, certain other fairly definite 
propositions may be made : - 
1. Glycogen is found most abundantly in 
the liver, insomuch that, with due precau- 
tions, it can always be detected there : after 
a certain time sugar takes the place of gly- 
cogen, but the exact mode and time of this 
conversion are not known. 
2. Nevertheless, it is fairly certain that the 
sugar called glucose can always be detected 
in the liver ; still more certain that it is to be 
found in the blood ; but 
3. This sugar never appears in any nota- 
ble quantity during a state of health in the 
urine. 
4. As sugar is not to be found in any appre- 
ciable quantity in any other of the excre- 
tions, it follows: 
5. That this sugar must disappear in the 
body. 
6. It is commonly asserted, and, upon the 
whole, believed, that sugar is less plentiful in 
venous than in arterial blood. 
7. From this, if true, it follows that sugar 
must be used up in the course of the circula- 
tion. 
8. Where the combustion, or oxidation, oc- 
curs is not quite clear. 
9. But it is plain that, from a fault in either 
direction, sugar may become over-abundant 
in the blood, namely :- 
(a) By over-production, or 
(6) By diminished consumption. 
10. The over-production and the diminished 
consumption of sugar in the body may depend 
on various causes. The most notable of these 
are (a) an increased ingestion of saccharine 
material into the stomach and bowels, with- 
out a corresponding destruction; and (&) such 
an alteration of nerve-influence as will com- 
pletely modify the relative proportions of the 
sugar produced and the sugar destroyed. 
11. With an excess of sugar in the blood, 
only one easy road of egress from the body is 
available, that is, by way of the kidneys ; but 
this is not a sufficient outlet when there is 
great superabundance in the blood. Sugar DIABETES MELLITUS 
455 
may then be found in almost every one of the 
secretions or excretions. 
12. With this unnatural discharge of sugar 
there is usually a corresponding discharge of 
urine, but not always. 
13. Thus there may be no greatly increased 
flow of urine, yet the urine may be rich in 
sugar. 
14. And yet, again, there may be a copious 
flow of urine without any sugar, as in poly- 
uria. 
15. Hence the over-production or the dimin- 
ished consumption of sugar in the system has 
no necessary connexion with increased flow 
of urine. 
16. Both the abnormal action of the liver 
and that of the kidneys seem in the main to 
depend on similar but not identical causes. 
17. Both seem to be under the control of 
the sympathetic, but the special fibres are not 
the same as regards the two organs. 
(a) In the case of the liver, the fibres seem 
to originate in the medulla oblongata, to de- 
scend in the spinal cord to the lower cervical 
or upper dorsal vertebrae, thence to leave the 
cord to join the gangliated sympathetic, and 
so ultimately to reach the liver. 
(6) In the case of the kidneys, the active 
fibres proceed further down the spinal cord, 
but are ultimately connected with the great ab- 
dominal plexus, for such it may well be called, 
whence the fibres proceed to the kidneys. 
^Etiology.-The classification of cases of 
diabetes according to causation is in very 
many cases practically impossible. 
As to the circumstances that call the mor- 
bid processes into play, we know very little. 
It is certain, however, that the disease is 
much more frequent among men than among 
women, and among the middle-aged than 
among the very young or the very old. 
The disease is very much more fatal in 
young adults than in those over, say, forty- 
five. That the disease is more rife in certain 
districts than in others may probably be best 
explained by its undoubted tendency to here- 
dity. This heredity, as in many other mala- 
dies, is peculiar; the diabetic tendency in one 
branch of a family being represented in an- 
other branch by various nervous disorders, 
especially epilepsy and imbecility. 
Of the so-called exciting causes there are 
two of the first rank, namely, injury or dis- 
ease of the brain; and mental excitement, 
or, perhaps still more, worry. Tumours and 
other local brain-mischiefs sometimes give 
rise to a fatal diabetes. Certain mental emo- 
tions, at once powerful and prolonged, which 
may be epitomised in the single word ' strain,' 
apparently act as exciting causes of diabetes, 
such as continuous anxiety, long-lasting grief, 
or excitement followed by reaction. Certain 
errors of diet-such as excessive use of hydro- 
carbons, especially sugar, or other interfer- 
ence with the laws of health, may originate 
a fatal diabetes, especially in those who have 
any hereditary tendency to the disease. It 
is possible that the frequency of the malady 
among the Jews (as noted by Seegen) may 
be accounted for on dietetic grounds. 
Anatomical Characters.-Many patho- 
logical conditions have been recorded as 
occurring in those -who had been the sub- 
jects of diabetes, but we know little of its 
real pathology. In many cases nothing which 
cm be directly connected with the diabetes 
has been found post mortem. Latterly atten- 
tion has been mainly directed to the investi- 
gation of certain parts of the nervous system 
and of the liver itself. Perhaps the most 
reliable data for the ordinary anatomical 
appearances are to be found in Seegen's ana- 
lysis of Rokitansky's experience, embracing 
30 necropsies. 
Connected with the brain and spinal cord 
various lesions have been found, such as 
tumours of different kinds pressing on the 
medulla, and softening, with or without the 
marks of extravasated blood. In some cases 
extravasation has been the only morbid 
change discovered. In two cases under the 
writer's care there were extravasations of 
blood in the spinal canal in the cervical and 
upper dorsal regions, and the same was ob- 
served in another case under the care of a 
colleague. In one of these there was very 
marked softening of the cord in the regions 
named. In these three cases death took 
place suddenly. Dr. Dickinson's theory of 
the origin of diabetes in lesions of the ner- 
vous system, represented by enlarged peri- 
vascular spaces, the sites of existent or pre- 
existent extravasations of blood with destruc- 
tion of the surrounding nerve-tissue, is hardly 
tenable. The exploration of the sympathetic 
system has not been more satisfactory. 
Rokitansky found (in 15 out of 30 cases) 
that the liver was enlarged, hypersemic, and 
hard, of a dark-brown colour, with its acini 
imperfectly defined. The same conditions 
were present in the cases examined by the 
writer. When the disease has lasted a long 
time, the liver may be smaller than natural. 
The same would appear to hold good with 
regard to the cells themselves. Early in the 
disease, the cells, especially in the outer por- 
tions of the acini, are large, plump, and 
rounded, instead of angular, with large and 
distinct nuclei. They tend to assume a wine- 
red colour with solution of iodine, from the 
presence of unchanged glycogen. There are 
also sometimes found signs of active cell- 
growth at this early stage. Later the cells 
seem smaller, and as if undergoing pigmen- 
tary degeneration. 
The condition of the pancreas in diabetes 
is highly interesting. In 13 out of Rokitan- 
sky's 30 cases, it was strikingly small, hard, 
and bloodless ; and in many cases it has been 
found so shrunken and altered as to be hardly 
recognisable save by its connexions. Such 
was the case in one instance the writer has 456 
DIABETES MELLITUS 
seen, and in all his other cases the pancreas 
has been abnormal, usually contracted here 
and there, hard and knotty. In one case, 
however, the organ was enlarged and more 
succulent than usual, probably the first stage 
of the mischief. The occurrence of so im- 
portant pancreatic changes in about one-half 
the cases of diabetes would seem to indicate 
more than a casual connexion with the dis- 
ease. What this connexion really is remains 
unascertained. Klebs has associated the 
changes with disease of the cceliac plexus. 
One result from the pancreatic mischief is 
inability to digest fat. This was seen in one 
of the cases referred to above. See Pancreas, 
Diseases of. 
The kidneys Rokitansky found diseased in 
20 instances, but the changes were not uni- 
form. Usually they presented the ordinary 
indications of hypersemia, being enlarged, 
dark red, and full of blood. Occasionally 
there were signs of more extensive mischief, 
the substance of the kidney as well as its 
vessels and epithelium being involved, and 
the organ harder than natural. Often fatty 
changes occur. In one case of the writer's 
amyloid changes had begun in the Malpighian 
bodies. 
The lungs are frequently diseased: in only 
7 of his cases did Rokitansky find them nor- 
mal ; Dr. Dickinson only twice out of 27 in- 
stances. The changes included all stages, 
from acute or chronic pneumonia, to the for- 
mation of numerous cavities, or even to gan- 
grene. In one of the writer's cases the whole 
of the upper lobe of one lung was converted 
into a huge cavity filled with solid and semi- 
fluid detritus, having no gangrenous odour. 
There had been no expectoration, and no 
haemorrhage, though vessels were exposed. 
The stomach and intestinal canal present 
little beyond the ordinary signs of recurrent 
or chronic catarrh-thickening, mammilla- 
tion, and slaty pigmentation; erosions and 
ulcerations may, however, occur. 
Symptoms.-The following sketch compre- 
hends the more characteristic clinical features 
of diabetes; but there are often important 
variations in individual cases, though a cer- 
tain number of features are common to all: 
The patient, most likely a male between 
twenty and forty-five, when he comes before 
the physician has in all probability been 
suffering from the disease for some time; 
for it usually comes on insidiously. He may 
say that he has been in failing health for a 
varying period ; that he has been very thirsty, 
and has passed much water, having to get up 
repeatedly for this purpose during the night. 
His appetite has been more than hearty ; but 
his food, seems to do him no good, for he has 
been constantly growing thinner, and he feels 
weak and ill. On closer examination it is 
found that he is daily passing as much per- 
haps as eight, ten, or more pints of urine, 
light in colour and of a peculiar sweetish 
odour, of a high specific gravity, perhaps 
1040°, and containing an abundance of sugar. 
The skin is dry and harsh ; the tongue red 
and glazed or slightly furred ; the mouth dry 
and clammy; the lips, teeth, and gums are 
covered with scanty, sticky mucus; the breath 
is often sweetish, or it may be unpleasant 
from the state of the mouth ; the bowels are 
confined ; and the countenance wears an ex- 
pression of weariness and fatigue. 
From this point the malady may progress 
in one or other of two directions. Under 
judicious management the symptoms may 
ameliorate. Often the first indication of im- 
provement is a copious perspiration; the 
thirst diminishes; less urine is passed; the 
appetite is not so ravenous ; the' sugar de- 
creases in quantity; and with it the specific 
gravity is lessened. Emaciation ceases, and 
the patient begins to regain weight. This 
auspicious commencement may, with time 
and care, end in a more or less complete 
return to health. Unfortunately there is 
another side to the picture, for, notwith- 
standing all our efforts, the patient often goes 
from bad to worse. We fail to reduce the 
quantity of sugar beyond a certain point. 
The appetite gets more and more voracious, 
especially for starchy articles of food, to 
obtain which the patient will sometimes lie 
or steal, and yet there is often no feeling 
of satiety. Sometimes the appetite fails, and 
then emaciation goes on still more rapidly. 
All sexual power and feeling have long ago 
been lost, the testes sometimes undergoing 
almost complete atrophy. The harsh, dry, 
and itchy skin becomes the seat of boils, or 
even of carbuncles. Often the sight is injured 
by cloudiness of the refractive media, es- 
pecially of the lens, or by retinitis and other 
morbid changes. All this time the tem- 
perature is low, perhaps sub-normal; but 
towards the later stages of the malady it 
often rises. Such a rise indicates the ac- 
cession of a formidable complication which 
might almost be said to be the natural ter- 
mination of diabetes. This superadded mis- 
chief is a peculiar insidious kind of pneu- 
monia, resembling acute pneumonic phthisis, 
and giving rise to local signs resembling those 
characteristic of that malady. The progress 
of this lung-mischief is rapid; the fever 
increases; and often there is irrepressible 
diarrhoea, sometimes of fatty-looking matter. 
As the end approaches, the sugar usually 
disappears from the urine, which may become 
albuminous and scanty. There may even be 
some oedema of the extremities. The end 
often comes swiftly, and without warning, 
by acute pneumonia, or by what, for want 
of a better name, we call diabetic coma, or 
more slowly by gradual exhaustion. After 
the onset of pulmonary symptoms it is never 
very long delayed. Such may be said to be 
the ordinary course of a well-marked case of 
diabetes. There are cases slighter, where the DIABETES MELLITUS 
457 
history is different; but in both sets of cases 
there are certain symptoms, which demand 
further consideration than has just been 
given them. 
The Urine.-The characteristic of the 
urine in diabetes is the presence in it of 
sugar in notable quantity, though this varies 
greatly in different cases. In the earliest 
and slightest forms of diabetes, small quan- 
tities of sugar may be passed now and again, 
as after a meal or the consumption of an 
unusual quantity of starchy or saccharine 
food; but the sugar may completely dis- 
appear in the interval, or may do so finally 
by the use of an animal diet. The sugar 
thus excreted is glucose of the kind called 
dextrose, from turning polarised light to the 
right, is readily soluble in water and alcohol, 
and easily ferments. When diabetic urine is 
allowed to stand in a warm place, fermenta- 
tion soon sets in, gas being disengaged, and 
yeast deposited at the bottom of the vessel. 
The proportion of sugar to urine is usually 
from 8 to 12 per cent., but varies; the total 
quantity passed amounting to 20 or 25 
ounces, or even more. Its presence in such 
proportion causes an increased specific gra- 
vity, though this is not invariably the case, 
inasmuch as it may vary from 1008 to 1060 
or 1070. Along with the presence of sugar, 
we almost invariably find an increase in the 
quantity of the urine. But neither is this an 
invariable feature of diabetes, for sugar may 
exist with a normal quantity of urine, con- 
stituting the so-called diabetes decipiens. But 
in most cases there is a marked increase, the 
quantity passed amounting to eight, ten, or 
fifteen pints daily; and even the highest of 
these rates has been greatly exceeded. With an 
excessive amount of urine, its colour becomes 
lighter; sometimes it has a faint greenish 
tint, and when passed is quite clear. On 
standing there is no ordinary sediment, 
though, as already said, sporules of yeast may 
be deposited after a time. There is, on the 
whole, an excess-sometimes a large excess 
-of urea; and if the quantity of urine passed 
be small, deposits of uric acid or of the 
amorphous urates may appear. Very great 
inconvenience may arise in diabetic females, 
or even in males, by the arrest of saccharine 
urine about the external genitals, producing 
a raw or eczematous condition of the inside 
of the thighs and groins. The urine, being 
also almost invariably acid, is highly irritat- 
ing to the raw and swollen parts. Enuresis 
is common, especially at night, and among 
diabetic children. Albumen makes its ap- 
pearance sometimes in the progress of the 
disease, or in its later stages. 
The Digestive Organs.- As the correlative 
of the unusual flow of urine we have also, as 
a marked and early symptom of diabetes, 
extreme thirst, a thirst, too, which cannot be 
satisfied, for apparently the more the patient 
drinks the greater is the thirst. This sensa- 
tion is in some part due to the dry and 
clammy condition of the mouth, which it is 
difficult to relieve. Hunger, or even a 
voracious desire for food, is usually a 
prominent feature in diabetes, but is not 
invariably present, and in the later stages 
there may be complete loss of appetite, 
amounting to a loathing, especially for a 
restricted diet. It is often impossible to 
satisfy the intense craving for food, and 
should satiety be attained the sensation lasts 
but for a little time. The mouth is usually 
dry and parched, the saliva being scanty and 
tenacious. Often particles of food are re- 
tained about the teeth, and there putrefy, 
giving rise to unpleasant odours. The 
buccal fluid is almost always acid instead 
of alkaline, probably from the formation of 
lactic acid. The tongue is rarely perfectly 
natural. Seegen describes it as usually 
thickened and increased in volume, with 
fissures and glazed blood-red islands on its 
surface, which, however, may present a 
general coating. The teeth often fall out 
without pain, from the retraction of the gums, 
and are singularly liable to caries. Digestion 
is usually good, except during catarrh of the 
stomach, which is a rather frequent condition. 
Constipation is the rule in diabetes, often to 
a troublesome extent. This arises partly 
from the deficiency of water in the bowel; 
partly also from the small quantity of fecal 
residue from an exclusively meat diet. 
Diarrhoea, on the other hand, is not uncom- 
mon, and rapidly diminishes the patient's 
strength. 
General Symptoms. - Emaciation is an 
early and marked symptom of diabetes, but 
not invariably so, for diabetes often occurs and 
persists in stout persons, without removing 
the obesity. These are cases of the more 
tractable kind, the patients being usually 
somewhat advanced in life. Their complete 
cure is seldom effected, but they do not seem 
to suffer greatly from the malady. Though 
the emaciation is in great part due to the re- 
moval of fat, and in part to the abstraction of 
water from the tissues, there seems to be also 
an actual waste of muscular substance, espe- 
cially in the advanced stages of the disease. 
With this emaciation are associated weak- 
ness, weariness, and disinclination to exertion. 
These are often among the earliest symptoms 
of the disease, and may occur long before 
wasting is noticed, but increase markedly 
towards the close of the malady. From 
various causes (one being, doubtless, weaken- 
ing of the heart), cedema of the lower extremi- 
ties may occur, with or without albuminuria. 
Gangrene of the extremities, of the senile 
kind, has been observed. 
Respiratory Apparatus.-With regard to 
the respiratory organs, a peculiar apple- or 
hay-like odour of the breath is sometimes ob- 
served, probably arising from the production 
of acetone mixed with alcohol. But the most 458 
DIABETES MELLITUS 
serious pulmonary symptoms are those of 
phthisis, resulting from a more or less chronic 
pneumonia. This mischief is usually indi- 
cated by a nightly rise in the temperature, 
but otherwise may remain for a time almost 
latent. It is most common in the young, and 
towards the end of the disease. The expec- 
torated matters may contain sugar. Gangrene 
of the lung, or a form of necrosis of the lung- 
tissues, has been noticed. "With this form of 
gangrene the sputum may be odourless. 
Skin.-The skin is usually dry and scurfy, 
often extremely itchy; wounds inflicted by 
scratching heal with difficulty. Copious sac- 
charine sweat is observed in a certain number 
of instances. There is a marked tendency to 
the formation of boils and carbuncles. Boils 
often occur early in the disease, and may give 
the clue to the existence of diabetes. Car- 
buncles occurring late in the disease may be 
the immediate cause of death. 
Nervous System and Special Senses.-1The 
sight is often affected in diabetes, most fre- 
quently by the formation of diabetic cataract. 
Operations in such cases do badly till the 
disease is cured, and are seldom tried, for the 
cataract occurs late in the disease, and ad- 
vances rapidly. A form of retinitis not unlike 
that of albuminuria is sometimes found. Other 
forms of imperfect vision of uncertain origin 
occur in diabetes. They go by the general 
term of diabetic amblyopia. 
Along with the physical, the mental powers 
fail, and the moral sentiments become blunted, 
which, to the friends of the patient, is not the 
least distressing feature of the malady. 
Genital Organs.-Early in the history of 
the disease, all sexual appetite disappears, 
and sexual power soon fails in the male- 
but with improvement this may return. In 
the advanced stages amenorrhoea is not un- 
usual amongst females. 
Complications.-Several of the symptoms 
just described are regarded by some authori- 
ties as complications of diabetes rather than 
as belonging essentially to the disease. Such 
are especially diabetic cataract and ambly- 
opia, boils and carbuncles, and the chronic 
pneumonia or phthisis in which diabetes so 
frequently ends. 
Amongst the intercurrent diseases that 
are specially to be watched for and seriously 
regarded, one of the most important is albu- 
minuria, the appearance of which may en- 
courage a false prognosis, from the fall in 
specific gravity of the urine that attends it. 
Diabetic Coma.-This is a not infrequent- 
terminal symptom of diabetes. It is more 
liable to occur'in the early stages of severe 
cases in young persons. It is especially noted 
after muscular exertion, and after the first 
adoption of an anti-diabetic diet. Constipa- 
tion predisposes to its development. Cases 
of diabetic coma are divided into three groups. 
In the first group the attack begins with head- 
ache or epigastric pain and nausea, followed 
by a great feeling of anxiety, or by restlessness 
and perhaps delirium, after which a peculiar 
dyspnoea sets in. The dyspnoea affects both 
inspiration and expiration, and no physical 
cause can be found for it on examination of 
the chest, and there is usually no cyanosis. 
Comatose symptoms then come on, which 
gradually deepen. The pulse is much quick- 
ened, and the temperature is abnormal. The 
coma generally ends fatally within forty-eight 
hours, and only a few cases have been known 
to recover. The symptoms of the second 
group closely resemble those of renal uraemia. 
The dyspnoea is not so well marked as in the 
preceding form. The patient complains of 
general weakness, becomes drowsy, lapses 
into a state of coma with low temperature and 
small pulse, and soon dies. The third form 
exhibits all the symptoms of acute alcoholic 
intoxication. The patient does not show the 
same muscular weakness as is observed in 
the two preceding forms. He is attacked sud- 
denly by great excitement, staggering gait, and 
drunken delirium. Gradually drowsiness and 
coma develop as in the other forms, and death 
ensues. In all these forms, and during and 
preceding the attack, a peculiar sweet smell, 
resembling chloroform, is perceived in the 
breath. The urine has a similar odour; and 
it gives the so-called ' acetone reaction ' with 
perchloride of iron-that is, when a solution 
of perchloride of iron is added in excess a 
deep red port-wine colour is produced. 
The pathology of diabetic coma has been 
much debated. Kussmaul believed that the 
symptoms were due to the presence of ace- 
tone in the blood; but it has been shown 
that other substances besides acetone give 
the peculiar reaction with perchloride of iron. 
The blood of diabetics has been often observed 
to contain excessive quantities of fat. Drs. 
Sanders and Hamilton described a case of 
diabetic coma, in which much fat was found 
in the blood, and numerous fat-emboli were 
seen in the pulmonary capillaries; and they 
suggested that fat-emboli in the lungs and 
brain were the cause of the symptoms. Similar 
cases have been described by others. Drs. 
Dreschfeld and Taylor, however, were unable 
to find fat-emboli in seven cases examined by 
them, although the blood was exceedingly rich 
in fat. 
Diagnosis.-The diagnosis of diabetes de- 
pends on the discovery of sugar, in notable 
quantity, in the urine of the patient. But be- 
fore the investigation for sugar is undertaken, 
there have usually been observed by the pa- 
tient some of the early indications of diabetes, 
of which the following are the most frequent, 
though no one definite symptom invariably 
heralds the disease : (1) dryness of the mouth 
and thirst; (2) bodily weakness and gradual 
emaciation ; (3) dryness of skin, with itching 
and a tendency to successive crops of boils; 
(4) urination in increased quantity, the urine 
being of a greenish-yellow tint, with the odour DIABETES MELLITUS 
459 
described; (5) defects of vision. Occasionally 
the attention of the patient is drawn to the 
state of his urine by the attraction it presents 
to ants, flies, and other insects; or by the 
formation of white spots of sugar on his dress 
and boots left by the urine on evaporation. 
We must not forget that in true diabetes 
we find sugar in notable quantity. There 
are often present in the urine other reducing 
agents (such as uric acid and colouring mat- 
ters), so that the amount of sugar detected 
must be such as to admit of no doubt what- 
ever. Again, the presence of the sugar must 
be persistent, hence a single examination will 
not suffice for diagnosis unless sugar be found 
in large quantity. It may so happen that the 
patient when seen is not passing sugar, from 
the influence of restricted diet, or from some 
other cause, such as pneumonia or other 
feverish condition. It is then best to examine 
the urine passed an hour or two after a meal, 
or even to permit the use of starchy food for 
a day or two, so that the constitutional pro- 
clivities of the patient may be the better ascer- 
tained. To determine the existence of sugar 
is not enough : it is always necessary to deter- 
mine the quantity passed, so as to obtain a 
clue to the intensity of the disease, and to 
judge of the effects of treatment. 
Qualitative Testing for Sugar.-The 
presence of sugar in the urine may be de- 
tected in various ways. When saccharine 
urine is mixed with yeast and kept in a warm 
place, it speedily ferments, with production 
of alcohol and evolution of carbonic acid; 
and as no other substance is capable of under- 
going this transformation, the occurrence of 
fermentation with yeast is certain proof of 
the presence of sugar. The signs of fermen- 
tation are evolution of carbonic acid and the 
lowering of the specific gravity. By the 
latter of these two signs considerably less 
than one per cent, of sugar can be detected 
in the urine. The method of carrying out 
this test is fully described under the head of 
quantitative testing. 
Moore's or Heller's test. - When sac- 
charine urine is boiled with liquor potass® 
the sugar is decomposed, and a compound is 
formed, giving its colour, black or brown, to 
the fluid. A convenient test-tube is filled 
one-third full with the urine, and an equal 
quantity of liquor potass® is added. The 
two should then be well mixed by shaking, 
and the heat of a spirit-lamp applied to the 
upper portion of the mixed fluids. If sugar 
be present this portion will gradually darken, 
the tint assumed varying in depth according 
to the quantity of sugar present. This test 
is very convenient, but it is liable to several 
objections, notably these (a) It is far from 
delicate, requiring as much as three parts in 
a thousand, or a grain and a half of sugar to 
the ounce, to afford any satisfactory indica- 
tion. (6) It is practically useless for quan- 
titative purposes, though the plan has been 
tried of comparing the colour produced with 
the colours of solutions containing known 
quantities of sugar, as is done in the Nessler' 
process for substances producing ammonia 
and its allies, (c) It is liable to two notable 
fallacies. (1) High-coloured urine is always 
darkened in tint, sometimes blackened, by 
boiling with liquor potass®. (2) Liquor 
potass® very often contains lead, which is 
liable to be converted into black sulphide 
when boiled with caustic potash, if albumen 
or any organic matter be present in the 
urine. The former of these risks cannot well 
be obviated; the latter may, by first testing 
the purity of the liquor potass®, and keep- 
ing it in green glass instead of white glass 
bottles. 
Indigo-carmine test.--If a solution of in- 
digo-carmine be rendered alkaline by car- 
bonate of sodium, and boiled with a small 
quantity of grape-sugar, the indigo-blue be- 
comes reduced to indigo-white, and causes 
the blue solution to assume a yellow colour. 
This test, originally introduced by Mulder, 
has been recommended by Dr. George Oliver, 
who makes use of it in the convenient form of 
test-papers. Two test-papers, one saturated 
with indigo-carmine, and the other with car- 
bonate of sodium, are digested in a small 
quantity of water, the result being a clear 
blue solution. To this one drop of the sus- 
pected urine is added, and the mixtures 
boiled ; if sugar be present the blue colour 
will successively give place to reddish-violet, 
different shades of red, and finally to a pale 
yellow tint. On standing, the solution re- 
absorbs oxygen from the air, and gradually 
returns to its original blue. 
Picric acid test.-This test was introduced 
by Dr. George Johnson. The principle of the 
method depends on the power of grape-sugar 
to change a yellow solution of picric acid, in 
the presence of caustic potash, to a red solu- 
tion of picramic acid-and the depth of the 
red colour varies with the amount of sugar 
present. Dr. Johnson has also applied this 
method for quantitative determination. The 
test is, however, less delicate than that of 
Fehling, to be presently described. 
Trommer's test.-Equal volumes of the 
suspected urine and liquor potass® are mixed 
together in a test-tube with a few drops of a 
10 per cent, solution of sulphate of copper. 
Heat is then applied ; and, if sugar be pre- 
sent, when the boiling-point is reached an 
orange-coloured precipitate of suboxide of 
copper is produced. This mode of applying 
the copper-test is, however, far inferior to the 
following. 
Fehling's test or method.-This testing 
fluid may be procured ready-made, but the 
following is the formula for it, as slightly 
modified by Dr. Pavy, and fitted for daily 
use :-Five grains of sulphate of copper, ten 
grains of neutral tartrate of potassium, and 
two drachms of liquor potass®. A more exact 460 
DIABETES MELLITUS 
formula will be given farther on. The fluid thus 
formed is of an intense blue colour, clear and 
bright. When the test-fluid is to be used, a 
small quantity of it should first be raised to the 
boiling-point, because by prolonged keeping 
the tartaric acid undergoes change, a sub- 
stance being formed from it which is capable 
of reducing copper, and might give rise to 
confusion. But if on boiling the test-fluid 
no copper is thrown down, the suspected 
urine should be added drop by drop, the 
mixed fluid being at the boiling-point. If 
sugar be present in quantity, it will throw 
down the copper in the form of a red or 
orange precipitate. The quantity of urine 
added must never exceed the bulk of the 
test-fluid, and the upper portion of the fluid 
should be heated, so as to contrast with the 
lower portion. Should suboxide of copper 
be thrown down when the test-fluid is boiled, 
the fluid must be filtered before adding the 
suspected urine, or, still better, a new fluid 
be prepared. To obviate as far as possible 
such inconveniences, the cupric and alkaline 
fluids should be kept in separate bottles until 
about to be used. 
When the quantity of sugar in the urine 
is very small, as may occur in ordinary dia- 
betes after long fasting or the use of a rigidly 
restricted diet, or during an access of fever, 
still more minute precautions must be taken. 
The most important of these is to use a great 
excess of the test. When the copper solution 
is added drop by drop to a healthy urine, at 
a boiling heat, the blue colour is immediately 
discharged, although not a particle of sugar 
be present, and the urine assumes a deep 
amber tint. The degree to which urines 
exercise this decolorising property over Feh- 
ling's test varies with their concentration. 
A dense urine (sugar free) will discharge the 
colour from nearly its own bulk of Fehling's 
standard solution; but even the most dilute 
urines have a considerable power this way. 
To avoid this fallacy, and secure an excess of 
the test, the most certain method is to heat 
the solution first, as already recommended, 
and to add the suspected urine afterwards- 
and never to add more, but always something 
less, than the bulk of the test-solution. The 
mixture is then again raised to the boiling- 
point. It then changes (if sugar be present) 
to an intense opaque yellowish-green, and 
slowly a bright yellow deposit subsides. If 
the urine contain less than half a grain per 
cent, the precipitation does not take place 
immediately, but occurs as the liquid cools- 
in five, ten, or twenty minutes-and the 
manner of the change is peculiar. First 
the mixture loses its transparency and passes 
from a clear olive-green to a milky opacity. 
This green milky appearance is quite charac- 
teristic of sugar. Some of the natural urinary 
ingredients have a certain power of reducing 
the oxide of copper to a state of suboxide, and 
of becoming thereby a source of fallacy in 
using this test for the detection of sugar. But 
this fallacy is easily avoided by not prolong- 
ing the ebullition. The fluid should simply 
be raised to the boiling-point, and then allowed 
to slowly cool. If such a proceeding fail to 
yield an indication of sugar, no amount of 
boiling will develop a trustworthy reaction. 
An increased delicacy can be imparted to this 
method by the following process, first sug- 
gested by Seegen. The urine is repeatedly 
filtered through animal charcoal until it is 
completely colourless. A little pure water 
is then passed through the filter, and to this 
water the test is applied in the usual way. 
An exceedingly minute trace of sugar (0'01 
per cent.) can be detected by this procedure. 
Quantitative Testing for Sugar.- 
Fehling's volumetric method.-This method, 
now in common use, is founded on the fact 
that the proportion in which sugar reduces 
copper is constant. One equivalent of grape- 
sugar decomposes exactly ten of sulphate of 
copper, or 180 parts by weight of grape-sugar 
decompose 1246'8 parts by weight of sulphate 
of copper. This being borne in mind, and a 
copper solution of known strength being used, 
it is easy to determine the quantity of sugar 
in any given specimen of urine. The quan- 
tities may be calculated according to the 
metric system, or by grains and minims. If 
we adopt the metric system, our fluid will 
consist of the following ingredients :- 
Sulphate of Copper (crystals) 40 grammes. 
Tartrate of Potassium (neutral) 160 
grammes. 
Liquor Sodae (sp. gr. 1T2) 750 grammes. 
Water to 1154'5 cubic centimetres. 
These should be carefully mixed; or, what 
is better, the copper and alkaline solutions 
are made separately, so that five cubic centi- 
metres of each, or ten of the mixed fluids, 
will exactly decompose '05 gramme or 50 
milligrammes of sugar. 
According to the English system of mea- 
surement, Dr. Pavy's solution is the most 
convenient. It consists of sulphate of copper, 
320 grains, dissolved in ten ounces of distilled 
water; and tartrate of potassium (neutral), 
640 grains, with caustic potash 1280 grains, 
also dissolved in ten ounces of distilled water. 
These fluids may be kept separate or mixed. 
In mixing, the copper should be added to the 
alkaline solution, not vice versa, to prevent 
the formation of any precipitate. One hun- 
dred minims of this mixed fluid are decom- 
posed by half a grain of sugar. Only a minim 
measure and a porcelain capsule, or other 
vessel which will stand heat, are required for 
Dr. Pavy's solution in the procedure, which is 
as follows: Most specimens of diabetic urine, 
containing too much sugar for accurate test- 
ing, first require dilution with water; and the 
most convenient degree of dilution is when 
one-tenth of the fluid is urine. Next put 
ten cubic centimetres of the metric copper 
solution, or one hundred minims of Pavy's DIABETES MELLITUS 
461 
solution, carefully measured, in a small porce- 
lain capsule. The fluid being deep blue is better 
for dilution, so as to diminish the intensity of 
tint. Of course this does not alter the quan- 
tity of copper present in it. The porcelain 
capsule with its contents is to be placed on an 
iron retort-stand, at such a level that the flame 
of a spirit-lamp will easily play on the capsule. 
Meanwhile a pipette, graduated from above 
downwards, either in minims or cubic centi- 
metres, is filled up exactly to the 0 in the 
graduated scale with the diluted urine. When 
the solution of copper is boiling, the urine is 
added to it from the pipette, drop by drop, 
stirring carefully the while, until signs are 
shown of a decoloration of the cupric solution. 
The moment all the copper has been thrown 
down as suboxide, and all shade of blue or 
green has disappeared, the addition of the 
diluted urine is stopped, and the quantity 
already used read off on the graduated pipette. 
To ascertain the quantity of sugar in the urine 
is now a simple calculation. We know how 
much urine has been employed in reducing 
the 10 cubic centimetres, or the 100 minims, of 
the cupric fluid, but these measures represent 
exactly 50 milligrammes and half a grain of 
sugar respectively. The quantity contained 
in the diluted urine being hence deduced, 
multiply this by ten, to get the quantity con- 
tained in the urine as passed. Next multiply 
by the total quantity of urine passed in twenty- 
four hours, to ascertain the full amount of 
sugar passed in this period. In all such ana- 
lyses the sample examined should be taken 
from the mixed urine passed during the whole 
twenty-four hours. That passed after pro- 
longed fasting is the richest, that passed three 
or four hours after a meal the poorest, in 
sugar. 
Roberts's fermentation method.-We have 
already noticed the fermentation method for 
demonstrating the existence of sugar in urine. 
Sir William Roberts has also devised from it 
a highly accurate quantitative process. It is 
as follows :- 
Put about four ounces of the suspected 
urine into a clean eight- or twelve-ounce glass 
bottle. Introduce a piece of dry German 
yeast, about the size of a cob-nut, but divided 
into small pieces. Cork the bottle with a 
grooved cork to allow the escape of gas. Fill 
a companion bottle quite full with the urine- 
Cork quite tightly, and set the two side by 
side for twenty-four hours in a warm place- 
the mantelpiece will do. By the end of that 
time fermentation will probably have ceased, 
and the yeast fallen to the bottom. The spe- 
cific gravity of the two specimens must now 
be carefully taken with an accurate urinome- 
ter, that of the unfermented bottle being taken 
as the standard. The fermented urine will 
have lost density from two causes: First, the 
sugar which gave the increased specific gravity 
has been destroyed ; and, second, in its place 
have been formed alcohol, which is lighter 
than water, and carbonic acid, which has es- 
caped. Every degree of specific gravity thus 
lost represents a grain of sugar in the ounce 
of urine. Thus, if there is a loss of twenty- 
five degrees of specific gravity, the urine 
would contain twenty-five grains of sugar in 
each ounce. Multiply this by the total number 
of ounces passed, to get the amount of sugar 
discharged per diem. This plan is especially 
useful for noting the quantity of sugar passed 
day by day, and can be easily undertaken by 
the patient or his friends. 
Estimation by the polariscope.-A plan of 
estimating sugar employed a good deal abroad 
depends upon the power of diabetic sugar to 
turn the plane of polarisation to the right. 
The degree of rotation is in proportion to the 
quantity of sugar contained in the urine. The 
apparatus used commonly goes by the name 
of the Ventske-Soleil apparatus, from its in- 
ventors. It is best adapted for light-coloured 
urines. If the urine be deep in colour it re- 
quires to be diluted. 
Prognosis, Course, and Terminations.- 
The prognosis of confirmed diabetes is ever 
unfavourable. Amelioration is common, but 
a perfect cure, save in exceptional cases, is 
rare. Diabetes coming on suddenly and from 
special causes, such as injury to the head, is 
more likely to do well than when more gra- 
dually developed. The younger the patient, 
the more sugar passed, the greater the ema- 
ciation and debility, the worse is the prognosis. 
Diabetes persistent with pure flesh diet is 
worse than if persistent only with a free 
starchy or saccharine diet. Loss of appetite 
and of digestive power, as indicated by the 
condition of the faeces, is of evil omen. When 
albumen appears in the urine in the course of 
diabetes, the specific gravity of the fluid di- 
minishes, often giving rise to a false impres- 
sion to the effect that, as the specific gravity 
has decreased, the diabetic state must be im- 
proved. The only true test of recovery is the 
power of consuming ordinary mixed food with 
impunity; but Seegen says that out of two 
hundred cases he had never seen this result. 
But by rigid or limited dieting, the patient 
may live, and even enjoy life, for many years. 
Heredity, directly or collaterally, adds to the 
darkness of the outlook. Cases resulting 
from injury to the brain or other parts of the 
nervous system are often the most hopeful 
with which we have to deal, though by no 
means always so. 
The course of diabetes is on the whole 
chronic. Most frequently it develops gradu- 
ally, though in some cases suddenly; and it 
generally lasts from six months to three or 
four years. In stout elderly persons it may 
exist much longer, especially with good diges- 
tion and a limited dietary. On the other hand, 
Sir William Roberts records a case which 
proved fatal, after a well-marked onset, in 
eight days-the shortest period known to the 
writer. Another case was fatal in three weeks, 462 
DIABETES MELLITES 
the patient being three years old. Some cases 
are recorded of death at still earlier periods, 
but these were most probably cases of long 
duration in an unnoticed shape suddenly de- 
veloped into an aggravated form. A fatal 
termination of diabetes may be brought about, 
as already indicated, in various ways. One is 
by diabetic coma, not unlike the first stages 
of uraemia. In the advanced stages of dia- 
betes, the strength being very low, compara- 
tively slight causes may produce fatal effects. 
Treatment.-Though we are ignorant on 
many points as regards diabetes, yet when 
we come to its treatment, we have these un- 
doubted facts-that sugar cannot be formed 
out of nothing; and that the series of sub- 
stances out of which it may be formed is 
limited. And though we cannot absolutely 
succeed in feeding the patient on substances 
which will not yield sugar, we can supply 
a nourishing diet furnishing sugar-forming 
materials in the scantiest proportion-an end 
best attained by a pure meat diet. But 
besides dietetic measures, other, though sub- 
sidiary, means may be taken to limit the 
formation of sugar by suitable hygienic and 
medicinal treatment. It is convenient to 
treat of these separately, though they should 
be employed in conjunction. 
Dietetic treatment.-All authorities agree 
that meat should be the main constituent of 
the patient's food, and that starch, and cane 
and grape sugar, should be avoided, as well 
as the substances containing them. It is 
very important in constructing a diet scale 
to give the patient as much variety of form 
as possible, the basis remaining the same. 
As the diet of the patient is the main factor 
in his treatment, it is worth the practitioner's 
while to study the various changes and com- 
binations of food which may be given with 
impunity. As regards vegetables, the rule is 
that all green vegetables, or the green parts 
of vegetables, may be eaten; for where chloro- 
phyll is abundant, starch and sugar are com- 
monly scanty; but this rule has important 
exceptions, which will readily occur to the 
reader. Thus the green parts of asparagus 
and celery may be used, whilst the white 
portion is highly saccharine. Globe arti- 
chokes may be used; Jerusalem artichokes 
are objectionable. Cabbage, endive, spinach, 
broccoli, Brussels sprouts, lettuce, spring 
onions, water-cress, mustard and garden 
cress, and celery may be used freely. Most 
fruits are forbidden, but nuts may be used if 
they can be digested. French beans may be 
used when quite green; when older the beans 
themselves must be removed. Haricot beans, 
peas, and all cereals; tapioca, sago, arrowroot, 
all forms of macaroni, potatoes, carrots, 
turnips, parsnips, and beetroot are in the for- 
bidden list. Cheese, especially of the poorer 
kinds, may be used. Cream, butter, and 
other fatty articles may be used freely. To 
sweeten tea or coffee, gluside has been 
suggested; but both will soon be found more 
refreshing without any sweetness. Cocoa 
made from the nibs can be used. Small 
quantities of cold tea without milk or sugar, 
with slices of lemon in it, will often be 
found palatable, cleansing the mouth and 
relieving thirst. Rinsing the mouth with 
iced water will often give more relief than a 
hearty draught. Slowly sucking ice is a very 
good plan for relieving thirst. All sweet 
drinks are in the forbidden list, including 
most sherries and ports, though some of the 
former may be found nearly sugar-free. 
Nearly all brandies contain sugar. Light 
French and German wines contain little or 
no sugar. Gingerbeer and lemonade are very 
objectionable; so are champagne, sweet beer, 
cider, porter and stout, rum and gin. Whisky 
is probably the best form of spirit. The 
use of alcohol in these cases has been gravely 
questioned. Where alcohol has not been 
used before the onset of the disease, the 
patient is probably better without it; but it 
is quite clear that in many cases it may be 
taken in moderation with advantage. 
There is difficulty in procuring a substitute 
for bread and potatoes. Three imperfect sub- 
stitutes are employed-namely, gluten bread, 
bran bread, and almond bread. Gluten bread, 
as introduced by Bouchardat, consists of flour 
out of which nearly, but not quite, all the 
starch has been washed. It is tough, and 
patients tire of it; better forms of gluten 
bread may be easily obtained in London. 
This last is palatable and nearly starch-free, 
but does not keep well. Bran bread is 
now often made, in the form of biscuits or 
cakes; the bran should always be washed 
nearly free of flour. Bran bread is hardly 
admissible when there is a tendency to 
diarrhoea, but may be useful in constipation. 
Almond cakes were first introduced by 
Dr. Pavy. They are rather rich to be eaten 
with meat, but used by themselves or with 
wine are excellent. Almond flour may now 
be obtained from which much of the oil has 
been expressed. 
We pass over Dr. Donkin's skim-milk 
treatment of diabetes with the remark that 
in the hands of Dr. Donkin and some others 
the method has been successful; in the hands 
of many eminent physicians, both at home 
and abroad, it has done unmitigated harm. 
Probably the explanation of any successful 
cases maybe found in the fact, that in certain 
conditions of diabetes, milk-sugar, as well as 
certain other substances, does not give rise to 
grape-sugar. If milk is to be used, butter- 
milk or sour milk will be best. The treat- 
ment by sugar or glycerine is self-con- 
demned. 
Hygienic treatment.-In this the first and 
most important point is regular exercise, es- 
pecially riding or walking, short of fatigue. 
Bouchardat has strongly advocated gymnastic 
exercises. These would be useful in modera- DIABETES MELLITUS 
DIAPHORETICS 
463 
tion, especially in bad weather. Nothing is 
more grateful or beneficial to the skin after 
such exercise, or even without it, than a 
warm bath, temp. 80° to 90°, with a little 
common washing soda in it. In all cases 
the avoidance of wet and cold is important. 
Flannels, frequently changed, should be worn; 
and it is always safer to change the clothes 
after the slightest exposure to damp. Little 
may suffice to give rise to a fatal pneumonia. 
Medicinal treatment.-This must be con- 
sidered as subsidiary to dieting, but there are 
many cases where undoubted benefit results 
from drugs. Of those which have been found 
of real value, the foremost is opium. Yet 
there is no unanimity of opinion as to the 
mode in which opium acts, and its apparent 
effects are most discordant-in some cases 
reducing both sugar and urine without sleepi- 
ness, in others speedily giving rise to drowsi- 
ness and even apparently to coma. The varied 
susceptibility of different patients to this drug 
is very striking. Some will take 20 or even 
50 or 60 grains a day with no apparent phy- 
siological effect beyond slight contraction of 
the pupil; others again cannot endure even 
a few grains. The writer's experience is 
decidedly in favour of opium. Morphine an- 
swers well in some cases. Codeine has been 
strongly recommended by Dr. Pavy as being 
the influential ingredient in the raw opium. 
He begins with doses of half a grain. Next 
to opium come alkalis, and especially some 
alkaline waters. Alkalis themselves may be 
given in various forms-as cream of tartar to 
relieve thirst, as citrate or bicarbonate of 
potassium, or, if there is a tendency to gastro- 
intestinal catarrh, as liquor potassae, with or 
without a bitter. The waters in most repute 
in diabetes are those of Carlsbad, Vichy, Vais, 
Bethesda, and Contrexeville. An annual visit 
to Carlsbad, with the rigid system of regimen 
and dietary carried out under the resident 
physicians, often suffices, with due care, to 
keep the patient fairly well for many years. 
Lactic acid has been strongly advocated by 
Cantani. His results seem good, but he also 
makes use of a most rigid dietary. Pepsin 
and rennet have been used, but without real 
advantage. 
Of secondary remedial agents, the three 
most important are strychnine, iron, and cod- 
liver oil; these favour nutrition, and the cod- 
liver oil seems to improve the temperature 
somewhat. Laxatives, not purgatives, should 
be used for the troublesome costiveness. 
Mineral waters, castor oil, or alkaline purga- 
tives suit best. Phosphorus in combination 
with iron as hypophosphite, taken in pills, has 
proved useful. 
Management of a Case of Diabetes.- 
By way of recapitulation we may say a few 
words here on the management of a case of 
diabetes. "When a case comes under the 
care of the practitioner he must first ascer- 
tain the general state of the patient as a basis 
for future comparison. The patient's weight 
must be carefully taken, and the state of his 
bowels noted. The quantity and characters of 
urine passed should be noted daily for a short 
time, the patient still consuming ordinary diet, 
unless there be some urgent reason to the 
contrary. After a day or two the restricted 
diet should be gradually commenced, sugar 
and potatoes being first cut off. Next the 
bread should go, being first of all cut down 
and used toasted hard or torrefied, and this 
should merge into the use of bran cakes or 
gluten bread. Above all things, the patient 
must not be disgusted with his food, for this 
favours the secret consumption of forbidden 
dainties. Week by week the weight should 
be taken ; day by day the sugar estimated, as 
may easily be done by Roberts's method, and 
the whole arranged on a card so as to be seen 
at a glance. Warm baths, exercise, and the 
other adjuvants must be assiduously em- 
ployed; and as soon as the effects of the 
limited diet are clearly marked, opium may 
be tried, if required. If well borne it should 
be used determinedly, and pushed to its physio- 
logical effects, as indicated by the contracted 
pupil. If the patient is seen daily, his diet 
should be regulated each day; if only at in- 
tervals, certain available changes should be 
indicated. When convalescence begins, and 
the urine has for some time been free from 
sugar, the diet may be gradually relaxed, 
beginning with substances containing little 
starch or sugar, gradually extending to bread 
in small quantity ; potatoes should come last; 
sugar itself never. When, with every care, 
restriction of diet effects no diminution of 
sugar, or, if that be limited, emaciation and 
weakness rapidly go on, it will be a question 
whether it may not be best, as it often is, to 
return to a practically unrestricted di et. 
Alexander Silver. 
DIAGNOSIS of Disease.-Nee Dis- 
ease, Diagnosis of. 
DIAPHORESIS (8w, through; and 
(fiopea), I convey).-The act of perspiring. 
The term is more generally applied to per- 
spiration artificially induced. 
DIAPHORETICS (8ia, through; and 
tpopew, I convey). 
Definition. - Remedies which increase 
the secretion of sweat. When the increase 
is so great as to cause the perspiration to 
stand in beads upon the surface, they are 
usually termed sudorifics. 
Enumeration.-The principal diaphoretic 
measures are-The Vapour Bath, Turkish 
Bath, and Wet Pack ; Warm Drinks; Warm 
Clothing; Jaborandi, Pilocarpine; prepara- 
tions of Antimony; Ipecacuanha; Opium 
and Morphine with their preparations ; Sar- 
saparilla, Guaiacum, Serpentary, Sassafras, 
Senega, Mezereon, Camphor; Sulphur; 
Ammonia and its Carbonate, Acetate, and 464 
DIAPHORETICS 
DIAPHRAGM, DISEASES OF 
Citrate; Alcohol; Ethers (especially Nitrous 
Ether) ; and Chloroform. 
Action.-The secretion of sweat usually 
consists of two parts, namely, a free supply 
of blood to the sweat-glands, and the abstrac- 
tion from it of the materials for sweat by 
the cells of the gland. These two processes 
sometimes occur independently of each other. 
In fevers the supply of blood to the glands is 
abundant, but they do not secrete; and a 
similar condition is observed in belladonna- 
poisoning. Belladonna and atropine possess 
the power of paralysing the secreting nerves 
of the sweat-glands, just as they do those of 
the salivary glands, and thus the skin re- 
mains dry, although the cutaneous vessels 
are much dilated. In collapse the cutaneous 
glands secrete a cold sweat profusely, al- 
though the supply of blood to them is 
deficient. 
The secreting cells appear to be under the 
influence of nerves, by exciting which secre- 
tion occurs. The centres for the secreting 
nerves of the sweat-glands appear to be situ- 
ated in the spinal cord, and in the medulla 
oblongata. The fibres seem to run in the 
same path as the vaso-motor nerves. The 
secretory nerves of the sweat-glands may be 
excited directly by stimulation of the nervous 
trunks in which they run; and the sweat- 
centres may also be reflekly excited by irri- 
tation of various sensory nerves. Certain 
substances, such as nicotine and carbonic 
acid, seem to stimulate the sweat-centres; 
whilst other drugs, such as pilocarpine, appear 
to act upon the peripheral terminations of 
the secretory nerves in the sweat-glands 
themselves. Several remedies, at the same 
time that they excite secretion, likewise in- 
crease the flow of blood through the skin, 
rendering it redder, warmer, and more vas- 
cular. Others, again, excite the secretion at 
the same time that they diminish the cuta- 
neous circulation. Diaphoretics have there- 
fore been divided into two classes, the former 
kind being termed stimulant, and the latter 
sedative diaphoretics. The exact mode in 
which each drug already enumerated pro- 
duces diaphoresis has not yet been ascer- 
tained ; but antimony, ipecacuanha, and 
jaborandi are classed as sedative diapho- 
retics, and all the others as stimulating ones. 
The supply of blood and the secretion are 
both increased by the application of warmth, 
by the ingestion of warm fluids, and by the 
action of jaborandi. 
Uses.-Diaphoretics are employed to in- 
crease the flow of blood to the surface, and 
possibly to aid the elimination of excremen- 
titious products in internal congestion, such 
as catarrh of the respiratory passages or 
digestive tract, and in febrile conditions 
generally. In fevers, the cutaneous circula- 
tion is generally active, and the so-called 
sedative diaphoretics are then most useful. 
Diaphoretics are also used to increase the 
elimination of water by the skin, and thus 
lessen the accumulation of fluid in dropsy, or 
to relieve other excreting organs, such as 
the kidneys in albuminuria and diabetes 
insipidus, or the intestines in diarrhoea. In 
these cases stimulant diaphoretics are indi- 
cated. T. Lauder Brunton. 
DIAPHRAGM, Diseases of the. 
The diaphragm is an important part of the re- 
spiratory apparatus, in relation to the move- 
ments of breathing, and by no means receives 
the attention from a pathological and clinical 
point of view which it deserves. Only a brief 
outline of its affections can be given within 
the limits of the present article ; and for 
practical purposes they may be conveniently 
discussed according to the following arrange- 
ment :- 
1. Physical Interference with the Dia- 
phragm, and Displacement. 
2. Functional Disorders, (a) Paralysis. 
(6) Spasm. 
3. Organic Lesions, (a) Injury, Perfo- 
ration, and Rupture-Diaphragmatic 
Hernia. (6) Inflammation, acute or 
chronic, (c) Muscular Rheumatism. 
(tZ) Atrophy and Degeneration, (e) Mor- 
bid Formations. 
1. Physical Interference with the 
Diaphragm, and Displacement.-The dia- 
phragm is frequently interfered with by 
morbid conditions within the chest or abdo- 
men, which impede its movements, displace 
it more or less, either upwards or downwards, 
or render it tense and stretched. The entire 
structure may be thus affected, or only a 
portion of it, such as one lateral half or its 
central part. The chief thoracic conditions 
by which the diaphragm may be thus affected 
are pleuritic effusion, empyema, or pneumo- 
thorax, emphysema of the lungs, abundant 
pericardial effusion, enlargements of the heart, 
and tumours within the chest. Chronic con- 
tracting affections of the lung and pleura tend 
to draw it upwards, by a process of suction. 
Pleuritic adhesions, considered indepen- 
dently, have rather a depressing influence 
than otherwise (Walshe). The principal 
abdominal conditions which may raise the 
diaphragm are a distended stomach, tym- 
panites, ascites, peritonitis, pregnancy, large 
fecal accumulations, and tumours or enlarged 
organs which attain considerable dimensions, 
especially ovarian, hepatic, splenic, or renal 
tumours. It sometimes happens that the 
diaphragm is interfered with both from its 
thoracic and its abdominal aspects. Tight 
lacing may materially embarrass and alter 
the position of this structure. 
Symptoms. - The symptoms induced by 
this mechanical interference are readily ex- 
plained by its effects. A sense of uneasiness 
and discomfort is often experienced around 
the lower part of the chest, amounting some- 
times to considerable tension or tightness. DIAPHRAGM, DISEASES OF 
465 
There is not any actual pain, but in some in- 
stances, where the diaphragm is much pushed 
down, the patient complains of a painful 
sensation referred to the ensiform cartilage, 
as if the attachment of the diaphragm at 
this point were being severely dragged upon. 
The act of respiration is more or less impeded, 
and this often seems to be the cause of the 
discomfort experienced. A sensation fre- 
quently complained of by patients is that 
they cannot take a full breath. Respiration 
may be much hurried, or oppressed and 
laboured; and not uncommonly the normal 
relation between the thoracic and abdominal 
movements is markedly altered, as observed 
on inspection and palpation, and the dia- 
phragm may so act as to draw in the lower 
part of the chest-walls in inspiration. Occa- 
sionally a kind of spasmodic cough seems to 
be excited by the tension of the diaphragm 
produced by certain conditions. The act of 
coughing is also frequently rendered more or 
less difficult and ineffectual. 
The actual position of the different parts 
of the diaphragm in a particular case can only 
be determined by carefully noting the phy- 
sical signs afforded by the structures in con- 
tact with it, on its thoracic and abdominal 
aspects respectively. 
2. Functional Disorders.-The affections 
of the diaphragm included within this group 
are (a) Paralysis; and (&) Spasm. It will 
be understood that in the cases now under 
consideration there is no structural change in 
the diaphragm itself. 
a. Paralysis.-The diaphragm is com- 
pletely paralysed when the spinal cord is 
destroyed at the origin of the phrenic nerve, 
whether as the result of injury or disease. 
If one or both phrenic nerves be cut across, 
destroyed by disease, or even severely com- 
pressed, the same effect will be produced, 
either one lateral half or the whole of the 
diaphragm being paralysed, according as one 
or both nerves are involved. This structure 
may also be implicated in diphtheritic para- 
lysis; lead-palsy; and hysteria. Diaphragm- 
atic paralysis has also been attributed to cold. 
See Phrenic Nerve, Diseases of. 
Symptoms.-Where paralysis of the whole 
diaphragm is suddenly produced, death 
speedily ensues from the grave impediment 
to the respiratory function resulting there- 
from. If it is brought about gradually, or 
if only part of the structure is involved, the 
effects are seen in more or less interference 
with this function, and with the acts in which 
respiration is concerned. Thus there will be 
a subjective sensation of a want of power to 
breathe; while the respiratory movements 
may be hurried and shallow. It has been 
noted, however, that, when the patient is at 
rest, breathing is often quite easy, but any 
exertion causes it at once to become frequent, 
and brings the extraordinary muscles of 
respiration into play. Physical examination 
shows that, if a deep inspiration be taken, 
the epigastrium and hypochondria sink in 
instead of protruding, while during expiration 
these regions bulge out again. If only one 
half of the diaphragm is affected, this abnor- 
mal movement is unilateral. Coughing and 
sneezing cannot be performed efficiently, and 
sputa cannot be easily expelled; while the ab- 
dominal acts for which a tense diaphragm is 
required, such as defaecation or vomiting, are 
also ineffectual or impracticable. A pecu- 
liar dysphonia has been described, in which 
the voice loses its power as the day advances, 
becoming at last a mere cracked whisper. 
The lower parts of the lungs tend to be 
more or less collapsed and congested; and 
if bronchitis sets in, the patient is in grave 
danger. 
6. Spasm. -The diaphragm may be the 
seat either of clonic or tonic spasm or cramp. 
The disorder may depend upon disease of the 
nerve-centre at the origin of the phrenic 
nerves; irritation of these nerves in their 
course ; direct excitation of the diaphragm ; 
or reflex causes. Tonic spasm is most strik- 
ingly observed in cases of tetanus ; of poison- 
ing by strychnine; or of hydrophobia. A 
form of asthmatic attack has also been at- 
tributed to this condition of the diaphragm ; 
and it may result from immoderate laughter. 
Symptoms.-The symptoms will vary in 
different cases. Tonic contraction of the 
diaphragm gives rise to severe pain, and 
a sense of constriction in the corresponding 
region, which may come on in paroxysms ; 
clonic spasms also originate painful sensa- 
tions after a time, which may become very 
considerable. Hiccough is probably due 
mainly to a clonic spasm of the diaphragm (see 
Hiccough). If this structure should become 
rigidly fixed, respiration is gravely interfered 
with, and the patient soon presents the phe- 
nomena of apnoea, which will end fatally if 
the spasm is not relieved. In the form of 
asthma supposed to be due to diaphragmatic 
spasm, expiration is very difficult and greatly 
prolonged, inspiration being short and abrupt; 
the lungs are distended; great distress is felt; 
and there may be signs of impending death 
from suffocation. A spasmodic cough may 
be due to clonic spasm of the diaphragm. 
3. Organic Lesions.-These may be briefly 
considered in the order in which they were 
enumerated at the commencement of this 
article. 
a. Injury, Perforation, and Rup- 
ture - Diaphragmatic Hernia. - The 
diaphragm may be perforated, lacerated, or 
ruptured in connexion with various forms of 
injury, such as crushing accidents, fractured 
ribs, penetrating wounds, or gunshot injuries. 
Should the patient recover, a permanent 
opening may be left. Rupture of the dia- 
phragm may also occur from violent strain, 
as of persistent retching, or during parturi- 
tion ; and from the effort to conceal or 466 
DIAPHRAGM, DISEASES OF 
suppress the cries of pain in parturition. In 
medical practice perforation of this structure 
may be met with as a congenital condition ; 
as the result of the bursting of some fluid- 
collection through it, such as an empyema, 
pulmonary abscess, a sub-diaphragmatic, 
hepatic, renal, or other abscess,-or a hydatid- 
cyst ; or from its destruction in the progress 
of some organic lesion, such as malignant 
disease, an aneurysm, or a chronic gastric 
ulcer. It may occasionally occur indepen- 
dently of these causes, owing to the yielding 
of a weak portion of the diaphragm, especi- 
ally between the attachment to the ensiform 
cartilage and the seventh rib. Congenital 
perforation is rare, but a considerable portion 
of the diaphragm may be thus deficient. 
The size and other characters of the perfora- 
tion differ much in different cases. If it is 
produced by the opening through the dia- 
phragm of a fluid-accumulation, this fluid 
escapes from the abdominal into the thoracic 
cavity, or vice versa, the latter being excep- 
tional ; in other instances portions of the 
thoracic or abdominal organs pass through 
the perforation, constituting forms of dia- 
phragmatic hernia. The writer had the op- 
portunity of observing a remarkable instance 
in which the entire stomach had passed 
through an opening in the diaphragm into 
the cavity of the chest. In a case reported 
by Dr. Little, of Dublin, the diaphragm pre- 
sented an almost circular opening, well- 
defined, sharp, with somewhat thick edges, 
and through this opening passed a hernia 
consisting of peritoneum containing some 
omentum, and about fifteen inches of the 
transverse and descending colon. The 
stomach and colon most frequently pass 
through the diaphragm. In rare instances 
the small intestines, spleen, or other struc- 
ture form part of the hernia. 
. Symptoms.-To recognise clinically a per- 
foration or rupture of the diaphragm is 
generally no easy matter. In cases of sudden 
and extensive rupture, there will probably be 
grave collapse and speedy death, and the 
patient may present marked risus sardonicus. 
Often there are no symptoms referable to the 
diaphragm, though there may be signs indi- 
cating that its functions are more or less im- 
peded. The occurrence of sudden perforation 
may be known from the previous existence 
of some condition likely to cause this event, 
such as empyema, or an abdominal abscess; 
the supervention of acute pain, accompanied 
with in dications of shock or collapse, and the 
disappearance or modification of the signs of 
the original morbid condition; followed by 
the development of phenomena revealing 
that fluid has passed through the diaphragm, 
and accumulated in the thoracic or abdominal 
cavity, as the case may be, or that some 
secondary affection has been set up as the 
result of the perforation, such as peritonitis 
or pleurisy. A fluid collection may, however, 
penetrate the diaphragm without giving rise 
to any very evident disturbance. When an 
organ passes through this structure, the 
symptoms present, if any, are more likely to 
be associated with this organ than with the 
diaphragm, and physical examination may 
possibly detect the displacement. In the 
case of hernia of the stomach already re- 
ferred to, the chief symptom was urgent 
vomiting, which occurred immediately after 
taking any food or drink. 
b. Inflammation-Diaphragmitis. - 
The serous covering of the diaphragm, either 
on its thoracic or abdominal aspect, is not 
uncommonly involved in cases of acute 
pleurisy or peritonitis respectively, and the 
inflammatory process may penetrate its 
structure. It may also be involved by exten- 
sion from pericarditis. Inflammation of the 
substance of the diaphragm may further arise 
from injury, direct irritation, pyaemia, or 
without any evident cause. The anatomical 
conditions observed are increased vascularity 
and sometimes ecchymosis; the formation 
of lymph upon its surfaces, or exudation into 
its substance ; softening and degeneration of 
its muscular tissue or central tendon; or, in 
rare instances, suppuration, an abscess form- 
ing in the substance of the diaphragm, or pus 
collecting under one or other of its serous 
coverings. Ulceration and gangrene have 
been noticed in exceptional instances. 
Chronic inflammation of the diaphragm may 
occur, leading to a fibroid change in its 
muscular portions, either by extension from 
neighbouring structures, or as the result of 
chronic local irritation. 
Symptoms.-The symptoms of acute in- 
flammation of the diaphragm are generally 
very obscure and ill-defined. The condition 
may be indicated by severe pain in the region 
of this structure, of burning and constrictive 
character, obviously increased by breathing, 
so that the respiration becomes instinctively 
thoracic, as well as hurried and shallow; and 
also much aggravated by coughing, defae- 
cation, or any other act which disturbs the 
diaphragm, as well as by movements of the 
trunk, and pressure over the epigastrium. 
Sighing, hiccough, painful dysphagia, risus 
sardonicus, and violent delirium are other 
symptoms described. The movements of re- 
spiration will indicate more or less complete 
paralysis of the diaphragm. The patient 
will probably be much distressed. More or 
less pyrexia will be observed. If an abscess 
should form, this might burst either into the 
chest or abdomen, and thus lead to secon- 
dary pleurisy or peritonitis. The inflamma- 
tion might also spread to the pericardium. 
Chronic inflammation and its consequences 
may possibly be suspected from a want of 
free movement in the diaphragm, associated 
with conditions likely to originate this 
change; but it could scarcely be recognised 
with any certainty. DIAPHRAGM, DISEASES OF 
DIARRHOEA 
467 
c. Muscular Rheumatism.-The dia- 
phragm may be involved in this complaint, 
whatever its nature may be; probably it is 
attended with structural changes in the tis- 
sues. The affection is characterised by pain 
referred: to the diaphragm, which may be 
very acute when it is in any way brought 
into play. So long as it is kept at rest, there 
may be no discomfort, but deep breathing 
causes considerable pain, so that the respira- 
tion is carried on in a shallow manner, and 
may be entirely thoracic. Such acts as 
coughing or defaecation cause much pain and 
a sense of aching. 
d. Atrophy and Degeneration.-The 
diaphragm may be involved in the course of 
progressive muscular atrophy; it may also 
be atrophied from causes which produce 
general wasting; or undergo senile atrophy 
and degeneration; or be similarly affected 
from local causes, such as interference with 
its blood-supply from vascular degeneration, 
want of action, or after chronic inflammation. 
Fatty and fibroid degeneration are the chief 
forms met with. Brawny induration has 
been noticed in scurvy. These conditions 
tend to give rise to more or less evident 
interference with the functions of the dia- 
phragm, which in extreme cases would 
amount to their total cessation, diaphragm- 
atic breathing being rendered impossible, 
the symptoms being then the same as when 
the diaphragm is paralysed. In cases of pro- 
gressive muscular atrophy the fatal termina- 
tion may arise from this cause. There would 
not be any pain, but uncomfortable sensations 
might arise from the impeded respiration. 
e. Morbid Formations. - The dia- 
phragm is occasionally the seat of malignant 
disease, being usually involved by extension 
from some neighbouring structure. Syphi- 
litic and other non-malignant solid growths 
have in rare instances been found, in it. 
Parasitic formations may also occur in it- 
namely, hydatids, cysticercus, and trichina 
spiralis. Tubercle is occasionally found in 
the diaphragm. Possibly malignant disease 
might be indicated by signs of impeded dia- 
phragmatic movements, with localised pain, 
accompanying indications of cancer in other 
parts. The implication of the diaphragm in 
trichinosis may also be recognised in some 
instances by severe pains, spasmodic con- 
tractions, and serious interference with dia- 
phragmatic respiration. In most cases, how- 
ever, the presence of any morbid growth in 
connexion with the diaphragm cannot be 
diagnosed during life, and is only discovered 
at the post-mortem examination. 
Treatment.-But little can be done in 
most cases in the way of direct treatment in 
connexion with affections of the diaphragm. 
One of the most obvious indications is to 
get rid, if possible, of any condition which is 
mechanically displacing it, or impeding its 
movements, and preventing it from perform- 
ing its functions. In the next place, any 
disease of which the condition of the dia- 
phragm is but a part must receive due atten- 
tion, such as progressive muscular atrophy, 
centric nervous disease, diphtheritic paralysis, 
lead-poisoning, hysteria, or trichinosis. Col- 
lapse or shock due to a sudden diaphragmatic 
lesion must be treated on the usual princi- 
ples. Painful affections might be relieved 
by local applications of dry heat, fomenta- 
tions, support by a bandage, or anodynes; 
and if acute inflammation is suspected, a 
few leeches might be applied. Paralysis or 
spasm of the diaphragm may call for the 
employment of electrical treatment, applied 
through the phrenic nerve; and various 
remedies are found useful in hiccough. See 
Phrenic Nerve, Diseases of; and Hiccough. 
Frederick T. Roberts. 
DIAPHRAGMATIC HERNIA. - 
See Diaphragm, Diseases of the. 
DIAPHRAGMITIS. - Inflammation 
of the diaphragm. See Diaphragm, Diseases 
of the. 
DIARRHOEA (Siappeo, I flow away).- 
Synon. : Defluxio', Alvi Fluxus ; Purging; 
Fr. Cours de Ventre; Devoiement; Ger. Der 
Durchfall\ Bauchfluss', Durchlauf. 
Definition.-A frequent and profuse dis- 
charge of loose or of fluid alvine evacuations, 
without tenesmus, mainly due to increased 
peristalsis of the large intestine. 
^Etiology.-The causes predisposing to 
diarrhoea are individual peculiarity; child- 
hood-especially the period of first dentition; 
the climacteric period; and hereditary or 
acquired weakness of the digestive organs.- 
The exciting causes may be thus classified: 
1. Direct irritation of the intestines by: 
(a) Food in excess, or of improper quality- 
for example, salted meat, shell-fish, sour un- 
ripe fruit and vegetables, diseased, decom- 
posed, or imperfectly masticated; the pro- 
ducts of faulty digestion prematurely passing 
the pylorus; imperfectly elaborated and fer- 
menting chyme ; impure water, such as that 
containing from 3 to 10 grains of putrescent 
animal matter per gallon (Parkes); or imper- 
fectly fermented malt liquors. Acute diar- 
rhoea, especially in hand-fed infants, is very 
frequently caused by fermentation of milk 
either previous to or after ingestion-the 
irritant effect being due either to undigested 
casein, to the products of acid or alkaline 
fermentation, or to the formation of poison- 
ous ptomaines or the presence of bacteria. 
(&) Purgative medicines and irritant poi- 
sons. (c) Bile, excessive or acrid, (d) Fceces, 
retained, (e) Entozoa-lumbrici, taeniae, trich- 
inae, and entophyta-mycosis enteralis (Buhl 
and others). (/) The contents of a ruptured 
abscess or hydatid-cyst, (g) Intestinal lesion 
-such as tubercular or other ulceration. 468 
DIARRHCEA 
2. Defective hygiene.-Diarrhoea may arise 
from the dwelling being damp, cold, dark, 
and unventilated; or from foul emanations 
from decaying organic, especially animal 
matter, sewage, or faecal collections. 3. 
Chills, climatic variations, de. Diarrhoea 
has been attributed to insufficient clothing; 
sudden exposure to cold and damp ; chills, as 
from wet feet, and damp bed or clothing; 
and rapid variations of temperature, such as 
hot days and cold nights. 4. Nervous dis- 
turbances, for example, depressing emotions 
-fright, grief; neuralgia, hepatalgia (Trous- 
seau), dentition, and other causes of reflex 
disorder. 5. Defective absorption with aug- 
mented peristalsis of the small intestines, so 
that the food is passed unaltered-lienteric 
diarrhoea. 6. Symptomatic in various morbid 
states, for instance, in passive congestion of 
the portal vein from disease of the liver, 
heart, or lungs; peritonitis, especially puer- 
peral ; organic disease of the intestines- 
ulceration (simple, stercoral, typhoid, tuber- 
cular, cancerous), lardaceous degeneration, 
enteritis, acute or chronic ; cholera ; typhoid 
fever; dysentery; occasionally in pyaemia, 
measles, scarlatina, confluent small-pox, 
malaria, gout, Bright's disease (its later 
stages), and in anaemia and exhaustion, as 
from over-lactation, phthisis, cancer, Addi- 
son's disease, Hodgkin's disease, exophthal- 
mic goitre, leukaemia, and other affections. 
Frequently diarrhoea arises from the com- 
bined action of several exciting causes, as 
when the disease is epidemic during summer 
and autumn. Pollution of air, water, and 
food by foul emanations from organic matter 
decomposing in very hot weather, over- 
crowding, food (and especially fruit) in a 
state of incipient decay, excessive heat, and 
chills, may then collectively determine the 
result. In children the exalted irritability 
of the nervous system during dentition pre- 
disposes to diarrhoea from slight determining 
causes. In several forms of diarrhoea fer- 
mentation of the intestinal contents plays an 
important part-e.g. in infantile and summer 
diarrhoea. 
Description and Varieties.-Diarrhoea 
may be broadly divided into the acute or 
occasional, and the chronic forms; and the 
numerous clinical and pathological peculiari- 
ties of different cases are conveniently 
grouped into typical varieties. The general 
effects, varying according to the intensity and 
duration of the flux, are mainly these :- 
Emaciation, and, in children, also arrest of 
growth-the weight either diminishing or 
ceasing to be progressive ; anaemia, indicating 
defective luematosis ; desiccation of the tissues 
from the rapid draining of serum from the 
blood-hence the thirst, and the very con- 
centrated, acid, and even albuminous urine 
observed when there is a copious watery out- 
flow from the bowels, as in choleraic and 
similar forms of diarrhoea. 
It will be expedient to describe briefly the 
principal forms of diarrhoea. 
1. Irritative Diarrhoea. - Synon. : 
Diarrhoea crapulosa (Cullen).-Simple flux 
from direct irritation of the intestines is the 
most common variety of diarrhoea. The 
evacuations, usually preceded by severe grip- 
ing pains, are at first feculent and usually 
fetid and sour, then watery. In children 
(especially hand-fed) they are often like pale 
clay or putty, or they contain dense masses 
of undigested casein before being loose ; after 
evacuation they frequently become greenish, 
like chopped spinach, from contact with very 
concentrated acid urine converting the brown 
colouring matter of the bile into green bili- 
verdin ; or they are dark green when passed, 
and may be so acrid as to excoriate the anus, 
the genitals, the inner parts of the thighs, and 
even the heels. Fever is usually absent. 
Diarrhoea from irritation is frequently a 
preliminary stage of the inflammatory, dysen- 
teric and choleraic varieties. 
2. Inflammatory Diarrhoea.-Synon. : 
Diarrhoea serosa. - When the causes of 
simple irritation excite inflammation of the 
mucous membrane of the bowels, fever sets 
in, and the diarrhoea increases. Usually the 
evacuations become more serous, and con- 
tain shreds of fibrin or mucus or pus. Be- 
fore the attack passes off, the large bowel 
is apt to be the main seat of inflammation; 
then the motions are scanty, frequent, more 
mucous or glairy, contain streaks of blood, 
and are passed with severe straining. At 
the same time the skin is hot and dry. 
3. Choleriform Diarrhoea. - Synon. : 
Choleraic diarrhoea; Thermic diarrhoea. This 
form prevails mostly in hot weather. The 
onset, indicated by vomiting and purging, is 
usually sudden. At first the vomited matters 
are mucous and bile-tinted, and the dejections 
are feculent-both quickly, however, becom- 
ing more and more abundant, watery, and 
colourless. The copious and incessant out- 
flow of serum may in a short time, and espe- 
cially in children, induce a striking resem- 
blance to the symptoms of Asiatic cholera- 
a drawn, sunken, and cyanotic appearance, 
loss of temperature, scanty secretion of urine, 
insatiable thirst, and cramps. Even in ex- 
treme cases, however, the fluids from the 
stomach and bowels are rarely free from bile, 
and are not so like rice-water as in true 
cholera. The collapsed algid condition, as 
a rule, rapidly gives place to recovery in 
previously healthy adults, while it is apt to 
become fatal in delicate children, children 
prematurely weaned, the debilitated, and the 
aged. Rarely, the cold stage being outlived, 
the patient becomes hot, and passes into a 
state of stupor, with either bilious vomiting 
or purging and tympanites-the typhoid 
stage. In children death is almost invari- 
able if the cold stage exceeds twenty-four 
hours. DIARRHCEA 
469 
4. Nervous Diarrhoea.-The peristaltic 
movements, and the activity of the glands, of 
the alimentary canal, are often increased by 
causes operating through the nervous system. 
Diarrhcea from mental, and especially emo- 
tional, perturbation, is the most common 
example. Even a chronic looseness may be 
maintained by debility of the nervous system, 
induced by worry and anxiety. Exalted in- 
nervation of the bowels may be natural, a 
proneness to diarrhoea from slight exciting 
causes having always existed; or acquired, 
when, for instance, a flux once established is 
apt to be maintained. The unstable nervous 
system of the periods of rapid development 
and of the climacteric change predisposes to 
it. It is often an important factor in chronic 
diarrhcea. The intestinal nerve-centres may 
become so sensitive (as in delicate children) 
that every meal, however small, may induce 
an immediate call to stool, the motions being 
liquid or pultaceous, and pale, but otherwise 
healthy. The peristaltic movements may 
be even so increased as to hurry the food 
through the stomach and bowels, so that it 
appears unchanged in the stools. Time is 
not allowed for digestion or absorption to be 
even begun. This form has been termed 
Diarrhoea lienterica, and is most frequent 
in children before the period of the second 
dentition. The increased tonicity of the 
muscular fibres of the alimentary tract may 
have resulted from previous inflammation of 
the mucous surface, or is the propagation 
upwards of some irritation (ulcer, inflamma- 
tion, &c.) of the mucous membrane of the 
rectum; or it arises from the products of 
imperfect primary digestion entering the 
duodenum. Indigestion is the usual cause 
in adults. The appetite is, as a rule, vora- 
cious ; and debility may become extreme. 
In painful or difficult dentition, diarrhoea 
arises from irritation of the nerves of the 
stomach and bowels; digestion is arrested; 
and the contents of the alimentary canal be- 
come acid from fermentation, and are ejected 
by vomiting and purging. 
5. Vicarious Diarrhoea. - Embarrass- 
ment or suppression of the functions of the 
skin, kidneys, or lungs may lead to the 
bowels performing additional excretory work. 
The flux thus set up is salutary, because 
compensatory. Diarrhoea from chills (sup- 
pressed perspiration) is a common instance, 
while that from renal and pulmonary causes 
is less frequently observed, and may be mis- 
construed by the practitioner. Inasmuch as 
diarrhcea usually diminishes the quantity of 
urine, even sometimes to the verge of sup- 
pression, the reverse of this clinical fact may 
be easily overlooked or misinterpreted. Even 
when forewarned, the observer may at times 
-especially when the urine is free from 
albumen - find it difficult to determine 
whether the diarrhcea is a cause or an effect 
of imperfect renal elimination : a distinction 
having all-important hearings on the treat- 
ment. The uraemic and eliminatory cha- 
racter of it may be easily decided when the 
kidneys are known to be diseased; not so, 
however, when the only thing ascertainable 
is scanty-may be albuminous-urine, or 
total suppression of urine in an elderly 
patient. In such a case there may or may 
not be organic disease of the kidneys, and 
still the diarrhoea may be uraemic, inasmuch 
as.it may depend on 'renal inadequacy.' 
Diarrhoea from pulmonary embarrassment 
generally affords relief to breathing and 
cough. The chronic looseness of some gouty 
patients is also eliminatory: when it is 
checked, gout is apt to advance, and the 
health to suffer. 
6. Diarrhoea from Mechanical Con- 
gestion. - Draining of serum into the 
bowels is a common result of overloading 
of the portal vein from an impediment to 
the flow of blood, either in the vein itself, 
the vena cava, or the right side of the 
heart. 
7. Chronic Diarrhoea. - Synon. : Ca- 
chectic diarrhoea.-Chronic diarrhoea is fre- 
quently, if not generally, unconnected with 
intestinal lesions. It may be maintained by 
chronic catarrh of the intestines, or by an 
exhausted and impoverished state of the 
system, as in inanition, either from insuffi- 
ciency of food or from enfeebled digestion, or 
in chronic wasting diseases, such as syphilis, 
malaria, or scurvy. The flux increasing, the 
debility on which it depends thereby per- 
petuates itself, arid this vicious circle tends 
more and more to destroy life by anaemia 
and exhaustion, and even after apparent 
recovery the diarrhoea has a strong disposi- 
tion to relapse. These clinical features of 
chronic diarrhcea are well illustrated by the 
malady which, from the paleness of the 
stools, is commonly known in India as 
' White Flux '-a result of deterioration of 
health by climate and malaria (see Psilosis). 
When accompanied by fever and night-sweats, 
chronic diarrhcea is nearly always due to 
tuberculisation. 
Diagnosis.-The different forms of diar- 
rhoea may be readily distinguished from each 
other by a careful consideration of the causes 
and symptoms. The diseases most apt to be 
mistaken for diarrhoea are epidemic cholera, 
dysentery, and mucous irritation of the bowels 
from retention of faeces. 
(a) Cholera, in its less definite forms, may 
resemble bilious diarrhcea and choleraic diar- 
rhoea. The probability in favour of it may 
be determined by the absence of ordinary 
causes of diarrhcea, the paleness and watery 
character of the stools, tormina being slight 
or absent, the suppression of urine, and the 
early exhaustion. The presence of bile in the 
stools is always in favour of diarrhcea. Vomit- 
ing is more frequent in cholera; when it oc- 
curs in diarrhoea the vomited matter usually 470 
DIARRHCEA 
contains bile and undigested food, while in 
cholera it is a colourless fluid. 
(6) Dysentery is usually characterised 
by fever, tormina, and tenesmus, and fre- 
quent scanty muco-sanguinolent evacuations. 
Sometimes, however, in the early stage, the 
motions are copious, watery, and feculent, as 
in ordinary diarrhoea; but the presence of 
tormina and tenesmus, and tenderness in the 
regions of the caecum and sigmoid flexure, 
indicate the dysenteric nature of the disease. 
Chronic diarrhoea may be distinguished from 
chronic dysentery by the absence of a history 
of acute dysentery, and of mucus and tenes- 
mus, and by the less frequent discharge of 
blood in the evacuations. 
(c) Mucous irritation of the bowels from 
retention of faeces may induce a condition 
resembling diarrhoea-frequent, thin, muco- 
feculent evacuations, which are, however, 
shown, on inquiry, to be somewhat scanty, 
and voided with straining. See Faeces, 
Retention of. 
Treatment.-(a) Diet and Hygiene.-In 
acute or occasional attacks of diarrhoea, 
everything should be taken in small quan- 
tity, and tepid or cold, never hot. Farinacea- 
arrowroot, sago, rice, tapioca, flour, and the 
like-are useful, and may be taken in milk, 
or in chicken or mutton broth, or weak beef- 
tea. Animal broths-and especially beef- 
tea-when concentrated, or in large quan- 
tity, are apt to aggravate diarrhoea. De- 
mulcent drinks-white of egg in water or 
milk, rice or barley or arrowroot water ; and 
astringent liquids-infusion of dried whortle- 
berries or roasted acorns, red light wines- 
may be given. Brandy is often of service, 
and may be giveft in an aromatic water or 
with the farinacea. Lime-water with milk is 
in many cases of much value. 
Rest in bed secures a uniform warmth of 
skin, and favours the cessation of diarrhoea. 
In children, errors of feeding should be 
corrected. Lumps of casein in the motions 
may be prevented by reducing the quan- 
tity of milk, or by adding thin arrowroot or 
barley-water, with or without lime-water or 
bicarbonate of sodium, to the milk; and by 
regulating the time between meals, providing 
a wet nurse, or substituting the milk of the 
goat or ass for that of the cow. In infantile 
diarrhoea the milk should be previously boiled 
and diluted-one part in two or three of 
barley-water-and given regularly every hour 
in small quantities (two or three teaspoonfuls). 
The feeding-bottle, when not in use, should be 
kept in a weak solution of permanganate of 
potassium. Sometimes, however, milk in any 
form must be given up, when barley-water 
or thin rice-water, sweetened by saccharin or 
milk-sugar, may be substituted. The abdomen 
should be protected by a flannel bandage, and 
the feet and legs by warm clothing. See 
Infants, Diseases of; and Dentition, Dis- 
orders of. 
Inasmuch as in chronic diarrhoea the flux 
is perpetuated by the debility and anaemia 
which it induces, and by the activity of in- 
testinal digestion, it has become a leading 
principle of treatment to prescribe food rich 
in materials for the construction of the blood 
and the tissues, and almost wholly disposed 
of by the stomach. Hence the happy results 
frequently observed from a diet exclusively 
animal, either raw or lightly cooked, the 
digestion of which may be aided by hydro- 
chloric acid, alone or with pepsin. Indi- 
vidual peculiarity may be gratified, and 
variety obtained from the use of mutton, 
veal, chicken, pigeon, and game. Beef, the 
tough parts of veal, and pork are, as a rule, 
to be avoided. Milk and farinacea are gra- 
dually permitted during the progress towards 
recovery, but the period during which they 
should be interdicted may require to be very 
prolonged-even months. The treatment with 
raw meat, strongly advocated by Trousseau 
and Niemeyer, has been successfully applied 
to nearly every variety of chronic diarrhoea, 
but especially to that obstinate form occurring 
from the time of weaning to the close of the 
first dentition. The meat may be pounded 
into a pulp or finely minced ; then mixed with 
salt, sugar, fruit jelly, or conserve of roses; 
or diffused through clear gravy soup, or cho- 
colate made with water or wine. Or the juice 
may be extracted from it by pressure. Not- 
withstanding the prohibition of other food, 
it is best to begin with a small quantity, and 
to increase it gradually. The only drink 
allowable is water containing white of egg. 
Trousseau found opium in small doses, chalk, 
and bismuth, at and between meals, to assist 
this regimen. When a restricted animal diet 
cannot be digested, causes loathing, or aggra- 
vates the flux, other varieties of food may be 
added, and the feeding should be as generous 
and varied as possible, and adapted to the 
digestion of the individual. Articles of diet 
appearing undigested in the motions should 
be avoided. Low and damp situations should 
be exchanged for dry and open ones. Warm 
clothing, flannel next the skin, and flannel 
waist-belts should be worn. Chronic diar- 
rhoea (lienteric and chronic tropical diarrhoea) 
has also been successfully treated by a strict 
milk diet and rest; and by rest along with 
massage.1 
(&) Medicinal Treatment.-The kind and 
degree of interference required should first 
be decided in each case of diarrhoea. A rou- 
tine prescription of astringents is much to be 
deprecated. When the flux is moderate and 
salutary-for example, removing undigested 
or indigestible materials or irritating secre- 
tions, relieving an engorged portal vein, or 
supplementing a suppressed secretion-it 
may be left uncontrolled by medicine, or 
may be encouraged by laxatives, such as 
castor oil, rhubarb, or a saline aperient, 
1 Eccles, Practitioner, Dec. 1890 and Jan. 1891. DIARRHCEA 
471 
combined with a mild sedative, such as hen- 
bane or opium. As a rule, the treatment of 
diarrhoea should begin by removing irritating 
substances from the alimentary canal by laxa- 
tives, guarded by small doses of opium; and 
astringents, such as chalk-mixture with kino, 
catechu, haematoxylum, and opium, should 
be held in reserve. The laxative may increase 
the flux, which, however, soon subsides. 
Trousseau advocated the use of salines- 
sodii sulphas, soda tartarata, magnesii sul- 
phas-in progressively decreasing doses, dis- 
solved in a small bulk of water, in the morn- 
ing, fasting, while others prefer castor oil, 
or rhubarb. Castor oil is by far the most 
useful remedy for children, as well as for 
adults. For the former it should be emulsi- 
fied in gum and syrup, for the latter in yolk 
of egg; and as occasion requires it may be 
combined with a small opiate, for example, 
compound tincture of camphor, or the wine or 
tincture of opium, in proper doses. 
In choleriform or summer diarrhoea, the 
best results are obtained from castor oil 
guarded by a small dose of laudanum at the 
commencement, and repeated if the disease 
is severe; while astringents and opiates alone 
are withheld until the bowels are relieved of 
offensive materials, as in the later stages, the 
stools being copious and watery, griping and 
distension of the abdomen absent, and the 
tongue clean. Vomiting should be encouraged 
by copious draughts of warm water, and, if 
need be, by emetics of mustard or ipecacuanha. 
In children, when the motions are colourless, 
profuse, and incessant, it is best to give hy- 
drargyrum cum creta in small doses every hour 
or two, and a very small enema of starch, 
containing plumbi acetas or cupri sulphas, 
with laudanum, which may be repeated if 
necessary. Remedies which are believed to 
arrest abnormal intestinal fermentation (such 
as naphthaline, calomel in small repeated 
doses, perchloride of mercury, potassio-mer- 
curic iodide, carbolic acid, resorcin, salol, 
salicylate of sodium) have lately been em- 
ployed with success in infantile and summer 
diarrhoea. Dr. Luff has obtained the most 
gratifying results from potassio - mercuric 
iodide, preferring the following formula: 
R Liquoris hydrargyri perchloridi Dpxij.; 
potassii iodidi gr. J ; chloral hydratis gr. j.; 
aquae ad 3j.; to be given every four hours to 
infants up to six months, and the dose to be 
doubled for children of more than one year 
old.1 In the cold stage there have been re- 
commended mustard baths (for twelve or 
fifteen minutes, several times a day); emetics 
(ipecacuanha 2 to 3 grains twice or three 
times in twenty-four hours); diffusible stimu- 
lants (ether in syrup every hour or half-hour). 
In the stage of reaction, saline aperients 
or calomel in small doses may be given; 
white of egg in water as a drink throughout; 
and, vomiting having ceased, and diarrhoea 
being established, bismuth, chalk or lime- 
water. 
In nervous diarrhoea the first indication is 
to allay reflex excitability by the bromides; 
or, these failing, by opium. When diarrhoea 
is excited by food, the dose should be given 
shortly before meals. In lienteric diarrhoea 
arsenic is invaluable. Mal-digestion should 
be met by hydrochloric acid, bismuth with 
alkalis, or other appropriate remedies, ac- 
cording to the indications. Occasional doses 
of castor oil - alone, or with bismuth or 
small doses of opium or henbane-are useful 
in clearing away fermentescible matters, 
which are apt to maintain an irritable state 
of the bowels. Astringents should only be 
prescribed after the failure of these or similar 
measures. 
In vicarious diarrhoea the skin should be 
made to act freely by warm baths, or hot 
air or vapour baths. In renal inadequacy 
counter-irritation across the loins, digitalis, 
and nitrate of potassium may be likewise indi- 
cated. The diarrhoea should not be arrested 
or even checked unless it be profuse and ex- 
hausting, especially after restoring or aug- 
menting the action of the skin and the kid- 
neys ; it is sometimes advisable to nurse and 
encourage it. 
Diarrhoea from passive congestion of the 
portal vein is to be met by treating the cause, 
for example, disease of the heart, by digitalis, 
iron, and other remedies. 
The flux of chronic diarrhoea (lienteric 
and the chronic tropical diarrhoea known 
as sprue or psilosis) cannot, as a rule, be 
stopped altogether by astringents only-the 
evacuations while thus retained may decom- 
pose, and induce flatulence and colic, or fever. 
The general health should be restored and 
anaemia removed; the secretions will then 
generally improve and the diarrhoea subside. 
Tonics-iron, arsenic, quinine, strychnine - 
may be aided by astringents -mineral acids, 
opium, bismuth, chalk, or haematoxylum. 
The best preparations of iron are iron-alum 
-3 to 5 grains, and liquor ferri pernitratis- 
10 to 40 minims. Ipecacuanha and taraxa- 
cum are useful when the skin and liver are 
inactive: from 1 to 3 grains of powdered ipe- 
cacuanha may be given night and morning. 
Podophyllum-2 or 3 minims of a solution 
of 1 grain in 1 drachm of rectified spirit 
three or four times a day-is indicated when 
the motions are watery, pale or high-coloured, 
and passed with severe cutting pains. Saline 
purgatives in the early morning have been 
recommended-2 drachms of sulphate of 
sodium, sulphate of magnesium, or soda tar- 
tarata on the first day; then 1 drachm for four- 
teen days, dissolved in a small bulk of water, 
with avoidance of fluids after the dose. Lately 
Mr. Begg has reported successful results in 
the treatment of chronic tropical diarrhoea by 
santonin (the yellow crystals) gr. v., well mixed 
in a teaspoonful of olive oil, given in the early 
1 Lancet, Dec. 20,1890. 472 
DIARRHCEA 
DIET 
morning or at bedtime for six days.1 The 
profuse sweating and colliquative diarrhcea 
of hectic is best met by heematoxylum and 
diluted sulphuric acid, or opium with astrin- 
gent mineral salts-nitrate of silver, sulphate 
of copper, or acetate of lead-given by the 
mouth or rectum. 
Suppressed secretions, particular cachexiae, 
disturbed innervation, congestion of the por- 
tal vein, and organic diseases of the intestines, 
form special indications for treatment when 
diarrhoea is present. 
George Oliver. 
DIATHESIS (^laridqyi, I dispose).-A 
morbid constitution, predisposing to the de- 
velopment of a particular disease. See Con- 
stitution, with which, in a somewhat more 
limited sense, this term is synonymous. 
DIATHETIC DISEASES.-Consti- 
tutional diseases. See Constitutional Dis- 
eases. 
DICROTISM (8is, double ; and Kporos, a 
stroke) is a term applied to the second great 
wave of the pulse. This dicrotic wave, or 
dicrotism, is due to a second expansion of 
the artery which occurs during the diastole of 
the ventricle. The pulsus bis feriens of old 
authors was a pulse in which a second beat 
became perceptible to the finger; an occur- 
rence observed occasionally as an antecedent 
of haemorrhage, and also in the course of 
fevers. The second beat perceived by the 
finger is not always the true dicrotic wave, 
but may in some cases be an exaggerated 
tidal wave. This is the wave perceived in the 
high arterial tension sometimes antecedent 
to haemorrhage. Dicrotism is favoured by a 
low state of arterial tension, by elasticity of 
the arterial coats, and by quick and strong 
ventricular contractions. It is central in its 
origin, and is a secondary wave of pressure 
produced in the blood-column by the elastic 
recoil of the aorta after its distension by the 
blood injected at each ventricular systole. 
The recoil of the aorta causes the wave to 
spring towards the periphery from the closed 
aortic valves as a point d'appui. See Pulse. 
B. Walter Foster. 
DIET.-Definition.-The term 'diet ' as 
here employed may be understood to express 
the regulation of food to the requirements of 
health and the treatment of disease. 
General Principles.-In order to sustain 
life, a diet must consist of a proper appor- 
tionment of the following alimentary princi- 
ples :- 
1. Nitrogenous principles. 
2. Non-nitrogenous principles (fats, carbo- 
hydrates, &c.) 
3. Inorganic materials (saline matters and 
water). 
Whilst these principles hold different relative 
positions of value, the absence or deficiency 
of either group will render a diet unfit for the 
support of life. Milk, the product provided 
by Nature as the sole article of sustenance 
during the early period of the life of mammals, 
may be regarded as furnishing us with a 
typical dietetic representative of all these 
principles. The egg also holds a like posi- 
tion, and, as all the parts of the young animal 
are evolved from it, must needs comprise all 
the materials for the development and growth 
of the body. 
The required principles are contained in 
food derived from both the animal and 
vegetable kingdoms, and the diet may be 
drawn from either; but, looking to man's 
general inclination and the conformation of 
his digestive apparatus, it may be assumed 
that a mixed diet is that which is designed in 
the plan of Nature for his subsistence, and it 
is that upon which he attains the highest 
state of physical development and intellectual 
vigour. 
Animal food, being identical in composition 
with the body to be nourished by it, is in a 
state to be more easily appropriated than 
vegetable food. It also appeases hunger 
more thoroughly and satisfies longer: in other 
words, it gives, as general experience will 
confirm, a feeling of greater stay to the 
stomach. Animal food possesses stimulant 
properties which have sufficed in certain in- 
stances, as after starvation, and in those 
accustomed to a vegetable diet, to produce a 
state allied to intoxication. This stimulating 
effect is further illustrated by looking at the 
relative character of animal and vegetable 
feeders. Liebig says that it is essentially 
their food which makes carnivorous animals 
in general bolder and more combative than 
the herbivora which are their prey. He then 
relates that a bear kept at the Anatomical 
Museum of Giessen showed a quiet gentle 
nature as long as it was fed upon bread, but 
a few days' feeding on meat made it vicious 
and dangerous. 
The standard diet framed by Moleschott 
has been accepted as furnishing a model of 
what maybe considered the requisite propor- 
tion of alimentary principles for maintaining 
health in a person of average stature under 
exposure to a temperate climate, and the per- 
formance of a moderate amount of muscular 
work. It runs as follows:- 
Alimentary substances in a dry state 
required daily. 
Dry Food 
Albuminous matter . 
Fatty matter . . 
Carbohydrates . . 
Salts . • • • 
In ounces avoir. 
. 4-587 
. 2-964 
. 14-250 
. 1-058 
22-859 
This, it will be seen, furnishes a supply of 
about 23 ounces of dry solid matter, of which 
1 Practitioner, Jan. 1891. DIET 
473 
one-fifth is nitrogenous. If we reckon that 
ordinary food contains about 50 per cent, of 
water, then 23 ounces will correspond to 46 
ounces of solid food in the condition in which 
it is consumed. To complete the alimentary 
ingesta, a further quantity of from 50 ounces 
to 80 ounces of water may be assumed to be 
required to be taken daily under some form 
or other. 
For a life of inactivity, it must be stated 
that a much smaller amount of food will 
suffice. The diet, for instance, which is 
ordinarily supplied to the patients of Guy's 
Hospital, and which suffices to satisfy and 
properly sustain them, only contains about 
30 ounces of solid food, equivalent to about 
17 ounces of water-free material. 
It has been mentioned that there are 
reasons for regarding a mixed diet of animal 
and vegetable food as best adapted to our 
nature, and it may probably be considered 
that the most suitable admixture contains 
about one-fourth or rather more of animal 
food. 
Looked at from the following point of view, 
it will be seen that an admixture of animal 
and vegetable food more economically sup- 
plies what is wanted than either kind taken 
alone, unless the adjustment should be made 
with the proper apportionment of fat as a 
representative of a non-nitrogenous article. 
It is estimated that for a man of medium 
stature, and performing a moderate amount 
of work, about 300 grains of nitrogen and 
4,800 grains of carbon are required to be in- 
troduced daily into the system with the food, 
to compensate for the outgoing of these ele- 
ments that occurs. Now this is yielded, as 
nearly as possible, in the case of both ele- 
ments, by 2 lbs. of bread and J lb. of meat- 
that is, 44 ounces of solid food, of which about 
one-fourth consists of animal matter. If the 
lean of meat only were consumed, rather over 
6 lbs. would be needed to furnish the requisite 
amount of carbon, and there would be a very 
large surplus of unutilisable nitrogen; whilst 
if bread only were taken, the amount ne- 
cessary to supply the requisite quantity of 
nitrogen would be rather more than 4 lbs., 
and this contains nearly double the amount 
of carbon wanted. 
In order to preserve health it is necessary 
that a portion of the food consumed should 
be in the fresh state, and this applies to both 
animal and vegetable food. There may be 
no lack of quantity, and yet disease and death 
may be induced by inattention to this fact. 
Affections of the scorbutic class are produced, 
which can only be checked and removed by 
the supply of fresh food or the juice of some 
kind of succulent vegetable or fruit. The 
efficacy of lemon and lime juice, for instance, 
is well known in the prevention and cure of 
scurvy. 
Climate influences the demand for food, and 
instinct leads to the adaptation of diet to the 
requirements that exist. Not only is there a 
correspondence between the amount of food 
required and the inclination for taking it, 
but the nature of the food selected in different 
countries varies and stands in harmony with 
that which is most in conformity with what 
is needed. The dwellers in the arctic re- 
gions, besides consuming a large quantity of 
food, partake of that kind which abounds in 
the most efficient form of heat-generating 
material-namely, oleaginous matter. In 
the tropics, on the other hand, it is upon 
vegetable products, largely charged with 
principles belonging to the carbohydrate 
group, that the native inhabitants mainly 
subsist. 
Labour necessitates a supply of food in 
proportion to the amount of work done. The 
employer finds that the appetite of a work- 
man may be taken as a measure of capacity 
for work-in other words, that a falling off of 
the appetite means a diminished capacity for 
the performance of labour. 
Until recently it was considered, in accord- 
ance with the teaching of Liebig, that mus- 
cular and nervous action resulted from an 
oxidation of muscular and nervous tissue, 
and that according to the amount of action 
occurring, so was there created a demand for 
the supply of nitrogenous alimentary prin- 
ciples to replace the oxidised material. It is 
now held, however, that the non-nitrogenous 
elements of food contribute, as well as the 
nitrogenous, to the production of muscular 
and nervous force. Fick and Wislicenus 
undertook a known amount of work upon a 
non-nitrogenous diet, and proved that the oxi- 
dation of their muscular tissue, as measured 
by the amount of nitrogen voided with the 
urine, sufficed only for the production of a 
small proportion of the force expended in the 
accomplishment of the work performed. 
The muscles, in reality, appear to stand in 
the position of instruments for effecting the 
conversion of the chemical energy evolved 
by the oxidation of combustible matter into 
working power. Fats and carbohydrates 
can furnish the combustible matter required, 
and, under ordinary circumstances, pro- 
bably do largely, if not chiefly, supply it. 
Nitrogenous matter can do so likewise, but 
it has to undergo a preparatory metamorpho- 
sis for effecting the separation of nitrogen in 
a suitable form for elimination. It must be 
said, however, that experience shows that 
hard work is best performed under a liberal 
supply of nitrogen-containing food. The ex- 
planation of this probably is that it leads to 
a better-nourished condition of the muscles 
and of the body generally. Under the use, 
for instance, of animal food, which is charac- 
terised by its richness in nitrogenous matter, 
the muscles are observed to be firmer and 
richer in solid constituents than under sub- 
sistence upon vegetable food. 
Persons who lead a sedentary and indoor 474 
DIET 
life naturally require less food than those en- 
gaged in active work, and less should be con- 
sumed by them to prevent the system be- 
coming clogged with effete products, which 
act perniciously in various ways upon the 
body. The food should also be largely con- 
stituted of non-nitrogenous principles, as these 
tax the excretory organs less than the nitro- 
genous. 
The diet of infants is a branch of dietetics 
the importance of which can scarcely be over- 
rated. The proper food during the first 
period of infancy is that which has been pro- 
vided by Nature for the young of mammals- 
namely, milk. Up to about the eighth month 
the infant is designed to be sustained solely 
by its parent's milk. The teeth, which ordi- 
narily begin to show themselves about this 
time, indicate that some solid matter should 
now be consumed, and one of the farinaceous 
products will be the most suitable with which 
to commence. Bread, baked flour, plain bis- 
cuit, or one of the numerous kinds of nursery 
biscuits that are made, may be employed for 
a time as a supplement to the former food. 
At about the tenth month the mother, who 
ought previously to have commenced lessen- 
ing her own supply, should now cease it alto- 
gether. As the child advances through its 
second year, and the teeth become more de- 
veloped, meat, preceded for awhile by gravy, 
may be given. If the mother cannot suckle 
her child, and if a wet nurse, whose supply 
stands next best to that of the mother, can- 
not be provided, the milk of one of the lower 
animals should be obtained, and that of the 
cow gives the nearest approach to what is 
wanted. Cow's milk, however, is richer in 
all its solid constituent principles than 
woman's, and the addition of a solution of 
sugar or-what is more in conformity with the 
natural supply-sugar of milk (lactose), in the 
proportion of an ounce to three-quarters of a 
pint of water, is needed to bring the two into 
closer approximation. The milk of the goat 
is even richer in solid constituents than that 
of the cow, and therefore stands somewhat 
further removed from that of the human sub- 
ject. If, however, it is not adapted for in- 
fants, it is highly useful for improving the 
condition of badly nourished children, and 
is sometimes employed for this purpose. 
Therapeutical Applications.-The ap- 
plication of the principles of dietetics may 
be successfully brought into use in the treat- 
ment of corpulency and thinness. A diet 
rich in nitrogenous matter, conjoined with 
exercise, promotes the growth of muscle, but 
the fat undergoes no increase. The condi- 
tions most conducive to an increased accu- 
mulation of fat are a diet rich in either fat or 
carbohydrates (provided the requisite amount 
of nitrogenous matter be present for afford- 
ing what is wanted for the nutritive opera- 
tions of life), exposure to a warm atmosphere, 
and inactive habits. A supply of fat in a 
direct manner leads to an increased depo- 
sition of fat in the system, but the carbo- 
hydrates require in the first place to undergo 
assimilative change before they can be ap- 
plied in the same direction. 
The details of the dietary to be prescribed 
where the aim is to produce increased stout- 
ness and an improved condition of the body, 
should comprise such articles as fat meats, 
butter, cream, milk, cocoa, chocolate, bread, 
potatoes, farinaceous and flour puddings, 
oatmeal porridge, sugar and sweets, sweet 
wines, porter, stout, and ales. 
The converse mode of dieting is necessary 
for reducing stoutness. Mr. Banting, by his 
noted system of dieting, reduced his weight 
from 14 st. 6 lbs. to 11 st. 2 lbs. in about a 
year. Besides altering, however, the charac- 
ter of his food, he limited the quantity in a 
manner that must have contributed an im- 
portant share towards producing the effect 
observed - not more than twenty-two to 
twenty-six ounces of solid food (corresponding 
with eleven to thirteen ounces of water-free 
material) being consumed, according to his 
statement, in the twenty-four hours. 
As a guide to the corpulent, it may be said 
that the fat of meat, butter, cream, sugar and 
sweets, pastry, puddings, farinaceous articles- 
as rice, sago, tapioca, &c., potatoes, carrots, 
parsnips, beetroot, sweet ales, porter, stout, 
port wine, and all sweet wines, should be 
avoided, or only very sparingly consumed. 
"Wheaten bread should only be partaken of 
moderately, and brown bread is to some ex- 
tent better than white. The gluten biscuits 
which are prepared for the diabetic may, on 
account of their comparative freedom from 
starch, be advantageously used as a substitute 
for bread in the treatment of obesity. The 
articles that may be taken to the extent of 
satisfying a natural appetite are lean meat, 
poultry, game, eggs, green vegetables, succu- 
lent fruits, light wines, dry sherry, and spirits. 
Milk should only be taken sparingly. 
Holding the position that food does in rela- 
tion to the operations of life, the art of dietetics 
not only bears on the maintenance of health, 
but is capable of being turned to advant ageous 
account as a therapeutic agency; and it is 
not too much to say that success in the treat- 
ment of disease is oftentimes dependent upon 
a display of judicious management in regard 
to food. 
In the therapeutic application of dietetics 
the maxim should be held in view that, whilst 
the particular requirements are secured, there 
should otherwise be no greater deviation from 
what is natural than the special circumstances 
of the case demand. 
The quantity of food consumed may re- 
quire to be regulated as well as its nature. 
The quantity administered at a time should 
stand in relation to the power of digesting it; 
and to properly compensate for a diminished 
capacity for taking quantity there should be DIET 
475 
a corresponding increase in the frequency of 
administration. ' Little and often ' is the 
maxim to be followed upon many occasions, 
and much will sometimes depend upon the 
strictness with which it is acted up to ; for, 
apart from harmonising with what is wanted, 
upon the principle that has just been referred 
to, it meets the defective aptitude that exists 
in sickness for sustaining any lengthened dura- 
tion of abstinence from food. 
In febrile, acute inflammatory, and other 
conditions where there is a failure of digestive 
power, the food administered should be such 
as not to tax the stomach, and should there- 
fore consist of liquid materials. • Solid matter 
by remaining undigested-and solids of an 
animal nature are particularly likely to do so 
-would act as a source of irritation in the 
stomach, and only serve to aggravate the con- 
dition of the patient. The articles under such 
circumstances to be selected from are beef- 
tea, mutton-, veal-, or chicken-broth, whey, 
calfs-foot and other kinds of jelly, arrowroot 
and such-like farinaceous articles, barley 
water, rice mucilage, gum water, fruit jelly, 
and the juice of fruits, as of lemons, oranges, 
&c., made into drinks. Where a little latitude 
is allowable, the employment of milk and of 
eggs in a fluid form may be sanctioned. As 
circumstances permit, an advance may be 
made to solid substances which do not throw 
much work on the stomach, as rice, sago, 
tapioca, bread and custard puddings, and 
stale bread or toast sopped. Next may be 
allowed fish, beginning with whiting. As 
power becomes restored, calves' feet, chicken, 
game, and butcher's meat-mutton to begin 
with-may be permitted to follow. 
In cases of ordinary dyspepsia the aim of 
the physician should be rather directed to 
raising, by appropriate treatment, the digestive 
capacity to the level of digesting light but 
ordinary food, than to reducing the food to an 
adjustment with a low standard of digestive 
power. Of butcher's meat, mutton is almost 
invariably found to be the most suitable; 
chicken and game are allowable, also white 
fish (boiled or broiled), particularly whiting, 
sole, flounder, and plaice. Stale bread, dry 
toast, plain biscuits, floury potatoes, rice, and 
the various farinaceous articles form the kind 
of food derived from the vegetable kingdom 
to be selected. Green and other succulent 
vegetables, it is found, are more apt to create 
flatulence than other kinds of food, and 
articles belonging to the cabbage tribe are 
particularly to be regarded as obnoxious to 
those who have a tendency to this form of 
derangement. 
Much depends in cases of weak digestion 
upon the state in which the food reaches the 
stomach. Thorough mastication affords great 
assistance to the performance of digestion; 
and when the teeth are bad, the food should 
be finely minced, or otherwise minutely 
divided, before being eaten. Regularity in 
the periods of taking food tends to promote 
the orderly working of the digestive organs. 
An interval of more than four or five hours' 
duration between the meals is to be avoided, 
as it acts perniciously in several ways. By 
inducing an exhausted state of the system it 
diminishes the energy of the digestive organs, 
and whilst having this effect it at the same 
time calls for the periodical exercise of in- 
creased energy, on account of the larger 
amount of food which must be taken at each 
meal to compensate for the length of time 
that is allowed to elapse between them. 
In cases of ulcer of the stomach, acute 
gastric catarrh, and vomiting, the food must 
he selected from that which is nutritious and 
which atthe same time taxesleastthe digestive 
powers. Milk-and this is often better borne 
after being boiled-milk and water, or milk 
and soda-water, will frequently be found to 
be tolerated when other articles excite irrita- 
tion and are returned. Sometimes the milk 
may be advantageously mixed with isinglass, 
arrowroot, ground rice, or biscuit powder. 
In dysentery and other forms of ulcerative 
disease of the intestine, scrupulous attention 
must be paid to diet. The food should con- 
sist of articles which are known to exert the 
least stimulant and irritant action on the 
mucous membrane and muscular coat of the 
alimentary canal, and those which best 
meet the demand in question are such as 
milk, isinglass, and the various farinaceous 
products, amongst which rice is pre-eminently 
valuable. Next to these come eggs, white 
fish, white-fleshed poultry, fresh game, and 
fresh meat. Salted and dried meats are 
highly objectionable, and fruits and succulent 
vegetables, with the exception of a floury 
potato, should be strictly shunned. See Pep- 
tonised Food. 
The development of gout is known to be 
favoured by the consumption of a highly 
nitrogenised diet, especially if conjoined 
with sedentary habits. With those who have 
already experienced symptoms of the disease, 
and those also who have grounds for appre- 
hending its invasion, it is important that an 
excess of nitrogenous food should be avoided. 
The diet should be simple, in order that the 
temptation may be avoided of eating too 
much, and should at the same time be 
adjusted to the mode of life. The principle 
to observe is that the higher the degree 
of inactivity the greater ought to be the pre- 
ponderance of food derived from the vege- 
table kingdom. 
Even of more importance than what is 
eaten is what is drunk, where the question 
of gout is concerned; and observation shows 
that it is not distilled spirits, but the stronger 
wines and malt liquors, which favour the 
production of the disorder. Nothing is more 
potent than port wine in leading to the pro- 
duction of gout, and a few years' liberal 
indulgence in it has often been known to be 476 
DIET 
DIGESTION, DISORDERS OF 
instrumental in bringing on the disease 
where no family predisposition had existed. 
Dry sherry and the light wines, as claret, 
hock, &c., may be drunk, certainly in modera- 
tion, with comparatively little or no fear of 
inducing the disease, although any kind of 
wine appears capable of sometimes acting as 
the exciting cause of a paroxysm where the 
gouty disposition is already established. 
Stout, porter, and the stronger ales, espe- 
cially those that have become hard from 
age, rank next to port wine in their power 
of predisposing to gout. As regards the light 
bitter beers, which are so extensively used at 
the present time, the same must be said of 
them as of the light wines, viz. that with 
little, if any, disposition to induce the disease, 
they nevertheless appear capable of some- 
times exciting its manifestation in a gouty 
subject. A pure spirit, as whisky, hollands, 
or brandy, diluted with water, often forms 
the only kind of alcoholic drink that is found 
to agree with those who are suffering from 
gout. 
In Bright's disease with threatening urae- 
mic poisoning it is a point of consideration 
to diminish as far as practicable the amount 
of excretory matter to be eliminated by the 
kidneys. The fats and carbohydrates throw 
no work upon the kidneys. Their products 
of destruction escape through another chan- 
nel. Nitrogenous matters, on the other 
hand, undergo metamorphosis in the system, 
and yield nitrogen-containing compounds-■ 
chiefly urea-to escape by the kidneys. In 
this way the kidneys become taxed by nitro- 
genous food, and, to lessen the work demanded 
of them, reason suggests that the diet should 
preponderate in food, derived from the vege- 
table kingdom. 
In diabetes mellitus there is a want of 
assimilative power over the saccharine and 
starchy principles of food. "Whilst these 
principles become utilised and lost sight of 
when ingested by a healthy person, in the 
system of the diabetic they fail to become 
consumed, but pass off under the form of 
sugar in the urine, giving rise to severity of 
symptoms in proportion to the amount of 
sugar escaping. Much may be done towards 
subduing the symptoms of the disease by a 
properly arranged dietetic scheme, and the 
principle upon which it requires to be 
framed is the exclusion, as far as practicable, 
both from what is eaten and what is drunk, 
of articles containing saccharine or starchy 
matters. 
Observation has shown that the reaction of 
the urine is susceptible of being influenced 
by the character of the food. The effect of 
animal food is to increase the acidity of the 
secretion, whilst that of vegetable food is to 
diminish it, and even, it may be, to produce 
alkalinity. Hence, on persons affected with 
the lithic-acid diathesis, benefit is conferred 
by a plan of diet in which animal food is 
limited, and succulent vegetables and fruits, 
with the light wines, as claret, hock, &c., are 
freely supplied. On the other hand, with the 
phosphatic diathesis, the converse principle 
of action should be adopted. 
F. W. Pavy. 
DIGESTION, Disorders of.-The 
function of digestion is of a physico-chemical 
nature, being compounded of certain mus- 
cular acts, and of certain processes exercised 
by the digestive fluids on the ingesta, which 
are thereby converted into a fluid and diffusi- 
ble state. 
Any interference with the due performance 
of the several components of the function 
will lead to indigestion; and though it may 
for convenience be desirable to consider these 
disturbances separately, it must be remem- 
bered that the occurrence of one condition is 
apt to be quickly associated with another, 
and hence the forms of dyspepsia as they 
usually present themselves are of a complex 
nature, however simple the primary fault 
may have been. It appears to the writer to 
be very undesirable to restrict the application 
of the term indigestion or its synonym dys- 
pepsia to the perverted actions of any one 
part of the alimentary system, such as the 
stomach, or to any one special morbid state, 
such as gastric or intestinal catarrh; but 
rather that it should include all departures 
from normal function which any part of the 
digestive tract may present. Nor is it possi- 
ble to consider irregularities of digestion only 
from the point of view of the organs imme- 
diately concerned. Complicated as our or- 
ganism is, disturbances of other functions will 
speedily make themselves felt in the one under 
consideration; and failures in the absorption 
of the digested food, or in its subsequent 
metabolic changes and elimination, will tell 
back sooner or later on that process which 
is, strictly speaking, limited to its prepara- 
tion. 
Causes of Dyspepsia.-Dyspepsia may be 
immediately traced to (1) the food; (2) dis- 
turbances of the so-called mechanical pro- 
cesses-namely, the muscular acts, solution, 
&c.; (3) deficiencies in the chemical changes 
exercised by the digestive secretions; or (4) 
imperfect absorption of digested products. 
It is to be understood that the three last-men- 
tioned groups of causes which bring about 
indigestion are determined by certain gross 
or minute abnormal changes in the struc- 
tural tissues of the organs concerned, as 
described in the article Digestive Organs, 
Diseases of the. 
1. Imperfections of Food.-Imperfec- 
tions of food, whether in quality or quantity, 
are among the most frequent causes of diges- 
tive disorders. A thorough knowledge of the 
principles of dietetics is essential, that the 
errors may be recognised and remedied. 
Since our digestive capability is limited, it DIGESTION, DISORDERS OF 
477 
is obvious that, when those limits are over- 
stepped, the domain of disease is entered 
upon; and although no very absolute lines 
may be laid down for universal application, 
the general rules for quantity and kind are 
capable of being stated. See Diet. 
(a) Deficiency of Food.-Except under 
rare conditions, such as famine, &c., this is 
not a common cause of disease. Of the 
signs and symptoms of starvation it is not 
needed here to treat. But there are fre- 
quent occasions when, with no deficiency in 
the total bulk of food taken, there is yet 
a serious want in one or perhaps more of 
the needful alimentary principles, and this 
is especially liable to occur in the feeding 
of children. Setting aside those gross cases 
of cruelty, when infants and the youngest 
children are fed almost from their birth 
with bread, broth, or even meat, there are 
still too often to be met with children 
whose diet-scale is almost entirely wanting 
in nitrogenous matter. Fed chiefly upon 
infants' foods, the latter consisting of little 
more than starchy material, their tissues are 
ill-formed for the want of proteids, which, 
during the period of growth, are required in 
a larger relative proportion. The relationship 
of rickets to prolonged suckling, with the 
accompanying deficiency in necessary food- 
stuffs, is now generally recognised. 
The effect of a deficiency of food is a gene- 
ral state of malnutrition, in which any here- 
ditary tendencies to disease that may exist 
have a more favourable field for development. 
There is a gradual diminution in the weight 
of the body, and an imperfect performance of 
its functions, as indicated by muscular weak- 
ness, mental lassitude, &c. 
The specially dyspeptic symptoms referable 
to a want of food are, mainly, perversions of 
sensation, such as a feeling of sinking, emp- 
tiness, or even pain at the epigastrium, or 
generally in the abdomen. Constipation is 
frequent from lack of stimulus to normal 
peristalsis, and it is probable that the diges- 
tive secretions are defective in quality and 
quantity, thereby causing imperfect digestion 
of the food that is taken. A weak digestion 
is not seldom due to want of the needful 
stimulation of sufficient food. 
The deficiency in food taken may result 
not so much from a defective supply of nutri- 
ment, as from a disinclination to eat, a com- 
mon symptom of many diseases, especially 
febrile states; self-imposed fasting too fre- 
quent or prolonged; the anorexia of the 
hysterical temperament; or from obstruction 
to the entrance of food into the stomach 
from stricture of the oesophagus. Or the appe- 
tite may be impaired by over-indulgence in 
alcohol or tobacco. See Appetite. 
(3) Excess of Food.-There is very little 
doubt but that more food is daily in the habit 
of being taken than is actually required to 
restore the tissue-waste, most active lives 
being led on an amount far below what is 
ordinarily regarded as being necessary ; and 
there is equally little doubt that much of 
what is taken is not in the most digestible 
form. It is open to question whether the 
appetite would be satisfied by the ingestion 
of merely sufficient to balance the waste, 
particularly if the gross bulk of the food 
taken were diminished by the removal, as 
far as possible, of all indigestible matters, 
leaving little more than the needful alimen- 
tary principles. At the same time it must 
not be forgotten that the appetite is very 
easily controlled by custom, and determina- 
tion can in time overcome a vicious habit. 
An habitual excess of food, at least in this 
country, usually errs in the disproportionate 
amount of nitrogenous matter it contains. 
Remembering the relatively small quantity 
of this principle that is essential, and in 
what a number of the ordinary articles of 
diet it occurs, this statement will be the 
more readily accepted. Since all the proteid 
principles require, to fit them for absorption 
into the blood, a considerable amount of 
chemical alteration, and, physiologically 
speaking, there is good reason to believe 
that the subsequent metabolic changes of 
these matters, when absorbed, are more 
complex than those undergone by fats and 
amyloids, it would follow that the organs 
concerned in effecting these changes are 
very prone to suffer from overwork and its 
sequelae. Also many of the substances result- 
ing from the metabolism of nitrogenous 
matter are liable to become positive poisons 
in the economy, and the proper elimination 
of such materials is specially provided for 
by such organs as the kidneys and skin. The 
frequency with which these organs become 
the seat of disease may at least indicate the 
probability of errors of diet being an impor- 
tant factor in determining the morbid changes, 
especially as considerable relief is often the 
result of a restriction of nitrogenous food. 
There can be little doubt but that the large 
group of diseases associated with failure in 
elimination of nitrogenous waste has for a 
prominent cause an habitual excess of nitro- 
genous food. 
The results of an excessive ingestion of 
food are as numerous as they are diverse. 
In many cases there does not seem to -be 
either impairment of health or shortening of 
life. In some obesity and in others leanness 
ensues. In a large majority of individuals 
whose food is much in excess of their wants, 
particularly if the exercise taken be but little, 
there are variable symptoms of indigestion, 
such as a general feeling of lassitude and 
want of energy, both muscular and mental, 
a liability to headaches chiefly frontal, con- 
stipation, or more rarely diarrhoea, high- 
coloured urine depositing abundance of 
urates, a general disposition to sleep, vari- 
ous skin-eruptions, particularly acne, and not 478 
DIGESTION, DISORDERS OF 
infrequently a feeble heart's action from com- 
mencing fatty degeneration of its substance. 
Any or all of these symptoms may exist, and 
may be more or less completely relieved by 
a restricted diet. It is impossible to lay 
down any exact rules for the quantity of food 
that should be daily consumed; though it is 
desirable to remember that the tendency is 
to take too much, at the same time that age, 
season of year, and occupation are all circum- 
stances determining variations both in quan- 
tity and kind. 
(y) Improper Food.-Setting aside those 
extreme cases of perverted appetite occasion- 
ally seen in the hysterical condition, there 
yet remains a very constant violation of the 
dietetic proprieties. These errors may be 
classed under the following heads1. Sub- 
stances which are indigestible; either essen- 
tially so, or from imperfect preparation 
(cooking, &c.) 2. Substances which, though 
digestible, are innutritious or even poisonous. 
In the first group are included such bodies as 
the pips and seeds as well as the skins and 
rinds of fruits, the husks of corn and bran, 
the stalks and fibres of leaves, and gristle, 
elastic tissue, and hairs in animal food. For 
the reducing of these to a fluid and diffusible 
condition no chemical arrangement exists in 
the human organism, and they are voided 
very much in the same state as they are 
swallowed. Many articles of diet depend in 
great part for their digestibility on their 
proper preparation by division, cooking, &c. 
Thus most vegetables when taken in the raw 
state are but imperfectly digested, and such 
nutritious food as potatoes becomes when 
uncooked positively harmful. The apparent 
value of raw green vegetables, as lettuce, 
endive, cress, &c., would seem to depend on 
the peculiar condition of their mineral con- 
stituents, rather than on the vegetable tissues. 
Such substances as the above-mentioned 
are apt to produce perversions of digestion in 
virtue of the mechanical irritation they give 
rise to, indicated by more or less pain of a 
griping character (colic), and frequently ac- 
companied by diarrhoea. The constant in- 
gestion of the more formidable may even set 
up a gastro-enteritis, acute or chronic. Occa- 
sionally articles of food, such as brown bread, 
oatmeal porridge, &c., are taken for the very 
aperient action they induce, owing to the 
irritating nature of the indigestible husks 
they contain. Symptoms of acute dyspepsia 
very frequently follow the taking of meat 
foods enveloped in greasy sauces, since the 
fat, being undigested in the stomach, prevents 
the action of the gastric juice on the proteid 
matter, which then passes on into the intes- 
tines, setting up irritation like any other in- 
digestible substance. The most interesting 
among those articles of diet which, though 
easily digested, may be poisonous, are those 
producing their effects only on certain indi- 
viduals. Such, for example, are certain 
mushrooms, shell-fish, or indeed any fish. 
Remarkable cases are authentically recorded 
of serious and even fatal results following 
their ingestion. The symptoms may be 
those of an acute gastro-enteritis; or, as is 
very frequently the case, an urticaria is the 
result, with or without swelling of the eyes 
and throat. Severe nervous prostration has 
been met with occasionally. Be it under- 
stood that other people have partaken of the 
same diet with no ill results. The writer is 
acquainted with a gentleman who for many 
years was unable to remain in the room 
when fish of any kind was on the table, its 
presence inducing severe vomiting, abdo- 
minal pain, and general illness; and although 
the effects are now but slight from the mere 
smell of such food, very marked symptoms 
follow on partaking of any. The most diges- 
tible and nutritious articles of food may de- 
termine indigestion when taken too hot or 
too cold. 
Finally must be included those substances 
which accidentally find their way into the 
alimentary canal with the food, as entozoa, 
ergot of rye, pins, needles, coins, buttons, 
&c., or lead and other poisons off the hands 
of workers in them, all of which give rise to 
definite and for the most part characteristic 
symptoms. 
2. Irregularities of the Mechanism 
of Digestion.-The motor factors of the 
digestive process depend for their due and 
normal performance on the integrity of the 
muscular tissue, the nerve-centres, and the 
connecting nerves. The several stages of the 
entire process are mastication, deglutition, 
the churning movements of the stomach, the 
peristaltic action of the intestines, and de- 
fecation. Each of these is liable to impair- 
ment, in the direction of increased activity, 
or of deficiency (paralysis), due either to 
lesions, or to reflex stimulation of the nerve- 
centres whence the motor stimuli emanate, of 
the nerve-fibres by which these stimuli are 
conveyed, or of the muscular tissue by which 
the movements are performed. Not infre- 
quently more than one of these tissues may 
be at fault. 
Lastly, obstructions to the movements may 
be caused by tumours, cicatrices, adhesions 
to adjacent structures, &c. Irregularities of 
mastication, deglutition, and defecation are 
fully considered elsewhere. 
(1) Paralysis.-Apart from possible struc- 
tural affections of the intrinsic nervous 
mechanism of the gastro-intestinal tract- 
Auerbach's plexus-of which, indeed, little is 
known, arrest of the peristaltic action of the 
gullet, stomach, or intestines is undoubtedly 
often associated with diseased conditions of 
the central nervous organs ; but the exact 
connexion is far from being satisfactorily 
determined. Those lesions which interfere 
with the action of the vagus nerve, and re- 
move its accelerating influence over the peri- DIGESTION, DISORDERS OF 
479 
etaltic movements, have been regarded as 
most likely to bring about this condition; 
but stimulation of the splanchnic nerves, by 
which inhibitory impulses reach the stomach 
and bowels, will produce the same result. 
The nervous exhaustion induced by long 
fasting, continued vomiting, previous violent 
peristalsis from purgatives, hysteria, and such 
diseases as chronic anaemia, typhus, and puer- 
peral fever; also over-brainwork, with the 
attendant altered conditions of cerebral vas- 
cularity, and extremes of blood temperature 
in pyrexia, or great cold, have been found to 
be accompanied with symptoms indicating 
loss of power of the muscular coat of the 
bowel. Possibly in these cases the result is 
due to arrest of the vagus influence. 
Paralysis of the stomach and intestines is 
a frequent result of affection of these organs 
themselves. Inflammation of the peritoneal 
or mucous coats, with the subsequent infiltra- 
tion of the muscular coat with the inflamma- 
tory products, materially diminishes the 
power of the contractile tissue. Degenera- 
tion of the organs, particularly the lardaceous 
variety, which, commencing in the mucous, 
subsequently invades the muscular coat, ob- 
viously interferes with the movements. Over- 
distension from whatever cause will also en- 
feeble the contractile power of the muscular 
fibres of the stomach or intestine, whilst 
moderate distension is the normal stimulus 
to their activity. If, as is supposed, the 
energetic contractions of the pyloric part of 
the stomach, whereby the chyme is propelled 
into the duodenum, be normally excited by 
the acidity of the gastric juice, it may be 
expected that any diminution of this acidity 
will lead to deficient propulsion of the con- 
tents, and their undue retention in the 
stomach. The movements of the alimentary 
canal may be considerably lessened by the 
administration of certain drugs, such as 
opium, which diminish the excitability of the 
augmentor centres, or stimulate the inhibitory 
control. 
The results of these various paralytic affec- 
tions are in most cases sufficiently apparent. 
The palsied lips and cheeks and tongue tell 
their own tale by the half-opened mouth, the 
dribbling saliva, and the cheeks distended 
with food which cannot be kept between the 
teeth. When the fauces and pharynx are 
affected, the painful efforts at swallowing, 
the rejection of food through the nose, and 
the passage of food into the larynx, are signs 
not to be mistaken. Paralysis of the stomach 
and intestines is mainly recognised by the 
constipation from inability of the canal to 
propel its contents, and by symptoms of 
dyspepsia, such as flatulence due to deficient 
gastric secretion from want of the requisite 
stimulation afforded by the churning of the 
stomach-contents, and to consequent delayed 
digestion, leading to abnormal fermentative 
changes. A paralytic condition of the 
sphincter ani will be indicated by an in- 
• ability to retain the faeces. It should not be 
forgotten that, normally, the gastric move- 
ments cease during sleep. 
(2) Excessive activity.-Excessive activity 
of the muscular structures of the alimentary 
canal will be manifested by an increased peri- 
stalsis of the stomach and intestine, or by 
tonic spasms of limited regions. The former 
condition, by hurrying along the contents at 
the expense of their proper digestion and 
absorption, is an effective cause of diarrhoea. 
The latter, which is altogether abnormal and 
not a mere exaggeration of a healthy action, 
will, in proportion to its severity and extent, 
determine obstruction to the passage of the 
food. The spasmodic affections are almost 
always associated with pain - intestinal 
cramp, colic, tormina, &c.; and varying de- 
grees of discomfort usually accompany exalted 
peristalsis. 
The causes leading to these states may, as 
in paralysis, be referred (a) to the cerebro- 
spinal centres, or (&) to the local neuro-mus- 
cular structures. Excluding spasms of the 
muscles of mastication, deglutition, and de- 
fecation, which are elsewhere treated of, in- 
creased gastro-intestinal movements (a) may 
follow on (i.) emotional states; (ii.) some 
structural lesions of brain and spinal cord, 
such as basilar meningitis and locomotor 
ataxy; (iii.) the increased excitability of the 
neuro-muscular apparatus caused by drugs- 
as strychnine, and septic poisons; (iv.) cutane- 
ous irritation, as from cold, reflexly stimulat- 
ing the accelerator nerves; affections of other 
viscera, especially uterine and ovarian, may 
act in a similar manner. Whilst the first- 
and last-mentioned causes tend to cause in- 
creased peristalsis of the canal, the other 
causes mentioned rather lead to tonic spasm. 
(6) Causes which may be regarded as excit- 
ing gastro-intestinal movements by their 
local effect may be grouped thus : (i.) irrita- 
tion due to the character of the contents, 
such as its indigestible nature, acidity, ex- 
treme coldness or even excessive bulk, foreign 
bodies in the food, as pins, buttons, &c., irri- 
tant drugs, or worms; (ii.) drugs which ap- 
pear to act directly on the gastro-intestinal 
plexuses and muscle-fibres, as lead, nicotine, 
&c.; (iii.) increased irritability of the mucous 
surface, as from inflammation or ulceration, 
thereby favouring the action of the ordinary 
stimulants to cofitraction. Certain blood- 
states, such as that occurring in the uric- 
acid diathesis, ansemia, or any other condition 
in which there is a deficiency of circulating 
oxygen and overcharge of carbonic acid, are 
liable to excite spasm or increased peristalsis, 
probably acting on the nerve-centres con- 
cerned, as well as directly on the tissues 
of the canal itself. Spasm of the pylorus, 
described as of occasional occurrence, is of 
theoretic rather than practical interest; a 
paralytic state of this sphincter is probably 480 
DIGESTION, DISORDERS OF 
more common. The normal tonicity of the 
sphincter ani may give place to painful 
spasm, a condition which is very apt to 
complicate fissure and ulcer of the anus. 
(3) Mechanical difficulties.-The due per- 
formance of the mechanism of digestion may 
be interfered with by alterations in the condi- 
tion of the alimentary canal caused by various 
kinds of obstruction or dilatation. Thus de- 
glutition may be rendered difficult or even 
impossible by a swollen tongue or tonsils, 
post-pharyngeal abscess, tumours of the oeso- 
phagus or larynx, or new-growths situated at 
the cardiac aperture of the stomach. The 
various obstructive diseases of the pylorus 
and intestines will obviously interfere with 
the proper passage of the contents, and in 
those dilatations of the canal which are liable 
to develop above a stricture, the food accumu- 
lates and is delayed in its passage. The 
adhesion of coils of the bowels to each other 
or to adjacent structures is a further source 
of imperfect movement. 
(4) Diseases of the teeth.-Lastly, the sub- 
division of the solid food, so necessary for 
the effective action of the digestive juices, 
is only imperfectly performed when the teeth 
are deficient in number or are carious, and 
to this cause a large proportion of cases of 
dyspepsia may be fairly assigned. 
So marked a perversion of the mechanism 
of digestion as vomiting is more fitly de- 
scribed by itself, though it is a very frequent 
symptom of indigestion. 
3. Imperfections in the Chemical 
Changes.-Our knowledge of the normal 
chemistry of digestion, much as it has ad- 
vanced of late, is still very far from complete; 
and, in face of our ignorance, but little can 
be said of the conditions existing in disease. 
Yet there are certainly no departures from the 
healthy working of the body so common as are 
those associated with the digestion of the food. 
The various secretions, whose office it is to 
convert into a fluid and diffusible form those 
alimentary principles which cannot be ab- 
sorbed without such preparation, are formed 
from the blood by the salivary, gastric, pan- 
creatic, hepatic, and intestinal glands. It is 
clear that, for these juices to be secreted in 
proper quantity or of proper composition, the 
blood, no less than the secreting cells, must 
be in a healthy condition, and the trophic in- 
fluence of the nervous centres upon the latter 
must be unimpaired. If the circulating fluid 
be laden with imperfectly secreted products 
of tissue-change, or if it be charged with 
poison, of whatever origin, it is not to be 
expected that a normal secretion is to be 
obtained from it; whilst, on the other hand, 
a degenerated secreting epithelium is unable 
to perform a function intimately dependent 
on the integrity of its protoplasm. Of neces- 
sity these two factors-blood and cells- 
react on one another; any flaw in the one is 
reciprocated by the other, and thus becomes 
intensified by mutual interdependence. Ex- 
periment leads us to ascribe the efficacy of 
these juices in the changes they effect to the 
existence in them of certain so-called fer- 
ments, whilst the result they bring about is 
mainly one of hydration. How far the various 
mineral constituents of the secretions aid in 
the process is uncertain, but at least their 
presence cannot be dispensed with. In this 
way, the insoluble starches of our food are 
converted by the saliva, the pancreatic, and 
possibly the intestinal juices, into soluble 
and diffusible sugars; the various proteids 
are rendered capable of absorption into the 
blood, by the gastric and pancreatic juices, 
and perhaps also the succus entericus, being 
changed into bodies known as peptones. The 
fats are prepared for absorption by the bile 
and pancreatic juice, by being in part reduced 
to a sufficiently minute state of subdivision 
(emulsion) to permit of their passage through 
the tissue-interstices, and partly by being 
chemically altered into soaps. However 
closely we may imitate the separate actions 
of these fluids in our test-tubes and labora- 
tories, the conditions are undoubtedly much 
more complicated in the alimentary canal, 
where so many changes are simultaneously 
going on, and so many sets of products are 
formed. 
The various secretions may be morbidly 
affected in respect to their quantity or com- 
position ; alterations which must of neces- 
sity profoundly modify the digestive process, 
though with our present imperfect knowledge 
we may not be able to refer with accuracy 
any particular symptoms of indigestion to 
a special change in either of the secretions. 
The saliva may be increased in amount 
(see Salivation), the fluid being poor in solids 
and ferment. It may be difficult to trace any 
definite digestive troubles to this condition, 
since there is no evidence that the carbo- 
hydrates are insufficiently converted; but it 
is probable that the quantity of slightly alka- 
line fluid swallowed may interfere with the 
changes in the stomach. The general wasting 
which frequently follows on this state may be 
in part attributable to the anorexia which is 
so commonly associated with it. Nor can a 
diminution in the saliva, such as occurs in 
fever, be held responsible for any special 
dyspeptic symptom. Should the fluids of the 
mouth become acid, as from lactic or other 
fermentation of food therein, a stomatitis of 
varying severity may be induced, so com- 
monly seen in infants. 
Within the past few years considerable 
attention has been paid to the behaviour of 
the gastric juice in disease, and much valu- 
able information has been obtained, mainly 
in reference to the acid constituents. The 
want of a reliable test for the acids has been 
felt, but for all ordinary practical purposes, 
so far as present investigation has gone, 
Gunzburg's reagent would seem to be suffi- DIGESTION, DISORDERS OF 
481 
cient for the detection of hydrochloric acid. 
This is an orange-brown fluid composed of 
2 grms. of phloroglucin and 1 grm. of vanillin 
dissolved in 30 c.c. of absolute alcohol. A few 
drops of this, gently heated in a porcelain 
dish with a similar quantity of the fluid 
obtained by filtering the vomit (or gastric 
contents withdrawn by stomach-pump or 
syphon-tube), give a deep crimson crystalline 
deposit if HC1 be present. Lactic acid is de- 
tected by it deepening the faint yellow tint 
of a very dilute solution of ferric chloride. 
It is now ascertained that during the earliest 
stage of gastric digestion of an ordinary meal, 
lactic acid derived by fermentation of the 
carbohydrates or directly from the ingesta, 
is alone to be found ; later the hydrochloric 
acid becomes manifest, and at the end of diges- 
tion should be the only acid obtainable. Ex- 
amination of the vomited or withdrawn gastric 
contents will determine the presence or ab- 
sence of these acids, and their quantitative 
analysis may be also approximately esti- 
mated. Repeated observations have now 
shown that the HC1 is diminished in amount 
in pyrexia, anaemia, certain general cachectic 
states, some gastric neuroses, and in chronic 
gastric catarrh, whilst it cannot be detected 
at all in most cases of gastric cancer and 
atrophic and degenerated states of the mucous 
membrane. As a means of diagnosis, there- 
fore, the examination of the vomit in this 
particular becomes of great importance (see 
Stomach, Diseases of). An increase in the 
amount of HC1 in the stomach may be due 
to actual hyper-secretion following on the in- 
troduction of food, and also to an accumula- 
tion of the juice during fasting. Normally 
there should be no gastric juice in the empty 
stomach; but in some nervous diseases, such 
as hysteria and tabes, large quantities of fluid 
containing a marked excess of HC1 may be 
vomited, independently of food, with epigas- 
tric pain and acid eructations. This condi- 
tion is said to lead to gastro-ectasis and pre- 
dispose to gastric ulcer. The more frequent 
cause, however, of ' acidity ' is an excess of 
lactic acid from fermentation of the sugars 
present, and under these circumstances the 
HC1 is diminished in amount and does not 
replace the former as it normally should. 
Butyric, acetic, and other acids of the series 
may also occur as results of ferrhentation of 
the stomach contents. Facts concerning the 
variation in quality or quantity of the pepsin 
are wanting, but it would appear to vary with 
the hydrochloric acid; and the same may be 
said of the rennet ferment. The efficacy of 
the gastric juice is impaired by the presence 
in the stomach of strong alcohol or of bile, 
which precipitates the pepsin; and an excess 
of mucus, such as occurs in gastric catarrh, 
acts prejudicially by preventing the food 
coming in sufficiently close contact with the 
secreting surface. During sleep, also, the 
gastric secretion is diminished. 
Notwithstanding that the normal pancrea- 
tic juice effects active digestive changes in the 
proteid, fat, and carbohydrate constituents of 
the food, the results which follow' its deficiency 
in quantity or quality cannot be indicated 
w'ith precision; possibly its absence may be 
in part compensated for by the bile and 
intestinal secretion. It is not to be forgotten 
that its effective working largely depends on 
the previous gastric digestion having been 
properly carried out. There is no doubt but 
that in many cases, when the pancreatic fluid 
is completely cut off from the' duodenum, 
the digestion of fats is very considerably 
interfered with, as shown by the character of 
the stools, and the rapid emaciation of the 
patient; but this result is not invariable, and 
is certainly most marked when the bile is 
also wanting. In fever the secretion is said 
to be diminished. 
An excessive secretion of bile is not clini- 
cally recognised except as the result of the 
administration of certain drugs, but a defi- 
ciency or complete absence is of common 
occurrence in those morbid states associated 
with obstruction of the bile-ducts, and, to a 
less degree, in fever. The dyspeptic symp- 
toms directly referable to this state are speci- 
ally due to the impaired fat digestion, as evi- 
denced by the clayey foetid stools. Abnormal 
fermentations, manifested by flatulence, may 
also take place. The absence of bile further 
exerts a prejudicial effect on the course of 
proteid digestion, from the failure to neutra- 
lise the acid chyme and consequent pre- 
cipitation of peptones and arrest of peptic 
fermentation. The exact changes which 
ensue are unknown, but there is little doubt 
that the duodenal digestion of proteids is 
seriously interfered with by the absence of 
bile. 
So little is known of the action of the tn- 
testinal juice in health, that nothing can 
with certainty be affirmed of the part it may 
play in disease. It is really doubtful which 
of the alimentary principles it can affect, or 
W'hether its action is not limited to effecting 
further changes in the already partially 
digested food-stuffs. An excess of the secre- 
tion appears to occur, and to form the bulk 
of the fluid in the diarrhoea of cholera, which 
may be compared to the salivation and 
gastric hyper-secretion of certain nerve- 
states. 
In addition to the changes in the ingesta 
effected by the above-mentioned secretions, 
there is reason to believe that similar changes 
of a solvent character may be brought about 
by the action of micro-organisms in the 
stomach and intestines. Recent observations 
have demonstrated that numbers of these 
fungi are normal inhabitants of different 
parts of the alimentary canal, and that cer- 
tain species are peculiar to special regions. 
Originally introduced ab extra, they propagate 
enormously, at the same time being subject 482 
DIGESTION, DISORDERS OF 
to great variation in number, and to some 
extent in kind, with the food taken. These 
microbes would seem for the most part to 
play a minor part in ordinary digestion; 
although the lactic-acid fermentation of carbo- 
hydrates in the stomach, and certain changes 
in the proteids in the duodenum, resulting in 
the formation of such bodies as indol, are to 
be ascribed to their agency. How far, how- 
ever, such changes are normal and essential 
is uncertain; but there is no doubt they may 
be very readily induced and very consider- 
ably extended-such as the butyric- and 
acetic-acid fermentations. In this way may 
be formed other products of putrefactive de- 
composition-ptomaines and tox-albumens- 
often of a poisonous character, and mainly 
responsible for many remote dyspeptic symp- 
toms ; as well as accumulations of such 
gases as carbonic acid, hydrogen, sulphuretted 
hydrogen, and marsh-gas, productive of all 
degrees of flatulence. The exact conditions 
which permit these abnormal fermentations 
are not known with certainty. Delay in the 
propulsion of the gastro-intestinal contents 
is probably an important factor; and still 
more so is the proper composition and 
quantity of the different digestive secretions, 
by which the activity of many toxic organ- 
isms is undoubtedly held in check. Diseases 
such as cholera and enteric fever, due to 
specific germs, are not ordinarily accounted 
as ' disorders of digestion,' though many of 
their most marked symptoms as well as 
anatomical lesions are connected with the 
digestive system. 
4. Deficient Absorption of the Di- 
gested Products.-This may reasonably be 
supposed to cause indigestion, as it certainly 
does the subsequent impairment of nutrition. 
The accumulation in the stomach and intes- 
tines of materials which should have been 
gradually absorbed into the blood or chyle 
vessels must interfere with the healthy ac- 
tion of the digestive secretions, much in 
the same way, probably, as the alcoholic 
fermentation of sugar is arrested in time 
by the presence of the very products of such 
fermentation. 
Data for estimating the normal rate of ab- 
sorption from the alimentary mucous mem- 
brane of the ordinary results of digestion are 
very imperfect; and, until they are more 
clearly ascertained, it is not possible to dia- 
gnose with certainty this functional defect, 
though its existence may often be inferred 
with much probability, and may suggest 
modifications in the size if not in the quality 
of the meals taken 
Conditions upon which an impaired ab- 
sorption of the digesta may be assumed to 
depend, are (i.) failure in converting the food 
to a diffusible state from inefficiency of the 
secretions; (ii.) impaired peristalsis, where- 
by the materials are not brought into sufii- 
eiently close contact with the mucous mem- 
brane; (iii.) deficient circulation of the blood 
and lymph in the chylopoietic area, and con- 
sequent hindering of osmosis; (iv.) disease of 
the vessel-walls, impairing their permeability; 
and (v.) degeneration of the epithelium, with 
the same result. 
Symptoms of Dyspepsia. - The almost 
numberless symptoms which indicate the 
perverted functions above described, and are 
primarily dependent on morbid structural 
changes in the organs concerned, may be 
conveniently grouped into local and remote. 
Many so-called dyspeptic symptoms, how- 
ever, are more properly referable to subse- 
quent perversions of metabolism than to 
actual digestive imperfections. 
The local symptoms-those, that is, which 
are connected directly with the affected 
structures-are, perversions of sensation; 
constipation or diarrhoea; vomiting; pyrosis 
and acidity; haematemesis; flatulence ; 
eructation and foul breath; salivation or 
dry mouth; morbid states of the tongue; 
abnormal character of the stools. Except- 
ing the first-mentioned, these receive de- 
tailed description in the present work under 
their respective headings. 
Ordinarily we are unconscious of the process 
of digestion, but in disease the function may 
be accompanied by alterations of sensation 
varying from a mere sense of weight and 
discomfort in the abdomen to the severe 
spasmodic pain of colic. Such, however, 
are not constant, for very definite indigestion 
may exist without the patient ever complain- 
ing of abdominal sensations. The ingestion 
of food may be followed by a feeling of ab- 
normal repletion, or of emptiness with crav- 
ing for food; or there may be heartburn, an 
ill-defined sense of burning felt in the epigas- 
trium or over the chest or extending to the 
throat; or positive pain, or tenderness over 
some tolerably definite area. Sensations as 
of excessive movements of the bowels, of 
sinking, or of tightness across the abdomen 
are of frequent occurrence. 
Among the numerous remote symptoms are 
pain in shoulder, back, or limbs; headache- 
frontal, occipital, and vertical; vertigo and gid- 
diness ; muscae volitantes; tinnitus aurium ; 
cramps in the limbs; muscular weakness; 
palpitation, cardiac irregularity, flushings, 
and anginous attacks; cough and singultus; 
impaired appetite; all degrees of mental 
perversion, from irritability to apathy and 
hypochondriasis; drowsiness or insomnia ; 
a peculiar sallow, muddy-looking skin; 
various cutaneous eruptions, chiefly papu- 
lar; jaundice; and abnormalities of urine. 
Mal-digestion may also determine a condi- 
tion of fever, which may be so severe as 
to reach the typhoid state and end in 
coma. Such general perversions of nutri- 
tion as wasting and obesity may result from 
indigestion. Many of these symptoms may 
be regarded as reflex in causation, such as distal pains and cough, the afferent nerve- 
path for which is probably the vagus ; others 
are doubtless to be attributed to actual want 
of proper materials for the nourishment of 
the tissues, owing to their improper prepa- 
ration in the alimentary canal; and others 
again are possibly toxic in character, due to 
poisonous substances produced in the course 
of the perverted digestion. 
The extreme diversity of these symptoms 
is remarkable : there is scarcely a function 
of the body that may not be implicated in 
the disturbance of digestion, and contribute 
its share to the total symptoms of any 
given case. The degree to which these mani- 
festations may be present is, moreover, most 
varied: in one patient the malady may be 
mainly represented by a headache, in another 
the evidences of illness are most numerous. 
And, again, the different ways in which these 
symptoms are associated in different cases 
are almost as many as the cases themselves. 
It is impossible, therefore, to attempt any 
description of a case of indigestion which 
shall have other than the most limited ap- 
plication; and since the symptoms set forth 
find their fuller explanation elsewhere in this 
work, the bare enumeration of them must 
suffice here. It is important to remember 
that many of the symptoms mentioned as 
indicative of disordered digestion are of not 
infrequent occurrence in the course of mala- 
dies quite distinct, or at least primarily so, 
from digestive diseases : headache, vomiting, 
cough, palpitation, &c., are illustrations of 
this. So that, although the recognition of the 
symptoms be not difficult, care and experi- 
ence are needful to ascribe them to dyspepsia. 
But supposing that causes other than indiges- 
tion have been excluded, there still remains 
the task of referring the manifestations of 
disease which any case may present to 
their causal perversions in the digestive 
process: to determine, that is to say, what 
may be the morbid change which has taken 
place in the secretions and consequent chemi- 
cal processes, or the disturbances of motility, 
or may be the error of diet; and, if possible, to 
infer beyond these conditions the underlying 
structural lesions. The intimate interdepen- 
dence of the various factors of digestion renders 
the discrimination of the primary fault, from 
the symptoms present, a matter of exceeding 
difficulty; and it is this which makes the ac- 
curate diagnosis of a case of dyspepsia so un- 
certain, and its treatment often so empirical. 
Many of the signs and symptoms, without 
doubt, indicate with tolerable certainty the 
region of the alimentary system which is at 
fault, and may even suggest the nature of the 
disease; but how far, and in what manner, 
morbid change in one part of the canal, or 
at one stage of the digestive process, may deter- 
mine subsequent changes, and what the exact 
nature of these may be, and their relation to 
the symptoms manifested, are data at present 
DIGESTION, DISORDERS OF 
almost unknown. The progressive character 
of the function of digestion-that is to say, 
the continuous series of stages, whereby the 
later ones are dependent on those preceding- 
renders affections of this system very dif- 
ferent in their detection from those of other 
organs. Alterations in the physical cha- 
racters of the digestive organs, such as 
a dilated stomach or an enlarged liver, 
may usually be ascertained with accuracy, 
and some symptoms may be reasonably 
asserted to follow from these conditions, 
whilst their relation to other morbid mani- 
festations is often of doubtful inference. 
Modifications in the quantity or quality of 
the digestive secretions may be demon- 
strated with certainty, but their connexion 
with many of the symptoms which may 
be present is often most obscure. And, 
again, there may be most persistent and 
serious disturbance of digestion, with severe 
discomfort to the patient, and it may be 
quite uncertain which organ is primarily at 
fault, and still more doubtful what the real 
morbid change is. So far as individual 
symptoms may be referred to definite dis- 
eases of the various digestive organs, this 
is attempted in the articles treating of the 
diseases of the stomach, intestines, liver, 
pancreas, &c., which are complementary to 
this section. 
Treatment.-The essential basis for the 
successful treatment of indigestion is the 
recognition of the cause. Oftener perhaps than 
may be supposed this is a removable one; in 
every case it must be well sought for, and 
corrected if possible. A carefully regulated 
diet, both as regards ordinary food and special 
idiosyncrasies, is all-important, and the means 
from which much good is to be expected, both 
by way of prevention and cure. To lay down 
a requisite diet entails a general knowledge 
of the average composition of food-stuffs and 
of the changes which they normally undergo 
in the process of digestion, together with the 
nature of the influence exerted by various 
ingredients of the food upon the digestion 
of the others-e.g. 'the retarding effect of 
tea and coffee on peptic digestion' (Roberts). 
Whether or not any given article of diet 
should or should not be allowed must de- 
pend upon its digestibility in the given case, 
apart from what may be its value under 
healthy circumstances, and also upon what 
harmful by-products of digestion it may give 
rise to under the diseased conditions which 
may be present. Exact information on several 
of these points is not yet available, and at 
the same time it is to be remembered that 
articles of food which normally are regarded as 
of the most digestible and innocent character 
may at times seriously disagree, whilst most 
indigestible articles may be taken with im- 
punity. The writer is convinced that, whilst 
fully recognising the great importance of diet, 
it is nevertheless the case that not a few 
483 484 
DIGESTION, DISORDERS OF 
DIGESTIVE ORGANS 
dyspeptics may trace their ailment to a long- 
continued adhesion to a strict diet which might 
theoretically fulfil all physiological require- 
ments, and that many cases of indigestion may 
be considerably benefited by a laxity which 
might not always be justified on physiological 
grounds. As useful adjuncts to dietetic treat- 
ment are the various artificial partially or 
wholly digested food stuffs, such as maltines, 
peptones, and emulsions of different kinds. 
Such details of general hygiene as exercise, 
bathing, occupation-mental and bodily, 
change of scene and air, require attention 
scarcely, if at all, secondary to diet. Undoubt- 
edly, much may be done with drugs, both in 
relieving the symptoms and in treating the 
conditions on which the symptoms may de- 
pend. The latter are met by such means as 
abstinence from food for periods, with conse- 
quent rest to the organs concerned, the requi- 
site nutriment being supplied per rectum; by 
artificially digested aliment, thus helping the 
digestive juices; and by supplying the ele- 
ments of the secretions-acids, alkalis, and 
ferments, when there is reason to suppose 
they may be deficient. Irregularities of move- 
ments of the canal may be remedied by such 
drugs as strychnine, nux vomica, belladonna, 
and opium, or more active aperients or as- 
tringents. Pain and other sensory disturb- 
ances of the stomach or intestines may be 
relieved by alkalis, bismuth, hydrocyanic 
acid, morphine, or opium. Among the long 
list of drugs whose value is assured in different 
cases of dyspepsia are arsenic, iron, the vege- 
table bitters, silver, creasote, charcoal, vale- 
rian, the hyposulphites, and the various 
carminatives. 
Conclusion.-In the foregoing remarks no 
attempt has been made to enter into a de- 
tailed description of the various symptoms of 
disordered digestion, or to do more than indi- 
cate very generally the treatment to be fol- 
lowed. Such subjects are left to the diseases 
treated of in their respective sections. Nor 
has it been thought desirable in this article 
to treat the subject from the ill-defined point 
of view of ' varieties of dyspepsia.' Rather 
it has been sought to bring the matter of 
indigestion within the limits of an anatomico- 
physiological basis, since it is only on such 
lines that the protean symptoms of dyspepsia 
can be accurately defined. At the same time, 
whilst for clearness the various causes have 
been made to assume a somewhat tabular 
form, it is not intended that the interdepend- 
ence of these states should be overlooked, or 
to suggest that one only of the causes men- 
tioned is at work in any given case. The com- 
plexity and harmony of our functions alike 
forbid such a mistake being made. Yet for 
that mental analysis which the formation of a 
diagnosis presupposes, some such scheme as 
the foregoing is essential, no less than for the 
adoption of a rational treatment. 
W. H. Allchin. 
DIGESTIVE ORGANS, Diseases 
of the.-The organs comprised in the diges- 
tive system have for their function the pre- 
paration of the solid and fluid ingesta of the 
body, so as to fit them for absorption into the 
blood. Some of the food requires little or 
even no such preparation ; some needs con- 
siderable treatment, both physical and chemi- 
cal. To effect this object it would appear to 
follow that there should be some receptacle 
or series of receptacles into which the food 
may readily be taken, and from which the 
worthless residue may escape, provided with 
muscular structures to ensure a movement 
of its contents. It would further follow that 
there should be certain organs communicat- 
ing with the foregoing, whose function it 
should be to prepare those materials neces- 
sary to effect the required chemical changes 
in the food ; and, lastly, that some arrange- 
ment should exist to permit of the ready ab- 
sorption of the digestive materials. Such 
requirements we find supplied in the alimen- 
tary canal, with its terminal apertures, and 
its continuous muscular coat so arranged as 
to maintain a progressive advance of the con- 
tained food, though with varying degrees of 
speed-for some lengths, as through the 
gullet, without any arrest; through others, 
as the stomach, with considerable delay. 
Into this canal open numerous glands (mu- 
cous, salivary, gastric, intestinal, hepatic, and 
pancreatic), the secretions of which play each 
their special part in the conversion of the 
food to a fluid and diffusible state. From an 
anatomical, and indeed a genetic, .point of 
view, these glands may be regarded as more 
or less complicated diverticula of the mucous 
surface. In order that the food when so 
treated may gain a ready entrance into the 
blood, the surface of the canal in contact 
with the digesting food-mucous membrane 
-offers various modifications-villi, &c.-to 
facilitate the process of absorption. Lastly, 
in beings so complex in structure as man, 
there is need for some controlling influence 
to bring the operation of this system of organs 
into harmony with the actions of other and 
interdependent systems. Such power of 
co-ordination is exercised via, the nervous 
system, sympathetic and cerebro-spinal. 
By the expression ' diseases of the digestive 
organs ' is meant, departures from the normal 
■ structure of the tissues of which these organs 
are composed. 
The constructive tissues of the alimentary 
organs are:-(1) the Epithelial; (2) the Con- 
nective, including the Lymphoid; (3) the 
Muscular; (4) the Nervous; and (5) a com- 
pound texture-the Vascular. Each of these 
is subject co its own perversions, either alone 
or in common with others. 
Etiology.-If we consider diseases to be 
altered functions dependent on altered struc- 
ture, the latter being determined by some 
perversion in the normal stimuli to nutrition, DIGESTIVE ORGANS, DISEASES OF 
485 
either hereditary or acquired, we shall at 
once recognise that the opportunities for ab- 
normal stimulation in the case of the diges- 
tive organs are most numerous. Communi- 
cating with the external world, and continu- 
ously subject to the admission of foreign 
matter, we have in the character of the 
ingesta abundant sources of disease. Toxic 
agents, living and dead, find ready entrance ; 
and excesses in quantity of food, no less than 
imperfection in its quality, alike serve to pro- 
duce those departures from the normal struc- 
ture on which perversions of function depend. 
Furthermore, the tissues of the alimentary 
viscera are, equally with those of the body 
generally, subject to those more obscure 
hereditary influences which determine irregu- 
larities in structure and their sequence. And, 
finally, arrests in development of organs, not 
infrequent in those under consideration, 
complete the list of possible diseases to which 
the alimentary system is liable. 
Nor is this system independent of morbid 
conditions affecting other organs. So com- 
plicated as is the human body, it is impossible 
that disease should for long be limited to one 
region. Sooner or later the functions which 
are acting the one with the other, to consti- 
tute the harmonious working of healthy life, 
will feel the effects of the one that is out of 
gear, and will respond each in its own man- 
ner to the abnormal condition of its environ- 
ment. A disease primarily located in the 
nervous system will produce an effect in the 
working of the nutritive functions, none the 
less real because the exact lesion cannot as 
yet be determined. Failures in elimination of 
the products of tissue-waste, from structural 
diseases of the excretory glands, must tell 
back on the organs concerned in the prepara- 
tion and elaboration of the ingesta; and such 
conditions constitute a frequent cause of dis- 
orders of digestion. The causes may be thus 
tabulated:- 
A. Hereditary. 
1. Arrests in development of tissues and 
organs. 
2. Abnormal nutritive stimuli, determin- 
ing new-growths, &c. 
B. Acquired. 
1. Poisons. 
2. Imperfections in quantity or quality 
of normal ingesta. 
3. Failure of excretory functions, with 
consequent circulation of an impure 
blood, and malnutrition of tissues. 
4. Trophic disturbances acting vid the 
nervous system. 
5. Traumatic. 
Varieties of Disease of the Digestive 
Organs.-There is scarcely any form of 
diseased structure that is not to be met with 
in the tissues comprising the digestive organs. 
Since almost every variety of texture is found 
in them, and there is so extensive a liability 
to the causes of disease, this result is only to 
be expected. 
I. Affections of the Vascular State. 
Regarded collectively, the organs of diges- 
tion present several points worthy of remark 
in respect to their blood-supply. First, the 
arrangement of the vessels is such as to 
ensure a very extensive, and at the same 
time very direct, supply. The arteries to 
those alimentary organs situate in the abdo 
men are almost all primary branches of the 
aorta ; and this, together with the numerous 
and free anastomoses between them, reduces 
to a minimum the chance of failure in circu- 
lation. Secondly, the blood from the same 
area is all collected into one large vein- the 
portal-and after circulating through the liver 
is carried by one-the hepatic-directly into 
the inferior vena cava, close to the right 
auricle. Such an arrangement, whilst con- 
siderably reducing the speed of the blood-flow 
through the hepatic capillaries, offers a 
double chance-viz. in the liver and in the 
heart-of producing a general state of con- 
gestion of the alimentary organs. Thirdly, 
the existence of such an organ as the spleen, 
which by its position and structure, as well 
as its periodic rhythmic contractions, allows 
of great variation in the amount of blood it 
contains, will materially affect the extent of 
vascularity of the digestive organs. And, 
lastly, the alimentary organs probably un- 
dergo, within normal physiological limits, a 
wider variation in amount of blood than does 
any other system. The post-mortem appear- 
ances of the vascularity of the canal, both 
normal and morbid, are most deceptive, and 
give little or no indication of what actually 
exists during life. This is due in great part 
to the constriction of the vessels after death, 
and a consequent bloodless state of the 
tissues. 
1. Hypercemia.-Hyperaemia is here taken 
to mean an excess of blood in the arterial side 
of the capillaries. How far a determination of 
blood to the alimentary canal may exist, unac- 
companied by any change in the tissues, is a 
matter of doubt: it rarely if ever leads to any 
recognisable morbid state. In the normal 
process of digestion this condition obtains, 
but with it there is an alteration in the 
glandular epithelia, if in no other tissue - 
elements. It is conceivable, however, that a 
vaso motor paralysis with consequent fluxion 
may occur, and such may be the case in cer- 
tain mental states, as indicated by diarrhoea. 
The majority of circumstances that produce 
hyperaemia do not stop at that point, but 
bring about a state of catarrh and inflamma- 
tion, in which the epithelial and connective 
tissues are also engaged. 
Among the digestive glands, the liver un- 
doubtedly manifests states of simple hyper- 
aemia without any appreciable changes in the 
hepatic tissues. Excessive feeding, irritants 
such as spices and alcohol, hot climates and 486 
DIGESTIVE ORGANS, DISEASES OF 
malaria, suppressed menstruation, have all 
been recognised as producing temporary en- 
largements of the liver from active vascular 
engorgement, although without doubt these 
causes if continued lead to structural affec- 
tions. 
2. Congestion.-An excess of blood pri- 
marily in the venous side of the capillaries, 
brought about by some impediment to the 
return of the blood in the veins, has little or 
no analogy with any normal physiological 
action. As a condition of disease it is more 
important and far more common than the 
preceding. 
There are two chief causes leading to its oc- 
currence : (A) It may be part of a general con- 
gestion due to obstruction at the right side of 
the heart from tricuspid dilatation. Owing to 
the very direct communication of the veins 
of the chylopoietic viscera and the right 
auricle, these organs are among the first to 
experience the effects of the cardiac obstruc- 
tion. (B) Obstruction through the portal 
circulation in the liver, either by compression 
of the portal capillaries by cirrhosis, &c., or 
by pressure on the portal trunk by enlarged 
glands, tumours, &c., will directly produce 
congestion of the gastro-intestinal tract and 
pancreas. Congestion of the alimentary 
canal and glands, when due to either of these 
causes, is in the main progressive in its nature, 
though occasionally liable to temporary varia- 
tions in degree. 
As a rule, changes which are strictly limited 
to alterations in the fulness of the vessels are 
not to be detected with certainty after death; 
but extreme conditions, especially if associated 
with any haemorrhage into the sub-epithelial 
tissue, may present post-mortem appearances 
often mistaken for irritant poisoning. 
3. Results of Increased Vascularity.- 
(a) Hcemorrhage. Over-fulness of the capil- 
laries, from whatever cause, is liable to lead 
to extravasation of blood, either by diapedesis 
of the corpuscles and transfusion of the fluid 
part of the blood, or from actual rupture of 
the vessels. It is much more common and far 
more extensive in venous congestion than in 
arterial hyperaemia. It must not be too readily 
assumed post mortem that either of these 
conditions alone is the cause of the haemor- 
rhage, since minute ulcers of the mucous 
membrane communicating with main vessels 
have been met with. Dependent on the 
cause and situation, the effused blood may 
vary in colour from bright red to a coffee- 
ground appearance. Haemorrhage may be 
also due to altered states of the blood, such 
as purpura and scurvy. (/3) (Edema. An 
over-distension of the vessels, especially of 
the veins, if it be at all persistent, is invari- 
ably accompanied by an effusion of serum 
into the substance of the viscera themselves, 
and into the alimentary canal, in the latter 
case producing diarrhoea, (y) Tissues the 
seat of a chronic congestion in time undergo 
certain structural changes as the result of 
their impaired nutrition, resulting in atrophy 
or degeneration', or they may be characterised 
by the presence of an excessive amount of 
connective tissue, containing fewer proto- 
plasmic elements than normal, and exhibit- 
ing a marked tendency to contract. This 
fibroid substitution may occur throughout 
the entire digestive system, but is particularly 
noticeable in the stomach, intestines, liver, 
and pancreas. (8) Another result of a long- 
continued congestion is to develop- often to 
an enormous extent-collateral circulations, 
especially at the points of communication 
between the vessels of the portal and systemic 
areas; e.y.the connexions between the gastric 
and oesophageal veins around the cardiac 
orifice, and by the latter with the phrenic, 
intercostal, and azygos veins, and thence with 
the inferior vena cava, or the junctions be- 
tween the hsemorrhoidal veins and branches 
of the internal iliacs. Considerable compen- 
sation is thereby very frequently established, 
but the over-distension to which the vessels 
are subject especially favours their rupture. 
4. Anaemia.-The alimentary viscera, in 
common with the rest of the body, may share 
in a general bloodlessness due to excessive 
loss or extreme malnutrition from wasting 
disease, &c. A deficiency of blood limited to 
these organs is not clinically met with. 
5. Infarctions.-As compared with the 
brain, spleen, and kidneys, the organs of the 
alimentary system would appear to be less 
prone to suffer from emboli and thrombi, or 
at all events from the effects of these obstruc- 
tions. A partial exception to this general 
statement must be made in the case of the 
liver, which is a frequent seat of abscess 
determined by the arrest in the portal capil- 
laries of septic particles taken up by the 
portal radicals in dysentery, &c. Any of the 
vessels of the liver may be occluded by 
emboli, or thrombosis following on endar- 
teritis or endophlebitis, but they are condi- 
tions of very rare occurrence. The superior 
mesenteric artery has been known to be blocked 
by an embolus, with consequent infarction 
and profuse intestinal haemorrhage. Minute 
emboli in the gastric arterioles, or thrombosis 
from degeneration, atheromatous or hyaline, 
of these vessels is an undoubted cause of 
ulcer of the stomach, though not the only one. 
II. Structural Affections.-1. Inflam- 
mation.-This term is applied to express 
those changes which take place in the nutri- 
tion of a tissue subsequent to the application 
of some abnormal stimulus which shall not 
have been sufficiently powerful to produce 
destruction. The changes in the structural 
elements of the textures result partly in the 
production of some material which is unlike 
the normal constituents of the part affected, 
and partly also in certain destructive pheno- 
mena. One or other of these phases may 
predominate, as suppuration and abscess or ulceration, &c. Certain variations present 
themselves in the nature of the new-formed 
material, and also in the general course of the 
process, constituting forms of inflammation, 
as simple catarrhal, diphtheritic, phlegmon- 
ous, &c. In vascular tissues there are, in 
addition to the tissue-changes, certain altera- 
tions in the circulation in the affected region, 
commencing with hyperaemia and leading to 
a variable amount of stasis and oedema. 
Inflammation as it affects the alimentary 
tract offers no exception to this description. 
It is rare for the muscular tissue to share in 
the process, which is practically limited to the 
epithelium, mucosa, and submucosa. The 
transition, so far as anatomical appearances 
are concerned, from the normal state of 
activity of the organs, with their increased 
vascularity and cloudy appearance of the 
epithelial cells, to that of simple inflam- 
mation or catarrh, is but a step marked by 
no abrupt line. 
Different sections of the entire canal ap- 
pear to be more prone to certain forms of 
inflammation than are others. It is un- 
usual for the whole length to be involved, and 
certain regions, notably the jejunum, are but 
exceptionally affected. The mouth, pharynx, 
stomach, lower part of the ileum, and colon 
are the usual seats. Catarrhal inflamma- 
tion, characterised by intense redness and 
swelling of the mucous membrane, with an 
excessive secretion, mucous or serous, and 
desquamation of the epithelial cells, is of 
commonest occurrence almost throughout the 
canal (see Stomatitis; Stomach, Diseases of; 
and Intestines, Diseases of). When but 
limited areas are affected and the cause is 
removed, this condition runs an acute course 
and tends to recovery; but when the greater 
part of the canal is involved and the cause 
is of specific virulence, the effects are more 
serious. This is the case in cholera, whether 
of the Asiatic or English type, the anatomical 
lesion of which is essentially an intestinal 
catarrh. It is noticeable that the epithelia 
of this tract are but little prone to manifest a 
purulent inflammation, as is so characteristic 
of some other mucous surfaces, such as the 
nasal, bronchial, and vaginal. Phlegmonous 
inflammation, probably bacterial in origin, 
corresponding to erysipelas of the skin, and 
distinguished by the formation of pus in the 
mucosa and submucosa, represents a more 
severe inflammatory process, accompanied by 
a more severe constitutional disturbance. It 
is of most frequent occurrence in the fauces 
and tonsils, where it is common (see Tonsils, 
Diseases of), and far more rarely in the 
stomach, where it constitutes a very serious 
disease. Under the term membranous or 
pellicular are included those forms of in- 
flammation in which the new material 
assumes the form of a false membrane on 
or in the mucous surface. This is repre- 
sented in the mildest degree by aphthae, 
DIGESTIVE ORGANS, DISEASES OF 
which characterise a special form of stoma- 
titis, and are small patches of coagulated 
exudation from the blood involving leucocytes 
and the deeper layers of the stratified oral 
epithelium. After a day or two's duration 
they break down and are thrown off, leaving 
an abrasion or not according to the extent to 
which the tissues are included in the patch. 
The more severe forms of inflammation as- 
sociated with formation of'false membrane 
are termed croupous and diphtheritic, words 
which have been extensively misapplied, with 
much resulting confusion. The former de- 
notes that form of inflammatory product 
which consists of a coagulated fibrinous exu- 
dation effused among the necrosed epithelial 
cells and into the mucosa, together with 
many leucocytes and a few red blood-cells; 
in the latter, the necrosis of the tissue-ele- 
ments is more extensive and the adherence 
of the membrane is more intimate. The 
fauces are by far the most frequent seats of 
these states, but patches of false membrane 
are of occasional occurrence in the stomach, 
and more commonly on the edges of the 
saccules of the large intestine. It is doubt- 
ful, however, whether such membranes are 
diphtheritic in the clinical sense of the 
term, however closely they may correspond 
in anatomical characters. 
An acute or sub-acute attack of catarrhal 
inflammation of the stomach or intestines is 
likely, if the cause persist, to become chronic, 
the structural features of which are especially 
an atrophy of the epithelium, with or with- 
out much fibroid thickening of the mucosa. 
The wasting of the epithelium is often very 
marked, and when the villi also become 
shrunken the surface of the mucous mem- 
brane appears smooth and glazed over large 
areas. In young children this atrophy ap- 
pears frequently to follow a single attack of 
acute intestinal catarrh. Some forms of 
stomatitis, though persisting a long time, 
can scarcely be said to be chronic in the 
sense of leading to permanent structural 
changes; the utmost that occurs is a thicken- 
ing of the epithelium, which usually dis- 
appears in time. The fibroid overgrowth 
may affect the stomach or parts of the in- 
testine tolerably uniformly, or not infrequently 
form polypoid elevations. 
Certain peculiarities in the inflammations 
of special regions, such as the caecum, colon, 
and rectum, are fully described elsewhere. 
See Caecum, Diseases of; Rectum, Diseases 
of; and Typhlitis. 
The accessory glands (salivary, pancreas, 
and liver), which genetically are but diver- 
ticula of the primitive digestion-tube, essen- 
tially consist in the adult state of a glan- 
dular epithelium arranged in various ways 
and supported by a connective-tissue stroma 
which carries vessels, lymphatics, and nerves. 
In structure, therefore, they correspond, to the 
mucous membrane of the alimentary canal, 
487 488 
DIGESTIVE ORGANS, DISEASES OF 
and, like it, they are subject, though much 
more rarely, to similar inflammatory changes. 
The communicating ducts of these organs 
with the mouth and duodenum respectively 
are lined by a mucous membrane continuous 
with that of the cavities into which they 
open. Catarrh of the ducts, usually caused by 
extension or by the irritation of calculi, may 
be acute or chronic, and may lead, by the 
retention of the secretions from the blocked 
lumen, to inflammation and other changes 
in the proper gland tissue. 
The causes of inflammatory affections of 
the digestive organs are very numerous. 
Among those which may be regarded as 
predisposing are (i.) the exposure of the 
mucous membrane to injury or irritation 
from injurious ingesta; (ii.) age, which 
confers special liability, as witness the fre- 
quency of stomatitis and gastro-enteric 
catarrh in children ; (iii.) season, such as ex- 
tremes of heat and excessive moisture, which 
are most active in determining epidemics of 
gastro-intestinal inflammations ; (iv.) morbid 
conditions of the mucous membrane, more 
especially chronic congestion and degenera- 
tion, which favour the development of the 
catarrhal state. Exciting causes are (i.) the 
nature of the ingesta, whether mechani- 
cally or chemically irritating, corrosive 
poisons, toxic micro-organisms, ptomaines, 
and other bodies which may occur in the 
course of mal-digestion ; (ii.) catching cold ; 
(iii.) dentition; (iv.) wounds or malpositions 
of the bowels, herniae, &c., impacted faeces; 
(v.) extension from the peritoneum; (vi.) the 
irritation of new-growths; (vii.) secondary 
to many acute febrile states, and some chronic 
diseases, such as phthisis and diabetes. 
Among the chief results of inflammation 
are:- 
(a) Abscess.-This may occur in any part 
of the submucous tissue, in the so-called 
phlegmonous and pyaemic inflammations, but 
is of most common occurrence in the gums - 
gumboil, in the tonsils, and in the liver ; often 
in the latter situation it is the result of in- 
flammation determined by absorption into 
the mesenteric veins of septic particles from 
dysenteric ulceration. 
(3) Ulceration.-The mucous membrane 
of the alimentary canal is particularly liable 
to this morbid process. Some preference is 
exhibited for the different forms of ulcer by 
certain regions of the canal, and a difference 
exists in the tendency to perforate the entire 
thickness of the tube, those of shorter dura- 
tion frequently producing this result, whilst 
the chronic ulcers are usually accompanied 
by a slow formation of indurated connective 
tissue, which proceeds pari passu with the 
destructive process, and is especially likely 
to institute adhesions between the canal 
and adjacent organs. Ulcers are met with 
in the salivary, hepatic, and pancreatic 
ducts, very frequently as a sequence of in- 
flammation determined by the passage of 
calculi. 
The ulcers which are usually acute in their 
course are :-(1) Simple or catarrhal. (2) 
Aphthous. These forms, though they may 
occur in any part of the mucous membrane, 
are far more commonly situated on the gums, 
cheeks, tongue, and palate. (3) Acute specific 
ulcerations: as diphtheritic and scarlatinal, 
mainly affecting the fauces: or typhoid, 
limited to the jejunum and ileum, and origi- 
nating in the'solitary and agminated glands. 
(4) Dysenteric. 
The ulcers that are commonly chronic in 
their course are:-(1) Gastric. (2) Tubercular, 
which may occur in any part of the canal, but 
are usually limited to the same situation as 
the typhoid. (3) Syphilitic, most common in 
the mouth, fauces, and rectum. (4) Can- 
cerous. (5) Dysenteric and chronic catarrhal. 
(y) Sloughing and Gangrene.-The in- 
flammatory state may be so intense as to 
lead to molar death of the area affected, with 
the production of slough. This often follows 
scarlatinal inflammation of the fauces, and 
the surface of the large intestine in dysentery 
is frequently covered by large and numerous 
sloughs. 
Gangrene is almost entirely limited to the 
mouth in children, when it produces the con- 
dition termed noma. The cheeks are usually 
affected first, the process rapidly involving 
the gums, jaws, &c. Portions of bowel that 
have been strangulated readily become gan- 
grenous. 
Post-mortem softening and destruction of 
the stomach and intestines is frequently met 
with, and is due to an actual digestion of the 
viscera by the gastric juice, which, thus 
escaping from the stomach, may cause de- 
struction of adjacent organs. It is usually 
met with when death has occurred during 
the process of gastric digestion, and is more 
common in infants, possibly from the greater 
acidity of the products of digestion. 
2. Hypertrophy.-A general overgrowth 
of the normal tissues of the digestive organs 
is practically unknown. Certain parts may 
manifest this condition, notably the muscular 
tissue of parts of the canal above an obstruc- 
tion. Patches of hypertrophied epithelium 
are seen in the mouth following on persistent 
mechanical irritation of broken teeth, &c., or 
as the result of syphilis. The overgrowth 
may be limited to the epithelium of the 
lingual papilla. Considerable hyperplasia 
of the sub-epithelial connective tissue may be 
caused by a chronic inflammation of any part 
of the canal. The liver is described as being 
occasionally hypertrophied in certain cases 
of diabetes. 
3. Atrophy.-The alimentary organs may 
share in the general atrophy and wasting of 
old age or inanition. This condition is apt 
to follow disease of certain parts, especially 
the epithelia in chronic inflammation, or DIGESTIVE ORGANS, DISEASES OF 
489 
may be seen in the thinning and shrinking of 
the stomach and intestines beyond an obstruc- 
tion or an artificial anus, or when these organs 
are permanently dilated. Pressure on the 
organs, as by tight-lacing, &c., may lead to 
the same result. 
4. Degenerations.-Those morbid processes 
to which the term ' degeneration ' is applied, 
and which essentially consist in the conver- 
sion of th^ tissues into ' materials of a less 
complex chemical composition than normal, 
associated with a diminished vital activity, 
may affect any or all of the structural ele- 
ments of which the digestive organs are com- 
posed. Albuminoid infiltration or cloudy 
swelling is the invariable accompaniment of 
inflammation of the epithelial and muscular 
tissues. Fatty degeneration is a further re- 
sult of inflammation or of other malnutrition, 
and has been found in the gastric mucous 
membrane, as well as in the muscular coat 
at various parts of the canal. Although not 
the commonest organs to be so affected, yet 
not infrequently the intestine and stomach 
are the seat of lardaceous degeneration, not 
always limited to the vessels, but affecting 
also the epithelial, fibrous, and muscular 
coats. The liver is especially liable to undergo 
degeneration, both fatty and lardaceous. 
Deposition of pigment may be found in the 
deeper epithelial strata of the mouth and 
intestines in Addison's disease, in the gastric 
and intestinal mucous membrane as the 
result of changes in effused blood associated 
with chronic inflammation, and in the liver 
in certain cases of blood diseases and inter- 
mittent fevers. The sulphides of such metals 
as lead may be deposited in the mucous 
membrane of mouth or intestines in lines 
and spots of black or bluish appearance. 
5. Changes in or retention of the secretions 
of the various glands may result in the pro- 
duction of calculi-salivary, pancreatic, or 
biliary. 
6. New-growths.-There is scarcely any 
known form of neoplasm which may not be 
found in some region or another of the ali- 
mentary tract. 
The new-growths limited to the epithelial 
coat, or commencing in it, are condylomata, 
papillomata, and various forms of carcinoma. 
In the fibrous tissue occur sarcoma, fibroma, 
myeloid, adenoid, gumma, enchondroma, and 
lipoma. 
In addition there may be polypi or tumours 
of the mucous membrane; myxoma ; muscu- 
lar-tissue tumour; cysts; vascular growths, 
such as naevi and haemorrhoids; and the 
infective granulomata, viz. tubercle, lupus, 
and syphilis. 
7. Traumatic.-Certain parts of the ali- 
mentary tract are, from their position, more 
liable than others to external injury. Incised 
and punctured wounds of the mouth, oeso- 
phagus, stomach, intestines, and liver are of 
occasional occurrence, and rupture of the 
abdominal viscera .is sometimes met with. 
The ingestion of corrosive substances may 
produce destruction of certain parts of the 
canal, and wounds may be determined by 
foreign bodies, as pins, fish-bones, &c., which 
have been swallowed. 
III. Malformations and Malposi- 
tions.-1. Hereditary.-Of these the most 
important are hare-lip; cleft palate ; macro- 
glossia; fistulous communication between 
the pharynx and the exterior, or between the 
gullet and trachea; intestinal caeca; imper- 
forate anus; and herniae. 
2. Acquired.-Malformation and malposi- 
tion of the viscera may follow from disease. 
Communications between the stomach and 
intestines, or between different coils of intes- 
tine, or between the gall-bladder and the gut, 
may result from chronic ulceration. Many 
herniae are not developed until long after 
birth, from violent strains, &c. 
Stricture of various parts of the canal is 
frequently associated with the healing of 
ulcers, and with new-growths. Dilatation of 
the canal is apt to occur on the proximal, and 
contraction on the distal side of such stric- 
tures. The intestines may be considerably 
displaced from adhesions following periton- 
itis. Twists (volvulus), intussusception, inter- 
nal strangulations, and prolapsus ani, are more 
or less common affections of the intestines. 
IV. Abnormal Contents. - Concre- 
tions.-1These are found occasionally in the sac- 
cules of the large intestine, caecum, appendix, 
and, more rarely, stomach and small intestine. 
They usually are made up of concentric 
layers of earthy and organic matter, the 
former being principally phosphates of lime 
and magnesia. They frequently have as a 
nucleus some foreign body. Similar bodies 
have been met with, formed of chalk, mag- 
nesia, or oxide of bismuth, which have been 
swallowed. Much larger masses, mainly com- 
posed of densely felted hairs or vegetable husks 
and fibres, with earthy and faecal matter, are 
sometimes seen; gasteroliths are generally of 
this variety (see Calculi). Foreign bodies, 
such as pins, bones, fruit-stones, coins, &c., 
may also lodge in the alimentary canal. 
Parasites.-The alimentary organs are in- 
fested by numerous forms of micro-organisms, 
belonging for the. most part to the vegetable 
kingdom. The greater number are comprised 
in the Schizomycetes, or bacteria, but a few, 
such as the Actinomyces, found in the mouth 
and liver, are included in the division Hypho- 
mycetes, or moulds; and as an example of the 
Blastomycetes, or yeasts, may be mentioned 
the thrush-fungus, Saccharomyces albicans. 
These all obtain entrance to the canal from 
the exterior, chiefly with the food, and the 
majority give rise to no symptoms of disease 
provided proper cleanliness be observed. 
That many propagate and flourish in different 
parts of the tube is certain, and some appear 
to take a definite share in converting the food 490 
DIGESTIVE ORGANS 
DILUENTS 
to a diffusible state, especially in the intes- 
tines, and to that extent are true digestive 
agents. The ferments which set up the lactic- 
acid change in the stomach are to be con- 
sidered as normal, whilst those which 
develop butyric acid are clearly abnormal. 
The true pathogenic organisms, such as those 
producing tubercle, typhoid fever, diphtheria, 
and cholera, develop as they may find their 
surroundings suitable ; but it is also probable 
that some forms of gastro-intestinal dis- 
turbance, such as summer diarrhoea of infants, 
are due to the activities of bacteria, which 
produce toxic substances-ptomaines-in the 
course of putrefactive changes set up by 
them in the intestinal contents. 
A few species of Protozoa have been met 
with in the intestines, such as Amoeba coli, 
Paramaecium coli, Cercomonas intestinalis, 
and Psorospermiae. The other and larger 
parasites belong to the flat or round worms, 
and include the various species of Taenia and 
Bothriocephalus among the former, Ascaris 
lumbricoides, Oxyuris vermicularis, Tricho- 
cephalus dispar, and Ankylostoma duodenale 
among the latter. See Entozoa. 
Gases.-The gases normally occurring in 
the stomach or intestines, whether they be 
swallowed with the food or formed during 
fermentation in the canal, are often much 
increased in amount, especially carbonic acid, 
sulphuretted hydrogen, and marsh gas, the 
last named being inflammable, and occasion- 
ally eructated in considerable quantity. 
W. H. Allchin. 
DILATATION (dilato, I enlarge). 
^Etiology.-Dilatation of any of the cavi- 
ties, tubes, or orifices of the body may either 
result from increased pressure from within, 
or from diminution in the resisting power of 
the walls of the tubes or cavities. These two 
causes are frequently combined, and, indeed, 
the latter is often the result of a long con- 
tinuance of the former. Increased pressure 
from within may be due either to increased 
secretion of the normal contents of the 
cavity, or to some other effusion into it. 
This is the usual cause of dilatation of the 
closed cavities of the body; we have ex- 
amples in the ventricles of the brain, the 
pericardium, the synovial cavities, the bursae, 
the follicles of the thyroid body in cystic 
goitre, and the Graafian vesicles in some 
forms of ovarian dropsy. In the various 
tubes of the body, increased pressure from 
within may arise from obstruction, and the 
consequent accumulation behind the seat of 
obstruction of the substances which it is the 
function of the tubes to transmit. 
Varieties and Characters. - 1. Cystic 
dilatation.-In tubes which begin by blind 
extremities the result of dilatation is generally 
the formation of a cyst, and this is the usual 
mode of origin of the large class of retention- 
cysts, or cystic dilatation. We have ex- 
amples in the sebaceous cysts, in the cysts 
of mucous membranes, due to the ducts of 
the mucous glands becoming obstructed by 
the products of catarrhal inflammation, in 
cysts of the kidney formed by dilatations 
of the Malpighian capsules and uriniferous 
tubules, and in dilatations of the gall-bladder, 
and of the pelvis of the kidney. 
2. Uniform or cylindrical dilatation.-In 
tubes not beginning by blind extremities, the 
effect of the obstruction is usually to produce 
a uniform or cylindrical, and not a cystic 
dilatation; though sometimes one part of the 
wall will yield, and so cause a diverticulum 
or sacculus. These uniform and cylindrical 
dilatations may occur in all the tubes of the 
body. They are met with in the oesophagus 
and all parts of the digestive canal, in the 
heart, veins, bladder, ureters, bile-ducts, &c. 
This form of dilatation may be attended 
either with thickening and hypertrophy, or 
with thinning and atrophy of the walls. 
Usually when the tubes are in the main 
muscular, hypertrophy occurs, from increased 
exercise of the muscular fibres in their efforts 
to overcome the obstruction; but when the 
walls are mainly fibrous or elastic, they 
generally become atrophied and thinned. 
3. Compensatory or collateral dilatation. 
Another form of dilatation from increased 
internal pressure may be termed compensa- 
tory or collateral dilatation; it is produced 
by the tubes having to transmit an increased 
quantity of fluid in consequence of the ob- 
struction of other channels. Besides the 
blood-vessels, we may meet with examples 
of compensatory dilatation in one ureter 
when the other is blocked, and in the bron- 
chial tubes and other parts. Resembling 
this form in its mode of origin is the dilata- 
tion caused by tubes having to transmit 
substances of too large a calibre, as, for 
example, in the passage of calculi down the 
gall-duct and ureters. 
4. Dilatation from changes in the walls. 
The last class of dilatations consists of those 
due to diminished power of resistance in the 
walls of the tubes or cavities. The most 
important examples of this class occur in 
the circulatory and respiratory systems: in 
the heart from fatty degeneration; in the 
arteries from atheromatous changes. In the 
respiratory organs it occurs both in the 
bronchial tubes and in the air-cells. Here, 
however, the loss of resisting power is itself 
usually caused by prolonged increased pres- 
sure from within; which in the air-cells, as 
their walls are elastic and not muscular, 
rapidly causes atrophy, and subsequent dila- 
tation. W. Cayley. 
DILUENTS (diluo, I wash or dilute). 
Definition.-Remedies which increase the 
proportion of fluid in the blood. 
Enumeration.- Water is the only real 
diluent. It is given for this purpose in various DILUENTS 
DIPHTHERIA 
491 
forms-soups, tisanes, barley water, toast and 
water, milk, lemonade, aerated waters, &c.- 
to quench thirst, and increase secretion. 
Uses.-Diluents are employed to lessen 
thirst, as in fever and diabetes, and to remove 
the products of tissue-waste. As the thirst 
may depend upon local dryness of the throat, 
as well as upon general want of fluid in the 
system, the power of water to quench thirst 
may be greatly increased by adding to it a 
little vegetable or mineral acid, or some aro- 
matic, such as lemon or orange peel, which 
will stimulate the flow of saliva, and thus tend 
to keep the mouth moist after the liquid itself 
has been swallowed. The thirst-quenching 
power of water is also aided by the addition 
of mucilaginous substances, such as oatmeal, 
or linseed tea, which, leaving a mucilaginous 
coat on the inside of the mouth and pharynx, 
retard evaporation, and thus lessen the dry- 
ness of the mucous membrane. The free use 
of water, and especially drinking hot water on 
rising in the morning, or on going to bed at 
night, and between meals, is useful in gout, 
chronic rheumatism, and biliary lithiasis, 
lessening or preventing the occurrence of 
acute attacks. T. Lauder Brunton. 
DIPHTHERIA (8af)0epa, a skin).- 
Synon. : Fr. Diphtherite; Diphtheric; Ger. 
Diphtheritis; Diphtherie. 
Definition.-An acute, specific, contagious 
and infectious, and often epidemic, general 
disease ; accompanied by pyrexia and great 
weakness; having as its local manifestation 
inflammation of various mucous membranes, 
particularly those of the throat and larynx, 
and the formation upon them, or upon ex- 
ternal wounds, of ulcers covered by a fibrin- 
ous false membrane; and often followed by 
paralysis of varied distribution. 
History.-From the writings of the most 
ancient physicians, it is evident that the 
disease we know as diphtheria existed in the 
earliest ages, and then had main features 
differing little, if at all, from those with which 
it presents itself to us now. Hippocrates, 
Aretaeus, Galen, Celsus, and Aetius, have all 
left fragmentary accounts of a disease pre- 
valent in their time, which serve for its iden- 
tification with diphtheria. From the six- 
teenth century onwards, since which time 
medical observation has been more fully re- 
corded, we have reliable descriptions of epi- 
demic diphtheria occurring at times in various 
parts of Europe, which leave no doubt as to 
the nature of the disease, and show that 
essentially it had not changed for centuries. 
Bretonneau, in a work published in 1826, gave 
an account of his experience of the disease, 
beginning with an epidemic in Tours in 1818; 
and from this description dates the copious 
modern literature upon the subject. Bre- 
tonneau, too, gave the modern name to the 
disease, by calling it diphtherite, and later 
diphtherie, in allusion to the production of 
membranes or skins-a special character of 
the malady. The most severe outbreak of 
diphtheria which has occurred in England 
was that which attained its height about the 
year 1858. But while later epidemics may 
not have been so severe as this, their occur- 
rence has become more frequent, and, as will 
be discussed in the section on Pathology, the 
disease is now endemic in our large towns. 
In the article upon Croup, the writer has 
given his reasons for believing that at least 
a large majority of cases classed under this 
head are really true diphtheria having its 
primary seat in the larynx. But membranous 
croup and diphtheria are even yet considered 
by some physicians as distinct diseases, and 
in former times this view was much more 
prevalent. Consequently, many of the out- 
breaks of ' croup ' in Scotland and England 
must be considered as epidemics of diph- 
theria. It is noteworthy, too, that the recent 
returns of the Registrar-General show an 
increase in the number of cases of diphtheria 
and a decrease in those of croup, doubtless 
from the recognition of most cases of the 
latter disease as examples of laryngeal 
diphtheria. 
Incubation.-After exposure to the poison 
of diphtheria a certain interval elapses before 
definite phenomena of the disease appear, 
whether these be of the nature of general 
symptoms or the beginnings of the local 
lesion. This period of incubation varies 
greatly. It is much shorter after direct in- 
oculation than when the poison is taken into 
the system by other channels. When animals 
are inoculated with diphtheritic poison, signs 
of the disease may appear in about twelve 
hours, or may be delayed as long as three 
days. In the human subject such inocula- 
tion occasionally takes place, as when diph- 
theritic membrane comes in contact with an 
open wound in another patient, or when 
instruments which have been used for an 
operation upon a diphtheritic subject have 
not been thoroughly cleansed and disinfected 
before being used for other purposes. In 
such cases the period of incubation resembles 
that seen in the experiments upon animals, 
but may be prolonged to four days. When, 
however, the poison is received in other and 
more indirect ways, the incubation time is 
much more variable, and probably its or- 
dinarylimits are from two to eight days. Yet 
certainly the lower limit is frequently anti- 
cipated, for there is no reason to doubt the 
accuracy of many published cases, in which 
the disease began a few hours only after ex- 
posure to infection. Cases are on record, 
too, where the incubation seemed to have 
been much longer, but these are more doubt- 
ful. Not only may it be suggested that a 
second exposure had occurred, but it is 
likely that, where this can be disproved, the 
poison was not received into the body at 
the time of exposure, but was held by fomites 492 
DIPHTHERIA 
until a period much nearer to the outbreak, 
when the patient was in a more favourable 
state to receive the disease. 
A difficulty in determining the period of 
incubation is caused by the invasion of the 
disease being not infrequently insidious. 
During the incubation, while there may be 
no symptoms at all, there may be mere 
indefinite feelings of malaise, not to be dis- 
tinguished from the early symptoms of inva- 
sion in a mild attack. 
There is reason to believe that the more 
intense the poison, or the more liable the 
patient, the shorter is the period of incuba- 
tion. 
Symptoms.-Invasion.-According to the 
severity of the disease in its clinical aspects, 
three separate types of diphtheria may be 
distinguished-the benign, the ordinary, and 
the malignant. These are not natural orders, 
but relative terms. Numerous cases occur 
which throughout their .course may be clas- 
sified as belonging to one or other of these 
groups. Yet, on the other hand, instances 
are also numerous which show a transition 
from one to the other group, which,beginning, 
for example, after the benign type, afterwards 
show the most serious symptoms or sequelae 
of the disease ; or which, presenting only 
ordinary symptoms at the onset, rapidly 
assume the features of the malignant type. 
1. It will be convenient to describe in the 
first place the symptoms of the disease as 
it is ordinarily met with. 
In such cases, after a period of incubation, 
the patient, as a rule gradually, but often 
almost suddenly, feels ill. He has wandering 
aches and pains, disinclination for exertion, 
slight headache, chilliness, loss of appetite, 
nausea-and rarely even vomiting, thirst, 
and the general discomfort of a febrile condi- 
tion. The temperature of the body is raised, 
but not to a great degree-in most cases, 
at the onset, to not more than 100° or 
101° F. At this time, however, the local 
symptoms of the disease appear in the form 
of soreness and tenderness of the throat, and 
slight enlargement of the glands at the angles 
of the jaws. The fauces, tonsils, soft palate, 
and pharynx are swollen, and show a diffuse 
dusky redness. The pulse and the respiration 
are hurried, in accordance with the general 
febrile state. The urine presents the usual 
febrile condition. 
The symptoms rapidly increase in severity. 
The bodily weakness becomes extreme, and 
anaemia soon presents itself. The glands, not 
only those at the angles of the jaws, but their 
lymphatic connexions also, become greatly 
swollen, painful, and tender; and their cover- 
ing of skin may be reddened. The pulse is 
frequent, feeble, and of low arterial tension; 
the respirations are more hurried. The local 
disorder now becomes characteristic. The 
tonsils themselves assume a paler aspect, but 
are surrounded by the reddened mucous 
membrane. Soon a white haziness appears 
in patches on the tonsils, the soft palate, or 
the pharynx. While the swelling of the 
parts already mentioned greatly increases, 
the haziness becomes more pronounced, until 
in disseminated patches a distinct false mem- 
brane is seen, slightly raised from the sur- 
rounding parts, yellowish-white in colour, 
ragged in outline, and surrounded by a zone 
of congestion distinguishable even from the 
general redness of the neighbourhood. At 
first the membrane can be detached from the 
underlying parts; and when removed it leaves 
an intensely red surface behind. But very 
soon it becomes more adherent, and its re- 
moval is only attained by laceration of the 
mucous membrane and the exposure of a 
bleeding ulcerated surface, on which a new 
layer of false membrane is formed in a short 
time. The membrane spreads, and may 
cover the whole of the fauces and pharynx. 
When this occurs there is usually so much 
swelling of the parts that scarcely any open- 
ing of the fauces can be seen. Further, the 
aspect of the membrane changes. From 
being yellowish-white, thin, and delicate, it 
becomes thicker, of a brownish tint, firm and 
leathery in texture. The difference in colour 
is due to admixture with decomposed blood- 
pigment, the entanglement of atmospheric 
particles, and drying of the exudation. Signs 
of coryza are present, and from the nostrils a 
thin acrid discharge issues. 
The tongue is dry, coated with a white or 
brownish fur, and red at the tip. Appetite 
is entirely lost, and as a rare symptom there 
may be vomiting. Swallowing is difficult 
and painful. The bowels are, as a rule, con- 
stipated. The temperature becomes higher, 
but does not attain the extreme degree seen 
in many other fevers. Its ordinary height 
is between 102° and 103° F. The exami- 
nation of the chest at this time, provided 
the case is uncomplicated, reveals either 
nothing at all, or only the rhonchi and rales 
of bronchial congestion. The urine is still 
febrile, and in a large number of cases con- 
tains albumen. Slight delirium may occur, 
but is not a frequent symptom in the or- 
dinary type. 
When such cases tend to a favourable issue, 
the duration of the disease is variable. Even 
after such a moderately severe form as that 
just described, the symptoms may begin to 
decline at about the fourth day; the patches 
of false membrane, after separating, cease 
to re-form ; and the patient rapidly resumes 
his ordinary health. Usually, however, both 
the general and the local symptoms are pro- 
longed for a much longer period, say up to 
the twelfth or fourteenth day, when slow con- 
valescence begins. 
Such is a description of the form in which 
diphtheria ordinarily presents itself, without 
any of the numerous complications which 
may occur. Many of the symptoms, how- DIPHTHERIA 
493 
ever, require a more detailed description, and 
this will be given below. 
2. The benign form is so mild that a con- 
siderable number of patients pass through it 
with so little feeling of illness that they con- 
sider it unnecessary to consult a medical 
man at all. There can be no doubt that such 
ambulant cases are important factors in 
spreading the disease. The patient suffers 
from but slight malaise and weakness, with 
loss of appetite and slight fever. The urine 
is usually not albuminous. No complaint 
whatever may be made of soreness of throat; 
and for this reason the nature of the com- 
plaint is frequently overlooked, even by medi- 
cal men. Generally, however, there is some 
soreness in swallowing, and a little enlarge- 
ment of the glands at the angles of the jaws. 
On examination, a few white patches of false 
membrane, easily detached, will be seen on 
the tonsils, rarely on the soft palate or pharynx. 
Rarely, with only mild general symptoms, 
very extensive deposit may be seen in the 
throat. In a few days the patches disappear, 
either by being coughed out or by gradual 
dissolution; no more form; the symptoms, 
slight as they were, decline ; and the patient 
rapidly resumes his usual health. During 
the whole period of the disease it is possible 
for the patient to walk about, and even 
attend to his usual duties. But this is very 
undesirable, not only because such cases 
are as capable of spreading infection as more 
severe ones, but because, however slight 
may be the condition at the onset, at any 
time more serious symptoms may arise, and 
in this, the benign, form there is no exemp- 
tion from the most dangerous complications 
and sequelae of the disease, such as spread 
of the membrane to the larynx, cardiac failure, 
and paralysis. 
3. The malignant form of diphtheria is cha- 
racterised by severity rather of the general 
symptoms than of the local lesions. Com- 
monly, from the first the symptoms are 
severe, though the early features of the case 
may be those of the ordinary or even of the 
benign form. There is extreme prostration; 
the pulse is rapid, feeble, and of low tension; 
and the respirations are hurried and shallow. 
The skin is dry, pungent to the touch, and of 
a generally dusky hue. The tongue is dry 
and brown. V ery soon the ' typhoid ' state 
develops, and there may be sometimes a mut- 
tering delirium, though in most cases this 
is absent. A haemorrhagic diathesis is a fre- 
quent phenomenon in this condition, and is 
shown by the occurrence of haemorrhages 
from various mucous membranes, or beneath 
the conjunctiva, and by the appearance of a 
purpuric rash on the skin. The temperature 
may be highly febrile, or not unduly raised. 
The urine is albuminous. While the symp- 
toms of the throat-lesion are not very evident, 
yet its signs are characteristic. The false 
membrane is soft, pultaceous, and very dark- 
sometimes black, in colour. It is often ex- 
tensive ; and the tissues around are sloughing 
or gangrenous. A foul smell comes from the 
putrifying mass at the back of the throat. 
In most cases, too, the false membrane has 
spread to the nose; and a sanious discharge, 
also of foul smell, issues from the nostrils, 
and by its irritation excoriates the skin around 
with which it comes into contact. The glands 
of the neck are always much enlarged and 
inflamed. Such a condition in most cases 
ends fatally in a short time. 
This general description of the three types 
of diphtheria requires to be supplemented by 
a detailed account of some of the symptoms. 
Formation and Spread of the False Mem- 
brane.-The presence of the false membrane 
is the characteristic feature of diphtheria, and 
that from which it derives its name. It is 
the special local manifestation of the disease. 
But, as will be clear from the descriptions 
given, in diphtheria we have to deal with 
general symptoms which, in point of severity, 
may have no relation to the extent of the 
local lesion. In the benign form we may 
sometimes find the general symptoms very 
slight, or practically absent, while a large 
quantity of membrane may be seen in the 
throat. In the malignant form we may have 
the most severe general symptoms when the 
local phenomena, severe it may be, are not 
so prominent as the signs of general disease. 
The question then arises whether we may 
occasionally meet with general symptoms of 
diphtheritic fever, not only without signs of 
any local lesion, but without the appearance 
of any false membrane, and with merely con- 
gestion and swelling of the fauces, having no 
specialised character. It is in the experience 
of clinicians that this occurs, but certainly 
very rarely. It is possible that, in the course 
of an epidemic of diphtheria, instances of the 
benign form may be met with without more 
local lesion than the early congestion de- 
scribed ; yet in such cases a slight formation 
of false membrane may easily be overlooked. 
Because of the existence of such a condition, 
Virchow originally described a catarrhal 
form of diphtheria, in which no membrane 
at all was formed. But it is beyond doubt 
that the poison of diphtheria may act so 
powerfully upon the system as to, in ex- 
tremely rare cases, kill the patient before the 
local lesion has time to develop. It is only 
such cases as these which can without fear 
of error be used for argument; but they have 
been recorded by such competent observers 
that it must be admitted that diphtheria may 
at times occur without any specialised local 
lesion. 
In by far the majority of cases, however, 
false membrane does appear. Generally it 
occurs first on some part of the throat-either 
on the tonsils, soft palate, or the back of the 
pharynx. Usually, too, it is seen in one or 
more spots simultaneously on both sides, and 494 
DIPHTHERIA 
most commonly on the tonsils. Yet, occa- 
sionally, at an early period but one side may 
be attacked, but soon, however, an affection 
of the opposite side follows. The membrane 
can, at quite its early appearance, be detached 
with but slight difficulty, leaving a very red 
or haemorrhagic surface behind. But very 
soon its connexions to the subjacent parts 
become much firmer; it can be removed only 
by some force, and leaves behind a rough, 
bleeding, and ulcerated surface. In all but 
extremely slight cases, a new formation of 
membrane then occurs ; and this may be re- 
peated many times if the disease continues. 
The detachment of membrane also takes 
place naturally, not only at the termination 
of the case, but during its height, new mem- 
branes being again formed. In this way, the 
patient may expel from the mouth, usually 
by coughing, large quantities of the false 
membrane, in small or large shreds. Where 
the larynx and trachea are attacked, complete 
casts of these cavities may be thus expec- 
torated ; and in still more serious cases even 
moulds of the smaller bronchi are occasion- 
ally coughed up. 
In the early stages, the membrane appears 
as a thin whitish deposit, which rapidly 
thickens. The colour, too, soon changes, 
passing through stages of grey, greyish- 
yellow, yellow, brown, and even black. Its 
consistence increases, becoming in most cases 
very firm, and resembling shreds of kid- 
leather. In the malignant form, the mem- 
brane becomes softened, and even pultaceous. 
Its colour then is still darker, and the mem- 
brane becomes mixed with blood or the pro- 
ducts of its decomposition. 
The isolated patches in which the mem- 
brane first appears soon spread and amalga- 
mate, until the whole of the throat, as seen 
on opening the mouth, is entirely covered. 
But the affection spreads farther. One of 
the most dangerous complications of diph- 
theria, and also one of the most frequent, is 
the spread of the membrane to the larynx. 
This is more frequent in children; and, while 
dangerous in adults, is still more so in chil- 
dren, because of the greater ease with which 
it diminishes the lumen of the glottis. The 
signs by which the complication may be 
diagnosed are the following. The patient 
feels soreness in the larynx, and is greatly 
troubled by cough. The breathing becomes 
first wheezy, then stridulous, and always 
more hurried than before. The cough is 
harsh; the voice is hoarse and husky, and 
finally lost. The patient, if a child, clutches 
at the throat as if to remove an obstruction. 
Soon the narrowing of the larynx interferes 
greatly with the entrance of air into the 
lungs. All the extraordinary muscles of 
inspiration are brought into action. The 
lower ribs cease to move outwards, and later 
on are depressed at each inspiration. The 
supra-clavicular spaces are similarly de- 
pressed. These signs are more obvious in 
children: in very young subjects, and es- 
pecially in those affected by rickets, the whole 
chest-wall may be depressed as each breath 
is drawn. Signs of cyanosis may now be 
observed in blueness of the lips and cheeks; 
but more commonly the face is pallid. The 
pulse is very rapid. The temperature is no 
more raised than it was before, and may 
indeed be only slightly above the normal. 
The forehead, and even the whole body, 
becomes covered with a cold clammy sweat. 
If unrelieved by operation, this condition 
soon ends in death, occasionally preceded, 
in young subjects, by convulsions. 
The opinions of observers of great expe- 
rience vary as to the period of the disease 
at which extension of membrane from the 
pharynx to the trachea is most likely to oc- 
cur. Sir William Jenner stated that he had 
never known this complication commence 
after the expiration of the first week of the 
disease. Oertel, on the other hand, speaks of 
its occurrence as late as the thirteenth day; 
and Henoch saw it begin fourteen days after 
the commencement of the primary disease. 
Sir William Jenner's statement, however, is 
correct for the majority of cases; and we may 
place the usual time of appearance of secon- 
dary laryngeal symptoms at three to six days 
after the onset of the diphtheria. It is 
rather in the mild and in the ordinary forms 
than in the malignant that this complication 
may be looked for. Yet its appearance is a 
sign of extreme danger; most of the deaths 
from diphtheria are due to this cause. Sir 
William Jenner again states that he had 
seen death occur twelve hours after the onset 
of laryngeal symptoms, and had never known 
it delayed more than five days ; and his ex- 
perience agreed with that of Bretonneau. 
The membrane frequently spreads to the 
nares also. This is almost invariably the 
case in the malignant, but occurs, too, in the 
ordinary form. The symptoms of the com- 
plication are snoring or snuffling respiration, 
and the discharge of an acrid fluid from the 
nostrils, which excoriates the surrounding 
skin. The excoriations may in their turn 
become covered by diphtheritic membrane 
when the disease is severe. Shreds of mem- 
brane, too, may be discharged from the 
nostrils. Epistaxis is of frequent occurrence. 
Sometimes, as stated in the account of 
malignant diphtheria, this is due to the 
general tendency to haemorrhage found in 
septic diseases, but it is also a sign of inva- 
sion of the nasal mucous membrane. From 
the nose the lacrymal ducts, and even the 
conjunctivae, may be infected, leading oc- 
casionally to destruction of the eyeball. 
Spreading from the throat, the membranous 
formation easily reaches the upper pharynx, 
and by way of this proceeds to the middle 
ear. Great pain and sense of distension are 
thereby produced, and severe otitis media DIPHTHERIA 
495 
with destruction of the parts, or even otitis 
interna and externa, and necrosis of the bone, 
may result. 
The oesophagus, too, may be affected in the 
whole of its length, and even the stomach 
and intestines, as will be mentioned in the 
pathological description. 
Sometimes false membrane may appear in 
various parts of the mouth, probably by the 
infection of abrasions of surface. 
In most cases, as above described, the 
membrane makes its first appearance in the 
throat. Yet numerous cases are now on 
record in which it has first been seen else- 
where. 
The primary laryngeal form of the dis- 
ease is well recognised, and has been known 
by the name of Diphtheritic Croup. The 
general symptoms of the disease are then 
the same as in the ordinary form, but signs 
of the trouble in the larynx occur early and 
before any affection of the pharynx can be 
detected. With the laryngoscope, if the pa- 
tient will allow of it being used, false mem- 
brane, having the ordinary appearance, can 
be seen covering the posterior surface of the 
epiglottis, the whole of the interior of the 
larynx, and even of the trachea. The affec- 
tion may remain localised in the larynx 
until death, or may extend thence to the 
pharynx and other parts. 
A primary nasal form is rare, but some- 
times met with. Here the coryzal symp- 
toms and the muco-purulent or sanious dis- 
charge from the nostrils occur early in the 
disease; and, when the affection is advanced, 
false membrane may be seen near the an- 
terior nares. From the posterior nares the 
lesion may spread to the pharynx, as in the 
laryngeal form. Such cases are often over- 
looked in their early stages, because of the 
obscure position of the characteristic mem- 
brane. They are generally severe in cha- 
racter. 
External wounds or abrasions maybe secon- 
darily infected and covered by false mem- 
brane in the course of the ordinary disease. 
But, on the other hand, there happen cases 
in which not only has the first local appear- 
ance of the disease been seen in an external 
wound, but the inoculation of such a wound 
has been the means of infecting the general 
system. Thus diphtheria has originated 
from the use of an infected instrument in 
the operation of circumcision, diphtheritic 
membrane first developing on the wound. 
Dr. Hill has recently described cases in 
which the primary lesion was on the peri- 
naeum. Dr. Braxton Hicks and others have 
also described cases where the first appear- 
ance of the false membrane was on some 
part of the female genital organs, doubtless 
as the result of accidental inoculation. 
Affection of the Glands. - The glands 
beneath the jaw are swollen and tender in all 
but very exceptional cases of diphtheria. In 
most they are so large as to be easily seen; 
in nearly all they can be felt. But in by far 
the larger majority of cases the swelling of 
the glands is a very marked feature. In 
severe cases, too, it is not only the glands 
beneath the jaw, but also all those of the 
neck, on both sides, though the affection of 
one side may predominate. The skin cover- 
ing them is swollen,reddened, and oedematous. 
Sometimes, too, the tissue lying between the 
glands is greatly inflamed; and in a few cases 
a brawny hardness, extending from the jaw 
to the clavicle and involving apparently all 
the tissues of the neck, an angina Ludovici, 
has been observed. Rarely, the glandular 
inflammation may proceed to suppuration, 
causing a large and formidable abscess. The 
affection of the glands and surrounding tissue 
is more marked in the severe, and especially 
in the malignant forms. 
Condition of the Urine.-The urine in 
diphtheria resembles in its general characters 
that of other febrile diseases, though the fea- 
tures are less marked than in other affections. 
It is diminished in quantity, high-coloured, 
and deposits urates and uric acid. Sometimes, 
too, it may appear but little changed. But a 
special feature of the disease is the occurrence 
of albuminuria, as first pointed out by Dr. 
Wade of Birmingham, in the Midland Quar- 
terly Journal of Medicine, 1857. This appear- 
ance is very frequent, and is found, according 
to statistics, in one-half or even two-thirds of 
the total number of cases. The amount of 
albumen may be only slight, or, on the other 
hand, very great; and it may disappear from 
day to day, to again return. With it may be 
found in the urine hyaline or epithelial casts, 
but only very rarely blood, and the occurrence 
of albuminuria is in only extremely ex- 
ceptional cases accompanied by anasarca or 
followed by any uraemic symptoms. Whether 
albuminuria is present or not, the daily ex- 
cretion of urea is normal, or increased. It 
differs markedly from the albuminuria of 
scarlet fever, in making its appearance nearly 
always during the acute course of the disease : 
very seldom at the time of convalescence. In 
most cases it appears on the third or fourth 
day. Sann£, amongst others, has made ex- 
tended investigations into this complication. 
He examined, in reference to albuminuria, 
224 cases; and found that it appeared on the 
first day in three, on the second day in ten, 
on the third and also on the fourth day in 
thirty, on the fifth day in twenty-two. After 
the fifteenth day albuminuria occurred only 
once for the first time. As a general rule, the 
greater the quantity of albumen in the urine, 
and the earlier its appearance, the more severe 
is the case ; but the mere presence of albumi- 
nuria does not affect the prognosis of the 
diphtheria. In most cases the albumen dis- 
appears during convalescence ; though, as the 
writer can confirm, it may continue in the 
urine for months in moderate amount, and 496 
DIPHTHERIA 
unaccompanied by other symptoms, beyond 
slight weakness and anaemia. On the other 
hand, the writer has reason to believe that 
in exceptional cases chronic nephritis may 
have its origin in an attack of diphtheria. 
Temperature.-The temperature in diph- 
theria has no definite course. It rises suddenly 
early in the disease, and as a rule continues, 
with morning remissions, until the beginning 
of convalescence, when it declines gradually. 
The average temperature at the height of the 
attack is from 102° to 103°, and very rarely 
does it exceed 104° F. It may become raised 
above the average limit by the advent of 
complications, such as broncho-pneumonia or 
suppuration in the neck ; but, with these ex- 
ceptions, the height of the temperature is no 
certain guide to the severity of the general 
disease or to the extent of the local lesion. 
In cases of prolonged diphtheria, such as will 
be noted below, after remissions or even inter- 
missions of the raised temperature, renewed 
attacks of pyrexia are met with, generally as- 
sociated with increase of the general symp- 
toms. 
The Pulse and Heart.-The pulse in diph- 
theria is throughout of an asthenic character, 
short, ill-sustained, and of low tension. In 
the majority of cases it is frequent, above the 
degree to be expected from the fever. Dr. 
Sidney Phillips, in the British Medical 
Journal, 1890, i. p. 960, has analysed 100 
cases of diphtheria with reference to the 
states of the circulation which may occur. 
In three per cent, of his cases the pulse was 
unduly slow, and these instances were cha- 
racterised by vomiting and by a fatal issue. 
He concludes that a very rapid pulse, also 
a very dangerous symptom, may occur with- 
out any other phenomenon, but may be ac- 
companied by vomiting and extreme drow- 
siness. Irregularity both in the rhythm and 
the force of the pulse is not uncommon and 
not unfavourable. The heart-sounds are 
feeble, and the first sound short. Disturb- 
ances of the intervals between the sounds 
are, in the opinion of the writer, of great im- 
portance. A rapid sequence of the second 
sound upon the first, but especially 'spacing' 
of the sounds, as heard at the apex of the 
heart-that is, an equalling of the intervals 
between the first and second, and the second 
and succeeding first sound respectively-are 
of most serious import, and indicate a lia- 
bility to sudden cardiac failure, the most dan- 
gerous complication of diphtheria. These 
alterations in the sounds of the heart may be 
detected both at the height of the fever and 
during convalescence, and are equally im- 
portant at either time. Acute dilatation of 
the heart, usually of the right ventricle, 
sometimes of the left, is not infrequent in 
diphtheria. It may be accompanied by a 
systolic murmur, heard at the apex or over 
the area of the pulmonary artery. But such 
a murmur is not due to endocarditis. Bou- 
chard and Labadie-Lagrave have maintained 
that endocarditis is a frequent complication 
of diphtheria, but their opinion has been sup- 
ported by no other observers. The cardiac 
dilatation does not occasion dropsy, as it does 
in most other conditions, but the weakness 
of the heart's impulse is the cause of the 
thrombosis of the large veins which some- 
times, though rarely, occurs. 
Rash.-A certain degree of efflorescence 
on the skin is not uncommon in unmixed 
cases of diphtheria, and especially in the 
severe variety. It is usually seen about the 
neck and the upper part of the chest. It 
is a diffuse redness, not punctate, and not 
papular in the slightest degree. This is not 
a specific rash, and must be carefully distin- 
guished from that of scarlet fever. To the 
writer, it has appeared to be somewhat 
darker in colour than the rash of scarlet 
fever. In the malignant forms purpuric 
spots of different sizes may be observed, 
scattered over the whole surface of the body 
in great numbers. 
Complications and Sequel®.-Many of 
the complications have already been described 
in the foregoing account of the disorder, and 
such will be here only enumerated. 
1. Extension of the false membrane to the 
larynx and lower air-passages, to the nose, 
ear, and eye. 
2. Formation of false membrane on ex- 
ternal wounds and abrasions. 
3. Extensive ulceration, and even gangrene, 
of the tissues of the throat. Henoch men- 
tions perforation of the palate as an occa- 
sional result. 
4. Great inflammation in the neck, and 
rarely suppuration. 
5. Albuminuria. 
6. Suppression of urine, and uraemia. This 
has been described by Oertel and by a few 
other observers, but its occurrence is con- 
trary to general experience; and, as Dr. 
Hilton Fagge has remarked, it is probable 
that scarlet fever has been overlooked in 
such cases. 
7. Dilatation of the heart. 
8. Cardiac failure, syncope, and sudden 
death. This complication is the most dan- 
gerous which can occur in diphtheria, and 
may come on at any period of the disease, and 
even during convalescence. It is preceded 
usually by a very frequent, sometimes by a 
slow, pulse, but its special warning is an 
alteration in the sounds of the heart, as 
described above. The cardiac failure may in 
some case sshow itself by a gradual failure 
of the circulation, but usually by sudden 
syncope, which is nearly always fatal. The 
most distressing cases in which this occurs 
are those where the patient, some time after 
the decline of pyrexia, is in full convales- 
cence, or even in apparently good health, yet 
suddenly faints and almost instantly dies. 
No patient is absolutely safe from this fatal DIPHTHERIA 
497 
mishap until at least six weeks after the 
apparent end of the disease. 
9. Haemorrhages. These may occur, not 
only from the ulcerated mucous membranes, 
but also from any mucous surface. They 
may be so copious as to seriously weaken 
the patient. 
10. Thrombosis of veins. 
11. Affections of the bronchi and lungs. 
General bronchitis may be met with in 
diphtheria before the larynx is attacked, and 
may be followed by extensive broncho-pneu- 
monia. Both these complications are, how- 
ever, more frequent when the air-passages be- 
come involved in the special diphtheritic in- 
flammation. Collapse of lung, emphysema, 
and haemorrhage into the tissues of the lung 
are also met with at times. Their special 
symptoms are added to those of the original 
complaint, and need not be here detailed. 
12. Paralysis. Though paralysis may 
follow other febrile disorders, yet it is so 
frequently an association of diphtheria as to 
form a characteristic feature of the disease. 
The paralysis, as statistics show, varies in its 
frequency in different epidemics. Cadet de 
Gassicourt found that it occurred in 128 
cases out of 937. Dr. Gowers states that its 
frequency has been reported as from 8 to 66 
per cent., and that probably one-fourth of the 
cases which do not die from the primary 
disease suffer from paralysis. The paralysis 
as a rule appears about two or three weeks 
after the decline of the pyrexia, but it may 
occur during the height of the disease, even 
as early as the second day (Sanne), and it 
may be delayed until the fourth or fifth week 
from the attack. As Landouzy has shown, 
the older the patient the more liable he is 
to this sequela. It is more common after 
slight cases of diphtheria, but its onset is 
earlier in the severe forms. 
The first part to be affected by the paralysis 
is the soft palate. The patient then speaks 
with a nasal voice, and is unable to swallow 
fluids, since the immobile palate no longer 
closes the entrance to the posterior nares, and 
so fluids regurgitate through the nose. The 
palate hangs motionless during respiration 
and phonation, and is insensitive to touch. 
Occasionally, and for a time only, one side of 
the palate remains unaffected, and then the 
uvula is drawn to one side and the curves of 
the palatal edges are unequal. In rare cases 
the inability to swallow extends to solids 
also, from paralysis of the muscles of the 
pharynx. 
The next most common paralysis is that 
of the eye. The most obvious effect of this 
paralysis, and that which most readily attracts 
the attention of the patient's friends, is an 
external strabismus from paralysis of the 
internal rectus muscle. But this is not the 
most common result. More frequently we 
meet with a paralysis of the ciliary muscle, 
usually in both eyes, which has as its effect 
a loss of the power of accommodation. Un- 
less the patient has previously been myopic, 
he is now unable to adjust his eye for near 
objects, as, for instance, in the act of reading, 
while vision for distant objects remains un- 
altered. The pupil, too, is sluggish in con- 
tracting to light. Other muscles of the eye- 
ball may suffer, so that various forms of 
squint are met with, and sometimes ptosis; 
while, in exceptional cases, one or even both 
eyes have become absolutely motionless from 
paralysis of all their muscles. Concentric 
contraction of the fields of vision has been 
described. 
Other organs of sense suffer but rarely, but 
Dr. Gowers states that he has met with loss 
of taste, and loss of smell without loss of 
taste. 
The limbs next suffer from the paralysis, 
and usually the lower before the upper limbs. 
The paralysis is generally preceded by tingling 
feelings, sense of : pins and needles,' or 
actual pain, in the parts about to be attacked. 
Then gradually and slowly the paralysis sets 
in. It is but rarely complete, but always 
sufficient to render the muscles practically 
useless. The muscles are flaccid and soon 
begin to atrophy. The knee-jerks are lost; 
but this phenomenon may be met with, as 
Dr. Buzzard and Dr. Hadden have shown, 
early in the primary disease ; and Dr. Angel 
Money has found that there may be a 
previous exaggeration of the knee-jerks. All 
reflexes are abolished. The affected muscles 
after a time cannot be stimulated to contrac- 
tion by the faradic current, though they still 
retain their reaction to galvanism. Together 
with the paralysis, and sometimes without it, 
a certain amount of ataxy is not infrequently 
seen, most obvious in the legs, though also 
sometimes found in the arms. 
Sensation, in one or all of its varieties, is 
usually lost to a greater or less extent, but 
not always in proportion to the loss of muscu- 
lar power. The distribution of the anaesthesia 
varies. It may be spread over the whole 
limb, or appear only in patches. It is usu- 
ally most marked in the fingers and toes. 
These affections of the limbs are usually 
bilateral, though not necessarily equal on the 
two sides. 
There is scarcely a part of the body which 
may not be affected by the paralysis, but 
other parts than those mentioned are com- 
paratively rarely attacked, and only in severe 
cases. The intercostal muscles may be 
paralysed,'and less frequently the diaphragm, 
so that respiration becomes difficult or even 
impossible. The head falls forward, if the 
patient is in the upright position, from weak- 
ness of the neck muscles. The muscles of 
the larynx are sometimes attacked. The 
muscles attached to the epiglottis cease to 
close the orifice of the larynx, and food may 
then reach the air-passages. More rarely, the 
muscles of the vocal cords themselves are 498 
DIPHTHERIA 
weakened or paralysed, and the voice is 
altered in quality or entirely lost. The 
bladder and rectum may be affected in severe 
cases, but generally they are unaffected. 
Amongst the muscles most rarely attacked 
are those of the face and tongue. 
In the most severe cases it is possible for 
nearly all the muscles above-mentioned to be 
paralysed at the same time, so that the patient 
lies in bed utterly helpless. This condition, 
however, is extremely rare. More usually, 
the paralysis recovers in one part while it 
progresses in another, and as a rule does not 
recur in a part it has already left. A patient 
the subject of diphtheritic paralysis is in 
most danger of heart-failure, for this compli- 
cation, while liable to set in during the 
height of the primary disorder, is specially 
prone to occur during paralysis. The nutri- 
tion of the body may fail from the inability 
to swallow food; and from food entering the 
larynx pneumonia may arise. In very rare 
cases death ensues from paralysis of the 
respiratory muscles. Yet all these dangers 
are comparatively rare ; and usually the para- 
lysis, however severe, after a time gradually 
and entirely disappears. According to Dr. 
Gowers, the average duration of the paralysis 
is from six to eight weeks in cases that 
recover, but it remains longest in the limbs, 
and may there last for as long as four or six 
months. 
Terminations. - (1) Resolution. - When 
the attack ends favourably the fever declines 
by lysis; the membranes soften, separate, and 
do not reappear; the patient gradually re- 
covers strength, and resumes his ordinary 
health. The duration of ordinary cases is 
about ten to fourteen days, but the attack 
may be prolonged by recrudescences to a 
much longer period. 
(2) Death.-Death occurs in diphtheria 
(a) by gradual asthenia from mal-nutrition; 
(&) by rapid asthenia from excessive effect of 
the poison; (c) by cardiac failure; (d) by as- 
phyxia from spread of the membrane to the 
larynx, or paralysis of the respiratory muscles; 
or (e) by any of the complications enumerated 
above. 
Anatomical Characters.-False mem- 
brane.-The naked-eye appearances of the 
false membrane have already been sufficiently 
described. When a section of the mucous 
membrane covered by the exudation is ex- 
amined under the microscope, the false mem- 
brane is seen to consist of either threads or 
shapeless masses of fibrin, in which are em- 
bedded leucocytes, more or less degenerated, 
red blood-corpuscles, and shrivelled cell- 
nuclei. In the deeper layers of the false 
membrane the outlines of epithelial cells can 
be seen, showing their bodies swollen into a 
hyaline or granular mass; the nuclei are not 
visible; and these cells no longer easily take 
the ordinary stains. No definite line of 
demarcation between the false membrane 
and the true mucous membrane can be seen : 
the one joins the other gradually and irregu- 
larly. The mucous membrane shows swell- 
ing and proliferation of its epithelial cells, 
and is infiltrated with leucocytes. Its blood- 
vessels are congested, sometimes thrombosed, 
and haemorrhages are seen in the tissue. 
Numerous micro-organisms, of which a fuller 
account will be given in the next section, are 
found, not only in the false membrane, but in 
the tissue of the mucous membrane, its veins 
and lymphatics. In the later stages, further 
degenerative changes are found in the false 
membrane. It is then much more granular, 
as seen under the microscope ; contains num- 
bers of fatty globules and crystals of fatty 
acids and cholesterin ; and swarms with the 
micro-organisms of putrescence. The false 
membrane consists in part of an exudation 
of fibrin elements, but mainly of the products 
of coagulative necrosis of the epithelial cells. 
Hence its close connexion with the mucous 
membrane. 
Glands.-The swollen glands are, on sec- 
tion, soft, red, and pulpy, resembling splenic 
tissue. They show the changes of acute 
lymphadenitis, and contain micrococci. The 
lymphatics leading to them are also enlarged 
and inflamed, and contain micro-organisms. 
Spots of suppuration are occasionally, but 
rarely, found in the glands. 
Respiratory organs.-The larynx, trachea, 
and bronchi may be covered by false mem- 
brane. Its characters here are slightly dif- 
ferent from those found in the pharynx. It 
is thinner, somewhat softer, and more easily 
separated from its attachments. These cha- 
racters are due to no peculiarity in the mem- 
brane itself, but probably to the thinner layer 
of epithelium from which in this situation it 
takes its rise. The membrane may be pro- 
longed into the smallest bronchi which can 
be followed out. More commonly, however, 
after proceeding down the trachea a little 
way, it becomes soft, loose, and at last con- 
tinuous with a thick purulent or muco- 
purulent exudation, which covers the mucous 
membrane of the bronchi, but is not attached 
to it. The lungs may be congested, or show 
the changes of broncho-pneumonia or of 
pulmonary apoplexy. Very frequently, too, 
emphysema or insufflation of the lungs is 
seen in patches. 
The mediastinal glands may be swollen, 
and resemble in appearance those of the 
neck. 
Circulatory organs.-The cavities of the 
heart, especially those of the right side, con- 
tain ante-mortem clots firmly adherent to the 
endocardium. Endocarditis is not found. The 
muscular tissue of the heart is nearly always 
softened, and may sometimes show carditis or 
fatty degeneration. In a few cases, as the 
writer has found, colonies of micro-organisms 
may be seen embedded in the muscular 
tissue. Frequently, and especially if there DIPHTHERIA 
499 
has been difficulty of respiration, small punc- 
tiform haemorrhages may be observed beneath 
the visceral layers of the pericardium and 
pleurae. In the malignant form, the blood 
after death is found to be of a dark chocolate 
colour, and very fluid. 
Pleurisy and pericarditis are only rarely 
seen. 
Digestive organs.-The false membrane 
may be found extending down the whole of 
the oesophagus, and may affect the mucous 
membrane of the stomach, and even that of 
the intestines. The Peyer's patches and 
the lymphatic nodules of the intestines are 
swollen, and may sometimes show ulcera- 
tions. The liver is congested. The spleen 
is enlarged, but not excessively so, and on 
section is found to be softened and pulpy. 
Urinary organs.-The kidneys, in all 
cases, show the change of their epithelial 
cells called cloudy degeneration. "When 
albuminuria has been present during life, 
the kidneys present the usual appearances 
of acute parenchymatous nephritis. The 
organs are swollen, pale in colour, and soft 
on section. The cortical portion is unduly 
enlarged, and of a yellowish-white colour. 
On microscopic examination, the cells of the 
convoluted tubes, and also those of the 
glomerular and capsular epithelium are seen 
to be swollen, and often proliferated. The 
changes only differ from those of scarlatinal 
nephritis in being of a less intense degree, 
less haemorrhagic, and in being present often 
in scattered patches rather than diffused over 
the whole organ. Sanne asserted that in 
most cases only one kidney was affected, and 
thus explained the absence of uraemia and 
dropsical symptoms. This assertion, how- 
ever, is not confirmed by the observations of 
the writer or of others. 
Muscles and joints.-The external muscles, 
and sometimes those of the heart, may show 
the waxy degeneration of Zenker. In rare 
cases the joints may be found inflamed. 
Nervous system.-Associated with the para- 
lysis, changes have been found in the spinal 
cord and the peripheric nerves. Degenera- 
tion and atrophy of the anterior cornua of 
the spinal cord have been observed by Drs. 
Abercrombie, Percy Kidd, Mott, and others, 
while extensive degeneration of the peripheric 
nerves was first clearly and fully demonstrated 
by Dej erine, an observation since confirmed by 
many others. The degeneration of the nerves 
is seldom found in the whole of their extent, 
and may attack the portions near the spinal 
cord or those more remote. The change 
corresponds in its distribution and degree 
with the region and severity of the paralysis. 
The affected muscles show granular and fatty 
degeneration. 
Pathology.-The older discussions as to 
whether diphtheria was from the first a 
general disease with a local manifestation 
in the throat - comparable, indeed, to enteric 
fever-need now be merely mentioned. It 
is at the present time beyond doubt that 
the primary local lesion in diphtheria is due 
to changes at the site of inoculation, and 
that from this are absorbed the poisonous 
matters which give rise to the general symp- 
toms. In the false membrane there are 
found swarms of micro-organisms, most of 
which, however, are either entrapped by the 
fibrinous exudation or are the accompani- 
ment of the putrefactive changes going on 
in the membrane and in its vicinity. Such 
adventitious organisms are found only in the 
superficial layers of the false membrane, 
except in the malignant form, where they 
may be met with in the deeper tissues, in 
the thrombosed vessels, and in the lymphatics 
and glands. In 1883 Klebs discovered a 
bacillus in the deeper layer of the membrane, 
which he believed to be the specific organism 
of the disease. Its relation to the disease was 
afterwards fully worked out by Loftier in 
1884, who showed that its cultivations, when 
injected into guinea-pigs, produce changes at 
the site of the inoculation identical with 
those found in the throat of man, and after- 
wards the general symptoms of the human 
disease. Further progress in this direction 
has been made by Dr. Klein, who, in 
the Report of the Medical Officer to the 
Local Government Board for 1889, has 
shown that the bacilli described by Klebs 
and Loftier are of two different kinds, which 
he has separated. Both are found in all 
parts of the diphtheritic membrane, but are 
free from other organisms in the deeper 
layers. One of these bacilli, styled by Dr. 
Klein the pseudo-diphtheritic bacillus, is not 
constant in its presence, and can only be 
cultivated at a raised temperature. The 
other, asserted by Dr. Klein to be the true 
bacillus of the disease, grows on gelatine at 
the ordinary temperature of a room, and has 
other technical differences which serve for 
its separation. It grows readily in milk. 
These bacilli are only found at the site of 
the local manifestation of the diphtheria and 
in the neighbouring glands; never, except 
in cows, in the blood or deeper tissues; so 
that if they are the cause of the disease, 
the general symptoms must be due to 
poisoning by some chemical product of the 
growth of the bacillus. This poison, or 
what is believed to be such a poison, has 
been separated from growths of the bacillus 
by Roux and Yersin, Frankel and Brieger, 
and others; and by means of its inocula- 
tion they were able to produce the general 
symptoms of the disease. The theory, then, 
which at present best explains the pathology 
of the disease, is that we have an infection 
of the throat or of a superficial wound by 
the diphtheria bacillus, which there takes 
root, and by the products of its growth infects 
the whole organism. How its poison produces 
the general symptoms of the disease we have 500 
DIPHTHERIA 
at present no theories to explain. Recently, 
experiments have been made by Behring and 
Kitasato, Brieger and Frankel, and Loftier, 
as to the possibility of weakening the action 
of the bacillus by various methods, and so con- 
ferring immunity against its further action; 
but, so far, no results have been obtained 
which are of use in human therapeutics. 
The pathology of the cardiac failure so 
often met with is also obscure. It may be 
due to actual poisoning of the heart-muscle 
by the virus of the disease; and this may 
be the prqcess at work when this accident 
occurs in the early stages of the fever. The 
stoppage of heart, though in regard to its 
symptoms a sudden phenomenon, may be 
really due to a gradually accumulating weak- 
ness. Dr. Sidney Phillips has shown that from 
cardiac weakness there may be a gradual filling 
up of the right ventricle by thrombus, accom- 
panied by symptoms scarcely appreciable in 
the midst of the general febrile disturbance. 
Sudden death, however, will occur when 
in the right ventricle and pulmonary artery 
there is not left sufficient room for the cir- 
culation to be carried on. In the later stages, 
the cardiac failure is probably due to changes 
in the pneumogastric nerve or its central 
connexions-changes, however, which as yet 
have not been demonstrated. 
The changes in the nerves have been found 
to be parenchymatous in nature, except in 
one case reported by Meyer, where nodular 
enlargements were seen, due to infiltration 
of the nerve-sheath. Though the changes 
are generally described as due to 'parenchy- 
matous neuritis,' there is no proof of their 
being inflammatory, and the appearances 
observed are degenerative. In some cases of 
post-diphtheritic paralysis there is great diffi- 
culty in tracing the affection to an antece- 
dent sore-throat, and the question has arisen 
whether the sequelae may occur without any 
specific local lesion. That there may be a 
non-membranous primary diphtheria has been 
argued above, and this may be followed by 
paralysis. A remarkable series of cases 
illustrating the difficulties in which the 
physician may be involved, is recorded 
by Boissarie in the Gazette Hehdomadaire, 
1881, p. 310, amongst which, during an epi- 
demic, the first symptoms observed were 
those of paralysis in many cases, in some 
followed by angina, whereas, in succeeding 
cases, the disease had its accustomed course. 
The albuminuria may be due to several 
causes. In many cases, of course, the organic 
changes in the kidney sufficiently account for 
the symptom. But in other cases, and es- 
pecially in those where it is an early symptom 
of the disease and quickly disappears, it would 
appear to the writer to be due to a disorder 
of the circulation dependent upon the weak- 
ness of the heart's action. This may be com- 
bined with organic change, as it is in all cases 
of Bright's disease, but the essential factor in 
the production of the albuminuria is the dis- 
order of circulation. 
Mode of access of the poison to the 
system.- Diphtheria is eminently a con- 
tagious disorder. A large number of the cases 
can be traced to actual contact with diph- 
theritic membrane or the secretions there- 
from. Thus, surgeons who, after performing 
tracheotomy, have sucked out the secretion 
which blocked the tube, have very frequently 
contracted the disease, as have also relations 
who have kissed a patient. The cases alluded 
to earlier in this article, in which wounds have 
been inoculated by diphtheritic poison, are 
also demonstrative of this fact. 
But diphtheria is also infectious, as is shown 
by its spread from one district and from one 
country to another. It occurs most frequently 
in epidemics, and yet in the present day it is 
so endemic in our large towns that they are 
never free from it. It forms a large item in 
the regular annual bills of mortality. 
Its spread seems to have no connexion 
with the water-supply. But instances are 
now numerous in which outbreaks of diph- 
theria have been associated with a particular 
supply of milk. Here we may not only 
have to deal with a mere transference of the 
poison from man to man, milk being merely 
the vehicle, as is the case with scarlet fever, 
but the question also arises whether there 
may be a disease in cows which is identical 
in pathology with human diphtheria and 
capable of producing the latter. Dr. Klein's 
recent observations are of great importance 
in this connexion. During epidemics, it had 
been noted in a few instances that the cows, 
from which the infected milk had been de- 
rived, had had chaps or sores on the teats. 
Dr. Klein inoculated healthy cows with culti- 
vations of his diphtheria bacillus, and in con- 
sequence of this observed not only a local 
affection at the point of inoculation, and 
general symptoms too, but also an eruption 
on the teats and udders. He also succeeded 
in obtaining cultivations of his diphtheria ba- 
cillus from the milk of such a cow, and, further, 
an outbreak of diphtheria amongst the cats 
of the Brown Institution was traceable to two 
cats who had been accidentally fed on the 
milk of the infected cows. These observations 
are extremely suggestive, and, if confirmed, 
will throw great light upon the aetiology of 
diphtheria. 
Medical men have, at different times, at- 
tributed outbreaks of diphtheria in man to 
infection or spread of infection from cats and 
other domestic animals, but no distinct proof 
of such a method of attack has hitherto been 
published. Nevertheless, Dr. Klein has 
shown that cats spontaneously suffer from a 
disease which is associated with the presence 
of his diphtheria bacillus, and also that the 
same disease is produced in them by in- 
oculation on the cornea with poison derived 
from human diphtheria. Dr. Klein is of DIPHTHERIA 
501 
opinion that in cats the primary seat of in- 
fection, in idiopathic cases, is the lungs. 
^Etiology.-The exciting cause of diph- 
theria is doubtless an organised poison, and 
it may be accepted, provisionally at least, 
that it is the diphtheria bacillus described 
by Dr. Klein. The means, however, by which 
this germ obtains access to the body, and is 
allowed to work its ill effects therein, are of 
all importance, and constitute the predispos- 
ing causes of the disease. These may shortly 
be discussed as follows :- 
1. Age.-The statistics of the incidence of 
diphtheria at various ages have been collated 
by Dr. Thorne Thorne in his ' Milroy Lectures ' 
for 1891. The greatest number of cases, he 
remarks, occur between the ages of two and 
five years, or, more widely stated, between 
three and twelve years, and this excess may 
possibly be due to the greater exposure to 
infection during this period from the aggrega- 
tion of children in schools. 
2. Sea?.-The disease is more frequent in 
females, possibly, according to Dr. Thorne, 
because of the greater danger of infection 
they undergo in nursing the sick. 
3. Heredity. - There undoubtedly are 
some families in whom a more than usual 
number of cases of diphtheria occur, and this 
probably is due to an inherited weakness, 
rendering the members unduly receptive of 
the poison. 
4. Season.-Dr. Tatham, when medical 
officer of health for Salford, published in 
his reports most careful statistics as to the 
number of cases occurring in that locality, 
where diphtheria is especially rife, at various 
times of the year. Dr. Tatham has kindly 
furnished the writer with the table which 
follows, in which it is clearly shown that an 
increase in the number of cases of diphtheria 
begins in the third quarter of the year; the 
number attains its maximum in the fourth 
quarter, and, while declining in the first 
quarter, nevertheless is still in excess of the 
number occurring in the second quarter. 
the milder cases occur, and the greatest num - 
her of deaths in the fourth and first quarters, 
the excess in the first quarter being probably 
due to a legacy of severe cases left from the 
preceding quarter. 
5. Hank.-The disease is more prevalent 
among the poor, probably because overcrowd- 
ing increases facilities for contagion and infec- 
tion. 
6. Hygienic conditions. - There is no 
doubt that exposure to sewage emanations 
is a fruitful source of diphtheria. How this 
comes about is not precisely certain: we do 
not yet know that the diphtheria-germ grows 
in sewage, or is given off in sewage-gas. The 
cases reported by Dr. Hill of perineal diph- 
theria, already mentioned, tend, to show that 
this might be the mode of infection. Dr. 
Thorne, however, is of opinion that sewage- 
gas produces a morbid condition of the fauces 
which renders the patient more liable to the 
reception of the diphtheria poison. He 
makes the very apposite remark that diph- 
theria has greatly increased of late years, and 
especially in towns, whilst improvement in 
hygienic surroundings, and especially in the 
disposal of sewage, has received much more 
attention, and in consequence of this, diseases 
undoubtedly due to sewage infection, such as 
enteric fever, have greatly diminished. This 
is a fact which militates against the view 
that diphtheria is connected with poisoning 
by sewage, but the statistics of the association 
between the two are very positive. 
In former years, diphtheria was more com- 
mon in country districts than in towns, or, to 
speak more accurately, in the sparsely popu- 
lated than in the densely populated parts. In 
recent times, as shown by Dr. Longstaff in 
the Report of the Medical Officer to the 
Local Government Board for 1888, this re- 
lation has been reversed, and now diphtheria 
is the more common in thickly populated 
districts. The statistics also show that the 
geological conditions have but little effect 
on the incidence of the disease. Dr. Thorne, 
however, asserts that this is only true as 
regards the structure of the soil itself, in 
relation to drainage. A clay soil may be 
rendered immune from diphtheria by the 
possibility of free drainage. But where 
moisture is accumulated, and also allowed to 
remain stagnant, there diphtheria is rife. 
7. Influence of other diseases.-The way 
for the diphtheria poison may be prepared 
by other diseases, such as tonsillitis, render- 
ing the fauces a vulnerable point, or by 
diseases which weaken the system and so 
diminish its power of resistance. Probably 
the puerperal state should be associated with 
the latter group of conditions. 
In most works on diphtheria hitherto pub- 
lished, it has been customary to speak of a 
primary and of a secondary form of the dis- 
ease. The former is that ordinarily met with. 
By the latter is understood the occurrence 
Borough of Salford. 
Reported Attacks of Diphtheria in the several 
Quarters of the Seven Years 1883-1889. 
(Dr. Tatham.') 
Reported cases.... 
Proportion to whole. . 
Deaths amongst the 
above reported cases. 
Case fatality .... 
1 
270 
22% 
79 
29% 
First quarters 
(Jan., Feb., March) 
233 
19% 
62 
27% 
Second quarters 
(April, May, June) 
290 
24% 
58 
20% 
Third quarters 
(July, Aug., Sept.) 
431 
35% 
125 
29% 
F urth quarters 
(Oct., Nov., Dec.) 
The table also shows (see percentage of 
deaths) that in the third quarter of the year 502 
DIPHTHERIA 
of diphtheritic lesions and symptoms after 
various other diseases, amongst which the 
principal are scarlet fever and measles. It 
must be remembered in connexion with 
this subject, that the mere appearance of a 
false membrane is not a proof of the existence 
of diphtheria. The same process, coagulative 
necrosis, which is the main factor in pro- 
ducing the diphtheritic membrane, also takes 
place on mucous surfaces as the result of 
many other intense inflammations. Thus, 
in scarlet fever, the occurrence of a false 
membrane on the fauces may be due only 
to a specially irritative effect of the scarla- 
tinal poison. Nevertheless, cases not infre- 
quently occur-and the writer has had many 
opportunities of examining such-where, 
together with positive symptoms of scarla- 
tina, large quantities of diphtheritic mem- 
brane have formed in the throat, and have 
even extended to the larynx, and where also 
after a time the characteristic paralyses of 
diphtheria have shown themselves. Such 
cases are specially prone to occur when epi- 
demics of scarlet fever and diphtheria co- 
etaneously exist, and there is reasonable 
ground for believing that they are due to a 
dual infection by the poison of both diseases. 
In attacks of ' scarlatinal diphtheria ' a 
special streptococcus has been found by 
several observers, but the evidence of its 
identity is still incomplete. 
8. Previous attacks.-One attack of diph- 
theria confers no immunity upon its subject. 
Even during convalescence the patient has 
been known to incubate the disease afresh, 
and this process may be repeated more than 
once. 
Diagnosis.-Almost any affection of the 
throat may be mistaken for diphtheria, but 
the mistake is only likely to happen in 
the case of acute follicular tonsillitis, scar- 
let fever, and syphilitic affections. Their 
points of difference may be summarised 
thus:- 
1. Acute follicular tonsillitis.-Here the 
amount of fever may be equal to or even greater 
than that found in diphtheria. Usually the 
fever begins more suddenly, without prodro- 
mata, and is accompanied by more pain in 
the throat and more disagreeable general 
symptoms than occur in the early stage of 
diphther'a. In fact, the less serious disease 
I as in most cases the more severe symptoms. 
In acute follicular tonsillitis, even from the 
first, exudation can be seen issuing from the 
tonsillar crypts, forming many small white 
points upon the surface of the swollen tonsils, 
and nowhere else. In diphtheria some 
hours, or even days, usually elapse before 
more than one patch of membrane is seen, 
and this may possibly not be upon the tonsil; 
or, if there be more than one, a patch situated 
elsewhere than on the tonsil will decide the 
diagnosis. The diphtheritic membrane, too, 
soon becomes thick and leathery, and is not 
easily removed, while the exudation of ton- 
sillitis remains soft and creamy and is easily 
wiped away with a brush. In acute tonsillitis 
nasal catarrh is not often met with, while in 
diphtheria of moderate severity it is frequently 
an early symptom. 
2. Scarlet fever.-Diphtheria rarely begins 
with the same suddenness as scarlet fever; 
and vomiting, too, is not usually an early 
symptom. The temperature in scarlet fever 
rapidly rises to a height which is rarely 
found in diphtheria, and then only in the later 
stages of an acute attack. After twenty-four 
hours, too, the scarlet-fever rash appears. 
This may possibly be mistaken for the ery- 
thema rarely seen in diphtheria. But the 
diphtheria-rash, when present, does not 
spread over the whole body, being limited to 
the upper parts of the chest and the neck ; it 
is not punctate; and it is never an early symp- 
tom. The special albuminuria of scarlet 
fever first makes its appearance late in the 
disease or at the beginning of convalescence ; 
and if albuminuria should occur earlier, it is 
only slight, and such as may accompany any 
febrile state. The urine, too, in scarlet fever 
frequently contains blood together with the 
albumen. In diphtheria, on the other hand, 
albuminuria is an early symptom; and in a 
doubtful case, if the urine contains much 
albumen after only two or three days of the 
fever, a diagnosis of diphtheria is the more 
probable. The urine in diphtheria rarely 
contains blood. The throat affections of the 
two diseases may resemble each other very 
closely, for in scarlet fever, not only may the 
slough of the mucous membrane simulate the 
false membrane of malignant diphtheria, but, 
as already stated, there may occur in scarlet 
fever a false membrane having the same 
pathology as that of diphtheria. Yet, in 
scarlet fever, ulceration is more prominent 
than in diphtheria; shreds of membrane are 
not expectorated, and there is no tendency of 
the throat-affection to spread to the larynx. 
The writer has already mentioned, as his 
opinion, that in the cases where laryngeal 
affection has ensued upon scarlatinal symp- 
toms, there has been a double infection by the 
two poisons. 
3. Syphilitic affections.-Syphilis, in the 
secondary stage, may produce white patches 
over various parts of the throat, due to coagu- 
lative necrosis of the epithelial cells. These 
may be mistaken for diphtheritic membrane. 
But they are never accompanied by so much 
fever as occurs in diphtheria; they are not so 
raised as diphtheritic patches ; and the parts 
around are not so swollen as in diphtheria. 
Moreover, the rash of secondary syphilis pre- 
sent on the body-surface at the same time is 
diagnostic. The ulceration of the throat 
which may appear in the tertiary stage of 
syphilis might be mistaken for a diphtheritic 
condition during an epidemic of diphtheria ; 
but the remembrance of the possibility of its DIPHTHERIA 
503 
occurrence should be sufficient to remove 
the chance of error. 
The paralysis of diphtheria has the charac- 
ters of paralysis due to peripheral neuritis, in 
the article upon which subject details will be 
found as to its diagnosis. The special charac- 
ters distinguishing it as of diphtheritic origin 
are-the history of the throat trouble, if this 
be obtainable; the peculiar progress of the 
paralysis; and the early affection of the palate 
and eyes, which are rarely touched by other 
forms of peripheral neuritis. See Neuritis, 
Peripheral. 
Prognosis.-The prognosis in diphtheria 
must always be guarded, even in the mild 
cases, for serious symptoms may at any time 
break out. The prognosis is the more serious 
the greater the quantity of membrane to be 
seen in the throat, the higher the temperature, 
and the greater the weakness and the severity 
oi the general symptoms. The early signs 
of heart-failure-namely, an unduly slow or 
very rapid pulse, and the alterations in the 
cardiac sounds already detailed-are warnings 
of impending great peril. The malignant 
form is nearly always fatal; and consequently 
the occurrence of much haemorrhage from 
the throat or nose, a gangrenous condition 
of the false membrane and surrounding parts 
of the throat, or signs of much nasal affec- 
tion, are of grave significance. The occur- 
rence of albuminuria adds nothing at all to 
the severity of the original disease, and 
therefore is per se of no consequence in judg- 
ing the prognosis. But, with this exception, 
any one of the complications mentioned above 
adds to the gravity of the attack. This is 
especially the case with extension of the dis- 
ease to the larynx, which, if unrelieved by 
operation, in nearly all cases will kill the 
patient. After operation, too, a large number 
of patients die either from the severity of 
the original attack, or from extension of the 
membrane down the bronchi and consequent 
occurrence of diffused pneumonia. In the ex- 
perience of the writer, those cases of laryn- 
geal diphtheria which have followed on scar- 
latinal symptoms are specially fatal. Gene- 
rally speaking, the prognosis is the less favour- 
able the younger the subject. 
The prognosis of diphtheritic paralysis is 
on the whole favourable. Nearly always the 
paralysis recovers. The unfavourable cases 
are those in which the muscles of the larynx 
and those of the trunk are paralysed. 
Treatment. - 1. Prophylaxis. - Diph- 
theria is undoubtedly both contagious and 
infectious. The infection lies in the exha- 
lations of the patient, and especially in the 
portions of false membrane expelled from the 
throat. For this reason it is necessary that 
a case of diphtheria should be stringently 
isolated, and that all false membrane coughed 
up should be at once received into a vessel 
containing an antiseptic fluid, such as carbolic 
acid (1 in 20) or perchloride of mercury (1 in 
500). During the course of an epidemic no 
milk should be partaken of by healthy persons 
unless boiled shortly before being used. In 
the light of our present knowledge, doubtful 
though this may be, it would also be well to 
banish cats and birds from a household 
during an outbreak of diphtheria. Loffler 
has fixed eight days after the apparent disap* 
pearance of the disorder, as the period during 
which a patient should remain in quarantine. 
2. Surroundings of the patient. - The 
patient should be kept in a warm, well-venti- 
lated room. If there is any sign of affection 
of the respiratory passages the air of the 
room should be kept moist, and this may be 
effected by allowing the nozzle of a bron- 
chitis-kettle to enter within the covering of 
a tent-bed. A warning may here be given 
that, without due care, cool and not hot 
moisture may thus be supplied to the patient, 
and may be extremely harmful by depressing 
the vital powers and inducing pneumonia. 
Heed to this point is especially necessary 
after the performance of tracheotomy. 
3. Diet.-The extremely weakening effect 
of diphtheria must always be borne in mind, 
and every effort made to help the patient to 
assimilate nutriment during the attack. This, 
however, is a difficult matter, for not only 
does the patient frequently loathe food, but if, 
in spite of this, it be administered in inju- 
dicious quantities, vomiting may be set up, 
which will totally preclude nutriment being 
given in the ordinary way. In these matters 
the judgment of the careful physician maybe 
taxed to the utmost, and must decide on the 
merits of each individual case apart from any 
general laws. As a rule, milk must be the 
staple article of diet. It may with advantage 
be peptonised, and mixed with lime-water or 
soda-water 'in the proportion of 2 in 3. It 
should be given at intervals of two hours, or, 
if only small quantities can be taken at a 
time, every hour. With it, twice or thrice a 
day, the yolk of an egg may be beaten up, or 
arrowroot boiled in milk may occasionally be 
substituted. Again, strong beef-tea should 
at intervals be given, not only as a relief to 
the milk-diet, but also for its stimulant 
effects. If the condition of the throat do 
not debar the patient from swallowing them, 
beef-jelly, or chicken- or beef-essence, may 
be given similarly. Where milk disagrees, 
raw beef-juice will sometimes be found of 
great value. Children will not infrequently 
refuse to swallow food, even when the throat- 
affection does not interfere with its passage. 
Here two means may be made use of to 
maintain the nutrition : either the child may 
be fed by the nasal tube, a disagreeable pro- 
ceeding which is rarely applicable in diph- 
theria, or the feeding may be carried on per 
rectum by means of nutrient enemata or sup- 
positories. The latter method must always 
be resorted to when severe vomiting prevents 
food being given by the mouth. 504 
DIPHTHERIA 
4. Stimulants.-Alcohol is needed in 
every case of severe diphtheria, and is best 
given in the form of champagne or brandy, at 
intervals of two or three hours, in quantities 
proportionate to the age of the patient and 
the severity of the attack. It must always 
be given freely when any of the signs of 
cardiac failure are perceived. 
5. Internal medication.-Of recent years 
rational therapeutics has been employed 
with great advantage in the treatment of 
diphtheria. The disease has long been 
thought to be due to the action of germs or 
of the products of their growth, and for this 
reason many germicide remedies have been 
proposed. Quinine was used before any such 
theories were mooted, but is a most valuable 
remedy. Again, the perchloride and also 
the periodide of mercury have been employed 
with great success. The perchloride of mer- 
cury, j'j to of a grain, with sulphate of 
quinine 2 grains, administered to an adult 
patient every third or fourth hour, is an effi- 
cacious combination. The periodide of mer- 
cury can best be given in the soluble form 
recently introduced by pharmacists. A still 
more powerful drug, the cyanide of mercury, 
has been recommended, but cannot be other 
than a dangerous remedy. Salicylic acid 
and its compounds, too, have been used 
with apparent benefit. Of the older and 
empiric remedies, perchloride of iron and 
chlorate of potassium have been the most em- 
ployed, and are undoubtedly of great value. 
They may be given in combination together 
with glycerine, and the iron should be ad- 
ministered freely so long as vomiting does 
not occur. The general antifebrile remedies 
may also be given in diphtheria, but acids are 
preferable to alkaline compounds, since the 
latter are depressing to the circulation. On 
no account whatever should antifebrin, anti- 
pyrin, or any of the so-called new anti- 
pyretics be used in diphtheria. 
The number of other drugs which have 
been employed in the treatment of this dis- 
ease is very large, but as the writer has no 
experience of them he can do no more than 
mention them. Amongst them are peroxide 
of hydrogen, hyposulphite of sodium, and 
turpentine, not to say chloral and jaborandi, 
which in the opinion of the writer are dan- 
gerous. 
The older physicians frequently adminis- 
tered emetics in diphtheria, with the object 
of detaching and expelling false membranes 
from the air-passages and throat. Their 
results from this treatment were often good. 
But now that more is known of the heart- 
failure so common in diphtheria, and of the 
depressant effects which emetics have upon 
the circulation, they are used more rarely. 
If employed at all, only the least depressant, 
such as sulphate of zinc, ipecacuanha, or 
apomorphine should be given. 
6. Local remedies.-The throat is the 
locality from which the specific poison of 
diphtheria is absorbed into the system, but 
it is very doubtful whether remedies applied 
thereto are of any effect upon the poison 
itself. Nevertheless, we have in diphtheria a 
poisoning by general septic matter, the result 
of the putrefactive changes going on in the 
throat, and much good can be done by 
remedies which arrest this process. No force 
whatever should be used to remove the mem- 
branes, but the throat should be sponged out 
frequently with a solution of perchloride ox 
mercury (1 in 500), of carbolic acid (1 in 40), 
or of resorcin (1 in 20). An excellent appli- 
cation, too, is the solution of the perchloride 
of iron, either alone or mixed with an equal 
quantity of glycerine. The tincture of iodine 
applied locally has also been found very bene- 
ficial.1 These applications may be alternated 
with the use of the carbolic spray. A large 
number of other applications have been re- 
commended at various times, but those just 
mentioned will be found the most useful. 
Many of those which have been used have 
no other merit than that of being harmless. 
Some, such as papain, &c., have been recom- 
mended because they had the power of dis- 
solving diphtheritic membrane outside the 
body. They have, however, not been found 
so efficacious in dissolving the membrane in 
situ; and, if they had been, they would only 
have been of use when the membrane at- 
tacked the air-passages. Their thorough 
application, in such conditions, is difficult 
or impossible, and, moreover, in the same 
circumstances, other treatment is more 
urgently required. 
7. Treatment of certain complications.- 
(a) Spread of the membrane to the air- 
passages.-In view of the extreme fatality of 
this complication, operative treatment is at 
once called for, as soon as it is diagnosed by 
the signs already detailed, even though it be 
in an early stage. The opinion of surgeons 
is as yet divided as to the comparative merits 
of tracheotomy and Dr. O'Dwyer's intuba- 
tion of the larynx, but one or other operation 
must be performed. It is true that even after 
this the prognosis is still bad, for death from 
pneumonia is very common; yet the best 
chance has been afforded to the patient. 
(b) Spread of membrane to the nares.- 
"When this occurs, antiseptic solutions similar 
to those used for the throat should be injected 
frequently into the nares. Care, too, should 
be taken to quickly wipe away all secretion 
issuing from the nostrils, in order that ex- 
coriations and secondary infection may be 
avoided. 
(c) Vomiting.-This is best treated by the 
sucking of ice, and the administration of car- 
bolic acid, creasote, or bismuth. Ice to the 
1 In a note to the writer, Dr. Adamson, of Rye, 
reports highly of the internal use of tincture of 
iodine in frequent doses of 3 to 7 minims. It 
produced no ill effects, and was easily taken. DIPHTHERIA 
DIPSOMANIA 
505 
epigastrium, or a blister over the epigastrium, 
will frequently be of use; but if a blister be 
used, care must be employed that the re- 
sulting sore be not infected by the diphthe- 
ritic membrane. If the vomiting is severe, 
food must be given by the rectum. 
(d) Heart-failure.-Here free stimulation 
must be resorted to, both during the attack 
and -when it is threatened. During the 
attack remedies are not of much avail, for 
death is so frequently sudden; but, if possible, 
nitrite of amyl or nitroglycerine may be ad- 
ministered. The subcutaneous injection of 
liquor strychninaa hydrochloratis in doses of 
three minims repeated every half hour (for 
adults) will sometimes tide the patient through 
the dangerous period. When the signs of 
heart-failure are perceived, even if the patient 
is apparently convalescent, he must be kept 
in the recumbent posture at absolute rest. 
General tonic remedies should be given, 
together with strychnine, iron, and digitalis. 
(e) Paralysis.-For this complication the 
most efficacious remedies are good diet, good 
air, and the administration of iron and strych- 
nine. Massage, when the extremities are 
affected, is often of value, and the application 
of a weak faradic current seems sometimes 
to promote recovery. 
Robert Maguire. 
DIPHTHERITIC.-Relating to diph- 
theria. The term is applied to the mem- 
brane formed in diphtheria; and it is also 
associated with certain symptoms occurring 
in the course of the disease, such as diphthe- 
ritic paralysis. See Croupous ; and Diph- 
theria. 
DIPLOE, Diseases of. - See Skull, 
Diseases of. 
DIPLOPIA(SurXooy, double; and o7rrogat, 
I see).-Double vision. See Strabismus. 
DIPSOMANIA 06/™, thirst; and p.avla, 
madness).-Synon. : Oinomania ; Fr. Manie 
Ebrieuse, or Crapuleuse; Ger. Trunksucht. 
Definition.-An irritable condition of the 
nervous system, characterised by a craving, 
generally periodic, for alcoholic and other 
stimulants. 
Aetiology.-This peculiar condition may 
be brought on by a course of intemperate 
drinking; but it is seldom the result of that 
cause alone, and is not infrequent in persons 
who have never been intemperate prior 
to the development of the morbid craving. 
The occurrence of this form of insanity, as 
of other degenerative nervous diseases, may 
generally be traced in the family history of 
the patients. But sunstroke, a blow on the 
head, or other direct injury to the brain may 
excite it; and it may be symptomatic of 
epilepsy, or of structural disease of the brain. 
It may be developed at any period of adult 
life; but most frequently declares itself 
during the pubescent and climacteric periods. 
Symptoms.-An instability of character and 
indications of peculiar nervous irritability 
may generally be recognised as having pre- 
ceded the distinct development of the craving. 
It is also usual to find such persons as are 
predisposed to the disorder abnormally sen- 
sitive to the influence of stimulants. Some- 
times very small quantities of alcohol produce 
appreciable intoxication. The duration of 
the periods of craving is variable ; but most 
commonly they last one or two weeks. 
The remissions continue for periods vary- 
ing from two to twelve months. During 
the period of craving the whole moral being 
is enthralled by the morbid desire ; and the 
regard for truth, decency, or duty is generally 
altogether lost. Moderate indulgence in a 
stimulant may bring on the morbid craving; 
but the desire is frequently developed without 
any such introduction. Members of the 
household in which a patient lives can indeed 
often recognise the indications of a coming 
attack by a restlessness and depression which 
precede any such indulgence. During the 
intervals the patient seems, except when the 
brain has been weakened by frequent attacks, 
to recover completely; and he generally 
displays great confidence in his ability to 
resist the tendency in future. Repeated 
attacks always produce a permanent degrada- 
tion, both intellectual and moral; and if the 
patient live long enough he lapses into a 
state of dementia. It sometimes happens that 
some cerebral lesion, of which the dipso- 
mania had been symptomatic, manifests 
itself in paralytic or convulsive symptoms; 
and the appearance of such phenomena is often 
accompanied by a modification of the craving. 
Diagnosis.-True dipsomania may easily 
be, and often is, confounded with mere 
habitual drunkenness. In dipsomania, how- 
ever, there is, as a fundamental condition, a 
pathological condition of the brain which 
manifests itself irrespective of external cir- 
cumstances of temptation. In habitual 
drunkenness the craving consists mainly in 
a desire to keep up a condition of stimula- 
tion to which the brain has become accus- 
tomed. The habit is the result merely of 
compliance with a vicious custom, and there 
is no such periodicity or independence of 
external influences in the symptoms as is 
found in the true disease. 
Treatment.-Prolonged abstinence from 
stimulants, and adherence to the tonic regi- 
men, are the only measures from which any 
amelioration can be hoped for. It is seldom 
possible to restrain the gratification of the 
craving without compulsory seclusion; and 
even when this has been successfully en- 
forced for a considerable period, the morbid 
tendency is seldom eradicated. By the 
'Habitual Drunkards Act, 1879,' amended 
and made perpetual by the ' Inebriates Act, 
1888,' a person who is, by reason of habitual 
intemperance, at times dangerous to himself 506 
DIPSOMANIA 
DISEASE 
or others, or incapable of managing himself 
or his affairs, may, upon his own written 
application, attested by two justices, be ad- 
mitted into a licensed 1 Retreat,' and detained 
for such period, not exceeding twelve months, 
as he may specify in such application. 
Several retreats have been licensed under 
the provisions of this Act for the treatment 
of dipsomaniacs, with, in many cases, satis- 
factory results. John Sibbald. 
DISCRETE (discerno, I separate).-This 
adjective is used in reference to certain cuta- 
neous eruptions, in which the spots or pus- 
tules are separate from each other; for ex- 
ample, discrete small-pox as distinguished 
from confluent. 
D1SCUTIENTS (discutio, I drive 
away). 
Definition.-Local applications which are 
supposed to remove or disperse the congestion 
and effusion of inflamed parts, and the swelling 
of the skin over them. 
Enumeration.-The chief discutient mea- 
sures or agents are :-Friction; Pressure; 
Warm moist applications; Counter-irritation 
by blisters or liniments; Mercury and its 
preparations; Iodine and its preparations, 
including the Iodides of Potassium, Lead, and 
Cadmium. 
Uses.-These remedies are generally ap- 
plied over enlarged joints, enlarged glands, or 
cystic tumours. The most powerful amongst 
them are blisters, which sometimes remove 
enlargements with great rapidity; next to 
these come mercury and iodine and their 
preparations, either alone or in combination. 
Their action is aided by heat and pressure. 
The effect of the former is seen in the Indian 
treatment of goitre, which consists in rubbing 
iodide of mercury ointment over the tumour, 
and exposing the patient to the full rays of 
the sun, or to the warmth of a large fire. 
The beneficial effects of pressure are observed 
in the diminution which takes place in en- 
larged and swollen joints under the applica- 
tion of mercurial ointment or strapping, the 
friction with the hand in applying the oint- 
ment, and the pressure exerted by the strap- 
ping greatly increasing the efficacy of the 
mercurial preparation in removing swelling. 
See Friction. T. Lauder Brunton. 
DISEASE (des, from; and aise, ease). 
Synon. : Fr. Maladie ; Ger. Krankheit. 
Definition.-Disease may be defined as a 
deviation from the standard of health in any 
of the functions or component materials of 
the body. See Pathology. 
The expression ' a disease ' is frequently 
used with reference to a supposed unit of 
causation. Thus, it may be applied to some 
simple phenomenon, for example, neuralgia, 
when that phenomenon is the sole effect of a 
cause, such as a carious tooth; or it may in- 
clude many concurrent or consecutive result- 
ant phenomena, such as those of syphilis or 
typhoid fever. 
General Considerations. - It is well 
known that changes of function and of struc- 
ture are brought about and influenced by 
a great variety of agencies. These agencies, 
some of which act from within, others from 
without, are recognised as the causes of 
disease. Such changes, whether they be 
functional, affecting more especially the vital 
properties of the body without manifest altera- 
tions of structure, or structural, clearly affect- 
ing its physical properties, constitute what is 
familiarly known as Disease, which is hence 
said to be functional or structural respec- 
tively. These changes are merely the evidence 
of an altered or perverted action, which is 
then in operation or has already occurred, the 
nature of which is considered under the head 
of Pathology. When these deviations from 
health can be recognised during life they are 
described as the symptoms or signs of disease. 
For example, when a person, after exposure, 
it may be to wet or to cold, or both, is found 
to have an increase of temperature, with a 
quick pulse and perverted secretions, to 
complain of thirst, and of pain at the joints 
with effusion in and around them, we say 
that such person is labouring under disease ; 
and we call it ' rheumatism,' because that 
name has been assigned to a complexus of 
deviations from health, such as those then 
presented by this individual. When typhoid 
poison has been introduced into the body, it 
leads in like manner to a number of func- 
tional and structural changes, which, taken 
together, constitute what we call ' typhoid 
fever.' Or, again, under certain circum- 
stances there appears to be generated in the 
system, whether as the result of a tendency 
established before birth (hereditary) or by 
habits of life (acquired), an agency which, 
acting morbifically, produces a series of 
phenomena which we call ' gout.' These 
several forms of disease may be classified 
in groups, arranged in accordance with the 
causes which give rise to them, or their 
nature, their seat, their duration, &c. Rules 
are laid down for the modes of distinguish- 
ing or diagnosticating one disease from 
another; for prognosticating, as far as may 
be, their result; and for their prevention 
and treatment. 
Thus it comes that the discussion or de- 
scription of any particular disease consists of 
an account of the causes that give rise to it, 
or its Aetiology ; the changes of structure 
or of function which constitute it, that is, its 
Anatomical Characters and Pathology ; 
the phenomena attending these changes, 
otherwise, the Symptoms and Signs of the 
disease; the facts that serve to distinguish 
this particular disease from other diseases, 
that is, its Diagnosis; the means of fore- 
casting its progress and termination, which 
constitute its Prognosis ; and finally the DISEASE 
DISEASE, CAUSES OP 
507 
measures by which it may be prevented, 
relieved, or removed, that is, its Treatment. 
Throughout this work the various diseases 
are, as far as is practicable, discussed upon 
this uniform plan. 
It is well to remember that, as thus un- 
derstood, Disease is an abstract or relative 
term, and not an entity having a special 
and independent existence. Physiology has 
in recent days diffused a clear and penetrat- 
ing light over many of the processes of life 
in health, which were previously dark and 
obscure. Pathology, which is physiology 
applied to the study of unhealthy function 
and structure, earnestly follows the foot- 
steps of the sister science. We are therefore 
not hoping and believing too much when we 
express our conviction, that the time is not 
remote when we shall be able to trace those 
early and subtle changes which constitute dis- 
ease, as well as the causes which give them 
origin, and that we shall thus be enabled to 
define in a more philosophic form and with 
more practical results what disease really is. 
In the meantime we must be content to work 
upon the phenomena before us, to investigate 
so far as we can the causes of disease, how to 
recognise its presence and its nature, how to 
estimate its progress and its duration, and 
finally how to prevent its occurrence or to 
cure it when it has occurred. These varied 
and important points will be found discussed, 
as above stated, under suitable headings, in 
the articles immediately following, and in 
other parts of this work. 
Richard Quain. 
DISEASE, Causes of.-Definition.- 
Whatever is capable of damaging the struc- 
ture of any organ or tissue of the body, or of 
interfering with its function, may be a cause 
of disease. This definition implies that such 
causes are numerous, and that of many of them 
science is yet ignorant. To give a succinct 
account of them is therefore difficult, nor is 
the difficulty diminished by the fact that, in 
most diseases, we can trace a succession or 
combination of causes. 
General Classification.-The causes of 
disease have been divided into (1) Predispos- 
ing or Remote, and (2) Exciting or Proxi- 
mate. Illustrations will explain what is 
meant by these terms :-Two individuals are 
exposed to the contagion of typhus in equal 
degree; one, wearied by bodily and mental 
labour, ' catches ' the disease-that is to say, 
his condition has predisposed him to the 
exciting cause of the malady; the other, in 
vigorous health, escapes the contagion-the 
exciting cause of disease. Predisposition in 
fact prepares persons by rendering them 
more susceptible to the influence of exciting 
causes of disease. Many persons are predis- 
posed to emphysema because of heredity; 
they contract bronchitis, which, by its at- 
tendant cough, easily excites the malady. 
Such illustrations might be extended to a 
multitude of diseases. Predisposition may be 
inherited ; or it may be acquired, and be due 
to various accidental causes. In most cases 
there is a combination of predisposing causes; 
in a man, for example, lowered by fatigue, 
want of food, exposure and debauch, an 
attack of bronchitis or pneumonia will be 
readily excited. Though where many factors 
unite in creating the predisposition to disease, 
it is not infrequently possible to estimate the 
part played by each, yet practically it is often 
difficult to say even how much is due to 
predisposition. 
Moreover it is not always easy to distin- 
guish predisposing from exciting causes. 
Predisposition carried to excess becomes in 
some cases an exciting cause of disease, and 
often there is a combination of both causes. 
There are certain distinct exciting causes- 
for example, heat, cold, or injuries of various 
kinds; but most of these can also claim a 
predisposing power. The contagia of specific 
diseases are good examples of direct exciting 
causes. 
In proceeding to discuss the subject of aetio- 
logy, no attempt will be made to separate 
definitely predisposing from exciting causes 
of disease. The writers will endeavour rather 
to indicate as far as possible, under the head 
of each factor of causation, the direction in 
which it especially acts. 
The following causes will be considered : 
(1) Race, (2) Heredity, (3) Sex, (4) Age, 
(5) Intermarriage, (6) Temperament, (7) Cli- 
mate, (8) Town and country, (9) Hygienic 
conditions, (10) Occupation, (11) Air, 
(12) Previous disease, (13) Mental and 
moral conditions, (14) External physical 
conditions, (15) Cold and chill, (16) Poisons, 
(17) Diet, (18) Epidemic diseases, conta- 
gion, malaria, parasites, and growths. 
1. Race.-The statements formerly ad- 
duced to show the influence of this factor 
of life in the production of disease, have 
been of late years subjected to a searching 
criticism, with the result that many are 
either rejected as inaccurate, or resolved into 
other factors, such as climate, dress, and diet. 
What is left of them may be thus sum- 
marised. ' Lethargy ' and ' ainhum ' are 
diseases peculiar to negroes, who also seem 
especially liable to small-pox and leprosy. 
In the same race, on the other hand, hae- 
morrhoids and calculi are unusually rare; 
and an almost complete immunity from yel- 
low fever is enjoyed by its members. This 
immunity is said to be proportioned to the 
purity of the race, but probably may be lost 
or diminished by residence in a colder zone 
(Hirsch). Among Europeans, the manifesta- 
tions of hysteria and insanity are most marked 
in the Latin races. 
2. Heredity.-This is one ofthe most com- 
plex predisposing causes, and is therefore pro- 
portionately difficult to estimate. In the first 508 
DISEASE, CAUSES OF 
place it is unquestionable that certain specific 
diseases, such as small-pox and syphilis, may 
be directly transmitted from parent to child. 
The second and more complex problem is to 
determine whether or to what extent im- 
munity from, or susceptibility to, specific con- 
tagia, disordered functions, or diseased tissues, 
can be transmitted from parent to child. The 
terms ' temperament ' and ' idiosyncrasy ' are, 
as Mr. Hutchinson has pointed out, simply 
expressions of individual heredity. 
A virgin community suffers more severely 
from an epidemic of small-pox than one in 
which the disease has long been known. 
Some kind of transmitted immunity is there- 
fore probable. Some specific diseases run in 
families. Of these the best example is tuber- 
cle, with which have been classed leprosy 
and even typhoid fever and diphtheria. Here 
it is probably a predisposition to, not a direct 
transmission of, the disease in question. 
There is amongst mankind not only an inherit- 
ance of such prominent diseases as phthisis, 
but of peculiarities in the manner they meet 
and pass through minor ailments. Thus, in 
families with a ' nervous history,' we meet 
with predisposition to headaches of nervous 
type, irregularities of digestion in the form of 
diarrhoea and vomiting, and a multitude of 
conditions which have been ascribed to vaso- 
motor disturbances. The members of some 
families live long in spite of exposure to 
almost every exciting source of mischief, and 
contrast most favourably with others who, as 
far as one can determine, have all things in 
their favour. There is no doubt that a 
tendency to gout, the heemorrhagic diathesis, 
pseudo-hypertrophic paralysis, Friedreich's 
disease, hay fever, enuresis, and other dis- 
eases is handed down from generation to 
generation. Of many minor complaints there 
is less certainty ; but it is exceedingly prob- 
able that persons are predisposed to bron- 
chitis and other catarrhs by inheritance. It 
is acknowledged that epilepsy descends from 
parent to child, and that, in fact, individuals, 
because of heredity, are often the subjects 
of nervous diseases excited by causes which 
those from a different stock are enabled to 
throw off readily. The various forms of in- 
sanity are striking examples. It is supposed 
that the inheritance lies in the tissues them- 
selves-that there is a something in the 
tissue-elements which predisposes to certain 
diseases in certain families. Too much 
attention is generally bestowed on direct 
transmission of diseases from parent to child, 
and too little on tendencies resulting from the 
sum of forces acting through the innumerable 
generations of the past. See Atavism ; and 
Heredity. 
3. Sex.-There are great differences in 
the organs and functions of the sexes, and in 
consequence a great contrast in their pre- 
disposition to disease. The female is more 
delicately constructed than the male, and 
those organs which the two sexes possess in 
common differ in weight and in ' fineness '; 
and a general consideration at once indicates 
that the female is less fitted than the male 
to resist many exciting causes of disease. 
This is particularly evident at climacteric 
periods of life: with the onset of puberty 
girls suffer far more than males, and especi- 
ally from a variety of reflex spasmodic dis- 
orders, which require but little provocation 
for their development. All the phenomena 
classed under the head of hysteria often occur 
at this period. At the same time, and shortly 
afterwards, there is a tendency to ulcer of the 
stomach, to persistent constipation, to pecu- 
liar attacks of neuralgia-especially of the 
intercostal nerves, and to acute rheumatism, 
lapsing into the subacute or chronic kind. 
Anaemia and chlorosis are also commonly 
met with at the period of puberty, and if 
then neglected they are apt to persist, and 
predispose the individual still more to dis- 
ease. Goitre, too, is more prevalent among 
females than among males. 
Even so early as the period of puberty the 
external circumstances of the sexes differ, 
and on this depends, in a certain measure, the 
difference in their predisposition. Education, 
domestic habits and customs, and, above all, 
occupation, play an important part, and these 
are largely influential in the production of the 
diseases just mentioned. But, underlying 
these outside influences, there is inherent in 
the sexes a difference in predisposition; for 
when they are exposed, as often happens, to 
the same surroundings, they suffer from 
widely separated diseases. Males are more 
subject to epilepsy, tetanus, gout, diabetes, 
locomotor ataxy, pseudo-hypertrophic paraly- 
sis, haemophilia, vesical diseases, and acute 
lung-affections, than females. The list shows 
that occupations which involve hard mental 
and bodily work and constant exposure ex- 
plain some of the varieties in predisposition. 
It is probable that females are more frequently 
ailing than males, but very often their ill- 
nesses are associated with the menstrual 
functions, and are trifling in degree; and, 
though more males are born than females, 
towards the later years of life the average of 
the sexes becomes more equally balanced, 
or even reversed, because the mortality of 
males is greater than that of females. It is 
sufficient to allude to the fact that pregnancy 
and lying-in predispose females to diseases 
from which males are entirely exempt; and 
that there is a considerable difference in the 
sexes as regards venereal affections, both as to 
predisposition and the effects of the diseases. 
4. Age.-This has a most important in- 
fluence as a predisposing cause of disease. 
In Wagner's Manual of General Pathology 
the periods of age are thus subdivided :- 
(1) Nursing age (infancy)-from birth to 7th- 
10th month. 
(2) Childhood-from 1st to 2nd dentition. DISEASE, CAUSES OF 
509 
(3) Boyhood-from 2nd dentition to puberty. 
(4) Adolescence-from puberty to 20th-25th 
year. 
(5) Early manhood-from 25th to 45th year. 
(6) Later manhood-from 45th to 60th year. 
(7) Old age-from 60th onwards. 
This division is excellent, but in no defini- 
tion is there more need to look out for excep- 
tions than in that of age. The term age is 
strictly comparative; some individuals are 
old at forty, others young at sixty. Persons 
fail with regard to particular organs while 
young in years; and, on the other hand, 
others acquire an increased power in the 
same as years advance, of which the brain 
affords an apt illustration. The minor organs 
of the body betray the like peculiarities, and 
in the early decay of teeth, the changes in 
the hair and the skin, we meet with indica- 
tions of old age though the individuals are 
young in years. But, generally, the predis- 
positions of the young and old are striking by 
their contrast. The young are exempt from 
fatty degenerations, which are so common 
amongst those of advanced life, and, in con- 
sequence, many diseases amongst them are, 
cceteris paribus, less deadly; and not only 
does age, by reason of the changes which 
naturally occur as life goes on, predispose to 
disease, but all outward conditions become 
changed. Children-speaking generally- 
are apt to suffer from acute catarrhal affec- 
tions of the mucous tracts, glandular diseases, 
skin-diseases, tuberculosis of acute type, ' scro- 
fula,' inflammation of endo- and pericardium, 
and a variety of complaints traceable to im- 
properfeeding, bad ventilation, overcrowding, 
and to hereditary tendencies. From acute 
tuberculosis the aged are almost entirely 
exempt, and in them the manifestations of 
hereditary tendencies are observed less fre- 
quently than in the young. The very young 
and the very old are equally subject to bron- 
chial catarrh, and the mortality from this 
disease at each extreme of life is exceedingly 
great. But in the young the predisposition 
to this affection is almost invariably asso- 
ciated with catarrh of the intestinal tract, 
and diseases which indicate a general con- 
stitutional depression; while in the old a 
predisposition to bronchial catarrh is caused 
by a degenerative change in the lungs them- 
selves, or in the air-passages. During infancy 
the nervous system is rapidly developing, and 
during this stage general convulsions and 
convulsive disorders, such as laryngismus 
stridulus, result from slight forms of reflex 
irritation. As age advances the tendency to 
spasm decreases, and convulsions become 
much less marked. The nervous system 
furnishes other illustrations of ' epochal ' 
diseases. From five to fifteen chorea is 
common, but differs from convulsions in 
the greater frequency with which girls are 
attacked (three to one). Hysteria and the 
various sensations and vaso-motor disorders 
which characterise the climacteric period are 
also largely ' epochal,' and almost exclusively 
confined to the female sex. 
Some of the specific diseases, especially 
measles, scarlatina, and pertussis, are more 
common amongst children than adults, which 
is partly explained by the fact that the latter 
class have passed through the ordeal of those 
diseases, and are thus proof against them. 
Rickets also is essentially a disease of infancy 
and early childhood. 
The onset of puberty is a constant source 
of predisposition to disease, for with it comes 
a complete transformation in the mental and 
physical characters, so that the individual, if 
not very carefully watched, deviates from 
even the most perfect health into a perma- 
nent tendency to disease. The system at 
this period-especially in the case of females 
-is frequently unable to bear anything which 
interrupts or interferes with its activity. The 
generative organs undergo great changes, and 
with them the whole moral and physical nature 
is altered. At this period of life there is a pre- 
disposition to both bodily and mental diseases; 
and though constipation, want of sleep, and 
excessive work at school, especially among 
girls, are important factors in the causation 
of disease at this time, perversions of any 
organ or faculty may be started, and, once 
started, they are apt to continue; so that 
there is established, literally, a permanent 
predisposition to disease, and this predisposi- 
tion swells very largely the list of affections 
which are dealt with under the generic term 
Hysteria. Lung-affections-excepting pure 
bronchitis-are more common at and shortly 
after the time of puberty than in previous 
years ; but, excepting in the instance of 
phthisis, hereditary tendencies are less mani- 
fested than during childhood. Even here- 
ditary epilepsy is, if postponed beyond early 
years, likely to be postponed to the period of 
adult life. 
As has been said, the degenerations of 
organs and tissues begin to show with much 
uncertainty, but after the fortieth year of life 
we almost invariably meet with one or other 
of them. Their degree and their conse- 
quences vary with the surroundings of the 
individual-with his habits, temperament, 
occupation, and like influences. Diseases of 
the large vessels are especially common at 
this epoch, such as aneurysms of the aorta 
and of the large arterial trunks in the ex- 
tremities. Henceforward all the diseases 
peculiar to advancing age become common. 
The results of previous disease are now 
declared by a decided predisposition to ex- 
citing causes which have been hitherto with- 
stood. Old age is a relative term. A man 
is old and predisposed to trifling excitants 
because his lungs have lost their elasticity, 
or his brain its regularity of circulation, or 
his heart its vigour : in each of these cases, 
as in a host of others, the predisposition is 510 
DISEASE, CAUSES OF 
strictly one of degeneration-most frequently 
of the vascular system. Again, inherited 
diseases do not declare themselves in some 
cases till the later years of life, and of this 
carcinoma is a striking example. The old 
are predisposed to lowering diseases-low 
pneumonia or bronchitis; and to a variety of 
nervous affections which the vigorous can re- 
sist. In short, they succumb to insignificant 
exciting causes, because of the general or 
partial decay of the tissues and textures of 
the body. 
5. Intermarriage.-Intermarriage cer- 
tainly predisposes to disease, but it is not easy 
to determine how far its predisposing powers 
extend. Hereditary influences are thereby 
intensified. If the practice were confined 
to carefully selected cases, some advantage 
might ensue. Breeders of first-class animals 
practise intermarriage, and thereby develop 
speed, quality, and endurance in the offspring. 
It is beyond question that this practice of 
breeders of racehorses is eminently success- 
ful for the time, but it by no means follows 
that the permanent results are good. We 
are bound to look not only to the immediate, 
but to the ultimate results of intermarriage 
-in short, to decide whether intermarriages 
predispose to disease, to the injury of the 
community. But no rule, free from excep- 
tion, can be laid down on this subject, for 
beyond all doubt many intermarriages have 
led to both physical, moral, and mental ad- 
vantages. There is no doubt that malforma- 
tions are handed down, and that where these 
are marked in families it is injudicious for 
persons to intermarry. Where also serious 
diseases, such as phthisis, insanity, or cancer, 
have been met with on both sides, it is most 
advisable that intermarriage should not take 
place. 
6. Temperament.-Temperament is only 
of importance as expressing certain inherited 
predispositions to disease. It is not in itself 
either a predisposing or an exciting cause. 
Many forms of temperament were described 
by the older writers. According to them, 
persons of sanguine temperament are disposed 
to congestions of organs, and haemorrhages, on 
comparatively small provocation. Phlegmatic 
individuals are the subjects of those diseases 
which are readily excited by want of mental 
and bodily energy and activity. A third set 
belong to the nervous temperament; such 
persons are easily excited and easily depressed, 
and are prone among other diseases to hys- 
teria or hypochondriasis. Nervous persons 
suffer quickly from delirium and other brain- 
symptoms, which aggravate and render dan- 
gerous an otherwise hopeful malady. In the 
acute specific diseases this is particularly 
manifested; nervous people are undoubtedly 
predisposed to them, and when once attacked 
are unduly liable to dangerous complications. 
Practically we meet with ' mixed ' tempera- 
ments, though one may especially prevail. 
On the whole, much confusion might be 
avoided if these terms were altogether dis- 
carded, and the connotation of each, stated in 
definite language expressing what is actually 
observed in each case, substituted. It would 
then be evident upon how slight a basis 
statements regarding temperament are often 
grounded. See Temperament. 
7. Climate.-This includes many factors, 
all of which may predispose to disease. 
Amongst these, the influence of altitude, mois- 
ture, temperature, season, and soil will be con- 
sidered :- (a) Altitude. Dwellers in moun- 
tainous regions suffer with excessive fre- 
quency from cardiac hypertrophy and from 
hernia, though the causes of these should be 
more properly sought under ' occupation ' 
than ' climate.' ' Mountain sickness ' is 
wholly dependent on barometric pressure, 
and is only rarely met with below a level of 
10,000 ft. The prevalence of both malaria 
and phthisis is almost inversely proportional 
to the height of the district above the sea- 
level. Cholera is most prevalent in valleys and 
plains. (&) Moisture. Dry air is generally 
considered less provocative of bronchitis than 
moist, and this disease maybe regarded as one 
of moist climate, (c) Temperature. In the 
tropics various endemic fevers prevail which 
are unknown in this country, for they cease 
to exist when the temperature sinks below a 
certain level (about 60° F.), probably be- 
cause the micro-organisms concerned in their 
spread are unable to thrive below that tem- 
perature. Frost very often cuts short epi- 
demics in our own country in like manner. 
Particular organs are predisposed to disease 
by climate-the liver in the East Indies, the 
lungs and the kidneys in regions where the 
temperature is capricious. Tropical heat is 
essential to the existence of yellow fever, 
malaria, and dengue; and is an important 
factor in the production of such diseases as 
cholera, tropical stomatitis, dysentery, and 
hepatitis. Heat may kill suddenly, as in sun- 
stroke and heatstroke, or excite cerebral mis- 
chief just short of death, especially in con- 
fined, ill-ventilated places. Long-continued 
heat lowers the vital powers, and may excite 
such slight diseases as eczema of a simple 
character, or such grave affections as in- 
flammation of the membranes of the brain. 
Choleraic attacks in this country usually are 
associated with exposure to immoderate heat. 
(d) Season. The influence of season may be 
resolved into the influences of temperature, 
rainfall, and prevalent winds. Animal para- 
sitic diseases are more prevalent in the 
summer. Yellow fever, malaria, and dengue 
are rife in the summer and autumn, when the 
rainfall is heavy. Deaths from lung-diseases 
are most numerous in the winter, and from 
nervous diseases in the spring, (e) Soil. No 
better proof of the tendency to disease 
dependent upon the nature of the soil can be 
given than that yielded by the many careful DISEASE, CAUSES OF 
511 
observations which have shown that where 
a proper system of drainage of soil-water is 
carried out, the tendency to pulmonary 
diseases is very greatly diminished. Clay 
soils are cold, damp, and impermeable, and 
favour diseases aroused by these combined 
agencies ; sandy and gravelly soils readily 
drain themselves, are warm and dry, and 
thus far tend to protect those who live on 
them against disease. Climates are also 
modified by trees, rocks, rivers, lakes, and 
other physical conditions. Detritus carried 
down by streams and deposited along their 
banks or at their estuaries, has, like ground 
vegetation and its decay, an undoubted pre- 
disposing influence in the spread of malaria. 
The upturning of large tracts with imperfect 
cultivation is also frequently followed by out- 
breaks of malaria. Particular districts also 
predispose to certain diseases. Cretinism is 
most common in close valleys; urinary cal- 
culus is endemic in many districts of Great 
Britain and elsewhere. In some circum- 
scribed areas in Scotland, in Norfolk, and 
other districts, individuals are especially 
liable to stone. 
Fogs in large cities depress most people; 
and it is not too much to say that many 
diseases may be traced to a predisposition 
which ' bad weather ' has started. Alco- 
holism has been provoked in this way. It 
is clear, therefore, that under the head of 
climate there are many combining influences, 
which affect the moral, mental, and bodily 
nature of individuals, and through one or all 
may predispose to disease. In this country, 
and probably elsewhere, those who dwell on 
mountains are less liable to disease than 
the dwellers on plains-marshy plains es- 
pecially. New comers are more prone to 
the endemic diseases of a district than the 
natives. The best instances of this are dysen- 
tery and malaria. It should be remembered, 
however, that it is not climate alone which 
varies the predisposition amongst persons 
residing in different regions ; for their habits, 
diet, and social conditions differ far more 
than the climate in which they dwell, and 
predisposition to disease should never be 
ascribed solely to climatic conditions unless 
accidental influences have been investigated 
and eliminated.1 See Climate. 
8. Town and Country.-The influences 
of town and country, as predisposing to dis- 
ease, require separate consideration. "With 
them may be considered dwellings, and a 
variety of minor sources of predisposition. 
The mortality of country districts is less 
than that of towns, but towns differ in this 
respect amongst themselves. The health of 
the largest city in Great Britain, for example, 
compares favourably with any of the large 
manufacturing towns and with many rural 
communities. It is easy to understand that 
differences must depend on the occupation, 
food, and habits of the people, and on their 
external surroundings-air, light, drainage, 
and like conditions. In larger towns occu- 
pations are more lowering than in country 
districts ; while the physical and mental 
strain is greater, and has fewer interruptions. 
Late hours, intemperance, and prostitution 
prevail in towns ; but it is by no means 
certain that, in proportion to the population, 
these ills are less frequent in the more remote 
districts. In towns overcrowding checks 
ventilation, makes drainage difficult, so that 
subsoils become saturated, clouds the atmo- 
sphere with smoke and dust, intermingles 
the sexes (amongst the lower classes), so that 
succeeding generations are stunted in their 
development, and in a variety of other ways 
predisposes to disease. But in some towns 
these evils have been obviated by sanitary 
measures, and as a consequence towns often 
predispose less than country districts to 
diseases due to defective drainage and over- 
crowding. Some startling illustrations of 
this fact have occurred since sanitary science 
has been acknowledged to be of national 
importance. In villages, for instance, repu- 
tedly ' model,' epidemics of disease associated 
with defective drainage and evil domestic 
arrangements have decimated the inhabitants, 
and the virulence of these epidemics has been 
greater than that of those met with in large 
towns. The latter are nowadays for the 
most part better drained than country dis- 
tricts ; thus milk-epidemics of typhoid fever 
have been imported into large cities from 
isolated farms where the drainage alone 
seemed to be at fault. Amongst children, 
rickets, scrofula, tuberculosis, and choleraic 
diarrhcea are far more prevalent in town than 
country ; and the more crowded the popula- 
tion the greater the mortality from phthisis. 
The mortality amongst young children is far 
greater in towns than in country districts. 
Adulterations are an evil in large communi- 
ties, affecting people of all ages. From many 
of these country districts are free. Un- 
adulterated milk is now as easily obtained in 
towns as in the country. So while dwellers 
in the country may have bad drainage and 
bad houses, they have pure air, as a rule, and 
every opportunity of breathing it out of doors. 
Even the alcoholised drinks in many country 
districts are home made and harmless when 
compared with the adulterated raw spirits 
taken by the lower classes of large towns. 
On the other hand, however, dysentery is a 
disease of villages rather than of towns. 
9. Hygienic Conditions.-One of the 
most common causes of disease coming under 
this head is want of cleanliness. To this is 
1 Imperfect drainage leads to what are popularly- 
known as ' damp walls ' in dwellings, and thus pre- 
disposes to pulmonary diseases by interfering with 
ventilation-in fact, by preventing the admission of 
pure air into such dwellings. This truth bears out 
the teachings we have derived from Dr. Buchanan's 
investigations at Ely and elsewhere. 512 
DISEASE, CAUSES OF 
due a variety of skin-diseases, such as eczema 
of the scalp in children, and diseases caused 
by pediculi. It interferes with the functions 
of the skin generally, and by it even a com- 
mon cold is modified. Clothing is a part of 
the subject. Insufficient, improper, or exces- 
sive clothing are most important sources of 
predisposition, amongst the rich as well as 
amongst the poor; for, though the climate 
of this country is so variable, corresponding 
adaptations of dress are for the most part 
neglected. Clothing is used to prevent the 
loss of heat, which occurs in three ways-by 
radiation, conduction, and evaporation; and 
a proper adaptation should prevent undue 
loss of heat, allowing for the escape, instead 
of ensuring the condensation, of the secretions 
from the skin, and should be sufficiently 
loose to permit the movement of the limbs 
and thorax. Non-conducting, loosely woven, 
flexible materials are clearly the best adapted 
for this purpose. Neglect of these require- 
ments is largely instrumental in the causation 
of disease, particularly in young women of 
our large towns. A very common cause of 
predisposition to disease is neglect of proper 
bedding. Deficient ventilation and over- 
crowding are prolific sources of mischief. 
Overcrowding and insufficient ventilation are 
among the greatest evils of our chief cities 
and towns ; and not only is it in their homes 
and workshops that populations are over- 
crowded, but in their places of recreation and 
of religious worship. Briefly it may be said 
that overcrowding predisposes to moral, men- 
tal, and physical deterioration; to all com- 
municable diseases, including all septic and 
parasitic conditions, and especially to typhus 
fever and tubercle; to pulmonary affections ; 
and to a variety of nervous diseases. By 
lowering the morale of populations it in- 
creases all other predispositions, and, in 
fact, passes into an active exciting cause of 
disease. 
10. Occupation.-Occupation acts in two 
ways as a factor in the production of disease. 
(1) It may expose the worker to certain dele- 
terious influences which are themselves ex- 
citing causes of disease. Of this class the 
best illustration is furnished by workers in 
poisonous substances, such as antimony, 
arsenic, copper, brass, lead, mercury, mineral 
acids, phosphorus, and indiarubber. Turners, 
knife-grinders, and stone-masons suffer from 
inflammatory diseases of their air-passages 
and lungs, induced by the inhalation of fine 
particles resulting from their work. Corns, 
chronic inflammatory nodules, and various 
deformities are produced in those whose oc- 
cupation involves constant pressure on any 
one part. Shoemakers and chair-makers 
illustrate this statement, the latter presenting 
a characteristic corn and subjacent pleural 
thickening in the first right interspace. 
(2) Occupation has a still wider predispos- 
ing influence. The general health may be 
lowered, and the resisting power diminished, 
by the conditions of life in which many occu- 
pations are carried on. Among these are 
(a) the breathing of vitiated air due to over- 
crowding or to deficient ventilation; (6) de- 
ficient exercise', (c) exhaustion, physical or 
mental, from overwork; (d) the excessive 
use of particular parts of the body ; (e) ex- 
posure to cold and wet, or to excessive 
changes of temperature ; (/) improper or 
irregular feeding; (y) or, on the contrary, 
absence of adequate employment. These in- 
fluences are often combined and their effects 
proportionately increased. 
Physical overwork is often conjoined with 
exposure and improper or irregular food- 
supply, and the combination has a marked 
effect. It has so predisposed armies to dis- 
ease that their ranks have been decimated 
by fever, pneumonia, and bronchitis, far 
more than by actual fighting. Not a few 
medical men have been affected by the con- 
tagia of the acute specific diseases, because 
when exposed to them they were worn out 
by bodily and mental exertion, and by pro- 
tracted fasting. 
Many other illustrations might be given. 
Soldiers are most liable to thoracic aneurysm 
and sunstroke; and young women with no 
fixed employment, or exhausted from over- 
work and anxiety, to hysteria. A coachman 
who uses for many hours his pectoral mus- 
cles in driving, suffers chiefly in them when 
he has an attack of muscular rheumatism. 
Many of the diseases mainly dependent on 
occupation may be avoided or alleviated by 
careful attention to hygienic precautions. 
11. Air.-The question of air has already 
been alluded to, in considering climate, 
occupation, town and country, overcrowding, 
&c., and it is scarcely necessary to dwell 
much more on its aetiological effects. Air 
influences the predisposition to disease ac- 
cording to its degree of rarefaction, moisture 
or dryness, warmth or coldness, and the 
impurities, mechanical or chemical, which 
may adulterate it. In the article Climate 
many of these atmospheric conditions are 
fully dwelt upon, and their tendencies ex- 
plained. Impurities in the air are exceed- 
ingly prevalent; and mechanical substances 
suspended in it can excite irritable conditions 
of the air-passages which may pass on to 
inflammation, and even destruction, of the 
lungs. Pharyngeal and laryngeal affections 
are a common consequence of these impurities, 
and occur largely amongst certain classes 
whose occupation loads the air with fine parti- 
cles as already described. There is scarcely a 
mineral used in the arts which cannot, by 
inhalation, excite or predispose to disease. 
The air may also be rendered impure by 
chemical agencies, and the moment the 
normal proportion of its elements is disturbed 
it becomes a source of disease. Excess of 
carbonic acid is especially an element of DISEASE, CAUSES OF 
513 
mischief-causing headache, dyspepsia, and 
nervous depression. The presence of am- 
monia and of sulphuretted hydrogen is 
attended by like results. The human economy 
is, however, so framed that its organs can 
often very rapidly throw off the evil effects 
of these gases when breathed in overcrowded 
rooms, so that no permanent mischief is 
established. Poisoned air plays a part in the 
production of tubercle, anaemia, and lowered 
conditions generally ; but it is an incomplete 
comprehension of the causes of these condi- 
tions to set down all to this one. The air, 
also, may be poisoned by other gases, such as 
carburetted hydrogen. 
The atmosphere is modified by currents- 
sometimes to the relief, sometimes to the 
damage of mankind. Winds can remove 
sources of contagion-they can ' clear the 
air.' But according to many authorities 
they can also bring contagion into localities. 
Cholera and other diseases have, it is said, 
followed aerial currents, that is, have been 
carried by them. The influence of winds 
upon health varies with the individual con- 
cerned. Some persons are invigorated by 
warm south-westerly breezes. A north- 
easterly wind will stimulate the energy of 
one person, but reduce another to a condition 
of abject misery. The colder winds generally 
exert their tonic action to most advantage 
during the middle periods of life. While 
easterly winds prevail, acute lung-diseases 
prevail, particularly in the aged. Eczematous 
conditions often owe their origin to the same 
cause. 
12. Previous Disease.-Previous disease 
often predisposes to the same or to some 
other affection, and no clinical history is of 
value unless it includes an account of former 
illnesses. In difficult and doubtful cases a 
true statement of these often gives the clue 
to diagnosis, and even patients themselves are 
alive to the value set upon an accurate 
account of their life-ailments. An attack of 
croupous pneumonia predisposes to recur- 
rence, especially during the three months 
succeeding the attack; and it may leave 
behind a predisposition extending far beyond 
the original disease. Chorea, acute rheuma- 
tism, tonsillitis, malarial fevers, and epilepsy 
tend to recur, as also do the ordinary con- 
vulsions of children; but in all these and 
many other cases it is difficult to estimate 
the exact part played by derived predisposi- 
tion, because in all the primary predisposition 
may be the main agent in the subsequent 
attacks. In practical medicine it is distinctly 
recognised that certain diseases predispose to 
disease, and in their case recurrence is, very 
properly, jealously guarded against. Pertussis 
is supposed to predispose to measles, and 
vice versa,. There is distinctly a connexion 
between chorea, rheumatism, and scarlet 
feVer, and these diseases may follow one an- 
other in any order. Again, previous disease 
may leave behind pathological conditions 
which remain in abeyance, until excited by 
causes which the healthy individual could 
readily withstand. Pertussis often ends, to 
all appearances, favourably, but afterwards 
the patients may suffer from severe lung- 
affections, upon trifling exposure to exciting 
influences. Caseated or calcified tubercles 
in the lungs may after a long period of 
quiescence excite acute phthisis; hepatic 
mischief followed by collection of gall-stones 
in the gall-bladder may cause peritonitis and 
other diseases. Slight complaints are even 
more marked in their predisposing powers 
than serious diseases. On the other hand, 
previous disease sometimes protects indivi- 
duals and communities; for example, vaccina- 
tion can save nations from the most terrible 
of epidemics-small-pox. In the case of 
scarlet fever, typhus, pertussis, measles, &c., 
an almost perfect immunity is acquired by 
those who have already suffered from them. 
Of course, as with small-pox, no one denies 
that second attacks of these diseases do occur, 
but such attacks are wholly exceptional. 
13. Mental and Moral Conditions.- 
Bad news may cause sudden death, or, short 
of this, may interfere with the functions of 
particular organs. Sudden mental worry 
may excite dangerous interference with diges- 
tion, or start an abnormal cardiac rhythm. 
Fright has turned the hair white within a few 
days or hours in healthy persons. Mental 
and moral shock may check or increase the 
flow of urine, and, in fact, may affect all 
the excreting and secreting organs of the 
economy. Mental overwork may excite cere- 
bral symptoms of a dangerous and even fatal 
nature, probably dependent upon a general 
inflammatory hypereemia. It may also in- 
crease the predisposition to tubercular menin- 
gitis. Undue or sudden emotional disturb- 
ances can excite serious mischief, just as they 
can predispose to it. Again, the mind is 
affected by imitative influences; thus a single 
hysterical patient may arouse in others symp- 
toms almost identical with her own. The 
subject of the direct influence of the mental 
and moral state on disease is, however, too 
wide to be here dwelt upon. 
14. External Physical Conditions.- 
These are very numerous as exciting causes of 
disease. Violent or over-exertion may cause 
herniae, haemorrhages, as from the vessels of 
the lungs, cerebral congestions, and even 
ruptures of the valves of the heart, and in one 
or all of these cases lead directly to death. 
Over-exertion with the voice maybe followed 
by pharyngitis or laryngitis. Syncope has 
occurred in the most healthy from violent 
exertion in hill-climbing, in boat-racing, 
walking and running matches, &c., acute 
dilatation of the ventricles probably occurring. 
In less marked cases an ' irritable heart ' 
may result. Various forms of direct injury 
are frequent causes of disease. 514 
DISEASE, CAUSES OF 
15. Cold, and Chill. -Cold carried to 
excess may prove fatal at once. The in- 
fluences of severe cold are described under 
its own heading, and it is only with the 
diseases excited by cold in the everyday 
acceptation of these terms that we shall 
deal here. See Cold, Effects of Severe or 
Extreme. 
Cold is the most common cause of disease 
in temperate climates, especially in the 
changeable climate of this country. It can 
excite disease directly, and can affect prob- 
ably all the organs of the body, causing 
either disturbed function or organic mischief. 
Cold, when severe, contracts the vessels; 
interferes with the circulation, and all vital 
activity; and in this way may cause death. 
But it is with moderate degrees of cold we 
have chiefly to deal. A momentary exposure 
to a cold draught is as frequent an excitant 
of disease as general exposure for a long time. 
A cold draught playing on the cheek may 
cause facial paralysis, sore-throat, or bron- 
chitis ; that is to say, cold applied locally may 
excite disease in the neighbourhood of its 
application or in distant organs. It is prob- 
able, therefore, that cold may act in several 
ways: (1) it may interfere with circulation; 
(2) it may affect the extremities of nerves 
and excite disease by reflex action ; or* (3) it 
may check secretions of the skin, the mucous 
membranes, or other parts. 
We cannot wonder, therefore, that diseases 
of the throat, larynx, and lungs are frequently 
excited by cold. Bronchitis and pneumonia 
are its most common results; and as the young 
and the old are less capable of enduring cold 
than adults, its results are, in their case, more 
frequently fatal. Diarrhoea, renal diseases, 
congestion of the liver, acute and chronic 
rheumatism, simple dyspepsia, and a host of 
other affections, are traceable in many in- 
stances only to cold. Predisposition has much 
to do with the effects of cold: some individuals 
suffer from one form of disease when exposed 
to it, others from entirely different affections. 
In some, ' a common cold ' is most evidenced 
by severe muscular pains and fever, in others 
by a nasal discharge, in others by headache, 
and so on. Some persons never suffer from 
' cold ' without having an attack of herpes 
labialis; and some are most prone to ' catch 
cold ' whenever the weather suddenly becomes 
warm. Numerous similar idiosyncrasies 
might be given. The effects of cold should 
always be considered in almost all predis- 
posing causes of disease. ' Cold ' is a vague 
term and not thoroughly understood; there 
is, therefore, all the more reason why, when 
it comes under consideration in individual 
cases, its precise effects should be most care- 
fully considered and recorded. 
16. Poisons.-Poisonous gases are power- 
ful excitants of disease, and so are poisons 
generally, whether animal, vegetable, or 
inorganic. They may kill quickly, or excite 
a disease of long-continued or even permanent 
nature. 
17. Diet.-Food and drink may by their 
abuse excite disease, and gluttony is as cer- 
tainly an excitant as drunkenness, though 
this fact is often lost sight of. Excess of food 
does not refer simply to the quantity taken, 
but to its quality-its nature, richness, and 
the times when it is taken. Excess of food 
overloads the stomach, makes calls upon it 
which it cannot meet, and dyspepsia is the 
result. Excess of food, if digested, charges 
the blood with materials not demanded by 
the economy, and disease of excretory organs 
or fatty degenerations may thus be excited. 
Want of food, by diminishing the resisting 
power, also predisposes to disease, such as 
pneumonia and bronchitis. When the proper 
proportions of the elements of food are 
neglected, disease results, as e.g. scurvy from 
deficiency of fresh vegetables. Rickets, ac- 
cording to Dr. Cheadle, is due to want of fat, 
while gout is often provoked by a largely nitro- 
genous diet, and diabetes by an excessively 
saccharine one. Particular foods will imme- 
diately excite violent gastric catarrhs in some 
individuals, while others can bear them per- 
fectly well. Clotted lumps of casein or starchy 
foods may irritate the alimentary canal of an 
infant, as well as, from their indigestibility, 
afford no nourishment. Many deaths ascribed 
to ' consumptive bowels' are due to this cause. 
Putrid food is an active poison. Certain kinds 
of fish are poisonous in themselves, and so 
may be shell-fish and crustaceans. The 
Bothriocephalus latus enters the body through 
the flesh of the pike; and, according to 
Hutchinson,leprosy is derived from salted fish. 
Diseased rye produces ergotism, and diseased 
maize pellagra. Flesh from animals suffering 
from ' trembles,' is believed to give rise to 
' milk sickness '; trichinosis and the common 
forms of tape-worm result from the ingestion 
of beef or pork affected with the particular 
parasite in question; and some vegetable 
foods laden with salts of lime have been 
supposed to cause urinary calculi. Water 
and milk are prolific sources of mischief, 
through the impurities they so often contain. 
The drinking-waters of large towns are 
usually derived from rivers, and filtration is 
not a sufficient purification; or, if obtained 
from a purer source, they may become con- 
taminated in transit or storage, so that disease 
may be excited by their use, especially typhoid 
fever. Scarlet fever, cholera, and malaria have, 
according to some, been traced to the same 
source. Many parasites thus find entrance, 
e.g. the ova of the Taenia solium (develop- 
ing in the cystic stage), Distoma haemato- 
bium, Ankylostoma duodenale, Filaria san- 
guinis hominis, and Guinea-worm. Hydatids 
may be derived from the same source, or con- 
veyed directly to the food from the nose or 
faeces of an infected dog. Diarrhoea, dysen- 
tery, Oriental boil, and various forms of DISEASE, CAUSES OF 
DISEASE, CLASSIFICATION OF 
515 
metallic poisoning (lead, copper, arsenic, 
zinc, and mercury) sometimes owe their pre- 
sence to the minute quantities taken in drink- 
ing-water. Goitre and cretinism have been 
attributed to inorganic impurity in water. 
Alcohol is a most extensive source of disease: 
it causes, when taken in excess, cerebral, gas- 
tric, intestinal, hepatic, and renal affections, 
and can lower the system so far as to pre- 
dispose to other diseases. See Alcoholism; 
Entozoa ; and Poisonous Food. 
18. Epidemic Diseases, Contagion, 
Malaria, Parasites, and Growths are 
treated of under separate headings. It is 
now generally established that the diseases 
known as the acute specific diseases are mostly 
direct consequences of some contagium. So 
among the most common exciting causes of 
disease we must class the contagia of the 
several fevers, of syphilis, tubercle, and many 
others. See Contagion ; Personal Health ; 
and Public Health. 
J. Pearson Irvine. 
H. Montague Murray. 
DISEASE, Classification of.-Various 
classifications of diseases, or systems of noso- 
logy, have been adopted by different writers, 
but it is beyond the province of this work to 
discuss these arrangements, neither of which 
fulfils all that is required, or can be regarded 
as satisfactory. All that can be done here is 
to point out the characters upon which the 
chief divisions of diseases are founded. 
The first classification deserving of men- 
tion is that into (1) General and (2) Local. 
General diseases include those in which 
the whole system is involved from the com- 
mencement, and it comprehends as sub- 
divisions : (a) The acute specific fevers, and 
certain other diseases due to the introduction 
of some special morbific agent into the body 
from without, or in some instances developed 
within the system-for example, typhus and 
typhoid fevers, scarlatina, small-pox, malarial 
fevers, hydrophobia, syphilis, pyaemia, and 
septicaemia. (6) The so-called constitutional, 
cachectic, diathetic, or blood-diseases, some 
of which seem to depend upon the production 
of deleterious elements within the system, 
which are capable of recognition, such as 
rheumatism and gout; while others are 
independent of any such obvious pathological 
causes, but are supposed to be severally 
associated with a peculiar dyscrasia or 
diathesis-for instance, cancer, tuberculosis, 
scurvy, rickets. Local diseases are those 
which primarily affect particular organs or 
tissues, each being liable to its own peculiar 
lesions. Thus we have diseases of the lungs, 
heart, stomach, liver, kidneys, brain, and the 
other organs; of the mucous membranes, 
serous or fibro-serous membranes, skin, 
periosteum, bone, and other structures. 
This division into general and local diseases 
is useful within proper limits, but it must be 
remembered that general maladies are often 
revealed or accompanied by local lesions, and 
that complaints which are originally local 
often more or less speedily set up general 
disturbance. Moreover, it is still a question 
whether some maladies are to be regarded as 
general or local in the first instance. See 
Symmetry, in Relation to Disease. 
Another division of diseases, which applies 
more particularly to those which are of a 
local nature, is into (1) Organic or Struc- 
tural, and (2) Functional. These terms 
are self-explanatory, the former implying 
that there is some organic change in the 
affected part, which we can discover and 
demonstrate ; the latter indicating that there 
is mere functional disorder, which is indepen- 
dent of any recognisable lesion. That there 
are structural changes in many affections 
which are regarded as functional, is, however, 
highly probable, though our means of obser- 
vation are not sufficiently powerful to enable 
us to detect them. In connexion with each 
organ, a special classification of its individual 
complaints under one or other of these 
primary headings is usually adopted, this 
subdivision depending upon the affections to 
which the particular organ is liable. As 
illustrations of functional disorders may be 
mentioned disturbed action of certain organs, 
as of the heart, causing palpitation; derange- 
ment of the secretory or excretory functions, 
as in the case of the stomach, liver, or 
kidneys; and many nervous disorders. 
Organic diseases are exemplified by inflam- 
mation and its consequences; alterations in 
growth and development; degenerations; 
malformations; and new-growths. In this 
work it has not been deemed advisable to 
describe the diseases of the several organs 
according to any definite scientific arrange- 
ment, but in some cases an alphabetical order 
has been adopted, while in others individual 
writers have had free scope to classify the 
affections of a particular organ according to 
their own judgment. 
Again, diseases may be classified accord- 
ing to their causation and mode of origin. 
Thus they are divided into : (1) Hereditary, 
or those which are transmitted either directly 
from parents to children, or indirectly, as the 
result of a family taint; and (2) Acquired, 
or those which are developed anew in per- 
sons free from hereditary taint. When a 
morbid condition exists at birth, it is said to 
be Congenital. Other divisions, founded 
on an aetiological basis, are into : (1) Conta- 
gious or Infectious, and (2) Non-con- 
tagious ; and into (1) Specific, or those 
diseases which are due to a specific cause, and 
(2) Non-specific. 
There are other classifications of diseases, 
which need only be mentioned here. Thus, 
according to their intensity and duration, 
they are said to be: (1) Acute; (2) Sub- 
acute ; or (3) Chronic. Another arrange- 516 
DISEASE, CLASSIFICATION OF 
DISEASE, DIAGNOSIS OF 
ment, founded on their mode of progress, is 
into : (1) Continuous ; (2) Periodical, or 
affections which come on at more or less 
definite intervals ; (3) Paroxysmal, or those 
which are characterised by sudden or acute 
paroxysms ; and (4) Recurrent, or diseases 
which tend to recur. Lastly, according to 
their mode of distribution amongst communi- 
ties or in districts, complaints are said to be : 
(1) Sporadic ; (2) Epidemic; (3) Ende- 
mic ; and (4) Pandemic. The meanings of 
these terms are defined under their several 
headings, but they are sufficiently familiar 
as indicating the mode of distribution of the 
diseases to which they respectively belong. 
With regard to the classification of diseases 
which is likely to be permanently adopted in 
the future for general use, it is probable that 
this will be founded on a pathological basis, 
and that, as our knowledge of morbid con- 
ditions and processes becomes more extensive, 
accurate, and definite, it may become possible 
to establish a system of nosology which will 
be both scientific and practically useful. 
Frederick T. .Roberts. 
DISEASE, Diagnosis of (8ia, apart; 
and yivaaKo), I know).-Synon. : Fr. Dia- 
gnose] Ger. Diagnose. 
Definition.-Diagnosis is the art of re- 
cognising the presence of disease, and of 
distinguishing different diseases from each 
other. The term is also applied to the result 
obtained. 
General Considerations.-The general 
principles only of diagnosis will be here dis- 
cussed. Special diagnoses will be treated 
of in connexion with the several diseases to 
which they have reference. 
In many respects diagnosis is a subject of 
great interest and importance. First, in a 
scientific point of view, it is essential that all 
knowledge should be accurate. Secondly, 
accuracy of diagnosis, founded upon a sound 
pathology, enables us to frame a scientific 
classification of disease in its diverse forms. 
Thirdly, it is by an accurate determination 
of the nature of the disease which may be 
present in any given case that we are able 
to anticipate its course, and to employ the 
right kind of remedies in its treatment. It 
is imperfection of diagnosis which leads in 
many instances to an under-estimate of the 
value of therapeutical agents ; for when the 
nature of a disease is mistaken we are led to 
employ improper and unsuitable remedies, 
the failure of which is then erroneously 
attributed to the inefficiency of the agents, 
and not to the unfitness of the treatment 
employed. If our diagnosis had been correct 
or complete, the remedy employed would 
more often have had the desired effect. 
In order to arrive at a diagnosis we must 
study the phenomena or characters of each 
individual case, and then trace its connexion 
with those groups of symptoms which have 
been previously recognised and described as 
belonging to special or distinct classes of dis- 
ease. Assuming that the classification has 
been already made, we proceed to deal with 
the means which enable us to identify each 
individual case, and to connect it with pre- 
viously classified forms of disease. 
Means of Diagnosis.-To obtain accuracy 
in diagnosis we must be prepared with a 
knowledge of the several forms and the 
varieties which disease assumes; we must be 
familiar also with the functions and structure 
of the several organs of the body in health. 
It is by observing and comparing the changes 
wrought by disease in these functions and 
structures that we are enabled to discover 
the presence of, and to determine the nature 
of, the morbid process going on. In forming, 
then, a diagnosis in any particular case, the 
physician must, as far as possible, keep in 
view the real or the ideal condition of the 
patient in a state of health. He must endea- 
vour to place him in as natural a position as 
may be, and as little disturbed by the pre- 
sence of his attendant, or by external cir- 
cumstances, as possible. The physician must 
then obtain a history from the patient him- 
self or from others of the incidence of the dis- 
ease ; and having done this he must proceed 
to investigate for himself the condition of the 
patient. 
1. Previous history of the patient.-The 
history implies of course a statement of the 
age and sex of the patient, as of his home and 
his employment-each of which may have a 
special relation to disease. It should also in- 
clude an inquiry into the antecedent genera- 
tions of the patient, and how far he may 
have any proclivity to congenital disease or 
malformation. This inquiry should have re- 
ference to both positive and negative facts. 
It should extend not only to the previous 
existence of disease in the family, but also 
to the absence of particular diseases or types 
of constitution. The patient's history should 
include a statement as regards the diseases 
and injuries from which he may previously 
have suffered; the remedies used for them ; 
and the climatic and other influences to which 
he has been exposed. Nor must the physician 
neglect to ascertain the history of any children 
that the patient may have had, as the nature 
of disease from which the offspring have 
suffered in many instances throws light upon 
the health of the parent. 
2. History of present illness- The history 
of the present illness should include the de- 
termination of the date of its commence- 
ment ; its probable cause; its earliest pheno- 
mena and its progress as influenced by ex- 
ternal circumstances, including treatment. 
3. The present condition of the patient.- 
Here we have to deal with two classes of 
phenomena; namely (a) those feelings or 
facts of self-consciousness which the patient 
describes to us-subjective phenomena; and DISEASE, DIAGNOSIS OF 
517 
(&) those signs which we ourselves observe- 
objective phenomena. 
(a) Subjective phenomena.-The patient 
describes to us his feelings-as of strength or 
weakness, of numbness, tingling or pain, of 
wakefulness or wandering; he can tell of 
affections of vision, of hearing, of smell, or 
of taste; of breathlessness, cough, palpita- 
tion, or of feelings of sinking or faintness; 
of difficulty of swallowing, thirst, loss of ap- 
petite, nausea or sickness, or various sensa- 
tions and actions connected with the abdo- 
men ; of feelings associated with the genito- 
urinary organs, such as pain or difficulty in 
passing water; of cramps, spasms, or other 
alterations of sensation or motility; or of 
disturbances of sensibility and activity, &c. 
Each of these signs of deviation from health 
will have its own value and significance. 
The physician must at the same time care- 
fully note how far the condition of the patient 
is in accordance with his statements, and 
whether there may not be present some reason 
or cause for concealment or for exaggera- 
tion. 
(6) Objective phenomena.-In studying the 
objective phenomena connected with disease, 
the physician makes use of his special senses, 
assisted by the several instruments with which 
modern science has provided him. 
First, in matters of eyesight, he sees the 
general aspect and expression of the patient, 
which will include the colour of the skin (such 
as may result from the fulness or emptiness 
of the blood-vessels, from the yellowness 
caused by jaundice, from the blueness of 
cyanosis, or from pigmentation, &c.); the pre- 
sence and character of cutaneous eruptions 
(especially in the exanthemata); the ex- 
pression proper, such as that of ease or suf- 
fering, and of depression or excitement; the 
conditions of obesity and plethora, or of wast- 
ing and bloodlessness. He will also observe 
the position of the patient-how he lies, or sits, 
or stands ; how he breathes; the appearance 
of the eyes, the tongue, &c. Further, the 
sense of sight will be employed in determining 
conditions of a local or less general nature. 
Observation must be made of the size, the 
shape, and movements of parts, and of their 
expansion or contraction. With the aid of 
special instruments, such as the ophthalmo- 
scope, the laryngoscope, the cystoscope, the 
various specula, sounds, &c., the physician 
will be able to examine parts of the body of 
the patient beyond the reach of the unassisted 
eye. The chest-measurer or the stethometer 
will render more exact the information 
already obtained by the eye and hand as 
to the size and mobility of parts. The use of 
each of the several instruments above men- 
tioned, as a means of diagnosis, will be found 
described under the heads of their respective 
names, or in the article on Physical Ex- 
amination. 
The sense of hearing tells of the character 
of the breathing, the voice and speech of 
the patient, including cough, hoarseness or 
aphonia,'aphasia,' &c. But the ear is especi- 
ally applied to the study by auscultation of 
the sounds produced in connexion with the 
heart, the lungs, and other organs. The signs 
thus elicited will be found fully described 
elsewhere. 
The sense of touch, or feeling, will com- 
municate-a knowledge of the temperature, of 
moisture or dryness, of size, shape, elevation 
or depression, of smoothness or roughness, 
of the pulse or pulsation, vibration, fremitus, 
of extent of movement, resistance, softness or 
hardness, and of fluctuation. The accuracy 
of the results of these observations by touch 
may be tested by the use of the thermometer, 
the calipers, and the tape-measure. 
The sense of smell aids diagnosis in certain 
cases. The general odour of the patient may 
be observed in small-pox, in rheumatism, and 
some wasting diseases (such as phthisis), and 
in syphilis; and the odour of particular parts 
and secretions, as the urine in diabetes, the 
faeces in jaundice, &c., and in cases of the 
use of certain drugs, or in poisoning. In- 
formation is also afforded by the odour of 
certain discharges, as in ozaena, leucorrhcea, 
cancer, &c. 
The sense of taste is seldom employed in 
clinical investigation, but the physician may 
make use of the patient's taste, as in tasting 
the urine in diabetes. 
Further aids in diagnosis.-Having thus 
summarily described the employment of the 
special senses in diagnosis, and given examples 
of their use, we may briefly mention some 
other agencies of more general application. 
The acuteness of the patient's sense of touch 
may be determined by the aesthesiometer. 
The capacity of the lungs may be measured 
by the spirometer; the strength of muscles by 
the dynamometer; the contractility of mus- 
cles by galvanism; and the force and character 
of the pulse are determined by the sphygmo- 
graph. Constant use is found for the micro- 
scope, the test-tube, the spectroscope, the 
endoscope, and polariscope, which aid in de- 
termining the character of the various secre- 
tions or morbid products that require to be 
submitted to investigation. The result of 
treatment may also be mentioned as an aid 
to diagnosis, as, for example, when an in- 
durated sore yields to the use of-mercury. 
Again, the knowledge that a person has been 
in a malarious district enables us to decide on 
the intermittent nature of certain symptoms 
that may be present. In some cases it may 
be necessary to render a patient insensible 
by anaesthetics, with a view to making a com- 
plete examination, or in investigating feigned 
diseases. The administration of small doses 
of charcoal has been suggested as a means 
of determining the presence of a passage 
through the bowels when more or less 
obstruction exists. 518 
DISEASE, DIAGNOSIS OF 
DISEASE, DURATION OF 
Such, then, are the means used for taking 
note of those deviations from health which 
occur in the several functions and structures 
of the body, and which constitute what are 
known as the symptoms and signs of 
disease, these are terms which will be found 
more specially treated of under the heads, 
Disease, Symptoms and Signs of; and 
Physical Examination. 
The Difficulties of Diagnosis.-It need 
scarcely be said here that the practice of 
diagnosis is not free from great difficulties. 
We know how hard it is to obtain in ordinary 
daily life a reliable account or description of 
any past or present event. There must be 
still greater difficulty in obtaining an accurate 
medical history of a patient's case. He has 
to tell of facts of which practically he may 
know much, but scientifically very little. He 
may be forgetful or ignorant on points about 
which we most need to be informed. He may 
be inclined to exaggerate or to suppress facts 
of material import. Nor are the difficulties 
less in regard to the objective phenomena 
with which we have to deal. The symptoms 
of a disease are not always so clear and definite 
as to mark its nature-that is, to be patho- 
gnomonic. They are more often slight, un- 
defined, obscure, and to be found with diffi- 
culty. The symptoms of one disease may 
very closely resemble those of another, whilst 
those of the same disease will vary at different 
stages, and in different individuals. Again, 
the symptoms of a disease may be compli- 
cated by the co-existence of those of another 
disease; whilst a symptom sufficiently strik- 
ing in itself may be common to, and present 
in, several different diseases. We need only 
mention, for example, feverishness, pain, 
cough, breathlessness, and blood-spitting. 
These are some of the difficulties which he 
who has to study the operation of disease in 
life, has to contend with. He must come 
prepared for the duty with a knowledge, as 
we have already said, of the body, its struc- 
ture and its functions in health, and with 
a knowledge, too, of those combinations of 
morbid actions which constitute special forms 
of disease. For, as regards this latter know- 
ledge, all the observations made would re- 
main as isolated phenomena if they could 
not in each case be grouped as constituting 
distinct diseases. 
We have thus indicated the difficulties of 
obtaining accurate knowledge as regards both 
the subjective and objective phenomena. The 
difficulties are not less when the exercise of 
the intellectual and reasoning faculties is 
called upon to analyse, to compare, and to 
group these phenomena. 
The physician may commence his inquiry 
by tracing up the history of the case and its 
several incidents, a method which is called 
the synthetical; or he may commence by 
ascertaining the present condition of the 
patient, and going as it were backwards in 
his inquiry-a method which is known as 
the analytical. As a general rule, both 
methods are combined in the practice of 
diagnosis. 
Observers can sometimes arrive at a direct 
diagnosis, aided by the presence of some 
characteristic symptom or sign of disease. 
When diseases which are essentially different 
have symptoms more or less common to both, 
the physician will have to institute a com- 
parison between them, until he finds sufficient 
evidence, in the presence or in the absence of 
some distinctive symptom or sign, to satisfy 
him as to the nature of the disease which is 
present. By being able thus to trace the 
absence or the presence of a given symptom, 
he may be able to exclude the possibility of 
the existence of one or other of the diseases 
under investigation. These modes of investi- 
gation will be found fully illustrated in the 
diagnosis of the several diseases described 
throughout this work. 
In conclusion, it must be remembered that 
these investigations, which call for the exer- 
cise of the highest mental faculties, should 
be conducted without prejudice and without 
haste. We should never be ready to accept 
as clear that which is obscure, as established 
that which is open to question ; above all, 
we should remember that, though to err is 
human, it is our duty to endeavour to ascer- 
tain in each and every case, before commenc- 
ing its treatment, what its real nature is, as 
far as it may be possible for us to do so. It 
cannot be too often repeated that the applica- 
tion of a right remedy depends on an accurate 
diagnosis, and that the prevention and the 
cure of disease are the aims and ultimate 
objects of our science. 
Richard Quain. 
DISEASE, Duration of.-The dura- 
tion of a disease signifies the period which 
elapses between its onset and its termina- 
tion, in whatever way this may take place. 
In some instances disease can hardly be said 
to have any duration, a sudden lesion occur- 
ring, which instantaneously, or in a very 
short time, destroys life ; under such circum- 
stances, however, some previous disease has 
usually existed, though perhaps without 
giving any clinical evidence of its presence, 
which determines the occurrence of the sud- 
den event. This may be illustrated by some 
cases of apoplexy, and of rupture of the heart 
or of an aneurysm. Most affections, as re- 
gards their duration, come under one of the 
three categories already referred to under the 
Classification of Disease-namely, acute, 
subacute, or chronic; but it does not serve 
any useful purpose to fix upon any definite 
limit of time as specially expressed by these 
several terms. See Acute ; and Chronic. 
Acute diseases are of limited duration, and 
in many of them this is remarkably uniform 
on the whole, as may be illustrated by the DISEASE, DURATION OF 
DISEASE, PROGNOSIS OF 
acute specific fevers and acute idiopathic 
pneumonia. Even in such affections, how- 
ever, there are deviations from the ordinary 
course, instances occurring in which the 
duration is longer or shorter than that usually 
observed, and this fact depends on various 
circumstances, of which the most obvious are 
the intensity of the disease in any particular 
case, the previous condition and surrounding 
circumstances of the patient, the occurrence 
of complications, and the treatment adopted. 
Complaints which are sub-acute as regards 
their duration may be exemplified by many 
cases of whooping cough and chorea, and by 
some cases of pleurisy, phthisis, pneumonia, 
gastric or enteric catarrh, and certain skin 
affections. A large number of diseases are 
chronic in their duration, and many of these 
when once established become permanent, 
whilst others are ultimately capable of being 
cured. As illustrations may be mentioned 
organic diseases of the heart, most cases of 
phthisis, cirrhosis of the liver, chronic Bright's 
disease, dyspepsia, many skin affections, and 
also morbid growths in various structures. 
Some complaints, as regards their dura- 
tion, can only belong to one or other of the 
groups just indicated, but a considerable pro- 
portion may in different cases be either acute, 
sub-acute, or chronic. Again,it must be borne 
in mind that a disease may be acute or even 
sudden in its origin, but afterwards may sub- 
side into a chronic malady. Certain affections 
are chronic as regards their entire duration, 
but are characterised by the occurrence at 
regular or irregular intervals of acute or even 
sudden attacks, lasting a more or less definite 
time, which course of events is exemplified by 
cases of ague, epilepsy, and asthma. 
Frederick T. Roberts. 
DISEASE, Germs of.-See Germs of 
Disease. 
DISEASE, Prognosis of (irpb, before ; 
and yivaaKO), I know).-Synon. : Fr. Pro- 
nostic; Ger. Prognose. 
Definition.-Prognosis is the art of fore- 
casting the progress and termination of any 
given case of disease. The term is also ap- 
plied to the foreknowledge thus obtained. 
General Considerations.-It is a matter 
of interest and often of great importance to 
be able to indicate with precision how a case 
of disease or injury will be likely to advance 
and terminate. This question must be always 
present to the physician's mind ; and it can 
rarely be absent from that of the patient and 
of those who are interested in his well-being. 
It can thus be easily seen how much depends 
upon the answer of the physician to the ques- 
tions constantly proposed to him, How long 
is this illness likely to last ? How is it likely 
to terminate ? If in recovery, will the re- 
covery be complete or partial ? If in death, 
when and how ? 
Grounds of Prognosis.-The knowledge 
which can give trustworthy answers to such 
questions as the preceding must be founded 
upon an accurate diagnosis of the nature of 
the disease from which the individual is 
suffering; upon the capability of remedies 
to control it; and, lastly, upon an estimate 
of the constitutional and vital powers of the 
patient. 
First, as regards the nature of the disease. 
Some diseases which are mild in their nature 
run a definite course and end favourably: 
take, for example, a simple catarrh. Others 
commence with great intensity, and come 
to a favourable or unfavourable termination 
very rapidly: for instance, Asiatic cholera, of 
which many of the subjects die in less than 
twenty-four hours from the time of their first 
becoming manifestly ill. A third group, such 
as typhus, typhoid fever, and certain of the 
exanthemata, run a longer and more defined 
course, seldom terminating in death except 
after the lapse of many days, nor in recovery 
except after a period of weeks. Another 
class of maladies, chronic in character, rarely 
acute, such as tuberculous diseases of the 
lungs, render the patient more or less an 
invalid so long as he lives, and generally end 
fatally. The like observation will apply to 
the so-called malignant diseases. 
Secondly, the intensity of the particular 
attach affords further grounds for prognosti- 
cating the result. Thus, in a fever, great pro- 
stration, high temperature, and rapid pulse, 
indicative of the severity of the disease, 
must lead to the formation of an unfavour- 
able prognosis; just as great debility and 
wasting, with disturbance of the nutritive 
functions generally, would indicate a like 
result in chronic diseases. 
Thirdly, with regard to local diseases or com- 
plications, whatever the nature of the disease 
may be, the organ affected must form an im- 
portant element in prognosis. Thus disease 
of the brain, or of the heart, or of the lungs, 
or, in a lesser degree, of other viscera, must, 
even when not specially severe, be looked 
upon as affording grounds for anxiety, from 
a prognostic point of view. 
Fourthly, as regards the constitution, age, 
and sex of the patient, it may be safely 
anticipated that in a patient with a good 
constitution the prognosis will be more 
favourable than in a person with a feeble 
or broken-down constitution. Persons whose 
vital powers are unimpaired will resist dis- 
ease, and recover under circumstances which 
would be fatal to other individuals, in whom, 
on the one hand, plethoric habits may pre- 
dispose to acute and rapid changes, or who, 
on the other hand, by degeneration of tissues 
or by the existence of chronic disease may 
be rendered liable to succumb, and that 
rapidly, to morbid influences which healthier 
textures could resist and overcome. 
Disease is badly borne by the very young 
519 520 
DISEASE, PROGNOSIS OF 
DISEASE, SYMPTOMS OF 
and the very old. In very young children 
disease rapidly runs its course, favourably 
or unfavourably. The aged have little pow^r 
of reaction or of resistance; and disease 
in them, though less pronounced, more fre- 
quently ends unfavourably. In middle life, 
disease may be expected to assume an acute 
or sthenic form. 
As a rule, sex has little influence on the 
prognosis of disease, except that usually dis- 
eases of equal severity are more amenable to 
treatment in females than in males. Nervous 
symptoms are, however, more easily developed 
in women, exaggerating a condition that 
might not otherwise be unfavourable. Men- 
struation, pregnancy, parturition, and lacta- 
tion have all a certain amount of influence, 
sometimes favourable and sometimes the re- 
verse, on disease in the female. 
Fifthly, with respect to treatment: a more 
or less favourable prognosis may be founded 
upon the fact that the patient can enjoy all 
the advantages afforded by rest, diet, change 
of climate, &c., which may not be available 
under other circumstances for like cases. It 
is well known that there are some remedies 
which have a specific effect upon certain dis- 
eases, as quinine upon intermittent fever; 
mercury in some manifestations of syphilis; 
iodide of potassium in certain stages of the 
same disease ; and colchicum in gout. In 
such cases a much more favourable prognosis 
can, of course, be given than in those for which 
no such specific remedies are known to exist. 
Experience, however, tells us that favourable 
results follow in many other cases in which 
suitable though not actually specific remedies 
can be applied. 
Taking into consideration, then, the above 
conditions-the nature, the intensity, and 
the seat of the disease; the constitution, the 
resisting power, the age, and the sex of the 
patient; and the possibility of applying suit- 
able and efficient remedies-we are able, in 
a large number of cases, to arrive at an ac- 
curate conclusion as to what the course and 
result of a disease will be. 
Difficulties of Prognosis.- Still, to ar- 
rive at an accurate prognosis is often most 
difficult. Disease is not always identical in 
its character, nor definite in its progress or 
results. The constitutions of individuals vary, 
and it is often very difficult to measure their 
powers of resistance. Remedies, too, vary in 
their action and their operation; and some- 
times we are deceived in the best-founded 
conclusion as to the results that they can 
accomplish. There are few physicians who 
cannot recount errors of prognosis made 
by themselves or by their colleagues. Many 
persons now live who were doomed to 
die; and many persons have died whose 
death was not anticipated. It is the duty 
of the physician, when asked for his opinion, 
to state it honestly, but with great discretion, 
and in general with as much hope as is 
fairly admissible. He must be guarded as to 
the manner in which his opinion is commu- 
nicated to the patient, for there are many 
individuals whose temperament is such that 
the progress of their disease would be greatly 
influenced for good or for evil by the expres- 
sion of a favourable or of an unfavourable 
opinion. At the same time, the physician 
must avoid deceit; and if there be risk or 
danger in communicating an unfavourable 
prognosis to the patient, he must at least 
communicate it to some judicious individual 
amongst the patient's friends. Altogether, 
too much caution cannot be exercised in stat- 
ing, in any obscure case, what its progress 
and result will be. There are many cases in 
which the medical attendant will be justified 
in replying that he is a physician, and not a 
prophet. He cannot always foretell results, 
his aim and object ever being to mitigate the 
patient's suffering, to prolong life, and to cure 
the disease if possible ; full often to profess or 
to do more than this is beyond his art. 
Richard Quain. 
DISEASE, Symptoms and Signs of. 
When disease affects any of the functions or 
structures of the body it produces certain 
altered actions or changes, which, when ob- 
served during life, become evidences of its 
presence and often of its nature, and which 
then are called the symptoms and signs of 
disease. 
The terms symptom and sign are often 
used synonymously, though the deriva- 
tions of the words are by no means the 
same. Symptom, according to its derivation 
(<rv^7TT&^a = a coincidence), means simply a 
coincidence ; that is to say, it coincides with 
the presence of certain phenomena. The 
term sign (from signum) is more distinctive, 
and seems more directly to point to some 
special or peculiar condition. Recently, how- 
ever, an attempt has been made to give a 
more special meaning to these terms. Symp- 
tom, more especially if it be characterised by 
the prefix vital, is intended to refer to modi- 
fications of functions, or to such subjective 
phenomena as we can learn from the patient's 
account of his feelings. On the other hand, 
the term sign, more markedly with the pre- 
fix physical, indicates those morbid changes 
which are objective, or may be recognised by 
the senses of the physician, assisted by other 
appliances. 
It would possibly be well if the meanings 
of the words-symptoms and signs of disease 
-as above stated, were to come into general 
use; but there are many difficulties in the 
way. For example, if the ear be applied to 
the chest in the case of incompetence of the 
aortic valves, we hear a murmur, and we say 
that there are ' physical signs ' of aortic valve 
imperfection; but the locomotive pulse, and 
its peculiar beat, would by many be called a 
' symptom ' of incompetence of the aortic DISEASE, SYMPTOMS OF 
DISEASE, TERMINATIONS OF 
521 
valves. It is therefore extremely difficult to 
draw the distinction between the terms 
' symptom ' and ' sign.' 
By whatever name these phenomena may 
be called, we must rely upon them as the chief 
means by which we are enabled to form our 
diagnosis. The more accurate and complete 
our knowledge of the functions of the body 
and of its component parts, and the more 
capable we are of interpreting, with all the 
completeness possible, the changes produced 
by disease, the more accurate will be our 
diagnosis as to its presence and its nature. 
How these phenomena may be-best observed 
will be found discussed under the articles on 
Disease, Diagnosis of; and Physical Exam- 
ination. Richard Quain. 
DISEASE, Terminations of. - The 
terminations of a disease must be regarded 
both from a pathological and from a clinical 
point of view. 
Each pathological process or condition has 
modes of ending peculiar to itself, but it is 
beyond the province of this article to dis- 
cuss these at any length, and one or two 
illustrations must suffice. Thus inflamma- 
tion may terminate by resolution; by the 
formation of different effusions or exuda- 
tions ; or by causing suppuration, softening, 
induration, ulceration, or gangrene. Fever, 
if it end favourably, may terminate by crisis, 
lysis, or a combination of these modes, or in an 
irregular fashion. An effusion of blood may 
remain, more or less altered; may become 
organised; may soften and undergo a puri- 
form change; may form a cyst; or may be 
altogether absorbed. 
The clinical terminations of diseases are 
highly important, and demand more consi- 
deration. In the first place, a disease fre- 
quently terminates in the death of the 
patient. This event may take place suddenly 
or very rapidly, from the occurrence of some 
serious lesion, or of grave functional disorder 
of an organ essential for carrying on the phe- 
nomena which constitute life. In other cases 
death is the termination of a more or less 
acute illness, either affecting a person pre- 
viously in the enjoyment of good health ; or, 
what is not uncommon, being the consum- 
mation of a chronic malady, which has 
existed for a longer or shorter period. In 
still other instances, death is a slow and 
chronic process, the patient gradually sink- 
ing, several causes and morbid conditions 
often ultimately contributing to the fatal 
event. The modes in which death occurs 
are described elsewhere, and therefore need 
not be discussed in this article. See Death, 
Modes of. 
In the next place, a large proportion of 
cases of disease end in complete and entire 
recovery, the patients being restored to their 
previous state of health, and no organic 
mischief remaining. This result may be ex- 
pected in most of the ailments or functional 
disorders which are of such common occur- 
rence, provided proper treatment is carried 
out. Again, the great majority of cases of 
acute disease terminate in complete recovery, 
taking them in the mass, though several 
affections of this class, when they do not 
prove fatal, are liable to leave behind more 
or less serious deterioration of the general 
health, or even actual organic disease. In this 
class of cases, when recovery does ensue, it 
is usually only after a more or less prolonged 
period of convalescence. Chronic complaints, 
if they are of a structural nature, cannot in 
most instances end in complete recovery, 
although to all appearance the patient may 
often be quite restored to health. Even in 
these cases, however, an actual cure may 
sometimes be effected, and that after a dis- 
ease has had a prolonged duration. This 
is illustrated by several chronic skin-affec- 
tions, syphilis, and chronic inflammation of 
mucous surfaces. Or it may happen that 
the patient recovers perfectly, only with the 
destruction of some structure which is not 
essential to life, such as a group of lymphatic 
glands. 
Thirdly, partial or incomplete recovery is 
a very common mode of termination. This 
is observed in many cases of acute disease, 
where either the patient remains perman- 
ently in a state of general ill-health, without 
any actual structural lesion being discover- 
able ; or some positive organic affection has 
been established, of which phthisis remain- 
ing after acute pneumonia, or cardiac disease 
following acute rheumatism, afford apt illus- 
trations. An attack of an acute malady may 
also serve to bring out some latent constitu- 
tional predisposition; or may leave the patient 
in such a condition that certain so-called con- 
stitutional maladies are readily originated 
from slight causes. Partial recovery, amount- 
ing often to very marked improvement, may 
take place in many serious diseases of a 
chronic nature. This is illustrated by nu- 
merous cases of pulmonary consumption, in 
which disease great improvement is often 
observed, not only as regards the symptoms, 
but also in the local lesions, so much so that 
patients not uncommonly regard themselves 
as cured. Again, there are some complaints 
in which apparent recovery is brought about, 
but a tendency to recurrence remains, either 
without any obvious reason or from slight 
causes. Such affections are exemplified by 
ague, asthma, neuralgia, intestinal catarrh, 
bronchitis, and certain skin-diseases. As in- 
stances of incomplete recovery may be also 
mentioned the cure of some prominent symp- 
tom or symptoms, while the disease which 
originates these phenomena continues un- 
altered. Thus, it may be possible to get rid 
of ascites, which the patient regards as the 
disease from which he suffers, while cirrhosis 
of the liver, upon which the ascites depends, 522 
DISEASE, TERMINATIONS OF 
DISEASE, TREATMENT OF 
is a permanent condition; extensive dropsy 
and other symptoms associated with cardiac 
disease may also be got rid of, while the or- 
ganic mischief still remains. Sudden lesions 
may terminate in partial recovery. For 
instance, a case in which a sudden haemor- 
rhage into the brain has occurred, attended 
with marked apoplectic and paralytic symp- 
toms, not uncommonly improves remarkably 
in course of time, the clot being more or less 
absorbed. Some complaints, which are usu- 
ally sudden in their onset, may apparently 
be recovered from completely, but sometimes 
set up conditions which ultimately lead to 
permanent disease. Thus the passage of a 
gall-stone or of a renal calculus may excite 
such irritation as to cause an inflammatory 
process to be set up, which may induce per- 
manent mischief, such as closure of the bile- 
duct or of the ureter in the several instances, 
and the effects may not be perceptible until 
a considerable interval has elapsed. 
Lastly, it must be remarked that some 
affections can hardly be said to have any 
termination. They continue during the life 
of the individual, perhaps interfering but 
little or not at all with the health, or at all 
events not in any way contributing to the 
death of the patient, when that event does 
happen. This applies to many of the ail- 
ments from which people suffer; as well as 
to many chronic organic diseases not in 
themselves serious or giving rise to any im- 
portant symptoms, and not implicating struc- 
tures essential to life. 
Frederick T. Roberts. 
DISEASE, Treatment of.-This term 
has reference to the means by which disease 
may be prevented-prophylactic or preven- 
tive treatment; or its effects counteracted 
when it occurs-remedial or curative treat- 
ment. 
1. Preventive Treatment will be found 
discussed under the heads - Contagion; 
Climate; Disease, Causes of; Disinfection; 
Malaria ; Personal Health ; Public 
Health ; Vaccination, &c. ; as well as in the 
several articles treating of special diseases. 
It is therefore unnecessary to say more upon 
the subject in this place. 
2. Curative Treatment.-Bearing in 
mind that disease is a deviation from health 
in the functions or component materials of 
the body, it must be remembered that there 
is in organised bodies a tendency to maintain 
their healthy function and structure, and in 
case of disease or injury to resume it. This 
is especially manifest in the lower types of 
animals, many of which when mutilated 
are capable of resuming more or less com- 
pletely their original form, to the extent 
even of the restoration of lost parts. In 
man and the higher animals this power of 
complete restoration is confined to the ele- 
mentary cells and least complex structures 
of which the body consists; the more com- 
plex tissues are not reproduced, nor are lost 
parts restored. There is, however, in man, 
as in all organised beings, a tendency to 
rectify deviations from health, and to restore 
the organisation to its normal condition. To 
remove or subdue the causes of disease, and 
to aid this restorative power in the establish- 
ment of healthy function and structure, is for 
the cure of disease the most philosophical in- 
dication that can be adopted. But our know- 
ledge of disease and of remedial agents is not 
sufficient to enable us always to carry out 
these principles. As the treatment of disease 
has been directed sometimes to the one ob- 
ject and sometimes to the other, frequently 
to neither, it has given origin to a great 
variety of systems or methods of practice. 
Thus in the earliest history of the healing art, 
means the most diverse were used for the 
relief of suffering. Sometimes the suffering 
or the disease yielded whilst these means 
were being employed; and it was concluded, 
on very insufficient grounds, that these agents 
had ' cured ' the disease. Persons who had 
felt, as they supposed, the beneficial effects 
of these particular remedies, communicated 
them to others as the result of their experi- 
ence; and thus was established what has been 
known in Medicine as- 
Empiricism.-This mode of practice has 
its advantages and its disadvantages. When 
aided by accurate knowledge and discrimina- 
tion it often leads to satisfactory results; and 
many remedies suggested by experience, and 
that alone, are now found to be in accord 
with our more advanced scientific knowledge; 
take, for example, the use of mercury in 
syphilis, which, though long used empirically, 
is now known to act by its control over the 
nutrition of young cellular growths. So also 
with respect to quinine and other remedies 
of now established usefulness. On the other 
hand, mere empiricism, when vaguely ap- 
plied, taints and damages to this day the 
treatment of disease. It is this practice which, 
for example, suggests opium to quiet a cough 
or a colic, without reference to the cause of 
the one or the other, and when an expectorant 
or a purgative would have been the suitable 
remedy; and it is this empiricism which does 
such harm in the hands of amateur prac- 
titioners, leading them to recommend for 
the relief of symptoms, remedies which 
they supposed had relieved like symptoms 
in other cases, however different the real 
nature or causes of these symptoms may 
have been. 
Rational treatment.-On the other hand, 
modern science endeavours to take cognisance 
of the nature of disease, and also of the specific 
action of remedies; it seeks to counteract the 
operation of the one by the influence of the 
other. This constitutes the rational treatment 
of disease. To extend this system should be 
the object of the scientific practitioner. On the one side, it is his duty to study the nature 
of disease itself, its causes, and their effects ; 
on the other, to study the action of various 
agents on the living body in health and in 
disease; and, if possible, to trace how far the 
one is capable of combating and subduing the 
other. This study of scientific therapeutics 
is of comparatively recent date, and is now 
pursued with great zeal. The results already 
arrived at are alike satisfactory and encou- 
raging. As rational treatment becomes more 
firmly established, scientific medicine will 
take a more elevated and nobler position. 
The modes or methods by which the two 
great principles just alluded to, the founda- 
tions as they are of the healing art, have been 
applied are extremely various, and, although 
these different methods may be traced to 
the one or to the other, they have received 
distinctive names, according as they are 
marked by some special characteristic. A 
few of these modes of treatment may be 
briefly enumerated. 
1. Expectant treatment is founded on the 
principle that the restorative power of nature 
should be allowed entire freedom of action, 
the practitioner neither assisting nor inter- 
fering with its operation. 
2. What is called homoeopathic treatment 
would by some persons be included under the 
preceding head. It proposes to treat disease 
by giving in infinitesimal doses substances 
that are supposed to be capable of producing 
a diseased condition like that which they are 
intended to cure. It may be described in the 
words of Moliere, who wrote long before 
Hahnemann, the inventor of homoeopathy, 
as I'art d'amuser le malade pendant que la 
nature guerit. There is no doubt that in 
this and in similar methods of treatment, 
the imagination plays an active and useful 
part. 
3. Palliative treatment consists simply in 
the adoption of means which are calculated 
to soothe, and to lessen suffering, and thereby 
to prolong life when the cure of disease is not 
possible. 
4. Stimulant treatment is founded on a 
doctrine which regards most forms of disease 
as associated with or dependent on a lowered 
state of the vital powers, and which teaches 
that in such cases the free use of stimulants 
is the practice most to be relied on. See 
Stimulants. 
5. Antiphlogistic treatment is the opposite 
of the preceding. It recognises in many forms 
of disease increased nervous excitement and 
vascular fulness, which are to be remedied by 
depressing agencies, such as low diet, bleeding, 
purgation, &c. See Blood, Abstraction of; and 
Depletion. 
6. Purgative, diaphoretic, or otherwise eli- 
minative treatment aims at removing by the 
intestinal mucous membrane, by the skin, or 
by the secreting glands, respectively, certain 
morbid matters; and thus allowing the re- 
DISEASE, TREATMENT OF 
storative power of the system to operate more 
efficiently. See Purgatives, &c. 
7. The Water cure, including baths, acts 
partly on the principle of elimination, partly 
by exerting a tonic influence. See Baths; 
and Hydro-therapeutics. 
8. Revulsive treatment acts by producing 
counter-irritation by means of blisters, setons, 
issues, and the like. See Counter-Irritants ; 
Revulsents, &c. 
9. Antiseptic treatment aims at destroying 
the germs of disease, whether on the surface 
of, or within, the body. See Antiseptic 
Treatment ; and Disinfection. 
10. Dietetic treatment constitutes a greater 
or less portion of all modes of treatment. 
It implies a reference to the kind of food 
which is adapted to the circumstances in 
which the patient is placed, and which is 
suitable in the disease from which he is 
suffering. See Diet. 
11. The treatment by climate operates 
more or less by removing the patient Beyond 
the region of noxious influences, and placing 
him in circumstances which promote healthy 
action of the several functions. 
It is well known that under these several 
and varied modes of treatment disease may 
yield and patients may get well. Hence it 
has been said that, as different means are 
made use of to obtain a single result, the 
treatment of disease can never be absolutely 
scientific. Phthisis is pointed to, for ex- 
ample, as a disease which one person seeks to 
relieve by cod-liver oil, another by climate, 
a third by tonics, a fourth by sedatives, a fifth 
by attention to the digestive organs, and a 
sixth by counter-irritation. We need scarcely 
say that the disease bearing the name of 
phthisis is an aggregate of phenomena or con- 
ditions, the relief of any one of which may 
lead to the amelioration of the others. Thus 
the general health might be improved by 
climate, and with it all the other symptoms. 
Cod-liver oil, with remedies calculated to 
improve the digestion, may lead to healthy 
nutrition, and thus to a mitigation of all the 
symptoms. The like remark applies to the 
other agencies mentioned. The treatment of 
disease must not, then, be condemned as un- 
scientific because it cannot remedy a variety 
of morbid states by a single agent, but would 
aim, on still strictly scientific principles, by 
different agencies to overcome disease, the 
effects of which are manifested in different 
forms. 
In conclusion, it may be repeated that the 
end and aim of the practitioner should be, if 
possible, firstly, to discover the cause or 
causes on which the disease depends, and to 
remove or counteract them if practicable; 
and, secondly, to endeavour, by every avail- 
able means, to restore to health the functions 
of the body, and with that object to guide 
and assist Nature, but never to thwart her 
operations. Richard Quain. 
523 524 
DISEASES, TYPES OF 
DISINFECTION 
DISEASES, Types and Varieties 
of.-In the case of many diseases more or 
less distinct varieties are recognised, which 
in some instances constitute well-defined 
types. It is important to understand the 
precise significance of these terms in different 
cases. 
In the first place the varieties of a particu- 
lar affection may be founded upon diversities 
observed in its clinical history. Thus, ac- 
cording to the intensity of the symptoms and 
their duration, a large number of complaints 
are, as has already been pointed out, divided 
into acute, sub-acute, and chronic varieties. 
Again, many diseases, while presenting in the 
majority of cases a certain group of symptoms, 
upon which their general clinical description 
is founded, exhibit striking differences in the 
exact nature of the phenomena observed, as 
well as in their gravity, when the mass of 
cases is taken into account, and on these 
differences varieties or types are founded. 
This is well-exemplified by some of the acute 
specific fevers, such as typhoid fever, scarla- 
tina, measles, and small-pox. Of these affec- 
tions several varieties are described, depen- 
dent upon the severity of the symptoms, the 
nature of those which are most prominent, 
or the characters of the eruption. 
In the next place, the classification of a 
disease into varieties may be founded upon 
a pathological basis. For instance, pul- 
monary phthisis may, in the writer's opinion, 
arise from different morbid processes, and 
many attempts have been made to arrange 
the cases of this disease into corresponding 
groups. Illustrations of these pathological 
varieties are also found in the different forms 
of cancer ; in the varieties of pneumonia, of 
laryngitis, and of fatty disease of the heart; 
and in the classification of serous inflamma- 
tions according to their morbid products, such 
as fibrinous, serous, purulent, &c. Again, such 
a pathological condition as dropsy or fever 
may be divided into varieties. Thus dropsy 
is arranged according to its situation and 
distribution, as anasarca, ascites, &c.; or 
according to its pathological cause, whether 
cardiac, pulmonary, hepatic, &c. Fever is 
recognised as having several important types, 
founded upon its intensity, its course, and the 
exact nature of the phenomena accompany- 
ing the pyrexial state. 
Another division of a disease into varieties 
is (Etiological, the cases being grouped ac- 
cording to their causation, either the immedi- 
ate pathological or the more remote exciting 
causes being employed as the basis of 
division. Thus we have the different forms 
of meningitis (simple, tubercular, rheumatic, 
&c.); the (etiological varieties of pleurisy or 
peritonitis (idiopathic, traumatic, perforative, 
tubercular, secondary, &c.); those of joint- 
inflammation (simple, rheumatic, gouty, 
scrofulous, &c.) ; or those of intestinal ob- 
struction. ^Etiological varieties are often at 
the same time characterised by differences in 
the pathological results and products. 
Lastly, it must be mentioned that some- 
times a certain group of symptoms is summed 
up for convenience under some single term, 
which symptoms really depend upon very 
different morbid conditions and causes ; and 
therefore it often becomes necessary to classify 
affections thus named into varieties. Dys- 
pepsia, neuralgia, apoplexy, epilepsy, and 
paralysis will afford illustrations of such an 
arrangement. 
Frederick T. Roberts. 
DISINFECTION-Synon. : Fr. Des- 
infection; Ger. Desinficiren. 
Definition.-Disinfection, in the proper 
sense of the term, means any process by 
which the contagium of a given disease may 
be destroyed or be rendered inert. 
Disinfectants, however, are used in prac- 
tice for several objects, and in consequence 
the term has often been vaguely applied to 
the use of heat or chemical means for pre- 
venting the generation or for the destruction 
of noxious agents, whether products of 
specific disease or not. In this vague and 
erroneous sense disinfectants have been con- 
founded with deodorants, which merely 
cover or destroy offensive odours without 
affecting the contagia ; and with antiseptics, 
which ' are fatal to the growth and multipli- 
cation of microzymes.' Following the line 
indicated by the late Dr. Baxter in his valu- 
able report on an experimental study of certain 
disinfectants, it is necessary to distinguish- 
1. The true meaning of the word-that of 
acting on the specific poisons of communi- 
cable diseases in such a way as prevents their 
spreading. 
2. That of acting upon organic substances 
in such a way as renders them less liable to 
undergo molecular change and decomposition, 
whether spontaneously or under the influence 
of catalytic agents, as in the case of emulsin 
upon amygdalin; or under the influence of 
living organisms, such as are connected with 
fermentation and putrefaction. Examples of 
this kind of action are seen in salting meat, 
and in preserving small animals in weak 
solutions of carbolic acid. 
3. That of preventing or arresting decom- 
position by killing the torulae associated with 
fermentation in slightly acid media, or the 
bacteroid organisms associated with putrefac- 
tion in neutral or alkaline media. . Properly 
speaking, this is the action of an antiseptic, 
but the relative power of disinfectants has 
been largely estimated by their efficacy in 
this respect-partly, no doubt, because anti- 
septic power is desirable in a disinfectant, 
but chiefly because it is so difficult to sub- 
mit disinfectants to their proper test by 
experimenting upon contagium. Recent ex- 
periments upon inhibition of growth of patho- 
genic bacteria show that mercuric chloride, DISINFECTION 
525 
allyl alcohol, oil of mustard, and certain 
other ethereal oils prevent the growth of 
anthrax bacilli in extreme dilution. Quinine, 
two parts per thousand, prevents the develop- 
ment of anthrax bacilli or that of the Spiro- 
chaetae of relapsing fever. 
4. That of the destruction of the noxious 
products of the metabolism of dead organic 
matter, however brought about. These pro- 
ducts consist chiefly of gases or vapours, 
many of which, such as sulphuretted hydro- 
gen, ammonia, and sulphide of ammonium, 
are easily destroyed by appropriate agents, 
even when used in a very dilute state; and 
success in this respect is no proof of the value 
of a disinfectant in its true sense, though the 
power of destroying such emanations is 
possessed by almost all disinfectants of prac- 
tical utility. 
General Remarks.-It has been proved 
that the contagia of several diseases must 
consist of minute solid particles, for they are 
neither soluble, nor diffusible, nor volatile ; 
they can be seen with the microscope, and 
can be cultivated out of the body; and we 
may infer that all other contagia are particu- 
late likewise. A characteristic of contagium, 
due to its particulate nature, is that dilution 
lessens the chance of infection, but has little 
effect upon the case if the disease be taken. 
There is either no effect at all, or a full 
specific effect. Contagium particles are apt 
to exist as clouds in air, water, or milk, 
instead of being equally distributed through- 
out ; and this bears upon practical disin- 
fection. The particulate and non-gaseous 
form of contagium floating in the atmosphere 
prevents it from being absorbed by any liquid 
or solid disinfectant which does not wash 
or come into intimate contact with every 
portion of the air, and as this is impracti- 
cable, infected air can only be purified by 
gaseous disinfectants, such as sulphurous acid 
or chlorine. Disinfectants of this kind, to be 
effective, must be present in such a quantity 
as is incompatible with the existence of 
human beings. From this it follows that 
saucers of disinfecting fluids, or irritating 
vapours and gases in the sick-room, are 
merely a useless annoyance to the patient, 
except in so far as they may be desired as 
deodorants. The best method for dealing 
with infected air is to replace it by ventila- 
tion, especially by means of ventilating open 
fire-places. The proper use of volatile dis- 
infectants is the purification of walls, ceilings, 
and inaccessible places; and for this purpose, 
if possible, enough should be used to saturate 
the atmosphere, remembering that the viru- 
lent particles are most likely protected by 
being buried in a bit of epithelium or sur- 
rounded by an albuminous envelope.1 
The nature of the medium in which con- 
tagious particles are suspended has the most 
important bearing upon the selection of a 
disinfectant. The presence of albumen is 
found to protect septic germs to a consider- 
able extent against the action of permanga- 
nate of potassium and chlorine, but has little 
or no influence upon the action of sulphurous 
acid and carbolic acid. A striking instance 
of this was noticed by Schill and Fischer, 
who found that fresh tubercular sputum 
containing bacilli and spores was not disin- 
fected in twenty-four hours by an equal 
volume of solution of mercuric chloride 1 in 
500, though an equal volume of 5 per cent, 
carbolic acid solution accomplished the dis- 
infection in that time. This possibly explains 
in part the contradictory results obtained 
from experiments with disinfectants, and also 
shows the necessity of thoroughly mixing 
disinfectants with liquids or substances to be 
disinfected. 
Some pathogenic organisms, such as the 
bacilli of anthrax, are very easily killed, 
while others, such as the spores of the same 
bacilli, are extremely resistant. It is pos- 
sible that in many cases the contagium may 
be of a species or at a stage when it can be 
readily destroyed by a feeble disinfectant, but 
in the absence of knowledge prudence re- 
quires the opposite assumption. 
A cardinal principle in disinfection is that 
it should be carried out at the source, or as 
near the source, of the contagion as possible. 
Inunction with lard, with carbolised oil (1 to 
40), or with glycerine, to clog epithelial scales, 
and regular washing and change of clothing, 
will do much to protect the purity of the air 
against contagium proceeding from the skin 
in such diseases as scarlet fever and small-pox. 
One part of ethereal solution of peroxide of 
hydrogen to eight parts of lard is an excellent 
application for the skin in typhus. Discharges 
from the mouth, nose, and bowels, as well as 
the urine, should be received in vessels con- 
taining disinfecting solutions to cover them 
and give protection to the air; and then larger 
quantities, or more concentrated solutions, 
as the case may be, should be thoroughly in- 
corporated with the discharges before they 
are removed from the original vessels. 
Of all agencies for preventing the spread 
of communicable disease, cleanliness is one of 
the most important. Facts have been ad- 
duced pointing to the conclusion that filth, 
when undergoing change of a fermentative 
or putrefactive nature, is in a condition the 
most conducive to the extension of infectious 
destroying or rendering incapable of change the 
organic matters evolved from the skin and lungs, 
which are always very noxious, and may be espe- 
cially so in disease. These organic matters are 
necessarily more or less re-breathed unless the 
patient be placed in a current of air. If ventilation 
sufficient to prevent all odour cannot be provided, 
then some gas, such as chlorine or ozone, that will 
destroy the cause of the odour, is certainly desirable 
1 Though disinfectant or antiseptic gases of such 
strength as can be tolerated in the sick-room are 
utterly inept as regards useful effect upon contagium, 
it is just possible that they may be of service in 526 
DISINFECTION 
disease. This is probably explained by the 
rapid multiplication of any specific disease- 
organisms contained in the filth. Pending 
the removal of accumulations of dirt, and for 
the protection of workmen, fermentation may 
be delayed by the application of crude car- 
bolic acid, or solution of mercuric chloride. 
The ultimate fate of contagium is to be de- 
stroyed by putrefaction, and this appears in- 
variably to destroy its specific infective power. 
In certain cases where real disinfection is 
impracticable, as in dealing with the accu- 
mulation of manure and litter from a number 
of animals suffering from cattle-plague, the 
natural processes may be hastened by stack- 
ing the material so that it shall ' heat,' or 
may even be destroyed by spontaneous com- 
bustion. Certainly putrefaction should not 
be delayed by small additions of disinfec- 
tants, which cannot accomplish the destruc- 
tion of all noxious matter present. 
Special Disinfectants.-1. Heat.-Heat, 
dry or moist, is perhaps the best disinfectant 
we possess. High temperature and length 
of exposure are, to a certain extent, mutually 
compensatory, but it appears that a tempera- 
ture below 140° F. (60° C.) will not disinfect 
vaccine even with long exposure. Tyndall 
points out that some germs seem to be in a 
dormant condition, in which they resist the 
action of heat unless applied very long or in- 
termittently, so as to start their vitality into 
growth, when they are easily killed. Disin- 
fection by dry heat (which is, however, best 
for the destruction of insect vermin) is now 
being superseded by steam. Dry heat pene- 
trates so slowly into fabrics that they are in- 
jured before a disinfecting temperature is 
attained throughout. The presence of mois- 
ture assists the action of hot air, as it like- 
wise does that of gaseous SO,2 and Cl. Koch 
found that hour's exposure within test- 
tubes in an oven containing air saturated with 
moisture at a temperature from 230° F. to 
245° F. destroyed sporeless micro-organisms 
and spores of fungi, but did not affect spores 
of the bacilli of potato, hay, and anthrax, nor 
the spores of garden earth. These were all 
destroyed by three hours' exposure to 284° F. 
A current of steam at 212° F. destroyed spores 
of earth, anthrax, and tubercle-bacilli in less 
than fifteen minutes, when they were freely 
exposed. Steam penetrates clothing quickly, 
but may take some time to raise the tem- 
perature of sheltered articles, especially if 
wet. Modern steam-disinfectors are made 
with a jacket space to which live steam may 
be admitted, so that the internal chamber 
may be used as a simple hot-air chamber 
where steam is not admitted directly to it. 
With a proper apparatus the articles come 
out dry. Steam instantly ruins leather, and 
fixes permanently any stains of blood or 
discharges. Stained clothing should be pre- 
viously soaked in cold water and the water 
afterwards disinfected by mercuric chloride. 
It has been abundantly proved that ordi- 
nary boiling and washing will completely 
disinfect the linen of a fever hospital. The 
water should attain the full temperature of 
212° F. 
Nearly all the chemical agents used in 
disinfection are mutually incompatible, and 
therefore only one should be used at a 
time. 
2. Carbolic Acid.-A solution of this 
substance of the strength of 5 per cent., or 
1 in 20, is the only one fit for use in disinfec- 
tion. For steeping fine clothing a solution 
should be made from crystals. The solution 
generally useful is that obtained by making 
up one gallon of crude 80 per cent, acid to six- 
teen gallons with water. The results of the 
experiments of Baxter and others prove that 
' no virulent liquid can be considered disin- 
fected by carbolic acid unless it contain at 
least 2 per cent, by weight of the pure acid.' 
More recent experiments show that in some 
cases this proportion of carbolic acid is not 
nearly enough. Anthrax spores required to 
soak over twenty-four hours in 5 per cent, 
carbolic solution to be destroyed, though 
blood containing anthrax bacilli was almost 
instantly sterilised by a 1 per cent, solution. 
"With our present knowledge it would be safer 
to employ stronger acid, or in any case to use 
a large quantity of 5 per cent. Combinations 
of carbolic acid are greatly inferior to the 
pure acid, and its solutions in oil and alcohol 
are found to be absolutely inert. Thymol 
and salicylic acid are affected in the same 
way by solution in oil. Judging from the 
light of experiments, carbolic acid vapour is 
quite useless. Very small quantities of the 
liquid acid mixed with organic fluids enable 
them to remain fresh and resist decay for a 
long time. So little as one-fifth per cent, 
preserves milk. It is obvious then that small 
quantities of this disinfectant, instead of de- 
stroying contagium, may actually preserve 
its activity, when otherwise it would have 
succumbed to the action of natural agencies. 
This danger may accompany the limited use 
of any disinfectant that has a ' pickling ' or 
preservative action in small quantity. Owing 
partly to the volatility of carbolic acid, which 
removes it in time, and partly to the pecu- 
liarity of its action, another danger attends 
its use in anything short of full strength and 
large quantity when applied to kill contagium. 
The acid may, for a time, deprive the conta- 
gium of its infective power without perma- 
nently abolishing it, and the virulent proper- 
ties may be regained whenever the acid has 
evaporated. This has been proved experi- 
mentally by Dr. Dougall, of Glasgow, who 
found that vaccine mixed with carbolic acid 
(1 in 50) regained its infective power after 
10 days' exposure to the air. 
For removing odour from the hands after 
working in the dissecting-room, a 1 per cent, 
solution of carbolic acid is superior in efficacy DISINFECTION 
527 
to permanganate of potassium, even when 
strong enough to stain the skin, and is also 
preferable to chlorinated lime. 
3. Sulphur Dioxide. - The aqueous 
solution of this substance contains sulphurous 
acid. It destroys sulphuretted hydrogen thus, 
SO2 + 2H2S = 2H2O + S3, and combines with 
ammonia. For aerial disinfection the best 
plan is simply to burn sulphur in very large 
quantities. Even in presence of abundant 
moisture, Koch pronounces SO2 useless for 
practical disinfection. By volume, 10-5 per 
cent, of the gas in a room failed to affect 
spores of anthrax, &c., in twenty-four hours, 
whether wet or dry. About 3 per cent, in 
forty-eight hours had not destroyed the vitality 
of micrococcus prodigiosus, pink yeast, or 
bacteria of blue pus. In an ordinary room a 
gaseous disinfectant rapidly disappears. On 
the other hand, Cyrus Edson tries, from the 
statistics of the Health Department, N.Y., to 
prove the efficacy of SO2 fumigation (3 lbs. 
sulphur to 1,000 cubic feet) in small-pox, 
scarlet fever, and to a less extent in measles- 
and diphtheria-infected houses. The statistics 
are not convincing to the present writer. 
Sulphur dioxide destroys the activity of dry 
vaccine on points very rapidly, and even 
when much diluted stops the amoeboid move- 
ments of living cells, kills vibrios, and acts 
deleteriously on vegetation. Sulphur dioxide 
preserves meat and other substances, when 
in closed vessels, for very long periods. It 
bleaches vegetable colours, attacks iron, and 
is absorbed by cloth and leather-facts to be 
remembered in practical disinfection. 1 lb. 
of sulphur, when burned, produces 11*7 cubic 
feet of sulphur dioxide gas. 
4. Chlorine.-Chlorine is most easily ob- 
tained from ' chloride of lime ' or bleaching 
powder, by adding hydrochloric or sulphuric 
acid. Exact proportions cannot be stated, as 
the value of the bleaching powders varies; 
but rather more acid than of the equal parts 
of bleaching powder and strong hydrochloric 
acid may be taken. The acid should be diluted 
before use. For deodorising water-closets, 
some crystals of potassium chlorate may be 
thrown into a wide-mouthed bottle containing 
dilute hydrochloric acid. Euchlorine comes 
off gradually, and is both more effective and 
more agreeable than chlorine. The most 
marked character of chlorine is its strong 
affinity for hydrogen, which enables it to 
break up compounds containing that body, 
and to set free in a nascent or active state 
the oxygen combined with hydrogen in 
water. It is, therefore, one of the most 
universally applicable and powerful deodo- 
risers in existence. When merely used as a 
deodoriser, enough euchlorine may be expelled 
from moist1 chloride of lime ' by the carbonic 
acid of the air for most purposes. In air 
saturated with moisture 0'3 per cent, chlorine 
kills all minor organisms that are freely 
exposed; but any cover, such as a piece of 
blotting-paper, prevents the result. Less 
moisture demands 1 per cent, chlorine. 
5. Permanganate of Potassium.- 
This substance is non-poisonous, and is a 
good deodorant, especially for the emanations 
from organic bodies. It is, moreover, free 
from odour, and its aqueous solution shows, 
by loss of colour, when it is exhausted. It is 
a very suitable deodorant for the sick room, 
as, when dissolved in water and a large 
surface of the solution exposed to the air, it 
will absorb gases to some extent. Contagium, 
being non-gaseous, is not affected, unless in 
contact with the solution. Permanganate 
of potassium is a true disinfectant, oxidising 
and destroying contagia as well as putrid 
matters; but the quantity required and the 
price render its use almost impossible, for 
enough permanganate has .to be used to 
destroy the medium or vehicle bearing 
contagium as well as the contagium itself. 
The solution should contain 5 per cent, 
permanganate after all chemical action has 
subsided. Condy's fluid is a solution of this 
substance in water. When the virulent 
liquid or matters are small in quantity, 
permanganate solution forms a capital reci- 
pient, and may stand by the bedside as a 
deodorant till required as a disinfectant. 
Permanganate has no effect in restraining 
the appearance of bacteria, or preventing 
the onset of putrefaction. 
6. Acids.-The mineral acids and glacial 
acetic acid have all disinfecting power when 
used in sufficient quantity for a long time, 
but there are serious difficulties in the way 
of their use. HC1, 2 per cent, in solution, 
required ten days to kill anthrax spores. 
7. Nitrous Acid.-Nitrous acid can be 
easily disengaged as a gas by putting bits of 
copper into nitric acid, or pouring nitric acid 
upon sawdust or starch. It is the best deodo- 
rant for the deadhouse, and, without doubt, it 
is a disinfectant, but it is too dangerous for 
ordinary use, as it may easily be breathed 
in quantity sufficient to cause fatal bron- 
chitis. 
8. Chlorinated Lime. - Bleaching- 
powder, commonly known as ' chloride of 
lime,' gives off chlorine easily, and this 
probably explains its disinfecting power. It 
is very cheap and manageable, and hence of 
much importance. 
9. Quicklime. - Liborius Kitasato and 
Pfuhl, confirmed by Drs. Richard and Chante - 
messe, state that fresh excreta of cholera, 
enteric fever, and dysentery are sterilised, and 
the bacilli destroyed, so that the stools are 
disinfected, by 2 per cent, of a 20 per cent, 
fresh milk of lime in a few hours. The 
experiments detailed are not conclusive to 
the writer as to real disinfection in all cases. 
Quicklime is so cheap and abundant, that it 
could be used in any quantity. It is soluble 
in water in the proportion of only 1 in about 
700. 528 
DISINFECTION 
10. Mercuric Chloride.-Perchloride 
of Mercury, Corrosive Sublimate, Malleus 
Metallorum, the most powerful chemical dis- 
infectant known, dissolves in 1G parts of cold 
water, is extremely poisonous, and corrodes 
metals. With albuminous matters it forms 
insoluble precipitates, which are prevented 
by addition of common salt, HC1, or tartaric 
acid. Precipitates must be prevented where 
disinfection has to be repeated, as they might 
be dangerous. The solution with tartaric acid 
is not stable, and should be freshly made. A 
spray of 1 in 1,000, or washing with 1 in 5,000, 
killed the most resistant organisms in ten 
minutes. Enough should be used to leave 
1 in 5,000 after any HgCl, is precipitated by 
sulphur or albumen. After disinfection is 
finished, copious washing with water removes 
the remaining mercury salt. For utensils, 
clothing, &c., 1 in 2,000, and for excreta an 
equal bulk of 1 in 1,000 solution, are recom- 
mended. 
In regard to the agents hitherto considered, 
we have more or less of the sure light of 
direct experiment upon contagium ; but the 
claims of the following and a legion of other 
substances asserted to be ' powerful disinfec- 
tants, of which it is impossible to speak too 
highly,' rest entirely upon chemical theories, 
or the opinions of physicians, or upon their 
power of coagulating albumen, or of delaying 
or preventing putrefaction and fermentation, 
or of deodorising. It will be scarcely neces- 
sary to do more than enumerate the best, as 
follows:- 
11. Metallic Salts.-Metallic salts in- 
clude-(a) Bichromate of potassium. (6) Sul- 
phate of copper, (c) Chloride of zinc. A 
5 per cent, solution had no effect on anthrax 
spores in a month, and 1 per cent, failed to 
kill micrococcus prodigiosus in forty-eight 
hours, (ft) Chloride of aluminium. (e) Ferric 
chloride, which, if strong, liberates offensive 
fumes from animal matters, but is a fair anti- 
septic and preservative. (/) Ferrous sulphate. 
(y) The waste chlorides, from the manufacture 
of chlorine, contain MnCl2, Fe2Clfi, and free 
HC1, which cost next to nothing, and might 
be used for larger masses of filth or drains. 
12. Ozone.-This body, got by half-im- 
mersing a stick of phosphorus in tepid water, 
or by mixing gradually 3 parts of strong sul- 
phuric acid and 2 parts permanganate of 
potassium, oxidises organic matter, and so 
destroys odours. Terebene and cupralum, a 
preparation containing terebene, are good 
deodorants, and give rise to ozone. 
13. Charcoal.-Charcoal condenses gases 
within its pores, where combustible gases are 
destroyed by the condensed oxygen. Con- 
tagium, unless in water, does not enter the 
pores, for, being particulate, it is not absorbed 
from the air as gases are. 
Practical Disinfection.-In conclusion, 
a few remarks may be offered as to the 
modes of carrying out disinfection under 
circumstances in which it is commonly re- 
quired. 
1. Clothing and Bedding.-In dealing 
with the ragged and worthless articles of the 
poor, local authorities will generally find it 
most satisfactory to both parties to burn 
them and replace them with new. By such 
discreet generosity danger is averted, and 
goodwill created, which helps in getting early 
information and carrying out measures, and 
so, by shortening epidemics, saves expense. 
If not burned, clothing may be steamed as 
described under Heat, or well boiled with 
soda. Before coming to the washhouse they 
may be steeped in 5 per cent, carbolic solu- 
tion, or perchloride of mercury (1 in 2,000), 
or chlorinated lime (2 oz. to the gallon). 
2. Rooms.-The essential process for dis- 
infecting rooms is thorough cleansing with 
soft soap and hot water, which may contain 5 
per cent, carbolic acid, but the carbolic solu- 
tion is not so easily handled. The walls and 
ceiling should be brushed, and wall-paper re- 
moved. Furniture, if iron-a bedstead for ex- 
ample-is to be taken down and washed with 
carbolic solution, and removed from the room, 
or smeared with vaseline if to be fumigated. 
Textile fabrics should be steamed or boiled, 
or spread out in the room for fumigation; 
but this is not so effective, and colours are 
bleached. Should it be considered desirable 
to fumigate, the room should be steamed 
for some hours. The chimney, doors, and 
windows are to be closed, and crevices 
covered with paper pasted on. Then 15 lbs. 
chlorinated lime per 1,000 cubic feet, made 
into cream with water in shallow dishes, 
has 22 lbs. HC1 added from vessels which tilt 
over as the operator escapes. The door is to 
be shut until next day, when the windows 
and doors are all to be opened, and kept open 
for twenty-four hours. In white-washed rooms 
the walls should be scraped, and then washed 
with hot lime in addition to the fumigation. 
3. Drains, Water-closets, &c.-Propei 
drains remove sewage so swiftly and com- 
pletely, that little or no sewage-gas is formed 
if ventilation is given. For bad drains .car- 
bolic acid, chloride of zinc, or waste chlorides 
from the manufacture of chlorine, are fair 
palliatives. The excreta from cases of infec- 
tious diseases require a very large quantity 
of disinfectant, which should be applied in a 
concentrated form before they are thrown 
into the water-closet or house-pipes. When 
a reliable amount of disinfectant is in these 
cases sent down the pipes, it is apt to corrode 
them unless it has been allowed to expend 
its energy on the excreta alone in the first 
place. If small quantities of disinfectants 
are poured down water-closets, it is better to 
mix them with the after-flush water which 
fills traps and basins, so that the little 
energy available may be devoted to the 
destruction of any slime adhering, or portions 
of organic matter retained. Permanganate DISINFECTION 
DIURETICS 
529 
of potassium is the most pleasant agent for 
this purpose, though expensive. When there 
are no water-closets, the excreta, in cases of 
cholera and typhoid fever, should be received 
in a vessel containing half a pint or more 
of a l-in-20 solution of commercial hydro- 
chloric or sulphuric acid, and then put, along 
with some chlorinated lime, into a covered 
stoneware vessel in the back yard. After a 
few hours the contents of this vessel may be 
thrown into the cesspool or upon the midden. 
4. Dead. Bodies.-Dead bodies, if putrid 
or bearing contagium, should be wrapped in 
sheets wet with l-in-20 carbolic solution, or 
1-in-1,000 perchloride of mercury ; or, if 
coffined, sawdust saturated with one of these 
solutions should be packed around them. 
It is necessary clearly to keep in view the 
object desired when selecting disinfectants, 
deodorants, or antiseptics ; whether it be 
destruction of contagium, merely ' pickling ' 
and preserving, arresting putrefaction and 
fermentation, or deodorisation. From all 
that has been said it is evident that the 
different ' disinfecting ' nostrums, applied as 
their inventors direct, can have little effect 
upon contagium, but may have more or less 
power in the other directions indicated. 
James A. Russell. 
DISLOCATION OF ORGANS (dis, 
apart; and locus, a place).-See Organs, Dis- 
placement of. 
DISPLACEMENT OF ORGANS. 
See Organs, Displacement of. 
DISSECTION WOUNDS. - See 
Post-Mortem Wounds. 
DISTOMA.-See Entozoa. 
DISTOMA RINGERI vel PUL- 
MONALE.-Under this name the writer 
originally described in the Medical Times 
and Gazette (July 8, 1882) a species of 
fluke, the mature form of which inhabits 
the human lung, where it was first found 
in Formosa, by Dr. B. 8. Ringer, in 1879. 
The ova of the parasite have frequently been 
found by Professor Baelz, of Tokio, by the 
writer, and by others, and by them are as- 
sociated with a peculiar form of recurrent 
haemoptysis, to which the term endemic 
hcemoptysis has been applied. 
Symptoms and Pathology.-The symp- 
toms of disease associated with the presence 
of the distoma Ringeri are a slight cough; 
the expectoration of a characteristic rusty- 
brown, viscid mucus; and at times haemo- 
ptysis, slight or copious. The haemorrhage 
occurs at irregular intervals during many 
years. The expectoration of rusty bronchial 
mucus is persistent, and in this the ova are 
readily discovered with the microscope. These 
are pale brown bodies (3^ in. x in.), ovoid, 
double-outlined, operculated at the broad end, 
and containing protoplasmic globules having 
very active molecular movements. If the 
sputum is occasionally shaken up in fresh 
water, there is developed in most of the ova, 
in the course of six weeks to two months, an 
active ciliated embryo which in time escapes 
by forcing back the operculum. It may be 
concluded from this that drinking-water, or 
a fresh-water animal acting as intermediary 
host, is the medium by which the disease 
passes from one human subject to another. 
See Entozoa. 
This disease has hitherto been found only 
in Japan, Corea, and Formosa, but its dis- 
tribution is probably much more extended. 
The mature parasite measures from 8 to 
10 mm. by 5 to 6 mm. It resides in 
cavities and burrows connected with the 
smaller bronchi, into which it discharges its 
ova. As many as twenty of these parasites 
have been found in one case. 
Treatment. - Inhalations of sulphurous 
acid, sprays of turpentine, as well as kousso, 
quassia, and santonin, have been adminis- 
tered without much apparent benefit. 
Patrick Manson. 
DIURESIS (3ia, through; and ovpfa, 
I pass water).-A free excretion of urine, 
whether naturally or artificially induced. 
See Diuretics. 
DIURETICS (Sta, through; and ovpeu, 
I pass water). 
Definition.-Remedies which increase the 
secretion of urine. 
Enumeration. - The following comprise 
the most important diuretics: Water; Milk; 
salts of Potassium, Sodium, and Lithium; 
Calomel; Alcohol, Nitrous Ether, solution of 
Ethyl Nitrite; Turpentine, Juniper, Copaiba; 
Cantharides; Digitalis, Strophanthus, Squill; 
Caffeine, Theobromine, and its compound 
with Salicylic Acid and Sodium termed 
' Diuretin '; Tobacco; Scoparium, and Spar- 
teine. The action of diuretics is often aided 
by brisk purgation, depletion, counter-irrita- 
tion over the loins, and sometimes by the 
use of mercury. 
Action.-The secretion of urine appears 
to consist partly of filtration of fluid through 
the glomeruli of the kidney, and partly of 
secretion by the cells of the urinary tubules. 
The amount of urine excreted depends on the 
rapidity with which the blood flows through 
the glomeruli, and this again depends on the 
height of the systemic blood-pressure and the 
dilatation or contraction of the renal arteries. 
The secretion is increased by anything which 
raises the blood-pressure throughout the sys- 
tem generally, or in the renal arteries locally. 
The systemic blood-pressure may be raised 
by cold to the surface, digitalis, squill, and 
tobacco. Digitalis, and possibly other drugs, 
have also a local action on the renal arte- 
ries, which are more readily affected by 
some drugs than other arteries in the body. 
Nitrous ether and solution of ethyl nitrite 
probably act as diuretics by dilating the 530 
DIURETICS 
DOUCHE 
renal arteries. The exact mode of action 
of the other diureticsis not determined; but 
common salt, nitrate of potassium, urates, and 
urea increase the flow of urine even although 
the pressure in the vessels of the kidney is 
very low. It is therefore probable that they 
stimulate secretion by acting on the nerves 
or cells in the kidney itself; and probably 
caffeine acts in a similar manner. 
Uses.-Diuretics are employed to increase 
the flow of urine, and thus remove water or 
excrementitious products like urea from the 
body. They are used in cases of general 
dropsy, or of accumulation of fluid in the 
peritoneum or pleura. In febrile conditions 
they are given to aid in the elimination of 
waste matter. They are also employed in 
order to render the urine more watery, and 
thus prevent the deposition of solids from it, 
and the formation of calculi in the kidney 
or bladder, or to redissolve such concretions 
when they are already formed. Digitalis and 
squill are most useful in dropsy dependent on 
heart-disease; the other remedies are more 
effective in dropsy dependent on disease of 
the kidneys or liver. The action of digitalis 
and squill is greatly assisted by the addition 
of a little blue pill; and when the kidneys are 
much congested or pressed upon from with- 
out by accumulation of fluid in the abdomi- 
nal cavity, diuretics sometimes fail to act 
until the congestion has been relieved by de- 
pletion from the loins or the use of a brisk 
purgative, and the pressure removed by para- 
centesis. See Dropsy. 
T. Lauder Brunton. 
DIZZINESS.-See Vertigo. 
DOCHMIUS(86A7uoS, twisted).-A genus 
of nematode worms established by Dujardin. 
See Entozoa. 
DORDRECHT, in Cape Colony.- 
See Africa, South. 
DOTHIENENTERITIS (3o^v, a pus- 
tule ; and evrepov, the intestine).-A synonym 
for a form of enteritis, accompanied by an 
enlargement of the follicles, which causes 
them to resemble pustules. See Intestine, 
Diseases of. 
DOUCHE (Fr.).-Definition.-A jet of 
water propelled against some part of the body 
through a doccia or pipe. The size of the jet 
of water, the degree of its impetus, and its 
temperature can all be regulated. A douche 
differs from simple affusion in its application 
being more local, and the force with which 
it is applied being greater. 
Application and Action.-Douches of cold 
and of hot water, of vapour, and occasionally 
of gas, are employed; but those by far the 
most commonly used, except where there are 
hot natural waters, are of cold water. 
The immediate effect produced by a cold 
douche on those who are unaccustomed to it 
is a feeling of shock, spasmodic shortness of 
breathing, palpitation of the heart, and some- 
times pain in the back of the head. Locally 
the first effect of a douche is to deaden the 
sensibility of the part to which it is applied; 
but if the douche be powerful enough, reaction 
of the part comes on in about forty seconds. 
This continues for a time ; but if the douche 
be kept up for three or four minutes, the 
pulse falls seven or eight beats, the deaden- 
ing of sensibility returns, and the tempera- 
ture of the part is greatly lowered; when the 
douche is withdrawn, reaction again takes 
place. This alternate sedative and stimula- 
ting effect, producing emptiness and turges- 
cence of the vessels, quickens the action of 
the capillaries of the part, and thus favours 
the transmutation of tissue. The mecha- 
nical effect of the force with which the douche 
is applied must not be overlooked. If great, 
it produces the highest amount of stimulation, 
which may almost amount to inflammation. 
Different portions of the body have different 
degrees of tolerance of the douche. Thus the 
extremities and the head bear it better than 
the chest, and the chest somewhat better than 
the abdomen; and the posterior aspect of the 
body bears it much better than the anterior. 
Patients soon get accustomed to the cold. 
Warm douches produce less shock, and are 
more easily borne, but they are, comparatively 
speaking, little employed in private houses. 
An alternation of hot and cold douches, known 
somehow by the name of Scotch, is a valuable 
remedy; in it the hot water rapidly restores 
the irritability of the part deadened by the 
cold water, and there is a maximum of action 
and reaction of the part obtained. Under par- 
ticular circumstances it may be expedient to 
use a jet of steam, but this, of course, must 
be done with caution; and a jet of carbonic 
acid is sometimes propelled against the eye 
or ear, or the neck of the uterus. So-called 
ascending douches are used for the rectum 
or the vagina. Douches for the eye and 
the ear have been used of late years. In a 
certain sense what the English call pumping 
is a variety of the douche, and the shower- 
bath is in reality merely a multiplication of 
fine douches. The action of douches is more 
or less general according to the portion of the 
body to which they are applied. Thus the 
application of a douche to the head has the 
most general action, and that to the spine 
the next. In either case it is impossible 
to limit it very strictly, and there is a certain 
amount of affusion besides the direct douche. 
A douche, again, applied to one of the ex- 
tremities may easily be localised; and a 
douche may be applied only to one part or to 
several parts of the body, in succession. 
Douches merely require a pipe with nozzles 
of various sizes in connexion with a cistern 
at a certain elevation, or with a pumping 
machine; they can easily be improvised. 
Shower-baths can be procured with equal 
facility. A vapour-douche can be got by DOUCHE 
DROPSY 
531 
attaching a pipe to a vessel of boiling water. 
In the case of fine douches used for the eye, 
the water is propelled with sufficient force by 
the action of a caoutchouc bag worked by 
the hand. Carbonic acid is practically little 
used, and only where there is an abundant 
natural supply of the gas. 
Perhaps 50° F. may be considered the aver- 
age temperature of a cold douche, and from four 
minutes to a quarter of an hour its average 
duration The course of douching will prob- 
ably extend at least over a fortnight. As to 
the actual temperature of the water, the sen- 
sation it produces in the patient depends 
most on his condition. Thus water of 45c F. 
may feel ice-cold to one who has just quitted 
a hot bath. In like manner a douche of 
slightly-heated water may appear quite warm 
when applied to a part cooled by a cold douche. 
The temperature of a douche should vary ac- 
cording to the condition of the patient. 
Uses.-As a general rule we may say that 
douches are only applicable in cases of chronic 
disease; that cold douches are most useful 
in constitutional diseases; and that warm 
douches, and the alternation of hot and cold, 
are most suitable in local affections. The 
use of hot and cold douches alternately has 
been much and successfully employed of 
late in France, for the treatment of certain 
nervous diseases. 
The cold douche, when it is employed 
gradually and with judgment, is found ser- 
viceable in chlorotic and hysterical conditions, 
in hysterical paralysis, and in over-sensibility 
of the skin, with tendency to catch cold ; and 
of late years it has formed a part of the special 
treatment of phthisis in elevated places. As 
cold affusion on the head is very serviceable 
in infantile convulsions, so the application of a 
douche of cold water to the head is a calmative 
and hypnotic in maniacal cases. It is, perhaps, 
not so much used in this way as formerly, 
because it has, like the shower-bath, come to 
be considered a sort of punishment to trouble- 
some lunatics. Still it is a valuable agent. 
Hydropathic practitioners have found douches 
useful revulsives in congestion of the liver and 
of the uterus. 
Locally douches have been used, but with 
moderate benefit only, in some cases of skin- 
affections and of chronic ulcers. Their prin- 
cipal local application, however, is in cases of 
old sprains, in chronic rheumatism or gouty 
thickenings of joints, in lumbago, in some 
neuralgias, and in paralysis when it is not 
too recent. The Scotch is far the most 
effective for these purposes, and there seems 
to be some evidence of its having been effi- 
cacious in threatened tabes dorsalis-cer- 
tainly more efficacious than any other remedy. 
Douches might be used more extensively in 
private houses; still, as assistance is always 
required by the patient, public baths have 
advantages for their application. 
John Macpherson. 
DRACUNCULUS (ffracunculus, a little 
dragon).-See Entozoa. 
DRAINAGE.-See Public Health. 
DRAKENSBERG MOUNTAINS, 
in Natal.-See Africa, South. 
DRASTICS (8paw, I act).-Definition. 
Violent purgatives. 
Enumeration.-The drastics most fre- 
quently employed are :-Hellebore, Podo- 
phyllin, Gamboge, Elaterin, Scammony, 
Jalap, and Croton Oil. 
For action and uses of drastics, see Pur- 
gatives. T. Lauder Brunton. 
DRIBURG, in Westphalia.-Strong 
Chalybeate Waters. See Mineral Waters. 
DROITWICH, in Worcestershire. 
Common Salt Waters. See Mineral Waters. 
DROPSY from v8wp, water; and 
aspect, appearance).-Synon. : Er. Hy- 
dropisie ; Ger. Wasser sucht. 
Definition.-Accumulation of serous fluid 
in the subcutaneous cellular tissue, or in a 
serous cavity. 
Dropsy is known by various other names, 
according to the portion of the body affected. 
"When confined to the subcutaneous cellular 
tissue it is termed oedema or anasarca; to the 
peritoneal cavity, ascites. The term is often 
limited to these two forms of the disease; and 
exudations similar to that of ascites in other 
cavities are termed hydropericardium, hy- 
drocephalus, hydrocele, hydrops oculi, hy- 
drops articuli, and hydrothorax or pleural 
effusion, according as they are contained in 
the pericardium, arachnoid, tunica vaginalis, 
eye, joint, and pleural cavity respectively. 
Pathology.-The accumulation of fluid in 
the tissues, or in a serous cavity, depends upon 
more fluid exuding from the blood-vessels 
than can be taken up by the absorbents. 
This condition may depend on an increase 
in the rapidity of exudation above the nor- 
mal, or on a diminution in the absorption, or 
on both together. Increased exudation may 
be due to alteration (1) in the calibre of the 
arteries or capillaries; (2) in the condition of 
their walls; (3) in the condition of the blood ; 
and (4) possibly also in the condition of the 
tissues. Diminished absorption is chiefly 
due to obstruction of the absorbents, although 
alteration in the tissues may also play a part. 
Obstruction may be (1) local or (2) general. 
So long as no obstruction to absorption occurs, 
it rarely happens that more fluid can exude 
from the blood-vessels than the absorbents 
can again take up. Absorption is partly car- 
ried on by the veins, and partly by the lym- 
phatics ; principally, however, by the veins. 
When venous obstruction takes place, fluid is 
apt to accumulate in that part of the body 
from which the blood ought to return by the 
obstructed vessel. But it does not always so 532 
accumulate ; for it may happen that the lym- 
phatics are able to absorb all the fluid which 
exudes from the capillaries, and to return it 
into the general circulation. Thus it has 
been found by Ranvier that ligature of the 
vena cava in a dog does not usually produce 
oedema of the lower extremities, but if one 
sciatic nerve be divided in such an animal, 
the corresponding leg at once becomes oede- 
matous. The reason of this is that, so long 
as the nerve is intact, the lymphatics can 
absorb all the fluid which exudes from the 
capillaries ; but when the nerve is divided the 
arteries dilate, more fluid is poured out than 
the lymphatics can absorb, it accumulates in 
the tissues, and oedema ensues. This oedema 
is not due to paralysis of the limb, but to 
paralysis of the vessels. For if the sympa- 
thetic fibres through which the vaso-motor 
nerves pass to the sciatic nerve are divided 
before they join the motor fibres of that nerve 
in the sacral plexus, the power of movement 
remains unimpaired, but oedema occurs just 
as if the whole nerve had been divided. If, 
on the other hand, the motor strands of the 
sacral plexus are cut before they are joined 
by the sympathetic fibres, the limb is as 
completely paralysed as if the sciatic nerve 
had been cut, but no oedema takes place. Any 
obstruction to the venous flow will operate 
in the same w ay as ligature of a vein, though 
to a less extent, the effect varying according 
to the amount of obstruction. Thus regur- 
gitation of blood through the tricuspid valve 
tends to produce general anasarca, and ob- 
struction to the portal vein by cirrhosis of 
the liver tends to cause accumulation of fluid 
in the abdominal cavity. 
It has been mentioned how great an in- 
fluence dilatation of the arteries from vaso- 
motor paralysis has upon the production of 
oedema in cases where the veins are ob- 
structed. Arterial dilatation may also produce 
a local oedema, even when no such obstruction 
is present, as, for instance, in the tissues 
around an inflamed part. It has been shown, 
however, by Winniwarter, that the walls of 
vessels in an inflamed part are more perme- 
able, and allow fluids to pass through them 
more easily than healthy vessels will do. It 
is probably in consequence of this that we 
find that a slight stimulus, such as scratch- 
ing the skin, which ordinarily produces in a 
healthy person only slight dilatation of the 
capillaries, and consequently redness of the 
part scratched, will produce an effusion from 
the vessels, and local swelling of the part at 
the point scratched, in persons suffering from 
urticaria. The same thing takes place w'hen 
the skin is scratched in the neighbourhood of 
a part stung by a wasp. 
But this alteration in the vessels is not the 
only cause of the oedema, which may occur 
without any obstruetion to the circulation. 
An alteration in the composition of the blood 
appears to allow it to permeate more easily 
DROPSY 
into the tissues, and to produce oedema, even 
when there is no obstruction of the veins. 
In cases of anaemia we find oedema, occur- 
ring at the ankles, although there is no ob- 
struction to the venous circulation other than 
that caused by the weight of the column of 
blood itself. In these cases, however, we 
have dilatation of the vessels, as is shown 
by the form of the sphygmographic tracing, 
and an altered composition of the blood is 
evidenced by the anaemic look of the patient. 
In albuminuria the altered composition of 
the blood appears to be the chief factor in the 
production of oedema, as the pulse in such 
cases may be hard, evidencing arterial con- 
traction, and not relaxation. 
^Etiology.--General dropsy affecting the 
subcutaneous tissue, the peritoneal cavity, 
and the internal serous cavities and organs 
generally, is usually the result of albumin- 
uria, and most frequently of that form which 
depends on acute nephritis, or on fatty degene- 
ration of the kidney. In cirrhotic' disease of 
the kidney the loss of albumen in the urine is 
much less, and the alteration in the composi- 
tion of the blood consequently is not so great 
as in the first-mentioned form. The arterial 
tension also is greater than usual, instead of 
being less. In the amyloid form the oedema 
is generally moderate. 
The next most common cause of dropsy is 
tricuspid regurgitation, obstructing the venous 
circulation throughout the body. This re- 
gurgitation generally depends on dilatation of 
the right ventricle consequent upon obstruc- 
tion to the flow of blood through the lungs, 
either from chronic bronchitis and emphy- 
sema, or mitral obstruction and regurgita- 
tion. Dropsy from cardiac disease generally 
appears first in the feet if the patient has 
been for some time in an upright position, 
while dropsy with albuminuria is often first 
remarked by a puffiness of the eyelids. In 
the former it appears where the greatest 
obstruction to re-absorption takes place, and 
in the latter case in those parts where loose- 
ness of the cellular tissue most readily allows 
of exudation. 
Local dropsies have, as a rule, local causes. 
Even the swelling of the feet in anaemic 
young women, although dependent on a 
general cause, namely, dilatation of the ves- 
sels, and altered composition of the blood, is 
determined locally by the greater obstruction 
to the venous circulation which the pressure 
of the long column of blood in the veins 
between the feet and the heart presents. In 
general dropsy also, those parts which are 
most dependent are apt to become most 
swollen. It is not, however, always so, as in 
certain cases the dependent parts have been 
noticed to be less dropsical than the others. 
This curious phenomenon seems to be due to 
some vaso-motor nervous influence on the 
vessels of the dependent part. The local 
oedema of a brawny character, often noticed DROPSY 
533 
around inflamed parts, is partially due to 
swelling of the tissues themselves, and par- 
tially to effusion of fluid between them. This 
effusion, as has already been mentioned, 
appears to be caused both by the dilatation 
of the vessels observed in inflamed parts, and 
by the greater readiness with which fluids 
pass through them. 
Dropsy in Serous Cavities. - The 
serous cavities of the body-the arachnoid, 
pleura, pericardium, peritoneum, &c.-are 
now known to be large lymph-sacs, in com- 
munication with the general lymphatic sys- 
tem of the body. The fluid which exudes 
into them from the blood-vessels is, in the 
peritoneum and pleura, removed, at least in 
part, by a pumping action in the movements 
of respiration. The central tendon of the 
diaphragm contains spaces, the walls of 
which are alternately drawn apart and pushed 
together during its ascent and descent. 
Their separation draws up lymph from the 
abdominal cavity, and their compression 
forces it onwards through the lymphatic 
vessels. The same thing occurs in the costal 
pleura, during the respiratory expansion and 
contraction of the chest. The accumulation 
of fluid in serous cavities may be due, like its 
accumulation in the cellular tissues, either to 
diminished absorption or increased exudation. 
The diminished absorption occurs here in 
consequence of pressure upon veins, and 
possibly also from interference with the 
pumping action just described. Accumula- 
tion of fluid in the ventricles of the brain, or 
in the sub-arachnoid cavity, is chiefly due to 
compression of the veins of Galen. In the 
peritoneum it may be due to obstruction of 
the portal vein by cirrhosis of the liver or by 
the pressure of tumours ; and it may occur to 
a greater or less extent in all cavities of the 
body from general obstruction of the venous 
circulation, by disease of the heart or lungs, 
in the same way as anasarca. It may also 
occur in these cavities from alteration in the 
blood, as in Bright's disease. Active dropsy 
may occur in a serous cavity from inflamma- 
tion, and here the exudation of fluid is much 
more rapid than in passive dropsy, the ves- 
sels of the inflamed part being dilated and 
more pervious than usual. 
Treatment.-The first thing to be con- 
sidered in the treatment of dropsy is the 
removal of its cause, if this be at all possible. 
Where it is due to obstruction of a vein we 
must hinder, as much as possible, the accu- 
mulation of fluid in the vein, by preventing the 
part from remaining in a dependent position, 
while at the same time we try to aid the ab- 
sorption of fluid by the lymphatics by gentle 
upward friction. Where it is due to obstruc- 
tion of the circulation in the lungs, we must 
diminish, as far as possible, all obstruction 
to the pulmonary circulation by inhalations, 
emetics, and expectorants, pushed if necessary 
so far as to cause nausea or even vomiting. 
Where the obstruction is due to dilatation or 
valvular disease of the heart, we must lessen 
the work the heart has to do, and insist in bad 
cases on absolute rest in bed or on a couch, in 
which the patient's position can be altered, 
but which he should not leave. An absolute 
milk diet, like that used in typhoid fever, is 
often of the greatest possible service, if it can 
be borne. At the same time we should aid the 
heart to contract more powerfully by the use 
of cardiac stimulants, such as alcohol and 
digitalis. Digitalis probably has a threefold 
action in cardiac dropsy, by strengthening 
the heart, by contracting the vessels, and by 
stimulating the kidneys. It strengthens at the 
same time that it slows the cardiac pulsa- 
tions, and by making the heart contract more 
powerfully it keeps up the onward current 
of the blood more efficiently, and at the 
same time lessens the dilatation which tends 
to render the valves incompetent. Besides 
its effect on the heart, digitalis has also an 
action on the vessels, causing the arterioles 
to contract, and probably reducing the dropsy 
in this way. For the contraction of the 
arterioles produced by digitalis is exactly the 
converse of the condition which occurs after 
division of the vaso-motor nerves, and which, 
as we have seen, produces dropsy whenever 
any obstruction of the circulation exists. It 
is not known at present whether digitalis 
also causes increased absorption, but it seems 
highly probable that it does so, because we 
know that it stimulates the vaso-motor centre, 
and stimulation of this part of the nervous 
system has been shown by Goltz to increase 
greatly the rapidity of absorption from the 
lymph-sac of the frog. In addition to this 
action on the heart and vessels generally, 
digitalis possesses a specific action upon the 
vessels of the kidney. It is a powerful diuretic, 
and by thus lessening the amount of water 
in the blood it will tend to increase the ab- 
sorption of serous fluid either from the cel- 
lular tissue or serous cavities. When digitalis 
alone does not succeed, the addition of squill 
and of a small quantity of blue pill frequently 
increases its efficacy. Digitalis succeeds best 
in dropsy caused by valvular disease or dila- 
tation of the heart. Sometimes strophanthus, 
convallaria, or adonis vernalis may succeed 
when digitalis fails; but in general digitalis 
is best. It is not so useful in dropsy arising 
from renal disease, and here other diuretics 
are preferable. One of the best is spirit of 
juniper, given either as a mixture or in the 
form of Hollands gm. Spirit of nitrous ether, 
nitre, bitartrate of potassium, and broom 
are useful in all forms of dropsy. Caffeine 
is sometimes very useful. Theobromine, the 
active principle of cocoa, seems also to be 
useful, and a compound of it with salicylic 
acid and soda has been recommended under 
the name of ' diuretin.' Copaiba occasion- 
ally succeeds where other diuretics fail. It 
seems to be most successful in dropsy due to 534 
cirrhosis of the liver. Hydragogue cathar- 
tics, such as compound jalap powder, elaterin, 
&c., which cause copious watery secretion 
from the intestines, supplement the action of 
diuretics, and relieve or remove dropsy by 
removing water from the body, as well as 
altering its nutrition. Calomel seems to have 
an almost specific diuretic action, and is 
useful either alone or in combination with 
other diuretics or purgatives. In some cases 
of Bright's disease considerable relief has 
been obtained by the profuse sweating in- 
duced by vapour baths, hot-air baths, jabor- 
andi, or pilocarpine. When the dropsy does 
not yield to other remedies, the fluid must be 
removed by paracentesis in the case of serous 
cavities, and by small superficial incisions 
or punctures, or by the insertion of very fine 
trocars with drainage-tubes attached, in the 
case of the limbs. 
T. Lauder Brunton. 
DROWNING, Death by.-The term 
' drowning ' is employed, in an extended sense, 
to signify death from submersion in a liquid 
medium, and in a more restricted sense to 
signify death in consequence of obstruction 
of respiration so caused. Now, though death 
must necessarily ensue from asphyxia, when 
the air-passages are submerged, apart from any 
other complication, asphyxia is not always 
the mode of death in those who were alive at 
the moment of submersion. For death may 
result from mechanical injuries, concussion, 
shock, syncope, or apoplexy in the very act, 
or at the moment, of falling into the water. 
Devergie estimates that 12'5 per cent, of 
deaths occur from one or other of these 
causes. In the remaining 87'5 per cent, the 
phenomena of asphyxia pure and simple are 
present only in 25 per cent., while in 62'5 per 
cent, these are mofe or less modified by the 
causes above-mentioned, to which must be 
added the benumbing influence of cold. 
When death is not sudden from shock, &c., 
the ultimate result is the same in the swim- 
mer or non-swimmer, if there be no escape 
or rescue. All efforts to keep above water 
fail, vain clutchings are made at whatever 
comes within reach, water is drawn into the 
lungs and more or less swallowed, all strug- 
gles finally cease, and the body sinks. 
The indications of such instinctive efforts 
form the most important evidence of submer- 
sion during life. Drowning is not necessarily 
to be inferred in the case of a dead body re- 
moved from the water; for the body may 
have been thrown in after death from other 
causes-asphyxia among the rest. 
The Evidence of Death from Drowning. 
This is cumulative, for we can scarcely say 
that there is any one indication invariably 
present which can be looked upon as due to 
drowning and to nothing else. But one or 
other, or more, of the following appearances 
are generally found. 
DROPSY 
External.-The face is either pale, or 
slightly livid, and frequently bloated if the 
body has lain some hours in the water. 
Water flows from the mouth when the body 
is turned face downwards. Foam at the mouth 
and nostrils is common; and the tongue is 
swollen and congested, closely applied to the 
teeth, or even clenched between them. The 
skin is pale, or marked here and there by 
livid discolorations, and the muscles of the 
hair-bulbs are rigidly contracted, causing the 
appearance of goose-skin, or cutis anserina. 
The penis, according to Casper, is retracted, 
but the more common condition is one of 
semi-erection. 
Indications of struggling are sometimes 
seen in excoriations of the hands, mud and 
sand under the nails, or even weeds, straws, 
or other small objects tightly clenched in the 
hands. 
Internal.- The trachea, bronchi, and 
smaller air-tubes are congested and filled 
with a mucous froth, more or less tinged with 
blood. The lungs themselves are congested, 
cedematous, and pit on pressure. Pressure 
on them causes froth to exude into the 
smaller bronchial tubes,, and on section a 
sanguinolent froth and water escape. Indi- 
cations may be seen of sand, mud, or small 
weeds drawn deep into the air-passages along 
with the water in which submersion took 
place. Water is often found in the pleural 
cavity. 
The stomach occasionally contains water. 
If this has any special character by which it 
can be identified with that in which submer- 
sion occurred, and not likely to have been 
drunk to quench thirst, it excludes the theory 
of its having been swallowed before submer- 
sion, and is a strong presumption, if it can- 
not be said to be a certainty, that it was 
swallowed during the death-agony, and did 
not find its way into the stomach after death. 
The same may be said of water in the 
lungs. 
The right side of the heart and venous sys- 
tem in general frequently present the appear- 
ances characteristic of asphyxia; and the 
brain is often congested. See Asphyxia. 
Without relying on any one sign as conclu- 
sive, we may say that a body which exhibits 
goose-skin, semi-erection of the penis, ex- 
coriations, &c., of the hands, froth at the 
mouth, water in the lungs and stomach, and 
congestion of the right heart and venous 
system, certainly died from drowning. In 
the presence of some and in the absence of 
other indications, a careful weighing of all 
the facts is necessary; but in most cases a 
satisfactory conclusion can be arrived at. 
Complete submersion is usually sufficient 
to cause death within two minutes ; but cases 
have been recorded of resuscitation after a 
much longer period. Many of these can be 
attributed to the exaggerated estimation of 
time by anxious on-lookers; but there are 
DROWNING, DEATH BY DROWNING, DEATH BY 
DRUG-ERUPTIONS 
535 
other well-authenticated instances, which 
may be explained by the supervention of 
syncope and temporary cessation of the re- 
spiratory process. That which renders re- 
suscitation after submersion less likely than 
after a corresponding period of mere suffoca- 
tion is the entry of water into the lungs by 
aspiration. 
Treatment.-The treatment of the drowned 
consists in the persistent use of artificial 
respiration (see Artificial Respiration ; and 
Resuscitation) so long as any signs of life 
remain, together with the application of 
means to counteract the great abstraction of 
body-heat which occurs even when the aerial 
temperature is comparatively high. Before 
commencing the movements of artificial 
respiration, the mouth and nostrils should be 
freed from water and froth, by holding the 
head somewhat low, face downwards, for a 
few seconds. Artificial respiration should 
then be immediately proceeded with. At 
the same time the wet clothes should be 
removed, and the body wrapped up in warm 
clothes obtained from bystanders, pending 
the arrival of warm blankets, hot bottles or 
bricks, &c., from the nearest house. Assiduous 
friction of the extremities should also be kept 
up. These directions-artificial respiration 
excepted-naturally presuppose assistance. If 
this be not at hand, the operator must rely 
mainly on artificial respiration. In the per- 
formance of artificial respiration by Sylvester's 
method, especial care must be taken against 
pressing on the stomach, for as it so fre- 
quently contains water, this may be forced 
up the oesophagus, and drawn into the lungs 
by the next inspiratory movement. 
When spontaneous respiratory movements 
commence, attention should be directed to 
maintain life by the application of warmth 
externally, assiduous friction of the limbs 
upwards, and the administration of brandy 
and water, wine, or coffee. Lung-complica- 
tions should be watched for and counteracted. 
D. Ferrier. 
DROWSINESS.-Inclination to sleep. 
See Sleep, Disorders of. 
DRUG-ERUPTIONS.-Synon. : Der- 
matitis medicamentosa. 
Many medicines produce at times various 
eruptions or discolorations of the skin, owing 
to idiosyncrasy, irritability of the gastro- 
intestinal mucous membrane, or defective 
power of elimination on the part of the 
patient; or, on the side of the drug, from the 
largeness of the dose or its long-continued 
administration. 
These toxic lesions may be divided into 
three classes :-(1) Those inflammatory 
eruptions which are special to the drug, 
such as the agminated pustular eruptions 
produced by bromine or iodine compounds 
(see Bromism; and Iodism). (2) Various 
inflammatory eruptions not distinctive in 
themselves, their nature being only recog- 
nisable from the surrounding circumstances. 
(3) Discolorations of the skin, such as are 
produced by arsenic and nitrate of silver. 
See Pigmentary Diseases. 
The great bulk of medicinal eruptions are 
either erythematous or urticarial, but the 
kind of eruption produced by the same drug 
often varies according to the individual who 
takes it. With the exception of the special 
eruption of iodides and bromides, the lesions 
are probably due to irritation of the gastro- 
intestinal mucous membrane acting refiexly 
on the vascular nerves of the skin; for in many 
instances the dose has been too small, and the 
eruption has followed too quickly on the inges- 
tion of the drug, for the rash to be due to the 
absorption and circulation of the substance 
itself. With the exception of the special 
bromide and iodide eruptions, the diagnosis 
cannot be made from the aspect of the rash. 
The following lists do not pretend to be quite 
complete, but represent all the chief erup- 
tions and the drugs which produce them 
List of Drugs and of the Rashes 
which they Produce. 
Antipyrine (Phenazone).-Erythema-dif- 
fuse, patchy, papular, or morbilliform; urti- 
caria ; miliaria. 
Arsenic.-Erythema-diffuse and erysi- 
pelas-like, papular; acuminate or morbilli- 
form ; urticaria, vesicles, pustules, furuncles, 
herpes zoster, gangrene, pigmentation. 
Belladonna.-Erythema-diffuse, scarlati- 
niform, or patchy. 
Benzoate of sodium.-Erythema-patchy. 
Borax.-Psoriasis, or a scaly eruption 
like it. 
Boric acid.-Erythema, followed by vesi- 
cles. 
. Bromine compounds.-iErythema-diffuse, 
patchy, papular or morbilliform, ' nodosum '- 
like; urticaria, bullae, pustules-discrete or 
agminated, furuncles, ecthyma (indirectly), 
eczema. 
Calomel injection.-Erythema, scarlatini- 
form in one case. 
Cannabis ind/ica.-Vesicles. 
Chlor alamide.-Erythema. 
Chloral hydrate.-Erythema-diffuse, pa- 
pular, and scarlatiniform ; urticaria, vesicles, 
bullae, pustules, purpura, shedding of nails. 
Chlorate of potassium.-Erythema, papu- 
lar ; discoloration, bluish or icteric. 
Chloroform.-Purpura. 
Chrysarobin. -Erythema- diffuse, with 
oedema, eczema, once pityriasis rubra. 
Cod-liver oil.-Vesicular, pustular. 
Copaiba.-Erythema-diffuse, patchy, or 
scarlatiniform; miliary papules, petechiae, 
vesicles, bullae, urticaria. 
Cubebs.-Erythema-papular, miliary, or 
morbilliform. 
Digitalis.-Erythema-scarlatiniform or 
papular. 536 
DRUG-ERUPTIONS 
DUMBNESS 
lodine and its compounds.-Erythema- 
diffuse, papular, morbilliform, or nodosum- 
like; urticaria, discrete pustules, vesicles, pur- 
pura, gangrene. 
Iodoform.-Erythema-diffuse or scarla- 
tiniform; papules, vesicles, bullae, eczema, 
purpura. 
Mercury.-Erythema-diffuse, like erysi- 
pelas. 
Morphine and opium.-Erythema-scarla- 
tiniform, papular, morbilliform; vesicles and 
bullae; never any rash from hypodermic in- 
jection. 
Phosphorus.-Bullae, purpura, icterus. 
Quinine.-Erythema-diffuse or patchy, 
scarlatiniform; papules, acuminate or mor- 
billiform, urticaria, vesicles, bullae, furuncles. 
Salicylic acid and its compounds.-Ery- 
thema- diffuse ; urticaria, vesicles, pustules, 
purpura. 
Salol.-Urticaria. 
Santonin.-Urticaria. 
Strychnine.-Erythema-scarlatiniform. 
Tar.-Erythema; locally a form of acne. 
Tcrebene.-Erythema-papular. 
Turpentine.-Erythema-diffuse, papular, 
acuminate, or morbilliform ; vesicles. 
List of Eruptions and of the Drugs 
which produce them. 
Diffuse or patchy erythema.-Antipyrine, 
arsenic, belladonna, benzoate of sodium, boric 
acid, bromides, chloralamide, chloral hydrate, 
chrysarobin, copaiba, iodides, salicylic acid, 
stramonium, tar. 
Scarlatiniform erythema.-Belladonna, 
chloral hydrate, copaiba, iodoform, quinine, 
strychnine, bromide of nickel. 
Papular or morbilliform erythema.- 
Antipyrine, arsenic, bromides, chloral hydrate, 
cubebs, morphine, quinine, terebene, turpen- 
tine. 
Nodosum-like erythema.-Bromides and 
iodides. 
Urticaria.-Antipyrine, arsenic, bromides, 
copaiba, iodides, morphine, quinine, resin, 
salicylic acid, salol, santonin. 
Vesicles.-Cannabis indica, chloral hydrate, 
cod-liver oil, copaiba, iodides, morphine, qui- 
nine, salicylic acid, and turpentine. 
Bullce.-Bromides, cannabis indica, chlo- 
ral hydrate, copaiba, iodides, morphine, phos- 
phoric acid, quinine. 
Pustules.-Arsenic, bromides (confluent), 
chloral hydrate, iodides (isolated), salicylic 
acid. 
Purpura.-Chloral hydrate, chloroform in- 
halation, iodides, quinine, salicylic acid. 
Pityriasis rubra (?).-Bichromate of potas- 
sium. 
Psoriasis (?).-Borax, bichromate of potas- 
sium. 
Eczema.-Bicarbonate of potassium, bro- 
mides, chrysarobin, iodoform. 
Gangrene.-Arsenic, ergot, iodides, quinine. 
• Persistent desquamation.-Quinine. 
A bscess.-Quinine. 
Furuncles.-Arsenic, bromides, quinine. 
Keratosis p almaris.-Arsenic. 
Pigmentation.-Arsenic, nitrate of silver, 
picric acid. 
Herpes Zoster.-Arsenic. 
H. Radcliffe Crocker. 
DRY.-Synon.: Fr. Sec, Ger.Trocken.- 
A term applied to certain morbid condi- 
tions, to express the entire or compara- 
tive absence of fluid exudation or secretion, 
which is often present in such conditions; 
for example, Dry Gangrene, Dry Cavity, Dry 
Catarrh, and Dry Pleurisy. The word is 
also associated with certain auscultatory 
signs, which convey the impression of want 
of moisture ; for example, Dry Rhonchus and 
Dry Crackle. See Physical Examination. 
DUCHENNE'S PARALYSIS.-See 
Pseudo-Hypertrophic Muscular Paraly- 
sis. 
DUCTUS ARTERIOSUS, Patency 
of.-See Heart, Malformations of. 
DUMBNESS.-Definition.-The con- 
dition of an individual considered incapable 
of articulating sounds. 
Dumbness may arise from a variety of 
causes, and its prognosis and treatment vary 
accordingly. 
1. Dumbness due to deafness.-The 
most frequent cause of so-called dumbness is 
congenital or early acquired complete deaf- 
ness, or defective power of hearing, so that 
the patient is unable to acquire in an ordinary 
way the knowledge of articulate sounds. It 
is important to bear in mind that complete 
deafness is not essential to this peculiarity. 
Dumbness is frequently met writh in children 
and others where the only cause is defective 
power of hearing. 
Treatment. - Whether the outcome of 
complete or partial deafness, the treatment 
must be based on the belief that the articu- 
lating power is latent, and may be developed 
by teaching the patient to imitate the process 
of speaking in others, and by a methodical 
training in lip-language. It is most important 
that sign-language should not be cultivated at 
the same time, and that if a language of signs, 
whether by the hand or gesture, has been pre- 
viously taught, it should be thoroughly and 
at once discarded. With patients who have 
full intellectual power, and who are trained 
as indicated above, it will be found that for 
them dumbness is a misnomer, articulate 
sounds, although with a defective modula- 
tion, being readily acquired. Individuals 
coming under this category are erroneously 
called deaf-mutes. 
2. Dumbness from central lesion of 
the hypoglossal nerve.-This may arise 
from cerebral haemorrhage, tumours, or em- 
bolism, and the prognosis is most unfavour- DUMBNESS 
DUODENUM, DISEASES OF 
537 
able. It is usually associated with other 
paralytic conditions, but is of all the most 
persistent. 
3. Dumbness from peripheral lesion 
of the hypoglossal nerve.-This is much 
less frequent as a cause of dumbness than 
central lesions; nevertheless cases are met 
with where hydatid or other tumours result 
in dumbness through pressure on the nerve 
itself. 
4. Dumbness from lead-poisoning.- 
Among the paralyses arising from the slow 
effects of imbibition of lead is paralysis of the 
tongue, with consequent loss of articulating 
power. This defect is usually associated with 
grave impairment of other parts. 
Treatment.-The treatment of dumbness 
due to lead-poisoning will be best effected by 
elimination of the poison by the administra- 
tion of iodide of potassium, and the judicious 
employment of galvanism to the nervous 
system. 
5. Dumbness from congenital defects 
of the tongue or of the palate.-Various 
congenital local lesions are met with giving 
rise to dumbness. 
Treatment.-Many of these cases are re- 
mediable by surgical or surgico-dental help, 
followed by methodical teaching. 
6. Dumbness from emotional lesions. 
Dumbness occasionally arises from great 
emotional disturbance, such as great anger 
or sudden fright. Moreover, it is often met 
with, without such marked cause, in indi- 
viduals, especially of the female sex, having a 
highly developed emotional life. 
Treatment.-Cases of this kind are usually 
successfully treated by faradisation about the 
muscles of the neck ; the patient at the same 
time being encouraged to call his articulating 
power into action, and in proportion to his 
success the faradic current being discon- 
tinued. The moral treatment here indicated 
may be greatly assisted by promoting the 
general health, and placing the patient under 
the best possible circumstances as to hygiene 
and moral discipline. 
7. Dumbness from intellectual dis- 
orders.-This is by far the most common 
cause of true dumbness. It may arise from 
idiocy or imbecility of a congenital nature; 
from that which has been acquired early in 
life; or from dementia as the outcome of 
acute or chronic brain-disease in middle or 
advanced life. Among the congenitally 
feeble-minded, dumbness is a very frequent 
phenomenon. This arises from the associa- 
tion therewith of deformed mouths and 
highly-arched palates; from defective power 
of co-ordination of the muscles of the tongue ; 
and from an inability to transform ideas into 
word-signs. In the most profound cases 
there is such an absence of ideas that language 
of any kind is not required. 
Treatment.-The treatment of this kind 
of dumbness is one which requires great tact, 
patience, and energy; and the success will be 
commensurate with these aids. 
The physical health of the individual 
should be carefully attended to, so as to 
induce, by judicious food, frequent bathing, 
and warm temperature, the highest amount 
of nervous energy. The power of co-ordina- 
tion should be sedulously cultivated by 
methodical exercises, especially of the hands, 
leading up to well-devised tongue-gymnastics. 
He should then be taught monosyllabic 
sounds, by being shown the object represented 
by the sound, while he imitates the sound 
when watching the teacher's lips. Having 
thus acquired the power of producing the 
word-sign by imitation purely, he is next 
taught to repeat it from memory when shown 
the object only. After norms have thus been 
taught, the names of qualities and adverbial 
expressions should be added, and in this 
manner articulate speech built up. 
Where the feeble-mindedness has been 
acquired after birth, the dumbness resulting 
therefrom should be treated in a somewhat 
similar manner to that having a congenital 
origin, but the prognosis is not so good. 
Still more unfavourable is the forecast of 
dumbness when the result of dementia. 
J. Langdon Down. 
DUODENUM, Diseases of.-These 
may be considered under the heads of- 
(1) Functional disorder; and (2) Organic 
diseases. 
1. Functional disorder.-Disorder of the 
duodenum is said to produce a form of dyspep- 
sia, characterised by pain in the epigastrium 
and right hypochondrium two or three hours 
after meals, vomiting, and the distant effects of 
ordinary dyspepsia-vertigo, headache, drow- 
siness, burning sensation in the soles of the 
feet and palms of the hands, &c. Imperfect 
chymification, which attends ordinary dys- 
pepsia, may induce these symptoms by gene- 
rating products which irritate the duodenum. 
Treatment.-The treatment is mainly that 
of disordered digestion. The bowels and the 
diet are to be carefully regulated; and such 
remedies as alkalis, bismuth, oxide of man- 
ganese, prussic acid or hydrochloric acid ex- 
hibited, according to the special requirements 
of each case. 
2. Organic diseases.-These are (a) in- 
flammation; (&) ulceration; and (c) new- 
growths. 
(a) Inflammation.-Synon. : Duodenitis; 
Fr. Duodenite.-Acute inflammation of the 
duodenum is usually of a mild catarrhal cha- 
racter. It either forms part of an enteritis, or 
is an extension downwards of a similar affec- 
tion of the stomach. The ordinary exciting 
causes are exposure to cold, and irritating in- 
gesta or acrid bile. Usually the symptoms of 
slight gastric catarrh-a loaded tongue, ano- 
rexia, nausea, vomiting of tenacious mucus 
-are followed by jaundice. When the 538 
DUODENUM, DISEASES OF 
DYNAMOMETER 
duodenum is invaded there is said to be fulness 
and tenderness of the right hypochondrium. 
As a rule, however, new symptoms are not 
set up unless the bile ducts become obstructed 
by mucus from extension of the catarrh into 
them, when jaundice supervenes without pain. 
The attack usually lasts a week or a fort- 
night, and, with suitable hygienic and dietetic 
treatment, it passes safely off. It is, however, 
sometimes followed by jaundice unusually 
prolonged, and, even when the bile-ducts are 
free, by prostration and wasting out of pro- 
portion to the mildness of the disease in itself. 
While catarrhal duodenitis does not afford 
characteristic symptoms, its presence is, how- 
ever, usually suggested by painless jaundice 
following exposure to cold, catarrh of the 
stomach, and enteritis. 
Treatment.-This consists in rest in bed, 
warmth, liquid diet, counter-irritation by 
blisters, mustard or hot poultices, and effer- 
vescing salines. 
Chronic inflammation, resulting in thicken- 
ing of the mucous and submucous tissue, and 
even adhesion of the duodenum to adjacent 
organs, is usually associated with chronic 
ulceration, or with cancer of the duodenum, 
pancreas, liver, or other structures. Con- 
traction of the duodenum produces symptoms 
of obstruction similar to those arising from 
stricture of the pylorus. 
(b) Ulceration.-Perforating ulcer, simi- 
lar to that of the stomach, is said to be more 
frequent in men than in women (about 10 
to 1), and rarely to occur during childhood; 
while it sometimes follows severe and exten- 
sive burns and scalds.1 Fatal ulceration has 
not infrequently been reported in previously 
healthy subjects. It may then possibly arise 
from an accidental abrasion of the duodenal 
mucous membrane (by some indigestible 
substance), becoming subsequently subjected 
to the deleterious action of the gastric juice.2 
The ulcer, usually single and found in the 
upper horizontal portion, when recent has 
clean-cut edges free from swelling. The wall 
of the duodenum may be perforated, either 
without previous adhesion, being followed by 
the signs of general peritonitis; or with ad- 
hesion to adjacent parts, such as the liver, 
the gall-bladder, the pancreas, the colon, the 
hepatic artery, or the posterior wall of the 
abdomen-into which ulceration extends to a 
variable extent. Cicatrisation may take place 
with recovery, or it may induce stricture of 
the duodenum or obliteration of the bile-duct. 
As a rule the symptoms greatly resemble 
those of perforating ulcer of the stomach; 
more frequently, however, the disease is 
latent, and induces very obscure dyspeptic 
symptoms prior to fatal perforation. Jaundice 
is not more common than in the similar affec- 
tion of the stomach. In burns and scalds per- 
foration seldom occurs before the tenth day. 
The treatment should be the same as that 
laid down for gastric ulcer. See Stomach, 
Diseases of. 
The duodenum may be ulcerated by the 
action of a gall-stone passing into it directly 
from the gall-bladder. 
(c) New-Growths.-The most important 
of these is scirrhous cancer, which may in- 
volve the walls of the duodenum, usually by 
extension. It tends to produce obstruction, 
or it may set up chronic duodenitis, or block 
up the bile-duct and thus give rise to jaun- 
dice. George Oliver. 
DURA MATER, Diseases of.-See 
Meninges, Diseases of. 
DURATION OF DISEASE.-See 
Disease, Duration of. 
DYNAMOMETER (Surcquf, power; and 
p.trpov, a measure). 
Description.-The dynamometer is an in- 
strument originally invented by M. Duchenne, 
of Boulogne, for measuring and accurately 
recording the strength of the hand-grasp, 
and also for measuring the traction power 
capable of being exerted by other groups of 
muscles. The result is shown by an index, 
which traverses a semicircular dial bearing 
a scale graduated so as to enable the observer 
to record the number of kilogrammes which 
the applied pressure or traction represents. 
In practice this instrument has been prin- 
cipally employed for estimating the absolute 
or comparative force of the hand-grasp; and, 
in view of this restriction, Duchenne's in- 
strument is needlessly complex. It has, 
moreover, the absolute disadvantage of being 
a little too broad, and of requiring too 
much strength on the part of the patient 
to move the index,over the lower figures of 
the dial. A patient with a small amount of 
motor power, especially if the hand is small, 
is often unable to set the index of this dyna- 
mometer in motion. A cheaper, simpler, 
and narrower instrument has therefore been 
devised by English makers, the index of 
which can be moved by the application of a 
much smaller amount of power. This con- 
sists of a simple elliptical ring of steel, to 
1 In explanation of the connexion between 
severe burns and duodenitis ending in perforative 
ulceration, Dr. William Hunter infers from his 
experiments with the subcutaneous injection of 
toluylendiamin (which he found to set up inflamma- 
tion of the duodenum) that there may be derived 
from the burnt tissues and excreted through the 
bile irritant substances which excite ulcerative in- 
flammation. Some recent observers (Fayrer, Bowlby, 
and Perry), however, have failed to discover post- 
mortem evidence of the alleged causal relation 
between burns and duodenal ulceration; while 
others (Wilks and Macarthy) have shown the rarity 
of it. Doubtless the association is much less fre- 
quent than has hitherto been held; for example, 
Raymond Johnson found in the records of Univer- 
sity College Hospital only two cases of ulceration 
out of ninety-three cases of burns (Trans. Path. 
Soc. Lond., 1890). 
2 Myers, Trans. Path. Soc. Land., 1890. DYNAMOMETER 
DYSENTERY 
539 
the inner and anterior face of which is 
attached a brass semicircular dial graduated 
with two rows of figures representing pounds 
instead of kilogrammes. The compression 
of the steel ring, by lessening its shorter 
diameter, moves a metal bar projecting from 
and sliding in a groove behind the dial, and 
this by rack-work communicates its move- 
ment to the index. 
Uses.-The dynamometer is a useful in- 
strument, inasmuch as it enables us ac- 
curately to ascertain the relative compressing 
powers of the two hands in cases of incipient 
or actually developed hemiplegia, and also to 
learn in a positive and definite manner, from 
time to time, the amount of improvement or 
the reverse which may have taken place.. 
Since the power of the muscles of the fore- 
arm and hand, like that of other groups of 
muscles, varies a good deal with the general 
state of health of the patient, the dynamo- 
meter is also capable of yielding valuable 
information concerning the strength of the 
patient, even where we have to do with 
general debility from any cause rather than 
with a case of paralysis. Any instrument 
which, in the place of fleeting and more or less 
vague impressions made upon the mind of 
the practitioner at the time, enables him to 
make a more accurate record in figures in 
his note-book, is a clear gain to practical 
medicine-more especially when its use in- 
volves no appreciable loss of time. 
H. Charlton Bastian. 
DYS2ESTHESIA (Sao--, with difficulty; 
and ataOdvopai, I feel). -A term applied to 
impairment of any of the senses, but espe- 
cially to that of touch. See Sensation, Dis- 
orders of. 
DYSCRASIA (3v<r-, with difficulty, or 
badly; and update, a mixture).-A morbid 
condition of blood. 
This term signifies more than a disposition 
to disease; it implies the presence of some 
general disease exerting its pernicious effects 
upon the blood. Hectic fever, septicaemia, 
and metastatic inflammations are diseased 
conditions referable to dyscrasiae. A person 
sickening for a fever is the subject of a spe- 
cific dyscrasia. See Blood-Disease. 
R. Douglas Powell. 
DYSENTERY (3v<r-, with difficulty; and 
evrepov, an intestine).-Synon. : Fr. Dysen- 
teric ; Ger. Dysenteric. 
Definition.-A specific febrile disease, ac- 
companied by considerable nervous prostra- 
tion, and characterised by inflammation of 
the solitary and tubular glands of the large 
intestine; sometimes ending in resolution, but 
frequently terminating in ulceration, occa- 
sionally in more or less sloughing or gan- 
grene ; always, in the acute stage, accom- 
panied by tormina and tenesmus, the latter 
being most marked when the disease is situ- 
ated in the rectum or lower end of the 
sigmoid flexure; stools at first more or less 
faeculent, later on yielding dysenteric products 
without much if any faeculence, such as blood, 
mucus, slime, and gelatinoid. exudation, or- 
as in the sloughing or gangrenous forms-like 
the washings of meat, and possessing a putrid 
or gangrenous odour, and so-called epithelial, 
ash-coloured, black, gangrenous, pus-infil- 
trated or tubular sloughs, chiefly consisting ot 
tough, imperfectly organised exudation. 
Etiology and Pathology.-In almost all, 
if not in all, situations where malarious fevers 
abound, as in the vicinity of the swamps and 
sluggish rivers of tropical and sub-tropical 
countries, dysentery prevails in proportion to 
the intensity and frequency of these fevers. 
Where, on the other hand, intermittents and 
remittents have been extinguished by im- 
proved drainage and the conversion of marsh 
into cultivated land, it becomes equally un- 
known. In or near the tropics, Great Britain, 
Canada, the United States, and in many other 
parts of the world, its diminution has pro- 
ceeded pari passu with the decrement of 
malarious fevers. There would, therefore, 
seem to be some intimate connexion between 
the causation of dysentery and intermittent 
and remittent fevers. Not that the immediate 
causes of malarial fevers and dysentery are 
identical: all that is meant is that under 
certain conditions they concur. 
Paroxysmal fevers interfere materially with 
the nutrition and functions of the digestive 
organs, and with the proper nourishment and 
constitution of the blood. Violent congestion 
of the abdominal viscera is one of the special 
conditions of the different forms of ague. 
Both the liver and spleen are liable to tem- 
porary and repeated engorgement, and so in 
fact are all the organs which minister to 
gastric and intestinal digestion. Even where 
malarious poisoning may never have resulted 
in any of the various forms of periodic fever, 
it may impair the power of the organic nerve- 
centres and the muscular tone of the blood- 
vessels, thus disturbing the balance of the 
portal circulation, and leading to more or less 
permanent repletion or congestion. As the 
congestion is most embarrassing during diges- 
tion, interfering with the appetite, and the 
capacity for digesting and assimilating food, 
its repeated and prolonged existence must 
deteriorate the quality and modify the quan- 
tity of such important secretions as the gastric 
juice, the bile, the pancreatic juice, and those 
furnished by the follicles of Lieberkuhn, and 
by Brunner's and the solitary glands. Crude 
alimentary principles are thus assimilated 
from the intestinal tract. The liver is especi- 
ally liable to functional derangement from the 
stagnation and slowing of the portal circula- 
tion, and thus it happens that in dysentery 
hepatic impairment is almost an invariable 
accompaniment. Such being some of the ab- 
normal conditions produced by the operation 540 
DYSENTERY 
of malaria in its active or latent form 
upon the chylopoietic viscera, it is not sur- 
prising that, under the prolonged strain, 
certain portions of the alimentary mucous 
membrane should break down. Why the 
solitary glands of the large intestine should 
be the special seat of dysentery, whilst the 
corresponding glands in the small intestine 
should, with few exceptions, escape, it is, in 
the present state of our knowledge, impossible 
to say. The most that can be hazarded is, 
that the elementary structures of these glands 
take on morbid action through the operation 
upon them of a materies morbi derived 
directly from their blood-supply. That this 
poison exists in the blood may be inferred 
from the fact that constitutional disturbance 
invariably precedes and accompanies the 
earlier stages of acute dysentery. 
Unwholesome drinking-water is a fertile 
proximate and exciting cause of dysenteric 
disease. Bad and unwholesome food of what- 
ever description, by providing aliment inca- 
pable of being perfectly digested, may act in 
producing the disease. In like manner im- 
pure air may, by preventing the proper aera- 
tion and depuration of the blood, and by pro- 
moting the retention in it of inassimilable 
material, light up dysenteric inflammation 
of the solitary glands. The transit of acrid 
and vitiated bile and other secretions poured 
into the digestive canal, often operates as an 
exciting cause, and frequently determines a 
morbid action which might be otherwise 
righted by resolution, to advance to ulcera- 
tion, sloughing, or gangrene. It is thus that 
many a simple but neglected case, scarcely 
at first distinguishable from diarrhoea-un- 
less indeed every evacuation is most carefully 
washed and scrutinised-ends in destruction 
of large masses of the mucous membrane, 
and death, from the conjoint effect of ex- 
haustion and shock from the separation of 
the sloughs. Indigestible articles of diet, 
which cannot be reduced by the juices of 
the digestive tract to a condition admitting of 
ready absorption, may act as local irritants 
and exciting causes. Not only is this so in 
the earliest visible stage or that of active 
congestion, but it becomes much more sus- 
ceptible of demonstration in the exudative 
and ulcerative phases of the disease, by the 
repeated investigation of the subjective and 
objective indications. Thus the aggravation 
of the tormina and tenesmus in adults and 
children is traceable to indiscretion in diet, 
or to the passage of undigested morsels of 
food, recognisable in the stools. Sudden 
vicissitudes of temperature from a high to a 
low range, or exposure to damp and cold 
combined, especially when the vital powers 
are physiologically depressed, by checking 
the excretory action of the skin and diminish- 
ing the cutaneous circulation, augment the 
portal congestion and excite dysenteric dis- 
ease. This is probably the reason why, in a 
large proportion of cases, the onset of the 
disease is ushered in towards midnight or 
the early morning. The operation of epidemic 
influences in the causation of dysentery, 
signifies only that it is most prevalent at 
those seasons when malarious fevers are most 
abundant. As there is an intimate connexion 
between the existence of malaria and the pre- 
valence of dysentery, it is not difficult to 
understand why, both as regards type and 
seasonal frequency, dysentery should bear a 
striking relation to the severity and seasonal 
prevalence of malarious fevers. 
Is dysentery a contagious or communicable 
disease ?-"Whilst many of the older physi- 
cians held that dysentery might be spread by 
contagion from person to person, it may be 
affirmed that the experience of most modern 
practitioners is altogether opposed to this 
view. There is no clear and unimpeachable 
evidence to demonstrate that it is propagated 
in the same way as typhus or small-pox. 
Dysentery may possibly be communicable, 
like typhoid fever, through air, water, or 
food-liquid or solid-charged with material 
derived from the undisinfected and putrefying 
products of the disorder. Be this, however, 
as it may, the complete disinfection or de- 
struction of the alvine evacuations should 
always be regarded as a sanitary measure 
of supreme importance.1 
Anatomical Characters and Pathology.- 
The dysenteric process generally consists of 
a specific inflammation of the solitary glands 
(Parkes, Baly, and others). Theyirst visible 
change is congestion, the vessels surrounding 
and penetrating the capsules being turgid and 
engorged with blood. The second change is 
augmentation of their contents from the ac- 
cumulation of albuminous exudation, and 
enlargement ' from the size of a millet-seed 
1 It is more than probable that there are several 
varieties of dysentery, each of which is attribu- 
table to its own specific cause. Different micro- 
organisms have from time to time been described in 
this connexion; but, as there seems to be no con- 
sensus of opinion on the subject among observers, 
it is premature to conclude that dysentery is brought 
about by the direct action on the glands of the 
colon of any known micro-organism. The only 
parasite which has established anything like a claim 
to be considered specific to dysentery is the Amoeba 
coli, discovered by Lbsch in 1875. This amoeba has 
of late years been frequently found in dysenteric 
discharges in places so widely separated as Russia, 
Central Europe, Egypt, the United States of Ame- 
rica, and India. Moreover, it has been found, on 
more than one occasion, in the pus and walls of liver- 
abscess complicating dysentery. This association is 
not without significance; but, as the amoeba is cer- 
tainly not present in every case of dysentery or 
dysenteric abscess of the liver, we are as yet justified 
in regarding it mainly as an epiphenomenon grafted 
on certain cases of colitis and liver-abscess, and not 
as the specific cause of these diseases. The Amoeba 
coli, which when alive displays the characteristic 
amoeboid movements, varies in size from 0'02 to 
0'035 mm., is coarsely granular, nucleated, and 
possesses one or more non-contractile vacuoles. See 
Entozoa.-Editor. DYSENTERY 
541 
to a small shot ' (Baly). The third change, 
provided the inflammation advances, is rup- 
ture of some of the capillaries in the interior 
of these little vascular glands, extravasation 
of blood, with the area, of the ordinary dark 
point on the free aspect increased. The 
fourth stage is now marked by atrophy and 
molecular disintegration of the free aspect of 
the capsular wall, and escape of its morbid 
gelatinoid blood-tinged contents into the 
canal of the intestine. This is the rule ; but, 
in very exceptional cases, the capsule may 
burst through the attached portion, lighting 
up inflammation in the neighbouring con- 
nective tissue and muscular coat. In a large 
number of instances the morbid process may 
stop short, under proper treatment, at any 
of the first three stages, and repair is then 
effected by resolution. In many cases the 
morbid action is cut short after the comple- 
tion of the fourth stage, without further ex- 
tension of the disease. The adjoining folli- 
cles of Lieberkuhn do not, in these cases, 
necessarily participate, to any great extent, 
in the diseased process. Under these condi- 
tions, when the whole of the exudation has 
been expelled, the glands regain their tone 
and functions, and recovery - rapid and com- 
plete-ensues. It is not often possible to 
illustrate these conditions in the post-mortem 
room; because, when death supervenes from 
dysentery alone, the ravages committed upon 
every structure of the mucous membrane are 
so extensive as to destroy the earlier physical 
phases of the disease. In some cases, how- 
ever, which have died from intercurrent 
affections, the writer has been able to de- 
monstrate the earliest stages successfully to 
his students, at a period prior to the impli- 
cation of Lieberkuhn's follicles, of which the 
mucous membrane is in great part composed, 
and to exhibit to them the gelatinoid exuda- 
tion, termed by others ' gelatinous mucus,' 
free from or tinged with blood taken from 
enlarged and diseased solitary glands (Indian 
Annals of Medical Science, p. 190, No. xxiii., 
1868). 
When, owing to neglect, to constitutional 
defect in spite of the most careful therapeu- 
tic and hygienic management, or to intensity 
or quantity of the specific poison, the disease 
is not cured by resolution, the disintegrating 
or ulcerative process is developed. The whole 
of the solitary glands engaged perish. The 
ulceration involves the neighbouring tubular 
glands, leading to ulcers varying from the 
size of a mustard-seed to that of a florin or 
more, in depth generally extending to the 
submucous connective tissue, and not infre- 
quently laying bare the circular lamina of 
the muscular coat, sometimes involving the 
longitudinal layer and perforating it as well 
as the peritoneal coat, thus admitting of the 
extravasation of the contents of the bowel 
into the peritoneal cavity, and lighting up 
peritonitis, which, if general, is invariably 
fatal, but which, if local and confined to the 
close vicinity of the perforating ulcer, is not 
necessarily so. 
The ulcers vary in appearance, size, and 
shape. They may be mere abrasions without 
much loss of structure; minute, though pene- 
trating rather deeply into the submucous 
connective tissue; irregular, serpentine, or 
rodent, with here and there portions of the 
surrounding mucous membrane undermined 
and patulous; transverse, embracing partially, 
or completely, the entire circular outline of 
the mucous membrane; circular or oval, 
with regular and even margins; or tuber- 
cular, involving the whole substance of the 
mucous membrane, looking as if they had 
been punched out of it. These ulcers, as 
generally observed in the post-mortem room, 
are free from sloughs, and present a pale 
ashy appearance. Sometimes they are of a 
vermilion or purple colour, from active or 
passive congestion. They are often covered 
with flakes of tenacious lymph or exudation, 
and this may sometimes be seen spread over 
the neighbouring mucous membrane. The 
floors of these ulcers are usually formed by 
inflamed and thickened submucous areolar 
tissue ; but sometimes this has all been de- 
stroyed, and then they are constituted of the 
muscular coat, thickened and infiltrated by 
inflammatory products; and when the mus- 
cular structure has itself yielded to the ulcer- 
ative process, they are made up of congested 
and swollen peritoneum, which, as already 
stated, occasionally becomes perforated. 
When the ulceration proceeds solely by 
molecular disintegration massive sloughs are 
not observed. But when, as not uncommonly 
happens in asthenic, malaria-stricken, tuber- 
cular and worn-out constitutions, tissue-death 
occurs en masse, at an early period of tho 
attack, sloughing of the mucous membrane 
is to be seen, together with portions of the 
muscular coats, or gangrene. These sloughs, or 
gangrenous portions of tissue, may be limited 
in extent. Some or all of them may be suc- 
cessfully detached during life, and can be iden- 
tified as they are examined from time to time 
in the stools. In the post-mortem room they 
may be found partly detached and lying loose, 
mixed with the fluid contents of the bowel, 
or attached more or less firmly; sometimes 
compact, nodular, ecchymosed, grey or olive- 
coloured, green or yellow and pus-infiltrated, 
black, flaky, shreddy, shaggy, flocculent like 
pieces of teased cotton-wool, or ragged and 
stringy. In the truly gangrenous dysentery, 
the mucous and muscular coats are enor- 
mously thickened, and large portions are 
found gangrenous, varying in colour from a 
pale olive to purple or black. These appear- 
ances and conditions may be restricted to the 
caecum and ascending colon, or to the sigmoid 
flexure, but sometimes they are co-extensive 
with the internal structure of the large intes- 
tine from the ileo-colic valve to the anus. 542 
DYSENTERY 
When the ileo-colic valve becomes destroyed, 
invagination of the lower end of the ileum 
into the caecum sometimes happens, causing 
intestinal obstruction. Occasionally many 
inches of the gangrenous mucous membrane, 
with or without the muscular coat, are found 
either hanging loose in the lower part of the 
gut, or in process of being detruded from the 
anus. 
In ordinary acute dysentery, advancing to 
ulceration or sloughing, repair is doubtless 
accomplished, as a general rule, by granula- 
tion and cicatrisation. This process can be 
readily observed in dysenteric lesions of the 
mucous membrane of the lower end of the 
rectum, and in healing of the surgical ulcer 
within the verge of the anus. The reason 
why repair is frequently accomplished so 
slowly is because, owing to the irritation 
caused by the exalted vermicular contraction 
of the gut and the passage of flatus, feces, 
and other products, it is impossible to com- 
mand the physiological rest necessary for 
speedy and substantial granulation and cica- 
trisation. Unless the destruction of tissue is 
very great, the contraction due to cicatrisa- 
tion does not occasion much future incon- 
venience. But if it embraces a large portion 
or the whole circumference of the mucous 
membrane, the subsequent contraction may 
produce dangerous narrowing of the calibre 
of the gut, or stricture of the sigmoid flexure 
or rectum. The thickening and contraction, 
especially in the attenuated victims of chronic 
dysentery, can be identified by physical ex- 
amination. These constrictions are fre- 
quently the mechanical cause of constipation 
and fecal accumulations. 
There is no valid reason for believing that 
the lost tissue is ever actually reproduced in 
true dysenteric ulceration. When the ulcers 
have been small, the contraction following 
repair is sufficient to bring the follicles of 
Lieberkuhn on all sides into close juxta- 
position. And this it is which has given rise 
to the impression among some pathologists, 
that the lost tissues have been renewed by a 
process of development and growth. But 
whenever the ulcers have been too large to 
admit of obliteration, microscopical examina- 
tion shows that they have been bridged over 
by cicatricial tissue, devoid of solitary and 
tubular glands, and sparingly supplied with 
blood-vessels and absorbents. 
In addition to the above anatomical cha- 
racters, the mesenteric glands are generally 
found to be enlarged; and as an accompani- 
ment or sequel, organic disease of the liver, 
or abscess, is not infrequently discovered to 
complicate the disease. 
Symptoms.-Every attack of acute dysen- 
tery is preceded by disordered digestion and 
constitutional disturbance, indicated by loss or 
capriciousness of appetite and furred tongue, 
constipation alone or alternated with loose- 
ness, dryness of skin, occasional chilliness 
and general malaise, with slight rise of the 
evening temperature. These signs may be 
viewed as contemporaneous with the progress 
of the morbid action going on in the solitary 
glands. As the disease advances, there is 
more marked chilliness, succeeded by distinct 
feverishness. If the bowels have been con- 
fined, they now act spontaneously-expelling, 
at one or more acts of defecation, almost the 
whole of the contents of the large intestine. 
If they have been loose, with or without 
aperient medicines, the feculence is not so 
great in quantity. But in either case, beyond 
a little mucus, there is not as yet any dis- 
coverable dysenteric product in the stools. 
Prior to this conservative evacuation of the 
bowels, the febrile excitement sometimes 
runs high; there is thirst, bad taste in the 
mouth, flatulency, a variable amount of ner- 
vous and muscular debility, griping, an ac- 
celerated and irritable pulse, restlessness, 
disturbed sleep or actual insomnia. During, 
and immediately after, each evacuation there 
is tenesmus or painful straining-most in- 
tense in those cases where the disease is 
situated in the descending colon, sigmoid 
flexure, and rectum. The stools are offensive, 
but there is nothing at this stage pathogno- 
monic in their odour. If, as frequently hap- 
pens in private practice, the patient comes 
under treatment at this period, a small dose 
of castor oil guarded by laudanum, or a full 
dose of ipecacuanha, with absolute rest in 
bed and blandliquid nourishment's sufficient, 
in a certain proportion of cases, to put a stop 
to the morbid action, and to promote cure by 
resolution in from twenty-four to forty-eight 
hours. 
When, however, the disease persists, the 
symptoms continue in an aggravated form. 
The tormina and tenesmus become intensi- 
fied; the desire to go to stool is more fre- 
quent, and to remain on the stool or bed-pan 
more irresistible and enduring, especially if 
the disease be concentrated in the sigmoid 
flexure or rectum. In rectal dysentery, 
there is dysuria, frequent micturition, and 
sometimes retention, from spasm due to 
reflex action, necessitating catheterism. The 
consumption of solid food-even of the most 
digestible kind-provokes and aggravates the 
tormina. The griping and tenesmus are now 
so intensified in degree, and increased in fre- 
quency, that each recurrence of them pro- 
duces much depression and exhaustion, and a 
pinched and anxious expression of the coun- 
tenance, with augmented frequency and weak- 
ness of the pulse. There is abdominal tender- 
ness. During the acme of the tormina, the 
patient experiences difficulty in localising this 
tenderness. He will then declare that he feels 
agonising pain over the greater part of the 
abdomen, with or without the application of 
pressure. But in the absence of the tormina, 
careful palpation will enable the practitioner 
to localise it in those portions of the intestine DYSENTERY 
543 
above the rectum which are affected by dysen- 
teric inflammation. At this stage the tumefac- 
tion of the walls of the gut is seldom great 
enough to be distinguished through the ab- 
dominal parietes. The scanty stools are now 
characteristic, consisting of mucoid exudation 
tinged with blood, or bloody mucus or slime 
from the inflamedtubular glands, with isolated 
portions of gelatinoid exudation, more or less 
coloured with blood from inflamed and rup- 
tured solitary glands, and with little or no 
feculence. These conditions are contempo- 
raneous with the rupture of the affected 
solitary glands and a highly inflamed state 
of the adjacent follicles of Lieberkuhn, as 
well as of the subjacent and intervening con- 
nective tissue. The muscular tissue, though 
not yet necessarily inflamed, is nevertheless 
hyperaesthetic. It is this hyperaesthesia which 
has more to do with the production of the 
agonising tormina than the diseased glandular 
organs implanted in and forming a consti- 
tuent portion of the mucous membrane. 
These are the symptoms presented in a 
goodly number of cases met with in private 
practice, and in a smaller proportion admitted 
into hospital. The disease is said to have 
lasted from two to six or eight days. In un- 
complicated cases, occurring in tolerably good 
constitutions, they generally yield, without 
extension of the mischief, to rest, bland liquid 
food, and full doses of ipecacuanha. 
In cases which have been neglected or 
aggravated by indiscretions in diet and drink, 
or by diathetic or other defect of constitution, 
the dysenteric process passes on to ulceration. 
If the patient have not been brought under 
proper therapeutic and hygienic management, 
the tormina, tenesmus, local tenderness, and 
hardening of the superimposed abdominal 
muscles are augmented. The calls to stool 
are more frequent and painful. The urine is 
scanty and high-coloured, and is surcharged 
with lithates and biliary pigment. The stools 
mainly consist of the foreign products already 
described, but in greater quantity; are now 
possessed of a peculiar sickly smell; and yield 
portions of exudation in masses of greater or 
smaller size, simulating sloughs, but which, 
on microscopical examination, are seldom 
found to afford positive evidence of dead 
tissue-elements. 
Unless the disease bend to treatment, it may 
terminate in sloughing. This may be either 
restricted or extensive. Death of portions of 
the mucous membrane is always accompanied 
by vital depression or well-defined muscular 
and nervous prostration, cardiac enervation, 
and an accelerated and feeble pulse. In some 
cases tissue-death en masse happens at an 
earlier period, even before the rupture of the 
solitary glands; and the sloughs can be dis- 
covered in the stools on from the eighth to 
the thirteenth day. The acme of vital pro- 
stration is manifested during the detachment 
of the sloughs, when the exhaustion is often 
much increased, by haemorrhage. Improve- 
ment in the strength, volume, and slowing of 
the pulse, and. in the expression of the coun- 
tenance, the comparative relief from tormina 
and tenesmus, cleaning of the tongue, and 
the substitution of faeculence for dysenteric 
products in the stools, signify, in these cases, 
the probable cessation or turning-point of the 
disease. The converse implies that the slough- 
ing is extending, and a succession of sloughs 
of various kinds, with or without muscular 
structure, continues to be passed, which, in 
the process of separation, is accompanied by 
much bleeding, especially in patients poisoned 
by malaria or afflicted with the scorbutic or 
haemorrhagic diathesis. The abdominal ten- 
derness and hardening of the parietal muscles 
are marked during the separation of the 
sloughs. The affected portions of the colon 
can be felt to be swollen, doughy, and ' pud- 
dingy ' (Chevers). The skin, in unfavourable 
cases, becomes clammy, features and eyes 
shrunken, body emaciated, appetite in abey- 
ance, thirst great and distressing, tongue dry 
and brown, pulse feeble and running; the 
stools extremely offensive, bloody, slimy or 
watery, with varieties of sloughs and exuda- 
tion. The sensibility becomes so blunted 
that the stools are passed without much pain 
-often involuntarily; and the patient even- 
tually dies from sheer exhaustion from the 
extension of the sloughing, or the end may 
be accelerated by perforation of the bowel in 
one or more places, leading to extravasation 
of some of the contents of the intestine into 
the peritoneum, and general peritonitis. 
Sometimes, from the commencement of 
an attack, or during the course of acute 
dysentery, rapid sloughing forms the chief 
pathological condition, passing into gangrene 
of large patches of mucous membrane, at- 
tended by increasing prostration and soon 
merging into collapse. As this extends until, in 
many instances, it involves almost the whole 
of the mucous membrane, submucous tissue, 
and muscular structure, it is characterised by 
intensified collapse. The tormina and the 
tenesmus, at first excruciating, suddenly dis- 
appear, to the delusive relief of the sufferer. 
Until the gangrene has spread to a great ex- 
tent, the stools contain a large quantity of 
slime, blood, peculiar-lcoking exudaticn, and 
much gelatinoid exudation; but as the living 
mucous membrane becomes diminished, these 
products also decrease, and, in their room, we 
notice a watery product of a dark purple or 
black colour, resembling the washings of 
meat, giving off an incomparably offensive 
and gangrenous odour. To the naked eye, 
and on washing, these stools seem to be ab- 
solutely devoid of faeculence. They yield a 
granular sediment of a black colour-gangre- 
nous debris blackened by the combination of 
sulphur with the iron of disorganised cruorin. 
The abdomen, at first doughy, becomes 
tympanitic and free from pain on pressure, 544 
DYSENTERY 
and the surface cold and clammy; the coun- 
tenance resembles the haggard and sunken 
appearance presented during the algid stage 
of cholera; the tongue is dry, brown, and 
fissured ; the pulse is thready and rapid; food 
and medicines are rejected ; the dejecta are 
passed involuntarily; perception is blunted; 
delirium supervenes ; and the patient at last 
succumbs, worn out and exhausted, on from 
the sixth to the thirteenth day, according to 
the range and severity of the disease, and the 
constitutional power which he possesses. 
Chrome Dysentery.-This is sometimes 
the result of acute dysentery, in spite of the 
most appropriate management, in persons 
poisoned by malaria and weakened by fatty 
or waxy degeneration of the spleen or liver, 
or both, and in strumous or scorbutic consti- 
tutions. The dyscrasia may be so pronounced 
that the material exuded is incapable of heal- 
ing up the ulcers by granulation and cicatri- 
sation. The ulcers are repeatedly disturbed by 
peristalsis and the passage of flatus, faeces, un- 
digested morsels of solid food, and the acrid 
unutilised secretions of the liver, stomach, and 
pancreas. Thus they are liable to become 
irritable from renewed congestion and inflam- 
mation. The muscular coat participates in 
the excitement, and becomes infiltrated with 
exudation, which eventually becomes organ- 
ised and leads to thickening. The floors and 
sides of the ulcers are constituted of unhealthy 
structure. The difficulty thus experienced in 
effecting repair is augmented. In other cases 
the intestine becomes atrophied, attenuated, 
and transparent. The stools are made up of 
serous exudation, slime, blood, and sometimes 
of puriform material, with faeculence generally 
unformed. Almost every stool will be found 
on washing to contain dysenteric products. 
Very frequently, especially in cases which 
have been carefully dieted for a time, fieither 
blood nor mucus can be detected in the 
stools, which appear to be of a purely diar- 
rhoeic nature. The appetite is uncertain ; the 
tongue often clean, shining, and devoid of 
epithelium; the pulse weak and irritable ; and 
the abdominal tenderness easily localised. 
Thickening can often be detected. Tormina 
are always present; and unless the disease 
be confined to the caecum or ascending and 
transverse colon, there is tenesmus. Multiple 
abscesses of the liver frequently supervene 
and carry off the patient; or after months or 
years of suffering he may perish from in- 
anition and exhaustion, or from intercurrent 
disease. 
Complications.-Acute dysentery is fre- 
quently complicated by the various forms of 
malarious fever, typhoid fever, the tuber- 
cular or the haemorrhagic diathesis, purpura, 
scurvy, hepatic and splenic enlargement, 
malarious cachexia, or abscess of the liver; 
and in children by dentition. In every case 
of dysentery the strictest attention should be 
paid to existing complications. In patients 
inhabiting marshy districts, and those fol- 
lowing a seafaring life, the gums should be 
carefully scrutinised, and the cutaneous sur- 
face examined, with a view to ascertain the 
freedom or otherwise from purpuric or scor- 
butic taint. The history of the patient 
should be gone into, in order to make out 
the probable diathetic proclivities-acquired 
or hereditary. 
Sequelae.-That abscess of the liver, single 
or multiple, frequently follows acute and 
chronic dysentery, is indisputable; but 
whether as a result of the general condition 
existing, or of local pyaemic poisoning or 
embolism originating in the veins within the 
area of the ulcers, is still an open question. 
Dysentery sometimes terminates in perma- 
nent thickening of the parietes of the gut 
with eventual contraction or stricture, caus- 
ing constipation, faecal accumulation or ob- 
struction. When the seat of stricture can 
be reached, as in the lower part of the rectum, 
much relief can be afforded by simple in- 
cision and subsequent dilatation by means of 
bougies. Fissure of the anus, or ulcer with- 
in the verge of the anus, is a common sequel. 
Once diagnosed by examination of the stools 
and by means of the speculum, it admits of 
speedy relief by incision and after-surgical 
management. 
Diagnosis.-Dysentery can be diagnosed 
from diarrhoea by the abdominal tender- 
ness, tormina, tenesmus, and the existence 
of dysenteric products in the stools. Dr. 
Edward Goodeve, late Professor of Medicine 
in the Calcutta Medical College, was the first 
to carry out the practice of washing the 
stools in dysentery and diarrhoea. The stools 
are first examined as they lie in the stool- 
pan. Water is then added in considerable 
quantity. After a short interval, to allow 
the dysenteric products to sink to the bottom, 
the supernatant fluid is gradually poured off. 
The washing is repeated until the foreign 
products remain clean and destitute of much 
smell. When these products are putrescent, 
or perhaps in all cases, it is convenient to 
wash the stools with a solution of carbolic 
acid or other colourless disinfectant. Dysen- 
tery is diagnosed from fissure or ulcer of the 
rectum by the fluid or loose character of the 
stools, with dysenteric products, and by the 
absence of ulcer, as determined by examina- 
tion by means of the anal speculum. 
Prognosis.-Favourable.-The following 
are to be regarded as favourable features in 
the prognosis of any given case: The ordi- 
nary uncomplicated form of acute dysentery; 
early subsidence of the constitutional disturb- 
ance ; a steady, firm, and strong pulse, with 
diminishing frequency and increasing power; 
moderate abdominal tenderness; absence of 
tympanites; a placid and normal expression 
of countenance ; absence of sloughs or 
putrescent matters in the stools; early sub- 
sidence of tormina and tenesmus, with the DYSENTERY 
545 
appearance of faeculence and the contempo- 
raneous decrease of dysenteric products; 
return of appetite and power of digesting 
and assimilating food; and the absence of 
inflammatory or suppurative mischief in the 
liver. 
Unfavourable.-Unfavourable features, on 
the contrary, are-The persistence of an 
elevated temperature; quick pulse, with in- 
creasing feebleness; sudden freedom from 
tormina, tenesmus, and abdominal tender- 
ness, with great vital depression or collapse; 
doughy thickening of the colon, with dulness 
on percussion where there should be re- 
sonance ; sudden increase of abdominal ten- 
derness, with hiccough, nausea, vomiting, and 
great nervous prostration, tympanites, and 
peritonitic pain with constant hardness and 
tension of the abdominal muscles; increase 
of putrescent and gangrenous products in 
the stools, like the washings of decomposing 
flesh ; excessive haemorrhage from the bowel; 
bleeding from chapped and fissured lips, 
gums, and mouth; harsh, dry, black or 
glazed tongue ; delirium; picking at the bed- 
clothes; and scantiness or suppression of 
urine. 
Treatment.-Should an aperient be re- 
quired in the congestive, exudative, or ulcer- 
ative stages of acute dysentery, or in sudden 
relapses supervening upon chronic forms of 
the disease, the readiest, simplest, and most 
painless is a tepid water enema of from two 
to four pints. After the operation of the 
enema, or immediately the patient presents 
himself suffering from any of these dysen- 
teric conditions, in those cases where no pre- 
liminary aperient is indicated, a turpentine 
epithem or mustard plaster should be ap- 
plied to the epigastrium for twenty minutes. 
At the same time, from twenty grains 
to a drachm of ipecacuanha, suspended in 
two drachms of syrup of orange-peel and 
four drachms of water, or in half an ounce 
of infusion of chamomile, with ten grains of 
carbonate of sodium or bismuth, or simply 
made up into conveniently sized pills, should 
be administered. The recumbent posture, 
with the head lower than usual, should be 
enforced. Liquids should be resisted as 
much as possible for an hour or two. Food 
should not be given for at least three hours 
before, and six hours after, the administration 
of the drug. Movement of every kind must 
be avoided; and the saliva should not be swal- 
lowed, but wiped away with a cloth. Thirst 
may be quenched by sucking pieces of ice, 
or, when this cannot be procured, by cold 
water in teaspoonsful at a time. Nausea 
will probably occur; perhaps, in some cases, 
retching and vomiting. "When vomiting does 
occur it seldom happens before the lapse of 
an hour after the exhibition of the drug, andthe 
ejected matter usually consists of small quanti- 
ties of gastric secretion. Should the ipecacu- 
anha be rejected, the dose should be repeated 
as soon as the stomach has been tranquillised. 
It will be found beneficial to time the large 
doses, so as to allow of one being given night 
and morning, as long as their use is con- 
sidered necessary. The signal for the re- 
linquishment of these doses is freedom from 
tormina and tenesmus, with the occurrence 
of refreshing sleep, faeculent, bilious, or ipe- 
cacuanha stools, and restoration of the 
primary processes of assimilation. If no 
great amount of disorganisation of the 
mucous membrane have taken place, these 
favourable changes are frequently noticed 
after the administration of the first or second 
dose; and even if undoubted liberation have 
set in, they are generally discerned on the 
second or third day, or earlier. In either 
case the drug should be abandoned, as the 
disappearance of the tormina and tenesmus, 
and the absence of mucus, blood, and slime 
from the stools, indicate the cessation of dy- 
senteric inflammation, and that the affected 
portions of the bowel have been placed 
in the most favourable condition to undergo 
cure by ' resolution,' if the case have not pro- 
ceeded to ulceration, or by ' granulation and 
cicatrisation,' if ulceration or even sloughing 
have already taken place. Chalk-mixture 
with hyoscyamus and astringents is now 
quite sufficient to complete the cure. In 
some cases ferruginous and bitter tonics are 
demanded, to give tone to the digestive 
organs, and to improve the condition of the 
blood. Counter-irritation, by means of tur- 
pentine epithems and mustard plasters to 
the abdomen, or fomentations, is a valuable 
adjunct in the management of the disease. 
The diet should consist of chicken-broth, 
beef-tea, essences of chicken, mutton, or beef; 
sago, arrowroot, or tapioca; and small quan- 
tities of good port wine or brandy. During the 
active period of the disease all food should be 
given in a liquid form. The disturbing effect 
of the ipecacuanha given as above directed is 
only temporary. Abundance of time is, 
therefore, available between the large doses 
for the digestion and assimilation of liquid 
food. At the outset of dysentery, and as long 
as the tongue is coated, food should be avoided 
as much as possible; and when taken it should 
consist of very weak chicken-tea or barley- 
water. As soon as the tongue is clean a 
purely milk diet is the best. As the stools 
become more faeculent and consistent, solid 
food in the shape of tender chicken, lamb, and 
mutton, with biscuit and bread, light'sago, 
rice, or tapioca pudding should be allowed. 
Potatoes and other vegetables should be 
avoided until the tone of the digestive system 
has been fully re-established. When the 
dysentery is complicated with a purpuric or 
scorbutic condition of the blood, the admini- 
stration of the juice of the grape, orange, 
pomegranate or lime, and bael sherbet, are 
essentially necessary as dietetic rather than 
therapeutic agents. 546 
DYSENTERY 
Opium by the mouth is seldom required. 
When swallowed it ' locks up ' the secretions 
of the liver, pancreas, and alimentary mucous 
membrane, rather favouring than reducing 
the inflammation of the solitary and tubular 
glands. These bad effects counterbalance the 
benefits derived from the sleep, diminution of 
peristaltic action, and temporary decrease of 
tormina and tenesmus consequent on nar- 
cotism. This explains why the real character 
of the disease is often completely masked by 
opium, and why apparent amendment is 
taking place whilst destructive ulceration and 
slougbing of the mucous membrane is rapidly 
extending. As ipecacuanha speedily brings 
about all the good without any of the evil 
effects of opium, this narcotic is not only 
superfluous but injurious in any form, ex- 
cepting as an enema or suppository to relieve 
tenesmus, particularly in sigmoidal or rectal 
dysentery. There is less objection to uniting 
the ipecacuanha with such remedies as are 
acknowledged to possess the power of lessen- 
ing the irritability of the stomach, and of 
increasing its tolerance of the drug, without 
interfering with the functional activity of 
those organs whose secretions we are endea- 
vouring to promote with a view to rectify the 
disturbed balance of the portal circulation. 
On the contrary, medicines of this order may 
be beneficially associated with ipecacuanha- 
such as carbonate of sodium, bismuth, chloro- 
form, camphor, and hyoscyamus. 
When dysentery occurs in pregnant women, 
large doses of ipecacuanha are not contra- 
indicated ; because, if the disease be allowed 
to proceed (which is more likely to happen 
under the old than the ipecacuanha treat- 
ment) abortion or premature labour is almost 
certain to follow; and when such a complica- 
tion supervenes, in the later months of gesta- 
tion, the mortality almost surpasses that of 
any other disease. When the dysenteric 
inflammation is summarily put a stop to by 
the ipecacuanha, abortion or premature labour 
is prevented. Under the opiate method of 
management, premature labour is not averted, 
but, in the majority of cases, occurs at the 
acme of the disease, when the sloughs are 
being thrown off; and the patient succumbs 
to the conjoint shock to the system. In 
dysentery complicated with pregnancy opiate 
enemata to relieve irritation in the rectum are 
more essential and permissible than under 
other circumstances. 
In the acute dysentery of children ipe- 
cacuanha is invaluable. For a child of six 
months a grain, and for a child of one year 
two grains, should be given, with an equal 
quantity of carbonate of sodium, night and 
morning, until the tormina, tenesmus, and 
slimy and bloody stools are replaced by relief 
from pain and by faeculent evacuations. It 
will not often be necessary to continue the 
drug beyond two or three days at a time. 
But it should be remembered that the disease 
adheres with greater tenacity to children than 
to adults; and although we observe that ipe- 
cacuanha has an immediately beneficial effect 
in diminishing the blood, mucus, slime, and 
frequent stools, still we find that dysenteric or 
slimy motions with undigested food continue 
to pass. In that case the ipecacuanha, com- 
bined with chalk, bismuth, carbonate of sodium, 
or aromatic powder, should be repeated, once 
or twice a day, for a certain period, till healthy 
evacuations are restored. The gums must be 
lanced when necessary ; turpentine liniment 
or stupes may be applied to the abdomen; 
weak chicken-broth or arrowroot should be 
temporarily substituted for milk ; and, above 
all, food must be given in small quantities 
at a time, and at regularly stated periods. 
From the age of one year the dose is regulated 
by adding one grain for each additional year 
of age up to eighteen, when the doses indi- 
cated for adults should be employed. 
In cases where evident malarious taint 
pervades the system and complicates acute 
dysentery, sulphate of quinine is indispen- 
sably necessary. A scruple of the antiperiodic 
will be most speedily absorbed if dissolved in 
water acidulated with sulphuric acid, and the 
exhibition of this may precede by an hour the 
first dose of ipecacuanha. Ten-grain doses 
should be given midway between the large 
doses of ipecacuanha, or during abatement of 
febrile excitement, until the feverish symp- 
toms have been subdued. Quinine here is 
quite as important as ipecacuanha, for, until 
it has successfully checked the disturbing in- 
fluence which malarious poisoning exercises 
upon the capillaries of the portal and general 
circulatory systems, the good effects which 
ipecacuanha produces are only temporary and 
incomplete. The mildest febrile exacerba- 
tions of a miasmatic origin re-excite dysen- 
teric action, and thus undo the good effected 
by the action of the ipecacuanha. Hence the 
urgent necessity for removing without delay 
every vestige of masked or active malarious 
fever complicating dysentery. No drug en- 
ables us to accomplish this object so safely 
and so quickly as the sulphate of quinine in 
large doses. 
When ipecacuanha fails to preserve the life 
of the patient, its failure may be generally 
attributed to-(1) coexistence of abscess of 
the liver; (2) unchecked malarious poison- 
ing ; (3) permanent enlargement of spleen or 
liver, or both; (4) irretrievable constitutional 
cachexia ; (5) Addison's disease of the supra- 
renal capsules; (6) morbus Brightii; (7) 
phthisis or tuberculosis ; (8) strumous disease 
of the mesenteric glands; (9) peritonitis, with 
or without perforation of the gut; or (10) the 
existence of extensive sloughing or gangrene. 
The advantages of the 'ipecacuanha treat- 
ment ' (for the revival of which the profes- 
sion in India and England is indebted to 
Mr. Scott Docker, of the 2nd battalion of 
the 7th Royal Fusiliers, stationed at the DYSENTERY 
547 
Mauritius,-Lancet of July 31 and August 
14, 1858) in the congestive, exudative, and 
ulcerative stages of almost every form and 
type of acute dysentery, as well as in the acute 
attacks supervening upon chronic dysentery, 
may be briefly stated. They consist in (1) its 
simplicity, (2) its safety, (3) its certainty com- 
pared with any other method, (4) the promp- 
titude with which the inflammation is stopped, 
(5) the rapidity with which repair takes place 
-(a) by resolution or (6) by granulation and 
cicatrisation, (6) conservation of the constitu- 
tional powers, (7) abbreviation of the period 
required for convalescence, (8) decrease in the 
frequency of chronic dysentery, (9) decrease 
in the frequency of abscess of the liver, (10) 
diminution of mortality to cases treated-all 
of which are accomplished, (a) without local 
or general blood-letting, (b) without saliva- 
tion, (c) without calomel and irritating pur- 
gatives, and (d) without opium by the mouth. 
Ipecacuanha in large doses may be said to 
fulfil many important indications. It pro- 
duces : (1) all the benefits that have been 
ascribed to blood-letting without robbing the 
system of one drop of blood, (2) all the advan- 
tages of mercurial and other purgatives with- 
out their irritating action, (3) all the good 
results of antimonials and sudorifics without 
any of their uncertainty, (4) all the euthanasia 
ascribed to opium without masking, if not 
aggravating, the disease whilst the mischief is 
silently accumulating within. Thus, we pos- 
sess in ipecacuanha a non-spoliative anti- 
phlogistic, a certain cholagogue and unirri- 
tating purgative, a powerful sudorific, and 
a harmless sedative to the heart and the 
muscular fibres of the intestines. 
The objections which have been urged 
against large doses of ipecacuanha in dy- 
sentery are, first, its ' depressing influence ' 
kept up by nausea and. vomiting; and, 
secondly, that it is liable to set up ' uncon- 
trollable vomiting.' 
First, the depressing power, nausea, and 
vomiting have all been over-estimated. 
Nausea is only a temporary and evanes- 
cent effect. Vomiting is an exceptional 
occurrence; and even when it does super- 
vene, it seldom lasts long. As much nourish- 
ment, therefore, as may be required to 
support the strength can be given in the 
intervals between the large doses of ipe- 
cacuanha. But what contributes more to 
the conservation of the patient's stamina 
and to the prevention of depression or as- 
thenia, is the speedy cessation of the dysen- 
teric process accomplished by the drug, fol- 
lowed by refreshing sleep and the power of 
digesting and assimilating nourishing food. 
Such remarkable results as these soon recon- 
cile any patient suffering from dysentery to 
an otherwise disagreeable remedy. 
Secondly, when uncontrollable sickness 
and vomiting succeed the employment of 
this drug in the manner already recom- 
mended, the existence of one or other of 
the serious conditions previously enumerated 
may be more than suspected. In the ab- 
sence of these complications, unmanageable 
vomiting is seldom if ever witnessed. Hence, 
in a preponderating maj ority of the cases of 
dysentery met with this objection is quite 
untenable. The truth is that every physician 
who has used ipecacuanha in heroic doses 
soon learns that depression of the vital 
powers from it is not to be feared, and is 
surprised at the small amount of vomiting 
that follows its administration, and at the 
unexpected ease with which the stomach 
tolerates its presence. 
When dysentery becomes chronic no time 
should be lost in counselling removal from a 
malarious to a non-malarious and mild cli- 
mate. A sea voyage-provided easily diges- 
tible food can be secured-is often attended 
by the happiest results. To men so afflicted 
4 the salt ration,' as remarked by Dr. Mac- 
lean, 'is simply destruction.' The clothing 
should be warm, and flannels always worn 
round the abdomen; Dr. Maclean also re- 
commends 4 the use of a water belt over the 
abdomen for some hours daily. This acts as 
a fomentation, and the steady uniform pres- 
sure it maintains seems to favour the absorp- 
tion of the fibrin effused between the intes- 
tinal coats. If there be much uneasiness 
about the fundament, a water compress over 
the anus affords more relief than opiate ene- 
mata.' The food should be chiefly concen- 
trated soups, milk and lime-water, and sago, 
cornflour, arrowroot, &c., egg-flip with port, 
sherry, or brandy; or, if solid food can be 
digested, the tenderest chicken, lamb, or mut- 
ton, with bread and biscuit, may be allowed. 
Beyond airing in a carriage or chair, no ex- 
ercise should be attempted. The position 
should generally be recumbent or semi-recum- 
bent. The erect position excites peristaltic 
action, and thus disturbs the physiological 
rest required to facilitate the repair of the 
ulcers. Antiscorbutic juices should be given 
where there is the least taint of scurvy or 
purpura. Frequent blistering does much 
good; and all forms of counter-irritation are 
beneficial. In all obstinate cases a diet con- 
sisting of milk only ought to be tried; and 
also enemata of a solution of nitrate of silver 
(| grain to 1 fl. oz. of distilled water), two or 
three pints being passed up whilst the patient 
is in the knee-shoulder position and the 
pelvis well raised. 
Gallic acid, acetate of lead, sulphate of 
copper, and nitrate of silver, are reputed to act 
beneficially. Dr. Maclean's favourite remedy, 
4 particularly in men returning from tropical 
regions, anaemic from loss of blood and the 
depraving influence of malaria, is the solu- 
tion of the pernitrate of iron. Under this 
remedy the whole system often rallies won- 
derfully, the condition of the blood improves, 
colour returns to the blanched cheek, the 548 
stools become more natural and less frequent, 
the appetite improves, and digestion is more 
perfectly performed. The citrate of iron and 
quinine may after a time be substituted.' As 
nearly all chronic cases are underlain by a 
malarious taint, quinine should form an im- 
portant element in the therapeutic manage- 
ment, and the greatest care should be taken 
to secure for the residence of the patient a 
climate at once mild and temperate and free 
from suspicion of malaria. Bathing during 
convalescence is an efficient and welcome 
auxiliary. Tepid or warm baths, medicated 
withTidman's sea-salt or with nitro-muriatic 
acid, act in stimulating the secreting function 
of the skin. But it will often happen that, 
in spite of the most careful dietetic, hygienic, 
and therapeutic management, no substantial 
progress towards the repair of the ulcers is 
made, and the patient eventually dies, worn 
out from suffering and the asthenia conse- 
quent literally on inanition. 
Joseph Ewart. 
DYSIDROSIS (five--, with difficulty; and 
JSpwff, sweat).-See Sudoriparous Glands, 
Disorders of. 
DYSENTERY 
D YSMENORRIICE A (Sva-, with diffi- 
culty ; pr/p, a month; and pta>, I flow).- 
Difficult and painful menstruation. See 
Menstruation, Disorders of. 
DYSOREXIA (8va-, with difficulty; and 
opt^ts, the appetite).-An obsolete term for 
impaired or depraved appetite. See Appe- 
tite. 
DYSPEPSIA (8vcr-, with difficulty; and 
7r«7TT<a, I concoct).-A synonym for indiges- 
tion. See Digestion, Disorders of. 
DYSPHAGIA (8v<r-jwith difficulty; and 
(f>dya>, I eat).-Difficulty in swallowing. See 
Deglutition, Disorders of. 
DYSPHONIA (3v<r-, with difficulty; and 
<pa>prj, the voice).-Difficulty in producing 
vocal sounds, so that the voice is more or 
less enfeebled. See Voice, Disorders of. 
DYSPNOEA (8va-, with difficulty; and 
TTvea, I breathe).-Difficulty of breathing. 
See Respiration, Disorders of. 
DYSURIA ^va-, with difficulty; and 
ovpew, I pass water).-Difficult or painful 
micturition. See Micturition, Disorders of. 
EAR, DISEASES OF 
EAR, Diseases of.-Synon. : Fr. Mala- 
dies de I'Oreille; Ger. Ohrenkrankheiten. 
The natural division of the ear into external, 
middle, and internal, suggests a rational as 
well as a convenient classification of the dis- 
orders to which the auditory apparatus is 
liable. 
I. External Ear.-In examination of the 
external meatus and tympanic membrane, 
bright diffused daylight, or, when this is not 
obtainable, light from a bull's-eye lamp lit 
with gas or electric light, is the best for illu- 
mination, and the light should be reflected 
from a concave perforated mirror of eight- 
inch focus down a tubular speculum. In any 
operative proceedings the mirror should be 
worn on the forehead, as in examining the 
throat, but otherwise should be held in the 
hand. As great variations in the calibre of 
the auditory meatus are met with, it is 
necessary to be provided with specula of 
several sizes, the most convenient form being 
that known as Gruber's. 
Of the affections of the external ear the 
most important are the following:- 
1. Eczema.-Although the acute form cf 
eczema occasionally affects the auricle and 
external auditory meatus, it is far more com- 
mon to meet with the chronic variety. 
Elderly females are especially subject to 
eczema of the ear, and it is to its long con- 
tinuance that the remarkable narrowing of 
the external meatus throughout its whole 
extent, met with occasionally in the subjects 
of this complaint, is generally attributable. 
Such narrowing will often amount to almost 
complete closure, and it is in these instances 
that eczema becomes the cause of greatly 
impaired hearing; for when this condition is 
arrived at, the passage down to the tympanic 
membrane is at times so small as only to 
admit of a very small probe. It is for this 
reason that, although no special methods of 
treatment are called for, beyond what is 
necessary when parts other than the ear are 
affected with eczema, it is of the greatest 
importance to keep the meatus sedulously 
free from secretion, and this occasionally is 
not a very easy matter. 
2. Changes in cartilage.-Another con- 
dition, in which the external passage becomes 
subject to partial closure, is shrinking of the 
cartilaginous part of the meatus. This, again, 
is a complaint of old age, and is attributable 
to no known cause. It is readily relieved by 
the patient wearing a piece of silver tube, to 
keep the passage patent. 
3. Bony Growths.-Bony growths in the 
external auditory canal are of two kinds, 
true exostoses and hyperostoses. 
(1) True exostoses arise from the junction 
of the osseous and cartilaginous portions of EAR, DISEASES OF 
549 
the canal, owe their origin to acute inflamma- 
tion, and are somewhat rapid in their growth. 
They present very little difficulty in their re- 
moval, inasmuch as they are attached by a 
pedicle, and are not composed of very dense 
tissue. 
(2) Hyperostoses arise from the osseous 
part of the canal. These growths are of ivory 
hardness, and have a large base. They are 
occasionally single and confined to one ear, 
but generally are multiple, and more usually 
than not affect the meatus of both ears simul- 
taneously. The form which they habitually 
assume is that of three growths, the apices of 
which meet, or nearly so, in the axis of the 
canal. Thus, seeing that a very small opening 
is quite enough to permit of the passage of 
sonorous vibrations to the tympanum, their 
presence remains undiscovered until a minute 
piece of cerumen completely closes an 
already nearly closed canal, and so by the 
deafness thus produced leads to their detec- 
tion. Their growth is very slow, as they are 
observed to remain without increase for many 
years, and although without doubt they are 
at times congenital, it would seem that their 
existence is often called into being by a local 
irritation, first, because in a large number of 
cases the individuals so suffering have been 
for long periods addicted to diving; secondly, 
they are frequently preceded by a discharge 
passing for years through a perforated mem- 
brane and over the canal. 
Treatment.-The occasions when these 
growths should be removed ought to be 
strictly limited to two conditions : 1st, when 
they interfere with the escape of purulent 
discharge, and so place the patient in danger 
of cerebral inflammation; 2nd, when by ab- 
solutely closing the canal they induce great 
deafness. In the large proportion of cases 
the occasional removal of cerumen which 
blocks up the small opening that remains is 
all that is necessary, and this should be done 
by the use of a small hook rather than by 
syringing, as the passage of water behind the 
growths is to be avoided. When, however, 
it is imperative to remove bony growths for 
either of the above-named reasons, the best 
method consists in drilling them away with 
a dental engine, to which may be attached 
drills of various shapes and sizes. This 
operation should be performed under reflected 
light, and ether must be given. Owing to 
the extreme hardness of the growths, this 
process occupies considerable time, but with 
due care it is not a dangerous proceeding. 
When the object in view is simply the relief 
of deafness, it is sufficient to drill away the 
apices of the growths, but when it is done for 
the purpose of providing a complete escape 
to purulent matter it is desirable to remove 
the chief part of the enlargement. 
4. Inflammation. The external audi- 
tory meatus is subject to inflammation, dif- 
fused or circumscribed, the latter occurring 
in the form of small abscesses or boils. Both 
affections are attended by acute pain, and in 
each the general health of the patient has 
been out of order for some time previous to 
the local trouble. 
Treatment.-Treatment in the direction 
of improving the general health, and local 
bleeding by means of leeches applied in front 
of the tragus, will often rapidly relieve the 
diffused form of inflammation; but when it 
has continued for a long period '(as it not 
infrequently does), in addition to the soft 
tissues the periosteum becomes affected. 
The passage then throughout its whole extent 
becomes so swelled as to nearly close the ex- 
ternal opening, and pain is constant. The 
only treatment which gives complete and 
permanent relief under these circumstances 
is to make two or three free incisions down 
to the bone, along the whole extent of the 
osseous part of the canal. A convenient 
instrument for this purpose is a small sharp- 
pointed curved bistoury. As to the propriety 
of opening abscesses in this situation there 
can be no question, for, owing to the extreme 
denseness of the tissues and their approxima- 
tion to bone in the external auditory canal, 
abscess in this part is slow in its progress and 
attended with very great suffering. These 
abscesses being especially liable to recur, a 
proper regimen and medicines appropriate 
to the failure in general health are required. 
5. Fungi.-The external auditory meatus 
has been occasionally found to be the seat of 
two varieties of vegetable fungus, namely, 
Aspergillus flavus and nigricans. The 
symptoms which they have given rise to 
have been great irritation and a slight dis- 
charge. They have been readily destroyed 
by syringing, and the local application of 
diluted spirit of wine or weak mercurial 
ointment. 
6. Polypus.-Polypus of the ear is usually 
preceded by inflammation in the tympanic 
cavity and perforation of the membrane; it is 
considered along with diseases of the middle 
ear. 
7. Haematoma Auris. See Hematoma 
Auris. 
II. Middle Ear.-All affections of the 
middle ear originate in some part of that 
tract of mucous membrane which, commenc- 
ing where the Eustachian tube opens into 
the pharynx, forms the lining of this tube 
and of the cavity of the tympanum, finally 
becoming the innermost layer of the tym- 
panic membrane. To the character of this 
tissue is due the term ' catarrh,' which, in its 
two forms of purulent and non-purulent, is 
used in describing any deviation from health 
which, directly or indirectly, is the cause of 
pathological change in the Eustachian tube 
or tympanum. 
1. Obstruction of the Eustachian 
Tube.-One of the most frequent conditions 
under which the Eustachian tubes become 550 
EAR, DISEASES OF 
the seat of obstruction is that met with in 
children or young persons. The subjects of 
this affection present a very characteristic 
aspect. They breathe almost entirely through 
the mouth, which, sleeping or waking, is 
kept partially open; their tonsils are often 
enlarged, and they snore loudly during sleep. 
The mucous membrane of the nares and 
pharynx is swollen, and secretes in excess. 
Owing to this tumid state of the fauces the 
passages to the Eustachian tubes in this 
situation do not admit of the constant neces- 
sary supply of air to the tympana. The air 
in these cavities undergoes partial absorp- 
tion, and thus becomes more rare than that 
external to the tympanic membrane; the 
density of the outer air remaining the same, 
the equilibrium from pressure is destroyed; 
the membrane, consequently, is retracted, 
the chain of ossicles is pressed inwards, 
and thus the conduction of sound becomes 
interfered with-in short, the patient is more 
or less deaf. In these cases inspection of 
the tympanic membrane at once reveals the 
state of affairs. As the cavity of the tym- 
panum is not involved in the catarrhal 
change, its translucency and lustre are not 
impaired; the handle of the malleus is tilted 
inwards, the head of this bone is unusually 
prominent, and there is a distinct fold cross- 
ing the upper part of the posterior section of 
the membrane. Where the obstruction has 
lasted for a long period, the membrane will 
appear to be almost fallen in upon the walls 
of the tympanum, and the promontory and 
incus may be distinguished. If under these 
conditions the tympanum be inflated on 
Politzer's plan,1 an instant return to good 
hearing follows, but in the course of a few 
days the improved hearing partially dies 
away, leaving the patient, however, in some 
degree better than before the operation. 
In all these cases a thorough examination 
of the pharynx should be made, inasmuch as 
it will be frequently found that the symptoms 
above mentioned are due to masses of aden- 
oid growths in the vault of the pharynx. 
This condition is especially indicated when, 
in addition to the apparent nasal obstruction, 
the intonation of the voice is of that peculiar 
kind as of a person speaking with a bad cold: 
thus-" dinety-dine ' ' instead of " ninety-nine." 
The only effectual way to explore the pharynx 
is to place the forefinger behind the soft 
palate as far up as the posterior nares. 
When adenoid vegetations are present, they 
can in this way be readily felt, and their size 
and position estimated. The posterior nares 
will often be found to be completely closed, 
and in severe cases the pharynx throughout 
is absolutely filled with them. A rhino- 
scopic examination gives but a very inade- 
quate idea of the condition. 
Treatment.-When adenoid growths are 
present they should be removed, and if this 
is done thoroughly the patients recover their 
hearing completely in the course of a few 
weeks, and what is almost of equal import- 
ance (this applies to the general health), nasal 
respiration is quite restored. The best plan 
is without doubt to clear the pharynx at one 
sitting. This may be done either under 
ether, or without. In each case the patient's 
body should be well bent forward, in order 
that the blood should pass out through the 
nostrils. Unless this position is carefully 
attended to in the case of a patient under 
ether, there is great risk of blood dribbling 
into the larynx and being inhaled; for, these 
growths being very vascular, there is a 
good deal of bleeding. With this precaution, 
however, the pharynx can be cleared of 
adenoid growths by the nail of the forefinger 
in cases where they are very soft and friable; 
or in other cases (the larger proportion), when 
they are of firmer consistence, by the use 
of a steel nail (introduced to notice by the 
writer), adjusted to the forefinger. When 
it is found upon examination that adenoid 
growths are not present, the treatment of 
obstruction of the Eustachian tubes will be 
of a more simple character. It should in- 
clude the gentle syringing of the inferior 
nares with warm alkaline solutions. The 
most useful of these contain bicarbonate of 
sodium and borax. In using them the head 
should be bent forward, and a small nasal 
syringe employed; this is preferable to the 
nasal douche, since the stream from the 
douche is so powerful as sometimes to rush 
into the Eustachian tubes, and so excite 
inflammation of the tympanum. Politzer's 
inflation should be employed, but not more 
frequently than two or three times in a week. 
If the tonsils are so much enlarged as to 
interfere with the respiration, it will be 
necessary to remove them; but the reason 
for this proceeding is not that they press 
upon the openings of the Eustachian tubes, 
but because their presence keeps up the 
unhealthy condition of the pharynx. 
Under this routine of treatment the pa- 
tients completely recover their hearing; the 
space of time during which it is necessary to 
continue treatment varying according to the 
obstinacy which each case manifests. 
Obstruction of the Eustachian tubes in 
adults presents certain well-marked differ- 
ences from the affection as it prevails in 
children. An ordinary cold is the beginning 
of the trouble. It is more usual to find one 
instead of both tubes obstructed, and more 
often than not the tympanic cavity is in- 
volved in the catarrh. Where this is not 
the case-and it will be evident from the 
1 This method of inflating the middle ear (now in 
such general use) consists in passing a stream of 
air from an india-rubber bag through one nostril 
whilst the patient swallows some water. The oper- 
ator at the same time closes one nostril with the 
forefinger of the left hand, and completes the 
closure of the other with the thumb. The mouth 
must be kept firmly shut. EAR, DISEASES OF 
551 
retained lustre and transparency of the mem- 
brane-the same principles of treatment as 
are pursued in the case of children will hold 
good, except in so far that the affection in 
grown-up persons is less persistent after the 
tube has been once artificially opened; and 
that, to effect this, Politzer's method is some- 
times not sufficient, or, even if so, not as 
efficacious as the Eustachian catheter. It 
must also be borne in mind that in the 
treatment of cases in which one ear is 
healthy, by means of the catheter the af- 
fected ear exclusively may be subjected to the 
air-douche, whilst with Politzer's method it 
is impossible to avoid forcing a stream of air 
into the healthy tympanum, and this is not 
always an advisable proceeding. 
The Eustachian Catheter.-'The following 
is the mode of using the Eustachian cathe- 
ter : ' Place the patient in a chair, and let 
him lean back, and steady his head with the 
left hand firmly fixed on the top of it; hold the 
catheter lightly in the right hand, with the 
curve downwards, and pass it quickly in this 
position through the inferior meatus of the 
nose to the posterior wall of the pharynx. 
When this is felt, withdraw the catheter 
about half an inch, and tilt the point of the 
curved end rather upwards, and to the left 
or right, according to the side which is being 
operated upon. Now hold the catheter and 
end of the patient's nose steadily between 
the thumb and the first two fingers of the 
left hand. All this time the ear of the 
patient and that of the surgeon are connected 
with the otoscope. The point of the catheter 
is now supposed to be in the pharyngeal 
orifice of the Eustachian tube; but the only 
certain sign of this being the case is that 
when air is forced into the catheter it will be 
heard through the otoscope to impinge upon 
the tympanic membrane when a stream of 
air is passed down the catheter.' 
The catheter may be made of silver or of 
vulcanite, but, of whatever material, it must 
be inflexible whilst being used. Beyond this, 
suffice it to say here that in practised hands 
its employment is invaluable, and indispens- 
able in the treatment of most affections of 
the middle ear, not only in overcoming ob- 
struction of the Eustachian tube, but also as 
a means by which injection of fluids may be 
applied to the cavity of the tympanum. In 
making use of the air-douche an india-rubber 
bag fitted to the catheter should be employed, 
and in using injections to the tympanum a 
similar arrangement is necessary. 
2. Catarrhal Inflammation of the 
Tympanum.-When the tympanic cavity 
has become involved in the catarrhal state, 
or when the affection, instead of proceeding 
up the Eustachian tubes, begins in the tym- 
panum, as it frequently does, those changes 
have commenced which, of all others, form 
the most frequent impediments to the conduc- 
tion of sound-in other words, which make 
the subjects in whom they are found more 
or less deaf; and it may be broadly stated 
that the extent to which this affection is re- 
mediable depends directly upon the time at 
which the patients suffering from it apply for 
treatment. In the early stages, the obstruc- 
tion to the passage of sound through the tym- 
panum is solely due to the effusion of mucus 
in this situation, and this is easily demon- 
strated by the moist gurgling sound which 
inflation of the tympanum produces, as may 
be heard upon connecting the ears of the 
patient and surgeon by means of a piece of 
india-rubber tubing.1 Afterwards comes what 
may be termed the dry stage, i.e. when the 
fluid portion of the mucus has suffered ab- 
sorption, and when any of the products of 
inflammation may have become more or less 
organised, or at least in a condition which, 
if not interfered with, suffers no further 
change. The morbid conditions which re- 
sult from non-purulent catarrh of the tym- 
panum are twofold. First, those which affect 
the tympanic membrane, and are, therefore, 
demonstrable during life; secondly, those 
which are met with after death in the tym- 
panic cavity. The first of these include 
changes in curvature, in colour, and in con- 
sistence. 
The slighter changes in curvature have 
been noticed in speaking of obstruction of 
the Eustachian tubes, which condition is ne- 
cessarily more or less present in all cases 
where the tympanum has been the seat of 
catarrh, and these changes are met with 
indefinitely increased until the state of com- 
plete collapse is reached. 
In this condition the membrane has the 
appearance of being in close apposition to the 
walls of the tympanum, and lapped round 
the ossicles, so that the forms of the malleus, 
incus, and sometimes the stapes are distinctly 
traceable. 
In so extreme an example, the membrane 
is generally bound down to the tympanic 
wall by adhesions. The first change which 
the membrane exhibits is a loss of its lustre 
and transparency : it becomes opaque. Fur- 
ther alterations in colour, in cases of long 
standing, consist in the formation of patches 
of brown, yellow (colour of parchment), and 
white. Variations in consistency will include 
thickening throughout the membrane, or in 
parts of it, especially in the cases of dense 
chalk deposits (phosphate of lime); and thin- 
ning in places, so observable sometimes that 
inflation will induce bladder-like protrusions, 
which, as inflation is suspended, fall back 
again: changes in all these respects com- 
pletely metamorphosing the appearance of 
the membrane. After death, within the 
1 This tubing should always be used, whether air 
or fluids are being injected through the Eustachian 
tube, for upon the sounds thus heard, as well as on 
the patient's own perception, depends the answer 
to the question whether the inflation is complete. 552 
EAR, DISEASES OF 
tympanum may be found collections of dried 
mucus around the ossicles; thickening of the 
lining membrane ; bands of adhesion in all 
directions; and ankylosis of the ossicles to 
each other, as well as between the stapes and 
fenestra ovalis. 
As additional evidence during life of ob- 
struction in the tympanum, it may be men- 
tioned that sounds from a vibrating tuning- 
fork placed on the vertex are intensified when 
such obstruction exists, and the nerve re- 
mains unimpaired. This test is especially 
valuable where one ear is healthy, inasmuch 
as the sound will be heard exclusively on the 
deaf side, this being due to the fact that vi- 
brations of sound thus conveyed to the audi- 
tory nerve, on their passage outwards through 
the tympanum, meet with the obstruction in 
this position, and are reflected on to the laby- 
rinth. The appearances above described, 
together with the history of the case, serve 
sufficiently to distinguish affections of the 
conducting from those of the nervous appa- 
ratus; and the sounds which are produced 
upon inflation of the tympanum, whether of 
a moist or dry character, give evidence as to 
whether the mucus in the cavity of the tym- 
panum is in a more or less fluid state, or has 
reached the dry stage where the fluid part of 
the secretion has become absorbed, the more 
solid portion remaining. 
Treatment.-In the first of these condi- 
tions, the inflation at once increases the hear- 
ing power; in the second, it produces no 
change in the hearing. An indication in this 
direction is a most useful guide in respect of 
treatment, which may be said to include in- 
jections of fluid or vapours into the cavities 
of the tympana. In the matter of the selec- 
tion of these remedies, the greatest diversity 
of practice exists in the hands of capable 
authorities. Astringent solutions of sulphate 
of zinc, alkaline injections of bicarbonate of 
sodium, iodide of potassium, chloride of am- 
monium, and the vapours of iodine, chloride 
of ammonium, each and all find favour. If 
fluids are injected, a few drops only are to be 
introduced through the Eustachian catheter, 
a small bulb of india-rubber being used to 
force the fluid through the catheter. Vapours 
are employed by means of the many appa- 
ratus in general use. The diversity of opinion 
on this subject shows how difficult a problem 
is the treatment of the ulterior effects of 
catarrh of the tympanum. 
The degree of improvement varies within 
wide limits, but the greater benefits may 
always unhesitatingly be predicted during 
the moist stage of the catarrh. Indeed, the 
necessity for early treatment is abundantly 
shown, in the instance of catarrhal affection 
of the middle ear, by the extremely satisfac- 
tory termination of cases treated early in 
the disease, and the slight relief which but 
too often follows when the affection has been 
allowed to proceed for years unchecked. In 
such cases as the latter, the fact that con- 
siderable quantities of inspissated mucus 
have been found in the tympanic cavities, 
first suggested the operation of making an 
incision into the tympanic membrane, and 
attempting the removal of mucus through 
the incision by passing a stream of air 
through the tympanum. This proceeding, 
with certain modifications afterwards intro- 
duced, is no doubt very useful in cases favour- 
able for its employment, but it should be 
reserved tor those which have defied the less 
severe means, and where there is unmistak- 
able evidence of an obstruction to the passage 
of sound through the tympanum. Experi- 
ments with the tuning-fork, already referred 
to, give valuable evidence in this direction; 
but for a detailed account of this method of 
treatment, introduced some years ago by the 
late Mr. Hinton, the reader is referred to Ques- 
tions of Aural Surgery. Suffice it to say here 
that an incision about one-eighth of an inch in 
length is made in the posterior section of the 
membrane with a cataract-needle, and through 
this opening an attempt is made to expel 
from the tympanum the morbid secretion. 
It is not within the compass of this article to 
refer to the many operations which have 
during the past fifteen years been suggested 
for the relief of tympanic affections, but as in 
most of these cases there is no doubt that the 
mucous membrane which lines the tympanic 
cavity is the primary seat of the disorder, not 
sufficient success has attended these efforts 
to stand the test of time, or probably some of 
them would be practised habitually by aural 
surgeons in this country, on the Continent, 
and in America. Such, however, is not the 
case. One of the causes of failure in all 
operative measures on the tympanic mem- 
brane is to be found in the fact that it is 
impossible to keep any opening in this struc- 
ture from healing. That such attempts at 
relief should have been made is not surprising 
when it is remembered how intractable some 
of these cases are, how one of the forms of 
catarrh which affects the tympanum is slow 
and insidious in its 'progress, and sufficiently 
distinctive in its character, to have applied to 
it by general consent the term proliferous 
progressive catarrh. 
3. Purulent Catarrh of the Tym- 
panum.-Perforation.-The form of tym- 
panitis in which the effused products become 
purulent, is an acute and generally an ex- 
tremely painful affection. Usually the pus 
rapidly makes its escape from the tympanum 
into the external meatus, by a process of 
ulceration through the tympanic membrane, 
leaving as its result a perforation of this 
structure. In quite the early stage the 
affection may often be cut short by the free 
application of leeches in front of the tragus, 
followed by fomentations, but more often than 
not the membrane has given way before the 
patient comes under observation. Even then, EAR, DISEASES OF 
553 
if the tympanic cavity be emptied of the pus 
by the free use of Politzer's inflation and 
repeated syringing, the opening will often 
close, and leave very little, indeed sometimes 
hardly any, appreciable deafness. If, how- 
ever, a purulent discharge through the open- 
ing be allowed to go on unheeded for any 
length of time, it is the exception for the 
perforation to heal. This condition is con- 
stantly seen after scarlet fever, measles, or 
any of the exanthemata. A perforation of 
the tympanic membrane presents an infinite 
variety of aspects, from a small pinhole to 
nearly complete loss of the membrane, but 
there will always be a slight remaining 
external rim of membrane. This latter is 
perhaps the most frequent of all forms of 
perforation, and especially when the ulcera- 
tion dates from an attack of scarlet fever. 
Although the handle of the malleus occasion- 
ally remains, it more usually comes away in 
these and other cases where the loss of tissue 
is very extensive. The head of this bone, 
however, may always be distinguished, unless 
there has been complete disorganisation of 
the tympanic cavity. Among other forms of 
perforation commonly met with may be 
mentioned those in which the anterior or 
posterior half of the membrane is left, and is 
bounded internally by the handle of the 
malleus ; the so-called reniform perforation, 
where the lower part of the membrane is 
lost, and the umbo of the malleus indicates 
the position of the hilus of the kidney; and 
the small, smooth-edged circular perforation 
which is common alike to all parts of the 
membrane. Occasionally, though not very 
often, the tympanic membrane is the seat of 
a double perforation. Similar variations in 
hearing accompany this condition, between 
slight deafness and total loss of hearing 
power. The size of the perforation affords 
no guide in this respect, extreme loss of 
hearing being met with when the perforation 
is very small, and very slight deafness where 
the loss of tissue has been most extensive, so 
that it may be unhesitatingly stated that the 
loss of the membrane is but in a very small 
degree the cause of the deafness in these 
cases, the disorganisation in the tympanic 
cavity mainly accounting for this. Such dis- 
organisation is at times so complete (es- 
pecially after scarlet fever) as to include the 
loss of all the ossicles, total deafness, and 
paralysis of the muscles supplied by the 
portio dura. A very small perforation in the 
anterior and superior part of the membrane 
may from its position escape notice, but the 
diagnosis can be always verified by the 
facility with which air may be made to pass 
through the opening, or the reverse, provided 
that the communication between the Eusta- 
chian tube and the tympanum is not closed 
by cicatricial tissue-a very rare condition 
when so little of the membrane has suffered 
ulceration. 
One other form of perforation deserves 
mention, rather on account of its frequency 
than its importance, namely, perforation of 
Shrapnell's membrane, which is that part of 
the membrane proper lying just above the short 
process of the malleus. Ulceration of this 
small area, which is merely a protective 
membrane, may exist without any impair- 
ment to hearing so long as the remainder of 
the tympanic membrane is entire, so that it 
would appear to perform no function so far 
as a conducting medium is concerned, but it 
is important to bear in mind that when it is 
perforated the lesion is at times connected 
with exposed bone. 
* Treatment.-The treatment of purulent 
tympanitis and perforation will include as- 
siduous cleanliness; keeping the Eustachian 
tube free from obstruction; and the use of 
local remedies. Amongst the most useful of 
these are weak solutions of alcohol, and in- 
sufflation of gallic acid or boric acid. As 
the condition of the ear improves under 
these measures, so will the hearing power 
vastly increase when it has not been com- 
pletely lost; but there still remains the oft- 
times invaluable application of what is spoken 
of as the artificial membrane. Of all kinds, 
the best undoubtedly is the flattened pad of 
moistened cotton-wool, applied by the patient, 
every morning, with a pair of forceps con- 
structed for the purpose. Until this be tried 
in each case it is impossible to say whether 
it will do good; but when it is useful-as it 
is in a large number of cases-by its help the 
patient will recover very good hearing, and 
this even when the perforation has existed 
for a period of many years. That its effects 
depend upon the support which it gives to the 
ossicles, thus re-establishing the normal pres- 
sure of the stapes upon the fenestra ovalis, 
has been unquestionably demonstrated. 
4. Polypus.-One of the most frequent 
complications in cases of perforation of the 
tympanic membrane is polypus, a term em- 
ployed to designate a fleshy tumour in the 
ear. Although polypi are occasionally present 
in the meatus independently of perforation, 
the most usual situation from which they 
arise is the lining membrane of the tympa- 
num. Sometimes the exact point of origin 
is the edge of a perforation, and still more 
rarely the sides of the meatus. In size these 
growths vary from a small protrusion through 
a perforation, to a tumour which entirely fills 
the meatus and projects exterpally from the 
ear. In this latter instance the growth pre- 
sents a very distinctive appearance, not 
unlike a raspberry. Sections of aural polypi 
hardened in chromic acid with few exceptions 
show the structure to be fibro-cellular, the 
fibrous element preponderating over the cel- 
lular in proportion to the age of the tumour. 
Treatment.-In all cases polypi should be 
removed, and the best instruments for this 
purpose are the rectangular ring polypus 554 
forceps, or, in the case of a large growth, a 
Wilde's snare. Owing to their remarkable 
tendency to recur, removal is only the pre- 
liminary step in treatment. The principal 
part of this consists in their complete eradi- 
cation by caustics. Of these the most effica- 
cious and convenient is chloro-acetic acid, and 
later in the treatment nitrate of silver. The 
acid should be applied with great care by 
using it on the point of a probe defended 
by a small twist of cotton, and a convenient 
form of nitrate of silver is a bulb of the 
melted salt fused on to a probe or plati- 
num wire. The caustic should be applied 
daily for some time after the polypus has 
been removed, and then less frequently. The 
treatment should also include the same 
scrupulous cleanliness and application of as- 
tringents, so desirable in the case of perfora- 
tions. It is simply to the want of attention 
to details that failure in the treatment of aural 
polypus may be ascribed. 
Complications of Tympanic Disease.- 
(a) Facial Paralysis.-This is due to inflam- 
mation around the portio dura in its passage 
through the aqueduct of Fallopius. When 
suppuration in the tympanic cavity, with 
caries of the bony canal, precedes or accom- 
panies the loss of function in the nerve, re- 
covery is hopeless; but when the paralysis 
follows a subacute catarrh of the tympanum, 
not ending in a perforation, as is sometimes 
the case, the paralysis in time disappears no 
less certainly than when it is dependent upon 
an affection of the nerve at a point after its 
exit from the temporal bone. 
(6) Pycemia; Cerebral Abscess ; and. Men- 
ingitis.-When the mastoid cells become the 
seat of inflammation, the pain, tenderness, 
and pitting on pressure over the mastoid pro- 
cess, will at once suggest an early incision 
down to the bone, and it may be truly said that 
this is often delayed too long, and perhaps 
is never done too soon. Again, when the 
symptoms point definitely to pus within the 
mastoid cells, the bone should be pierced so 
as to make the external opening communi- 
cate freely with the cells. Relief given in 
this way will occasionally be the means of 
saving life, by preventing the absorption of 
poisoned material into the lateral sinus. Be- 
sides pyaemia thus induced, other fatal issues 
which suppuration in the middle ear fre- 
quently entails have their starting-point in 
the tympanic cavity, and in such instances 
cerebral abscess or meningitis may be the im- 
mediate cause of death. In the latter case a 
post-mortem examination reveals pus in the 
arachnoid cavity, or between the roof of the 
tympanum and the dura mater; in the 
former case, the seat of the abscess may be 
either in the cerebrum or cerebellum; this 
portion of the brain (the cerebellum) being 
more generally, though not always, the part 
affected when the mastoid cells are involved 
as well as the tympanum. 
EAR, DISEASES OF 
The experience of the past few years has 
amply demonstrated the success which has 
attended the operation of trephining in those 
cases where symptoms' point to cerebral 
abscess rather than to general meningitis. 
The operation should be done under strictly 
antiseptic conditions; the point selected 
should be over the temporo-sphenoidal lobe; 
and when pus is found after an exploration 
through this opening the wound should be 
kept carefully drained. 
Fatal terminations of this nature most 
frequently occur when cleanliness and local 
treatment of the ear have been neglected. 
Hence the necessity for such care. 
But the fact that even under the most 
favourable conditions such events are pos- 
sible, when there is a fistulous opening in the 
tympanic cavity, should induce caution with 
insurance offices in accepting the lives of per- 
sons with this lesion, at the ordinary pre- 
miums. Fatal cases of this kind might seem 
in practice to be almost divisible into two 
classes-namely, those in which cerebral 
symptoms come on soon after the establish- 
ment of the perforation; and others where 
there has been a purulent discharge from 
the ear (that is, from the tympanum) for 
many years before the advent of such symp- 
toms. In this latter class must be included 
those cases in which the temporal bone has 
become the seat of caries; and it may be 
stated, subject to no exceptions, that when- 
ever exposed bone can be detected by means 
of examination with a probe within the cavity 
of the tympanum, the subjects of this con- 
dition are always more or less in a peril- 
ous state, and that at any time fatal symp- 
toms may commence with a severe rigor, the 
earliest of all succeeding symptoms. For 
this reason, even when exposed bone cannot 
be absolutely demonstrated in the way men- 
tioned, the existence of bone-granulations 
where there is a perforation of the tympanic 
membrane should be regarded as a most 
serious complication. The same danger, 
though in a very much less degree, may be 
said to be present when dead bone can be 
detected in the mastoid process-in a less 
degree, because the outer table of the bone 
is often affected whilst the inner remains 
healthy. The dead bone then in the former 
position becomes exfoliated, and the external 
wound heals. Such are briefly the points of 
importance in connexion with caries of the 
temporal bone. How caries of the mastoid 
process may be obviated by a timely perfora- 
tion of the mastoid cells, and how the chief 
part of the temporal bone may when carious 
be removed and the patient survive, may be 
seen on reference to a paper entitled ' Disease 
of the Mastoid Bone,' by the writer of this 
article, in the Transactions of the Medical 
and Chirurgical Society for 1879. 
(c) Malignant Disease.-In the paper just 
mentioned is also reported a case of malig- EAR, DISEASES OF 
EBURNATION 
555 
nant disease of the ear, in which the cavity 
of the tympanum, having been the seat of 
suppuration for some time, became affected 
with epithelial growth, which caused the 
death of the patient. From all recorded 
cases of malignant disease of the ear, as 
well as those which have come under the 
writer's notice, it would seem that the seat 
of origin of the new-growth will be found to 
be the lining membrane of the tympanic 
cavity, and that a purulent discharge from 
this surface always precedes the appearance 
of the cancer, and must therefore be regarded 
as the exciting cause of the growth. In its 
early stages cancer in this situation bears a 
strong resemblance to the ordinary forms 
of polypus. The same cause, then, which in 
some cases calls into being a polypus, may 
occasionally give rise to malignant disease, 
and this without any predisposing cause (so far 
as can be ascertained) in the patient towards 
cancerous growth. 
III. Internal Ear.-Apart from deafness 
due to local changes in the external or middle 
ear, the function of hearing is subject to im- 
pairment from causes which have their seat 
in the nervous structures of the ear; in other 
words, although the conduction of sound may 
be good, the perception of sound may be 
faulty. The inability to hear the vibrations 
of sound conveyed through the cranial bones, 
such as from a vibrating tuning-fork placed 
upon the vertex, is indicative of this condition. 
For the rest, the absence of tympanic disease, 
and the history of the case, must supply the 
evidence required for a diagnosis. Familiar 
examples of this nature are the deafness 
which often accompanies old age, or which is 
left after fevers when the middle ear has not 
suffered ; the two forms of syphilitic nervous 
affection to be presently mentioned; the sud- 
den and sometimes total loss of hearing which 
occasionally follows severe mental shock ; the 
deafness after loud explosions near the ear, 
so common in artillerymen and naval men ; 
and that which is caused by blows on the 
head and boxes on the ear. An attack of 
mumps will sometimes leave behind an irre- 
mediable loss of hearing in one or both ears, 
unattended with any discoverable change in 
the tympanum. In a similar way weakly 
women occasionally become more or less 
deaf during their confinement, and this symp- 
tom becomes aggravated as each successive 
child is born. In connexion with this sub- 
ject, prolonged suckling may be mentioned 
as one of the numerous debilitating causes 
which undoubtedly aggravate the trouble of 
an already impaired ear. 
Among the nervous affections of the audi- 
tory apparatus possessing certain character- 
istics which serve to distinguish it from others 
is the so-termed Meniere's disease, an attack 
of which at times gives rise to symptoms 
which would be alarming if their true origin 
passed unrecognised. A patient who suffers 
in this way is seized with an attack of vertigo 
so severe that he not infrequently falls, and 
for some hours afterwards requires assistance 
in walking; occasionally vomiting succeeds 
the giddiness; and he recovers to find him- 
self very deaf in one ear, with which pre- 
viously he had heard well. Milder attacks 
of the same nature generally follow the first, 
and each one leaves the patient more deaf. 
Although with many writers it is a favourite 
theory that the seat of morbid changes in 
this disease is in the semicircular canals, up 
to the present the point has not been satis- 
factorily determined. No treatment appears 
to exercise any influence upon the disease. 
See Vertigo. 
Syphilis.-The affections of the ear due 
to syphilitic disease demand separate con- 
sideration. They occur under the following 
varieties : Firstly, in the form of sores and 
warts in the external meatus, which yield 
to local treatment. Secondly, affections of 
the middle ear during the secondary ulcera- 
tion of the throat, the treatment for which, 
beyond specific medicines, in no way differs 
from what is useful in the ordinary catarrh 
of the same parts. Thirdly, failure in hear- 
ing power during the secondary stages, un- 
attended with any change in the middle ear. 
This disappears under constitutional reme- 
dies. Fourthly, the loss of function in the 
auditory nerve, so commonly met with in 
the subjects of inherited syphilis. In these 
patients the hearing power begins to fail be- 
tween five and fifteen years of age (very sel- 
dom later in life), and proceeds to very great 
and often total deafness, the period between 
good hearing and the extreme point of deaf- 
ness arrived at varying from a few weeks to 
several years. From this cause children 
sometimes become in the course of a month 
or six weeks totally deaf, but such rapidity 
is exceptional. Experience has shown how 
powerless treatment is to arrest the progress 
of this affection, so that attention should be 
confined to preventing its subjects from be- 
coming dumb, if they are attacked after they 
have acquired speech, and before they are 
likely to forget it, namely, from about four to 
seven years of age. This is best attained by 
teaching them lip-reading; and if they can 
read, by making them do so (aloud) several 
times each day. In this way a child will retain 
its recollection of language when otherwise 
speech would pass away. W. B. Dalby. 
EAUX-BONNES, in France.-Sul- 
phur waters. See Mineral "Waters. 
EAUX-CHAUDES, in France.-Sul- 
phur waters. See Mineral Waters. 
EBURNATION" (ebur, ivory).-A state 
of bone-tissue in which it assumes the white- 
ness, smoothness, and hardness of ivory, in 
consequence of an increased deposit of calca- 
reous matter. It occurs chiefly in rheumatic 
arthritis. See Rheumatic Arthritis. 556 
ECBOLICS (eK^okr], abortion). - This 
name is given to the measures which produce 
abortion, or expulsion of the contents of the 
uterus. In moderate doses ecbolic drugs may 
act as emmenagogues. See Emmenagogues. 
ECCHYMOSIS (eK, out of; and yv/i6s, 
juice).-An extravasation of blood into the 
cellular tissue, due either to injury or to dis- 
ease. It presents at first a more or less blue 
or bluish-black appearance, which changes 
with age, passing through green to yellow. 
See Extravasation. 
ECHINOCOCCUS (^os, a hedgehog; 
and kokkos, a grain or berry).-See Entozoa. 
ECLAMPSIA (eVX^Trw, I flash, I ex- 
plode).-This term is now used as a synonym 
for convulsions, whatever may be their cause. 
See Convulsions. 
ECPHYMA (tK, out of; and a 
swelling).-A growth from the integument. 
The term was employed by Mason Good as 
a designation for warts and corns, but is at 
present almost obsolete. 
ECSTASY I amaze).-Defini- 
tion.-The term ' ecstasy ' has been applied 
to certain morbid states of the nervous system, 
in which the attention is occupied exclu- 
sively by one idea, and the cerebral control 
is in part withdrawn from the lower centres 
and those for certain reflex functions. These 
latter centres may be in a condition of inertia, 
or of insubordinate activity, presenting vari- 
ous disordered phenomena, for the most part 
motor. 
Description.-The subjects of ecstatic 
phenomena are commonly of the female sex, 
or are men who lead celibate and ascetic 
lives. To such individuals, they are in the 
present day almost confined. In the middle 
ages, on several occasions, under special 
circumstances, an intense dominant emotion, 
with some attendant ecstatic manifestations, 
was known to spread widely by a sort of 
moral contagion. 
Women who are the subjects of this morbid 
state are usually single, frequently present 
menstrual irregularities, and often distinct 
evidences of hysteria, of which the ecstatic 
condition may be but a part. The immediate 
cause of the attack is usually some repeated 
vivid emotion, commonly religious, sometimes 
one of fear. The direction taken by the 
motor or other phenomena of the ecstatic 
state is often very obviously determined by 
imitation. With this direction there is 
associated, in some cases, the assertion of 
supposed facts, which transcend the ordinary 
course of natural phenomena, and which have 
been proved, in many instances, to depend on 
intentional fraud. 
As forms of ecstasy we have the condition 
of some religious enthusiasts, in whose domi- 
ECBOLICS 
nant state all other mental processes are 
merged. Dreams and visions are determined 
by the ecstatic emotion and add to its inten- 
sity. Consciousness of the body may even 
be lost, so that all sensation is gone for a 
time; while the corporeal functions, includ- 
ing ingestion and egestion, are reduced to a 
minimum, and a little exaggeration may 
represent them as in complete abeyance. 
Hence the ' fasting girls ' that have arisen 
in various countries, by whom ' stigmata ' 
marks, in the positions of the-nails employed 
in crucifixion, are sometimes presented, prob- 
ably by artificial production, but possibly 
by the influence of the mental state on the 
processes of nutrition in the parts to which 
attention is directed. In some hystero-epi- 
leptics a state of ecstasy-of rapt, intense 
emotion-forms part of the paroxysmal 
seizures, and then wild muscular spasms 
replace the tranquil repose of the more voli- 
tional ecstatics. Occasionally-when an in- 
tense emotion is shared by many persons- 
insubordinate muscular movements occur, of 
a rhythmical character, seen in the Jumpers 
and Shakers of the present day, and more 
strikingly in some of the dancing religious 
ceremonies of half-civilised races, and in the 
dancing epidemics of the middle ages. Such 
was the original dance of St. Vitus, in which 
the exciting emotion was religious; and such 
also the ' tarantella,' in which the excitant 
W'as terror at the supposed consequences of 
the bite of the tarantula, which the dance 
was intended to avert. The phenomena now 
manifested in the epidemics that have been 
described under the name of the ' Jumpers,' 
&c., merit, indeed, more detailed notice, since 
they have been observed in remarkable de- 
gree and conspicuous form in certain races 
in whom the process of brain development 
concerned in what we term ' civilisation ' 
is taking place-with a slowness that is prob- 
ably alike typical as regards the past, and 
instructive as to the process. The conditions 
especially favourable for the development of 
these disorders appear to be generated by the 
close contact of such races with those in 
whom the process of evolution of the ner- 
vous system has been carried farther; and 
the less developed organisation is, as it were, 
strained by a connexion which it is not 
strong enough to endure. At all periods a 
pathogenic influence has probably also been 
exerted by the excessive tension placed on 
some mental faculties by certain religious 
systems, but the effect is greater when the 
strain comes from without, and the nervous 
constitution is warped by the inequality be- 
tween its own strength and that of the race 
with which it is not only in contact but 
attachment. The cerebral functions may be 
deformed by emotions that would be power- 
less to disturb a brain whose functions were 
strengthened by equal development in all 
parts. 
ECSTASY ECSTASY 
ECZEMA 
557 
It is especially among the negro tribes in 
contact with more civilised white races, that 
the most conspicuous forms of ecstatic disease 
have been observed. A condition described 
by Hammond under the term ' Miryachit ' 
(Russian, Miriatchit = ' playing the fool ') is 
almost identical with that met with in the 
so-called Jumpers. The subjects of this 
condition have been met with chiefly in 
Siberia; but an exactly similar condition is 
met with in Java, where it is known as 
' Lata ' or ' Latak.' Both sexes are liable, 
but most sufferers are females. It occurs in 
epidemics, especially involving several mem- 
bers of the same family; although sporadic 
cases are often met with. Contact with a 
person who is the subject of this affection 
is often the exciting cause; but sometimes 
the malady is distinctly hereditary. Natives 
and acclimatised immigrants are exclusively 
attacked, and of them only children and 
persons of a low intellectual development. 
The characteristic of the disease is that its 
subjects are compelled to imitate any sound, 
gesture, grimace, or act, even if it gives rise 
to pain, anger, or remonstrance. As a rule 
the malady is chronic, but presents spon- 
taneous remissions. The general health is 
unaffected, and the patient is not incapaci- 
tated from work. Thus the chief difference 
between this condition and most other ec- 
static states is, that the subjects of Miryachit 
re-act only and simply to impulses entering 
through the afferent optic and auditory chan- 
nels ; and when an order is given they do 
not perform the acts, but simply repeat the 
words of the order. 
The state of ' somnolentia,' or ' sleep- 
drunkermess,' is closely allied, psychically, to 
the conditions under discussion, although 
differing in its associations, by which it is 
connected more closely with epileptic mania 
than with the ecstatic disorders. The sub- 
jects of this condition perform some act, it 
may be even of violence or murder, on being 
suddenly awakened from sleep-the action 
being often prompted by a dream. 
The close resemblance between ecstasy and 
some forms of hysteria has already been 
alluded to; but what is of still greater interest 
is the fact that suggestion plays a most impor- 
tant part in all the conditions that have here 
been discussed, and that all these conditions 
seem, as it were, to form links in the chain 
which connects the dancing epidemics of the 
middle ages with the phenomena of sugges- 
tion and hypnotism of the present day. 
A remarkable case is quoted by Hammond, 
of a gentleman who would perform any act 
he was told to by a person whispering into 
his ear while he was asleep. 
Treatment.-It is rarely now that ecstatic 
manifestations have to be treated except as 
part of pronounced hysteria, and the treat- 
ment is that of the hysterical state which 
underlies the ecstasy. The measures of para- 
mount importance are the substitution of a 
' healthy moral atmosphere ' for that under 
which the symptoms have arisen; and the 
exposure of actual fraud. Occasionally, even 
now, examples of solitary ecstasy come under 
observation. In these cases considerable care 
and tact are needed. Ecstatics are not amen- 
able to the motives which influence most 
persons, and, if there is actual fraud, will 
sometimes die rather than be found out. In 
the case of fasting girls, due observation of 
the body-weight during a short time will 
answer as well as, and is much safer than, a 
long exclusion of food. But the removal of 
the ecstatic to other surroundings is the most 
important step for both detection and cure. 
W. R. Gowers. J. S. Risien Russell. 
ECTHYMA (eK0va>, I burst out).-A pus- 
tule or pimple ; pathologically occupying a 
mid-place between a pustule and a furuncle. 
The so-called tar-acne, the small inflamma- 
tory pustules developed around a mother- 
boil, and the commoner eruptions produced 
by iodine and bromine, are examples of ec- 
thyma. See Skin, Diseases of. 
ECTOPIA (eK, out of; and ron-os, a place). 
An abnormal protrusion or displacement of 
a part; for example, ectopia vesicce, protru- 
sion of the bladder. See Organs, Displace- 
ment of. 
ECTOZOA (tKTos, without; and ^ov, an 
animal).-A term employed by some natura- 
lists to embrace all the external parasites. 
See Epizoa. 
ECTROPION 
ECTROPIUM 
(etc, out of; and Tperra, I 
turn).-A condition in which the eyelid be- 
comes everted, so that the conjunctival sur- 
face is exposed. See Eye and its Append- 
ages, Diseases of. 
ECTROTIC (eKTiTpa>aKa>, I miscarry).-■ 
A term applied to arrest of the course of a 
morbid process, for example, the develop- 
ment of small-pox. The agent by which the 
pustule is made to abort, named the ectrotic, 
may in this instance be a point of nitrate of 
silver. A coating of plaster, and especially 
substances which will exclude the light, 
such as mercurial ointment, or an ointment 
of lampblack, are likewise employed as 
ectrotics of small-pox. 
Erasmus Wilson. 
ECZEMA I bubble up).-Synon. : 
Fr. Eczema; Ger. Eczem. 
Definition.-An inflammatory disease of 
the skin, which in its typical form is associated 
with the formation of papules and vesicles 
which quickly burst, and leave a more or less 
excoriated surface, discharging a gummy 
serous fluid, which stiffens into a thin crust 
as it dries. The disease is always attended 
with itching. 558 
^Etiology.-Eczema is by far the most 
common disease of the skin, and is said to 
constitute about one-third of all the cases of 
skin-disease. It occurs at all periods of life, 
from infancy to old age, but is probably rather 
more common during the first and second 
dentitions, and in the later period of life, than 
in youth or middle age.; on this point, how- 
ever, there is some difference of opinion, and 
in any case, age is not a very constant factor 
in its development. It is generally admitted 
to be somewhat more common in males than 
in females. 
The principal causes of eczema may be 
conveniently divided into three groups: 
(1) those that are strictly local, such as varicose 
veins, and tne various forms of local irrita- 
tion ; (2) more general causes, such as teeth- 
ing, errors of diet, overwork, and anxieties of 
all kinds; (3) a constitutional tendency to 
the disease. It must be admitted, however, 
that there are cases of eczema for which no 
definite assignable cause can be found. 
With regard to strictly local causes, varicose 
veins are perhaps the most important. Irri- 
tants, however, such as tincture of arnica, 
stimulating plasters and embrocations, often 
give rise to local attacks of eczema in those 
who are predisposed to it. Exposure to ex- 
treme heat or cold is amongst the well-recog- 
nised exciting causes of the malady, which is 
often a source of annoyance to Europeans living 
in the tropics. A Turkish bath will sometimes 
produce a papular eczema such as we also 
meet with in stokers. The handling of irritat- 
ing materials, which is incidental to certain 
trades, occasionally gives rise to local eczema 
of the hands. Too frequent washing in hard 
water may be mentioned as a common excit- 
ing cause in those predisposed to the disease. 
The general causes of eczema are of more 
importance than the local causes, although 
they are less certain and definite in their 
action. In children, the process of teeth- 
ing, an injudicious diet, and worms may be 
mentioned as generally recognised exciting 
causes of the disease; of these three, in- 
judicious feeding is the most important, and 
is by no means confined to infancy or child- 
hood. Constipation and a general neglect of 
the action of the bowels, is another common 
cause of the perpetuation, if not of the de- 
velopment, of the malady. 
With regard to a constitutional tendency 
to the disease, it is, without doubt, common. 
In some instances, this tendency is so strong 
that eczema may be said to be always present 
throughout life, or with but short intervals of 
freedom. It is generally believed that gouty 
families and individuals are more liable to 
eczema than those that have no tendency to 
gout; the writer does not doubt this fact, but 
that is very different from the common state- 
ment that gout gives rise to eczema, for which 
there is not much foundation. 
Symptoms.-Eczema is remarkable for the 
ECZEMA 
varying appearance it assumes, according to 
the acuteness of the inflammation, the stage 
of the disease, and the parts affected. In an 
early stage it generally consists of a red and 
slightly swollen patch; later on, this may be 
covered with papules and vesicles, which are 
usually of short duration, to be followed by 
the development of a moist excoriated sur- 
face, discharging a serous or gummy fluid. 
When the process of healing begins, the patch 
becomes dry, and covered with thin scaly 
crusts, which ultimately fall off, and leave 
the skin in a comparatively healthy con- 
dition. Although this is the description of 
typical eczema, yet the varieties in the course 
and character of the eruption are so great 
that they require a brief notice. 
There are three principal variations in the 
development of the eruption : (1) The inflam- 
mation may be very acute, and the exudation 
of serous fluid into the skin and subcutaneous 
structures so rapid and excessive as to pro- 
duce great swelling of the tissues. This is espe- 
cially met with in acute eczema of the face, in 
which there is sometimes closure of the eye- 
lids, and a complete alteration in the features, 
so that the patient can be hardly recognised. 
(2) A very common variation from the nor- 
mal course of the eruption is the develop- 
ment, from the first, of dry, red, slightly scaly 
patches, which are never moist, and but little 
swollen. Eczema of this kind is always 
attended with much itching, but with no 
pain or tenderness on pressure. (3) A general 
eruption of minute red papules over the body 
and limbs, is another very common form of 
the disease. The papules usually develop 
rapidly, and are distributed symmetrically 
over the body, reminding one, at a little dis- 
tance, of a scarlatina rash. The eruption 
generally aborts, dries up, and desquamates 
without the formation of visible vesicles, 
though now and then a few may be found 
amongst the bright red papules. 
The various forms or stages of eczema are 
sometimes indicated by qualifying names; thus 
the earliest phase consists simply of hyperaemic 
patches and is calledeczema erythematosum; 
later on we may have eczema papulosum, 
and vesiculosum; soon the vesicles burst., 
and leave a raw, discharging, excoriated sur- 
face, to which the term ichorosum has been 
applied; when the congestion is great, it is 
called eczema rubrum. The formation of a 
puriform discharge is indicated by the name 
impetiginosum; and lastly, eczema squamo- 
sum is applied to the disease in its scaly con- 
dition. One or all of these phases of eczema 
may sometimes be seen in different regions 
of the body at the same time. 
Although the skin of any part of the body 
is liable to be attacked by eczema, yet it may 
be said to have a preference for certain re- 
gions, as, for example, the flexor surfaces of 
the limbs, the hands, the scalp, and the points 
of junction of the skin with the mucous ECZEMA 
559 
membranes. In some of these regions, such 
as the hands, the lips, and the anus, local 
causes play an important part in the per- 
petuation, if not in the development, of the 
malady. Eczema is generally distributed 
symmetrically, though there are many ex- 
ceptions to the rule. With regard to subjec- 
tive sensations, it may be said that they are 
always present, and form one of the most 
troublesome symptoms of the disease. In 
most cases itching is a very characteristic 
feature; the only exception to this rule is 
met with in acute eczema, in which the sen- 
sations of pain, burning, and smarting for a 
time mask or take the place of itching; but 
when the inflammation subsides, itching is 
sure to arise. In no other affection, except 
prurigo, is itching so constantly present. 
Diagnosis.-Eczema is liable to be mis- 
taken for the following diseases: erysipelas, 
scabies, psoriasis, sycosis, tinea tonsurans, 
superficial lupus, and some syphilitic erup- 
tions. 
Eczema and Erysipelas.-Acute eczema 
of the face, with much exudation into the 
subcutaneous tissue, is the only form liable 
to be mistaken for erysipelas. The following 
points will aid the differential diagnosis: 
(1) In erysipelas, the eruption is preceded by 
rigors. (2) The pulse, temperature, and feb- 
rile symptoms generally are higher than in 
eczema. (3) There is almost always headache, 
and often albuminuria. (4) Erysipelas has a 
more sharply defined margin, and a smoother 
and more glazed surface. (5) Erysipelas 
commonly begins round or below one orbit, 
and is, more often than eczema, unilateral at 
first, although, in the end, both sides may be 
affected. 
Eczema and Scabies.-These two diseases 
are often confounded, for the very obvious 
reason that scabies leads to a kind of artificial 
eczema. Apart from the use of the micro- 
scope, which cannot always be applied, the 
following considerations will aid the differ- 
ential diagnosis. Scabies especially attacks 
certain regions, and when a pimply eruption 
is met with between the fingers, and on the 
flexor surface of the wrists, and also at the 
same time on the lower part of the abdomen, 
penis, and nates, a very careful examination 
should be made for other signs of scabies. 
An examination over the wrist with a common 
magnifying-glass will often lead to the detec- 
tion of the scabies cuniculus, looking very 
like a pin-scratch. The history of the case 
will also aid the diagnosis. 
Eczema and Psoriasis.-Dry scaly forms 
of eczema may be mistaken for psoriasis, 
though the more sharply defined and raised 
margin of the latter, with a tendency to form 
rings, usually makes the diagnosis easy. The 
development of the eruption on the points of 
the elbows and just below the knee-caps, is 
very distinctive of psoriasis. 
Eczema and Sycosis.-The very chronic 
character of sycosis, and the absence of any 
running exudation, together with its strict 
limitation to the hairy parts of the face, will 
generally serve to distinguish it from eczema. 
In a recent attack the differential diagnosis 
is difficult, but not of much importance, as 
the two diseases are very closely allied. 
Eczema and Tinea Tonsurans.-It is only 
ringworm of the body that can be mistaken 
for eczema. A solitary patch of dry eczema- 
like eruption, spreading at the margin, at 
once suggests the probability of ringworm. 
The diagnosis will be rendered almost cer- 
tain if a narrow margin of the round patch 
is sharply defined, slightly raised, and of a 
brighter colour than the other parts. If no 
treatment has been adopted, the microscope 
will complete the diagnosis ; but if any active 
remedies have been applied, the microscopic 
examination is useless. 
Eczema and Lupus.-Patches of superficial 
lupus sometimes become covered with scales 
and eczema-like crusts, which mask the real 
nature of the disease. A careful examination 
will, in any doubtful case, lead to a correct 
diagnosis. 
Eczema and Dermato-syphilis.-Pustular 
syphilitic eruption of the scalp may be mis- 
taken for impetiginous eczema. The presence 
of superficial ulceration, and a peculiar offen- 
sive smell, are characteristic of the syphilitic 
eruption, apart from other signs of syphilis. 
Dry, cracked eczema of the palm is very com- 
mon, and is sometimes confounded with a 
similar condition which is due to syphilis, 
and often miscalled ' psoriasis palmaris.' This 
kind of eczema is generally attended with 
much itching, which is not the case with the 
syphilitic eruption. Eczema is, moreover, 
rarely confined to one palm, while the syphi- 
litic eruption is often unilateral. The history 
of the case will also aid the diagnosis. 
Treatment.-The variations in the charac- 
ter of eczema are so great that it is impossible 
to lay down rules of treatment that will meet 
all cases. Some general directions may, how- 
ever, be given, which will serve as guides, 
though nothing can supply the place of prac- 
tical experience. 
Acute Eczema.-The treatment of acute 
eczema is simple. In all very severe cases 
the patient must be confined to bed or the 
couch. Moderate or free purging with sul- 
phate of magnesium or sulphate of sodium is 
always indicated, some care being of course 
required in the case of weakly or elderly 
people. When the attack is of gouty origin, 
the purgative treatment may be supplemented 
by the use of alkalis with iodide of potas- 
sium or colchicum, according to circum- 
stances. In the local treatment of acute 
eczema, all ointments of a stimulating kind 
should be strictly avoided. If the inflam- 
mation is confined to the limbs, water-dress- 
ing or a weak lead lotion is often the best 
application, but it must never be allowed to 560 
ECZEMA 
get dry. During the day, when the dressing 
can easily be kept moist, it is better not to 
cover it with gutta-percha tissue; but at night 
this plan may be adopted, in order to prevent 
the lint from getting quite dry. It is difficult 
to apply water dressing to the head and face, 
and under these circumstances fuller's earth 
or starch and zinc powder is a useful applica- 
tion. If, however, this does not suit, the lini- 
mentum calcis, made with sweet almond oil, 
may be used; it should be either applied on 
lint or simply painted on several times daily. 
Some patients derive great benefit from thin 
linseed meal poultices, which do not require 
changing so often as water-dressings, other- 
wise the principle of treatment is the same in 
both. 
Sub-acute or Chronic Eczema. - The 
general treatment of sub-acute or chronic 
eczema will depend more on the character of 
the eruption, and the age of the patient, than 
on the parts affected; the local treatment, 
on the other hand, must be modified to suit 
the regions attacked. The general treatment 
would include rest, change of air, diet, and 
medicine, according to the severity of the 
case, and other attendant circumstances. If 
the patient is suffering from gouty symptoms, 
dyspepsia, or constipation, the plan of treat- 
ment should be adapted to meet these con- 
ditions, with a considerable probability that 
it will also be the most suitable treatment for 
the eczema, which may of course be dealt 
with at the same time by local means. When, 
however, the patient is young and in good 
health, arsenic in moderate doses will be 
found the most generally useful remedy. In 
children between the ages of two and five, 
one-drop doses of the liquor arsenicalis given 
after meals three times daily is usually 
enough ; it may be combined with alkalis 
or laxatives or tonics according to circum- 
stances. The routine practice of treating 
ordinary eczema in young children with iron 
and cod-liver oil generally ends in failure, 
especially when the eczema is of an irritable 
kind. In the pustular forms of eczema, how- 
ever, iron is useful, and then the arsenic may 
be combined with the vinum ferri or some 
other preparation of iron. In people of middle 
age, arsenic is not so generally useful as in 
children. In the sub-acute irritable forms of 
eczema, vinum antimoniale in small doses, 
with diuretics, may often be given with ad- 
vantage instead of arsenic. 
In all forms of eczema the greatest atten- 
tion should be paid to the action of the 
bowels. The malady is often associated with 
constipation, and even when this is not the 
case, some increase in the natural action of 
the bowels is highly benefic al. The kind 
of purgative to be used will depend on the 
age of the patient and other circumstances. 
In infancy, fluid magnesia in milk is one of 
the best; in childhood, sulphur powders 
or lozenges, or mild saline purgatives, are 
most suitable; for adults, sulphate of mag- 
nesium or sulphate of sodium, given either 
before breakfast in full doses, or in smaller 
doses with some tonic two or three times 
daily, is suitable; lastly, in old age, mild 
aloetic pills may be given. 
The use of Tar in Eczema.-For many 
forms of chronic dry eczema, the various pre- 
parations of tar are among the most useful 
local remedies. They do more to relieve the 
intolerable itching than any other class of 
remedies, the chief drawbacks being their dis- 
agreeable colour and smell. Before applying 
tar preparations to eczema, it is always ad- 
visable to try the effect in a much diluted 
form, or over a very limited area ; for when 
applied to unsuitable cases they some- 
times produce a great aggravation of the 
disease. The ordinary tar ointment may be 
freely diluted with any other ointment, such 
as zinc ointment, and subsequently the 
quantity of tar increased or diminished ac- 
cording to circumstances. The tar lotions 
are less disagreeable than tar ointment; they 
are made by combining the liquor carbonis 
detergens (made from coal tar), or the liquor 
picis compositus (made from vegetable tar) 
with water, or some simple lotion, such as the 
ordinary lead lotion. One to four per cent, 
of the tar solution is usually enough. 
Local forms of Eczema.-Eczema 
of the Scalp.-Special local treatment is 
sometimes required when eczema attacks 
certain regions of the body. On the scalp, 
when it is attended with much discharge, the 
hair should be cut and kept quite short. All 
the scabs should be softened by a poultice, 
and then removed by bathing with warm 
water. The head should then be carefully 
dried, and dressed with an ointment consist- 
ing of acetate of lead gr. xv, zinc oint- 
ment 5ij. calomel gr. xx, nitrate of mercury 
ointment gr. xx, vaseline Jij, benzoated 
lard ^ss. When the inflammation has sub- 
sided, the white precipitate ointment, diluted 
with an equal quantity of vaseline, may be 
used. In dry, scurfy eczema of the scalp, the 
best salve is the red oxide of mercury oint- 
ment ^ij, white vaseline 5vj 5 this should be 
applied in small quantities every day. Some- 
times when there is much active inflamma- 
tion, a lotion may be used instead of an oint- 
ment until the inflammation has subsided. 
The most useful are weak sulphate of zinc or 
boric acid lotions, or carbolic-acid lotion of 
strength of about one part in a hundred 
parts of distilled water. Whenever a lotion 
is used it should never be allowed to get dry; 
the dressing may be conveniently kept in its 
place by a light thread or cotton nightcap. 
Eczema of the hairy parts of the face 
should be treated very much like eczema of 
the scalp. If, however, there is pus-forma- 
tion in the hair-follicles, it is best to remove 
the hairs that pass through pustules, and 
allow the pus to escape; tben to wash with ECZEMA 
561 
weak, strained gruel, and after carefully dry- 
ing the skin to apply a lotion of calamine and 
oxide of zinc, so as to dry up the discharge as 
quickly as possible. The crusts which form, 
if firmly attached, should be allowed to 
remain, but when loose from exudation 
underneath, they should be removed, and, 
the hair being carefully cut, the surface should 
then be dabbed with a little medicated wool, 
and the lotion again applied. 
Eczema of the Anus.-This is a most 
troublesome malady, the itching being often 
out of all proportion to the amount of visible 
eruption; when this is the case, it is com- 
monly called pruritus ani. The most impor- 
tant point in the local treatment of eczema 
in this region, is always to wash directly 
after the bowels have acted, without the use 
of paper. For this purpose a jug and basin 
and a very soft old towel should always be 
kept in the water-closet. After washing, the 
eczema should be very carefully dried, and 
some suitable ointment immediately applied. 
Among the best are the calomel, the diluted 
oxide of mercury, and the calamine oint- 
ments ; a very small quantity of the crea- 
sote ointment may be advantageously com- 
bined with any of these whenever pruritus 
is the chief feature of the disease. An oc- 
casional painting with a solution of nitrate of 
silver (gr. x ad §j) is very useful. Although 
it is essentials to wash directly after the 
bowels have acted, yet this should not 
generally be repeated until the bowels act 
again, too frequent washing being bad for 
the eczema. A little cotton-wool placed so 
as to keep the skin on the two sides from 
touching is very useful. 
Eczema of the Auditory Meatus.-Any 
accumulation of crusts should be first 
removed by syringing with warm water; 
this should be followed by the use of a tepid 
sulphate of zinc lotion (gr. iij-vj ad Jj) several 
times daily; an occasional painting with a 
solution of nitrate of silver (gr. viij ad §j) is 
often useful. When the eczema is of the dry 
kind, citrine ointment diluted with six parts 
of oil or vaseline, and applied to the inside of 
the ear carefully with a camel's-hair brush, is 
the best remedy. 
Fissures in Eczema.-Fissures are apt to 
occur in eczema at the corners of the mouth, 
between the toes, about the anus, and along 
the.lines of flexure in the palm of the hand. 
The best treatment for these is to carefully 
paint a solution of nitrate of silver (gr. xv 
ad Jj) into the bottom of the crack, with a 
very fine camel's-hair brush, once a day. 
Eczema of the Nipple is often difficult to 
cure. It should be protected from touching 
the clothes by a shield, and painted daily 
with a solution of nitrate of silver (gr. x 
ad $j). 
Chronic Eczema of the Palm is a most 
obstinate malady. This arises from the 
natural thickness of the cuticle, which does 
not readily allow the escape of exudation, 
but cracks and leaves troublesome fissures, 
especially at the lines of flexure. Moreover, 
the hands are constantly exposed to the 
unfavourable conditions of movement and 
frequent washing. In these cases, if the 
outer cuticle is much hardened and thickened, 
it is necessary to remove it. This may be 
done either by macerating it with a weak 
lotion of liquor potassae and distilled water 
(Jij ad Jviij) applied on lint, or by painting 
it for a few days with a saturated solution of 
salicylic acid in flexible collodion. When the 
hard cuticle is removed, the hand should be 
dressed with the oleate of zinc, or some other 
soothing ointment. Gloves should be con- 
stantly worn, so as to avoid the necessity of 
washing until the hand is quite well. 
Eczema of the Leg.-The special indication 
in the treatment of eczema of the leg is care- 
ful bandaging from the foot up to the knee. 
In some few cases the solid india-rubber 
bandages are most useful, but they are not 
always easily borne. 
Pruriginous Eczema.-Some forms of dry 
eczema affecting large areas of the body are 
attended with such intense itching that the 
patient loses all power to resist the tempta- 
tion to scratch. As a consequence the skin 
is torn and lacerated with the nails of the 
sufferer, which only gives temporary relief. 
Under these circumstances Professor Unna 
recommends a kind of gelatine paint made by 
combining zinc oxide and gelatine, each one 
part, and glycerine and water each four 
parts. This is melted when required by 
placing the jar in hot water, and then painted 
on with a soft shaving brush. The remedy 
is rather a disagreeable one, but sometimes 
useful to prevent scratching in severe cases. 
Diet.-A careful diet is of considerable 
importance in the treatment of eczema, 
especially in children, and in gouty or 
dyspeptic people. Children suffering from 
pustular eczema require a liberal diet, and 
especially a little beer or wine, and plenty 
of fresh meat and vegetables. Even infants 
with pustular eruptions often require alcohol 
in small quantities, the best form being from 
15 to 20 drops of French brandy in milk two 
or three times daily according to circum- 
stances. It is the formation of pus which 
appears to indicate the use of small doses of 
alcohol. On the other hand, dry irritable 
eczema in adults is often benefited by a 
reduction in the usual amount of alcohol. 
Some kinds of food, such as highly salted 
meat and fish, sweets-including dried fruits, 
coffee, and oatmeal, appear to be unsuitable 
for most kinds of eczema. 
Washing in Eczema.-Perhaps there is 
no more common mistake in the treatment 
of eczema than too frequent washing; 
indeed, the mistake is a very natural one. 
In all ordinary cases of eczema, washing 
with soap and water must be forbidden', and 562 
this is most essential when the eczema is 
healing, and the new, delicate cuticle is 
forming, for then water macerates and 
destroys it, and thus the duration of the 
disease is needlessly prolonged. As a matter 
of fact, starch or fuller's earth powder keeps 
the skin quite clean, and also favours the 
healing process. If washing is absolutely 
necessary, as it is sometimes in an early 
stage of the disease where there is much 
discharge, weak, strained gruel, made with 
soft or distilled water, is always preferable 
to soap and water, but even that should 
not be used often. 
Baths in Eczema.-It is difficult to lay 
down any definite rule with regard to the 
use of baths in eczema. In some forms of 
eczema, especially in young children, baths 
do much harm. In gouty people, on the 
other hand, who suffer from dry chronic 
eczema resembling psoriasis, a course of 
mild alkaline baths is often very beneficial. 
Great discrimination, however, is required 
in the choice of baths. The summer is the 
most suitable time of the year for the bath 
treatment. Egbert Liveing. 
ECZEMA MARGINATUM. - See 
Tinea trichophytina ; and Erythrasma. 
EFFUSION (e, out; and/umZo, I pour). 
The escape of a fluid from its natural channel 
or cavity into the substance of organs or the 
cellular tissue, or from free surfaces. As ex- 
amples may be mentioned dropsy in its 
various forms, and effusions resulting from 
inflammation. 
EGYPT, UPPER.-A very dry, tonic, 
winter climate. Mean winter temperature, 
62° F. Season, October to March. See Cli- 
mate, Treatment of Disease by. 
ELECTRICITY IN MEDICINE.- 
The purposes for which electricity is em- 
ployed in medicine are various. It is used 
as a stimulant to excite muscular and ner- 
vous tissue which is the seat of paralysis 
or pain, and as a stimulant to the tissues 
generally; its chemical action may be em- 
ployed for dissolving tissues and coagulat- 
ing blood within aneurysmal sacs; and its 
thermal effects are employed in surgery 
for heating cauteries. The incandescent 
electric light has been adapted for the illu- 
mination of the throat, as well as of the 
bladder and other cavities of the body. 
Electricity is used in its three forms of- 
(1) Franklinic, static, or frictional elec- 
tricity ; (2) Faradism, i.e. electricity gene- 
rated by induction, whether voltaic or mag- 
netic; and (3) Galvanism or Voltaism, which 
owes its existence to chemical action. 
Apparatus. - 1. Franklinic electricity, 
which is generated by the friction of glass discs 
or cylinders, and which was formerly much in 
vogue, may again possibly take its place as a 
ECZEMA 
ELECTRICITY IN MEDICINE 
recognised therapeutic agent. Charcot con- 
tends that in some cases of muscular wasting, 
franklinism will produce a contraction where 
both faradism and galvanism fail to do so; 
and in some cases of ' hysteria ' also frank- 
linism seems to be of undoubted service. 
2. Faradic 'batteries should consist of (a) 
a coil of insulated copper wire, the ends of 
which are in connexion with tbe plates of a 
galvanic cell. This is called the primary 
coil, and contains a bundle of soft iron wire 
in its interior. (6) A second coil of insulated 
copper wire, made of finer wire, and contain- 
ing a greater number of spirals than the 
primary, over which it is made to slide; 
this is called the secondary coil, (c) An in- 
terrupter, capable of interrupting the current 
automatically and with great rapidity, by 
means of the constantly recurring magnetic 
action of the bundle of iron wires in the in- 
terior of the primary coil. These batteries 
should have means of graduating the in- 
tensity of the current of either coil, and of 
including the patient in the circuit of either 
coil without altering the connexions of the 
conducting wires. Sometimes the galvanic 
element is replaced by a large magnet, as in 
the well-known rotating magneto-induction 
apparatus. 
3. Galvanic batteries, when used for thera- 
peutic or electrolytic purposes, should be 
composed of (a) a large number of small 
cells of low electromotive force, and as con- 
stant in their action as possible. The cells 
known as the ' Leclanche ' are the best, (b) 
Means of including in the circuit any number 
of cells at will, so that thereby the intensity 
of the current may be regulated, (c) Means 
of opening or closing the circuit at will, and 
of reversing the direction of the current with- 
out altering the position of the current- 
carriers (rheophores) on the patient's body. 
This is effected by means of a simple con- 
trivance known as a key and commutator, 
(d) A galvanometer. Practitioners who only 
make occasional use of electricity should 
select batteries of the simplest construction; 
and for rough therapeutic purposes a box of 
cells provided with screw terminals (one 
terminal for every third or fourth cell) is all 
that is necessary. Accessories, such as inter- 
rupters, reversers, and galvanometers, should, 
if needed, be purchased independently and 
connected with the battery when required. 
The galvanometer is, for the purposes of 
exact diagnosis, for physiological experiment, 
and for electrolytic operations, quite indis- 
pensable, as by its use alone are we able to 
say what strength of current is operating. 
Not only does the electromotive force of the 
cells employed vary momentarily, but the 
resistance of the body varies in the same and 
in different individuals, so that to say that a 
current from ' so many cells ' has been used 
is no guide. The galvanometer alone is able 
to measure the intensity of the current em- ELECTRICITY IN MEDICINE 
ployed, and these instruments are calibrated 
to register intensity in milliamperes; and in 
recording we say that ' the muscle contracted 
with a current of so many milliamperes,' &c. 
Batteries which are required for heating 
wires and cauteries must be composed of 
cells of high electromotive force, and as large 
as is practically possible. The number of 
cells or elements is of less importance than 
their size. It is not unusual to have, for this 
purpose, Groves's or Bunsen's cells capable of 
containing a pint of liquid each. Accumu- 
lators or storage batteries are now much used 
for this purpose. 
The essential and distinctive differences 
of the two forms of current (galvanic and 
faradic) will now be described. 
The Galvanic Current.-The galvanic 
current is (1) continuously evolved; hence it 
is spoken of frequently as the 'continuous 
current; ' (2) It flows always in the same 
direction-i.e. from the positive pole, which 
is in connexion with the copper or receiving 
plate, to the negative pole, which is in con- 
nexion with the zinc or generating plate. 
This fact must be constantly borne in mind, 
because the action of the two poles is 
markedly different, and it has been asserted 
(on very doubtful evidence, however) that 
the direction of the current in the body, 
whether towards the nerve-centres or to- 
wards the periphery, has an important effect 
upon the physiological and therapeutical re- 
sults. (3) It has well-marked chemical and 
thermal effects. This action is most marked 
at the negative pole, with which, if a mode- 
rately intense current be used, heat, redness, 
inflammation, and even sloughing of the skin 
maybe readily produced. It is therefore always 
necessary to frequently change the position 
of the negative pole on the body. (4) It has 
electrolytic effects. When a galvanic current 
is passed through a conducting compound 
liquid, decomposition of the liquid results, 
oxygen (if water only be used) and acids (if 
saline solutions be used) being evolved at the 
positive pole, while hydrogen or alkalis, as 
the case may be, are evolved at the negative 
pole. Since the human body consists of a 
mass of cells which contain and are bathed 
in saline fluids, many of the phenomena ob- 
served on passing galvanic currents through 
the human body, or any part of it, are prob- 
ably due to this electrolytic action. Faraday 
called the positive pole the anode, and the 
negative pole the cathode, and these terms 
are frequently employed. 
Induced Current.-With regard to the 
induced current, the following points must 
be remembered. (1) It is momentary in 
duration. (2) Its direction is constantly 
changing, so that, in using it, it is less neces- 
sary to distinguish between the poles. (3) 
Its chemical, thermal, and electrolytic effects 
are nil. (4) It has much greater ' tension ' 
than the galvanic current-that is, it over- 
comes the resistance of the body with far 
greater ease. (5) It causes the contraction 
of healthy muscle far more readily than 
the galvanic current. Muscular contractions 
only occur at the moment of making or 
breaking a current, and it is mainly to the 
rapid interruptions of the induced current 
that its high stimulating power is due. The 
current of the secondary coil has greater 
tension, more penetrating power, and greater 
stimulating power than the current of the 
primary coil or ' extra-current.' This is due 
to its being composed of finer wire, and 
having a greater number of turns. 
The stimulating effects of the galvanic 
current which cause muscular contraction 
occur only at the moment of making or 
breaking the current, and not during its con- 
tinuance, and the stimulating effect of the 
two poles is different, as may be demon- 
strated by the ' polar method of investiga- 
tion,' instituted by Brenner of St. Peters- 
burg. If one rheophore be placed on an 
indifferent part of the body, as the back, and 
the other be placed over a nerve-trunk or 
muscle, we are able by means of the commu- 
tator and key to study the action of either 
pole on nerves and muscles during the 
making and breaking of the current. With 
weak currents it is found that contraction 
ensues only when the stimulating rheophore 
is negative (cathode), and only on closing 
the circuit. This is called Cathodal Closure 
Contraction (C.C.C.) If the strength of the 
current be slightly increased, we get contrac 
tion also when the stimulating rheophore is 
positive (anode), and the circuit is opened 
(A.O.C.) Next follows Anodal Closure Con- 
traction (A.C.C.), but Cathodal Opening Con- 
tractions (C.O.C.) never occur in healthy 
muscles with any currents short of those of 
unbearable intensity. 
The galvanic current, unlike the induced 
current, affects the nerves of special sense. 
If it be applied in the neighbourhood of the 
eyes, flashes of light are seen, and blindness 
has resulted in one case from the incautious 
application of strong currents to the face. 
The gustatory nerve is affected in a similar 
way, and the ' galvanic taste ' is perceived 
when the rheophores are placed on the cheek. 
The taste is acid with the positive, but metal- 
lic and coppery with the negative pole. If 
the rheophores are held to the ear, rumbling 
noises are produced, and it is said that stimu- 
lation of the olfactory nerve will give rise to 
a peculiar smell. 
Onimus has pointed out a further distinc- 
tion between the induced and the galvanic 
current. ' An induced current,' he says, 
' only acts during the infinitely short time 
of its passage, after which everything returns 
to order. ... It can never be anything else 
but a series of slight excitements. With con- 
stant currents real excitement is determined 
only at the times of making and breaking. 
563 564 
. . . It is during the silent period, however, 
that the principal action of the continuous 
current makes itself felt.' 
It is certain that the rapid interruptions of 
the induced current, and the strong muscular 
contractions caused thereby, are capable, if 
the current be moderately strong, of rapidly 
and completely exhausting the irritability of 
a muscle, and, if this fact be not constantly 
borne in mind, harm instead of good will 
result from the application of faradism. The 
galvanic current, on the contrary, possesses 
remarkable refreshing effects, a fact which 
has been demonstrated by Heidenhain on 
frogs, and by the writer on the human sub- 
ject. It is found that a man can sustain a 
weight at arm's length far longer than he 
otherwise could, if a galvanic current be 
passed through the nerves of the limb. The 
feeling of fatigue can be removed by the ap- 
plication of the current, and the force of mus- 
cular contraction is increased thereby. These 
facts have important therapeutic bearings. 
Modes of Application.-To apply elec- 
tricity we need to have conducting wires and 
rheophores or current-carriers attached to the 
battery. The best conductors are made of 
ordinary telegraph wire, which should be as 
thick as is compatible with pliability. Tele- 
graph wire is not damaged by moisture, and 
can be readily connected to all forms of bat- 
teries and rheophores, and is therefore econo- 
mical as well as convenient. Rheophores 
vary much in design. They should all have 
insulating handles, and the junction between 
the conductor and rheophore should be 
about the middle of its length, so that both 
conductors may be held in one hand without 
risk of the metallic junctions coming in con- 
tact. The most generally useful rheophore 
is the sponge-holder. An excellent sponge- 
holder, which retains the sponge with abso- 
lute firmness, is that designed by Kidder of 
New York. Rheophores should be of differ- 
ent sizes, from a sponge as big as half-a-crown 
to the pointed extremity of an olive-shaped 
conductor. They should be made of metal 
and not carbon, because the latter is too 
brittle. They may be obtained in the form 
of discs, balls, points ; and of endless design 
for reaching particular organs and regions, 
as the eye, ear, larynx, bladder, rectum, and 
uterus. They are usually covered with wash- 
leather, and used moist. A wire brush is 
useful for influencing the skin. The dry hand 
of the operator, who allows the current to 
pass through his own body to that of the 
patient, may be used for the same purpose. 
It is often convenient to fix one rheophore to 
the patient'sbody,whichmay be accomplished 
by placing an ordinary sponge on the surface 
of the body, laying thereupon the naked end 
of the conducting wire, and securing the whole 
with one turn of a bandage. If we wish to 
influence the surface only, we may use one 
rheophore dry; but if we wish to affect 
ELECTRICITY IN MEDICINE 
deeper-lying structures, we must overcome 
the resistance of the epidermis by thoroughly 
moistening it with hot salt-and-water. We 
may use one rheophore dry, and one moist; 
or we may use as a rheophore a porcelain 
or gutta-percha vessel containing water, into 
which the limb is placed. 
There are two methods of applying elec- 
tricity, known as general electrisation and 
localised electrisation. By the former method 
we pass the current through the entire body 
or great part of it; it has been employed for 
many diseases, but its utility is doubtful. By 
the latter method, which we owe to Duchenne, 
we seek to influence special nerves, muscles, 
or organs, and to limit the action of the cur- 
rent strictly to these parts. ' If we wish to 
influence a muscle, we may do so either by 
applying the rheophores directly over the 
fibres of a muscle, both the rheophores being 
held in one hand and ' promenaded ' over the 
whole surface of the muscle. This is the 
direct method, and is the method advocated 
by Duchenne. Or, instead of trying to in- 
fluence the muscle itself, we may stimulate 
the nerve supplying it, and so cause the 
muscle to contract. This is the indirect 
method, advocated by Ziemssen. It is effected 
by using two rheophores of different sizes. A 
large rheophore is affixed to an indifferent 
part of the body, while with a small pointed 
rheophore an endeavour is made to touch the 
exact point where the nerve we seek to influ- 
ence is most superficial. Neither of these 
methods is to be exclusively adhered to. Cer- 
tain deep-lying muscles, such as the dia- 
phragm and the supinator brevis, are only 
capable of indirect stimulation. It will be 
found also that, in certain diseased conditions, 
muscles will not respond to stimulation 
through the nerves, but only to the direct 
application of the current. When we wish to 
use the refreshing effects of the current, as in 
cases of paralysis which are on the road to re- 
covery, or in cases of fatigued muscles, &c., it 
is advisable to combine the application of the 
galvanic current with a rhythmical exercise 
of the affected muscles. Benedict lays it down 
as a rule that the locus morbi, be it brain, 
spinal cord, nerve, or muscle, should always 
be included between the rheophores. 
Diagnostic and Therapeutical Uses.- 
1. Diagnostic Uses of Electricity.-For 
purposes of diagnosis, electricity is of un- 
doubted service, since by its means we are 
often enabled to distinguish between paralysis 
due to central lesion and paralysis due to 
peripheral lesion. We are accustomed to 
speak of a paralysis as ' central ' so long as 
that portion of a nerve-centre is sound from 
which the nerves supplying the paralysed 
muscles take origin. Thus in cases of damage 
to one internal capsule, the spinal cord and 
the greater part of the brain being healthy, 
we speak of the case as one of central 
paralysis. In cases, too, of paraplegia from local injury, the cord below the injury being 
healthy (notwithstanding that all mental 
control is cut off), we speak of the paralysis 
as central. In such cases of central paralysis 
we find (a) that reflex stimulation of the 
muscles is possible, (&) that the muscles 
undergo but little wasting, and (c) that the 
irritability of the muscles to faradism is 
scarcely diminished. We speak of paralysis 
as due to a ' peripheral ' lesion whenever the 
paralysed muscles are cut off from communi- 
cation with their nerve-centres, or directly 
communicate with centres whose physio- 
logical activity has been destroyed by disease. 
In such cases we find (a) that reflex stimu- 
lation of the paralysed muscles is no longer 
possible, (6) that the paralysed muscles waste 
with remarkable rapidity, and (c) that the 
irritability of the muscles to faradism is 
rapidly diminished, and, as a rule, is ulti- 
mately destroyed. To establish the fact of 
diminished irritability to faradism is generally 
not difficult, and in cases of paralysis affecting 
one side of the body only it is done by com- 
paring the paralysed muscles with their 
healthy fellows. We must take care that 
the current does not vary in intensity, and 
that it passes through exactly similar lengths 
of the body for the stimulation of both sets 
of muscles. It will be found convenient to 
fasten one rheophore to the middle line of 
the body (a big sponge tied to the back of 
the neck answers well), and then, when the 
patient's limbs are arranged exactly sym- 
metrically, test the healthy muscles first with 
a small or pointed rheophore, and determine 
the current of least intensity which will cause 
contraction. Then the rheophore is to be 
applied to exactly the same spot on the oppo- 
site limb, and, if contraction follows as 
readily as on the healthy side, we know that 
there is no diminution of irritability. If, 
however, contraction do not follow, we in- 
crease the strength of current, and so deter- 
mine to what extent the irritability is dimin- 
ished, and whether or no it is completely 
extinguished. We should add that in cases 
of peripheral paralysis the diminution and 
extinction of irritability do not supervene 
immediately on the occurrence of the para- 
lysing lesion, but only after the lapse of a 
week or ten days. In paraplegia or other 
morbid conditions in which paralysis affects 
both sides of the body it is, of course, impos- 
sible to compare a paralysed muscle with its 
healthy fellow, and in such cases we can only 
judge of the amount of irritability by expe- 
rience and mental comparison with previous 
instances. It is found, in cases of peripheral 
paralysis, that after complete extinction of 
faradic irritability the muscles will respond 
to a slowly interrupted galvanic current, and 
that not infrequently the irritability of the 
muscles to galvanism is greater on the para- 
lysed than on the sound side of the body. 
It sometimes happens that not merely quan- 
ELECTRICITY IN MEDICINE 
titative but qualitative changes take place in 
the irritability of these muscles, and that the 
Anodal Closure Contraction (A.C.C.) soon 
becomes very marked, and equals or even 
surpasses in force the Cathodal Closure 
Contraction (C.C.C.); and further that the 
Cathodal Opening Contraction soon becomes 
more marked than the Anodal Opening Con- 
traction. These reactions, which are sup- 
posed to depend upon degenerative changes 
in the muscle and motor nerve-endings, have 
been spoken of as the degenerative reactions. 
These quantitative and qualitative changes 
in irritability are found (1) in some forms of 
paraplegia due to degenerative changes in 
the cord; (2) in so-called spinal paralysis 
both of infants and adults; (3) in traumatic 
paralysis due to injury of the nerve-trunks; 
(4) in rheumatic paralysis, that is, paralysis 
due to 'rheumatic' thickenings of the neuri- 
lemma ; and (5) in lead-paralysis. 
Its occurrence is probably determined by 
the degeneration of the motor nerve. In one 
form of 'rheumatic' paralysis-paralysis of 
the musculo-spinal nerve from cold, as de- 
scribed by Duchenne-the reactions of the 
paralysed muscle remain normal. 
In ordinary hemiplegia the irritability of 
the muscles remains, as a rule, unchanged. 
In some cases, however, the irritability is 
increased in the early stages ; and occasion- 
ally after the paralysis has lasted some time 
we find slight diminution of irritability. In 
some of the conditions confusedly known as 
progressive muscular atrophy, the irrita- 
bility of the wasted muscles to faradism 
remains undiminished to the end. 
2. Therapeutical Uses of Electricity. 
a. In Paralysis.-The treatment of paralysis 
by means of electricity must be conducted 
rationally and with discrimination. By 
means of electricity we may attempt to re- 
move the cause of the paralysis, by influencing 
the nutrition of the parts where such cause is 
situated, by acting on the sympathetic nerve- 
branches supplying the walls of the blood- 
vessels. Thus it is asserted that the absorption 
of a clot in the brain may be hastened, and 
that the nutrition of a damaged brain may 
be improved, by acting upon the cervical 
sympathetic nerve. To influence the cervical 
sympathetic we place one rheophore over 
the superior cervical ganglion (which may be 
reached by pressing inwards behind the angle 
of the jaw), and the other on the back, over 
the first and second cervical vertebrae. The 
use of such a proceeding is more than doubt- 
ful, and in case of any improvement occur- 
ring it would be impossible to know to what 
such improvement ought to be attributed, 
since the passage of a current' across the 
upper part of the neck must influence many 
important nerves besides the sympathetic. 
On the who'e, we think that galvanisation of 
the sympathetic is not to be advised in the 
early stages of paralysis. Galvanisation of 
565 566 
the sympathetic has been employed in chronic 
degenerative changes in the brain or cord, but 
with very doubtful success. 
The localised application of the electric 
current to the paralysed muscles is of un- 
doubted service, and in employing it we 
should bear in mind the following rules. 
1. As to the object of our treatment, we should 
remember the words of Sir Thomas Watson, 
' That our aim is to preserve the muscular 
part of the locomotive apparatus in a state of 
health and readiness, until peradventure that 
portion of the brain from which volition pro- 
ceeds havingrecovered its function, or the road 
by which its messages travel having been re- 
paired, the influence of the will shall again 
reach and reanimate the palsied limbs.' 
2. Always to employ that form of current to 
which the muscles most readily respond. 
Thus if the muscles act readily to faradism, 
then faradism is to be used. In some cases 
of peripheral palsy we find that contraction 
follows only on the application of a very 
strong galvanic current, very slowly inter- 
rupted, and accordingly a slowly interrupted 
galvanic current must be used. As the case 
improves we shall find that a weaker current 
produces similar results, and that the muscle 
contracts with moderately rapid interruptions. 
And so will improvement gradually take 
place in favourable cases till faradic irrita- 
bility and lastly voluntary power are restored. 
3. Always to employ the weakest currents 
which will cause muscular contraction, and 
never to run the risk of exhausting a 
muscle by causing a too prolonged contrac- 
tion. Each muscle should be taken in turn, 
and be made to contract two or three times 
in succession, and having gone over the 
whole of the paralysed muscles seriatim the 
process may be repeated. An application of 
this kind every other day is usually sufficient. 
4. If the paralysis to the will remain absolute, 
and if the contractility of the muscles be 
perfect, we do no good by persevering with 
electrical treatment. This condition is often 
met with in hemiplegia. The patient is 
absolutely helpless on one side, although the 
paralysed muscles are in no degree wasted, 
and their irritability remains normal. 5. If 
the paralysis to the will remain absolute, and 
if the irritability of the muscles be diminished, 
then electricity is useful, in so far as it helps 
to improve the nutrition of the muscles and 
restore their normal degree of irritability. 
The normal degree of irritability and nutri- 
tion being restored (the paralysis to the 
will remaining absolute) electrical treatment 
may be discontinued. 6. If the irritability 
to both forms of current has completely dis- 
appeared, we are not justified in persevering 
too long, nor in holding out delusive hopes 
to the patient. Nevertheless, treatment 
should not be abandoned without a patient 
trial. [For the treatment of special forms 
of paralysis by electricity, the reader is re- 
ELECTRICITY IN MEDICINE 
ferred to the appropriate sections of this 
work.] 
ft. In Painful Affections.-The power of 
electricity to relieve pain is very great. The 
relief is usually temporary, but in many 
cases is permanent. Electricity may act by 
serving to divert the mind from troubles real 
or fancied, or its counter-irritating effects 
may serve the same purpose as other counter- 
irritants whpse power to relieve pain is well 
recognised. Occasionally electricity will give 
relief when every known remedy has failed, 
and in such cases we must suppose that it 
acts by bringing about some change in the 
nerves themselves by its specific action on 
nervous tissue. All three forms of electricity 
are employed for the relief of pain, but the 
galvanic current will be found the most 
generally applicable. Some writers insist 
that the anode (positive pole) shall be applied 
to the painful spot. Strong faradisation 
serves in some cases to give relief. The 
effects of galvanism should be tried in every 
case of neuralgia, but it is not capable of 
relieving all cases, and disappointment is not 
infrequent. Where muscular movements 
increase the neuralgic pains, a rhythmical 
exercise of the affected muscles should be 
conjoined with the galvanism. Headache of 
all kinds not infrequently yields to electri- 
city ; lumbago, sciatica, and those painful 
muscular conditions which we call 'rheu- 
matic,' are quickly relieved by it. Tinnitus 
aurium will sometimes yield to the galvanic 
current when all other remedies have failed. 
•y. In Spasmodic Diseases.-In the treat- 
ment of spasmodic diseases, electricity is of 
limited utility. Some forms of tremor are 
relieyed by it. Some aggravated cases of 
writer's cramp have yielded to it when all 
other remedies have failed, and a few cases 
of clonic torticollis have received undoubted 
benefit by its judicious application. Tonic 
spasm of internal organs, such as the bowel 
and bladder, has been relieved by the galvanic 
current. 
8. In other Diseases.-In addition to the 
treatment of diseases of a purely nervous 
character, electricity has been employed as a 
remedial agent in diseases whose origin is not 
so obviously connected with the nervous 
system. It has relieved the paroxysms of 
angina pectoris, and the burning pains which 
accompany herpes zoster. It has been 
employed in the treatment of many obstinate 
skin-diseases by American physicians, and 
Dr. Cheadle has recorded a case in which 
the dilated vessels in acne rosacea were 
made to contract by faradisation. Rheu- 
matic gout is said to have been benefited 
by a ' central ' application of galvanism (one 
pole to the nucha, and the other to the 
epigastrium). The flow of urine in diabetes 
has been stated to be diminished by a similar 
process; and the symptoms of exophthalmic 
goitre have (it is said) been diminished by ELECTRICITY IN MEDICINE 
ELEPHANTIASIS ARABUM 
567 
galvanisation of the cervical sympathetic. 
There is in fact scarcely a disease, from 
epilepsy to chilblains, in which it has not 
been alleged that electricity has been of use. 
In obstetric medicine, for the arrest of post- 
partum haemorrhage, faradisation is now one 
of the recognised means to be employed ; and 
it has been of more doubtful service for the 
rectification of displacements of the uterus. 
Ovarian pain and tenderness have been 
relieved by the galvanic current, and amenor- 
rhcea has often yielded to electricity. 
e. Gain ano-cautery and Galvano-puncture. 
The chemical and thermal effects of galvanism 
are largely employed both in surgery and 
medicine. Its thermal effect has been used 
for the heating of cauteries ; and cauteries so 
heated have very obvious advantages over all 
other forms. The chemical effect of the 
negative pole has been used as a caustic for 
the destruction of tissues, and tumours of 
considerable size have, it is said, been ' dis- 
persed' by this means. The treatment of 
uterine fibroids, as recommended by Apostoli, 
by passing a current of 250 or more milli- 
amperes by means of a big clay rheophore 
applied to the abdomen and a special platinum 
rheophore inserted in the uterus, is a mode of 
treatment which is occupying the attention 
of obstetricians, and is still sub judice. The 
same may be said of similar measures applied 
to cancerous and other tumours. Galvano- 
puncture has been used in the treatment of 
hydatid cysts of the liver, but it is at least 
doubtful whether simple puncture is not quite 
as serviceable. Galvano-puncture seemed at 
one time likely to take a recognised position 
among the means at our disposal for the 
treatment of aortic aneurysms. Several cases 
were recorded in which improvement followed 
this method of treatment, but the success 
attending it has not on the whole been 
encouraging, and it has fallen almost entirely 
into disuse. G. V. Poore. 
ELEPHANTIASIS ARABUM (A/. 
<^as, an elephant).-Synon. : Fr. Elephan- 
tiasis ; Ger. Elephantiasis. 
Definition.-A non-contagious disease, 
characterised by recurrence of febrile pa- 
roxysms, attended by inflammation and pro- 
gressive hypertrophy of the integument and 
areolar tissue, chiefly of the extremities and 
genital organs ; and occasionally by swelling 
of the lymphatic glands, enlargement and 
dilatation of the lymphatics, and in some 
cases by the co-existence of chyluria, and the 
presence in the blood of certain nematode 
haematozoa ; together with various symptoms 
indicative of a morbid or depraved state of 
nutrition. 
^Etiology.-Elephantiasis is endemic in 
India, the Malayan peninsula, China, Egypt, 
Arabia, the West Indies, and parts of Ame- 
rica, chiefly in localities within the influence 
of the sea air ; and it occurs sporadically all 
over the globe, excepting, perhaps, in the ex- 
treme north and south. Certain conditions 
of soil and climate, such as humidity, heat, 
malarious influences, and proximity to the 
sea-coast, seem to be concerned in producing 
the disease and influencing its development. 
Removal from the endemic area frequently 
checks the disease, whilst return there re- 
produces it. Elephantiasis affects both sexes, 
and persons of all ages and conditions of life, 
but more men suffer from it than women. 
No race is exempt, but it is much more fre- 
quent in dark than in fair races. It occurs 
at all ages, but is most common in adult and 
middle life, comparatively rarely beginning in 
young children or in the aged. Elephantiasis 
is doubtfully hereditary; but Richards found 
that of 236 persons, 73 per cent, had one or 
both parents affected. Various causes are 
assigned for the disease. Air, water, food, 
and, as it is common near the sea-coast, eat- 
ing fish have been frequently credited with 
producing it. Certain forms of vegetation, 
and the geological formation of the soil, have 
also been regarded as predisposing and de- 
termining causes. Climate and locality, 
combined with bad living, are doubtless the 
real predisposing causes ; and it is probable 
that, as the late Dr. T. Lewis suggested, it 
may be found to be intimately associated with, 
if not entirely dependent on, the presence in 
the blood of certain parasites. No race is 
exempt from the disease, but, whatever may 
be the explanation, the white suffer less than 
the dark races. It does occur occasionally, 
though very rarely, in the pure European 
in India, but more frequently in those of 
mixed descent; it will generally be found 
that where it occurs in persons of apparently 
European parentage, there is a mixture, how- 
ever slight, of dark blood. 
Anatomical Characters.-The hypertro- 
phy of elephantiasis in most cases appears 
to be simply an increase in the natural ele- 
ments of the part, the blood-vessels and lym- 
phatics sharing in the growth. In other 
cases the lymphatics and lymph-spaces are 
most concerned, giving rise to a condition 
that has been described as ncevoid elephanti- 
asis, in which the appearance is presented of 
a soft and fluctuating swelling, which when 
punctured gives issue to a white or pinkish 
fluid, very closely resembling chyle. The 
lymphatic glands also share in the enlarge- 
ment. In other respects the progress of this 
variety is like that of the ordinary form of 
the disease. 
The Filaria sanguinis hominis is some- 
times found in great numbers in the blood of 
persons suffering from elephantiasis; and the 
mosquito is considered to be the medium by 
which the haematozoon is transmitted to 
water, and thence to the human body; but its 
causal relations to the disease are not abso- 
lutely established. See Filaria Sanguinis 
Hominis. 568 
ELEPHANTIASIS ARABUM 
Symptoms.-The ordinary form in which 
elephantiasis presents itself is hypertrophy 
of the integument and areolar tissue of some 
part of the trunk or limbs, and notably of the 
legs and genital organs. The skin becomes 
enormously thickened by hypertrophy of all 
the fibrous elements of its structure, attended 
by the deposit of a quantity of albuminous 
fluid in the interstices of the areolar tissue. 
The papillae are prominent and much in- 
creased in size. The integument is formed 
into hard masses or folds, with a rugose con- 
dition of the surface, not unlike the appear- 
ance of an elephant's leg. The feet and toes 
are sometimes almost hidden, and the scro- 
tum or labia form enormous outgrowths. The 
scrotum often attains great weight, and may 
be accompanied by large hydroceles. Scrotal 
tumours have been removed weighing up- 
wards of 100 lbs. 
The onset of elephantiasis is frequently 
violent and attended with great suffering. 
There is high fever; intense pain in the 
lumbar region, groin, spermatic cords, and 
testes, which become swollen; while acute 
hydroceles form. These symptoms are often 
attended with sympathetic vomiting, nausea, 
and rapid erythematous swelling of the ex- 
ternal parts; and, if the extremities be 
attacked, the swelling may be tense and 
painful, accompanied by much effusion into 
the areolar tissue. The surface of the in- 
teguments is much inflamed, and sometimes 
discharges a serous ichor or chyle-like fluid, 
according to the extent to which the lym- 
phatics are engaged in the particular case. 
The great tension and swelling of the sper- 
matic cords are apt to dilate the abdominal 
rings so widely, that after recovery the 
patient may suffer from hernia. 
In some cases of elephantiasis the integu- 
ments are also the seat of a dilated and turgid 
condition of the lymphatic vessels, which 
during the periods of vascular excitement, 
when the febrile attacks occur, give way and 
discharge a chyle-like fluid ; in other cases 
the surface temporarily assumes a herpetic 
condition, which exudes an acrid and offen- 
sive serous fluid. See Chyluria. 
Elephantiasis not infrequently occurs with- 
out much or any obvious injury to, or dis- 
turbance of the general health during the 
intervals between the febrile attacks, which 
in some cases are few and slight. The appe- 
tite, spirits, and strength are good, the func- 
tions are all normally performed, and the 
only inconvenience is that due to the size and 
weight of the outgrowth. On the other hand, 
it is frequently quite the reverse : the rapidly 
recurring febrile attacks, pain, exhaustion, 
suffering, and visceral complications induce 
a state of cachexia and debility sometimes so 
serious as to render even surgical interference 
impracticable. Withal, hepatic and splenic 
enlargements do not as a rule result from the 
persistence of the elephantoid fever alone; 
though not infrequently, as a more direct 
result of malarious poisoning, they seriously 
complicate the evils of the sufferer's condi- 
tion. Albuminuria, as well as chyluria, is 
occasionally present. 
In somO cases, after the outgrowth has at- 
tained a certain bulk, it ceases to grow alto- 
gether, or increases slowly and insidiously 
without febrile disturbance, and in such cases 
the general health remains good. But there 
is generally a tendency to recurrence of the 
fever once or twice a month, when the parts 
affected become tense, hot, painful, and 
swollen, and often discharge a serous or 
lymph-like fluid, which may be acrid and 
offensive. Some tumours, on the other hand, 
are very slightly, if at all, so affected, and re- 
main perfectly dry. In all cases, however, 
some growth goes on; and even when, as oc- 
casionally happens, fever has ceased to recur, 
there may be a gradual, but slow and pain- 
less, increase of the hypertrophy. The 
greatest variety and uncertainty obtain in 
the duration and progress of the growth: 
sometimes it is very rapid, at other times it 
is slow, with intermissions of activity and 
indolence of development. The disease else- 
where than in the genitals, unless it be ac- 
companied by exhaustion and debility, causes 
no failure in the generative powers in either 
sex. Women may have a tendency to mis- 
carry when suffering from elephantiasis. 
Course, Duration, and Terminations.- 
According to Richards, the average duration 
of the disease, as deduced from the observa- 
tion of 636 cases, was 11| years; and he 
notes that the earliest age was nine years, 
whilst the latest at which he observed it was 
eighty years. It appears from this that the 
disease has little influence in shortening life. 
Pathology.-The outgrowths in elephan- 
tiasis are the local expressions of a constitu- 
tional disease, and are not to be regarded 
merely from their local point of interest. 
They are the result of certain climatic in- 
fluences whose exact nature is not at present 
determined; though, considering the geo- 
graphical range of the area where the disease 
is endemic, it seems probable that, whatever 
other cause may be at work, the so-called 
malarious influences play some part in its 
production. 
The researches of the late Dr. T. Lewis into 
the pathology of chyluria in India, and his 
discovery of certain haematozoa in the blood 
of those affected with that disease, coupled 
with the fact that the subjects of chyluria and 
haematozoa are also frequently, if not always, 
affected by elephantiasis with its febrile 
paroxysms, hypertrophied integument, and 
lymphatic disturbance, are very suggestive of 
a community of origin of these morbid con- 
ditions. Dr. P. Manson's investigations into 
the connexion of the mosquito with the 
transmission of the filaria are also most im- 
portant and interesting. ELEPHANTIASIS ARABUM 
EMBOLISM 
569 
Treatment.-Little has yet been done by 
constitutional treatment in cases of elephan- 
tiasis. Remedies useful during the febrile 
paroxysms have little power in preventing 
recurrence of, or in checking the disease. 
Iodine, combined with quinine, arsenic, and 
iron, has been found useful to a certain extent. 
During the febrile state salines, diaphoretics, 
and such remedies as are needed during the 
pyrexial state of malarious fevers, are indi- 
cated. Opium may be necessary to relieve 
the intense pain which often accompanies the 
onset of the stage of excitement. When the 
febrile stage has passed, quinine is useful, 
which, if anaemia exist, should be combined 
with iron. The local application of iodine, in 
such forms as the iodide of lead or biniodide 
of mercury ointment, has been thought useful; 
but as this is generally combined with pres- 
sure in the recumbent posture, the benefit is 
probably due to the latter. Such measures, 
along with improved hygienic conditions, 
may no doubt control the progress of the dis- 
ease and relieve suffering. No remedy, how- 
ever, is so potent as change of climate, by 
removal from the endemic site of the dis- 
ease. This, if effected in the earliest stages, 
may completely arrest the disease, and per- 
haps even disperse any incipient structural 
change. This has been observed in the rare 
cases in which elephantiasis occurs in 
Europeans, who, on returning to Europe, 
have after a time lost the disease, and almost, 
or entirely, any hypertrophic changes that 
may have occurred. Natives of India im- 
prove if they leave the endemic area during 
the early stages, and go and reside in other 
and drier localities. However, when the 
hypertrophy is advanced, the paroxysms of 
fever are still liable to recur, even when 
the climate is changed, though with less 
violence. 
Surgical treatment, when the hypertrophy 
is advanced, is often most successful in re- 
lieving the sufferer, not only of the local 
trouble, but also of the fever. Tumours of 
the genital organs, sometimes of enormous 
size, are now removed with complete success 
and comparatively small mortality. Before 
commencing the operation, especially in the 
case of a large scrotal tumour, it is well to 
drain it of blood by placing the patient on his 
back, and elevating the tumour on the abdo- 
men for an hour or so, during which time 
pressure by a bandage (a modification of 
Esmarch's) may be tried, and cold (ice) may 
be applied. During the operation, the appli- 
cation of a whipcord ligature drawn tightly 
round the neck of the tumour also prevents 
loss of blood. 
The removal of a scrotal tumour is effected 
by incisions along the course of the cords and 
the dorsum penis. The cords, testicles, and 
penis are turned out by a few touches of the 
knife, and then reflected and held up on the 
abdomen, while the mass of the tumour is 
rapidly swept away by a few bold incisions 
in the perinaeum. The numerous venous and 
arterial bleeding points should then be ar- 
rested, and the wound dressed with antiseptic 
applications. No attempt should be made 
to preserve flaps of integument either for the 
penis or testes. It is unnecessary, and 
almost certain to be followed by recurrence 
of the disease. The process of cicatrisation 
goes on rapidly, and in from two to four 
months all is closed in by cicatricial tissue, 
which gradually perfects itself, and has no 
liability to become the seat of a return of the 
disease. Joseph Fayrer. 
ELSTER, in Saxony.-Alkaline sul- 
phated waters. See Mineral Waters. 
EMACIATION" (emacio, I make lean). 
Wasting or loss of flesh. The term is applied 
both to the process of wasting and to the 
condition that results therefrom. See 
Atrophy ; and Atrophy, General. 
EMBOLISM (epfidKov, a plug).-Synon. : 
Fr. Embolie ; Ger. Embolic. 
Definition.-The arrest in the arteries or 
capillaries of some solid body, which has been 
carried along in the course of the circulation. 
Pathology. - Emboli usually consist of 
portions of fibrin derived from thrombi of 
the veins or heart, or of vegetations detached 
from the cardiac valves. They may, however, 
be formed by fragments of tumours which 
have grown into the blood-vessels, or of other 
foreign bodies, including fat, which have ob- 
tained entrance into the circulation. 
The effects of embolism may be divided 
into two classes: First, those which are 
caused by the arrest of the circulation; and 
secondly, those which are due to any specially 
irritating properties of the embolus. 
1. The embolus may, first, be supposed to 
consist of some indifferent substance not pos- 
sessing any irritating qualities. The effects 
which may then be caused by arterial embo- 
lism are mainly these : First, a transient an- 
aemia of the territory supplied by the blocked 
artery. This may pass away without leav- 
ing any permanent consequences. Secondly, 
necrosis of this territory. This may be 
either sudden, in the form of gangrene; or 
more gradual, in the form of softening or 
withering. Thirdly, the formation of a 
haemorrhagic infarction, that is, congestion 
of the territory, followed by extravasation of 
blood into the tissues, and so the formation of 
a firm, solid patch of a dark red colour, 
usually of a wedge shape, with the apex to- 
wards the embolus, and the base towards the 
periphery. In very soft organs, as the brain, 
the extravasation may break down the tissue 
and cause the ordinary phenomena of an 
apoplectic clot. These haemorrhagic infarc- 
tions undergo various subsequent changes. 
Usually a process of degeneration sets in; 570 
the blood-pigment passes through its familiar 
transformations; the patch changes from dark 
red to tawny and yellow, undergoes molecular 
disintegration, shrinks away, and ultimately 
leaves a depressed fibrous patch, in which the 
remains of the altered blood, crystals of 
haematoidin, &c., may often be recognised. 
Sometimes the patch softens down into a 
puriform fluid, which may become surrounded 
by a fibrous capsule, and ultimately dry up, 
or even calcify. When recent, these patches 
are usually surrounded by a halo of con- 
gested vessels. 
The cause which determines these different 
results of arterial embolism is, in the main, 
the anatomical arrangement of the blood- 
vessels. Supposing the embolus to be lodged 
in an artery which gives off anastomotic 
branches between the seat of the embolus 
and the final capillary distribution, the effect 
in most cases will be transient anaemia, the 
collateral channels will enlarge, and the cir- 
culation will be again restored. A thrombus 
will form on the embolus and will extend 
back to the next arterial branch, and the 
changes described in the article on throm- 
bosis will take place in it (see Thrombosis). 
If the blocked artery be of large size, and 
supply important organs, the symptoms of 
temporary arrest of function of the part sup- 
plied by the artery will follow, as transient 
paralysis, dyspnoea, coldness of the extremi- 
ties, &c., according to the artery affected. 
Should, however, the artery be small, and 
not supply important organs, no symptoms 
whatever will be caused; and this is the case 
in the majority of embolisms. Supposing, 
however, the artery is what Cohnheim calls a 
terminal artery-i.e. one which gives off no 
anastomotic branches between the embolus 
and the final capillary distribution, and that 
the capillary anastomosis with other arterial 
territories is insufficient to supply a col- 
lateral circulation, and that the presence 
of valves prevents the reflux of blood into 
the territory from the veins, it is manifest 
that the embolism must completely cut 
off the blood-supply, and consequently, in 
some form or other, cause necrosis of the 
territory. 
The network of anastomosing channels is, 
however, so close in most parts of the body 
that, in order to produce this effect, it is neces- 
sary either that the main artery of the part 
be obstructed, or else that there be multiple 
embolisms blocking up at the same time 
several arterial branches, and so stopping 
the channels of collateral circulation. 
The mode in which the haemorrhagic in- 
farction is produced is still a subject of dis- 
pute. According to Cohnheim, whose views 
until recently were generally accepted, the 
haemorrhage is due to a reflux from the veins 
into the territory supplied by the blocked 
artery. This first causes congestion, and then 
extravasation, in consequence of impairment 
EMBOLISM 
of nutrition of the walls of the blood-vessels 
for the integrity of which the circulation oi 
the blood is essential. According, then, to 
Cohnheim, in order to produce the phenomena 
of the haemorrhagic infarction it is neces- 
sary that the artery be a terminal one- i.e. 
one which gives off no anastomotic branches 
for some distance before its final capillary 
distribution, and that the veins be not fur- 
nished with valves. These conditions are 
met with in the spleen, the kidney, the brain, 
certain branches of the pulmonary artery 
supplying surface lobules, and the central 
artery of the retina; and on these grounds 
he accounts for the frequent occurrence of 
haemorrhagic infarctions in these organs, 
though there is no reason to suppose that, 
with the exception of the lungs, embolisms 
are more frequent in them than in other 
parts. 
The more recent researches of Dr. M. 
Litten, Zeitschrift fur klinische Medicin, 
vol. i. p. 189, render, however, these views 
no longer tenable. He shows by experiments 
on the kidney, spleen, lung, &c., that if the 
blocked artery be a strictly terminal one-i.e. 
one whose area of distribution has no other 
arterial supply, the phenomena of the haemor- 
rhagic infarction do not occur, even though 
the vein have no valves; and under other 
circumstances that the infarction takes place 
although the vein has been ligatured; hence 
the cause of the infarction cannot be venous 
reflux. Thus, if both the renal artery and 
vein be ligatured, infarction of the kidney 
takes place, the kidney receiving a sufficient 
collateral supply of blood from other sources; 
but if the capsule be first stripped off, and the 
kidney left attached only by the renal artery 
and vein, no infarction takes place, though 
the vein is left pervious. Similar results 
were obtained in other organs. Hence it would 
seem evident that the congestion and infarc- 
tion following embolism are produced by an 
afflux of arterial blood into the territory from 
collateral channels. Should these be nume- 
rous, and should small arteries open directly 
into the anaemic territory, the circulation will 
soon be restored, and no infarction will take 
place ; should, however, the communication 
be imperfect, and chiefly by means of capil- 
laries, a congestion of the territory, leading 
to diapedesis, and infarction will result, the vis 
a tergo being insufficient to propel the blood 
onwards into the veins. 
Litten has also shown that the vessels in 
which the circulation has been arrested retain 
their integrity much longer than was supposed 
by Cohnheim; and that in the kidney, long 
before the vessels suffer, necrosis of the epi- 
thelium takes place, the nuclei of the cells 
disappear, their protoplasm coagulates, and 
they become converted into swollen hyaline 
masses (coagulation necrosis'), which have a 
remarkable tendency to calcification. Hence 
the wedge-shaped white embolisms often seen EMBOLISM 
EMETICS 
571 
in the kidney are not produced by decolor- 
isation of haemorrhagic infarctions, but are 
simply the result of the necrosis of the 
epithelium ; and the halo of injection which 
is often seen to surround them is due to in- 
flammatory congestion caused by the pre- 
sence of the necrosed patch. 
This explanation of the mode of produc- 
tion of the haemorrhagic infarction is more 
closely in accord with the view originally 
propounded by Virchow, who regarded the 
haemorrhage as due to collateral fluxion. 
2. We have now to consider the effects of 
emboli which possess irritating or poisonous 
qualities, such as those derived from the puri- 
form softening of venous thrombi in cases 
of septic inflammation. The mechanical 
effects will be the same as those of the pre- 
vious class; but, in addition, these emboli 
set up a suppurative inflammation in their 
vicinity, quite independent of any obstruc- 
tion of the circulation. Hence it is that we 
meet with pyaemic abscesses, as the result of 
infecting emboli, in all parts of the body, 
while the effects of obstructed circulation 
are, for the most part, confined to certain 
organs. Thus the liver is very frequently the 
seat of embolic abscesses, while haemorrhagic 
infarctions do not occur there. In the lung, 
where in parts terminal arteries are found 
but for the most part there is free anastomosis, 
the two processes are often seen side by side. 
The different effects of these two classes of 
embolism are very manifest in the capillaries. 
Simple emboli, of such small size as to be- 
come first arrested in the capillaries, either 
cause no permanent change at all, or, at most, 
produce a punctiform haemorrhage. Infect- 
ing emboli, on the other hand, give rise to 
the miliary abscesses so often seen in pyaemia. 
W. Cayley. 
EMESIS (enea>, I vomit).-A synonym 
for vomiting. See Vomiting. 
EMETICS (e/xew, I vomit).-Synon. : Fr. 
Emetiques; Ger. Brechmittel. 
Definition.-Agents that produce vomit- 
ing. 
Enumeration.-Copious draughts of Luke- 
warm Water, Mustard, Sulphate of Zinc, 
Sulphate of Copper, Carbonate of Ammonium, 
Common Salt, Alum, Chamomile, Tartar 
Emetic, Ipecacuanha, and Apomorphine. 
Action.-The act of vomiting consists in 
the simultaneous spasmodic contraction of 
the diaphragm and abdominal muscles, and 
relaxation of the cardiac orifice of the 
stomach, so that its contents are expelled. 
When the diaphragm and abdominal muscles 
contract, but the cardiac orifice remains 
closed, so that the contents of the stomach 
cannot escape, the expulsive efforts are 
termed retching. The nervous centre which 
regulates these movements is situated in the 
medulla oblongata; and it may be excited 
either directly by the action upon it of drugs 
carried to it by the blood, or reflexly by 
irritation of various nerves. The drugs that 
act directly upon it have the same action, 
whether they are introduced immediately 
into the circulation or absorbed by the 
stomach. They may thus produce vomiting 
and evacuation of the stomach without being 
taken into the stomach at all, and on this 
account they are termed indirect emetics, 
although they act directly upon the vomit- 
ing centre. Such are ipecacuanha, apomor- 
phine, and tartar emetic. Similarly the 
drugs that excite it reflexly are still termed 
direct emetics, because they are applied 
directly to the stomach. Such are the sul- 
phates of zinc, copper, and aluminium; car- 
bonate of ammonium; salt; mustard; and 
chamomile, which irritate the nerves of the 
stomach. Tickling the fauces with a feather, 
or with the finger, also excites reflex vomit- 
ing, and may be adopted either alone, or in 
order to aid the action of other emetics. 
The terms direct and indirect, therefore, as 
applied to emetics, relate to the stomach, 
and not to the centre for vomiting. 
Direct emetics, as they stimulate the 
nerves of the stomach only, have little action 
except that of simply exciting vomiting. 
The indirect emetics, which excite vomiting 
by their action on the medulla oblongata, 
act also on other parts of the nervous system, 
and cause secretion of saliva, secretion of 
mucus from the oesophagus, stomach, and 
bronchial tubes, and perspiration. They also 
cause much nausea, depression of the cir- 
culation, and loss of nervous and muscular 
power. Further, the vomiting they induce 
is more continuous and violent, and often 
expels the contents of the gall-bladder, caus- 
ing part of the bile to flow into the stomach, 
and be thus evacuated. 
Uses.-Emetics are employed to remove 
the contents of the stomach under various 
circumstances. Firstly, when the food is 
causing irritation, and not undergoing proper 
digestion, as, for example, in dyspepsia or sick- 
headache; and in such cases large draughts 
of lukewarm water, of mustard and water, or 
of an infusion of chamomile are usually 
found beneficial. Secondly, in cases of poi- 
soning ; and here mustard, sulphate of zinc, 
and sulphate of copper are best, as they empty 
the stomach most quickly and effectually. 
Thirdly, to cause the expulsion of bile from 
the gall-bladder, or remove bile from the 
body, in biliousness, fevers, and ague. When 
the bile-duct is stopped by a small gall-stone, 
the pressure exerted on the gall-bladder 
during vomiting has been known to cause 
the expulsion of the calculus. In bilious- 
ness, excess of bile is more readily removed 
by vomiting than by purging, as there is no 
opportunity for the bile to be absorbed on 
its way from the gall-bladder to the mouth, 
whereas it may undergo absorption on its pas- 
sage through the intestines. It is supposed by some that various poisons circulate occa- 
sionally in the bile, such as the malarious 
poison which occasions ague, and possibly 
certain septic poisons which give rise to 
fevers. The advantage of emetics in ague is 
undoubted, as it can certainly sometimes be 
cured by them without quinine, and the 
action of quinine is always aided by their 
use. They have also been recommended in 
the early stages of continued fevers. In 
such cases tartar emetic or ipecacuanha is 
most serviceable. Fourthly, to cause expul- 
sion from the air-passages of false membrane 
in croup or diphtheria, or of secretions in 
bronchitis and phthisis. For these purposes 
ipecacuanha is the emetic most frequently 
chosen; but if it do not act rapidly in croup, 
sulphate of zinc or sulphate of copper may 
be employed, or a teaspoonful of powdered 
alum and honey. In cases of either croup or 
bronchitis, where there is great depression of 
the circulation, carbonate of ammonium may 
be used with advantage, as it not only causes 
vomiting, but at the same time stimulates 
the circulation. 
T. Lauder Brunton. 
EMMENAGOGUES (e^va, the 
menses; and ay a, I move or expel). 
Definition.-Emmenagogues are remedial 
agents which stimulate or restore the normal 
menstrual function of the uterus, when it is 
irregular or absent. 
Enumeration.- Emmenagogues may be 
either indirect, as Iron, Strychnine, and 
other tonics, Warm Hip-baths, Leeches, Mus- 
tard, Aloetic purgatives, &c.; or direct, as 
Rue, Borax, Savin, Myrrh, Cantharides, 
Guaiacum, Apiol, Quinine, Digitalis, and 
Ergot-most of which, when given in larger 
doses, produce abortion, and are called 
ecbolics. The most efficient means, how- 
ever, of obtaining this last-named action are 
those of a mechanical nature, so well known 
to obstetricians, and directed either to the 
actual rupture of the membranes, or to their 
separation from the cervix. 
Action.-The indirect emmenagogues act 
by improving the quality of the blood, giving 
tone to the nervous system, or irritating ad- 
jacent parts or organs, from which a stimu- 
lating influence is conveyed by reflex action 
to the w'omb. 
The direct drugs in moderate doses gently 
stimulate the uterus, thus promoting the 
menstrual flow, or even checking it when 
in excess; but when further pushed they 
may cause powerful contraction of the un- 
striped muscular fibre, of which its walls 
are mainly composed. Ergot is believed to 
act either directly on the muscular tissues 
themselves, or through the intermediate in- 
tervention of some central or peripheral 
nervous influence. 
Uses.-Checked or retarded menstruation 
frequently results from anaamia or general 
572 
EMETICS 
debility, and the indirect emmenagogues will 
under these circumstances usually effect a 
cure. If, however, the case prove more obsti- 
nate, one or more of the direct emmenagogues 
will often restore the suspended function. 
Should even this do no good, some mechani- 
cal impediment probably exists, or some 
altered physical condition of the womb which 
mere drugs cannot rectify. 
Robert Farquharson. 
EMOLLIENTS (emollio, I soften).- 
Synon. : Fr. Emollients; Ger. Erweichende 
Mittel. 
Definition.-Substances that soften and 
relax the parts to which they are applied. 
Enumeration. - The principal emollient 
applications are: - Warm water, Steam, 
Poultices made of substances which retain 
heat and moisture, for example, linseed-meal, 
bread, bran, flour, oatmeal, and figs; Fatty 
substances, as linseed, olive, almond, and 
neat's-foot oil, lard, and suet; Spermaceti, 
Wax; Soap Liniment and other liniments; 
Glycerine; Paraffines; and Lanolin. To these 
may be added such substances as do not pro- 
perly relax the tissues, but protect the sur- 
face from irritation, such as White of Egg, 
Gelatine, Isinglass, Collodion, and Cotton- 
wool. 
Action.-Emollients relieve the tension 
and pain of inflamed parts by their action 
both upon the blood-vessels and upon the 
tissues themselves. They cause all the con- 
tractile tissues to relax and dilate, and thus, 
lessening pressure upon the nerves of the 
part, they relieve pain. They soften super- 
ficial parts by supplying them with either 
fat or moisture, and by increasing the supply 
of blood. In this way they prevent the skin 
from cracking after exposure to cold. When 
the cuticle is lost they form a covering, under 
which the skin may heal; and they prevent 
the injurious consequences of friction from 
without. 
Uses.-Fatty emollients are used to pre- 
vent the skin or mucous membranes from 
cracking; to prevent irritation or ulceration 
between parts constantly in contact, as on 
the limbs of children near the joints; to 
prevent bed-sores; to aid the healing of 
blisters; or in skin-diseases, such as eczema. 
They are also used, especially in the form of 
linimentum calcis, as applications in burns 
and scalds, for which purpose such sub- 
stances as cotton-wool are likewise fre- 
quently employed. Mucilaginous substances 
are useful, when swallowed, to relieve pain 
and irritation in the throat, and to lessen 
irritable cough; and such substances as figs 
are employed to protect the intestines from 
injury by hard and pointed substances which 
have been swallowed. Warmth and mois- 
ture are applied in the form of poultices to 
the surface in pustules, boils, carbuncles, and 
deep-seated inflammation of the limbs, and 
EMOLLIENTS EMOLLIENTS 
EMPHYSEMA, SUBCUTANEOUS 
573 
in inflammation of the internal organs (see 
Poultice). In the form of vapour they are 
useful in inflammation of the air-passages. 
See Inhalations, Therapeutic Uses of. 
T. Lauder Brunton. 
EMPHYSEMA OF LUNGS.-See 
Lungs, Emphysema of. 
EMPHYSEMA, SUBCUTANEOUS 
(ev, in; and cf>v<ra, wind). - Synon. : Fr. 
Emphyseme] Ger. Emphysem ; Windge- 
schwulst. 
Description.-Subcutaneous emphysema 
is the distension of the spaces of the areolar 
tissue with air or any other gas. There 
is thus produced a swelling, in slight cases 
affecting a very limited area, in extreme 
cases extending to the subcutaneous tissue 
of the whole body. Unless the tension is 
great, the swelling is slightly lobulated; it 
is elastic, and although the finger sinks 
readily into it, no lasting impression is 
left. When the area affected is small, the 
gas can be driven in any direction by the 
pressure of the hand. On palpation a pecu- 
liar fine crepitation is felt, which is ab- 
solutely diagnostic. On percussion there is 
superficial resonance, the note resembling 
that obtainable from a bladder loosely filled 
with air. Unless the gas causing the em- 
physema is the product of decomposition of 
gangrenous tissues, as in spreading gangrene, 
there is no redness of the skin. The swelling 
usually forms rapidly, and may extend in a 
few minutes over the greater part of the 
body. In such cases it is most marked 
where the subcutaneous tissue is lax. In 
the face the features are obliterated, and the 
eyes closed by the swelling of the lids. The 
scrotum and penis become enormously dis- 
tended. 
^Etiology and Pathology.-Wound of the 
lung from a broken rib or from a stab is the 
most common cause of subcutaneous em- 
physema. If from a stab, it can only occur 
when the opening in the pleura and that in 
the skin no longer correspond with each 
other, in consequence of an alteration in the 
position of the patient, or when the wound 
has been artificially closed. When from 
wound of the lung, it may occur with or with- 
out pneumothorax. Nothing is more com- 
mon than to find a limited emphysematous 
swelling round a fractured rib, without any 
signs of air in the pleural cavity. This arises 
either from adhesions existing between the 
parietal and visceral layers, or from the escape 
of air being very limited. In severe cases 
with pneumothorax the mechanism of the 
production of emphysema is as follows: A 
wound in the lung always allows air to pass 
from it readily, but from the way in which 
the soft pulmonary tissue falls together, no 
amount of force can drive air through the 
wound in the opposite direction. It thus acts 
somewhat like the valve of an air-pump. 
The first effect of the escape of air into the 
pleural cavity is to cause collapse of the lung. 
As the chest expands with each inspiration 
air rushes from the wound in the lung into 
the pleural cavity ; as it contracts in expira- 
tion, the air, being unable to pass back by 
the wound, is driven through the opening in 
the parietal pleura into the subcutaneous 
cellular tissue. In such cases there is gradu- 
ally increasing dyspnoea, with great disten- 
sion of the subcutaneous cellular tissue; 
and unless relief is given, the patient dies 
asphyxiated. 
Emphysema occasionally occurs from rup- 
ture of some of the air-vesicles during a vio- 
lent expiratory effort. Dr. Walshe states that 
this accident has happened from 'the efforts 
in parturition, defsecation, raising weights, 
coitus, violent coughing, paroxysms of rage, 
excessive laughter, and hysterical convul- 
sions.' The air usually escapes first into the 
cellular tissue between the lobules of the lung, 
giving rise to the condition known as inter- 
lobular emphysema. It then finds its way 
into the mediastinum, and thence to the root 
of the neck. Interlobular emphysema gives 
rise to intense dyspncea, and has been known 
to cause sudden death. Emphysema has 
also been seen as a consequence of ulceration 
of the trachea, and in a few very rare cases 
as the result of ulceration proceeding from a 
cavity in the lung through the adherent 
pleura and intercostal muscles to the subcu- 
taneous cellular tissue. 
Localised emphysema of the face is a symp- 
tom of fractures implicating the antrum. 
Emphysema of the flanks is an occasional 
symptom of rupture of the third part of the 
duodenum, behind the peritoneum, and of 
perforation of the caecum at its posterior 
part. 
Emphysema of the perinaeum and scrotum 
may arise from a wound of the bowel in the 
administration of an enema. 
In non-penetrating wounds of the thorax 
and abdomen, a small quantity of air may 
find its way into the areolar tissue in the im- 
mediate neighbourhood, in consequence of 
the movements of respiration. In compound 
fractures emphysema is often found extend- 
ing some distance above and below the wound, 
if the patient has been carried some distance 
and the injured limb much shaken. 
Emphysema from the gases produced by 
decomposition is only seen in cases of rapidly 
spreading moist gangrene-emphysematous 
gangrene. 
Progress and Terminations.-The effects 
of emphysema differ with the source of the 
gas. When the air comes from a superficial 
wound of the lung, it has no tendency to 
cause decomposition of the effused blood with 
which it may come into contact. Thus, in 
surgical cases, no evil consequences result 
from emphysema around a simple fracture of 574 
EMPHYSEMA, SUBCUTANEOUS 
ENDERMIC MEDICATION 
a rib. This is explained by the fact that the | 
gas in the air-vesicles is absolutely free from I 
solid particles of any kind, including micro- 
organisms, as shown by Tyndall's experiment, 
in which the residual air, in forced expiration, 
makes a gap in the beam of an electric light 
when breathed across it. On the other hand, 
air admitted from without, as in a compound 
fracture, tends to favour the decomposition of 
the effused blood, and renders treatment by 
occlusion or by antiseptic dressing difficult 
and uncertain. In ordinary cases the effused 
air is rapidly absorbed without causing incon- 
venience of any kind. If the amount of air 
in the tissues be very great, and the case be 
complicated by pneumothorax, fatal dyspnoea 
may occur, unless relieved by treatment. 
Treatment.-The swelling itself requires 
usually no treatment, the gas being absorbed 
without difficulty. If it is complicated by 
pneumothorax, or if the dyspnoea be such as 
to threaten death, the wound, if one exists, 
must be opened up; or, if there is none, a free 
opening must be made into the pleural cavity. 
If the swelling be such as seriously to incon- 
venience the patient, a few punctures may be 
made with a triangular needle. Emphysema 
from intestinal flatus is always limited, and 
requires no treatment beyond that applicable 
to the cause of the escape of gas. 
Marcus Beck. 
EMPIRICAL (ev, by; and mipa, experi- 
ence).-This term is applied to treatment 
founded on experience, as contrasted with 
rational, which is founded on scientific 
reasoning. See Disease, Treatment of. 
EMPROSTHOTONOS (epnpo^v, for- 
wards; and reivw, I stretch).-A bending or 
drawing forwards of the body, due to tonic 
contraction of the muscles, observed in some 
cases of tetanic convulsions. See Tetanus. 
EMPYEMA (eV, in; and nvov, pus).- 
Strictly speaking, this term signifies a collec- 
tion of pus within the cavity of the pleura, 
but it is often conventionally used to denote 
any inflammatory effusion in that situation 
which has assumed a chronic character. See 
Pleura, Diseases of. 
EMS, in Germany.-Thermal muriated 
alkaline waters. See Mineral Waters. 
EN CEPHALITIS (eyKetjniXos, thebrain). 
Inflammation of the brain and its mem- 
branes ; or, more properly, inflammation of 
the brain-substance itself. See Brain, In- 
flammation of. 
ENCEPHALOCELE (eyK^aXos, the 
brain; and KrjXr], a tumour).-A hernial pro- 
trusion of a portion of the brain-substance 
through an opening in the skull, which may 
be either congenital or the result of accident, 
of surgical operation, or of disease. See 
Brain, Malformations of. 
ENCEPHALOID (tyKetfraXos, the brain). 
A form of cancer, so named on account of 
its obvious resemblance to brain-tissue. See 
Cancer. 
ENCHONDROMA («V, in; and %6v8pos, 
cartilage).-A new-growth consisting of car- 
tilaginous tissue. See Tumours. 
ENCYSTED (eV, in; and kvotis, a blad- 
der).-Contained within a cyst. A term ap- 
plied to new-growths or collections of fluid 
thus enclosed, or limited by adhesions. 
ENDARTERITIS (evftov, within; and 
dprrjpia, an artery).-Inflammation of the 
internal coat of an artery. The disease is 
generally chronic or subacute, rarely acute. 
Two special forms of endarteritis have been 
described-namely, endarteritis deformans, 
or atheromatous disease (see Arteries, Dis- 
eases of; and Atheroma) ; and syphilitic 
endarteritis, which frequently affects the 
vessels of the brain. See Syphilis; and 
Brain, Vessels of, Diseases of. 
ENDEMIC (tv, in; and 8r/pos, a people). 
This term is applied to diseases that prevail 
in particular localities or districts, and which 
are due to special setiological conditions 
existing there. See Disease, Causes of. 
ENDERMIC MEDICATION (eV, in; 
and Sepna, the skin).-Fr. La Methode En- 
dermique; Ger. Intracutane Arzneiappli- 
cation. 
Definition.-The method of using reme- 
dies either by rubbing them into the skin 
or by sprinkling them on a surface which 
has been previously denuded of its epidermis. 
Endermic medication was strongly advo- 
cated and practised by Lembert, Valleix, 
Trousseau, Anthony Todd Thomson, and 
others, but it has almost, if not entirely, 
given place to hypodermic injection, (1) be- 
cause the endermic method is the more 
painful; (2) because it is slower in action- 
thus, Trousseau found that twelve minutes 
were required for one-sixth of a grain of 
morphine endermically administered to take 
effect, whereas, hypodermically, the action of 
the same dose is observed in less than one 
minute, in fact, almost immediately; (3) 
because in many parts of the body endermic 
medication is totally inapplicable. 
Method and Uses.-The epidermis should 
first be detached either by some ordinary 
vesicant, such as cantharides plaster, or by 
the application of a cautery. The drug to be 
used is then laid on the raw surface in the 
form of powder rubbed up with starch, sugar, 
sulphate of sodium, or some other unirritating 
substance, paste made with water or thin 
mucilage, or ointment. In this way, neural- 
gia, sciatica, and other painful affections may 
be treated with the morphine salts in doses of ENDERMIC MEDICATION 
ENDOSCOPY 
575 
one-sixth of a grain and upwards; local para- 
lyses and other nerve-troubles with strych- 
nine in doses of one-fiftieth of a grain and 
upwards; and many other alkaloids may be 
used in the same way in various diseases. 
A. S. Currie. 
ENDOCARDITIS (e^Sor, within; and 
Kap8ia, the heart).-Inflammation of the 
lining membrane of the heart. See Heart, 
Inflammation of. 
ENDOGASTRITIS within; and 
yuarrip, the stomach).-Inflammation of the 
mucous membrane of the stomach. See 
Stomach, Diseases of. 
ENDOMETRITIS (evSov, within; and 
the womb). - Inflammation of the 
lining membrane of the uterus. See Womb, 
Diseases of. 
ENDOPERICARDITIS.-Inflamma- 
tion of the endocardium and pericardium 
together. See Heart, Inflammation of; and 
Pericardium, Diseases of. 
ENDOSCOPY (evSov, within; and 
o-KOTreco, I look).-Definition.-The inspec- 
tion of internal surfaces. Taken inclusively, 
this definition comprises ophthalmoscopy, 
otoscopy, laryngoscopy, rhinoscopy, urethro- 
scopy, cystoscopy, and inspection of the 
gullet, stomach, and rectum. But in ordinary 
parlance, the word signifies inspection of the 
urethra only ; special terms being used when 
inspection of other parts is meant. 
Introduction.-An internal surface may 
be illuminated by letting light, such as day- 
light, fall through a straight tube (direct 
illumination); or by rays collected and 
thrown by mirrors placed conveniently 
through a tube on to the surface to be ex- 
amined, and reflected directly to the eye of the 
observer, or through lenses set at suitable 
angles (reflected illumination); or, lastly, by 
light generated within the body and reflected 
to the eye of the observer (internal illumina- 
tion). This last method, in which the electric 
lamp was placed at the inner end of the tube, 
and its light thrown directly on to the exposed 
part, has been abandoned for examining the 
urethra, on account of the difficulty in shield- 
ing that canal from the beat of the glow-lamp ; 
though it is still the mode of illuminating the 
bladder or other cavities, the walls of which 
are not in contact with the instrument. 
The present mode of examining the 
urethra and other surfaces is the outcome of 
the work of many experimenters, the earliest 
of whom was probably Bozzini (1807), fol- 
lowed by Segalas in 1826. In 1840-46, 
Avery of London devised the tubes which 
are still in general use. But the methods of 
illumination now employed, by gas or elec- 
tricity, are far superior to those obtainable in 
Avery's time. Desormeaux improved Avery's 
method of illumination, and this was further 
bettered by Cruise. Still, the apparatus re- 
mained too cumbrous for easy use until 
Griinfeld simplified the application of illu- 
mination between 1875 and 1880, and Leiter 
between 1880 and 1887 perfected the electric 
method by reflecting light from a glow-lamp 
along the tubes on to the exposed surfaces. 
About this time Griinfeld, Dittel, and others, 
employing these more manageable instru- 
ments, were able to describe methodically the 
appearances of the normal urethra in its 
several parts, and also many of the changes 
caused by disease. 
Apparatus.-The apparatus may be ar- 
ranged in three varieties: in Desormeaux' 
and Leiter's the lamp and tube are fixed to- 
gether ; in a second, the light is distinct, but 
the reflectors and lenses are fixed to the 
tube; in a third, the light and reflector, a 
concave mirror fastened to the forehead or 
held in the hand, are both separate from the 
tube. 
The best apparatus is that of Leiter, where 
the light of an Edison's glow-lamp of 0'5 to 1 
ampere is affixed below the outer end of the 
tube, and its rays reflected through the tube 
on to the exposed portion of the urethra and 
back again to the eye of the observer. It 
comprises a set of straight silver tubes five 
inches long and of internal diameter ranging 
between 18 and 26 millimetres. Their inner 
ends are cut off either transversely or 
obliquely, and the outer ends have a wide 
mouth and flange, on to which the funnel and 
mirror may be fitted. Each tube has a vul- 
canite plug with a smooth or rounded end 
that projects beyond the tube, to facilitate its 
passage along the urethra. The interior is 
blackened to prevent confusion by reflection 
from its sides. Dr. William K. Otis, of New 
York, has contrived curved tubes which can 
be passed along the urethra to the posterior 
portion with ease ; but curved tubes require a 
reflector at the end, and the one supplied with 
the tubes is too clumsy to be of much service. 
Griinfeld has improved the windowed tubes 
of Avery-that is, tubes with some part of 
the side or the end closed by a piece of glass 
-and for some purposes these windowed 
tubes are more useful than the open ones. 
In addition to tubes, lamps, and mirrors, small 
mops of cotton wool are needed to wipe the 
mucus, pus, and blood from the displayed 
surfaces, so that the cleaned and dried mem- 
brane may be viewed. For the treatment of 
the various affections, additional armamenta 
are strong astringent or caustic solutions, 
hsemostatics, such as hamamelis, iron, or 
tannin, and pencils of cupric sulphate or of 
lunar caustic. To them may be added small 
electric cauteries, probes, forceps, snares, 
knives, scissors, curettes, and tubes for insuf- 
flation of astringent powders. Griinfeld has 
also contrived to place outside his endoscopic 
tube another fine one, through which he can 576 
ENDOSCOPY 
inject drops of astringent solutions on to 
inflamed patches. 
Batteries of various make are used: that 
for illumination should have a power of eight 
to twelve volts; that for cautery, of twenty 
to thirty volts. Carbolic oil (1 in 16) or 
glycerine for lubricating the tubes is also 
needful. 
Application.-When inspecting the ure- 
thra it is convenient to divide the canal into 
two portions-that before the triangular 
ligament being the anterior, that behind it 
the posterior. Not infrequently the inflam- 
mation set up by gonorrhoea is confined to 
the anterior portion ; while, on the other 
hand, in gleets of long standing the posterior 
part may be alone affected, when the anterior 
section is quite clear of disease. 
In the anterior portion are the meatus and 
the fossa navicularis, the spongy and bulbous 
parts, into which, with a forward direction, 
open the ducts of mucous glands and those 
of Cowper's glands. In the posterior are the 
verumontanum, the sinus pocularis, and the 
openings of the spermatic ducts and of those 
of the prostate itself. 
Before examining the urethra, it is ad- 
visable to pass along the canal a sound or 
bougie slightly larger than the inspecting tube, 
in order to be sure that no constriction exists 
which would prevent the passage of the tube, 
and also to familiarise the urethra with the 
presence of instruments. It is well also to 
refrain from introducing the tube into the 
posterior portion until that part has become 
accustomed to instruments by the repeated 
passage of bougies or sounds. The calibre of 
the tube should not be large enough to 
stretch the urethra; if it is, the walls are 
more or less blanched, and the operation is 
apt to give pain. These drawbacks avoided, 
the larger the tube the more easy the ex- 
amination. 
Examination of the anterior portion of 
the urethra.-The best position is the half- 
recumbent one on a high couch, with the 
knees bent and the legs hanging over the edge. 
The observer seats himself on a low stool 
opposite his patient, his eyes about level with 
the urethra. If the patient be well accustomed 
to manipulation he may stand upright on 
a stool against a wall, to bring his pelvis 
level with the eyes of the observer sitting 
before him. All being ready, the operator 
introduces the tube. If the meatus be much 
contracted, either congenitally or by fibrous 
bands after inflammation, it is well to divide 
the tight bands by the touch of a probe- 
pointed bistoury, after rendering the part 
insensible with cocaine. A No. 24 or 26 tube, 
with its plug, is then slowly passed along the 
passage until the bulb is reached. The plug 
is then withdrawn, and the area of the 
urethra exposed at the end of the tube is well 
mopped and dried, and the light adjusted. If 
the urethra is healthy and not scarred or 
blanched by previous inflammation, the part 
now seen is of a delicate rose-pink or purplish 
pink hue, faintly striated with longitudinal 
lines. The most distinct streaks or furrows 
are in the floor at each end of the transversely 
disposed lumen. Faintly marked crimson 
papillae are visible in the anterior portion, but 
are lost near to the navicular fossa. As the 
tube is slowly withdrawn, the urethra col- 
lapses closely behind it evenly on all sides. 
The lumen or central figure is an even trans- 
verse line or slightly oval figure of sym- 
metrical thickness. The orifice of a lacuna 
Morgagni is indicated by a little dark dot; 
though these lacunae may be difficult to dis- 
tinguish unless sought for in the way to be 
described presently. When inflamed, ulcer- 
ated, or indurated, these openings are easily 
distinguished. As the tube continues to re- 
treat at about three inches from the meatus, 
the colour of the mucous membrane grows 
paler in many persons, to become again dull 
pink or bluish pink at the sinus navicularis. 
Here, also, the lumen changes from a trans- 
verse position to a vertical one, being oval or 
triangular in form. In the roof of the urethra 
it is not difficult to detect in this fossa the 
mouths of two or three or more ducts of muci- 
parous glands, and the wall of the passage is 
not so evenly resilient as it is more posteriorly. 
To find the lacunae Morgagni in a healthy 
urethra, it is often necessary to slightly 
divert the tube from the axis of the urethra 
to cause the wall to bulge slightly into the 
open end of the tube. By this, a larger area 
of the wall is brightly illuminated. If a 
lacuna be within the illuminated area, it is 
distinguished by a dark dot due to want of 
reflexion, because the floor of the lacuna is 
lower than the general surface. So, also, the 
position of a lacuna is revealed during slow 
retraction of the tube by the sudden appear- 
ance of a fine furrow or seam in the wall, 
radiating from the lumen and made more 
distinct by the greater brilliancy of the light 
reflected from each side of the furrow. Very 
shortly the seeming furrow or line disappears 
as the tube passes from it. The openings of 
the ducts of Cowper can be more easily found, 
as they have a more constant position in the 
urethra. They open into the bulbous portion, 
where they appear as two dark dots, side by 
side, soon after the lumen has assumed its 
transverse linear form. 
Examination of the posterior portion of 
the urethra.-In this portion, proceeding from 
behind forwards, are to be seen the os inter- 
num urethrse, the walls of the prostatic por- 
tion, the verumontanum, the openings of 
the prostatic ducts and of the ejaculatory 
ducts, and the membranous portion of the 
urethra. 
The ordinary straight tube with open end, 
five inches long and of the calibre suitable 
for the anterior part of the urethra, is the 
best to use for this purpose. A special move- ENDOSCOPY 
ENEMA 
577 
ment is required to pass the tube through the 
triangular ligament without exciting contrac- 
tion of the voluntary muscles which encom- 
pass that portion of the canal, and which 
resist the passage of the tube, and thereby 
hurt the patient. 
In introducing the tube, the end rounded 
by the plug should be pressed gently down 
the urethra so that it follows the floor, not 
the roof, until it reaches the triangular liga- 
ment. There, while steady pressure is main- 
tained, the hand is lowered deeply between 
the thighs until the deeper end rises and 
slips on in spite of the slight resistance 
always made to its onward passage. When 
resistance ceases, the tube is pushed back- 
wards for another inch or so, and held steadily 
while the plug is withdrawn and the light 
adjusted. If this is done slowly, the pain, 
should the patient feel any, ceases as soon 
as the instrument stops moving. It is often 
well to get the patient to hold the tube him- 
self during the adjustment of the lamp, as 
he is less likely than the operator to move it 
inadvertently. But a steady, gentle pressure 
must be kept on the tube while it is in this 
region, or it will be ejected by the muscles of 
the urethra, and will be suddenly thrust forth 
into the bulbous portion. The part being 
well wiped and the light thrown on, this 
portion of the urethra will appear funnel- 
shaped, and of full rosy hue or pale purple, or 
yellowish white if there have been inflam- 
mation or induration of the prostatic portion 
at some time before. At the os internum 
the lumen is long, horizontal, and marked at 
each end by two radiating creases. If now 
the tube be pushed back a little, it is quickly 
filled by urine, and a misty yellow light is 
all that is visible. This accident is easily 
avoided by practice; but if it happens, the 
tube must be withdrawn a little, and its outer 
end depressed that the urine may flow out. 
This done, the mops dry up the remaining 
moisture, and the inspection may begin. 
Besides the conditions already mentioned, 
in some cases fine longitudinal striae or 
creases are seen to radiate pretty uniformly 
from the centre. These are probably rows 
of fine papillae along shallow folds of the 
membrane. The tube is slowly withdrawn, 
bit by bit; and, as it recedes, here and there 
a dot or depression may be noted placed in 
no definite position on the wail. These dots 
are orifices of ducts of the prostate. Gradu- 
ally, while the end of the tube recedes, there 
rises into view a saddle-shaped eminence like 
an inverted U, with the top at the highest 
point of the exposed surface, around which 
the walls closely conform. This is the veru- 
montanum, or caput gallinaginis. It has 
usually a paler colour than the wall, but is 
never white unless diseased. Presently, when 
the saddle-shaped eminence is at the highest, 
two small red fossae or furrows can often be 
seen on either side of the central ridge, and 
equidistant from it. These are the outlets of 
the ejaculatory ducts; and usually near them, 
but more outward, some more dots appear, 
signifying the orifices of the prostatic ducts. 
Occasionally, if the tube be kept still or 
pressed firmly against the floor, a little 
whitish-grey bead-forms on one of the sym- 
metrically placed hollows. This is semen, 
and, if wiped away and put under the micro- 
scope, is seen to contain the characteristic 
spermatozoids. Not infrequently the mouths 
of the ejaculatory ducts are not found by this 
method. They may then be generally de- 
tected by pushing the tube back a little and 
pressing it up against the roof to allow the 
floor to rise more. If the outer end of the 
tube be now raised, the light shines more 
strongly on the yeru, and as the tube recedes 
the furrows generally become distinct. When 
they are clearly seen, a fine whalebone bougie 
or silver probe may, it is said, sometimes be 
coaxed into them for a short distance. On 
still further withdrawing the tube the saddle- 
shaped eminence widens at its base, the 
lumen loses the shape of an inverted U, and 
grows circular or oval, with the long diameter 
vertical. The walls also rise up into the area 
before the tube, and have a paler hue, making 
a broad pinkish ring inside the tube. When 
this appears, the membranous portion has 
been reached. If there have been bygone 
inflammation of the part, the ridge of the 
veru, instead of being like an inverted U, is 
like an inverted V, and of much lighter 
colour, even white, from induration and 
wasting. Small veins, showing as dark 
sinuous lines, are not uncommonly seen in 
the prostatic portion, and, but less frequently, 
in the anterior portion also. 
Berkeley Hill. 
ENEMA (tviyyi, I inject).-Synon. : Lave- 
ment ; Clyster; Fr. Clysters; Lavement; 
Ger. Klystier. 
Definition.-An enema is a liquid injected 
by means of a suitable instrument into or 
through the rectum. 
Instruments.-Various instruments are 
used for the administration of enemata: 
1. A simple elastic bottle with ivory or gum- 
elastic pipe, which has superseded the old 
bladder and pipe. 2. An indiarubber bottle 
with flexible tube at either end and double 
action, as in Higginson's instrument. 3. An 
ordinary piston syringe, worked by the hand, 
which is either simple, or provided with a 
double action, so as to supply a continuous 
stream. 4. A French instrument, known as 
the irrigateur, worked by a spring. 5. The 
hydraulic enema, which consists of a piece 
or indiarubber tubing about six feet long, 
furnished with an ordinary ivory rectum- 
pipe at the one end, and a metal cone, or 
a screw nozzle, at the other. The tube, being 
filled with the injection, has one end placed 
in the containing reservoir, or is connected 578 
by the screw; while the pipe at the other 
end is introduced into the bowel. The vessel 
supplying the injection being placed on an 
elevation, the liquid gravitates into the bowel, 
filling the large intestine. W'hen it is desir- 
able to inject a large quantity the patient 
should lie first on the left side, then on the 
back, and lastly on the right side, to promote 
the filling of the intestine. In all cases care 
should be taken to prevent the injection of 
air into the bowel, and also to ascertain that 
the nozzle of the injecting pipe is free in the 
rectum, not in contact with the sphincter, 
not thrust against the sacrum or into a 
hard fecal mass. The process of injection 
must be carried on slowly, with occasional 
pauses, otherwise premature contraction of 
the bowel with expulsion of the enema will 
result. 
Varieties and Uses.-The chief varieties 
and uses of enemata are as follows :- 
1. Anthelmintic Enemata.-To cure 
thread-worms injections of salt and water, 
or lime-water, or from two to four drachms 
of spirit of turpentine diffused by yolk of 
egg in four ounces of water, are serviceable. 
The enema of aloes or of asafetida may 
also be employed in the small quantity just 
named. 
2. Antispasmodic Enemata.-Puer- 
peral convulsions have been relieved by the 
injection of half a drachm or more of chloral 
hydrate. Injections of asafoetida or of rue 
are also given. Injections of warm water 
with two or three fluid-drachms of sulphuric 
ether have sometimes relieved spasmodic in- 
vagination of the bowels. When the intestine 
is tympanitic and distended, the enema tere- 
binthinse, or enema asafcetidae, will act well 
as a stimulant and carminative. 
3. Astringent Enemata.-These are 
used either to check diarrhoea, to arrest 
haemorrhage, or to remedy ulceration and 
mucous discharges. For the first of these 
purposes the enema opii is valuable. In cases 
of haemorrhage from the bowels, as well as 
from the womb, injections of ice-cold water 
are frequently used. Ulceration with mucous 
discharge is often successfully treated with 
enemata of nitrate of silver (five grains to one 
pint of distilled water), of sulphate of zinc or 
alum (one or two grains to the ounce of 
water), or of sulphate of copper (one grain to 
the ounce of water). 
4. Emollient Enemata.-Demulcents, 
such as decoctions of starch, linseed, or barley, 
or pure linseed oil, are at times used with 
the object of imparting nourishment to the 
system, and of soothing an irritable mucous 
membrane. 
In dysentery, from four to six pints of 
warm water, or of milk and water, have been 
injected as a form of internal fomentation. 
5. Nutrient Enemata.-In cases of ex- 
haustion, enemata of peptonised milk, beef- 
tea and eggs beaten up are used. About 
ENEMA 
four or six ounces should be given at once 
by means of an indiarubber bottle with an 
elastic-gum rectum tube. When properly 
given, they will remain and be absorbed. 
Should the rectum become irritable, the irri- 
tability may be often lessened by adding a 
few drops of laudanum to each enema. A 
solution of defibrinated blood, in its recent 
or dried form, has been recommended as a 
materia] for nutrient enemata (see paper by 
Dr. Sansom on Supplementary Alimentation, 
Lancet, 1881, vol. i. p. 288). The digestion 
and assimilation of nutrient enemata may 
be facilitated by the addition of preparations 
of pancreatin and pepsin. See Peptonised 
Food. 
Injections of brandy and water, or beef-tea 
and brandy, have been given with benefit in 
prostration from uterine haemorrhage or 
other causes. 
6. Sedative Enemata.-These are often 
employed in painful affections of the rec- 
tum and bladder. The enema opii is 
very useful. In spasm of the bowels and 
in hernia the enema tabaci has been re- 
sorted to, but it must be used with caution, 
as it may produce faintness and collapse. 
7. Purgative Enemata. - These are 
used to overcome constipation. For this 
purpose-in the case of an adult-from one 
to two pints of fluid must be slowly pumped 
into the bowel. When the process is con- 
ducted gradually, stopping occasionally and 
making pressure on the anus if the injection 
threaten to come away, as much as four or 
five pints can be got into the bowel. The 
injection should be retained as long as pos- 
sible, as thus a complete evacuation is en- 
sured. As a general rule, about a pint of 
liquid is enough for an adult; for an infant 
an ounce ; for a child of four years, four to 
six ounces. 
Composition.-Soap and water, gruel with 
olive-oil, castor-oil, and sometimes oil alone, 
may be used. The enema magnesii sulphatis 
is an efficient purgative. Enema aloes is also 
valuable. 
Glycerine is now used in cases of defec- 
tive action of the bowels. From one to two 
drachms are injected by a suitable syringe 
into the rectum, and in from five to thirty 
minutes action of the bowels will follow. 
There is often more or less straining, with 
expulsion of flatus ; and, if the quantity used 
be too large, violent and spasmodic action 
may result. 
Glycerine suppositories have been added to 
the Pharmacopoeia. Their action is attended 
with less spasm than is that of the fluid in- 
jection. The glycerine acts as a stimulant 
and irritant to the rectum; for while some 
amount of burning is felt, a thermometer 
shows increased temperature in the rectum. 
Where the accumulation lies high up in the 
intestine, glycerine injection has little or no 
effect in causing its expulsion. In cases of intestinal obstruction the intro- 
duction of a large volume of soap and water 
-with oil, perhaps, added-by means of 
the gravitation-tube, may be had recourse 
to with advantage. Obstruction due to im- 
pacted faeces generally yields to this method 
of treatment, especially if assisted by judi- 
cious massage of the abdomen. 
The gradual injection of air by means of a 
bellows and rubber tube, or a Lund's insuf- 
flator, into the large intestine has proved a 
successful method of treating intussusception 
of the bowel in young children, especially in 
cases where the intussusception can be easily 
felt by the rectum, and where enemata are at 
once returned. See Intestinal Obstruction. 
The frequent use of very large injections 
is undesirable, lest undue distension result, 
with weakness and loss of tonicity in the 
bowel. The habitual use of injections washes 
away the mucus designed to lubricate the 
bowel. 
John 0. Thorowgood. 
ENGADINE, UPPER; in Switzer- 
land.-A bracing mountain climate. Eleva- 
tion of valley 5,000 to 6.000 feet. Season, 
June to September. Some places are also 
open during the winter. See Climate, Treat- 
ment of Disease by. 
ENGHIEN, in France. - Sulphur 
waters. See Mineral Waters. 
ENGLISH CHOLERA.-A synonym 
for simple cholera or choleraic diarrhoea. See 
Choleraic Diarrhoea. 
ENGORGEMENT. -Overloading of 
the vessels, or of the heart, with blood. A 
synonym for congestion. See Circulation, 
Disorders of. 
ENTERALGIA (evrepov, the intestine; 
and aXyos, pain).- Synon. : Enterodynia ; 
Neuralgia mesenterica vel mesaraica; Colic. 
The terms enteralgia and colic-generally 
regarded as synonymous-include all forms 
and degrees of paroxysmal intestinal pain in 
cases where there is no febrile disturbance. 
Enteralgia, implying more especially the 
neuralgic nature of the sensori-motor dis- 
turbance, is sometimes preferred, as by those 
who hold that colic proper-of which lead- 
colic is a typical example, as distinguished 
from symptomatic colicky pains-is a vis- 
ceral neuralgia. It is likewise frequently 
applied to colic occurring in the neurotic- 
in whom there is not uncommonly a record 
of other forms of neuralgia in the individual 
or family history-the asthenic, the anaemic, 
or the gouty, even when there is a local 
exciting cause, such as flatus, retained faeces, 
&c.; and to conditions in which pain pre- 
dominates over spasm. The clinical features 
of enteralgia are, however, as a rule, indistin- 
guishable from those of colic. A similar local 
disturbance-pain either sudden and sharp 
ENEMA 
or gradual and dull, either about the umbili- 
cus or in the right iliac region-according to 
its intensity, is reflected by the nerves to the 
heart and the peripheral arteries. The action- 
of the former becomes slow and feeble, and 
the latter contract; hence arising the small, 
infrequent, tense pulse, the cool pale skin, 
and the other signs of collapse which mark 
the distant effects of colic. And, as in this 
disorder, the termination of the attack may 
be sudden, perhaps following the expulsion 
of flatus or faeces-a free perspiration, a 
copious flow of pale urine, the menstrual or 
lochial or other discharge, or a fit of the 
gout. As a rule, the more severe the paroxysm 
the shorter will be its duration. Th# exciting 
cause is not uncommonly a chill (wet feet, 
&c.), or mental over-strain and worry. Per- 
sistent enteralgia is now and then indicative 
of spinal disease, such as caries. 
Treatment.-The main indications in the 
treatment of enteralgia are to endeavour to 
remove any cause of the pain: to administer 
opium or belladonna by the mouth or rec- 
tum, or subcutaneous morphine, and to apply 
hot fomentations, 'with laudanum and turpen- 
tine, for the relief of the suffering (see Colic, 
Intestinal); and, during the intervals be- 
tween the seizures, to restore the nutrition 
and tone of the nervous system, and improve 
the general health. Among medicines, courses 
of the hypophosphites, belladonna, quinine, 
and arsenic may be found most useful. 
George Oliver. 
ENTERIC FEVER.-A synonym for 
typhoid fever. See Typhoid Fever. 
ENTERITIS {^pov, the bowel).-In- 
flammation of the intestines. See Intestines, 
Diseases of. 
ENTEROCELE (evrfpov. the bowel; and 
Kr)\r), a tumour).-A hernia containing a por- 
tion of bowel. See Hernia. 
ENTOPHYTE(euros,within; and cfyurov, 
a plant).-A plant parasitic in any part of the 
body. Entophytic diseases are diseases 
that are supposed to depend upon the growth 
of such plants, as, for example, fungus-foot. 
See Fungus-Disease of India. 
ENTOZOA(evros, within ; and an 
animal). 
Man, in common with other animals, ver- 
tebrate and invertebrate, is liable to entertain 
various forms of entozoa. In comparison 
w'ith other vertebrates, even with members 
of his own order, Primates, the number 
known to infest man is singularly small. 
This is attributable in a large measure to 
the fact that his food is submitted to the 
process of cooking. The various entozoa 
found in the human subject are truly para- 
sitic, and not examples of commensalism. 
A parasite inhabits a living organism, and 
ENTOZOA 
579 580 
ENTOZOA 
obtains nourishment from its body. In 
commensalism creatures live within the 
bodies of larger animals, like parasites, but 
share its food, or live upon the refuse of its 
body instead of the juices and tissues of the 
host. The more important entozoa found in 
man are:- 
I. Cestoda, Tapeworms. 
II. Trematoda, Flukes. 
III. Nematoda, Round-worms. 
IV. Gregarinidce, Psorosperma. 
V. Rhizopoda, Amoeba coli. 
I. Cestoda, or Tapeworms (Keo-ros, a 
girdle).-Fr. Cesto'ides, Tenia; Ger. Band- 
wurm. 
Varieties:- 
a. Tcenia solium. 
b. Tcenia mediocanellata vel saginata. 
c. Tcenia bothriocephalus latus. 
d. Tcenia cucumerina vel elliptica. 
e. Tcenia nana. 
f. Tcenia echinococcus. 
a. Tcenia solium.-This worm when fully 
developed may attain a length of 2 to 3 
feet. The vertex or head, about the size 
of a small pinhead, is furnished with four 
suckers, a rostellum, and twenty-six booklets 
(fig. 34). A narrow neck succeeds the head, 
and at a short distance the segments begin 
to be visible. At first their breadth exceeds 
their length; but farther from the head they 
lengthen, until the mature segments are 
reached. These average 12 mm. in length 
and 5 mm. in width. 
Each mature segment contains male and 
female generative organs. The genital open- 
ings are at the sides of the segments near 
the middle : the ovary presents seven to 
ten branches, each ending in a dendritic 
manner (fig. 36). 
T. soliicm inhabits the small intestine of 
man, and is acquired by eating pork. Infec- 
tion takes place in the following manner: 
The eggs, either free or contained in the 
segments (proglottides), are evacuated from 
the host, and are conveyed either by means 
of food or drinking-water into the body of a 
pig or other animal. When the eggs reach the 
stomach of the pig the capsule is dissolved, 
and the liberated embryo makes its way into 
the wall of the intestines or is carried by the 
blood-current into other parts of the body. 
The young tapeworm, when it emerges from 
the egg, possesses six booklets, and is known 
as the 4 six-hooked embryo.' After settling 
in the tissues it becomes metamorphosed, and 
is now furnished with a head and becomes 
enveloped by a membrane. In this condition 
it is known as a 4 measle ' or Cysticercus cel- 
luloses (kvcttls, a bladder; and KtpKos,a tail) (fig. 
32), Pork containing the cysticercus is said to 
be4 measle d.' The cysticerci are destroyed by 
thorough cooking, either by boiling or the 
more satisfactory process of roasting. When 
a cysticercus is introduced into the intestine, 
the head (scolex) fixes itself into the mucous 
membrane, the cyst-membrane is dissolved, 
a chain of segments or proglottides develop, 
and a tapeworm is the result. 
The cysticercus occurs also in man, and is 
probably due to the introduction of the eggs 
of T. solium into the 
stomach. Gysticerci 
have been found in the 
aqueous and vitreous 
chambers of the eye, 
in the subcutaneous 
tissue, and in muscles. 
When encysted they 
retain their vitality for 
many years. The pre- 
sence of these small 
bodies exciteslocal irri- 
tation, inducing inflam- 
matory thickening. In 
muscles and intermus- 
cular tissue they occa- 
sionally cause swellings 
resembling tumours. In the brain, when 
numerous, they induce fatal results. A few 
may exist in the cortex of the cerebrum 
without producing any obvious effect, but 
in the neighbourhood of the medulla two 
cysticerci have been known to cause death. 
In the eye cysticerci have been detected by 
means of the ophthalmoscope. In this situa- 
tion they present a striking and characteristic 
appearance. 
b. Tcenia mediocanellata vel saginata.- 
This tapeworm differs from T. solium in 
several important particulars. When fully 
developed it may attain a length of 4 
feet. The segments are thicker and wider 
than in T. solium-, it has no rostellum or 
booklets, but four suckers or proboscides and 
Fig. 32. - Cysticercus 
(telce) cellulosa, re- 
moved from the hu- 
man eye by Macken- 
zie. x 5diam. After 
Allen Thomson. 
Fig. 83.-Unarmed Head 
of Tcenia mediocanel- 
lata. x 10 diam. After 
G. Fritsch. 
Fig. 84.-Armed Head 
of Tcenia solium. 
x 10 diam. After 
G. Fritsch. 
a median canal (fig. 33). The mature seg- 
ments have a larger number of uterine diver- 
ticula, and they do not end dendritically 
(fig. 35). The cysticercus of this tapeworm 
infests the muscles of oxen. The tapeworm 
itself is acquired by man in consequence 
of eating underdone beef. In the accom- 
panying sketches the heads and proglottides 
of Tcenia solium and Ttenia mediocanellata 
are arranged side by side for comparison. ENTOZOA 
581 
c. Tcenia bothriocephalus latus.-This is 
the largest tapeworm infesting man; when 
mature it attains a length of 5 to 8 feet, 
and contains two, three, and even four 
mena, such as chorea, convulsions, or epilep- 
tiform seizures, insanity, mania, squint, and 
other untoward conditions, have been known 
to coincide with the presence of tapeworms in 
the alimentary canal, and to disappear when 
the worms have been expelled. Many other 
grave phenomena have been attributed to 
their presence. It is equally true that hun- 
dreds of individuals entertain tapeworms and 
suffer no inconvenience in consequence, nay, 
even are unaware of their guests until ap- 
prised of the fact by the appearance of two 
or three feet of cestode segments passed per 
anum. 
Treatment.-Many drugs have been re- 
commended, such as turpentine, kousso, 
kamala, areca-nut, and other anthelmintic 
remedies. The late Dr. Cobbold, after a long 
experience, came to the conclusion that 
the liquid extract of male fern is the most 
reliable drug. The patient, if adult, should 
take a dose of castor-oil at night, a drachm 
of extract early next morning on an empty 
stomach, to'be followed in three hours by a 
small dose of castor-oil. The fragments of 
worms should be examined in order to ascer- 
tairi'if the head be expelled. 
y. Ttenia, echinococcus and Hydatids 
(vSarts, a drop of water).-Fr. Hydatide; Ger. 
Blasenwurm.-Tsenia echinococcus is espe- 
cially interesting because its larval stages 
occur in man under the name of hydatid 
cysts. 
The mature taenia inhabits the intestine 
of dogs, jackals, and wolves. It is about 4 
mm. in length, and consists 
of only four segments, of 
which the terminal one alone 
is mature. Its head has four 
suckers, a rostellum, and two 
rows of booklets, varying 
in number from fourteen to 
twenty-five in each row. 
The eggs of this worm are 
introduced into the alimen- 
tary canal w ith the food, but 
more commonly with drink- 
ing-water. The six-hooked 
embryo, emerging from the 
egg, makes its way into sur- 
rounding tissues, and is fre- 
quently carried along by the 
blood-current in the veins as 
an embolus, to find a resting- 
place in lungs, kidney, liver, 
omentum, or brain, and be- 
comes gradually transformed 
into an hydatid cyst. 
For the history of the early stages of these 
cysts we are indebted to the zeal and indus- 
try of Leuckart. At first they are small 
white dots, with thick, homogeneous, trans- 
parent capsules, with concentric lamination, 
enclosing coarsely granular contents (fig. 38). 
After the cyst has been growing five months, 
and has attained a diameter of half an inch, 
Fig. 35.-Proglottis of 
Tcenia mediocanel- 
lata. x If diam. 
After G. Fritsch. 
Fig. 36.-Proglottis of 
Tcenia solium. x 
If diam. After G. 
Fritsch. 
thousand segments. The uterus has the 
form of a coiled ribbon, and the genital open- 
ing is near the middle of the ventral surface. 
This worm lives in the small intestine, and 
is met with mainly in Switzerland and north- 
eastern Europe. It has been reported as 
occurring in Ireland. 
It has long been suspected that fish were 
the intermediate host of this cestode, and 
Braun has demonstrated its occurrence in 
the larval stage in the muscles and viscera 
of pike, trout, and turbot. 
d. Tcenia cucumerina vel elliptica.-This 
is a small tapeworm, common in cats and 
dogs, rarely found in man. It has a rostellum 
and about sixty booklets arranged in four 
irregular rows. The intermediate host is the 
dog-louse, Trichodectes canis. This fact ex- 
plains the large number of taenia found in 
dogs not cleanly kept. The lice worry the 
dog, and it licks the irritated parts, and thus 
takes the lice with the cysticerci into the 
alimentary canal. Stroking dogs, or receiving 
their lingual caresses, is probably the means 
by which man is infected. It is noteworthy 
that children have furnished nearly all the 
specimens of this worm which have been 
reported in the human subject. 
e. Tcenia nana.-This is a small tapeworm. 
The head has four suckers, a rostellum, and 
circlet of twenty-two to twenty-eight hook- 
lets. Bilharz found it in great numbers in 
the duodenum of a boy in Egypt. It is very 
rarely entertained in the alimentary canal of 
man. 
Symptoms.-The presence of tapeworms 
is indicated by a great variety of symp- 
toms. Among the more important may be 
mentioned interference with the digestive 
process, irritability, and restlessness at night. 
Anaemia, headache, and vertigo are not un- 
common. Irritation about the anus is some- 
times a source of annoyance. Reflex pheno- 
Fig. 37.-Tania 
echinococcus. echinococcus-heads begin to bud from its 
walls. Each of these heads, when fully 
formed, is about 0'3 mm. in length when 
fully distended, and represents the head and 
neck of an adult echinococcus (fig. 39). Each 
head is furnished with four suckers and an 
armed rostellum, the booklets of which are 
582 
ENTOZOA 
capsules are developed from the parenchyma; 
each brood-capsule, like the parent-cyst, has 
two layers, an outer parenchymatous and an 
inner cuticular, thus reversing the conditions 
of the mother-cyst. Leuckart maintains that 
the scolices bud from the outer wall of the 
capsule; but when fully developed invaginate, 
so that what was formerly the internal cuti- 
cular surface of the head now becomes 
external. This view requires confirmation. 
The mother-cyst grows larger as fresh brood- 
capsules are formed. Every echinococcus 
cyst does not develop brood-capsules, and may 
attain a large size yet remain sterile. The 
presence of the cyst irritates the surrounding 
structures, and leads to the formation of a 
spurious capsule of fibrous tissue, sometimes 
of great thickness and usually very vascular. 
The brood-capsules, with their contained 
scolices, occur in clusters ; each capsule is of 
the size of a No. 5 shot. Occasionally the 
capsules become much larger and form 
internal daughter-cysts attaining in some 
specimens the size of a Tangerine orange. 
Such daughter-cysts may develop cysts of 
their own, or granddaughter-cysts. When 
endogenous daughter-cysts are present, the 
mother-cyst is, as a rule, of very large size, 
and contains as many as two or three thousand 
daughter-cysts varying in size from a pea to 
an orange. Occasionally, we find in echino- 
coccus cysts occurring in cattle, that daughter- 
cysts are formed from the cuticle and protrude 
beyond the external wall of the parent-cyst, 
and form brood-capsules. A few examples 
of this condition have been reported in the 
human subject. 
Echinococcus multilocularis is a variety 
of hydatid, which has been described as 
affecting the liver. It forms a hard tumour 
made up of alveoli, separated by fibrous 
tissue. The alveoli are filled with gelatinous 
transparent material, stained at times with 
bile. Such specimens were formerly described 
as colloid cancer of the liver, until Virchow 
pointed out that they were composed of 
echinococcus cysts, and occasionally con- 
tained scolices. Nearly all the reported 
cases have occurred in South Germany and 
Switzerland. The true nature of this form 
requires elucidation. The recognition of E. 
multilocularis is rendered more difficult by 
the circumstance that they sometimes ulcer- 
ate. This condition may easily be confounded 
with actinomycosis of the liver. 
Anatomical Characters in Man.-The 
human body frequently contains echinococcus 
cysts; there is scarcely an organ in which 
it has not been found, even in the medullary 
cavities of bones. Like the cysticercus cel- 
luloses, the embryo of T. echinococcus has 
its favourite situations : the former selects 
chiefly the intermuscular connective tissue 
and brain, the latter selects mainly the 
viscera, especially the liver. The liability 
of organs to entertain hydatids may be in- 
Fig. 88.-Hydatid of four 
weeks' growth, showing 
ectocyst and endocyst, 
x 60. After Leuckart. 
Fig. 39.-The so-called 
Echinococcus head, 
showing hooks, suck- 
ers, cilia, and corpus- 
cles. x 250 diam. 
After Huxley. 
very small. Numerous calcareous particles 
are lodged in its parenchyma. The rostellum 
with its hooks and suckers can be retracted 
and extended. In examining such specimens 
under the microscope it is usual to find them 
in the inverted or retracted condition shown 
in fig. 40. The heads or scolices are formed 
within brood-capsules, and Leuckart empha- 
tically states that they are throughout life 
Fig. 40.-Group of Echinococci, with their hook- 
crowns inverted, x 180 diam. After Busk. 
directly continuous with each other by means 
of the parenchyma of the main cyst, and 
cannot roam about the cavity and retain 
their vitality. The w'alls of hydatids consist 
of two layers, an outer or cuticular and an 
inner layer or parenchyma. The cuticular 
layer is highly elastic and curls up when 
divided; the parenchyma consists of granular 
matter, cells, and muscle-fibre. The brood- ENTOZOA 
583 
ferred from Neisser's tables as quoted by 
Leuckart. They are based upon an analysis 
of 986 cases : Liver, 451; lungs and pleura, 
84; kidney, 80; brain, 68 ; muscles, dermis, 
and orbit, 72; spinal cord, 13; pelvis, 36; 
circulatory organs, 29 ; spleen and bones, 28, 
and so on. This table is only useful as show- 
ing the greater liability of viscera to harbour 
this parasite. In the bones, eye, orbit, 
mamma, thyroid body, and heart it is of 
extremely rare occurrence. 
It is strange that, though the liver is such 
a favourite viscus for hydatids, it is rare to 
find more than one cyst present in this 
organ at the same time in the human subject; 
yet in swine they are frequently multiple. 
In man, one large cyst may be lodged in the 
liver, and twenty, thirty, or even a hundred 
occupy the omentum, mesentery, &c. This 
condition is, however, very uncommon. 
Symptoms.-The danger caused by these 
cysts arises mainly from the mechanical 
pressure they exercise on surrounding parts. 
Thus, in the brain or heart, a cyst the size of 
a hazel-nut gives rise to serious disturbance, 
but one as large as a man's head is often 
tolerated in the liver or pelvis. These cysts 
are often found post mortem when their 
presence had never been suspected during 
life, although they attained goodly propor- 
tions. The parasite may die early in its 
career, and the cyst-wall calcify; hydatid 
membranes seem very prone to this change, 
the calcareous matter resembling very old 
dried mortar. Hydatid cysts cause death in a 
variety of ways. In the brain they simulate 
cerebral tumour, and induce death early, 
especially when growing near the bulb. In 
the spinal cord they produce paraplegia. In 
the liver they may be accidentally ruptured, 
and cause death in a few hours from shock 
and haemorrhage combined, or, later, from 
peritonitis. In some instances, after injury 
or meddlesome tapping, suppuration takes 
place with septic troubles, which the forma- 
tion of-pus entails. Liver cysts may per- 
forate the diaphragm, and rupture into the 
pleura, or communicate with the lung and its 
bronchi. Occasionally they open into stomach 
or bowel, the scolices being discharged per 
anum. They have been known to rupture 
into the bile-passages, the transit of the 
scolices causing biliary colic. Among the 
rarer sites of rupture may be mentioned the 
pericardium, vena cava inferior, or through 
the parietes of abdomen or thorax. 
In the lung pressure upon the air-cells 
or bronchi may cause gangrene and other 
troubles which follow bronchial obstruction. 
Hydatid cysts of the thyroid body are very 
rare; they usually rupture into the trachea 
and cause death by suffocation. 
Diagnosis.-The diagnosis of hydatid cysts, 
in organs other than the liver, is attended 
with very great difficulty; and as these cysts 
frequently appear at post-mortem examina- 
tions and astonish the physicians, so are they 
one of the most fertile sources of surprise to 
enterprising surgeons. In the liver a hydatid 
cyst may be suspected when a tumour can be 
made out unaccompanied by pain, cachexia, 
high temperature, or wasting. 
The conditions most likely to be confounded 
with hydatid cysts in the liver are abscess, dis- 
tended gall-bladder, effusion in the right 
pleura, aneurysm of the abdominal aorta or 
hepatic artery, cancer of the liver, renal cysts, 
dilated stomach, pancreatic cyst, ovarian 
tumours, and dropsy due to closure of Win- 
slow's foramen. See Liver, Hydatid Dis- 
ease of. 
It is not wise to rely on the fact that the 
patient has lived among dogs or in a pastoral 
country. Individuals who have never kept 
or lived with dogs often develop hydatids. 
When an abdominal or thoracic tumour is 
suspected to be a hydatid cyst (these are the 
situations in which physicians are most fre- 
quently called upon to diagnose them), the 
nature of the swelling should be ascertained 
by puncturing it with a trocar, and drawing 
off some of the fluid. The characters which 
determine its echinococcus nature are the 
following:- 
The fluid is limpid, colourless (occasionally 
bile-stained when growing in the liver), and 
in specific gravity varies from 1009 to 1015. 
Free from albumen, it contains chloride of 
sodium, and is said to furnish traces of 
succinic acid, leucin and tyrosin. The three 
last are present in quantities too small to 
be of any clinical value. The most positive 
signs are the presence of brood-capsules, sco- 
lices, booklets, or the gelatinous, trembling, 
laminated membrane which forms the true 
wall of the cyst, and is in itself absolutely 
peculiar to hydatids. 
It must also be remembered that hydatid 
cysts are occasionally sterile-that is, they 
contain no brood-capsules and furnish no 
booklets. Such cysts frequently attain a 
large size, and seem to occur most frequently 
in the pelvis; they are as a rule mistaken for 
other forms of cysts. 
Treatment.-The treatment of hydatid 
cysts is entirely surgical. In such an organ 
as the liver the cyst should be freely opened, 
and its edges stitched to the sides of the in- 
cision and drained. The walls collapse, the 
cyst-membrane comes away during the ope- 
ration, or is subsequently discharged piece- 
meal. The cavity then slowly granulates. 
When hydatids are lodged in the omentum 
they are easily removed by abdominal sec- 
tion. When deeply placed in the pelvis they 
may be situated between the bladder and the 
rectum in the male, or burrow between the 
layers of the broad ligament in the female. 
These are better treated by incision and 
drainage. Hydatid cysts have many times 
been recorded in the kidney, but it is very 
unusual for them to exceed the dimensions of 584 
ENTOZOA 
an orange. They exhibit a marked tendency 
to discharge into the renal pelvis, the vesi- 
cles escaping by way of the urethra. Should 
the cyst attain such proportions as to give 
rise to a palpable tumour, it should be ex- 
plored by a lumbar incision, and treated in 
the way recommended for the liver. Such 
cysts arising in the kidney have been known 
to open into the lung, into the stomach, or 
communicate with the intestine. Intra-tho- 
racic hydatids are best treated on the same 
surgical lines as empyema. In the subcutane- 
ous tissues and orbit they are rarely diagnosed 
-indeed, these cysts in such situations can 
only be suspected; the suspicion is confirmed 
when the vesicles or portions of membranes 
escape during removal of the tumour. Intra- 
cranial hydatids have in Sydney, Australia, 
been successfully submitted to surgical pro- 
cedure. It is certain that no tumour or cyst 
connected with the brain offers a more favour- 
able prospect to surgeons than a hydatid 
cyst connected with the cerebral cortex. 
II. Trematoda, or Flukes (rpijpa, a 
hole).-Fr. Trematodes ; Ger. Trematoden; 
Saugwiirmer.-These forms have only one 
opening to the digestive cavity. 
Varieties :- 
a. Distoma hepaticum. 
b. Distoma lanceolatum. 
c. Distoma hcematobium vel Bilharzia 
hcematobia. 
d. Distoma Ringeri.-See p. 259. 
a., b. The first two are rarely seen, though 
they are common enough in the biliary pas- 
sages of sheep and oxen. They are vulgarly 
known as flukes, and are the cause of the 
destructive disease known as ' the rot ' of 
sheep. When flukes, with the exception of 
the Bilharzia hcematobia, occur in man, 
they occupy the biliary passages, but are 
usually present in such limited number as to 
rarely cause any serious disturbance of health. 
c. Bilharzia hcematobia, or Distoma hcema- 
tobium, unlike other forms of flukes, has the 
sexes distinct. The male is 12-14 mm. long, 
and has a flattened body, which, at its posterior 
part, is rolled into a kind of tube, constituting 
the gynaecophoric canal. The female is almost 
cylindrical in form, and 16-19 mm. long, being 
lodged within the gynaecophoric canal (fig. 41). 
The mature worms live in the inferior vena 
cava, portal, splenic, mesenteric, vesical, and 
heemorrhoidal veins of men and monkeys. 
The ova pass into the mucous membrane of 
the bladder and intestine, probably escaping 
as a consequence of the rupture of small 
vessels. Occasionally the ova may be found 
in the ureter and the pelvis of the kidney. 
The ova, often present in great numbers, are 
furnished with either a terminal or a lateral 
spine. Dr. Zancarol says that ova with a 
lateral spine occur in tlie intestine; those 
with the terminal spine in the mucous mem- 
brane of the bladder. The use of this ap- 
pendage has not yet been satisfactorily ex- 
plained (fig. 42). See Appendix. 
The Bilharzia is common in Egypt, Abys- 
sinia, the Cape, and Natal. The cercaria, as 
Fig. 41. - Bilharzia 
hcematobia, male 
and female sexually 
combined. Magni- 
fied. After Kiichen- 
meister. 
Fig. 42.-Ovum of 
Bilharzia hcema- 
tobia with con- 
tained embryo 
and free sarcode- 
granules. x 234 
diam. Original. 
the larval forms are termed, abound in rivers 
and canals, and are especially common in the 
Nile. When taken into the alimentary canal 
the cercaria quickly work their way into the 
mucous membranes, gain access to blood- 
vessels (veins), and develop into mature flukes. 
Symptoms.-When lodged in the intestines 
they give rise to dysentery; in the bladder 
and ureters, to cystitis, haematuria, and 
vesical calculus. The haemorrhage caused 
by their presence in the genito-urmary tract 
is known as ' endemic haematuria.' The 
eggs, whilst still within their host, may de- 
velop ciliated embryos. The disease may 
be suspected when haematuria occurs in 
persons coming from countries where the 
Bilharzia abounds: the diagnosis is con- 
firmed by finding under the microscope the 
ova embedded in fragments and shreds of 
mucous membrane passed with the urine. 
Treatment.-Means must be taken to 
allay the vesical irritation by such remedies 
as buchu, uva ursi, hyoscyamus, and the like. 
No remedy is known that acts as a parasiti- 
cide to the Bilharzia. It is wise to remove 
the patient, if possible, from an infected 
locality. Cure is likely to be protracted, and 
as yet we are ignorant of the duration of life 
of the fluke. 
III. Nematoda, or Round-worms 
(v^a, a thread).- Fr. Nematoides; Ger. 
Fadenwiirmer. 
Varieties:-■ 
a. Ascaris lumbricoides. 
b. Oxyuris vermicularis. 
c. Trichocephalus dispar. 
d. Ankylostoma duodenale. 
e. Filaria medinensis. 
f. Trichina spiralis. 
g. Filaria sanguinis hominis. ENTOZOA 
585 
Most of these inhabit the alimentary canal, 
and when restricted to this region rarely give 
rise to dangerous symptoms, unless they be 
very numerous; but they are 
apt to migrate and invade other 
organs, and thus give rise to 
dangerous and often disastrous 
results. 
a. Ascaris lumbricoides.- 
This, the common round or 
maw-worm, is of cylindrical 
shape, pointed at each end, 
and of a light brown colour. 
The female, as is usual among 
nematodes, exceeds the male 
in size. The length of the 
female varies from 25 to 40 
cm. The male is distinguished 
by the presence of two chitin- 
ous spines near the caudal end 
of the body (fig. 43). This 
extremity is also bent and 
hook-like. The spines indicate 
the male genital orifice. In 
the female the genital pore is 
situated near the middle of 
the body. The ova are very 
numerous; when mature they 
possess a double shell sur- 
rounded by an albuminous 
coating, have considerable 
power of resistance, and are 
not killed by dryingorfreezing. 
The life-history of the worm 
is not fully known, and we are 
ignorant of its intermediate 
host. Dr. Cobbold was of 
opinion that it did not require 
one, but that the eggs develop 
in water. 
This worm lives chiefly in 
the small intestine, but may 
wander into the stomach, and 
even pass up the oesophagus 
and be discharged through the 
mouth. An ascaris has been 
knowrn to creep into the bile- 
duct and cause jaundice. In 
cases of perforation of the in- 
testine in fatal cases of typhoid 
fever, these worms have been 
found lodged in the aperture. 
We must not conclude from 
this that the worm caused the 
perforation ; it is more reason- 
able to believe that when the 
accident happened the ascaris 
was passively lodged in the 
opening during the outward 
rush of the fluid contents of 
the bowel. It is possible that 
worms may occasionally per- 
forate the intestinal wall, and, getting into 
the subserous tissue, give rise to abscess. 
Such cases have been recorded. The wander- 
ing habit of ascarides is often fatal to them. 
Any foreign body m the intestine is sure to 
attract their attention and to form a sort of 
' worm-trap.' Thus they have bepn strangled 
by metallic buttons, hooks and eyes, open- 
topped thimbles and the like (Cobbold). 
Symptoms.-It is unusual for an individual 
to harbour more than two or three round 
worms, and as a rule they rarely give rise to 
symptoms. When present in large numbers 
-a condition of things most common in chil- 
dren-diarrhoea, colic, nausea, vomiting, and 
convulsions may occur. Children have been 
known to pass in the course of a few years 
one hundred worms, and in one case 510 
worms were voided by a child. Generally 
the passage of a worm by the anus or mouth 
is the first and only indication of its pre- 
sence. 
Treatment.-The most reliable drug is 
santonin, in the form of a powder: for chil- 
dren two to four grains, followed by a saline 
purge or castor oil; for adults five grains 
daily; for three days each dose to be followed 
by castor oil. Among other useful remedies 
we may mention aloes, scammony, jalap, 
calomel, kamala, sulphur, and turpentine. 
6. Oxyuris vermicularis 
{Thread- or Seat-worm).- 
The thread-worm is an in- 
habitant of the colon and 
adjacent parts of the ileum. 
The female is usually about 
10 mm. and the male 4 mm. 
long. In addition to its 
greater size the female has 
a sharp-pointed tail, whereas 
in the male it is blunt and 
furnished with a spiculum 
(fig. 44). Some helmintho- 
logists are of opinion that 
the mature females inhabit 
the colon, whilst the males 
and immature females are 
found in the ileum. 
Oxyurides are often present 
in large numbers, and wander 
into the rectum. They often 
cause intense irritation in the 
Fig. 43.-Asca- 
ris lumbri- 
coides: male, 
with exserted 
spicules. Nat. 
size(Cobbo)d). 
Fig. 44.-Oxyuris 
vermicularis, 
female. Highly 
magnified. Af- 
ter Leuckart. 
Fig. 45.-Eggs of Oxy- 
uris vermicularis, en- 
closing tadpole-shaped 
embryos, x 450diam. 
Original. 
neighbourhood of the anus, and in females 
cause great distress by creeping into the 
genital passages, especially during the night. 
The eggs of oxyuris are expelled with the faeces 586 
ENTOZOA 
and require to be taken into the stomach 
before they re-develop (fig. 45). Persons re- 
infect themselves by scratching the anus, 
and conveying the ova, by means of the 
finger-nails, to the mouth. 
Symptoms.-Among the local symptoms 
heat and irritation around the anus and nose 
are common. In children especially we often 
find restlessness, nervous irritation, choreic 
symptoms, and convulsions. Signs suggest- 
ing such severe conditions as meningitis are 
by no means infrequent. The existence of 
thread-worms is easily verified by admin- 
istering a mild purgative and examining the 
faeces. As a rule, they will be found in 
considerable numbers. In the case of 
children the attention of the nurse is called 
by finding the worms on the sheets. 
Treatment.-Brisk saline purgatives to 
expel the worms, and extreme cleanliness to 
prevent re-infection, are usually all that is 
required. Fruits and vegetables should be 
thoroughly cooked. In adults treatment re- 
quires to be carried out more vigorously, with 
such drugs as calomel, scammony, aloes, 
jalap, santonin, and asafoetida, in conjunction 
with enemata of infusion of quassia, or salt 
and water. 
c. Trichocephalus dispar, or Whip-worm. 
-The male and female equal each other in 
four curved teeth; the dorsal, two straight 
ones. The caudal end in the male has a 
three-lobed bursa and two spines (fig. 47). 
This worm infests the small 
intestine and bores its way 
into the mucous membrane. 
The effects of ankylo- 
stoma on the gut are very 
characteristic. The dam- 
aged spot is indicated by 
a small ecchymosis, with 
a central depressed white 
spot, in which the head of 
the worm lodged; occasion- 
ally it may be found still 
anchored to the mucous 
membrane. When present 
in large numbers these 
worms produce anaemia, 
sometimes called Egyptian 
chlorosis. The ankylo- 
stoma is very common in 
Egypt and Brazil. One 
stage of the worm is passed 
in muddy or dirty water; 
it gains access to the ali- 
mentary canal in drinking- 
water, and there attains its 
maturity. 
Symptoms.-The presence of this worm is 
indicated by the usual signs of anaemia, viz. 
pallor of the mucous membranes, weakness, 
palpitation, and faintness. Diarrhoea and 
dropsical effusions sometimes occur. The 
anaemia is due to the loss of blood conse- 
quent on the injuries inflicted by these para- 
sites on the intestinal mucous membrane. 
Treatment.--The worms should be eva- 
cuated by calomel and santonin combined, 
given at intervals over a period of a few 
weeks, for it must not be imagined that one 
or two doses will destroy the thousands of 
helminths lodged in the intestines in a severe 
example of this disease. The liquid extract 
of male fern is a useful remedy. The patient 
will require nourishing diet, easily digestible 
food, and good wine, with the usual tonic 
remedies. 
e. Filaria medinensis, Dracunculus, or 
Guinea-worm.-This is a fine thread-like 
worm from 60 to 100 cm. in length, and 
about 2 mm. broad. The female only is 
known. The embryos develop within the 
uterus. The intermediate host is a minute 
crustacean (Cyclops), which inhabits drink- 
YiGAl.-Ankylo- 
stoma duoden- 
ale ; male (a), 
and female (b). 
x 5 diam. 
Fig. 46.-Trichocephalus; male (a), and female (&). 
Enlarged one-fourth. 
length; as a rule they average 4 to 5 mm. 
The anterior part of these worms is fine and 
thread-like, the posterior is thicker, and con- 
tains the genital organs. In the male the 
caudal end is rolled into a spiral; near the 
extremity it is furnished with a spine 
(fig. 46). 
The trichocephalus resides mainly in the 
caecum. The early stages are passed in 
water or damp earth. The worm is very 
common in France: Davaine calculated 
that half the Parisians are infested by it. 
In England it is rare. Unless present in 
great quantities it is not often a source of 
trouble. 
d. Ankylostoma duodenale.-This small 
worm is also known as Sclerostoma duode- 
nale, Dochmius, or Strongylus duodenalis. 
Occasionally it is referred to as the tunnel- 
worm, on account of the disasters it caused 
among the men engaged in the Mount St. 
Gothard Tunnel. The female averages twelve 
mm. in length, the male is slightly smaller. 
The cephalic end is furnished with an oral 
capsule, which possesses a cleft covered by 
two chitinous lamellae. The ventral lip has 
ing-water. Within the Cyclops they are in- 
troduced into the human stomach, and then 
migrate into the subcutaneous tissues, where 
they become mature. A common situation 
is the tissue beneath the skin of the legs and 
feet; the heel is a favourite situation. 
Fig. 48.-Filaria medinensis. Reduced to J. ENTOZOA 
587 
The worm is confined to certain districts 
of Asia, Africa, and Brazil. It is supposed 
to be identical with the fiery serpents men- 
tioned in the Pentateuch. 
When the worm first lodges in the subcu- 
taneous tissue it gives rise to little trouble ; 
as it grows an abscess forms and gradually 
exposes the worm. Treatment consists in 
carefully winding the worm with gentle 
traction around a slender stick of ivory, bone, 
or wood, an inch or so daily, taking care not 
to break it. This method seems to have 
been employed of old by Persian surgeons. 
f. Trichina spiralis.-The mature worm 
inhabits the intestinal canal. The female is 
3 mm. long; the male is much smaller, and 
is further distinguished by presenting on 
the dorsal side of the tail two mammillary 
protuberances, which are turned towards the 
ventral aspect, and include between them 
four wart-like nodules (fig. 49). The young 
are developed in the uterus, and are born in 
a free state. The immature trichina inhabits 
sules are digested and the worms set free. 
In two days and a half they become mature, 
and pair. The embryos commence to be born 
on the seventh day; and the female may con- 
tinue to bring forth worms for many days. 
The mature worm lives but a few weeks, but 
during this brief life may bring forth a thou- 
sand or thirteen hundred embryos. The 
young then seek for striated muscle-fibre, 
and migrate through the wall of the intes- 
tine and the subperitoneal tissue. A few may 
get into vessels and are distributed by the 
circulation. On gaining access to a muscle 
they penetrate the fasciculi, becoming in 
about fourteen days mature muscle-trichinae. 
In due course they become encysted; the 
cyst is said to be in part due to a secretion 
furnished by the trichina. After a time the 
cyst-wall calcifies; should the trichina die, 
the cyst-contents also calcify. The duration 
of life of the worm in the muscle is very 
long, and even survives for a time the death 
of its host. The trichinae are found most 
abundantly in the intercostal muscles, dia- 
phragm, and laryngeal muscles. In the limb 
muscles they are less abundant, and cluster 
near the union of the muscle with its tendon. 
The trichinae so accurately select the volun- 
tary muscles that the pharyngeal constrictors 
and upper part of the oesophagus will lodge 
hundreds of them, while the rest of the tube 
contains none. 
Symptoms.-Human beings usually acquire 
the disease from eating trichinosed pork. The 
symptoms may be divided into two stages : 
the first consists of gastro-intestinal disturb- 
ance due to the introduction of the parasite ; 
the second corresponds to the migration of 
the worm, and is characterised by muscular 
troubles and febrile disturbance. 
The gravity of the symptoms depends upon 
the number of trichinae taken. The initial 
gastro-intestinal catarrh lasts usually about 
a week. The second stage is characterised 
by high fever and pain in the limbs and 
muscles, often mistaken for rheumatism. The 
muscles sometimes swell, become cedematous, 
and occasionally are partially paralysed. In 
grave cases delirium ensues, the limbs be- 
come flexed and paralysed, there is excessive 
diarrhoea, terminating in death. The dura- 
tion of the second stage lasts four or five 
weeks. In fatal cases, death usually occurs 
about the third or fourth week. 
At the end of five weeks the migration is 
usually complete, and the trichinae once en- 
cysted give rise to no further trouble. That 
this is so is clear from the fact that, in dis- 
secting-rooms, subjects occasionally occur 
with many hundred thousand trichinae en- 
cysted in the voluntary muscles of all parts 
of the body, from the head to the sole of the 
foot. The diagnosis may sometimes be estab- 
lished during life by an examination of sus- 
pected articles of food, or by the detection of 
adult trichinae in the evacuations during the 
Fig. 49.-Trichina 
spiralis magni- 
fied ; male (a), 
and female (b). 
After Leuckart. 
Fig. 50.-Portion of human 
muscle, enclosing a single 
capsuled trichina . Highly 
magnified. After Leuc- 
kart. 
voluntary muscular fibre, where it is usually 
coiled into a spiral, embedded in granular 
tissue and surrounded by a cyst-wall, which 
frequently contains calcareous particles (fig. 
50). These capsules are visible to the naked 
eye as minute white specks. Each capsule 
usually contains one trichina, but two, three, 
and even five may be present. 
The relation of the two forms is as follows. 
When a piece of muscle containing living 
trichinae is taken into the stomach, the cap- 588 
ENTOZOA 
course of the disease. The most certain plan 
is to remove a fragment of affected muscle 
and examine it under the microscope. 
Treatment.-If it can be at once ascer- 
tained that trichinosed food has been taken 
into the stomach, an emetic should be admin- 
istered without delay, followed by a brisk pur- 
gative ; this treatment should be pursued for 
several days to expel the worms before they 
become mature. Calomel alone, or combined 
with scammony or jalap, is recommended. 
Even when the young filariae have begun 
their migrations, brisk cathartics still do good; 
but the patient's strength will require support 
during this critical stage by solutions of 
meat, broth, eggs, milk, and the judicious 
administration of wine or brandy. As the 
patient becomes convalescent ordmary tonics 
will be needed. 
Preventive treatment consists in rejecting 
suspected trichinosed food, especially pork. 
The disease is rare in Great Britain, but 
fairly frequent in Germany, where it is the 
custom to eat'Wurst,' or sausages made of 
smoked ham. 
g. Filaria sanguinis hominis.-This para- 
site and its embryo are separately described. 
See Filaria Sanguinis Hominis. 
IV. Gregarinidse {gr eg arias, from grex, 
a flock).-Fr. Gregarines-, Ger. Gregarinen. 
VarietyCoccidium oviforme. 
The disease produced by the presence of 
the coccidium oviforme is known as Psoro- 
spermia ^(hpa or \/swprj, a cutaneous disease- 
the itch, scab, or mange. The Latin equiva- 
lent is scabies). The French use the word 
psore as a generic title for vesicular and 
pustular maladies of the skin. J. Muller 
seemsto have first used the word ' psorosperm' 
to indicate a parasitic affection of the skin, 
gills, muscles, and kidneys of fish and frogs. 
In the skin of fish the disease consisted of 
small sacs containing oval bodies, some with 
and some without tails; these he termed 
psorosperm saccules. 
It has long been known that the destruc- 
tive liver-disease of rabbits is due to the 
presence of small oval bodies named coccidia 
oviformia, lodged in the bile-ducts. The 
coccidium is thus described by Leuckart: 
It is egg-shaped, 0 033 to 0'37 mm. long, and 
0'015 to 0'02 mm. wide, with a thick smooth 
shell, possessing at one end, usually the nar- 
rower, a micropyle. The coccidia resemble 
very closely the eggs of certain entozoa. 
It has been known since 1858 that this 
coccidium occurs in the human subject, and 
since that date numerous cases have been 
observed. Among the recent cases, one de- 
scribed by Mr. Silcock may be mentioned. A 
woman, fifty-three years of age, was thought 
to be suffering from typhoid fever. The 
illness dated from a chill taken seven weeks 
before death. The symptoms were pain in 
the limbs, nausea, and occasional' sickness, 
tenderness over the liver and spleen, fever 
of remittent type, the temperature reaching 
103° F., and slight diarrhoea. The urine was 
albuminous, the splenic and hepatic dulness 
increased, and the tongue dry and coated 
with brown fur. Death resulted from cardiac 
failure. 
On post-mortem examination the liver 
weighed eighty-three ounces, and contained 
numerous small caseous foci ; the spleen 
weighed sixteen ounces, and presented similar 
foci varying in size from a pin's head to 
a pea. Papule-like elevations dotted the 
mucous membrane of the ileum and large 
intestine. The naked-eye characters of these 
nodules resembled tubercle, but on micro- 
scopic examination they were found to be 
coccidium nodules. 
The mucous membrane of the ureters is 
a favourite situation for these nodules. In 
this situation they give rise to hsematuria, 
frequent micturition, and death from ex- 
haustion. 
There is reason to believe that these para- 
sites invade the orifices of the follicular ducts 
of the skin and give rise to molluscum con- 
tagiosum and chronic eczema of the nipple 
(Darier). Confirmatory observations have 
been made in London. 
V. Rhizopoda (pfa, a root; and ttovs, a 
foot).-Fr. lihizopodes ; Ger. Wiizopoden. 
Amoeba coli.-Lambl appears to have been 
the first to detect amoebae as human para- 
sites, but the first satisfactory investigations 
were made by Lbsch in 1875. He found 
them in the stools of a Russian peasant suf- 
fering from ulceration of the large intestine. 
In this case the amoebae were five to eight 
times larger than the red blood-corpuscles; 
their protoplasm, which was coarsely granu- 
lar, presented a few blunt processes, a round 
nucleus, and several vacuoles. 
Lbsch found them in great number; as 
many as sixty could be seen in one field of 
view with a magnifying power of 500. The 
peasant who was the subject of Lbsch's 
researches had lived a miserable life; his 
illness presented all the signs of violent 
dysentery. Pleurisy and pneumonia super- 
vened, accompanied by anaemia, exhaustion, 
and death. The fresh dejections from this 
patient were injected into dogs per os et 
anum, but with incomplete results. In 1883 
Kartulis examined in Egypt 150 bodies of 
persons dead of dysentery, and found the 
amoeba in every case. In twelve post-mortem 
examinations amoebae were found in the ulcers. 
Subsequently Kartulis extended his observa- 
tions to hepatic abscess complicating dysen- 
tery, and found amoebae in sections of the 
abscess-wall. They resembled those found 
in the intestine. He has since extended his 
researches so as to include 500 cases of 
dysentery, with confirmatory results. 
The amoeba coli has been found in the 
intestines of dysenteric patients by other ob- 
ser\ers-Massentin, Baumgarten, and Osler. ENTOZOA 
EPIDEMIC 
589 
Dr. Osler's observations were made on a 
doctor, twenty-nine years of age, resident in 
Panama for nearly six years, who had suffered 
from chronic dysentery. When he came 
under Dr. Osler's care, abscess of the liver was 
detected and drained. As the pus came from 
the drainage-tube, samples were taken at once 
to the laboratory and examined. Amoebae 
were present in large numbers, and continued 
to be present until the patient died. Amoebae 
were also found in the stools, and in every 
respect identical with those from the abscess. 
They were rarely found in the brownish 
stools, but were more frequent in the mucus 
and in the greyish fragments of sloughs. 
The amoebae in size ranged from 10-20 mm., 
and were somewhat larger than those found 
by Kartulis. When once recognised there 
was not the slightest difficulty in distinguish- 
ing them, even when at rest, from pus-cells, 
not merely by their size, but from the en- 
tirely different appearance of their proto- 
plasm. 
How far these bodies are the exciting 
agents of the disease is uncertain, because 
amoebae have been found in normal faeces; 
nevertheless they are deserving of extended 
study. They have been found in Egypt, 
Athens, St. Petersburg, London, and America. 
J. Bland Sutton. 
ENTOZOON FOLLICULORUM.- 
A synonym of the animalcule of the follicles 
of the skin, otherwise named acarus (Simon), 
demodex (Owen), and steatozoon folliculorum 
(Erasmus Wilson). See Acarus. 
ENTROPION (tv, in; andrpeTrw, I turn). 
A morbid condition in which the eyelid is 
inverted, so that its free margin is directed 
towards the eye. See Eye and its Append- 
ages, Diseases of. 
ENURESIS (tv, in; and ovptw, I pass 
the urine).-Involuntary discharge or in- 
continence of urine. See Micturition, 
Disorders of. 
EPHELIS. - Synon. : Sunburn ; Fr. 
Fphelide-, Ger. Sonnenflecken.-This word 
is applied to pigmentary discoloration of the 
skin, of a brown, grey, or black colour, in- 
creased by the stimulus of light and heat, as 
of the sun's rays, or scorching by fire. Two 
principal varieties of the affection have been 
noted, namely, Ephelis Solaris, and Ephelis 
ignealis. See Pigmentary Skin-Diseases. 
Erasmus Wilson. 
EPHEMERAL FEVER (em, upon; 
and fyj.tpa, a day).-A mild form of milk- 
fever, so called on account of the rapidity 
with which it subsides, lasting not more than 
a day. See Milk-Fever. 
EPHIDROSIS (erri, upon; and i8p6a>, I 
sweat).-A term signifying a state of sweat- 
ing, and synonymous with idrosis. See 
Perspiration, Disorders of. 
EPIDEMIC (epidemicus, affecting the 
people ; from eW, upon; and. brjuos, a people). 
The word ' epidemic ' is used in two senses 
by medical writers and by medical men, 
namely, (1) in a general sense, and (2) in a 
technical sense. 
As a general term the word signifies ' com- 
mon to, or affecting, a whole people, or a 
great number in a community; prevalent; 
general' (Webster's Dictionary). It is in 
this sense that the word is used when it is 
applied to mental, moral, and social phe- 
nomena, as, for example, when we speak or 
write of 'epidemic suicide,' 'epidemic folly.' 
This employment of the word is consistent 
with received literary practice. Thus we 
read, ' There was a time when wit was epi- 
demic ' (Athenceum). Again, M. Littre, 
writing to the Temps : ' It argues great 
confidence in oneself and one's own en- 
lightenment to treat with haughty disdain, 
and without reserving any compromise, the 
opinion of so many citizens, and to regard 
it as a case of epidemic aberration.' 
As a technical term, having reference to 
disease, the word ' epidemic ' has several dif- 
ferent meanings attached to it. All these 
meanings include the notion of general pre- 
valence among a community or a people, but 
some of them would go on, beyond what 
etymology justifies, to attach a peculiar 
hypothetical or theoretical conception to the 
term. Thus (a) Mayne restricts the term to 
diseases which are contagious, making con- 
tagion the essence of epidemicity, as he 
would phrase it; (b) Dunglison implies by 
the term a particular constitution of the air 
(' constitutio aeris, or condition of the atmo- 
sphere ') ; (c) other authoritative writers use 
the term as signifying a widespread cause, 
telluric, atmospheric, cosmic, as the case may 
be, acting at the same moment of time on 
many individuals, or as something occult, 
regarding which speculation is vain, and 
which they designate epidemic constitution 
or epidemic influence. 
The foregoing technical significations at- 
tached to the word * epidemic ' are not less 
misleading than insufficient. Mayne's defi- 
nition imposes an arbitrary limitation upon 
the meaning of the word, while it involves 
but a partial notion of the phenomena of 
epidemic prevalence of contagious diseases. 
Dunglison's definition does not rest upon a 
scientific foundation, and its phraseology, 
derived from a period when medicine was 
still hampered with semi-mystical specula- 
tions, cannot well be dispossessed of the 
vague traditional meanings which adhere 
to the word ' constitution.' Other technical 
definitions (if that can be called a definition 
which makes obscure what should be ren- 
dered clear) rest on mere assumptions, or 
relegate the term to the incomprehensible 
and insoluble. Of these last-named defi- 
nitions Leon Colin has said: ' They signify EPIDEMIC 
590 
implicitly a common cause, apparently in- 
decomposable, to which individuals are not 
exposed successively but simultaneously . . . 
a something isolated, impersonal, inaccessible 
to reason, detached from the disease itself, 
the epidemic genius [constitution, influence] 
... a creative force of the different epidemic 
affections, compelling, directing, extinguishing 
them.' 
The promiscuous use of the word ' epidemic ' 
in medical literature and medical talk, and 
the different irreconcilable significations at- 
tached to it as a technical term, have been, 
and still continue to be, sources of almost 
hopeless confusion in treating of diseases in 
respect to which the phenomenon of (etymo- 
logically) epidemic prevalence is observed. 
It is not difficult to apprehend how this has 
come about. The diseases in question (the 
morbi populares of some writers) include 
among their number plague, the eruptive and 
continued fevers, influenza, malignant cho- 
lera, &c. ' They have the peculiar character 
of attacking at intervals great numbers of 
people within a short period of time; they 
distinguish one country from another, one 
year from another; they have proved epochs 
in chronology; and, as Niebuhr has shown, 
have influenced not only the fate of cities, 
such as Athens and Florence, but of empires; 
they decimate armies, disable fleets; they 
take the lives of criminals that justice has 
not condemned; they redouble the dangers 
of crowded hospitals; they infest the habi- 
tations of the poor, and strike the artisan in 
his strength down from comfort into helpless 
poverty; they carry away the infant from the 
mother's breast, and the old man at the end 
of life; but their direst eruptions are exces- 
sively fatal to men in the prime and vigour 
of age ' (Wm. Farr). Exercising at all times 
in their greater and more fatal prevalence the 
profoundest influence over the mind, as well 
of the people generally as of the medical 
profession, these diseases, partly from the 
terror they inspire, partly from the extreme 
complexity of the phenomena they display, 
have formed a never-ceasing subject of the 
wildest speculation. No part of medicine has 
retained so much of the semi-mystical teach- 
ings of the older physicians as that which 
relates to epidemics, and general history has 
contributed with medical history to propagate 
in regard to epidemics that habit of thought 
which refers the unknown to the occult- 
using the latter term in the sense in which 
it is applied with regard to the imaginary 
sciences of the Middle Ages. Much of the 
speculation as to epidemics which passes 
current for science at the present day is in 
reality an unsuspected continuation of the 
mystical teachings of earlier medicine-mag- 
netism, or electricity, for example, taking 
the place of Saturn or Mercury in the scheme 
of causation. The terminology is modernised, 
but the underlying conception remains the 
same. Again, the so-called ' precursors ' of 
epidemics, which still find a place in treatises 
on medicine, are the relics of the doctrine of 
portents of the Middle Ages. They rest on 
the assumption of an epidemic being deter- 
mined by some common extra-mundane or 
intra-mundane cause, of which it is but one 
of several effects. The celestial 'portents,' 
such as comets and meteors, and the more 
manifest telluric 'portents,' such as earth- 
quakes and volcanic eruptions, have been 
discarded; but the ' portents ' derived from 
exceptional developments of insect life, from 
murrain, from unusual prevalence of certain 
diseases, and from remarkable perturbations 
of the weather, are retained under the de- 
nomination of 'precursors.' For example, 
the earlier epidemics of malignant cholera 
which visited Europe were believed to have 
been heralded by an unusual prevalence of 
' fevers ' and of diarrhoeal affections. The 
epidemic of 1865-66 gave an excellent oppor- 
tunity of studying the facts bearing on this 
question. Europe was taken by surprise 
when cholera appeared in 1865, on the south 
coast of the Mediterranean, at Alexandria, 
and began thence to extend rapidly to the 
southern and eastern shores of that sea. It 
was not, indeed, until the disease had effected 
a lodgment in several parts of the Continent 
that the attention of governments and the 
public with regard to it was fully aroused. 
No change of the public health in the several 
places visited by the epidemic had occurred 
of such a nature as to give rise to any, even 
the least, suspicion of impending pestilence. 
Moreover, notwithstanding the prevalence of 
steppe-murrain and of cerebro-spinal fever 
in Northern Europe at the beginning of 1865, 
there was nothing to suggest (indeed it was 
not suggested) that these phenomena were 
' precursors ' of the coming epidemic of cho- 
lera, or of the extension of yellow fever to 
the shores of England the same year. In 
fact, the different occurrences were parts of 
contemporaneous rather than successive phe- 
nomena. The condition of the public health 
preceding the appearance of cholera in Eng- 
land, and especially in respect to diarrhoea 
antecedents, was made the subject of careful 
study by the late Professor Parkes and others. 
These observers failed to obtain any inkling 
of a change in the public health which could 
be regarded as presaging pestilence-of the 
existence, in short, of any so-called ' epidemic 
constitution.' It is true that John Sutherland 
had described an increase of ' fevers ' and 
diarrhoeal disease in Malta, as preceding the 
appearance of cholera there, in June 1865, 
observing that: ' These facts are sufficient 
to show that, long before cholera began to 
come towards the north-west, there were in- 
dications of a changed condition of the public 
health in Malta; ' and after giving an account 
of two groups of choleraic cases which 
occurred in May, he adds, ' It appears to me EPIDEMIC 
591 
scarcely possible to escape from the conclu- 
sion that, long before cholera appeared in 
Malta, possibly before the first outbreak in 
Arabia, the earliest wave of the coming epi- 
demic had passed over those islands.' But 
while, according to Dr. Sutherland, the com- 
ing epidemic was thus clearly foreshadowed 
in Malta, no change in the public health 
presaged its appearance in Gibraltar in July. 
The absence of all foreshadowing of the epi- 
demic at Gibraltar can hardly be reconciled 
with the suggested presence of such fore- 
shadowing at Malta. The facts which have 
been interpreted as presaging the appearance 
of cholera in the latter island are, indeed, to 
be regarded as coincidental rather than re- 
lated. It is true, also, that MM. Didiot and 
Gues have endeavoured to show that, prior to 
the appearance of cholera at Alexandria in 
1865, choleraic disease existed in Marseilles, 
and that the outbreak of the epidemic in the 
latter town was preceded by 'une constitution 
medicale cholerique.' The evidence they 
advance in support of their conclusions 
simply shows that deaths from infantile 
cholera, which, as they properly remark, is, 
' a la verite, frequente A Marseille,' and from 
so-called ' sporadic ' cholera, are apt to occur 
in Marseilles during the months of May and 
June, as perhaps in every city and town of 
Southern and Central Europe. 
Another illustration to the same effect as 
. the above, in regard to the ' precursors ' of 
epidemics, is furnished by the history of the 
small-pox epidemic of 1869-73, the greatest 
epidemic of this disease in recent times-a 
true pandemic (rrdvSrjfjLos, from rav, all; and 
8ijp.os, the people) extension of the malady. 
The acutest observers were taken by surprise 
with the malignity and diffusibility of the 
disease during the epidemic-phenomena 
wholly unforeseen. Here, again, the study of 
the diseases preceding or accompanying the 
epidemic yields no facts of variation in their 
prevalence, from which the approach of a great 
epidemic might have been inferred, nor gives 
any hint that they were dependent with it on 
some common cause. 
There were concurrent phenomena of dis- 
ease during both epidemics, but they were 
concurrences of certain diseases existing at 
the same time among the population affected 
by the great epidemic, and some of them 
probably having certain secondary elements 
of causation in common. This is a different 
question to that of an assumed ' epidemic in- 
fluence ' or ' epidemic constitution.' The sub- 
ject of the concurrence of epidemics is a new 
field of investigation, which has lately been 
opened by an arithmetical study of George 
Buchanan's, relating to epidemics in numer- 
ous extra-metropolitan registration sub-dis- 
tricts in England. This study was directed 
to ascertain-as necessarily introductory to a 
statistical investigation regarding community 
of causation or mutual antagonism of various 
epidemics-the arithmetical probability of 
their concurring as a mere matter of chance. 
The data used were taken from a particular 
quarterly return of the Registrar-General, and 
they extended to 946 occurrences of epidemics 
(small-pox, measles, scarlet-fever, diphtheria, 
whooping-cough, fevers, and diarrhoea and 
simple cholera) in 1,490 districts. The result 
showed a good deal of general correspondence 
between the calculated number of concur- 
rences and the actually observed number, but 
with departures, of more or less magnitude, 
of the actual from the calculated degree of 
concurrence, which deserve to be followed 
up by further investigation. The departures 
were shown in an excessive frequency of the 
concurrence of measles with the other epi- 
demics, of diarrhoea with all other epidemics 
except small-pox, and of scarlet-fever with 
the ' fever ' of the Registrar-General. On the 
other hand, it is of interest to observe that 
there was an absence of any notable excess 
of frequency of concurrence between scarlet- 
fever and diphtheria, or between scarlet-fever 
and whooping-cough. 
In view of the extreme looseness with 
which the word 'epidemic ' is used in medicine, 
sometimes simply as a descriptive term, some- 
times as a technical or quasi-technical term 
involving various hypothetical and theoretical 
conceptions inconsistent with each other, and 
sometimes as implying an occult influence, 
it would be well if it could be discarded from 
medical literature and language. ' Epidemic,' 
in its present medical uses, is an instance of 
words which, as Bacon says, when writing of 
the effects exercised by a bad and inapt for- 
mation of words on the human mind, ' force 
the understanding, throw everything into 
confusion, and lead mankind into vain and 
innumerable controversies ' (Nov. Org. App. 
43). But the retention of the word, from its 
long and familiar usage, is practically a ne- 
cessity in medicine; moreover, it would be 
difficult, if not impossible, to find a substitute 
which, if the word be used in its ordinary sig- 
nification, would supply its place. 
It is suggested here that the technical 
meaning of the word ' epidemic ' should be as- 
similated to the common meaning; or, more 
accurately, that the technical meanings now 
attached to the word should be abandoned, 
and the word used in medicine in the same 
sense as in general literature and in ordinary 
converse; that is to say, as a merely quanti- 
tative term applicable to particular pheno- 
mena, whether pathological, mental, or social, 
in so far as they are ' common to a whole 
people, or to a great number in a community,' 
or, in a word, are ' prevalent ' or ' general.' 
In this way not only would the confusion 
arising from the present medical uses of the 
word be got rid of, but the scientific study 
of epidemic phenomena would be facilitated 
in the only direction which gives promise of 
successful issue. As Leon Colin has aptly 592 
EPIDEMIC 
EPIGASTRIC REGION 
written: ' It is the disease which constitutes 
the epidemic, not the epidemic the disease. 
The evil always remains the same, the num- 
ber of affected alone being increased.' The 
medical study of epidemics is essentially a 
study of the individual diseases which are apt 
to become epidemic, and not, as has been too 
commonly the case hitherto, of some figment 
of the imagination (epidemic constitution, 
or influence, or genius), apart from the dis- 
eases. It is only in proportion as researches 
have been directed to particular diseases 
liable to become epidemic, and to the condi- 
tions under which they prevailed epidemically, 
that recent advances in our knowledge of 
epidemics have been made. In this country 
the two most important events which have 
occurred in this connexion of late years were 
the discrimination of typhus from typhoid 
fever, by A. P. Stewart and William Jenner, 
and the researches on the typhus of horned 
cattle (steppe-murrain, cattle-plague) pro- 
moted by the Royal Commission of 1865-66 
on Cattle-Plague. The discrimination of 
typhus from typhoid fever proved that the 
voluminous speculations which to that time 
were current on the epidemiology of the 
continued fevers of this country, then re- 
garded as but one disease presenting several 
varieties, were for the most part meaning- 
less verbiage, by showing that the two most 
common forms of fever were distinct dis- 
eases, clinically, pathologically, and setiologi- 
cally. This discovery proved to be the in- 
auguration of a true method of investigation 
concerning epidemics, by making evident that 
epidemic phenomena did not admit of accu- 
rate study, except in so far as it was based 
upon a just discrimination of the diseases 
manifesting them, and upon their clinical and 
pathological histories. The same lesson was 
taught, not less clearly, although in another 
fashion, by the researches promoted by the 
Royal Commission on Cattle-Plague, with 
which the names of Lionel Beale and Burdon 
Sanderson are especially connected. These 
researches demonstrated the essentially infec- 
tious nature of the malady, and that its pre- 
valence was dependent upon the dissemina- 
tion of the infection, directly or indirectly, 
from animals sick of the disease to the healthy. 
It was shown, indeed, in the pathological 
laboratory, that preconceived doctrines of 
some occult epidemic influence which had 
been submitted to the Commission as deter- 
mining the prevalence of the cattle-plague 
had no existence in fact when the disease 
was subjected to experimental study, and that 
its conditions of prevalence were fully within 
human control. These researches proved the 
starting-point of those important investiga- 
tions on the intimate pathology of contagion 
carried out by Burdon Sanderson and Klein, 
for the PriVy Council, under the direction of 
John Simon, and to which William Roberts 
and others have independently contributed so 
largely, and which have been followed by the 
investigations into the intimate pathology of 
scarlatina and diphtheria by Klein acting 
under the instructions of George Buchanan 
for the Local Government Board. See also 
Periodicity in Disease. 
J. Netten Radcliffe. Shirley F. Murphy. 
EPIDEMIC CEREBRO-SPINAL 
MENINGITIS.-A synonym for cerebro- 
spinal fever. See Cerebro-spinal Fever. 
EPIDEMICS, Occurrence of.-See 
Periodicity in Disease. 
EPIDERMIS, Diseases of.-See Skin, 
Diseases of. 
EPI DERM OPHYTON upon; 
8tppa, the skin ; and fyvrov, a plant).-The 
name of the epiphyte, or parasitic fungus, ct 
pityriasis versicolor; also called microsporon. 
See Epiphyta. 
EPIDIDYMITIS upon; and 8i8v- 
pw, a testicle).-Inflammation of the epi- 
didymis. See Testes, Diseases of. 
EPIGASTRIC REGION.-This re- 
gion is situated at the upper and central part 
of the abdomen, just below the ensiform 
cartilage, and between the sloping margins 
of the thorax down to the level of the ninth 
cartilage, corresponding to what is popularly 
known as the ' pit of the stomach.' The 
structures within the abdominal cavity which 
normally occupy the epigastrium are the 
greater part of the stomach, a small portion 
of the liver, and more deeply a part of the 
pancreas, the aorta giving off the cceliac axis 
and superior mesenteric branch, the vena 
cava inferior, the veins forming the com- 
mencement of the portal vein, the recep- 
taculum chyli, and the solar plexus. 
Clinical Investigation.-Clinically, it will 
be found that patients frequently complain of 
abnormal sensations specially referred to the 
epigastrium. These are generally associated 
with the stomach, and may merely amount 
to a sense of discomfort, fulness, or tightness; 
or to actual pain of varying character, more 
or less severe according to the condition upon 
which it depends, and often much influenced 
by the ingestion of food. Sensations of 
trembling, throbbing, or sinking at the pit of 
the stomach are also of common occurrence, 
especially in females. These are often 
merely of a nervous character. In some 
cases there is evident tenderness, either over 
the entire epigastrium or in some limited 
spot, and it is important ro recognise whether 
this is superficial or felt more or less deeply, 
for it may be connected with the superficial 
structures, the peritoneum, the liver, the 
stomach, or the pancreas. The sensation 
experienced in connexion with hunger is 
referred mainly to the epigastrium, and it 
may be of a painful character. Here mav EPIGASTRIC REGION 
EPILEPSY 
also be noticed the epigastric pain termed 
gastralgia or gastrodynia, which is usually 
felt chiefly when the stomach is empty, being 
relieved by taking food. A most unpleasant 
sensation at the pit of the stomach accom- 
panies nausea, which may be of a horrible 
but indescribable character; while violent 
vomiting or retching causes considerable pain 
or aching in this region, partly associated 
with the stomach, partly with the abdominal 
walls. Heartburn is another sensation which 
seems to start from the epigastrium. Some- 
times the pain is situated deeply, or shoots 
towards the back. This may depend upon 
disease affecting the posterior wall of the 
stomach, pancreatic disease, aneurysm, or 
other causes. A sensation of tension or 
actual pain is sometimes experienced just 
below the ensiform cartilage in cases where 
the diaphragm is much pressed downwards, 
as from extreme emphysema, abundant 
accumulation of fluid or air in the pleura, or 
extensive pericardial effusion. A deep pain 
is not uncommonly referred to the epigastrium 
in cases of Addison's disease, and also in those 
of pernicious anaemia. Probably this is con- 
nected with the sympathetic plexuses. 
Physical examination of the epigastric 
region is often of the greatest value, and 
important objective signs of various morbid 
conditions may thus be readily recognised. 
Of course organs which normally occupy 
other regions may enlarge so as to extend 
into the epigastrium, or may become very 
movable and consequently be felt in this 
region. It may, moreover, be occupied, along 
with other parts of the abdomen, by growths 
or accumulations of fluid. The objective 
signs and conditions which are more especi- 
ally connected with the epigastrium may be 
indicated as follows :- 
1. It is customary to apply the hand over 
the epigastrium for the purpose of counting 
the respirations, if these cannot be reckoned 
by merely watching the patient breathing. 
2. Morbid conditions of the abdominal 
walls may be confined to the epigastric region, 
such as an abscess; and here it may be re- 
marked that the recti muscles frequently 
become very hard and rigid when palpation 
is practised over this part, and so might be 
in danger of being mistaken for some serious 
lesion, unless care were exercised in the 
examination. 
3. Growths connected with the peritoneum, 
especially the great omentum, may be felt 
chiefly or entirely in the epigastrium in some 
instances. 
4. Abnormal states of the stomach are 
necessarily revealed mainly by corresponding 
signs in the epigastrium. Thus there may be 
evidence of dilatation of this organ; of carci- 
nomatous infiltration or thickening of its an- 
terior wall; of a localised tumour; or of some 
accumulation in its interior, whether solid or 
liquid. It must be remarked, however, that 
the stomach, when diseased, frequently ex- 
tends into other regions beyond the epigas- 
trium, or is actually displaced. 
5. When the liver is the seat of organic 
disease, this is often revealed in the epigastric 
region, usually along with other regions, but 
sometimes the abnormal physical signs are 
noticed specially in this part. Thus a can- 
cerous mass may present here, or a hydatid 
tumour or hepatic abscess may tend in this 
direction. The gall-bladder has also occasion- 
ally been found, when the seat of some 
accumulation or of malignant disease, to have 
been displaced towards the epigastrium and 
become fixed there. 
6. Pulsation is not uncommonly felt in the 
epigastrium. When situated at its upper 
part, just below the ensiform cartilage, it 
depends upon the heart, usually its right 
side, being due either to shortness of the 
sternum, displacement of the heart, or en- 
largement of its right cavities. Very often a 
pulsation is felt, and sometimes even seen, 
due to a pulsating aorta, especially in thin 
and anaemic subjects ; and an impulse from 
this vessel may be transmitted through an 
enlarged pancreas, or through an abscess 
of the liver, of which the writer has seen a 
marked example. Occasionally an impulse 
in the epigastrium is connected with an 
aneurysm, either of the aorta or of one of its 
branches. A pulsation in this region has also 
been attributed to regurgitation of blood from 
the right auricle into the inferior vena cava 
and hepatic veins, in cases of tricuspid in- 
competency. A murmur may sometimes be 
heard in the epigastrium. Usually this is a 
conducted cardiac murmur, but occasionally 
it depends on an aneurysm. 
Frederick T. Roberts. 
EPIGLOTTIS, Diseases of. - See 
Larynx, Diseases of. 
EPILEPSY (eartXag^di/w, I seize upon).- 
Synon. : Morbus comitialis, sacer, major, 
<£c.; Fr. Epilepsie, haut mal, de.; Ger. 
Fallsucht. 
Definition.-In its common form this apy- 
retic affection is a neurosis, characterised hy 
seizures of loss of consciousness, with tonic 
or clonic convulsions. When either of these 
manifestations recurs in fits, epilepsy exists, 
although incomplete, as shown by the fol- 
lowing facts : first, that patients who gene- 
rally have convulsions only are sometimes 
seized also with unconsciousness; secondly, 
that others who usually have seizures of loss 
of consciousness, without marked spasmodic 
action, sometimes have complete fits of 
epilepsy- 
Some writers confine the name of Epi- 
lepsy to the well-defined form of that neurosis 
known as idiopathic. Others consider as 
belonging to epilepsy most of, if not all, the 
non-febrile affections recurring in fits, and of 
593 594 
EPILEPSY 
which we sometimes have good instances in 
cases of paroxysmal aphasia, amaurosis, para- 
lysis, or involuntary movements, either dis- 
ordered or well co-ordinated, &c. There is 
no doubt that all apyretic nervous affections, 
appearing in seizures, have, on account of 
this special feature, a common link with 
epilepsy. In this article, however, the writer 
will only study the ordinary forms of the 
morbus comitialis and the epileptiform mani- 
festations due to brain-disease. 
Aetiology.-Under this head we will study, 
first, what relates to the causation of the 
morbid state in which epilepsy essentially 
consists; secondly the causes of attacks. 
Predisposing Causes.-Heredity deserves 
to be noticed first, not because it is the most 
frequent, but because it is a most undeni- 
able cause. Pritchard has shown that all 
neuroses have the greatest relationship one 
to another. It is but natural, therefore, that 
epileptics are very often found to have had 
a father or a mother who suffered from 
some kind of nervous disorder. Moreau 
has shown that epileptics are often the off- 
spring of insane parents. It is quite certain 
that people attacked either with organic dis- 
ease of the brain, and having had no convul- 
sions, or with any kind of neurosis or any 
form of insanity, very frequently have chil- 
dren who become epileptic. Important statis- 
tical data, given by Fere, show that, among 
the direct ascendants of 594 epileptics, 70 
had suffered from epilepsy, 166 from insanity, 
88 from paralysis, 21 from general paralysis, 
72 from hysteria, 73 from senile dementia, 
33 from puerperal eclampsia, 61 from chorea. 
The number of cases of nervous disorders 
among the direct ascendants of those 594 
epileptics was 1,024. Inherited epilepsy, ac- 
cording to the writer's experience, which 
agrees with that of Fere, chiefly appears 
between the ages of 12 and 18 ; but its per- 
centage remains high up to the age of 40, as, 
according to Dr. Gowers, out of 235 epilep- 
tics from 20 to 39 years old, 80 had inherited 
this affection, which gives 34 per cent. This 
shows how erroneous is the view of some able 
physicians, who maintain that after the age 
of 20 inherited epilepsy is not to be dreaded. 
It is certain, however, that this inheritance be- 
comes relatively extremely rare in advanced 
life. But it can yet show itself at the ages of 
70 (Poilroux) and. 71 (Dr. Gowers). Still, we 
strongly advise that symptoms of an organic 
disease, and especially of a cerebral tumour, 
be most carefully sought for in all cases 
of supposed inherited idiopathic epilepsy in 
patiems over 50. 
The power of alcoholism in parents is so 
great that, out of the 594 epileptics studied 
by Fere, 258 had parents addicted to habits 
of hard drinking. 
As regards the influence of sex, there is a 
marked difference between men and women 
of somewhat advanced age, the proportion of 
epileptic females being then larger than that 
of males; but for people under 25 years of 
age the reverse is true. 
Independently of sex, age has certainly a 
decided influence on the appearance of epi- 
lepsy. The following table, borrowed from 
Hasse and Dr. Gowers, is important, as the 
results are grounded on most extensive sta- 
tistical data. These results agree fully with 
the writer's own observations. 
Age at 
No. attacked 
commencement 
Hasse 
Gowera 
Under 10 . 
. . . 393 
422 
11 to 20 . 
. . . 864 
665 
21 to 80 . 
. . . Ill 
224 
81 to 40 . 
• • • 59 
87 
41 to 50 . 
. . . 51 
81 
51 to 60 . 
. . . 13 
16 
61 to 70 . 
. . . 4 
4 
At 71 . 
. . . 0 
1 
995 
1,450 
The writer's experience seems to show that 
hereditary epilepsy makes its appearance 
chiefly between 10 and 12 in both sexes. 
At any rate it is certain that inheritance 
manifests itself rather before than during the 
period of change that puberty causes. Korn- 
berg, Dr. Russell Reynolds, and others have 
already pointed out that such is the general 
rule. 
Puberty itself is a cause of epilepsy. This 
is clearly proved by the large number of 
epileptics who, as shown in the preceding 
table, have been attacked between the ages 
of 10 and 20 (364 out of 995, and 665 out of 
1,450). 
Of other causes, the most powerful are per- 
haps not those usually stated. In patients 
under 15 years of age the most frequent 
cause, after heredity, is some obscure altera- 
tion of nutrition of the brain, or congestion 
of that organ or of its membranes, lasting a 
more or less considerable time after typhoid 
fever or scarlatina. It is frequent, indeed, 
that in examining such patients (even when 
there are reasons to believe in heredity) 
there are a number of symptoms showing 
some deficiency in the action of the brain, 
as regards its motor, sensitive, or sensorial 
functions. It is most important to detect 
these symptoms, as the form of epilepsy due 
to or allied with the cerebral alteration then 
existing is often curable, or at least can be 
considerably benefited by treatment. 
Alterations of blood, in quantity or quality, 
often contribute to the production of epilepsy. 
But, however true it is that a rapid and con- 
siderable loss of blood can cause an epilepti- 
form attack, it has not been shown that such 
a cause has ever produced a lasting epilepsy. 
It is nevertheless well known that anaemia 
is a very frequent factor in the causation of 
that neurosis or of any other. A weak and 
slow action of the heart also is found in a 
number of cases to be among the causes of 
epilepsy (Sir W. Burnett, Bloudeau). But the reverse is sometimes observed; and, ac- 
cording to the writer's practice, cases of epi- 
lepsy are not very rare in which the pulse 
was strong and beating more than 90 or 100 
times a minute, without any organic affection 
that could account for this phenomenon. In 
these cases the only morbid condition that 
could be looked upon as a cause of epilepsy 
was the abnormal circulation, which may be 
remediable. 
There is no doubt that, when epilepsy ap- 
pears in cases of Bright's disease, of affections 
of the liver or other viscera, it is due, at least 
in most cases, to the presence of some toxic 
agent in the blood; but other setiological 
factors exist sometimes. Among them one 
especially deserves attention-it is an irrita- 
tion of the nerves of the diseased viscus. 
Secondary syphilis is a frequent cause of 
epilepsy. Undoubtedly syphilis then acts 
chiefly through the alterations it produces 
in the brain and meninges ; but it often acts 
also on the cranial periosteum, and in dis- 
turbing nutrition and sanguification. 
Of other dyscrasiae gout has very little 
power ; but rheumatism, although not fre- 
quently, can cause epilepsy by its morbid 
influences on the brain and its membranes, 
and by the production of diseases of the heart 
and the great blood-vessels. 
Diabetes has been classed among affections 
sometimes causing epilepsy, but the question 
is then whether it is the presence of sugar in 
the blood or some affection of the medulla 
oblongata which brings on this affection. 
Oxide of carbon, carbonic acid, lead, ab- 
sinthe, alcohol, and a number of other toxic 
agents have sometimes produced a lasting 
epilepsy. Asphyxia by strangulation was in 
one case the cause of epilepsy (A. Beardsley). 
Purely psychical or emotional causes have 
much less power than has been supposed. 
But their influence is great in bringing on 
attacks when epilepsy exists. 
Determining Causes.-The most frequent 
causes of epilepsy, however, are not the pre- 
ceding, which generally are only predisposing 
circumstances. The really active efficient 
causes of epileptiform convulsions, and even 
sometimes of genuine and complete morbus 
comitialis, are to be found in the four fol- 
lowing groups of organic morbid states: 
(1) Lesions of some parts of the brain; 
(2) morbid conditions of the meninges or of 
the periosteum of the cranium; (3) lesions of 
the spinal cord or its membranes; (4) peri- 
pheric lesions anywhere. It is only for con- 
venience sake that the writer establishes 
these divisions, as he looks upon all the 
four groups as quite alike. In neither of 
the four kinds of cases is the location of 
the lesion the seat of the neurosis, that 
place being only the seat of an irritative 
cause. Each of these kinds of causes will 
now be studied, the first one only with some 
development. 
EPILEPSY 
1. Lesions of the brain considered as 
causes of epilepsy.-This subject must be 
subdivided as follows: (a) parts of the brain 
that give rise to that affection ; (5) kinds of 
brain-lesion which bring on that neurosis. 
(a) What are the parts of the brain which 
can produce epilepsy ? Facts answer that 
all parts have that power, as will be proved 
hereafter. On account of the importance of 
this subject as regards diagnosis and thera- 
peutics of the nervous centres, the writer has 
noted down for more than twenty years all 
that relates to convulsions out of many 
thousands of cases of cerebral disease. Un- 
fortunately, for a long time not having 
counted the cases without convulsions, he 
cannot say out of how many cases of brain 
disease come the 1,688 cases of convulsions 
he has collected. 
The first important result of these re- 
searches is that partial or unilateral convul- 
sions are more frequent than bilateral or 
general convulsions. Out of the 1,688 cases 
there are 887 in which the convulsions were 
altogether limited to one or two limbs, or 
began in one side before reaching the other, 
or were more violent in one side than in the 
other ; while the number of general convul- 
sions was 801. 
The 887 cases of unilateral convulsions can 
be classified as follows:- 
595 
Side of Convulsions 
Side of Lesion 
Right . 
102 
. . Right 
Left . 
90 
. . Left 
Right . 
294 
• . Left 
Left 
247 
. . Right 
Right . 
73 
. . Two sides 
Left 
81 
. . Two sides 
As seen in this table, there were 192 cases 
of direct and 541 of crossed convulsions, with 
154 cases of unilateral convulsions due to 
lesion in the two sides. 
Of the 801 cases of convulsions in both 
sides of the body, there were 525 due to a 
unilateral lesion and 276 caused by a lesion 
in the two sides of the brain. In the 525 
cases, the lesion in 235 was in the right side, 
and in 290 it was in the left. 
It is remarkable that, contrary to what 
was long believed by the writer and other 
authors, the number of cases of convulsions 
(partial or general) due to a lesion in the 
right side of the brain is notably less fre- 
quent than that of cases of lesion in the left, 
as shown in this table :- 
Side of Lesion 
Convulsions 
Right 
Left 
235 
290 
, . Two-sided 
247 
294 
, . Crossed 
102 
90 
Direct 
- 
584 
674 
It is very remarkable also that convulsions 
do not take place much more frequently on 
the right side of the body than on the left, 596 
the numbers being for the right 469 cases, for 
the left 418 cases. 
As regards the parts of the brain where a 
lesion is found, it is not possible to make use 
of all the facts, because, when a lesion is in 
the two sides, it very rarely occupies similar 
parts in both; and also in a rather large 
proportion of cases the lesion occupied two 
or more parts of the brain. The following 
table gives the number of cases for lesions in 
all the important parts of the encephalon :- 
EPILEPSY 
It would be wrong to imagine that, because 
the number of cases of convulsions was much 
larger when disease existed in the parietal 
lobe (140 cases), that that part has more 
power to originate epileptiform contractions 
than the occipital lobe (89 cases). The re- 
verse is true, because, in opposition to all that 
is taught on this point, this last lobe has more 
power than the parietal in that respect (if we 
leave aside what relates to the ascending 
parietal). This can easily be proved. The 
number of cases of organic disease (especially 
haemorrhage, as one can see in Gintrac's great 
work containing 127 cases of haemorrhage in 
the parietal lobe and only 33 in the occipital) 
of the parietal lobe is more than treble that 
of cases of lesion of the occipital; while the 
number of cases of convulsions due to disease 
of the first of these parts not only is not 
three times as large as that of cases of con- 
vulsions due to the occipital lobe, but is 
even far from being the double. This last 
part, therefore, although supposed not to be 
motor, has more influence than the parietal 
lobe in giving rise to epileptiform convulsions. 
Taking into account the frequency of dis- 
ease in the four cerebral lobes, the number 
of cases of lesions which in each of them 
generate convulsions, shows that the frontal 
lobe is the one which has the greatest influ- 
ence as regards the production of epileptiform 
convulsions. Next to it comes the occipital 
lobe, and, after these two lobes, we have to 
place almost on a similar level the parietal 
and the temporo-sphenoidal lobes. 
Considering the frequency of disease, and 
especially of haemorrhage, in the corpus 
striatum, which has been supposed to have 
a great influence in producing epileptiform 
convulsions, it is remarkable that , that part of 
the brain has given rise to convulsions only 
25 times (hardly more than 2 per cent.) 
The percentage given by the optic thalamus 
in that respect is higher (3*6 per cent.) 
All the internal parts of the brain (centrum 
ovale, the lateral ventricles, and the central 
ganglia) give only 164 cases (15 per cent.), 
not much more than the frontal lobe (144 
cases, almost 13 per cent.), although the 
central parts of the cerebrum are far more 
frequently diseased than the anterior lobe. 
(b) There is certainly a very great difference 
between the various kinds of disease of or 
injury to the brain with regard to their power 
of giving rise to genuine epilepsy or to epilep- 
tiform convulsions. Still, it is very difficult 
to draw positive conclusions out of what has 
been published on this point, because the sub- 
ject has not been studied as it should have 
been. Certain parts of the brain will give 
rise to convulsions, while others will not, 
under one and the same kind of lesion; but 
a part like the frontal lobe, for instance, which 
will so often generate genuine epilepsy or 
epileptiform convulsions under causes such 
as an injury, a tumour, an abscess, or an 
1. So-called motor centres . . . 196 cases 
2. Cortex cerebri out of the motor zone 173 „ 
8. Surface or internal parts frontal lobe 144 „ 
4. „ „ „ parietal „ 140 „ 
5. Base of the brain . . . . 91 „ 
6. Surface or internal parts of occipital 
lobe 89 „ 
7. Cerebellum 57 „ 
8. Surface or internal parts sph. temp, 
lobe 54 „ 
9. Centrum ovale 52 „ 
10. Optic thalamus 42 „ 
11. Corp, str., opt. thal. & internal capsule 25 „ 
12. Corpus striatum. . . . . 24 „ 
13. Lateral ventricle . . . . 21 „ 
14. Cornu Ammonia 7 „ 
1,115 ,, 
It is essential to remark that the number 
oi cases of lesion of the cortex cerebri in the 
so-called motor zone or out of it (369 out of 
1,115 cases-i.e. about 33 per cent.) is possibly 
greater than it should have been, owing to 
the probable co-existence, in some cases, of a 
meningeal affection with the lesion of the 
brain-tissue. The writer must say that he 
has eliminated as completely as he could from 
the cases he has collected of disease of the 
cerebral surface those in which there was a 
complication of meningitis. If we add to 
these 369 cases one-half of those of disease of 
the four cerebral lobes (214 out of427)-which 
ought to be done, because in more than one- 
half of these last cases the surface was partly 
the seat of the lesion-there are 583 cases of 
convulsions from disease of the cortex cerebri 
(583 out of 1,115-i.e. about 52 per cent.) 
The cerebral convolutions have more power 
than the rest of the brain to give rise to 
convulsions, but the cortex, outside of the 
so-called motor zone, has at least as much 
power as that zone. 
Concerning the parts of the brain con- 
sidered as not motor, we find that there are 
89 cases of lesion of the occipital lobe and 54 
of the spheno-temporal lobe, giving a total of 
143 cases; to which we have to add the 173 
cases of superficial lesion out of the motor 
zone; so that there are 316 cases of convul- 
sion from a lesion in parts which, according 
to many authorities, ought not to have pro- 
duced such a symptom. In more than one- 
half of the cases of disease of the cerebellum 
there was no pressure on the base of the 
brain, so that we could add a good many of 
the 57 cases of lesion of that nervous centre 
to the 316 cases above mentioned. EPILEPSY 
597 
inflammatory softening, will rarely produce 
convulsions under a cause which is an in- 
jury, but of a peculiar kind-i.e. a haemor- 
rhage. In other parts, on the contrary, a 
haemorrhage will most frequently give origin 
to convulsions. The following table, from 
data furnished by Gintrac, is interesting 
in that respect; it shows what has been 
the frequency of convulsions in cases of 
haemorrhage:- 
were alterations in brain-tissue or a rupture 
of the aneurysmal sac. 
Abscesses of the brain have more influence 
in the causation of epileptiform convulsions 
than is generally admitted. Out of 87 cases 
of unilateral abscess collected by the writer, 
convulsions occurred in 43 cases. 
Unilateral atrophy of the brain, of a very 
old date as regards its origin, is known to be 
allied not rarely to epilepsy (partial or 
general). Summing up 78 cases given by 
Cotard, Boyd, Turner, and Gintrac, the 
writer finds that epileptiform convulsions or 
genuine epilepsy existed in 20 cases. It is 
of great importance against the views of those 
who try to locate epilepsy in the so-called 
motor centres, that not only those parts were 
absolutely destroyed in more than one-half of 
those 20 cases, but that the so-called motor 
track in the brain and spinal cord was deeply 
altered if not destroyed, at least in certain 
parts of its length, and that nevertheless 
convulsions occurred, either anywhere, or 
chiefly or exclusively in the paralysed limbs. 
Softening due to embolism causes convul- 
sions almost as often as inflammatory soften- 
ing, except when the seat of the lesion is the 
cortex cerebri. White softening of vessels 
of the occipital and of the frontal lobes pro- 
duces convulsions more frequently than the 
same lesion in the parietal lobe. Embolism 
without any marked softening very rarely 
produces convulsions. 
All kinds of entozoa in the brain very fre- 
quently give rise to convulsions, but none so 
often as cysticerci, if Kuchenmeister is right. 
He states that out of 30 cases of cysticerci in 
the encephalon there were 24 cases with con- 
vulsions. No other cause of irritation, what- 
ever be its seat in the brain, originates con- 
vulsions so often as that. 
The application of a ligature on one of the 
carotid arteries has brought on convulsions 
in a number of instances; and, what is re- 
markable, when the convulsions were uni- 
lateral they appeared on the corresponding 
side in more cases than on the opposite side. 
2. Lesions of the meninges considered as 
causes of epilepsy.-The reader may refer 
to the articles on the Diseases of the Men- 
inges and Diseases of the Cranium for what 
relates to convulsions due to these morbid 
states. Complete and persistent epilepsy due 
to chronic meningitis is very rare; but syphi- 
litic affections either of the dura mater or 
of the periosteum of the cranium not very 
rarely will give rise to this affection. See 
Meninges,Cerebral, Diseases of; and Skull, 
Diseases and Deformities of. 
3. Lesions of the spinal cord considered 
as causes of epilepsy.-'In the writer's work 
on Epilepsy he has shown that this affection 
can arise from disease of the spinal cord. 
Since 1857, when that work appeared, many 
facts have come to his knowledge establishing 
that his conclusion was right. He only 
Cases of 
Cases of 
haemorrhage 
convulsions 
43 in cortex cerebri . . 
. 11 
127 „ parietal lobe . . 
. 25 
33 „ occipital „ . , 
. 7 
17 „ frontal „ , , 
. 2 
38 „ optic thalamus. 
. 20 
72 „ corpus striatum 
. 0 
48 „ both central ganglia. 
. 5 
46 „ lateral ventricles 
. 14 
56 „ cerebellum . . 
. 10 
70 „ ponsVarolii . . 
. 25 
5 „ crus cerebri . . 
. 2 
- 
555 
121 
It is a most remarkable fact that out of 38 
cases of haemorrhage in the optic thalamus 
there were convulsions in 20-i.e. more than 
one-half of the cases ; while there were none 
in any of the 72 cases of haemorrhage in the 
corpus striatum. It is perhaps more remark- 
able that when both ganglia were the seat of 
the effusion of blood there were only 5 cases 
of convulsions out of 48 of haemorrhage. 
Tumour and tubercle are, with haemor- 
rhages and inflammatory softening, the 
lesions of the brain which give rise most 
frequently to partial or general convulsions. 
While tumours of the frontal lobe produce 
epilepsy or epileptiform convulsions in more 
than two-thirds of the cases, tumours of the 
temporo-sphenoidal lobe give rise to convul- 
sions in about one-half, and tumours of the 
parietal and the occipital lobes in only about 
one-third of the cases. A remarkable fact 
which comes out of the study of cases of 
tumour of the brain published by Ladame, 
Bernhardt, Gintrac, and others, is that the 
base of the brain under the irritation of 
tumours gives rise to convulsions very much 
less frequently than the surface of the brain. 
Indeed, one part of the brain-the medulla 
oblongata-did not originate convulsions in 
one single instance out of 21 cases of tumour 
published by Bernhardt. This kind of dis- 
ease of the medulla oblongata is not, how- 
ever, incapable of giving rise to epileptiform 
attacks, as the writer knows of five cases of 
tumour of that organ causing convulsions. 
There is no kind of lesion which may not 
give origin to convulsions. But there is one 
species of tumour, namely, aneurysm, which 
causes convulsions considerably less fre- 
quently than any other. Out of 86 cases 
of aneurysm of the various encephalic 
arteries, given by Gintrac, there were con- 
vulsions only in three, if we put aside, as 
ought to be done, the cases in which there 598 
maintained-and he does not now go beyond 
that assertion-that epilepsy sometimes has 
its cause in the spinal cord. 
4. Peripheric lesions.-That genuine epi- 
lepsy can have its cause in any part of the 
body is now a recognised truth. But, be- 
sides that form of the morbus comitialis, 
what may be called the cerebral form, con- 
sisting in unilateral convulsions, can be 
originated by an irritation of either a nerve 
or a viscus. Among the parts of the body 
having the greatest power with regard to 
the production of epileptiform convulsions, 
we may name the bowels, the trigeminal and 
the sciatic nerves, the abdominal sympathetic 
nerve, and the sexual organs. Indigestible 
food may be the cause of an attack. In coun- 
tries chiefly inhabited by the Anglo-Saxon 
race, children of the two sexes being less 
watched and less warned than elsewhere 
against the dangers of onanism, epilepsy due 
to this fatal habit is particularly frequent. 
The great importance of a thorough know- 
ledge of certain symptoms of cerebral epi- 
lepsy, especially as regards surgical treatment, 
makes it necessary that these symptoms 
should be carefully studied. It must be first 
stated that every kind of organic brain dis- 
ease, wherever situated, may cause any form 
of epilepsy, and that, on the other hand, every 
form of this neurosis may exist without any 
cerebral organic affection. To this must 
be added that any part of the brain may be 
the seat of any kind of disease without con- 
vulsions appearing anywhere. In more than 
two thousand cases of brain disease analysed 
by the writer for other purposes, there were no 
convulsions. Out of that number there were 
more than one hundred cases of simply irri- 
tative lesion of the so-called motor centres, 
limited to them or invading the neighbour- 
ing parts, in which there were various symp- 
toms, but no convulsions. In more than 160 
cases of disease (destructive and irritative, or 
simply irritative) of the base of the brain 
there were no convulsions. Simply irritative 
lesions of the so-called motor tract, the in- 
ternal capsule, between the great cerebral 
ganglia, did not cause convulsions in more 
than 45 cases. The part which gives the 
smallest number of cases without convulsions 
is the optic thalamus, and the part most able 
to bear any kind of irritation without pro- 
ducing convulsions is the corpus striatum. 
These negative facts show as well as the 
positive ones-i.e. those in which convulsions 
take place-that that symptom appears or not 
according only to the excitability of certain 
parts of the nervous centres in different in- 
dividuals. This result is borne out also by 
the study of unilateral convulsions, as is 
shown by an analysis of 887 cases collected 
by the writer. 
The conclusions to be drawn from the study 
of these cases can be summed up as follows: 
(1) These convulsions can be produced by a 
EPILEPSY 
lesion in almost any part of the brain; (2) 
they can be caused by any kind of lesion; 
(3) they can begin in any muscle or group 
of muscles, or simultaneously in every 
part of one-half of the body (eye, face, neck, 
trunk, and limbs); (4) they can be preceded by 
any kind of aura, local or general; (5) they 
can be associated with any other symptom of 
brain disease, or be, for some time or till 
death, the only existing cerebral symptom; 
(6) they often precede general convulsions or 
appear at the end of such an attack; (7) they 
usually last longer than general convulsions 
even due to brain disease, but they especially 
last much longer than seizures of idiopathic 
epilepsy ; (8) like other convulsions due to 
an encephalic affection, they often appear 
without loss of consciousness at the begin- 
ning or during the whole time they last; 
(9) they can take place either on the side of 
the brain-lesion that causes them or on the 
opposite side ; (10) the proportion of cases of 
direct convulsions to cross ones, when the 
lesion is in the cerebrum, is about one to three, 
but the direct convulsions are more frequent 
than the cross ones, when that cause is in the 
base of the brain (crus cerebri, pons, and me- 
dulla) ; (11) the right limbs are more fre- 
quently attacked than the left (right 396 cases, 
left 337), and this rule is true for direct as 
well as for cross convulsions; (12) in the 
same individual, even w'hen there is but one 
lesion, they can appear at first on the side of 
the lesion and afterwards on the opposite 
side, or vice versa,; (13) they can occur on 
the side where exists a cross hemiplegia or on 
the opposite side; but they can also be direct, 
the paralysis also being direct; or they can 
be cross, the paralysis being direct; (14) Jack- 
sonian convulsions (either when exclusively 
and persistently unilateral or only tempo- 
rarily so) can appear on the side of the lesion, 
or from a lesion in parts of the brain belong- 
ing neither to the so-called motor zone nor 
to the first and second frontal convolutions, 
which Dr. Hughlings Jackson now supposes 
to be psycho-motor. 
On account of the importance of Jack- 
sonian convulsions for surgical treatment, it 
must be said that, as stated in the last of the 
above conclusions, they may appear, as shown 
by a number of cases, on the side of the lesion. 
In a case of that kind the surgeon, by press- 
ing on the dura-mater on the right side, in- 
creased convulsions of the right limbs (Leroy). 
Many cases show that surgeons led by the 
views of localisers might make great mis- 
takes. For instance, in a typical case of Dr. 
Hughlings Jackson's, instead of the toes it 
was a finger which was first convulsed, 
although the lesion was in the paracentral 
lobe; in a case of Andral's, Jacksonian con- 
vulsions limited to the right arm were 
caused by a tumour between the left posterior 
lobe and the cerebellum; in a case of Prof. 
Virchow, Jacksonian convulsions beginning EPILEPSY 
599 
in the left leg were due to a tumour of the 
right posterior lobe ; in a celebrated case of 
Moreau (De Tours) there was a notable aura 
in the left hand and convulsions of the left 
arm due to a cyst in the anterior lobe near 
the right corpus striatum and the lateral ven- 
tricle. A good many facts show that Jack- 
sonian convulsions, although caused generally 
by lesions of the first and second frontal or 
the two ascending convolutions, can be pro- 
duced by lesions in many other parts of the 
brain very far from those convolutions. 
Of the 887 cases of unilateral convul- 
sions analysed by the writer, the arm or the 
leg alone, or one of these limbs at times, the 
other in other attacks, were the parts affected 
in 381 cases. The following table shows 
what parts of the brain were the seats of the 
lesion producing these partial convulsions. 
bellum (37 per cent.), the parietal lobe (35 
per cent.), and the frontal lobe (33-3 per cent.) 
A lesion of almost the whole brain (19 per 
cent.) and of the base of the brain (23'8 per 
cent.) give the smallest percentages. 
As regards the leg, the largest percentage 
is furnished by the cerebral ganglia, next to 
which come the base of the brain, the cere- 
bellum, the surface of the spheno-temporal and 
occipital lobes, and the so-called motor centres. 
It is evident from the facts relating to the leg, 
but still more from those concerning the arm, 
that great mistakes in the diagnosis of the 
localisation of disease might be made if con- 
vulsions of the leg or arm were looked upon as 
a proof that the cerebral lesion causing them 
is located in the motor zone, even if we in- 
clude in it, according to Dr. Hughlings Jack- 
son's views, the two first frontal convolutions. 
Convulsions from brain disease may be 
alternate-i.e. they may affect the limbs on 
one side and the face on the other-and this 
owing to a lesion of either one or both sides 
of the cerebrum or the base of the brain. 
It is important to know that unilateral 
convulsions are sometimes due to a peripheric 
irritation (in the bowels, the liver, the kid- 
ney, &c.), without any kind of disease exist- 
ing in the brain. 
There is no doubt that convulsions of one 
arm are often associated with spasmodic 
movements of the face; but there is no doubt 
also that the most heterogeneous associations 
of partial convulsions are sometimes wit- 
nessed : convulsions in one leg and in one 
eye, of the thoracic muscles and the face or 
of the neck and legs, and a great many other 
associations, from lesions which cannot give 
the key of these singular facts. The two arms 
or the two legs are not rarely affected to- 
gether, even under the influence of lesions of 
only one side of the brain. 
The kind of association between paralysis 
and convulsions is most interesting. French 
surgeons, till a somewhat recent period, gave 
it as a law that when convulsions from brain 
disease occur without paralysis they show 
themselves on the opposite side to that of the 
cerebral lesion; but that when there is para- 
lysis, this symptom appears on the side op- 
posite to that of the lesion, and convulsions 
occur on the corresponding side. This is the 
reverse of what is seen in the great majority 
of cases, in which paralysis and convulsions 
coexist on the same side. But there are two 
kinds of cases in which the convulsions are 
on one side and paralysis on the other. The 
writer has collected more than 200 cases in 
which the convulsions were on the side of 
the lesion, and paralysis on the opposite side; 
and 16 cases in which the contrary existed- 
i.e. convulsions on the opposite, and paralysis 
on the corresponding side. Here ajso we 
have a proof of the great variety of effects 
that can come from an irritation of the same 
or of various parts of the brain. 
Arm 
Leg Leg or arm 
Motor centres . 
81 
12 
1 
Surface frontal lobe . 
17 
1 
1 
„ parietal lobe . 
13 
1 
2 
„ sphen. temp, lobe . 
8 
1 
0 
„ occipital lobe 
12 
1 
0 
„ several lobes. 
22 
2 
2 
Almost whole hemisph. . 
7 
0 
1 
Frontal lobe . . . 
16 
1 
0 
Parietal lobe 
15 
0 
1 
Sph. temp, lobe 
9 
0 
0 
Occipital lobe . . 
10 
1 
1 
Centrum ovale • . 
20 
1 
0 
Lateral ventricle 
9 
2 
0 
Two central ganglia . . 
5 
2 
0 
Optic thalamus . . 
8 
4 
1 
Corpus striatum . . 
4 
2 
1 
Base of brain . , . 
16 
5 
0 
Cerebellum . . . 
10 
2 
0 
Several parts 
83 
1 
0 
■ - 
■1 1 
315 
89 
11 
This table shows that the so-called motor 
zone and the rest of the cerebral cortex gave 
rise to a very large proportion of convulsions 
of one limb alone. There were 153 cases of 
convulsions of the arm, 18 of the leg, and 6 
of leg and arm alternately. It will also 
be seen that the base of the brain, if it gave 
a small proportion of cases of convulsions of 
the arm, gave a large one of convulsions of 
the leg. But the most remarkable point is 
that all parts of the brain can give rise to 
convulsions of the arm, and that most parts 
can produce convulsions in the leg. 
Most important conclusions can be drawn 
from the study of the percentage of cases of 
convulsions of the arm in the number of 
cases of unilateral convulsions. Thus it can 
be easily ascertained that the percentage is 
enormous-82 per cent.-for cases with a 
lesion of the spheno-temporal lobe ; it is also 
very large for cases of lesion of the surface 
of the occipital lobe (50 per cent.); of the 
spheno-temporal lobe (47'6 per cent.); and of 
the frontal lobe (45'9 per cent.) Next come 
the so-called motor centres (45 per cent.), 
the mass of the occipital lobe (40 per cent.), 
the centrum ovale (37'7 per cent.), the cere- 600 
EPILEPSY 
Unilateral convulsions have no essential 
connexion with psycho-motor centres, as is 
proved by cases of lesion of those centres on 
one side causing that kind of convulsions 
sometimes in one side of the body, sometimes 
in the other. The writer has seen two such 
cases and collected 42 other cases, some from 
most able observers, including Dr. Hughlings 
Jackson. 
Many cases of epilepsy in man are on 
record, resembling the special kind seen in 
certain animals, particularly in this respect, 
that an attack can easily be produced by a 
peripheric irritation. The writer has col- 
lected more than sixty such cases. They 
form two principal groups-one in which an 
irritation of almost any part of the body was 
able to give rise to an attack; the other in 
which certain parts only had that power. 
Many of those cases belonged to the class of 
organic cerebral epilepsy; some depended on 
diseases of the pericranium, of the spine 
or its contents, of nerves or of one of the 
thoracic or abdominal viscera; while in other 
cases there was a genuine idiopathic epilepsy. 
The parts of the body which are most fre- 
quently found giving rise to an attack, are 
the pit of the stomach (under the influence 
of even a very slight pressure) and the skin 
of the neck laterally from the lower jaw to 
the collar-bone. 
Symptoms.-We shall consider this part of 
the subject under three heads-the premoni- 
tory, the paroxysmal, and the inter-paroxys- 
mal symptoms. 
1. Premonitory.-The frequency of pre- 
monitory symptoms, according to the writer's 
experience, is much greater than is generally 
known. It is extremely important to find 
out the existence of these warnings, as in 
many cases attacks may easily be prevented 
if we know when they are on the point of 
taking place. When we say that premonitory 
indications are extremely frequent, we do not 
mean that the classic or Galenic aura is often 
found. That vague, queer, and unexplained 
sensation, whether accompanied or not by a 
muscular contraction, is certainly more fre- 
quent than is admitted, but is-considerably 
less frequent than the other kinds of warn- 
ing. Among the premonitory symptoms 
there are four oftener observed than others ; 
one is a change of temper (irascibility, appear- 
ing or increasing); another is a contraction 
of the vessels in the feet or hands, producing 
a diminution of temperature; and the two 
others are a spasmodic state of some muscle, 
or an optical illusion or hallucination. The 
following list mentions but a part of the 
various manifestations which indicate that 
an epileptic attack is threatening. Altera- 
tions of the various functions of the brain, 
sensatipns of any kind, headache or backache, 
vertigo, sensorial disturbances, sleeplessness 
or sleepiness, palpitation of the heart, dilata- 
tion or contraction of blood-vessels anywhere, 
altered breathing, diminution or increase of 
the various secretions (of the skin, mucous 
membranes, or of the visceral glands), 
haemorrhages from the nostrils or other parts, 
fever, more or less marked weakness (general 
or local), hunger or thirst, disgust for food or 
drinks, an increase of the sexual appetite or 
the diminution or loss of sexual desire or 
power, spontaneous erection, and spasm of 
the bladder-sometimes accompanied by in- 
voluntary evacuations of urine-involuntary 
expulsion of faeces, cramps, trembling, choreic 
movements, tendency to run forwards, back- 
wards, or round, rigidity or convulsions of a 
limb or other parts, paralysis of a limb or 
other parts-such is an abbreviated list of the 
forerunners noticed by a number of observers, 
and all of which the writer has seen or knows 
to have occurred in his patients. 
Sometimes one or several of hese symp- 
toms will appear a day or two before the 
attack, but generally the warning shows 
itself a few hours, or a very much shorter 
time (even only a few seconds or a minute 
or two), before the seizure. Not rarely in 
cases of epilepsy due to an organic cerebral 
disease, or to cerebral congestion, a drawing 
of the head towards one shoulder will take 
place either before or during an attack. 
Premonitory symptoms unfortunately may 
be deceptive, as they can appear without 
being followed by the attack; and even in 
cases in which warnings usually exist there 
are sometimes attacks without any fore- 
runner. 
2. Paroxysmal.-The paroxysmal symp- 
toms vary considerably according to the 
kind of attack. If the fit is one of petit mat 
(epilepsia mitior), there may be no other 
symptom than a loss of consciousness, with 
either a fixed state of the muscles of the 
eye or a slight contraction of one or more 
muscles of the face or neck, or a movement 
of the lips, tongue, and throat, as in the act 
of swallowing. According to his personal 
observation, the writer is inclined to affirm 
than an attack of petit mat never consists in 
a loss of consciousness only-i.e. without the 
least trace of any other trouble whatsoever. 
Dr. Russell Reynolds, however, states that he 
has seen such attacks, and therefore we must 
admit that sometimes a pure and simple loss 
of perception and volition is all that exists in 
a seizure of epilepsia mitior. In such an 
attack the patient may, if walking, continue 
to walk ; but, if talking, he stops-generally 
for so short a time, however, that the trouble 
may pass absolutely unnoticed by listeners. 
Such an attack usually lasts only from one 
to four or a few more seconds. 
Haut Mal.-In a complete attack of epi- 
lepsy, an irritation proceeding from a moral 
or physical source is the cause of an act of 
inhibition of the mental activity, and of a 
reflex contraction of blood-vessels in the 
cerebral lobes. Loss of consciousness is, of EPILEPSY 
601 
course, the consequence of that inhibition. 
Together with Kussmaul and Tenner, the 
writer had long looked upon spasm of cere- 
bral vessels as the cause of the loss of con- 
sciousness. He had a confirmation of that 
supposition in his epileptic guinea-pigs, in 
which he found that the blood-vessels of the 
brain contracted when consciousness disap- 
peared. Since then, however, he has ascer- 
tained that consciousness was lost in the 
seizure, even after the excision of the upper 
cervical ganglia of the two sympathetic 
nerves-when, of course, the cerebral vessels 
remained dilated before, during, and after the 
fit-just as it is lost in animals having con- 
traction of these vessels. Dr. W. Alexander 
has observed that in man, loss of conscious- 
ness in fits occurs after the excision of these 
ganglia, the same as before that operation. 
It is evident, therefore, that a spasm of the 
vessels of the brain is not an essential element 
in the causation of the loss of mental faculty. 
Still, when that spasm exists, and so long as 
it lasts, the lack of blood in the cerebral hemi- 
spheres must necessarily contribute to the 
cessation of the mental activity. The reasons 
for admitting that an act of inhibition is the 
first or principal cause of the loss of con- 
sciousness will be found in the writer's 
published papers on this subject. 
Muscular spasms of a tonic character begin 
at the same moment that consciousness dis- 
appears. They may begin first in any part 
of the body, whether the attack is to be 
general, or to remain in one half of the body, 
or in one limb. Rather frequently the mus- 
cles of the face, the eyes, and the neck are 
seized before those of other parts, but the 
time is so very short between the appearance of 
spasm in these muscles and the general stiff- 
ness, that it is almost always very difficult to 
detect that these phenomena are not simulta- 
neous. ' Together with the first appearance of a 
spasmodic condition in the face and neck there 
is also in a great many cases a contraction of 
some muscles of the larynx and of the expi- 
ratory muscles of the thorax and abdomen, 
producing the so-called epileptic cry, the cha- 
racter of which is so special that, when once 
heard, it can always be recognised even when 
the patient is not seen. When an epileptic 
is standing, at the onset of a complete attack, 
he falls. This is not due solely to loss of 
consciousness, as we know that in fits of 
petit mat this accident may not occur. The 
fall is sometimes an active one: the patient 
is precipitated more or less violently forward, 
backward, or laterally by muscular contrac- 
tions. Then the fall may be either a para- 
lytic or a convulsive one. 
Generally a period of rigidity exists before 
the clonic convulsions appear. This stage 
of tonic spasm almost always lasts only a 
few seconds; but it may constitute the whole 
attack, and then it may last longer. On 
the contrary, clonic convulsions may appear 
at the onset of the seizure. In almost all 
cases, however, they follow a general stiff- 
ness, and form a second stage or period of 
the fit of which by their violence and dura- 
tion they are the principal part. The clonic 
spasmodic contractions as a rule last hardly 
more than from one to three minutes in 
idiopathic cases. 
When a fit lasts five, six, eight, or ten min- 
utes, even if there be no sign of an organic 
disease of the brain, there is some reason to 
suspect that the attack is brought on by such 
a cause. Generally, in complete seizures, the 
limbs on the two sides of the body have simi- 
lar convulsions, but in cases of brain-disease 
there may be clonic convulsions on the one 
side and tonic rigidity on the other. In the 
face, the eyes, the neck, differences between 
the sides are frequent, or at least not rare, 
even in idiopathic epilepsy. In most cases, 
the eyes are drawn up under the upper eye- 
lid, and they roll from side to side. It is not 
rare that the eyes, face, and head turn con- 
vulsively towards the left or the right side, 
sometimes jerking, however, alternately from 
one to the other side. When the head is 
carried sideways-to the right, for instance- 
it is chiefly owing to a spasm of the left sterno- 
cleido-mastoideus, but also to the group of mus- 
cles of the top of the neck on the right side. 
Breathing is considerably interfered with 
during the whole attack. After the spasmodic 
action of the expiratory muscles contribut- 
ing to the shriek, there is almost always 
for a time (not longer usually than one or two 
seconds) a stoppage of respiration from the 
persistence of that initial spasm. During 
the whole fit respiration is convulsive, irregu- 
lar, jerky, or gasping, and always incomplete. 
A real asphyxia, going as far as cyanosis, 
soon shows itself. The face, which was pale 
at the onset, becomes red, and promptly as- 
sumes a livid, dark, purple or bluish-violet 
hue. A frothy saliva, frequently of a red- 
dish tinge, from effused blood coming from 
the biting of the tongue or lips, issues, little 
by little, from the mouth. It is extremely 
rare that the movements of the heart are 
modified at the onset; but palpitation, or a 
diminution (and even a complete inhibition) 
of the cardiac movements has been noticed 
by the writer in a few instances. Soon, how- 
ever, the heart becomes very much excited 
and beats quickly, as in ordinary asphyxia. 
The temperature rises (1° or 2° F. and some- 
times a little more); and the whole trunk, 
the face, and limbs, are covered with perspira- 
tion. The pupils always dilate considerably, 
sometimes after an evident contraction; the 
eyes are bloodshot; and haemorrhage may 
occur there or in other parts, such as the 
nostrils, the ears, the bronchi, or even the 
capillaries of the skin or of the brain. Urine 
may be expelled from a spasm of the blad- 
der at the onset, or from paralysis of the 
sphincter at the end of the fit. 602 
EPILEPSY 
As a rule, at the end of the convulsions 
the patient passes, without recovering con- 
sciousness, into a heavy sleep, with more or less 
violent stertorous breathing. A real comatose 
state is not rare. There is no doubt that 
these symptoms are more intense if no care 
be taken as regards the tongue and head. The 
patient should not be left on his back; and the 
tongue, which falls and covers the laryngeal 
opening, should be drawn forward. Some 
alleviation is almost always obtained when 
this is done for the tongue, and when the 
body, and especially the bead, are placed on 
one side. Generally the sleep following a 
paroxysm does not last much more than an 
hour, sometimes not as long as that ; but it 
is exceedingly rare that there is no sleep at 
all. The more violent the convulsions have 
been, the more there is relaxation of the 
muscles after they have ceased. When lifted 
up, the limbs may fall as if they were com- 
pletely paralysed. 
On waking from the sleep following a 
seizure most patients are very tired, the 
limbs and trunk aching, as well as the head. 
Usually there is some mental alteration, 
often consisting of confusion or stupor, and 
sometimes delirium. The mind, however, 
may be quite clear, even after a violent 
attack, and the head free from pain, the 
only effect of the fit being general lassitude. 
On the contrary, after an apparently slight 
seizure there is sometimes considerable men- 
tal disorder. The degree and duration of 
stupor after an attack have no relation to 
the duration of the convulsive period. Stupor 
is chiefly an effect of asphyxia, and is there- 
fore in direct relation with laryngismus, 
trachelism, and the spasms of the thoracic 
muscles, of the diaphragm, and perhaps of 
the bronchial tubes also. It has been stated, 
and denied, that the urine passed after an 
attack of epilepsy sometimes contains albu- 
men in patients free from kidney-disease. In 
at least five cases the writer has ascertained 
that there was a notable amount of albumen 
in the first issue of urine after attacks in 
which there had been violent spasmodic con- 
tractions of the abdominal and thoracic 
muscles. There was no disease of the kid- 
neys or of the heart in those patients. 
Attacks of epilepsy are sometimes very 
slight, consisting only, besides the loss of 
consciousness, of an extremely short tonic 
spasm of muscles of the trunk, the neck, the 
head, and the limbs. But even in the short- 
est and slightest attack of that kind the epi- 
leptic cry may be uttered, the tongue may 
be bitten, and there may be a somewhat co- 
matose sleep after the fit. 
It is now very well known that frequently 
there is after a fit a real paralysis, whicb 
sometimes persists for a long time. This loss 
of power is supposed to be the result of ex- 
haustion from discharge of nerve-force, while 
it is evidently the effect of an act of inhibi- 
tion associated with the convulsions-inhibi- 
tion striking other motor elements than the 
excitation which causes convulsions. If it 
were an exhaustion from over-action the fol- 
lowing facts could not exist: (1) the paralysis 
may appear after attacks which are not 
violent, and not show itself after most violent 
and prolonged convulsions ; (2) there may be 
a paralysis in one or two limbs after an at- 
tack of petit mat, in which no convulsion has 
taken place in those parts; (3) after equal con- 
vulsions on the two sides of the body there 
may be a paralysis of one side only ; (4) after 
unilateral convulsions there may be a paraly- 
sis of one limb only (especially the arm), 
while both have been convulsed; (5) the 
writer has seen a case in which a patient 
alternately had attacks of only paralysis or 
convulsions, or of convulsion followed by 
paralysis, always in the same limb-the left 
arm; (6) the writer has seen three cases of 
hemiplegia from brain-disease, in which the 
paralysis slightly but evidently diminished 
after each attack of convulsions. Several 
similar facts are on record; (7) Fere has 
found a loss of power after convulsions in 
21 per cent, of his cases in the right arm, and 
in 23 per cent, in the left arm, while in cases in 
which, without convulsions, there was vertigo 
with or without loss of consciousness, the 
loss of power was 30 per cent, in the right 
arm and 27 per cent, in the left; (8) Dr. 
Hughlings Jackson has seen in those cases in 
which an abortion of the attack can be pro- 
duced, that paralysis not only may appear, 
but can be greater than if convulsions had 
occurred. All these facts are in harmony 
with the idea that paralysis occurring in 
seizures either after or without convulsions is 
due to inhibition and not to exhaustion. 
There are many reasons also to consider in- 
hibition and not exhaustion as the cause of 
all the other losses of power which are some- 
times observed after an attack of epilepsy, 
such as aphasia, amnesia, anaesthesia, loss 
of the muscular sense, amaurosis, deafness, 
anosmia, loss of taste, loss of knee-jerk. This 
is so true, that certain of these kinds of loss 
of function are sometimes, or even very fre- 
quently, as is the case for knee-jerk (Beevor), 
replaced by an increase of power. 
Petit Mal.-The symptoms of a seizure of 
epilepsia mitior are very different from 
those of a violently convulsive attack of 
epilepsy (haut mat). The loss of conscious- 
ness occurs only for one or a few seconds, 
and the spasmodic contractions take place in 
a few muscles only-in the face, tongue, 
throat, eyes, and neck. If seized while stand- 
ing up the patient rarely falls, and, on the 
contrary, if walking he may continue his 
movement as regularly as before the fit. If 
attacked while speaking, he generally stops 
while the consciousness is lost, and on re- 
covering it he may complete the unfinished 
sentence, so that the bystanders may know EPILEPSY 
603 
nothing of what has occurred. Sometimes, 
however, the patient's mind is deeply altered, 
even when the attack of petit mat has been 
as short and slight as possible. 
Nocturnal attacks of epilepsy may occur 
without any knowledge of their having taken 
place. Indeed, the writer has sometimes 
been consulted by persons who only asked 
for advice on account of headaches, and who 
had no pain in the head except after noc- 
turnal attacks of epilepsy occurring with- 
out their knowledge. In such cases, the 
patient, after a seizure during sleep, wakes 
up tired, as if he had walked consider- 
ably ; he has pains in the limbs, the back, 
and the head. He finds his mind con- 
fused, and his memory affected; he feels 
disinclined to get out of bed or to exert 
himself in any way; and often he is excit- 
able or depressed. Sometimes his tongue 
or his lips are sore, and if the pillow is ex- 
amined it shows bloody spots. More rarely 
it is found that an involuntary evacuation of 
urine has soiled the bed. Anyone sleeping 
within hearing distance of the patient may 
be wakened by the piercing epileptic cry, and 
then hear the noise of the shaking of the 
bed, caused by the convulsive movements. 
Such attacks, although very frequent and 
also very violent, may remain altogether un- 
known and unsuspected by the patient and 
his friends. 
3. Inter-paroxysmal. - The general 
health of epileptics is usually very poor. Be- 
sides the alterations of their mental powers, 
and especially of their memory, they show a 
great deal of excitability and often depression 
of spirits. Their circulation and their diges- 
tion are often affected. There is nothing 
special, however, either in the morbid state 
of their mind and of their feelings, or in the 
disturbances of their physical health. Cer- 
tainly the mental aberrations observed in 
the inter-paroxysmal state are not essential 
elements in the symptomatology of epilepsy. 
These aberrations can exist without epilepsy, 
and in a great many cases they are missing. 
The frequency of attacks varies immensely 
in epilepsy. In one case the writer learned 
that for more than seventeen years the 
patient had passed no night without a fit, 
and for more than ten years the average 
nightly number of fits had been about 
twelve, which gives a total of more than 
forty thousand attacks in ten years. On the 
other hand, he was once consulted by a 
patient, sixty-two years old, who had had but 
seven attacks, the first of which occurred 
when he was nineteen years old, the interval 
between that and the second fit having been 
thirteen years, and the interval between the 
two last seizures having been seven years. 
Between extremely different cases like the two 
just mentioned we find the greatest variety 
as regards the frequency of attacks. Usually, 
however, there are a number of fits every 
month. If there are attacks with extremely 
violent convulsions, the frequency is gene- 
rally much less than when the convulsions 
are slight. Seizures of petit mat are usually 
very frequent. A perfect periodicity is ex- 
tremely rare, but an approximation to period- 
icity is not rare, especially in women. There 
may be singular and inexplicable periods ; 
the writer knows of a number of cases with a 
weekly periodicity, and of a case in which 
for years attacks recurred every forty-nine 
days. 
Status Epilepticus.-Bourneville, Fere, 
and Dr. Gowers have studied carefully this 
dangerous condition, which is often fatal to 
epileptics. As the writer will show about the 
treatment of morbus comitialis, it is impor- 
tant to know that this recurrence of a large 
number of fits, within a short period of time, 
with no return of consciousness between the 
attacks, may be the only kind of epileptic 
manifestations in some patients, in whom, 
after variable but sometimes almost perfectly 
periodical intervals, this so - called status 
epilepticus reappears. Usually, however, this 
frightful and very rapid succession of violent 
fits occurs in the worst cases of organic epi- 
lepsy due to disease of the brain, kidneys, or 
liver, and frequently then destroys the life of 
the patient. 
Complications and Sequel®.-Epilepsy 
has no necessary or usual complication. The 
diseases which often accompany it are fre- 
quently its causes and not complications. 
Bright's disease and other organic affections 
of the kidneys, diseases of the liver, the womb, 
and other viscera, when allied with epilepsy, 
if they have not been the first and only cause 
of it, are powerful additional causes. As 
regards sequelae, the important researches of 
Dr. Hughlings Jackson, Dr. Hughes Bennett, 
and Dr, Fere have established that difficult 
speech, aphasia, amnesia, trembling, general 
physical and mental weakening, as well as 
any mental disorder, paresis or paralysis, 
anaesthesia, or great disturbances in the 
various organic functions, may not only ap- 
pear temporarily as post-paroxysmal phe- 
nomena in epilepsy, but may persist and 
increase after each fit. The most common 
of those effects of seizures of this neurosis, 
and especially of petit mal, is amnesia, 
which may last, even if the epileptiform 
affection is cured. 
Pathology.-The writer does not pretend 
to know what is the nature of epilepsy, so 
that when he tries to explain how that affec- 
tion is produced and how its manifestations 
are generated, he will only state facts, and 
the conclusions they forcibly lead to. 
I. As early as 1857 he endeavoured to 
show that one of the most essential features 
of epilepsy is an increased excitability of the 
reflecto-motor parts of the nervous system, 
which may exist not only in many parts of 
the centres, but also in some peripheric parts 604 
EPILEPSY 
of the nervous system. The analysis of the 
phenomena which appear, after certain in- 
juries, in guinea-pigs or cats in which epi- 
lepsy can be gradually produced, leads forcibly 
to this view. In these animals, a few days 
after a lesion which causes epilepsy (espe- 
cially a section either of the sciatic nerve 
or of a lateral half of the spinal cord, in the 
dorsal region) the first morbid change to be 
detected consists in an increase of the reflex 
power of certain parts of the skin of the 
face and neck, while a greater excitability 
supervenes in the medulla oblongata, in the 
upper part of the cervical region of the 
spinal cord, and in some parts of the tri- 
geminal and of the two or three first cervical 
nerves. Gradually the reflex excitability of 
the nerve-cells in direct communication with 
the fibres of the nerves we have named in- 
creases, so that irritation of the skin of the 
face and neck, instead of producing only, as 
at first, a reflex contraction of the neighbour- 
ing muscles, causes tonic or clonic spasms of 
all the muscles of the trunk, neck, and head, 
on the side of both the lesion and the irri- 
tation of the skin. Later on, the reflex spas- 
modic action extends to the other side, and 
at last (a month or later after the traumatic 
injury from which proceeds this series of 
effects) a complete attack of epilepsy takes 
place, characterised, as in man, by loss of 
consciousness, with tonic and clonic con- 
vulsions. 
In cases of injury to certain parts of the 
base of the brain in some animals, the same 
changes may occur, but with two differences: 
1st, the rapidity of increase in the reflex ex- 
citability of the parts above-named is very 
much greater than after an injury to the 
spinal cord or to the sciatic nerve ; 2nd, the 
zone of skin that acquires the power, when 
irritated, to give rise to an attack is on the 
side opposite to that of the brain-injury, 
while it is on the side of the lesion of a 
nerve or of the spinal cord. 
The writer cannot give here the many 
reasons showing that what takes place in 
animals rendered epileptic by the lesions 
mentioned, may be applied in a great measure 
to the production of epilepsy in man. He 
will only say that cases identical with those 
of his guinea-pigs have been published by 
several clinical writers. 
After the important discovery of Fritsch 
and Hitzig, concerning the galvanic excita- 
bility of a certain zone of the cortex cerebri, 
it has been found that epileptiform convul- 
sions can easily be produced by an irritation of 
that zone in monkeys, dogs, and cats. It is 
clear, therefore, that perfectly healthy ani- 
mals can be rapidly rendered epileptic. Man 
also can be seized almost at once after a 
haemorrhage in the brain or a fracture of the 
cranium. 
II. In cases in which for the first time 
these spasmodic phenomena take place, the 
irritation which brings them on does this 
only after having given rise to a morbid 
change constituting epilepsy or an epilepti- 
form affection. A longer time is necessary 
for the appearance of these convulsive move- 
ments than for any kind of natural reflex 
contractions. 
The facts relating to the production of an 
attack of epilepsy by the galvanisation oi 
certain parts of the cortex cerebri in mon- 
"keys, dogs, and cats, also show that a cer- 
tain time is necessary for the production of 
the morbid state in which epilepsy consists. 
In that case also, as hereafter shown, the 
spinal cord is partly the seat of the genuine 
epilepsy generated. In pther words, two dis- 
tinct effects result from the irritative lesion 
-the one the genesis of the disease, i.e. of 
the morbid condition allied with which is 
the power of giving rise to epileptic or epi- 
leptiform attacks; the other, the production 
of a seizure. 
III. Experiments in sudden crushing of 
the head in animals show that epilepsy can 
appear, although nothing remains of any 
part of the brain, not even a portion of the 
medulla oblongata, the connexion between 
the encephalon and the spinal cord having 
been altogether severed. Epilepsy, in the 
case of the crushing of the head, has its seat 
in the spinal cord, whatever be the share of 
the brain in giving origin to it. The writer, 
although recognising that fact about the loca- 
tion of this affection in such special circum- 
stances, is not, and has never been, ready 
to admit that the spinal cord in all cases is 
the seat of this neurosis. 
IV. The writer believes that the supposed 
absolute distinctions between the various 
kinds of convulsions (eclampsia and other 
forms of epilepsy due either to peripheric 
causes or to the state of the blood, &c.) are 
purely artificial and based only on the know- 
ledge of the cause. All kinds of epilepsy 
may cause attacks, exhibiting the same es- 
sential features. In idiopathic, as well as in 
any other kind of epilepsy, an irritation 
which may come from any of the reflecto- 
motor parts of the nervous system, goes to 
a great many other parts of the nervous 
system, producing in some an inhibition of 
action or of power of action, and in others 
a simple expenditure of the normal or mor- 
bidly accumulated nerve-force, or, together 
with an expenditure, an increased generation 
of force (dynamogeny '). 
Two facts forcibly show how these vari- 
ous effects of an irritation are produced. 
1 The writer designates by that name just the 
contrary to inhibition. That action is the effect of 
a transformation of force due to an irritation, and 
in virtue of which there is a sudden or rapid pro- 
duction of force. A great many facts establish the 
dynamogenetic power of certain parts of the nervous 
system over other parts of that system and over 
contractile tissues. See his article ' Dynamogenie,' 
in the Diction. Encyclop. des Sciences Medicates. EPILEPSY 
605 
(1) Under the influence of a very slight irri- 
tation-that of a superficial prick of the me- 
dulla oblongata, close by the nib of the 
calamus-the brain may be suddenly and 
(so far as the writer knows) irrevocably 
inhibited, so that all the powers and func- 
tions of that organ disappear, while, on the 
contrary, the spinal cord, the nerves, and 
the muscles gain immensely in power: they 
are dynamogenised. The loss of cerebral 
activity is not due to a diminution or a 
cessation of circulation in the brain, as, on 
the one hand, the heart, for a time, shows 
no great weakness, although breathing is 
stopped ; and, on the other hand, the experi- 
ment succeeds although the cerebral blood- 
vessels are dilated owing to the previous ex- 
tirpation of the two superior cervical ganglia. 
(2) The other fact shows the simultaneous 
production of convulsions with inhibition 
and dynamogeny. Instead of pricking the 
medulla oblongata, that organ is suddenly 
crushed, and then it is found, first, that the 
powers of the cervical and of a part of the 
dorsal spinal cord are inhibited, sometimes 
so completely that they can be galvanised 
without producing any muscular action; 
secondly, that, for a longer time than in 
death by asphyxia, either tonic or clonic con- 
vulsions alone, or tonic followed by clonic 
muscular contractions, take place in the 
hind limbs; and, thirdly, that the power of 
that part of the spinal cord giving rise to 
convulsions is considerably increased, as 
shown not only by their violence and dura- 
tion, notwithstanding the cessation of circu- 
lation, but also by the fact that reflex actions 
can continue to exist after convulsions have 
ceased. 
The first of these facts clearly proves that 
one and the same cause-a very slight irrita- 
tion in a certain part of the nervous centres 
-can change at once and everywhere the 
dynamical condition of the nervous and 
muscular tissues, inhibiting all the powers 
of the brain and increasing considerably the 
powers of the spinal cord, of its nerves, and 
of all muscles. 
The second fact positively shows that an 
irritation of a certain part of the nervous 
centres can give rise simultaneously to three 
radically different effects-an inhibition; a 
production of nerve-force; convulsions due 
to an expenditure of nerve-force. 
V. These facts throw a flood of light on 
the phenomena of epilepsy. First, they 
clearly show that it is by an act of inhibition 
that the loss of consciousness takes place. 
Secondly, they lead to the conclusion that 
convulsions do not require the pre-existence 
of a great quantity of nerve-force in any 
part of the nervous centres, and that they 
can take place, with great violence and last 
a long time, from irritations which need not 
be very great. The supposition that epilepti- 
form fits depend on a sudden discharge of 
previously accumulated nerve-force is no 
longer necessary. 
VI. The lesions found in many parts of 
the brain in epileptic patients do not show 
the seat of epilepsy-they only have one or 
the other of the three following significations: 
First, they are places of irritation generating 
that neurosis in the same way as peripheric 
lesions in the skin, in mucous membranes, 
in nerves, &c., produce it. Second, they may 
be mere co-existing alterations, having no 
influence over the epileptic affection. Third, 
they may be, and very often are, effects of 
the changes in circulation, in the state of the 
blood, and in cerebral nutrition, during fits. 
The alterations of the medulla oblongata, 
described by Schroeder van der Kolk, and 
more completely by Ch. Bouchard, are cer- 
tainly, as pointed out by this last observer, 
effects of fits, but able, however, at certain 
stages of their development to have a share 
in some of the convulsive phenomena. The 
last effort recently made by Dr. Chaslin to 
establish that. in idiopathic epilepsy there is 
a constant lesion, has failed like all others. 
That lesion, consisting in the existence of a 
diffuse sclerosis located chiefly in the grey 
matter, is so little the essential organic 
cerebral cause of that form of morbus 
comitialis, that Fere, in a case of cure of 
that affection, found that the brain was the 
seat of the cortical sclerosis, besides having 
an induration of the two cornua Ammonis. 
VII. One only of the supposed seats of 
epilepsy in the brain deserves some atten- 
tion. It is that part which is the most fre- 
quently found diseased in cases of unilateral 
epileptiform convulsions, whether J acksonian 
in character or not-the so-called motor zone. 
That part is also very often diseased in cases 
of general epileptiform convulsions, and, not 
rarely, besides, in cases of apparently pure 
idiopathic epilepsy. This frequency of lesion 
of the so-called motor centres, in epileptic 
cases, may as well be due to the fact that 
an irritation starting from that place has 
given rise in other parts of the nervous 
centres to the morbid state in which epilepsy 
consists, as due to the fact that this peculiar 
morbid condition is really located there. In 
other words, a lesion of the cortex cerebri 
along the Rolandic fissure, like that of a 
nerve anywhere, may be only the location 
of an irritative cause and not the seat of 
this neurosis. 
Many facts observed in animals and in 
man show that this supposition is the correct 
one. Experiments on dogs have shown to 
the writer that every part of the motor tract 
in the encephalon, after the production of 
an epileptic attack by the galvanisation of 
the so-called motor centres, can, on galvanic 
irritation, give rise to an identical convulsive 
seizure. They have also established the fact 
that it is on the motor cells of the base of 
the brain and of the spinal cord that the 606 
EPILEPSY 
irritation of the cortex cerebri acts, in pro- 
ducing, first, the morbid state constituting 
epilepsy, and afterwards genuine epileptic 
attacks. 
VIII. What is proved for dogs is, at least, 
extremely probable for man. Clinical facts 
show that most frequently any kind of lesion 
of the so-called motor centres or of the 
neighbouring frontal convolutions1 has given 
origin either to genuine and complete epilep- 
tic fits, or to the greatest variety of epilepti- 
form manifestations. This has led to the 
erroneous conclusion that epilepsy has its 
seat in certain cortical parts of the brain. 
It can be shown that all parts of the cere- 
brum, of the cerebellum, of the base of the 
brain, and also the cerebral meninges, the 
spinal cord, and the centripetal nerves, can 
produce epilepsy. On the other hand, irri- 
tative lesions are known to have existed, in 
many cases, in one or another part of the 
frontal or parietal lobes without the appear- 
ance of epilepsy. 
When any kind or form of that affection 
appears under the influence of a disease or of 
an injury to the cortex cerebri in the parts 
looked upon as its real location, the altered 
tissue, as the following facts well show, may 
be only the seat of an irritation acting on 
other parts of the nervous centres, so as to 
give rise to epilepsy and to its manifestations. 
This view is proved by the facts-1st, that 
when this neurosis is due to a worm in the 
bowels, it can be cured by the expulsion of 
the irritating cause; 2nd, that when it de- 
pends on a neuroma, or neuritis, it can be 
cured by the section of a nerve between the 
diseased peripheric part and the nervous cen- 
tres ; 3rd, that when caused by some patho- 
logical alteration of a cerebral convolution, 
it can be cured by the excision of the dis- 
eased part. In all those cases there is a 
cure, not because the seat of this convul- 
sive affection is separated from the nervous 
centres, but because the irritating cause is 
suppressed. 
Sometimes, as is well known, epilepsy will 
continue after the expulsion of a worm, the 
section of a nerve, and the excision of a 
diseased convolution, or the opening of a 
cerebral abscess. In the first place, the irri- 
tative cause may be only partly suppressed 
by those means ; in the second place, as said 
already, the morbid state in which epilepsy 
consists may exist in other parts of the 
nervous system than those where the irri- 
tative causes are located. That morbid con- 
dition may persist, remaining able, under 
the influence of other irritations than those 
which acted previously, to give rise to 
seizures. 
IX. Together with the conclusions flowing 
from the facts and arguments above dis- 
cussed, the writer will give some others, the 
grounds for which lack of space does not 
permit him to mention :- 
1. Epilepsy is a reflex neurosis even when 
positively allied with an organic lesion of 
the brain. Its only constant feature is an 
increase of the reflex excitability of a number 
of nerve-cells located in various parts of the 
cerebro-spinal centres. That hyper-excita- 
bility is generally, but not necessarily, greater 
at the time of an impending fit. 
2. No distinction can be made between 
the kinds of epilepsy, with predominances 
either of considerable disturbance of the 
mental functions or of the higher senses, or 
of convulsive movements, or of any symptom. 
The greatest variety of epileptiform manifes- 
tations can arise from a similar lesion in any 
part of the brain or elsewhere. 
3. Some parts of the nervous centres 
are always ready to cause, rapidly but not 
immediately, all or some of the phenomena 
of epilepsy, under the influence of an irrita- 
tion, and especially a sudden one, proceeding 
from any central or peripheric part of the 
incito-motor nervous system. Two succes- 
sive and absolutely distinct actions take place 
then: the first is a morbid change in the 
properties of a number of cells of the nervous 
centres-change according to which epilepsy 
or an epileptiform affection is generated; 
the second is a reaction from those cells 
bringing outwardly the manifestations of 
the special kind of the neurosis produced. 
4. All the manifestations of genuine 
epilepsy, even in its worst and inherited 
form, in certain animals, can take place after 
the destruction of the whole brain, including 
every part of the medulla oblongata. 
5. The seat of epilepsy is not where an 
organic lesion or a traumatic injury is found, 
either in the brain proper, the cerebellum, or 
any other part of the nervous centres, nor in 
any nerve or viscus. All organic lesions are 
only foci of irritation, seats of causes. The 
true location of the morbid state constituting 
epilepsy or an epileptiform affection is in 
reflecto-motor nerve-cells in parts of the 
central nervous system varying extremely. 
6. Attacks of epilepsy are not essentially 
due to an overflow of nerve-force accumu- 
lated anywhere. The same irritating cause 
which brings on an attack can produce 
nerve-force at the same time that it deter- 
mines convulsions by discharges of that 
force. 
Diagnosis.-In most cases it is easy to dis- 
tinguish epilepsy from the few affections which 
resemble it. Sometimes, however, difficulties 
exist. There is no essential difference be- 
tween the attacks of eclampsia in women and 
children and attacks of epilepsy, except the 
1 Dr. J. Hughlings Jackson, in his late remark- 
able ' Lumleian Lectures,' has put forward the sup- 
position that the seat of 'complete or genuine' 
epilepsy is in the prefrontal lobes. Against this 
supposition the writer will only say that all the 
characteristics of this affection have existed when 
these lobes were either absolutely normal or com- 
pletely destroyed. EPILEPSY 
607 
existence in eclampsia of a peripheric cause 
of irritation, which is likely to disappear. 
But those purely reflex epileptiform attacks 
in women and children are sometimes 
succeeded by genuine attacks of epilepsy. 
Changes in the nervous centres occur during 
the eclamptic attacks, and lay the founda- 
tion of persistent epilepsy, although the peri- 
pheric irritation, which was the first cause, 
has ceased to exist. It is sometimes, there- 
fore, almost impossible, as regards children 
especially, to say if we have to deal with 
eclampsia or epilepsy. The same may be 
said of all kinds of attacks of loss of con- 
sciousness and convulsions due to a peripheric 
cause, whether we call the affection eclamp- 
sia or reflex epilepsy (see Convulsions). 
The first cause in these cases may cease to 
exist without our discovering positively that 
it has disappeared, and still attacks may 
continue. A mistake is not dangerous, as 
the treatment will be very much the same, 
except that in purely reflex epilepsy we 
have to fight against the peripheric cause, 
besides making use of means against epilepsy 
itself. 
As regards the known facts concerning the 
setiology of epilepsy and hysteroid affections, 
it must be remembered : (1) That, instead of 
epilepsy, hysteria may appear in the descen- 
dants of epileptics; (2) that an organic disease 
of the brain can give rise to genuine hysteria 
or to mixed forms of hysteria and epilepsy; 
(3) that diseases of the womb or even of the 
ovaries can give origin to epilepsy, and diseases 
of the testicles to.hysteria ; (4) that traumatic 
causes, and especially injuries to nerves, can 
sometimes produce hysteria; (5) that syphilis, 
uraemia, worms in the bowels, lead poisoning, 
can give rise to hysteroid affections. ^Etiology 
alone cannot, therefore, be decisive for the 
diagnosis between epilepsy and hysteria. 
The aura hysterica and the epileptic aura 
are generally very different one from the 
other, but they may be quite similar. The 
writer has seen a case of idiopathic epilepsy 
in an adult male, in whom the globus hyste- 
ricus was the warning of almost every attack. 
As regards other means of diagnosis, we will 
refer to the articles Hysteria and Hystero- 
epilepsy. 
Epilepsia mitior (petit maT) sometimes 
cannot be recognised easily from syncope. 
In petit mat, however, the loss of conscious- 
ness is absolutely sudden; the eyes are fixed; 
almost always some muscles of the face are 
contracted; sometimes other muscles, in the 
neck and elsewhere, are also contracted; if 
the patient is standing he rarely falls, and if 
he is walking he may continue to do it. The 
attack is very short, and there may be no ap- 
pearance of its having occurred, except that 
some mental disorder may follow it; the pulse 
may be diminished, but it never disappears 
altogether. Syncope differs from petit mal 
in all those characteristics. 
It is not necessary to draw here the lines 
of diagnosis between idiopathic epilepsy and 
cerebral epilepsy. The characteristic features 
of this last affection have been described at 
length in several parts of this article. 
Prognosis.-Inherited epilepsy is very 
rarely cured. The writer can positively 
state, however, that it may be cured. Among 
other good cases of persistent cure, he has 
seen two extremely remarkable. The patients 
were first cousins, and had inherited the dis- 
ease from a grandmother : one of them died 
from a fall while intoxicated, five years after 
his last attack of epilepsy; the other died 
from typhoid fever, seven years after his last 
attack. They had both been treated for 
about two years, in 1852 and 1853. 
There is a very great difference as regards 
prognosis between pure idiopathic epilepsy 
and other forms of that neurosis. The 
possibility of cure is greater when some 
curable or amendable organic alteration 
exists as a cause of epilepsy. One form of 
this nervous affection-that which is due to 
some congestion or even a more serious 
alteration of the brain, consecutive to ty- 
phoid fever, scarlatina, or measles-is often 
much benefited by treatment, if not cured. 
Already, before the great progress in the 
treatment of epilepsy through surgical means, 
the writer looked upon epilepsy caused by 
disease of the brain-syphilitic or not-as 
much more curable than any of the forms 
of this neurosis, excepting, perhaps, that 
which is due to an easily removable peri- 
pheric irritation. Epilepsy beginning in 
childhood, from teething or a bowel com- 
plaint, and having lasted many years, is 
almost incurable. 
Treatment.-Abortion of the attach.-A 
most important fact ought at first to be 
pointed out under this head: it is that, as 
every attack causes in the nervous centres 
changes which prepare other attacks, it is 
essential to produce, if possible, the abor- 
tion of attacks whenever warnings occur. 
The treatment to obtain such an abortion 
varies with the kind of warning. In cases 
in which a real aura exists many means can 
be employed with the greatest benefit. The 
writer long since showed that the old- 
fashioned mode of prevention of attacks, 
consisting in the application of a ligature 
round a limb, acts not as the Galenic doc- 
trine supposed that it did-that is, by barring 
the way to something going up to the brain; 
but, on the contrary, in doing just the re- 
verse-that is, by sending an irritation to- 
wards or rather to the nervous centres. The 
writer has also shown that the ligature need 
not be left applied, and that a greater success 
is obtained by tying suddenly a handker- 
chief or a band, and repeating this tying 
several times in succession, than by applying 
the ligature even very tightly and leaving 
it so. Besides, he has found: (1) that the 608 
EPILEPSY 
ligature can do good even when applied on 
another limb than that where the aura is 
felt, although it is more efficacious on the 
latter; and (2) that pinching or striking the 
skin, or irritating its nerves by heat, by cold, 
by galvanism, or by repeated pricks with a 
needle, will generally do as much good as 
the ligature. 
In those cases in which an involuntary 
muscular contraction takes place before an 
attack-that is, before the loss of conscious- 
ness-one of the most efficient means to 
produce an abortion of the fit is to draw 
forcibly on the contracted muscles, so as to 
elongate them. For instance, in those cases 
in which the unconsciousness is preceded by 
a contraction of the muscles of the neck, 
which draws the chin towards one shoulder, 
turning forcibly and rapidly the head towards 
the opposite shoulder gives in most cases a 
very good chance of checking completely the 
tendency to the fit. In case of contraction 
of the flexor muscles of the forearm, forcible 
extension of the hand over the forearm may 
succeed in preventing the attack. A blow, 
pressure, or friction on parts where some 
muscles become rigid, may have the same 
favourable effect. 
If there are disturbances of breathing 
among the premonitory symptoms, the in- 
halation of ether or chloroform may prove 
successful. In cases of laryngismus similar 
means, or the cauterisation of the fauces by 
a strong solution of nitrate of silver, has been 
found most useful by the writer. The use of 
anaesthetics as a means of warding off an 
attack is too much neglected. By the help 
of ether in inhalations the writer suc- 
ceeded, with Mr. R. Dunn, in preventing an 
attack in a patient who had had a fracture 
of the arm in a previous seizure, and who 
used to have a fit regularly every week. A 
whole week was gained in that way. In 
some cases the recurrence of attacks has 
been warded off by giving chloroform or 
ether (by inhalation) to patients who had 
had the first of what would have been other- 
wise a series of many fits. There is, in cases in 
which a fit is expected, a considerable chance 
of preventing it by anaesthetics. 
According to the kind of warning and to 
its seat, one means or another out of a very 
large number (some of which only shall be 
mentioned here) ought to be used. An 
emetic, a purgative, a stimulant, the immer- 
sion of the two hands in hot water, the applica- 
tion of a lump of ice to the back of the neck 
or between the shoulder-blades, the subcu- 
taneous injection of a solution of of a grain 
of sulphate of atropine with | of a grain of 
acetate of morphine, powdered asarum taken 
as snuff, a dose of 25 grains of hydrate of 
chloral, the inhalation of a small dose of 
nitrite of amyl, extremely rapid and ample 
voluntary respiratory movements for five or 
six minutes, jumping, running for at least 
ten minutes, reading very loud and fast- 
such are some of the means which the writer 
has found to be the most successful. 
In a number of cases, patients under the 
writer's care obtained abortion of an impend- 
ing fit by making energetic movements 
Sometimes, however, even when the warning 
allowed the performance of very powerful 
general movements for a long time, the fit 
came with its usual violence. These facts 
are in decided opposition to the view that 
attacks of epilepsy are the effects of dis- 
charges of accumulated nerve-force by the 
so-called motor centres, or by other parts of 
the brain. Just as the tension of vapour 
diminishes in a boiler when steam is let 
off, the amount of nerve-force should dimi- 
nish as a necessary consequence of the ex- 
penditure taking place in voluntary move- 
ment. 
The second point of importance about 
treatment is to try to discover a part of the 
body which can by irritation give rise to a 
premonitory symptom of an attack, or even 
to an attack itself. If such a part is dis- 
covered, counter-irritation of some kind is 
to be applied there. Our remarks must be 
confined to saying that hard pressure on 
certain parts of the head, the spine, the 
breast, the abdomen, or the limbs, has in a 
number of cases produced an attack or some 
symptoms of it. We have seen the passage 
of a galvanic current produce the same 
effect. In such cases a blister or other local 
application has done good in diminishing 
the violence or frequency of attacks, and 
even, in a few instances, helped notably to a 
cure. 
It is a remarkable fact that, whether a 
sensory or muscular aura exists from some 
affection or injury in the neighbourhood of 
its seat in the periphery, or from an organic 
affection or a traumatic injury of the nervous 
centres, the best place of application of any 
means of abortion of an attack, or of cure of 
epilepsy, is the same-i.e. the skin near the 
seat of the aura, or along the passage of 
nerves going to that seat. If a place, which 
is not connected with an aura, is found to be 
capable under an irritation of giving rise to 
a fit, there also is the best situation for the 
application of counter-irritants and other 
means of treatment against the epileptic 
affection. One of the most powerful means 
of counter-irritation, in all cases like the 
above, is a circular blister to be applied all 
round a finger, a toe, or an arm or leg. 
This means, used also with benefit by Dr. 
Buzzard, has led him to find that some- 
times the aura, under the influence of a 
circular blister, disappears from the limb so 
treated, and is transferred to homologous 
places of the other side. In a case of epilepsy 
of Recamier's, a sensory aura changed place 
a great many times, and each time after an 
application of a small blister. The aura EPILEPSY 
609 
so pursued disappeared, and the patient was 
cured. 
Treatment during the attach.-The best 
plan in most cases of epilepsy is simply to 
save the patient from the danger of striking 
anything which might cause a bruise; to 
loosen his clothing, cravat, &c., so as to give 
freedom to respiratory movements; to wash 
the face with cold water if it become covered 
with perspiration; and at last to turn the 
head and face at the end of the fit, so as to 
prevent the falling back of the tongue on the 
glottis, and even to draw forward the tongue 
if there is deep stertorous or comatose 
breathing. There is, however, one means of 
treatment which has certainly proved some- 
times successful in curtailing an attack even 
in so-called idiopathic epilepsy, although it 
is more powerful in partial epilepsy due to 
brain disease or to some peripheric irritation : 
this is pressure on the part of the neck where 
lie the carotid arteries. The idea was to 
lessen the amount of blood going to the brain. 
"Whether obtaining that effect is really of 
service or not the writer cannot say, but, as 
often stated by him, it is not possible to press 
strongly over the carotid arteries without 
pressing also on the cervical sympathetic 
and on the nervi vagi. It is known that 
Augustus Waller and Czermak have ascer- 
tained that in man, as in the mammalians, 
pressure on the carotid artery acts sufficiently 
on that nerve to inhibit the heart more or 
less completely. This effect is certainly 
quite capable of curtailing a fit. The writer 
has shown also that such pressure can act 
on the nerve so as to modify favourably the 
condition of the respiratory centres, and he 
has proposed to employ pressure on both 
carotids and neighbouring nerves in those 
cases of epilepsy (and also of apoplexy) in 
which the heart beats very violently, while 
the respiratory muscles partake of the general 
convulsions. 
Treatment of epilepsy itself.-The modes 
of treatment of the various forms of epilepsy 
which chiefly deserve to be noticed, must be 
divided into two classes, the internal and the 
external and surgical. We will first speak 
of internal means. 
Against idiopathic epilepsy the most 
powerful means consists in the simultaneous 
use of some tonic remedy (such as strychnine 
or arsenic) to be taken after meals; and of 
a mixture composed more or less like the 
following:- 
R Potassii iodidi Jij. 
Potassii bromidi Jj. 
Ammonii bromidi Jiij. 
Potassii bicarbonatis 3j. 
Tinct. calumbae ?j. 
Aquae destillatae 3vj. 
Of this solution four doses a day may be 
given to adults, three of one teaspoonful 
each before meals, and the fourth of three 
teaspoonfuls at bedtime, with as much water 
as desired. According to many circum- 
stances the dose of one or another of the 
ingredients is to be changed. For example, 
if the petit mat exists alone, or co-exists with 
the complete epilepsy, the dose of the bromide 
of ammonium must be larger, and that of the 
other bromide diminished. If there is a 
weak pulse, carbonate of ammonium is to 
be substituted for the bicarbonate of potas- 
sium. In the writer's work on functional 
nervous affections all the rules relating to 
this mixture are given, and he will only say 
now that its use is considerably more bene- 
ficial than that of any of its ingredients alone, 
or any two of them. Two essential rules are 
to be followed when bromides are employed 
against epilepsy. The first is, that there 
ought to be no cessation whatever in the use 
of such remedies, as the whole benefit that 
may have been obtained may be lost at once 
after an interruption of even only a few days; 
the second is, that the treatment must be 
persevered with for at least two years after 
the date of the last attack. There is no evi- 
dent harm in the great majority of cases 
from a prolonged use of a mixture like the 
above; a large number of patients have taken 
it for many years without any marked bad 
effect. 
The writer has tried many other bromides 
than the two of this mixture. None has 
answered so well as these two. In a great 
many cases he has made use simultaneously 
of this mixture and of one or another of the 
many remedies which have been proposed 
for epilepsy. None of them has proved very 
useful except when there was some local 
affection which could be benefited by the 
added remedy. Such has been the case with 
atropine, ergotin, cannabis indica, digitalis, 
aconitine, cod-liver oil, &c. 
In those cases in which the above mixture 
either did not produce a sufficiently good 
effect, or, still more, allowed of an increase 
of the convulsive neurosis or of petit mat, the 
use of atropine, of the ammoniated sulphate 
of copper, of borax, of the oxide or other salt 
of zinc, has frequently proved useful. It is 
not possible to say in what kind of cases one 
of these remedies is to be used rather than 
the others, except that zinc seems to be of 
better use when hysteria is more or less 
mixed up with epilepsy. 
The writer has obtained a permanent cure 
of two cases of idiopathic epilepsy through 
the agency of nitrate of silver, without any 
discoloration of the skin. He employed a 
small dose (| of a grain three times a day), 
and stopped giving the medicine for eight or. 
ten days after having had it used for three 
weeks. It required nearly a year for the 
complete cessation of the fits, and the use 
of the remedy was continued a few months 
after the last attack. 
Petit mat, as well as complete epilepsy, can 
be treated advantageously with the above- 
mentioned mixture. Much benefit will some- 610 
EPILEPSY 
times be obtained in the treatment of this 
special neurosis by the addition of arsenic 
or of atropine. 
It is hardly necessary to say that, when 
syphilis is the cause of epilepsy, the dose of 
the iodide of potassium in the prescription 
is to be notably increased (it must be at 
least a drachm a day), and also that fric- 
tions with the mercurial ointment are often 
to be resorted to. If epilepsy depend on 
some visceral affection, it is clear that the 
treatment should be directed against that 
affection. But if the liver is diseased from 
some influence of malaria, the sulphate of 
quinine should not be given, as it is almost 
always a bad remedy to employ in epilepsy, 
often more hurtful than useful. Arsenic 
should then be the remedy used for the 
sequelae of fever and ague. If quinine must 
be employed in cases of clearly periodical 
epilepsy, the valerianate should be given. 
The writer's experience shows that in most 
cases of epilepsy iron is harmful rather than 
useful. It is only in cases allied with or 
caused by chlorosis or considerable anaemia 
that the good effects of iron or manganese 
are often very marked. Still, the citrate of 
iron, although less powerful against a defi- 
ciency of blood-globules, may be used, because 
it is less apt to give rise to attacks than are 
most ferruginous preparations. Writers who 
disagree with these views (which are accepted 
by Dr. Hughlings Jackson) have lately tried 
to show that iron can always do some, if not 
much, good, and can do no harm; but they 
have, in support of their statements, given 
cases belonging rather to hysteroid affections 
than to epilepsy. 
The writer has obtained no decided good 
effects from nitrite of amyl, antipyrin, picro- 
toxine, curara, or simulo. 
It is important to state that, in cases of 
status epilepticus, the prompt and continued 
use of anaesthetics (ether, chloroform) may 
stop the tendency to the recurrence of fits. 
The condition of the tongue must then be 
watched carefully. If, as is usual, the fits 
are very violent, this organ falls over the 
larynx and increases the state of asphyxia, 
which contributes to the return of con- 
vulsions. The tongue is to be drawn forward, 
and any accumulation of frothy or bloody 
mucus in the throat must be wiped out. 
Anaesthetics have some power of curtailing, 
if not stopping at once, the tendency to a 
return of fits. 
External and surgical means.-The 
notion that, if epilepsy depends on a peri- 
pheric cause which can be removed, it is 
right to employ surgical means, has often 
been acted upon, and with decided benefit. 
The number of cases is large in which a 
cause has been profitably suppressed by an 
operation or some other means. In a good 
many such cases, the section of a nerve or 
the extirpation of a foreign body or a tumour 
has proved successful. Lately some cases 
of stretching of nerves, followed by cure or 
amelioration, have been published. A great 
deal is to be expected from counter-irritation. 
Ice applied on the bare skin, the actual 
cautery, or sedative applications on sores, 
may do much good. 
As regards cases of idiopathic or cerebral 
epilepsy, all kinds of counter-irritation on 
the nape of the neck or at the level of the 
first and second dorsal vertebrae may prove 
useful, especially if there is considerable pain 
or heat in the head. When attacks are very 
violent and frequent, a decided amelioration 
may be obtained from croton-oil applications 
on a great part of the shaved scalp. Setons 
and issues very rarely do any good, and often 
weaken and irritate. 
Among surgical means against epilepsy, two 
bold and somewhat strange operations have 
successively been proposed by an able surgeon, 
Dr. W. Alexander, of Liverpool: the one was 
supposed to act in producing anaemia in the 
base of the brain; the other, on the contrary, 
was to cause a vascular fulness. The first oi 
these means consisted in the ligature of 
both vertebral arteries. Out of 36 cases 
there was a temporary cure or a persistent 
amelioration in 19 cases-certainly a very 
large proportion. Having given up this thera- 
peutical means, Dr. Alexander formed the idea 
of taking away on the two sides the superior 
cervical ganglion of the sympathetic nerve, 
and obtained this remarkable result-that 
there was a cure or an improvement in 25 
per cent, of the cases, while it is generally 
admitted that medical treatment gives about 
7 per cent, of cure or improvement. The 
writer, notwithstanding the apparent supe- 
riority of this kind of treatment, would be 
quite indisposed to recommend it except after 
complete failure of all the best internal 
remedies. 
Operations on the genital organs of epilep- 
tics of the two sexes are only to be resorted 
to in desperate cases. 
Trephining against epilepsy, during a great 
part of this century, although employed in- 
discriminately, has nevertheless frequently 
proved useful. It is now, in appearance, used 
according to rational scientific principles-in 
reality sometimes quite faulty. Statistics 
show that, with the addition of very bold 
operations, it is not so frequently useful as it 
previously was. In other parts of this article 
(Etiology ; Symptoms) there are facts show- 
ing that recognition of the seat of a tumour 
or of some other organic disease of the brain 
is not always possible, and must in many 
cases be extremely difficult. Be that as it 
may, it is quite certain that not rarely after 
the laying bare of the dura mater or the 
cerebral convolutions, surgeons have been 
disappointed in not detecting an expected 
morbid state to which they attributed an 
existing epileptic affection. -On the other hand, however, they were, sometimes, agree- 
ably surprised in finding that in such circum- 
stances the affection disappeared. In 1857, 
after having given all the details of a case of 
the kind, furnished to him by Dr. van Buren, 
the writer in his work on Epilepsy put for- 
ward a view, very tersely expressed a few 
years ago by Dr. Gowers in the following 
sentence: ' It is possible that the measure 
(trephining) is sometimes beneficial as an 
energetic form of counter-irritation, but it is 
doubtful whether for this object its perform- 
ance is justifiable.' 
Knowing how powerful counter-irritation 
may be against epilepsy caused by a blow on 
the head or allied with some tenderness of 
a point of the scalp, the writer long ago 
proposed that, before resorting to trephining, 
the most energetic means of counter-irrita- 
tion should be employed. Trials should be 
made of ice applied on the shaved and bare 
skin of the head twice a day for an hour 
each time, of the actual cautery, of blistering, 
of croton oil, and of a means which the 
writer (imitating Pouteau) used successfully 
in two cases, consisting in a deep crucial 
incision of the scalp and the pericranium 
(the cuts being of one inch and a quarter). 
It is possible that it was a more or less similar 
operation, and not the trephining, which was 
the means of success in the cases above 
mentioned. 
When we read of cases of cure after the 
extirpation of bony spicul® or of a mass of 
cicatricial tissue, of a tumour, or of a certain 
amount of the convolutions of the brain, it is 
impossible not to be struck with the resem- 
blance of these facts to the cases of cure of 
epilepsy by the expulsion of worms from the 
bowels, or the removal of a neuroma or a 
foreign body pressing on a nerve, or of other 
causes of peripheric irritation. The analogy 
between the cerebral and the peripheric 
cases is very great: both are cases of reflex 
epilepsy. In both kinds of cases there may 
be a failure of the means used, owing, no 
doubt, to changes having occurred in the 
nervous centres which are able to give rise 
to attacks of epilepsy. In such cases the 
excision of the supposed centre of certain 
muscles may not be followed by a cessation 
of convulsions of those parts. So it was in 
the case of a boy spoken of by Dr. Ferrier, 
and who had been operated upon by Mr. V. 
Horsley. 
Notwithstanding the diminution of risks 
due to antiseptics, great is still the propor- 
tion of deaths following, if not caused by, 
the operation of trephining, with the abla- 
tion of morbid parts of the brain, and some- 
times, alas ! of perfectly healthy - looking 
parts. 
There is no doubt that surgeons are 
entitled, in certain cases, to employ trephin- 
ing against epilepsy; but, for the reasons 
above briefly given, the writer thinks that, 
EPILEPSY 
before resorting to this operation, when there 
is no clear evidence that some morbid parts 
are to be removed or an abscess to be opened, 
or some necessity arising from a fracture, it 
would be wise to first exhaust all means of 
counter-irritation. 
C. E. Brown-Sequard. 
EPILEPTIC INSANITY.-Synon. : 
Fr. Folie epileptique; Ger. Epileptisches 
Irresein. 
Definition.-Mental disorder which is the 
outcome of the epileptic neurosis, and which 
is generally, though not invariably, accom- 
panied by motor epilepsy. 
Aetiology.-The statements in the article 
Epilepsy may be taken generally as applic- 
able to epileptic insanity. But an exception 
must be made in regard to what is said con- 
cerning sympathetic epilepsy, the insanity 
described here being associated only with 
epilepsy of cerebral origin. 
Pathology.-The structural changes asso- 
ciated with epileptic insanity have their seat 
in the cerebral cortex, and involve an altered 
nutrition of certain of the nerve-cells. This 
altered nutrition is usually due to idiopathic 
degeneration; but it may also be due to 
morbid growths or other irritative lesions in 
neighbouring parts of the brain. It seems 
probable that functional disturbance of the 
cells in the higher centres or psychic areas 
may be excited by radiation from the motor 
area in which an epileptic discharge origi- 
nates ; but in most cases there can be little 
doubt that the cells in the psychic are® are 
themselves the subject of structural change. 
In some cases, indeed, the psychic centres 
are the first affected, and the discharges may 
be at least for a time limited to these centres. 
In such cases the discharges are manifested 
by loss of consciousness, hallucinations, or 
outbursts of mania unaccompanied by con- 
vulsions. The structural change chiefly occurs 
in the small irregularly shaped nerve-cells 
which are found in the second cortical layer. 
Bevan Lewis regards as of a highly charac- 
teristic nature a fatty degeneration of the 
nuclei of these cells, which goes on to vacuo- 
lation, and ends in complete disintegration 
of the cells. He describes similar changes as 
usually affecting to some extent the other 
layers of the cortex. This form of degenera- 
tion is not, however, as Bevan Lewis himself 
shows, peculiar to epilepsy; and other ob- 
servers, though using Bevan Lewis's own 
method of examination, have failed to find it 
in some cases of epilepsy. When a patient 
dies in a fit, there is usually found intense 
venous engorgement with sometimes puncti- 
form h®morrhages in all the viscera, including 
the brain. This condition has important 
pathological bearings; but it is post-epileptic 
in its nature, and is properly regarded, not 
as the cause, but as a result of the epileptic 
seizure. 
EPILEPTIC INSANITY 
611 612 
Description.-It is necessary to consider 
separately three aspects of the unsoundness 
of mind which is associated with epilepsy, 
according as it appears (1) as arrested or im- 
peded mental development-epileptic idiocy 
and epileptic imbecility ; (2) as progressive 
mental degeneration-chronic epileptic in- 
sanity ; and (3) as transient mental disorder 
-acute epileptic insanity or epileptic mania. 
These three conditions are to be regarded as 
different phases and not as different kinds of 
epileptic insanity. They are intimately con- 
nected with one another, and occasionally 
they may all be illustrated in the progress 
of a single case. Thus epilepsy supervening 
during infancy or youth may so retard mental 
development as to produce imbecility; the 
subsequent periodical recurrence of epileptic 
fits during adult life may gradually pervert 
anddeprave the alreadyimperfect intelligence, 
causing it to pass through a phase charac- 
terised by emotional disorder, hallucinations, 
and delusions, and ending in the hebetude of 
complete dementia; this progress may occupy 
many years, and it may be interrupted by 
irtercurrent outbursts of acute maniacal ex- 
citement. Though it is necessary, therefore, 
for the purpose of description to deal with 
each of the phases separately, their inter- 
dependence must not be overlooked. 
1. Epileptic Idiocy and Epileptic Im- 
becility.-These terms are used to indicate 
different degrees of the same affection-a more 
or less complete arrest of mental develop- 
ment due to epilepsy. Those individuals 
in whom epilepsy supervenes in infancy, 
where there is no development-' of mind, or 
very little, are called idiots. Those in whom 
epilepsy commences after substantial pro- 
gress has been made in mental growth, or in 
whom the epileptic seizures, though appear- 
ing early, do not recur frequently, and where 
there is considerable though defective mental 
development, are called imbeciles. The effect 
of the fits upon the mental condition of chil- 
dren differs greatly in different cases. The 
fits are usually followed by more or less 
mental retrogression. In many cases after a 
fit, and especially after a series of fits, the 
patients fall into a state of prostration and 
stupor of some duration. The educational 
training of the epileptic imbecile is seriously 
embarrassed by the occurrence of such at- 
tacks. A great part of what has previously 
been learnt seems to be wiped out, and re- 
quires to be learnt over again. In cases 
where the fits cease the evolution of the in- 
tellect may resume its course, but the mental 
organisation always remains damaged. It is 
estimated that about one-third of the total 
number of cases of idiocy are due to epilepsy. 
2. Chronic Epileptic Insanity.-In 
a large number of epileptics, estimated by 
Russell Reynolds at about one-third of the 
total number, the mental condition is not 
affected to such a degree as to be recognised 
EPILEPTIC INSANITY 
as abnormal; and in a small number of cases 
the disorder is limited to a few brief attacks, 
sometimes to a single attack, of maniacal ex- 
citement. In about two-thirds of the cases 
there is an appreciable mental enfeeblement 
which gradually increases so long as the fits 
continue to recur, in some cases never going 
farther than a peculiar emotional mobility 
and weakness of memory, and in others pa is- 
ing on to profound dementia. This progressive 
mental degeneration, though varying greatly 
in degree, is very uniform in type, and it is 
important to be able to recognise it. In the 
mildest cases there are usually to be detected 
lapses of memory, fits of absent-mindedness, 
and transient confusions of thought; and 
there is always more or less instability of 
mood and morbid irritability. The instability 
is the most characteristic mental feature of 
the epileptic. At one time he will be gloomy, 
despairing, conscious of his mental enfeeble- 
ment, and lamenting its hopeless nature ; at 
another time he will exhibit a surprising 
self-satisfaction, hopefulness, and confidence. 
Many epileptics are liable to fits of intensely 
passionate anger, occurring without apparent 
cause. The changes of mood often take place 
with a startling suddenness which is im- 
portant as a diagnostic indication. In the 
fully developed chronic insanity of the epi- 
leptic the variableness of the mental condition 
may show itself in the intellectual as well as 
in the emotional state. A patient who usually 
exhibits confusion of thought, weak memory, 
and little power of attention may suddenly 
awake to a state of great mental activity, 
and show remarkable clearness and rapidity 
of thought, vivid memory, and great power of 
concentration. A common condition is to be 
habitually quarrelsome, argumentative, fond 
of teasing, insolent in demeanour, and given 
to capricious cruelty; yet such patients will 
sometimes be found marvellously sweet in 
disposition, benevolent, affectionate, and con- 
siderate. In the advanced stages of the dis- 
order the moral nature is generally deeply 
degraded, as shown in repulsive obsequious- 
ness of demeanour, low cunning, treachery, 
and cruelty. The intellectual condition also 
passes through stages of degradation. Delu- 
sions of being injured by other persons fill 
the mind, and visual and auditory hallucina- 
tions occur. When these are present the 
patient, with his tendency to impulsive pas- 
sion, is dangerous to persons near him. The 
last stage is marked by complete loss of 
moral sense and mental capacity. Nothing 
remains but the lower instincts in their most 
degraded form ; and this is accompanied by 
a physical debasement which accords only too 
well with the mental condition. 
3. Acute Epileptic Insanity-Epi- 
leptic Mania.-The term ' epileptic mania ' 
is used to denote a peculiar automatic form 
of acute mania which sometimes follows 
epileptic seizures, and more rarely occurs in EPILEPTIC INSANITY 
613 
persons with the epileptic neurosis who have 
never had a convulsive attack-or at least 
who have not been known to have one. 
There is generally some transient mental 
perturbation preceding or following a con- 
vulsive seizure, which does not attain the 
intensity of mania, but which may be fitly 
alluded to here. The pre-paroxysmal phase 
of' these perturbations may last for a few 
hours or a few days. They consist in a 
development of conditions which have been 
already described as characteristic of the 
early stage of chronic epileptic insanity. 
Sometimes there is morbid irritability, de- 
pression, or exaltation, sometimes confusion 
of thought or loss of memory. Immediately 
before the occurrence of a fit there is often 
some special idea which rivets the attention, 
the recollection of some particular scene, or a 
special hallucination such as a flame, a red 
colour, a spectre, or a peculiar odour. When 
there is a particular idea, or an hallucination, 
it is usually the same which recurs at each 
seizure, and it generally has some relation to 
the circumstances in which the first fit oc- 
curred. After the convulsive fit has passed 
off, there is frequently a short period of con- 
fusion of thought, and lethargy. The condi- 
tion known as epileptic mania is an outburst 
of maniacal excitement lasting from a few 
hours to several days. The general features 
which are distinctive of these attacks are the 
suddenness of their onset, the violence and 
abrupt rapidity of the acts of the patients, the 
painful and appalling nature of the ideas and 
hallucinations from which they suffer, the 
suddenness as well as the completeness of the 
return to sanity, and the entire, or nearly en- 
tire, forgetfulness of what has happened during 
the course of the attacks. During an attack 
the impulsive acts are often of a homicidal or 
suicidal character, and this makes epileptic 
mania one of the most dangerous of all kinds 
of insanity. Sometimes the attack is charac- 
terised by furious maniacal excitement during 
its whole course, but there are also cases in 
which there is an apparent calmness of conduct. 
In a typical case of this kind the patient is irri- 
table, suffers from a vague terror, seems im- 
pelled by a force, which he feels irresistible, 
to commit acts without conscious purpose. 
In this state the patients will walk long dis- 
tances without object, steal or destroy articles 
in an unaccountable way, and will commit 
homicide or suicide with apparent delibera- 
tion. They seem insensible to everything 
which does not fall in with their dominant 
idea or impulse. This automatic action is a 
special characteristic of epileptic mania, both 
in the cases where there is violent excitement, 
and in those where there is an appearance of 
deliberate co-ordination of thought and act. 
The patients are as if in a waking dream; and 
when they awake suddenly to rational con- 
sciousness, they feel as if they had passed 
through a dream which they dimly conceive 
to have been of a distressing and frightful 
nature, but of whose details they have no 
recollection, or only a very vague one. 
The relation of the mental disorder to the 
convulsive seizures is concisely given in the 
following sentences. When the fits are fre- 
quent, and continue through a course of years, 
they are generally associated with chronic 
epileptic insanity, though there are excep- 
tional cases in which the mind is not seriously 
affected. Where the fits are frequent, and are 
of the character of petit mat, the mental de- 
generation is usually more rapid and com- 
plete than where the motor symptoms are 
more severe, as in the grand mat. The 
calmer type of epileptic mania, called by 
Falret petit mat intellectuel, is most fre- 
quently associated with fits of the character 
of petit mol and with nocturnal fits; while 
the violent excitement, called by Falret grand 
mat intellectuel, is most frequently associated 
with the severe motor fits. Epileptic mania 
is most frequent after a fit or a series of fits, 
is less frequent before a fit, and least frequent 
in the intervening periods; it is specially a,pt 
to occur after a recrudescence of fits following 
a long period of freedom from them. It is 
also apt to occur after a rapid succession of 
abortive fits. It is rare in the first stages of 
epilepsy, most frequent in the middle stage, 
and rare after dementia has begun. 
Treatment.-In the treatment of epileptic 
insanity everything which is useful in the 
treatment of epilepsy is to be included (see 
Epilepsy). The bromides are the most im- 
portant remedies, especially bromide of potas- 
sium. It should be given persistently in 
doses just short of producing bromism, com- 
bined with small doses of arsenic. It may 
be given for years if necessary. When syphi- 
lis is present, the bromide should be com- 
bined with the iodide. When pre-paroxysmal 
symptoms are observed, 20 grains of chloral 
hydrate should be given and the patient put 
to bed. The same treatment is useful after 
a fit; and it may also arrest a fit, or series 
of fits, or ward off an attack of epileptic 
mania. Constipation and overloading of 
the stomach with food should be carefully 
avoided. There should be complete absti- 
nence from alcohol; it is apt to bring on fits 
and also mania. 
Medico-legal Relations.-Where respon- 
sibility for acts committed in what seems to 
have been an attack of epileptic mania is in 
question, the whole character of the mental 
symptoms and the evidence of other epileptic 
conditions must be kept in view. The diffi- 
cult cases are those in which there has been 
no violent excitement, and when the conduct 
has had the character of the calmer type of 
epileptic mania. Here it is important to 
bring clearly out the automatic character of 
the conduct. But the most important point 
is the existence of the fits. It may happen 
that the fits have not been recognised though 614 
EPILEPTIC INSANITY 
EPIPHYTIC SKIN-DISEASES 
they were really present. Nocturnal fits are 
the most likely to escape recognition. It 
must not be forgotten that they may have 
occurred without the knowledge of the patient 
himself. Careful inquiry should therefore 
be made for signs of their occurrence, such 
as biting of the tongue, of the lips, or of the 
cheek; spots of bl ood on the pillow; gathering 
of froth about the mouth on waking ; uncon- 
scious emission of urine; peculiar fits of snor- 
ing; or the occurrence of numerous small 
ecchymoses under the skin of the neck or 
forehead, the last being a sign the importance 
of which is strongly insisted on by Trousseau. 
When no convulsive fits can be ascertained, 
evidence of vertigo, or of brief losses of con- 
sciousness occurring periodically or in series, 
should be looked for. If in the opinion of a 
medical witness an act of violence has been 
the result of epileptic insanity, it is his duty 
to show that not merely the act itself, but 
also the conduct and condition of the accused 
otherwise, are symptomatic of the epileptic 
condition. John Sibbald. 
Classification.-The vegetable parasites 
are all fungi and belong to the subdivi- 
sions Schizomycetes (bacteria), Blastomycetes 
(yeasts), and Hyphomycetes (moulds). In 
addition to the pathogenic microbes of 
anthrax, glanders, erysipelas, leprosy, tuber- 
culosis, &c., which may occur in the skin 
in association with these diseases, there 
exists under normal conditions a number 
of micro-organisms amongst the scales of 
the skin and its appendages, in nature be- 
tween saprophytes and genuine parasites. 
There is a growing tendency to assume that, 
under certain conditions, this ' dermatological 
flora ' may possess pathogenic properties. 
There may also be found from time to time 
accidental organisms of various kinds, and 
these are the pyogenic microbes. A parasitic 
origin has been ascribed to alopecia areata, 
but not proved ; and the aetiological connexion 
of certain organisms found in furuncles, 
oriental sore, and impetigo contagiosa, &c., 
is still unsettled. Lastly, there are the 
bacteria of bromidrosis and red sweat, and 
the organisms associated with certain hair 
conditions, such as tinea nodosa, piedra, and 
forms of sycosis. 
Apart from all such, however, there is the 
distinct group of Hyphomycetes, achloro- 
phyllous thallophytes, living only on organic 
carbon compounds and needing oxygen, which 
constitutes the long-established class of true 
epiphytic diseases. The group is composed 
thus:- 
1. Tinea favosa or favus, caused by the 
Achorion, discovered by Schonlein. The 
phases occurring in the scalp, beard, non- 
hairy parts, and nails may be specially noted. 
2. Tinea trichophytina or ringworm, 
caused by the Trichophyton tonsurans of 
Gruby and Malmsten. Here also the phases 
occurring in the scalp, beard, non-hairy parts, 
and nails have special characteristics. 
3. Tinea imbricata or Tokelau ringworm, 
a special (?) form found in Polynesia, and the 
Malay and Indian Archipelagos. 
4. Tinea versicolor or chromophytosis, 
caused by the Microsporon furfur of Eich- 
stedt. 
5 Erythrasma, caused by the Microsporon 
minutissimum of Burckhardt. 
To this list are usually added mycetoma 
or the fungus-disease of India, due to the 
Chionyphe Carteri; and an obscure disease 
of Mexico and parts of Central America 
called pinta. 
This group of the Hyphomycetes, whose 
natural history is even yet not fully known, 
stands apart by itself, but its members are 
most nearly allied to the Mucorinae. The 
difficulty of determining their affinities and 
classification has given rise to much contro- 
versy, now almost subsided. Increased 
knowledge of their morphology, direct ex- 
periment, and successful pure cultures have 
established that these dermato-mycoses are 
EPILEPTIFORM 
EPILEPTOID 
.-Partaking of the 
characters of epilepsy; terms generally ap- 
plied to convulsions. See Convulsions. 
EPIPHORA (em, upon; and (f)tpa), I 
carry).-A flow of tears so persistent that 
they run down the cheek, due either to 
obstruction of the lacrymal duct or to exces- 
sive secretion. See Lacrymal Apparatus, 
Diseases of. 
EPIPHYTA (firl, upon; and t^vrov, a 
plant).-These are the plant-like organisms 
found on the skin and its appendages, or on 
mucous surfaces, the so-called vegetable- 
parasites, originating certain diseases, such 
as the various forms of tinea and thrush. The 
more important of them are the achorion, 
trichophyton, and microsporon. The acho- 
rion Schbnleinii is the vegetable fungus 
which constitutes the mass of the crusts of 
favus, and belongs to the group of oidia. 
The trichophyton is the dermatophyte of 
tinea and sycosis, and is found in the sub- 
stance of the hair as well as in the epidermis. 
The microsporon, termed epidermophyton 
by Bazin, is the parasitic fungus of pityriasis 
versicolor. Both the latter are members of 
the group of torulaceae. See Epiphytic 
Skin-Diseases; and Aphthae. 
Erasmus Wilson. 
EPIPHYTIC SKIN-DISEASES.- 
Synon.: Tineae; Dermato-mycoses or Der- 
mato-phytoses ; Ringworms ; Fr. Tricho- 
phytees (Besnier); Teignes; Ger. Flechte. 
Definition.-An epiphyte is a living vege- 
table organism which grows in the superficial 
parts of the skin or mucous membrane of 
another organism, and is parasitic-i.e. lives 
at the expense of its host. EPIPHYTIC SKIN-DISEASES 
615 
not due to polymorphic forms of some mould, 
such as Penicillium, Aspergillus, Mucor, &c., 
but are distinct species, with different vegeta- 
tions, growing in a constant and determined 
form, with different behaviour under at- 
tempted cultivation, and always giving rise 
to similar objective symptoms. Tinea tricho- 
phytina, favosa, and versicolor cannot give 
rise to one another, but breed true. These 
dermato-mycoses are contagious, and are 
inoculated from person to person and from 
animals. Their fungi have no sporangia, 
but consist of spores and simple or branched, 
jointed or unjointed, filaments or tubes, 
which are either mycelial (vegetative) or 
spore-bearing. The spores become isolated, 
or are arranged in moniliform threads or in 
masses. Balzer says, ' Everything is derived 
from the spore, which by elongation forms a 
tube or filament of mycelium ; in the interior 
of this tube the substance of the nucleus 
(protoplasm) buds, sends out lateral pro- 
cesses and segments, so as to form the spore- 
bearing tube; when, later on, segmentation 
of the sheath occurs in its turn and imprisons 
the segments of the central substance, new 
spores are thus formed and will evolve, in 
their turn, in a similar manner.' 
Description. - To examine the fungus, 
some epidermic scales should be scraped, or 
a hair placed on a slide, and soaked for a 
time in 20 to 40 per cent, soda, potash, or 
ammonia solution or in acetic acid. Then 
the specimen should be gently pressed out by 
the cover-glass to ensure proper focussing, 
and examined by a microscopic power of 300 
or more diameters. If there is much fat 
present, the material must be previously 
soaked in ether. For more accurate and 
delicate examination, coloration of the speci- 
men is necessary with methyl violet, eosin, 
or iodine. The erythrasma fungus needs 
high powers and staining. It is often impos- 
sible to name with certainty isolated spores or 
even filaments of these epiphytes, but when 
seen in bulk and in connexion with the 
clinical symptoms, there is rarely any diffi- 
culty. Unfortunately there are no elective 
stains to differentiate them. The abundant 
Microsporon minutissimum is so minute and 
slender as to be unmistakable. M. furfur also 
is very characteristic, with its roe-like masses 
of large uniform spores, and its short, much 
curved pieces of mycelium. The Achorion 
and Trichophyton are much more difficult to 
distinguish apart from cultures, and they 
differ from the other two epiphytes in attack- 
ing the hairs, though achorion does so to a 
much less extent than trichophyton. Kaposi 
says achorion displays a predominance of 
conidia of very variable size and shape, a 
comparatively short and remarkably jointed 
mycelium, a scarcity of smooth-bordered 
tubes, and a facility for breaking up into 
single cells; trichophyton less numerous, 
smaller and more uniform conidia, and more 
tenacious, branched, and smooth-bordered 
mycelium. In the hair and nails, however, 
trichophyton forms conidia with the greatest 
freedom. 
Anatomical Seat.-These dermato-phytes 
flourish in the epidermic tissue-i.e. the epi- 
dermis, hairs, and nails. We know little of 
many of the conditions of the soil favourable 
or otherwise to their growth. Achorion and 
trichophyton prefer the skin of the young and 
such as grows fine hair. These fungi are 
more likely to attack and flourish in un- 
cared-for children, and hence the prevalent 
idea that ill-health or dirt are essential fac- 
tors. A certain degree and combination of 
moisture and temperature are favourable, as 
exemplified by the affection of calves after 
being shut up in winter quarters, and by 
tropical ringworm. 
Effects.-The effects which epiphytes pro- 
duce are, firstly, to mechanically dissociate 
and thus destroy the epidermic cells, on the 
nitrogenous products of which they live; and, 
secondly, to cause local inflammation, chiefly 
in all probability by the formation of irri- 
tating chemical substances. The degree of 
inflammation excited varies for each fungus 
and with different individuals; and it is diffi- 
cult to determine the relative parts played by 
individual susceptibility, and the powers of 
irritation possessed by the fungus under the 
different conditions of its source of origin, the 
character of the nutrient medium, &c. The 
inflammation may be evidenced only by hy- 
peraemia and desquamation, or by exudation 
and the formation of papules, vesicles, pus- 
tules, &c. As the fungus tends to grow 
equally in all directions, a rounded area of 
inflammation is formed, which subsides in 
the older central parts, so that a ringed 
eruption is commonly produced. 
The general health is not perceptibly 
affected by any absorption of the products of 
fungus-growth, nor is there evidence of any 
auto-vaccination preserving from a second 
attack. 
These dermato-mycoses are inoculable from 
human beings and some lower animals di- 
rectly, and by means of infected caps, towels, 
brushes, razors, clothes, &c. Their course is 
usually very chronic, but the soil may become 
exhausted and unfavourable. 
Diagnosis.-The diagnosis, when the clini- 
cal symptoms are well-marked, is clear ; but 
scientifically, and even practically at certain 
stages, it is necessary to search microscopic- 
ally for the fungus. 
Prognosis and Treatment.-The progno- 
sis depends on the site affected and the nature 
of the fungus; but the dermato-mycoses are 
all amenable to treatment by parasiticides 
and the mechanical removal of the fungus. 
Great inconvenience and annoyance, however, 
are occasioned, and sometimes disfigurement. 
See Tinea tonsurans; Tinea versicolor; 
and Favus. T. Colcott Fox. 616 
EPIPLOITIS 
EPISTAXIS 
EPIPLOITIS (e7rm\oov, the omentum). 
Inflammation of the epiploon or great omen- 
tum. See Peritoneum, Diseases of. 
EPISPADIAS (fTri, upon; and aTram, I 
tear).-A malformation of the penis, in which 
the urethra opens on its upper surface. See 
Penis, Diseases of. 
EPISPASTICS (em, upon; and <rirda>, I 
draw).-Substances which, when applied to 
the skin, are capable of producing a blister. 
See Counter-irritants. 
EPISTAXIS («rt, upon; and ara^m, I 
drop).-Synon. : Er. Epistaxis ', Ger. Nasen- 
bluten. 
Definition.-Epistaxis signifies a bleed- 
ing from the nose. 
^Etiology.-Epistaxis is either traumatic 
or idiopathic. 
The traumatic form may be occasioned by 
a blow, by violent sneezing, by snuffing up irri- 
tating substances, or by direct violence ; but 
in these cases there frequently appear to be 
general or local predisposing causes to ac- 
count for the readiness with which it occurs, 
such as a haemorrhagic diathesis, an inflam- 
matory or congestive hyperaemia, or some 
ulceration of the mucous membrane. 
The idiopathic form of epistaxis frequently 
occurs in children, particularly boys, just be- 
fore or about the age of puberty, and in girls 
as a form of vicarious menstruation. Epi- 
staxis may be one of the forms of bleeding in 
persons of haemorrhagic diathesis, in which 
case it is a source of anxiety and difficulty. 
Occurring in advanced life, it may be in- 
dicative of over-distension or obstruction of 
the cerebral venous system from chronic 
Bright's or cardiac disease; and the blood 
which flows is then often venous in appear- 
ance. Occasionally it occurs as a spontaneous 
relief to determination of blood to the head, 
in which form the blood generally proceeds 
from one nostril only. In other instances 
epistaxis is connected with serious disorder 
of the blood, as in the specific fevers. Thus 
it is often associated from the outset with 
remittent, enteric, typhus, or scarlet fever, 
and is indeed regarded in some degree as 
pathognomonic of enteric fever. It may also 
attend scurvy, purpura haemorrhagica, sple- 
nic disease, pyaemia, and erysipelas, being a 
consequence of the septic condition. 
In its passive form, epistaxis may be asso- 
ciated with organic disease of the heart, 
pleurisy, emphysema; or with ascites or 
ovarian dropsy, on account of pressure on the 
diaphragm inducing a stasis of the venous 
circulation. It may occur spontaneously 
from exposure either to great cold or great 
heat, or a sudden change from cold to heat, 
or from the diminution of atmospheric pres- 
sure, as in going up high mountains. 
Symptoms.-Haemorrhage from the nose 
is too familiar to demand description in this 
place. The flow of blood may be either con- 
tinuous or drop by drop. As a rule, the 
escape of blood is from one nostril, bleeding 
from both being rare. It may last a very 
short time, or for some hours, and in severe 
instances for days, causing syncope, or even 
being attended with fatal results. It is at 
times met with as occurring periodically. 
Diagnosis.-Epistaxis must not be con- 
founded with haemoptysis, as may happen if 
the epistaxis takes place posteriorly, and the 
blood passes into the mouth. 
Treatment.-When epistaxis is obviously 
a salutary process, as it undoubtedly is in a 
good many instances, it subsides spontane- 
ously; where it occurs frequently and se- 
verely, recourse must be had to mechanical, 
cutaneous, or internal remedies. The local 
application of cold, in the form of cold-water 
or iced compresses to the nose, neck, or fore- 
head is most useful, acting as these agents do 
either directly or by inducing a reflex effect 
on the vaso-motor nerves. Simple pressure 
upon the nostril, or upon the septum nasi, by 
compressing the bleeding nostril with the 
finger of the opposite hand, while the arm of 
the affected side is raised above the head, is 
the most readily practicable and effectual of 
all measures. The application of mustard 
over the stomach or upon the ankles is some- 
times successful. When simple means fail, 
astringents, either in the form of solution or 
powders, may be injected into the cavities, or 
applied on plugs of lint or cotton-wool; such 
as alum, acetate of lead, the salts of iron, or 
gallic or tannic acid. 
Internally, the frequent administration of 
saline purgatives, tincture of perchloride of 
iron, turpentine, bromide of potassium, bella- 
donna and quinine, ergotin (subcutaneously), 
sulphuric acid, or acetate of lead, may be 
necessary in cases of periodic attacks. 
In very severe cases the operation of plug- 
ging the nares, and thereby favouring the 
formation of a clot, must be resorted to; and 
the most ready and easiest method is by the 
employment of Bellocq's sound, or, more 
properly, cannula. If, however, this instru- 
ment be not at hand, a catheter or an eyed 
probe should be threaded with a stout silk or 
hemp ligature, and pushed along the floor of 
the nose until it protrudes beyond the velum 
palati; one end of the thread should now be 
pulled out of the mouth by the fingers or 
forceps, and a roll of lint or a piece of sponge 
tied to it, and then pushed up behind the 
velum. The catheter and the attached thread 
being now withdrawn through the nostril, 
the plug is pulled forcibly against the pos- 
terior nares, and by the pressure exerted the 
haemorrhage can generally be arrested. The 
intra-nasal plug is invaluable. It consists of 
a thin indiarubber bag, connected with a 
tube provided with a stopcock. The bag is 
passed empty along the floor of the nose into 
the nasal fossae, and. then blown up or filled EPISTAXIS 
EPITHELIOMA 
617 
with water. Transfusion is indicated in very 
severe cases, where there is danger of delay. 
The strictest antiseptic precautions should be 
used in 'plugging'-such as puffing with 
iodoform, or syringing with the various anti- 
septics, as it not infrequently happens that 
the condition known as ozaena commences 
after severe cases of epistaxis. 
Edward Bellamy. 
EPISTHOTOJNOS (enurGev, forwards; 
and Tei'pw, I extend).-A synonym for empro- 
sthotonos. See Emprosthotonos. 
EPITHELIOMA (tnl, upon; and ^Xj), 
the nipple (the word ' epithelium ' being at 
first used for the tissue covering the nipple); 
and oma, a termination indicating a tumour). 
-Synon. : Epithelial Cancer ; Cancroid ; Fr. 
Epithelioma\ Ger. Epithelkrebs. 
Definition.- Cancerous disease of the 
skin and mucous membranes, caused by 
growth inwards of the epithelial cells of 
the rete mucosum and of the mucous mem- 
brane, leading to destruction of connective 
tissue and progressive ulceration. 
.Etiology.-Epithelioma is a disease of 
advanced age, occurring mostly after forty, 
although it is found occasionally in young, 
and, rarely, in very young, individuals. It is 
more common in men than in women, and is 
usually considered hereditary. 
The frequency with which it begins in a 
wart, shows that certain histological con- 
ditions of the skin predispose to its develop- 
ment. The exciting cause is often to be found 
in local irritation, of which a striking example 
is seen in the frequency with which cancer 
of the Jower lip in men is caused by the 
tobacco-pipe. Cancer caused by soot gives 
rise to chimney-sweep's cancer. It may 
develop in chronic ulcers, in lupus, in syphi- 
litic scars, and in cicatrices. The irritation 
of bad teeth may cause it on the cheek. In 
Cashmere, where braziers are frequently ap- 
plied to the abdomen and thigh, epithelioma 
occasionally results. Leukoplakia of the 
mouth in certain cases ends in cancer. 
Three cases have been reported in which it 
developed in warts growing on the hands of 
persons employed in tar and petroleum works. 
It may be set up by the irritation of old-stand- 
ing eczema. In Kaposi's disease a great 
number of cancerous epitheliomatous ulcers 
develop in the skin, following the deposition 
of patches of pigment. Four cases have been 
reported in which epithelioma developed in 
old-standing psoriatic patches. It is, how- 
ever, abundantly proved that chronic irrita- 
tion of the most various kinds may, in certain 
persons, result in producing epithelioma; but 
in what the predisposition consists, or in 
what way the irritation produces the epithe- 
liomatous growth, are questions upon which 
no light has yet been thrown. 
Description.-In the early stage of epithe- 
lioma of the skin the affected surface is found 
to be hard, more or less nodular, and charac- 
terised by small, closely-set, irregularly de- 
fined papules which are covered with epi- 
thelial scales. These scales are constantly 
being shed and re-formed; and if the detached 
epidermis is removed, a red granular surface 
is exposed. The thickened and elevated area 
gradually enlarges, forming a superficial hard 
tumour, which is raised above the level of the 
surrounding skin, with an abrupt margin. For 
some time the tumour moves with the skin 
in which it has grown; but, as it extends, it 
becomes fixed to the underlying tissues, and 
a growth is formed, which may either be of 
very limited extent, or may involve an area 
of considerable size. Eventually the growth 
ulcerates; or ulceration may occur so early 
that the initial indurated stage may not have 
been noticed, and the first morbid appearance 
that attracts attention is a small, dry, yellow 
or blackish crust covering a fissure in the 
epidermis. 
Not infrequently the first development of 
epithelioma is in a warty growth which be- 
comes fissured after having remained of a 
simple nature for a long period of time. 
The wart finally indurates, then ulcerates, 
and a typical epithelioma is the result. 
The epitheliomatous ulcer has usually an 
uneven surface, and is irregularly bounded 
by hard, livid, everted edges. It is covered 
by minute granulations or by a greyish crust, 
which after removal is quickly renewed. It 
discharges a thin, scanty, sanious ichor, 
which is usually inoffensive; and it bleeds 
easily when touched. In some cases there 
is very little or no pain. In other cases the 
pain is severe and lancinating, or there may 
be stinging or pricking sensations, which 
cause frequent scratching and consequent 
irritation. The ulcer is usually round, oval, 
or elongated. Its essential character is the 
hardness of its borders and base, which is 
produced by the infiltration which is an in- 
variable feature of the disease. The indu- 
rated boundary can be felt as a distinct mass 
adherent to the subjacent tissues. The bor- 
ders are generally raised, sinuous, or nodu- 
lated, frequently everted, and sometimes 
undermined. The surface of the ulcer is 
concave, unequal, nodular, or warty. As 
the disease progresses, the ulceration extends 
in depth, and causes destruction of the sub- 
cutaneous tissues, muscles, and bones. Whilst 
ulceration and destruction are proceeding in 
the centre, the small papillary nodules with 
a scaly surface, which mark the early stage, 
are found on the circumference of the sore, 
and they may increase till they form small 
tumours before being finally involved in the 
extension of the ulceration. 
In course of time the lymphatic glands corre- 
sponding to the affected part become enlarged, 
being felt at first as small, hard, movable, 
isolated tumours producing little inflamma- 
tory reaction. As they increase in size they 618 
EPITHELIOMA 
become incorporated in a single, somewhat 
lobulated mass, which eventually softens. 
From the infected glands the disease may 
extend further towards the trunk, but more 
frequently the proximate glands alone be- 
come cancerous. The affected glands may 
inflame, suppurate, and lead to cancerous 
ulcers, in which the peculiarities of the dis- 
ease are reproduced. Secondary epithelio- 
matous growths are occasionally, but not 
frequently, found in the internal organs. 
In the earlier stages of an epitheliomatous 
growth the destruction may take place chiefly 
in the corium, in which case the growth is 
not much elevated above the normal level of 
the skin. If, however, development takes 
place chiefly in the papillary layer, we have 
a permanent and warty growth, whilst if it 
grows freely in the subcutaneous tissue we 
have a deep-seated, flat, or rounded mass. 
These different varieties may more or less 
intermingle, and thus in the earlier stages of 
an epithelioma we may have a variety of ap- 
pearances. This depends to some extent on 
the anatomical peculiarities of the part in 
which the disease develops. In all cases 
before ulceration takes place the affected part 
is unusually hard and enlarged. The lip, for 
example, pouts and projects like one over- 
grown. 
The chief varieties of epithelioma are the 
superficial and the deep-seated forms, which 
respectively depend on the greater or less 
resistance opposed by the pars reticularis 
corii to the extension inwards of the epi- 
thelial growth. If the morbid epithelium 
be for a long time unable to penetrate the 
strong, firm bundles of the corium, and con- 
tents itself with ' cropping off,' as Erasmus 
Wilson has expressed it, the highly organised 
corpus papillare, we have a typical superficial 
form which, whilst it extends on the surface, 
makes an effort at healing in the centre. 
The disease presents the appearance of an 
extending cicatrix somewhat like that of a 
burn, the centre appearing to be healed 
whilst the advanced border which surrounds 
the cicatrix is in a state of slow ulceration. 
But when, either from the greater destructive 
power of the cancerous epithelium or from 
weakness of the fibrous tissues of the corium, 
the growing epithelium pierces the pars reti- 
cularis, the clinical aspects are much more 
serious, and are very different. The growth 
having once penetrated into the subcutaneous 
tissue, extends, usually with comparative 
rapidity, producing the destruction which is 
characteristic of deep-seated epithelioma. 
When the chief feature of the epithelioma is 
a projecting papillary growth, we have the 
so-called papillary epithelioma or malignant 
papilloma. This form is not infrequent 
when the disease develops in a wart. It 
may have begun as a papilloma or a papillary 
growth, or may develop subsequently on a 
superficial or more frequently on a nodulating, 
ulcerating epithelioma. It may project con- 
siderably above the level of the surrounding 
skin, and may be seated either on a broad 
base or have a constricted neck, assuming a 
fungating form. The surface is formed of 
cicatrices and enlarged papillae, which are 
cylindrical, pyriform, or conical, and single 
or in clusters. They are very vascular, the 
surface chiefly covered with an opaque, white 
cuticle, of a pink, vermilion, or brightly 
florid hue. When the loose epidermic scales 
are washed off, we have the granulated and 
lobulated surface known as ' cauliflower-like 
excrescence.' The epithelial cells may con- 
tain melanotic matter, which is also found 
between the cells, and we have then 
melanotic epithelioma. In discoid epithe- 
lioma there is a sharply bordered circular or 
oval disc, the margins being bounded by 
healthy integument, which is raised and 
slightly everted by the growth. 
An epithelial cancer may grow up in the 
form of a cone, although such cases are rare. 
Sir James Paget removed one from the lower 
lip half an inch high, and nearly as much in 
diameter at its base, and another in a chim- 
ney-sweep's neck of a similar kind. In both 
cases the growth was covered with a thick 
laminated scab, not easy at first to distin- 
guish from syphilitic rupia. Mr. Henry 
Morris has seen one in the outer dorsum of 
the foot in a man aged fifty-six. Or the 
growths may even be pendulous. Sir James 
Paget refers to growths on the lower lip and 
anus consisting of masses of very firm granu- 
lations far overhanging the adjacent healthy 
skin. 
The tendency in all these forms is to pro- 
duce continued destruction of healthy tissue, 
unless the morbid growth is removed by 
operation. In the later stages of the malady 
exhaustion supervenes, and the patient even- 
tually succumbs, worn out by pain and 
increasing discharge from the ulcerating 
surface. 
Seats.-Epithelioma may develop at any 
part of the integument, but is most frequent 
on the face. In 102 cases 78 were on the 
face, 48 of these being in the lip, 4 were on 
the extremities, and 10 on the mucous mem- 
brane of the mouth. The local ravages may 
be very extensive before they cause death, 
and in the face may produce hideous de- 
formity, laying bare the bones, teeth, and 
fauces, destroying portions of the skull until 
the dura mater is exposed. 
The lower lip is a very common seat of 
epithelioma, which commences there either 
as a warty growth, or as a fissure from the 
edges of which the disease spreads. The 
whole lip becomes thickened and hard, pro- 
jecting outwards, and allowing the saliva to 
flow from the mouth. The surface ulcerates 
progressively; and if the affected tissue is not 
removed, the disease extends to the mucous 
membrane of the cheeks, giving rise to EPITHELIOMA 
619 
ulceration, and eventually the throat and 
bones become affected. 
In the penis epithelioma may commence 
as a nodular swelling of the prepuce, or as a 
hard scirrhous infiltration of the glans, or 
between the prepuce and glans. In the 
latter case a discharge may be the first 
symptom observed. A tight prepuce and 
phimotic condition of the parts favour the 
development of the disease. In epithelioma 
of the glans and sulcus there early occurs 
thickening of the dorsal lymphatic vessel of 
the penis, which can be felt as a thick, hard, 
nodulated tract extending towards the pubes, 
to be continued towards the inguinal glands, 
which enlarge into hard, nodulated masses. 
Abscess and ulceration eventually occur. 
Primitive epithelioma of the vulva fre- 
quently develops as a small warty tumour ; at 
other times it is preceded by pruritus or a long- 
standing leukoplakia. The point of origin is 
not infrequently on the mucous surface of the 
labium majus, or at the junction of the skin 
and mucous membrane. There is usually a 
discharge of bloody, ill-smelling serum. A 
tumour may form as large as a nut or hen's 
egg, with a hard, shining, papillated surface. 
It may or may not be pedunculated. The 
labium minus may be the seat of infiltration 
of a hard consistence and reddish colour, and 
there may be a tumour, more or less pedun- 
culated, of the clitoris. After the first symp- 
tom of pruritus there is a sensation of cold 
and fulness of the pelvis, especially in walk- 
ing or standing. The progress is usually slow. 
At the beginning, epithelioma of the vulva 
may be mistaken for chronic granular vagin- 
itis, or non-malignant tumour, and in the 
ulcerative period for a primary syphilitic sore 
or a gumma. The severe lancinating pains 
and extension of the ulceration remove the 
doubts which may have existed during an 
earlier period. 
Epithelioma of the anus is rare. It occurs 
as a notched and protuberant growth at the 
anal orifice, and extends into the gut. 
In the limbs, usually the leg, epithelioma 
mostly develops in cicatrices, varicose 
ulcers, syphilis, and lupus. 
Epithelioma of the mucous membrane of 
the nose, conjunctiva, vagina, and rectum may 
appear either primarily, or secondarily as an 
extension from the adjacent skin. Cancer of 
the tongue and mucous membrane of the 
cheek is not uncommon, in which situations 
it may develop on the seat of syphilitic 
change, or on a patch of leukoplakia. On the 
tongue it begins as a raw granulated surface, 
which is sometimes thickly set with white 
points, tender to pressure; and it may be the 
seat of pain, nodular infiltration developing 
under the sore. Sometimes the nodular in- 
filtration precedes the ulceration. On the 
mucous membrane of the cheek epithelioma 
is rarer, and is generally flat but sometimes 
fungoid when it occurs. 
Anatomical Characters and Pathology. 
The pathology of epithelioma may be 
summed up briefly in describing it as an 
epithelial neoplasm, which leads to the de- 
struction of the vascular tissues amongst 
which it grows.. From the rete mucosum 
there occur offshoots of epithelial growth, 
which travel along the papillary layer, pierce 
the corium, and (wherever they grow) produce, 
in the first instance, well-marked develop- 
ments of inflammatory action. "Wherever 
the epithelioma comes in contact with the 
vascular tissue, it acts like a poison, and 
evidences of destruction are found. The 
essential feature is not that there is a new 
growth of epithelium, but that there is a 
growth of a new kind of epithelium, which 
is, in effect, a connective-tissue poison. Like 
all poisons, this epithelial poison exerts an 
irritating influence on the adjacent blood- 
vessels, as is witnessed by abundant small 
cell infiltration, serous effusion, redness, and 
other evidences of engorged blood-vessels. 
Cancerous epithelium has then two abnor- 
mal qualities: one in that it grows inwards 
into the connective tissue ; the second, that 
wherever it grows it produces inflammatory 
action. When a vertical section is made 
through the edge of an epitheliomatous 
ulcer, we find on the outer border which 
is adjacent to the healthy tissue prolonga- 
tions inwards of the rete mucosum, whilst in 
the connective tissue of the papillary layer 
and cutis we find sections of apparently iso- 
lated masses of epithelial growth. These 
isolated masses, which are mostly in a cylin- 
drical form,were really in unbroken continuity 
with growths from the rete; but as the 
growths, after they have penetrated down- 
wards, follow to a certain extent the lines of 
least resistance, they cease to be in a direct 
line with the interpapillary cone from which 
they have come, and therefore, in a thin sec- 
tion, appear to be detached. It is this ap- 
parent isolation that led to the erroneous in- 
terpretation that epithelial cancer was caused 
by a heterologous growth of connective-tissue 
corpuscles. That in cancerous tissue the 
epithelium takes its origin in the rete mucosum 
is a fact that was recognised so long ago as 
1852 by Hannover, but was lost sight of for 
many years after Virchow's views on cellular 
pathology became generally accepted. It 
was again clearly shown by Thiersch in 
1865. 
There is a special epithelial physiognomy 
peculiar to the morbid growth in each in- 
dividual case. In many instances the cell 
columns undergo an extreme degree of horny 
change, and we find in the sections groups 
of very large horny cells clustering concentri- 
cally, giving rise to the so-called laminated 
capsules or ' nests.' In some cases the cell- 
columns do not take on the extreme horny 
metamorphosis, all the cells retaining the 
ordinary apparent characters of rete cells. 620 
EPITHELIOMA 
The large horny cells frequently break down, 
and in their cavities numbers of nuclei are 
found, an appearance which has suggested 
the theory ofso-called ' mother ' and ' daughter' 
cells. The appearance is, however, equally 
in harmony with the probable theory that 
leucocytes have found their way into the in- 
terior of the broken-down cells. 
The new cells are generally supposed 
to be formed by cell-fission-a process, how- 
ever, which is not found when sections are 
examined. Whatever the exact method may 
be by which this epithelial growth takes 
place, there is no reason to believe that in 
principle it differs from that which is charac- 
teristic of increase of epithelium in healthy 
conditions. 
When the changes in the connective tissue 
which lead eventually to ulceration are care- 
fully scrutinised, it is found that under the 
influence of the epithelial poison there is an 
extensive emigration of white and red cor- 
puscles, a splitting up of the bundles of con- 
nective tissue into the primary or elementary 
bundles of which they are composed, and 
eventually disintegration of the bundles al- 
together, a granular detritus taking their 
place. Immediately under and bounding the 
ulceration, masses of small cells are found, 
numbers of engorged and dilated blood-ves- 
sels, and many free blood-corpuscles. 
The diseased epithelium not only possesses 
the power of destroying the connective tissue, 
but finds its way into the lymphatic vessels, 
and by them .into the lymphatic glands. 
Occasionally it is conveyed into the viscera, 
leading to cancerous deposits in the internal 
organs. 
Attempts to associate cancerous develop- 
ments with the presence of micro-organisms 
have not yet been confirmed. Dr. Yakimoff 
has stated that in cancer the blood-vessels, 
not only near the tumour but throughout the 
body, acquire thickened walls with diminished 
lumen. Mr. Ballance and Mr. Shattock have 
described in cancerous tissue, after sterile in- 
cubation, a projection of nuclear granules 
into the cell protoplasm, and they suggest 
that the stimulus which excites the epithe- 
lial growth may be due to these particles. 
Diagnosis.-Before ulceration has taken 
place it is possible in the early stage to con- 
found epithelioma with sebaceous acne, with 
warts, and with certain forms of lupus. If 
in acne sebacea the crusts on the affected 
part are removed, by rubbing with soft soap 
or other means, a healthy skin with distended 
sebaceous follicles is laid bare, the disease not 
extending deeply into the true skin. In dis- 
tinguishing between epithelioma and lupus, 
it is to be borne in mind that in lupus the 
patient is, as a rule, either young or has a 
history of having suffered from the disease 
in early youth. In lupus the characteristic 
infiltration will be found on or near the 
borders of the affected part. In an ulcerat- 
ing lupus the edges of the ulcer are soft and 
regular and not everted. The ulceration ex- 
tends more on the surface than in depth. 
It must not be forgotten that epithelioma 
may develop in the seat of lupus. 
A tubercular syphilide is distinguished 
by the colour and grouping of the tubercles, 
which are multiple; whilst epithelioma begins 
usually by a single tubercle, runs a slower 
course and lasts longer, and is not affected by 
a course of iodide of potassium. The dia- 
gnosis between epithelioma and syphilis is 
sometimes difficult, and without microsco- 
pical examination is occasionally impossible. 
Syphilomata presenting this difficulty are 
not infrequent on the tongue and lower lip, 
the diagnosis being rendered difficult by their 
late appearance, and often by their long period 
of latency. In such cases it is of great im- 
portance that a small portion of the affected 
surface should be excised and subjected to 
microscopical examination. In syphilitic 
ulcers the ulceration progresses usually more 
rapidly than in epithelioma. The ulcers are 
multiple, whilst in epithelioma the ulcer is 
usually single. Whilst the tissues surround- 
ing the epitheliomatous ulcer are infiltrated 
and hard, in syphilis the diseased surface is 
usually bounded by apparently healthy skin. 
The pain which is frequently present in 
epithelioma is not usually present in syphilis, 
and when it is present it yields to palliatives. 
It may be difficult to distinguish between 
a simple wart and an epithelioma which 
begins in a warty growth. If a tumour of 
this kind develops in an elderly person, shows 
a tendency to spread, and is the seat of fre- 
quent desquamation with excessive formation 
of epidermis, the probability is in favour of 
epithelioma. 
It is sometimes not easy to distinguish epi- 
thelioma on clinical grounds alone from rodent 
ulcer, which is a form of superficial cancer 
depending on a specific epithelial cell. A 
typical epidermic epithelioma and a typical 
rodent ulcer can be distinguished; but there 
are cases in which, without microscopical 
examination, the diagnosis for a time is im- 
possible. Rodent ulcer produces less inflam- 
mation in the surrounding tissues, and usu- 
ally after ulceration occurs; it takes place at 
first slowly and superficially. If the glands 
become affected we may feel confident that 
we are dealing with an epithelioma. Either 
of these forms may occur on any part of the 
body,but in the majority of cases epithelioma 
occurs on the lip, whilst rodent ulcer is found 
on the upper part of the face. The rolled- 
over edge, which is frequent but not constant 
in rodent ulcer, is very characteristic. See 
Rodent Ulcer. 
Prognosis.-The prognosis in epithelioma 
of the skin is not so grave as that in other 
forms of cancer, because its course is slow, 
and because it is frequently well within reach 
of radical treatment. If removed sufficiently EPITHELIOMA 
EPITHELIUM, DISEASES OF 
621 
early and completely it will not return at all. 
Metastasis is rare. The gravity in any spe- 
cial case depends upon whether the ulcera- 
tion remains localised on the surface or pene- 
trates deeply. In the deep-seated form the 
danger to life is considerable. The disease 
may last a long time before the health be- 
comes seriously affected. Unless, however, 
relieved by successful treatment, the patient's 
strength eventually fails, the characteristic 
pain of cancer increases, and death usually 
takes place from exhaustion; sometimes from 
haemorrhage caused by blood-vessels being 
exposed in the progress of the disease. 
Treatment.-No medicines administered 
internally have any effect on this disease; 
but so long as the new-growth remains single 
and is within the reach of surgical treatment, 
we may hope for a successful result. As 
soon as the nature of the growth is ascer- 
tained, the whole of the diseased tissue should 
be removed, where this is possible, either by 
the knife or with caustics. The surgeon will 
naturally, when it is possible, have recourse 
to a cutting operation; and where the ulcer 
has attained a certain size and there is con- 
siderable infiltration present, complete ex- 
cision of the whole of the diseased tissue is 
a very effectual method of dealing with the 
disease. In the early stages of the affection 
there is no doubt that it is within the reach 
of caustics. An epithelioma in a limited 
warty condition may, when the affected sur- 
face is small, be successfully treated in this 
way after scraping with a curette. In severe 
cases, too advanced to be reached by the 
knife, the progress of the disease may some- 
times, to a certain extent, be arrested by cau- 
terisation, under which the condition of the 
ulcerated surface improves, pain is dimi- 
nished, the discomforts of the patient's con- 
dition lessened, and life prolonged. If the 
knife is used, it is necessary to cut well be- 
yond the affected tissue, as there is little 
doubt that relapses, when they do occur, are 
due to the fact that a nidus of infected cells 
has been left behind, although they had not 
developed sufficiently to enable the surgeon 
to recognise the extent to which the disease 
had spread. We have found by microscopi- 
cal examination of excised epitheliomata, that 
sections from the part next the line of in- 
cision have contained cancerous epithelium 
between the connective-tissue bundles. 
The caustics generally used are caustic 
potash, chloride of zinc, pyrogallic acid, and 
arsenic. Caustic potash may be used either 
in stick or in solution. It has the advantage 
of being thorough in its action, and of not 
leaving much pain after it has been used. 
The growth, of course, should be thoroughly 
cauterised. Pyrogallic acid is used as a 10 
per cent, ointment, which is spread on linen 
and kept continuously applied for from three 
to six days. It is less painful than chloride of 
zinc. Chloride of zinc is used as a paste in 
the proportion of one part to three parts of 
gum mixed with a little water. The paste 
is laid over the diseased surface, which must 
be blistered if the skin is entire, the surround- 
ing healthy skin being protected by adhesive 
plaster. A strip of plaster cover should be 
placed over the whole. The paste will de- 
stroy structures equal to three or four times 
its own thickness. The zinc paste which is 
used at the Middlesex Hospital is composed 
of equal parts of chloride of zinc and liquor 
opii, with sufficient flour to make it into a 
paste. Resorcin has been recently recom- 
mended for epitheliomata. There are cases 
in which it answers well; in other cases its 
action does not seem sufficiently energetic. 
The writer has used it as incorporated in 
Beiersdorf's (Hamburg) gutta-percha plas- 
ters, aiding its action by painting the surface 
with a solution in alcohol. The treatment 
is comparatively painless, and interferes 
little with the comfort of the patient. Lactic 
acid has also been recommended for epithe- 
lioma. It is supposed to have a destructive 
effect on the diseased tissue, whilst it spares 
the healthy structures; but the alleged ad- 
vantages have not yet been sufficiently con- 
firmed. 
Amongst the various caustic pastes which 
have been used in epithelioma arsenical 
paste, as regards efficiency, occupies a high 
place, although, on account of the danger 
attending absorption, it requires special care. 
The writer cannot speak from his own ex- 
perience ; but he has the testimony to the 
merits of the paste recommended by Dr. 
Marsden of his friend Dr. MacLaurin of 
Sydney, who has used it extensively in hos- 
pital and private practice, and is satisfied 
that for a considerable number of cases it 
possesses very great advantages. 
G. Thin. 
EPITHELIUM, Diseases of.- The 
different kinds of epithelium must be sepa- 
rately considered, as they differ in their 
pathological relations - namely, squamous 
and cylindrical epithelium of mucous sur- 
faces; serous epithelium, or endothelium', and 
finally spheroidal or glandular epithelium. 
The last kind will be better treated of under 
the heads of the several glands. 
A. Diseases of Squamous and Cylindrical 
Epithelium. - 1. Catarrhal Inflamma- 
tion.-Both varieties of epithelium occurring 
on mucous surfaces are subject to inflamma- 
tion, which usually takes what is called the 
catarrhal form. 
Catarrhal inflammation is characterised by 
hypersemia, swelling of the tissue, rapid pro- 
duction and casting-off of cells, and increased 
production of the normal mucous secretion 
of the parts, without the production of any 
coagulable exudation, or any layer of new 
material. The cells thrown off are partly 
epithelial, partly leucocytes or pus-cells. The 622 
EPITHELIUM, DISEASES OF 
secretion contains mucin. The proportion of 
the various factors of catarrhal inflammation 
varies greatly, sometimes hyperaemia with 
swelling, sometimes cell-production, some- 
times fluid secretion predominating; and these 
differences sometimes mark different degrees 
or stages of the inflammatory process. When 
the number of leucocytes thrown off is very 
large, the catarrh becomes purulent, which 
differs only from the other in degree. Catar- 
rhal inflammation is the ordinary result of 
irritation applied to a mucous surface ; but it 
persists after the irritation has ceased, and 
has a marked tendency to become chronic. 
While the chief share in producing and main- 
taining the phenomena of catarrh must be 
referred to the condition of the blood-vessels 
which keeps up the congestion, and allows 
increased transudation and copious emigra- 
tion of leucocytes, the part played by the 
epithelial cells in these processes is a point 
of great interest and importance, though 
as yet imperfectly determined. These cells, 
whether squamous or cylindrical, enlarge and 
alter in shape, sometimes containing vacuoles 
or mucous drops ; while there must be (since 
so many are shed) a rapid new formation of 
them; but the seat of this new formation, 
whether in the normal or the pathological con- 
dition, is still obscure. All that can be clearly 
seen is that new epithelial cells grow up from 
the basement membrane by the side of the 
old ones. Further, it is not unusual to find 
swollen epithelial cells which show division 
of the nuclei or partial division of the cell 
itself, and others which show within their 
substance several smaller, roundish bodies, 
with the general character of young cells. 
These appearances have been regarded as in- 
dicating (1) multiplication of cells by fission, 
(2) endogenous cell-formation within the 
mother-cells, and (3) the origin of the nume- 
rous pus-corpuscles seen on the inflamed sur- 
face. There is, however, no reason for think- 
ing that new epithelial cells, or still less that 
pus-corpuscles, are formed in this way. The 
presence of pus-corpuscles or young cells 
within the epithelia] cells is probably an acci- 
dental complication, the young cells which 
possess the power of migration being absorbed 
into the protoplasm of the epithelial cells, 
so as to appear as if originally formed there. 
The production of vacuoles or mucous drop- 
lets in the epithelia appears to show an 
abnormally rapid production of mucus, and 
indicates also the death of the cell producing 
it. It is, therefore, an evidence of excessive 
mucous formation,'and explains also the rapid 
desquamation of the mucous epithelium. 
2. Croupous Inflammation. - Crou- 
pous inflammation is distinguished by show- 
ing, in addition to hyperaemia and swelling, 
the production of a layer of new material, or 
false membrane, easily detached from the 
surface. This form is usually, if not exclu- 
sively, seen on surfaces covered with cylindri- 
cal epithelium, as in the air-passages. The 
false membrane, composed of fibrin cement- 
ing together layers of detached epithelium 
and leucocytes, does not owe its origin to any 
alteration of the epithelium itself. 
Croupous inflammation of epithelial sur- 
faces has been regarded as always indicating 
some specific form of inflammation. It now 
appears, however, that it may be produced by 
simple irritation, such as that which produces 
the catarrhal form, provided the irritation be 
sufficiently intense and destroys the super- 
ficial epithelium. 
3. Diphtheritic Inflammation.-This 
is a name used with much variation of mean- 
ing, but generally to signify a process in 
which there is production of a false mem- 
brane closely adherent to the epithelial sur- 
face, and which is accompanied by some de- 
gree of necrosis or gangrene. In the produc- 
tion of the diphtheritic false membrane an 
important part has been assigned to the epi- 
thelium, it being held that the new material, 
which appears like exuded fibrin, is really 
produced by a metamorphosis (the so-called 
fibrinous transformation) of the pavement 
epithelium. It is pretty clear that when this 
condition occurs on surfaces covered with 
this variety of epithelium some such change 
in the epithelium does take place, but not that 
the membrane is made up wholly or even in 
any large degree of such altered cells. More- 
over, even this cannot be clearly traced on 
surfaces covered with cylindrical epithelium. 
The membranes consist in large measure of 
cast-off epithelium, and also(as the writer holds) 
partly of fibrin, though the presence of the 
latter constituent is denied by some authors. 
It should be noted that the terms croupous 
and diphtheritic inflammation, as here used, 
are not synonymous with the diseases named 
croup and diphtheria. Micro-organisms, either 
micrococci or bacilli, especially the former, 
are always found in the diphtheritic false 
membrane. Some may be regarded as mere 
saprophytes, living in the dead tissues; but 
there is apparently at least one species, pos- 
sibly more than one, capable of originating 
the morbid process, and causing necrosis of 
the epithelium. See Diphtheria. 
4. Fatty Degeneration. - It is very 
common to find the protoplasm of both squa- 
mous and cylindrical epithelial cells dotted 
with oil-globules, so much so that this must 
be considered normal, to a certain extent, in 
some glandular epithelium (as kidney), and 
does not appear to interfere with the function 
of the cells. When the fatty change, how- 
ever, is extensive, and more especially when 
the whole body of the cell is opaque, the con- 
dition must be regarded as one of fatty de- 
generation {see Fatty Degeneration). Thisis 
seen in the stomach in cases of alcoholism, in 
poisoning with metals or phosphorus, and in 
cases which are probably nothing more than 
chronic catarrh. It is also seen in the alve- EPITHELIUM, DISEASES OF 
ERGOTISM 
623 
olar epithelium in pulmonary emphysema. 
Fatty degeneration in epithelium appears to 
be a process leading to atrophy or destruc- 
tion. 
5. Mucous or Colloid Degeneration. 
Epithelial cells, especially in parts which are 
naturally adapted to the production of mucus, 
particularly cylindrical epithelium, are liable 
to undergo a form of degeneration in which 
a portion of their protoplasm becomes con- 
verted into mucous substance, and thus lique- 
fied. Cells having this character are often 
seen in catarrhal conditions of the mucous 
membrane of the air-passages, but the change 
is probably only an exaggeration of the phy- 
siological production of mucus in the interior 
of the cell. It has not been traced in squa- 
mous epithelium. 
6. Albuminoid (Waxy or Amyloid) 
Degeneration.-This form comparatively 
rarely affects epithelial cells, but still in cases 
of albuminoid disease we may sometimes find 
that the mucous surface of the intestines is 
stained with iodine in the characteristic man- 
ner. In one or two cases the writer has ob- 
served a similar change in the surface of the 
pelvis of the kidney, and even the bladder, 
where there has been albuminoid disease of 
the kidney. 
B. Diseases of Endothelium.-The single 
layer of flat epithelium found on serous sur- 
faces, now generally known as endothelium, 
differs also in its pathological relations. 
1. Catarrhal Inflammation.-This is 
unknown on serous membranes, their charac- 
teristic form of inflammation being exudative 
and fibrinous, corresponding thus to the 
2. Croupous Inflammation of mucous 
surfaces. In this inflammation the endo- 
thelium does not necessarily take any part; 
though when the inflammation is once estab- 
lished, the endothelium, in part, is simply 
shed, in part shows changes of a proliferative 
kind ; cell-division, multiplication, and endo- 
genous cell-formation being observed here 
with less ambiguity (as it appears to the writer) 
than in the epithelium of mucous surfaces. 
Similar changes appear to occur in chronic 
inflammation of serous surfaces, and to play 
an important part in the production of fibrous 
adhesions between opposing surfaces. 
3. Fatty Degeneration. - Endothelial 
cells are also subject to fatty degeneration, 
which may be very clearly seen in surfaces 
macerated by a collection of fluid, as in serous 
effusions of the peritoneum or pleura. 
The other pathological changes of endothe- 
lium have not been studied. 
The epithelium (or endothelium) lining the 
inner surfaces of the walls of arteries and 
veins closely resembles the endothelium of 
serous surfaces. It is very subject to fatty 
degeneration, as may be seen on examining 
atheromatous arteries. A distinct fatty de- 
generation of this tissue also occurs quite 
independently of atheroma, or of any in- 
flammatory process. Proliferative changes 
have also been traced by some observers in 
the process of occlusion of ligatured arteries 
or veins obstructed by thrombosis ; but they 
do not appear to play any important part 
in idiopathic disease. 
C. Diseases of Glandular Epithelium.- 
The diseases of glandular epithelium are best 
spoken of under the head of diseases of the 
several glands. See Breast, Diseases of; 
Salivary Glands, Diseases of; &c. 
J. F. Payne. 
EPITHEM (tin, upon; and Tidrjpi, I place). 
A general term for a class of external appli- 
cations which are soft and moist, such as 
poultices and fomentations. See Fomenta- 
tions ; and Poultice. 
EPIZOA.-See Entozoa. 
EPULIS (em, upon; and ovXov, the gum). 
See Mouth, Diseases of. 
EQUIETA (equus, ahorse).-A synonym 
for glanders. See Glanders. 
ERETHISM (epedifa, I irritate).-A 
condition of excitement or irritation, affecting 
either the whole system or a particular organ 
or tissue. The word has been especially 
applied to the condition of the body in the 
early stage of acute diseases, and also to 
that induced by the too free use of mer- 
cury (mercurial erethism). See Mercury, 
Poisoning by. 
ERGOTISM.-Synon.: Morbus cerealis', 
Fr. Ergotisme', Ger. Ergotismus; Kriebel- 
krankheit. 
Definition.-A disease due to the action 
of ergot. 
^Etiology.-This disease derives its name 
from the fact that it is the result of the in- 
gestion of ergot-the sclerotium of a fungus 
called Claviceps purpurea, which grows 
parasitically in the ear of the rye. In some 
seasons this form of blight affects the grain 
so extensively that ten per cent, of the meal 
may consist of ergot. The phenomena to be 
described as symptoms of ergotism have been 
regularly and exclusively traced to the use 
of articles of food made from rye-meal thus 
contaminated. The appearance and severity 
of the disease vary with the amount of ergot 
consumed. Children at the breast are never 
attacked. Ergotism has frequently broken 
out in well-marked epidemics, after unfavour- 
able harvests. In ruder times it constituted 
a severe form of scourge; but now it usually 
occurs sporadically, or is limited to families 
or small communities. 
Anatomical Characters. - Ergotism is 
characterised by definite anatomical changes, 
mainly in connexion with the vessels and 
the spinal cord. The arterioles are found 
post mortem to be contracted, and to be the 
seat of a peculiar hyaline degeneration of the 624 
ERGOTISM 
EROSION 
intima, with thrombosis and diminution, or 
even complete disappearance or occlusion, of 
their lumen. Gangrene is the ultimate result 
of these morbid changes. The posterior 
columns of the spinal cord are the seat of a 
degenerative or sclerosing process, somewhat 
resembling the lesion so familiar to us in 
locomotor ataxy. 
Symptoms.-Within a few days of the first 
ingestion of rye-meal contaminated with 
ergot, the ordinary phenomena of irritant 
poisoning are developed, namely, vomiting, 
diarrhoea, severe abdominal pains and cramps, 
and general depression-giddiness and head- 
ache being specially marked. 
Along with the preceding, certain specific 
symptoms gradually make their appearance. 
The first and most characteristic of these is 
formication (a sensation of insects running 
along the skin), attended with severe itching 
of the extremities. The other special senses, 
such as vision and hearing, may also become 
disordered. Occasional tearing pains occur 
in the limbs, and clonic spasms of the mus- 
cles. Ravenous hunger is said to be a striking 
symptom in some instances. The pulse is 
infrequent and small. Respiration is not 
markedly disturbed. 
The remaining phenomena peculiar to 
ergotism are usually described as belonging 
to two forms, the gangrenous and the spas- 
modic, according as the circulation or the 
nervous system is chiefly affected. 
(a) Gangrenous ergotism.-The gangrene 
produced by ergot is peculiar only in respect 
of its cause. The toes, fingers, feet, ears, and 
nose are the parts most commonly attacked. 
The incipient discoloration, pain, and swell- 
ing are observed within a period of two days 
to three weeks from the commencement of 
the other toxic symptoms. The necrotic 
process passes through the ordinary stages 
of development; may be either 4 wet ' or 
4 dry; ' and advances to complete separation 
of the part, if this have not been previously 
removed by operation. 
(b) Spasmodic ergotism. - The leading 
symptom of this form of the disease is the 
occurrence of severe intermittent cramps or 
painful spasms, specially affecting the lower 
extremities. These develop into tonic con- 
traction of the muscles, with fixation of the 
limbs; and end perhaps in general convul- 
sions, prostration, various kinds of mental 
derangement, unconsciousness, and death. 
Abortion does not appear to be of frequent 
occurrence. 
Course, Duration, and Terminations.- 
Many cases of ergotism are acute rather than 
chronic; but when gangrene appears, the 
course may be very protracted and variable. 
Spasmodic ergotism may last from two weeks 
to as many months. The mortality is said 
to have fallen from sixty to ten per cent. In 
a few cases, resolution occurs in affected 
extremities. 
Pathology.-Beyond its effect as an irri- 
tant poison, the specific influence of ergot is 
mainly exerted upon the organs of circulation, 
the central nervous system, and the uterus. 
The different effects have now been satisfac- 
torily traced to the actions of the different 
organic constituents of the diseased grain. 
Cornutine, an alkaloid, one of the four 
important organic constituents of ergot, pro- 
duces slowing of the cardiac rhythm by 
stimulation of the vagus at its central ex- 
tremity. The contraction and hyaline change 
of the walls of the arteries are due to the 
action of a second constituent, sphacelinic 
acid. The result of these effects on the 
heart and arteries is that the blood-pressure 
rises. The gangrene is readily accounted 
for by the vascular changes, and is thus defi- 
nitely referable to the sphacelinic acid. 
The painful spasms, as well as the formi- 
cation and other sensory disturbances, are 
the direct result of the action of the cornutine 
upon the spinal cord. 
The action of ergot upon the uterus is ex- 
plained by some authorities as due to stimu- 
lation by cornutine of the uterine centre in 
the cord. Other authorities maintain that it 
is set up by the local anaemia produced by 
the vascular contraction; whilst others, again, 
consider that ergot acts directly upon the 
muscular fibres of the organ. 
Diagnosis.-The occurrence of gangrene 
in a number of young and previously healthy 
persons, in countries where rye-meal is an 
article of food, should remove all difficulty 
from the diagnosis of ergotism. The spas- 
modic form of the disease can usually be 
distinguished from epidemic cerebro-spinal 
fever by the absence of pyrexia. 
Prognosis.-The prognosis depends chiefly 
upon the early recognition and removal of 
the cause. The probability of the escape of 
affected extremities may be estimated by the 
degree to which the gangrenous process has 
advanced. 
Treatment.-The treatment of ergotism 
must commence with the removal of the 
cause. An attempt must then be made to 
hasten the elimination of the poison by the 
cautious administration of emetics and pur- 
gatives ; to allay the symptoms of gastro- 
enteritis ; and to support the strength of the 
patient by internal and external stimulants, 
such as alcohol, warmth, and friction. The 
treatment of less acute ergotism, including 
spasmodic cases, is symptomatic. Gangrene 
must be averted by careful local stimulation 
-by means, for example, of warm fomenta- 
tions ; or treated surgically if it make its 
appearance. See Gangrene. 
J. Mitchell Bruce. 
EROSION (erodo, I gnaw).-A super- 
ficial destruction of tissue, caused especially 
by friction, pressure, corrosion, or certain 
forms of ulceration. EROTOMANIA 
ERYSIPELAS 
625 
EROTOMANIA (epaw, love ; and pavla, 
madness).-Synon.: Love-melancholy; Satyr- 
iasis (in men); Nymphomania (in women); 
Fr. Monomanie erotique; Ger. Liebeswuth.- 
Insanity characterised by excessive sexual 
excitement; sometimes symptomatic of cere- 
bral lesion, sometimes of disorder in the re- 
productive organs. See Insanity. 
ERRATIC (erro, I wander).-Wandering, 
shifting, or irregular. Applied to pains, 
eruptions on the skin, and other morbid 
phenomena, when they shift or move from 
place to place. 
ERUCTATION (eructo, I belch).- 
Definition.-The sudden escape or expul- 
sion of gas from the stomach upwards, with 
or without an admixture of portions of liquid 
or solid food, or of gastric juice or other liquids. 
Description.-The act of eructation may 
be voluntary or involuntary. In the former 
case a small portion of air is first swallowed, 
and by the over-distension thus produced the 
escape of a portion of the gaseous contents of 
the stomach is favoured. When involuntary, 
we must suppose that the cardiac orifice, 
which is closed in the normal state of diges- 
tion, is relaxed, and thus permits the rejection 
of portions of undigested matter. From the 
violence with which eructations often take 
place, we may also assume that the muscular 
coat of the stomach contracts spasmodically 
at the same moment that the relaxation of 
the cardiac opening occurs. The nature of 
the material rejected varies greatly. Some- 
times it is tasteless, at other times acid, and 
in rarer instances alkaline. 
Etiology.-Eructations occur in all gastric 
diseases attended with an undue formation of 
gas. They are constantly complained of in 
atonic dyspepsia, more especially in that form 
which occurs in elderly people, and are pro- 
bably the result of an imperfect contraction of 
the stomach, preventing the due expulsion of 
the digested food into the intestine. They form 
a prominent and distressing symptom in dila- 
tation of the stomach. In such cases the 
patient often complains of a sense of fermen- 
tation in his abdomen, and immense quanti- 
ties of gas are expelled, generally mixed with 
an acid or acrid fluid. 
Treatment.-The indications in the treat- 
ment of eructations are to prevent the decom- 
position of food, and the formation of gases 
and other products; to restore tone to the 
stomach, and remove any morbid condition 
of this organ; and to give remedies with the 
view of absorbing gases, or assisting the act of 
eructation.1 See Stomach, Diseases of. 
Samuel Fenwick. 
ERUPTION (eruptio, a bursting forth).- 
This term is commonly applied to a patholo- 
gical manifestation in the skin, more or less 
general; sometimes marked by colour, some- 
times by prominence, but more frequently by 
both. When sudden and hyperaemic, a term 
derived from the efflorescence of a plant, 
namely, exanthema, is employed, as in the 
instance of the exanthematous eruptions- 
scarlatina, rubeola, roseola, and variola. The 
term is equally applicable to less acute forms 
of dermatosis, such as urticaria, eczema, im- 
petigo, ecthyma, acne, and furunculus; and 
is also used for still more chronic forms of 
disease, for example, psoriasis vulgaris ; and 
for outgrowths of the skin due to aberration 
of nutrition, as in the instance of warts and 
molluscous tumours. Erasmus Wilson. 
ERYSIPELAS (fpvflpos, red; andTreXXa, 
skin).-Synon.:-Lat. Erysipelas', Fr. Ery- 
sipele; Ger. Erysipelas. Popular names:- 
St. Anthony's Fire (English); the Rose 
(Scotch); der Rothlaibf, and die Ease (Ger.) 
Definition.-Inflammation of the integu- 
ment tending to spread indefinitely (Royal 
College of Physicians' Nomenclature of 
Diseases'). The vagueness of this definition 
indicates the looseness with which the term 
is employed. The features common to all 
inflammations usually spoken of as erysipela- 
tous are fever, sometimes apparently preced- 
ing the local phenomena; and an inflamma- 
tion tending to spread indefinitely by means 
of the lymph-spaces and lymphatic vessels of 
the affected part. 
Summary of Varieties.- Erysipelas is 
usually divided into: (a) simple cu taneous; 
(6) phlegmonous or cellulo-cutaneous; and 
(c) cellular or diffuse cellulitis (Nunneley). 
In the first of these the inflammation is seated 
in the cutis vera, the subcutaneous tissue being 
often cedematous, but not actually implicated 
in the morbid process. There is practically no 
tendency to suppuration in simple cutaneous 
erysipelas. In phlegmonous or cellulo- 
cutaneous erysipelas the subcutaneous areo- 
lar tissue is primarily affected, but the skin 
covering the inflamed area is speedily im- 
plicated. If not relieved by treatment, the 
inflammation tends inevitably to diffuse 
suppuration, often accompanied by extensive 
sloughing of the cutaneous and subcutaneous 
tissues. In cellular erysipelas or diffuse cellu- 
litis, deep-seated planes of areolar tissue are 
affected, such as those of the pelvis. The 
course of the disease is the same as in cellulo- 
cutaneous erysipelas, tending to terminate in 
diffuse suppuration and sloughing. In addi- 
tion to these three chief varieties, erysipela- 
tous inflammation of the lymphatic vessels 
and veins, and of serous and mucous mem- 
branes, is also described. 
.Etiology and Pathology. - All these 
affections grouped together as erysipelatous 
belong to the class of infective inflammations; 
1 Hepatic disorder frequently requires attention, 
with, remedies directed to the liver. Lavage may 
be called for in the severe type of eructation which 
attends dilatation.-Ed. 626 
ERYSIPELAS 
that is to say, they are dependent upon a 
virus which increases in quantity in the 
affected area, thus causing the characteristic 
spreading of the inflammation. The virus is 
present in the fluids of the inflamed area, and 
the disease can be communicated from one 
individual to another by inoculation of the 
inflammatory products; and in the case of 
cutaneous erysipelas, at least, there seems 
reason to believe that the poison may also be 
carried by the air. In all erysipelatous in- 
flammations the virus diffuses itself by the 
lymph-spaces and lymphatic vessels of the 
affected part, showing little or no tendency 
to invade the blood-vessels, and to be dis- 
seminated by the blood-stream to distant 
parts. It is probable that there is more than 
one virus which may thus give rise to a 
spreading lymphatic inflammation; but in the 
vast majority of cases clinically described as 
erysipelas, which have been submitted to ex- 
amination, a micro-organism of a definite 
form has been found, which is believed to be 
the actual virus. In 1869 Hueter suggested 
that the virus of erysipelas was probably a 
micro-organism, and thought that he had 
found it in the discharges of the inflamed 
part. In 1880 Lukomsky, Tillmanns, and 
others discovered the presence of micrococci 
in the lymph-spaces of the skin at the ad- 
vancing edge of the rash in cutaneous ery- 
sipelas ; but in 1882 the relation of these 
organisms to the disease was clearly demon- 
strated by Fehleisen. A small piece of the 
skin from the advancing edge of the rash was 
removed with proper precautions to avoid 
contamination, and planted upon some nu- 
trient gelatine. From this a film soon spread 
over the gelatine, which on microscopic exa- 
mination proved to be a pure cultivation of 
a micrococcus. The organism belongs to the 
genus streptococcus-that is to say, it shows 
a tendency to grow in chains or pairs. It 
does not liquefy the gelatine in its growth. 
This organism, after cultivation for several 
generations upon gelatine, gave rise to typical 
erysipelas when inoculated on the ear of a 
rahbit. Subsequently inoculations were 
made on the human subject with the inten- 
tion of setting up erysipelas for the relief of 
lupus or incurable cancer. Seven cases were 
thus treated and genuine cutaneous erysipelas 
followed the inoculation in six ; the seventh 
patient had recovered from an attack of ery- 
sipelas a few months before. Other observa- 
tions seemed to show that one attack of ery- 
sipelas confers upon the patient a short period 
of i mmunity to the disease. 
In all forms of cellulo-cutaneous erysipelas 
and in diffuse cellulitis a streptococcus exactly 
resembling that described by Fehleisen is 
found in the fluid filling the lymph-spaces of 
the affected part, whether it be purulent or 
serous. It cannot be distinguished from that 
found in cutaneous erysipelas by its reaction 
to aniline dyes, by its mode of growth, or 
microscopic appearances. To this micro- 
coccus Rosenbach gave the name of strepto- 
coccus pyogenes. Cultivations of this or- 
ganism cause acute suppuration when in- 
oculated on animals; but it has lately been 
asserted that when inoculated superficially 
on the ear of a rabbit typical cutaneous ery- 
sipelas is set up. It has been stated that cul- 
tivations of the streptococcus erysipelatosus 
from the human subject injected into the sub- 
cutaneous tissue of the rabbit have given rise 
to deep-seated phlegmonous inflammation and 
suppuration. This is, however, denied by 
Fehleisen, who asserts that he has repeatedly 
injected erysipelas micrococci into the sub- 
cutaneous tissue and muscles of rabbits with- 
out causing inflammation or suppuration. 
The identity of the organisms must, there- 
fore, be considered an open question at the 
present time. Clinically the simple cutaneous 
variety of erysipelas differs so widely from 
the subcutaneous forms that it is difficult to 
believe they are due to the same virus. In 
cutaneous erysipelas the streptococci are 
found in the lymph-spaces of the cutis at the 
advancing margin of the rash. Their pre- 
sence excites the ordinary phenomena of in- 
flammation-the blood-vessels are injected, 
and abundant migration of colourless corpus- 
cles takes place. These seem to destroy the 
micro-organisms, which are not to be found 
in the more central parts of the rash. The 
persistence of the phenomena of inflammation 
in the parts in which no streptococci can be 
demonstrated must be supposed to be due to 
the damage done to the tissues by the chemical 
products formed during the growth of the 
organisms. The organisms never enter the 
blood-vessels locally, and though very pro- 
bably some may find their way into the 
blood-stream by the lymphatics, there is no 
reason to believe that they multiply in the 
blood. The constitutional symptoms are 
therefore due to the entrance of the chemical 
products of the local process into the blood- 
stream, and not to any general infective 
process. In phlegmonous erysipelas and in 
cellulitis the streptococci can be easily de- 
monstrated in the inflammatory exudation 
filling the lymph-spaces in the whole affected 
area, and not only at the advancing margin; 
but, as in the cutaneous form, the organisms 
have not been proved to infect the blood. 
Further evidence of the absence of blood 
infection is furnished by Fehleisen's experi- 
ment on the rabbit's ear. Having induced 
typical cutaneous erysipelas by the inocula- 
tion of a pure cultivation of the streptococcus, 
he amputated the ear with a Paquelin's cau- 
tery, with the effect of immediately relieving 
the elevation of temperature and all other 
constitutional symptoms. It is not proved, 
however, that the virus may not enter the 
circulation from the alimentary canal or the 
air-passages, and be carried by the blood, 
without actually infecting it, to some part ERYSIPELAS 
627 
which, from local injury or other cause, may 
form a suitable point for its development. 
On the assumption that the streptococcus is 
the actual virus, this seems the only possible 
explanation of many cases of erysipelas, es- 
pecially of the cellulo-cutaneous or cutaneous 
variety, in which no evidence of direct inocula- 
tion by a wound or otherwise can be obtained. 
The streptococcus grows readily at ordinary 
temperatures on gelatine, agar-agar, and po- 
tatoes, and probably on almost any damp 
organic matter. It has been said to have been 
found on the floor of an affected ward. This 
explains the well-known fact that hospital 
wards are apt to become infected, case after 
case breaking out until the ward is closed 
and disinfected. In military practice, ery- 
sipelas is very rare except in cases treated in 
civil hospitals. In this respect it differs from 
hospital gangrene and pyaemia, which can 
always be generated by crowding the wounded 
in buildings of any kind. It seems probable 
therefore that the virus is really specific, like 
that of scarlet fever or smallpox. That it 
can be carried by the air seems also to be 
proved, as the streptococcus has been detected 
on potato cultivations made from the air of in- 
fected wards. The cultivations thus obtained 
gave rise to erysipelas when inoculated on a 
rabbit. There is little doubt, however, that 
it is more commonly conveyed by the hands 
or clothes of the attendants. Erysipelas cer- 
tainly does not show the same degree of in- 
fectiousness as most of the acute specific dis- 
eases. 
The micro-organism is killed in 45 seconds 
by a 1 in 30 solution of carbolic acid, and in 
15 seconds by a 1 in 1,000 solution of per- 
chloride of mercury. 
All the evidence above given tends there- 
fore to show that erysipelas is a local disease, 
dependent on the invasion of the tissues by 
a specific micro-organism, and that the con- 
stitutional disturbance is secondary to the 
local. The opposite view has been held by 
many authorities, who have classed erysipelas 
with the acute specific fevers, regarding the 
rash as the local manifestation of a general 
condition. The arguments in favour of the 
latter are briefly as follows : (a) In many 
cases there is a distinct period of invasion in 
which the constitutional symptoms are pre- 
sent without the local; (6) there is frequently 
no evident point of inoculation ; (c) the con- 
stitutional symptoms in cutaneous erysipelas 
are often much more severe than the local 
inflammation seems sufficient to account for. 
Against these it is urged by those who sup- 
port the local theory: (a) that even during the 
apparent period of invasion without local 
phenomena, a careful examination will detect 
some swelling of the lymphatic glands or 
other evidence of local mischief; (&) that the 
minutest abrasion merely being necessary 
for inoculation, it is very easily overlooked; 
and (c) that when we consider the intensely 
poisonous nature of the products of the growth 
of micro-organisms in albuminous fluids, 
the constitutional symptoms are not greater 
than might be expected. The results of the 
inoculations, and Fehleisen's experiment of 
amputation of the rabbit's ear above men- 
tioned, and the fact that inoculation of the 
blood has never communicated the disease, 
nor have organisms been satisfactorily de- 
monstrated in it, are further proofs of the local 
nature of the disease. Moreover the disease 
does not run a definite course like an acute 
specific fever. The fever continues as long 
as the rash is extending, and ceases as soon 
as that comes to an end. It must be remem- 
bered, however, that it is not proved that the 
blood may not serve as a carrier of the virus, 
though not as a medium for its growth, as in 
many other infective diseases-tubercle, for 
example. Granting therefore that erysipelas 
is an infective disease, and that the micro- 
organism above described is the actual virus, 
the predisposing causes may be divided into 
(1) those favouring the growth and dissemi- 
nation of the organism out of the body; and 
(2) those predisposing the patient to receive it. 
1. (a) Accumulations of decaying animal 
or vegetable matter, upon which the organ- 
ism can develop, will predispose to the dis- 
ease. Thus the presence of a dust-heap near 
a window of a ward, has been known to cause 
repeated outbreaks of erysipelas in the nearest 
bed. Dampness of the floors, from repeated 
washing, has also been said to predispose to 
erysipelas. Decomposing discharges from 
wounds, and want of cleanliness in dressings, 
are also important causes. (6) Certain me- 
teorological conditions are said to predispose 
to erysipelas. East winds, low temperature, 
excessive moisture, cold and heat, have all 
been considered causes, but the evidence on 
these points is very unsatisfactory. It is cer- 
tainly least common in the hottest and driest 
part of the year, and more common in spring 
and late autumn, (c) Bad ventilation leads 
to concentration of the virus and increases 
the chances of infection, (d) The virus can 
undoubtedly be carried by the medicAl and 
other attendants, but risk of this happening 
is greatly diminished by the proper use of 
antiseptics. 
2. (a) A constitutional predisposition to 
erysipelas is occasionally met with, which is 
sometimes hereditary. The patient usually 
suffers from repeated attacks of the disease. 
One attack of erysipelas is therefore said to 
predispose the patient to another. (6) Ex- 
posure to the impure atmosphere of badly 
ventilated or overcrowded wards increases 
the liability to erysipelas. (c) Imperfect 
hygienic conditions generally, such as bad or 
insufficient food, impure water, &c., predispose 
the patient to the disease, (d) Diseases of 
the liver or kidneys make a patient especially 
liable to it. (e) The abuse of alcohol is one 
of the most important of all predisposing 628 
ERYSIPELAS 
causes. The great majority of the cases of 
fatal phlegmonous erysipelas occur in hard 
drinkers. (/) Age has no influence, (y) The 
disease is said to be more common in women, 
especially at the menstrual period, (h) The 
presence of a wound or abrasion to serve as 
the seat of inoculation is the only important 
local predisposing cause of erysipelas. 
Erysipelas undoubtedly occurs in epi- 
demics, and the type of the disease varies in 
different outbreaks. We know nothing of the 
causes which render the disease epidemic. 
We shall now proceed to discuss in detail 
the several varieties of erysipelas summarised 
above. 
I. Simple Cutaneous Erysipelas.- 
This is the most typical form of the disease. 
Anatomical Characters.-The post-mor- 
tem appearances of erysipelas are by no 
means characteristic. The redness of the 
inflamed area of course fades after death, 
leaving a faint yellowish tint. The skin feels 
hard and inelastic, and the subcutaneous 
tissue contains an excess of serous fluid. In 
very acute cases there may be the usual 
signs of blood-change seen in all malignant 
fevers : early post-mortem staining, imperfect 
coagulation of the blood, subserous petechi®, 
swollen and soft spleen, and cloudy swelling 
of the liver and kidneys. Hiller states that 
microscopic examination of the blood before 
death shows many of the white corpuscles 
to have undergone degenerative changes and 
become converted into masses of highly re- 
fracting granules. Busk has described plugs 
of such altered corpuscles in the small vessels 
of the lung, and Bastian has observed a 
similar condition in the vessels of the brain. 
Microscopic examination of the affected part 
of the skin shows large numbers of migrating 
leucocytes, lying in the spaces of the fibrous 
tissue, amongst the fat-cells, and in the lumen 
of the lymphatic vessels. They are especially 
abundant round the small vessels. The 
micro-organisms found in the lymph-spaces 
of the skin at the advancing margin of the 
rash have been already described. 
Symptoms.-In simple erysipelas the con- 
stitutional symptoms often appear to precede 
the local. The invasion is marked by chilli- 
ness, seldom by an actual rigor ; loss of appe- 
tite ; general malaise; nausea, but seldom 
actual vomiting; headache; pain in the 
limbs; and the usual signs of pyrexia. The 
invasion is tolerably sudden. The tempe- 
rature rapidly rises, to about 103° F., or 
higher. The rarer symptoms at this stage 
are epistaxis in adults, and convulsions in 
children. Usually within twenty-four hours 
of the. invasion the characteristic cutaneous 
inflammation becomes evident. It may, 
however, commence simultaneously with the 
febrile disturbance, or be delayed even for 
two or three days. Frequently the lymphatic 
glands nearest to the part are swollen before 
the cutaneous eruption appears; afterwards 
they are invariably enlarged and tender. The 
local inflammation usually, if not always, 
starts from some wound, scratch, or abrasion. 
It commences indifferently in a fresh wound 
or a granulating sore. When no wound can 
be recognised as its starting-point, it usually 
starts from the junction of mucous mem- 
brane and skin, most commonly from the 
corner of the eye, causing a swelling across 
the bridge of the nose. It may also start 
from the angle of the mouth, the external 
auditory meatus, or the anus. It may com- 
mence in the nasal fossae or pharynx, and 
extend outward to the skin of the face. 
Possibly in all cases it starts from some 
slight abrasion which is scarcely to be de- 
tected (Trousseau). The inflamed skin is 
bright red in colour, with sometimes a yel- 
lowish tinge; the redness advances in all 
directions, but usually most rapidly in that 
of the lymph-stream. The advancing margin 
is irregular, sharply defined, and very slightly 
raised. The cutis is oedematous, and pressure 
with the finger-nail leaves a deep and abiding 
mark. Where the subcutaneous areolar tissue 
is lax, as in the eyelids or scrotum, it also 
becomes greatly swollen. In the limbs the 
subcutaneous swelling is great only in severe 
cases. In many cases small vesicles rise, 
which may coalesce, forming blebs of con- 
siderable size. These ordinarily contain clear 
yellow serum, which, in bad cases, may be 
stained with blood-pigment. As these bull® 
burst they dry up, forming scabs on the sur- 
face, but no ulceration takes place beneath 
these scabs. The inflammation has but little 
tendency to end in suppuration; when this 
does occur it is in those parts in which the 
oedema has been greatest, as the eyelids. 
There is heat, tension, and pain in the affected 
part, and a peculiar sensation of stiffness, 
which may even precede the appearance of 
the redness. 
The febrile symptoms which usher in the 
attack remain unrelieved so long as the 
redness continues to spread. The pulse is 
at first quick and full, but it soon loses 
force, and in bad cases becomes extremely 
rapid and feeble. It is by the pulse, more 
than anything else, that the gravity of the 
case is marked. The temperature seldom 
rises above 106° F., though 107'5° F. has 
been recorded. The daily variations are not 
great, there being merely the usual slight 
morning fall and evening rise. Delirium is 
not uncommon at night, even in mild cases. 
In erysipelas of the head it may be a pro- 
minent symptom. It is usually due to the 
blood-condition, and not, as was formerly 
supposed, to extension of the inflammation 
to the membranes of the brain. This, how- 
ever, does occur in rare cases, especially in 
erysipelas of the orbit, or in that following a 
compound fracture of the skull. The tongue 
is always foul, and usually dry ; in bad cases 
becoming cracked and brown, with sordes on the lips and teeth. In erysipelas of the head 
the fauces are always red and congested, even 
when the inflammation has not actually ex- 
tended to that part. The bowels are sometimes 
confined, but diarrhoea with offensive motions 
is liable to occur. There is nothing charac- 
teristic about the urine. As in other acute 
febrile diseases, it frequently contains a small 
quantity of albumen. In erysipelas of the 
head, when the disease reaches its height, 
the appearance is often hideous in the ex- 
treme, the features being completely oblite- 
rated by the swelling of the lax subcutaneous 
tissue, and the face further disfigured by the 
scabs formed by the dried blebs. 
The duration of simple erysipelas is very 
uncertain. The cessation of the disease is 
marked by the inflammation ceasing to extend, 
and by a simultaneous fall of temperature, 
often very sudden. This may occur as early as 
the fifth day, or be delayed till the end of the 
second or middle of the third week. As the 
rash fades its margin loses its distinct out- 
line, and the redness shades off insensibly. 
It is not uncommon to see the inflammation 
spreading at one part, fading at another. 
After the subsidence of the inflammation 
there is desquamation of the cuticle, and in 
erysipelas of the head often complete loss 
of hair, which is, however, never permanent. 
Even after a mild attack the patient's strength 
is much reduced, and he often remains weak 
and anaemic for a considerable time. Re- 
lapses are by no means uncommon. When 
death occurs from simple cutaneous erysipe- 
las, it arises most frequently from exhaustion. 
It may also be due to the gravity of the 
blood-change. Occasionally the fatal ter- 
mination is preceded by violent delirium 
ending in coma. Sometimes it is due to 
complications, as pleurisy or pneumonia, or in 
very rare cases meningitis. When sloughing 
of the skin or suppuration occurs, death may 
take place from septicaemia or pyaemia. 
Varieties.-Some writers have divided 
simple erysipelas into medical and surgical 
-or idiopathic and traumatic, and have 
described these varieties as distinct diseases. 
They are, however, probably identical, for 
the following reasons : they closely resemble 
each other in mode of invasion, course, and 
pathological changes; infection from so- 
called idiopathic erysipelas will give rise to 
the traumatic form in patients suffering from 
an open wound; and during an outbreak of 
erysipelas in a surgical ward, patients with- 
out open wounds are occasionally attacked by 
the idiopathic form. Erysipelas has also been 
subdivided according to the part it attacks, as 
erysipelas faciei, capitis, scroti, &c. 
Erysipelas occasionally affects the mucous 
membrane of the pharynx and upper part of 
the larynx. This form presents some pecu- 
liarities, and is spoken of as erysipelatous 
pharyngitis and laryngitis. The invasion 
and constitutional symptoms are similar to 
ERYSIPELAS 
those of simple cutaneous erysipelas. There 
is a bright redness of the back of the pharynx 
and the fauces, always accompanied by con- 
siderable oedema of the soft palate and some 
swelling of the tonsil. The glands at the 
angle of the jaw are swollen and tender. 
The danger of this affection arises from ex- 
tension to the glottis, causing oedema glot- 
tidis, with intense dyspnoea, expiration being 
more easy than inspiration, and both liable 
to obstruction by spasm. In such cases 
tracheotomy or laryngotomy may be required 
at any moment, to prevent death from 
asphyxia. In other cases the inflammation 
may extend forwards and appear on the face, 
either at the nostril or mouth, and afterwards 
extend as ordinary facial erysipelas. 
Erysipelas occasionally attacks new-born 
infants, starting from the navel or genitals. 
This form has been spoken of as E. neona- 
torum. Serous membranes, especially the 
peritoneum, are said sometimes to be affected 
by erysipelas following wounds. In lying-in 
women the poison of erysipelas seems, in 
common with that of many other unhealthy 
inflammations, to be capable of causing puer- 
peral fever. 
Dermatologists have, according to their 
wont, invented a name for every possible 
variation. Thus when the inflammation 
spreads at one part while fading at another 
it has been called E. ambulans or erraticum ; 
when spreading in a winding course, E. 
serpens; when causing small vesicles, E. 
vesiculare or miliare; when blebs form, 
E. bullosum ; when there is much swelling, 
E. cedematosum, &c. Such names are use- 
less, and might be multiplied ad infinitum. 
Diagnosis. -When erysipelas is fully de- 
veloped it is scarcely possible to mistake 
the disease. During the stage of invasion, 
before the appearance of the rash, diagnosis 
is impossible. Simple diffuse inflammation 
around a wound or abscess is distinguished 
from erysipelas by the absence of the 
characteristic invasion, and of the sharply 
defined border. Simple erythema differs 
from erysipelas in the absence of fever, and 
in the eruption being composed of numerous 
isolated patches. Occasionally, in malignant 
smallpox, there may be much redness and 
swelling of the face before the appearance of 
the vesicles, but the symptoms of invasion are 
much more severe than those of erysipelas. 
Prognosis.-The prognosis depends chiefly 
upon the gravity of the general symptoms. 
The following are bad signs: high fever, 
violent delirium, excessive diarrhoea, early 
prostration, and very dry tongue with sordes. 
The extent of the inflammation is of less im- 
portance. Old age, disease of the kidneys or 
liver, and especially chronic alcoholism, add 
greatly to the gravity of the case. When 
erysipelas affects the pharynx there is always 
danger from oedema glottidis. In uncompli- 
cated cases the death-rate is not high. Of 
629 630 
25 patients treated in the medical wards of 
University College Hospital for facial erysipe- 
las from 1872 to 1876, only one died, and he 
was suffering from chronic Bright's disease. 
Treatment.-1. Constitutional.-Erysipe- 
las being a most exhausting and depressing 
disease, no antiphlogistic treatment is ever 
justifiable. Clear the bowels at the com- 
mencement of the attack, but avoid violent 
purgation. Only two drugs have any reputa- 
tion in the treatment of erysipelas. The 
tincture of perchloride of iron, in large and 
repeated doses, has been strongly recom- 
mended by Dr. Reynolds and others, and is 
stated by some to act as a specific. To be of 
any use it must be given in doses of forty 
minims every four hours. Aconite, if ad- 
ministered as soon as the temperature begins 
to rise, is said to cut the attack short. It 
may be given in half-minim or minim doses 
of the tincture, at first every quarter of an 
hour for one or two hours, and afterwards 
hourly, till the skin becomes moist and the 
temperature falls, hut its effects must be very 
carefully watched, to avoid dangerous de- 
pression. The diet must be as nourishing as 
possible-beef-tea, eggs and milk, &c. Solid 
food can never be taken during the advance 
of the disease. Stimulants are usually re- 
quired, and the amount must be regulated 
by the pulse. Large quantities are often 
necessary. 
2. Local.-Local treatment is very various. 
Warmth and avoidance of variations of tem- 
perature are essential. Cold is utterly inad- 
missible ; it aggravates the inflammation, 
and tends to cause suppuration or even 
sloughing. Hot fomentations or hot baths 
may be employed when the part affected 
renders them admissible. In other cases dry 
warmth must be used; it is best obtained by 
covering the affected part with a thick layer 
of cotton-wool. Poultices should be avoided, 
as they needlessly irritate the skin, and are 
dirty and apt to get cold. With the applica- 
tion of warmth innumerable varieties of local 
applications have been recommended. These 
may be divided thus : (a) Indifferent appli- 
cations. These are intended only to exclude 
the air, but they have the disadvantage of 
shutting in the secretion of the skin. The 
most common of these are collodion, oil, and 
a thick layer of flour or starch under cotton- 
wool. (6) Sedative applications. The most 
important remedy of this class is belladonna. 
It is best applied as a paint composed of 
equal parts of the extract and glycerine. It 
is especially useful when there is much 
inflammation of the lymphatic vessels and 
glands, (c) Powerful astringents. Valette. 
of Lyons, recommends a 30 per cent, solution 
of perchloride of iron ; Higginbottom a solu- 
tion of the ' brittle stick of nitrate of silver ' 
-20 grains to one drachm of water. Before 
applying either of these, the skin must be 
carefully washed with soap and water to free 
ERYSIPELAS 
it from grease. The perchloride of iron must 
be rubbed in with a glove, (d) Antiseptic 
applications. Marshall recommends crea- 
sote made into a paste with kaoline; Dewar, 
equal parts of sulphurous acid (B.P.) and 
glycerine. Tincture of iodine is a common 
application. Koch recommends an ointment 
composed of creolin 1 part, iodoform 4 parts, 
and lanolin 10 parts. Hueter practised the 
subcutaneous injection of a 1 in 30 solution 
of carbolic acid. He stated that this causes 
an immediate arrest of the inflammation for 
a small distance round the puncture; if, 
therefore, the treatment be adopted at so early 
a stage that the area of inflammation can be 
surrounded by four or five punctures, the 
disease may be checked. Beyond this there 
would be danger of carbolic-acid poisoning. 
Kraske and Riedel recommend scarification 
of the advancing margin with a special 
instrument, and the subsequent application 
of lint soaked in a 1 in 500 solution of corro- 
sive sublimate, (e) Drawing a limiting line 
in front of the advancing rash. This has 
been done with solid nitrate of silver and 
with blistering fluid. It is utterly useless. 
Wolfl er recommends the application of pres- 
sure immediately in front of the advancing 
line of redness by means of adhesive plaster. 
He believes this prevents the invasion of the 
lymph-spaces by the micrococci. 
Erysipelas of the fauces is best treated by 
the local application of a strong solution of 
perchloride of iron. If there be cedema glot- 
tidis the swollen parts must be scarified, and 
if this fails to give relief, tracheotomy may 
be necessary. 
II. Phlegmonous or Cellulo-cuta- 
neous Erysipelas.-This was described 
by Dupuytren under the name of ' diffuse 
phlegmon.' 
Anatomical Characters.-Incisions made 
into the inflamed part in the early stages 
show the spaces of the areolar tissue dis- 
tended with a semi-solid inflammatory exu- 
dation; a little later this is found to be a 
turbid and puriform fluid; later still the sub- 
cutaneous cellular tissue is represented by 
masses of shreddy sloughs soaked in pus. 
Unless exposed to the air by incisions or by 
sloughing of the skin, these sloughs are free 
from any odour of decomposition, and contain 
no gas. The streptococcus already described 
can invariably be demonstrated in the exu- 
dation fluids of the affected part. There is 
nothing characteristic in the post-mortem 
appearances of the internal organs. 
Symptoms. - The invasion is usually 
marked by chilliness or a rigor, elevation of 
temperature, nausea, headache, and general 
malaise. The local inflammation may com- 
mence in some wound or abrasion, but it 
may also arise spontaneously. From the 
beginning there is marked oedema of the 
subcutaneous tissue. The skin is reddened, 
but the margin of the redness is not sharply ERYSIPELAS 
631 
defined, and swelling and tenderness of the 
lymphatic glands are often absent. As the 
area of inflammation extends, the affected 
part becomes tense and brawny, and vesicles 
or large blebs form. The tension may be- 
come so great that firm pressure with the 
finger scarcely makes any impression. In a 
few days from the commencement of the 
disease, the greater part of a limb may be 
involved. If unrelieved by treatment, the 
tint of the redness becomes more dusky, and 
dark purple patches appear. At the same 
time the tension becomes less, and gives 
place to a soft, boggy feeling, indicating 
sloughing of the subcutaneous cellular tissue. 
Then livid patches appear, which break down 
into sloughs. As these sloughs separate, 
large shreddy masses of gangrenous cellular 
tissue can be drawn out, leaving the under- 
mined skin connected with the deeper parts 
only by bands containing the larger vessels. 
Finally, the remaining skin being insuffi- 
ciently nourished may become thin and melt 
away, leaving large tracts of the fascia or 
muscles beneath exposed to view. In this 
way, if proper treatment be not adopted in 
time, the greater part of a limb may be 
denuded of its cutaneous and subcutaneous 
covering. The extreme stage may be reached 
in a week or ten days, but a longer time 
usually elapses before all the sloughs have 
separated. In the earlier stages there is 
much burning and tensive pain, but this 
subsides as gangrene sets in. The constitu- 
tional symptoms are grave from the begin- 
ning. There is high fever, the thermometer 
often reaching 105° F. The tongue is dry 
and brown, and sordes accumulate on the 
lips and teeth ; there is total loss of appetite; 
and diarrhoea is a frequent symptom. The 
pulse, at first full and bounding, soon loses 
force, becoming rapid and weak. Delirium, 
usually of the muttering type, is always 
present in severe cases. Death occurs from 
exhaustion, or from some complication, such 
as pneumonia, pleurisy, &c. During the 
separation of the sloughs septicaemia and 
pyaemia are of frequent occurrence. The 
disease most commonly attacks one of the 
limbs, but it is occasionally seen in the 
scrotum, and a peculiarly virulent form has 
been described as affecting the face. Phleg- 
monous erysipelas most commonly occurs in 
adult patients of broken constitution, suffer- 
ing usually from the effects of the abuse of 
alcohol, or from some disease of the liver or 
kidneys. 
Diagnosis.-From simple erysipelas the 
phlegmonous form is distinguished by the 
great swelling and brawny hardness, by the 
want of a sharply defined edge, and by the 
early tendency to sloughing; from spreading 
gangrene by its slower progress, and the 
absence of the rapid decomposition and 
development of gas in the tissues. Acute 
necrosis somewhat resembles it, but this 
disease is limited to young subjects, the 
swelling is less brawny, and when pus forms 
there is distinct fluctuation and not the boggy 
feeling of phlegmonous erysipelas. 
Prognosis. - The prognosis is always 
grave, especially if there be any delay in 
adopting the proper treatment. Early failure 
of the heart's force, excessively dry tongue, 
diarrhoea and vomiting are bad signs. The 
gravity of the case increases directly with the 
area affected. 
Treatment.-The patient must be sup- 
ported by good beef-tea, milk and eggs, and 
stimulants are usually required to be freely 
given. No depletory measures are ever 
justifiable. Ammonia with bark is sometimes 
of service. Locally the treatment in very 
mild and doubtful cases must consist in the 
application of hot fomentations, and extract 
of belladonna made into a paint with an 
equal amount of glycerine. As soon as there 
are any signs of tension, free incisions must 
be made to relieve it. The strictest anti- 
septic precautions should be adopted in 
making these incisions, and some efficient 
antiseptic dressing applied afterwards. Hot 
boric acid fomentations frequently changed, 
or sheets of salicylic wool (10 per cent.), 
moistened with boiling water and applied 
like a poultice, will be found very useful. 
III. Diffuse Cellulitis, or Cellular 
Erysipelas.-In this disease the inflam- 
mation is confined to the subcutaneous cel- 
lular tissue, or to the planes of areolar tissue 
amongst muscles or beneath fasciae. The 
course of the inflammation is similar in 
many respects to that of phlegmonous ery- 
sipelas, the only important difference being 
that the skin remains unaffected, or is only 
implicated in the later stages, as a conse- 
quence of the sloughing of the subcutaneous 
tissues. 
Anatomical Characters.-The post-mor- 
tem appearances are similar to those of 
phlegmonous erysipelas. 
Symptoms.-The local signs of diffuse cel- 
lulitis, when occurring in the subcutaneous 
tissue or beneath the superficial fascia, are 
marked cedematous swelling, gradually be- 
coming brawny, slight redness of the skin, 
and usually mottling from over-distension 
of the superficial veins. There is no sharp 
limit to the swelling. There is intense 
tensive or burning pain, increased by move- 
ment, and acute tenderness on pressure. 
The neighbouring lymphatic glands are in 
most cases swollen and tender. As the dis- 
ease advances, the swelling becomes doughy, 
and possibly an indistinct sensation of fluc- 
tuation may be felt. The skin now becomes 
redder, and the gangrenous inflammation 
may even extend to it, unless prevented by 
treatment. An incision in the cedematous 
or brawny stage merely shows the areolar 
spaces distended with serum, sometimes 
clear, more often turbid. If the incision be 632 
ERYSIPELAS 
ERYTHEMA 
delayed till the later stages, the affected 
cellular tissue is reduced to a mass of shreddy 
sloughs soaked in pus. Gas does not form 
amongst these sloughs till after air has been 
admitted from without. In mild cases the 
inflammation may localise itself, and lead to 
the formation of a large abscess. The con- 
stitutional symptoms are always grave. The 
temperature is high, 104° to 106° F. There 
are the usual symptoms of fever; the tongue 
is foul and speedily becomes dry; vomiting 
and diarrhoea are not uncommon; the pulse, 
at first quick and full, soon becomes feeble 
and rapid. There is almost always delirium. 
The disease usually runs a rapid course, two 
or three days sometimes being sufficient for 
it to reach its extreme stage. 
Diffused cellulitis, as above described, is 
most frequently the result of a poisoned 
wound; it may then start from the wound 
or make its appearance at a distant part. It 
forms the most fatal variety of post-mortem 
wound ; and, as is well known, in such cases 
the puncture may appear healthy, whilst the 
areolar tissue in the pectoral region may be 
the seat of most acute diffused inflammation. 
The bite of the less poisonous reptiles causes 
a similar diffuse inflammation. Diffuse cellu- 
litis of the pelvis is a common cause of death 
after lithotomy, and is not uncommon in 
women after labour. Diffuse cellulitis be- 
neath the pericranial aponeurosis is of fre- 
quent occurrence after scalp wounds. Oc- 
casionally the disease arises spontaneously, 
and it is then most common in the upper 
limb; but it has been seen in the areolar tis- 
sue of the neck and in many other regions. 
In pyaemia and septicaemia patches of diffuse 
cellulitis may appear in intermuscular spaces, 
or in the subcutaneous tissue. 
Diagnosis.-The diagnosis of cellulitis is 
often difficult when the mischief is deep- 
seated. The oedema, pain, and tenderness, 
with the severe constitutional symptoms, are 
the chief guides; but even when these are 
well-marked, the extent of the inflammation 
and the necessity for active treatment are 
often difficult to determine. 
Prognosis.-This depends much upon the 
cause, and upon the previous health of the 
patient. It is a very bad sign when the 
gravity of the general symptoms is out of 
proportion to the local mischief. In the pel- 
vis cellulitis may be fatal from peritonitis; 
in the neck it is very fatal; it is much less 
dangerous in the limbs. When it occurs as a 
part of pyaemia or septicaemia the prognosis 
is of course very grave. 
Treatment.-Early incisions into the in- 
flamed cellular tissue, with antiseptic appli- 
cations and abundant support, form the only 
reliable treatment in severe cases. In slight 
cases the application of extract of belladonna 
and glycerine (equal parts), with hot fomenta- 
tions, may lead to resolution or limitation of 
the inflammation. 
IV. Erysipelatous Lymphangitis.- 
Inflammation of the superficial lymphatic 
vessels is a common accompaniment of all 
varieties of erysipelas; but in some cases it 
forms by far the most prominent local mor- 
bid condition. 
Symptoms.-This affection is characterised 
by red lines running in the course of the 
lymphatic vessels from some local sore or 
wound. The lines are at first tolerably 
sharply defined, and about a quarter of an 
inch in width, but after a short time they 
spread out and several may coalesce, forming 
a patch exactly resembling simple cutaneous 
erysipelas. There is slight oedema, some pain 
and stiffness, and acute tenderness on pres- 
sure. The lymphatic glands to which the 
vessels lead are swollen and tender. The 
constitutional symptoms are the same as in 
simple erysipelas. 
Diagnosis.-This affection can only be 
mistaken for phlebitis; but the diagnosis is 
easily made by observing the course of the 
lines, and by the absence of the knotted cord 
formed by the coagulation of the blood in an 
inflamed vein. 
Treatment.-The treatment is the same 
as in simple erysipelas. The extract of 
belladonna and glycerine is especially use- 
ful in this form of erysipelatous inflamma- 
tion. 
V. Erysipelatous Phlebitis.-Inflam- 
mation of the superficial veins, rapidly 
spreading in the course of the circulation, 
accompanied by thrombosis, redness of the 
skin, and acute tenderness, has been supposed 
by some authors to be erysipelatous in cha- 
racter. The only evidence in favour of this 
view is that the invasion and the constitu- 
tional symptoms resemble those of erysipelas, 
and that the affection is not uncommon dur- 
ing epidemics of erysipelas. See Veins, Dis- 
eases of. 
Various other diseases have been classed 
as erysipelatous; the chief of these are whit- 
low, some forms of puerperal fever, and 
diffuse peritonitis after operations affecting 
the peritoneum; all these will be described 
elsewhere. Diffuse inflammation not infre- 
quently occurs after punctures made to allow 
of the escape of the fluid in the dropsy oi 
cardiac or of renal disease. That punctures 
made into feebly nourished tissues bathed 
in decomposable serous fluid should set up 
diffuse inflammation is not surprising, but 
evidence is wanting to prove that such in- 
flammation is necessarily connected with 
erysipelas. Marcus Beck. 
ERYTHEMA (epvdpos, red).- Synon. : 
Rose-rash ; Fr. Erytheme; Ger. Hautrothe. 
Definition. - A non-infective superficial 
inflammation of the skin, the essential cha- 
racteristic of which is redness, that disap- 
pears on pressure by the finger, reappearing 
when the pressure is removed. The hue may ERYTHEMA 
633 
vary from a bright rose to a dark blue red ; 
it may or may not be accompanied by swell- 
ing ; the part may be hotter than natural; 
and the appearance may present itself as 
spots, circumscribed or diffuse, or as wheals. 
It is sometimes attended by a sensation of 
slight burning or itching, but generally gives 
rise to no subjective symptoms. After it has 
disappeared the skin is either normal, or re- 
mains slightly pigmented, or desquamates. 
Generally there is an increase of tempera- 
ture, with slight feverish symptoms. Ery- 
thema may be either symptomatic or idio- 
pathic. 
Symptomatic Erythema.-Etiology 
and Varieties.-Erythema occurs in rare 
instances after the administration of drugs. 
Cases are recorded after the ingestion of 
arsenic, belladonna, chloral hydrate, copaiba, 
cubebs, digitalis, iodides, opium, quinine, 
salicylic acid, stramonium, strychnine, phe- 
nazone, and turpentine. The rash usually 
appears immediately after the absorption of 
the medicine into the circulation; after 
arsenic it appears at a later period. See 
Drug Eruptions. 
Exposure to heat or cold, and contact with 
various acrid or poisonous substances, are also 
common causes of erythema. Friction and 
(in the absence of cleanliness) the secretions 
of the skin itself, may give rise to it, as when 
erythema intertrigo is produced between the 
scrotum and thighs by the irritation of pro- 
fuse sweat and sebaceous secretions. The 
blush of shame or of anger is an erythema 
produced by the immediate action of the 
vaso-motor nervous system. 
Variola, cholera, enteric fever, typhus, sep- 
ticaemia, rheumatic fever, and various other 
less distinctly defined febrile conditions, are 
frequently accompanied during various stages 
of their course by a more or less generally 
diffused and mostly ephemeral form of ery- 
thema. 
The roseola infantilis of authors is an ery- 
thema that accompanies intestinal disturb- 
ance, teething, and various other disordered 
conditions of the system in children. Its 
appearance may exactly simulate that of 
measles or scarlatina; but it differs from 
these in disappearing in less than twenty- 
four hours, and in leaving no desquamation 
behind it. 
The erythema that accompanies smallpox 
-roseola variolosa-appears generally on the 
second day of the disease, either as a diffuse 
redness of the whole integument, or as bright 
red spots, which are seen first on the face and 
then on other parts of the body. It lasts from 
twelve to thirty-six hours, and disappears 
when the smallpox eruption begins to show 
itself. A special limited form of erythema 
has been observed on the second and third 
days of smallpox, extending from the hypo- 
gastrium down the front of the upper two- 
thirds of the thighs; the affected surface, 
when the legs are closed, having the form of 
a triangle the base of which is across the 
lower part of the abdomen. This surface re- 
mains almost or entirely free from the vario- 
lous pustules, and many of the cases in which 
it is present end fatally. 
From the third to the eighteenth day after 
vaccination, small or large erythematous 
patches-roseola vaccina - are sometimes 
seen, generally on the arms, but also on other 
parts of the body. They usually disappear 
within twenty-four hours, and leave neither 
desquamation nor pigmentation. 
The forms of erythema mentioned above 
cannot be considered as being in themselves 
specific varieties of disease, and pathologically 
consist in a temporary injection of the capil- 
lary blood-vessels of the skin. They are to 
be distinguished from the erythemata that 
run a distinct course, terminating in pigmen- 
tation. and desquamation, and in which the 
capillary injection is accompanied by exuda- 
tion. 
Idiopathic Erythema.-I. Erythema 
multiforme.-This form of idiopathic ery- 
thema is most commonly seen in spring and 
autumn, and is distinguished by its localisa- 
tion. It begins on the backs of the hands 
and feet, and frequently is found in these 
situations only. In some cases it extends 
upwards to the shoulders and hips, and in 
very rare cases is also found on the trunk. 
The appearance consists in flattened pa- 
pules, from the size of a pea to that of a bean, 
of a dark blue or brown-red colour. They 
are surrounded on their first appearance by 
a red zone, which soon disappears, and the 
border of the papule then stands out in fuller 
relief. The mildest form of this disease con- 
sists in papules which disappear after a few 
days-erythema papulatum vel tubercula- 
tum. Instead of thus disappearing it may 
spread outwards from the edge, and flatten 
and become pale in the centre, thus forming 
a red ring, the condition being known as ery- 
thema annulare. While the first circle per- 
sists, a second ring may form around it, and 
the circles may be constituted by small pa- 
pules, forming the condition recognised as 
erythema iris vel mamellatum. Another 
stage maybe reached by the enlarging circles 
meeting, and so forming segments of a circle, 
constituting the form known as erythema 
gyratum vel marginatum. In consequence 
of increased exudation erythema papulatum 
may assume the aspect of a wheal, forming 
erythema urticatum or lichen urticatus. 
This condition is attended with considerable 
itching; and, in consequence of scratching, the 
centre of the papular wheal is often covered 
by a minute bloody crust. The exudation 
may be sufficient to give the eruption the 
aspect of vesicles or bullse, the so-called ery- 
thema vesiculosum and erythema bullosum. 
Concentric circles of vesicles produce the 
appearance called herpes iris. 634 
ERYTHEMA 
At any of these stages the eruption may 
disappear. The sequelae are slight pigmen- 
tation and desquamation. 
The disease, whose different stages have 
received the several names above indicated, 
has been designated, on account of the vari- 
ous forms under which it is seen, erythema 
exsudativum multiforme. It is accompanied 
by a slight feeling of burning, or by very 
slight itching. In the majority of cases con- 
stitutional symptoms are either absent, or 
are so insignificant as not to excite attention. 
There are, however, cases in which the symp- 
toms are as marked as those which precede 
and accompany an eruptive fever. The pro- 
dromal symptoms are usually pain in the 
back, head, limbs, and joints, with gastric 
disturbance, and sometimes a congested con- 
dition of the throat and fauces. In severe 
cases the prodromal period has been ob- 
served during four to six days; and amongst 
other symptoms sneezing, bleeding at the 
nose, laryngitis, bronchitis, intense sweating, 
mental disturbance, and fever have been ob- 
served. All these symptoms may become 
aggravated during the period of eruption. In 
well-marked cases the disease may last from 
a fortnight to a month, but in exceptional 
circumstances the symptoms may be pro- 
longed by fresh outbreaks of eruption. Sim- 
ultaneously with the eruption on the skin, 
red spots may appear on the mouth and 
pharynx, from which the epithelium quickly 
disappears, leaving the parts raw and pain- 
ful. Cases are recorded in which symptoms 
of severe intestinal disturbance, shiver- 
ing, high fever, intense inflammation and 
ulceration of the mucous membrane of 
the throat, severe mental depression, and a 
painful condition of the joints, have been 
present. 
In some cases the erythema is punctiform, 
and so much resembles the appearance of 
scarlatina that authors have described an 
erythema scarlatiniforme. It is distin- 
guished from scarlatina by the absence or 
very slight degree of fever. The fauces, 
although red, are not swollen. There is no 
characteristic appearance on the tongue; and 
the pulse is little affected. There are no 
sequelae. 
Hebra relates that in a woman who died 
whilst an eruption of erythema gyratum was 
on the skin, similar red rings were found in 
the small intestine. It is most common in 
adolescence, and is more frequent in males 
than in females. 
II. Erythema nodosum.-This name is 
given to a disease characterised by the ap- 
pearance, chiefly on the surface of the lower 
extremities, of pale red hemispherical or 
oval swellings. These vary in size from 
that of a pea to that of a hen's egg, and 
are painful on pressure. Fever is sometimes 
present. 
The swellings are at first pale red with a 
yellowish tinge, later dark red, and finally 
livid; after they disappear they leave behind 
them a yellow pigmentation similar to that 
which follows a contusion. The number of 
swellings may vary from a very few on the 
lower extremities to successive crops on dif- 
ferent parts of the limbs and trunk. In the 
latter case the feverish symptoms are well- 
marked. The course of the disease is com- 
pleted in from two to four weeks. The swell- 
ings never suppurate, never itch, are always 
painful, and the redness never spreads to the 
adjoining skin. This variety can occur in 
combination with the previously described 
forms of erythema multiforme. 
Erythema nodosum is found to be so fre- 
quently associated with definite rheumatic 
symptoms, such as arthritis, sour sweats, sore- 
throat, endocarditis, and even myocarditis, 
that it may be considered very probable that 
the affection is allied with the rheumatic 
diathesis. 
A case has been reported in which phlebitis 
leading to embolism has complicated the dis- 
ease. 
^Etiology.-The cause of erythema nodo- 
sum is not definitely known, although, as we 
have remarked, it is frequently associated with 
rheumatism. Some authors favour the view 
that it may be considered as a typical an- 
gioneurosis, whilst others believe that it is 
always an infective constitutional disease. It 
may occur at every age, but generally from 
eighteen to thirty, and most frequently in 
women. It occurs at all seasons, and debility 
predisposes to attacks. 
Anatomical Characters.-The micro- 
scopical appearances are those of an inflam- 
matory hyperaemia. Leucocytes are found 
around the blood-vessels, and there are extra- 
vasations of red corpuscles. There is also an 
effusion of serum between the cells of the 
epidermis. 
Prognosis.-The prognosis of the special 
forms of erythema-multiforme and nodosum 
-is usually favourable, but cases are reported 
in which death has been caused by visceral 
complications. It is assumed that in these 
exceptional cases both the skin-eruption and 
the visceral lesions are produced by some 
infective poison. Those varieties seen in the 
course of other diseases do not as a rule 
modify the prognosis of the particular disease 
which each accompanies. 
Treatment.-The treatment of erythema 
consists in palliating the attendant symptoms. 
Dusting with flour, or the application of 
spirit-lotion, should be employed when pro- 
ductive of a sense of comfort to the patient. 
In erythema nodosum warm applications of 
infusion of poppies or chamomile are sooth- 
ing ; while aperients and, when fever is 
present, gentle diaphoretics may be given 
internally. In many such cases tonics, es- 
pecially quinine, are required. 
George Thin. ERYTHRASMA 
EUTHANASIA 
ERYTHRASMA ^pv0p6s, red).-This 
is a chronic, very slowly developing, con- 
tagious, epiphytic disease of the skin, cha- 
racterised by a very slight erythematous 
inflammation, which usually occupies the 
cruro-scrotal or axillary regions, but is capa- 
ble of wider generalisation; produced by the 
presence in the corneous layer of a remark- 
ably minute fungus-the microsporon mi- 
nutissimum (Burckhardt and Von Barens- 
prung). 
Description.-Erythrasma is little known, 
and generally confounded with eczema mar- 
ginatum. Fairly common in men, although 
it occasions little discomfort, it is less frequent 
in women, in whom it may be found about 
the axillary or perigenital regions. 
The patches are rounded, not marginate or 
sensibly raised, from f inch to 1| inches or 
upwards in diameter, uniformly roughened, 
and coloured yellowish-red or brownish. The 
pruritus and inflammation are very slight. 
There are abundant delicate mycelia and 
conidia present, forming a rich network 
round the cells. The fungus requires stain- 
ing and high powers for its demonstration. 
It is said to occur normally on parts of the 
skin, but erythrasma has been inoculated by 
Kobner. 
Treatment.-All parasiticide agents, such 
as iodine, resorcin, salicylic acid, and chry- 
sarobin, capable of causing exfoliation, suc- 
ceed in curing erythrasma. Relapses are apt 
to occur unless treatment is long-continued. 
T. Colcott Fox. 
ESCHAROTICS ^aXApa, a slough).- 
Synon. : Fr. Escharotiques ; Ger. Aetz- 
mittel. 
Definition.-Escharotics are substances 
that completely destroy the tissues to which 
they are applied, and produce a slough. They 
are distinguished from other caustics simply 
by the greater intensity of their action. 
Enumeration.-The chief escharotics are: 
Red-hot metal, Sulphuric Acid. Nitric Acid, 
Caustic Potash, Chloride of Antimony, Chlo- 
ride of Zinc, Acid Nitrate of Mercury, Bro- 
mine, Chromic Acid, and Lime. Weaker 
caustics are-Nitrate of Silver, Sulphate of 
Copper, Sulphate of Zinc, Iodine, Carbolic 
Acid, Arsenious Acid, Sulphide of Arsenic, 
and Dried Alum. 
Action.-Escharotics combine with the 
tissues and destroy them. Around the part 
thus killed inflammation is set up, and the 
part is separated as a slough. Besides their 
local action, these agents act reflexly on 
other parts of the body through the nerves of 
the region to which they are applied. 
Uses.-Escharotics are employed, first, to 
destroy the virus in, and the tissues around, 
a poisoned wound, and thus prevent the ab- 
sorption of the poison -for example, in bites 
by snakes or rabid animals, or in cases of 
inoculation with syphilis, or with animal- 
poison in dissection or post-mortem wounds. 
Secondly, they are used to destroy unhealthy 
tissue, such as exuberant granulations, and 
to remove excrescences and morbid growths, 
as warts, condylomata, naevi, polypi, haemor- 
rhoids, and cancer. Thirdly, they are used 
to open abscesses, especially those of the 
liver. For this purpose caustic potash is 
usually employed. Lastly, by means of 
escharotics it is usual to establish issues, and 
thus react beneficially on distant organs. 
T. Lauder Brunton. 
ESSENTIAL PARALYSIS. - A 
synonym for infantile paralysis. See Para- 
lysis, Infantile. 
ESTCOURT, in Natal.-See Africa, 
South. 
ETHER, Uses of.-See Anaesthetics. 
ETIOLOGY.-See Disease, Causes of. 
EUSTACHIAN TUBE, Diseases of 
See Ear, Diseases of. 
EUTHANASIA (rf, well; Oavaros, 
death). 
Definition.-Mental and physical distress 
too often attends the approach of death; and 
by the term 'euthanasia' we express the mea- 
sures by which we alleviate or seek to remove 
this distress. 
Importance of Euthanasia.-To procure 
euthanasia is of great moment to the patient, 
to the patient's friends, and to the prac- 
titioner. 
It is the duty, and should be the constant 
aim, of every thoughtful practitioner to ac- 
quire the art of successfully smoothing the 
death-bed of his patient. He will thereby be 
enabled, when this is necessary, to relieve 
him of much of the attendant suffering, and 
to prevent many troubles individually of 
smaller moment, but collectively the source 
of much discomfort or distress. The friends' 
anxiety will be lightened by the relief af- 
forded to the patient. Their own efforts in 
this direction are frequently unsuccessful; 
indeed may sometimes be prejudicial. The 
comfort of the dying is very often interfered 
with, and actual suffering induced, by the 
interference of well-meaning but inexperi- 
enced friends or relatives. Indeed they will 
sometimes question the action of the prac- 
titioner respecting the employment of a 
measure of which he may wish to avail him- 
self, or they will administer food and stimu- 
lants to the patient in quantities which may 
be excessive or deficient or given at improper 
intervals. Death may thus be very often 
accelerated, and not without discomfort. To 
the practitioner himself the subject of eutha- 
nasia is one of great importance. He is in- 
volved in a position of grave responsibility, 
demanding the display of much tact and 
judgment, and one by which his professional 
635 636 
EUTHANASIA 
character will certainly, in part, be estimated. 
Much of his success will depend on his 
natural possession of these qualities, and to 
lay down any strict or rigid rules for his 
guidance is obviously impossible. 
The Morbid States calling for Eutha- 
nasia.-1. Mental Condition.-The question 
of dealing with the mental distress of the 
dying is one which only secondarily con- 
cerns the practitioner, and will therefore be 
noticed but briefly here. The most impor- 
tant point to be decided is : Should the prac- 
titioner be the medium of communicating to 
his patient the hopelessness of his case ? 
Whenever possible, this painful duty should 
be relegated to the friends of the patient, 
who are always to be informed of the ap- 
proach of death, in order that due attention 
may be paid to the affairs of the sick person, 
both spiritual and worldly. The practitioner 
should not hastily take on himself to tell him 
of the inevitable result of his illness. The 
patient may or may not desire to know the 
truth, and when it is communicated to him 
it is certain to affect his peace of mind in 
the one or in the other direction. Some wel- 
come the announcement; whilst others are 
filled with dread. But it is a fact that the 
majority of persons seriously ill feel less on 
such matters than they would have felt in 
health : they ' mate and master,' as it were, 
' the fear of death.' With many patients, 
not to know the truth respecting the danger 
which they are in, is itself a form of unhap- 
piness which militates against the establish- 
ment of euthanasia. The practitioner should 
therefore most carefully study the individual 
case and the character of his patient. On 
the one hand he will exercise the greatest 
care not to falsely conceal their situation 
from the dying; on the other hand, he 
must keep in mind that a fatal termination 
is not always certain, and that in many 
cases the last chance of an over-sensitive 
patient may be destroyed by the prospect of 
problematical dangers (see Disease, Pro- 
gnosis of). Good sense, kind feeling, tact, and 
experience, will prove of the greatest value 
in discharging this delicate duty as it comes 
before us in a general practice. See Death, 
Modes of. 
2. Bodily Conditions.-The physical states 
which specially call for euthanasia are-pain; 
dyspnoea, cardiac distress, exhausting cough; 
laryngeal distress; difficult expectoration; 
restlessness and sleeplessness; thirst; hic- 
cough; abdominal distension; dropsy; bed- 
sores ; and exhausting discharges. These, 
and a few of the general and therapeutic 
measures at our command which ought ever 
to be present to the mind of the practitioner 
for abolishing or mitigating sufferings inci- 
dent to the dying state, will now be briefly 
touched upon. 
The removal of pain is essential for the 
promotion of euthanasia, and no other remedy 
is so successful for this purpose as opium or 
morphine cautiously administered. It is an 
adjunct of the greatest value to other mea- 
sures, and, moreover, successfully combats 
the exhaustion and sinking sensations which, 
in certain cases, are a source of indescribable 
distress. Its anodyne effect is enhanced by 
its cardiac action. Its administration, how- 
ever, often leads us into much fresh difficulty, 
by causing a dry tongue and distressing 
thirst; by arresting the excretions; in other 
instances by increasing the reluctance to take 
sustenance; or the presence of kidney-disease 
may prove a serious contra-indication to its 
employment. 
The question as to the patient remaining 
out of bed pillowed up in a suitable chair 
will sometimes arise when dyspnoea and 
flatulence are urgent; and will demand much 
judgment and care. By rendering moist the 
air of the bedroom with the vapour of hot 
water in a bronchitis-kettle placed upon a 
fire (not over gas or spirit-lamp contrivances, 
which only tend to vitiate the atmosphere of 
the sick-chamber), we can often insure the 
relief of pulmonary distress. Uraemic dys- 
pnoea will call for the administration or 
nitroglycerine, nitrite of amyl, or sulphuric 
ether. 
Painful cardiac palpitation, and its atten- 
dant distress, often derive relief from the 
administration of antispasmodics along with 
iodide of potassium, a belladonna plaster at 
the same time being applied over the prae- 
cordia. Digitalis, strophanthus, strychnine, 
or some of the other well-known excellent 
cardiac tonics, may also be resorted to with 
success. 
One of the most distressing symptoms in 
the dying is the exhausting cough of phthisis, 
which greatly exhausts the patient. It may 
be combated by judicious nursing; by an 
acid linctus, with or without the addition ox 
a little morphine; by a combination of respi- 
ratory sedatives; by the frequent adminis- 
tration of small quantities of alcoholic stimu- 
lants ; or by hot or cold liquid nourishment. 
The laryngeal distress which frequently at- 
tends the final stage of phthisis will best be 
relieved by morphine insufflations, cocaine 
sprays, or recourse may be had to rectal 
alimentation. The loud, noisy, gurgling rales 
met with in the last phases of bronchitis and 
other conditions will call for change of pos- 
ture and stimulants, although they are more 
distressing to the friends than a source of 
danger to the patient (see Stertor). When 
the attempts at expectoration are difficult, 
measures must be employed which possess 
the power of diminishing the viscidity of the 
expectoration, or of stimulating the respira- 
tory centre and the respiratory movements. 
See Expectorants. 
The restlessness and tossing of the limbs, 
irregular sighing, with coincident sleepless- 
ness, which so often attend the last days EUTHANASIA 
EXANTHEMA 
637 
of fatal illnesses, may sometimes be relieved 
by attention to the weight of the bedclothes, 
which can be conveniently reduced by em- 
ploying a suitable cradle. The arrangement 
of the pillows and attention to the posture of 
the dying patient constantly tax the ingenuity 
and resource of the attendants. The tem- 
perature and ventilation of the sick-room 
are also of great importance in this respect, 
closeness and over-heating being zealously 
prevented, as well as crowding of the sick- 
chamber with anxious friends. The feet 
and legs ought to be frequently examined, 
and if chilled they should be warmed by 
a carefully applied foot-warmer. The un- 
pleasant effects of cold sweats will also call 
for attention. The catheter will remove 
another often overlooked cause of inquietude 
-a distended bladder. By these and similar 
measures we may be able to counteract the 
cause or causes of insomnia, and thus secure 
for our patient a few precious hours of 
sleep. 
Thirst is often a most distressing symp- 
tom. It may best be relieved with ice, or 
with teaspoonfuls of iced water or acidulated, 
unsweetened, cold black tea or coffee. But 
in this connexion let it be understood that we 
must be careful to avoid the popular mis- 
take of forcing down liquids in cases where 
life is evidently fast ebbing away. Such a 
practice necessarily embarrasses respiration, 
and we have likewise to remember that at 
this time the act of deglutition very often is 
in abeyance. Death is occasionally accele- 
rated by injudicious attempts to raise the 
patient, open his mouth, and administer 
food. 
In the management of the dying we have 
always to contend with an enfeebled diges- 
tion. The diet in such cases should be one 
easy of assimilation. It not infrequently 
happens that the food given may be excessive 
or deficient in quantity, or that it is admin- 
istered at irregular intervals, thereby causing 
much distress to the patient. Success in this 
direction depends solely on the tact of the 
nurse. "Whilst in acute disease nothing con- 
duces more to success than definite instruc- 
tions as to the amount and kind of the food 
to be given, and the hours for its adminis- 
tration, it is impossible and inadvisable to 
observe these rigid rules in the feeding of the 
dying. 
In conjunction with nourishment we can 
often remove much of the suffering by the 
judicious selection and administration of 
alcoholic stimulants. If the patient tires of 
one form of stimulant, another should be 
tried, provided we are careful to use only 
such as are easily digested and assimilated, 
and given in divided quantities. A combina- 
tion of beef-tea, liquor strychninae hydro- 
chloratis, and brandy is often very acceptable, 
especially in bad cardiac cases. Another 
stimulant of extreme service is ether, which 
particularly alleviates painful attacks of 
spasmodic breathing. 
A sinapism to the epigastrium in conjunc- 
tion with the internal use of a little ether 
and brandy, will frequently relieve that some- 
times distressing symptom-hiccough. 
Distressing abdominal distension must be 
relieved by the employment of turpentine 
stupes and by enemata containing some anti- 
spasmodic. See Enema. 
The treatment of dropsy, abdominal dis- 
tension, bed-sores, and exhausting discharges 
is dealt with in other parts of this work. 
In addition to the conditions which call 
for euthanasia, it is clear that the severe 
dietetic restrictions which may have been 
enforced in a case of Bright's disease, dia- 
betes, &c., ought to be reconsidered and re- 
moved when it becomes apparent that the 
patient's condition is absolutely hopeless. 
The wishes and suggestions of the patient 
may generally be acquiesced in, and they 
will prove a useful guide to the practitioner 
as to the line of action to pursue. It is 
often the wisest course to humour cravings. 
Seeming extravagances as to diet, if persis- 
tently asked for, had better be granted, espe- 
cially when kind and gentle persuasion has 
failed to get the patient to waive his desire 
for them. 
In addition to the means already men- 
tioned, it need hardly be said that we still 
have all those measures which may be 
summed up in the expression ' perfect nurs- 
ing,' which implies carrying out many de- 
tails as well as exercising sympathy and tact 
-a nurse not overdrilled. A mere automa- 
ton thinks too much of her ' uniform ' and 
of her ' duty.' John Harold. 
EVACUANTS (evacuo, I empty).- 
Synon.: Fr. Evacuants-, Ger. Ausleerende 
Mittel. 
Definition.-Medicines used to produce 
some evacuation from the body. 
Enumeration.-The chief evacuants are : 
Sternutatories, Expectorants, Sialagogues, 
Emetics, Cholagogues, Purgatives, Diapho- 
retics, and Diuretics. See the several articles 
upon these subjects. 
EVIAN-LES-BAINS, in Savoy, 
France.-Alkaline waters. See Mineral 
Waters. 
EXACERBATION (exacerbo, I aggra- 
vate).-Increase in the severity of the symp- 
toms of a disease. See Disease, Duration of. 
EXANTHEMA; EXANTHE- 
MATA (e£, out; and av()ea>, I blossom). 
Synon. : Fr. Exantheme; Ger. Ausschlag. 
Definition.-A rash or eruption on the 
skin attending a specific fever. The specific 
fevers attended by rash. This term, once de- 
noting any cutaneous eruption, is now re- 
stricted to the eruptive fevers called the ex- 
anthemata. The febrile rashes or exanthems 638 
EXANTHEMA 
of local or individual origin - urticaria, 
erythema, and roseola-are not included 
with the true exanthemata, which are acute 
specific infectious diseases, namely, Typhus, 
Variola, Varicella, Morbilli, Rubella, Dengue, 
Scarlet Fever, Typhoid or Enteric Fever, 
and perhaps Erysipelas. As the leading fea- 
tures of these diseases will be discussed under 
their several heads, it is only necessary fur- 
ther to notice certain less defined and regular 
eruptions associated with fever. 
All the exanthemata are attended with 
fever and enlargement of the lymphatic 
glands. Convulsions in children may occur 
with the first fever; in some of the diseases 
before the rash appears. 
Typhus.-The mulberry rash appears sud- 
denly on the fourth and fifth days of illness 
as a dull red mottling of irregular, persis- 
tent, non-elevated spots ; the fever is high at 
the commencement, and continues to be so 
after the rash is fully developed. 
Typhoid.-In typhoid or enteric fever the 
small, raised rose-spots do not appear till the 
second week of fever; sparsely scattered on 
the trunk, they fade on pressure, disappearing 
in three or four days, while new spots arise. 
Smallpox.-Marked fever of sudden in- 
gress occurs two days before the raised erup- 
tion. Sometimes a rose-rash first appears, 
but the severe symptoms begin a full day 
before this, and not more than two days 
before the characteristic spots. The cervical 
glands are enlarged. 
Varicella.-The eruption begins on the 
first day of illness, with slight fever, increas- 
ing as fresh spots appear. The fever may be 
high and come on suddenly, but enlarged 
cervical glands and spots somewhere are 
always to be found at the same time. 
Measles.-Three days of fever and catarrh, 
with palpable enlargement of the cervical 
glands, precede the rash; there is then sud- 
den increase of fever, subsiding while the 
rash is at its height. 
Rubella; Rubeola sine catarrho. - The 
rash appears within a few hours of the first 
feeling of illness, which is slight and soon 
over. The rash is at first spotted rather 
than finely diffused. By the time it is fully 
out the fever has subsided, but the enlarged 
cervical glands which marked the ingress 
always remain to indicate a specific disease. 
Fine desquamation rarely follows, and there 
is no albuminuria. Rubella spreads by direct 
infection, the incubation being from two to 
three weeks. This long period of incubation 
causes the source of infection to be often 
overlooked, and even the possibility of it to 
be denied. When carried to a family or school 
either an unnecessary alarm of measles is 
raised; or contagion is denied, and the next 
sufferers are said to have a rose-rash from 
heat, or from irritation of the stomach. 
Dengue. - Widely spread in Africa, the 
warmer parts of America, and both the Indies, 
dengue may possibly be limited to hot cli- 
mates ; its presence with us is as yet undeter- 
mined. The rash is at first discrete, like that 
of measles, but follows soon after infection; 
and the disease in its general course is allied 
to influenza. 
Scarlet Fever.-The finely diffused redness 
is found on the skin and in the mouth and 
throat often within a few hours of the sudden 
ingress of fever. The fever increases with the 
development of the rash, both persisting for 
several days. Often the throat is first com- 
plained of; the glands at the angle of the jaw 
are full and tender; the tongue presents 
prominent red papillae projecting through 
the white fur. The skin is not swollen as 
in erysipelas, nor the redness so circum- 
scribed; the throat also is redder; the cervical 
glands are enlarged in both. Surgical scar- 
latina is often declared three or four days 
after operations; the rash of septicaemia at 
a later period. 
Epidemic Roseola.-This is a name for 
rotheln; also for a rash having such relation 
to scarlet fever as rubella to measles, but with 
slender claim to autonomy. Mild cases of 
scarlet fever often begin with a finely diffused 
redness shortly after some feeling of faintness 
or giddiness, and an incubation of from three 
days to a week; sometimes albuminuria occurs 
as an early symptom. The finely diffused rash, 
enlarged cervical glands, and slight sore-throat, 
even with very little elevation of temperature, 
raise the suspicion of scarlet fever; should 
albuminuria follow, or any shreddy desqua- 
mation of the hands and feet, no uncertainty 
remains. Scarlet fever so modified often 
spreads and gives rise to the severer forms of 
the disease, when it has been called only rose- 
rash or roseola ; the use of these terms with- 
out a distinctive qualification always leaves 
a doubt as to the completeness and safety of 
the diagnosis. 
Erythema.-Erythema comes nearest to 
these cases in appearance-so near as often 
to be spoken of as recurrent scarlet fever or 
erysipelas, but there is no enlargement of the 
cervical glands in erythema, and so little 
fever that the temperature of the reddened 
skin is barely elevated above the normal. 
Since Fuller's Exanthematologia this kind 
of flush passes under different names of 
roseola, according to the variations in shape 
of the red patches, or the seasons of the year 
at which they occur. 
Erythema nodosum.-This disease is often 
preceded by slight fever for a day or two, 
which may reach 102° F., but subsides as the 
red swellings appear. Locally there is little 
or no elevation of temperature, even when 
the tender part feels hot. 
Exanthematous Roseola.-This affection, 
occurring in the course of other specific dis- 
eases, is distinguished from the roseola which 
depends on nerve-irritation, such as that from 
acrid ingesta, by the presence either of high EXANTHEMA 
EXERCISE 
639 
fever, or of glandular enlargement, or of both, 
as when it precedes the true variolous erup- 
tion. During enteric fever this form of roseola 
may occur quite independently of the special 
lenticular rose-spots. 
An eruption of this kind is not infrequent 
in the early stages of diphtheria, sometimes as 
a diffused rash limited to certain parts of the 
chest and body, or as discrete spots on the 
limbs and back of the hands and feet. In- 
fluenza, and some forms of catarrh, winter 
' colds,' or summer diarrhoea as noticed by 
Bateman, may present various kinds of roseola 
on the back, shoulders, and chest; the cer- 
vical glands are perceptibly enlarged, though 
there may be little fever. In these cases it 
is not the roseola, but the specific disease on 
which it depends, that might, without pre- 
cautions, be communicated to others. 
Syphilitic Roseola. - A special roseola 
marks the secondary stage of syphilis; in ap- 
pearance it resembles the rash of measles. 
So does the roseola ab ingestis when produced 
by cubebs, but this has neither fever nor 
glandular enlargement. 
The absence of fever from the roseola after 
vaccination refers this form of eruption, like 
that occurring from dentition, to the class of 
rashes from nerve-irritation. Vaccinia is 
itself an exanthem in the wider definition of 
the term, reproduced after a definite period 
of incubation by inoculating a special con- 
tagium. Wanting this character, the different 
forms of herpes are excluded, unless resulting 
from a general febrile disturbance; though 
inoculable, ecthyma and impetigo are local 
affections not belonging to the exanthemata. 
William Squire. 
EXCITANTS (excito, I excite). -It 
seems hardly necessary to give any special 
consideration to this therapeutical class, as 
all that may be said on the subject ranges it- 
self with greater propriety under the heading 
Stimulants. Stimulation is, in fact, a de- 
gree of excitement; and it is only when its 
effects are more vigorously pushed, that we 
obtain that inebriation or exhilaration which 
is so commonly observed to follow the use of 
alcohol, ether, and the anaesthetic vapours. 
See Stimulants. 
Robert Farquharson. 
EXCITING CAUSES.- See Disease, 
Causes of. 
EXCITO-MOTOR DISORDERS.- 
See Reflex Disorders. 
EXCORIATION (ex,from; and corium, 
the skin).-The superficial destruction of a 
portion of the skin or mucous membrane. 
EXERCISE. - Definition. - In its 
widest and most correct signification, exercise 
is the setting in motion any active body; and 
when the term is used in a physiological 
connection, it may refer to the functional 
activity of any of the organs, whether 
muscular, nervous, nutritive, secretory, or 
reproductive. In this very comprehensive 
sense, the subject of exercise includes a large 
portion both of hygiene and of therapeutics. 
The popular signification of exercise is, how- 
ever, much more limited than the preceding, 
having reference only to the muscles directly, 
and to the parts called into play through the 
same-especially the circulatory and respira- 
tory systems. 
Whether in its wider or in its narrower 
sense, exercise has several important rela- 
tions to Medicine. 1. It is essential to the 
preservation ofhealth (see Personal Health). 
2. It has to be regarded as frequently asso- 
ciated with the causation of disease (see 
Disease, Causes of). 3. Exercise is a most 
rational and successful means of treatment 
in certain disorders and diseases (see Move- 
ment, Therapeutical Uses of). 4. Exercise 
is often abused; and excessive indulgence 
in some forms of it gives rise to serious con- 
sequences. The present article will be de- 
voted to the consideration of exercise in the 
last-named aspect only; and the subject will 
be discussed according to the more limited 
and popular definition of the term. 
Abuse of Exercise.-From the mo- 
ment an infant is born until the end of life, 
exercise, duly apportioned to rest, is the nor 
mal state of existence ; and whilst continued 
overstrain of any portion of the human ma- 
chine is the forerunner of disease, so, on the 
other hand, is equally, if not more so, that 
want of exercise which induces wasting and 
degeneration. 
Principles.-The late Dr. Parkes, in his 
Practical Hygiene, has given a very com- 
plete statement of the results of the inves- 
tigations of himself and others on the changes 
effected by the stimulus of muscular exercise 
on the various organs and tissues of the body, 
from which he has drawn the following con- 
clusions :- 
' The main effect of exercise is to increase 
the oxidation of carbon, perhaps also of hy- 
drogen. It also eliminates water from the 
body, and this action continues-as seen from 
Pettenkofer and Voit's experiments - for 
some time ; after exercise the body is there- 
fore poorer in water, especially of the blood; 
it increases the rapidity of circulation every- 
where, as well as the pressure on the vessels, 
and therefore it causes in all organs a more 
rapid outflow of plasma and a more active 
absorption-in other words, a quicker re- 
newal. 
' In this way, also, it removes the product 
of their action which accumulates in organs; 
and restores the power of action to the vari- 
ous parts of the body. It increases the out- 
flow of warmth from the body by increasing 
perspiration. It therefore strengthens all 
parts. It must be combined with increased 
supply both of nitrogen and carbon (the 640 
EXERCISE 
latter possibly in the form of fat), otherwise 
the absorption of oxygen, the molecular 
changes in the nitrogenous tissues, and the 
elimination of carbon, will be checked. There 
must also be an increased supply of salts, 
certainly of chloride of sodium, probably of 
potassium phosphate and chloride. There 
must be proper intervals of rest, or the store 
of oxygen, and of the material in the mus- 
cles which is to be metamorphosed during 
contraction, cannot take place. The integrity 
and perfect freedom of action both of the 
heart and lungs is essential, otherwise neither 
absorption of oxygen, nor elimination of car- 
bon, can go on, nor can the necessary increased 
supply of blood be conveyed to the acting 
muscles without injury.' 
The proper amount of exercise requisite 
for health is difficult to determine, in conse- 
quence of the varied constitutions of indi- 
viduals. It may, however, be accepted that 
whilst in youth the great spirit of emulation 
tends to an overstrain of mind or body, so, 
as life advances, one or other or both are 
liable to be allowed to pass into a state of 
unhealthy inactivity. 
Since the more general practice of gym- 
nastics in this country, and the stimulus 
that has been given to aquatic exercises by 
our University competitions, great attention 
has been drawn to the effect of bodily exer- 
cise on health, and more especially with 
regard to the heart and lungs, these being 
the organs upon which its influence is most 
immediately exerted. 
Prolonged and Excessive Exercise.- Of 
all exercises, rowing is the one which is 
generally accepted as the best variety to 
select, if we are to endeavour by a consider- 
ation of its influence upon those who prac- 
tise it to form an estimate of the effect of a 
continuous strain on the circulation and re- 
spiration ; yet the difficulty of procuring 
trustworthy evidence on such a subject is 
extreme. Dr. Morgan, in his University 
Oars, by collecting the various experiences 
of nearly all the men who rowed in the Uni- 
versity races from 1829 to 1869, has obtained 
about the most accurate testimony available 
in regard to one aspect of the subject. These 
men are unanimous in their belief that they 
experienced no injury from the great strain 
they underwent in their youth. But it must 
be borne in mind that they were the picked 
athletes of their colleges, men with large 
frames and full chests, typical specimens of 
health, capable of undergoing very prolonged 
exertion with but passing fatigue, and to 
whom no permanent injury could be antici- 
pated, after careful training, from an excep- 
tional display of strength. . Such evidence 
affords no clue to the effect of the strain im- 
posed on the heart by the two hundred or 
more of each University, who annually use 
the utmost exertion to belong to the chosen 
few, and many of whom, unguided in their 
violent efforts to achieve success, have in 
after-life to pay the penalty of allowing mere 
feeling or the spirit of emulation to overrule 
their reason. 
Exercise under Unnatural Conditions.- 
But it is not only the case that exercise which 
is excessive or too prolonged proves highly 
deleterious; even a moderate amount of ex- 
ercise under unnatural conditions may prove 
equally harmful. Thus the young soldier of 
light frame, with irritable palpitating heart, 
who has broken down in his preliminary 
training, is a marked and good example of 
the early injurious effect of overstrain of the 
heart, under the impediment caused by tight 
clothing and accoutrements to the free ex- 
pansion of his chest. "When at rest he feels 
perfectly well, and has little or no sensation 
of throbbing in his chest. So soon, however, 
as he puts on his tunic and accoutrements, 
and begins his drill, throbbing occurs with 
more or less violence, accompanied with a 
feeling of oppression, and with difficulty of 
breathing, and this being followed by a sen- 
sation of faintness, sickness, or dizziness, he 
has to fall out of the ranks. At first the con- 
dition of the heart is one purely of functional 
disturbance, which, though rendering him 
unfit for the duties of a soldier, does not in- 
terfere with his gaining his livelihood as a 
civilian. 
This functional derangement of the heart, 
which is readily shown by the dicrotism in 
the sphygmographic tracing of the radial 
pulse when auscultation can detect little or 
no change in the heart-sounds, is frequently 
found in those youths of delicate frame in 
our schools and colleges, who, ' breaking 
down ' in attempting feats of strength or in 
the preliminary training, experience no ill- 
effects in the ordinary avocations of after-life 
from that overstrain of heart which, if neg- 
lected, would be apt to lead to graver forms 
of heart-disease. 
Whether it be by sudden or prolonged 
violent exertion, by rowing, or by running, 
or by the many other severe exercises of the 
body entailed by labour or pleasure, there can 
be no doubt that the heart and lungs have at 
times an inordinate amount of strain forced 
upon them, which, in a state of health, or 
under favourable circumstances, they may 
reasonably be expected to bear with no more 
injury than temporary distress, and that this 
capability to bear strain is greatly enhanced 
by careful training. 
It is customary for the healthy boy, how- 
ever, owing to the character of his amuse- 
ments, always to be in training, so far as his 
body is concerned, and with very little super- 
vision he ought to suffer no harm from sudden 
and .exceptional strains. But it is very dif- 
ferent with men who have settled down into 
the real business of life, who, during their 
nominal periods of rest from their daily 
labours, undertake violent exercises without EXERCISE 
EXHAUSTION 
641 
any preliminary training, and thus throw such 
an unexpected strain on the heart and great 
blood-vessels, that instead of mere functional 
disturbance, as in early life, they sow the 
seeds of organic disease. Such being the 
case, how much more injurious must sudden 
overstrain be to a heart already weakened 
by disease ? There is often found amongst 
men a great aversion to having their hearts 
examined, and when disease is discovered it 
is sometimes considered of questionable ad- 
vantage to inform the sufferer of his con- 
dition ; but this is a mistake, for from want 
of knowledge of his state he may, by un- 
necessary strain, rapidly aggravate it, and 
thus shorten a life which might otherwise 
have been much prolonged. 
The purport of these observations is thus 
to point out that: First, whereas exercise is 
necessary to preserve our bodies in a proper 
state of healthy activity, its tendency, when 
carried to extremes, is to set up organic 
lesions. Secondly, that as in some athletic 
competitions a very great strain is thrown 
upon the thoracic organs, it is essential that 
no boys of delicate frame should be allowed 
to take part in them, or in the preliminary 
training, excepting under careful medical 
supervision. And, thirdly, that in manhood 
no violent competition should be undertaken, 
which would throw a great strain upon the 
thoracic organs, without their being pre- 
viously examined and pronounced sound, nor 
until their full powers bave been brought into 
play by careful preliminary training. 
A. B. R. Myers. 
EXFOLIATION (e®, from; and folium, 
a leaf).-The separation of a portion of dead 
bone or cartilage from the living tissue, in 
the form of layers (see Bone, Diseases of). 
The term is also applied to the separation of 
a false membrane, which has been mistaken 
for the whole mucous lining of the bladder or 
uterus. See Bladder, Diseases of. 
EXHAUSTION (ex, from; and haurio, 
I draw out). 
Definition.-Exhaustion is a phenomenon 
which all irritable tissues can be made to 
manifest, and consists in a failure to respond 
to stimulation. Exhaustion of muscle and 
nerve is brought about by excessive, quickly 
repeated, or continuous stimulation. It is 
favoured by cutting off, or by an alteration 
in the quality of, the blood-supply; by pre- 
vious insufficient exercise of function; by 
exposure to extremes of temperature; by an 
insufficient supply of oxygen; by an excessive 
supply of carbonic acid; and by exposure to 
certain toxic agents. These facts, which 
have been established by physiological ex- 
periments, are fully borne out by clinical 
experience. 
Exhaustion may be general or local. 
1. General Exhaustion.-General ex- 
haustion is brought about by over-work, 
whether physical or mental, and especially 
by unremitting and monotonous duties which 
keep the same paths of action in a state of 
constant activity. It is not often, if ever, 
that any permanent harm is produced in a 
healthy man by mere physical labour, how- 
ever great; but excessive mental labour, 
especially if it be monotonous, is certainly 
capable of permanently damaging the ner- 
vous tissues. When in addition to hard 
mental work, which is performed voluntarily, 
some constant stimulus, which cannot be 
arrested, unceasingly works upon the brain, 
exhaustion quickly results; as when, for 
example, a man who is harassed by trying 
to earn sufficient for his family meets with 
some shock to his nervous system (such as a 
railway accident, the sudden death of a dear 
relative, or a severe money loss) which haunts 
him like a spectre day and night, robs him 
of his rest, and deprives him of his appetite. 
General exhaustion is favoured by all con- 
ditions which give rise to anaemia or faulty 
nutrition, such as haemorrhage, prolonged 
pyrexia, inadequate diet, persistent morbid 
discharges, or venereal excess ; by the reten- 
tion in the tissues of the products of their 
activity, which is favoured by working in a 
foul atmosphere, or by derangement of the 
excreting functions; by exposure to extremes 
of temperature; and by a previous condition 
of excessive slothfulness. General exhaustion 
may occasionally be suddenly induced by 
physical causes, such as a severe injury 
(collapse from shock), or psychical causes, 
such as fright. 
Symptoms.-The symptoms of general ex- 
haustion are: 1. Loss of sleeping power, 
persistent dreaming, talking in the sleep, and 
somnambulism. The patient may wake in the 
morning feeling totally unrefreshed. 2. In- 
capacity for work, and inability to seriously 
apply the mind to one subject for any length 
of time. 3. Headache, and a feeling of oppres- 
sion in the head. 4. Languor and general 
lassitude. 5. A rapid feeble pulse. 6. An 
anxious expression of face; and (as stated by 
Dr. George Johnson) a contracted and slug- 
gish pupil. In addition to these we may get 
tremor, delirium, hypochondriasis, hysteria, 
epilepsy, chorea, mania, and general para- 
lysis. Two instances have come within the 
writer's knowledge of transient hemiplegic 
symptoms having been induced by excessive 
application to literary work. The digestion 
is often deranged, and functional disturbance 
of the heart is common. Occasionally the 
urine is altered in quality, and may contain 
alkaline phosphates or sugar. More rarely it 
manifests excessive acidity. 
2. Local Exhaustion.-Local exhaus- 
tion is the result of excessive local stimu- 
lation, and it is particularly liable to occur as 
a prominent symptom in patients who are 
suffering from general exhaustion. The loss 642 
EXHAUSTION 
EXOPHTHALMIC GOtTRE 
of power in the rectum which results from 
the excessive use of purgatives; the failure 
of the uterus in cases of protracted labour; 
and the failure of the voluntary muscles 
which occurs in those professional ailments 
of which ' writer's cramp ' is the type, may 
be taken as examples of local exhaustion. 
Treatment.-In the treatment of exhaus- 
tion the main indications are to lighten the 
labour, and obtain rest. In cases of general 
exhaustion it is often advisable to administer 
narcotics, such as opium, chloral, sulphonal, 
or bromide of potassium; and it will be gene- 
rally found that, when once refreshing sleep 
has been established, the more aggravated 
symptoms will subside. Fresh air and a good 
diet are most necessary. Stimulants must be 
used with great caution, for it is clearly not 
desirable to goad the exhausted organs into 
further action, although it may be necessary 
to employ stimulants to give temporary 
power while the faculty of sleeping is being 
re-established. All causes of anaemia must 
be removed. When recovery is established, 
the patient must be encouraged to relieve 
the monotony of his life by some pursuit 
which should be, as it were, the complement 
of his ordinary occupation. Thus the head- 
worker should endeavour to amuse himself 
in his leisure hours by gentle out-door exer- 
cise, by music or painting, or by practising 
some handicraft. See Debility ; and Fatigue. 
G. V. Poore. 
EXOMPHALOS (e£, out; and o^aKos, 
the navel).-A term applied to umbilical 
hernia. See Hernia. 
EXOPHTHALMIC GOITRE (^, 
out; d00aX/z6$, the eye; and guttur, the 
throat).-Synon. : Graves's Disease : Base- 
dow's Disease; Fr. Maladie de Graves; 
Goitre exophdhalmique ; Ger. Glotzaugen- 
ter opf", Basedow'sche Krankheit. 
Definition.-Enlargement with vascular 
turgescence of the thyroid gland, accom- 
panied by protrusion of the eyeballs, breath- 
lessness, palpitation, tachycardia, and an- 
aemia. 
Aetiology.-This disease is comparatively 
rare in men. It occurs most frequently 
in women between the ages of twenty and 
thirty, but is met with amongst older persons. 
Patients suffering from it often belong to the 
so-called nervous diathesis. Its occurrence 
is often preceded by menstrual disturbance 
and anaemia. Sometimes no exciting cause 
can be discovered, but in many cases it comes 
on after violent nervous excitement, some- 
times after acute disease. 
Symptoms.-Before exophthalmic goitre 
makes its appearance, alterations in temper 
are frequently observed, the patient becom- 
ing irritable and depressed. Functional dis- 
turbances of the circulation and heart occur 
at frequent intervals, the heart palpitating, 
the face flushing, and a sensation of fulness 
being felt in the head, eyes, and throat. The 
palpitation increases, the eyes become promi 
nent, and a visible swelling appears in con- 
nexion with the thyroid gland. The eyes 
are lustrous and projecting, and there is 
frequently a slight loss of co-ordination be- 
tween their movements and those of the 
eyelids, so that when the eyes are quickly 
cast down the eyelids follow them so slowly 
that a white ring of sclerotic may be no- 
ticed between the iris and the lower margin 
of the upper eyelid. Usually there is no 
disturbance of vision. The exophthalmos 
is most marked during emotional excite- 
ment and at the menstrual period, and at 
these times the patient suffers from an in- 
creased feeling of fulness in the eyeballs. 
Sometimes the projection of the eyeballs is 
so great that the lids do not perfectly cover 
them, and inflammation and ulceration may 
consequently occur. The thyroid is gener- 
ally unequally enlarged. Its size varies from 
time to time, increasing, like the protrusion 
of the eyeballs, with emotion. It is soft and 
elastic, and pulsates, so that it has sometimes 
been mistaken for aneurysm. The palpita- 
tion of the heart is generally noticed before 
either the exophthalmos or enlargement of 
the thyroid, and is the first symptom to at- 
tract the patient's attention. It is increased 
by emotion or exertion; and the violent 
cardiac action frequently produces a promi- 
nence of the praecordial region. The cardiac 
pulsations are rapid, and sometimes irre- 
gular. The cardiac sounds are loud; and 
a soft, systolic bellows-murmur is frequently 
audible at the base, and in the large arteries. 
The carotids are sometimes, but not always, 
dilated. The circulation appears to be rapid, 
the veins filling quickly when emptied, and 
pulsation being felt even in small arteries. 
The temperature is frequently high. There is 
a feeling of general debility. The digestion is 
sometimes normal, at other times the appe- 
tite is diminished or capricious, and diarrhoea 
may occur. The swelling of the neck may give 
rise to a feeling of difficulty of breathing ; and 
the voice sometimes becomes altered and 
hoarse, or may be lost entirely. The course of 
the disease varies considerably : it may some- 
times go on increasing for several months, 
then it becomes stationary for one or two 
years, and afterwards begins to decline. The 
temper improves, the appetite increases, and 
menstruation frequently is re-established. 
The palpitation, enlargement of the thyroid, 
and prominence of the eyes gradually dimi- 
nish, although they rarely disappear com- 
pletely. Death may occur from intercurrent 
disease, from organic, cardiac lesions, from 
uncontrollable diarrhoea, or from gradual 
wasting. Danger is also said to arise from 
pressure on the trachea by the enlarged 
thyroid. 
Pathology.-The protrusion of the eye- EXOPHTHALMIC GOITRE 
EXPECTORANTS 
643 
balls is due either to dilatation of the vessels 
in the orbit, or to contraction of the involun- 
tary muscular fibres in the orbital membrane 
which covers the spheno-maxillary fissure, or 
possibly to both causes combined. The en- 
largement of the thyroid is due to dilatation 
of the vessels of the gland. After the disease 
has lasted some time, increased formation of 
tissue in the thyroid gland may occur. Pal- 
pitation of the heart is probably due to stimu- 
lation of the accelerating cardiac nerves; and 
this, as well as the alteration in the nerves of 
the orbit and thyroid, has been ascribed to 
disease of the lower cervical sympathetic 
ganglia, in which increased connective tissue 
and diminution of ganglionic cells have been 
observed. 
Diagnosis.-When the three leading symp- 
toms are present, it is impossible to confound 
exophthalmic goitre with any other disease. 
The enlargement of the thyroid is distin- 
guished in this disease from that of cystic 
goitre by its greater elasticity, by its paroxys- 
mal enlargement, and by its pulsation. The 
exophthalmos is distinguished from that due 
to disease of the orbit or cranium by being 
equal in both eyes, and by the absence of 
squint. It is distinguished from prominence 
due to cardiac disease by the lustrous appear- 
ance of the eye; from hydrophthalmia by the 
natural condition of the pupil; and from the 
prominence which may occur in myopia by 
the vision being natural, and by the paroxys- 
mal increase of the prominence in exoph- 
thalmic goitre. 
Prognosis.-This must be guarded, the 
disease not being very amenable to treatment, 
and very rarely disappearing altogether, al- 
though after continuing for some years it 
may gradually improve. 
Treatment.-The treatment of exophthal- 
mic goitre chiefly consists in securing fresh 
air, gentle exercise, the avoidance of the least 
fatigue or emotional disturbance, and careful 
diet. Iron is sometimes useful, the milder 
forms, such as the tartarated iron or citrate 
of iron and ammonia, being preferable to the 
more powerful preparations. The writer be- 
lieves he has seen much improvement from 
saccharated solution of lime. Quinine, alone 
or in combination with digitalis-and perhaps 
with belladonna-often produces good results. 
Digitalis and strophanthus are occasionally, 
but not always, useful. Aloes and myrrh 
may be employed to keep the bowels open. 
Galvanism to the neck has sometimes been 
productive of benefit, one pole being placed 
on the nape of the neck and the other along 
the sides of the thyroid tumour. When the 
eyeballs are so prominent as to become liable 
to inflammation and ulceration, care must be 
taken, by means of a shade, to protect them 
from irritation ; and if this should prove un- 
availing, the inflammation must be treated 
by appropriate remedies. 
T. Lauder Brunton. 
EXOSTOSIS (e£, out of; and oareov, a 
bone).-A bony outgrowth from any part of 
the skeleton. See Bone, Diseases of. 
EXPECTANT ATTENTION.-An 
important mental state. See Mesmerism. 
EXPECTORANTS (ex, out of; and^ec- 
tus, the chest).-Synon. : Fr. Expectorants • 
Ger. Auswurfsbefbrdernde Mittel. 
Definition.-Medicines which facilitate 
the removal of secretions from the air-pas- 
sages. 
Enumeration.-The leading expectorants 
are :-(A) Ipecacuanha, Antimony, Apomor- 
phine, and Iodide of Potassium; Chlorides 
of Potassium, Sodium, and Ammonium; and 
Inhalation of Steam. (B) Squill, Senega, 
Benzoin, Benzoic Acid, Benzoate of Ammo- 
nium ; Myrrh, Storax, Balsam of Tolu, 
Balsam of Peru, Ammoniacum, Galbanum, 
Asafoetida, Anise, Fennel; Larch Bark, Tar, 
Terebene, Copaiba; Vapour of Chlorine, 
Iodine, Ammonia, Creasote, and Carbolic 
Acid. (C) Ammonia, Carbonate of Ammo- 
nium, Strychnine, Nux Vomica, and Bella- 
donna. 
Action.-The mode of action of expector- 
ants is not well understood, and any explana- 
tion of it in the present state of our know- 
ledge can only be regarded as provisional. 
Expectorants may be divided into two 
classes-(1) Those which modify the nature 
of the secretions from the respiratory pas- 
sages ; and (2) those which modify the respi- 
ratory movements by which the secretions 
are expelled. In considering the mode of 
action of the first class it must be remem- 
bered that the secretions from the respiratory 
passages depend, like many other secretions, 
on two factors, the direct influence of the 
nerves upon the secreting structures, and the 
amount of blood supplied to them. Each of 
these two factors may be influenced to a dif- 
ferent extent by various drugs. As has already 
been said, the exact action of each cannot be 
determined at present, but the first class of 
expectorants may be subdivided into two 
divisions which are distinguished in the fore- 
going enumeration as A and B. The division 
A rather diminish than increase the activity 
of the circulation, and are therefore called 
sedative expectorants. The division B some- 
what increase the circulation, and are called 
stimulating expectorants. Those comprised 
under C stimulate the respiratory centre in 
the medulla oblongata, and increase the re- 
spiratory movements. 
Uses.-Sedative expectorants (class A) are 
useful when there is congestion of the respira- 
tory passages, with very scanty, tough expec- 
toration, as in commencing bronchitis. In 
such circumstances, when dry rhonchi are 
heard abundantly, with few or no moist rales, 
the patient often coughs until quite exhausted, 
bringing up scarcely anything. The adminis- 
tration of sedative expectorants renders the 644 
EXPECTORANTS 
EXPECTORATION 
secretion from the respiratory passages more 
fluid, abundant, and easy to expectorate. 
"When these expectorants do not succeed in 
ordinary doses, their action may be much as- 
sisted by the administration of a purgative, 
or, still better, by giving either ipecacuanha 
or tartar emetic in such a large dose as to 
produce sickness and vomiting. "When the 
distress of the patient is great, the abstraction 
of a small quantity of blood by cupping or 
by venesection may give great relief. The 
inhalation of steam alone is also beneficial, 
and the air of the patient's chamber should 
be kept warm and moist. 
Stimulating expectorants (class B) do 
more harm than good when administered in 
the conditions just described, but are bene- 
ficial when the acute symptoms have passed 
off. When this is the case, but the expec- 
toration is tough and somewhat scanty, squill 
is a useful expectorant; but when the expec- 
toration is abundant, benzoin, balsams or 
ammoniacum would be preferable. In chronic 
bronchitis, inhalations of ammonia, chlorine, 
iodine, creasote, carbolic acid, eucalyptus, or 
pine oil are useful. When the expectoration 
is foetid, chlorine, iodine, and carbolic acid 
inhalations are best. 
The expectorants which act on the respi- 
ratory movements (class C) are useful in 
cases of debility, as they stimulate the respi- 
ratory nervous centre in the medulla oblon- 
gata, as well as assist the failing circulation. 
They may be advantageously combined with 
stimulating expectorants, such as squill or 
benzoin, according to the nature of the 
secretion. 
T. Lauder Brunton. 
EXPECTORATION (ex, out of; and 
pectus, the chest). 
Definition.- This word, which strictly 
means the act of expelling anything from the 
chest, is usually applied to the matter so 
expelled, which is also called sputum or 
phlegm. 
The Act of Expectoration.-The smaller 
bronchial tubes are kept free from obstruction 
by the action of ciliated epithelium. The area 
of the smaller tubes being greater than that 
of their trunks, the air passes more forcibly 
through the latter, and so tends, even in 
natural breathing, to carry speedily away any 
accumulated secretion. The forcible acts of 
coughing (see Cough) and ' hawking ' increase 
the natural force and fulness of the expiratory 
effort, and clear the air-passages; the repeated 
closure of the glottis in coughing increases 
still further the expulsive effect, by causing 
the air to escape in sudden jerks. If the 
glottis cannot close in consequence of laryn- 
geal disease, the act of expectoration becomes 
painful and difficult. Efforts at expectora- 
tion are also laboured and futile if the power 
to take a deep inspiration is lost in conse- 
quence of emphysema or muscular weakness. 
Inability to expectorate is often the imme- 
diate cause of death, the 'suffocative catarrh* 
of the dying being another name for accumu- 
lation of phlegm which the patient is power- 
less to remove. By teaching the patient 
' how to expectorate,' by the administration 
of a timely stimulant or a quickly acting 
emetic, or by change of posture, life may in 
such a case be prolonged. Should the suf- 
ferer be allowed to get flurried, the breathing 
becomes more and more shallow, and deep 
inspiration and free expectoration are impos- 
sible. If, however, the patient can be induced 
to breathe calmly and deeply, to assume a 
more easy posture, and to swallow a mixture of 
ammonia with ether, the breathing gradually 
becomes less shallow and rapid, air enters the 
deeper parts of the lung, and power is gained 
to evacuate the accumulated secretion (see 
Stertor). The act of expectoration is, as 
a rule, most easy in that posture in which 
respiration is most free. Sometimes when 
the secretion comes mainly from one lung, 
the aid of gravitation may be called in to 
empty the obstructed tubes. 
Characters and Varieties.-Before aus- 
cultation was practised, diagnosis was often 
based on the character of the expectoration, 
unwarrantable importance having been at- 
tached to the distinction between pus and 
mucus, on the assumption that pus was dia- 
gnostic of phthisis. At the present time we 
are apt to lose much useful information by 
falling into the opposite error. 
In health, the secretion from the mucous 
membrane of the air-tubes is a transparent, 
colourless, slightly glutinous liquid, like thin 
mucilage; it contains mucin, a varying quan- 
tity of saline matter, and water. 
The saline matter is abundant in the trans- 
parent viscid expectoration, deficient in the 
opaque and less tenacious kind, least in that 
which is actually purulent. 
The ordinary mucous secretion is increased 
in quantity and viscidity as a result of simple 
catarrhal inflammation of the bronchial mem- 
brane. "When bronchitis has existed for some 
days, a change occurs in the character of the 
secretion; instead of being transparent and 
viscid, it becomes semi-transparent and then 
opaque, the colour changing to a yellow or 
greenish hue. 
The sputum becomes frothy from the ad- 
mixture of air; and rusty or prune-juice- 
coloured if the inflammatory action extends 
to the ultimate bronchial ramifications, and 
is of so intense a kind as to allow of oozing 
from the capillary vessels. 
Fibrinous moulds of the bronchial tubes, 
or chalky masses consisting of inspissated 
and calcified cheesy matter, are not infre- 
quently expectorated. 
The dark grey or blackish stain often seen 
in expectoration may be derived from carbon 
in the atmosphere; or, if it fade on the addi- 
tion of nitric acid, it may be due to pulmo- nary pigment formed under slight irrita- 
tion. 
The expectoration may afford important 
aid in diagnosis, as may be illustrated by the 
following examples : If a person with severe 
chest-complaint coughs frequently and spits 
only frothy salivary fluid, we may suspect 
pleurisy. If the fluid is glairy, like white of 
egg, we may suspect bronchitis. If it has a 
rusty tinge and resembles thick gum-water 
coloured with blood, we are not likely to err 
in recording pneumonia. If there is a sud- 
den gush of foetid pus we may diagnose ab- 
scess in the lung or an empyema. 
Purulent expectoration may occur in bron- 
chitis as well as in phthisis; but if long con- 
tinued, and unaccompanied by distinct rhon- 
chus, it almost always comes from a vomica. 
The excessively offensive expectoration of 
pulmonary gangrene, and that arising from 
a bronchiectatic saccule, are diagnostic of the 
affections from which they spring. 
In phthisis the sputum is at first salivary 
or frothy, the result of irritation: then viscous, 
indicative of more confirmed affection of the 
mucous membrane; and subsequently dotted 
and streaked with blood. Whitish opaque 
spots, giving a pearly aspect to the expecto- 
ration, next appear; these enlarge, become 
flocculent and ultimately nummular, being 
inspissated and moulded in a cavity. As the 
disease advances and involves both lungs, the 
expectoration is entirely purulent, and shortly 
before death is often surrounded with a 
pinkish halo. On placing under the micro- 
scope one of the small pearly points described, 
masses consisting of several air-cells choked 
with granules, or mere fragments of elastic 
tissue may occasionally be seen. By the ad- 
dition of acetic acid the sputa may be ren- 
dered transparent, and the elastic tissue is 
then, if present, more certainly detected; but 
practically the experienced eye is the best 
guide in the selection of those small pin-head 
flocculi of expectoration, in which the micro- 
scopic particles of lung-tissue are to be de- 
tected. 
The microscope may also be helpful by in- 
dicating, from the character of the cells, the 
part of the respiratory tract involved, and 
the degree of disease existing. (For the de- 
tection of tubercle bacilli, a point of great 
practical importance, see Phthisis ; and Spu- 
tum, Examination of.) The existence of can- 
cer of the lung may sometimes be detected 
by a microscopical examination of the expec- 
toration. 
Treatment.-In treatment, much may be 
gained by study of the expectoration. The 
cough may often be relieved, and the dyspnoea 
and other symptoms removed, by effecting 
an alteration in the nature of the secre- 
tion. 
If by the frothy character of the sputa 
congestive disorder is indicated, this may 
be met by the application of warm poultices, 
EXPECTORATION 
turpentine stupes, or hot flannels externally; 
and by such means as are calculated to re- 
duce fever and irritability, namely, the ad- 
ministration of salines with antimony or 
aconite. If the expectoration is too viscid 
and glutinous for easy removal, lemon-juice, 
liquor potassse, soda, or various inhalations 
give relief, by lessening the tenacity of the 
secretion ; or the change from tenacious and 
transparent to opaque, less adhesive secretion 
may be hastened by giving iodide of potassium 
with a few drops of antimonial wine. 
When muco-purulent secretion is estab- 
lished and shows no sign of diminution, the 
use of senega and of the gum-resins is indi- 
cated ; these may be given in the form of 
lozenge, while benzoin, tolu, and copaiba are 
also of value. Acetic or tannic acid, given 
in small and frequently repeated doses, re- 
duces the quantity of secretion. 
When the combined glairy and muco- 
purulent condition of the expectoration and 
other symptoms give evidence of bronchitis 
of an established kind, associated with gout 
or abdominal torpor, a combination of calo- 
mel with antimony and guaiacum (as in 
Plummer's pill) is of the greatest service; 
but this treatment needs perseverance, dis- 
crimination, and watchfulness. The morbid 
surface may at the same time be medicated 
by the inhalation of tar, creasote, or oil of 
juniper, until, with the improvement of the 
general health, under cod-liver oil and iron, 
the evil is entirely removed. 
E. Symes Thompson. 
EXPOSURE, Effects of.-Were the 
term ' exposure ' to be taken in its widest 
significance, it might fairly claim to include 
a range of subjects only bounded by the 
limits of practical medicine. Infection 
naturally implies exposure to some contagious 
influence, poisonous gas, or malarious or 
other unhealthy emanation, bearing in its 
train a formidable sequence of ill results, 
and probably depending on the introduction 
within the system of a specific form of 
microbe. Many of the disorders which im- 
pair our comfort and shorten our lives may, 
indeed, be traced, in some degree, to expo- 
sure of some kind, to an excess of heat or of 
cold, to a variety of complicated reactions, 
arising, in whole or in part, from unnatural 
impressions made on the physiological pro- 
cesses of life by various external agencies. 
Any study of our subject, however, from this 
extended point of view, would clearly be out 
of place here, and effects of extreme elevation 
and depression of temperature will be fully 
considered elsewhere; so that exposure, in the 
sense in which it will be treated here, may be 
narrowed down to the results which ensue 
when persons of average constitutional power 
are submitted, for a longer or shorter time, to 
the influence of ordinary cold, or wet, or 
damp. Now, it is an old saying, that if five 
EXPOSURE, EFFECTS OF 
645 646 
EXPOSURE, EFFECTS OF 
EXTRAVASATION 
or six people, of either sex, suffer shipwreck, 
or are wet through, or excessively chilled by 
moist cold, each will probably suffer in some 
different way. One may altogether escape, 
and not experience inconvenience of any 
kind; a second may ' catch '-as the popular 
expression puts it-a sore-throat, or a ' bad 
cold; ' whilst a third may be seized with 
pneumonia; and a fourth with rheumatic 
fever. 
Individual constitution or idiosyncrasy 
partly explains these differences, and the 
familiar term of a ' weak point somewhere,' 
if not conveying much impression of scien- 
tific accuracy, is right so far in showing that 
the internal congestion caused by sudden 
contraction of cutaneous arterioles is most 
naturally directed to that organ whose vessels 
have been weakened by previous inflamma- 
tion. If the patient, therefore, have pre- 
viously suffered from tonsillitis, or bronchial 
congestion, or rheumatism, he will be predis- 
posed to a recurrence of the same affection 
on a renewal of the exciting cause. If, again, 
from sedentary occupation and over-indulg- 
ence in nitrogenous food, his blood be over- 
charged with the products of retrograde 
metamorphosis or of imperfect assimilation, 
it only needs the closure of the eliminatory 
agency of the skin, to provoke the irritation 
of internal organs, and to induce an attack of 
gout or rheumatism, or an acute inflamma- 
tion of kidneys or liver. The effects of expo- 
sure, even in this limited sense, are thus 
tolerably various both in extent and in degree, 
and may be studied on a large scale during 
our greater campaigns, and in lesser degree 
during the ordinary autumn manoeuvres, 
when the weather happens to be unfavourable. 
Here, however, everything injurious is mini- 
mised by the healthy condition of the men, 
their good clothing and food, and the enforced 
regularity of habits, which prevent, in great 
measure, one of the most fertile causes of 
damage from exposure; and among the most 
efficient means for preventing the potent in- 
fluence of bacilli for evil, we must place all 
hygienic means which improve the bodily 
vigour. It is now well known that nothing 
tends so seriously to impair the power of 
bearing either extreme of temperature as 
excessive indulgence in strong drink; so that 
in treating anyone who has been exposed to 
the influence of cold and wet, we must not 
forget to take also into account the probable 
combination of the depressing effects of 
alcohol on the nervous system. Illustrations 
of this must be familiar to all, and we must 
all have met with numerous cases in which 
tramps or other persons with weakened bodily 
vigour have been brought into our hospitals, 
suffering from the effects of exposure in 
various degree. 
Treatment.-In seeking to remedy the 
effects just described, it will be found that 
some of the cases will recover under the 
influence of warmth and good food, and the 
generally invigorating effects of careful nurs- 
ing ; whilst others, on the other hand, may 
succumb to the rapidly destructive tendencies 
of acute disease, or to the slower pathological 
processes of chronic lung or kidney degenera- 
tion. In the treatment, therefore, of such 
cases, we must not only add to the genial 
influences of home or hospital care such 
special drugs as the varied development of 
symptoms may require, but we must carefully 
take into account the occurrence of various 
serious or profoundly disorganising compli- 
cating causes. Thus if our patient has been 
found, in an insensible state, we may reason- 
ably suspect cerebral haemorrhage or alcoholic 
or narcotic poisoning, and act accordingly. 
And only when all such suspicion is finally 
removed can we rest on our oars, and confine 
our attention to the immediate effects which 
follow exposure of the kind indicated above. 
Warmth, rest, and the regulated use of 
stimulants and food will now be indicated, 
and must be employed, with all the precau- 
tions suggested by the ordinary principles of 
therapeutics and by common sense. 
Robert Farquharson. 
EXSANGUINE (ex, without; and 
sanguis, blood).-Deprived more or less of 
blood-bloodless. Sometimes used synony- 
mously with anaemic. See Anaemia. 
EXTRA-UTERINE FGETATION. 
See Pregnancy, Diseases and Disorders of. 
EXTRAVASATION (extra, without; 
and vasa, vessels).-Synon. : Fr. Extravasa- 
tion", Ger. Extravasat. 
Definition.-Extravasation is the escape 
of any of the fluids of the body, normal or 
abnormal, from the vessel, cavity, or canal 
that naturally contains it, and its diffusion 
into the surrounding tissues. The result of 
the effusion is also called an extravasation. 
Extravasation, being the effect of rupture 
or perforation of the walls of. a hollow organ, 
may be due to injury, to weakness of the 
parietal structures, to morbid conditions of 
the blood, or to increase of internal pressure. 
See Perforations and Ruptures. 
The fluids most frequently found extrava- 
sated are blood, urine, bile, the contents of 
the alimentary canal, and certain constituents 
of morbid growths and fluid collections. The 
present observations will have reference 
only to extravasation of blood; other kinds 
of extravasation being described under the 
heads of the several organs involved. 
Extravasation of Blood.-The blood 
is peculiarly liable to extravasation, the 
vessels being universally distributed, much 
exposed to injury-a very common cause 
of this lesion-and subject also to a con- 
stant pressure from within, which may be 
suddenly and greatly increased. Any portion of the circulatory system may give way: the 
heart, as in fatty degeneration ; the arteries, 
as in aneurysm; the capillaries, as in pul- 
monary haemorrhage; the veins, as in the 
subcutaneous rupture of a varix. 
"When the effusion takes place into one of 
the serous sacs, it forms a collection of blood, 
variously named hcemothorax, hcematocele, 
&c. If the subcutaneous, submucous, or 
other connective tissue, or the substance of 
an organ, be invaded, the effused blood finds 
its way between the elementary textures, 
separating and compressing them; and there 
are formed what are described simply as 
extravasations of blood, or more definitely, 
according to their extent, parenchymatous 
or interstitial hcemorrhages or apoplexies, 
suffusions, ecchymoses, petechice, or vibices. 
The extravasated blood generally coagulates; 
the fibrin and albuminous substances are 
absorbed; and the products of the decompo- 
sition of haemoglobin, which are much more 
slowly removed, give rise to the familiar 
discolorations. The seat of effusion first 
appears of the colour of blood or its deriva- 
tives ; but if much below the surface, the 
extravasation may not be visible for some 
days, after which time it appears of a bluish, 
greenish, or yellowish hue. Much less fre- 
quently the effused blood becomes encap- 
suled, forming a hcematoma or blood-cyst, such 
as is occasionally seen in connexion with the 
chest or abdomen. In other cases it decom- 
poses, and sets up gangrene around, or in- 
flammation of the nature of severe cellulitis, 
which may end in ulceration. When the 
blood is forced between the coats of the per- 
forated vessel, there is formed what is called 
a dissecting aneurysm. If the extravasated 
blood escape from the surface of the skm or 
mucous membranes, one form of hcemorrhage 
or a bloody flux is the result. 
The symptoms of extravasation of blood 
are so various that they cannot be stated in 
general terms. If extensive and affecting 
vital parts, the effusion may be attended with 
shock, syncope, or death ; and it may lead to 
constitutional disturbance in many forms. 
Local pain is not common unless the extra- 
vasation be severe. The pressure of the 
effused blood upon the vessels, nerves, and 
muscles of the part-in a limb, for example- 
may produce paralysis, disturbances of sensi- 
bility, oedema, loss of temperature, and even 
gangrene. As a rule, however, extravasations 
of blood are limited in size, give rise of them- 
selves to no serious symptoms, and readily 
disappear by absorption. 
J. Mitchell Bkuce. 
EXTROVERSION (extra, outwards; 
and ver to, I turn).-The eversion or turning 
inside out of a part, as the eyelids or bladder. 
In the bladder, extroversion is associated 
with that condition, usually congenital, in 
which the anterior wrall of this organ and of 
EXTRAVASATION 
the abdomen is deficient, and its posterior wall 
projects through the opening thus formed. 
EXUDATION (exudo, I sweat).-The 
process by which certain of the elements of 
the blood pass through the walls of the blood- 
vessels into the surrounding tissues, as in in- 
flammation. The term is also used to indi- 
cate the products of this process, when they 
are of a fibrinous or coagulable character. 
See Inflammation. 
EXUDATION - CORPUSCLES. - 
The cells found in inflammatory products, 
whatever their origin may be. See Inflam- 
mation. 
EYE, and its Appendages, Diseases 
of.-Synon. : Fr. Maladies des Yeux; Ger. 
Augen hr an Icheiten. 
It will be most convenient to arrange 
the consideration of the diseases of the eye 
according to the anatomical order of the 
structures affected, namely: I. Diseases of 
the Conjunctiva ; II. Diseases of the Cornea; 
III. Diseases of the Sclerotic; IV. Diseases 
of the Iris; V. Diseases of the Crystalline 
Lens; VI. Glaucoma ; VII. Diseases of the 
Optic Nerve and Retina; VIII. Diseases of 
the Choroid; IX. Diseases of the Vitreous 
Body; and, X. Diseases of the Eyelids.1 
I. Diseases of the Conjunctiva. 
1. Inflammation.-Synon.: Conjunctivitis. 
The conjunctiva is exceedingly liable to in- 
flammation, and its inflammations are com- 
monly arranged in groups, which are suf- 
ficiently distinct in their typical examples, 
but are not separated by any definite bound- 
ary lines. 
In their earlier stages inflammations of the 
conjunctiva possess many characters in com- 
mon. They are all attended by the four 
signs of inflammation-heat, redness, swell- 
ing, and pain ; although both the heat and 
the swelling are usually kept within limits by 
the discharge, which is often free, sometimes 
profuse, at first mucous, afterwards muco- 
purulent or truly purulent in character. If, 
however, the exudation be of a firmer consis- 
tence than usual, it not only produces a super- 
ficial discharge, but distends the meshes of 
the sub-mucous tissue, elevates the conjunc- 
tiva from the sclerotic, and causes it to over- 
lap the corneal margin as a swollen ridge; 
a condition which is known as chemosis. The 
redness depends, of course, on the degree of 
the congestion, which may or may not be suf- 
ficient to obliterate the intervascular meshes, 
and to produce a uniform colour; and the 
pain is not severe, except in cases of very 
dense sub-conjunctival swelling. From other 
forms of inflammation, that of the conjunc- 
tiva is distinguished by certain negative 
characters. Unless as a result of secondary 
changes, or as a mechanical effect of the 
EYE, DISEASES OF 
647 
1 See also Vision, Disorders of; Ophthalmoscope ; 
and Ophthalmoscope in Medicine. 648 
EYE, AND ITS APPENDAGES, DISEASES OF 
presence of a film of turbid secretion, the 
transparency of the cornea is not affected, 
and the acuteness of vision is not impaired. 
The congestion is limited to the conjunctiva, 
and the distended vessels can be emptied for 
a moment by pressure through the lower lid, 
so as to reveal a glimpse of the white scle- 
rotic underneath. 
In mild cases conjunctivitis is an unimpor- 
tant affection, but in its more severe forms it 
is attended by two distinct sources of danger. 
During its acute stage it may produce partial 
or complete necrosis of the cornea, leading to 
great impairment of sight and not seldom to 
blindness; and when chronic it often occa- 
sions great hypertrophy of the papillae of the 
portion of the membrane which lines the 
lids. These papillae may even become con- 
verted into shaggy or warty excrescences, 
which mechanically irritate the corneal sur- 
face, and cause the development of vessels 
beneath its epithelium. In time the papillae 
dwindle, and the effusion round about them 
contracts, thus rendering the tarsal cartilage 
(especially that of the upper lids) incurved, 
and bringing the cilia to rest upon the sur- 
face of the eyeball. Great distress and per- 
manent impairment of vision may be thus oc- 
casioned ; and the progress of the contraction 
may be so slow as to deprive it of any mani- 
fest connexion with the inflammation in 
which it had its origin. 
The chief varieties of conjunctivitis are: 
(a) infantile; (f) simple or catarrhal; (c) 
contagious; and (d) diphtheritic. 
(a) Infantile Conjunctivitis.-Synon. : Oph- 
thalmia neonatorum. 
^Etiology and Symptoms.-Infantile con- 
junctivitis is probably due, in most cases, to 
direct inoculation with vaginal secretion. It 
usually commences on or about the third day 
after birth, and passes rapidly into the puru- 
lent form. It is attended by considerable 
puffy swelling of the lids, and by profuse 
thick discharge, which soon dries upon the 
tarsal margins, and often causes them to 
cohere. If neglected or improperly treated, 
the disease often leads to sloughing of the 
cornea; but it may always be cured if it is 
seen while the cornea is still bright 
Treatment.- The treatment required is 
to wash away the discharge carefully and 
frequently; to apply an astringent lotion (the 
best is a solution of two grains of nitrate of 
silver to an ounce of distilled water) to the 
conjunctival surface every four hours, or less 
frequently when improvement is established; 
and to anoint the edges of the lids with sim- 
ple ointment to prevent their agglutination. 
In cases of inherited syphilis mercurial in- 
unction should be prescribed. The infant's 
food must be carefully regulated if it is 
brought up by hand; and if it is very feeble, 
it may take a little cod-liver oil, combined in 
an emulsion with two-minim doses of liquor 
cinchonae. Where the mother's milk fails, it 
is often desirable to obtain a wet-nurse; but 
the local treatment is that which is chiefly 
important, and upon which, in most cases, 
entire reliance may be placed. 
(6) Simple or Catarrhal Conjunctivitis. 
^Etiology and Symptoms.-This form of 
conjunctivitis is usually due to exposure to 
cold or to some chemical or mechanical irri- 
tant. Its most distinctive character is that 
the discharge is chiefly mucous, and has not 
much tendency to become purulent. 
Treatment.-In every case the surface of 
the eyeball, and the lining membrane of the 
lids, should be carefully examined for any 
foreign body which may be the cause of the 
trouble; and if such should be found and 
removed, there will seldom be need for 
further treatment. If there is no foreign 
body, the two-grain solution of nitrate of silver, 
or of sulphate of zinc, may be placed within 
the conjunctival sac, by means of a quill or 
dropping-bottle, every two or three hours, 
and speedy recovery will usually be the result. 
In cases of very mild type, one or two appli- 
cations of the astringent may be sufficient; 
and these may be supplemented by the use, 
in the same manner, of a solution of cocaine 
with boric acid. A. good formula for this 
purpose contains two grains of cocaine hydro- 
chlorate, and four of boric acid, to the ounce 
of distilled water. During the treatment the 
eyes should have functional rest, and should 
be sheltered from external cold, from dust, and 
from glare. 
(c) Contagious Conjunctivitis.-Synon. : 
Purulent Ophthalmia. 
^Etiology and Symptoms.-In this form 
the discharge rapidly assumes a purulent 
character. This may happen when the 
simple form is aggravated by the state of the 
patient or by accidental circumstances; or 
when the disease is produced by inoculation 
with the discharge from a similar case, 
or with contagious pus from the urethral or 
vaginal mucous membrane. The state of the 
patient which is most likely to promote the 
development of the contagious form is that 
in which the conjunctiva is beset with the 
granular semi-transparent bodies, formed by 
aggregations of lymph-corpuscles, which are 
known as ' sago-grains ' or follicular granu- 
lations. These bodies are commonly present 
in the eyelids of persons (especially of young 
persons) who are crowded together under 
insanitary conditions of living, as in barracks, 
camps, or badly regulated schools; and their 
presence renders the conjunctivitis of simple 
irritation prone to assume a purulent charac- 
ter. It is impossible to say how soon the dis- 
charge of conjunctivitis becomes contagious, 
or capable of reproducing the disease in others; 
but its activity in this respect seems to bear 
some proportion to the intensity of the inflam- 
mation which produces it; and the activity 
of gonorrhoeal pus is probably greater than 
that of any conjunctival product. In the EYE, AND ITS APPENDAGES, DISEASES OF 
649 
more intense forms of purulent ophthalmia 
there is great swelling of the lids and of the 
ocular conjunctiva, early chemosis, and a 
tendency to speedy sloughing of the cornea; 
while the milder forms pass into the catarrhal 
by imperceptible gradations. 
Treatment.-In the space available for 
the purpose in these pages, the treatment of 
contagious conjunctivitis cannot be described 
in detail. It mainly rests upon the action of 
local astringents, graduated in strength ac- 
cording to the severity and the stage of the 
disease. In the worst cases the eyelids must be 
everted, and the whole of the palpebral con- 
junctiva carefully touched with a stick com- 
posed of one part of nitrate of silver fused with 
four parts of nitrate of potash. The caustic 
should be neutralised by a drop or two of a 
solution of common salt, applied by means of a 
camel's-hair pencil, before the lid is suffered 
to return into contact with the cornea ; and 
the cauterisation must be done carefully and 
with a light hand, so that the resulting eschar 
may include only the epithelium ; for if the 
basement membrane is destroyed, there will 
be danger of subsequent adhesions between 
the eyelids and eyeball. The cauterisation 
should be repeated about every eight hours, 
or as soon as the eschar falls, and in the 
intervals, if the patient is awake, the con- 
junctiva should be gently sprayed or syringed 
every hour with a weak antiseptic lotion at a 
comfortable temperature. Diluted Condy's 
fluid, solution (1 in 5,000) of mercuric per- 
chloride, or (15 per cent.) of Barffs boro- 
glyceride, are all suitable for this purpose. 
The tension of chemosis may be diminished 
by radial incisions, outwards from the corneal 
margin, carried nearly down to the sclerotic. 
The strength must be supported by good diet 
and tonics; and the nervous system calmed 
by anodynes. In milder cases the principle 
of treatment must be the same, but the local 
applications less severe; and in chronic cases 
the local applications must be continued, 
after apparent recovery, so long as any resi- 
dual thickening, capable of undergoing even- 
tual contraction, can be found lurking in the 
palpebral folds. 
(d) Diphtheritic Conjunctivitis. - This 
malady has chiefly been made known to us 
by the observations of German writers, and 
very few authentic instances have been re- 
corded in this country. But it has from time 
to time prevailed extensively in Berlin, and 
might at any time make its appearance 
amongst ourselves. The writer has seen one 
remarkable instance in which the disease 
occurred with great severity in a child, whose 
eyes were bathed with milk as a domestic 
remedy for what seems to have been a mild 
ordinary conjunctivitis ; and the coincidence 
seems to have a special interest in relation to 
recent researches into the aetiology of diph- 
theria. 
Symptoms.-Diphtheritic conjunctivitis is 
attended with great heat and pain, and with 
very hard, brawny swelling of the eyelids; 
but its most characteristic symptom is the 
infiltration of the sub-conjunctival tissue by 
the so-called diphtheritic effusion, which does 
not form a pellicle upon the surface, but dis- 
tends and fills the cavities of the areolar 
tissue. The result is to produce a pale, firm 
swelling of the conjunctiva, and a great ten- 
dency to rapid sloughing of the cornea. The 
subjects of the malady are mostly feeble and 
badly fed children, and the cases are de- 
scribed as being almost hopeless unless early 
admitted into hospital. 
Treatment.-The indications for treat- 
ment are chiefly to support the strength by 
suitable regimen; to apply ice or bags of 
freezing mixture to the lids during the hot 
stage ; and to change the cold applications 
for hot ones as soon as the period of resolu- 
tion, absorption, or repair can be said to have 
commenced. In the meantime iron and 
quinine should generally be administered 
internally. 
Pemphigus of the Conjunctiva.-A very 
formidable, but fortunately rare, variety of 
conjunctival disease appears to be a kind of 
pemphigus. See Pemphigus. 
JEtiology and Symptoms.-In its early 
stage pemphigus of the conjunctiva displays 
itself by the formation of bullae, which are 
of small size and inconspicuous, and are 
seldom followed by the raw surfaces com- 
monly left elsewhere. This stage seldom 
excites much attention, and it is followed by 
a slow process of conjunctival atrophy, which, 
in time, leads on to disturbance of the corneal 
epithelium, and ultimately to complete 
opacity. The conjunctival atrophy gradu- 
ally obliterates the folds of the membrane, 
and renders the lids immovable upon the 
globe, frequently causing also inversion of 
cilia, which add to the pre-existing irritation. 
Treatment.-The only hope of dealing 
successfully with conjunctival pemphigus 
appears to depend upon the early recog- 
nition and constitutional treatment of the 
general malady ; for which purpose the chief 
reliance must be placed upon the prepara- 
tions of arsenic, in combination with tonics 
and anodynes. When the period of atrophy 
has commenced, it is seldom, if ever, arrested. 
The apparent adhesions between the lids and 
the globe often suggest operative measures, 
but these are not recorded ever to have been 
successful. In one case, the writer dissected 
off the whole of the affected conjunctiva of 
the globe, and replaced it by transplanting 
that of a rabbit. The graft united well, and, 
for a time, the disease appeared to be arrested. 
In a few weeks, however, or as soon as the 
graft had become completely dependent upon 
the nutritive processes of the patient, the 
new structure became affected by atrophy, 
and the malady pursued its usual destructive 
course. 650 
2. Episcleritis.-An affection which is ap- 
parently but not really conjunctival, being 
situated in the tissue between the conjunctiva 
and the sclerotic, is that which has received 
the name of episcleritis, and which was 
formerly described as ' sclerotitis with in- 
flammation of the insertion of a rectus 
muscle.' 
Symptoms. - It appears as an elevated 
patch of congestion, gradually passing into 
the natural level and appearance of the parts, 
and seated on the ocular surface near the 
corneal margin, most frequently on the tem- 
poral side. On close examination, the con- 
gestion, with the exception of a few dilated 
vessels, is seen to be sub-conjunctival, and to 
be attendant upon a circumscribed but not 
sharply defined swelling or thickening, which 
is adherent to the sclerotic, and which pre- 
sents, in the interstices between the blood- 
vessels, an appearance as if it consisted of 
some new deposit, generally of a yellowish 
tint, external to that membrane. The swell- 
ing is indolent, chronic, and in itself generally 
painless, although it is sometimes accom- 
panied by severe neuralgia. The subjects 
are most frequently women, especially such 
as are anaemic or otherwise out of condition. 
Episcleritis may last for months with little 
change, and it seems to be harmless as re- 
gards the other structures of the eye. 
Treatment.-The writer has found epi- 
scleritis resist all medication except the in- 
ternal administration of mercury, to which it 
will often yield in the course of a short time. 
The best preparation is the perchloride, in 
doses not exceeding of a grain, which may 
usually be combined with five or ten minims 
of the tincture of perchloride of iron, and often 
with quinine. At the same time it is often 
desirable to sprinkle a little dry calomel over 
the swelling once in twenty-four hours; but 
this application is less important than the in- 
ternal treatment, and should not be continued 
unless it is soon and distinctly beneficial. 
"When the congestion of the patch is consider- 
able, the action of other remedies will often 
be promoted by the occasional application of 
a leech to the temple of the affected side. 
3. Hcemorrhage.-Effusion of blood be- 
neath the conjunctiva may occur spontane- 
ously, but is generally traceable either to a 
direct injury or to violent exertion. Thus it 
may follow slight blows upon the eyeball, as 
from a twig or switch; or may be produced 
by a paroxysm of coughing, especially in per- 
tussis ; or may occur from the rupture of a 
vessel during parturition, or upon lifting a 
heavy weight. It is always unsightly. When 
traceable to any of the foregoing causes, the 
haemorrhage is usually a matter of no mo- 
ment ; but when it happens during the night 
in young people, it should lead to a suspicion 
of nocturnal epilepsy, which has often been 
first discovered by its means. Moreover, in 
advanced life, more especially when occur- 
EYE, AND ITS APPENDAGES, DISEASES OF 
ring without adequate cause, it may point to 
arterial brittleness, of a kind which may in- 
dicate danger of a like haemorrhage within 
the cranium. On these grounds it is a symp- 
tom which always calls for full inquiry into 
its causes, and which may sometimes afford 
useful warning of impending danger. 
Treatment.-Absorption may be promoted 
by covering the closed lids by a compress 
moistened with a lotion of spirit and water, 
or of tincture of arnica and water if an ap- 
pearance of more decided medication is de- 
sired. 
II. Diseases of the Cornea.-Dis- 
eases of the cornea, as already indicated, are 
often secondary to those of the conjunctiva, 
and may arise in their course as complica- 
tions. 
1. Ulceration. 
Aetiology and Symptoms.-To the present 
group belong all the corneal ulcerations of 
purulent ophthalmia, whether infantile or of 
a later period of life; and also the forms of 
corneal ulcer which are produced by the fric- 
tion of eyelids rendered rough by inflamma- 
tion, or by the friction of eyelashes which 
have been turned inwards by distortion of 
the tarsal cartilage. When ulceration of the 
cornea occurs in the course of conjunctivitis, 
it at once invests the latter malady with a 
highly formidable character. The corneal 
tissue, once destroyed by ulceration, is not 
reproduced in its original transparency, but 
only as a more or less dense and opaque white 
cicatrix, which is at the same time disfigur- 
ing to the appearance and an impediment 
to vision. If the ulcer should perforate, the 
iris almost necessarily becomes adherent to 
the cicatrix; and if the loss of substance is 
of large superficial extent, the resulting cica- 
trix is often thin and feeble, so that it is 
rendered prominent by the pressure within 
the eye, producing the condition which has 
been called ' staphyloma,' and gradually ele- 
vating and distorting the surrounding por- 
tions of clear cornea. The first effect of the 
healing of a corneal ulcer is generally to flat- 
ten the natural curvature of the membrane ; 
but the secondary effect, if the cicatrix be- 
comes prominent, may be to modify this 
curvature in various ways. Hence it follows, 
even when a cicatrix of the cornea is sur- 
rounded by a still transparent annulus, be- 
hind which an artificial pupil may easily be 
made by the excision of a portion of the iris, 
that the surgeon cannot predict with any 
certainty the quality of the vision which will 
be obtained, unless he is able, before operat- 
ing, to determine the state of the corneal 
curvature. This is only possible when the 
margin of the pupil is so far free that it can 
be dilated with atropine sufficiently to render 
the fundus of the eye visible with the ophthal- 
moscope. When this can be done, any portion 
of cornea through which a clear view of the 
retinal vessels can be obtained by the surgeon EYE, AND ITS APPENDAGES, DISEASES OF 
651 
will also afford clear vision of external objects 
to the patient; but, if no such place can be 
discovered, a very cautious opinion should 
be given with regard to the degree of benefit 
which may be hoped for from an opera- 
tion. 
Treatment.-The extreme importance of 
the cornea to the visual function renders it 
necessary that its integrity should be guarded 
with the greatest possible care. In any case 
of conjunctivitis, of even moderate severity, 
the cornea should be watched from day to 
day, and any appearance of turbidity about 
its central portion, or of elevation or irregu- 
larity of the epithelium at its margin, should 
lead to a reconsideration of the treatment 
which is being pursued. The former of these 
conditions is the ordinary precursor of slough- 
ing ulcer or necrosis; the latter, of the exten- 
sion to the cornea of an inflammatory process. 
The general principles which govern the 
treatment of sloughing ulcer are, that the eye 
should be kept under the influence of eserine, 
which has a marked effect in checking the ex- 
tension of ulceration by arresting the migra- 
tion of white corpuscles; that any astringents 
which may be applied to the conjunctiva 
should be prevented from coming into con- 
tact with the cornea; that strength should 
be supported, pain relieved, and local nutri- 
tion stimulated by hot applications. When 
the ulcer continues to spread, its progress 
may often be arrested by diminishing the 
tension of the globe by the evacuation of the 
aqueous humour; and this may be accom- 
plished either by repeated paracentesis at 
the corneal margin, or by Saemisch's method 
of cutting through the base of the ulcer, and 
reopening the incision daily until a process of 
repair is well established, or by the perform- 
ance of iridectomy. Of these three courses, 
the last-named is the most generally appli- 
cable. It not only produces the immediate 
effect which is desired, but it has also the 
incidental advantage of establishing an arti- 
ficial pupil at the side of the cicatrix. 
The application of eserine is best effected 
by using a solution of the neutral sulphate, 
of the .strength of four grains to the ounce of 
distilled water; and a drop of this solution 
may be placed within the conjunctival sac 
twice or thrice daily. 
The sloughing ulcers of the cornea which 
arise from causes other than conjunctivitis, 
as injury, or failure of nutrition, must be 
treated upon the principles which have al- 
ready been laid down. There are, however, 
inflammatory ulcers which require the use 
of local applications of a stimulating kind, 
among which dry calomel and other mer- 
curials hold a prominent place. Such ulcers 
have usually a leash of vessels running from 
the corneal margin, and are often obstinately 
recurrent; whence they are known as ' re- 
current vascular ulcers.' They are usually 
connected with some manifest systemic de- 
rangement, and are often attended by photo- 
phobia. They leave scars upon the cornea, 
of a size and opacity proportionate to their 
extent and depth; and on this account it is 
desirable, whatever constitutional treatment 
may be required, to heal the ulcers them- 
selves as speedily as possible, by the aid of 
local applications. In the early stages of the 
ulceration, eserine should be used ; but after- 
wards either dry calomel or an ointment con- 
taining from ten to thirty grains to the ounce 
of the precipitated yellow oxide of mercury. 
This ointment was introduced into practice 
by the late Dr. Pagenstecher, of Wiesbaden, 
and is often called by his name. In very 
obstinate cases the late Mr. Critchett recom- 
mended setons in the temporal regions; but 
the operation of iridectomy will often afford 
a still more efficacious remedy. "Where 
there is much photophobia, the use of eserine 
is especially indicated, because, in addition 
to its action above mentioned, it produces 
contraction of the pupil, and thus gives com- 
fort by lessening the quantity of light which 
is admitted into the eye. If the photophobia 
is very severe or intractable, it is often bene- 
ficial to divide the orbicularis muscle freely 
at the outer canthus, so as to diminish the 
pressure which is caused by its spasmodic 
contraction, and which sometimes seems to 
be a chief cause of the irritability. After 
such an incision, a cold compress should be 
applied, and the patient kept in the dark for 
a few hours, when there will often be a 
marked alleviation of this distressing symp- 
tom, and a greatly increased general amen- 
ability to treatment. 
2. Inflammation. - Synon. : Keratitis.- 
Inflammation of the cornea presents three 
distinct types, the suppurative, the vascular, 
and the interstitial. 
(a) Suppurative Keratitis.-Suppurative 
inflammation or abscess of the cornea seems 
to be essentially a phlegmon or boil of the 
corneal tissue, a portion of which dies, and is 
cast off in the form of a slough. 
Symptoms.-The abscess commences as a 
very tender grey spot in the cornea, sur- 
rounded by a zone of turbidity, and accom- 
panied by a good deal of ciliary neuralgia, as 
well as by a variable degree of lacrymation, 
conjunctival congestion, and intolerance of 
light. Under the influence of atropine, hot 
fomentations, and such constitutional treat- 
ment as the state of the patient may demand, 
the threatened suppuration is sometimes 
averted, and the turbidity clears away. 
More commonly pus is formed, and makes 
its way either externally, leaving an ordinary 
ulcer; or internally, producing the condition 
called hypopyon, in which there is pus in the 
anterior chamber. Sometimes it separates 
the corneal laminae, by gravitation, to a con- 
siderable extent before perforating them, and 
is then called onyx, from a resemblance to 
the lunula at the base of a finger-nail. EYE, AND ITS APPENDAGES, DISEASES OF 
652 
Treatment. - "When suppuration is no 
longer doubtful, the best practice is to 
evacuate the abscess by a puncture from 
within, by thrusting a cutting needle into the 
anterior chamber near the corneal margin, 
and then causing its point to penetrate the 
cavity of the abscess. The mingled pus and 
aqueous humour will escape as the needle is 
withdrawn, and its wound of entrance may 
be reopened once or twice daily by a probe, 
so as to insure the complete removal of all 
inflammatory products, until the healing pro- 
cess has made some way. If the abscess has 
burst internally before the case is seen, atro- 
pine should be applied without delay. If the 
pupil dilates fully, and the quantity of pus in 
the anterior chamber is but small, the case 
may be left to the vis medicatrix natures, 
care being taken to enforce rest and to ex- 
clude noxious influences. If the quantity of 
pus is large, it should be let out by paracen- 
tesis ; and if the atropine reveals adhesions 
of the iris, iridectomy should at once be per- 
formed. An abscess which has burst ex- 
ternally leaves simply an ulcer, generally 
with a disposition to heal readily, and re- 
quiring only such treatment as has already 
been described. 
(6) Vascular Keratitis.-Vascular inflam- 
mation of the cornea is often a very severe 
and protracted malady, which usually leaves 
behind permanent opacity and impairment 
of sight. 
Symptoms. - It commences, in typical 
cases, by the formation of two crescent- 
shaped patches of vascularity, one at the 
upper and the other at the lower portion of 
the cornea. The patches are formed by the 
development on the corneal surface of in- 
numerable fine blood-vessels, so closely 
packed together that the interstices which 
separate them are scarcely discernible by the 
naked eye, and the affected parts present a 
uniform aspect of vivid redness. The cres- 
cents are somewhat elevated above the 
general corneal surface, and each crescent is 
bordered, along its concave or advancing 
edge, by »> line of precursory epithelial tur- 
bidity. At the same time that the crescents 
increase in size, the borders of precursory 
turbidity are pushed before them; until at 
first these, and afterwards the crescents 
themselves, may meet and coalesce on the 
horizontal diameter of the cornea, so that its 
whole surface may become uniformly red. 
When this stage is reached, vision is almost 
abolished, but there may still be much in- 
tolerance of light. The corneal tissue is 
softened, and its margin is surrounded by a 
zone of sclerotic vascularity, which is visible 
through the congestion of the conjunctiva. 
As the inflammation subsides, the vascular 
crescents slowly recede from the centre of 
the cornea towards its circumference, and 
finally disappear, leaving behind them a 
dense opacity of an extremely obstinate 
character. A severe case of vascular keratitis 
generally affects both eyes, and threatens a 
long period of actual blindness, followed by a 
long period of very imperfect vision. The 
worst examples of the malady are those 
which have been treated at the outset by 
astringent or irritating applications; and, 
even in the slighter forms, the malady is 
nearly always obstinate and protracted. As 
long, however, as the march of the vascular 
crescents, or their precursory turbidity, has 
not encroached upon the portion of cornea 
in front of the pupil, so long vision is not 
seriously jeopardised. 
Treatment.-The great object of treatment 
is to arrest the new vascular development at 
a comparatively early stage; and for this 
purpose it is necessary to have recourse to 
eserine and sedatives locally, and to such 
constitutional treatment as the general con- 
dition may require. A solution of two grains 
of the neutral sulphate of eserine, with from 
two to four grains of hydrochlorate of cocaine, 
in an ounce of distilled water, should be 
dropped into the eye twice daily, and the 
closed lids should be frequently fomented 
with hot poppy decoction, or with cold solu- 
tion of extract of opium in water, according 
as one or the other temperature is the more 
agreeable to the feelings of the patient. 
Apart from any special indication, the medi- 
cines most generally useful are those which 
appear to influence local nutrition through 
the central nervous system, such as the iodide 
and bromide of potassium, and the sulphate 
of quinine. These, if they are likely to exert 
a beneficial effect, generally do so speedily; 
and if the malady should be rapidly extend- 
ing, it is always prudent to reconsider the 
prescription without much loss of time. In 
severe cases, especially when the lids are 
somewhat tumid and there is much photo- 
phobia, a leech may often be applied with 
advantage, usually over the temporal muscle, 
close to the outer margin of the orbit, or a 
little blood may be taken more rapidly, by 
means of Heurteloup's artificial leech; and 
when, notwithstanding treatment, the malady 
pursues its course unchecked, a large iridec- 
tomy shouldbe made without undue delay. Th.e 
operation not only tends to arrest the vascular 
formation, but it also leaves a lateral pupil 
through which good sight may often be 
obtained long before the transparency of the 
central parts of the cornea is restored. In 
some cases, the writer has seen excellent re- 
sults from peritomy; that is, from excising the 
annulus of conjunctival and subconjunctival 
tissue which immediately surrounds the cor- 
nea. The strip excised should be about 
8 mm. in width; and the excision may 
sometimes be limited to the bases of the 
vascular crescents. 
Development of vessels upon the cornea.- 
It is necessary carefully to distinguish vas- 
cular keratitis, properly so called, from that EYE, AND ITS APPENDAGES, DISEASES OF 
653 
development of vessels upon the cornea which 
may occur in connexion with the cicatrisation 
of ulcers, or in consequence of the friction of 
lids left granular by conjunctivitis. In both 
these forms the new vessels are arborescent 
and irregular in their distribution, instead of 
being closely packed together; and they are 
not attended by the pink zone of circum- 
corneal congestion, which is never absent in 
true corneal inflammation. 
The vessels which attend the formation of 
cicatrices generally dwindle in course of time; 
while those produced by granular lids, and 
which, when they are very abundant and 
closely set, constitute the condition called 
pannus, will often disappear without direct 
treatment if the state of the lids themselves 
can be favourably modified by the application 
of astringents or by other means. When 
residual granulations are large and nume- 
rous, they may be treated by crushing them 
with forceps, by scraping, or by electrolysis; 
for which purpose they should be separately 
punctured by a platinum needle, connected 
with the negative pole of a galvanic battery. 
A weak current only is required, and it may 
be suffered to pass through each granulation 
for from ten to twenty seconds. In many 
cases the vascular network of pannus will be 
comparatively absent from the lower third of 
the cornea, so that sight may be much im- 
proved by an artificial pupil made in a down- 
ward direction. When pannus covers the 
whole cornea with a close vascular net- 
work, so that sight is almost destroyed, and 
when it resists milder treatment, it may 
sometimes be cured by inoculation with the 
discharge of infantile purulent ophthalmia. 
The pus is inserted between the lids, and 
the artificial malady suffered to run its 
course unchecked, except by cleanliness and 
frequent bathing. When the discharge has 
ceased, the cornea will often clear in a 
surprising manner, and its abnormally vas- 
cular state protects it, to a very great de- 
gree, against the risk of sloughing. Still, 
this risk is by no means absent, and the 
treatment by inoculation should be regarded 
only as a last resource. A somewhat similar 
effect may be obtained by the inflammation 
which is excited by bathing the eyes with 
an infusion of the seeds of jequirity; but 
this method is scarcely less dangerous than 
that by inoculation. 
(c) Interstitial Keratitis.-This is a chronic 
malady which is seen chiefly, or perhaps 
exclusively, in the subjects of inherited 
syphilis, who possess the peculiar teeth and 
facies which Mr. Hutchinson has shown to 
be characteristic of their inheritance. The 
disease was long described as a variety of 
' strumous ophthalmia; ' and, although the 
late Sir William WTilde pointed out how 
frequently it was associated with deafness, 
and also laid stress upon the value of per- 
chloride of mercury in its treatment, its 
syphilitic character seems to have been first 
suspected by Mr. Hutchinson, who, having 
once obtained the clue, followed it with 
characteristic diligence until he arrived at a 
conclusive demonstration of the accuracy of 
his suspicion. 
Symptoms.-Interstitial keratitis com- 
mences as a slight cloudiness of the central 
portion of the cornea, with some roughening 
or irregularity of the epithelium. It extends 
from the centre towards the margin, and is 
liable to be attended, in different cases and 
at different stages of its course, by variable 
degrees of ciliary and corneal congestion, 
and intolerance of light. If neglected, or if 
treated by irritants, it is liable to assume the 
characters of vascular keratitis, and also to 
extend to the iris, in such instances often 
doing irreparable mischief. It is most 
common during childhood, but its appear- 
ance may be delayed until adolescence, or 
even until adult age; and, in such cases, 
usually appears to be determined by some 
general or local exciting cause, such as bodily 
illness, or direct injury. It attacks both 
eyes, one commonly somewhat later than the 
other, and its course is often protracted over 
several months. When severe, it leaves some 
residual cloudiness of the cornea, and, even 
when mild, it is doubtful whether the cornea 
ever entirely regains the transparency of 
health. Still, when a case is seen and judi- 
ciously treated early, the prognosis may 
generally be a favourable one. 
Treatment.-The treatment consists pri- 
marily in the avoidance of all irritants; the 
use of eserine and local sedatives, especially 
cocaine; and the administration of per- 
chloride of mercury, or of iodide of potassium, 
with or without iron or cod-liver oil. When 
they are not contra-indicated by any special 
circumstances, the perchloride of mercury 
and the oil are the remedies on which the 
greatest reliance may be placed. The earliest 
indications of photophobia, showing, as they 
do, that light is acting as an irritant, should 
be met by confinement to an almost darkened 
room, and by frequent bathing of the closed 
lids with cold water; but in fine weather 
daily exercise should be taken in the open air, 
the eyes being covered for the time with a 
black silk bandage and compresses of carded 
wool, so as to exclude light entirely. As soon 
as photophobia subsides, these precautions 
may be left aside-the eserine and mercury 
being still continued, at least until the acute 
stage of the malady has entirely passed away. 
After this the absorption of residual opacity 
may be promoted by the application, once 
daily, of a morsel of an ointment containing 
a small quantity (about ten grains to an 
ounce) of the precipitated yellow oxide of 
mercury. 
In cases which have been neglected, or 
aggravated by irritants in their early stages, 
and in which the phenomena of ordinary 654 
EYE, AND ITS APPENDAGES, DISEASES OF 
vascular keratitis become grafted upon the 
interstitial, it is generally desirable to perform 
iridectomy with as little delay as possible. 
3. Arcus Senilis.-The condition thus 
named (although the adjective is not always 
appropriate) is fully described elsewhere 
(see Arcus Senilis). It may be distinguished 
from the peripheral zones of opacity, which 
are sometimes left after the subsidence of 
certain forms of keratitis, by the circumstance 
that arcus never extends quite to the margin 
of the cornea, but is always surrounded by 
an annulus of transparent tissue. 
Besides the foregoing, there are a few other 
forms of corneal disease, of comparatively 
rare occurrence, which it would be beyond 
the limits of these pages to describe, but 
which must be treated on the same general 
principles; and there is also the malforma- 
tion known as ' conical cornea,' which falls 
wholly within the domain of surgery. 
III. Diseases of the Sclerotic.-Dis- 
eases of the sclerotic, which were once re- 
garded as a numerous and important group, 
have been reduced by recent investigations 
to comparatively insignificant proportions. 
Inflammation. - Synon. : Sclerotitis. - 
Excepting in a narrow annulus immediately 
around the cornea, the sclerotic is almost 
extra-vascular; and any real inflammation 
of its structure is almost confined to this 
particular region, where it seldom occurs 
excepting as a complication or as a part of 
some of the more severe forms of iritis or 
keratitis, especially when either of these 
affections extends to the ciliary body. In 
such cases we often see the sclerotic undergo 
inflammatory softening, as a result of which 
the ciliary region may be much altered in 
shape, yielding to the distension of the eye- 
ball and to the traction of the recti muscles, 
and becoming distinctly elongated. Occa- 
sionally the sclerotic may be so much 
softened and thinned as to bulge into irregular 
prominences around the cornea, generally 
under the upper lid; and this condition is 
described as sclerotic staphyloma. 
Treatment. - The inflammations thus 
arising call for no other treatment than that 
which is demanded by the more important 
inflammations of the cornea, the iris, or the 
ciliary body, with which they are associated; 
except that any evidence of yielding of the 
sclerotic would be a reason in itself for the 
performance of iridectomy, in order to pre- 
serve the shape of the eyeball by diminishing 
its tension. It was once believed that the 
sclerotic, in its character of a fibrous mem- 
brane, was especially prone to gouty or rheu- 
matic inflammation ; and it is perhaps true, 
though certainly not proven, that the ten- 
dency of iritis or of keratitis to spread to the 
anterior sclerotic zone is more marked in 
persons of gouty or rheumatic diathesis than 
in others. The possibility is at any rate 
sufficient to require, in all these cases, an in- 
vestigation of the tendency to lithic acid for- 
mation, and the use of appropriate remedies 
when this tendency is discovered. But a 
large proportion of the examples of supposed 
gouty or rheumatic ophthalmia are nothing 
more than cases of the sub-acute or remittent 
form of glaucoma; and the pain associated 
with them is not really rheumatic but simply 
tensive. Vision has been irretrievably lost, 
in hundreds of instances, because a belief in 
the rheumatic character of these affections 
has interfered with the timely performance 
of iridectomy ; and the proposal to adopt the 
epithet 'rheumatic,' in any form of eye- 
disease, is one which should be scrutinised 
very closely before it is accepted as a guide 
to practice. 
IV. Diseases of the Iris.-In so far 
as they come into the province of the phy- 
sician, diseases of the iris are not numerous, 
and are almost limited to the varieties of in- 
flammation of that membrane. 
1. Inflammation.-Synon. : Iritis.-Iritis 
may be classified, according to its actual or 
supposed causes, as rheumatic or syphilitic ; 
or according to the nature of the morbid pro- 
cess, as plastic, serous, or suppurative. The 
former classification must often rest upon 
very slender grounds, and the latter has the 
great advantage of expressing facts rather 
than inferences. 
(a) Plastic Iritis.-Symptoms.-In plastic 
iritis the first symptom is usually some loss 
of the natural lustre of the surface of the iris, 
and of the clear definition of its fibres, to- 
gether with some damping or alteration of 
its colour. These changes are probably 
always due to turbidity of the aqueous 
humour, and they may be imitated more or 
less closely by turbidity of the cornea, and 
especially by disturbance of its epithelium. 
In iritis, however, they are associated with a 
diminished range and quickness of pupillary 
variation under variations of light; and, in 
a short time, with the effusion of plastic 
lymph, by which the margin of the pupil 
becomes tied down, here and there, to the 
surface of the anterior capsule of the crystal- 
line lens. At the same time there is usually 
some congestion of the conjunctiva, and of the 
zone of fine vessels immediately around the 
cornea in the sclerotic. There is frequently 
more or less pain, especially towards night, 
but this is a very uncertain symptom. In 
severe cases, and especially in such as are 
clearly syphilitic in their character, the quan- 
tity of effused lymph may be very con- 
siderable, so as quite to cover the pupil, while 
in mild cases it is only sufficient to fasten 
down the margin here and there. Iritis is 
sometimes a very insidious and seemingly 
slight affection, the real gravity and import- 
ance of which may be wholly overlooked by 
the patient. 
Treatment.-The first principle of treat- 
ment is to prevent the formation of adhe- EYE, AND ITS APPENDAGES, DISEASES OF 
655 
sions, or to break them if they have been 
formed; and for this purpose our main re- 
liance must be placed upon the instillation of 
atropine. The anatomical structure of the 
eye is such that a moderately contracted 
pupil is in contact with the lens-surface, while 
a. fully dilated pupil is separated from it by a 
film of aqueous humour. Hence, as long as 
the pupil is contracted, any lymph which is 
effused tends to the immediate formation of 
adhesions; while, as soon as the pupil is 
dilated, the lymph diffuses itself harmlessly 
in the surrounding fluid, and no adhesions 
are produced. In ordinary circumstances, 
and in cases of only ordinary severity, the 
iritis then runs its course without inflicting 
any permanent injury, and vision is com- 
pletely restored as soon as resolution has 
taken place. When, on the contrary, the 
pupil cannot be dilated, the lymph deposited 
in the area of the pupil forms an impediment 
to vision; and the adhesions themselves tend 
to render the iritis a recurrent affection, 
which is apt to return again and again until 
the eye is disorganised and destroyed. 
The first principle of treatment is, there- 
fore, to produce and maintain dilatation of the 
pupil; and for this purpose it is necessary to 
use some active mydriatic. The neutral 
sulphate of atropine is usually the most 
convenient agent for the purpose, and it 
should be used in a solution containing four 
grains to the ounce of distilled water. The 
pharmacopceial solution of atropine, which 
contains spirit, should be avoided on account 
of its irritating action. Of the pure watery 
solution, a drop should be carefully placed 
within the lids by a dropping-tube or quill, 
repeated in five minutes, and again in another 
five minutes, and this threefold application 
should be repeated three times a day. A 
mydriatic agent still more powerful and more 
rapid in its action than atropine has lately 
been introduced into practice in duboisine, 
the active principle of an Australian shrub, 
Duboisia myoporoides. Duboisine should be 
used in a watery solution, of the strength of 
four grains to the ounce; and it is said to 
have less tendency than atropine to produce 
local irritation. The hydrochlorate of cocaine 
may be combined in solution with either of 
the foregoing, and will not only assist their 
mydriatic action, but will also greatly pro- 
mote the comfort of the patient. If the 
pupil can be fully dilated in twenty-four 
hours, no other treatment will be necessary 
than to maintain the dilatation by using the 
mydriatic less frequently, and to protect the 
eye from being injured by exertion, or by 
exposure to great variations of temperature 
or of light. If, on the contrary, after the use 
of atropine or duboisine for twenty-four hours, 
the pupil either remains contracted or dilates 
irregularly, showing that it is bound down 
here and there, it is necessary to have re- 
course to mercury without further delay, and 
to use one of the preparations, such as blue 
pill or calomel, with which the effect of 
the medicine upon the system can be 
rapidly secured. There is never any occa- 
sion to carry the effect of the mercury far- 
ther than to the formation of a slight line 
upon the gums ; and, in most cases, as soon 
as this line is perceptible, a notable amelior- 
ation of the eye-symptoms will be observed. 
It is desirable, however, that this degree of 
mercurial influence should be reached quickly, 
in order to cut short the disease as soon as 
possible; and when it has been reached, it 
will usually require to be maintained, for 
some days at least, by the administration of 
smaller and less frequent doses. In favour- 
able cases, under the combined influence of 
mydriatics and mercury, the effused lymph 
will be absorbed, the adhesions broken 
through, and the eye restored to its original 
condition. In those of a less favourable 
character, the inflammation will, indeed, sub- 
side ; but the adhesions will remain, and the 
pupil will be left permanently more or less 
crippled and distorted. Whether or not sight 
will be impaired will chiefly depend upon 
whether the effused lymph has formed a 
film or membrane across the pupillary open- 
ing. In the worst cases, notwithstanding 
treatment, the inflammation may extend to 
the ciliary body and choroid, and may produce 
functional destruction of the eye. This 
scarcely happens except when the iritis has 
been of great original severity, and when it 
has been neglected, or aggravated by irritants, 
in its early stages. Even the suspicion of 
iritis should absolutely preclude the use of 
the astringent applications on which we have 
mainly to rely in the treatment of the in- 
flammations of the conjunctiva. 
If an iritis is not seen until it has been 
three or four days in existence, so that the 
adhesions have had time to acquire a certain 
degree of firmness, it is not desirable to wait 
twenty-four hours before having recourse to 
mercury. The mineral should be given with- 
out further delay, so that it may be aban- 
doned if atropine should dilate the pupil, 
and may be pushed if dilatation cannot be 
produced. 
While the atropine, or atropine and mer- 
cury, are being employed, the remainder of 
the treatment must be governed by general 
considerations. Rest of the other eye must 
be strictly enforced; local depletion may be 
practised whenever the congestion is consider- 
able in degree ; and such a regimen and mode 
of life must be prescribed as the patient can 
bear. Unless there is photophobia, it is sel- 
dom or never necessary to exclude light alto- 
gether from the eye ; and, when photophobia 
is present, it is better to apply a protective 
bandage than to keep the patient in a dark 
room. The latter practically excludes him 
from cheerful companionship, and leaves him 
to dwell upon his troubles in darkness and 656 
EYE, AND ITS APPENDAGES, DISEASES OF 
solitude. Pain, if present notwithstanding 
the use of cocaine, should always be subdued, 
either by combining a sufficient dose of opium 
with the mercury, or by the subcutaneous 
injection of a solution of morphine. However 
the anodyne is administered, provision should 
be made for repeating it sufficiently often to 
produce and maintain the desired effect. 
When recovery takes place leaving adhe- 
sions, these will, in the majority of cases, 
lead to a second attack of iritis, and this is 
almost always the predecessor of regular re- 
currence. In a few cases, however, the 
second attack does not follow; but, when- 
ever it occurs, the tendency to future mis- 
chief should be stopped by surgical means, 
either by the detachment of the adhesions or 
by the performance of iridectomy. 
(6) Aplastic Iritis.-The aplastic form of 
iritis differs from the plastic in the greater 
quantity and the more liquid condition of the 
effusion, which does not form adhesions, but 
distends the eyeball and compresses its con- 
tained structures. In a well-marked case the 
pupil is contracted and insensible to atropine 
(which in all probability is not absorbed); 
the aqueous humour is turbid; the iris is 
pushed back and its anterior surface appears 
concave; vision is greatly impaired; and 
the eyeball is perceptibly hardened to the 
touch. 
Treatment.-Until the distension is re- 
lieved, no remedies will be effectual; and, 
when it is relieved, they generally cease to 
be needed. The treatment should be either 
by frequently repeated paracentesis of the 
anterior chamber or by a large iridectomy or 
sclerotomy, and the latter is generally to be 
preferred. Aplastic iritis occurs chiefly in 
persons of unhealthy or broken-down con- 
stitution; which may perhaps account for 
the unorganisable character of its products. 
As soon as the distension of the eyeball is 
relieved, the pupil is readily dilated, and the 
iritis soon subsides. 
(c) Suppurative Iritis.-In a small num- 
ber of cases iritis assumes from the first a 
suppurative character, and leads to the 
formation of pus in the anterior chamber. 
Treatment.-Such a condition calls for 
atropine ; for stimulating and tonic medicines 
rather than for mercury; and for the evacua- 
tion of the pus by paracentesis if it is con- 
siderable in quantity, or if its presence 
appears to be a source of increased irritation. 
(d) Serous Iritis.-This term, which would 
perhaps be more appropriately used for the 
aplastic form of iritis, has been applied by 
continental writers to a form of disease which 
was described in old books as ' aquo-capsulitis,' 
and in which the posterior surface of the 
cornea participates with the iris in the in- 
flammation. 
^Etiology and Symptoms.-Serous iritis 
usually first attracts attention by occasioning 
a slight dimness of vision. There will often 
be no congestion, or scarcely any, but the 
movements of the pupil will be sluggish, and 
careful examination will discover one or more 
fine points of adhesion to the anterior cap- 
sule. But the most characteristic appear- 
ance of the disease is situate upon the lining 
membrane of the cornea, which will be found 
covered by a number of minute circular dots, 
ranged in a pyramidal outline. The base of 
the pyramid corresponds with the lower 
corneal margin ; the apex encroaches more 
or less upon the pupillary region. As the 
disease progresses, the dotted pyramid in- 
creases in density and conspicuousness, and 
the pupillary adhesions increase in number 
and extent. The malady usually runs a very 
chronic course, and often leaves some per- 
manent diminution of vision. In a certain 
proportion of cases it seems to be indepen- 
dent of any known cause ; in others it follows 
some constitutional affection (the writer has 
seen a very severe case, in a young lady, 
consecutive to mumps) ; in others it is as- 
sociated with constitutional syphilis. After 
injury to an eye, serous iritis sometimes 
appears in the other as the first stage of 
sympathetic ophthalmia. 
Treatment. - This will include, in the 
first place, careful consideration of the state 
of the general health, and endeavours to 
correct whatever may be amiss. The eyes 
should be kept at rest, the pupils dilated but 
protected from bright light, and mercuric 
chloride, or iodide of potassium, or both, 
may be given in suitable doses, the efficacy 
of these remedies being manifest in the non- 
syphilitic as well as in the syphilitic sub- 
jects of the disease. Where the adhesions 
are numerous, iridectomy may be required 
to relieve dragging. The cases are usually 
chronic, and many months may elapse before 
the eyes are restored to usefulness. 
2. Inflammation of the ciliary body and 
choroid.-Synon. : Cyclitis; Irido-choroiditis. 
In some instances, which fortunately are not 
numerous, iritis is not confined to the mem- 
brane in which it originates, but spreads 
backwards to the ciliary body and the choroid. 
The most marked examples are those in 
which the original inflammation has been 
excited by morbid changes, resulting some- 
times from disease, but more frequently 
from injury, in the opposite eye; and these 
cases are called sympathetic ophthalmia. 
They have been generally supposed to de- 
pend upon the propagation of peripheral irri- 
tation through a nervous centre, and to point 
very clearly to the presence of some central 
nerve-irritation, or functional failure, as the 
essential point of difference between the 
iritis which dies out as a localised affec- 
tion, and that which spreads by continuity 
to the deeper parts of the eye. Recent 
observers have endeavoured to connect the 
phenomena with the presence and the migra- 
tions of microbes. However occasioned, the EYE, AND ITS APPENDAGES, DISEASES OF 
657 
issue of declared irido-cyclitis or irido-cho- 
roiditis is generally disastrous; for the in- 
flammation is always of a plastic character, 
and the effused lymph is scarcely ever ab- 
sorbed in time, or with sufficient complete- 
ness, to prevent its contraction from inflicting 
profound injury upon the visual apparatus. 
The perceptive layer of the retina is not only 
in contact with the choroid, but the rods and 
cones derive the materials of their nutrition 
from the chorio-capillaris; and hence, as 
regards these delicate structures, an inflam- 
mation of the choroid, upon which they are 
directly dependent, is of far greater impor- 
tance than an inflammation of the retina 
itself, which may be limited to the connective 
tissue of the fibre layer, and may leave the 
precipient elements almost unaffected. 
Symptoms.-The first sign of the extension 
backwards of iritis is usually furnished by 
tenderness of the ciliary zone, so that this 
region feels acutely the slightest touch of a 
probe, or of the end of a rolled paper spill, 
which is a more delicate instrument for test- 
ing the sensibility of the ocular surface. At 
the same time there is always a greater degree 
of impairment of vision than the iritis alone 
will explain, together with increased general 
congestion of the eye, and, in many cases, 
with an appearance of visible vessels on the 
iris. 
Treatment.-The treatment to be pursued 
does not differ materially from that w'hich is 
required by the more severe forms of simple 
iritis; and consists of depletion from the 
temple, generally by means of Heurteloup's 
leech; the application of atropine; the ad- 
ministration of mercury, both internally and 
by inunction upon the brow; the control of 
pain; and the maintenance of strength. In 
sympathetic cases, the eye in which the 
mischief originated should be removed, even 
although the usefulness of this proceeding is 
somewhat doubtful when once the secondary 
affection is established. It is often necessary 
carefully to continue the use of mercury for 
a long period, generally in the form of small 
doses of the perchloride combined with iron; 
and it is chiefly when this has been done 
that some small vestige of vision is saved out 
of the wreck. The lens, in such cases, often 
becomes coated by lymph, and ultimately 
requires removal; and it may be necessary 
to perform iridectomy for closure of the pupil 
more than once, in consequence of the 
tendency of the artificial opening to be 
drawn together again by contraction. On 
account of the severity of sympathetic oph- 
thalmia, and of its generally unfavourable 
termination, it is a rule of practice to antici- 
pate its occurrence, and to remove a diseased 
or injured eye which is likely to produce it, 
before the mischief has been done. 
V. Diseases of the Crystalline Lens 
are separately treated of under the article 
Cataract. 
VI. Glaucoma.-In its modern signifi- 
cation, this word is applied to denote all the 
conditions which are produced by a morbid 
increase of tension within the eye-that is 
to say, by an excess of its contained fluids; 
and the different forms of the affection are 
mainly due to differences in the rate at 
which the tension increases. 
Symptoms.-If the increase be rapid, the 
loss of sight will be rapidly produced, and 
will be associated with other changes occa- 
sioned by sudden interference with the 
circulation and innervation, and by sudden 
stretching of the ocular tunics. When, on 
the other hand, the increase of tension is 
very gradual, so that the eye has time to 
become accustomed to the new conditions 
as they are produced, the symptoms often 
present a deceptive resemblance to simple 
atrophy; and these cases were at one time 
described as ' atrophy with excavation of the 
optic nerve.' In some of the more acute 
forms of increased tension, the pupil presents 
a clouded aspect of a greenish colour; and 
it was to cases of this class that the word 
glaucoma (from yXavKos, sea-green) was 
originally applied, at a time when the patho- 
logy of the condition was not understood. 
When this pathology was rendered clear, 
and when it became known that the glau- 
coma of the ancients was in all essential 
respects identical with cases in which the 
most manifest symptoms were of a different 
kind, the word was retained as a convenient 
general term, to express states of disease to 
which it had no longer any apparent refer- 
ence ; and hence we still speak of glaucoma, 
although, in the great majority of the cases 
in which we do so, the green aspect of the 
pupil is conspicuous by its absence. 
The normal tension of the eye appears to 
be maintained, in the face of continued in- 
ternal secretion of fluid, mainly by the 
transudation of this fluid, at the so-called 
' filtration area,' in the angle formed between 
the cornea and the iris, into the plexus of 
veins contained in the canal of Schlemm. 
In order that this transudation may be free, 
it is necessary that the angle should be open, 
and the access of fluid to the filtration area 
unimpeded. In certain relations of the lens 
to the neighbouring structures, and, possibly, 
in consequence of increased bulk of the lens 
in advancing life, the periphery of the iris 
may be so pushed forward towards the cornea 
as to produce partial closure of the angle, and 
impeded access of fluid to the filtration area. 
Such conditions tend necessarily to increase ; 
and they are liable to be increased still 
further by dilatation of the pupil, which im- 
plies thickening of the peripheral portion of 
the iris, and the occupancy, by this portion, of 
an abnormal amount of space. At a later 
period, as the tension continues to increase, 
the peripheral portion of the iris may even be 
applied to the margin of the cornea after the 658 
EYE, AND ITS APPENDAGES, DISEASES OF 
fashion of a valve, and transudation may 
be completely arrested. 
The estimation of increased tension by the 
fingers is a matter which requires the tactus 
eruditus, and is best accomplished by direct- 
ing the patient to close the eyes gently, and 
to cast them downwards. The tips of the 
two forefingers should then be placed upon 
the upper lid immediately below the margin 
of the orbit, and, when one finger has fixed 
the eye by holding it gently back against the 
orbital contents as far as it will recede, the 
other estimates the degree in which it may 
be dimpled by slight pressure. This degree 
varies to some extent in different persons 
within physiological limits, but a morbid in- 
crease of tension can scarcely be missed if 
it is looked for. Moreover, the diagnosis of 
glaucoma does not rest upon increased tension 
alone, but upon the combination of increased 
tension with decreasing sight. The rate of 
slow increase which may simulate atrophy, 
or of rapid increase which may simulate in- 
flammation, are matters of detail which 
should not, in either case, be suffered to 
obscure the true nature of the morbid process. 
The symptoms of glaucoma depend upon 
the more or less gradual interference with 
the ocular circulation, and compression of the 
ocular nerves, by reason of increasing pres- 
sure within the eye. In consequence of the 
interference with the circulation, the blood 
enters and leaves the eyeball with difficulty. 
The first indication of this difficulty is 
afforded by the small veins which pierce the 
anterior portion of the sclerotic near the cor- 
nea, and course backwards beneath the con- 
junctiva towards the equator. These veins, 
which are invisible, or at least inconspicuous, 
in health, become distended and tortuous 
when the impediment to the venous outflow 
reaches a certain degree. At the same time, 
the ophthalmoscope will usually discover 
pulsation of the retinal vessels upon the optic 
disc, a pulsation first observed in the veins, 
and afterwards also in the arteries. It w'ould 
seem that the contents of the veins are 
pushed back by the entering arterial current, 
and that the latter is only able to make good 
its way at the acme of the pulse-wave. 
The symptoms which depend upon com- 
pression of the nerves will vary, of course, 
with the functions which these fulfil. Com- 
mencing with ordinary sensation, a moderate 
compression of the filaments derived from 
the fifth produces diminished sensibility of 
the corneal surface ; while a pronounced in- 
crease of tension, especially if rapidly pro- 
duced, occasions severe pain by the stretching 
of the ocular tunics. Proceeding to the 
motor filaments, compression of those derived 
from the third produces paresis of the ciliary 
muscle and of the sphincter pupillae; the 
former evidenced by rapidly increasing im- 
pairment of accommodation, the latter by 
sluggishness and dilatation of the pupil, the 
dilatation usually moderate in degree, but 
often causing the aperture to assume an 
elliptical outline, with its major axis hori- 
zontal. This pupillary dilatation is apt to be 
increased by the forward pressure of the 
crystalline lens; and, however produced, it 
tends, in the way already described, to occa- 
sion a still farther increase of tension. The 
compression of the retina causes impairment 
of visual function, first manifested in the 
portions most remote from the central blood- 
supply ; and hence taking the form of con- 
traction of the field of vision, usually first 
displayed and most marked on the nasal 
side. Contemporaneously with this, central 
vision will be more or less reduced ; and, at 
the same time, the increasing intra-ocular 
pressure will occasion yielding from within 
wherever such yielding is possible, and hence 
chiefly over the area of the optic disc, the 
structures composing which will be to some 
extent pushed back out of the eye, leading to 
the formation of a ' cup ' or excavation, which 
is one of the most conspicuous of the ophthal- 
moscopic signs of heightened tension. Finally, 
the general nutrition of the eyeball will 
suffer, in a manner which is often first dis- 
played by the surface epithelium of the cor- 
nea, which is apt to become disturbed, irre- 
gular, or, as it were, ' steamy,' presenting an 
aspect somewhat as if it had been breathed 
upon, and constituting a cause of further 
serious impairment of the already diminished 
vision. 
Such being the chief symptoms, one or 
more of which will be recognisable by ex- 
amination in glaucoma, those complained of 
by the patient are often exceedingly charac- 
teristic. Glaucomatous tension is apt to in- 
crease in waves, separated by intervals in 
which it may decrease, or in which the struc- 
tures pressed upon acquire some tolerance 
of the new conditions. We therefore often 
hear complaints of sudden ' clouds ' or ' ob- 
scurations ' of vision, which pass away after 
a few minutes or a few hours, and return at 
uncertain intervals. The intervening re- 
covery in such cases is seldom complete; 
each ' cloud ' usually leaving the sight per- 
manently worse than before. The depth of 
the cloud, the period of its duration, and the 
presence or absence of pain, are conditions 
which will be governed by the extent and 
the rapidity with which tension has been in- 
creased. When the cloud has passed away, 
we shall usually find diminution of central 
vision, contraction of the field, especially on 
the nasal side, and sluggishness of the rather 
large pupil. At the same time, it will often 
be found that the sensitiveness of the corneal 
surface is diminished ; and the patient will 
often admit, on inquiry, that artificial lights of 
feeble intensity-candle flames, for example- 
are frequently surrounded by coloured halos. 
But the combinations and the order of oc- 
currence of symptoms will differ widely in EYE, AND ITS APPENDAGES, DISEASES OF 
659 
different cases; and all that can be called 
essential, in order to constitute glaucoma, is 
a combination of impaired central vision and 
diminution of the field, with increased tension 
discoverable by the educated finger. When 
this combination is present, there should be 
no doubt as to the diagnosis, as there will 
certainly be no time to waste in inefficient 
treatment. 
Treatment.-The treatment of glaucoma 
is entirely surgical, the affection being capable 
of arrest by iridectomy or sclerotomy in the 
great majority of cases. In the more acute 
forms, an operation, if performed sufficiently 
early, usually restores vision to its integrity; 
but the time during which this can be done 
is limited, and in the more chronic forms no 
operation will do more than preserve what 
amount of sight is still retained. Hence it is 
important that treatment should not be 
delayed by any error of diagnosis; and the 
points to which attention should chiefly be 
directed, in any case of impairment of vision 
in which the question may arise, are increas- 
ing hardness of the eyeball as determined by 
palpation, and gradual contraction of the 
field of vision. Whenever the eye is becom- 
ing harder, and the circumferential extent of 
vision is narrowing in, the case is one in which 
an operation should be accomplished with as 
little delay as possible. At the same time, 
until the operation can be performed, a four- 
grain solution of eserine should be applied 
every four hours ; this drug having a marked 
effect in controlling and diminishing tension, 
and being apparently indebted for this power 
to its mechanical action upon the iris, which, 
by the contraction of the pupil, is thinned out 
and drawn away from the filtration area. It 
is hardly necessary to add that in any case 
of actual or threatened glaucoma, the use 
of a mydriatic would be highly dangerous. 
The more acute cases of glaucoma are 
attended by much pain from the distension 
of the ocular tunics, and often by congestion 
and inflammation, the results of this disten- 
sion ; and such cases were at one time de- 
scribed as ' acute internal arthritic ophthal- 
mia,' or by some similar name. Vision has 
been irretrievably lost, in hundreds of cases, 
by endeavours to control this form of glau- 
coma by medical treatment, to the neglect of 
operation ; and the erroneous practice has 
been kept alive by the circumstance that 
some of the cases will undergo partial and 
temporary amendment. In such circum- 
stances, however, the vision never rises to 
the degree of acuteness which existed prior 
to the attack, and the amendment is never 
more than temporary. Another increase of 
tension soon occurs; and, without surgical 
aid, blindness sooner or later closes the 
scene. 
VII. Diseases of the Optic Nerve 
and. Retina.-As shown by the ophthal- 
moscope, these diseases cover a very wide 
field of pathology. In order to understand 
them accurately, it is necessary to bear in 
mind the anatomy and relative arrangement 
of the affected tissues. The optic nerve in 
the orbit is invested by a double sheath, and 
the interval between the layers of this sheath, 
which is continuous with the sub-arachnoid 
space, terminates in a cul-de-sac towards the 
eyeball, the two layers becoming intimately 
united where they blend with the sclerotic. 
At this point, the opening in the sclerotic for 
the admission of the optic nerve is crossed 
by a film of perforated connective tissue, the 
lamina cribrosa, with which the sheaths of 
the nerve-fibres blend, or in which they are 
lost, so that the nerve anterior to the lamina 
consists of a bundle of unsheathed fibres, 
enveloping the central artery of the retina, 
which enters the eye with them, and the 
central vein of the retina, which passes out 
in the same position. On entering the eye 
the nerve-fibres bend round to form the 
anterior layer of the retina, which con- 
tains also the retinal blood-vessels almost 
to their ultimate divisions, together with 
some delicate connective tissue. The capil- 
lary circulation of the nerve itself is derived 
from the anterior cerebral artery, and is 
distinct, save for a very slight amount of 
anastomosis, from the capillary circulation 
of the sheath, which is fed by the arteries 
of the pia mater. It follows that hypersemia 
of the sheath, or of the circle surrounding 
the nerve, may exist without hypersemia of 
the proper nerve-tissue, and it has been sup- 
posed that fluid pressure in the intervaginal 
space may interpose an obstacle to the cir- 
culation in the vessels which pass through 
the sclerotic foramen, and may thus occasion 
dropsy of the termination of the nerve within 
the eye. Of the two foregoing conditions, 
either may undergo resolution harmlessly, or 
may produce such changes in or around the 
nerve as to occasion atrophy and loss of sight. 
Neither of them interferes w'ith sight directly, 
because the circulation may be seriously dis- 
turbed by a degree of pressure which is insuf- 
ficient to stop the conduction of impressions 
through the nerve-fibres. There is yet a 
third condition, properly called optic neuritis, 
or neuritis descendens, in which the capillary 
network of the nerve itself participates in 
changes propagated downwards, and in which 
impairment of vision holds a very early place 
among the symptoms. 
1. Perineuritis.-The true perineuritis, in 
which the unchanged nerve-disc is sur- 
rounded by a zone of high vascularity, is 
only seen af- a result of meningitis, which 
may be either tubercular or due to other 
causes. It wTas at one time hoped by Bouchut, 
by whom this especial phenomenon was first 
described, that perineuritis might serve as a 
diagnostic sign in cases of doubtful meningeal 
inflammation; but this expectation has not 
been realised. The perineuritis itself has only EYE, AND ITS APPENDAGES, DISEASES OF 
660 
been observed in cases the character of which 
was scarcely doubtful, and which, in most 
instances, have terminated fatally. Very pro- 
bably, however, it would be found, if looked 
for, in those cases of exanthematous and 
other fevers which are attended by cerebral 
symptoms, followed after recovery by impair- 
ment of vision. In these we eventually find, 
as a rule, a partial nerve-atrophy, which does 
not lead on to complete blindness, but which 
does not appear to be susceptible of improve- 
ment; and this partial atrophy may no doubt 
be due to the pressure of perineural exudation 
during its contracting stage. 
Treatment.-The treatment of perineuritis 
must generally be that of the affection in 
which it has its origin ; but, in any fever in 
which this symptom had been detected, it 
would be a question whether mercury should 
not be cautiously administered for a consider- 
able t'ime after convalescence, in order to 
promote the absorption of any effused lymph 
by which the optic-nerve entrance might be 
constricted. 
2. Choked Disc.-Synon. : Dropsy of the 
Optic-Nerve Entrance.-This is a condition 
chiefly seen in connexion with intracranial 
tumours, whether syphilitic, tubercular, or of 
some other kind; and it almost invariably 
affects both eyes. It was formerly supposed 
to be due to the pressure of fluid driven down 
the intervaginal space around the nerve, 
and so constricting the latter at the terminal 
cul-de-sac as to impede the outflow of venous 
blood. This hypothesis is not now universally 
accepted, but the condition visible with the 
ophthalmoscope is one of distension and 
tortuosity of the retinal veins; arrest of the 
capillary circulation; impediment to the 
arterial inflow; dropsical effusion into the 
disc-tissues; and, sometimes, secondary in- 
flammatory changes, such as effusion and 
cell-proliferation, comparable to the erythema 
which occurs in the integument of a dropsical 
limb. All these changes may exist without 
impairment of vision, because they neither 
affect the perceptive layer of the retina, nor 
arrest the conduction through the nerve- 
fibres. At a later period, however, when 
any plastic elements in the exudation begin 
to undergo contraction, the interference with 
the circulation becomes more complete, the 
nerve-fibres themselves become compressed, 
and then failure of sight commonly occurs. 
At the same period, the nerve passes into a 
state of atrophy from the interference with 
its circulation; and these cases of nerve- 
atrophy were once sources of great perplexity 
to surgeons, and were referred to alcohol, to- 
bacco, and to other causes which probably 
had very little to do with them. In conse- 
quence of the sight not being affected during 
the preliminary stage, the occurrence of this 
stage was for a long time absolutely over- 
looked, and was only discovered when phy- 
sicians began to use the ophthalmoscope, as 
an ordinary instrument of diagnosis, in all 
cases of cerebral affection. It was then soon 
established, notably by the labours of Drs. 
Hughlings Jackson, Buzzard, and Clifford* 
Allbutt, that the atrophy had been preceded 
by swelling of the disc and by obstruction of 
its circulation; and it was shown before long 
that the cases of atrophy which had this 
history were recognisable, after the swelling 
had passed away, by the tortuosity of the 
retinal veins which was left behind, and by 
the way in which these veins were lifted into 
bold curves at the margin of the disc; this 
alteration of their original course having been 
due to the swelling, and remaining after the 
swelling had subsided. The contraction of 
the effusion, and the consequent atrophy of 
the nerve-fibres and closure of the capillary 
vessels, would be likely to occur earlier in 
some parts of the disc than in others; and 
hence, at the time when commencing failure 
of sight first induced the patient to seek 
advice on account of it, the disc was com- 
monly seen to be invaded by sectors of white- 
ness, but to retain its vascularity, or perhaps 
more than its normal vascularity, in other 
parts; while, at the same time, the sight was 
first lost in those regions of the retina the 
fibres from which were first compressed. 
Hence it follows that a partial invasion of 
the disc by atrophic changes, and a partial 
invasion of the field of vision by blind por- 
tions, are among the earliest symptoms in 
cases of the class under consideration; and 
these symptoms were at one time referred 
rather to the nervous centres than to the 
retina or the disc itself, to changes in which 
they are now attributed. A not uncommon 
clinical history in such cases is that there 
has been constitutional syphilis, imperfectly 
treated, and ultimately producing headache 
or other cerebral symptoms, which have pro- 
bably called for the administration of iodide 
of potassium and have been relieved by it. 
Some weeks afterwards there is for the first 
time a complaint of failing sight; and then 
the ophthalmoscope reveals that the discs 
are passing into atrophy, that the retinal 
veins are lifted into prominent curves at the 
disc-margins, and that their further course 
over the retina is generally serpentine. In 
many cases, the recovery of the patient, as 
far as general health is concerned, leaves the 
precise character of the intracranial mischief 
doubtful; but, in fatal cases, a tumour is the 
morbid condition most frequently discovered. 
See Ophthalmoscope in Medicine. 
When the merely passive dropsical effusion 
into the disc becomes complicated with in- 
flammatory changes, as results of the disturb- 
ance of the tissues, the sight begins to fail 
before atrophic changes become manifest; 
and such cases are very difficult to dis- 
tinguish from those in which there is pri- 
mary or descending neuritis. The blood- 
supply of the optic nerve being derived from EYE, AND ITS APPENDAGES, DISEASES OF 
661 
the anterior cerebral artery, we may reason- 
ably expect to find capillary engorgement of 
the nerve-substance of the disc in connexion 
with arterial hyperaemia of the brain ; and 
this capillary engorgement may pass into 
inflammation, either of local origin or by 
transmission downwards from above. In any 
case, if the first changes in the disc are of 
the character of neuritis rather than of ob- 
struction, we see capillary or arterial hyper- 
temia of the nerve-substance rather than 
venous congestion ; and effusion of plastic 
material upon the disc itself, with compara- 
tively little prominence or disc-swelling, and 
with comparatively little extension over the 
disc-margins upon the surrounding retina. 
At the same time, even in the early stage of 
the affection, we find great impairment of 
sight, the conducting power of the nerve- 
fibres being seriously injured. Such cases 
are frequently syphilitic, and, unless the ab- 
sorption of the effusion should be quickly 
brought about by treatment, its contraction, 
like that of the effusion of obstruction, soon 
occasions atrophic changes. In these cases, 
however, the swelling having been absent or 
inconsiderable, the vessels do not show that 
elevation into bold curves at the disc-margin 
which has already been described; and the 
contraction being interstitial in the nerve- 
substance, and from the first affecting veins 
and arteries in an equal degree, the arterial 
inflow is diminished^ari passu with the dim- 
inution of the vein-channels, and the latter 
vessels are seldom distended in such a 
manner as to render them distinctly varicose 
or tortuous. The ultimate result is a white 
disc, on which the arteries and veins are 
dwindled to threads, or at least greatly re- 
duced from their normal calibre. 
We may therefore have three conditions 
which in their typical forms are tolerably 
distinct, but which are prone to run into one 
another by almost imperceptible gradations, 
and which may all lead on to atrophy and 
complete blindness: namely, perineuritis, neu- 
ritis, and choked disc. The liability to the last- 
mentioned condition should be carefully 
remembered by physicians, and should lead 
to careful ophthalmoscopic examination in 
all cases of obstinate headache or other 
cerebral symptoms of obscure origin, more 
especially in a patient with a syphilitic history. 
Treatment.-It is manifest that the best 
hope of preventing ultimate blindness in 
persons in whom choked disc has occurred 
will be secured by the administration of 
medicines calculated to assist the absorption 
of the effusion, and by continuing these 
medicines, with comparatively small refer- 
ence to the general symptoms, until the discs 
have cleared. The writer has seen such 
clearing occur, without loss of sight, in cir- 
cumstances which rendered it almost certain 
that neglect of the disc-effusions would have 
been followed by blindness at no distant 
date. The same general rule will apply, of 
course, to the more directly inflammatory 
effusions of neuritis or perineuritis; and, 
when we find any one of the three conditions 
passing into atrophy, or when we find com- 
mencing atrophy in discs which show traces 
of past effusion, the principle of treatment is 
to endeavour to promote the absorption of 
any contracting material which may be the 
physical cause of the atrophy; and then, 
when this has been done, to seek to stimu- 
late the nutrition of the nerve-fibres, and to 
assist them to recover from the shock w'hich 
they have sustained. The mode of fulfilment 
of the first indication must depend mainly 
upon whether there is a history of syphilis, 
and, if so, upon the manner in which it has 
been treated. In the numerous cases in 
which a short course of mercury has been 
administered, enough to alleviate secondary 
symptoms, but wholly insufficient to eradi- 
cate the disease, it will generally be desirable 
to give iodide of potassium in full doses for 
a time, and to follow this by the prolonged 
administration of the perchloride of mercury, 
in the hope of really curing the patient. 
There are, in the writer's opinion, few things 
better worth remembering in therapeutics 
than that the iodide, immeasurably the most 
valuable drug which we possess as a remedy 
for a late syphilitic symptom, is, none the 
less, almost useless as a remedy for constitu- 
tional syphilis. It will remove the present 
symptom, speedily and often completely ; but 
it can scarcely be said to have any tendency 
to prevent the recurrence of syphilitic symp- 
toms at a future time, in the same or in some 
different form. For this purpose, the only 
trustworthy agent is mercury; and there- 
fore, while the administration of the iodide 
for a sufficient time, and in sufficient quan- 
tities to test its power of doing good, will be 
enough in the cases in which syphilis is 
neither known nor suspected, the iodide must 
be followed by mercury whenever a syphilitic 
history of the affection is either clear or 
highly probable. The second indication, to 
stimulate the nutrition of the nerve-fibres, is 
usually best accomplished by strychnine, giveh 
at such intervals and in such doses as to pro- 
duce evidence of its constitutional effect be- 
fore its administration is abandoned. It may 
perhaps be most effectually given by hypo- 
dermic injection; but this is a point which 
must be settled in accordance with the cir- 
cumstances of the case in each individual 
instance. During the last two or three years, 
in cases of great disc swelling with impair- 
ment or loss of sight, the writer has on four 
occasions incised the sheath of the optic 
nerve behind the eye, so as to give exit to 
any accumulation of fluid in the intervaginal 
space, or to release an inflamed nerve from 
the pressure of its unyielding covering. The 
results have been generally satisfactory ; and 
in one of the patients, who had been totally 662 
blind for several days, vision was completely 
restored. 
3. Toxic Amblyopia. Toxic Central Neu- 
ritis.-Much attention has been bestowed of 
late years upon a form of gradual failure of 
vision which first affects chiefly the central 
portions of the retinae, and which appears to 
depend upon a chronic neuritis attacking 
originally the portion of the optic nerve- 
trunk which contains the fibres destined for 
the region of the macula lutea. This affec- 
tion has often been connected with the ex- 
cessive use of the stronger forms of tobacco, 
as well as with the abuse of ardent spirits, 
or with both these conditions in combination. 
It is characterised by impairment of sight, 
and also of colour-sense, the impairment 
being at first limited to the central portion 
of the field, and the colour-sense often becom- 
ing changed before form-vision is very notice- 
ably affected. It may extend, if neglected, 
over the whole of the nerve-fibres, and may 
ultimately lead to practical, but seldom to 
absolute, blindness, perception of light and of 
large objects being often retained. In order 
to test for central loss of colour-sense, it is 
necessary to be provided with small red and 
green objects which may be moved in suc- 
cession over various parts of the field, and 
which, in typical cases, will appear much 
less bright in the centre than when they are 
held a little to one side of the direct line of 
vision. 
Treatment.-This consists, firstly, in the 
abandonment of tobacco and alcohol; secon- 
darily, in endeavours to improve the general 
health ; thirdly, in the use of medicines, such 
as iodide of potassium and mercury, by which 
chronic inflammatory conditions are likely to 
be controlled; and, lastly, in stimulation of 
the weakened nerves by the careful employ- 
ment of strychnine. A very careful prognosis 
should be given in the first instance ; but, if 
improvement once commences, the case will 
usually terminate in recovery. 
4. Sclerosis of the Optic Nerve.-Besides 
the consecutive forms of atrophy above enu- 
merated, there is yet another of common 
occurrence, which is either a primary sclerosis 
of the optic nerve, or a sclerosis secondary to 
a similar affection of other parts of the ner- 
vous centres. This form of atrophy is not 
preceded by effusion, nor is it attended by 
any marked decrease in the calibre of the 
central vessels of the retina, even when the 
capillary circulation of the disc has almost 
wholly disappeared. It is often seen in con- 
nexion with disease of the spinal cord, as in 
locomotor ataxy; and also occurs in appa- 
rently healthy people, seemingly as a purely 
local affection. 
Sclerosis is easily distinguished from the 
atrophies consecutive to effusion, whether 
active or passive, by the circumstance that 
the effusion, as it undergoes contraction, 
tends to render the nerve-tissues opaque as 
EYE, AND ITS APPENDAGES, DISEASES OF 
well as to bleach them, and thus leaves a disc- 
surface of an almost ivory whiteness and of 
uniform colour. In sclerosis, on the other 
hand, the nerve-tissue disappears to a great 
extent, and reveals the mottled surface, often 
of a bluish-white tint, of the lamina cribrosa. 
When this is plainly seen, and when, at the 
same time, the vessels are neither much 
diminished in calibre nor altered in their 
normal curvatures, sclerosis may be assumed 
to exist; and this form of atrophy may also 
be distinguished from that which is produced 
by the most chronic forms of glaucoma, by 
the circumstance that in the latter the vessels 
bend into the excavated disc at its margin, 
while in the former they pass over the margin 
in straight lines or nearly so. Chronic glau- 
coma would also usually be distinguished by 
the character of the failure of sight, which 
would be marked by the ordinary contraction 
of the field of vision, even when central 
vision was only a little impaired; and also 
by the gradual hardening of the eyeball, 
which would be present in glaucoma and 
absent in nerve-sclerosis. Still it cannot be 
denied that this particular diagnosis is not 
without its difficulties, and that in certain 
cases it has given rise to differences of opinion 
between men of large experience on all sides 
of the question at issue. 
The diagnosis is important as well as diffi- 
cult, since the mischief of glaucoma may 
admit of arrest by iridectomy or sclerotomy ; 
so that to mistake chronic glaucoma for 
atrophy, and to neglect operation, may be to 
condemn the patient to unnecessary blind- 
ness. The opposite error can at least do no 
harm; and therefore, whenever a doubt really 
exists upon the point, the most proper course 
is to give the benefit of that doubt to the 
patient, and to advise the performance of an 
operation which cannot injure, and which 
may relieve him. The atrophy of sclerosis 
scarcely admits of treatment, but it may per- 
haps sometimes be delayed, or even prevented 
from becoming complete, by the administra- 
tion of full doses of strychnine and iron. 
5. Atrophy from other causes.-Besides 
the foregoing forms of atrophy, there is a 
variety which appears to be associated with 
chronic lead-poisoning, and in which the discs 
may acquire a peculiar grey or bluish tint; 
and the optic nerves may also undergo 
secondary wasting in consequence of other 
conditions presently to be mentioned, such as 
obstruction of the central artery by an em- 
bolus, or the long continuance of pigmentary 
retinitis. 
6. Retinal Hcemorrhage.-The chief dis- 
orders of the retinal circulation displayed by 
the ophthalmoscope are haemorrhages, which 
may be attended by very different circum- 
stances, and may present widely different 
characters. 
a. Single.-When blood proceeds from one 
of the larger veins of the retina, which yield EYE, AND ITS APPENDAGES, DISEASES OF 
663 
a considerable quantity, and which are situ- 
ated immediately underneath the limiting 
membrane, the haemorrhage usually spreads 
out over the fundus as a red patch of uniform 
colour and aspect, and vision is suddenly, 
and sometimes almost totally, obscured. The 
writer has seen such bleeding occur from the 
yielding of a vessel during parturition; but 
this accident is extremely rare, and the large 
haemorrhages in question are certainly more 
common in women at the period of cessation 
of the menstrual function than in any other 
circumstances. At this time, and when the 
health is not seriously affected, a favourable 
prognosis may be given with some confidence; 
for the blood will before long be absorbed, 
and restoration of vision, at least in a con- 
siderable degree, may be expected. The 
writer has once seen complete restoration to 
the normal standard, but this is an excep- 
tional occurrence. 
Treatment.-The only treatment neces- 
sary is to pay attention to the requirements 
of the general health; and to prescribe such 
diet, medicines, regimen, and habits as may 
tend to calm and equalise the circulation, 
and to prevent local congestions. The oc- 
currence of sudden loss of sight in one eye 
will justify the suspicion of haemorrhage; 
but the suspicion can only be converted into 
certainty by the ophthalmoscope. 
b. Multiple.-A form of venous haemor- 
rhage which at first seems less formidable, 
because it is attended by a smaller degree of 
immediate interference with sight, but which 
calls for a less favourable prognosis, is that 
in which the haemorrhages are multiple, often 
singly of small size, and scattered over the 
whole fundus of the eye. The appearances 
which they present differ, apparently in ac- 
cordance with their precise position in the 
retina. If they proceed from vessels which 
are superficial, the blood is spread out, as in 
the last variety, in round or oval patches 
beneath the limiting membrane ; but if the 
vessels lie a little deeper, and are fairly 
engaged in the fibre-layer, the blood will 
separate the fibres and find its way between 
them, forming flame-shaped or brush-like 
patches, which are often very numerous. 
Such multiple haemorrhages are very slowly 
absorbed, and have a tendency to recur; so 
that they must always be regarded as placing 
the sight in serious jeopardy. They are often 
monocular, and they do not point to any 
definite disturbance of the general health. 
The only endeavour so to connect them with 
which the writer is acquainted was made by 
Mr. Hutchinson, who described some cases 
of flame-shaped haemorrhage in persons all 
of whom he said were ' gouty '; but it will 
certainly be the experience of most prac- 
titioners that flame-shaped haemorrhages oc- 
cur in many patients who are not ' gouty ' in 
the ordinary sense, and that they do not 
occur in vast numbers of those about the 
reality of whose gout there can be no ques- 
tion. The presence of multiple haemorrhages 
is sometimes attended by a considerable 
degree of irritation, or even inflammation, 
in the tissues among" which the blood has 
been effused; and this condition, in which 
the retina between the blood-spots may be- 
come opalescent or turbid, has been described 
as a form of retinitis-retinitis apoplectica. 
The element of inflammation, in such in- 
stances, is probably merely a reaction con- 
sequent upon the injury inflicted upon the 
tissues, and it cannot be inferred that the 
bleeding is itself the result of any inflam- 
matory process. 
Treatment.-In this, as in the former 
variety, there is no special indication for 
treatment, which must be confined to the 
correction of any manifest disorder of the 
general health, followed, in most instances, 
by the administration of iodides or bromides, 
as medicines calculated to assist in the 
absorption and removal of the effused pro- 
ducts. Any indication of a general haemor- 
rhagic tendency, or of a state allied to purpura 
or scurvy, would require, of course, full con- 
sideration and appropriate treatment. The 
extent of the ultimate injury to sight will 
usually depend upon the extent to which the 
perceptive elements of the retina have been 
compressed or disorganised, either by the 
bleeding itself, or by other changes consecu- 
tive to it. 
c. Arterial. - Haemorrhages which are 
distinctly arterial are not uncommon in the 
fundus of the eye, and can generally be dis- 
tinguished without difficulty from the venous 
variety, not only by the colour of the effused 
blood, but also by the situation of the blood- 
patch, and by its manifest relations to a 
small arterial branch, which may often be 
seen to have dwindled or closed beyond the 
point at which it has given way. Arterial 
haemorrhages are mostly multiple, but of 
small individual extent; and, when not in 
the immediate neighbourhood of the optic 
disc, are most commonly seen near the outer 
limits of the ophthalmoscopic field of view. 
They are generally attended by sufficient 
impairment of vision to occasion complaint, 
and thus to lead to their detection ; but they 
seldom occasion blindness. They call for 
an examination of the urine for albumen, 
and, failing any evidence of renal mischief, 
they are chiefly important as indications of 
a weakened and brittle state of the arterioles, 
likely to lead to intracranial haemorrhage. 
Treatment.-Arterial haemorrhages into 
the retina point to the necessity of diminish- 
ing, as much as may be possible, the strain 
upon the arterial coats, by such means as the 
avoidance of muscular exertion or mental 
emotion, and by seeking to diminish the 
quantity of the circulating blood by a dimi- 
nution in the quantity of fluid ingested. Even 
when all precautions have been taken, arterial 664 
EYE, AND ITS APPENDAGES, DISEASES OF 
retinal haemorrhages are common forerunners 
of apoplexy. 
7. Embolism of the Central Artery of the 
Retina.-Embolism of the central artery of 
the retina, or of one of its branches, is a con- 
dition of not infrequent occurrence. 
Symptoms.-When sudden blindness of one 
eye occurs in a person who is the subject of 
valvular disease of the heart, the diagnosis 
can scarcely be doubtful; but the ophthal- 
moscopic appearances will suffice to remove 
doubt if it should exist. The immediate 
effect of the sudden arrest of the arterial 
circulation of the retina is to render that 
membrane opaque and of a milky whiteness, 
except over the macula lutea, where the ab- 
sence of connective tissue prevents any such 
change from being produced. Here, and here 
only, the original transparency is retained, 
and the colour of the choroid is still visible, 
with the result that the macula appears as a 
cherry-red spot in the midst of a white surface. 
When not concealed by the opacity, the larger 
veins of the retina are diminished in calibre 
and contents, and their blood is sometimes 
broken up into detached portions separated 
by interspaces. The arteries are empty, and 
are either invisible or traceable as white 
lines of fibrous tissue in the general milkiness 
of the fundus. The disc is usually bleached, 
but it will sometimes happen that its condi- 
tion may be temporarily obscured by arterial 
haemorrhage, occurring from some twig given 
off just below the seat of the embolus, and 
entering the eye independently. 
The driving home of the embolus will 
throw upon such a twig the whole force of 
the circulatory vis a tergo, and may thus 
rupture it-an occurrence of which the 
writer has seen several examples. The blood 
so effused is usually absorbed in a very few 
days, revealing the white disc and the 
collapsed arteries, and removing any uncer- 
tainty which might have existed with regard 
to the diagnosis. The opalescence of the 
retina also disappears before long, and then 
only the secondary nerve-atrophy and the 
disappearance of the arteries remain to dis- 
close the nature of the original affection. 
Embolism seems to be a perfectly hopeless 
condition, because there is no anastomosis 
between the retinal and other vessels of a 
sufficient extent to maintain a collateral 
circulation. The writer has met with one 
instance in which only a sector of the field 
was affected, and with one in which embolism 
of a very small branch produced loss of sight 
over all the peripheral parts of the field, 
leaving central vision almost intact; but 
such cases are among the curiosities of 
ophthalmology, and complete and permanent 
loss of sight of the affected eye is the result 
which must always be anticipated. 
8. Retinitis.-Retinitis is commonly de- 
scribed as occurring in three chief forms- 
the albuminuric, the syphilitic, and the/uy- 
mentary ; but the writer is inclined to believe 
that only the last of these three is a genuine 
retinitis, and that in the others the inflam- 
mation, if it should exist, is merely a secon- 
dary consequence of the irritation produced 
by the presence of adventitious deposits. 
a. Albuminuric Retinitis.-In the so- 
called albuminuric retinitis, the sequence of 
events appears to lend support to the con- 
tention of the late Sir William Gull and 
Dr. Sutton, to the effect that the renal 
disease is not an original affection, but only 
a result of morbid or degenerative changes 
which are common to the whole of the small 
arteries of the body. 
Symptoms.-In many cases of albuminuria, 
the sight is not affected from first to last, and 
the retinae remain healthy. In some, the 
retinal changes precede the appearance of 
albumen in the urine; and, in the majority, 
the renal and retinal changes are coincident. 
The retinal changes are of two kinds: 
namely, arterial haemorrhages, occurring in 
the fibre-layer, so that the blood-patches 
assume a fibrillated aspect with brush-like 
terminations; and the formation of white 
patches, either of cholesterine deposit or of 
fatty degeneration, or of both combined, 
scattered irregularly over the fundus, but 
often grouped into a stellate figure around 
the macula lutea, and into an irregular ring 
around the disc. To these appearances are 
added, in some cases, those of swelling of the 
disc-margins with effusion into the retinal 
fibre-layer; and, when the last-named appear- 
ances are presented, there is always a far 
greater deterioration of sight than when they 
are absent. It is a matter of daily occur- 
rence that the existence of renal disease is 
not suspected until impairment of sight leads 
to an ophthalmoscopic examination, and this 
to the discovery of the retinal changes ; and, 
in every hospital, cases which apply for re- 
lief to the ophthalmic department are con- 
stantly, on this ground, transferred to the 
physician. 
Treatment.-The treatment of the renal 
maladies which produce albuminuria is in no 
way modified on account of the presence of a 
retinal complication; and the unfavourable 
prognosis which must generally be given as 
regards life throws into comparative insigni- 
ficance the gradual failure of vision, which 
seldom proceeds to complete blindness. 
b. Syphilitic Retinitis.-This is usually an 
incident of the most advanced stages of the 
disease, and is most frequently seen in per- 
sons who have been inadequately treated 
during the primary stage, but who have for 
some months or even for a year or two been 
free from symptoms. 
Symptoms.-Dimness of sight is then com- 
plained of, and the retina is found to present 
scattered patches of very irregular outline, 
and of a filmy whitish aspect. Such patches 
may be more or less obscured by slight EYE, AND ITS APPENDAGES, DISEASES OF 
665 
general turbidity of the retina itself, or of the 
vitreous body in its immediate vicinity, the 
latter condition being of itself almost conclu- 
sive of the nature of the malady. 
Treatment. - The treatment must be 
greatly governed by the past history of the 
case, but may in most instances turn upon 
the use of iodide of potassium for the relief 
of the retinal troubles, followed by a sufficient 
course of mercury for the eradication of the 
syphilitic taint. 
c. Pigmentary Retinitis.-This appears to 
be a true inflammation of the retina, dif- 
fering from the foregoing affections in that 
it attacks the percipient elements, instead of 
the fibre-layer or the connective tissue of the 
membrane. 
^Etiology.-The subjects of pigmentary 
retinitis are of all ages, from nine or ten 
years to seventy; and, in some instances, 
the duration of the disease has been as much 
as twenty years, from the first appearance of 
the symptoms to their ultimate termination in 
blindness. As a rule, however, the patients 
are young adults, or persons not past middle 
age. 
It is a remarkable feature of pigmentary 
retinitis that it almost invariably attacks 
more than one member of a family; and it 
has been said to be especially frequent in the 
offspring of marriages of consanguinity, but 
this statement is not borne out by English 
experience. During the last twenty years 
the writer has only met with one family in 
whom the malady had this history. 
Anatomical Characters.-From the ex- 
treme chronicity of its course, from its ob- 
stinacy, and from its peculiar anatomical 
distribution, pigmentary retinitis should pro- 
bably be regarded, together with some forms 
of choroiditis, as having its analogies among 
some of the chronic diseases of the skin. It 
usually appears to commence in a narrow 
annulus near the equator of the eyeball, 
and gradually spreads inwards towards the 
optic disc; the tissues affected are the per- 
ceptive and pigmentary layers of the retina 
and the subjacent chorio-capillaris, which 
slowly become disorganised and matted to- 
gether in one common degeneration. Coin- 
cidently with the progress of the disease, 
pigment is deposited in the parts affected, 
and in the retina superficial to them, in the 
form of irregular lines and striations, and 
especially along the course of the main 
arterial branches. As the annulus of disease 
gradually closes in upon the macula, the optic 
disc undergoes atrophy of a kind which gives 
it a peculiar tint of whiteness, very readily 
recognisable when it has once been noticed, 
and the central vessels, both veins and 
arteries, dwindle in size. 
Symptoms.-The subjective symptoms are 
as characteristic as the ophthalmoscopic ap- 
pearances. Over the region actually invaded, 
the perceptive elements of the retina are de- 
stroyed, and the power to receive visual im- 
pressions is lost. The fibre-layer not being 
implicated, the conduction of impressions 
from parts of the retina more peripheral than 
the disease may remain unaffected; and 
hence we may have a blind zone surround- 
ing the centre of the field of vision, and sur- 
rounded itself by a zone still more external, 
in which dim vision is preserved. But the 
salient symptoms are two-the gradual con- 
traction of the field of vision due to the pro- 
gressive encroachments of the disease; and 
night-blindness, due to the nerve-atrophy, 
which interferes with the conduction or per- 
ception of any but strong impressions. When 
these symptoms co-exist; when the field of 
vision is small and becoming gradually 
smaller; and when the patient, who can still 
see fairly in the daytime, can scarcely find 
his way about as dusk begins to fall, we may 
predict the ophthalmoscopic appearances 
with a very near approach to certainty. The 
optic disc will be unnaturally pale, and the 
fundus overstrewn, towards the periphery, 
with irregular black lines and stripes, of 
which it is quite possible that none may be 
visible within that portion of the field of the 
ophthalmoscope which includes the disc. 
Diagnosis.-Pigmentary retinitis may pos- 
sibly be mistaken for the most chronic form 
of glaucoma, on account of the contraction 
of the field of vision ; but it may be distin- 
guished by the absence of high tension, by 
the night-blindness, and by the pigmentation 
of the retina. It may also be mistaken for 
the atrophy of sclerosis, but only if the oph- 
thalmoscopic examination is limited to the 
nerve-disc, to the exclusion of the surround- 
ing parts of the fundus. 
Treatment.-In the treatment of a disease 
so essentially chronic, it is difficult to arrive 
at any trustworthy evidence concerning the 
efficacy of a remedy, but the prolonged ad- 
ministration of iron, rather as a food than as 
a medicine, is at least of a certain degree of 
utility in arresting the progress of the malady. 
The preparation employed is probably not 
material, and some may be found to suit 
particular persons better than others; but the 
writer is accustomed to begin with the tinc- 
ture of the perchloride, in doses of five 
minims, well diluted and given three times a 
day as part of a meal. 
9. Detachment of the Retina.-Synon. : 
Subretinal Dropsy.-This is a condition the 
causes of which have never been satisfactorily 
explained, but it has been attributed to the 
contraction of inflammatory effusions in the 
vitreous body, which have been supposed 
thus to exert traction on the retina. 
The first symptom which attracts the at- 
tention of the patient is the loss of part, 
usually either the upper or the lower part, of 
the field of vision ; and it is manifest that 
loss of the upper part of the field means de- 
tachment of the lower part of the retina, and 666 
EYE, AND ITS APPENDAGES, DISEASES OF 
vice versa. Detachment is sometimes pro- 
duced by a blow or injury, but more fre- 
quently it occurs without any assignable 
cause, either local or constitutional. One or 
both eyes may be affected. 
The diagnosis of the disease is rendered 
easy by the ophthalmoscope, which exhibits 
the detached portion as a sort of floating 
prominence, projecting into the interior of the 
eyeball, generally bluish-white in colour, and 
crossed by the retinal blood-vessels. 
The prognosis is very unfavourable in the 
majority of instances, and treatment is seldom 
effectual. 
Treatment.-Cases have been recorded in 
which disappearance of the sub-retinal fluid, 
and restoration of vision, have followed pro- 
longed confinement in the supine posture; 
and the occurrence of improvement after 
spontaneous rupture of the detached portion 
suggested to von Graefe the advisability of 
producing such a rupture by artificial means. 
Various operations have been undertaken for 
this purpose, and also for the evacuation of 
the sub-retinal fluid through a puncture in 
the outer tunics of the eye, and have in a few 
instances been partially successful; but the 
evidence in their favour is at present very 
feeble, and hardly establishes more than that 
attempts of such a nature may be made, if it 
is certain that the sight will be irretrievably 
lost in the absence of interference. The 
writer once obtained an excellent result by 
puncturing a detached retina in an eye from 
which cataract had been removed eleven 
years before; but the puncture was greatly 
facilitated, and its risks were in a correspond- 
ing degree diminished, by the absence of the 
lens. Two or three years later, however, the 
detachment returned and became complete. 
The tendency of detachment, especially in 
the upper portion of the retina, is to increase 
until the whole membrane is elevated from 
the choroid, and vision is entirely destroyed. 
It must be borne in'mind that detachment 
may be simulated, or may even be caused, 
by the growth of intra-ocular tumours, sarco- 
matous or gliomatous, which may demand 
the early removal of the eyeball. Such cases 
would usually be distinguished from simple 
detachment by the increased hardness of the 
eyeball, which the morbid growth almost 
necessarily occasions, and which would be the 
more significant inasmuch as detachment 
alone is usually accompanied by diminished 
tension. It must nevertheless be remembered 
that normal tension does not absolutely pre- 
clude the presence of tumour; as there are 
well-authenticated cases in which the absorp- 
tion of the ocular fluids has, for a time, pre- 
cisely kept pace with the increase of the 
growth. 
10. Glioma.-This name has been given by 
Virchow to a malignant growth which has its 
origin in the neuroglia, or connective tissue of 
the nervous system, and which was formerly 
described as encephaloid cancer. When 
originating in the retina, it early produces 
loss of sight, and presently shows through 
the pupil as a substance of a primrose-yellow 
colour, by which the still transparent lens is 
pressed forward towards the cornea. It is 
chiefly a disease of childhood, and has been 
seen by the writer as early as the fifth week 
of infant life. It is liable, by superficial 
observers, to be mistaken for congenital or 
infantile cataract, an error which must be 
carefully guarded against, because the early 
and entire removal of the eye, together with 
as much of the optic nerve as can be reached, 
furnishes the only hope of preserving the life 
of the patient. When the operation is per- 
formed sufficiently early, it has in a few in- 
stances been completely successful, cases 
having been recorded in which no recurrence 
of cancer has happened after the lapse of 
years. In the great majority, however, re- 
currence and death have terminated the 
history. 
11. Sarcoma.-This differs from glioma in 
having its origin in the choroid, and in being 
of a darker colour, and sometimes pigmented 
or melanotic. It is at least equally malignant, 
produces similar symptoms, and requires the 
same treatment. 
VIII. Diseases of the Choroid.-Dis- 
eases of the choroid, recognisable by the oph- 
thalmoscope, are almost limited to certain 
chronic forms of inflammation and of atrophy; 
for, in any acute choroiditis, there is always 
too much turbidity of the vitreous body to 
allow the state of the membrane to be seen. 
Chronic Choroiditis.-The chronic forms 
of choroiditis are remarkable for leading 
to an undue formation, or to a great dis- 
placement, of the choroidal pigment; and 
to the ultimate complete wasting and disap- 
pearance of the portions of the choroid which 
are affected, so that over these portions there 
will ultimately be no choroid visible, and the 
ordinary red colour of the fundus will be re- 
placed by the ivory whiteness of the inner 
surface of the sclerotic. 
Chronic choroiditis may be divided into 
two chief varieties-the disseminated and the 
diffused. The disseminated occurs chiefly 
in children, and chiefly, perhaps exclusively, 
in those who are the subjects of inherited 
syphilis. It is seldom seen until its period 
of activity is passed. A child is brought on 
account of defective vision, which has pro- 
bably existed from birth or from a time but 
little subsequent to it; and the ophthalmo- 
scope displays a number of small white spots, 
with black borders, scattered irregularly over 
the fundus of the eye. The white spots are 
patches of choroidal atrophy, and the black 
borders are rings of increased pigment-forma- 
tion, by which the spots of inflammation, 
which must have been comparable to little 
pimples, have been surrounded. 
Treatment.-Such cases admit of no treat- EYE, AND ITS APPENDAGES, DISEASES OF 
667 
ment, except in the rare instances in which 
some active mischief may be detected, in the 
shape of small patches or spots in which 
effusion has not yet passed into atrophy, and 
in which such an antisyphilitic treatment 
should be employed as the state of the patient 
may otherwise permit or indicate. 
Diffused choroiditis is more frequently an 
affection of adult age; and, although very 
frequently syphilitic, is not invariably so. It 
differs from the foregoing chiefly in the ab- 
sence of any defined shape or precise limi- 
tation of the parts affected. In the early 
stages the choroid is seen to be troubled by 
congestion or effusion, and these conditions 
pass gradually into abnormal pigmentation 
and atrophy. The course of the disease may 
be very chronic and irregular, and different 
stages of it may be seen at the same time in 
different parts of the same eye. 
The prognosis may in general be moderately 
favourable; for, although the choroiditis de- 
stroys the portion of retina immediately in 
front of it, its extension is very capricious, 
and it may often be arrested in time to leave 
large portions of the eye, and especially the 
central portions, unhurt. When it occurs in 
the vicinity of the macula lutea, so as to 
imperil central vision, it is much more for- 
midable than when confined to the more 
peripheral parts of the choroidal membrane. 
Treatment.-Whenever there is a history 
of syphilis, this must be taken as the clue to 
treatment; and, if no syphilis can be dis- 
covered, the chief reliance must be placed 
upon rest of the eyes, occasional depletion 
from the temples by Heurteloup's leech, 
counter-irritation by blisters or setons, and 
such internal medication as the general state 
of the patient may suggest. 
IX. Diseases of the Vitreous Body. 
Diseases of the vitreous body are as yet very 
imperfectly understood, and we know little 
more concerning them than that this sub- 
stance is liable to become turbid in certain 
forms of acute general inflammation of the 
eye; and that it is sometimes rendered turbid, 
without inflammation, by the presence of 
floating films which may be readily seen by 
the ophthalmoscope, and which may be so 
numerous as to form a serious impediment 
to vision. 
1. Turbidity.-1Turbidity of the vitreous 
is very common in syphilitic cases; but the 
films referred to are seen when no syphilis 
can be suspected. Their number, and their 
free movements, show that the vitreous must 
in great measure have lost its natural semi- 
solid consistence, and have become fluid; 
but little or nothing is known of their actual 
pathology. 
Treatment.-The most effectual treatment 
for flocculi in the vitreous is usually diapho- 
resis by the subcutaneous injection of from 
two to four minims of a 10 per cent, solution 
of hydrochlorate of pilocarpine, which may 
be repeated on alternate days. Local counter- 
irritation with iodine may also be practised; 
and iodide of potassium may be given inter- 
nally in such doses as circumstances will 
allow. 
2. Muscce Volitantes.-A phenomenon re- 
ferred to the vitreous body is the appearance 
of the moving particles, or strings of beaded 
filaments, which are commonly called muscce 
volitantes. True muscae are known by the 
negative character that the particles which 
produce them cannot be seen by the ophthal- 
moscope ; and by the positive character that 
they never so intervene between the eye and an 
object, however small, as to exclude the latter 
from view. They are seen most readily against 
a white field, as a white wall or a white 
cloud, or in the illuminated field of a micro- 
scope when there is no object in view; and 
they float about with uncertain movements, 
but always a little out of the direct line of 
sight. They are occasioned by the filamen- 
tous framework of the vitreous body, and by 
the cell-nuclei or other irregularities upon 
the filaments. These bodies, without being 
opaque, yet differ in the precise degree of 
their transparency from the fluid which 
surrounds them ; and hence they cast upon 
the retina shadows, which are then mentally 
projected outwards into space as floating 
objects. The projected shadows appear, oi 
course, enormously larger than the micro- 
scopic specks which produce them, and the 
latter are wholly unimportant and of no 
morbid signification. Muscae may be dis- 
covered by any person by the simple expe- 
dient of looking through a very fine perfora- 
tion in a metal disc at a bright surface; and 
they are more conspicuous to some persons 
than to others, on account of the varying 
differences which may exist in different eyes 
or in the same eyes at different times or 
under different conditions, between the index 
of refraction of the filaments and nuclei and 
that of the surrounding fluid. Moreover, by 
the operation of an obvious physical law, the 
more distant the particle from the retina, the 
larger will be its shadow upon that mem- 
brane, and the larger and more conspicuous 
will it appear. For this reason, and on ac- 
count of the elongation of the myopic eyeball, 
muscae are usually more complained of by 
the short-sighted than by others. They are 
often sources of great uneasiness to patients; 
but, when once their true character is known, 
they may be entirely disregarded as harmless 
appearances, the natural results of physio- 
logical structure. It is often important that 
the physician should be able to make their 
nature understood, in order that he may dis- 
sipate, once for all, the unfounded apprehen- 
sions which may be occasioned by their pre- 
sence. 
X. Diseases of the Evelids. - The 
external surfaces of the eyelids, as parts of 
the common integument, are liable to all its 668 
EYE, AND ITS APPENDAGES, DISEASES OF 
diseases, and may thus participate in erysipe- 
latous inflammation, in eruptions, and in the 
results of injury, besides becoming the seats 
of naevi, moles, warts, and other growths. 
Among the diseases special to the formation 
of the eyelids, the most important are the 
variations of shape to which they are subject, 
generally from the contraction of inflamma- 
tory exudations, but sometimes from per- 
verted muscular action; the cystic tumours 
which are produced by obstruction of the 
orifices of Meibomian glands; the inflam- 
mation of the follicles of the eyelashes, or 
blepharitis; spasmodic closure, from ab- 
normal muscular contraction; and either 
patency or passive closure, from paralysis. 
Many of these affections are distinctly sur- 
gical, and others are only parts or symptoms 
of more general disorders. 
1. Blepharitis.-Blepharitis, or inflamma- 
tion of the follicles of the eyelashes, has re- 
ceived a great variety of names from different 
writers, and is frequently known as tinea 
tarsi, or, in its more advanced stage, as 
lippitudo. The disease consists essentially 
of an inflammation of the lining membrane 
of a hair-follicle from which an eyelash 
springs. 
Symptoms.-The first manifest symptoms 
are a small swelling close to the edge of the 
eyelid, generally of the upper lid ; and the 
formation of a crust around the bases of the 
cilia which proceed from the swollen part. 
The swelling does not extend farther up the 
lid than to the breadth of about a line, but it 
soon spreads along the border until the whole 
length is involved, and it usually spreads also 
to the lower lid, manifestly in consequence 
of the contagious character of the discharge. 
If the crust is removed, and if the part from 
which it springs is magnified and carefully 
examined, it will be seen that the mouths of 
the follicles are somewhat open, no longer 
fitting closely to the issuing hairs ; and, in a 
few moments, a clear fluid will be seen to 
exude, and speedily to dry into a crust or 
film, which covers the opening as if with a 
varnish. Many of the hairs in the affected 
follicles are loosened, and fall readily, or 
may be removed painlessly by slight trac- 
tion. If the case is neglected, the follicles 
are before long destroyed as hair-bearing 
organs, so that the lost cilia are no longer 
reproduced; and, at the same time, the 
exudation which constitutes the subcutane- 
ous swelling of the lid-margin begins to 
undergo contraction, and in this way gra- 
dually everts the cartilage of the lid. The 
edges of the lids become red, swollen, and 
unsightly; the lachrymal puncta are dis- 
placed outwards in such a manner that they 
can no longer take up the tears; the eyes 
have lost the protection of the lashes, and 
are exposed to numerous sources of irritation 
from atmospheric particles and other causes, 
so as to be especially prone to conjunctival 
and corneal inflammations; and these results 
are almost incurable. It is therefore very 
important that blepharitis should be effec- 
tually treated in its early stages, when, if 
only due care be taken in the selection and 
use of remedies, it is an exceedingly trivial 
affection. 
Treatment.-The most essential part of 
the treatment is to remember that the secre- 
tion which forms the crust is of such a nature 
that it is not very easy of removal, and that, 
while it remains in situ, no remedies, how- 
ever judiciously chosen, can obtain access to 
the parts really affected by the disease. The 
crust is composed partly of the already men- 
tioned secretion from the inflamed surfaces, 
partly of the greasy secretion of the Mei- 
bomian glands; and it is the admixture of 
the latter which renders the crusts difficult 
of removal by water alone. A solution of 
bicarbonate of sodium, of the strength of five 
grains to the ounce of warm water, will re- 
move them readily; and this solution should 
be applied in such a manner as to soak into 
the crusts and loosen them thoroughly be- 
fore any attempt is made to detach them. 
As soon as they are detached, the surface 
beneath should be gently dried with a morsel 
of absorbent rag, and then an astringent 
should be applied immediately, so that it 
may find its way down into the depths of 
the hair-follicles, and may thus reach the 
seat of the malady. The best astringent is 
generally the ointment of the precipitated 
.yellow oxide of mercury, or Pagenstecher's 
ointment, already recommended for the cure 
of ulcers of the cornea; and this may be 
applied to the affected part by the tip of a 
finger. If amendment does not speedily fol- 
low, it may be suspected that the crusts have 
been imperfectly removed, or the applications 
imperfectly made, and it will be well for the 
practitioner personally to superintend the pro- 
cess. When this has been done, if the affec- 
tion continues obstinate, some other astrin- 
gent should be tried, and the nitrate of silver 
is among the best for this purpose. Amend- 
ment of the lid-margin may generally be 
quickly produced; but the disease will for a 
long time lurk in the depths of the follicles, 
and the treatment must be continued until 
all subcutaneous swelling has disappeared 
from the lid-margins. Unless this be done, 
speedy relapse is inevitable, the inflammation 
soon creeping out of the follicles again and 
recovering the ground of which it had been 
deprived. Such a result is constantly seen 
in hospital practice, in spite of all efforts to 
guard against it, and, in prescribing for 
blepharitis, it is always desirable to warn 
parents of the perseverance which will be 
required, and of the great importance of 
obtaining a radical cure. There can be no 
doubt that blepharitis is exceedingly con- 
tagious through the medium of its secretion, 
conveyed upon sponges, towels, or fingers, EYE, AND ITS APPENDAGES, DISEASES OF 
669 
and this should be fully recognised whenever 
it attacks children who are attending a school. 
The name ' tinea tarsi ' may perhaps be taken 
as the expression of a belief that the disease 
is allied to tinea tonsurans, and that it is 
produced by the growth of a parasitic fungus. 
The writer does not at present see any suffi- 
cient ground for the adoption of this opinion. 
2. Entropium and Ectropium. -Incurva- 
tion and excurvation of the eyelids may be 
looked upon as purely surgical maladies. 
The former exposes the eyes to injury from the 
irritation of inturned eyelashes (trichiasis'); 
the latter from foreign bodies of various 
kinds. 
Treatment.-The remedy for both, when 
any is practicable, must usually be sought in 
a surgical operation. An exception depends 
upon the fact that ectropium is sometimes pro- 
duced by paralysis of the facial nerve, which 
renders the orbicularis muscle flaccid and 
powerless, and permits the lower lid to fall 
downwards under the influence of gravity. 
The cure of the general nerve-affection may 
restore the power of the muscle, and may in 
time lead to complete recovery of the natural 
position of the lid. In such cases, even if 
electricity does not form part of the general 
treatment of the paralysis, it may often be 
applied with benefit to the orbicularis. 
3. Blepharospasmus.-This term is gene- 
rally employed to denote an intermittent 
closure of the eyelids by an involuntary 
action of the orbicularis, in response to some 
concealed source of irritation; and is thus 
broadly distinguished from the spasm which 
accompanies photophobia. 
Symptoms.-The spasm is most liable to 
occur in circumstances of mental excitement. 
Thus, in one of the writer's patients, who 
was a skilful cook, the eyes were apt to close, 
and to remain closed for some minutes, at 
the critical period of an important dish. 
Another patient was a schoolmistress, and 
the spasm would interrupt the progress of a 
lesson to a class, being doubtless to some ex- 
tent excited by the dread of its occurrence. 
In a third case, the patient being a gentle- 
man habituated to riding and driving, the 
spasm would be excited by physical irritants, 
such as wind or dust, and, almost certainly, 
by circumstances which required the eyes to 
be wide open as a condition of safe guidance. 
The motor nerves appear, as a rule, to be 
merely the passive conductors of a reflected 
impulse, and the trouble seems usually to be 
dependent upon a morbid condition of the 
fifth, or upon a source of irritation in some 
peripheral part from which a twig of the 
fifth passes to the centre. 
Treatment.-In the treatment of such 
cases, it is sometimes possible to find the 
twig which conveys the impression ; that is 
to say, to discover a point where pressure, 
sufficiently firm to arrest conduction, will at 
once relax the spasm. Such points should 
be looked for at the supra-orbital notch, over 
the malar bone, and in any other situation 
suggested by special circumstances; and, if 
a point at which pressure will arrest the 
spasm is discovered, we learn at once by 
what branch of the fifth, and therefore ap- 
proximately from what region, the irritation 
is conveyed, and where its source is to be 
sought for. If nothing can be discovered by 
careful examination, decayed teeth, accumu- 
lations of cerumen in the ears, and conjunc- 
tival granulations are possible conditions 
which should be looked for, and which should 
receive attention if they are found. When 
all other treatment has failed, the spasm has 
sometimes been stopped by subcutaneous 
section of a sensory nerve; and this may 
always be practised hopefully if the spasm 
can be arrested by pressure on some definite 
spot, which must then serve for the guidance 
of the knife. If no such spot can be found, 
section of the supra-orbital nerve, and next of 
the subcutaneous malar, may be attempted; 
since neither of these is sufficiently impor- 
tant for its temporary disablement to be 
set against even the possibility of relief from 
a very distressing affection. In some cases, 
however, it would appear that the mischief 
must be central, and that no section of an 
afferent nerve can be useful. The division 
of the motor nerves of the orbicular muscles, 
if it could be successfully accomplished, 
would produce a paralysis even more in- 
jurious than the spasm; and the cases in 
which the latter is due to central irritation 
or other trouble, unless they can be relieved 
by medicine, and by the rectification of what- 
ever may be manifestly wrong in the con- 
dition of the patient, offer very small hope 
of improvement. See Facial Spasm. 
4. Ptosis.-Ptosis is a condition of perma- 
nent passive closure of an upper eyelid as a 
consequence of paralysis of its levator muscle, 
or it may happen in consequence of this 
muscle having been torn from its attachment 
to the tarsal cartilage, so that it can no longer 
modify the position of the lid. 
Symptoms.-Paralytic ptosis may be either 
partial or complete, according to the degree 
of the nerve-affection; and as the levator 
palpebrae is supplied by the third nerve, 
which supplies also the superior, the internal, 
and the inferior rectus, as well as the inferior 
oblique, the sphincter pupillse, and the ciliary 
muscle, ptosis is usually accompanied by 
paralysis of one or more of these muscles. 
When they are all affected, the eyeball is 
turned outwards by the action of the exter- 
nal rectus, and is immovable in other direc- 
tions excepting feebly by the superior oblique. 
The pupil is dilated, and the power of adjust- 
ing the eye for near vision is impaired or lost, 
although, when the lid is raised, near objects 
can still be distinctly seen by the aid of a 
convex lens. When all the muscles supplied 
by the third nerve are affected, the inference 670 
EYE, DISEASES OF 
FACIAL PARALYSIS 
is that the cause of paralysis is acting upon 
the common trunk of the nerve ; and such a 
cause is not infrequently the presence of 
periosteal swelling at the sphenoidal fissure. 
If only some of the muscles are affected, the 
inference is that the cause of the paralysis is 
either limited to the central nuclei of origin 
of certain filaments, or else that it is situated 
anteriorly to the division of the main trunk 
into the branches which proceed to different 
parts ; and it is conceivable that the limita- 
tions of the paralysis may point, with toler- 
able certainty, to the precise locality of the 
disorder. 
The causes of ptosis, as of other paralytic 
affections of single cranial nerves, apart from 
injuries and the pressure of morbid growths, 
may almost be reduced to syphilis and to 
impaired nutrition of the centres, the latter 
usually connected with hard mental work 
and worry. In every case, evidence of 
syphilis should be carefully sought for ; and, 
if found, should determine the nature of the 
treatment, as it will also of the prognosis, 
which, in such instances, may be generally 
favourable. In cases of the second class, 
where there is no evidence of syphilis, and 
where the symptoms point to general impair- 
ment of nervous energy, the administration 
of iodide of potassium, in combination with 
tonics, will sometimes be useful; but the 
main reliance must be placed, upon rest, good 
living, and external surroundings favourable 
to the restoration of health. 
5. Diplopia.-Double vision, although it 
has no proper relation to the subjects treated 
of in the present section, is yet so far allied 
to ptosis that, when occurring suddenly, it is 
almost always an effect of paralysis or of 
paresis either of the sixth nerve of one eye, 
supplying its external rectus, or of the branch 
of the third which supplies its internal rectus. 
In the former case the affected eye will deviate 
inwards, and will have limited range of move- 
ment towards the outer canthus; while in 
the latter case these conditions will be re- 
versed. 
As regards the causes and treatment of 
these limited forms of paralysis, there is no- 
thing to add to what has already been stated 
about ptosis. It is sometimes desirable, while 
the diplopia continues, to exclude the deviat- 
ing eye from vision by a shade, an opaque 
spectacle-glass, or other suitable contrivance, 
on account of the vertigo and uncertainty of 
gait which may be occasioned by the double 
images. 
See also Exophthalmic Goitre ; Lacrymal 
Apparatus, Diseases of; Lagophthalmos; 
Orbit, Diseases of; Strabismus ; Stye ; and 
Vision, Disorders of. 
R. Brudenell Carter. 
FACHINGrEN, in Nassau, Prussia. 
Acidulous gaseous waters.-See Mineral 
Waters. 
FACIAL PARALYSIS. - Synon. : 
Paralysis of the Portio dura; Bell's Para- 
lysis. 
Definition.-Paralysis of the muscles of 
the face, due to disease or injury of the 
nucleus or fibres of the seventh nerve (the 
portio dura of the seventh pair, according 
to the older nomenclature). 
Above the nucleus, the motor path for 
the face decussates, and joins that from the 
arm and leg; damage, therefore, in the pons 
(above the crossing), in the crus, internal 
capsule, or hemispheres, may produce facial 
paralysis, but does so usually as a part of 
hemiplegia. This paralysis, which is on the 
same side as that in the limbs, is partial 
only, affecting chiefly the muscles of especial 
unilateral use (as the zygomatici); and very 
little those of solely bilateral use, in the 
upper part of the face-e.g. the frontales. 
In this article paralysis from damage to the 
fibres or nucleus of the nerve itself will 
alone be considered. 
^Etiology.-(1) The most common causes 
of facial palsy are unilateral, and damage the 
nerve as it passes through the narrow canal 
in the temporal bone. There, the slightest 
inflammatory effusion will cause pressure on 
the nerve. Such neuritis may be due to ex- 
posure to cold (and is often then called 'rheu- 
matic'); to contiguous bone-disease, as caries; 
and sometimes to syphilis. Haemorrhage into 
the sheath may also compress the nerve. 
Cold is the most common cause of palsy, 
but the exposure is often forgotten; it has 
been supposed to act by paralysing the peri- 
pheral nerve-twigs, but this is never the case 
in one-sided paralysis; in all cases lasting 
more than a few days, evidence of changed 
nutrition may be detected in the nerve-trunk 
as it emerges from the stylomastoid foramen. 
External cellulitis may extend into the canal. 
Tumours of the bone and fracture of the 
base may also damage the nerve as it passes 
through the bone. (2) Injury to the nerve 
outside the skull by blows, pressure by 
forceps in instrumental delivery, incised 
wounds-accidental or surgical, or parotid 
and other tumours, are occasional causes. 
(3) Within the skull the nerve may be dam- FACIAL PARALYSIS 
671 
aged by meningitis, acute or chronic, and 
especially by syphilitic inflammation, or by 
pressure of neighbouring growths. The radi- 
cular fibres within the pons, or the nucleus 
beneath the fourth ventricle, may be damaged 
by haemorrhage, softening, or by tumours 
involving that part. 
Double facial paralysis is very rare, and 
is due to damage to both nerves at the base 
of the brain from meningitis or symme- 
trical syphilitic disease; to symmetrical 
otitis; or to an affection of the nuclei by 
disease of the pons, or to loss of function 
of the nerve-fibres in various forms of peri- 
pheral neuritis. It is probably by the latter 
agency that double facial paralysis some- 
times results from toxic blood states. Syphilis 
and diphtheria are the most common ante- 
cedents of double facial palsy not due to 
demonstrable injury to the nerves. Disease 
of the nuclei affects both sides most fre- 
quently when it is degenerative in nature; 
it is then commonly partial, involving espe- 
cially the lip muscles in labio-glossal para- 
lysis, or the orbicularis palpebrarum in rare 
cases of nuclear ophthalmoplegia. Lastly, it 
may be mentioned that the facial muscles 
(generally those in and about the lips-rarely 
all) are occasionally involved in idiopathic 
muscular atrophy, and an affection of the 
nerves may be thus simulated. 
Symptoms.-The onset of facial paralysis 
is usually rapid, when due to its common 
causes, including neuritis within the canal. 
It occupies from a few hours to three or four 
days in its development. It is found, for 
instance, one morning, in drinking, that the 
fluids run out of the side of the mouth ; the 
face is noticed to be a little unsymmetrical; 
at night the eye cannot be completely closed, 
and next morning the paralysis is found to 
be complete. Rarely the onset is in a few 
minutes; probably then a haemorrhage into 
the nerve-sheath is the cause. When in- 
flammation is excited by cold, the symptoms 
often commence within twenty-four hours 
of the exposure. They are usually preceded 
or accompanied by some pain about the ear 
or side of the head. 
In complete unilateral facial paralysis all 
the muscles on one side of the face are para- 
lysed. At rest, the smooth forehead and 
lowered angle of the mouth are the chief 
indications, but on movement the difference 
between the two sides becomes very marked; 
the one half of the forehead moves alone in 
frowning or elevation of the eyebrow. The 
eyelids cannot be brought together, and in 
the attempt to close the eye, the globe is 
rolled upwards, so that only the sclerotic 
appears between the gaping lids; the patient 
then often fancies that the eye is shut. 
During sleep the eye remains open. In 
smiling, the lips may be displaced altogether 
to the healthy side, from the unopposed 
action of the zygomatic muscles; the nostril 
of the affected side cannot be dilated; the 
upper lip cannot be raised ; the cheek flaps 
loosely, from the relaxation of the buccinator ; 
and, from the same cause, food accumulates 
between the jaws and the cheek. Whistling 
is impossible, from the paralysis of half of 
the orbicularis, and the lips cannot be ap- 
proximated sufficiently even to permit of a 
candle being blown out. When the lesion is 
between the junction with the large petrosal 
and that with the chorda tympani nerves, 
taste is partly or entirely lost in the front of 
the tongue. The loss of power of recognising 
acid and saline substances is most marked; 
but bitters and sweets are also not tasted in 
this part. Such loss is common in neuritis 
from cold, and shows that the inflammation 
has extended some distance up the canal. 
In rare instances, loss of taste has followed 
division of the nerve outside the skull, prob- 
ably always because secondary inflamma- 
tion has passed up the nerve. The palate 
is never paralysed from disease of the facial 
nerve. It is certain that the opposite 
statement rests on defective observation or 
interpretation. Obliquity of the uvula is 
common under normal conditions. Defect 
of movement, to be significant, must follow 
the course of any associated palsy of external 
muscles. The nerve-supply of the palatine 
muscles has been proved to be from the 
spinal accessory. 
In some cases giddiness attends the onset 
of facial paralysis. In slight forms there may 
not be complete loss of power; but the de- 
fect is at first pretty equally distributed over 
all parts of the face. 
In cases which recover, some return of 
power takes place in from a week to two 
months, and improvement is usually earliest 
in the upper part of the face ; the power of 
frowning, winking, and closing the eye being 
soonest regained; that of moving the lips and 
mouth returning last. Even after several 
months of immobility, recovery may take 
place, but in these cases it is rarely complete, 
and a troublesome condition is apt to super- 
vene : some of the muscles, especially the 
zygomatici, become shortened in late rigidity, 
and hence at rest the naso-labial wrinkle is 
deeper on the paralysed than on the healthy 
side, although the possible movement may 
be much slighter. This condition sometimes 
comes on rather rapidly; there is generally, 
in addition, an associated over-action of the 
upper and lower facial muscles, whereby, 
for instance, the orbicularis palpebrarum 
and the zygomatic and other muscles about 
the mouth act together in undue degree; 
in smiling, the eye shuts; and on closing 
the eye, the mouth is drawn upwards. 
Sometimes there are also spontaneous clonic 
contractions. This late rigidity and over- 
action may prove very troublesome and con- 
stitute a nuisance, especially to the young, 
not less than the original palsy, and more 672 
FACIAL PARALYSIS 
serious in that it is enduring. The writer has 
known it induce a good-looking girl to put an 
end to her life. If the interruption of the 
nerve is absolute and permanent, the muscles 
remain toneless, and no contracture super- 
venes. 
The electrical condition of the muscles is 
very important. It is that always seen in 
paralysis from nerve-lesion. The muscles, 
after a day or two of slightly increased irri- 
tability to both faradism and the slowly 
interrupted voltaic current, lose gradually 
their irritability to the former, retaining that 
to the latter, and even exhibiting to it increased 
irritability, so that they act to a smaller 
number of cells than do those on the healthy 
side. In the nerve, on the other hand, the 
irritability is lost to both forms of electricity, 
this loss proceeding pari passu with the de- 
generation which follows separation of the 
nerve from its nutrient centre. In slighter 
and more transient forms of facial paralysis, 
the change in irritability of muscle and nerve 
may be less; but even in most, which last 
only a few days, a slight change in irrita- 
bility may be discovered. In the slightest 
cases (and in the earliest stage of more severe 
forms) there may be an increased irrita- 
bility in the nerve, often most marked to 
the induced (faradic) 'shocks'-i.e. isolated 
currents. Considerable change in irritability 
is proof of considerable disease of the nerve, 
and is thus of the highest prognostic impor- 
tance, but it is not distinct until after a week; 
if absent at the end of a fortnight, the disease 
is slight, and although the paralysis may still 
be complete, it will probably not last long. 
Diagnosis.-The diagnosis of facial para- 
lysis (commonly so-called-i.e. that due to 
disease of the nerve or its nucleus) is easy. 
It depends (1) on the implication of all the 
facial muscles, including those of bilateral 
use that escape in hemiplegia, because re- 
lated to both cerebral hemispheres; (2) on 
the indication afforded by the electrical re- 
actions that the nerve or its nucleus is dis- 
eased. Hence it is important to observe 
all the muscles of the face, and to ascertain 
the electrical reaction, in order to determine 
whether it is the variety now described, or is 
cerebral and really part of hemiplegia. The 
recognition of the place of the lesion is less 
easy. When within the pons, it is often 
associated with paralysis of the sixth nerve, 
or with hemiplegia of the opposite side from 
damage to the motor path to the limbs. At 
the base of the brain the auditory nerve is 
usually affected at the same time, but care 
must be taken not to mistake deafness due 
to ear-disease for an affection of the auditory 
nerve within the skull. When there are no 
other paralyses, the disease is probably with- 
in the bony canal. Deviation of the uvula is 
of no significance; affection of taste in the 
front of the tongue indicates disease within 
the canal. Special inquiry should be made 
for exposure to cold, ear-disease, syphilis, or 
a blow. 
Prognosis.-The majority of cases of facial 
paralysis are due to disease of the nerve, and 
the prognosis depends on the evidence of the 
degree of damage to the fibres, especially on 
the indications afforded by an electrical ex- 
amination, and also on the cause of the 
lesion. When this is progressive in nature, 
the interference with the nerve is necessarily 
persistent in duration. Thus, in facial para- 
lysis due to a growth damaging the nerve, 
the prognosis must be grave. In syphilitic 
disease, on the other hand, it is good, pro- 
vided the duration of the damage to the 
nerve is short. This is also the case in 
paralysis from cold, in which, however, the 
evidence afforded by electricity is of special 
importance. 
In double facial paralysis, the evidence of 
central mischief renders the prognosis un- 
favourable, but recovery may be hoped for 
if the lesion is acute and the palsy incom- 
plete. In syphilitic cases, the prognosis is, 
on the whole, good. In all cases of double 
facial palsy from peripheral neuritis, there is 
a similar affection of other parts, and the 
prognosis must be determined by the general 
character and course of the affection, and 
especially the degree to which the morbid 
blood-state is amenable to treatment. 
Treatment.-The treatment of facial para- 
lysis will depend on the probable cause. 
When due to its common mechanism-neu- 
ritis from cold, hot fomentations to the side 
of the head and face should be employed in 
the early stage of the affection, followed by 
a blister behind the ear. A blister should 
never be applied in front of the ear, over the 
opening of the canal, because it will cause 
some subcutaneous cellulitis, and such cellu- 
litis may actually cause facial neuritis by 
spreading to the nerve-sheath in the canal. 
The side of the head should be protected 
from cold. Internal treatment of neuritis 
must vary according to the cause. If this is 
syphilis, iodide of potassium in 10 gr. doses 
may be given ; if exposure to cold, diuretics 
and small doses of mercury in the early 
stage, followed by tonics. Electricity to the 
muscles is needed if the damage to the 
nerve is so severe as to entail secondary 
degeneration and consequent changes in 
nutrition. If there is no change in irrita- 
bility at the end of a fortnight, recovery will 
probably occur so soon as to make electrical 
treatment superfluous. If needed, the voltaic 
current should be used, slowly interrupted by 
a commutator, or by the positive or nega- 
tive pole being moved over the individual 
muscles (according as they react more readily 
to the one or the other), the opposite pole being 
placed over the nerve. Only such strength 
should be employed as produces distinct 
muscular contraction. Although electricity 
probably does no more, it keeps up the FACIAL PARALYSIS 
FACIAL SPASM 
673 
nutrition of the muscular fibres while the 
nerve is recovering. Ultimate recovery is 
thus more speedy and more complete than 
without local treatment. The application 
can be made quite well by the patient, one 
electrode being kept over the place where 
the nerve divides, the other moved (1) across 
the forehead; (2) along the eyebrow; (3) 
along the lowered upper eyelid; (4) along 
the raised lower eyelid ; (5) beside the nose 
to the upper hp ; (6) along the upper lip ; 
(7) along the lower lip ; (8) from the zygoma 
to the angle of the mouth. In (3) and. (4) 
the current should be weaker than in the 
other places. Rubbing may be employed, 
the individual muscles being subjected to a 
process of gentle shampooing. The late con- 
traction which occurs in severe cases is but 
little influenced by treatment. Gentle elonga- 
tion of the muscles may be practised, and 
electrical applications should be stopped, 
since the stimulation of the sensory nerves 
may increase the late contraction by a reflex 
influence ; its occurrence shows that a point 
has been reached when the influence of 
electricity for good can be but small. 
In external mischief, and in intracranial 
disease, the treatment of the facial paralysis 
is usually subordinate to that of its cause. 
The treatment of double facial paralysis 
presents no special points for consideration, 
except when it is part of multiple neuritis, 
the indications for which are described in a 
special article. W. R. Gowers. 
FACIAL SPASM. - Synon. : Mimic 
cramp; Fr. Tic convulsif. When affecting 
the eyelids, Blepharospasm ; Nictitation. 
Definition.-Spasm, sometimes tonic but 
more often clonic, or both, involving some 
or all of the muscles supplied by the facial 
nerve, on one side or on both. 
./Etiology and Symptoms.- Spasm in the 
face maybe part of a wider convulsive move- 
ment, as in epilepsy, hysteria, chorea, or 
torticollis, diseases dependent on central 
changes. That which begins in, and is limited 
to one side of the face, may be due to irrita- 
tion of the trunk of the facial nerve by 
growths, by an aneurysm, or caries of the tem- 
poral bone, or to an actual lesion of the motor 
centre for the face in the cortex of the brain. 
Spasm due to disease of the nerve may follow 
facial paralysis (see Facial Paralysis). Much 
more frequent, however, are cases, unilateral 
or bilateral, in which the affection comes on 
gradually, chiefly in females in the second 
half of life, after depressing emotion. It is 
probable that such cases are due to deranged 
functional action of the cortical motor cells, 
through which, we may remember, emotion 
is so extensively expressed. In such cases 
the affection usually begins on one side, often 
in the orbicularis palpebrarum; and if it 
spreads to the other side, this muscle is first 
involved. In another group of cases, affec- 
tions of the eye lead to spasmodic closure of 
the lids - blepharospasm. In other cases 
beginning in the eyelids, no local cause can 
be detected, as in the local clonic spasm 
affecting the orbicularis palpebrarum, known 
as ' involuntary winking ' or nictitation, 
which seems to be a pathological develop- 
ment of the normal process. This is also 
a common seat of the spasm in the face that 
is part of 'habit-spasm' or 'habit-chorea,' 
but it has no connexion with true chorea. 
Facial spasm is painless. The spasm is 
usually increased by emotion, by voluntary 
movement, and by stimulation of the fifth 
nerve. Slight aural symptoms have been 
observed, referable to contraction of the 
stapedius. Usually the movement remains 
limited to the face; sometimes it spreads to 
the muscles of mastication, of the neck, &c. 
The spasm, in typical cases, is both tonic and 
clonic, clonic paroxysms occurring from time 
to time, and being fixed by tonic contractions, 
or vice versa. All forms cease during sleep. 
The only secondary form of facial spasm 
(besides that which supervenes on a paraly- 
sis of the nerve) is the clonic spasm in the 
frontales that is often met with in the form 
of ' torticollis ' to which the writer has given 
the name of ' retrocollic spasm.' In this 
there are bilateral contractions in the muscles 
of the back of the neck, jerking the head 
backwards. These muscles are physiologi- 
cally associated with the frontales, as may 
be seen when a person looks up, and this 
association is reproduced in disease. 
Prognosis.-The prognosis of facial spasm 
is seldom good. If the cause can be discovered, 
it can rarely be removed, and the affection 
is generally most obstinate. 
Treatment. - General tonics and local 
sedatives are the chief agents in the treat- 
ment of most forms of facial spasm. When 
there is evidence of direct irritation of the 
fifth or the facial nerve, counter-irritation 
by blisters may be tried. A careful search 
should be made for reflex causes, and if pos- 
sible they should be removed, decayed teeth 
being extracted, and neuralgia relieved, al- 
though the result is generally disappoint- 
ing, if the spasm has long existed. When 
there are tender places in the course of the 
fifth nerve, pressure on which stops the 
spasm, the hypodermic injection of cocaine at 
these places should be employed. Morphine, 
used as a sedative, has a general influence 
which makes the remedy almost worse than 
the disease. Iron, quinine, or valerianate of 
zinc are the best general tonics. The writer 
has once known recovery to follow the admin- 
istration of bromide, Indian hemp, and nux 
vomica; the case was characteristic,occurring 
late in life. The operation of nerve-stretch- 
ing has often arrested the spasm for a time, 
and, in a few cases, permanently. It de- 
serves a trial in severe cases, acting, perhaps, 
by the effect on the centres of the arrest of 674 
FACIAL SPASM 
FAECES, RETENTION OF 
afferent impulses produced by the muscular 
contractions. These must tend to maintain 
the morbid state of the deranged cells. Its 
effect might probably be augmented by the 
simultaneous use of sedatives, such as the 
injection of cocaine to lessen the influence of 
the fifth nerve on the facial centre. Where 
the affection springs from an habitual move- 
ment, facial gymnastics may be of service. 
A weak voltaic current, applied from the ear 
to the muscles, unbroken, has been recom- 
mended ; but it rarely, if ever, effects a cure. 
The same is true of the application of vol- 
taism to the sympathetic and to the back of 
the head. See Eye, and its Appendages, 
Diseases of. W. R. Gowers. 
FACIES HIPPOCRATICA (Lat.)- 
A peculiar expression of the face, so named 
from having been graphically described by 
Hippocrates. It is most strikingly observed 
in persons exhausted by copious discharges, 
as in cholera, by prolonged wasting diseases, 
or by starvation; and especially before im- 
pending death. It is thus described by 
Hippocrates : ' A sharp nose, hollow eyes, 
collapsed temples; the ears cold, contracted, 
and their lobes turned out; the skin about 
the forehead being rough, distended, and 
parched; the colour of the whole face being 
green, black, livid, or lead-coloured.' 
F2ECES,Examination of.-See Stools. 
FAECES, Involuntary Discharge of. 
See Defecation, Involuntary. 
F7ECES, Retention of.-^Etiology.- 
In the absence of mechanical obstruction, 
such as that due to adhesions, bands of false 
membrane, uterine pressure, stricture, tu- 
mours or haemorrhoids, the main causes of 
faecal accumulation are :-(a) A sub-paralysis 
of the intestinal muscular fibres from defec- 
tive innervation, or from over-distension of 
the walls of some portion of the large bowel; 
(6) loss of reflex irritability of the rectum; 
and (c) dryness of the mucous surface of the 
colon. Hence it is frequently met with in 
the debilitated, the bedridden, the paralysed, 
the aged, and the sedentary; and women are 
more prone to it than men. Loss of reflex 
sensibility in the rectum is frequently the 
sole cause. The faeces delivered into the 
rectum by the contractions of the sigmoid 
flexure and the descending colon no longer 
excite the act of defaecation; and collecting 
there as a large desiccated mass, they deter- 
mine a gradual and painless retention in the 
large intestine, and particularly in the most 
distensible parts-the sigmoid flexure and the 
caecum. The accumulation once set up tends 
also to perpetuate itself, by arresting more 
and more the peristaltic movements of the 
distended bowel around the collected faeces. 
Symptoms.-Faeces often accumulate slowly 
and without the knowledge of the patient. 
Hence in cases in which sensibility has been 
blunted by age, disease, or great debility, the 
discovery of large collections in the rectum 
or colon may surprise even the practitioner, 
who is generally led to a local examination 
by disturbances set up by the retention. 
There is usually constipation or an insuf- 
ficient discharge of solids; a regular and 
possibly excessive relief of the bowels does 
not, however, exclude accumulation, for even 
fluid faeces may pass through or over old 
collections. The evacuations are lumpy, or 
consist of detached hard, dry, dark scybala, 
or of a single mass; and when the accumu- 
lated matters are dislodged by aperients, they 
often emit an offensive and sour odour. Not 
uncommonly, however, the alvine discharges 
are entirely fluid or semifluid, and consist 
chiefly of mucus tinged with faeces. Faecal 
collections in the rectum and sigmoid flexure 
are apt to excite tenesmus and frequent 
voiding of mucus and blood-a condition 
resembling that of chronic dysentery, but 
without the putrid-flesh-like odour of dysen- 
teric evacuations; and the finger encounters 
a mass of hardened faeces in the rectum. A 
collection of fruit-seeds-as of the fig-in the 
rectal pouch will also set up these symptoms. 
An accumulation in the caecum, or in any 
part of the colon, may be detected through 
the abdominal wall as a tumour more or less 
movable, uneven or nodulated, and doughy 
to the touch ; and on the finger being firmly 
pressed into it, presenting a depression which 
may last for some minutes. In rare cases 
the large bowel throughout may be so greatly 
distended as to apparently fill the abdomen 
with a solid mass, which, like other faecal 
collections, yields to the firm pressure of the 
finger. A tympanitic state of the abdomen 
may, however, so obscure the examination as 
to prevent the recognition of even moder- 
ately large accumulations. The faecal tumour 
in the caecum is globular; but in any part of 
the colon it is usually elongated; and in the 
descending colon and sigmoid flexure it is 
harder than elsewhere, and very distinctly 
nodular from scybala. It may drag the 
transverse colon downwards, even as low as 
the symphysis pubis; and when confined to 
the right half of the transverse colon it may 
be mistaken for an enlarged liver. 
But in other cases the retained feces set up 
more or less severe abdominal disturbance- 
such as colicky pains, great distension, &c.- 
which may terminate either gradually or 
suddenly in complete intestinal obstruction, 
now and then proving fatal (see Intestinal 
Obstruction). Usually, however, several 
obstructive attacks of increasing severity 
succeed one another at intervals, being re- 
lieved either spontaneously or by the use of 
enemata and aperients. Ulceration of the 
intestinal mucous membrane is also apt to 
follow the continued retention of feces, and 
may lead to fatal perforative peritonitis, or 
to stricture from the healing of the stercoral F.ECES, RETENTION OF 
FALLOPIAN TUBES 
675 
ulcer. See Caecum, Diseases of; Colon, 
Diseases of; and Constipation. 
Treatment.-A hard ball of faeces, or of 
agglutinated scybala, or faecal concretions in 
the rectum resisting dislodgment by aperients 
or enemata, should be broken up and re- 
moved by introducing within the sphincter 
two or three fingers and a scoop, or the 
handle of a spoon; this procedure in the 
female being facilitated by the fingers in the 
vagina. An attempt may be made as a pre- 
liminary measure to macerate the hard faecal 
mass by a cacao-butter suppository or inject- 
ing a few ounces of W'arm olive-oil. Some- 
times a glycerine suppository or glycerine 
injection (5ij.) will excite and aid the natural 
efforts in expelling the obstruction. Symp- 
toms of obstruction should be met by in- 
jecting by the stomach-pump tube, or David- 
son's syringe, large quantities-from 80 to 
120 oz.-of some warm fluid such as soap- 
water or gruel, through the long rectal tube 
passed its full length ; and it is often advis- 
able to repeat at intervals the injection of 
even large quantities until relief is obtained. 
Care must be exercised in the use of the long 
tube not to injure the bowel; as well as in 
the injection of large quantities of fluid. If 
the indurated mass (as when in the lower 
parts of the large bowel) can be traversed by 
the tube, warm olive-oil should be slowly in- 
j ected, and afterwards the warm fluids in ample 
measure. As a rule, purgatives merely aggra- 
vate the vomiting induced by the obstruction, 
while large enemata usually afford direct 
relief. In the absence of vomiting, however, 
a brisk aperient-such as calomel, castor-oil, 
or colocynth with croton-oil-may afford 
timely aid in clearing away the faecal accu- 
mulation. When aperients and enemata fail 
to dislodge.the faecal collections, and the ab- 
domen becomes painfully distended, a com- 
bination of opium, belladonna, and aloes, 
given at regular intervals-the dose of aloes, 
at first small, being increased as the pain 
diminishes-may enable the bowel to over- 
come the difficulty; but when there is much 
pain, and, above all, obstinate and especially 
stercoraceous vomiting, opium and bella- 
donna, or subcutaneous injection of morphine, 
should be given until the subsidence of these 
symptoms. In such cases belladonna alone 
pushed to large doses has been known to 
effect relief after the failure of other means. 
Massage may afford aid in dispersing faecal 
collections and improving the peristaltic ac- 
tion of the bowel; to be applicable, there 
should be little or no tenderness, and it should 
be addressed first of all to the distal side of 
any detectable faecal tumour. Electricity 
may prove useful. See Constipation. 
Distressing tympanites, which, thwarting 
the peristaltic movements, often intensifies 
obstruction, has been overcome by puncturing 
the bowel with a fine trocar or aspirator- 
needle, after failure of other measures. 
The general medicinal treatment of the 
conditions that favour the recurrence of the 
difficulty should consist of a prolonged course 
of gentle, yet efficient, evacuants, combined 
with tonics. The gradual collection of faeces, 
the toneless state of the walls of the large 
bowel, the scanty secretion of intestinal 
mucus, and the loss, in many cases, of reflex 
sensibility in the rectum, require the perse 
vering use of these remedies. A pill con- 
taining aloes, iron, belladonna, and nux 
vomica generally affords the most satis- 
factory results. See Constipation. 
George Oliver. 
FAINTING.-A popular synonym for 
syncope. See Syncope. 
FAINTNESS. - Faintness signifies a 
feeling of great weakness or exhaustion, as if 
the subject of it were about to become ex- 
hausted, or to sink or faint. 
FALLING SICKNESS.-A popular 
synonym for epilepsy. See Epilepsy. 
FALLOPIAN TUBES, Diseases of. 
The oviducts are liable to the following mor- 
bid conditions :-(1) Malformations ; (2) Dis- 
placements; (3) Contractions; (4) Dilatations; 
(5) Inflammation; (G) New-Growths; and 
(7) Tubal Pregnancy. 
1. Malformations.-The Fallopian tubes 
may be congenitally wanting, either on one 
or on both sides; or they may be impervious; 
or, instead of a single opening into the ab- 
dominal cavity, there may be two or more. 
2. Displacements.-The tubes may be 
stretched or widely displaced from their 
normal position by growths or effusions in 
their neighbourhood, such as ovarian, or 
parovarian. 
3. Contractions.-These canals may be 
impervious, from inflammation of the lining 
membrane, or from peritonitis, pressure, or 
torsion. 
4. Dilatations. - The Fallopian tubes 
may be distended, even to a great extent, by 
(a) mucous or serous fluid (hydro-salpinx); 
(6) pus (pyo-salpinx); or (c) blood (hcemo- 
salpinx). In hydro-salpinx the tubes, if 
much distended, become sacculated, giving 
rise to a string of cystic tumours. The fluid 
collects chiefly at the abdominal end of the 
tube, but occasionally it may escape, and in 
large quantity, through the uterus. Should 
the tube burst and discharge its contents into 
the peritoneal cavity, the results will be 
serious, especially if the fl uid be pus. "When 
haemo-salpinx is the result of menstrual re- 
tention from atresia uteri, bursting of the 
tubes internally is liable to follow operations 
for the relief of the obstruction. 
5. Inflammation.-Inflammation of the 
Fallopian tubes (salpingitis) is apt to be 
caused by gonorrhoeal infection, or it may 
occur during the puerperal state. Stenosis 
or pyo-salpinx may be the result. 676 
6. New-Growths.-The Fallopian tubes 
may be the seat of the following new-growths: 
fibroid tumours, mucous polypi, cysts, can- 
cer, and tubercle. Fibroids resembling those 
of the uterus may attain a considerable size. 
Small polypi growing into the canal may 
partially obstruct the duct. The cysts are 
usually the so-called hydatids of Morgagni, 
an embryological relic; but other small 
simple cysts may be met with at the orifice 
of the tube, around the fimbriated extremity. 
Primary cancer of the Fallopian tubes rarely, 
if ever, occurs. Tubercle, however, may be 
primary, and may occur before puberty. It 
usually begins at the abdominal end, and 
may lead to blocking of the tube. 
7. Tubal Pregnancy.-An important 
affection of the Fallopian tubes is that aris- 
ing from disintegration of the lining mem- 
brane of the tube, producing destruction of 
the ciliated epithelium, and so affording a 
nidus for the attachment of the misplaced pro- 
duct of conception, which thus grows within 
the tube in some part of its course. This 
abnormality is apt to be attended with very 
grave results, bursting of the tube frequently 
occurring about the third month of gestation; 
and serious, sometimes fatal, internal haemor- 
rhage may hence ensue. Tubal gestation 
usually occurs on one side only, while other 
affections of the tubes are often symmetrical, 
a point of diagnostic importance. See Preg- 
nancy, Disorders of. 
Regurgitation of blood, of septic matters, 
and of fluids injected into the uterus, some- 
times takes place along the Fallopian tubes, 
and this accident is always attended by grave 
consequences. Hence the danger of inju- 
dicious intra-uterine irrigation with cor- 
rosive sublimate and other antiseptic solu- 
tions during the puerperal period, and more 
especially after early abortions. 
Mechanical Obstruction of the Fallo- 
pian tubes is not an infrequent cause of 
sterility. 
Treatment.-The diagnosis of affections 
of the Fallopian tubes being difficult, then- 
treatment is likewise obscure, and must be 
in a measure guided by general principles in 
each case. In pyo-salpinx severe peritonitis 
and death may result from rupture of the 
sac, as may speedy dissolution from internal 
haemorrhage in tubal gestation. In the 
former case, and in hydro-salpinx, puncture 
with the aspirator might be permissible were 
a clear and unequivocal diagnosis made ; or, 
failing this, the removal of the affected tube 
by salpingotomy as the only alternative. 
But, although in the hands of some eminent 
specialists this procedure has been attended 
with satisfactory results in many cases within 
the past few years, as a rule, under ordinary 
circumstances, the diagnosis is surrounded 
by so many difficulties that such an opera- 
tion can only rarely be justified. 
Alfred Wiltshire. T. More Madden. 
FALLOPIAN TUBES 
FALSE MEMBRANE.-An inflam- 
matory exudation of a fibrinous character, 
which is deposited in layers, chiefly on mu- 
cous surfaces, and occasionally on abrasions 
of the skin. It is well exemplified in diph- 
theria and plastic bronchitis. See Diph- 
theria. 
FAMILY DISEASES. - Diseases 
which are found to run in families, or dis- 
eases to which members of the same family 
seem peculiarly liable. See Disease,Causes of. 
FARADISATION, Uses of. - See 
Electricity in Medicine. 
FARCY.-See Glanders. 
FASCIAE (fascia, a band).-The fasciae 
are subjects of medical and surgical interest, 
with respect to their anatomical relations, 
the diseases to which they are liable, and 
certain points of diagnosis in connexion with 
them. 
I. Anatomical Relations of Fasciae.- 
The situation and connexions of the fasciae, 
according as they are fasciae of investment 
or fasciae of attachment, are of the greatest 
practical importance in the following classes 
of diseases : (1) Suppuration; (2) Extravasa- 
tions, and Cellular Emphysema; (3) Herniae; 
(4) Dislocations and other injuries; (5) Dis- 
eases of Encapsuled Organs; and (6) New- 
Growths. 
1. Suppuration.-The physical influences 
exerted by fasciae upon pus are chiefly two. 
First, fasciae may limit the size of an abscess, 
determine its tension and the many results 
of the same, and thus affect both the local 
phenomena and the general symptoms. 
Secondly, when the pus is not confined, the 
fasciae serve to determine the course that it 
will take, and the situation in which it will 
discharge. Every abscess may be said to be 
influenced in this way by the relations of 
fasciae, but certain fasciae have to be specially 
noted as causing pus to burrow, and hence 
they should be enumerated here. 
(a) Fascice of the Head and Neck.-The 
fasciae of the scalp ; the temporal fascia; the 
cervical fascia; and the post-pharyngeal 
fascia, which conducts pus from the cervical 
vertebrae to the parotid region and tonsil, 
and to the region of the carotid vessels. 
(b) Fascice of the Upper Extremity.- 
The axillary fascia; and the deep fascia of 
the upper extremity generally, including 
the palmar fascia and the sheaths of the 
tendons. 
(c) Fascice of the Thorax.-The fasciae of 
the intercostal spaces and of the mammary 
region; the fasciae reaching from the neck 
to the upper part of the pericardium and the 
aorta, and. to the posterior mediastinum, re- 
spectively ; the fasciae of the anterior medias- 
tinum ; and those connected with the dia- 
phragm-all of which determine the course 
of intrathoracic abscesses. 
FASCI2E FASCIAE 
677 
(d) Fascice of the Abdomen and Pelvis.- 
The transversalis fascia; the fasciae connected 
with the transversalis muscle, especially pos- 
teriorly, which influence the course of lumbar 
abscess; the sheaths of the psoas and the iliacus 
muscles; the pelvic, recto-vesical, obturator, 
and anal fasciae; the fascial investment of 
the prostate; the superficial and deep layers 
of the superficial fascia of the perinaeum; the 
superficial and deep layers of the triangular 
ligament; and the fascial investments of the 
rectum, bladder, uterus, and vagina, which 
determine the course of purulent collections 
in the pelvis. 
(e) Fascice of the Lower Extremity.- The 
fascia lata and its processes; the tensor fasciae 
femoris ; the popliteal fascia ; the deep fascia 
of the leg; and the plantar fascia and its 
compartments. 
2. Extravasations and Cellular Emphy- 
sema.-"When blood or urine escapes from its 
natural reservoirs, or when air or gas has 
found its way amongst the tissues, the direc- 
tion that the extravasated substance takes is 
markedly influenced by the fasciae with which 
it comes in contact. The principal fasciae of 
importance in this respect are as follows :-• 
(a) Fascice of the Head and Neck.-The 
fasciae of the scalp, and the cervical fascia. 
(b) Fascice of the Thorax.-The fasciae of 
the intercostal spaces; and the mediastinal 
fasciae, through connexions with the cer- 
vical. 
(c) Fascice of the Upper Extremity.-The 
deep fascia in general. 
(d) Fascice of the Abdomen and Pelvis.- 
Scarpa's fascia, or deep layer of the super- 
ficial fascia; both layers of the superficial 
and of the deep perineal fascia; and the 
fasciae of the prostate and bladder-all being 
of the greatest importance in cases of extra- 
vasation of urine or faeces. 
(e) Fascice of the Lower Extremity.-The 
fascia lata in general; the popliteal fascia; 
the deep fascia of the leg; and the plantar 
fascia. 
3. Herni®.- The occurrence of hernite, 
and the direction that they take, are in a 
great measure determined by the condition 
of the fasciae in contact with the viscera. 
Most important in this relation may be 
mentioned the fascia transversalis, the iliac 
fascia, the sheath of the femoral vessels, the 
obturator fascia, the cribriform fascia, and 
the fascia lata. 
4. Dislocations, &c.-Certain fasciae serve 
as supports for the heads of bones, and for the 
viscera; and these will have an important 
influence either in promoting or in prevent- 
ing dislocation, displacement, or other injury 
of these parts, as the case may be. The 
shoulder is supported by the costo-coraeoid 
fascia, and this relation considerably affects 
the signs of dislocation at that joint. In 
fractures of the patella, the fasciae of the 
knee-joint promote separation of the frag- 
ments. The fascia of the neck helps to sup- 
port the pericardium, and must limit the 
displacements of the heart. The bicipital 
fascia of the forearm protects the brachial 
artery beneath it in venesection, at the 
bend of the elbow. On the other hand, the 
attachment of the cervical fascia to the jugu- 
lar veins facilitates the entrance of air into 
the circulation through a wound at this point. 
And, lastly, the pelvic viscera are supported 
by the transversalis, pelvic, iliac, and recto- 
vesical fasciae; whilst the cord and testis 
have their special fasciae to keep them in 
position. 
5. Diseases of Encapsuled Organs.-A 
considerable number of organs, many im- 
portant vessels, and a great variety of 
muscles are contained in distinct fascial 
capsules, sheaths, or envelopes, which will 
affect the course of the diseases of these 
structures in many ways-defining their 
limits, or determining the direction in which 
they spread, and thus influencing both their 
local and general phenomena. This has 
been already alluded to under the first head; 
but it is necessary to enumerate here the 
principal fasciae that act in this way, namely: 
(a) Arterial sheaths: of the carotid, sub- 
clavian, thoracic-aortic, and femoral. (6) 
Muscular sheaths: of the masseter, buc- 
cinator, psoas, iliacus, quadratus lumborum, 
erector spinae, pectineus, rectus abdominis, 
levator ani, tensor vaginae femoris, and the 
palmar and plantar muscles, (c) Visceral 
capsules : of the thyroid gland, parotid and 
submaxillary glands, tongue, prostate, penis, 
vagina, bladder, rectum, and mamma. 
6. New-Growths.-The direction, rapidity, 
and extent of spread of new-growths are con- 
siderably modified in certain situations by the 
relations of the fasciae above described. 
II. Pathological Relations of Fas- 
ciae.-The principal diseases of fasciae are : 
(1) Inflammation and its results; (2) Ossi- 
fication ; (3) Calcification ; (4) Rheumatism ; 
(5) Gout; (6) Syphilis ; (7) Contraction ; and 
(8) Extension. None of these conditions can 
be said to be common, or of serious impor- 
tance. 
1. Inflammation.-Inflammation involv- 
ing a fascia is usually secondary, having 
spread to it from the neighbouring structures, 
and especially from the muscle or organ of 
which the fascia may form the sheath. Even 
under these circumstances, a fascia rather 
resists than participates in the inflammatory 
process, as has been described above; and 
when it is involved, it tends to ulcerate on 
account of its feeble vitality, and to be dis- 
charged in the form of sloughs. The healing 
process is extremely slow in fasciae, and after 
serious lesion their function is never com- 
pletely restored. 
2. Ossification.-Occasionally in aged per- 
sons portions of fasciae are found transformed 
into bony tissue. 678 
FASCIJ3 
FASTING 
3. Calcification.- Calcification is very 
rare in fasciae. 
4. Rheumatism.-The condition known as 
muscular rheumatism, or according to its 
situation as lumbago, torticollis, &c., is be- 
lieved by some authorities to involve the 
fibrous coverings or fasciae of the affected 
parts. In the same way, many of the aches 
of some forms of ' chronic rheumatism ' may 
possibly have their seat in fasciae ; and cer- 
tain cases of neuralgia are probably to be 
referred to rheumatic inflammation of the 
nerve-sheath. 
5. Gout.-Amongst the pains of the gouty 
subject are some which are no doubt due to 
affections of fasciae, such as pains in the heel 
and instep, and neuralgia of the sciatic, the 
anterior crural, and the brachial nerves. 
6. Syphilis.-Syphilis may attack the fas- 
ciae in the form of nodes, which in situa- 
tions of low vascularity are apt to ulcerate, 
as, for example, at the inner aspect of the 
knee. 
7. Contraction.-Contraction is the most 
obvious of the morbid conditions of fasciae, 
giving rise as it does to well-marked de- 
formities. The fasciae of the hand and foot 
are most liable to this change, with the result 
of unnatural flexion of the fingers and toes. 
Such contraction of the palmar and plantar 
fasciae may be due to wounds, burns, or in- 
flammation from any cause, or to gout or 
rheumatism ; it is sometimes congenital; 
and it sometimes occurs without evident 
cause. 
8. Extension.-A fascia or sheath, though 
extremely inelastic, is liable to be stretched 
by swelling of the parts which it envelops; 
and, if the cause do not speedily disappear, 
may remain more or less permanently ex- 
tended. The best instance of this condition 
is pendulous abdomen after pregnancy or 
other kind of abdominal enlargement. 
J. Mitchell Bruce. 
FASCIOLA {fasciola, a thin band).-A 
genus of trematode parasites of which the 
common liver-fluke forms a good type. This 
entozoon (F. hepatica') is characterised by 
the possession of a branched intestinal canal, 
thus differing from the flukes belonging to 
the genus Distoma, in which the canal is 
simple and bifurcated. The liver-fluke is of 
rare occurrence in man, though extremely 
abundant in, and destructive of, ruminating 
animals. See Entozoa. 
T. S. Cobbold. 
FASTING--The manifestation of vital 
activity implies consumption of material; 
and unless the supply of material in the form 
of food is equivalent to the loss occurring, a 
progressive wasting of the body and failure 
of power must ensue. Hence these pheno- 
mena constitute the necessary accompani- 
ments of fasting; and with its prolongation 
the question resolves itself into one of time 
-when the exhaustion of material shall have 
proceeded to such an extent as to render the 
continuance of life impossible. 
Pathology.-To Chossat we are indebted 
for showing that the immediate cause of 
death from fasting is a reduction of the body- 
temperature. At first there is a gradual, but 
not very extensive fall. Afterwards a more 
rapid decline occurs, until the reduction 
amounts to about 29° or 30° F. below the 
normal point, when death ensues. Chossat 
noticed that if, whilst in the state of torpor 
preceding death, the temperature of the 
animal experimented on was raised by ex- 
posure to artificial warmth, a restoration of 
consciousness and muscular power was in- 
duced ; and some of his subjects of experi- 
ment which were thus rescued from impend- 
ing death afterwards thoroughly revived on 
being supplied with food. 
Symptoms.-The most prominent symp- 
toms arising from fasting are those due to 
the special sensations produced by the ab- 
sence of food and fluid, and those attribut- 
able to a decline of the physical and mental 
powers. In the first place there is great 
uneasiness in the epigastrium. This is fol- 
lowed by a sense of sinking in the same 
region, accompanied by insatiable thirst; and 
if fluid be persistently withheld as well as 
food, the thirst becomes the chief source of 
distress. The countenance assumes a pale 
and cadaverous appearance, and a look of 
wildness is presented about the eyes. Ema- 
ciation becomes more and more marked, and 
with it there is a decline of the bodily strength. 
There is also failure of the mental power. 
Stupidity may advance to imbecility; and a 
state of maniacal delirium frequently super- 
venes. Life terminates either cahniy by 
gradually increasing torpidity, or, it may be, 
suddenly in a convulsive paroxysm. 
Duration of Life.-The usual duration 
of life under complete absence of food and 
drink may be said to be from eight to ten 
days. The special circumstances existing 
may, however, exert a modifying influence, 
and from the nature of these the period may 
be either diminished or increased. A stout 
person, as may be readily understood, has a 
chance of living longer than a thin one, on 
account of the store of combustible material 
which may be drawn upon being larger. 
Exposure to cold in conjunction with starva- 
tion very much hastens death. The presence 
of moisture in the atmosphere favours the 
prolongation of life, by diminishing the ex- 
halation of fluid from the body. It may be 
assumed to be owing to the existence of 
warmth and moisture that persons buried in 
mines, or otherwise similarly placed, have 
been known to live considerably beyond the 
ordinary period. 
The Welsh fasting girl, whose case caused 
so much sensational excitement in 1869, 
lived exactly eight days from the time she FASTING 
FATIGUE 
679 
was placed under systematic inspection to 
solve the problem of whether she could exist, 
as had been alleged by her parents, for an 
indefinite period without food. It appears 
that during the first part of the time she was 
cheerful and exhibited nothing extraordinary. 
Later on it was found that she could not be 
kept warm, and ultimately she sank into a 
state of torpor from which she could not be 
roused, and which speedily terminated in 
death. 
In the Troedyrhiw colliery near Ponty- 
pridd an inundation occurred in 1877, which 
led to the imprisonment of four men and a 
boy in one of the headings of the mine. The 
accident happened on Wednesday evening, 
the 11th of April. Efforts were at once made, 
by means of a cutting, to reach the chamber 
in which the imprisoned persons were con- 
fined, and to release them. This was not 
accomplished till the afternoon of Thursday, 
the 19th, when all were rescued alive and did 
well. They had been imprisoned in an 
atmosphere of compressed air nearly eight 
days, without food but within reach of water. 
The performances of professional fasting 
men give a much longer time as that during 
which life can be sustained without food. 
Two feats of fasting were performed before 
the London public during 1890 by separate 
men. The first was announced to be for a 
period of forty, and the second for a period of 
forty-five days. Both were carried on for the 
specified time, and, through the payments 
received from the crowds of spectators ad- 
mitted, must have proved lucrative under- 
takings. One of them subsequently became 
insane. Feats thus conducted, for pecuniary 
gain, and supervised, as was here the case, 
by newspaper reporters as watchers, can 
hardly, it may be considered, be regarded as 
holding a sufficiently trustworthy position to 
command acceptance for the purposes of a 
medical work like this, whatever the amount 
of popular credence given to them at the 
time. In the case of the Welsh fasting girl 
watchings of considerable duration had been 
performed through which she had success- 
fully passed, but the last watching was carried 
out by the experienced London nurses de- 
puted to undertake the task with a strictness 
that defied deception, and with the result that 
death took place as stated. 
In the case, again, of Ann Moore, of Tut- 
bury, in Staffordshire, which, from the ac- 
count published, must have attained great 
notoriety in the early part of the present 
century, watchings had been conducted in 
a manner to admit of testimony being given 
in support of her veracity ; but ultimately a 
watching was so seriously undertaken, and 
with such zeal carried out, as to lead to her 
being brought by the ninth day into a sink- 
ing condition, when she took food, and after- 
wards made a written confession of the im- 
position that had been previously practised. 
That a very small amount of food will 
suffice for sustaining life for a prolonged 
period is evidenced by what may be observed 
in some cases of constrictive disease affect- 
ing the oesophagus or cardiac orifice of the 
stomach. 
Treatment.-Caution is required in the 
administration of food after prolonged fast- 
ing. Sudden transitions of all kinds are 
trying to the body; and, instead of allowing 
the rescued sufferer to gratify his desire to 
eat and drink according to his inclination 
after several days' abstinence, the supply of 
both food and drink should at first be limited, 
and afterwards gradually increased. There is 
reason to believe that the non-observance of 
this rule has upon some occasions been fol- 
lowed by disastrous consequences, which a 
different plan might have averted. 
F. W. Pavy. 
FAT.-Fat becomes morbid under a 
variety of circumstances :- 
1. Obesity.-Fat may be found gene- 
rally diffused in excessive quantity beneath 
the skin, beneath serous membranes, and in 
and upon various tissues and organs of the 
body. This condition constitutes what is 
known as obesity. See Obesity. 
2. Partial Growth.-A partial growth 
of fat sometimes occurs in paralysed muscles, 
and constitutes a characteristic feature of 
what is called pseudo-muscular hypertrophy. 
See Progressive Muscular Dystrophy. 
3. Fatty Interstitial Growths.-Fat 
as fat-tissue more especially constitutes a 
disease when it is deposited upon and in the 
textures of organs, interfering with their 
structure and functions. This it does by 
pressing upon the histological elements of 
the organ invaded. Its effects are more 
clearly seen when it invades the muscular- 
tissue of such an organ as the heart, the 
fibres of which, becoming more or less atro- 
phied and distorted in their course and direc- 
tion, are rendered inadequate for the per- 
formance of their functions. See Heart, 
Fatty Growth on. 
4. Fatty Tumours.-Fat may also occur 
in isolated or circumscribed masses, consti- 
tuting what are known as fatty tumours or 
lipomata. See Tumours. 
5. Fatty Infiltration.-See Fatty In- 
filtration. Richard Quain. 
FATIGUE (fatigo, I weary).-Gene- 
ral Remarks.-Fatigue is a regular and 
constantly returning symptom experienced 
by all persons. Periods of functional ac- 
tivity invariably alternate with periods of 
repose, during which the waste caused by 
the exercise of function is repaired. We are 
indebted to Sir James Paget for having 
pointed out that 'rhythmic nutrition is a 
law of nature,' and although the truth of 
this dogma is recognised on all hands, and 
may be said to be axiomatic, it has hardly 680 
FATIGUE 
received that careful consideration at the 
hands of practical physicians which it de- 
serves. Our whole life is composed of a series 
of vibrations-periods of tension alternating 
with periods of relaxation ; and although the 
rapidity of these vibrations varies immensely, 
they are recognisable in all our acts, whether 
voluntary or otherwise. The vibrations of 
the heart are about seventy in a minute, those 
of the respiratory organs about sixteen. The 
whole body requires a certain period of abso- 
lute and continuous repose in each twenty- 
four hours (amounting to nearly cne-third of 
the period), so that we may say its rate of 
vibration is once in the twenty-four hours. 
In like manner, the period of relaxation of 
the heart is about one-third of the total period 
of action, and this proportional correspon- 
dence between a local and a general condi- 
tion is not a little interesting and suggestive. 
Again, it is universally ordained amongst 
civilised nations that once in every seven 
days there shall be a remission cf labour and 
a change of occupation; and we recognise 
the fact that it is highly advisable for those 
who are occupied m one pursuit to break 
away from it at least once a year and in- 
dulge in that variety of work which we call 
amusement. 
Fatigue occurs directly we attempt to alter 
the rhythm of our vital vibrations by pro- 
longing the periods of tension at the expense 
of the period of relaxation, or by demanding 
for any length of time a quickening of the 
normal rate of vibration. We recognise the 
fact that athletes who over-train run risks of 
cardiac troubles and loss of wind; that the 
man who from any cause is unable to sleep 
runs a serious risk of permanent impairment 
of health; and when we find patients pur- 
suing their avocations too zealously we know 
that, if such offence against the laws of nature 
be persisted in, general paralysis, or other 
forms of ' break-down,' are likely to be the 
result. 
Description.-Fatigue may be either gene- 
ral or local, and both forms may be either 
acute or chronic. That fatigue in all its 
forms is due to impaired nutrition there can 
be little doubt, and. we shall find that the 
symptoms of chronic fatigue are often the 
prelude of definite and recognisable degene- 
rative changes. 
General Fatigue. - General fatigue is 
recognised with ease both in its acute and 
chronic forms. There is a disability to per- 
form either mental or physical work, and this 
disability is noticed first in work requiring 
attention or sustained effort, and last in 
those acts which have become automatic or 
secondarily automatic. The symptoms of 
general fatigue are usually referable to the 
nervous centres. 
Local Fatigue.-Local fatigue is either 
acute or chronic, and the symptoms of it are 
referable usually to the muscles; but we 
must always bear in mind that muscle and 
motor-nerve are practically one and indi- 
visible, and that recent experiments have 
given great probability to the idea that every 
muscle is connected with a certain definite 
spot in the brain. When, therefore, we speak 
of a sense of fatigue, we must necessarily be 
in doubt, notwithstanding the fact that the 
symptoms are apparently located in the 
muscles, whether the brain, nerve, or muscle, 
one or all of them, be really at fault. 
Acute local fatigue.-The first symptom 
of acute local fatigue is loss of power to a 
greater or less extent. By too frequent or 
too prolonged stimulation the irritability of 
the muscular tissue becomes exhausted, and 
it either refuses to respond, or responds but 
feebly to the stimulus of the will; whilst our 
power of adjusting the force of contraction 
to the act to be accomplished is lessened, 
and accuracy of movement and delicacy of 
co-ordination are destroyed. The second 
symptom is tremor, as everyone must have 
experienced who has been called upon for 
any unusual exertion. The third symptom 
is cramp-like contraction; and the fourth is 
pain, the pain being the pain of fatigue, 
and absolutely distinct from other varieties 
of pain. Fatigue is caused far sooner by 
prolonged muscular effort than by repeti- 
tions of short muscular efforts having due 
intervals of relaxation between them. Any 
one who has attempted to hold out a weight 
at arm's length knows the impossibility 
of continuing the effort for any length of 
time; and it is proverbially true that stand- 
ing in one position is, to most people, far 
more tiring than walking, the reason being 
that in standing the muscles which sup- 
port the body are subjected to a prolonged 
strain, while in walking we use the muscles 
on either side of the body alternately. The 
great increase of power which we obtain by 
using the muscles on either side of the body 
alternately would seem to be one of the chief 
reasons for the bilateral symmetry of the body. 
Not only is sustained effcrt a far more potent 
cause of fatigue than repeated effort, but we 
find that when fatigue supervenes, actions 
requiring sustained effort are the first to fail; 
and in this local fatigue resembles general 
fatigue. The last acts to be affected by 
fatigue are such as are automatic, and are 
accomplished without mental effort, and by 
the expenditure of the least possible amount 
of force. It is quite possible to exhaust a 
muscle by artificial stimulation, and if one of 
the small interossei muscles be continuously 
faradised, it will be found that in time its 
power of contraction to any form of stimulus 
may be absolutely abolished. It is tolerably 
certain that the brain can have no share in 
artificial fatigue thus produced, and there 
seems good reason to suppose that, in some 
people of energetic temperament, the irrita- 
bility of a muscle may be exhausted, while FATIGUE 
FATTY DEGENERATION 
681 
the power of mental stimulation remains 
almost unimpaired. 
Chronic local fatigue. - This form of 
fatigue has causes and symptoms similar to 
those of acute local fatigue, and there can be 
little doubt that this condition is a common 
cause of many of those chronic maladies 
which seem to result from over-work, and are 
characterised by irregular muscular action. 
That some cases of writer's cramp (see 
Writer's Cramp) are due to chronic fatigue 
of certain muscles employed in writing, and 
particularly of those subjected to prolonged 
effort, cannot be doubted. Some cases of 
torticollis seem due to the same cause. 
Duchenne and Brudenell-Carter have pointed 
out how, in cases of ' short sight,' the strain 
on the internal recti has caused troubles 
of vision, and even brain symptoms; and 
Mr. C. B. Taylor of Nottingham has shown 
reason for including in the category of 
fatigue-diseases a peculiar form of nystag- 
mus, occurring amongst miners, who try 
their eyes by working in the dark. Dr. 
Augustus Waller, working at this subject 
from the physiological point of view, states 
that when a muscle is fatigued by over-stimu- 
lation of a motor nerve, it is the motor end- 
plate (the junction between nerve and muscle) 
which first fails to conduct the stimulus; and 
Dr. Reid, working in conjunction with Dr. 
Waller, has shown that when stimulation 
takes place from the brain, failure by con- 
duction occurs first in the cord, where the 
ganglionic cell forms a junction between the 
fibre of the pyramidal tract and the fibre of 
the anterior nerve-root. 
Treatment. - The treatment of fatigue 
in all its forms is rest, and the restoration 
of the proper rhythm of nutrition, if this be 
found perverted, by substituting rhythmical 
exercises for unrhythmical efforts. 
G. V. Poore. 
FATTY DEGENERATION. - Sy- 
non. : Fr. Deg ever escence graisseuse ; Ger. 
Fettige Metamorphose. 
Definition.-The process by which protein 
elements are converted into a granular fatty 
matter. 
Seats of Occurrence.-This change may 
occur in any of the component elements of 
the body, whether normal or abnormal. 
Physiologically.-The production of milk 
from the protoplasm of the mammary cells, 
and of sebum from the cells of the sebaceous 
glands, are instances of fatty degeneration. 
The cells of the corpus luteum are partly in a 
condition of fatty degeneration; and it is by 
a similar change in the peripheral cells of the 
mature foetal portion of the placenta that 
normal involution of that organ is accom- 
plished. Non-vascular structures, such as 
the cartilages, the cornea, and the intima of 
blood-vessels, frequently undergo fatty trans- 
formation of part of their substance. In a 
less marked form, fatty degeneration occurs 
in the walls of the uterus and other muscular 
organs when returning to their ordinary size 
after temporary hypertrophy. 
Pathologically.-As a purely morbid pro- 
cess, fatty change is most frequently met 
with in the muscular tissue of the heart, in 
the walls of capillaries, and in the urinary 
tubules; but it also occurs in the central 
nervous system, constituting the condition 
known as ' white softening ' ; in the liver ; 
and in tubercular deposits, cancerous growths, 
infarcts, and inflammatory products in any 
situation whatsoever. 
Anatomical Characters.-Physical cha- 
racters.-.An organ that has undergone fatty 
degeneration presents the following physical 
characters. The bulk and weight are gene- 
rally increased; the consistence is reduced-• 
sometimes to a pulp, as in white softening of 
the brain; the colour is changed, either as a 
whole or in the affected portions of the organ, 
into a huffy or yellowish bloodless hue ; and 
the resistance or firmness is diminished, so 
that the affected tissue is markedly flabby, 
and readily yields to pressure. The solid cut 
surface may appear compact and shining; 
and the section leaves a greasy stain upon 
the knife and fingers. When fatty degener- 
ation is greatly advanced, as it may be seen, 
for example, in the liver, a portion of the 
organ thrown into water will float. 
Microscopical characters.-In fatty de- 
generation the muscular tissue of the heart 
(see fig. 60) and the walls of capillaries are 
most suitable-especially those of the brain- 
for microscopical investigation. The earliest 
changes in the cardiac muscle in fatty de- 
generation are loss of sharpness of the indi- 
vidual striae, and the appearance of minute 
particles of oil between the elements. These 
changes, beginning near the nuclei, spread 
throughout the fibres in a longitudinal di- 
rection, while the particles increase in size, 
and assume the well-known characters of oil- 
globules. When the process is advanced, the 
whole of the sarcous substance is replaced by 
fatty particles contained within a delicate 
albuminous envelope. Finally the degener- 
ated fibres either become atrophied by ab- 
sorption of certain parts of the fat, and so 
disappear; or suffer rupture with discharge 
of their contents. The fatty nature of the 
change is proved by the solubility in ether of 
the particles that have escaped from the fibres. 
Fatty degeneration of the walls of vessels 
is best seen in the capillaries and smallest 
arteries. The tunics first lose their normal 
translucency; minute granules appear in 
their substance; and these increase to form 
unmistakable oil-globules. Finally, the vessel 
gives way, and the oily particles and blood are 
discharged into the perivascular spaces. 
In the other organs referred to, the micro- 
scopical characters agree with those just de- 
scribed, with certain differences dependent 682 
FATTY DEGENERATION 
upon the special structure of each. Thus 
fatty degeneration of a leucocyte leads to the 
formation of the body known as a compound 
granular corpuscle, in which the oil-drops 
finally replace the whole of the protoplasm. 
In ' white softening ' of nervous tissue, the 
nerve-cells and probably all the nuclei of the 
part are converted in a great measure into 
granular corpuscles; and these breaking 
down into a fatty detritus, the whole con- 
stitutes a soft creamy-looking substance, 
which, as Virchow expresses it, ' is milk in 
the brain, instead of in the mammary gland.' 
' Yellow tubercle ' consists in part of cells 
and nuclei that have undergone fatty de- 
generation, and of fatty detritus. In the case 
of the uterus during involution the fat is 
probably rapidly absorbed, so that the appear- 
ances presented to the eye are those rather of 
atrophy than of replacement of the muscular 
substance by fat. 
Pathology.-We have now to trace whence 
comes the fat that is found in this form of de- 
generation, and how. It is evident that in a 
number of instances-such as the production 
of milk and sebum-fatty degeneration is a 
truly physiological change, which is sub- 
servient to health when active, while its de- 
rangement or cessation constitutes disease. 
In other cases the process is essentially patho- 
logical, as, for example, in fatty degeneration 
of the heart and white softening of the brain; 
the functional activity of the part being im- 
paired, or so abolished that the name of 
necrobiosis, or death-in-life, has been given 
to the condition. The fatty change in the 
two instances is, however, manifestly one 
and the same. The condition known as fatty 
degeneration had long been described, and it 
has always been a favourite subj ect with patho- 
Jogists to discover its nature and its cause. 
It was generally assumed that the fatty 
matter present was introduced from without, 
being deposited from the blood as morbid 
material in place of the pre-existing tissues 
which were absorbed. Modern research has 
demonstrated that this is not so, and that 
fat is derived from a molecular change in 
the tissue or textures in which it is found. 
The subject is one of immense importance, 
involving the whole field of pathology; and 
it is but right to state that our acquaintance 
with the true nature of the process is almost 
entirely due to the investigations of Dr., now 
Sir Richard, Quain, which were published 
in the Medico-Chirurgical Transactions for 
1850, and with reference to which Sir James 
Paget has remarked: ' Dr. Quain has can- 
didly referred to many previous observers 
by whom similar changes wrere recognised; 
but the honour of the full proof, and of the 
right use of it, belongs to himself alone.'1 
Quain's conclusion, as then stated, was that 
the molecular fatty matter in the degene- 
rated fibre was the result of a chemical or 
physical change in the composition of the 
tissue, occurring independently of those pro- 
cesses which we call vital. The arguments 
which he adduced in support of this view 
were the following: (1) That in the forma- 
tion of the substance known as adipocere 
from albuminous material after death, the 
places of the muscular fibres, blood-vessels, 
and nerves are occupied by fatty matter 
which could not have existed in them as 
such during life. (2) That a true fatty de- 
generation may be artificially produced post 
mortem. (3) That masses of albuminous 
material deprived of nutrition in any part of 
the body, or the centre of non-vascular struc- 
tures such as tubercle, undergo fatty degene- 
ration to a marked degree. (4) That the 
circumstances under which fatty degeneration 
occurs in the living body exhibit impairment 
of general and local nutrition, such as blood- 
disorder, or disease of the nutrient vessels. 
More than twenty years later (1871) these 
conclusions were experimentally confirmed 
in the living animal by the investigations 
of Professors Bauer and Voit, of Munich. 
On administering phosphorus to a starving 
dog, in which the amount of nitrogen (urea) 
daily excreted had become constant, these 
experimenters found that the amount of the 
excretion was thereby increased threefold; 
that this nitrogen was derived from the 
albumen of the tissues and not of the blood; 
and at the same time that three times the 
normal amount of oil had accumulated in 
the viscera. This oil could have its origin 
only in the transformed or decomposed 
albumen of the organism; the other product 
being the urea which had been excreted. 
The same results have been observed in 
poisoning by phosphorus in the human body. 
Many other instances of the formation of 
a fatty from a nitrogenous body might be 
adduced if necessary, such as the ripening of 
cheese ; the increased flow of milk on a meat 
diet; the formation of wax by bees from sugar 
and albumen; the production of fatty acids 
and their allies from proteid compounds in 
the process of pancreatic digestion; the in- 
crease of oil in olives by keeping; and the 
development of a rancid oil in the flake of 
salmon under similar circumstances. The 
numerous instances just adduced combine to 
strengthen the position-which was, how- 
ever, sufficiently established by Sir Richard 
Quain-that in true fatty degeneration, the 
nitrogenous material of the tissues them- 
selves, and not the blood, must be considered 
the source of the oily matter. It has been 
said that the circumstances under which 
fatty degeneration occurs are further con- 
firmatory evidence in the same direction. 
These must now be considered. 
Conditions of Occurrence -The circum. 
stances under which fatty degeneration 
occurs are either such as affect the nutrition 
1 Lectures on Surgical Pathology, 1st ed. vol. i. 
p. 107, note. FATTY DEGENERATION 
FATTY INFILTRATION 
683 
of the whole system generally, or of a given 
organ, or portion of it, specially. 
General.-When the amount of blood in 
the body is quickly reduced-for example, by 
severe but not actually sudden haemorrhage, 
and in anaemia-death may occur from fatty 
degeneration of the heart, the voluntary 
muscles and the other viscera being likewise, 
but less seriously, affected. Again, general 
fatty degeneration is frequently due to de- 
praved quality of blood, and especially to the 
presence in it of certain poisons, such as phos- 
phorus, arsenic, antimony, and the more com- 
plex animal-poisons of the acute specific fevers. 
Local.-Disease of the nutrient artery 
of a part is the morbid condition most fre- 
quently associated with localised fatty de- 
generation. A good instance of this is fur- 
nished by fatty degeneration of patches of 
the muscular tissue of the heart correspond- 
ing with degeneration, obstruction, or com- 
pression of a branch of a coronary artery. 
Another excellent example of the same is 
white softening of the brain from vascular 
degeneration. This is analogous to what 
occurs in dry gangrene, with the exception 
that decomposition takes place in the latter, 
probably from exposure to air. 
Summary.-When we review the circum- 
stances under which fatty degeneration is 
found to occur, we discover that the condition 
that is common to them all is interference 
with nutrition, and especially with the pro- 
cess of oxidation. The red corpuscles are 
believed to be primarily affected in phos- 
phorus-poisoning; they are numerically re- 
duced in continued haemorrhage; and they 
do not reach the tissues in sufficient numbers 
when the vessels are obstructed, or otherwise 
diseased. In the cases of the hypertrophied 
uterus and heart, of the placenta, and perhaps 
of the corpus luteum, the degeneration is prob- 
ably due to the decline or cessation of func- 
tional activity, and the consequent decrease 
in the blood-supply to the large mass of proto- 
plasmic structures. 
With respect to the intimate or essential 
nature of fatty degeneration, it may be stated 
as highly probable, as far as our present 
knowledge extends, that the metabolism or 
decomposition that is constantly going on in 
living protoplasm is not simple or immediate; 
but that a primary decomposition occurs 
of albuminous substances into urea (or its 
allies) and fat, and a further or secondary 
decomposition of the fat into carbonic acid 
and water. If the amount of oxygen fur- 
nished by the blood is deficient, whether 
absolutely or relatively, the primary decom- 
position of the protoplasm alone may be 
effected; and the secondary decomposition, 
or the oxidation of fat into carbonic acid and 
water, may not occur. The result therefore 
of an absolute or relative deficiency of oxygen 
in protoplasmic tissues will be the accumu- 
lation of fat within them. 
Effects.-The physical effects of fatty 
degeneration of a tissue have been already 
described under the head of physical charac- 
ters, being chiefly-change of colour, dimin- 
ished consistence and resisting power, soften- 
ing, rupture, dilatation and excavation, and 
alteration of size. The chief physiological 
effect is diminished functional power or 
activity, which is especially marked in mus- 
cular parts such as the heart, and in secret- 
ing organs, including the kidneys. 
Treatment.-The subject of the treatment 
of fatty degeneration will be found discussed 
under the head of the diseases of the several 
organs which it may affect. 
J. Mitchell Bruce. 
FATTY INFILTRATION.-Fat in 
the form of oily particles is found to be pre- 
sent in excess in the cells of various secreting 
organs, constituting fatty infiltration. Thus 
it appears in the epithelium of the intestinal 
mucous membrane during digestion ; in the 
cells of the liver and biliary passages; and 
in the kidneys of certain animals-for in- 
stance, the cat. When this condition be- 
comes permai ent it constitutes a disease. 
Glandular organs thus affected, as in the 
case of the liver, assume a buff or yellow 
colour, and they become softer and more 
friable than normal; whilst microscopically 
their cells are found to contain one or more 
large well-defined oil-globules, which tend to 
coalesce and occupy the cell. The quantity 
of oily matter in the cells may, however, 
vary from time to time, and the infiltration 
may be either of a transient or of a per- 
manent character. In the one case, the 
function of the organ may not be materially 
interfered with; in the other case, the ac- 
tion of the cells may be so far affected as 
greatly to impair the secreting functions of 
the organ. 
The causes of fatty infiltration are of two 
kinds-general and local. First, the general 
causes are (a) a superabundance of fatty 
matters in the blood, such as occurs in persons 
who indulge in rich food and in beverages 
containing alcohol; (6) imperfect oxidation, 
as in chronic tuberculosis of the lungs ; and 
(c), according to some observers, the meta- 
stasis of fatty deposits from one part of the 
body to another. 
Secondly, with respect to the local causes 
of fatty infiltration, one is a peculiar affinity 
or selective power of the cells of certain 
tissues, by virtue of which they incorporate 
with their substance oily or fatty matter. 
This facility has been explained, in the case 
of the cells of the liver and of the passages 
traversed by bile, by the presence of that 
fluid, which, as Virchow and others describe, 
is a powerfully determining cause of the 
infiltration of fat into protoplasm. Another 
local cause of the accumulation of oil in 
cells is their inactivity or imperfect power of 684 
FATTY INFILTRATION 
FAVUS 
eliminating it, as is found to occur in the 
cartilages of the aged, and in inactive or 
unused muscles. 
It must be said here, with respect to the 
appearance of fat in the last-named situations, 
that though, in some cases, it is derived un- 
questionably from the fat contained in the 
blood or chyle, it may in other instances be 
derived from the disintegration of the protein 
elements of the tissues. This subject, how- 
ever, will be found discussed in the article 
upon Fatty Degeneration. 
Richard Quain. 
FATUITY (fatuus, silly).-Mental im- 
becility. See Imbecility. 
FAUCES, Diseases of.-See Throat, 
Diseases of. 
FAVUS (Lat. a honeycomb).-Synon. : 
Tinea favosa; Dermato-mycosis achorina ; 
Honeycomb Ringworm; Fr. Teigne faveuse; 
Ger. Erb grind. 
Definition.-A chronic, contagious, para- 
sitic disease of the skin of man and some 
animals, caused by the growth of the Acho- 
rion fungus (discovered by Schbnlein in 
1839), and characterised by the formation 
of peculiar yellow crusts, and by the occur- 
rence of inflammatory and often atrophic 
changes. 
Etiology.-Favus is somewhat less con- 
tagious than ordinary ringworm, and indi- 
vidual predisposition has a marked influence 
in its spread. The young are most prone to 
attack, and children living amidst sordid 
surroundings. Propagation occurs by direct 
contact and inoculation, and transmission of 
the complaint has been observed to and 
from mice, to the rat, cat, dog, fowl, guinea- 
pig, rabbit, horse, and ox. In England, 
where it is uncommon, favus is seen mostly 
in foreign immigrants; but it occurs more 
frequently in Edinburgh and Glasgow. It 
is comparatively common in the southern 
provinces of France and Italy, and amongst 
the male Jewish population of Russia, Poland, 
Galizia, and the Levant; the Mohammedans 
of Turkey, Asia Minor, Syria, Persia, Egypt, 
Algiers, and Morocco; also in parts of India, 
China, and Brazil. 
Symptoms.-The fungus develops beneath 
the upper layers of the epidermis, around 
the hair, setting up some inflammation, and 
presently appears as a little yellowish eleva- 
tion. In some weeks the latter forms a 
characteristic, sulphur-yellow, sub-epidermic, 
lentil-sized, umbilicated disc (the godet fa- 
vique, scutulum, favus), lying in a red, 
moist, cup-like bed fashioned by the pres- 
sure of the growth, and traversed by a hair. 
Gradually the tungus invades the hair- 
sheaths and then the hair, growing perhaps 
three or four centimetres above the level 
of implantation. The bulb usually remains 
free, and indeed the hair in favus is not 
invaded so quickly or abundantly as in 
trichophytosis, and, as a rule, is not nearly 
so disintegrated. The hairs become lustre- 
less, dusty-looking, loosened, and finally atro- 
phied and distorted. A characteristic mouldy 
smell is observable, which must be carefully 
distinguished from the stale scent of old 
dried-up pus. Favus may attack hairy 
regions, non-hairy parts, and the nails; but 
the scalp is far the most important site 
affected, on account of the intractability of 
the disease there, and the ensuing disfigure- 
ment. The characteristic cupuliform discs 
may attain to a diameter of about half an inch 
or more. They may remain isolated and 
disseminated, or be aggregated and more or 
less confluent. As they age, the colour fades 
or darkens by the admixture of exudations, 
and the consistence becomes more friable. 
They tend to lose their characteristic aspect, 
crumble and fall, to be replaced by others 
more or less imperfect. In course of time 
most irregular and atypical changes result 
from the effects of scratching and excoria- 
tion, and from pustulation. Secondary glan- 
dular inflammation can then arise. Finally, 
a disfiguring baldness may result; and as 
this occurs, the disease gradually dies out, 
but only after many years. 
Regions of the trunk, extremities, or face, 
commonly spoken of as non-hairy, may be 
attacked primarily or often secondarily to 
the scalp. Here the favi are surrounded by 
inflammatory halos, or preceded by a ring- 
worm-like eruption. 
One or several nails of the hands, or even 
of the feet, may be inoculated, and then the 
favi form beneath, and gradually erode the 
nail. At the same time the nutrition of the 
latter is much impaired, and the structure 
disorganised. 
Description of the Fungus.-The my- 
celium is composed of flexuous, ramified, 
tubular, partitioned, and articulated fila- 
ments. "When fructifying, the tubes are 
charged with granules, with nuclei, and with 
perfect nucleated gonidia or spores. Both 
the mycelium and the abundant gonidia are 
characterised by a great diversity of size and 
form. The gonidia are mostly rounded and 
oval, and may be isolated or united in 
chains. It is now established that the 
fungus can be distinguished in cultures; and 
when inoculated from animal to animal, and 
to man, it always gives rise to the character- 
istic clinical appearances. The godets con- 
sist of mycelial threads branching towards 
the central part, and then terminating in 
chains of gonidia and granules. 
Diagnosis.-In the various forms of favus 
where at some time or other more or less 
well-marked godets are observable, the dia- 
gnosis is clear; and the peculiar smell, the 
persistence of the malady, the condition of 
the hairs, and the occurrence of the disease 
in other members of the family, will attract FAVUS 
FEBRICULA 
685 
attention. In old-standing cases obscured 
by age or complications it is necessary to 
search thoroughly for the fungus, and to bear 
in mind the advice to be always on one's 
guard in the presence of a persistent, re- 
bellious scalp-affection, simulating psoriasis, 
eczema, seborrhcea, and the folliculites de- 
calvautes. 
Treatment.-Appropriate measures are 
necessary to counteract any disturbance of 
the general health that may be present in 
favus. At the outset all fa vic and other crusts 
and accumulations should be thoroughly re- 
moved by the usual softening and cleansing 
methods, and the hair should be completely 
cut away, and kept so. Mild antiseptic 
dressings may then be applied, to subdue 
any inflammation, or heal excoriated surfaces. 
This accomplished, the further treatment is 
nearly identical with that for ordinary ring- 
worm (see Tinea Tonsurans). Cases are 
often most rebellious. Favus of non-hairy 
parts is much more amenable. When the 
nails are affected it is necessary to remove 
mechanically as much of the diseased part 
as possible, and then thoroughly rub in, or 
keep the part soakqd with, parasiticides. 
T. Colcott Fox. 
FEBRICULA (febricula, slight fever).- 
Synon. : Fr. Febricule ; Ger. Febricula. 
Definition.-Simple fever, of one (ephe- 
mera) or not more than a few days' duration; 
not preceded by any one known invariable 
antecedent; and not attended by any one 
deflnite organic lesion. 
It may well be doubted, however, whether 
such a thing as simple fever, in the strict 
sense of the term, exists; anyhow it must be 
one of the rarer forms of disease. The con- 
ditions which, from our necessarily imperfect 
knowledge, it is convenient to call febricula 
are numerous and of great practical impor- 
tance. They may be somewhat roughly 
grouped as follows :- 
1. Abortive or incomplete forms of some 
one or other of the specific continued fevers- 
namely, typhus, typhoid, or relapsing. The 
writer's own experience leaves no doubt in 
his mind that such irregular forms are met 
with during epidemics of these diseases. 
2. Instances of some of the exanthemata, 
especially scarlatina and modified variola, in 
which the usual rash is either absent or so 
slight or brief as to pass unnoticed. 
3. Intermittent fevers, in which for some 
reason or other the paroxysms do not recur, 
or only at uncertain and distant intervals. 
4. Cases in which the local symptoms 
usually attending certain forms of fever are 
very slight or very obscure, and therefore 
difficult, perhaps impossible, to detect. In- 
stances of this occur in connexion with ton- 
sillitis, erysipelas, rheumatic fever, influenza, 
and tubercular disease. 
5. Cases in which considerable febrile 
movement is present during the development 
of the primary as well as of the secondary 
symptoms of syphilis, and of which it is not 
easy to ascertain the real cause. 
6. Fever as the consequence of exposure to 
a high external temperature-for instance, the 
febris ardens of tropical climates (Murchi- 
son) ; and of violent and prolonged mus- 
cular exertion. 
7. Fever as the consequence of irritation 
of any organ or tissue, such as of the stomach 
by indigestible matter, of the colon by scy- 
bala; or of catarrh of a mucous surface-for 
example, urethral fever. 
8. Certain ill-understood but not uncom- 
mon disorders of nervous centres, cerebral, 
spinal, or sympathetic, which are often fol- 
lowed by febrile movement. 
Anatomical Characters.-Fever, however 
caused, which runs high, produces congestions 
and tissue-changes in the viscera, especially 
in the lungs; but, in view of the short dura- 
tion of febricula, it would in most cases be 
impossible to decide whether any pathological 
changes found after death were the conse- 
quence or the cause of the febrile movement. 
It is possible, but not yet proved, that there 
may exist some contagion capable of produc- 
ing febricula, and febricula only. 
Symptoms.-Febricula is characterised by 
a rise of temperature, rarely exceeding 102'5° 
F., but sometimes, especially in cases due to 
exposure to heat, reaching 105° F. or even 
higher, although only for a short time. The 
access of fever may be gradual, or marked by 
slight rigors; and some or all of the common 
clinical symptoms of fever may be present in 
varying proportion and in greater or less 
degree, such as-general malaise ; dr}7 skin; 
frequent pulse, amounting to 100 or 120 per 
minute; tongue furred, with a more or less 
distinct, central, dry, reddish-brown streak; 
thirst, loss of appetite, and nausea; consti- 
pation ; scanty, high-coloured urine; and 
headache, intolerance of light, slight deafness, 
restlessness, sleeplessness, and slight delirium 
at night. 
Diagnosis.-The diagnosis of febricula rests 
upon the exclusion of all the other recognised 
kinds of idiopathic or of symptomatic fever. 
As a matter of practical diagnosis at the bed- 
side, almost every disease attended by rise of 
temperature is now and then, at its outset, 
mistaken for febricula. 
Prognosis.-The prognosis depends upon 
the degree and duration of the pyrexia, but 
in this country is almost always favourable. 
Treatment.-In the absence of any special 
inoication, rest in bed for a day or two, liquid 
food until the desire for solids returns, and, 
if constipation be a marked feature of the 
case, a moderate dose of some mild purgative, 
will be sufficient. It is, however, always 
prudent to remember that what seems to 
be febricula may be the beginning of some 
serious and perhaps highly infectious disease. 686 
FEBRICULA 
FEIGNED DISEASES 
Cooling drinks, such as citrate of potassium 
in effervescence, liquor ammonii acetatis with 
a little spirit of nitrous aether; or nitro- 
hydrochloric or dilute nitric acid (one drachm 
to a pint of water) with some fresh lemon- 
juice added, may be given according as the 
one or the other is grateful to the patient. 
Anything like active treatment, except spong- 
ing the skin or the use of the cold or tepid 
bath in cases of heat-fever, is unnecessary, 
rarely does yood, and is almost always posi- 
tively injurious. J. Andrew. 
FEBRIFUGES (febris, a fever; and 
fugo, I drive away).-Synon. : Antipyretics. 
Definition.-External applications or in- 
ternal remedies which tend to lower the 
bodily temperature, when it has been ab- 
normally raised by the processes of fever. 
Enumeration.-The principal febrifuges, 
given in the order of their activity, are:-Cold 
Baths; Cold Affusion or Wet Pack; Alcohol; 
Diaphoretics ; Salicylic Acid and its Salts, 
Quinine, Digitalis, and Aconite; Salicin, Phe- 
nazone, Acetanilide; and Water and Diluents 
generally. 
Action. - Following Professor Binz, we 
may divide febrifuges into two classes:- 
(1) those which directly withdraw heat from 
the fevered organism; and (2) those which 
lessen its production. 
1. In the first division we must give the 
foremost place to cold baths, the cold pack, 
and cold sponging, which powerfully abstract 
caloric from the surface of the body, and 
rapidly cool down the blood. Diaphoretics 
and alcohol act more feebly in the same di- 
rection, by dilating the cutaneous arterioles, 
and thus allowing the mass of the circulating 
fluid to be effectually exposed to the chilling 
influence of the air. See Cold, Therapeutics 
of; and Diaphoretics. 
2. Secondly, we have to consider those 
drugs which actually check the febrile con- 
dition itself, by diminishing oxidation, or 
by lessening the rapidity of the circulation 
through those parts of the body in which the 
increased tissue-change is taking place. It is 
probable that we must explain the antipyretic 
properties of such drugs as quinine by 
their specific influence over the germs on 
which malaria depends; and perhaps the pro- 
gress of science may enable us in the near 
future to nip febrile processes in the bud, by 
paralysing or destroying the bacilli which 
may start the chain of morbid processes 
which raise the temperature and depress the 
powers of life. The free use of water tends 
to promote excretion, and thus to remove the 
products of oxidation. Blisters possibly act 
by causing contraction of the vessels in the 
inflamed part. 
U ses.-Antipyretic treatment is not much 
adopted in this country as a matter of rou- 
tine, holding as we do that temperatures 
raised within certain limits are not per se 
elements of danger, and that, even although 
we may effectually cool down our patient, 
the progress of the disease may go cn quite 
unchecked. But prolonged fever causes ex- 
cessive tissue-change and fatty degeneration 
of the heart; and when the thermometer 
registers 105° F., and still tends upwards, 
we know that dangerous limits are reached, 
and that as a rule life is not long sustained 
above 107° F. It then becomes our duty to 
interfere; and this is best done by plunging 
our patient into a bath at 95°, and gradually 
cooling it down to 65°. When the tempera- 
ture descends to within 4° or 5° of the nor- 
mal we remove him to bed, remembering 
the dilatation of vessels which must follow 
the contracting effect of cold, and the con- 
sequent cooling process which must continue 
to go on. Here, as in all febrile conditions, 
the thermometer is our surest guide, and 
we must be directed by it as to when to re- 
sume the treatment, for frequent repetition 
may be needed, and on the Continent as 
many as '200 baths have been given in the 
course of a single illness. Along with this 
the Germans combine the use of large doses 
of quinine ; but, notwithstanding the marked 
tolerance of the drug under pyrexial condi- 
tions, the danger of perilous depression from 
such free medication is no imaginary one; 
and, putting ague apart, we find this valuable 
drug most beneficial in such fevers as seem 
to owe their origin to septic poisoning. Digi- 
talis is not a powerful antipyretic, and in 
large doses is too disturbing to the heart, 
and too apt to produce gastric derangement, 
to inspire much confidence; but phenazone 
causes profuse perspiration, and is much used 
in febrile disorders on account of its certain 
and rapid action, and acetanilide is effec- 
tual in smaller doses. The influence of sali- 
cylic acid over acute rheumatism is remark- 
able, as it seldom fails to reduce temperature 
and relieve pain in forty-eight hours; but in 
other feverish conditions its beneficial action 
is by no means so well-marked. Salicin also 
has numerous advocates, who prefer it to the 
salicylates as being less depressing to the 
circulation. Iron is of value in erysipelas, 
and exerts some controlling power over acute 
rheumatism. Aconite and diaphoretics are 
of undoubted service in aiding the deferves- 
cence of some of the minor febrile disorders. 
R. Farquharson. 
FEIGNED DISEASES.-No insignifi- 
cant part of the real difficulty in the practice 
of our profession depends on what we may 
call feigned diseases. The art of diagnosis 
consists in the power of recognising morbid 
conditions with skill and promptitude; and 
in proportion to the natural sharpness and 
well-digested experience of the medical man 
is his success in the discrimination of one 
symptom from another which resembles it 
more or less superficially. Many disorders FEIGNED DISEASES 
687 
possess a strong family likeness in their very 
early stages, whilst others may prove decep- 
tive throughout their whole course; and if to 
this we add the efforts at deception occasion- 
ally resorted to by impostors, we seethe caution 
which must of necessity be adopted by those 
who exercise their calling within wide limits. 
In considering, therefore, the subject of 
feigned diseases, a greater amount of order 
may attend our studies if we adopt the fol- 
lowing simple classification:- 
1. Those diseases which naturally re- 
semble one another, and in the deception 
attending the diagnosis of which the patient 
has no share. 
2. Those diseases which are also difficult 
of diagnosis, but in which the patient in- 
voluntarily deceives under some morbid 
nervous impulse. 
3. Cases in which the patient sets himself 
deliberately and elaborately to deceive those 
around him. 
1. Under this heading we may perhaps 
include the exanthemata and other acute 
feverish affections, which are confessedly 
difficult of diagnosis before the eruption or 
other marked points of difference are fully 
established. Important though it may be, in 
the case of public schools or large bodies of 
men, to act promptly in the face of such an 
emergency, the medical man will often feel 
himself compelled to postpone his decision; 
but he should at the same time act on the 
defensive by the timely exercise of quarantine 
and hygienic precautions. Some diseases, 
again, are difficult to distinguish from one 
another, even after their prodromata have 
passed away, and among these we may in- 
clude small-pox and pustular syphilis, which 
occasionally cause more than a shade of sus- 
picion to pass over the mind; whilst mild 
variola and severe varicella must always have 
too many points in common to render them 
otherwise than stumbling-blocks even to the 
initiated. Various forms of roseola may 
closely simulate measles; scabies is often 
hardly to be picked out from amongst the 
eruptions which its irritation causes; whilst 
throat-affections may apparently overlap each 
other and engender the idea of diphtheria 
where nothing more than superficial or aph- 
thous ulceration really exists. But it is when 
the ailment under which our patient labours 
resembles something else during its whole 
career that mistakes are naturally most 
likely to arise. We are frequently shocked 
with some scandal in which the innocent 
victim of brain- or other organic disease has 
been consigned to a police-cell, and where 
the plea of drunkenness has been attempted 
to be sustained by the guardians of the public 
peace. So difficult is it to make a really 
trustworthy diagnosis between the coma of 
alcohol, of uraemia, of opium, and of certain 
apoplectic conditions, that the truly cautious 
and well-informed practitioner would prefer 
not to attempt to do so offhand. It is im- 
possible to lay down any general rules, but 
we may remember that alcohol in poisonous 
doses lowers the temperature and dilates the 
pupil; that in uraemia an examination of the 
urine will put us in the right track; whereas 
opium will produce a contracted pupil; and 
in cerebral haemorrhage some elevation of the 
body-heat may not improbably be observed. 
But all these points may fail us from time 
to time, and we had best act at all times as 
though the case were really a serious one, 
and requiring treatment by all the best re- 
sources of the medical art. 
A very little consideration will enable 
every experienced practitioner to recall other 
instances of this sort of natural mimicry : ot 
the difficulty he must often have experienced 
in deciding between syphilitic and other 
brain-affections; of the close affinity between 
pulmonary consumption and dilatation of the 
bronchial tubes; of the resemblance between 
specific and malignant ulcerations; between 
various diseases of the testicle, the bladder, 
and the stomach, respectively. All these form 
part of the regular teaching of medicine and 
surgery, and will be found treated of elsewhere. 
2. We must now consider the cases in 
which diseases are feigned, not by the direct 
action of the patient himself, but because he 
is unable to resist the vagaries of his weak 
and excitable nervous system. 
Problems of the greatest complexity and 
difficulty are here presented to the medical 
man, and require for their due solution much 
tact and experience. Functional affections 
so closely simulate organic disease under 
these circumstances that suspicion is often 
completely disarmed, and treatment adopted 
the very opposite of that which would most 
probably prove curative. Hysteria, in its 
protean forms, supplies the greater number 
of these cases, and may very closely simulate 
a large variety, more especially, of neurotic 
conditions (see Hysteria). Paraplegia, in- 
continence of urine, joint-affections-in short, 
almost any disease which does not admit of 
palpable objective demonstration-may thus 
be feigned, and very severe treatment may 
even be adopted under the belief that real or- 
ganic changes have to be met by the usually 
appropriate remedies. It is only necessary 
for us to refer thus briefly to these perplexing 
cases here; but it must always remain an 
interesting problem as to how the mechanism 
of causation here works, so to speak, and 
whether the patient actually suffers the acute 
pain of which she complains so forcibly. 
Sympathy, as we well know, however, is quite 
thrown away when dealing with these per- 
sons ; and apparent roughness, with nervine 
tonics, and mental discipline, will often effect 
a cure, when the most elaborate combinations 
of other drugs ignominiously fail. A sudden 
shock, the pressure of poverty, or the abso- 
lute necessity for immediate exertion, will 688 
FEIGNED DISEASES 
often effectually and permanently arouse the 
bedridden hypochondriac of many years, and 
restore him to his friends as a useful member 
of society; and we need never despair of suc- 
cess even under apparently hopeless circum- 
stances. And although in minor measure 
the hypochondriac may fancy that every 
organ in succession is the seat of disease, and 
may even succeed in thus imposing on the 
unwary, the experienced practitioner will 
speedily detect the fiction, and be able to 
relieve the unhappy sufferer from the weight 
of his woes. See Neurasthenia. 
But let it not be forgotten that ' expectant 
attention,' or the constant direction of the 
mind to the supposed morbid condition of 
any particular organ, may actually catch the 
unconscious deceiver in his own net by 
converting mere functional disturbance into 
organic disease. 
3. To the third division of our subject can 
the term Feigned Diseases perhaps alone 
strictly be applied. Here we are met face 
to face with deliberate and premeditated im- 
posture; and there is nothing for it but to 
match our own wits against those of the 
deceiver, and to thwart his native cunning 
by the superior sharpness of science. Now, 
there is nothing in the history of medicine 
more remarkable than the elaborate expe- 
dients adopted, and the amount of actual 
discomfort and suffering endured, by persons 
who have been desirous of escaping military 
or other duty. The exhaustive works of 
Gavin and Marshall, and Boisseau and 
others, give us details no less ingenious than 
interesting of these devices ; but it is curious 
to note in how limited a range the more 
traditional modes of imposture seem to run, 
and how the same old stories are made to do 
duty over and over again. Thus we read of 
blindness, and deafness, and epilepsy, and 
paralysis being carefully imitated, and can 
hardly withhold our admiration from the as- 
tonishing tenacity with which the apparent 
symptoms were duly maintained. Inconti- 
nence of urine, dysentery, haemoptysis, jaun- 
dice, and insanity were among the most 
favourite roles in the repertoire ; and ingeni- 
ous as were the preparations for duly sus- 
taining the part, no less ingenious were the 
means for detection, which usually proved 
successful. However carefully the impostor 
had studied his character, some little point 
was usually omitted. The yellow conjunc- 
tiva of jaundice can hardly be feigned; the 
incontinence of urine was generally found to 
be attended by an expulsive effort; the blood 
apparently proceeding from the lungs was by 
no means intimately mixed with the pul- 
monary mucus; the blindness, or the deaf- 
ness, or the paralysis was not proof against 
some sudden shock or mental impression. 
Most of the cases so carefully described by 
writers on military medicine are now mere 
matter of history, and are hardly likely to 
occur again. And the reasons for this are 
twofold. First: the inducement for decep- 
tion is practically gone. In former days, 
when the soldier's pay was small and his 
hygienic condition bad, discharge from the 
service as an invalid was eagerly prized as a 
means of escaping irksome duty ; but matters 
have greatly changed for the better of late 
years. Not only are the emolument and the 
comfort of our army vastly increased, but short 
service and the reserve enable soldiers to 
retire early into civil life ; whilst the abolition 
of bounty has removed the principal pecu- 
niary inducement for frequent desertion and 
re-enlistment. It is now found much easier 
for a man simply to desert than to go through 
any elaborate process for the personification 
of disease. Again, the savage process of 
forcible impressment for naval service was 
naturally productive of many attempts to 
escape from the hard work and ferocious 
discipline of our men-of-war. Secondly: the 
progress of science and improved means of 
diagnosis have rendered the task of the im- 
postor difficult, if not well-nigh hopeless. 
Feigned blindness can hardly resist the test 
of the ophthalmoscope; electricity will clear 
up many apparently anomalous nervous 
symptoms; the stethoscope and the sphyg- 
mograph will tell us the real condition of the 
heart; and careful observation will detect 
the rougher attempts to deceive. Again, 
malingering may often be exposed by ex- 
amination under chloroform or ether. We 
are not likely now to be deceived by a piece 
of liver tied to the breast to simulate cancer, 
or by an artificial nasal polypus; but Mr. 
Gould records in the Lancet the case of a 
young woman sent to hospital for double 
buccal tumour, in whom on examination the 
swellings were found to consist of tightly 
wound balls of thread forcibly inserted be- 
tween the teeth and the cheek. Mr. Ander- 
son, of Richmond, fairly capped this in a 
subsequent number by narrating the vaga- 
ries of a schoolgirl who had produced a 
state bordering on gangrene of the hand by 
a ligature of ribbon resolutely applied to the 
forearm; and it is evident that although skin- 
diseases and ulcerations may be made or 
kept up by local applications, we only require 
a suspicion to cross our minds to put us on 
the right track for discovery. 
We are not, however, to suppose that all 
attempts at deception have finally passed 
away, that feigned diseases are now things 
of the past. Anyone whose practice lies 
among prisoners, or soldiers, or schoolboys, 
or the sufferers from railway accidents, will 
very soon be convinced to the contrary (see 
Railway Injuries). Experience, however, 
will speedily show him who the schemers are, 
and enable him to circumvent their en- 
deavours ; and the range of symptoms simu- 
lated will soon be found to be singularly 
narrow. Subjective sensations are, of course, FEIGNED DISEASES 
FEVER 
689 
very difficult to detect; and if a headache, or 
pain in the back or leg or arm, be complained 
of by the sufferer, real or assumed, we may 
often find it best for our own reputation to 
give him the benefit of the doubt. Whilst 
proceeding, therefore, with due caution, the 
practitioner must endeavour to hold the 
balance between an excess of suspicion and 
a too credulous attitude, remembering that 
the good of society and of the public service 
must be fairly considered, whilst all care 
must be taken not to confound the innocent 
with the guilty in dealing with disorders 
which ingenuity has occasionally been en- 
abled to feign. Robert Farquharson. 
FEIGNED INSANITY. - See In- 
sanity, Varieties of. 
FESTER.-A superficial suppuration, re- 
sulting from irritation of the skin; the pus 
being developed in vesicles of irregular figure 
and extent. The suppurating inflammation 
caused by a thorn or splinter of wood forced 
into the flesh is a common example of a fester. 
FEVER (ferveo, I am hot).-Synon. : 
Pyrexia; Fr. Fievre ; Ger. Fieber. 
Definition.-One of the most remarkable 
facts in connexion with disease is the rise of 
temperature which is attendant upon almost 
every disturbance to which the body is sub- 
jected. The rise of the temperature of the 
body, when it attains a certain height, and lasts 
a certain time, is called Fever; and is accom- 
panied by derangement of function, attribut- 
able to the febrile condition itself, and in a 
measure independent of the initial cause. 
General Considerations.-Fever plays so 
important a part in acute disease generally, 
is accepted so universally as a mark of the 
severity of the disease, and so often presents 
itself as apparently the chief antagonist with 
which the physician or surgeon has to con- 
tend, that the attempt to penetrate the secret 
of its essential nature has always been a 
favourite task, and every school in every age 
has had its theory of the febrile process. It 
is only, however, within comparatively few 
years that exact measurement of the body- 
heat by the clinical thermometer, combined 
with chemical examination of the various 
excretions at different temperatures, and aided 
by the experimental method of investigation, 
has furnished the data for such a theory (see 
Thermometer). A minute description of fever 
in the abstract, distinguishing, as would 
be required, between phenomena proper to 
fever and phenomena due to the condition or 
lesion on which the fever depended, would be 
lengthy, and so crowded with qualifications 
and exceptions as to be vague and unsatis- 
factory. The attempt, indeed, would have a 
more radical defect. Either some variety of 
fever must be taken as a type to which other 
forms are referred, which is vicious in prin- 
ciple ; or all the phenomena of all febrile 
conditions must be enumerated and classi- 
fied, which would confound the accidental 
with the essential, and would result in a 
heterogeneous collection of facts without due 
relation among themselves. 
A mere outline therefore will be given of the 
principal deviations from normal functional 
action observed in fever, and the space set 
apart for the subject will be reserved chiefly 
for an exposition of what is known of the 
nature of the febrile process. 
Description.-In every attack of fever 
there are traceable the three stages of in- 
vasion, domination, and decline, with or 
without an antecedent period of incubation. 
They may all be run through in the course 
of a few hours, as in a paroxysm of ague, or 
they may extend over weeks. 
The period of invasion is characterised by 
a rising internal temperature, while the sur- 
face may remain cold and pale, the patient 
feeling chilly and suffering from rigors or 
shivering; the pulse is frequent, but gene- 
rally small and long, from contraction of the 
arteries. During the dominance of fever 
the temperature remains high, the skin is 
hot, and the shiverings are replaced by a 
subjective sense of heat; the pulse is now 
large and bounding from relaxation of the 
arterial wall. The decline is indicated by a 
falling temperature, a softer and less frequent 
pulse, and by a return towards normal con- 
ditions generally; it may be initiated or 
accompanied by a critical sweat or other 
evacuation. Death may take place at any 
period of the disease. 
Taking the temperature as the index of the 
duration and character of each stage, we may 
find it in the first stage rising abruptly or 
gradually, continuously or with remissions. 
If the invasion extends over several days as 
in enteric fever, nocturnal exacerbations and 
morning remissions are, as a rule, observed. 
A rapid rise of temperature is usually con- 
tinuous, or nearly so. When the opportunity 
occurs of making the observation, as in inter- 
mittent or relapsing fever, or when fever is 
experimentally induced in animals, or in man 
by surgical operation or accidental septic in- 
oculation, the increased heat is found to be 
the initial phenomenon, preceding the rigors 
and all other symptoms. 
The end of the period of invasion, and the 
setting in of the stage of dominance, is more 
distinctly marked by the change in the cha- 
racter of the pulse, and by the determination 
of blood to the surface, together with the 
substitution of the subjective sensation of 
heat for that of cold, than by the thermometer. 
During the dominant stage the tempera- 
ture remains at, or oscillates about, a given 
point, and the fever is Considered to be 
moderate if the morning temperature is 102° F. 
or under, and the evening not above 103° ; to 
be high when it ranges between 103° in the 
morning and 104° in the evening; and to be 690 
FEVER 
severe when these limits are exceeded; while, 
with rare exceptions, a temperature of 106° 
indicates great danger. As the stage advances, 
the heat may gradually rise or fall; the oscil- 
lations being slight or considerable, and at 
times irregular and extreme. Except when 
the fever is due to local inflammation, or to 
continual entry into the blood of morbid 
particles or fluids, the duration of the domi- 
nance is usually in proportion to the time 
occupied by the invasion. 
The decline again is generally abrupt, and 
has the character of a crisis when the in- 
vasion has been rapid, and is protracted 
when it has been gradual. 
A fatal termination may be ushered in by 
hyperpyrexia; more commonly the tem- 
perature falls below the normal point and 
there is collapse. 
The pulse is always increased in frequency 
by fever, but while during the height of the 
disease there is usually some relation between 
the body-heat and the pulse-rate, the pulse is 
often extremely frequent before the tempera- 
ture has reached its height during the in- 
vasion, and it does not in all cases fall with 
it pari passu in the decline. The different 
stages are marked rather by differences in 
the character of the pulse than in its rapidity; 
during the period of invasion the arteries are 
more or less in spasm, and the pulse is small 
and long; during the dominance, with cer- 
tain exceptions, the arterial walls relax, the 
vessels are large, and the pulse sudden, short, 
and dicrotous; as the fever declines, the 
arteries are still further relaxed, but the 
action of the heart is less powerful, so that 
the pulse becomes softer. 
Respiration is frequent, following as a rule 
the pulse; the amount of carbonic acid ex- 
pired is greatly increased. 
The tongue is generally more or less furred, 
its appearance varying with the degree and 
kind of fever and with its cause. It becomes 
brown and dry, or unnaturally red, in pro- 
tracted and adynamic fever, when the teeth 
and lips may also be coated with sordes. There 
are almost always thirst and loss of appetite. 
The bowels are usually confined. 
The secretions are all more or less modi- 
fied. The perspiration may be greatly in- 
creased, as in acute rheumatism; more com- 
monly it is checked, causing the skin to be 
dry and burning. The amount of urine will 
vary to a certain extent inversely with the 
amount of perspiration ; but the tendency is 
to increase, and the solid organic matters- 
urea and other nitrogenised substances-are 
always considerably augmented in quantity. 
The chloride of sodium, on the contrary, is 
diminished. 
The characteristic nervous phenomena of 
the stage of invasion are rigors, which may 
be slight, and represented only by shivering 
or chilly sensations, or, on the other hand, 
may be intensified to convulsion. Severe 
headache is more common at this period than 
in the later stage, and there is usually con- 
siderable depression. When the fever has 
reached its height the rigors will have ceased, 
and there may be little or much delirium 
according to the severity of the attack, the 
idiosyncrasy of the patient, or the kind of 
disease giving rise to the fever. 
Pathology.-The description of the febrile 
state has been abbreviated in order to leave 
place for a discussion of the nature and cause 
of the febrile process. 
This will be facilitated by a brief reference 
to the production and regulation of the heat 
of the body in health, and would be com- 
paratively easy had physiologists arrived at 
a complete and satisfactory solution of this 
problem. In the normal state the main 
source of animal heat is blood- and tissue- 
combustion. It may perhaps be well to say 
here once for all that the terms ' combustion ' 
and ' oxidation ' are employed as conveniently 
short expressions for the disintegration of 
complex chemical and structural molecules 
by which heat is liberated, and not to convey 
the idea of direct combination of oxygen with 
the carbon and hydrogen of the hlood and 
tissues. Another very slight and unimpor- 
tant cause will be obstructed motion of the 
blood in the capillaries : of direct conversion 
of nerve-force into heat we know nothing 
definite. The interesting and difficult part 
of the question is that which relates to the 
regulation of the temperature. It has been 
found that the changes which evolve heat 
are most active in muscle, in the nervous 
structures, and in the abdominal viscera; 
while in the lungs any combustion which 
may take place is not more than will coun- 
teract the loss of heat by evaporation and 
by the expired air. The skin, on the other 
hand, is the great cooling agent; there is 
little combustion of its structures, and it is 
continually losing heat by conduction when 
the surrounding temperature is low, but still 
more abundantly by evaporation under all 
conditions of external temperature. Heat is 
thus abstracted from the blood circulating in, 
and immediately beneath, the skin. At first 
sight, then, it would seem that the mechanism 
by which the temperature is regulated was 
extremely simple, and that it was to be 
found in the vaso-motor system of nerves. 
There being an internal heat-producing mass 
of tissue, and an external refrigerating sur- 
face, in order to raise the temperature, the 
arterioles of the skin are contracted, shutting 
off the blood, while those of the deeper 
structures are relaxed, allowing it to reach 
them in greater abundance; in this way a 
double influence is exerted-less heat is lost 
by the skin, and more is produced in the 
muscles and other internal parts. Conversely, 
the temperature would be lowered by flush- 
ing the skin with blood-which would thus 
be exposed to cooling influences-and divert FEVER 
691 
ing it from the heat-forming, deep-seated 
structures. This explanation, however, is 
inadequate. It is true that the distribution 
of the blood, superficially or deeply, by means 
of the vaso-motor nervous system, contributes 
largely to the regulation of the temperature; 
but he at-production in muscle or gland is not 
directly proportionate simply to the amount 
of blood circulating through it. Tissue-com- 
bustion, and consequent evolution of heat, 
is excited or repressed by cerebro-spinal 
nerves which do not govern the arteries. The 
nervous stimulus which excites contraction 
in muscles determines in them at the same 
time evolution of heat, and this heat-produc- 
tion under nerve influence may be excited 
independently of contraction. The nervous 
system thus intervenes directly in heat-pro- 
duction chiefly by its action on the muscles, 
as well as indirectly through its influence on 
the circulation. This is not the place to 
discuss the question whether there are special 
thermal nerves and centres, but it seems 
probable that the muscles as thermogenic 
and as motor agents are under the control of 
the same central nervous mechanism. 
Taking the increased heat as the charac- 
teristic of fever, the first question which 
arises is whether this is due to increased 
production of heat, or to diminished loss. 
While the diminished circulation in the skin, 
in the early stage, will obviously tend to 
retain heat within the body, there is now no 
room for doubt that there is increased heat- 
production. The temperature rises in spite of 
profuse perspiration, when, of course, heat is 
very rapidly lost, as in acute rheumatism, or 
when perspiration has been induced by jabo- 
randi before a paroxysm of ague (Ringer); 
and it has been shown by direct experiment 
that in fever a man raises the temperature 
of a given quantity of water in which he is 
immersed more quickly, and to a higher 
point, than in health (Liebermeister). It is 
unnecessary to give other proofs or further 
refutation of the hypotheses which explain 
the heat of fever solely by diminished escape 
of heat from the body. 
It may further be taken as certain that the 
immediate cause of the increased generation 
of heat is increased blood- and tissue-oxida- 
tion. This is shown by the increased pro- 
ducts of combustion given off in the different 
excretions. The febrile elevation of tempera- 
ture is attended at once by increase in the 
amount of carbonic acid expired. This is 
more marked during the rise than when the 
heat has attained its maximum, because the 
increasing temperature expels the gases of 
the blood, and the greater rapidity of the 
circulation sends the blood more freely and 
quickly through the lungs, and exposes it 
more to the air. At first there will thus be 
eliminated not only the carbonic acid formed 
under the influence of the febrile process, 
but that which was held in solution by the 
cooler blood, and is driven off as its tempera- 
ture rises; when the expulsion of dissolved 
carbonic acid is completed, the amount ex- 
creted will be diminished by so much, but it 
still remains larger than at the normal tem- 
perature. 
A similar indication of increased tissue- 
combustion is furnished by the urine. The 
amount of urea is usually absolutely in- 
creased, notwithstanding a diminished con- 
sumption of nitrogenised food; or if the urea 
itself is not excreted in larger quantity, there 
is more nitrogenised waste in other forms. 
The total of nitrogenised matter contained in 
the urine is always augmented by fever. 
While, however, the products of combustion 
show that rapid metabolism is going on, it is 
not clear that it is adequate to account for 
the whole of the heat evolved; and Dr. Ord 
has advanced the luminous hypothesis that 
the energy normally absorbed by the con- 
structive operations taking place in the tis- 
sues is set free through the suspension of 
these processes by fever, and takes the form 
of heat. 
The real difficulty of the problem arises 
when we inquire what is the cause of the in- 
creased tissue-combustion, and especially how 
the febrile heat is regulated. It has been 
already stated that the distribution of the 
blood to the deep structures and organs and 
to the skin respectively is not a sufficient 
explanation of the physiological balance of 
heat; but it might be supposed that the 
greater rapidity of the circulation in fever, 
renewing the supply of oxygenated blood 
within the structures more frequently and 
more freely, would account for the greater 
oxidation. The rise of temperature, however, 
is not in proportion to the flow of blood 
through the vessels, and hyperpyrexia is 
often coincident with a failing circulation, 
the heat of the body, indeed, apparently in 
some cases actually increasing after death. 
Dr. Donald MacAlister has done much to 
elucidate the entire question in his Gulstonian 
Lectures, by bringing out more distinctly the 
thermogenic function of the muscles, and 
the thermotaxic or heat-regulating power of 
the nervous system, which operates through 
its influence upon thermogenesis in the 
muscles on the one hand, and upon the 
thermolytic action of the skin on the other. 
One step towards the solution which may 
be considered certain is that the nervous 
system is concerned in the maintenance of 
the heat of fever. Each disease has its own 
characteristic range and variations of tem- 
perature; and this fact alone, that febrile heat 
is not vague and irregular, but that there is 
the substitution of a morbid for a normal 
balance, is evidence of nervous control. 
Numerous observed facts and experiments 
point to the same conclusion. 
Another item of positive knowledge ob- 
tained by experiment is that pyrexia may be 692 
FEVER 
excited by the introduction into the blood of 
septic or other matters, which, it is important 
to note, need not be particulate, but may be 
diffusible fluid. The increased heat may 
therefore be independent of capillary embo- 
lisms, and of bacteroid or other organisms. 
Now in disease or after injuries we have 
almost always both causes in possible opera- 
tion-an impression on the, nervous system, 
and the entry of altered organic matters into 
the blood. In endeavouring to assign promi- 
nence to one or other, we have, on the one 
hand, such fact? as the hyperpyrexia of cere- 
bral lesions, which cannot be due to blood- 
contamination, and, on the ether, the teach- 
ings of antiseptic surgery, which demonstrate 
that absorption of putrescent discharges is 
the great cause of surgical fever. It still re- 
mains to be determined whether the presence 
in the blood of foreign matters gives rise 
directly to increased activity of oxidation, or 
whether the poison, as we may call it, pro- 
duces this result through its action on the 
nervous system, either by affecting the nerve- 
centres themselves, or by producing irritation 
in the capillaries, which is carried to the 
nerve-centres, and reflected along efferent 
nerves. In the present state of our know- 
ledge this question cannot be definitely 
settled. 
If a theory of the febrile process is to be 
formed, it must be based upon a theory of the 
relation between the nervous system and the 
processes of nutrition and oxidation, and es- 
pecially the latter. Numerous facts of dis- 
ease and of experiment point to the conclu- 
sion that the circulation of duly oxygenated 
blood through the tissues at the usual rate 
would, without some check to oxidation, re- 
sult in more rapid tissue-change, and the 
production of a higher temperature than the 
established norm. The restraining power is 
supplied by the nervous system, the loss of 
this influence being illustrated in hyper- 
pyrexia. The mode in which the nervous 
system acts may be represented as being 
through the tension maintained in the nerve- 
centres. All nervous actions have the cha- 
racter of phenomena of tension, and the 
tension generated in the cells is sustained in 
the nerve-fibres to their peripheral termina- 
tions, where they are merged in the struc- 
tures, and so blended with them that all 
nutritive and oxidative changes are common 
to the nerve-endings and the tissues in which 
they end. If we suppose that the nerve- 
tension can modify chemical action, as can 
electrical tension or thermal conditions, and 
that, vice versa, the nutritive and oxidation 
changes in the tissues can influence the ten- 
sion of the nervous structures, we can repre- 
sent to ourselves the interaction between the 
nervous system and the blood and tissues in 
the febrile process. When from disease or 
injury of the great nerve-centres their power 
of maintaining tension is lessened or abolished, 
and their influence proportionately diminished, 
so that the affinities of the blood and tis- 
sues have unrestricted play, the result is 
hyperoxidation and pyrexia. "When, on the 
other hand, septic matters or other substances 
are introduced into the blood, acting as fer- 
ments or in some other way, they increase 
oxidation, and directly raise the temperature, 
overpowering the restraining influence of the 
nerves until this is reinforced, which may 
possibly occur through increased evolution of 
energy, resulting from the increased activity 
of metamorphosis. We cannot, however, 
here develop or fully elaborate this hypothesis. 
Treatment.-The treatment of fever is of 
course primarily directed to the removal of 
the cause on which it depends, but together 
with the measures adapted to this end are 
usually employed means for the moderation 
of the febrile process as such, and these may 
at times take the first place. We can do 
little more than mention the more important 
of them, taking first what may be called the 
general methods, and premising that rest in 
bed, simple food, &c., are assumed to be under- 
stood. Venesection is now scarcely ever prac- 
tised as a means of combating fever. Purga- 
tives are often useful, as are also diaphoretic 
and diuretic salines, with abundance of water 
to drink, either alone or in the form of some 
agreeable tisane. Free action of the secre- 
tions, which is the object of these remedies, 
is of service in removing the increased pro- 
ducts of oxidation, the water taken co-operat- 
ing by acting as a solvent and vehicle; and it 
is possible that medicines which promote this 
activity -may directly bring down the tem- 
perature. When, for example, perspiration 
has been induced, a coincident fall of tem- 
perature may be due more to some change 
antecedent to the perspiration, than to the 
loss of heat by transpiration and evaporation. 
Of special measures for the reduction of 
febrile heat when this is becoming dangerous, 
either from its intensity or duration, the first 
to be mentioned is the cool or cold bath. 
This should be resorted to in all cases of 
hyperpyrexia, from whatever cause ; its effi- 
cacy, first established in the high temperature 
of acute rheumatism and enteric fever, has 
been proved also in cases of septic hyper- 
pyrexia after ovariotomy, and even in injuries 
to the brain. Here the water may be posi- 
tively cold. "When the bath is employed to 
control temperature, not dangerous from its 
height, but from its duration, as in enteric 
fever, the temperature need not be lower than 
70° or 65° F. An ice-cap devised by Mr. 
Knowsley Thornton, for applying cold of 32° 
to the entire head, has been found useful in 
hyperpyrexia following ovariotomy. 
Many substances have the property of 
reducing febrile temperatures when taken in 
large doses. Among the most powerful are the 
complex bodies recently introduced, phena- 
zone, acetanilide, exalgin, and others of the FEVER 
FIFTH NERVE, DISEASES OF 
693 
same class. Their influence on febrile heat 
is undoubted, and it may be exerted favour- 
ably in the early stage of sharp fever from 
whatever cause, but their continued use is 
attended with danger. The lowering of the 
temperature may be dearly purchased at the 
expense of the patient's strength. Another 
powerful agent often employed to combat 
fever is quinine. When given for this pur- 
pose, it is administered in doses of from 
ten to twenty or even thirty grains once in 
twenty-four or forty-eight hours; or three to 
six grains of the neutral sulphate may be 
injected under the skin. Salicylic acid has a 
remarkable influence on the temperature in 
acute rheumatism, and some effect, though 
far less marked, in fever from other causes. 
It may be added that when pericarditis has 
come on in rheumatic fever, this drug usually 
altogether fails to influence the temperature. 
The only other drug which need be specially 
mentioned is aconite, the mode of action of 
which is totally different from that of quinine, 
and of which it may almost be said that 
it antagonises the fever process rather 
than reduces temperature ; its most marked 
influence being on the force of the heart and 
the contraction of the arteries. The oppor- 
tunity for the manifestation of its powers 
occurs in the early stage of catarrhal fever, 
the result of chill. Given in frequent small 
doses (a drop or two of the tincture every five 
minutes till twenty minims or half a drachm 
has been taken) when the temperature is 
rising, the pulse frequent and hard, with 
headache and burning skin, the effects are 
often striking. When a local inflammation 
is established, it is no longer of much use; 
and when the fever is protracted, as in enteric 
fever, or when there is pneumonia, it may be 
dangerous, from its depressant influence on 
the heart. See Antipyretics. 
W. H. Broadbent. 
FIBRILLATION, Muscular. - A 
localised quivering or flickering of muscular 
fibres. See Motility, Disorders of. 
FIBRINOUS CLOT.-Nee Clot. 
FIBRINOUS CONCRETION.-Nee 
Concretion. 
FIBROID DEGENERATION. - A 
morbid change which consists in the substi- 
tution of a tissue somewhat resembling 
fibrous tissue for other structural elements ; 
some pathologists consider this change to be 
of the nature of a degeneration. See De- 
generation ; and Cirrhosis. 
FIBROID PHTHISIS. - A name 
given to certain cases of phthisis in which a 
considerable development of fibroid tissue 
occurs in the lungs. See Phthisis. 
FIBROMA.-A form of tumour com- 
posed of fibrous tissue. See Tumours. 
FIBRO-PLASTIC GROWTH. - A 
form of new-growth, composed of fibro-plastic 
elements. See Tumours. 
FICUS UNGUIUM (ficus, a fig; un- 
guis, a nail).-A disease of the posterior wall 
of the nail. See Nails, Diseases of. 
FIDERIS, in Switzerland..-Chaly- 
beate waters. See Mineral Waters. 
FIFTH NERVE, Diseases of.-The 
fifth or trifacial nerve (nervus trigeminus), 
the largest of the cranial nerves, consists of a 
motor and sensory portion, the sensory fibres 
passing through the Gasserian ganglion, and 
being distributed to the face and a portion of 
the head. The motor portion, much the 
smaller, is physiologically independent of the 
ganglion, and supplies the pterygoid, mas- 
seter, buccinator, and temporal muscles. The 
two first divisions-the ophthalmic and 
superior maxillary-are entirely sensory, and 
proceed from the ganglion. The third or 
inferior maxillary division proceeds also 
from the ganglion, but receives besides the 
whole of the motor root. Lesions of this 
nerve cause disorders of sensation, motion, 
and nutrition or secretion, according to the 
anatomical position and extent of the injury. 
The affections of the fifth nerve may be 
considered in the following order :- 
1. Trifacial Neuralgia. - Neuralgia 
may affect one or all of the three divisions 
of the nerve. It is fully described under the 
head of tic-douloureux. See Tic - Dou- 
loureux. 
2. Trifacial Anaesthesia.-Anaesthesia 
of the trigeminus, usually unilateral, may be 
dependent either upon (a) central lesion; 
or upon (b) peripheral lesion. 
(a) Central lesion. - Hemiplegia from 
haemorrhage, softening from thrombosis, 
tumour, or other coarse affection of the in- 
tracranial nervous system, is usually accom- 
panied by some anaesthesia in the district 
supplied by the trigeminus, arising probably 
from interference with the integrity of the 
fibres of origin of the nerve in their central 
course. The anaesthesia usually occurs on 
the same side of the body as the paralysis 
of motion, and therefore opposite to the seat 
of lesion. This is always the case when the 
lesion occupies a position above the pons 
Varolii. In disease of the pons Varolii, 
however, the loss of sensibility may involve 
both halves of the face, although it usually 
affects the same side as that upon which the 
limbs are paralysed, and opposite that upon 
which the portio dura and sixth nerves 
(when either or both of them are involved) 
are affected. In cases of apoplexy, the 
anaesthesia is usually very imperfect, and 
not sharply defined. It is short-lived, lasting 
from a few hours to days; but in certain 
cases it may continue, and even outlive the 
motor paralysis with which it is conjoined. 694 
FIFTH NERVE, DISEASES OF 
Intracranial tumours may produce more 
persistent anaesthesia, either by immediate 
destruction of sensory fibres, or, indirectly, 
by the cerebral enlargement, due to their 
growth, causing compression of the'fifth nerve 
as it traverses the floor of the skull. 
(b) Peripheral lesion.-Anaesthesia depen- 
dent upon lesion of the trigeminus in its 
peripheral course is a symptom of serious 
moment, which it is important to distinguish 
from that of central origin ; and this may be 
accomplished by noting the following points: 
The degree of peripheral anaesthesia far ex- 
ceeds that which obtains in cases owing their 
origin to a central cause. It is much more 
complete, and may involve, which the latter 
does not, trophic and vaso-motor complica- 
tions. Its extent varies according as the 
trunk of the nerve, including the Gasserian 
ganglion, is involved; or only one or two of 
its branches. Should the main trunk be 
affected, there is more or less complete anaes- 
thesia of one side of the face and part of 
the ear, conjunctiva, cornea, nostril, mouth, 
half the tongue, the gums on the same 
side, and a part of the palate. If the con- 
junctiva be touched with the finger, there 
is no reflex contraction of the eyelids. A 
glass from which the patient drinks seems 
to him as though it were broken, for he 
feels the material on the sound side and not 
on the affected side. The skin of the face 
is cool, and may be somewhat oedematous, 
and purplish in tint. After a few days, 
if the cause persists, the eye on that side 
looks dry, glazed, and congested; the cornea 
becomes cloudy, and in time sloughs and per- 
forates, the contents of the eyeball escaping 
to a varying extent, so that the organ is de- 
stroyed. There is dryness of the nostril on 
the affected side, and irritant substances ap- 
plied to it fail to produce sneezing. Taste 
is lost on that side of the tongue, except at 
the base, which is supplied by the glosso- 
pharyngeal nerve. The salivary secretion is 
diminished. In time there may be bleeding 
from the gums and ulceration of the mucous 
membrane. Should the lesion exist upon one 
of the three divisions of the trigeminus, the 
anaesthesia will be found sharply limited to 
the district supplied by that division. 
The nature of the lesion must be deter- 
mined by the examination of concomitant con- 
ditions. It may consist either in caries of the 
bone, tumour, aneurysm, or meningitis, acute 
or chronic. Whatever be the active cause by 
which the nerve is damaged, the effects will 
be the same : pressure upon, and disorgani- 
sation of the nerve-fibres will result in the 
disorders described-sensory, motor, trophic, 
and vaso-motor. In such circumstances, one 
or more of the other cranial nerves are usually 
affected* coincidently. In tubercular menin- 
gitis, the fifth nerve is shown to be paralysed 
(along with others traversing the floor of the 
skull) by the conjunctivitis and corneitis so 
often present in advanced stages of the dis- 
ease. Should the condition accompany bul- 
bar paralysis, the lesion must be referred 
to the nuclei of origin of the nerve in the 
medulla oblongata. 
Treatment.-Syphilitic gummata on the 
floor of the skull, developed either in the 
membranes of the brain or in the nerve itself, 
are so frequently the cause of the disorgani- 
sation of the fifth nerve which gives rise to 
anaesthesia, that in all cases it is right-un- 
less some other explanation is evident beyond 
all doubt-to bear in mind the possibility of 
such a cause, and to prescribe accordingly 
without delay. From 10 to 20 grains, or more, 
of iodide of potassium should be administered 
every four hours. Should there be a gumma 
pressing upon the trunk of the nerve, this 
treatment will probably have the effect of 
bringing about a rapid amelioration, and, in 
many cases, supposing it has been applied 
early enough, a complete cure. It is evi- 
dent that, as regards other causes, there is 
no particular indication for treatment, which 
must be adapted to the special circumstances 
of the case. 
3. Trifacial Hyperalgesia. - Hyper- 
algesia may accompany or precede neuralgia 
of the fifth nerve. It may also precede facial 
anaesthesia when this is due to neuritis. There 
are varieties in the degree of this hyper- 
algesia. It is sometimes so severe that the 
slightest touch occasions pain. The face 
cannot then be washed in the ordinary way, 
but the patient has to take a piece of sponge 
or wetted rag and cautiously dab the skin 
with it. Sometimes it is described as a feel- 
ing of soreness only when the hand is passed 
over the face. In either case the condition 
is accompanied by diminution of the tactile 
discrimination in the part. In mimetic 
spasm of the portio dura, there is often 
hyperalgesia in the region of one or more 
divisions of the fifth, and the lesion is then 
doubtless connected with the deep origin of 
this nerve. In blepharospasm it will often be 
found, if the face be carefully examined, that 
pressure with the finger at some point will 
check the spasm. Subcutaneous division of 
a twig of the fifth (or afferent nerve) at this 
point will often bring about a cure of the 
affection. The supra-orbital or subcutaneous 
malar are the nerves most commonly in fault. 
Photophobia is referable to hyperalgesia of 
the branches distributed to the conjunctiva. 
4. Motor Disorders.-Affections of the 
motor root of the fifth nerve are either (a) of 
a spasmodic; or (6) of a paralytic character. 
(a) Spasm.-Spasm of the muscles sup- 
plied by the trigeminal nerve may be tonic 
or clonic. In trismus, or ' locked jaw,' the 
teeth are clenched together by the tonic con- 
traction of the masticatory muscles, which 
can be felt tense to the touch. According' as 
the muscles are involved generally, or only 
partially, the lower jaw will be fixed in a FIFTH NERVE, DISEASES OF 
FILARIA SANGUINIS HOMINIS 
695 
symmetrical position, or be pulled over to 
one side, or advanced or receded. Clonic 
spasm of the same muscles is observed in 
various convulsive disorders; and slower 
movements of a horizontal character consti- 
tute the grinding of teeth sometimes indica- 
tive of cerebral disease. 
Trismus may either be one symptom of 
tetanus (see Tetanus), or it may occur by 
itself, and then it either arises from cold, or 
is of reflex origin, from irritation of the sen- 
sory portion of the nerve by decayed teeth, 
dentition, or disease of the jawbone. It may 
be due to the presence of a foreign body, 
possibly of very small size, lodged in the 
cicatrix of a wound upon the face, or even 
in some distant part of the body. Irritation 
from worms is a possible cause. It is still 
more commonly hysterical. 
Treatment.-When arising from cold, the 
constant current should be applied to the 
contracted muscles. Any source of irritation, 
whether from decayed teeth, or otherwise, 
must be sought for, and, if possible, removed 
or remedied. 
The removal of a foreign body will some- 
times bring about an immediate cure. This 
failing, the hypodermic injection of morphine, 
in doses of gr. |, may be employed, and 
bromide of potassium given internally in 
doses of 20 grains. When the presence of 
worms is suspected, appropriate treatment 
must be employed. If the affection be hys- 
terical, somewhat powerful faradic currents, 
directed to the muscles of the jaw, will 
scarcely ever fail to open the mouth and cure 
the ailment. Hysterical trismus cannot be 
mistaken for dislocation of the jaw, if it be 
remembered that in the latter accident the 
jaw is fixed with the mouth partly open. 
(b) Paralysis.-Paralysis of the masticatory 
muscles is not very common, but may be 
observed sometimes in cases of bulbar para- 
lysis, or it may accompany anaesthesia of the 
face, and depend upon tumour, abscess, 
aneurysm, or some such coarse disease en- 
croaching upon the trunk of the nerve within 
the cranium. To test the state of the muscles, 
the patient should be asked to move his jaw 
to and fro laterally, as well as in opening 
and shutting the mouth. Any irregularity 
of movement will be evident to the eye, and 
defective strength or absence of contraction 
in the affected muscles may be felt by placing 
a hand on each cheek, whilst the patient per- 
forms movements of mastication. When the 
jaw is found to fail in being carried to one 
side in a munching movement, the fault of 
course lies with the pterygoid muscles of the 
opposite side. The affection is more often 
unilateral than bilateral. Its importance is 
bound up with that of the lesion which gives 
rise to it. 
As in peripheral affections of the sensory 
portion of the nerve, especial attention should 
be paid to the causation, and if this probably ! 
depends upon a tumour, the possibility of its 
syphilitic character should be borne in mind, 
and iodide of potassium administered in 
doses of from 10 to 20 grains, or more. If 
these measures fail, the question of surgical 
operation may have to be entertained. See 
Neuralgia ; and Tic-Douloureux. 
T. Buzzard. 
FILARIA (filum, a thread).-A genus 
of nematode worms, not very clearly defined, 
but which contains a variety of thread-like 
parasites whose body is of uniform thickness 
throughout, and at least fifty times longer 
than it is broad. Under this head are often 
included several human parasites, such as 
the Dracunculus, or Guinea-worm (Filaria 
medinensis), and the lung strangle (F. bron- 
chialis), in addition to a variety of larval or 
sexually immature nematodes, whose genetic 
relations are only very imperfectly under- 
stood. In the latter category may be placed 
Bristowe and Rainey's entozoon (F. tra- 
chealis) ; von Nordmann's eye-worm (F. 
oculi-humani or F. lentis); the loa, infesting 
the eyes of the Angola coast and. Gaboon 
negroes (F. loa); and, lastly, the nematode 
haematozoon {F. sanguinis-hominis) de- 
scribed by the late Dr. Timothy Lewis. It 
may be doubted if any of the above-mentioned 
parasites ought to be included in the genus 
Filaria, as understood by modern helmin- 
thologists, but, practically, it is still found 
convenient thus to speak of them. The 
Dracunculus will be found described under 
Entozoa ; whilst the microscopic nematode 
infesting the blood will be found noticed 
under the articles Chyluria, and Filaria 
Sanguinis Hominis. T. S. Cobbold. . 
FILARIA SANGUINIS HOMINIS. 
This name was applied by Lewis to the 
embryo filaria which he discovered in human 
blood in 1872; and so long as no other similar 
parasite was found to have its habitat in 
the circulation, the name was appropriate. 
Recently, however, the writer has pointed 
out that the blood of certain Africans is 
liable to be infested by the embryos of two 
additional species of filaria; it therefore 
becomes necessary to modify Lewis's original 
name. Observation has shown that the 
filaria of Lewis appears in the blood only at 
night, disappearing from it during the day : 
whereas, of the two recently discovered species, 
one of them appears in the blood during the 
day only, disappearing from it at night; 
the other, in those individuals in which it 
occurs, is present in the circulation both 
during the day and during the night. Taking 
these facts as a basis for nomenclature, the 
writer proposes to name the three species-■ 
Filaria sanguinis hominis diurna. 
Filaria sanguinis hominis nocturna. 
Filaria sanguinis hominis perstans. 
Methods of demonstrating filaria em- 
bryos in the blood.-Blood is obtained in 696 
FILARIA SANGUINIS HOMINIS 
the usual way from a finger-tip ; but in look- 
ing for filariae, the respective habits of the 
different species must be borne in mind. 
Thus, if search is to be made for filaria 
sanguinis hominis diurna, the blood should 
be drawn between the hours of 11 a.m. 
and 6 p.m. ; if for filaria sanguinis hominis 
nocturna, between 9 p.m. and 6 a.m. ; if for 
filaria sanguinis hominis perstans, it may be 
drawn at any hour of the day or night. 
To study the movements of the filariae, 
ordinary preparations of freshly drawn blood 
must be used; but to warrant a positive 
opinion as to the absence or presence of 
embryos in the circulation, and for purposes 
of enumeration, a larger quantity of blood 
than can be dealt with rapidly in the ordinary 
way must be searched. The following is a good 
plan. Spread about half a drop of blood on 
a slide in a uniform layer over an area about 
1" by 1", and allow it to dry. The slide 
may be stained and examined at once, or 
stored away till such time as may suit the 
observer's convenience. All that is necessary 
to demonstrate the filariae in such slides, no 
matter how old they are, is to immerse them 
for two hours in a half-per-cent, solution of 
eosin, or a weak solution of fuchsin (one 
drop of the saturated alcoholic solution in an 
ounce of water), then wash them in one or 
two waters, and mount in Farrant's solution 
or glycerine jelly. So prepared, the filariae 
and white blood-corpuscles are stained, 
whilst the colour of the red blood-corpuscles 
is discharged. To demonstrate the sheath, 
shape, and structure of the filariae, make a 
thin film of blood by applying a clean slide 
oyer another slide having a droplet of fresh 
fluid blood on it; after allowing the blood to 
spread out between the slides, rapidly glide 
or pull them apart; immediately invert the 
slides over a capsule containing a few drops 
of acetic acid until they are dry; then im- 
merse them in a half-per-cent, solution of 
eosin for two minutes, wash thoroughly, dry 
slowly, and mount in balsam. So prepared, 
the filariae and leucocytes show pearly-white, 
whilst the red blood-cells are deeply, and 
the liquor sanguinis is lightly, stained by 
the eosin. 
No matter how prepared, the slides ought 
to be scrutinised in the first instance with a 
very low objective-an inch is sufficient- 
and every part of them examined. A quick- 
travelling mechanical stage is of great assist- 
ance in this, and ensures thoroughness. 
When a filaria is found it can be centred 
and examinee! with a quarter-inch or higher 
objective ; but it must not be forgotten that, 
in the first instance, only very low powers 
are suitable for searching. 
The three species of embryo filariae san- 
guinis hominis closely resemble each other. 
As seen in recently drawn blood, they are 
long, slender, gracefully formed, transparent, 
colourless, snake-shaped organisms, which 
for hours continue in a state of great activity, 
wriggling and twisting about on the slide 
like a wounded earth-worm, or an eel on a 
hook. After a time movement gradually 
slows down; but by a little management in 
preventing drying of the slide, the parasites 
can be kept alive for five or six days. In 
none of them can anything like an alimen- 
tary canal, or any definite internal structure, 
be made out. 
As far as is at present known, the points of 
contrast in the three species are as follows:- 
1. Filaria sanguinis hominis diurna 
(fig. 51).-The free haematozoal embryo of a 
species of filaria, the mature form of which 
is still unknown. Excepting that it enters 
the circulation during the day, this blood- 
worm resembles very closely in size, form, 
and habit the now familiar filaria sanguinis 
hominis nocturna of Lewis. The peculiarity 
in periodicity referred to is, doubtless, an 
adaptation to the habits of its unknown 
intermediary host. There is some reason 
for supposing that the filaria loa-a para- 
site living in the connective ' tissues, and 
sometimes showing itself underneath the con- 
junctiva in negroes-is the mature form of 
filaria sanguinis hominis diurna; for the geo- 
graphical distribution of both, as far as our 
knowledge of this extends, is the same, and 
the undoubted embryo of filaria loa resembles 
filaria sanguinis hominis diurna in shape, 
and possibly in size; and, moreover, a patient 
of the writer's, who had at one time a 
filaria loa under his conjunctiva, has now 
the filaria sanguinis hominis diurna in 
abundance in his blood. The parasite seems 
to be confined to the tropical zone of Africa, 
more especially to the west coast. Future 
observation is likely to show that a large 
proportion of the inhabitants of these dis- 
tricts are affected with these worms, and it 
is likely that in a proportion of instances 
some pathological condition may be traced 
to them. As yet our information on these 
points is much too fragmentary to warrant 
even speculation. 
2. Filaria sanguinis hominis nocturna (fig. 
52).-The free haemotozoal embryo of filaria 
Bancrofti. We owe the first notice of this 
parasite to Demarquay, who, in 1863, found 
numerous specimens of what, considering the 
circumstances of the case, must have been 
filaria sanguinis hominis nocturna, in the 
contents of a lymphous tumour of the thigh.1 
Later, in 1869, Wucherer in Bahia, and, quite 
independently, in 1870, Lewis in Calcutta, 
found the same parasite in chylous urine. 
It was not, however, until 1872, when Lewis 
showed that the normal habitat of this em- 
bryo worm was the human blood, that the 
discovery excited much interest. Since that 
date the significance of this parasite as a 
factor in tropical pathology has gradually 
come to be recognised, and many interesting 
1 Gaz. Med. 1863, p. 666. FILARIA SANGUINIS HOMINIS 
697 
points of a complicated life-history have been 
worked out. 
In the first issue of this Dictionary Lewis 
described the filaria sanguinis hominis noc- 
turna as follows: ' Its average length is 
(= 0-34 mm.); its breadth (= 0-007 mm'), 
or about equal to the diameter of a red blood- 
corpuscle. It is enclosed in a transparent 
tubular sac, within which it can be seen to 
alternately contract and elongate itself. This 
sac is extremely delicate and translucent, and 1 
may sometimes, when the worm has shortened [ 
itself more tnan usual, be seen collapsed and 
folded like a ribbon, and the next moment 
be instantaneously straightened again, by the 
extension of the filaria to its ordinary length. 
After death the worm may occupy either the 
entire length of the tubular sac, or be so 
contracted as to leave the tube empty at one 
or both ends, as may be observed in the 
woodcut (fig. 54).' 
As no sign of growth or of reproductive 
organs is distinguishable in this the haema- 
tozoal stage of tire parasite, it is evident-and 
Fig. 52. - Filaria sanguinis 
hominis nocturna x 180.-1. Mea- 
sures 5% in. by 35'7,0 in., or there- 
abouts. 2. Is provided with a 
coarser sheath. 3. Caudal end 
tapers graduallyfor about one- fifth 
of the entire length of the animal, 
and terminates in a sharp, or 
nearly sharp, point. 4. Cephalic 
end is rounded off, and has ob- 
scure oral movements of a pout- 
ing character. 5. No tongue-like 
organ visible. 6. Appears in the 
blood at night, disappearing 
during the day. 7. Has a wrig- 
gling, but no locomotive, move- 
ment. 8. Many specimens have 
a well-marked granular-looking 
aggregation about the middle of 
the body. 
Fig. 51. - Filaria sanguinis 
hominis diurn a x 180 (this fig. and 
figs. 52 and 53 from micro-photo- 
graphs by C. Detmold).- 1. Mea- 
sures in. by 35^0 in., or there- 
abouts. 2. Is provided with a very 
delicate sheath. 3. Caudal end ta- 
pers gradually for about one-fifth 
of the entire length of the animal, 
and terminates in a sharp, or 
nearly sharp, point. 4. Cephalic 
end is rounded off, and has dis- 
tinct oral movements of a pout- 
ing character. 5. No tongue-like 
organ visible. 6. Appears in the 
blood during the day, disappear- 
ing during the night. 7. Has a 
wriggling, but no locomotive, 
movement. 8. A few specimens 
have a faintly marked granular- 
looking aggregation about the 
middle of the body, but in none 
is it very well marked. 
Fig. 53. - Filaria sanguinis 
hominis perstans x 180.-1. Mea- 
sures in. by 5/Oo in , or there- 
abouts. 2. Has no sheath. 3. Cau- 
dal end tapers more gradually foi 
two-thirds of the entire length of 
the animal, and is abruptly trun- 
cated where it has tapered to 
about one-third of the diameter 
of the thickest part of the body. 
4. Cephalic end is either conical 
or truncated, passing from one 
form to the other rapidly by a 
peculiar jerking, extruding and 
retracting, movement. 5. From 
time to time, a minute tongue- 
like organ is rapidly protruded 
and withdrawn at the extremity 
of the cephalic end. 6. Observes 
no periodicity. 7. Has a loco- 
motive as well as a wriggling 
movement. 8. No granular ap- 
pearance. 
this was early recognised-that these blood- 
worms are only the immature young of 
parasites which must exist in a sexually 
mature form elsewhere in the tissues of the 
human host, and in intimate relationship with 
the circulation. Lewis made diligent search 
for the parental form soon after his discovery 
of the embryo, but it was not until 1877 that 
he found two living specimens-a male and 
a female-in the diseased tissues of a naevoid 
elephantiasis of the scrotum. Late in the 
previous year Bancroft, in Brisbane, found 
several mature females in a ' lymphatic ab- 
scess ' of the arm, and also in ' an encysted 
hydrocele of the cord.' The latter were care- 
fully examined by Cobbold, and the parasite 
was named by him filaria Bancrofti. Since 
that time the mature filaria Bancrofti has 
been found in India, China, and Brazil. It 
is a long, thread-like worm, about the thick- 
ness of a horse hair, of a white colour and 
firm consistence, and exhibits considerable 
activity, and a remarkable tendency to coil. 
Cobbold described the female as follows: 698 
FILARIA SANGUINIS HOMINIS 
'Body capillary, smooth, uniform in thick- 
ness. Head with a simple circular mouth, 
destitute of papillae (fig. 55). Neck narrow, 
57). Lewis gives the measurement of these, 
in which the embryos are distinctly visible, 
as by In a fresh specimen of the 
filaria examined by the writer the largest 
ova gave slightly greater measurements, and 
Fig. 57.-Ova and embryos of filaria sanguinis 
hominis nocturna. x 300 diameters. 
he saw that towards the vaginal end of the 
uterine horns the embryos lay outstretched, 
and that in the vagina they had very much 
the appearance they have in the blood, 
proving that under normal circumstances the 
parasite is viviparous. Lewis gives the 
breadth of the fragment of a male he exam- 
ined as Tgtf". 
It is now known that the parent worms 
live together in the lymphatics; that the 
embryo while in utero, by dint of vigorous 
movements, stretches its chorional envelope 
to form the long tubular sheath in which it 
lies extended, as we see it in the blood and 
lymph, and that, after this stretching of the 
chorion is complete, the embryo is born 
into the lymph-stream, which carries it 
through the glands, along the thoracic duct, 
and thus into the blood. Under ordinary 
circumstances of health and habit the haema- 
tozoon cannot be found in the blood during 
the day, but at evening it appears there. At 
first only a very few can be found; as night 
advances their numbers gradually increase; 
about midnight they attain their maximum- 
in some cases as many as 200 may be found 
in a single drop-after this they gradually 
diminish up to about 8 or 9 a.m., when they 
disappear for the day. An attack of fever 
may disturb this periodicity, and Dr. Stephen 
Mackenzie1 has shown-and his observations 
have been abundantly confirmed-that by 
causing the subject of filaria infection to 
sleep during the day and keep awake during 
the night, the habit of the embryo parasite 
in his blood is correspondingly changed: it 
then appears, contrary to its normal habit, 
in the blood during the day, and disappears 
from it at night. See Negro Lethargy. 
This singular periodicity is, apparently, an 
adaptation to the nocturnal habits of the 
female of a particular species of mosquito, 
which imbibes with the blood the young 
filaria, and acts as its intermediary host. 
Fro. 54.-Filaria 
sanguinis hominis 
nocturna. x 300. 
(Traced from a mi- 
cro-photograph.) 
Fig. 55.-Anterior 
end of mature filaria 
sanguinis hominis noe- 
tuma.-Mature form, 
x 100 diameters. 
about one-third of the width of the body. 
Tail of female simple, bluntly pointed; re- 
productive outlet close to the head; anus 
Fro. 56.-A portion of the mature 
filaria sanguinis hominis nocturna, 
showing uterine tubules filled with ova 
in various stages of development; also 
the intestinal tube, x 100 diameters. 
immediately above the tip of the tail. Length 
of largest females 3£ in., breadth ' In 
the female the uterine tubes are packed with 
ova in all stages of development (figs. 50 and 
1 Trans. Path. Soc. 1882, vol. xxxiii. FILARIA SANGUINIS HOMINIS 
699 
Transferred to the stomach of the mosquito, 
the filaria first casts its chorional envelope, 
and then bores its way into the thorax and 
thoracic muscles of the insect. Here it 
undergoes a remarkable metamorphosis, 
eventuating in its becoming possessed of an 
alimentary canal, a circumcaudal circle of 
papillae, and greatly increased size, power, 
and activity. This metamorphosis takes 
about six days to complete. At the end of 
this time the mosquito dies, after depositing 
her eggs on the surface of the water to which 
she resorts for this purpose. It is presumed 
that the filaria then escapes from the body 
of the insect to the water, into which the 
latter has probably fallen. Through this 
medium, it is believed, it gains access to the 
human body, being swallowed in drinking- 
water.1 
Geographical Distribution.-The filaria 
sanguinis hominis nocturna has been found 
in most tropical and subtropical countries in 
which it has been properly looked for. Its 
exact geographical distribution as an endemic 
parasite is doubtless in keeping with the 
geographical distribution of the particular 
species of mosquito subserving its interests 
as intermediary host; but, as the filaria may 
live for many years in the tissues of its 
human host, it is frequently brought by 
travellers from tropical and other countries 
to colder latitudes; and there is at least one 
well-authenticated instance in which it was 
found in a patient who had never quitted 
England. 
Pathological Relations.-Chyluria, nae- 
void elephantiasis or lymph-scrotum, chylous 
dropsy of the tunica vaginalis (variously 
termed chylocele, lymphocele, galactocele), 
varicose and indurated inguinal glands, chy- 
lous ascites, recurring orchitis, certain kinds 
of abscess occurring in the limbs-especially 
in the thighs and groins, lymphangitis, and 
lymphatic fever, are almost invariably ac- 
companied or preceded by the presence of 
the filaria in the blood or in the lymph, or in 
both. The association is so constant and so 
intimate, that in 99 cases out of 100 these 
diseases may be confidently attributed to 
the filaria, at all events when they are of 
tropical origin. 
Tropical elephantiasis arabum is also attri- 
buted to the filaria, although the parasite is 
by no means always found in the fully de- 
veloped cases. Theoretically, all elephantoid 
diseases are produced by some mechanical 
or other physical influence operating by ob- 
structing or irritating the lymphatic vessels. 
In tropical elephantiasis it is maintained 
that this influence is the filaria nocturna; 
and on the following grounds. Cases are on 
record of lymph-scrotum-a disease certainly 
attributable to the filaria-passing into true 
elephantiasis arabum; many cases of true 
elephantiasis arabum scroti have a history of 
antecedent lymph-scrotum; lymph-scrotum 
has supervened in flaps left after removal of 
an elephantiasis scroti by operation; elephan- 
tiasis of the leg has followed on the removal 
of a lymph-scrotum; lymph-scrotum and 
elephantiasis of the leg sometimes co-exist in 
the same individual; a case is on record of 
lymphorrhagia in an elephantoid leg co- 
existing with varicose inguinal glands and 
filariae, and in which chyluria subsequently 
developed; an instance is recorded in which 
a son developed a lymph-scrotum, and the 
mother-living in the same house-an ele- 
phantiasis of the leg; where elephantiasis is 
endemic, there too chyluria and lymph- 
scrotum are found. It is unreasonable to 
suppose that the combinations and concur- 
rences mentioned were, in every instance, 
simply coincidences; much more likely the 
same cause produced them all. This being 
proved to be the filaria in chyluria, lymph - 
scrotum, and varicose inguinal glands, it 
follows that it must be the filaria also that 
produces true tropical elephantiasis arabum. 
Furthermore, as far as known, the geo- 
graphical distribution of elephantiasis is co- 
extensive with that of the filaria. 
Because the filaria is not always found in 
elephantiasis, it has been maintained by some 
that this parasite cannot be the cause of this 
disease. The fact is, the filaria is mortal and 
may die before its host; nevertheless, the ill 
it has wrought may not disappear at its death. 
It sometimes happens that in chyluria and 
in lymph-scrotum no filariae can be found 
in the blood, urine, or lymph, although at 
one period they must have been present; 
sometimes it can be found in the lymph only, 
and not in the blood; and instances are on 
record in which the parasite disappeared from 
the blood and lymphous discharges whilst the 
cases were under observation, yet the charac- 
teristic morbid discharges persisted. In 
pathology, as in other things, a transient 
influence may produce a permanent lesion. 
It must be admitted, however, that the 
reason of the very frequent absence of the 
embryos of the filaria from the blood in 
developed elephantiasis is not known, and 
further observations bearing on this point 
are much wanted. 
From the fact that in many countries 
where the filaria is endemic quite 10 per 
cent, of the adult population harbour it, yet 
only a small proportion have any of the 
diseases enumerated, it is evident that the 
parasite does not necessarily give rise to 
disease. It would appear that so long as 
the parasite is healthy and normally situated 
it is innocuous. Should it die, it may act as 
a foreign body and cause abscess; the dead 
filaria has actually been found in lymphatic 
abscesses. But the precise way in which the 
1 For a detailed description of the metamorphosis 
of the filaria in the mosquito, see Trans. Linnean 
Soc. of London, vol. ii. part 10; 2nd ser. ' Zoology,' 
April 1884. 700 
FILARIA SANGUINIS HOMINIS 
parasite usually brings about pathological 
obstruction of the lymphatics is, as yet, to 
some extent a matter of conjecture. Of two 
ways in which it so acts there is good evi- 
dence. (1) The parent worm may cause 
lymphatic stasis by operating at a point high 
up the thoracic duct, either itself plugging 
that vessel, or giving rise to inflammatory 
thickening in or around its walls, ending in 
stricture. (2) As mentioned, there are in- 
stances on record in which, though the filaria 
was present in the chylous urine, or in the 
lymph drawn from a lymph-scrotum, or from 
varicose inguinal glands-yet, after the most 
careful and prolonged search, it could not be 
discovered in the blood. It is evident that 
in these cases there must have been com- 
plete obstruction of a lymphatic area, other- 
wise the filaria embryos must have appeared 
in the blood, as in ordinary examples of 
filarial infection. The obstruction could not 
possibly have been in the thoracic duct, for, 
if complete in this situation, it must have 
speedily brought about the death of the 
patient. It is safe, therefore, to infer that 
it must have been somewhere on the distal 
side of the receptaculum chyli. In two such 
cases the ova of the parasite have been 
found in the lymph; and it is believed that 
in this circumstance we have the explana- 
tion of the site and character of the lymph- 
atic obstruction in a large proportion of 
cases. Normally, the parasite is viviparous, 
and the long, slender, active embryo has 
no difficulty in finding its way along the 
lymphatics and through the glands into the 
circulation. But should the embryo be born 
prematurely, as in the two cases referred to, 
before the chorional envelope has undergone 
the stretching process already described- 
that is, should ova (seven or eight times 
the diameter of the outstretched young) 
be prematurely launched into the lymph- 
stream, they act as emboli, and, being very 
numerous, effectually plug the glands con- 
nected, directly or by anastomosis, with the 
lymphatic vessel in which the aborting parent 
lies. The location of the worm; the degree 
of obstruction, whether caused by embolism, 
pressure, or stricture; pressure by enlarged 
glands interfering with the compensating 
drainage of the affected areas by the veins; 
traumatic irritation of the congested lymph- 
atic area; the position of the part involved 
as regards dependence or elevation, a most 
important factor in elephantiasis; the health 
of the patient; and other circumstances, 
easily understood, will determine the site 
and exact character of the resulting disease. 
Treatment.-(a) Curative.-No means of 
killing the filaria have been discovered. The 
indications for treatment, when disease has 
developed, are supplied by the pathology. 
Best, elevation of the affected parts, elastic 
bandaging, and other means to facilitate the 
How of lymph through the damaged lymph- 
atics, are of great benefit. See Chyluria* 
and Elephantiasis Arabum. 
(6) Preventive.-The fact that the mosquito 
acts as intermediary host indicates the direc- 
tion that preventive measures should take. 
Drinking-water, in districts where the filaria 
is endemic, ought to be boiled and filtered; 
wells, cisterns, and receptacles for drinking- 
water ought to be covered with fine wire- 
gauze, to prevent the access of the mosquito; 
and persons known to harbour the parasite 
ought to sleep under properly constructed 
mosquito-curtains. By any or all of these 
means this parasite, in the course of a single 
generation, could be exterminated, and the 
diseases it produces made things of the past. 
3. Filaria sanguinis hominis perstans (fig. 
53).-The free haematozoal embryo of a 
species of nematode, the mature form of 
which is unknown. Hitherto this haemato- 
zoon has been found only in the blood of 
negroes from the West Coast of Africa, and 
it is probable that as an endemic cause it is 
restricted to this part of the world. Twice it 
has been found in company with the filaria 
sanguinis hominis diurna; in several other 
cases it was not so associated. We may 
therefore infer that the association of filaria 
perstans and filaria diurna in the two in- 
stances referred to was merely accidental. 
Attention to the points of contrast between 
filaria perstans and the other blood-worms, 
as set forth in the table in page 697, will lead 
to its recognition. In addition to what has 
been stated in this table, it may be mentioned 
that the body of this parasite is possessed in 
a high degree of powers of elongation and 
contraction, and that the measurements given 
in the table referred to are those of the animal 
when it is dead or moribund. When travel- 
ling actively among the blood-corpuscles it 
sometimes so extends itself as to appear a 
mere thread, the elongation concurring with 
a corresponding attenuation; at other times, 
and when not actively travelling, it assumes 
the proportions given. A very striking habit 
which it has is that of coiling itself up like a 
rope, and remaining motionless in this attitude 
for a few seconds before resuming its usual 
movements. Another peculiarity worth men- 
tioning is the result, apparently, of the loco- 
motive habits of this parasite: not infre- 
quently it is seen fixed to one spot on the 
slide, vainly endeavouring to break away, 
and constricted by a delicate rope of fibrin. 
It would seem that in moving about the 
slide it pushes the strings of fibrin in front 
of it, and at times becomes entangled in a rope 
of them. 
The filaria sanguinis hominis perstans is 
probably very common in the endemic region; 
for, of ten negroes from the West Coast of 
Africa whose blood was searched, it was found 
in five. 
That in certain cases it gives rise to patho- 
logical conditions is probable; but of what FILARIA SANGUINIS HOMINIS 
FLATULENCE 
701 
these are we are as yet ignorant. In one case 
the parasite was associated with the peculiar 
disease called Negro Lethargy or the Sleeping 
Sickness of the Congo; in another with in- 
sanity; but in the other three instances in 
which it was found there was no concomitant 
disease. There may be some grounds for 
associating it with a peculiar African disease 
called Craw-craw, a kind of itch, apparently 
induced by a filaria-like parasite, and not the 
acarus scabiei; as yet this supposition is little 
more than hypothetical. 
The presence of a beak, the absence of a 
sheath, the marked locomotor habits, the 
extensibility and pliancy of its body, and 
also the non-observance of any periodicity in 
its entrances and exits from the circulation, 
suggest that the 'embryo filaria sanguinis 
hominis perstans gains its freedom and enters 
its particular intermediary host by dint of 
its own efforts, and that it is not, as is the 
case with filaria sanguinis hominis nocturna, 
and probably diurna, dependent on the good 
offices of some species of mosquito ox other 
bloodsucker. Patrick Manson. 
FISSURE (findo, I cleave).-A narrow 
and superficial crack or solution of continuity, 
observed on the skin and mucous membranes, 
and especially near the line of junction of 
these structures, as on the lips and within the 
anus. See Anus, Diseases of; and Chaps. 
FISTULA (fistula, a pipe) -A narrow 
track or canal leading from a free surface, 
and extending more or less deeply to some 
seat of local irritation; or it may be consti- 
tuting an abnormal communication between 
two or more cavities, as in the case of 
vesico-vaginal or recto-vaginal fistula. See 
Abscess. 
FISTULA IN ANO.-See Rectum, 
Diseases of. 
FIT.-A popular synonym for a sudden 
seizure characterised by loss or disturbance 
of consciousness from any cause, with or 
without convulsions (see Convulsions ; Epi- 
lepsy; Hysteria; and Syncope). The term 
is also applied to a sudden or acute seizure 
of certain diseases, such as gout, asthma, 
and ague. 
FLATULENCE (flatus, a puff of wind). 
Synon. : Fr. Flatulence; Ger. Flatulenz. 
Definition. - The undue generation of 
gases m the stomach and intestines. 
^Etiology.-The principal cause of flatu- 
lence is fermentation or decomposition of the 
contents of the stomach and bowels-a con- 
dition usually induced by embarrassment of 
function. Hence it is a common symptom 
in dyspepsia-especially the atonic forms 
as met with in the debilitated and the aged, 
constipation, gastritis, enteritis, hepatic dis- 
orders, and intestinal obstruction. When 
flatus is generated too rapidly to be accounted 
for by fermentation, as in hysteria, hypo- 
chondriasis, and other forms of nervous de- 
bility, it has been ascribed to secretion of 
gases from the mucous membrane. 
Symptoms.-The clinical phenomena vary 
as flatus is retained or discharged; and with 
the seat of its formation, whether chiefly in 
the stomach or intestines. In the former the 
concomitant symptoms are those of dyspep- 
sia ; in the latter there is usually constipation. 
As a rifle, however, flatulence pervades at the 
same time more or less all the hollow viscera, 
and indicates torpor of the digestive organs. 
It is apt to lead to these further evils:- 
(a) Pain from distension or from irregular 
and forcible contractions of the walls-hence 
gastrodynia and colic are apt to arise; 
(b) arrest of the normal movements of the 
stomach and intestines, and consequent 
accumulation witbin them of fermentable 
matters, with further generation of gases, 
leading to paralytic distension: hence dilata- 
tion of the stomach and colon, tympanites 
or meteorism, and aggravation of pre-existing 
dyspepsia or constipation may ensue ; and 
(c) pressure on adjacent organs, such as the 
heart and lungs, inducing palpitation and 
irregular action of the heart, precordial 
anxiety, faintness, vertigo, dyspnoea, or even 
asphyxia. 
In tympanites there is a rapid generation 
of flatus, which overpowers the contractility 
of the hollow viscera; and the abdomen is 
round, tense, and tympanitic. See Tympa- 
nites. 
Treatment.-(a) Imprisoned flatus should 
be dislodged by friction of the abdomen with 
stimulating liniments, and gentle kneading 
of the most distended parts; large draughts 
of hot water; spirit and hot water; ammonia, 
ether, or spirit of chloroform; aromatic stimu- 
lants-ginger, capsicum, cloves, mint, anise, 
cajuput, camphor, or cascarilla. When flatu- 
lence is chiefly intestinal, enemata containing 
laudanum with asafoetida, turpentine, or rue ; 
and the compound asafoetida pill with extract 
of nux vomica, and an aperient, are the most 
useful measures. 
(&) The generation of flatus should be 
arrested. Fermentation may be checked by 
sulphite or sulpho-carbolate of sodium, sul- 
phurous acid, carbolic acid, creasote, terebene, 
salol, or charcoal-from the poplar or vege- 
table ivory, immediately after food ; and by 
correcting and toning the digestive organs. 
Repeated fractional doses of calomel will 
also frequently arrest fermentative flatulence. 
Food likely to ferment or lodge, such as 
starch, sugar, fruits or green vegetables, and 
warm liquids-especially tea and soups- 
should be avoided; the meals should be well 
masticated and solid throughout, and liquids 
should only be taken sparingly at the close or 
an hour after. In some cases, however, 
flatulence is connected with an insufficient 
supply of fluids, and should be met by 702 
FLATULENCE 
FCETUS, DISEASES OF THE 
increasing it; then also a tumblerful of hot 
water night and morning and an hour before 
each meal, which should consist of solids, 
may prove useful. Alkalis-carbonate of 
magnesium and bicarbonate of sodium-and 
bitters, especially strychnine, are often useful 
in the flatulence of hysteria, hypochondri- 
asis, of the very nervous and the aged; but 
perhaps the best results follow alkalis with 
nux vomica and bismuth an hour before, and 
hydrochloric acid alone or with some reliable 
preparation of pepsin after food. It is also 
essential to see that the action of the liver is 
healthy. George Oliver. 
FLEXION (flecto, I bend).-A bending. 
This term is applied either to the act of more 
or less forcible flexion, as in some methods 
of treatment, for example in the cure of 
aneurysm or the reduction of dislocations; 
or to the condition in which parts are bent, 
as the result of disease or of disorder, as 
when the limbs or certain internal organs are 
bent upon themselves. See Womb, Diseases 
of. 
FLINSBERG, in Silesia.-Chalybeate 
waters. See Mineral Waters. 
FLOODING-.-A popular term for ex- 
cessive discharge of blood from the womb. 
See Menstruation, Disorders of; and Preg- 
nancy, Disorders of. 
FLUCTUATION (fluctus, a wave).-A 
physical sign consisting in a wave-like or un- 
dulating sensation. It is elicited by a peculiar 
mode of palpation with the one hand, while 
percussion is made with the fingers of the 
other; and is due to the presence of a fluid 
in a natural cavity, such as the peritoneum, 
or in an abnormal closed space such as a cyst 
(see Physical Examination). The term ' fluc- 
tuation ' as used by the surgeon has a some- 
what different signification, being applied to 
the sensation of the presence of a fluid, which 
may be felt when alternate pressure with the 
fingers is made, as over the seat of an abscess. 
See Abscess. 
of disease. This article treats of the latter 
only. 
1. Amputation.-Amputation, partial or 
complete, of foetal limbs may take place, 
from constriction of the limb by a band of 
the amnion. An attempt at reproduction 
of the lost limb is sometimes seen, in the 
shape of rudimentary fingers and toes, pro- 
jecting from the stump. That such a stump 
is the result of amputation is proved by the 
fact that the part cut off has been found in 
utero. 
2. Spontaneous fractures and dislocations. 
Fractures and dislocations occur in utero, 
the latter being the more rare. They are 
due to some condition of the bones and 
ligaments respectively, leading to undue 
fragility of those structures; for they are 
always multiple, and are not accompanied 
with bruising of the adjacent soft parts. 
3. Tumours.-New-growths are met with 
in the foetus-cysts of various kinds, fibroma, 
lipoma, &c. That most special to the foetus 
is a tumour situated over the coccyx, which 
may be as large as a foetal head. Such 
tumours are spheroidal or ovoidal in shape, 
elastic in consistence, and present rounded 
inequalities on the surface. On section they 
are found to consist of strong fibrous trabe- 
culae, in the meshes of which are numerous 
small cysts lined with epithelium. It is 
thought by many that they originate in 
Luschka's gland. Another special kind of 
tumour is that known as a foetal inclusion- 
a swelling usually on the lower part of the 
trunk, and containing some part of another 
foetus, more or less imperfectly developed. 
4. Inflammation of serous membranes. 
This form of disease may occur in the foetus, 
such as pleurisy and peritonitis. The morbid 
anatomy of these changes does not differ from 
that in the adult. Peritonitis is often found 
associated with syphilis; and it appears to be 
almost always fatal to the foetus. 
5. Visceral inflammations.-Inflammation 
of the lungs has been met with, in the form 
of grey or white lobular hepatisation. It is 
most frequent in syphilis. Enteritis has also 
been described. Certain malformations of 
the heart which are met with can be ex- 
plained by supposing the occurrence of endo- 
carditis during foetal life; but there is no 
proof that the foetus is subject to rheumatism. 
6. Specific fevers.-The morbid changes 
of enteric fever have been found in the foetus. 
In pregnant women suffering from inter- 
mittent fever, paroxysms of convulsive move- 
ments of the child have been felt to occur as 
regularly as the attacks of ague in the mother; 
and the child when born has been found to 
have a large spleen. Children have also been 
born with skin-eruptions thought to resemble 
those of measles, scarlatina, and small-pox. 
The facts as to the last-named disease are 
the most numerous and probable. The 
eruption of variola in the foetus differs some- 
FLUKE.-See Entozoa. 
FLUOR 
FLUX 
.-A flow or excessive dis- 
charge from a mucous surface, through any of 
the natural passages, of serum, blood, mucus, 
pus, or the various secretions. As illustra- 
tions of fluxes may be mentioned salivation, 
bronchorrhoea, biliary flux, diarrhoea, dys- 
entery or bloody flux, cholera, and leucorrhoea 
or white flux (fluor alb us). 
FCETUS, Diseases of the. - Two 
classes of abnormal conditions are seen in 
the foetus, namely: Those which depend 
upon some interference with the process of 
development, such as malformations and 
monstrosities; and those which are the result FCETUS, DISEASES OF THE 
703 
what from that seen after birth, because, the 
skin of the foetus being bathed with fluid, no 
crusts form, and the pustules run a course 
like those on mucous membranes. 
7. Diseases of the skin.-The foetus is 
subject to skin-diseases. Pustules of ecthyma; 
patches of erythematous redness; ulceration 
of the skin, and syphilitic eruptions, have been 
seen. Intra-uterine ichthyosis is met with. 
Children have been born jaundiced, but only 
by mothers themselves suffering from that 
condition. But women with jaundice do not 
always bear jaundiced children. Jaundice is 
not necessarily fatal to the foetus. 
8. Syphilis.- Syphilis leads to various 
lesions in the foetus; and while it usually 
proves fatal, the subjects of it that may 
survive till birth are feeble and badly nour- 
ished. Flat tubercles occur on different 
parts of the skin, especially round the mucous 
orifices; and pemphigus may be seen, affect- 
ing chiefly the palms of the hands and the 
soles of the feet. The occurrence of peri- 
tonitis has already been mentioned. Yellow 
indurated nodules, of varying size and num- 
ber, may be found in the liver, as well as 
in the lungs. A peculiar change has been 
described in the thymus gland, in which 
this structure externally appears healthy, but 
when cut into and compressed exudes a 
whitish puriform fluid. Other changes have 
been recorded, affecting the spleen, pancreas, 
and suprarenal capsules, but they are not 
distinctive. Changes in the bones have 
also been described, consisting of an osteo- 
chrondritis, affecting the ends of the long 
bones, most frequently the lower end of the 
femur. 
9. Rachitis.-Foetal rickets is a disease 
somewhat different from that seen after birth. 
The limbs are short, very fat, the fat being 
thrown into rolls separated by transverse 
constrictions; the trunk, especially the abdo- 
men, is large; the head often hydrocephalic. 
The bones are short, often fractured and 
bent; there is swelling, softening, and de- 
layed ossification of the epiphyses. It may 
begin early, and cease before delivery; or the 
child may be born with the disease in pro- 
gress. Nothing is known of its causes. 
10. Tuberculosis.-Tuberculosis sometimes 
commences in the foetus, tubercles having 
been found in the mesentery and in the 
lungs. 
11. Dropsies.-Dropsy is met with in the 
foetus, sometimes of the serous cavities, of 
which hydrocephalus is the most common. 
It is often associated with rickets. Next in 
frequency comes ascites; and lastly hydro- 
thorax, which is very rare. These affections 
may destroy foetal life in utero; but they 
more often lead to death because they render 
destructive operations necessary before de- 
livery can be accomplished. General ana- 
sarca is also met with, and there is reason to 
believe that it depends upon disease of the 
placenta, impairing the excretory function of 
that organ. It is always fatal, if not before 
birth, within a few hours after it. 
12. Visceral diseases.-Hypertrophy of the 
liver, spleen, or kidneys may occur in the 
foetus. Cystic disease of the kidneys may be 
met with, the organs being converted into a 
mass of cysts containing no trace of secreting 
structure. Both kidneys are usually affected, 
and the disease is generally associated with 
some malformation elsewhere. Hydrone- 
phrosis, single or double, along with dilata- 
tion of the ureter, or ureters and bladder, has 
been seen, dependent upon impermeability of 
some part of the urinary passages. Any of 
these visceral diseases may form a tumour 
so large as to impede delivery. None of 
them can be diagnosed before birth. Con- 
cretions of uric acid and urates are not un- 
common. 
The Causes of Death of the Foetus. 
The various causes of death of the foetus in 
utero may now be briefly considered. The 
first of these is injury, as when the mother 
receives a blow upon the abdomen, or has 
a fall. Such occurrences rarely injure 
the foetus directly, although this has been 
known to happen. When they prove fatal 
to the foetus, they do so by leading to haemor- 
rhage into, or separation of, a portion of 
placenta, and consequent disturbance of the 
foetal circulation. Poisons in the mother's 
blood, such as lead, urea, bile, or carbonic 
acid (as in the case of heart-disease with 
cyanosis), may lead to death of the foetus. 
Syphilis has already been referred to. Epi- 
leptiform convulsions may destroy foetal life, 
either by asphyxia, or by leading to haemor- 
rhage into the placenta. Extreme ancemia 
and the cancerous cachexia are among the 
causes of foetal death. Any kind of disease 
attended with pyrexia will also destroy foetal 
life if the temperature rise high enough. A 
temperature exceeding 105° F. appears to 
be invariably fatal to the foetus. Certain 
diseases of its appendages may lead to death 
of the foetus, such as haemorrhages into the 
placenta, old organised clots forming what 
are called placental ' infarcts '; obliteration 
of the umbilical vessels ; or interruption of 
the circulation in the cord by knots in it, or 
pressure upon it. It is believed that there 
are some diseases of the mother's uterus 
which lead to death of the foetus ; but what 
they are is not known. It is said that some 
women acquire a habit of having dead chil- 
dren. This means that there are cases in 
which an apparently healthy woman will 
repeatedly have dead children, the cause of 
whose death a skilled observer cannot find 
out. In other words, there are causes of 
foetal death as yet unknown. 
The Consequences of Death of the 
Foetus.-A dead foetus while retained in 
utero, and thus protected from the air, does 
not putrefy, but undergoes a process of 704 
FCETUS, DISEASES OF THE 
FOMENTATION 
maceration. The whole body becomes soft 
and flaccid, its tissues being infiltrated with 
fluid; but it has no putrid odour. The skin 
presents bullai filled with reddish serum, and 
the epidermis is readily detached with slight 
friction. The surface is of a cyanotic colour, 
which after exposure to the air becomes of a 
more or less bright red; it is not greenish as 
is seen in putrefaction. The cellular tissue 
is infiltrated with bloody serum. The viscera 
have lost their distinctive tints, and become 
of a reddish-brown colour. The cranial 
bones are abnormally mobile, overlapping 
one another to a greater extent than normal; 
and the periosteum may be stripped off 
them. These appearances are much the 
same, whatever be the cause of death, but 
they vary in degree according to the length 
of time which has elapsed since death. 
Besides the diseases of the foetus described 
above, there are others which are not fatal, 
and the chief interest of which lies in their 
course and treatment after birth. These are 
discussed in other articles, and need not 
be mentioned here. G. E. Herman. 
FOLIE CIRCULAIRE (Fr.) -This 
term is applied by the French psycholo- 
gical physicians to a variety of insanity 
characterised by alternations of excitement 
and depression. The patient passes through 
an attack of mania of perhaps an ordinary 
character, but when he appears to have 
recovered he sinks into melancholia, and 
thence emerges again to become maniacal 
and excited. The duration of each stage 
may vary from weeks to months. Sometimes 
one state will follow the other immediately; 
in other cases a period of convalescence will 
intervene, during which the patient appears 
well, and can hardly be considered insane. 
Yet the prognosis is extremely unfavourable 
in all such cases; and it is of great importance 
in estimating the extent of recovery of a 
patient, that it should be clearly ascertained 
that the attack is not one of a series following 
one another in the manner mentioned. 
G. F. Blandford. 
FOLLICLES, Diseases of {folliculus, 
dim. of follis, a bag).-The name ' follicle ' 
has been applied to a great variety of different 
structures, which have in common the shape 
of a bag or sac, whether circular or elongated 
in outline; for example, the Graafian follicles, 
the lymphatic (Peyerian) follicles of the 
intestine, and the follicles of the mucous 
membrane of the stomach, intestine, and 
uterus. • The name has been further extended 
to include glands somewhat more complex 
in structure, such as the sudoriparous glands 
or sweat-follicles, the sebaceous follicles, and 
the tonsils; as well as the saccular depres- 
sions in which the hair and the teeth take 
their origin. The name synovial follicles 
is sometimes given to processes of synovial 
membrane invaginated in the capsule of a 
joint. 
For an account of the diseases of these 
various structures, the reader is referred to 
the several articles under which they are 
discussed; but so far as the true follicles are 
concerned, the following may be said to be 
the principal morbid changes to which they 
are liable : atrophy ; hypertrophy ; obstruc- 
tion, and distension; inflammation; ulcera- 
tion; cystic disease; new-growths; tubercle; 
acute specific processes, such as the typhoid; 
and parasitic disease. 
FOMENTATION (/owo, I keep warm). 
Synon. : Fr. Fomentation; Ger. Bahung. 
Definition.-Fomentation is the applica- 
tion to the surface of the body of flannels, 
cloths, or sponges moistened with hot water, 
either pure or containing some medicinal 
substance in solution. 
Action.-The action of a simple fomenta- 
tion is the same as that of a poultice. By 
its warmth and moisture it tends to relax the 
muscular fibres of the skin and soften the 
cuticle,thus relieving tension, and diminishing 
pain and irritation. In the early stages of 
inflammation it favours resolution, by main- 
taining the temperature, and promoting active 
circulation through the area which has 
suffered from the injurious influence which 
has started the process. In the later stages 
it promotes and hastens suppuration, by 
causing dilatation of the vessels, and encourag- 
ing exudation. A fomentation is superior to a 
poultice in lightness and cleanliness, but un- 
less care be taken it loses its heat more 
quickly. This disadvantage may be over- 
come by covering the fomentation with a 
thick layer of cotton-wool. 
Application and Uses.-A fomentation is 
thus applied: A piece of coarse flannel, 
sufficiently large to cover the affected part 
when folded into two layers, is put into a 
basin, and boiling water is poured upon it. 
It is then lifted from the basin with a pair of 
tongs or some convenient instrument, and 
dropped on the wringer. This is a stout 
piece of towelling with a stick attached to 
each end. The sticks then being twisted in 
opposite directions, as much water as possible 
is squeezed out of the flannel. It is then 
immediately placed on the affected part, and 
covered with a large piece of oiled silk or 
indiarubber sheet extending at least one inch 
on each side of it. Over this may be placed 
a thick layer of cotton-wool, and a bandage. 
If the flannel be not squeezed sufficiently dry, 
it will wet the bed or clothing. If not suf- 
ficiently covered with oiled silk and wool, it 
soon becomes cold. Whatever means may 
be taken to retain the heat of a fomentation, 
it can be kept above the temperature of the 
body only for a few minutes. If, therefore, 
the full effect of fomentation is desired to be 
obtained, the flannels must be changed every FOMENTATION 
FORCIBLE FEEDING- 
705 
twenty minutes. In many parts a sponge, 
or a piece of spongio-piline, wrung out of 
boiling water, forms a most convenient form 
of fomentation. When the fore-arm or hand 
is affected, a bath of .hot water may be sub- 
stituted for fomentations. The temperature 
of the water must be maintained by the re- 
peated addition of small quantities of boiling 
water. 
Fomentations are especially useful in all 
cases of erysipelas and diffuse cellulitis, and 
in boils. In peritonitis they are borne more 
easily than poultices, on account of their 
greater lightness. Whenever they can be 
employed they are superior to poultices, on 
account of their cleanliness. They are not 
applicable to cases in which there is a dis- 
charging wound or abscess, as under such 
conditions the cloths become foul. 
Varieties.-If it is desired to add some 
slight counter-irritation to the warmth and 
moisture, the fomentation may be sprinkled 
with turpentine before it is applied. This 
forms the ordinary turpentine-stupe. The 
sedative action of the fomentation may be 
increased by sprinkling it with laudanum. 
The ordinary poppy-fotnentation is often used 
with the same intention. It is thus pre- 
pared : Half a pound of poppy-heads with 
the seeds taken out is boiled for ten minutes 
in four pints of water, and the liquid then 
strained off. The decoction is kejat warm 
over a fire, and the flannels dipped in it and 
applied as before described about every half- 
hour. The term ' dry fomentation ' is some- 
times applied to bags of hot salt, bran, or 
chamomile-flowers; or pieces of flannel 
toasted before a fire and laid on hot. These 
often give relief in cases of intestinal, renal, 
or biliary colic. Marcus Beck. 
FOMITES (fames, touch-wood, tinder).- 
Substances capable of retaining contagium- 
particles, and thus of being the means of 
propagating any infectious disease. The most 
important fomites are bed-clothes, bedding, 
woollen garments, carpets, curtains, and 
letters. See Contagion, 
FOOD.-Sec Aliment ; and Diet. 
FOOD, ./Etiology of.-See Disease, 
Causes of; and Digestion, Disorders of. 
FORAMEN OVALE, Patency of.- 
See Heart, Malformations of. 
FORCIBLE FEEDING-. - In the 
treatment of insanity, and sometimes under 
other circumstances, it happens that we are 
compelled to administer food by force to 
patients who, for one reason or another, re- 
fuse to take it. The majority of these persons 
are melancholics who think they ought not 
to eat, or try to commit suicide by star- 
vation, and many are in a feeble bodily 
condition when they commence this refusal. 
Such persons must be fed by force. Strong 
patients may be allowed a longer time, for 
many refuse from whim or obstinacy, and 
hunger will overcome their disinclination. 
Some patients in a state of acute delirium 
will take no food ; they must be fed at once, 
and it is important that they should be fed 
without a protracted and exhausting struggle, 
for they will resist desperately unless com- 
pletely overmastered. In almost every case 
feeding should be done early : the sooner it 
is done, the shorter will be the period during 
which it will be required. The various plans 
to be adopted range from merely feeding with 
a spoon, as one feeds a child, to sending food 
down the oesophagus with a tube passed 
through the mouth or nose, the patient being 
restrained in a chair or on a bed by atten- 
dants or by mechanical means. The mode 
of feeding varies according to the resistance, 
and no one method is applicable to every case. 
There is no need to pass an oesophageal tube 
down the throat of a man whose resistance is 
passive and easily overcome; on the other 
hand, we occasionally find patients of great 
muscular strength and indomitable will, who 
can hardly be fed with safety in any way except 
by the stomach-tube. Of these we may speak 
first. 
In what position are they to be fed, sit- 
ting or lying down 2 If they are to be held 
by attendants, no doubt the recumbent pos- 
ture is the one in which the latter can ex- 
ercise most power. But when a man is so 
strong that, as we are told, five attendants 
must hold him, a struggle will not be unat- 
tended with danger, for the five are not all 
acting together, and he gets loose now a leg 
and now an arm, to the great discomposure 
of the operator; moreover, this struggle re- 
peated three times a day, soon renders him a 
mass of bruises. He should be placed in a 
strong wooden chair, and by sheets wound 
round his body, arms, and legs, he can be 
fastened to the chair so completely that he 
is quite incapable of movement; yet he gets 
no bruise, and the operator acts upon him 
free from all inconvenience. Some writers 
advocate feeding by the nose, and prefer 
this method to passing a tube through the 
mouth. It is well fitted for quiet patients, 
who do not make a desperate resistance 
and only close their teeth, but it has many 
disadvantages. A long tube may enter the 
larynx, or may curl forwards and be caught 
by the teeth. And if the food is passed 
into the nose by a short tube or funnel, 
it is often ejected, and a long time is spent 
in the operation. The time consumed in 
feeding by the nose is one of the great ob- 
jections, and much exhaustion is often thus 
produced. The only advantage of feeding 
in this way is that we are not compelled to 
force open the mouth. This is a work of 
difficulty, if the patient is strong and his 706 
FORCIBLE FEEDING 
FOURTH NERVE 
teeth perfect, unless we are provided with j 
the screw-key invented for this purpose: 
with this there is little difficulty, and only 
bungling will injure the teeth or gums, if 
the patient is properly secured and the head 
held by an attendant, not between his knees, 
but in his hands. If the oesophageal tube 
be of good size it cannot enter the larynx. 
The wooden termination of the tube must 
be short, so as to allow of its curving. The 
operator, standing in front, passes the tube 
through the hole of the gag, inclining it to 
the patient's left, so as to avoid the vertebrae. 
It may be held by the tongue, but at the 
first inspiration the hold is relaxed, and it 
glides down the oesophagus. The food may 
be poured down it by a funnel or pumped 
down by the pump. 
The next class of patients, making less re- 
sistance, may be fed by Paley's feeder, a glass 
vessel with a flattened spout which goes over 
the tongue; the food is emitted, a little at 
a time, by means of a spring, and finds its 
way down the gullet. A certain number of 
patients may be fed by getting a funnel be- 
hind the teeth and pouring food into it; and 
others by holding the mouth open by means 
of two spoons, and then pouring food in. 
The objection to the latter method, and to 
its many modifications, is the time taken up 
in the operation, whereby great fatigue and 
exhaustion are produced. 
The food must be in a more or less fluid 
form, and should consist of soups, milk, eggs, 
and the like. See Diet. 
G. F. Blandford. 
FORMICATION (formica, an ant).- 
An abnormal subjective sensation referred to 
the skin, which is described as of a ' creeping ' 
character, and as resembling the crawling of 
ants upon the surface. See Sensation, Dis- 
orders of. 
FOURTH NERVE, Diseases of.- 
Morbid states of the fourth nerve are shown 
by spasm or paralysis of the superior oblique 
muscle, which it supplies. 
Spasm.-Little is known of over-action of 
this muscle, except that clonic spasm in it is 
the cause of rotatory nystagmus when the 
quick movement of the upper end of the 
vertical axis is inwards. 
Paralysis. - Paralysis is not uncommon. 
Its usual causes are inflammation of the 
nerve-sheath from cold; haemorrhage into 
the nerve; syphilitic affections of the nerve 
or of its membranes ; cerebral tumours, &c., 
pressing on or injuring the nerve at its origin 
from the valve of Vieussens, or in its course 
around the crus; aneurysm; exostoses or 
growths in the orbit; and degeneration of 
the nucleus, in common with the nuclei of 
the other nerves of the ocular muscles, from 
which it is occasionally paralysed in tabes, 
in ' progressive external ophthalmoplegia,' in 
the rare acute inflammation of the nuclei, 
and in sudden lesions in this part of the mid- 
brain. It has also been known to be involved 
in the rare affection of the muscles of the eye- 
ball in diphtheritic paralysis. 
Symptoms.-Even in complete paralysis of 
the superior oblique muscle there is little 
obvious deviation of the affected eye. Move- 
ment downwards is, however, defective, and 
therefore diplopia exists when the eye is 
moved below a line which runs obliquely 
downwards from the healthy to the paralysed 
side, through the point of mid-fixation. The 
uncertainty which results from 'defective 
projection ' of the image formed by the affected 
eye occurs chiefly in looking down, and in the 
corresponding downward position of the head. 
It is common for the first discovery of the 
defect to be that the patient becomes giddy 
when he goes downstairs, and sees two flights 
of stairs before him instead of one. The chief 
visible defect in movement of the affected 
eye (examined alone) is downwards and in- 
wards, because it is when the eyeball is 
moved in this direction that the superior 
oblique has most influence on the vertical 
position of the eyeball. In the direct down- 
ward movement there is slight convergent 
strabismus, because the inferior rectus lacks 
the counteraction to its inward traction, so 
that its tendency to rotate the globe (lower 
end of vertical axis inwards) is also un- 
opposed and perceptible. The diplopia which 
exists when both eyes look down is homony- 
mous-that is, the image formed by the af- 
fected eye is on the same side as that eye. 
The left eye (if affected) being higher than 
the right, its image (the left) appears lower 
than the right image. The action of the 
superior oblique being to move the upper 
end of the vertical axis of the eye inwards, 
there is, in its paralysis, an abnormal diver- 
gence of the upper ends of the vertical axes, 
and the double images (being always in- 
verted) will converge; their upper ends being 
nearer together than the lower. This is due 
to the obliquity of the false image (e.g'.the left), 
and this obliquity is greatest when the eyeball 
is moved to the left and downwards, because 
in this position the rotatory power of the supe- 
rior oblique is greater, and the obliquity is 
least in looking inwards and downwards. 
Thus the convergence of the images is 
greatest when the difference in height is 
least, and vice versa. When the paralysis of 
the superior oblique has existed for some 
time, a secondary contraction of the inferior 
oblique may cause crossed diplopia on looking 
upwards. 
Treatment.-The treatment of paralysis 
of the fourth nerve is in the main that of its 
cause. When due, as it very commonly is, 
to syphilis, iodide of potassium in full doses, 
with or without mercury, is necessary. 
Smaller doses of iodide with quinine or 
iodide of iron are also useful for rheumatic 
paralysis. Blisters to the temple are bene- FOURTH NERVE 
FREMITUS 
707 
ficial in the early stages. A little good, but 
not much, may be effected by applying the 
constant current from the eyelid to the fore- 
head (Benedikt), a few cells only being used. 
W. R. Gowers. 
FRAGILITAS CRINIUM (fragili- 
tas, brittleness; crinis, the hair).-See Hair, 
Diseases of. 
FRAGILITAS OSSIUM.-A diseased 
condition of the bones, in which they are 
extremely fragile, so that they are liable to 
fracture from very slight causes. See Bone, 
Diseases of. 
FRAMBCESIA(/ramboise, a raspberry). 
Synon. : Yaws; Er. and Ger. Pian. 
Definition.-An exanthem consisting of an 
eruption of reddish-yellow tubercles, which 
gradually develop into moist fungous masses, 
without constitutional symptoms, or with only 
such debility as results from ulceration and 
prolonged discharge. 
.Etiology and Pathology. - Yaws is 
epidemic among the African race, both in 
their native country and in the West Indies, 
especially during childhood-then also pre- 
monitory symptoms and pyrexia are more 
distinct. The disease is contagious and inocu- 
lable, and presumably due to a microbe; it 
has no relationship to syphilis, as was once 
supposed from a likeness to condyloma. It 
is not hereditary, and does not recur. 
' Parangi ' in Ceylon, and ' Button Scurvy ' 
which occurred in Ireland prior to 1851, 
were diseases closely similar if not identical; 
and filthy water and excess of vegetable food 
appeared to promote them. 
Symptoms.-There is a period of incubation 
of from three to ten weeks in frambcesia, and 
pains in the limbs and malaise always precede 
the outbreak. The tubercles begin with little 
or no hyperaemia or tenderness, and range in 
size from that of a pin's head to a prominent 
mass two inches in diameter. Some subside 
without breaking the cuticle or destroying the 
derma; others become fungous, somewhat 
spheroidal masses, pinkish in colour, and 
with a dirty-yellow, sticky, foetid secretion. 
Later on the fungus shrinks and is converted 
into a brownish scab, or ulceration extends 
deeply and widely into the tissues. The 
subsidence of the fungus is succeeded by a 
pigmented stain, and the healing of the 
ulcer by a dark depressed cicatrix. 
Frambcesia selects by preference the face 
and neck, the joints, the feet, and the genital 
regions; and often forms a fringe of tubercles 
or a prominent ridge around the mouth, the 
nostrils, or the anus. The mucous membrane 
near these outlets may be affected in like 
manner. The lymphatic glands in the vicinity 
become large and tender. 
Duration and Results.-The duration of 
frambcesia averages three months, but may 
be prolonged to one or more years. Spon- 
taneous cure is usual; but in cachectic sub- 
jects and when its development is irregular 
the constitution suffers, the excretions become 
offensive, and there is extreme prostration. 
Then the joints swell; ulcers with excessive 
discharge form around them; and the patient 
may be crippled for life, or may perish from 
septicaemia or asthenia. 
Treatment. - The curative measures of 
yaws advised by the best authorities are clean- 
liness, generous diet, saline eliminants, and 
the local use of carbolic-acid lotions, diluted 
mercurial ointments, or iodoform. In the 
later stages constitutional remedies, such as 
mercury in minute doses, iodide of potassium, 
and tonics, are indicated. As regards preven- 
tion, every hygienic improvement is potent. 
In some parts of Africa and in Fiji a habit 
of inoculating the young prevails, so as to 
procure immunity in adult age, when fram- 
bcesia is much more severe. 
Erasmus Wilson. E. D. Mapother. 
FRANCE, South, of.-The eastern part 
(Mediterranean coast) is dry and bracing, 
with a very clear atmosphere. The chief 
resorts in it are Cannes, Mentone, Hyeres, 
and Nice. The western part is moist and 
mild but variable, the principal places in it 
being Arcachon, Biarritz, and Pau. See 
Climate, Treatment of Disease by. 
FRANZENSBAD, in Austria. - 
Alkaline sulphated waters. See Mineral 
Waters. 
FRECKLES.-Synon.: Lentigines', len- 
ticulce; Fr.Ephelides', Ger. Sommersprossen, 
Sommerflecken.-A freckle is a pigmentary 
discoloration of the skin, which has received 
its Latin or technical name from a resem- 
blance in colour, figure, and size to a lentil. 
It varies in tint from yellow to olive, from 
brown to black; and is met with on the 
exposed parts of the skin, particularly the 
face, neck, and hands, and occasionally on 
the covered parts of the body (' cold freckles '). 
It is usually found in children and women in 
whom the skin is sensitive and delicate, and 
has obtained its German synonyms from 
its greater frequency in the summer season. 
See Pigmentary Diseases of the Skin. 
Erasmus Wilson. 
FREMISSEMENT CATAIRE (fre- 
missement, purring ; cataire, connected with 
a cat).-A physical sign felt on applying the 
hand over the region of the heart or great 
vessels in certain morbid conditions, and 
compared to the sensation conveyed to the 
hand, by the purring of a cat. This sign is 
more commonly known as ' thrill ' or ' purr- 
ing tremor.' See Physical Examination. 
FREMITUS (fremitus, a low noise).- 
A group of physical signs, elicited by placing 
the hand over the respiratory organs, while 
the patient speaks (vocal fremitus), or coughs 708 
FREMITUS 
FROSTBITES 
(tussive fremitus'); or in certain morbid con- 
ditions when the patient simply breathes 
(rhonchal and friction fremitus). A fre- 
mitus may sometimes also be felt over the 
cardiac region in connexion with the move- 
ments of the heart, when the surfaces of the 
pericardium are much roughened. Another 
form of fremitus is a peculiar sensation called 
hydatid fremitus, which may be elicited by 
a special mode of percussion over hydatid 
tumours in some cases. See Physical Ex- 
amination. 
FRICTION. -Synon.: Rubbing; Fr. 
Friction; Ger. Reibung. 
Definition.-By friction we mean sur- 
face-rubbing, as distinguished from sham- 
pooing, or, as it is sometimes called, medi- 
cal rubbing, a process of manipulation by 
which deep pressure is made upon the 
muscles. 
Applications and Uses.-Friction is use- 
fully employed over the surface of a limb, or 
over the trunk, for a variety of purposes. It 
is especially useful when the circulation is 
enfeebled, either by the external applica- 
tion of cold, amounting, when in a severe 
degree, to frostbite, or in cases of paraly- 
sis. The effect is still further increased by 
the use of various stimulating liniments, 
more especially when it is desirable to ex- 
cite a certain amount of counter-irritation 
over a large cutaneous surface, for the relief 
of congestion or inflammation of internal 
organs. 
Another object with which friction is 
largely employed in medicine, is to facilitate 
the absorption and introduction into the 
system of various remedial agents applied 
externally. By this means gastric irritation 
and disturbance are avoided, and the effects 
of the remedies upon the system can be more 
closely watched and regulated. In this way 
mercury is frequently introduced into the 
system by the process commonly spoken of 
as rubbing in, and salivation can be more 
easily avoided or checked at its commence- 
ment than when mercury is administered by 
the mouth. The part of the body selected for 
this purpose is that along the inner side of 
the thigh up to the groin; and mercury, in 
the form of ointment, rubbed in every night 
and morning, will generally affect the system 
in a few days. 
Another instance of friction is to be found 
in the fattening of children by the process of 
rubbing in oil-fresh neat's-foot oil is the 
best-every night and morning, over the 
chest, abdomen, arms, and thighs. Emaci- 
ated children, thus treated, gain in weight 
by the absorption of the oil; and not only 
do they fatten, but their general nutrition 
and health are improved, often with the 
diminution of glandular swellings and the 
disappearance of coughs. 
William Adams. 
FRICTION-FREMITUS.-The form 
of fremitus produced by the rubbing together 
of surfaces roughened by various morbid con- 
ditions, as of the pleura in breathing, or of 
the pericardium from the movements of the 
heart. See Fremitus; and Physical Exami- 
nation. 
FRICTION-SOUND. - A physical 
sign, heard on auscultation, and due to the 
rubbing against each other of serous surfaces 
that have lost their natural smoothness and 
moistness from any cause. See Physical 
Examination. 
FRIEDRICHSHALL, in Germany. 
Sulphated waters. See Mineral Waters. 
FROSTBITES. - Definition. - The 
local effects of severe or extreme cold upon 
any exposed parts or tissues of the body, 
more serious than those described as ' chil- 
blains.' 
The parts of the body most frequently 
affected by frostbites are the toes and neigh- 
bouring parts of the lower extremities, the 
fingers and hands, the nose, and the ears, all 
because of their especial liability to exposure, 
and the first named because also of their 
remoteness from the heart, and other dis- 
advantages in their blood-supply. 
By far the largest proportion of cases occur 
among men in or about the prime of life : 
first, because from the nature of their occu- 
pations they are most liable to exposure; 
and secondly, because from constitutional 
vigour they better withstand any immediately 
fatal general effects of exposure, and so sur- 
vive with local damage. 
Signs and Symptoms.-The signs and symp- 
toms of frostbite vary in manifestation, in 
rapidity of occurrence and in succession, with 
the degree of cold, the medium and mode 
of application, and the duration of exposure, 
as also with the general condition of the suf- 
ferer. They may, however, be thus described : 
Transient redness of the part affected, ac- 
companied by hyperaesthesia and tingling 
sensations, is more or less quickly followed 
by purplish lividity with diminished sensi- 
bility. Blanching, with numbness, supervenes. 
Next, congelation takes place, signalised by 
whiteness, hardness, and absolute insensi- 
bility. Lastly, the freezing process may ex- 
tend more and more deeply, and be continued 
until all the tissues are literally ' frozen to 
death,' and their recovery is impossible. 
' Dry gangrene ' is then established, and the 
parts affected shrivel, dry up, and blacken. 
If the last stage indicated has not been 
reached, more or less complete recovery may 
be effected sooner or later. But ' moist gan- 
grene ' is liable to supervene, from inflam- 
mation after partial restoration of the circu- 
lation in the more severe cases; and other, 
though less serious trophic lesions, from 
similar cause, frequently occur in the milder FROSTBITES 
FUMIGATION 
709 
cases. Parts that have not been actually 
frozen, but have been subject to repeated or 
long exposure, may become gangrenous, or 
may suffer from more or less permanent 
impairment of nutrition and function, such 
effects being due to organic damage to the 
nerves and blood-vessels. See Gangrene. 
Treatment.-The treatment of a frost- 
bitten part essentially consists in such mea- 
sures as are calculated to restore warmth, 
and re-establish the circulation. The greatest 
care, judgment, patience, and perseverance 
are requisite, or the attempts made may 
only render the mischief worse. The pro- 
cess must be gradual and slow to be safe. 
The patient must not be brought at once 
into a warm room or near a fire, but should 
be kept in a moderately cold atmosphere, 
and in a recumbent position. The part 
affected should be somewhat raised, and 
gently rubbed with snow or bathed with ice- 
cold water for some time. Very gradually 
the temperature of the water may be raised, 
or oil may be substituted. Later, dry friction 
may be employed. The frictions should be 
carried considerably above the part obviously 
affected. From time to time the affected 
parts may be lightly enveloped in fur or 
wool, and the frictions repeated at intervals. 
After apparent restoration has been effected, 
treatment by friction, with or without some 
mildly stimulating liniment, should be per- 
severed with day by day for some consider- 
able period, and the part should be warmly 
clad. Consecutive inflammation of the skin, 
with vesication or superficial sloughing, oc- 
curs in some cases ; in other cases the deeper 
structures also suffer, and moist gangrene 
results. Such conditions are especially liable 
to occur in cases in which the change from 
cold to warmth has been too rapid. They 
are to be treated secundum artem. 
If, in spite of all efforts, restoration cannot 
be effected, and any part remains cold, dead, 
and gangrenous, or if from consecutive in- 
flammation moist gangrene should supervene, 
it is better to wait for complete or almost 
complete separation of the dead structures 
before proceeding to amputation or other 
operative measures. The adjoining parts 
remain for very long in such depressed vital 
condition that, if cut through, they are little 
likely to heal favourably, and very often 
slough after fresh injury inflicted by operation 
wounds. 
Parts that have been severely frostbitten, 
even if preserved, are liable to suffer per- 
manently from more or less serious impair- 
ment of nutrition, due probably to damage 
done to the trophic nerves as well as to the 
blood vessels. The skin of such parts is often 
discoloured, and in some cases is hyper- 
aesthetic or painful, and in others more or 
less numb. It is prone to become inflamed 
and to ulcerate; and if ulcerated or wounded, 
healing takes place very slowly as a rule. 
Protection against exposure to cold and in- 
jury should be carefully and constantly 
afforded. 
For the constitutional and general treat- 
ment of the frostbitten, see Cold, Effects 
of Severe or Extreme. 
Arthur E. Durham. 
FUMIGATION (fumigo, I smoke).- 
Synon. : Er. Fumigation-, Ger. Berduche- 
rung. 
Definition.-A mode of employing certain 
medicinal agents, which are capable of being 
volatilised by heat, the vapour being allowed 
to escape into an apartment, or to come in 
contact with articles of clothing and other 
objects, for purposes of disinfection; or being 
allowed to act upon the surface of the body 
for therapeutic purposes. The chief agents 
which are thus used are sulphur and mer- 
cury. 
Mode of Application and Uses. - Sul- 
phur.- The mode of using sulphur as a dis- 
infectant is explained in the article Disin- 
fection. The sulphurous acid may also be 
brought into contact with the body, sulphur 
being burnt in a suitable apparatus. It is 
sometimes thus used for the cure of scabies 
and ether affections. 
Mercury.- Mercurial fumigation, general 
or local, has long been employed in the treat- 
ment of syphilis, and many different pre- 
parations of mercury have been used in this 
way. 
General mercurial fumigation is now usu- 
ally effected by exposing the body to the 
fumes of calomel mixed with steam, the 
steam being added with the twofold object 
of inducing gentle perspiration, and of ren- 
dering the mercurial fumes less irritating 
to the respiratory passages. The best form 
of mercurial vapour-bath is that recom- 
mended by Mr. Henry Lee. The apparatus 
consists of a spirit-lamp which is enclosed 
in a case of wire gauze, on the top of which 
is a small plate surrounded by a porcelain 
trough. One ounce of water is poured into 
the trough, and the lamp is then lighted. 
When the water begins to boil, from 20 to 30 
grains of resublimed calomel are spread on 
the plate, and the apparatus is placed between 
the patient's legs as he sits on a chair un- 
dressed, but surrounded by a moleskin cloak 
long enough to reach the ground. The cloak 
is tied round the neck, but kept away from 
the rest of the body by a cane hoop. If it be 
thought desirable that the vapour should be 
inhaled, the slit of the cloak may be opened 
slightly from time to time. The patient 
should not be alone during the bath, as it 
sometimes causes faintness. When the 
calomel is exhausted, which usually takes 
about a quarter of an hour, the patient goes 
to bed wearing the cloak as a nightdress. The 
bath may be repeated every night, or less 
often, according to the case and the effect 710 
FUMIGATION 
FUNGUS-DISEASE OF INDIA 
produced. The state of the gums must be 
closely watched, and the dose of calomel 
regulated according to circumstances. 
General mercurial fumigation has been 
employed in all stages of syphilis, but is pro- 
bably best adapted for the secondary mani- 
festations, especially the widely spread dry 
eruptions. It may be tried whenever mer- 
cury is not well borne by the stomach. See 
Syphilis. 
Local mercurial fumigation has been found 
serviceable in treating obstinate affections of 
the skin and mucous membrane, in the later 
as well as in the earlier stages of syphilis. 
From 3 to 5 grains of calomel is the usual 
quantity for each fumigation. 
Geo. G. Gascoyen. Arthur Cooper. 
FUNCTIONAL DISEASES.-A class 
of diseases in which no anatomical or struc- 
tural change can be detected to account for 
their presence. See Disease, Classification of. 
FUNGI, Diseases due to.-See Para- 
sites, Vegetable; and Mushrooms, Poison- 
ing by. 
FUNGOID (fungus, a mushroom).-A 
term applied to superficial granulations and 
morbid growths, especially those of a malig- 
nant nature, when they sprout rapidly and 
assume an appearance somewhat like a 
mushroom. See Cancer ; and Ulcer and 
Ulceration. 
FUNGUS-DISEASE OF INDIA. 
Synon.: Madura Foot; Mycetoma; Morbus 
Tuberculosus Pedis; Fr. Degenerescence En- 
demique des Os du Pied; Perical. 
Definition.-A diseased condition of the 
hands and feet, occurring in India, charac- 
terised by enlargement and distortion of the 
affected extremity, due to thickening of the 
cutaneous tissues, with degeneration and 
subsequent fracture of the osseous structures. 
Two forms of the malady are described-the 
one, the pale or ochroid form, characterised 
by the presence of minute globular fatty par- 
ticles like fish-roe, and, though very rarely, 
by the existence of minute pink concretions 
not unlike red-pepper granules; the other, 
the melanoid or dark form, characterised by 
the existence of black or dark brown masses, 
varying in size from that of a grain of gun- 
powder to a walnut, and composed of fungoid 
filaments, cells, and pigmentary deposit. 
Description. - This remarkable disease 
had not been observed beyond the limits of 
Hindostan, until a solitary case of it was re- 
corded within the last few years in Italy. In 
India it has rarely been seen to affect any but 
natives. No case of a European or half-caste 
has been recorded as suffering from a typical 
form of the malady. The foot has been ob- 
served to be affected more often than the 
hand; hence it was common formerly to find 
the malady referred to as one peculiar to the 
foot. It has been recognised as a distinctive 
disease in India for more than thirty years, 
and was described by Goodfrey, of Madras, in 
the Lancet in 184G, and by Eyre in the Indian 
Anna ls of Medical Science in 1860. It is to 
Dr. Vandyke Carter, however, that we are 
chiefly indebted for what is known of the 
malady, clinically and pathologically, and his 
writings date as far back as I860. His pub- 
lished memoir on the disease (Mycetoma, or 
the Fungus-disease of India, 1874) contains 
a summary of all that had been written re- 
garding it up to the period of publication. 
The foot or hand affected with the disease 
presents appearances not unlike those ob- 
served in some forms of caries-especially 
caries of scrofulous origin. When the foot 
is affected, it is found to be considerably 
increased in circumference, the enlargement 
seldom extending far beyond the ankle; the 
foot is prone to run in a line with the leg, 
and may be everted or inverted. It is not, 
however, in the aspect presented by the limb 
that the leading peculiarity consists, but in 
the character of the discharges from the 
sinuses, the openings of which are scattered 
all over the surface of the affected tissue. It 
is this peculiarity which led Dr. Carter to 
separate the disease into two forms-(1) the 
' pale ' or ' ochroid,' the discharge of which 
consists of whitish-yellow roe-like bodies of 
about the size of millet-seed : and (2) the 
' dark ' or ' melanoid,' so called from the dark 
brown or even black granular bodies that 
constantly escape through the sinuses, not 
unlike grains of coarse gunpowder. The 
first form may be said to present two or 
three varieties, according to the modified 
character of the discharges; these will be 
referred to more definitely farther on. 
The malady would appear to occur more 
frequently in Madras, Bombay, and the more 
westerly and north-westerly parts of India 
than in Bengal proper. This, however, seems 
to apply more especially to the dark variety ; 
for, whilst no well-authenticated case of this 
form has been recorded as having manifestly 
originated in the last-named province, cases 
of the pale variety are not infrequent. So 
far as the foot is concerned, the pale form is 
apparently the one most commonly met with 
all over India. As regards the hand, however, 
this would not seem to be the case, for, whilst 
the writers have had the opportunity of ex- 
amining two or three hands affected with the 
dark variety, they have not seen one affected 
with the pale ; nor can they find any account 
of such a case having been witnessed. The 
distortion of the hand affected in this manner 
is very peculiar -it is shortened and thickened, 
owing to the destruction of the carpus and 
metacarpus, and the consequent irregular 
tension of the extensor and flexor tendons. 
Anatomical Characters.-On our laying 
open a characteristic specimen of the dis- FUNGUS-DISEASE OF INDIA 
711 
ease, the bones are found to be extremely 
softened, so that they can readily be divided 
by means of a common knife. The interior 
of the hand or foot is occupied by a series of 
sharply defined cavities, some quite isolated, 
but the majority communicating with one 
another and with the exterior, by a series of 
complex channels, or sinuses, containing 
glairy fluid and solid concretions in various 
proportions. Both cavities and channels are 
lined by a dense glistening membrane, com- 
posed of white fibrous and elastic tissues. 
The surrounding tissues are generally in a 
very fatty condition, and, where the disease 
is of long standing, are more or less com- 
pletely blended into an indistinguishable 
mass. So far a common description is ap- 
plicable to both forms of the disease ; but on 
proceeding to the consideration of the con- 
tents of the cavities, great differences present 
themselves. 
Pale form.-The pale or ochroid form is 
capable of subdivision into several varieties, 
according to the nature of its morbid pro- 
ducts. In the commonest and most charac- 
teristic variety the cavities and channels con- 
tain masses of spherical bodies like fish-roe, of 
a pinkish yellow or white colour, surrounded 
by gelatinous glairy matter. In certain cases, 
however, the roe-like bodies are almost or 
entirely absent, and the gelatinous matter 
and liquid oil are generally diffused through- 
out the tissues. In a third and very rare 
variety the section looks as though besprinkled 
with grains of red-pepper, from the presence 
of innumerable minute concretions of a bright 
red hue. 
Dark form.-The appearances presented 
in the dark form of the disease are strikingly 
different. Here, in place of the roe-like bodies 
of the previous form, the cavities and channels 
contain masses of a dark brown or black 
colour. These masses vary greatly in size, 
some not being larger than the normal fat- 
lobules surrounding them, others attaining to 
the size of a small orange. The larger masses 
greatly exceed any of the roe-like masses of 
the pale variety in size, and their consistence 
is also much firmer than that of the latter. 
They are tuberculated on the surface, and 
closely resemble truffles in appearance. On 
section, they present a more or less distinctly 
radiating structure, and the interior is gene- 
rally somewhat lighter in colour than the 
tuberculated exterior coating. In some cases 
they are tightly fitted into the cavities in 
which they lie, but in others they lie loose, 
and are surrounded by a certain amount of 
gelatinous matter. The amount of the latter 
present is, however, much less than in the 
pale form. 
The masses of morbid material in both 
forms are primarily situated in spaces nor- 
mally abounding in fat. Long series of them 
are frequently interpolated among the loculi 
in the subcutaneous tissue, between healthy 
fat-lobules; others occupy the interior of the 
bones; and a third series are developed in 
the pads of fat lying around muscles and 
tendons. The muscles and tendons in such 
cases may frequently be found quite intact, 
although surrounded by masses of the morbid 
material. Due to this persistence, fracture 
and crushing of the softened bones often 
occur, and it is on this that the distortion of 
the affected part is in many cases in great 
measure dependent. 
Minute characters of the morbid products. 
The roe-like particles are composed of a 
nucleus of granular, waxy consistence, sur- 
rounded by a fringe of radiating crystals. 
They appear to be almost entirely composed 
of fatty matter, and no traces of the presence 
of parasitic organisms of any kind can be 
detected in them. The bright red particles 
occurring in certain cases of the ochroid form 
are concretions, consisting in great part of 
phosphates and carbonates, and containing 
a considerable proportion of iron. 
The dark masses present in the other 
form of the disease are of much more com- 
plex structure. In all, or almost all, cases 
they contain septate fungoid filaments in 
greater or less proportion. These are some- 
times difficult to distinguish, but may gene- 
rally be detected by allowing portions of the 
material to soak for some days in liquor 
potassae. The proportion which the fila- 
ments bear to the entire mass, when thus 
separated, is in any case very small, and 
in some cases extremely so, for on the com- 
pletion of the soaking only a very small 
quantity of colourless flocculi, consisting of 
masses of branched filaments mixed with 
empty cyst-like cells, is left behind in the 
fluid. The latter has assumed a brown colour 
from the solution of the dark mass. The 
filaments and cysts (see the accompanying 
figure), in so far as tests have yet determined, 
Fig. 58.-Fungoid Filaments and Capsules obtained 
after prolonged maceration in caustic potash of 
the dark masses of fungus-disease, x 500. 
are indistinguishable from undoubted fungal 
elements. They are, as a rule, quite empty, 
and show no signs of growth, or indeed of 
life. The basis in which they are imbedded 712 
FUNGUS-DISEASE OF INDIA 
varies greatly in different cases. Tn some 
instances it is soft and. contains much oily 
matter, but in the more advanced cases this 
is almost absent. It is then only soluble by 
means of alkalis. The ash consists mainly 
of calcium phosphate, and is red, from the 
presence of oxide of iron. 
The fungoid filaments have never yet been 
shown to be capable of any further develop- 
ment. All attempts at cultivation have failed 
in causing them to assume any form by which 
their true nature and relationships may be 
determined. They have never given any un- 
equivocal signs of life external to the body, 
even when exposed to conditions favourable 
to the growth of fungi, as demonstrated by 
the development of various extraneous moulds 
upon the surface of the black masses them- 
selves, or on the media in which they were 
immersed.1 
Symptoms.--Dr. Carter writes : ' As a rule 
the local indications of this disease are the 
same for all its forms; for commonly it is not 
possible to discriminate the several varieties 
by simple inspection or bare clinical history 
of the case.' The statements made by the 
patients as to the mode of origin and progress 
of these complaints are very various; but, 
taken generally, they seem to imply that the 
symptoms are analogous to those usually 
observed in deep-seated disease of the 
osseous and adjoining tissues. Eventually a 
more or less hard lump is felt in the sole of 
the foot or palm of the hand, or in several 
places. Generally one or more abscess-like 
formations occur; and several sinuses are 
ultimately established, the latter, as a rule, 
presenting a peculiar mammillated appear- 
ance-the 'tubercles,' apparently, of earlier 
writers. Along with these changes, enlarge- 
ment and distortion of the affected member 
take place, but unaccompanied with severe 
pain. Discharges set in, more or less offen- 
sive, according to the nature of the subjacent 
degeneration, and the limb becomes not only 
useless, but a burden to its owner. Tn this 
manner the sufferer may go on for from one 
to fifteen or more years, unless relief be 
sought in a surgical operation. 
Course and Duration. -Both forms of 
fungus-disease run a very chronic course, and 
often without very materially affecting the 
general health of the patient; in some cases, 
however, great emaciation accompanies the 
disease. With regaid to the duration of the 
malady, it may be stated that cases have 
been recorded as having existed for various 
periods up to twenty-six or even thirty 
years. 
Pathology.-The occurrence of the fungoid 
filaments in the products of the dark variety 
of the disease has caused many authors to 
regard them as the essential cause of it. 
There are, however, good grounds for reject- 
ing such a conclusion. Had the dark form 
of the disease been the only one with which 
we were acquainted, there might have been 
some cause to regard it as due to parasitic 
agency. "When, however, we find that the 
pale form, whilst causing all the important 
lesions present in the other, shows a total 
absence of all fungoid elements in its pro- 
ducts, we are forced to regard such elements 
as of secondary importance. The only means 
of overcoming this objection would be a 
demonstration that the products of the pale 
form are due to a degeneration of the black 
matter, in the course of which the fungoid 
elements disappear. No such demonstration 
has been given, and, on the contrary, it has 
been shown that each form is capable of run- 
ning an entirely independent course, the 
gradual transformation of the normal fat 
having been traced in the one case to the 
production of the roe-like particles, and in 
the other to that of the black masses in 
which the fungoid elements are imbedded. 
Were the pale form the only one known, the 
disease might be described as a mere de- 
generation of the fatty tissues, with the re- 
sults consequent on the presence of the mor- 
bid products of the process in the surround- 
ing parts ; but this explanation, although so 
far applicable to the dark form, throws no 
light on the source of the fungoid elements. 
They are present in masses which are entirely 
isolated in the tissues, having no communi- 
cation with one another or with the exterior. 
There is no evidence of their passage from 
one cavity to another-on the contrary, they 
are absolutely limited to the contents of the 
cavities, the membranous walls of the latter 
and the intervening tissues never showing 
any traces of a spreading mycelium, or of 
any other fungal elements. 
Assuming the filaments to be of undoubted 
fungal origin, the facts point rather to their 
simultaneous and independent development 
in multiple centres, than to their spread from 
one to another. The fact of the necessity of 
a suitable soil or nidus, in addition to the 
mere presence of germs, in order to secure 
the development of organisms, is generally 
accepted. That germs of most various kinds 
must constantly be introduced into the blood, 
is a self-evident fact. Putting their intro- 
duction by means of the lungs out of the 
question, their constant introduction from 
the intestinal canal can hardly be denied. 
It can be demonstrated that the intestinal 
contents abound in vegetable organisms- 
spores, bacteria, &c.-in a living condition. 
As it is an ascertained fact that solid parti- 
cles of inorganic matter of far larger size 
than many of these germs can enter the cir- 
culation, it can hardly be denied that the 
latter may, and indeed must, enter also. So 
long as such bodies do not meet with con- 
1 The later researches of Dr. Carter and others 
(Lancet, July 2, 1892, p. 18) indicate that Fungus- 
Disease is identical with Actinomycosis. See Actino- 
mycosis.-Editor. FUNGUS-DISEASE OF INDIA 
GALL-BLADDER 
713 
ditions favourable to development, they are 
no doubt destroyed and utilised by the living 
matter of the blood and other tissues. If, 
however, they are deposited in a medium 
favourable to them, they will grow and 
undergo such development as they are 
capable of. The morbid products of the 
disease here described are practically dead 
material, external and extraneous to the 
body, and it has been experimentally demon- 
strated that, when removed from the body, 
they form a basis capable of supporting the 
growth of fungal organisms. Given these 
two conditions-the constant presence of 
germs in the circulation, and the possession 
of a suitable soil for fungi, and the difficulty 
of accounting for the presence of fungal 
elements in the latter appears in great part 
to be removed.1 
Treatment.-There are no instances re- 
corded of a spontaneous cure having been 
effected, nor have remedial applications 
proved of material permanent value in either 
form of the disease. Removal of all the dis- 
eased tissue, by amputation of the affected 
extremity, is the only remedy which meets 
with general approval. The subsequent 
treatment resolves itself into that of an 
ordinary surgical operation. 
D. D. Cunningham. T. R. Lewis. 
FUNGUS HJEMATODES {fungus, a 
mushroom ; alga, blood; and eiSos, form).-A 
synonym for soft malignant growths, which 
are exuberant and highly vascular, and there- 
fore peculiarly liable to bleed. See Cancer ; 
and Tumours. 
FURED, in Hungary.-Weak alkaline 
saline waters. See Mineral Waters. 
FURFUR (Lat. bran).-A bran-like de- 
squamation of the skin, met with in several 
cutaneous diseases, more especially pityriasis, 
psoriasis, and ichthyosis: scurf; dandruff. 
See Skin, Diseases of. 
FURFURACEOUS {furfur, bran).-A 
term applied to conditions in which the epi- 
dermis is shed in the form of bran-like scales. 
See Furfur. 
FURUNCULUS (Lat. a little rascal, 
dimin. of fur, a thief).-A synonym for boil. 
See Boil. 
GADFLY.-The popular name for a 
genus of insects whose larvae infest man 
and the lower animals. See (Estrus. 
GALACTAGOGUES {ya\a, milk; and 
aya>, I move). 
Definition.-Agencies which increase the 
secretion of the mammary gland. 
Enumeration.-The most common galac- 
tagogues are: Mental Emotions; Local 
Nervous Stimulation ; Warmth; good Food; 
Alcohol; Jaborandi; the fresh leaves of the 
Castor-Oil plant; Tonics ; and Electricity. 
Action.-When we consider how power- 
fully mental processes may affect the activity 
of nerves supplying the secreting structure of 
glands, we can understand how these may 
influence the secretion of milk, as of the 
sweat, the saliva, and the tears. The maternal 
feelings of joy, as well as the reflex stimula- 
tion of the infant's lips, act most rapidly in 
developing the functions of the breast. 
Warmth and good diet also play their part 
in the process. Alcohol in the form of malt 
liquors, or malt-extract, is a useful adjunct; 
and so are such tonics as iron, which counter- 
act in some measure the severe drain on the 
constitutional resources. Little use has yet 
been made in actual practice of those drugs 
which are specially credited with galact- 
agogue properties; but we are told on good 
authority that a poultice made of the fresh 
leaves of the castor-oil plant, aided by tea- 
spoonful doses of a fluid extract prepared 
from the same, has a markedly stimulating 
influence on the mammary secretion. Bella- 
donna is well known to dry up the milk ; and 
jaborandi, which is its antagonist in so many 
respects, has been shown to have here also a 
directly opposite effect, and to be a drug of 
which further use may yet be made when we 
wish to excite or re-establish the proper 
functions of the mammary gland. 
Robert Farquharson. 
GALACTIDROSIS (ydXa, milk; and 
perspiration). - A term signifying 
milky perspiration. See Sudoriparous 
Glands, Disorders of. 
GALACTORRHCEA (y<iXn, milk; and 
pew, I flow).-An excessive flow of milk. See 
Lactation, Disorders of. 
GALL-BLADDER AND GALL- 
DU CTS, Diseases of.-These affections 
may be considered in the following order: 
(1) Catarrh; (2) Inflammation and its Re- 
sults ; (3) Stricture; (4) Dilatation; (5) Can- 
cel ; (6) Foreign Bodies; (7) Enlargement 
1 See footnote on preceding page.-Editor. 714 
GALL-BLADDER 
of the Gall-bladder; (8) Perforation; and 
(9) Biliary Fistula. 
1. Catarrh of the Bile-passages.- 
This disease very rarely gives opportunities 
for examination after death. At the period 
after death at which it is customary to make 
post-mortem examinations in this country, 
all redness of the duct has usually disap- 
peared ; and there are left only swelling and 
pallor of the mucous membrane, which is 
covered with a tenacious glassy or purulent 
secretion. By this swelling and secretion 
the bore of the duct is often greatly narrowed; 
and it can be seen that no bile has passed 
over it for some days, as all colour has dis- 
appeared from the affected part of the tube. 
In judging of this, however, no pressure must 
have been made upon the gall-bladder during 
the earlier part of the examination. These 
appearances are most pronounced in the 
common duct and the gall-bladder; they are 
gradually lost in the hepatic duct and its 
branches in the liver. The process seems 
most intense at the duodenal end of the gall- 
duct, and the orifice of the papilla itself is 
often found plugged by mucus, an appearance 
which certainly favours the notion that the 
catarrh is propagated from the stomach and 
duodenum. This is believed to be the com- 
monest source of catarrh of the bile-ducts. 
It is also seen in nutmeg-liver and cirrhosis; 
and a tendency to chronic catarrh is set up 
by the presence of foreign bodies in the 
ducts, such as gall-stones. 
Symptoms.-Jaundice is often the first 
symptom which draws the attention of the 
patient to his health in a case of catarrh of 
the bile-ducts, although in a certain number 
of cases this is preceded by symptoms of 
gastric disorder, such as vomiting or sense of 
sickness, loss of appetite, and furred tongue ; 
or, on the other hand, by diarrhoea. The 
jaundice lasts usually about three weeks, 
sometimes as much as six or eight weeks. 
After this, suspicion should be aroused 
whether something more than a simple 
catarrh be not present. 
Diagnosis.-The diagnosis depends upon 
the absence of any physical signs indicating 
organic change in the liver; and on the 
presence of gastric symptoms. Thus nearly 
all cases of simple jaundice are diagnosti- 
cated by some physicians as cases of catarrh 
of the bile-ducts. As the greater number of 
the patients recover, very few opportunities 
are given for verifying this diagnosis; but in 
those which have been examined, plugs of 
mucus in the ducts have not infrequently 
been found. The catarrh caused by gall- 
stones is lost in the jaundice and pain asso- 
ciated therewith. 
Treatment.-The treatment should at first 
be directed to the gastric symptoms, begin- 
ning with a purgative, followed by a course 
of effervescing alkaline medicines, and re- 
stricted diet. Later on, dilute nitro-hydro- 
chloric acid taken before meals is often very 
useful. Daily enemata of one or two quarts 
of water, at a temperature of from 60° to 
90° F., to be retained as long as possible, 
have been recommended. 
2. Inflammation and its Results.- - 
In some cases of typhus and typhoid fever, 
and in other typhoid states, the gall-duct 
and gall-bladder become ulcerated, or filled 
with purulent fluid, or covered with croupous 
exudation. The same thing may happen 
when gall-stones are impacted in the ducts. 
The gall-ducts are sometimes obliterated by 
fibrous bands passing over them. Sometimes 
they suffer a congenital obliteration by the 
over-growth of the fibrous tissue around them. 
3. Stricture.-Stricture of the gall-duct 
is occasionally met with. Usually it is asso- 
ciated with the presence of gall-stones. It 
would seem most probable that it arises 
from inflammation and ulceration of the 
duct produced by the transit or impaction 
of calculi. On the other hand, it is possible, 
though not probable, that it may be primary, 
and by impeding the escape of bile give rise 
to gall-stones. Stricture of the gall-duct 
causes dilatation of the ducts or gall-bladder 
behind. 
4. Dilatation.-The gall-ducts and gall- 
bladder become dilated whenever there exists 
an obstruction, either pressing on the ducts 
from the outside, or formed within them. 
The first result is dilatation of the ducts 
behind the obstruction. The gall-bladder 
becomes much dilated, often filled with a 
thick green bile. If the obstruction last long, 
the coloured part of the bile is absorbed, and 
its place taken by a colourless fluid, either 
viscid or limpid. This fluid contains neither 
bile-pigment nor bile-acids, is often albu- 
minous, and contains abundance of mucus. 
The ducts outside the liver may be enormously 
distended. It is common to see them as big 
as the middle finger. Within the liver they 
are also dilated, but not to so great a degree; 
and they are more dilated on the left than on 
the right side. The dilatation of the ducts 
may become cystic, and sometimes monili- 
form. The writer (J. W. L.) has always been 
able to find columnar epithelium in these 
dilated ducts. In some cases of long-continued 
obstruction, the contents of the bile-ducts be- 
come colourless; in other cases, purulent; 
and small abscesses form around the bile- 
ducts, and open into them. These abscesses 
may be multiple ; or, more commonly, only 
a single large one is formed. The abscess or 
the dilated gall-ducts may rupture into the 
peritoneum, and cause fatal peritonitis. 
5. Cancer.-Primary cancer of the gall- 
ducts and gall-bladder is sometimes met 
with ; or they may be affected secondarily. 
6. Foreign Bodies.-Foreign bodies are 
occasionally met with in the gall-ducts. The 
most common of all are, of course, gall- 
stones. Much less common are entozoa, GALL-BLADDER 
GALL-STONES 
715 
such as the Distoma hepaticum, hydatids, 
or the two kinds of ascarides, especially 
lumbrici. 
Symptoms.-In all these different morbid 
states it is usually only possible to say at 
the bedside that the large bile-ducts are ob- 
structed ; a more complete diagnosis is com- 
monly impossible. Jaundice is an important 
symptom, as without it disease of the bile- 
ducts cannot be diagnosticated. It is com- 
monly very intense, the urine being deeply 
coloured, and the faeces quite colourless. The 
enlargement of the liver, if present, is com- 
monly uniform, the surface being smooth, 
and the edges well-defined. The gall-bladder 
may often be felt at the edge of the right lobe 
as a rounded tumour; this is then a sure 
sign of the obstruction of the gall-ducts. In 
simple diseases of the gall-ducts there is an 
absence of splenic tumour, of ascites, and of 
other symptoms of portal obstruction. In 
many cases, however, diseases of the liver 
and of the gall-ducts are so intimately bound 
up together, that they cannot, during life, be 
separated. 
Prognosis.-The prognosis, if simple ca- 
tarrh of the gall-ducts and gall-stones can be 
excluded, is unfavourable. 
Treatment.-The treatment must be con- 
ducted on general principles. 
7. Enlargement of the Gall-bladder. 
The gall-bladder cannot be felt in health 
during life. But it may often readily enough 
be made out where there exists any obstruc- 
tion in the common or cystic duct, so that it 
becomes distended with fluid. It may also 
be felt when the walls become fibrous or 
calcified, or the seat of cancer; or when its 
cavity is filled with gall-stones. A tumour 
may then be felt under the border of the 
right lobe of the liver, in the situation of 
the gall-bladder. When filled with fluid, a 
rounded, sometimes oblong, sometimes pear- 
shaped tumour is felt; in other cases it has 
an irregular shape, or a somewhat rounded 
outline. The gall-bladder usually enlarges 
in a direction obliquely downwards and for- 
wards in a line which, drawn from the tenth 
costal cartilage, crosses the middle line a 
little below the umbilicus (Mayo Robson). 
A greatly distended gall-bladder has been 
mistaken for ascites, and tapped. The dia- 
gnosis depends chiefly on the situation of the 
swelling, and even then the distended gall- 
bladder may be mistaken for hydatid disease 
of the liver-substance or of the omentum, or 
for a tumour of a neighbouring organ, es- 
pecially the right kidney, which has pressed 
against the liver. The difficulty of the dia- 
gnosis is much increased if the liver be moved 
from its natural place, for then the position 
of the gall-bladder becomes uncertain. Bam- 
berger says he has often mistaken a softened 
cancerous nodule of the liver for a distended 
gall-bladder. If it be certain that a fluctuat- 
ing tumour be the gall-bladder, and no jaun- 
dice be present, a diagnosis may safely be 
made of hydrops cystidis fellece, or dropsy of 
the gall-bladder ; but if jaundice be present, 
or if the tumour do not fluctuate but appear 
solid, there are then no definite rules for 
diagnosis : all depends upon the surrounding 
facts of the case. Dropsy of the gall-bladder 
is not a dangerous disorder, and requires 
no treatment; while the prognosis and treat- 
ment of the other states depend entirely on 
their respective causes. Surgical treatment 
is now extensively employed. 
8. Perforation.-Perforation of the gall- 
bladder or of the gall-ducts is generally the 
result of ulceration, due to gall-stones, in- 
flammation, and other causes. Fatal peri- 
tonitis ensues if the perforation occur into 
the abdominal cavity. Frequently, however, 
previous adhesions have been formed between 
the biliary reservoir or duct and the neigh- 
bouring organs, as the intestine, or the 
abdominal wall, and the result of this is- 
9. Biliary Fistula. - This may exist 
between the gall-bladder or gall-ducts and 
the surface of the body, the stomach, colon, 
or duodenum. Very rarely gall-stones find 
their way into the urinary tract. 
J. Wickham Legg. Stephen Mackenzie. 
GALL - STONES. - Synon. : Hepatic 
Calculi; Cholelithiasis ; Fr. Calculs biliaires; 
Ger. Gallensteine. 
Description.-Gall-stones are seen in man 
and most of the vertebrate animals, and in 
some molluscs. They are especially common 
in oxen. They are found in the biliary 
passages; most usually in the gall-bladder, 
or the cystic and common duct; more rarely 
in the hepatic duct, and in its branches within 
the liver. They vary in size from fine 
gravel to concretions five inches long. The 
largest are commonly single, and then they 
are rounded or oval in shape. The smaller 
calculi are usually numerous, being then 
tetrahedral or wedge-shaped, showing the 
facets or plane surfaces caused by mutual 
pressure or friction. They are never lighter 
than water when first removed from the 
body. Only after drying do they float. Their 
consistence when raised to the ordinary tem- 
perature of the body becomes much less, so 
that they can be moulded by the fingers. 
Their colour varies from white to almost 
black; most commonly it is brown. 
Dr. Thudichum thinks that the nuclei of 
gall-stones are mostly formed of casts of the 
hepatic ducts. There is rarely more than 
one nucleus. Its chemical composition is a 
compound of lime and bile-pigment, or traces 
of mucus and phosphatic earths. The chief 
chemical constituent of human gall-stones is 
cholesterin; some gall-stones are wholly 
composed of this substance; most contain 
70 or 80 per cent. Other constituents of 
gall-stones are the bile-pigments, either bv 
themselves or in combination with lime. Very 716 
GALL-STONES 
small quantities of the bile-acids are found, 
and these are also in combination with lime. 
It is rare to find gall-stones with any large 
amounts of carbonate or phosphate of lime, 
though the ash of nearly all gall-stones shows 
a large amount of carbonate of lime, the 
product of the combustion. Traces of copper, 
iron, and manganese are found in nearly all 
gall-stones. Lime-salts of the fatty acids are 
likewise found. 
^Etiology.-Age has an apparent influence 
in the production of gall-stones: they are 
exceedingly rare in infancy and childhood, 
their frequency increases after the age of 
nuberty, and they become still more common 
after thirty. Women are thought to be more 
liable than men to gall-stones. In cancer of 
the liver, gall-stones are certainly very com- 
monly found, while on the other hand in 
cirrhosis they are scarcely ever seen. Want 
of physical exercise and indulgence in rich 
diet seem to favour their production. 
Pathology.-What is the cause of the first 
formation of a gall-stone 'I It is not simply 
concentration of the bile, since the cholesterin 
and pigment remain in solution so long as 
the bile is unchanged; but the beginning of 
decomposition of the bile-acids causes a pre- 
cipitation. The cholesterin is likewise thrown 
down when the reaction of the bile changes 
from alkaline to acid. Gorup-Besanez and 
Dr. Thudichum have kept bile several months, 
and found the reaction at the end of that 
time acid, with an abundant sediment. It is 
thus probable that the retention of bile in 
the gall-bladder or gall-ducts favours the for- 
mation of these concretions. It is also prob- 
able that gall-stones may be dissolved spon- 
taneously, as erosions are sometimes seen on 
them; or they may break up, and thus pass 
out. 
Symptoms.-Gall-stones while still in the 
gall-bladder rarely give any signs of their 
presence. They are frequently found in the 
gall-bladders of persons who during life had 
no symptoms which could be referred to the 
liver. It is when they begin to leave the 
gall-bladder, and escape into the cystic and 
common duct, that symptoms arise of gall- 
stone colic. They often begin with a dull 
pain near the liver, with vomiting, rigors, 
and elevation of temperature; or, quite sud- 
denly, a severe pain in the right hypochon- 
drium comes on, described as shooting, 
stabbing, burning, &c. The pain extends 
into the epigastrium, rarely to the left hypo- 
chondrium, to the right shoulder, and, 
according to some, even into the extremities. 
The pain is very intense, and may give rise 
to delirium and convulsions in nervous per- 
sons, or to hysterical attacks in women. 
Vomiting is usually present; and, as the 
attacks most often come on after eating, at 
first only the food taken is thrown up, and 
then a colourless mucus. The right hypo- 
chondrium is usually very tender, and the 
muscles are rigid. The pulse, as a rule, is not 
increased in frequency, being indeed rather 
below than above the natural number. In 
violent attacks the pulse becomes very fre- 
quent and small, or almost imperceptible; the 
eyes are surrounded with dark marks; the 
nose is pointed ; the breath is cool; and cold 
sweats break out over the body. In this state 
death may occur, but it is a rare event. A 
few hours after the attack, the conjunctivae 
may show a yellow tinge, which will gradually 
spread from the upper part of the trunk all 
over the body. The jaundice is more or less 
intense according to the shape of the gall- 
stone-whether completely obstructing the 
duct, or merely causing a hindrance to the 
passage of the bile. In some cases jaundice 
may be altogether wanting, as when the 
stone is in the cystic duct. The jaundice 
may last an indefinite time. The duration 
of the attack of colic itself varies: usually 
not lasting more than a few hours, it may 
extend over several days. As soon as the 
gall-stone reaches the duodenum the attacks 
are over, the stools become dark, and the 
jaundice begins to disappear. When the 
gall-stones reach the intestine, they are com- 
monly evacuated with the feces; some cases 
have, however, been recorded in which they 
were so large that symptoms of intestinal 
obstruction were caused and death resulted. 
A gall-stone ulcerating its way into the in- 
testine may give rise to haemorrhage from 
the bowels. Other rare symptoms are oc- 
casionally associated with gall-stones, as in- 
termittent pyrexia, glycosuria, and enlarge- 
ment of the spleen. 
Diagnosis.-The diagnosis of gall-stones is 
often more or less difficult. Some physicians 
think that the diagnosis should not be made 
unless the concretions be found in the stools; 
and the search for them should be made by 
passing the feces through a sieve. It is 
thought by many that it cannot be made if 
there be no jaundice present. On the other 
hand, it has been proved that severe and 
even fatal attacks have occurred without the 
occurrence of jaundice or discoloration of 
the feces. Recurrent attacks of severe 
' spasm ' in the right hypochondrium or epi- 
gastrium should awaken a suspicion of gall- 
stones, even if no j aundice follow the attacks. 
Persistent jaundice is characteristic of cancer 
rather than of gall-stones, though the two 
may co-exist. Cancer of the head of the 
pancreas may readily be mistaken for gall- 
stones in the common duct. 
Prognosis. - It is almost impossible to 
make a trustworthy prognosis in these cases. 
The physician can never speak confidently, 
or feel quite happy when treating a case 
which he looks upon as one of gall-stones. 
Treatment.-The treatment of gall-stones 
may be discussed under two heads: during 
the paroxysm of the colic ; and between the 
attacks. GALL-STONES 
GANGLION 
717 
During the paroxysm the object is to re- 
lieve pain. This may best be done by full 
doses of morphine; and if this be rejected 
by vomiting, it may be administered hypo- 
dermically. Belladonna may also be used. 
The patient may be put in a warm bath and 
kept there, the heat being maintained by the 
renewal of the warm water. Should these 
means fail, chloroform or ether may be in- 
haled. 
Between the attacks of biliary colic dieting 
is of great importance. Limiting, or practi- 
cally excluding, saccharine and fatty matters 
sometimes leads to the cessation of attacks, 
which were previously frequent. A great 
number of remedies have been proposed: 
the most popular is Durande's, which con- 
sists of three parts of ether and twro parts of 
turpentine ; the best plan is to give 10 to 20 
minims of this mixture three times a day, 
enclosed in capsules or pearls. The German 
physicians have great confidence in the al- 
kaline mineral waters, especially Carlsbad. 
Some think the benefit is due simply to the 
large amount of water daily ingested, causing 
a large flow of bile. Lately, an old plan of 
treatment has been revived-namely, the ad- 
ministration of large doses of olive oil, as 
much as six to twelve ounces being given for 
a dose. Following the administration of the 
oil, numerous concretions have been found in 
the stools, which have been mistaken for gall- 
stones. They have, however, been proved to 
consist of neutral fats and free fatty acids, 
with a small proportion of cholesterin. Though 
the oil does not soften and bring away gall- 
stones as imagined, yet undoubted relief is 
sometimes afforded, with diminution in the 
size of the swollen liver. Dr. George Harley 
advocates extrusion of gall-stones blocking 
the ducts by digital manipulation. The 
obstruction has, in some cases, been over- 
come by this means, but it is treatment 
which should be carried out only with 
great care and gentleness, as the gall-duct, 
inflamed, softened, and ulcerated by the 
presence of a stone, might be ruptured by too 
forcible manipulation. In cases of enlarged 
gall-bladder from gall-stones, or repeated 
attacks of severe pain in the hepatic region, 
with or without jaundice or suppuration of 
the gall-ducts, the aid of a surgeon should 
be obtained, with a view to an exploratory 
operation or cholecystotomy. The cases re- 
corded where this and other operations on the 
gall-bladder and ducts have been performed 
justify a hope that in future many lives will 
be saved which would without operative in- 
terference be lost. Other kinds of treatment 
recommended are by purgatives, as castor oil, 
or by taraxacum or diluted nitro-hydrochloric 
acid. Emetics have been employed, but 
they are dangerous on account of the strain- 
ing which they cause, and which may lead 
to the rupture of a vessel. 
J. Wickham Legg. Stephen Mackenzie. 
GALLOPING CONSUMPTION. 
A popular name for phthisis when it runs an 
acute or rapid course. See Phthisis. 
GALVANISM, Uses of.-See Elec- 
tricity in Medicine. 
GANGLION (yayyXtov, a hard gather- 
ing).-This term is applied to a variety of 
somewhat different affections, including: 
1. The simple ganglion. This is a cystic 
tumour formed in connexion with the sheath 
of a tendon. 2. The compound or diffuse 
ganglion, which consists of a chronic effusion 
into the common sheath of a group of ten- 
dons, giving rise to a fluctuating swelling. 
One variety of this contains the so-called 
melon-seed-like bodies. 3. The term is ex- 
tended by some writers to enlargements of the 
bursae mucosae. See Bursae, Diseases of. 
1. Simple Ganglion.-Description.- 
The simple ganglion forms a rounded 
tumour, occasionally lobulated, in the imme- 
diate neighbourhood of some tendon. The 
most common situations are the dorsum of 
the hand, the dorsum of the foot, the palm of 
the hand at the root of a finger, and behind 
the outer or the inner malleolus. The tumour 
varies in size from a pea to a pigeon's egg. 
It may fluctuate distinctly, or be so tense 
as to seem solid. It is not adherent to 
the skin or to the tendon with which it is 
in relation. It is painless, but often gives 
rise to a sense of weakness in the affected 
part. The wall is composed of a more or less 
delicate fibrous tissue, fusing with the sur- 
rounding areolar tissue, and lined by an 
imperfect layer of endothelial cells. Its con- 
tents are most usually semi-sohd, like apple- 
jelly, but sometimes fluid; they are said to 
be neither albuminous nor gelatinous, but 
colloid in character. As to the exact nature 
of the tumour opinions differ, and probably 
it is not always the same. It is said to arise 
in the following ways : 1st. By a hernial 
protrusion from the sheath of a tendon, the 
neck of which becomes gradually contracted 
and finally closed, so giving rise to a cyst in 
intimate connexion with the sheath. 2nd. 
Gosselin has described small follicles or 
sub-synovial crypts, which he believes may 
become dilated, so as to form ganglia. 
3rd. The tumour may be a cyst of entirely 
new formation. 
Treatment.-Painting with iodine is of 
little or no use. Forcible rupture of the 
cyst by a blow or pressure sometimes effects 
a cure. The best treatment is to puncture 
the tumour with a clean grooved needle, and 
to squeeze out the contents, afterwards 
applying pressure or a blister over the col- 
lapsed cyst. This treatment may require to 
be repeated more than once. 
2. Compound or Diffuse Ganglion.- 
Description.-This disease is almost ex- 
clusively confined to the sheath of the com- 
mon flexors of the fingers. It may consist of 718 
GANGLION 
GANGRENE 
a simple dropsy of this sheath, forming an 
hourglass-shaped swelling in the front of the 
wrist, the constriction being caused by the 
annular ligament; or, in other cases, the 
tumour may contain melon-seed-like bodies, 
which give rise to a sense of soft crackling 
when it is manipulated. These melon-seed 
bodies are smooth, oval and flattish in shape, 
and of a pearly-white colour. They are of 
almost cartilaginous toughness, and on sec- 
tion present an appearance of concentric 
lamination. Under the microscope they are 
found to be composed of very imperfect 
fibroid tissue. Their origin is somewhat 
doubtful. They have been supposed to be 
due, first, to hypertrophy of the fringes nor- 
mally found on a synovial membrane, the 
pedunculated projections so formed being 
ultimately broken loose by the movement of 
the tendons; secondly, to the formation of 
pedunculated warty outgrowths on the syno- 
vial membrane, which become free in the 
same way; thirdly, to fibrinous deposits 
taking place from the fluid in the ganglion; 
and, fourthly, to the results of accidental 
haemorrhage. When these bodies are abun- 
dant, the fluid is usually scanty. 
^Etiology. - Recent observations have 
shown that in the great majority of cases, if 
not in all, the compound ganglion of the 
wrist is a chronic tubercular affection of the 
synovial membrane. Many cases have been 
recorded in which it was associated with 
tubercular disease of the carpus, but which 
was the primary affection is not certain. 
Treatment.-The treatment of compound 
ganglion is unsatisfactory. Iodine is useless. 
Aspiration followed by the injection of iodine 
has occasionally been of service. An incision 
made into each end of the tumour, followed 
by drainage under antiseptic dressing, is 
often of use. In extreme cases Syme recom- 
mended laying the whole cavity open, and 
allowing it to granulate. This always left 
much stiffness in the tendons. When melon- 
seed bodies are present, they must be re- 
moved by incision, and the case treated 
antiseptically, as septic suppuration would 
almost certainly lead to implication of the 
wrist-joint. Marcus Beck. 
GANGLIONIC NERVOUS SYS- 
TEM, Diseases of.-See Sympathetic 
System, Diseases of. 
GANGRENE (ypaiua>, I corrode).- 
Synon. : Mortification; Sphacelus; Fr. Gan- 
grene ; Ger. der Brand. 
Definition.-Gangrene is the arrest of the 
functions of organic life in a circumscribed 
portion of the soft parts of the body, leading 
to the complete death of the same. It im- 
plies destruction of a considerable area of 
tissue en masse, as distinguished from mole- 
cular disintegration or ulceration. 
The whole process of death is included 
under the term ' gangrene '; the result being 
mortification, sloughing, or necrosis of the 
invaded tissue, organ, or limb. 
Classification. - Clinically, gangrene 
varies greatly according to its position, 
cause, extent, the powers of the patient, and 
the existence of complications. The disease 
may also be classified (etiologically and 
pathologically into spontaneous or trau- 
matic, dry or moist, chronic or acute gan- 
grene, senile gangrene, and hospital gan- 
grene. The division into dry and moist 
gangrene, although convenient, has little 
pathological significance, being founded on 
physical characters. Both dry and moist 
gangrene may arise from similar causes, and 
coexist even, in different parts of the invaded 
structures; and it cannot always be predeter- 
mined whether a gangrene shall be of the 
dry or of the moist form. Dry gangrene is 
usually dependent on senile changes, chiefly 
arterial degeneration; and is more limited in 
extent, and chronic in progress. The parts 
first affected, having time to dry up as the dis- 
ease invades those adjacent, become mummi- 
fied, hard, and black, resembling the knuckle 
of a Spanish ham. Moist gangrene occurs 
from venous obstruction ; and when a large 
area of living tissue suddenly mortifies, more 
especially if it have been previously inflamed 
or gorged with fluid, the dead parts become 
rapidly transformed into a deliquescent putrid 
mass, infiltrated with gas. To this type be- 
long many different forms of gangrene-for 
instance, that following the obliteration of the 
main artery or vein of a limb, or their be- 
coming plugged by embolus; or the form 
called spreading traumatic gangrene; or gan- 
grene affecting an internal organ. 
Etiology.-The causes of gangrene may 
be local and constitutional, or a combination 
of both. Amongst local causes we find intense 
inflammation of some organ or tissue, such as 
occurs in pneumonia, noma, cellulitis, anthrax, 
or phlegmonous erysipelas. Injuries and 
mechanical violence of various kinds, caustics, 
and extremes of heat or cold, as seen in 
burns and scalds or in frostbite, also lead to 
gangrene. Gangrene may be produced either 
as the direct consequence of the long-con- 
tinued application of cold, or as the result of 
the subsequent inflammatory reaction. Local 
arrest of the circulation, as in a limb whose 
main blood-current is arrested by injury, the 
application of a ligature to an artery or em- 
bolic plugging, a strangulated hernia, an 
intussusception, or internal strangulation, a 
ligatured hEemorrhoid, a too tightly bandaged 
limb, or severe paraphimosis, may lead to 
gangrene. It may also occur from extra- 
vasation of urine or faeces. Continued 
pressure produces a variety of gangrene 
called bed-sore, especially in lowly vitalised 
parts, and in persons suffering from chronic 
diseases, or from certain lesions of the ner- 
vous centres. See Ulcer and Ulceration. GANGRENE 
719 
One of the most frequent constitutional or 
general causes of gangrene is deficient blood- 
supply to the part, dependent upon chronic 
disease of the arteries, the result of arteritis or 
degenerative senile changes, whence the term 
senile gangrene. Gangrene may occur in the 
course of certain diseases, as diabetes, typhus, 
typhoid, measles, and scarlatina; embolism 
being in many cases the immediate cause of 
the complication. The gangrene due to 
ergotism is probably induced by the effect 
of the poison on the blood-vessels. A 
peculiar form of gangrene sometimes met 
with in the extremities-the gangrene syme- 
trique of the French-is one in which no 
more definite cause can be found than 
anaemia and an extremely feeble circulation. 
Loss of nerve-influence is also a cause of gan- 
grene. Acute spreading traumatic gangrene 
is a manifestation of a hyperacute form of 
septic infection. And, finally, there is hospital 
gangrene-pourriture d'hopital-a disease 
seldom met with now except amongst wounded 
soldiers accumulated in great numbers in foul 
hospitals near a battle-field, contagious in 
nature, and due to a specific septic agency. 
See Raynaud's Disease. 
Symptoms.-The symptoms of gangrene 
vary with the species, the extent, and the 
stage of the disease, and with the rapidity of 
its progress ; and also according as it is dry 
or moist, incipient or complete. The import- 
ance of the tissue or organ invaded, and the 
presence or absence of complications, such 
as renal or cardiac disease, or of fever, also 
create differences. 
The earliest symptoms are those of dimin- 
ished circulation, sensibility, and tempera- 
ture, together with change of colour in the 
part affected. Pain is one of the primary 
symptoms, and often precedes the others. 
In dry, senile, or chronic gangrene there 
may in some cases be few symptoms beyond 
moderate local pain and discomfort, though 
oftentimes the pain is intense ; whilst, when 
the type is of the moist or acute variety, the 
symptoms are usually more severe, and have 
a tendency to lapse into those called typhoid 
or septicsemic. Between these two forms 
there is every intermediate grade of severity. 
The amount of fever varies at the outset, but 
it is usually considerable. The patient gene- 
rally suffers much from pain, restlessness, 
and want of sleep; the appetite is bad; the 
tongue is loaded; and the pulse is feeble or 
intermittent. When the disease becomes 
arrested, the dead portion of tissue slowly 
separates and drops off, or is removed ; very 
often, however, the disease steadily pro- 
gresses, and the patient dies from exhaus- 
tion, or more rapidly from the absorption of 
septic matter. 
Such being the principal symptoms of 
gangrene in general, we may next describe 
the symptoms of the leading varieties of the 
disease. 
Dry or Chronic Senile Gangrene.-In the 
dry form of senile gangrene the part is gradu- 
ally starved to death by reason of the dimin- 
ished blood-supply. Embolic plugging may 
also produce the dry variety. The arterial 
current is suddenly arrested, while the veins 
empty the blood from the limb. The limb 
becomes whitish-mottled and shrunken, then 
brown and black. Senile gangrene generally 
occurs in the toes, very rarely in the fingers ; 
and is either spontaneous or excited by some 
trivial cause. A discoloured patch appears 
on one of the toes, of a dusky reddish-brown 
colour, which soon becomes dry and black in 
the centre. The disease spreads very slowly 
to the adjacent parts. First, a zone of dis- 
coloration appears, from the blood stagnating 
in them; then they become livid, red, and 
inflamed; afterwards darker; and, finally, 
black and dry. One or several toes may be 
involved, or the foot in whole or in part. 
The patient generally dies sooner or later, 
exhausted by pain, and from general feeble- 
ness of the vital powers. Sometimes a line 
of demarcation appears, the dead parts sepa- 
rate, and recovery follows; but as a rule 
relapses take place. 
Moist or Acute Senile Gangrene.-This 
form of senile gangrene is more active in its 
progress, and more rapidly fatal. It is often 
ascribed to some slight local irritation or 
injury, such as an inflamed corn or nail. 
The affected toe becomes dusky-red, swollen, 
and extremely painful; soon after the dark 
hue of absolutely dead tissue appears, fol- 
lowing closely the zone of inflammation; 
and this gradually spreads onwards, till the 
whole foot or possibly the leg, if the patient 
survive, becomes implicated. Beyond the 
gangrenous area the skin is mottled, and 
presents all the appearances due to impeded 
circulation. In this type of gangrene, stasis 
of the blood and coagulation first take place 
in the capillaries, and extend thence to the 
smaller arteries. It occurs in elderly persons 
with feeble circulation, due to fatty heart and 
atheromatous arteries. Diabetic gangrene is 
commonly of this form. 
Gangrene from Arterial or Venous Ob- 
struction.-The most common form of moist 
gangrene is that due to sudden arterial ob- 
struction of a large vessel, when the col- 
lateral supply cannot establish itself with 
sufficient rapidity. It is acute ; and a large 
portion of the body being at once engaged, the 
tissues do not, as in dry gangrene, have time 
to desiccate pari passu with the spread of 
the disease. It may happen after ligature 
of a main trunk for aneurysm; or by the 
impaction of a fibrinous clot formed upon 
the roughened wall of an atheromatous vessel, 
and consequent plugging of the artery, or 
by embolism. This form of gangrene often 
assumes the dry character. An entire ex- 
tremity may be thus affected. Venous ob- 
struction does not produce gangrene unless 720 
GANGRENE 
complete. Collateral venous channels usually 
take the place of obstructed ones with ease. 
In cases due to embolism-a form rare in 
the upper limbs, but common in the lower 
extremities, and more especially at the bifur- 
cation of the tibial arteries-sudden and 
severe pain marks the onset of the disease. 
The temperature of the part rapidly falls; 
livid discoloration and loss of sensibility en- 
sue ; the blood stagnates in the veins; the 
skin mottles; bullae form, filled with turbid 
fluid; the colour changes from whitish-grey 
to green, olive, or black; and the affected 
tissue at length becomes a deliquescent 
putrid mass, often crepitating from gas im- 
prisoned in the meshes of the cellular tissue. 
The tendons, blood-vessels, nerves, and bone 
resist the disintegrating process longest. 
Gangrene from Inflammation. - Gan- 
grene as the result of intense inflammation 
is likewise of the moist type. When it super- 
venes, the tension, pain, and swelling of the 
inflamed area subside; the part becomes soft 
and doughy; the colour changes into dusky 
violet, brown, or black; and all the evidences 
of rapid decomposition, varying with the 
part affected and the acuteness of the in- 
flammation, make their appearance. 
Gangrene as a Complication of General 
Disease.-Gangrene is occasionally met with 
in the later stages of typhoid fever, or even 
during convalescence; and usually occurs in 
the lower limbs, though sometimes in the 
face or in the lungs. It is of vascular origin, 
and is a most grave complication. In form 
it may be either dry or moist, and may be 
of either of two kinds. One is of early occur- 
rence in the progress of the disease, and 
generally affects the toes symmetrically; the 
other occurs later, or during convalescence, 
and is of embolic origin. 
Measles is prone in some cases to occasion 
gangrene, generally affecting the face, the 
vulva, or the lungs. Scarlatina and some 
forms of erysipelas are also occasionally fol- 
lowed by extensive gangrene. The disease 
has been also observed during some epidemics 
of cholera. Gangrene produced by the pro- 
longed consumption of diseased rye-bread 
chiefly occurs in the male adult, and very 
rarely in women or children. Other symp- 
toms of ergotism will then be present, gan- 
grene being a late occurrence. Gangrene 
from ergotism precisely resembles ordinary 
senile gangrene. It almost invariably ap- 
pears in the lower limbs; and when a line of 
demarcation forms, this generally seems to 
correspond with the nearest joint. In dia- 
betic gangrene no special vascular deficiency 
can be traced. The vitality of the tissues 
seems impaired by the glycosuric condition, 
and some slight accidental cause provokes a 
gangrenous inflammation. 
Hospital Gangrene.-- Hospital gangrene 
presupposes a wound. The lesion on invasion 
ceases to discharge, and becomes covered 
with a grey tenacious slough extending from 
the centre towards the edges, which become 
much inflamed and everted. The patient 
rapidly lapses into a typhoid condition; and 
the issue is generally fatal. 
Acute Traumatic or Spreading Gangrene. 
This form also follows upon an injury, 
which may be either slight or severe. It 
is generally seen in one of the extremities, 
originating in a wound and rapidly spreading 
towards the trunk-gangrene foudroyante. 
It is in many cases intimately associated with, 
and probably induced by, septic infection ot 
the system. It is usually fatal, and scarcely 
amenable to any treatment short of very 
early amputation. 
Visceral Gangrene.-The gangrene of in- 
ternal organs will be found described in con- 
nexion with the diseases of the several organs. 
Progress.-The progress of gangrene de- 
pendent on constitutional causes is too often 
from bad to worse; and a fatal issue may 
supervene without any attempt at repair. 
The gangrenous inflammation, preceding the 
actual death of the part, continually invades 
fresh tissues; the fever increases; a sallow 
sunken countenance, with rapid thready 
pulse, sordes, muttering delirium, tympanites, 
hiccough, subsultus, scanty loaded urine or 
even suppression, supervene; the weakness 
increases; and death, preceded by collapse, 
takes place. 
In other cases, especially those dependent 
on local causes, there is a tendency to limita- 
tion ; and the process by which this is accom- 
plished is the same for all kinds of gangrene, 
in every part of the body. In superficial 
structures a red band of healthy inflammation 
will be observed at the junction of the living 
with the dead part, called the line of demar- 
cation ; active cell-infiltration takes place; 
and a separating wall of fibrin and young 
cells is established in the layer of living tissue 
nearest to the dead structures. This becomes 
by degrees converted into an ordinary granu- 
lating surface, and the dead tissue is detached 
and cast off. The time required for this 
separation varies with the bulk of the dead 
portion, the nature of the tissue, and the 
vitality of the individual. The risk of sep- 
ticaemic poisoning is present throughout the 
entire course of the disease. 
Diagnosis.-The diagnosis of gangrene of 
external parts cannot be attended with any 
difficulty-; the evidence of its presence being 
readily appreciated when the symptoms 
already described make their appearance. 
Prognosis.-The prognosis of a case of 
gangrene will mainly depend on the likeli- 
hood of the disease becoming limited, the 
strength of the patient, and the conditions 
in which he is placed; which are all at first 
difficult to determine. The cause of the gan- 
grene, and the presence or absence of organic 
mischief elsewhere, also exercise a great in- 
fluence. When the malady is dependent on GANGRENE 
GARGLE 
721 
a constitutional cause, there will be little 
tendency to delimitation and a bad prospect 
of recovery. When the cause is local, and 
the destruction of tissue neither extensive 
nor invading a vital part, the prognosis will 
be favourable. But a local injury, when the 
conditions are unfavourable, may be followed 
by a severe and extensive gangrene, or some 
essential part of the body may become im- 
plicated. 
Treatment.-When gangrene is imminent, 
our first care should be to adopt means to 
support the vital warmth of the part, and to 
encourage and relieve the embarrassed circu- 
lation. When the disease is fully developed, 
our attention must be directed to control as 
far as practicable the spread of the disease ; 
to favour the separation of the dead tissue; 
and to keep the parts as clean and harmless 
as possible. We must also anticipate com- 
plications, or combat them when they occur; 
and support the patient's strength by good 
food, stimulants, and fresh air, together with 
opiates sufficient to allay pain. A limited 
traumatic gangrene is to be treated as an 
ordinary sloughing wound. If a complete 
portion of a limb be involved, amputation 
should be performed as soon as the line of 
demarcation is established. In gangrene due 
to arterial obstruction, the extremity should 
be raised to assist the return of venous blood; 
antiseptic dressings and cotton-wool applied 
locally; and plenty of bland food administered 
at frequent intervals. When the whole limb 
is affected, nature may be assisted by com- 
pleting the amputation of the part as soon as 
the limiting line is distinct. In gangrene 
caused by the ligature or rupture of a main 
artery, or the pressure of an aneurysm, ampu- 
tation close to the seat of the lesion may at 
once be performed, as the gangrene will not 
extend higher than this point; but even under 
these circumstances it may often be safer to 
await indications of a commencing demar- 
cation than to amputate previously. In 
spreading traumatic gangrene early amputa- 
tion of the affected limb has been strongly 
recommended; but as this cannot remove 
the already poisoned condition of the blood, 
upon which in all probability the gangrene 
depends, it is generally a useless measure, 
as the gangrenous action would invade the 
stump. It affords, however, the only possible 
chance. In senile gangrene amputation is 
sometimes indicated, and the dead parts 
may be removed near to the demarcating 
line; but an amputation higher up, as in the 
thigh, has been advocated, where the pro- 
spects of repair due to the more vigorous 
circulation will be presumably better. In 
cases where traumatic gangrene is localised 
and dependent merely upon the violence of 
the injury, the vitality of the individual will 
be sufficient to neutralise the mischief, un- 
less it be very extensive. A line of demar- 
cation will appear, and then, but not before, 
will it be proper to amputate, unless the 
part be otherwise hopelessly injured, or a 
large articulation opened, when immediate 
amputation is indicated. 
For the treatment of gangrene occurring 
in internal organs the reader is referred to 
the articles on the diseases of the several 
viscera. William Mac Cormac. 
GARGLE (yapyapifa, I wash the throat). 
-Synon. : Fr. Gargarisme ; Ger. Gurgel- 
mittel. 
Definition.-Gargles are liquids employed 
for the production of local effects on the throat 
and pharynx. 
Mode of Gargling.-Gargling consists in 
taking about a tablespoonful, more or less, 
of the gargle into the mouth, throwing back 
the head, and agitating the liquid by the air 
expelled through the larynx. With some 
persons the gargle goes little beyond the uvula 
and base of the tongue; but if the head be 
thrown well back, the fluid can be made to 
pass into the cavity of the pharynx, and may 
even reach the larynx and vocal cords. The 
tension of the muscles, in thus throwing back 
the head, is apt to provoke efforts at degluti- 
tion, so that sometimes small portions of the 
gargle may be swallowed; and occasionally 
the effort terminates abruptly in the patient 
jerking his head forwards, and expelling the 
gargle forcibly through the nose. 
Dr. H. Guinier, of Cauterets, has demon- 
strated a method of gargling the laryngeal 
cavity. His instructions are as follows: 
(1) Slightly to raise the head; (2) to open the 
mouth moderately; (3) to protrude the chin 
and lower jaw ; (4) to emit the sound of the 
double vowel ce. These four movements 
open largely the back of the mouth, lift the 
velum palati and uvula, separate the base of 
the tongue from the posterior wall, and allow 
the liquid used for gargling to gravitate into 
the cavity of the larynx. One expiratory act 
is the only respiratory movement that is now 
possible, deglutition is under control, and the 
gargle bathes the pharynx and supraglottic 
portion of the larynx. When it is desirable 
to gargle the back of the pharynx and pos- 
terior nares, the patient must take a mouth- 
ful of the gargle, and use it as he lies flat on 
his back with his tongue drawn forward. 
Uses and Composition.-The use of gar- 
gles is contra-indicated in parenchymatous 
inflammations of the tonsils, and in all cases 
where movement of the fauces causes severe 
pain ; and where, as in some persons, an in- 
ability exists to retain liquid beyond the 
anterior pillars of the fauces: for these it is 
more convenient to apply the fluid to the 
fauces and pharynx, either by injection, or in 
the form of a medicated spray, or else by aid 
of a brush or sponge. 
Gargles vary in composition according to 
their object. If prescribed with the view of 
exercising the muscles of the soft palate and 722 
GARGLE 
GASTRALGIA 
pharynx, and thereby increasing their tone, 
cold or iced water is generally sufficient. If 
with the view of reducing and allaying local 
inflammatory conditions of the throat, solu- 
tions of chlorate or nitrate of potassium or of 
borax (two drachms to eight ounces), or of 
solution of acetate of ammonium (one part 
in four), combined with infusion of linseed, 
thin gruel, or water, and used warm, are the 
best. When it is desirable to excite the mu- 
cous membrane and neighbouring glands to 
further secretion, and thus reduce local con- 
gestion, stimulant gargles are useful, such as 
the tinctures of capsicum (half a drachm to 
eight ounces), arnica, myrrh, pyrethrum, and 
eucalyptus rostrata (two drachms to eight 
ounces); this class of gargles often relieving 
the deafness caused by obstruction of the Eus- 
tachian tubes, by increasing the pharyngeal 
secretion. To check excessive secretion, as- 
tringents are advisable in the form of the salts 
of iron and zinc, iron-alum or alum (forty 
grains to eight ounces), tannin (half a drachm 
to eight ounces), or infusion of rhatany. If 
we require to check ulceration, or to dilute 
and purify foul or putrid secretions from the 
throat and tonsils, antiseptic gargles will 
answer the purpose, composed of one or two 
drachms of liquor potassii permanganatis to 
a pint of water, or one drachm of solution of 
chlorinated soda to half a pint of water, or 
sulphurous acid one part to four, or glycerine 
of carbolic acid (half an ounce to eight 
ounces). In cases of syphilitic sore-throat, 
a gargle of perchloride of mercury (three 
grains to eight ounces) has been recom- 
mended. In many cases combinations of 
different kinds of gargles are beneficial. 
Water, barley-water, rose or orange-flower 
water sweetened with a little honey, glyce- 
rine, or syrup, constitute the bases of most 
gargles. John C. Thorowgood. 
GASTEIN, in the Austrian Alps. 
Simple thermal waters. See Mineral 
Waters. 
GASTRALGIA (yaar^p, the stomach; 
and akyos, pain).-Synon. : Gastrodynia ; Fr. 
Gastralgie', Ger. Gastralgie', Magenschmerz. 
Definition.-Pain in the stomach, which 
occurs in various disorders of that organ and 
related parts. 
Symptoms.-In acute erythematous gas- 
tritis a burning painful sensation affecting 
the stomach, and not infrequently extending 
up the oesophagus, is felt almost immediately 
after taking food or a stimulant liquid. In 
acute catarrhal gastritis pain is seldom com- 
plained of. In ordinary chronic gastritis it 
is usually absent; or, at most, only a slight 
heaviness or fulness after food forms a symp- 
tom of the malady. In what the writer has 
named ' eczema of the stomach ' the pain is 
very severe, comes on two or three hours 
after food, and is temporarily relieved by 
eating. The same kind of pain may be ob- 
served whenever there is profuse mucous 
secretion, but it is less severe than in cases 
where gastric disturbance replaces eruptions 
of the skin. The pain accompanying pyrosis 
is of a spasmodic character, and is relieved 
by the ejection of a tasteless fluid. Severe 
pain is a common accompaniment of atonic 
dyspepsia occurring in nervous or hysterical 
persons. It comes on when the stomach is 
empty, but is often aggravated directly after 
food, and is relieved by the escape of flatus, 
and by stimulants. The most severe gas- 
tralgia is that accompanying ulceration of 
the stomach. In this disorder it is referred 
to one spot, and is likewise often felt in the 
back. The mere fact that a pain in the epi- 
gastric region is confined to one small spot 
should induce the practitioner to view the 
case with suspicion. The pain in ulceration 
is usually absent when the stomach is empty, 
but comes on from two to ten minutes after 
food. In other instances a longer period, 
such as half an hour, elapses; but it is this 
definite relation to the digestive process that 
makes the pain of ulceration characteristic 
of the disease. It is usually said that when 
the pain comes on directly after food the 
cardiac region is the seat of the ulcer; and 
where a longer interval takes place the sore 
will be found near the pylorus. This, if true 
as a general rule, is, nevertheless, open to 
many exceptions; for, as a patient observed, 
the pain occurred later after taking food in 
proportion as she improved in health, and 
the first evidence of a relapse was the short- 
ness of the interval of ease after eating. In 
cancer the pain is more continuous than in 
simple ulcer ; it is less influenced by the 
digestive process, and is more diffused. It is, 
however, no uncommon circumstance to find 
cancer of the stomach without any complaint 
of pain. The softer kinds of malignant growth 
seem to the writer least apt to cause suffering, 
probably because the peritoneum is less liable 
in such cases, than in the other forms, to be 
affected with inflammatory action. 
Neuralgia of the stomach is a favourite dis- 
ease with some authors. There is no doubt 
that the normal sensibility of the stomach is 
vastly exaggerated under some conditions, but 
the writer's observation leads him to believe 
that neuralgic pain affecting the stomach in- 
dependently of other disease, is a much rarer 
complaint than is generally supposed (see 
Stomach, Diseases of). The writer has met 
with three different forms of pain in the 
region of the stomach ascribed to neuralgia, 
which are evidently of a different nature : 
(1) Where severe pain has come on at some 
period of the day at a certain hour, at a con- 
siderable period after the commencement of 
digestion. In many of these cases it has 
been evident on inquiry that the apparent 
periodicity was the result of the punctual 
disposal of the chief meal of the day. They 
were, in fact, cases of chronic catarrhal gas- GASTRALGIA 
GENERAL PARALYSIS 
723 
tritis attended with considerable secretion ; 
most of them occurred in gouty men, and 
might be classed under the head of eczema, 
rather than of neuralgia of the stomach. 
(2) Cases such as the following: A young lady 
had suffered for many months from agonising 
pain in the left hypochondrium, coming on 
at each menstrual period, and resisting all 
methods of treatment. In this and other 
similar cases, it will be found that the seat 
of the pain is really external, in the inter- 
costal nerve, and not in the stomach itself. 
(3) Severe attacks of pain in the left hypo- 
chondrium and epigastrium in females of a 
nervous temperament, who had either been 
born, or had passed most of their lives, in 
tropical countries. The real seat of the pain 
in such cases appears to be the colon ; there 
is always constipation; and a mild aperient 
and tonic treatment is usually effectual in 
removing or ameliorating the complaint. 
S. Fenwick. 
GASTRIC FEVER (ya^p, the 
stomach).-A popular name for a febrile 
condition attended with prominent gastric 
symptoms ; as well as for typhoid fever. See 
Typhoid Fever. 
GASTRIC GLANDS, Diseases of 
(yaargp, the stomach).-See Stomach, Dis- 
eases of. 
GASTRIC ULCER (yaargp, the 
stomach).-See Stomach, Diseases of. 
GASTRITIS (yatyrqp, the stomach).- 
Inflammation of the stomach. See Stomach, 
Diseases of. 
GASTRODYNIA (yaargp, the stomach; 
and obvvr), pain).-A painful affection of the 
stomach, generally considered as of a neu- 
ralgic nature. See Gastralgia. 
GASTRO-ENTERIC (yarn/p, the sto- 
mach ; and evrepov, the intestine).-This term 
is applied to those morbid states in which 
the stomach and intestine are simultane- 
ously affected. The continuity and similarity 
in structure of these viscera render them 
peculiarly liable to coincident disease; and 
this is more particularly noticed in affec- 
tions of an inflammatory type (gastro-enter- 
itis), or of a degenerative nature. At the 
same time, as gastritis may occur and run 
its course without giving any indication that 
the intestine is involved, so enteritis may be 
developed with little or no disorder of the 
stomach. The same causes appear to de- 
termine similar diseases in the stomach and 
in the intestine; but why at one time both 
should suffer, and at another time one should 
escape, is not known. Occasionally it would 
seem that the entire alimentary canal be- 
yond the oesophagus is attacked at once, and 
the gastro-intestinal catarrh of children is 
an example of this. Sometimes the disorder 
commences in one part of the canal, and 
spreads until both the stomach and the in- 
testine are involved. See Intestines, Dis- 
eases of; and Stomach, Diseases of. 
W. II. Allchin. 
GASTRORRHCEA (yatrrgp, the sto- 
mach ; and pew, I flow).-An excessive flow 
of mucus from the lining membrane of the 
stomach, due to catarrh. See Stomach, 
Diseases of. 
GELATINIFORM CANCER. - A 
synonym for colloid cancer. See Cancer. 
GENERAL.-This word, as employed 
in relation to medicine, has several applica- 
tions. Thus we speak of a general disease, 
which is a disease affecting the whole system, 
as distinguished from a local affection. As 
further examples may be mentioned general 
debility, general paralysis, and general 
dropsy. So, with respect to therapeutics, 
general treatment refers to remedial mea- 
sures intended to affect the organism as a 
whole. In connexion with the sciences of 
therapeutics, pathology, &c., the word general 
is intended to denote the essential principles 
of these sciences, as distinguished from their 
special divisions. 
GENERAL PARALYSIS OF THE 
INSANE.-Synon. : General Paresis ; De- 
mentia paralytica; Fr. Paralysie generate 
incomplete', Periencephalite chronique dif- 
fuse ; Ger. Allgemeine progressive Gehirn- 
lahmung; Paralytischer Blbdsinn. 
Definition.-A gradual loss of the power 
of co-ordinated movement, accompanied by 
gradually increasing mental disturbance and 
decay. 
Etiology.-The subjects of general para- 
lysis are most frequently of the male sex, 
and between 80 and 50 years of age. It may 
be brought on by excessive mental labour, by 
severe anxiety, by alcoholic or venereal excess, 
or by any prolonged strain upon the mental 
organisation. It may also be induced by a 
blow or other direct injury to the head. 
Hereditary predisposition is probably not 
without influence upon its production, but 
this is not so frequently present as in most 
other forms of insanity. The disease most 
frequently attacks persons who have previ- 
ously been apparently in the enjoyment of 
vigorous health. 
Anatomical Characters.-General para- 
lysis is characterised by atrophic and de- 
generative changes of the cerebrum chiefly 
affecting the convolutions of the vertex, of 
the anterior and middle lobes, and round the 
olfactory bulbs at the base. These changes 
involve destruction of the nerve-cells of the 
outer layers of the cortex, and augmentation 
of the lymph-connective system. There is 
also thickening of the membranes, adhesion 
of the pia to the surface of the convolutions, 
thickening of the coats of the blood-vessels, 724 
GENERAL PARALYSIS OF THE INSANE 
enlargement and sacculation of the perivas- 
cular canals, and engorgement with disin- 
tegrated material. In advanced cases the 
degenerative changes affect every part of the 
nervous system. 
Symptoms.-Physical.-The physical symp- 
toms of general paralysis of the insane are 
first apparent in the muscles of articulation 
and expression. There is an occasional 
thickness of utterance, perhaps observable 
only in the pronunciation of the more complex 
sounds, and a peculiar convulsive tremor of 
the upper lip accompanying the least excite- 
ment. A similar fibrillar trembling may 
also be observed in the tongue, when an 
attempt is made to hold it out. A loss of 
freedom of stroke in the handwriting is mani- 
fested at an early stage. This loss of muscu- 
lar control gradually spreads over the whole 
system, its onward course being, however, 
not infrequently interrupted by very remark- 
able though generally brief remissions. Be- 
fore the patient is laid completely prostrate, 
the affection both of articulation and of gait 
strongly resembles the failure of co-ordinate 
movement produced by drunkenness. In 
the last stage the patient lies quite helpless ; 
the power of articulation and every kind of 
voluntary movement are lost; there is also a 
strong tendency to the formation of bed-sores; 
and spots of ecchymosis are apt to appear on 
the application of even gentle pressure. In- 
equality of the pupils is usual from the com- 
mencement of the illness; but they do not 
often remain long in one condition, some- 
times one pupil and sometimes the other 
being dilated or contracted. A characteristic 
feature of the disease is the occurrence of 
congestive or epileptiform attacks, but they are 
very variable, both in their frequency and in 
the stage at which they are first observed. 
Mental.-The mental symptoms generally 
precede the physical, though some cases 
occur in which the condition of the mind 
is not such as to attract attention till some 
time after the motor symptoms have become 
obvious. Sleeplessness and general rest- 
lessness are usually the first indications of 
the derangement, and with these may 
be associated transient states of depression 
and hypochondriacal fancies. Enfeeblement, 
shown by forgetfulness and incapacity for 
continuous thought, is generally an early 
symptom; and in some cases a gradual 
increase of this enfeeblement, till absolute 
fatuity is reached, constitutes the prominent 
mental symptom. A common condition from 
the commencement is an inordinate disposi- 
tion to embark in any, even the most imprac- 
ticable, undertaking that may be suggested. 
There is always observed a peculiar facility 
of disposition, generally good-humoured, 
but liable to be interrupted by fits of pas- 
sionate excitement. Frequently there is a 
very remarkable extravagance, both in thought 
and act. In most cases acute maniacal attacks 
take place, in which the excitement presents 
a specially extravagant character. The sem- 
blance of probability and coherence found 
in ordinary acute mania is generally absent. 
The prevailing ideas are of grandeur, colossal 
size, infinite number, power, wealth, and rank, 
all heaped together in wild confusion. Every 
such maniacal attack marks an appreciable 
step in the progress of mental decay; and the 
tendency is always more or less steadily to 
complete fatuity. In some comparatively 
rare cases, especially where there is a ten- 
dency to phthisis, the mental condition is 
mainly one of depression. Remarkable re- 
missions of all the symptoms are sometimes 
met with. 
Diagnosis. - The diseases from which 
general paralysis of the insane requires to 
be distinguished are paralysis due to cere- 
bral haemorrhage, embolism, encephalitis, or 
tumour of the brain ; hysterical and toxic 
paralysis; syphilitic disease of the brain; 
locomotor ataxy; alcoholic insanity; senile 
dementia; and muscular atrophy. The dia- 
gnosis is generally easy, if attention be paid 
to the presence or absence of the convulsive 
tremors in the muscles of articulation at the 
commencement; the general and progressive 
course of the loss of co-ordination ; and the 
peculiar mental facility and extravagance. 
Prognosis.-Complete recovery seldom, if 
ever, takes place in general paralysis of the 
insane. The ordinary duration of the disease 
is from a few months to three or four years, 
though cases of ten years' duration occasion- 
ally occur. 
Treatment.-In ordinary circumstances 
the treatment cannot be properly carried out 
in a private house; removal to an asylum 
will therefore generally be necessary. Little 
benefit is to be derived from drugs. The diet 
ought to be nutritious, but non-stimulating. 
The food ought to be minced or pulpy, and 
care should be taken to prevent an accumu- 
lation of it in the pharynx, as fatal choking 
is sometimes produced in that way. If this 
should be threatened, the tongue should be 
immediately pulled forward, and the bolus 
extracted with the finger. On account of the 
liability to bed-sores, the patient should as 
long as possible be prevented from lying 
constantly in bed. John Sibbald. 
GERMS OF DISEASE.-This is a 
phrase in common use, the acceptation of 
which is various, and often more or less 
vague. So far as it refers to actual things 
or objects, they also are probably diverse in 
nature, though at present our knowledge of 
many of them is based rather upon conjecture 
than actual experience. 
As a phrase, ' germs of disease ' is most 
commonly used in the following modes :- 
(a) A person may be said to inherit the 
germs of disease when there is reason to 
believe that the constitutional, general, or GERMS OF DISEASE 
local disease from which he is suffering is of 
a kind which has been common in the family 
or stock whence he has descended, and when 
the disease is one which seems prone to 
manifest itself in this way. It may, in this 
sense, be said that a person inherits the 
germs of gout, scrofula, tuberculosis, cancer, 
or syphilis; and, in either of such cases (with 
the possible exception of the two latter), no 
one would, on reflection, be able to find that 
he meant anything else than that the patient 
had inherited a certain general disposition, 
habit, or bodily tendency, in which, under the 
influence of slight exciting causes, one of these 
morbid conditions should be prone to manifest 
itself. 
(b) In a still looser sense, the phrase is 
sometimes used to signify the mere com- 
mencement or initial stage of a certain 
disease, as when it is said that the germs of 
a phthisical patient's malady date from a 
certain catarrhal attack, or that a patient 
now suffering from a severe brain-affection 
contracted the germs of his disease in India 
or elsewhere on the occasion of some slight 
sunstroke. Here the expression would be 
used in a purely metaphorical sense. 
(c) The phrase is most commonly employed, 
however, in reference to the real or supposed 
causes of communicable morbid processes or 
diseases, either local or general-those which 
spread either from part to part in the same 
person, or from person to person in the same 
community. 
In the spread from part to part, as during 
the ' generalisation ' of some malignant new- 
growth, the agency of ' germs of disease ' is, 
perhaps, not infrequently more imaginary 
than real. Results are apt to be ascribed to 
' infection ' where nothing of the kind has 
been in operation-as when similar perverted 
tissue-changes may chance to manifest them- 
selves, either simultaneously or consecutively, 
in different parts of the body, as results of 
some single or similar underlying cause or 
tendency. 
In the spread from person to person of 
local or general contagious affections, the 
same possible source of fallacy has to be 
borne in mind. We must be upon' our guard 
against ascribing too general an influence to 
' germs of disease.' In certain cases these 
may have been in the first place non-existent, 
as when such a disease has been ' autogene- 
tic,' and in no sense a derivative of antecedent 
disease of the same kind. This caution is 
especially applicable in regard to such an 
affection as erysipelas-which, although cer- 
tainly contagious, is also on very good grounds 
judged to be ' generable,' especially during 
certain states of lowered health induced by 
renal disease and some other visceral affec- 
tions. If it is not so certainly established, it 
is by many deemed probable, that a similar 
caution may be necessary in regard to some 
more general contagious affections, such as 
diphtheria, typhoid, typhus, and relapsing 
fever, and cholera, which, though certainly 
contagious, may also be autogenetic. On this 
subject, however, much doubt and uncertainty 
still prevail. 
The consideration of this third use of the 
phrase ' germs of disease' conducts us natu- 
rally to the question as to the nature of the 
things or objects which may be included 
under the same name, and this again to the 
modes in which they operate. But as these 
are questions which are discussed under 
Contagion, further reference to them here is 
unnecessary. See also Micro-Organisms. 
H. Charlton Bastian. 
GERONTOXON (yepcov, an old man; 
and to^ov, a bow).-A synonym for arcus 
senilis. See Arcus senilis. 
GEYSERS, The, in Sonoma County, 
California, U.S.A. - Hot springs, with 
alum, iron, and sulphur. See Mineral 
Waters. 
GEYSERS, The, in Wyoming Terri- 
tory,U.S.A.-Thermal waters. See Mine- 
ral Waters. 
GIDDINESS (Sax. gidig, turning round). 
-A synonym for vertigo. See Vertigo. 
GIESSHUBEL, in Bohemia.-Acidu- 
lous alkaline table water. See Mineral 
Waters. 
GINGIVITIS {gingivce, the gums). 
Inflammation of the gums. See Mouth, 
Diseases of. 
GLANDERS (glans, an acorn).-Synon. : 
Equinia ; Fr. Morve; Ger. Rotz. Its asso- 
ciated condition is named Farcy; Fr. Far- 
cin', Ger. Wurm', Hautivurm. 
Definition.-A contagious febrile disease, 
associated with the presence of a specific 
microbe-the bacillus mallei', communicated 
to man from the horse, ass, or mule; charac- 
terised by inflammatory lesions of the nasal 
and respiratory mucous membranes, and of 
the lymphatic vessels and glands, with general 
pyrexia, pains in the joints and muscles, 
and great prostration, and usually accom- 
panied by a pustular cutaneous eruption. 
The local manifestations vary in order of 
appearance, and in comparative severity in 
different cases. In those in which the nasal 
and respiratory mucous membranes are 
earliest or most severely affected, the disease 
is customarily called ' glanders; ' while to 
those in which the lymphatic system first 
and especially suffers, the designation ' farcy ' 
is applied. But no sufficient reason exists 
for considering glanders and farcy as dis- 
tinct diseases. They are commonly asso- 
ciated ; and whichever set of symptoms may 
appear first, the other, as a rule, sooner or 
GLANDERS 
725 726 
later follows. Further, it has been proved 
that the same virus may give rise to either 
set of symptoms, or to both. And it would 
seem that the order of appearance is deter- 
mined in great measure by the mode of com- 
munication of the virus, as well as to some 
extent perhaps by the condition and consti- 
tution of the recipient. 
Glanders in man is a very rare disease; 
and it is only within the last sixty or seventy 
years that its occurrence has been clearly 
recognised, and its history made out. When 
it does occur, it proves fatal in a very large 
proportion of cases. Taking the acute and 
chronic cases together, 208 out of 245 are re- 
corded as having terminated fatally. Never- 
theless, out of 2,026,296 deaths in England 
and Wales during the four years 1871-1874 
no more than 19 were registered as due to 
glanders, and during the four years 1885- 
1888 only 18 out of 2,101,755 deaths. The 
slight decrease in the proportion during the 
later period is worthy of note as due in 
measure probably to the more stringent pre- 
cautions observed. During the year 1889, 
however, there were recorded 8 fatal cases of 
glanders out of 518,353 deaths. 
^Etiology.-There is no evidence to sug- 
gest that glanders ever originates in man, 
whatever may be the case with regard to the 
lower animals. It is always communicated; 
and almost always by direct inoculation of 
virus from a diseased animal. Horses, asses, 
mules, some carnivorous animals, as lions, 
tigers, &c., are liable to take the disease; and, 
among the smaller animals, guinea-pigs, 
hedgehogs, field-mice, and wood-mice. Oxen 
seem to enjoy immunity even when experi- 
mentally inoculated, as also rats, white mice, 
&c.; and pigs, dogs, sheep, and rabbits are 
only slightly susceptible. In some few in- 
s'tances the disease has been communicated 
from man to man. It is scarcely ever 
met with except in those who are more or 
less constantly employed among horses, and 
who are therefore liable from time to time to 
come in contact w'ith diseased animals, or 
the morbid discharges from them. The mode 
of communication can in most cases be easily 
traced; and generally the virus is derived 
from the secretion of the nasal mucous mem- 
brane of the diseased animal. The rarity of 
the disease in man, considered in conjunc- 
tion with its comparative frequency and the 
rapidity with which it spreads among horses, 
would seem to indicate that the virus is more 
or less fixed, and not readily diffusible through 
the air, and that man is not very susceptible 
to its influence. 
In most cases the history renders it clear 
that the virus has been received through 
some cut or abrasion of the skin or mucous 
membrane. In some few instances it ap- 
pears probable that the virus may have 
been absorbed through the unbroken mucous 
membrane or skin. The recent sad case 
GLANDERS 
resulting in the death of Dr. von Hofman, 
of Vienna, who was engaged in experimental 
investigations into the propagation of glan- 
ders, seems to show conclusively that ab- 
sorption may take place through the muc dus 
membrane of the respiratory tract from in- 
halation of the virus; and the observations 
of Dr. Bab&s, in Roumania (where glanders 
appears to be more common than in this 
country), go to prove that without solution of 
continuity of skin the glanders bacilli may 
penetrate by following the hair-follicles, in 
which they multiply and, proceeding thence, 
may infect the system. 
Symptoms and Course.-However the virus 
may have been communicated, a period of 
incubation varying from three to eight days, 
and in some rare instances prolonged even 
to three weeks or more, ensues before the 
symptoms of constitutional infection become 
manifest. The longer the period of incuba- 
tion, the less acute, as a rule, is the course of 
the disease. The duration of the disease, as 
well as the order of development of the local 
affections, varies greatly in different cases. 
Hence the classification, on the one hand, 
into cases of acute, subacute, and chronic 
glanders; and, on the other, into cases of 
acute and chronic glanders, and acute and 
chronic farcy. But nothing like clear lines 
of distinction can be drawn between any of 
these classes. 
The earliest constitutional symptoms are a 
sense of general discomfort, fatigue, prostra- 
tion, and chilliness, with headache, and 
obscure pains in the muscles and joints. As 
the disease advances, these pains become 
more severe, and simulate those of rheuma- 
tism. Pyrexia, at first but slight, rapidly 
becomes established. The pulse is quickened 
and sometimes full, the skin hot and dry, 
the tongue foul, the urine scanty and high- 
coloured ; and the patient suffers much from 
restlessness, sleeplessness, and loss of appe- 
tite, often with obstinate constipation. Some- 
times the feverishness is intermittent, but 
more frequently continued, or intermittent at 
very irregular intervals. Still later, rigors 
occur-more severe than such as may have 
occurred at an earlier period, followed by 
profuse sour perspirations and clamminess of 
skin; the pulse becomes very rapid, weak, 
and compressible ; diarrhoea, with very foetid 
stools, succeeds the constipation; the thirst 
is excessive ; respiration becomes more and 
more difficult and laboured; low delirium, 
with tremors, is followed by coma; and 
death ensues from exhaustion. In the acute 
form, the disease runs its course in an 
average period of about sixteen days; some 
cases have terminated fatally within a week; 
others have been prolonged for four weeks. 
In the less acute form the duration may be 
from six weeks to two months. And in the 
most chronic form, in which all the symptoms 
are less severe, the duration may extend over GLANDERS 
727 
several months, and in some cases recovery 
ultimately takes place. 
Local manifestations. - In association 
with the constitutional symptoms thus in- 
dicated, the following local manifestations 
present themselves, but, as already stated, 
somewhat differently in different cases. 
The wound or abrasion through which the 
virus has been introduced, or the spot at 
which it has been applied (for the wound 
may have healed), becomes inflamed, tense, 
painful, and surrounded by spreading erysi- 
pelatous redness. The ulcer which appears 
enlarges, assumes an unhealthy, corroded, 
chancroid aspect, and discharges dirty sanious 
and often offensive matters. 
The lymphatic vessels of the part become 
inflamed, and present a knotted, cord-like, 
and subsequently irregularly nodulated con- 
dition-the farcy-buds in the human subject. 
The glands are infiltrated and enlarged, and 
the whole part is swollen and cedematous. 
The lymphatic glands and vessels of other 
parts subsequently become affected, but not 
perhaps to the same extent as in the horse. 
Resolution and absorption to a greater or less 
extent sometimes take place; but much more 
frequently suppuration of low type, abscess- 
formation, and the production of foul, ulcer- 
ating cavities, with hard irregular edges, and 
fistulas follow. 
At a variable period in the course of the 
disease-from within forty-eight hours to the 
end of three or four weeks-an eruption, re- 
garded as characteristic, appears on the skin, 
especially on the face, chest, and abdomen. 
This first shows itself as irregularly scattered 
collections of red spots, ' which are very 
small and resemble fleabites, but soon acquire 
a papular elevation, subsequently rising above 
the level of the surface, like small shot, and 
assuming a yellowish colour. They lie each 
in a kind of hole in the corium, as if the latter 
had been punched out ' (Virchow). They 
appear to be due to the deposit of some neo- 
plastic material, which subsequently softens 
and breaks down. By-and-by they become 
vesicular (some say from the first they are 
vesicular), and then rapidly sero-purulent, 
with inflamed livid bases. The surrounding 
skin is red, swollen, and erysipelatous-like. 
When close together, these pustules become 
confluent, and give rise to irregular ulcerated 
surfaces, with soft, brownish, sloughy coating. 
Large collections of similar deposit in the 
subcutaneous tissue give rise to hard, painful, 
boil-like formations, which, breaking down, 
lead to extensive sloughing of the skin and 
deeper structures, with thick, dirty white or 
sanguineous offensive discharge. 
The mucous membranes-and first and 
especially that of the nose-are sooner or 
later affected by specific inflammation and 
ulceration. Whether the inflammatory pro- 
cess as a secondary affection more often be- 
gins in them or in the skin is not clearly 
made out. But in some cases in man, as 
commonly in the horse, the disease is prob- 
ably communicated by application of virus 
to the mucous membrane of the nose or other 
part of the respiratory passages, which thus 
becomes primarily affected. 
When the nose is affected (as is always the 
case primarily or secondarily in the form of 
the disease especially called glanders), there 
is first a discharge of comparatively thin, 
colourless, ' catarrhal ' mucus. This soon 
becomes thicker and coloured; and there is 
considerable pain, heat, redness, and cedema- 
tous swelling about the nose itself and the 
adjacent parts of the face. Ultimately the 
discharge becomes thick, sticky, tenacious, 
and semi-purulent, of a dirty yellowish or 
brownish colour, and often stained with blood. 
In all cases probably there is ulceration of 
the mucous membrane, following tubercle- 
like deposits in it; and the ulceration some- 
times extends so deeply as to lead to perfora- 
tion of the septum, or partial destruction of 
the turbinated or palate bones. The ulcera- 
tion often occurs only in the upper part of the 
nose; and the mucous membrane of the 
frontal and other sinuses is liable to be simi- 
larly affected. 
When the lymphatic and cutaneous sys- 
tems suffer first and especially, the nasal 
mucous membrane is not affected until to- 
wards the termination of the case; and in 
some instances death has occurred before this 
affection of the nose has taken place. 
Bronchial catarrh, with rhonchi heard all 
over the chest, accompanied by severe cough 
with profuse expectoration, indicates the im- 
plication of other parts of the respiratory 
mucous membrane. The conjunctiva and the 
mucous membrane of the mouth, gums, fauces, 
and especially the tonsils, are often affected 
to a serious extent; so also is the larynx; 
hoarseness, pain, and difficulty in speaking 
resulting therefrom. 
Anatomical Characters. - The patho- 
logical lesions found on post-mortem exami- 
nation are such as might be anticipated from 
the signs and symptoms manifested during 
life. To these, however, may be added fluidity 
of the blood ; softness and rottenness of the 
muscles, with haemorrhagic abscesses in them 
(considered by Billroth as characteristic) ; 
patches of grey hepatisation in the lungs, or 
lobular pneumonia; abscesses in the parotid, 
submaxillary, and cervical glands; and no- 
dules hard or softening down in the liver, 
spleen, and membranes of the brain. 
The characteristically associated bacilli 
may be found in the nodules (especially in 
such as are comparatively recent), in the 
mucous membranes, skin, liver, spleen, &c. 
They have also been found in the blood and 
various morbid secretions ; but in these they 
are often very difficult to discover. Fliigge 
describes them as ' thin rods, similar to the 
tubercle-bacilli, but more uniform in size. 728 
GLANDERS 
GLEET 
and somewhat broader; like these, they are 
often slightly curved.' This description of 
Flugge's has been adversely criticised by 
Frankel and others, who have worked with 
the bacilli of glanders. They are much more 
readily stained than are tubercle-bacilli; are 
shorter and much thicker; and they often 
present a single unstained spot midway be- 
tween the ends, quite unlike tubercle-bacilli. 
The specimens are best prepared by staining 
with alkaline methylene blue, and subse- 
quent careful treatment by very dilute acetic 
acid. When inoculated upon sterilised potato 
from a farcy bud, they present a character- 
istic tuberculated chocolata-coloured growth 
in forty-eight to seventy-two hours, if kept 
at the temperature of the blood. 
Diagnosis.-The diagnosis of glanders in 
man may be difficult in the early stage, par- 
ticularly if the history be defective and no 
external wound appear. But when the dis- 
ease is fully developed, the signs and symp- 
toms, especially if taken in conjunction with 
the occupation and history of the sufferer, 
are sufficiently characteristic. In some rare 
instances, however, in which the constitu- 
tional symptoms have been slight, and the 
local manifestations have very slowly deve- 
loped themselves, great difficulty has arisen, 
and the true nature of the disease has not even 
been recognised until after death. Rheuma- 
tism, typhoid fever, and pyaemia, and, in re- 
gard to the more chronic cases, syphilis and 
tuberculosis, are the diseases with which it 
is said that glanders may possibly be con- 
founded. The presence of the characteristic 
bacilli, if discovered, may be regarded as 
pathognomonic and conclusive; and in doubt- 
ful cases, at any rate, they should always be 
sought for in the morbid secretions and dis- 
charges.1 
Prognosis. - The prognosis in glanders 
must be extremely unfavourable. Two or 
three cases only are on record in which re- 
covery has taken place from the more acute 
form of the disease.2 In the more chronic 
forms, however, the deaths have been only 
about fifty per cent. The more slowly and 
less severely the symptoms develop them- 
selves, and the longer the patient survives, 
the better is the chance of ultimate recovery. 
Treatment.-The constitutional treatment 
should be supporting, stimulating, and sooth- 
ing, and varied from time to time according 
to the indications afforded. Quinine in large 
doses, and perchloride of iron with or with- 
out perchloride of mercury, may be useful. 
But at present, although very many drugs 
have been tried, none has been found having 
any marked specific effect on the course of 
the disease, unless indeed exception be made 
in favour of mercury. Gold reports a case 
successfully treated by prolonged mercurial in- 
unction. Locally any suspicious wound should 
be freely cauterised or excised as soon as at- 
tention is directed to it. All abscesses and col- 
lections of morbid material should, as far as 
possible, be freely incised, and their contents • 
thoroughly evacuated. The resulting cavities 
and fistulae should be frequently and tho- 
roughly washed out with germicide and dis- 
infectant solutions-perchloride of mercury, 
chloride of zinc, sulphate of copper, or carbolic 
acid in safe dilution; and antiseptic dressings, 
covered or not according to circumstances 
by poultices, should be applied. The operator 
and those who dress the wounds should wear 
indiarubber gloves. Inhalations of iodine, 
or carbolic acid vapours or sprays, should 
be frequently used, and the nasal passages 
and cavities should be thoroughly syringed 
from time to time with disinfectant solutions, 
as dilute carbolic acid, iodised water, or 
Condy's solution. 
Arthur E. Durham. 
GLANDULAR DISEASES.-A gene- 
ral denomination for diseases of glands of all 
kinds. See Bronchial Glands, Diseases of; 
Lymphatic System, Diseases of; and Mesen- 
teric Glands, Diseases of; also the several 
special glands. 
GLAUCOMA (yXavKoj, sea-green).-In 
its modern acceptation, this word is used to 
include all the conditions, whether acute or 
chronic, primary or secondary, which are 
produced by heightened tension or increased 
fluid-pressure within the eyeball. The word 
was originally applied only to those cases 
of heightened tension in which there is a 
greenish opaque appearance behind the 
pupil. See Eye, and its Appendages, Dis- 
eases of. 
GLEET.-Synon. : Fr. Goutte mili- 
taire; Ger. Nachtripper. 
Definition.-An urethral discharge, milky, 
viscid, scant in quantity, appearing as a drop 
at the meatus urinarius or as shreds floating 
in the urine, composed of leucocytes, epi- 
thelium cells of various forms, and crystals 
of phosphates and urates. 
1 In Eastern Prussia, where glanders is very fre- 
quent, an extract (mallein) of the bacillus mallei 
(obtained with glycerine at 95° F., from pure growths 
of the bacillus upon potato) has been employed in 
the diagnosis of doubtful cases of glanders or farcy 
in the horse. The extract is filtered free of bacilli, 
and concentrated; about four minims of this are 
injected under the skin of the suspected horse. If 
latent glanders be present, rise of temperature of 
more than 3° is said to follow within the next 
eight hours. If the animal be free from glanders 
or farcy, the temperature is said to rise, if at 
all, less than 2°. Favourable reports are already 
given of this method of diagnosis both in Germany 
and at the Institut Pasteur in Paris. Unfortunately 
the preparation of the extract is not devoid of 
danger. The manipulations have proved fatal to 
two investigators : one of them Dr. Kalning of Dor- 
pat, the original discoverer of mallein. 
2 Professor Karl Frankel, of Kbnigsberg, acci- 
dentally inoculated himself in the spring of 1891, 
and recovered, though after several months' ill- 
ness. GLEET 
729 
^Etiology and Symptoms.-In most cases of 
gleet, though some chronic urethral discharges 
arise from masturbation and excessive venery, 
a clap has preceded the discharge by some 
months or years. In such cases the discharge 
may escape notice for a time without really 
disappearing altogether, and again become 
plentiful without obvious cause. Pain is 
either absent, or a slight tickling or smart- 
ing at the parts inflamed is felt during mic- 
turition or at other times. But these symp- 
toms vary so greatly in different patients, 
that much reliance cannot be placed on them 
for indicating the seat of the inflammation. 
Nevertheless, when pain is described to be 
felt in the loins, thighs, or anus, the prostatic 
portion is generally affected. If the urine is 
voided in three portions, and the first portion 
is stocked with floating shreds, while the 
second and third portions are clear, the dis- 
charge is probably formed in front of the 
prostate. If there be a clear second portion, 
and a few shreds appear in the third por- 
tion, that being also fairly clear, some of 
the discharge is prostatic. If the third 
portion is turbid the uvula of the bladder is 
inflamed. 
Physical signs.-When seeking for the 
cause and locality of a gleet, it is well to 
divide the examination of the urethra into 
two parts; the pendulous and bulbous por- 
tions being examined first, the membranous 
and prostatic portions secondly. The precise 
situations of the lesions in the penile portion 
are ascertained by passing along the urethra 
a bullet-sound or bougie (No. 25 or 26 of the 
French scale), or Otis's urethrameter, if the 
meatus be too small to admit a bullet large 
enough to expand the passage to its full ex- 
tent. As the bullet reaches an inflamed spot 
a slight resistance is noted, and the patient 
feels pain when the instrument passes over 
the inflamed or rigid area. Both resistance 
and pain cease when the area is left behind. 
Should the inflammation have existed long 
enough to produce fibrous bands, the onward 
passage of the bullet-sound is impeded, or 
arrested if the bands be too short to permit 
the bullet to slip past. A smaller bullet 
must be taken, or the urethrameter's bulb 
must be contracted until the obstruction can 
be passed. By this means the amount to 
which the normal capacity of the urethra has 
been lessened is learned. The bullet-bougie 
is not usually passed farther than the bulb, 
though it may be pushed to the bladder by 
a little manceuvring. A tolerably accurate 
diagnosis can thus be made, though it is 
always advantageous, and sometimes indis- 
pensable, to complete the examination by 
ocular inspection. This is done by the endo- 
scope ; and, by its means, the condition of 
the obstructing patches may be more pre- 
cisely ascertained, and, as well, the absence 
or presence of inflammation of the glands 
of Littre and lacunae Morgagni, or of the 
numerous ducts which open into the mem- 
branous portions of the canal. See Endo- 
scopy. 
The conditions causing gleet are: (1) 
Chronic inflammation of areas of the mucous 
membrane ; (2) Granular patches ; (3) Warts; 
(4) Ulcers ; (5) Inflammation of glands and 
sinuses; (6) Chronic catarrh of the mucous 
surface and ducts of the prostate ; (7) Chronic 
prostatitis. 
1. Chronic inflammation of the mu- 
cons membrane.-In this, the most com- 
mon form of gleet, the interior of the urethra, 
naturally rosy-pink when not inflamed, is 
dull red or purplish-red in patches or streaks. 
It must not be forgotten that the mucous 
membrane of the urethra, especially of the 
penile portion, after several attacks of inflam- 
mation, may assume a greyish or slatish red 
hue, or a brownish stain from absorbed pig- 
ment, when the colouring matter of the 
blood has escaped into the tissues. Here and 
there viscid grey flocculi of muco-pus adhere 
to the inflamed surfaces. The red areas are 
less elastic than the unaffected parts, and in 
course of time may develop into bands of 
stricture-tissue, which more or less diminish 
the expansile power of the urethra. Common 
positions for these inflamed areas are the 
pars cavernosa at two or three inches from 
the meatus, or at four or six inches from it- 
i.e. in the bulbous portion of the urethra. 
But the membranous and prostatic portions 
are also the seats of chronic inflammation in 
gleet. In long-standing cases white unyield- 
ing areas are disposed among the patches of 
inflammation. They are fibrous toughenings 
of the tissues. These may remain or dis- 
appear. When they are left, some obstruc- 
tion is caused to the expansion of the urethra 
-that is, more or less stricture. Usually 
several months are needed for the patches 
of inflammation to develop into fibrous 
bands. 
2. Granular patches.-These are exces- 
sively common in any part of the penile and 
bulbous portions of the urethra, while they 
are not rare in the membranous and prostatic 
portions. They develop on the areas of 
chronic inflammation, especially if these 
patches have been excoriated or ulcerated ; 
and it is rare not to find them in a case of 
six months' duration on the third and fourth 
inches from the meatus. The bullet-bougie 
reveals their presence by a slight resistance 
to the passage of the sound, and by a smart- 
ing pain felt while the bullet passes over 
them. When the sound is withdrawn, it is 
often marked with a little bloody muco-pus. 
If the endoscope is then inserted, the granular 
patches appear as bright carmine-red areas 
of uneven or velvety aspect, readily bleeding 
if the instrument be roughly pushed over 
them. Here and there they are flecked with 
little dots of greyish mucus, which is very 
adherent, and which protects the granulation 730 
GLEET 
from the action of astringents. In course of 
time the granulations may heal into white 
fibrous scars, or may subside and leave the 
membrane pale and smooth, but supple as 
before. Their duration is very long and un- 
certain, and their cure is tedious. 
3. Warts.-Warts, which are most com- 
monly situate just within the meatus, may 
stud the whole length of the urethra. Near 
the meatus they are arboriform; lower down, 
sessile, or only slightly pedunculated. Iden- 
tical in structure with the warts on the glans 
or in the furrow of the penis, they are ordi- 
nary papillomata. They are also frequent 
in the membranous and. prostatic portions. 
Sometimes a single sessile wart in this posi- 
tion will be the sole cause of a gleet which 
is troublesome to the patient through its 
obstinacy, otherwise most harmless. 
4. Ulcers.-Ulcers are not uncommon in 
the early stages of chronic urethritis. They 
appear at any part of the canal, and are indi- 
cated by smarting felt at a particular point of 
the passage during micturition, or when the 
bullet-sound passes over them. But they 
can be diagnosed only with certainty by the 
endoscope. When seen, they appear as 
minute, round, shallow excoriations, with 
sharply defined edges and yellow floor. If 
left untreated, these shallow erosions may 
heal and contract into thin and somewhat 
prominent layers of scar-tissue, disposed 
sometimes longitudinally, more often ob- 
liquely or transversely across the urethra. 
When fully matured they constitute the 
' bridle stricture.' 
In persons who have tough, well-formed 
scars of stricture-tissue, ulceration of some 
parts of this scar-tissue is not uncommon. 
These ulcers form again and again, and are 
best treated by thorough dilatation of the 
strictures, and washing with mild astringent 
injections. 
5. Follicular sinuses.-These sinuses, 
inflamed during acute gonorrhoea, often se- 
crete discharges long after the gonorrhoea 
has ended. In the anterior urethra gene- 
rally only a few such crypts are chronically 
inflamed, but in the prostatic portion several 
crypts secrete a thin turbid fluid. This form 
of discharge may be considered to be caused 
by chronic prostatitis, and it will be described 
farther on. In cases of hypospadias, at the 
extreme end of the urethra, close to the mar- 
gin of the meatus in the glans penis, there is 
in many persons on each side of the orifice a 
crypt three-quarters of an inch long. These 
crypts often continue to discharge pus long 
after the gonorrhoea has subsided elsewhere. 
Other sinuses, but shorter ones, open into the 
interior of the normal urethra. These folli- 
cular sinuses do not form indurated patches 
in the substance of the urethra; hence they 
never cause stricture. Temporary narrowing 
may, however, result from the distension of 
an inflamed and suppurating sub-mucous 
follicle, which before the evacuation of its 
contents may project on the wall of the 
urethra. The discharge from such a cavity 
is much more copious than from a simple 
follicle, and is very slow to dry up, though 
this end is usually reached if there be no 
stricture in front of the suppurating follicle 
to impede the easy flow of the urine past the 
follicle. Usually the bulbous and mem- 
branous parts of the urethra are the slowest 
to recover. 
6. Chronic catarrh.-In chronic catarrh 
of the prostatic urethra, with a history of pre- 
ceding gonorrhoea, there may be a scanty 
milky-white discharge seen at the meatus 
when several hours have elapsed after mic- 
turition, or the orifice may be sealed by the 
dry discharge, or there may be only shreds 
or flocculi in the urine. In addition to the 
slight discharge, the patient may complain 
of occasional great increase of it after hard 
riding, or dancing, or free indulgence in 
wine, but this does not always happen. The 
shreds consist mainly of pus-cells held to- 
gether by mucus; there are also present 
epithelial cells of pavement and transitional 
forms, granular cells, crystals of urates, &c. 
They have no characteristic value, as simi- 
larly formed shreds are washed from granu- 
lar patches placed in the anterior urethra. 
Fine filamentous shreds are formed in the 
folds of the mucous membrane while the 
urethra is at rest. They are also formed as 
casts of the prostatic ducts when inflam- 
mation has extended into the body of the 
prostate. These casts are generally built 
up more of epithelial and granular cells, 
and less of pus-cells, than those formed in 
the urethra. The prostatic origin of these 
shreds is shown by the fact that urine drawn 
through a catheter from the bladder is bright, 
clear, and free of shreds. When the mucous 
membrane of the prostate is only, or mainly, 
affected, the symptoms of disease are very 
indefinite, and are often limited to the scanty 
viscid discharge. Hence no diagnosis can 
be positive without an examination of the 
urethra throughout its length. 
To examine the urethra with a sound, a No. 
25 or 26 of the French scale should be used. 
If a sound of this calibre will not enter the 
meatus, it is better to cocaine the mucous 
membrane within the meatus and nick the 
orifice at once to a sufficient size; for while 
the meatus is contracted, the cure of prostatic 
gleet is almost hopeless. The sound is then 
passed slowly and gently along the urethra. 
No pain is felt until the prostate is reached, 
when a hot or scalding pain is felt, which 
ceases directly the instrument is withdrawn. 
The pain is the same whether a curved sound 
or flexible bougie be used. When the pro- 
state is swollen there is more resistance, but 
the pain is less scalding to the patient. 
If the urethra between the triangular liga- 
■ ment and the orifice into the bladder be GLEET 
731 
inspected, several changes from healthy con- 
ditions may be found. The mucous membrane 
in health is pale pink, or bluish pink in colour, 
faintly marked with longitudinal carmine 
lines, which of course seem to radiate from 
the centre of the lumen, owing to the funnel- 
shaped contraction of that part of the urethra 
which is exposed to view by the endoscope. 
When there is chronic inflammation, and 
the surface has not become indurated, it is of 
deep carmine hue, closely beset with small 
eminences which give it a strawberry-like 
appearance, a resemblance often enhanced 
by the minute flocculi of pus which adhere 
to the surface among the prominent granula- 
tions, and simulate the yellowish seeds of the 
ripe strawberry. These vascular excrescences 
are at first general over the mucous mem- 
brane ; but, as time goes on, they subside, and 
are represented by a few papillary tufts or ex- 
coriations, which become permanent if not 
treated. The congested surface bleeds readily, 
so it must be well mopped, using tincture of 
hamamelis, if the bleeding is obstinate, before 
inspecting it or applying other astringents to 
the surface. Most commonly, in chronic 
catarrh of the urethra there are excoriations, 
sometimes granulations, and, rarely, pedun- 
culated warts. If the inflammation has 
lasted several months, the verumontanum is 
often shrunken and white, and the orifices of 
the ejaculatory ducts are invisible or show as 
dark greyish dots. 
7. Chronic prostatitis.-If there be 
general congestion of the organ, and not 
merely superficial catarrh, the symptoms are 
more pronounced. In such cases there is 
usually some pain, which is variously de- 
scribed. Sometimes it consists of a sensation 
of heat extending along the whole urethra, 
often radiating to the buttocks, but felt most 
after micturition. In other persons there is 
often dull pain in the perinaeum, a sense of 
weight or fulness of the rectum, rather worse 
by night than by day; aching above the 
pubes is often complained of. Micturition is 
called for twice or more by night. By day 
it is not increased in frequency. When 
micturition is attempted, the urine is often 
slow to come, and usually a few drops drib- 
ble off after the stream ceases. Walking 
fatigues easily, and brings on the sense of 
fulness in the rectum. The finger in the 
rectum generally finds some swelling and 
slight tenderness of the prostate. A sound 
traverses the urethra without causing pain 
till the bulbo-membranous portion is reached: 
the instrument is then grasped for a few 
seconds, to pass on again to the neck of the 
bladder; here again pain is felt, resistance is 
made, and the resistance ceases suddenly as 
the sound enters the bladder, though the 
pain, of a pressing or squeezing character, 
still remains. As the instrument is with- 
drawn, it is expelled rapidly until it is beyond 
the bulb, where it lies quietly enough and all 
pain ceases. When, however, the prostatic 
mucous membrane is also much congested, 
the pain attending the passage of a sound is, 
as already mentioned, hot or burning. 
Treatment.-1. Inflamed areas.-When 
the pain caused by the passage of the ex- 
ploring sound is acute, the resistance small, 
and the discharge white and thick, the con- 
dition is mainly one of congestion, which is 
benefited by instillations at the places where 
the pain is felt. A suitable solution is one of 
ten to twenty grains of nitrate of silver to the 
ounce of water, injected by means of a Guyon's 
bullet-catheter and syringe. This may be re- 
peated every three or four days, while an as- 
tringent injection of alum and sulphate of zinc 
is used in the intervals. If there be cling or 
hitch as the bullet passes along the urethra, 
the use of a No. 25 or No. 26 (millimetric 
scale) steel sound, or even a larger one, twice 
weekly, is requisite. When no cling exists, 
the last remains of the discharge can some- 
times be dried up by using soluble bougies 
at night containing chloride or sulphate of 
zinc in suspension ^porte-remede Reynal ') for 
ten or fourteen nights. Much may be done 
with injections by the patient himself when 
the inflammation is limited to that part of 
the urethra which extends in front of the tri- 
angular ligament. When the disease has 
extended behind that limit, very few patients 
can apply an injection to that portion, and 
the treatment must be carried out wholly by 
the surgeon. The injections ordinarily used 
for gonorrhoea are seldom sufficiently astrin- 
gent to penetrate into the mucous membrane, 
and solutions having a strength of four or five 
grains of alum, as much of sulphate of zinc, 
and of one-fourth or one-half grain of sul- 
phate of copper to the ounce of water, are 
needful in this chronic inflammation of small 
areas. 
When congestion has produced induration, 
or even contraction which does not yield to 
gradual dilatation, the fibrous band should 
be divided by an urethrotome of suitable 
shape, until the urethrameter, expanded to 
the largest size in which it moves freely 
along the unaffected parts, travels without 
hitch or cling past the contracted patches. 
Valuable aid can be obtained by means of 
the endoscope, through which the inflamed 
patches can be attacked with mops, used 
under the control of the eyesight, soaked in 
aqueous solutions of the nitrate of silver con- 
taining 10 to 20 per cent, of the salt. Indeed, 
many otherwise intractable affections of the 
urethra are easily managed if treated endo- 
scopically. 
2. Granular patches.-The treatment of 
granular patches is tedious and uncertain with- 
out the endoscope. Something may be done 
by instillations of solutions of nitrate of silver 
of fifteen or twenty grains to the ounce of 
water, while the patient employs a strong in- 
jection between the sittings. But the precise 732 
GLEET 
GLEICHENBERG 
applications of stronger caustics through the 
endoscope is far more sure and satisfac- 
tory. Brushing the granulations with a 20 
per cent, solution of nitrate of silver, or with 
a 1 per cent, solution of bichloride of mercury 
in alcohol, after scraping their surfaces with 
a curette, causes these granulations to dis- 
appear after four or five applications, and to 
leave no trace of their presence. The pain 
of this method is unimportant, and need not 
interfere with the patient's ordinary avoca- 
tions. Careful dilatation of the contractions 
is also most necessary during the application 
of the caustics. In treating granular patches, 
the writers have abandoned the use of soluble 
bougies and medicated bougies of all kinds, 
on account of their feeble and uncertain 
action. 
3. Warts yield only to topical treatment. 
When very small, they may be destroyed by 
pressing a pencil of cupric sulphate against 
them. They may be nipped off with scissors 
through the endoscopic tube. If arboriform 
and pedunculated, the galvanic cautery is the 
most effective treatment. It is well to cocaine 
the urethra by injecting into it ten minims 
of a 10 per cent, solution of hydrochlorate of 
cocaine, and allowing five minutes to elapse 
for absorption, before passing the endoscopic 
tube through which the topical application is 
made. 
4. Ulcers are usually cured by light touches 
of the cupric sulphate pencil, and by dilating 
any stricture which may be present. 
5. Follicular sinuses.-These often con- 
tinue to secrete pus, which, escaping into the 
urethra, forms shreds, which appear in the 
urine. The best treatment is mopping with 
an astringent solution (10 per cent, solution 
of silver nitrate), or pressing into the follicle 
a fine point of cupric sulphate. After this 
application, the patient should use a strong 
injection to wash the sinus freely for some 
days. In time the sinuses cease to secrete 
discharge even if not treated. But before 
this cessation takes place, the sinus may 
bepome distended and break again, commonly 
into the urethra as before ; rarely the collec- 
tion of matter may penetrate into the erectile 
tissue and through the fibrous tissue to the 
skin, and so reach the surface of the body. 
When this threatens, the abscess should be 
promptly incised; it usually closes after 
evacuation without further trouble. 
6. Chronic catarrh of the prostatic urethra 
is little benefited by general treatment or 
by drugs. Abstinence from stimulants, vio- 
lent exercise, and sexual excitement are 
requisite ; and when the secretion of pus is 
abundant, the specifics for catarrh, such as 
copaiba, cubebs, and buchu, are beneficial. 
But when there is little more than a shreddy 
discharge in the urine the proper treatment 
is topical. The remedies are local instilla- 
tions, by a Ulzmann's curved catheter syringe, 
of solutions of ten, fifteen, or twenty grains 
of nitrate of silver to the ounce of dis- 
tilled water directly on to the inflamed sur- 
faces, made at intervals of five or seven days, 
the length of time being decided by the 
amount of reaction caused by the instillation. 
All soreness and increase of discharge which 
follows the caustic application should subside 
before another is applied. Usually several 
such instillations, with solutions increasing 
in strength, must be made to obtain a 
cure. 
The use of the endoscope renders the treat- 
ment more certain and expeditious, as in 
treating similar patches in the anterior por- 
tion of the urethra. By this means the in- 
flamed areas can be distinctly seen, and the 
remedy applied directly to them. Useful 
astringents in which to dip the mops are 
tincture of iodine, solution of perchloride of 
iron of the British Pharmacopoeia, of mercuric 
chloride (1 per cent, in spirit), or of silver 
nitrate of 10 or 20 per cent, in water. These 
applications must be repeated, like the in- 
stillations, at intervals of a w'eek or more, 
according to the amount of irritation they 
set up. Often, under most favourable con- 
ditions, the cure is slow and sometimes very 
tedious, but it may be always gained with 
patience. 
7. For chronic prostatitis, when that is 
present as well as catarrh of the prostatic 
urethra, the treatment required is that need- 
ful for prostatitis. The general treatment is 
here of great value, including moderate exer- 
cise without fatigue, careful restriction of the 
diet to unstimulating food, tonics if required, 
removal of constipation, regular bathing in 
tepid or cold baths, occupation for the mind 
without lascivious or erotic excitement, and, 
when all congestion has been thus removed, 
cold injections into the rectum. Also, at this 
stage the passage of full-sized steel sounds, 
and instillations of solutions of silver nitrate 
into the previously cocained prostatic urethra, 
are among the most effective remedies for this 
troublesome ailment. Before caustic injec- 
tions are used it is well to empty the bladder 
of urine, and to inject eight or ten ounces of 
some bland fluid, such as cold boiled water, 
or cold saturated aqueous solution of boric 
acid, with which the patient may flush out 
the urethra after the caustic solution has 
taken effect. This precaution prevents much 
of the soreness which invariably follows the 
use of strong astringents in this region. The 
patient should also keep his bed, or at least 
his room, for a couple of days after each 
cauterisation, to lessen the probability of an 
acute inflammation of the prostate or of the 
uvula vesicae following the injection, of which 
there is always some risk. 
Berkeley Hill. Charles Stonham. 
G-LEICHENBERG, in Austria.- 
Muriated alkaline waters. See Mineral 
Waters. GLOBUS HYSTERICUS 
GLYCURONIC ACID 
733 
GLOBUS HYSTERICUS {globus, a 
ball; hystericus, connected with hysteria). 
Synon. : Fr. Globe hysterique; Ger. Hys- 
terische Kugel.-A subjective sensation ex- 
perienced by hysterical patients, as of chok- 
ing, or of a ball rising in the throat. See 
Hysteria. 
GLOSSALGIA {y\a>aaa, the tongue; 
and aXyos, pain).-Pain in the tongue. See 
Tongue, Diseases of. 
GLOSSITIS {yXaaaa, the tongue).-In- 
flammation of the tongue. See Tongue, 
Diseases of. 
GLOSSO-PHARYNGEAL NERVE, 
Diseases of.-The glosso-pharyngeal nerve 
is distributed to the back of the tongue and 
the soft palate, the upper portion of the 
pharynx, the Eustachian tube, and the tym- 
panum; and also to the stylo-pharyngeus, the 
middle constrictor of the pharynx, the levator 
palati, and the azygos uvulae muscles. But 
the nerve is connected with the fifth, facial, 
and pneumogastric nerves, and with the 
pharyngeal plexus; it is certain that many of 
its terminal branches merely distribute fibres 
from these other nerves ; and the early ideas 
of the function of the glosso-pharyngeal, 
founded on its terminal anatomy, are widely 
erroneous. Although its twigs go to the struc- 
tures that subserve taste on the back of the 
tongue, it is certain that these, with those for 
common sensation in the same part and in 
the fauces, come from the fifth nerve; and 
that the fibres that innervate the palatine 
muscles are derived from the spinal accessory. 
Paralysis.-Very little is known of the 
precise effects of paralysis limited to the 
glosso-pharyngeal nerve, since it is rarely 
paralysed alone. The middle constrictor of 
the pharynx is, however, paralysed, and the 
mucous membrane of the pharynx is rendered 
insensitive. From their position, the fibres 
of origin are commonly damaged in conjunc- 
tion with fibres of the hypoglossal, spinal 
accessory, and pneumogastric. The common 
causes of disease in this situation are men- 
ingitis, syphilitic and other growths, and bone- 
diseases. The nerve may also be paralysed 
from disease of its nucleus of origin in the 
medulla oblongata, and then commonly suffers 
in association with the nerves to the larynx, 
the tongue, and often the lips {see Labio- 
glosso-laryngeal Paralysis). The sensory 
part of the nerve may then escape, and only 
the motor part be paralysed, the chief effect 
of which is paralysis of the pharynx. The 
causes of paralysis from disease of the nucleus 
are slow degeneration, softening, haemorrhage, 
and the effects of diphtheria. 
Spasm.-Nothing is known of separate 
spasm in the muscles supplied by the glosso- 
pharyngeal nerve. In conjunction with 
the other motor and sensory nerves to the 
pharynx, it takes part in the production of 
the spasm of hydrophobia, and in some hys- 
terical phenomena. 
Treatment.-The treatment of disorders of 
the glosso-pharyngeal nerve is never special, 
but always that of the cause, and is suffi- 
ciently described in the several articles which 
deal with the above-mentioned aetiological 
conditions. W. R. Gowers. 
GLOSSO-PHARYNGEAL PARA- 
LYSIS A synonym for labio-glosso- 
laryngeal paralysis. See Labio-glosso- 
LARYNGEAL PARALYSIS. 
GLOSSY SKIN.-Glossy skin is the 
name given to a peculiar atrophic condition 
of the skin, seen principally in the hands, 
in consequence of irritative lesions of the 
nerves of the forearm. The skin of the back 
of the hand, fingers, and even of the palm, 
is thin, smooth, shining, without furrows, 
and redder than natural-either uniformly 
or in patches. The skin seems as if it 
were stretched over subjacent parts, which 
are firmer than natural. It may be more 
or less fissured, dr even denuded of epider- 
mis in patches. Secretion of sweat may be 
increased or altered in quality. The parts 
may or may not be the seat of neuralgic 
pains. It was thought by Sir James Paget 
(who described this condition in the Medical 
Times and Gazette for May, 1864) to be a 
very rare affection, but it was observed by 
Weir-Mitchell and his colleagues, in the late 
American war, no less than nineteen times 
in fifty cases of partial division of the nerves 
of the forearm. It may occur also as a 
sequence of dislocations of the wrist, where 
the median nerve is compressed or otherwise 
damaged. 
GLOTTIS, Diseases of.-See Larynx, 
Diseases of. 
GLYCOSURIA {yhvKvs, sweet ; and 
ovpov, urine).-A condition of urine in which 
sugar is present; generally used as a syno- 
nym for diabetes. See Diabetes Mellitus. 
GLYCURONIC ACID. - Glycuronic 
acid is a substance allied to the carbohydrates, 
and represented by the formula C6H10O7. It 
occurs as an abnormal constituent of urine, as 
the result of ingestion of certain chemical 
substances, chief among which are camphor, 
chloral hydrate, butyl chloral hydrate, mor- 
phine salts, nitro-benzol, and some of the 
quinine derivatives. After chloroform (but 
not ether) narcosis its presence can be de- 
tected in the urine of the patient. 
The presence of glycuronic acid in urine 
is of interest as it is liable to be mistaken 
for grape-sugar (dextrose), like which it is 
capable of reducing alkaline copper solutions 
(Fehling's test), as also Bottger's bismuth 
test {see Diabetes Mellitus). The possible 
presence of glycuronic acid ought to be kept 734 
GLYCURONIC ACID 
GOITRE 
before the mind in the examination of urine 
for sugar. Dextrose can be readily dis- 
tinguished from glycuronic acid by its be- 
haviour with yeast, glycuronic acid yielding 
a negative result when so treated. When 
pure it is not crystalline. It is readily soluble 
in water, much less so in absolute alcohol, 
very sparingly in ether. Its pure solutions 
are dextro-rotatory. The only reliable test 
at present known for the positive recognition 
of glycuronic acid is its isolation from the 
urine by a process long and tedious. 
John Harold. 
G-OITRE.-Synon. : Bronchocele; Derby- 
shire Neck; Fr. Goitre", Ger. Kropf', Struma. 
Definition.-Simple hypertrophy, or cystic, 
fibroid, or fibro-cystic enlargement of the 
thyroid gland. 
^Etiology.-a. Locality.-Goitre is preva- 
lent in magnesian-limestone districts, for ex- 
ample, Derbyshire-hence the name ' Derby- 
shire neck.' Amongst the continental coun- 
tries it prevails in are France, mostly in 
Savoy; Germany, mostly in the Black Forest; 
Austria, mostly in Styria; Northern Italy, 
mostly about the Alps ; Switzerland, mostly 
in the Valais ; and Russia, mostly about the 
Altai mountains in Siberia. 
Goitre is not only indigenous to moun- 
tainous districts, as has been supposed, but 
it is present in some plains-for instance, 
the plains of Lombardy. 
b. Water-supply.-Goitre is due in a large 
number of cases to an impurity in potable 
water. Snow-water was in former days con- 
sidered to be the cause, but this opinion is met 
by the statement that goitre does not exist in 
Greenland or Lapland, and that it is preva- 
lent in Sumatra, where there is never any 
snow. The impurity has been stated by many 
to be due to an excess of lime and magnesia, 
which theory seems borne out by a geological 
examination of the localities in which goitre 
is indigenous in England. In parts of the 
Indian Punjaub, where goitre affects 60 per 
cent, of the population, 59 grains of lime have 
been found in a gallon of water, ' 10 grains 
being an undesirable proportion ' (Professor 
Frankland). On the other hand, in many 
limestone localities bronchocele is entirely 
absent. Scotland, Ireland, Norway, and 
Sweden are comparatively exempt from the 
disease, although mountain limestone is found 
largely present in their geological formation. 
Several observers have attributed goitre to 
the presence of iron pyrites in the water- 
bearing strata. Dr. Thursfield, of Shrews- 
bury, who has personally investigated the 
disease in various parts of England, believes 
that impure water, although not always or 
necessarily a factor in the production of 
goitre, is frequently a strongly predisposing 
cause; and that when this is the case, the 
impurity in the water which causes goitre 
is undoubtedly protoxide of iron in carbonic 
solution. Thus is explained the fact that 
goitre is so often found in magnesian lime- 
stone districts; for iron pyrites, when brought 
into contact with water containing carbonate 
of lime and magnesia in carbonic solution, 
passes by a process of oxidation into the 
soluble carbonate of iron. 
c. Other causes.-Epidemics of goitre have 
been notified as chiefly occurring amongst 
soldiers in France, probably the result of 
forced marches through goitrous districts, com - 
bined with scarcity of food. In such districts 
the practice of carrying loads on the head 
seems largely to increase the ratio of the 
disease. Dr. Thursfield has proved by in- 
vestigation, spread over many years, that 
goitre has largely decreased in those districts 
where the practice of carrying weights on the 
head has decreased, although there has been 
no other change in the habits of the natives, 
nor in the condition of the water of the dis- 
trict. He has found that much walking up 
and down hills, diminished barometric pres- 
sure, and child-bearing are factors in goitrous 
districts. He believes goitre, if endemic, to 
be essentially a disease of childhood, disap- 
pearing at adolescence unless the above- 
mentioned causes are brought into play. He 
has also noted that ' the influence of here- 
dity, direct, collateral, and atavistic, is most 
strongly marked '; and ' that intermarriage in 
comparatively isolated communities, acting 
through successive generations, is a potent 
predisposing cause in the local prevalence of 
goitre.' 
Women in this country are much more 
liable to suffer from bronchocele than men, 
perhaps on account of their being more fre- 
quently water-drinkers, for in India it has 
been noticed that both sexes suffer alike. 
Besides, there is an association between the 
enlarged gland and the uterine functions. 
During the time of puberty the disease com- 
monly first attracts attention, although it 
may occur from any time of life up to forty 
years of age, children having even been born 
with a thyroid enlargement. 
Anatomical Characters.-The whole of 
the thyroid gland, or both lobes, or one lobe 
only, may be the seat of the goitrous enlarge- 
ment. The isthmus is rarely affected by 
itself. In exceptional cases an accessory lobe 
is present, and becomes enlarged. The en- 
largement may be simple soft hypertrophy ol 
the gland, cystic, or fibroid; or cysts may be 
found interspersed in the substance of a fibroid 
enlargement. Cysts are formed from the 
normal follicles of the thyroid, by their dis- 
tension with colloid material, the epithelial 
lining degenerating as the cysts increase in 
size. The cyst-wall is formed by the inter- 
lobular septa and capsule of the gland. In 
pure cysts the serous fluid which is secreted 
from the walls replaces the colloid contents. 
In the fibroid form the connective stroma 
increases at the expense of the follicles, and GOiTRE 
735 
tough bands of nucleated fibrous tissue tra- 
verse the organ in all directions, the change 
generally commencing centrally and extend- 
ing peripherally. The follicles mostly atrophy, 
but some may persist in the form of small 
cysts. 
Symptoms and Complications.-The ap- 
pearance of the swelling, and a sense of ful- 
ness in the neck, are often the only symptoms 
of goitre. Added to the sense of fulness, there 
may be a feeling of dragging or constriction 
about the throat. More serious symptoms 
are sometimes present-namely, dysphagia 
and dyspnoea. The former is rarely present 
except when the tumour has reached an im- 
mense size, or when it presses on the oeso- 
phagus, as happens when the lateral lobes 
meet behind the gullet. Dyspnoea, a more 
common symptom, may be due to pressure 
from the goitre on the front and sides of the 
trachea (found more commonly in young 
people, before the tracheal rings have gained 
much power of resistance), or on both recur- 
rent laryngeal nerves, causing partial para- 
lysis of the abductors of the vocal cords 
(crico-arytenoidei-postici muscles) ; or to a 
portion of the gland passing behind the 
trachea, or becoming enlarged beneath the 
sternum. There is often a temporary en- 
largement of a goitre during the catamenial 
period and pregnancy; and flooding in child- 
birth is not uncommon. A tendency to the 
haemorrhagic diathesis has been noted. Ex- 
ophthalmos, with palpitation of the heart, 
may accompany goitre. See Exophthalmic 
Goitre. 
Goitres in some countries are allowed to 
reach such dimensions that the inhabitants 
have to support them in bags. A cystic 
goitre projects externally far more often than 
the fibroid variety. 
Cretinism is met with, but rarely, in the 
goitrous districts of this country. More than 
half the number of cretins are born of goitrous 
parents; but a goitrous enlargement need not 
necessarily be present in a cretin, for instances 
of cretinism have been reported in which the 
gland has been entirely absent; still they 
have the same aetiological connexion. When 
the thyroid gland is absent and cretinism 
prevails, the late Dr. Hilton Fagge believed 
that fatty tumours will be found, almost with- 
out exception, in the posterior triangles of the 
neck. See Cretinism ; and Myxcedema. 
Diagnosis.-A soft hypertrophy of the 
thyroid gland can be diagnosed by its general 
diffusiveness, and the want of consistent 
hardness. 
The presence of a cystic goitre can be 
ascertained by the fluctuation of fluid within 
its walls. Illumination of the sac for the 
purpose of diagnosis is of no use. Any 
doubt can be cleared up by passing a very 
fine trochar into its centre. Owing to the 
fact that some cystic goitres contain a large 
amount of soft trabecular structure, the fluid 
withdrawn is likely to be mixed with blood. 
When the fluid has been entirely withdrawn 
from a pure cyst, it often happens that blood 
will be freely discharged from the mucous 
walls. 
A fibroid enlargement of the thyroid gland 
can be diagnosed by the consistency and 
hardness of its substance. In some cases, 
fibroid nodules lie scattered in a general 
hypertrophy of the gland, and may be of 
stony hardness. Some difficulty may be ex- 
perienced in distinguishing between a globular 
fibroid and a small cystic goitre that has 
thick walls, both of which lie deeply in the 
neck; but if the exploratory examination be 
made, as recommended above, the difference 
can at once be recognised. 
The diseases which simulate goitre are 
cancer of the thyroid gland; calculus em- 
bedded in its substance; lymphadenoma ; 
aneurysm; and fatty and other tumours of 
the neck. A leading point in making a dia- 
gnosis is to ascertain, by directing the patient 
to swallow, whether the swelling is attached 
to the trachea. In the cases of cancer and 
lymphadenoma, the history and general con- 
dition of the patient will give a leading clue. 
In connexion with cancer, it must be borne 
in mind that a fibroid enlargement of the 
gland may become the seat of carcinomatous 
change. When a fibrous goitre closely over- 
lies the carotid artery, it simulates an aneur- 
ysm, owing to the forcible pulsation conveyed 
through its substance. 
Prognosis.-The prognosis in goitre is 
favourable. The occurrence of death from 
suffocation, due solely to the effects of a 
goitrous enlargement, is rare. It occurs in 
those countries where little or no treatment 
is tried, the tumours being allowed to attain 
an immense size-their weight sometimes 
reaching several pounds. The disease is 
more likely to endanger life when the gland 
passes behind the trachea, and completely 
embraces it. All the varieties of goitre are 
amenable to treatment, but especially the 
cystic. Goitres have been known to disap- 
pear without any treatment. This result 
may be due to the removal of the affected 
person from endemic influences; or it may 
happen when the enlargement has arisen 
during pregnancy. 
Treatment.-The general rules requiring 
attention are rem oval of the patient from a goi- 
trous district, or complete abstinence from the 
drinking-water, unless it has been ascertained 
to be perfectly innocuous, also from carrying 
weights and ascending hills. General medi- 
cinal remedies are only of service when the 
gland is enlarged by fibroid change, and then 
iodide of potassium (two to three grains twice 
a day) may be tried. When the hypertrophy 
is of the simple soft form, blistering, or paint- 
ing the surface with the tincture of iodine, 
or the use of iodine ointment, will be suffi- 
cient. If the enlargement is fibroid and of 736 
GOITRE 
GONORRHCEA 
some consistence, then injections of the tinc- 
ture of iodine into, or setons passed through, 
the substance of the gland, are most useful. 
Fluoric acid has been given internally, with 
or without the injections, in some cases with 
success. The injection of 1){xv to 5j of tinc- 
ture of iodine should be used twice a week, 
then weekly, and afterwards fortnightly. 
The greater number of cases answer well to 
this treatment, whilst on others no impres- 
sion can be made. The time the treatment 
takes depends on the size of the goitre ; a 
month is the minimum required for the cure 
of a very small goitre. The process to 
be followed when injecting is as follows: 
Having frozen the skin over the portion 
decided upon for injection, by means of the 
ether spray, and care being taken to avoid 
transfixing any vein, or the trachea, the 
needle of the syringe is pushed into the sub- 
stance of the goitre, and the fluid injected 
slowly. The best form of syringe for the 
purpose is one similar to that used for hypo- 
dermic injection, made with a screw-piston. 
Pain in the course of neighbouring nerves is 
sometimes felt during the injection, for in- 
stance in the ear, or at the root of a tooth. 
When the operation is finished, the needle 
should be rapidly withdrawn, and the skin 
where the puncture has been made rolled 
between the finger and thumb, to prevent any 
escape of the iodine. If the needle be passed 
well into the substance of the goitre, no fear 
need be entertained of the formation of an 
abscess. In favourable cases there will be a 
gradual enlargement of the tumour, with a 
slight degree of pain, for some eight or twelve 
hours; after that time the bronchocele will 
very slowly decrease in size. As a rule, in 
two or three weeks' time it will be evident 
whether the injection is to prove effective. 
By this form of treatment all scars are 
avoided. The length of time required for its 
adoption is often an objection, even when im- 
provement is noted; a case occurred in the 
writer's experience in which the time needed 
for the completion of the cure was over a 
year, the neck being reduced from 17f to 13| 
inches. Setons made of from two to eight 
lengths of silk form a very serviceable plan 
for the treatment of fibrous goitres. In em- 
ploying either injections or setons, there may 
be a slight rise of temperature, but it is rarely 
necessary for the patient to discontinue his 
usual employment. 
Biniodide of mercury smeared over the 
enlargement, the patient being then made to 
sit with his neck exposed to the rays of the 
sun for many hours, has proved an effectual 
remedy in India. A Captain Cunningham, 
the originator of this plan, treated gratuitously 
about 60,000 natives in two years. He is 
said to have never produced salivation, and 
to have rarely failed in effecting a cure. 
Ligature of the thyroid arteries has only 
proved of temporary benefit. Division of the 
isthmus has been advised when dyspnoea is 
present. This operation may cause the rest 
of the gland to diminish. A goitre may be 
removed when it endangers life or keeps the 
patient from work. The operation, though a 
serious one, is of comparative safety under 
the antiseptic system, and when each vessel 
is divided between ligatures. Entire removal 
of the gland is, unhappily, often followed by 
myxcedema. See Myxiedema. 
The treatment of cystic goitre is of one 
kind, unless removal of cyst is practised, and 
is always successful. The plan consists in 
emptying, or partially emptying, the cyst 
with a trochar and cannula, and then inject- 
ing a solution of iron (two drachms of the 
solution or tincture of the perch lor ide to an 
ounce of water) sufficient to expand the 
cavity again. The patient should be kept in 
bed on account of the rise of temperature, 
after a successful injection, with the cannula 
plugged, until the third or fourth day, when 
a suppurative discharge should have been 
set up. Should the injection not be suc- 
cessful, it can be repeated at intervals of a 
few days, until a discharge is established. 
The metal cannula should then be replaced 
by an indiarubber one (made with a middle 
layer of webbing), the cannula being cut 
shorter as the cyst becomes smaller, and 
poultices applied until the goitre has dis- 
appeared. A cure will be effected in one 
month to four or five months. 
During the injection of the iron solution 
into cystic goitres, it may happen that air 
passes into a vein which has been wounded 
by the trochar. As this accident has been 
followed by instantaneous death, the writer, 
to prevent it, uses conjointly the two follow- 
ing plans, taking care to avoid superficial 
veins: (1) A tape is passed round the neck 
under the base of the goitre, and held tightly 
by an assistant standing behind the patient, 
whilst the injection is going on, and for two 
or three minutes after. (2) The nozzle is fixed 
at right angles to the body of the syringe, 
to enable the injection to be made without 
holding the syringe below the level of the 
opening into the cyst, thus preventing the 
injection of air. See Thyroid Gland, Dis- 
eases of. Pugin Thornton. 
GON AGRA (yow, the knee ; and "iypa, 
a seizure).-An attack of gout in the knee. 
See Gout. 
GON ARTHRITIS (yow, the knee; and 
apdpov, a joint).-Inflammation of the knee- 
joint. See Joints, Diseases of. 
GONORRIICEA (yovj), seed ; and p^at, 
I flow).-Synon. : Clap ; Blenorrhagia ; Fr. 
Chaudepisse; Ger. Tripper. 
Definition.-A contagious purulent in- 
flammation, affecting primarily, in men, the 
urethral, and in women the vaginal mucous 
membrane. Occasionally the conjunctival GONORRHCEA 
737 
and rectal mucous membranes, to which the 
nasal has been added on doubtful evidence, 
are attacked by gonorrhoea. Certain rheuma- 
toid affections and other complications, to be 
subsequently mentioned, may also attend the 
disease. 
^Etiology.-True gonorrhoeal inflamma- 
tion is due to inoculation of discharge from a 
surface already the seat of gonorrhoea. Mem- 
branes covered by pavement epithelium, and 
possessing a rich lymphatic supply, are the 
most readily affected ; those covered by 
columnar epithelium, e.g. the rectum, are not 
so liable to become diseased; while the mucous 
membrane of the mouth, stomach, and air 
passages appears to be exempt. Healthy 
mucous membranes are as liable to contract 
the disease as are those the seat of some 
morbid change. Although it is highly prob- 
able that gonorrhoea arises from gonorrhoea 
alone, there are cases met with of acute 
purulent inflammation of the mucous mem- 
branes of the vagina, uterus, bladder, con- 
junctiva, &c., where the disease appears to 
have arisen independently of contagion from 
specific gonorrhoeal pus. It is therefore 
better, in the present state of our knowledge, 
to admit the possibility that contagious in- 
flammations of these mucous membranes may 
originate from contact with pus secreted by 
acutely inflamed surfaces which have 'not 
been primarily affected by gonorrhoeal poison. 
There are, moreover, great difficulties attend- 
ing the isolation and cultivation of the micro- 
organism found in acute gonorrhoea-the 
gonococcus of Neisser. Previous to the 
discovery of this organism, various authors 
suggested and described certain forms of 
vegetable life which they maintained con- 
stantly appeared in gonorrhoeal pus, and to 
which they attributed causative properties 
when inoculated on suitable, mucous mem- 
branes. 
In 1879 Neisser first described a diplococcus 
found in gonorrhoeal pus, which he believes, 
and states that he has proved by experimental 
cultivation, to be the proper organism exciting 
gonorrhoea. This diplococcus, arranged in 
pairs or fours separated by a clear interval, is 
found on the surface and in the interior of 
the pus or pavement-epithelium cells, and 
also freely floating in the liquor puris; the 
organism is never found in the nuclei of the 
cells. The diplococcus is most numerous in 
the discharge from a recently infected case, 
and least so when the disease is of long 
standing. It is not at present proved incon- 
testably that the diplococcus in question 
is really the specific poison of gonorrhcea. 
A very similar organism is found in the 
buccal mucus of some persons; and even in 
gonorrhoeal pus it is often accompanied by 
other organisms which are at home in dis- 
charges not connected with gonorrhoea. The 
diplococcus gonorrhcese is cultivated with 
great difficulty. Neisser has cultivated it in 
human blood- serum, but many other observers, 
repeating his experiments, have failed to do 
so. Neisser declares that he has produced 
a contagious urethritis by inoculating the 
cultivated microbes in the human urethra. 
Bockhart claims to have met with similar 
success. Other observers state that they 
have found the gonococcus in the fluid from 
acutely inflamed joints, and even in the 
blood itself in cases of rheumatism origina- 
ting in urethral gonorrhuea. It is theoretically 
assumed that the organism penetrates and 
multiplies in the epithelium cells, and ad- 
vances into the underlying lymphatic spaces. 
Here it rapidly proliferates, exciting inflam- 
mation and exudation, the migrated leucocytes 
containing the microbes. The process ad- 
vancing, the diplococci pass into the substance 
of the corpus spongiosum, to the glands and 
lacunae of the urethra, to the erectile tissue of 
the corpora cavernosa, &c., and light up in- 
flammatory mischief in the parts affected. 
The facility with which the gonococci pass 
along the lymphatics explains why certain 
portions of the urogenital canal, e.g. the 
navicular fossa, bulb, neck of the bladder, 
and epididymis, are the parts most commonly 
affected. Moreover, the microbes, aggregated 
into masses, may be carried away in the 
lymphatic and blood currents as infective 
emboli; this would explain the occurrence 
of gonorrhoeal rheumatism, endocarditis, &c. 
Adopting the theory of phagocytosis, it 
may be supposed that the white cells, and 
others acting as phagocytes, are hostile to the 
development of the gonococcus, and this may 
serve, in some measure, perhaps, to explain 
the fact that different persons and organs are 
not equally affected by the gonorrhoeal poison; 
in certain persons or organs their innate 
strength of resistance to infective' poisons 
may be sufficient to destroy the microbes or 
arrest their development. "When the proli- 
feration of the poison takes place mainly in 
the pus-cells, the microbe has but little power, 
and consequently the course of the disease is 
mild; but if the organisms develop freely in 
the liquor puris the course is usually severe, 
and specially marked by involvement of lymph- 
atic structures, giving rise to lymphangitis and 
bubo. 
Assuming the gonococcus to be the active 
exciting cause of the disease, there are yet 
certain predisposing causes which may exert 
an influence on the development of the 
poison, and so augment or modify the severity 
of the disease. 
First, there is no doubt that the urethral 
mucous membrane differs greatly in its sus- 
ceptibility to inflame in different individuals. 
It is, moreover, asserted that both sexes grow 
accustomed to the contagious secretions of 
the same individual, so that they neither 
infect nor are infected by their usual com- 
panions, while they readily receive from or 
impart disease to strangers. 738 
GONORRHCEA 
In women the arrangement of the genital 
mucous membrane favours the retention of 
secretions coming in contact with it. Among 
other causes favouring the development of 
gonorrhoea may be mentioned the presence of 
gleet, alcoholic excess, and previous attacks. 
Men with slight hypospadias are specially 
liable to contract gonorrhcea. 
Incubation Period.-The symptoms of 
gonorrhoea are not usually manifested until 
four or five days after infection : presumably 
the contagion needs this time for multiplica- 
tion and development before it is capable of 
exciting inflammation. According to circum- 
stances, the incubative stage maybe shortened 
or prolonged, ranging from two to eight or ten 
days. As a general rule, the shorter the in- 
cubation stage the more severe is the disease. 
The period of incubation in the case of gonor- 
rhoeal conjunctivitis is shorter than that 
of urethritis, varying from six to seventy-two 
hours, the average time being about twenty- 
four hours. 
Gonorrhcea differs so considerably in the 
two sexes, owing to the difference in the 
seat of the affection, that it will be advis- 
able to describe it in the male and female 
separately. 
(a) Gonorrhoea in the Male.-Anato- 
mical Characters.-The fossa navicularis, 
rich in follicles and their ducts, is the primary 
seat of gonorrhcea in the male. The poison pass- 
ing into the ducts remains in security during 
the period of its development and multiplica- 
tion, and penetrates into the deeper tissues and 
lymphatic network. As the disease progresses 
it gradually passes backwards by direct exten- 
sion, but often pauses at the bulb or membran- 
ous part of the urethra. In more severe cases 
the disease may extend to the submucous tis- 
sue, the prostatic urethra and prostate, neck 
of the bladder, epididymis, bladder, and kid- 
neys. Pyelitis and nephritis are less often 
the result of direct extension of the inflam- 
matory process; more commonly they are 
the result of sympathetic irritation, especially 
in cases where the neck of the bladder is 
involved. 
In the acute stage of gonorrhoea, the mucous 
membrane, where inflamed, will be deeply con- 
gested and of a bright red colour; it is swollen, 
and the epithelium on the surface proliferates 
and desquamates. A thick, creamy, purulent 
discharge soon makes its appearance. The 
dorsal lymphatics are often found enlarged 
and tender, and the inguinal glands are not 
infrequently involved and may suppurate. 
As the disease subsides, the inflammation 
dies away first in those parts first attacked; 
the redness will then be less marked, and is 
often punctiform and patchy. When the dis- 
ease subsides, the products of inflammation 
are absorbed by the lymphatics. 
In mere severe cases the surface epithe- 
lium may be destroyed, and small ulcers and 
erosions formed; these may subsequently 
form granular patches (see Gleet), and may 
ultimately give rise to stricture. This necrosis 
of tissue very rarely extends beyond the sub- 
mucous tissue. The ulcers may heal without 
producing any ill effects. If, however, they 
become chronic, fibrous tissue develops in 
their bases and gradually tends to contract; 
in other cases granulations spring up, and 
may develop into warty growths, similar to 
those seen round the corona. 
From the varieties of intensity of the 
inflammation, various appearances are pro- 
duced which have given rise to a distinctive 
nomenclature being applied to them; thus: 
(1) In some cases several layers of epithe- 
lium-cells are raised into small eminences by 
serous effusion ; these burst and leave small 
erosions-phlyctenular gonorrhoea. (2) The 
inflammatory lymph, entangling leucocytes 
in its meshes, may form a continuous, more 
or less tough, membrane on the surface, 
which can be peeled off in flakes-diph- 
theritic gonorrhoea. (3) If the discharge is 
copious, and mixed with much serum and 
mucus, the case is sometimes spoken of as 
catarrhal. 
Symptoms.-Clinically, gonorrhcea may be 
conveniently divided into three stages corre- 
sponding with the development, period of 
vital activity, and destruction of the poison. 
During the first or incubative stage there 
is some tickling and itching at the meatus 
and tip of the penis, and slight scalding on 
micturition. A feeling of heat, tension, and 
weight in the testicles and perineum is 
often complained of. Nocturnal erections 
and emissions are not uncommon, and the 
sexual appetite is increased. Micturition is 
more frequent than usual. These symptoms 
may be so slight as to be unnoticed by the 
patient, and only come on during the latter 
half of the incubative stage. 
In the second or acute inflammatory stage 
the signs are pronounced. The lips of the 
meatus are swollen and red, the urethra is 
tender to the touch, and the corpus spongi- 
osum is swollen and engorged. The discharge 
soon makes its appearance; at first it is sero- 
purulent and scanty, but in a very short time 
it becomes greenish-yellow, thick, creamy, 
and copious. Micturition is frequent and 
painful; in consequence of the swelling of 
the urethral walls, the stream of urine is 
diminished in size, or it may escape in drops. 
The pain and scalding are often severe, es- 
pecially if raw patches are present in the 
passage, or if the urine is concentrated and 
highly acid. Swelling and tenderness of the 
dorsal lymphatics are common, with enlarge- 
ment of the inguinal glands (sometimes but 
not usually going on to suppuration). In 
more severe cases the whole penis becomes 
tender and swollen, and the subcutaneous 
veins engorged. As the disease spreads to 
the erectile tissue of the corpora caver- 
I nosa, it becomes infiltrated with inflamma GONORRHOEA 
739 
tory exudation, and the affected parts are 
no longer able to be distended with blood. 
Consequently, erections, which are very 
troublesome at night, are only partial, and 
the straining and tightening of the inflamed 
parts, by the distension of the uninflamed, 
produces severe pain, and alteration of the 
shape of the erect penis-chordee. 
In some cases copious haemorrhage occurs 
from the distended parts. Small quantities 
of blood, giving a red tinge to the discharge, 
may also come from ulcerated and eroded 
areas of the inflamed mucous surface. 
Peri-urethral swellings, giving the urethra 
a beaded feeling, are by no means uncom- 
mon, especially at the fossa navicularis and 
bulb. They are due to follicular inflamma- 
tion, and to exudation into the spongy tissue 
round the urethra. If this be very acute, 
peri-urethral abscess may result. 
When the disease spreads to the membrano- 
prostatic urethra and neck of the bladder, 
there is almost constant desire to micturate, 
with great pain and spasm following the act. 
Towards the end of micturition a few drops 
of pus and blood may escape. The discharge 
is less copious, and the urine often turbid 
from admixture with muco-pus, which forms 
a plentiful deposit. From inflammatory con- 
gestion of the passage micturition may be 
difficult, the urine dribbling away. In other 
cases the irritation in the passage excites 
spasm of the compressor urethrae muscle, 
resulting in complete retention. When the 
disease has extended so far back there is 
distinct heat and pain in the perineum ; if 
the patient have an emission of semen, which 
is likely on account of the inflammatory irri- 
tation of the verumontanum and ejaculatory 
ducts, the act will be painful, as if something 
had been torn in the perineum. The semen, 
instead of escaping in jets, gradually trickles 
away, and is often mixed with and followed 
by a few drops of blood. In cases of gonor- 
rhoea, fever may or may not be present; it 
is usually slight and transient, unless the 
disease be complicated. The duration of 
this second stage varies according to the 
severity of the disease, the treatment adopted, 
and the care of the patient himself. Usually 
the acute stage passes off gradually in from 
three to six weeks. The symptoms are, 
cceteris paribus, more severe in a first attack, 
but subsequent ones are more likely to be- 
come chronic. 
After a varying time the acute inflamma- 
tory stage of gonorrhoea passes into the third. 
The symptoms may gradually abate, the 
pain and discharge disappearing, and the 
disease terminate. In other cases the dis- 
charge becomes less in quantity, more watery, 
and of a sero-purulent nature; the other 
symptoms disappearing. Lastly, all the signs 
may subside with the exception of a thin 
whitish discharge, especially noticeable in 
the morning. In such cases the disease per- 
gists in a patchy form, and constitutes gleet. 
See Gleet. 
During the third stage the acute symptoms 
may at any time be lighted up again if the 
treatment be abandoned, or in consequence 
of injudicious conduct on the part of the 
patient. 
Diagnosis.-Acute urethritis is not in- 
variably gonorrhoeal; and it may be of great 
importance, especially in cases likely to lead 
to legal proceedings, to determine whether 
the urethral mischief be gonorrhoeal or not. 
Much credence must not be placed on the 
patient's statements. Certain complications 
are said only to follow gonorrhoea, and no 
other form of urethritis; but this is not so 
clearly established as to be of certain dia- 
gnostic value. In cases where a definite 
opinion as to the venereal nature of the case 
is necessary, the pus should be examined for 
the gonococcus by staining with fuchsin or 
methyl violet. But, as already stated in dis- 
cussing the Eetiology of gonorrhoea, there is 
still some doubt as to the specific properties 
of this organism. 
Urethritis may be easily distinguished from 
urethral chancre ; but it must be remembered 
that both conditions may be present. Ure- 
thral chancre is nearly always situate just 
within the meatus, never more than one inch 
from it; the ulcerated surface can be seen if 
the lips of the urethra be separated, and a 
short aural speculum introduced. 
The discharge from a chancre is not 
creamy, but shreddy, and the pain during 
micturition is stinging and limited to the raw 
surface. Occasionally a slight muco-purulent 
discharge, without pain or much swelling, 
is present during the initial stage of syphilis, 
but it subsides spontaneously in one or two 
weeks, and is accompanied by the indurated 
sore, and succeeded by secondary symptoms. 
In balanoposthitis (which may or may 
not be venereal in origin) there need be no 
urethral discharge. This can be ascertained 
by thoroughly syringing away all the pus 
from under the prepuce, and then squeez- 
ing the penis to see if pus escapes at the 
meatus. 
Prostatic and perineal abscesses may dis- 
charge into the urethra. In such conditions 
the discharge, profuse on one occasion, at 
once subsides to a scanty gleet. They may 
be diagnosed by the history of the case, and 
a careful examination of the patient, but it 
must be borne in mind that they occasionally 
complicate gonorrhoea. 
Prognosis.-The prognosis of gonorrhoea 
is usually favourable if proper precautions be 
taken early. But, in spite of attention and 
care, the disease is sometimes very severe, 
especially in young lads of lymphatic tem- 
perament, or in men of nervous, irritable 
constitution. Gonorrhoea is said also to be 
liable to run a severe course in persons who 
suffer from acne. It is more likely to become 740 
GONORRHCEA 
chronic after repeated attacks, and in those 
who suffer from stricture or have a narrow 
meatus. 
Various complications, to be afterwards 
referred to, may arise in the course of the 
disease, and certain sequelae follow it. In 
rare cases gonorrhoea terminates fatally by 
general pyaemia, or more frequently may 
lead to joint-affections of more or less 
severity. 
Treatment.-The so-called abortive treat- 
ment of gonorrhoea has, on account of its 
non-success and attendant risks, been prac- 
tically abandoned, and calls for very short 
notice here. It consists in the internal ad- 
ministration of large doses of copaiba or 
cubebs, or of injections of caustics or strong 
irritants and astringents. The former are 
open to the objection that they not infre- 
quently produce marked constitutional dis- 
turbance, and moreover are unsuccessful in 
attaining the object in view. Strong injec- 
tions too often aggravate, instead of reliev- 
ing, the local mischief, and may thereby make 
the course of the disease more severe and 
chronic. In the early stages of acute 
gonorrhoea, rest, if the patient can take it, 
is important. The bowels should be opened 
and kept acting by the use of saline aperi- 
ents, and the diet should be low and of a 
non-irritating description. All alcohol, especi- 
ally malt liquors, highly seasoned dishes, 
great exercise, and sexual excitement should 
be rigorously avoided. Warm baths and 
strict cleanliness of the parts, with support of 
the penis and testes, are useful. The salts of 
potassium, with tincture of hyoscyamus, are 
also useful, to diminish the acidity of the 
urine, and allay the smarting and pain during 
micturition ; the same may, if excessive, be 
relieved by immersing the penis in iced 
water during micturition. In extreme cases, 
cocaine may be injected before micturition. 
As long as there is much smarting and signs 
of acute inflammatory congestion, strong 
astringent injections should be avoided, but 
relief is obtained by washing out the urethra 
with tepid water after micturition. One- 
eighth gr. of permanganate of zinc to one 
fluid ounce of distilled water is an injection 
which may generally be employed in the 
earliest stage. When the acute stage has 
passed, the continuance of the congestion 
is shortened by astringent and antiseptic in- 
jections, and the internal administration of 
copaiba, sandal oil, or cubebs. Injections 
should not be strong at first-2 to 3 grs. of 
sulphate of zinc to the ounce being sufficient. 
The patient should be directed to pass his 
water, and then wash out the passage with 
a little tepid water ; after that the injection 
should be used, and kept in the urethra for 
two minutes. Many substances are used as 
injections, and it is difficult to say in a given 
case which will suit best. Sulphate of zinc 
grs. 2 to ^j, or mixed with acetate of lead; 
chloride of zinc gr. |-gr. 1 to Jj; sulpho- 
carbolate of zinc grs. 2 to ^j ; permanganate 
of zinc gr. | to Jj, are all useful. Alum, 
acetate of lead, hydrastis, and the extract of 
belladonna may also be used. Extract of 
belladonna should not be used with perman- 
ganates, as they form an explosive mixture. 
The mercuric chloride in solutions of various 
weakness, ^7^^ to utAhd is used on theo- 
retical grounds by some; but in the writers' 
experience they are most uncertain, and more 
often excite irritation than allay it in the 
urethra. 
Whatever injection is chosen, it must be 
used judiciously, and care taken that it does 
not aggravate the condition it is intended to 
benefit. As a rule, the injection should be 
made at least three times a day by the 
patient; if the membrano-prostatic urethra 
be involved it may be necessary for the 
surgeon to apply astringents himself (see 
Gleet). Iodoform and eucalyptus bougies 
are highly thought of by some ; they should 
be introduced at night. The writers have not 
seen any great benefit follow their use. If the 
injections increase the discharge, or heighten 
the soreness, they should be abandoned, and 
soothing internal remedies alone given. The 
chief internal specifics are copaiba, sandal 
oil, and cubebs ; infusion of uva ursi, Canada 
balsam, tolu, turpentine, and benzoic acid. 
They are often beneficial, but are apt to cause 
dyspepsia; and, in the case of copaiba, sandal 
wood, and Canada balsam, congestion of the 
kidneys, especially in the later stages of the 
disease. These remedies should be given 
thrice daily for several weeks. In the later 
stages the preparations of iron in combina- 
tion with quinine are often useful. 
Chordee is frequently a very troublesome 
symptom, for, in addition to the pain it 
causes, the patient's rest is broken, and con- 
sequently his health weakened. Perhaps the 
most useful remedy is a suppository at night 
of opium or belladonna in combination with 
camphor (1 gr. and 3 grs.); bromides, chloral 
hydrate, cannabis indica, and lupulin are 
also useful; while the erection can be im- 
mediately stopped by the application of cold 
water. In some cases a hot bath just before 
going to bed, with the use of the suppository 
mentioned, will prevent chordee. When 
gonorrhoea becomes chronic, accompanied by 
a gleety discharge, further treatment may be 
necessary. See Gleet. 
Complications and Sequel®.-Various 
complications may arise during the progress 
of gonorrhoeal urethritis ; many of these are 
referred to in special articles, to which the 
reader is referred for information. 
1. Balanitis and Balanoposthitis.-See 
Balanitis. 
2. Phimosis and Paraphimosis.-See 
Penis, Diseases of. 
3. Retention of urine may occur in con- 
sequence of swelling of the mucous mem- G0N0RRH(EA 
741 
brane, and muscular spasm closing the pas- 
sage at the membrano-prostatic portion; 
this is specially likely to occur if there is 
inflammation of the neck of the bladder. 
Under the influence of warm baths, saline 
aperients, rest, and morphine suppositories, 
the congestion is lessened, and the temporary 
retention is usually relieved. It causes great 
pain and anxiety when present. Gonorrhoea 
affecting a patient who is the subject of 
stricture may, by causing acute congestion 
of the narrowed portion of the urethra, 
temporarily occlude the passage and cause 
retention. The treatment is the same as 
given above ; in both cases it may be neces- 
sary to pass a fine soft instrument in order 
to afford immediate relief. In the case of 
stricture further treatment will be necessary 
when the gonorrhoea is cured. See Mic- 
turition, Disorders of. 
4. Lymphangitis and Bubo.-See Bubo ; 
and Lymphatic System, Diseases of. 
5. Hcemorrhage from the urethra, if 
profuse and continuous, is probably due to 
rupture of the corpus spongiosum during 
erection. A few drops of blood may come 
away with the discharge or after micturition ; 
this may be due to rupture of the congested 
vessels, or to the presence of a granular 
patch, and needs no special treatment. If 
haemorrhage is continuous, ice will be ser- 
viceable in arresting it, and hamamelis may 
be injected. In some cases a catheter may 
be passed, and the penis compressed by a 
bandage. See Hematuria. 
6. Peri-urethral abscess may occur close 
to the glans penis, between the layers of the 
perineal fasciae, or in the glands of Cowper. 
Peri-urethral abscess may cause acute symp- 
toms, but is often chronic in its progress. 
The pus may escape into the urethra, ex- 
ternally through the skin, or both ways ; in 
the latter case a urinary fistula is formed, 
which will, however, usually heal in time. 
"When peri-urethral abscess is diagnosed, it 
should be freely opened; if the abscess has 
originated in a distended follicle, and has 
burst into the urethra, it may be treated 
successfully by laying it open, through the 
endoscopic tube, with a canaliculus knife. 
7. Inflammation of the neck of the 
bladder, often erroneously spoken of as 
cystitis, is due to extension of the disease 
to the membrano-prostatic urethra. Cystitis 
itself is a rare complication. This compli- 
cation does not usually come on until the 
second or third week; it causes much pain 
and spasm, and has a very depressing effect 
on the patient's general health. 
Inflammation of the neck of the bladder 
causes great frequency of micturition, with 
pain during and scalding at the end of the 
act, caused by muscular spasm. A few 
drops of blood usually escape after the urine, 
with a little muco-pus. The usual gonorrhoeal 
discharge ceases almost entirely during the 
attack, but usually returns when the inflam- 
mation of the neck of the bladder subsides. 
.Relapses are common. 
Low diet, warm baths, rest, and anodynes 
will prove of great value in this complication. 
"When the bladder itself is affected, the 
disease usually attacks the base, and may 
spread to the kidneys. The inflammation 
may be acute or chronic, and may attack 
the mucous membrane only, or the whole 
thickness of the wall (parenchymatous 
cystitis). See Bladder, Diseases of. 
8. Prostatitis and prostatic abscess.- 
Prostatitis is a severe complication of gonor- 
rhoea. It is due to the spread of the disease 
to the uvula vesicte, and along the prostatic 
ducts to the body of the gland. It may be 
excited by injudicious treatment, wet and 
cold, or venereal excitement during gonor- 
rhoea. The disease may run on to suppura- 
tion, or may become chronic. 
In the acute form the gland is swollen 
and tender, causing painful and difficult mic- 
turition, and sometimes retention. There 
is a sense of weight, heat, and fulness in the 
perineum and above the pubes, with rectal 
irritation and pain on defecation. 
Should suppuration occur, the local and 
constitutional symptoms deepen. Eventu- 
ally the abscess bursts, commonly into the 
urethra, more rarely into the rectum or 
bladder or on to the perineum. The treat- 
ment is the same as that described for in- 
flammation of the neck of the bladder, com- 
bined with the passage of a catheter if re- 
tention should occur, and the evacuation of 
pus as soon as it shall be diagnosed. Such 
abscesses are best opened through the peri- 
neum ; should they burst into the urethra 
they will usually heal spontaneously; if not, 
a perineal opening must be made. See 
Prostate, Diseases of. 
9. Epididymitis and orchitis. - Inflam- 
mation of the epididymis is the most fre- 
quent complication of gonorrhoea. The dis- 
ease is usually unilateral, but in a small 
proportion (3'5 per cent.) of cases both sides 
are affected. The spread of gonorrhoea to 
the epididymis is much more commonly seen 
among hospital out-patients than among 
private patients, doubtless because the latter 
take more care of themselves. The epidi- 
dymis is not affected until the urethritis has 
spread backwards to the membrano-prostatic 
portion--i.e. towards the end of the third 
week. See Testes, Diseases of. 
10. Inflammation of the rectal mucous 
membrane occasionally occurs, more especi- 
ally in women. It is due to direct inocu- 
lation of the discharge. There is smarting 
and burning pain, much increased on de- 
fecation. The mucous surface is bright red, 
and may be granular and ulcerated. A 
yellowish discharge escapes per anum. 
Thorough cleanliness, with the use of astrin- 
gent lotions, will effect a cure. 742 
GONORRHfEA 
11. Gonorrhoeal conjunctivitis is a very 
grave complication, especially if not seen 
early, as it may destroy the whole eye. The 
patient should be warned that no discharge 
from the urethra must be allowed to get 
near the eye. See Eye, and its Appendages, 
Diseases of. 
12. Sclerotitis and iritis occasionally occur 
in the course of gonorrhoea, but are very rare. 
See Eye, and its Appendages, Diseases of. 
13. Rheumatism of the joints, fasciae, and 
great nerves, &c. See Rheumatism, Gonor- 
RHGiAL. 
14. Stricture may occur as a sequela. It 
usually follows granular urethritis, resulting 
from gonorrhoea. Some months or even 
years elapse before the stricture is estab- 
lished. See Urethra, Diseases of; and 
Gleet. 
15. Warts may occur on the glans penis 
or in the urethra. See Gleet ; Penis, Dis- 
eases of; Verucca. 
(b) Gonorrhoea in the Female- 
Vaginitis. - Morbid Anatomy. - In the 
female, gonorrhoea first attacks the lower part 
of the vagina, and may spread to the vulva 
and urethra, or upwards to the upper part of 
the vagina and the uterus; and, by continuous 
extension, to the Fallopian tubes, peritoneum, 
and ovaries in one direction, and to the bladder, 
ureters, and pelves of the kidneys in another 
direction, besides attacking the joints, fasciae, 
and eyes with rheumatic inflammation as in 
the male subject. The disease may become 
chronic, and be accompanied by complications 
to be afterwards mentioned. 
In the first stage the mucous membrane is 
congested, swollen, and tender; the parts 
are drier than natural, in consequence of a 
diminution of the natural secretions; but 
in a few hours there is a thin transparent 
mucous discharge, which quickly becomes 
sero-purulent, purulent, creamy, and copious. 
The discharge when fully established has 
often a greenish tinge, and is offensive and 
highly irritating. The affected mucous mem- 
brane is often studded with little eminences 
due to enlargement of the papillae (vaginitis 
granulosa). In more severe cases patches 
of erosion may be seen, especially if the 
disease spreads to the os uteri. Owing to 
the irritating nature of the vaginal discharge 
the vulva becomes inflamed, swollen, and ex- 
coriated. The glands of Bartholin not in- 
frequently become involved, and suppurate. 
The inflammation becomes chronic in from 
six to ten or twelve days, the pain, swelling, 
and congestion subsiding, and the discharge, 
now muco-purulent, remaining plentiful. In 
the chronic form, the upper part of the vagina, 
the cul de sac, and the neck of the uterus are 
the parts specially involved. They are of a 
brighter colour than the rest of the mucous 
membrane, and secrete the discharge. Not 
infrequently, when the inflammation has 
ceased in the vagina, pus can still be squeezed 
from the meatus urinarius or some of the 
crypts opening round that orifice, if the finger 
be drawn forwards along the under-surface 
of the urethra. 
Symptoms.-In the acute stage there is 
heat, itching, and swelling of the parts, smart- 
ing on making water, aching pains in the back 
and loins, with great tenderness on examina- 
tion. The bright red colour of the congested 
mucous membrane, together with the offen- 
sive greenish purulent discharge from the 
surface, is sufficient evidence of vaginitis, but 
is not sufficient to determine its specific 
origin. As the disease becomes more chronic 
the acute symptoms pass away, but there is 
still a plentiful discharge. 
Diagnosis.-The diagnosis of vaginitis 
and vulvitis is easy, but it is sometimes im- 
possible to speak with certainty as to its 
gonorrhoeal origin. The actual source of the 
discharge should be ascertained, since 
copious yellow irritating discharge may come 
from the cervix uteri, independently of any 
pre-existing vaginitis. If a positive opinion 
as to the gonorrhoeal nature of the case is 
required, the gonococcus must be sought for in 
the discharge. If there is purulent urethritis, 
the contagious nature of the case is satis- 
factorily determined, as irritating uterine dis- 
charges do not affect the urethra. 
Prognosis.-If assiduously treated, so that 
extension to the vaginal cul de sac and cervix 
uteri is prevented, the disease has a duration 
of about three weeks. If neglected, it may 
become chronic and prove very intractable, 
lasting sometimes for many months ; this is 
especially likely to be so if the disease has 
spread to the cervix uteri and endometrium, 
or to the urethra. Although many compli- 
cations may arise during the progress of the 
disease, but few are commonly of immediate 
danger. The length of time that the dis- 
charge remains contagious is most uncertain. 
Probably any discharge, however scanty and 
serous it may have become, may cause disease 
if increased by accidental irritation. 
Treatment. - In the acute stages of 
vaginitis the treatment consists in allaying 
irritation by rest in bed; warm baths; fre- 
quent injections of warm water, solution ot 
boric acid, or weak astringents-such as 
weak solutions of acetate of lead, of alum, 
&c.; and the administration of saline ape- 
rients. If the pain be great, a little laudanum 
may be added to the warm water injections. 
The diet should be low, all sources of irri- 
tation should be removed, and the habits and 
health of the patient regulated. When the 
acute stage has subsided, astringent injec- 
tions should be used somewhat stronger than 
those employed at first. The vulva should 
be protected from contact with the discharge 
by vaseline, and the labia should be sepa- 
rated by a piece of lint wetted with lead 
lotion. 
In the chronic forms of the disease the GONORRHCEA 
GOUT 
743 
strength of the astringent injections must be 
increased. The most useful are the sulphate, 
chloride, and sulpho-carbolate of zinc, tannic 
acid, and liquor carbonis detergens. In the 
intervals between the injections, tampons 
saturated with the astringent lotions may be 
introduced into the vagina, and alum or tan- 
nin may be applied to the deeper parts of 
the canal by means of the speculum. The 
injections must be efficiently done, after 
washing away the discharge with warm 
water, so that the whole mucous surface of 
the vagina, especially that of the cul de sac, 
is thoroughly laved. Astringent vaginal sup- 
positories are also useful. If in chronic 
cases there are patches of erosion, similar to 
those met with in cases of gleet in the male, 
they should be mopped with a 20 per cent, 
solution of silver nitrate. 
Internal remedies are useless unless the 
urethra is affected, when they have a certain 
value. 
Complications.-Vulvitis is one of the 
earliest and commonest complications of 
gonorrhoeal vaginitis. The labia, nymphse, 
and clitoris are red and swollen, and secrete a 
copious yellow foetid discharge. The nymphae 
often project between the swollen labia, and 
the parts may be excoriated in consequence 
of destruction of the surface epithelium, 
and sometimes from ulceration of the mucous 
follicles. There is considerable pruritus. 
Usually, if the parts are kept clean and free 
from irritation, the inflammation subsides in 
a few days. Warm baths and sedative lotions 
are useful to allay the irritation, and the labia 
should be separated by a piece of lint kept 
moist with lead and opium lotion. 
Urethritis is the most constant accompani- 
ment of gonorrhcea; rarely so acute as to 
cause much irritation, it may produce severe 
suffering. It begins with itching and smart- 
ing at the meatus, which is red and swollen. 
A purulent or muco-purulent discharge oozes 
from the passage unless the patient has just 
micturated; even then a little discharge can 
be found in the mouths of the follicles which 
open close to the meatus. This discharge is 
very persistent, and is probably a source of 
contagion long after the disease is cured else- 
where. The treatment of urethritis consists 
of frequent warm baths, astringent injections, 
and copaiba internally. Obstinate chronic 
discharges may be arrested by caustic solu- 
tions, carefully applied. 
Abscess of the glands of Bartholin is not 
uncommon in gonorrhcea. There is a pain- 
ful swelling, which may attain the size and 
somewhat the shape of a bantam's egg, lying 
in the labium majus, in which fluctuation can 
be detected early. The abscess may not 
empty itself through the duct, but into the 
cellular tissue of the labium, where a large 
collection may form before it opens superfici- 
ally. The treatment consists in free incision 
as soon as fluctuation is felt. Often a trouble- 
some fistula is left, which, alternately closing 
and opening, causes fresh accumulation and 
fresh discharge of pus from time to time. 
This is best treated by free incision and 
drainage. 
Bubo is rare in the female, but may occur 
when the urethra is involved. 
Acute inflammation of the cervix and os 
uteri is a frequent consequence of gonorrhoea. 
The neck of the uterus is swollen, red, and 
often excoriated about the os, whence a 
copious discharge issues, at first clear and 
viscid, then purulent. This subsides to a 
thin muco-pus, and either soon ceases or 
more commonly passes into chronic catarrhal 
discharge from the glands of the cervix, 
which lasts an indefinite time and long re- 
tains its contagious quality. Chronic cer- 
vical and corporeal endometritis, associated 
with a thick viscid discharge in the former 
and a thinner discharge in the latter, may re- 
sult from gonorrhoeal infection. In the acute 
forms, complete rest, warm baths, with as- 
tringent applications and saline aperients, 
may arrest the disease. In the chronic stage 
the treatment is that of uterine catarrh. See 
Womb, Diseases of. 
Among the rarer and more dangerous 
complications of gonorrhoea in the female 
may be mentioned metritis, perimetritis, 
salpingitis, pyosalpinx, hydrosalpinx, ovaritis, 
and peritonitis. Py®mic infection may occur 
through the vaginal veins. 
Certain complications, more general in 
their nature, may also occur as in the male 
sex. Gonorrhoeal rheumatism is less com- 
mon in women than in men. 
Berkeley Hill. Charles Stonham. 
GONORRIIffiAL RHEUMATISM. 
An affection of the joints associated with 
gonorrhoea. See Rheumatism, Gonorrhceal. 
GOOSE-SKIN.-A condition of the skin 
in which this structure is rough and wrinkled, 
like that of the plucked goose. It is of a 
transient character, being due to contraction 
of the muscular fibres of the skin, producing 
wrinkling of the integuments, and promi- 
nence of the hair-follicles-horripilation; and 
is observed as the result of the direct appli- 
cation of cold, or of a shock, and in the early 
stages of fevers. 
GOUT (gutta, a drop). - Synon. : Pod- 
agra, Chiragra, Gonagra (when the disease 
affects the foot, hand, or knee respectively) ; 
Fr. Goutte; Ger. Gicht. The name gout is 
supposed to have originated in the idea of 
the dropping of a morbid fluid into the joints, 
and is of very ancient date. 
Definition.-Gout is usually regarded as 
a general or constitutional disease, associated 
with the presence in the system of excess 
of uric acid, the complaint being commonly 
looked upon as a manifestation of the so- 
called lithic or uric acid diathesis, and as 744 
GOUT 
due to lithcemia. It may be hereditary or 
acquired; and is characterised ordinarily by 
a peculiar inflammation of the joints-arti- 
cular or regular gout, attended with the 
deposit of urates, consisting almost entirely 
of urate of sodium, in their structures, affect- 
ing usually and especially the smaller j oints, 
and at first more particularly the metatarso- 
phalangeal articulation of the great toe, but 
afterwards extending to other joints. Similar 
deposits of urate may occur in other tissues- 
tophaceous gout; and certain organs of the 
body are liable to become the seat of func- 
tional disorders, or of pathological changes, 
during the progress of the disease-non-arti- 
cular or irregular gout; while it is also 
usually attended with general symptoms. 
Gout in the early part of its course is in the 
large majority of cases an acute affection, 
occurring in periodic attacks or ' fits '; but 
subsequently it tends to become more or less 
chronic and permanent, though even then 
generally presenting exacerbations from time 
to time. The gouty diathesis may, how- 
ever, be present without giving rise to any 
joint-affection or other evident organic mis- 
chief. 
Etiology. - There are certain definite 
points which require consideration under 
this heading. 
1. It will be expedient at the outset to 
discuss the circumstances under which the 
gouty diathesis is developed, and to point 
out the more obvious causes with which this 
condition is associated. /Etiologically, cases 
of gout may be practically arranged into 
three main groups, according as the disease 
arises from-(a) Hereditary transmission. 
(&) Certain errors in regard to food and 
drink; often associated with deficient exer- 
cise. (c) Impregnation of the system with 
lead. In not a few instances, however, it 
must be remembered that these causes are 
more or less combined. 
(a) Hereditary transmission. Gout is one 
of the most striking examples of an hereditary 
disease, and, once established, it may be 
transmitted through several generations, even 
when every endeavour is made to eradicate 
it; but as the malady is, as a rule, more or 
less intensified by pernicious habits, it be- 
comes in most cases a permanent legacy. 
Sir Alfred Garrod found that in more than 
half his cases hereditary taint could be dis- 
tinctly traced; and the proportion is much 
greater among the upper classes. It some- 
times happens that when gout becomes de- 
veloped de novo in an individual, children 
born previously are free from the complaint, 
while those born subsequently are affected. 
Gout appears to be more readily transmitted 
by the female than the male line. Accord- 
ing to Hutchinson, the diathesis becomes 
stronger in the parent with advancing years, 
and consequently the disease shows itself 
with greater frequency, and in more marked 
form, in the younger than in the older mem- 
bers of a gouty family. Hereditary influence 
may be so powerful that the complaint arises 
without any other obvious cause ; but most 
commonly it is aided by more or less in- 
dulgence in certain injurious habits to be 
presently mentioned. Gout sometimes ex- 
emplifies the so-called ' law of atavism,' 
which is usually due to the fact that in the 
generation free from the complamt every 
precaution is taken to avoid causes which 
tend to originate a gouty paroxysm. It has 
been affirmed, however, that this ' missing 
a generation ' only applies to the transmission 
from a grandfather through his daughter to 
the grandson. The hereditary nature of gout 
is shown not infrequently in the age at which 
the disease reveals itself. Should the pre- 
disposition be powerful, the complaint may 
appear in very early life; and the younger 
the subject who is attacked, the more likely 
is there to be an hereditary taint. Hutchinson 
is of opinion that many obscure joint-affec- 
tions in young persons are due to hereditary 
gout. 
(6) Errors relating to food, drink, and 
exercise. In a considerable number of cases 
gout is originated de novo, in consequence of 
certain errors affecting the diet and habits; 
or an inherited tendency to the disease is 
thus considerably aggravated. In general 
terms these errors may be summed up as 
excessive eating, especially of particular 
articles of food; undue indulgence in al- 
coholic drinks; and indolent habits, with 
deficient exercise. They are frequently asso- 
ciated in the production of gout in individual 
instances. 
The gouty diathesis is chiefly promoted by 
foods which are rich in nitrogen, and espe- 
cially meat. Beef is believed by many to 
be particularly baneful. Undue consumption 
of sugar and starchy foods has also been re- 
garded as aiding materially in the develop- 
ment of gout. Many articles of diet, either 
from their inherent nature or from the 
manner in which they are cooked, may help 
in the production of the complaint, by giving 
rise to digestive disorders. 
The relation of intemperance in the use of 
alcoholic drinks to the gouty diathesis is 
highly important, and is abundantly proved 
by everyday experience, notwithstanding the 
attempts made by certain self-constituted 
' authorities ' on gout to cast a doubt upon 
this fact. The more potent wines have the 
greatest influence, and port wine has pro- 
verbially been regarded as the most injuri- 
ous of all. Champagne, burgundy, madeira, 
sherry, and marsala are also undoubtedly 
capable of developing or aggravating gout. 
Hock, sauterne, moselle, and light claret 
seem to be least injurious; but even these, 
if indulged in to excess, may in course of 
time set up, or, at any rate, intensify the 
gouty diathesis. Strong malt liquors stand GOUT 
745 
next to wines as originators of gout. Spirits 
are comparatively feeble in their power of 
producing the disease, and this is the ex- 
planation usually given of its infrequency in 
those countries or districts where this class 
of drinks are chiefly used, such as Scotland 
and Newcastle-on-Tyne, where whisky is the 
common beverage. Rum is said to form an 
exception to this statement. Cider and perry 
may unquestionably set up gout, if taken to 
excess, especially when sweet and not pro- 
perly fermented. Excessive indulgence in 
a mixture of alcoholic drinks is probably 
more deleterious than if one is adhered to. 
The quality of wines has much to do with 
their tendency to induce gout. Factitious 
wines and others of inferior quality, as well 
as those which are very sweet, or which con- 
tain much tannin, are most liable to produce 
this complaint. Drinks which cause a marked 
diuretic action are less injurious than those 
which have but little action of this kind. 
Deficient exercise undoubtedly promotes 
the development of gout in many cases. 
Persons who follow sedentary occupations, or 
who live indolent and lazy lives, are most 
liable to the disease ; and not a few become 
gouty because improvement in their circum- 
stances enables them to 'keep a carriage,' 
and they are thus deprived of the exercise 
which they were previously accustomed to 
take. 
(c) Another group of cases of gout are those 
which occur in connexion with impregnation 
of the system with lead. Sir Alfred Garrod 
found among his hospital patients that 33 
per cent, of those suffering from gout had 
been subjected to the influence of lead in 
their various occupations; and the associa- 
tion is now generally acknowledged. This 
metal does not appear, however, to originate 
the gouty diathesis, unless aided by more or 
less indulgence in alcoholic drinks, though 
the amount of the latter consumed is usually 
far less than would alone account for the con- 
dition. Gouty persons are remarkably sus- 
ceptible to the influence of lead; and when 
this metal is given to such subjects for medi- 
cinal purposes, it is very liable to bring on a 
severe attack of acute gout. 
It is important to note here that, according 
to Dr. Thomas Oliver, of Newcastle-on-Tyne 
(Goulstonian Lectures, 1891), this intimate 
relation between gout and saturnine poison- 
ing is not seen in the north. ' Workmen from 
the south develop it in the north of England. 
The natives of the north, though equally ex- 
posed, seldom become gouty even when the 
kidneys are affected.' This authority does 
not regard the difference in the drinking 
habits of the people as the explanation of 
the difference, but thinks it is probably the 
result of external conditions, though he can- 
not explain it. 
2. Predisposing causes.-Beginning with 
age, distinct gouty attacks in a large majority 
of cases make their first appearance in persons 
between thirty and thirty-five or forty years 
old. Those which occur under thirty are, 
with few exceptions, more or less hereditary. 
Well-marked gout is exceedingly rare under 
twenty, but it may occur in younger subjects, 
probably even in children. Dr. Lorimer, of 
Buxton, found that saturnine gout appears 
at an earlier age than non-saturnine. The 
complaint is usually declared before fifty, 
and becomes progressively less frequent in 
its manifestation for the first time after this 
period of life. It is quite exceptional for 
gout to commence after sixty-five, but it may 
begin even in extreme old age. With regard 
to sex, males are far more commonly the 
subjects of well-marked gout than females. 
This is mainly accounted for by the difference 
in the habits of the two sexes. It has also 
been partly attributed to the occurrence of 
menstruation in females, which is supposed 
to act as a safeguard, and in these subjects 
gout generally appears after the cessation of 
this function. When strongly hereditary, gout 
may, however, develop even in young females, 
of which the writer has seen some well-marked 
examples. 
Bodily conformation and temperament 
have been credited with a predisposing influ- 
ence in relation to gout, persons of a sanguine 
temperament, and of corpulent, plethoric 
habit of body, being supposed to be most 
subject to this disease, and to have it in 
its most acute form. These conditions are 
often produced by the very habits which 
originate gout, and certainly persons who are 
gouty by inheritance often do not present any 
of these characteristics, while those exhibiting 
marked contrasts in appearance and tempera- 
ment seem to be equally the subjects of the 
complaint. It is not uncommon in indivi- 
duals of a nervous temperament, thin and 
wiry in frame, and they are said to be more 
subject to the irregular and asthenic forms of 
the disease. Social position and occupation 
materially influence the occurrence of gout. 
Formerly the complaint was met with almost 
entirely among the higher classes, and it was 
looked upon as an aristocratic disease. Now, 
however, it is common enough among the 
middle classes, chiefly those who are in 
affluent circumstances; while it is very pre- 
valent amongst those following certain occu- 
pations, such as butlers, coachmen, butchers, 
publicans and barmen, coal-heavers, porters, 
hair-cutters, and painters or others who have 
to do with lead. Conditions which involve 
excessive mental labour and fatigue, prolonged 
worry or anxiety, and other effects which ex- 
haust and depress the nervous system, seem to 
predispose to gout. Sir Dyce Duckworth is of 
opinion that sexual indulgence in early life, 
by its generally enervating influence, is potent, 
not only in causing early and severe attacks 
of gout, but also in the premature induction 
of gouty cachexia. As regards climate those GOUT 
746 
climates which are cold or temperate, and 
especially at the same time damp and change- 
able, present by far the greatest number of 
cases of gout, and in most tropical countries 
this complaint is unknown. In the south of 
Europe it is far less frequent than here. Gout 
is much more prevalent in England than in 
Scotland or Ireland; though it is uncommon 
in the north of England. 
3. Causes of a gouty fit.-An acute pa- 
roxysm of gout may come on without any 
evident exciting cause whatever, especially 
if the disease is strongly hereditary, or has 
been long established. Under these circum- 
stances outbreaks of the complaint seem to 
become habitual at certain seasons, or they 
arise from very slight causes, which are 
less and less obvious as the case progresses. 
Often, however, some distinct exciting cause 
can be made out, affecting the digestive 
organs, the vascular or nervous systems, or 
the functions of the skin or kidneys, or dis- 
turbing the system in other ways. The most 
important are eating or drinking too much, 
either on some particular occasion, or habitu- 
ally for a longer or shorter period, until at 
last a fit of gout terminates the indulgence; 
indigestible articles of food; neglect of the 
act of defecation, or prolonged constipation ; 
undue physical work or exertion; exposure 
to cold or wet, or sudden suppression of per- 
spiration ; excessive mental work, worry, or 
anxiety; emotional causes, sudden, powerful, 
or depressing, such as joy, a fit of rage, fright, 
or deep grief; sexual indulgence or excess; 
haemorrhage, acute illness, or other like de- 
bilitating causes ; and injury. The indiscri- 
minate use of certain medicines, such as 
preparations of lead or iron, may excite a 
gouty paroxysm. The implication of a par- 
ticular joint may be due to a strain or injury, 
which may be very slight, such as the pres- 
sure of a tight boot, or the toe being trodden 
upon. Injury to the knee has caused that 
articulation to be first affected. As predis- 
posing causes of acute gouty attacks, climate 
and season are highly important. Un- 
doubtedly gouty paroxysms may often be 
averted by residence in a warm climate, either 
permanently or during the colder seasons of 
the year. Early attacks are most frequent in 
late winter or spring, and the first paroxysm 
occurs especially towards the end of January 
or beginning of February. Afterwards a fit 
of gout takes place also in the autumn; and 
subsequently the intervals become shorter 
and more irregular. One seizure predis- 
poses to another, and the peculiar tendency 
to recurrence in gout is increased with each 
succeeding paroxysm. The occupation of an 
individual may predispose to the occurrence 
of gout in particular joints; thus butlers 
have it in the feet, coachmen and washer- 
women in the hands. 
Pathology.-The pathology of gout is still 
in a very unsettled state. With some authori- 
ties it is a comparatively simple matter, while 
others regard the complaint as a highly com- 
plex condition, having wide relationships in 
diverse directions within the system. It will 
be impossible within the limits of this article 
to do more than bring out the main facts 
bearing upon the subject, and to indicate the 
chief theories founded thereon. 
1. Gout is by the large majority of writers 
referred to the general or constitutional group 
of diseases, and it is customary to speak of 
the gouty diathesis or dyscrasia, of which 
the local changes are but a manifestation. 
Further, it is believed by most authorities 
that a person may be truly gouty, and yet 
be free from any of the special lesions usually 
associated with the condition. According 
to Hutchinson, Charcot, Duckworth, and 
others, there exists a ' basic arthritic dia- 
thesis,' upon which may be built up, under 
the influence of special causes, a tendency to 
gout, rheumatism, or their various modifica- 
tions and combinations. 
At the present day it is almost universally 
admitted that gout has an intimate relation 
with the presence of lithic or uric acid in 
the system, which is generally regarded as 
the morbific agent or ' peccant matter.' As 
Duckworth expresses it-' No uric acid, no 
gout.' To Sir Alfred Garrod we are indebted 
for having clearly and positively demon- 
strated this relationship. In its pronounced 
form gout is characterised by the deposit of 
urate of sodium in connexion with the joints 
and other structures, which distinguishes it 
from all other complaints. Dr. Haig has re- 
cently revived the view that there is no real 
distinction between the rheumatic, gouty, 
and rheumatoid forms of arthritis, but that 
they are all due to uric acid. This question 
need not, however, be discussed here. 
Assuming the essential relationship be- 
tween gout and lithic acid to be established, 
beyond this point there is much diversity 
of opinion. Many adopt a simple humoral 
theory, attributing the disorder to excess of 
this acid in the blood and tissues. Some, 
however, do not so much regard the quantity 
of acid, as the conditions under which it 
exists, and its insolubility. Gout is often 
spoken of as a mere manifestation of the 
lithic or uric acid diathesis, and the condi- 
tion of the blood containing excess of the 
acid was termed lithcemia by the late Dr. 
Murchison. Sir William Roberts 1 has pro- 
posed the term uratosis as distinguished 
from lithaemia, to designate the ' precipita- 
tion of the crystal urates in the tissues or 
fluids of the body.' He draws attention to 
the fact that ' lithaemia is only an exaggera- 
tion of a normal condition, for traces of uric 
acid always exist in healthy blood; but 
uratosis, even in the minutest degree, is 
pathological.' He is of opinion that there 
are different kinds of uratosis, and would 
1 Med. Soc. Trans, vol. xiv. p. 84. GOUT 
747 
thus speak of gouty uratosis and saturnine 
uratosis, believing that the gouty diathesis 
and plumbism are radically distinct, differing 
in all respects except in their tendency to 
uratic deposits. He further considers it quite 
possible that precipitation of the crystalline 
urates may occur not only in the form of 
coarse masses, but also in the form of minute 
stars or detached crystals, which can only be 
detected with the microscope ; and that this 
' microscopic uratosis,' either in the substance 
of organs or in the blood itself, may account 
for the visceral neuroses, thrombosis and 
embolism, and the occasional sudden death, 
which are encountered in gout, and may 
explain some very obscure incidents in its 
history. 
Uric acid exists in the blood and in the 
fluid that diffuses therefrom mainly as a salt 
of sodium, but whether the combination be a 
quadriurate or a biurate, or a mixture of the 
two, or sometimes one and sometimes the 
other, is not known. The quadriurates are 
highly soluble in blood-serum, and cannot be 
thrown down therein in the crystalline state, 
while the biurates are very sparingly soluble 
in that medium, and are readily thrown down 
in it in a crystalline form (W. Roberts). The 
acid is being constantly formed in the system 
in connexion with the processes of nutrition 
and metabolism, but under ordinary circum- 
stances it is either destroyed or is eliminated 
by the kidneys, so that it is kept within 
normal limits. According to Garrod, the 
final stage is the production of urate of 
ammonium in the kidneys. 
We may now proceed to consider the main 
views held to explain more immediately the 
lithaamic condition, or the accumulation of 
uric acid in the tissues. They may be sum- 
marised as follows:-(a) Excessive forma- 
tion. It certainly appears reasonable to 
suppose that certain of the recognised causes 
of gout must lead to an absolute increase in 
the amount of uric acid formed in the system. 
Ebstein is of opinion that in the gouty this 
acid forms in perverse localities, as in muscles 
and the marrow of bones. (&) Undue reten- 
tion. Imperfect excretion or elimination of 
uric acid, leading to its retention in the body, 
can never be overlooked as an important factor 
in relation to the gouty condition. According 
to Garrod, such retention is due to defective 
action of the kidneys, either temporary or 
permanent, and when these organs are in a 
state of advanced organic disease, their ex- 
cretory functions must obviously be inter- 
fered wuth considerably. Sir William Roberts 
thinks it probable that the defective power 
of the kidneys to eliminate uric acid is due 
to diminished alkalescence of the blood, 
which renders it less soluble. He has found 
that if sodic quadriurate lingers too long in 
the blood it becomes converted into a biurate, 
and when the accumulation of this salt has 
reached a certain point of saturation, it is sud- 
denly precipitated as a crystalline deposit in 
the joints or elsewhere. Dr. Ralfe is of opinion 
that the first step in the production of gout is 
diminished alkalinity of the blood, by reason 
of the accumulation in it of acid and acid- 
salts ; and that retention in the system is due 
to a fault in the tissues, leading to incom- 
plete elimination. Haig, as the outcome of 
his extensive researches relating to uric acid, 
strongly supports the view that excess of this 
acid in the blood and system is generally due 
to retention, and that this is the result of 
deficient alkalinity of the blood, which leads 
to gradual accunmlation of the acid in cer- 
tain parts; he would thus explain all the 
phenomena of the gouty state. According 
to Garrod, with whom Haig agrees, it appears 
that uric acid is attracted in different degrees 
by different structures, and tends to be held 
back by, and accumulate in the liver and 
spleen, and in fibrous tissues, especially those 
of the joints, probably because these struc- 
tures are acid, or less alkaline than the rest 
of the tissues and fluids of the body, (c) Im- 
perfect reduction. According to this view, 
it is supposed that the normal process, by 
which uric acid is changed in the blood and 
certain organs into other substances more 
soluble and less noxious, fails, or is imper- 
fectly carried on, and thus it accumulates in 
the system. It used to be believed that uric 
acid was converted into urea, but more re- 
cent investigations are opposed to this idea. 
(d) Special views. It will be convenient 
under this heading to mention certain indi- 
vidual opinions with regard to the patho- 
logical relations of uric acid and gout. The 
late Dr. Murchison regarded gout as a mere 
result or variety of lithaemia, and attributed 
this condition to imperfect digestion, and 
more especially to ' functional derangement of 
the liver.' He brought forward facts to show 
that the healthy liver plays an important, 
and perhaps the principal, part in carrying on 
those chemical changes by which albuminous 
substances are disintegrated in the body, 
which normally result in the production of 
urea. If this process is persistently deranged, 
lithic acid, a less oxidised body, is formed. 
Professor Latham also advocates the hepatic 
origin of gout, but considers that ' imperfect 
metabolism of glycocine is the primary and 
essential defect.' Dr. Ord regards gout as 
arising from a tendency to a special form of 
degeneration, or want of tissue organisation 
in some of the fibroid tissues, with excessive 
formation of urate of sodium, which is dis- 
charged into the blood, and deposited in parts 
least freely supplied with vascular and lym- 
phatic structures. According to Ebstein, the 
primary factor in gout is nutritive tissue - 
disturbance, a necrotic change taking place in 
the affected structures, which is followed by 
deposit of urates. 
Such are the principal facts and theories 
bearing upon the relations of uric acid to 748 
GOUT 
gout. It must be mentioned that some 
eminent writers have disputed this close 
relationship, but it would not serve any 
practical purpose in this article to discuss 
the various hypotheses which have been 
advanced in the endeavour to explain the 
nature and origin of gout. 
One important point remains to be noticed, 
and that is the relation of the nervous system 
to gout. Other writers on the subject have 
maintained that such a connexion exists, but 
Sir Dyce Duckworth1 has developed this idea 
more fully, and has brought forward much 
evidence in favour of the view that gout is 
a neuro-humoral disease. He recognises 
a gouty neurosis, which may be primary or 
central, or secondary or induced; and main- 
tains that there is a functional disorder of a 
definite tract of the nervous system, which 
he is inclined to localise in some part of the 
medulla oblongata, but does not insist on 
this point. He further believes ' that this 
diathetic neurosis imposes its type upon the 
affected individual in definite nutritional 
modes, affecting the assimilating and excret- 
ing powers, exhibiting marked peculiarities 
in nervous impressibility, and determining, 
in a more or less degree, a physiognomy of 
the gouty.' This authority recognises the 
dependence of many gouty phenomena upon 
' perverted relations of uric acid and sodium 
salts in the economy ' which result from the 
morbid peculiarities just mentioned. He con- 
siders that in primary or inherited gout, the 
toxaemia is dependent on the gouty neurosis, 
of which it is a secondary manifestation; 
while in secondary or acquired gout, if, to- 
gether with toxaemia induced by certain 
habits, distinctly depressing and exhausting 
agencies, affecting the nervous system, come 
into operation, the special neurotic manifest- 
ations of the gouty diathesis will occur, and 
be impressed more or less deeply upon the 
individual and his offspring. 
Space will not permit the discussion of the 
modes in which the several causes which 
produce the gouty condition or its local 
manifestations individually act. In general 
terms, it may be stated that they produce 
their effects chiefly by increasing the amount 
of uric acid formed, or interfering with its 
elimination; disordering digestion and the 
hepatic functions; increasing the acidity of 
the blood and tissues; affecting tissue-change 
and metabolism ; influencing the circulation; 
or producing some change in the nervous 
system. 
2. We have thus far been concerned mainly 
with the pathology of the gouty diathesis, 
and it remains to offer a few remarks with 
regard to its local manifestations, and more 
especially to the occurrence of acute attacks 
of gout, and the formation of uratic deposits. 
According to the lithaemic theory, any cause 
which tends suddenly or rapidly to increase 
the amount of uric acid in the blood in a 
gouty individual may lead to acute articular 
gout, or some other obvious manifestation oi 
the disease. Dr. Haig would attribute the 
joint-affection to conditions increasing the 
acidity of the blood, and thus driving the uric 
acid into the joints, the structures of which 
are less alkaline than other tissues. Others 
call in the aid of the nervous system to explain 
the phenomena. As regards the gouty in- 
flammation, this is often looked upon as the 
result of the irritant action of the urate, and 
Garrod affirms that even after the first attack 
a deposit of this substance is found. Another 
idea is that the acute paroxysm is the con- 
sequence of an attempt on the part of the 
articular structures to destroy and eliminate 
the urates accumulated in connexion with 
them. The tendency to implication of joints 
and allied structures seems unquestionably to 
depend to a great extent upon their slight 
vascularity, and this especially applies to the 
smaller joints, which are chiefly affected in 
gout, and which are also distant from the 
centre of the circulation, so that the blood 
passes through them in a feeble and languid 
stream. They are, further, much exposed to 
the direct influence of cold, and are very 
liable to slight injury or strain, whereby their 
nutrition is affected, which predisposes them 
to the gouty change. The metatarso-phalan- 
geal joint of the great toe is subjected to 
much pressure, and also to sudden shocks 
(Garrod). 
It is an undoubted and well-known fact 
that marked gouty changes, with uratic 
deposits in the joints and elsewhere, may 
develop without any definite acute attacks; 
and as gout advances in a particular case, 
the deposit often becomes very abundant, 
while the paroxysms progressively diminish 
in intensity. Some writers think that true 
gouty lesions may occur, and yet without 
any formation of urates. 
The opinion is held by many authorities 
that uratic deposits only take place in struc- 
tures the nutrition of which is impaired, and 
which have already begun to degenerate. 
As already stated, Ebstein maintains that a 
nutritive disturbance of the affected tissue 
is the primary change, leading ultimately to 
its necrosis, and that uratic crystallisation 
is secondary, not occurring before complete 
death of the damaged texture. He looks upon 
sodium urate as a directly poisonous irritant 
wherever deposited, the injurious effects 
varying according to the quantity and con- 
centration of the deposit, and the vulner- 
ability of the special tissue involved, firm 
textures resisting better than those of looser 
character. He regards the incrustation as 
analogous to calcification; and believes that 
lime-salts may be subsequently deposited in 
gouty tissues. 
Anatomical Characters.- In its most 
typical manifestations gout is characterised 
1 A Treatise on Gout, 1889. GOUT 
749 
anatomically by the occurrence of a peculiar 
form of inflammation affecting certain joints, 
attended with the deposit of urate in con- 
nexion with their structures. Taking an 
individual articulation, this is at first usually 
the seat of an acute inflammatory process, 
indicated by the usual signs of increased 
vascularity and redness, tumefaction, and 
serous effusion into the interior of the joint, 
as well as into the surrounding tissues. The 
results of post-mortem examinations show 
that even in the very earliest period a deposit 
of urate takes place ; and as the attacks be- 
come repeated again and again, the signs of 
inflammation become less and less prominent, 
while the deposit increases, until at last it 
may form considerable masses, and infiltrate 
extensively all the structures entering into 
the formation of the articulation. The joint 
then becomes permanently enlarged and dis- 
torted, while the ligaments are thickened 
and more or less stiff or even quite rigid, until 
ultimately complete ankylosis may be pro- 
duced. The deposit seems to commence in 
the substance of the cartilage covering the 
ends of the bones, starting near its superficial 
or free surface, and gradually extending more 
deeply, though for a time a thin layer of 
cartilage lies between it and the cavity of 
the joint. This deposit at first forms a 
whitish opacity, but as it becomes more 
abundant it encrusts the cartilages, and also 
the inner surface of the ligaments, and the 
surfaces of fibro-cartilages where these exist. 
More or less extensive spots or patches be- 
come in time distinctly visible, and even the 
entire surfaces of the bones forming a joint 
may be covered with a chalky-looking sub- 
stance. 'The appearance of articular carti- 
lage in which simple deposit of urates has taken 
place exactly resembles that which would re- 
sult from smearing or splashing the surface 
with fresh white paint ' (Duckworth). The 
synovial membrane may also present white 
points, but the synovial fringes at their 
margins seem to escape, on account of their 
vascularity. In the larger articulations the 
synovial fluid may be thickened, and may 
even contain separate crystals or tufts of the 
urate. Subsequently the ligaments and ad- 
joining structures are infiltrated, and it is 
to this cause that the stiffness or rigidity of 
gouty joints is mainly due. Distinct masses 
of deposit may, however, form, which also 
interfere with movement. They are known 
as tophi or chalk-stones. In course of time 
the tissues covering a gouty joint may be 
destroyed, including the skin, the chalky- 
looking substance being thus exposed, and 
unhealthy suppuration and ulceration set up, 
or even gangrene. Very rarely suppuration 
takes place in a gouty joint itself, or haemor- 
rhage may occur. 
The opaque white substance characteristic 
of articular gout is found on microscopic 
examination to consist of fine crystals, in the 
form of needles or prisms. They are chiefly 
arranged in minute clusters, radiating from a 
centre ; and in the cartilages they form a 
more or less compact network. Chemical 
examination shows that they are usually 
composed almost entirely of urate of sodium. 
The metatarso-phalangeal articulation of 
the great toe is the one primarily attacked in 
the large majority of cases of gout; and this 
joint, on one or both sides, may alone present 
any change. As usually seen, however, the 
disease has progressively involved many 
joints. In the feet it may implicate all the 
articulations, but it is a curious fact that the 
tarso-metatarsal and the phalangeal joints 
of the great toe generally escape, or are but 
little affected. Similarly, all the joints of the 
hands and fingers are often involved, but the 
metacarpo-phalangeal joint of the forefinger 
is one of the most commonly attacked. The 
gouty change not uncommonly extends to 
the larger joints, more especially those of the 
leg, but the shoulder and hip-joints are very 
rarely implicated. In exceptional cases other 
articulations are found involved, such as the 
temporo-maxillary, those of the spinal column, 
of the pelvis, or even of the larynx in rare 
instances. 
Coming now to other structures, deposits 
of urate may occur in various parts of the 
body, sometimes abundant and widely spread, 
in connexion with bursae, tendons and aponeu- 
roses, sheaths or the substance of muscles, 
the sclerotic coat of the eye, the cartilages of 
the external ear, eyelids, nose, or larynx, 
under the skin, or rarely in the cerebral and 
spinal meninges. Urates have also been 
found in concretions on the aortic and mitral 
valves, and in plates from the arch of the 
aorta. More or less serous effusion may be 
present in bursae which are the seat of uratic 
deposits. The exact composition of these 
tophi varies, and they may contain calcium 
urate, oxalate, or phosphate, as well as 
sodium chloride and animal matter, in addi- 
tion to sodium urate. 
As regards bone, the periosteum is often 
affected, and some writers have described a 
deposit of urate in bone itself; but Garrod 
has not found evidence of its having origi- 
nated in this tissue. He considers that the 
periosteal formations sometimes acquire suffi- 
cient size to press on the osseous tissue, and 
to cause its absorption. 
The condition of the kidneys associated 
with gout is of great importance, and these 
organs probably begin to be affected at a 
very early period in the history of a case, for 
they may be found distinctly diseased when 
there have been little or no external mani- 
festations of the complaint. In the first in- 
stance a deposit of sodium urate takes place, 
probably within the renal tubuli, which after- 
wards involves their walls and penetrates to 
the intertubular tissue. This is seen in the 
form of white streaks in the course of the 750 
GOUT 
tubuli, and of white points at the extremities 
of the papillae. The deposit goes on in- 
creasing, and a chronic inflammatory process 
is set up, ending ultimately in the production 
of a variety of ' granular contracted kidney,' 
known as the ' gouty kidney ' (see Bright's 
Disease). Other morbid states in connexion 
with the urinary organs observed in some 
cases of gout are the presence of calcqli 
consisting of uric acid, urates, or oxalate of 
calcium ; chronic cystitis; or urethritis. 
It must again be noted here that many 
writers recognise degeneration of the in- 
volved structures as an essential part of the 
gouty change, and appearances characteristic 
of such degeneration have been described in 
different tissues; thus the cartilages are said 
to be generally fibrillated and eroded before 
the deposit of urates takes place. 
In the course of gout other morbid changes 
often arise, affecting different structures and 
organs, and either occurring as acute or even 
fatal events, or being of a chronic nature. 
Only the more prominent of these can be 
mentioned here, and they mainly include 
changes in the pharyngeal structures; con- 
gestion, catarrh, or more serious inflamma- 
tion of some part of the alimentary canal; 
congestion or catarrh of the air-passages, 
chronic bronchitis, emphysema, and, some 
think, pneumonia ; fatty disease of the liver, 
and perhaps cirrhosis; meningitis, neuritis, 
cerebral heemorrhage; cardiac changes, in- 
cluding chronic valvulitis and degeneration 
of the valves, and hypertrophy, followed by 
degeneration of the cardiac walls; athero- 
matous changes in the vessels, hypertrophy 
of the muscular coat of the small arteries, or 
arterio-capillary fibrosis; various diseases of 
the skin, such as erythema, urticaria, eczema, 
psoriasis, as well as changes in the nails; 
iritis, hemorrhagic retinitis, and other condi- 
tions of the eyes; and affections of the ear. 
How far some of these conditions can be 
directly attributed to the gouty diathesis, or 
are merely the result of the same causes which 
have induced this diathesis, may be fairly 
disputed. It is worthy of remark that acute 
inflammation in connexion with the heart is 
not met with in cases of gout, and this has 
been attributed to the great vascularity of 
the endocardium and other cardiac tissues, 
for which consequently the urate has no 
affinity, or it is destroyed in its passage 
through them." 
The condition of the blood in gout may be 
here noticed. In early cases the chief devia- 
tion from the healthy state presented by this 
fluid is that during the acute paroxysms the 
serum contains a distinct excess of uric acid, 
in the form of a salt of sodium ; and this can 
be obtained in appreciable quantity, even in 
a crystalline form. In the intervals the blood 
is quite normal. When the gouty condition 
becomes chronic, the excess of uric acid is 
constant; and oxalic acid can also be fre- 
quently detected. In course of time the 
serum becomes lowered in its specific gravity, 
its albumen is deficient, and its reaction is 
-less alkaline, in extreme cases becoming al- 
most neutral, owing to the presence of excess 
of acids. The red corpuscles often diminish 
in number, and the blood deteriorates in 
quality as a whole in many cases of chronic 
gout. 
Uric acid has been obtained from the 
fluid contained in the blebs produced by blis- 
ters; from inflammatory serous effusions; 
from dropsical accumulations, such as ascites; 
and from the subarachnoid fluid. 
Clinical History and Symptoms.-The 
clinical history of gout is a very varied one, 
and the symptoms observed in different cases 
which are regarded as of a gouty nature are 
exceedingly numerous and diverse. Whether 
they are always directly due to uric acid in 
the system is, to say the least, a matter of 
considerable doubt. The habits which gene- 
rate gout often give rise to symptoms, and 
even to definite morbid changes, which can- 
not justly be looked upon as part of this com- 
plaint. Again, the custom which some prac- 
titioners adopt, of looking upon every acute 
illness, particularly inflammation of organs, 
occurring in gouty subjects, as being due 
to the lithaemic condition, and of a special 
nature, and applying the term ' gouty ' to all 
such complaints, is certainly going too far, 
though it may be acknowledged that gout 
does often modify their clinical history. It 
is not easy within a limited space to give 
even a sketch of the various clinical phases 
of gout, but before considering the symptoms 
in detail it may be well to indicate their 
general nature. 1. In its typical form gout 
is attended with acute symptoms referable 
to certain joints, and these tend to recur at 
intervals, constituting ' fits of gout,' the inter- 
vening periods becoming shorter and shorter 
as the case progresses-acute articular or 
regular gout. 2. These attacks culminate in 
obvious chronic changes in the affected joints 
-chronic articular gout-but even then 
more or less acute paroxysms are liable to 
arise from time to time. 3. In connexion 
with the acute attacks, and sometimes pre- 
ceding them, general or constitutional symp- 
toms are usually observed; and symptoms 
belonging to this class become permanent 
in most cases of chronic gout. 4. When 
gout affects other organs and structures be- 
sides the joints, corresponding symptoms are 
developed, according to the part implicated. 
In general terms these are variously grouped 
as cases of non-articular, irregular, mis- 
placed, latent, mashed, or anomalous gout; 
and when such symptoms are acute in their 
character, affecting some internal organ, and 
coming on during the course of an attack ot 
acute articular gout, the joint-symptoms at 
the same time subsiding, this constitutes 
what is termed retrocedent gout. The GOUT 
751 
symptoms which may occur in these cases 
are conveniently subdivided as follows :- 
(a) Those indicating more or less functional 
disorder of certain organs, varying much in 
intensity, and either being constantly present, 
or only coming on at intervals. (6) Those due 
to acute inflammatory affections of organs, 
(c) Those resulting from the chronic struc- 
tural changes in tissues and organs induced 
by gout, and from the deposit of urates in 
different parts. Having given this outline, 
we may now discuss the symptoms of gout 
in some detail, but it will be convenient in 
doing so to adopt a rather different arrange- 
ment from that just sketched. 
1. Premonitory Symptoms. - There 
are certain symptoms, of a somewhat in- 
definite character, and not of any marked 
intensity, which are often met with in gouty 
subjects, or even in persons who have never 
actually suffered from declared gout, but 
which seem to be distinctly associated with 
the complaint. These may be regarded as 
premonitory symptoms, for they frequently 
give warning that the gouty condition is 
in process of development, and, if duly re- 
cognised, enable the patient so to regulate 
his mode of living as to ward off the dis- 
ease. Indeed, it will be found on careful 
inquiry that gouty phenomena, which may 
be very marked, are commonly noticed from 
time to time before the first actual fit of gout 
occurs, and there may even be suspicious 
twinges or uncomfortable sensations about 
the toes or fingers now and then. In a large 
number of cases, however, no definite pre- 
monitory symptoms immediately precede the 
first gouty paroxysm; but in connexion with 
subsequent paroxysms prodromata are usu- 
ally marked, so that confirmed gouty patients 
can predict when an attack is imminent. As 
to the nature of these symptoms, they vary 
in different persons, and this may depend 
upon individual predisposition. The most 
obvious are digestive and hepatic disorders, 
attended with marked flatulence and eructa- 
tions, heartburn, acidity, and constipation or 
diarrhoea, with unhealthy stools, the tongue 
being often large, flabby, and much furred; 
palpitation or uncomfortable sensations about 
the heart; catarrh of the throat and respira- 
tory passages, violent fits of sneezing, or 
asthmatic attacks ; derangements of the ner- 
vous and muscular systems, indicated by a 
liability to headache, giddiness, attacks of 
migraine, noises in the ears, disorders of 
vision, marked irritability of temper and 
fretfulness or lowness of spirits, languor, im- 
pairment of mental vigour and intellectual 
hebetude, heaviness or drowsiness, sleep, 
however, being restless, disturbed, and at- 
tended with unpleasant dreams, peculiar 
grinding of the teeth, sometimes associated 
with somnambulism, numbness or tingling 
in the limbs, especially in the fingers or toes, 
neuralgia or neuritis in various parts, twitch- 
ings, startings in the limbs, muscular cramps, 
especially in the calves of the legs, or possibly 
even convulsions, lumbago and other forms 
of muscular rheumatism; profuse perspira- 
tions ; certain skin-affections; and changes 
in the urine. This excretion usually tends 
to become high-coloured and deficient, and 
to deposit lithates abundantly, or even lithic 
acid crystals, though at the same time the 
quantity of this acid eliminated within the 
twenty-four hours is below the normal. In 
advanced cases of gout, however, the urine 
presents very different characters from those 
just stated, as will be hereafter pointed out, 
and when habitually depositing urates it 
may become pale, watery, and clear imme- 
diately before an acute attack supervenes. 
Some patients are warned of the approach 
of a gouty fit by feeling unusually well, both 
physically and mentally. 
2. Acute Articular Gout.-The first 
acute fit of gout comes on as a rule during 
the night, usually between 2 and 5 a.m. The 
patient is disturbed out of his sleep by un- 
easiness or pain, generally referred to the 
ball of the great toe on one side, and the 
joint is found to be inflamed, the inflamma- 
tion increasing in intensity, until it usually 
becomes extremely severe. In some in- 
stances the corresponding joints on both 
sides are attacked simultaneously, in rapid 
succession, or alternately. Although, how- 
ever, in the majority of cases gout first 
attacks the metatarso-phalangeal articulation 
of the great toe, it must not be forgotten 
that it may start in any of the smaller joints 
of the foot or hand, or even in the middle- 
sized joints, especially the knee or ankle. It 
has been affirmed that, next to the great toe, 
the metacarpo-phalangeal joint of the index- 
finger is most liable to be first attacked. 
Exceptional cases have come under the 
writer's notice, which there was every reason 
to believe were of a gouty nature, and in 
which the disease implicated several joints 
at a very early period of its course, the feet, 
however, being free. 
Proceeding now to notice the clinical 
characters of the joint-affection, severity of 
the pain is certainly a striking feature in the 
majority of cases of acute gout, especially in 
early attacks. When the foot is affected, 
any attempt to stand causes much suffering 
from the first, and the pain speedily increases, 
until it becomes very intense, or almost un- 
bearable. It is described in different cases as 
burning, throbbing, aching, tearing, plunging, 
boring, piercing, &c. The pain prevents 
sleep during the night, but towards morning 
it tends to diminish, and during the day 
there is usually comparative ease, an exacer- 
bation again taking place as evening ap- 
proaches, which goes on increasing towards 
night. Tenderness is very marked, and is 
often so exquisite that the patient dreads to 
be touched, and cannot bear the least move- 752 
GOUT 
ment or jarring of the affected part, or some- 
times even the weight of the bedclothes, or 
the slightest shaking of the room. The ob- 
jective signs of inflammation in connexion 
with a gouty joint also soon become very 
prominent as a rule. These are marked red- 
ness, which may be very deep and sometimes 
tends to lividity, while the veins are often 
enlarged and turgid; considerable local heat, 
as revealed to the touch and the clinical 
thermometer; and much swelling, the skin 
covering the part assuming a tense and 
shining appearance. When several joints 
in the foot or hand are affected, diffused red- 
ness and swelling are noticed. The tume- 
faction is due to effusion not only into the 
interior of the articulation, but also into the 
surrounding tissues, subcutaneous oedema 
being a marked feature in connexion with 
gouty inflammation. This can be better 
appreciated when the acute symptoms sub- 
side, so that pressure can be borne, which 
shows the pitting characteristic of oedema, 
and this may hold on for some time. How- 
ever intense the objective signs of inflam- 
mation may be, it is an extremely rare event 
for acute gout to end in suppuration. As 
they subside, marked desquamation of the 
skin usually takes place. As the swelling 
increases, the subjective sensations generally 
diminish in severity; but during the pro- 
gress towards recovery, intense itching is 
apt to supervene. 
An acute attack of gout is almost always 
attended with more or less general symp- 
toms; but it is an important fact that their 
severity depends upon the extent and in- 
tensity of the local manifestations of the dis- 
ease, and upon the accompanying symptoms. 
Chills or even actual rigors may be felt at 
the outset, followed by febrile phenomena, 
sometimes slight, in other cases marked, the 
pyrexia being as a rule strictly secondary or 
symptomatic. The skin feels hot, and usu- 
ally perspires, but not profusely; the tem- 
perature is moderately raised, presenting no 
definite variations, though marked remis- 
sions are generally observed towards morn- 
ing ; the pulse is increased in frequency; and 
the digestive organs are much disordered, as 
evidenced by anorexia, thirst, thickly furred 
tongue, offensive breath, and constipation. 
The urine is generally deficient in quantity, 
and may be very scanty, high-coloured, and 
concentrated; its acidity is increased; and 
on standing, an abundant deposit of amor- 
phous lithates often forms, varying in colour 
according to circumstances, being pale-buff, 
yellowish-red, dark or brick-red, or intense 
pink if the fever is high. The relative quan- 
tity of uric acid in a particular specimen of 
urine is often increased, but the absolute 
amount discharged within the twenty-four 
hours is much diminished. The patient is 
usually exceedingly restless, and cannot lie 
with comfort in any position ; sleep is much 
disturbed or altogether prevented; and cramps 
of the calves of the legs or of other muscles 
may still further aggravate the suffering. All 
these symptoms tend to increase the consti- 
tutional disorder. The temper is generally 
very irritable, or may even be violent. 
The duration of the first fit of gout varies 
according to its severity and other circum- 
stances. It usually ranges from four or five 
days to a week or ten days, but may last 
two or three weeks or more, there being 
then commonly intermissions or remissions, 
and several joints being involved in succes- 
sion. The termination of the gouty paroxysm 
may be attended with critical phenomena, 
such as free perspiration, diarrhoea, or a very 
abundant discharge of urates. After the at- 
tack the patient may not recover his former 
state of health for some time ; but not un- 
commonly he feels better than before, and as 
if the system had got rid of some deleterious 
element. As a rule, the affected joints are 
apparently quite restored after early attacks 
of gout; but more or less stiffness or even 
deformity may remain. (Edema may also 
persist for a considerable time, especially if 
the inflammatory condition has been pro- 
longed. 
One of the characteristic features of gout 
is the tendency which it exhibits to recurrence 
in its acute form. This may not happen if 
the patient is sufficiently careful, but such an 
event is rare. The rule is for the attacks to 
be repeated, and to recur with increasing 
frequency. In not a few instances the second 
fit does not occur until an interval of two or 
three years or more has elapsed, but in most 
this is not prolonged beyond a year. The 
same interval may be noticed between the 
next few paroxysms, but as the disease pro- 
gresses they return twice a year, then more 
frequently, and at last become more or less 
constant. At the same time the mischief 
extends as regards the joints. It may be 
limited to the great toe for some time, but in 
successive fits spreads to the other articula- 
tions of the foot, to the hands, the ankles and 
knees, the wrists and elbows, very rarely to 
the hips and shoulders. In short, gout tends 
in time to involve nearly all the joints indis- 
criminately, and several may be implicated 
during a fit. Moreover, those articulations 
which are repeatedly attacked become more 
and more disabled and deformed. The symp- 
toms in connexion with a particular joint 
tend to diminish in intensity the more often 
it is affected. As additional articulations 
become involved, however, the general symp- 
toms often increase in severity, and the 
patient does not recover in the intervals. 
The duration of the attacks becomes longer 
as their frequency increases. The rapidity 
of the progress of gout is very different in 
different cases; and the time taken to pro- 
duce permanent mischief in the joints varies 
considerably. GOUT 
753 
It must be borne in mind that considerable 
variations in the intensity and exact charac- 
ters of the symptoms of acute gout are ob- 
served in individual cases. In feeble persons 
the subjective and objective symptoms may 
be comparatively slight, the inflammation 
assuming an asthenic character, but then the 
ultimate effects upon the joints are often 
much worse. In some instances gout de- 
velops very insidiously, without any evident 
acute attacks. The pain in connexion with 
a particular joint depends considerably on 
its structure, being usually much more marked 
if its ligaments, or the parts around, are rigid 
and unyielding. Previous injury or disease 
affecting a joint may likewise modify the 
symptoms. Some individuals suffer much 
more than others, being more susceptible to 
painful impressions. 
3. Chronic Articular Gout.-In course 
of time more and more of the joints become 
permanently and obviously changed, and pre- 
vented from fulfilling their functions properly, 
so that a condition of chronic articular gout 
is established, exacerbations still occurring, 
however, from time to time. The per- 
manent changes are indicated by the arti- 
culations becoming enlarged, deformed, and 
irregular in shape, often presenting nodula- 
tions or bulgings, which may attain a large 
size. They are also stiff and crippled in 
their movements, at last becoming quite im- 
movable and rigid; and being either perma- 
nently flexed, extended, or sometimes even 
bent backwards. The interference with 
movement and the deformity do not bear 
any necessary proportion to each other, the 
one or the other predominating according to 
the mode in which the uratio deposit has 
taken place. The more this infiltrates the liga- 
ments and surrounding tendons, the greater 
becomes the impediment to movement. The 
fingers are particularly liable to be much 
altered in chronic gout. A common condi- 
tion is said to be stiff flexion of the meta- 
carpo - phalangeal and second phalangeal 
joints of a finger, with over-extension of the 
first phalangeal joint, so chat its knuckle 
presents a deep hollow. Deflexion of the 
fingers to the ulnar side of the fore-arm is 
observed in some gouty cases. The toes are 
also sometimes distorted towards the outer 
side of the foot. 
Gouty concretions in connexion with joints 
feel hard, and by their mere mechanical and 
irritative effects they are liable to cause 
damage to the adjoining structures. They 
may be seen stretching or shining through 
the skin, and causing it to assume a blood- 
less appearance, or, on the other hand, ren- 
dering it congested and bluish, the veins also 
being enlarged. Ultimately a gouty abscess 
may form around a concretion, which opens 
externally ; or the skin may merely give way 
from the continued pressure. Thus the 
challc-stones are exposed, and may come 
away either in a liquid, form or as solid, par- 
ticles or masses, or occasionally there is a 
free discharge of pus as well. Ulcers are 
left, of an unhealthy and atonic character, 
and usually presenting no disposition to heal. 
There may be a number of these ulcers 
in the same individual, on the hands and 
feet. 
When bursae are involved, much deformity 
is produced. They are easily felt, usually 
presenting a combination of hardness and 
fluctuation, due to the presence of both con- 
cretions and fluid in the bursal cavity. These 
signs are chiefly noticed in the bursa over 
the olecranon. Abscesses may also form in 
connexion with these deposits, and the latter 
may thus be completely got rid of, the ab- 
scess subsequently healing rapidly. 
In cases of chronic articular gout the gene- 
ral system tends to become permanently 
affected. The patients are generally more or 
less feeble and wanting in tone; they may be 
thin and pale or sallow-looking; or ple- 
thoric, but with flabby tissues, and presenting 
signs of languid circulation, with enlarged 
capillaries about the face. They often suffer 
from disorders of digestion and other symp- 
toms already described; but not uncom- 
monly, as gout assumes a more chronic form, 
patients feel better, becoming habituated to 
their condition. It is remarkable that those 
suffering from numerous gouty abscesses 
often exhibit but little constitutional disturb- 
ance. 
The urine in chronic gout generally be- 
comes abundant, very watery and pale, of low 
specific gravity, deficient in solid ingredients, 
especially in uric acid, which at times may 
be almost completely wanting, or it may be 
thrown out in an intermittent manner. De- 
posits of urates in urine are not often ob- 
served in cases of advanced chronic gout, 
except perhaps before an acute exacerbation. 
Glycosuria is not uncommon in gouty per- 
sons, and there may be distinct saccharine 
diabetes. Oxaluria is also frequent. 
4. Irregular Gout.-The clinical pheno- 
mena which are recognised as irregular mani- 
festations of gout may assume either an 
acute or chronic form. They may be ob- 
served in persons who are distinctly subject 
to articular gout; or in those in whom the 
disease is not so obviously revealed. More- 
over, their intensity is often in an inverse 
ratio to that of the joint-affection, and the 
two classes of symptoms may exhibit a re- 
markable tendency to alternation, when the 
articular symptoms are prominent those con- 
nected with other parts being slight or absent, 
and vice versa. Acute symptoms are parti- 
cularly liable to arise when, from any cause, 
during the progress of a gouty fit the joint- 
inflammation is checked suddenly or rapidly 
-retrocedent gout. At other times internal 
symptoms seem to be due to a want of 
development of the external phenomena- 754 
GOUT 
suppressed gout; and when the latter appear, 
the former subside. 
It must suffice to indicate here the general 
nature of the symptoms of irregular gout. 
The acute symptoms are mainly associated 
either with the digestive apparatus, the 
vascular system, the respiratory organs, or 
the nervous system. In connexion with the 
digestive apparatus, acute dysphagia may 
occur, attended with spasm of the pharynx 
and oesophagus. The most important symp- 
toms belonging to this group are, however, 
those due to gastric disturbance. This may 
be of the nature of severe cramp or gas- 
tralgia, characterised by a sudden, intense, 
spasmodic pain in the epigastrium, relieved 
by pressure, and accompanied with a sense 
of great weight and oppression ; the patient 
presenting an aspect of much suffering, dis- 
tress, and anxiety; or being even more or 
less collapsed and prostrated. In other cases 
the symptoms are those of acute gastritis, 
bilious vomiting being prominent. Intestinal 
colic, or even muco-enteritis, may also occur 
in connexion with gout. Hepatic disorder 
is common. The vascular system is not un- 
commonly implicated. The heart is liable 
to be disturbed in its action during the 
attacks of gastralgia, but this disturbance 
may also be observed independently. There 
may be severe palpitation, the action of the 
heart being very rapid, irregular, or even 
intermittent, accompanied with most un- 
pleasant sensations over the cardiac region, 
precordial anxiety, often a feeling of oppres- 
sion or constriction, dyspnoea or a sense of 
suffocation, and much distress, anxiety, and 
dread of death; the pulse tends to be weak 
and small, or may be irregular; and some- 
times the attacks are attended with signs of 
collapse. In other instances the cardiac dis- 
order is evidenced by very feeble or slow 
action, with a tendency to syncope. Again, 
there may be all the phenomena of a severe 
anginal attack {see Angina Pectoris). Irre- 
gular gout affecting the respiratory system 
is mainly indicated by asthmatic paroxysms. 
In some cases there is a marked liability to 
acute catarrh of the air-passages, and crys- 
tals of uric acid have been found in the ex- 
pectoration. Bronchitis is more obstinate 
in gouty subjects. Pulmonary congestion 
is also supposed to be a manifestation of 
retrocedent gout in some cases; and gouty 
pneumonia has been described. In con- 
nexion with the nervous system gout may 
give rise to attacks of severe headache or 
vertigo; delirium or even acute mania; epi- 
leptiform or convulsive fits; cerebral or 
spinal meningitis; acute neuralgia, either 
external or internal, and especially sciatica, 
probably due to neuritis; or severe muscular 
cramps. Apoplexy from cerebral haemorrhage 
has been attributed to suppressed or retro- 
cedent gout, but this can only occur if the 
vessels of the brain are diseased. Cerebral 
congestion might give rise to a temporary 
apoplectic attack. Among the acute mani- 
festations of irregular gout may be further 
mentioned certain skin-affections, as eczema, 
erythema, or urticaria; affections of mucous 
membranes, such as the conjunctivae and 
lacrymal passages ; functional renal dis- 
order, with albuminuria, or irritability of the 
bladder ; and external local signs of inflam- 
mation, associated with uratic deposit. 
Many of the more chronic symptoms asso- 
ciated with gout have already been pointed 
out, when speaking of its premonitory symp- 
toms, and only certain special phenomena 
need be alluded to here. Chronic skin- 
diseases are of frequent occurrence, namely, 
psoriasis, chronic eczema, prurigo-either 
local or general, and acne. These may alter- 
nate very distinctly with articular gout. The 
nails are sometimes peculiar, being coarse 
and fibrous, striated and fluted, or lined 
vertically. Their substance may grow thick 
and brittle. In some gouty subjects daily 
paroxysms of heat and redness of the nose, 
attended with severe itching and irritation, 
cause considerable annoyance or distress. 
Violent sneezing fits are common. Many of 
these individuals are also liable to chronic 
catarrh, affecting the throat and the air- 
passages ; and special appearances of the 
throat, tongue, and teeth have been described. 
In course of time gouty patients often become 
permanently asthmatic, the lungs being em- 
physematous, and dry bronchial catarrh being 
established. Gravel or urinary calculus may 
give rise to symptoms; or those indicative 
of chronic urethritis or cystitis may be pre- 
sent, especially in persons advanced in years. 
Permanent disorders of sensation, or slight 
local paralysis, may result from chronic 
changes involving particular nerves. Gouty 
persons are usually very sensitive to pain. 
Certain affections of the eyes have been 
attributed to gout, and amongst them a form 
of gouty iritis, described by Hutchinson as 
coming on insidiously, and almost painlessly, 
and ending in destruction of the eye. Changes 
in the external auditory meatus may also be 
associated with this complaint. 
With regard to tophi, these can be seen or 
felt, provided they are superficial. Those 
connected with the helix of the external ear 
are most common; but they may also be 
looked for in the sclerotic or eyelids, in the 
nose, and under the skin, in the region of 
tendinous aponeuroses, especially in the leg 
or thigh. Tophi are originally liquid, and if 
one is punctured at an early period, an 
opalescent or milky fluid escapes, which on 
microscopic examination is found to contain 
an abundance of delicate, acicular crystals; 
subsequently they become more consistent, 
and ultimately quite solid and hard, being 
then made up entirely of these crystals, 
which are closely aggregated together and 
interlaced. Taking the ear as an illustration, GOUT 
755 
at first a small elevation appears under the 
skm of the helix, like a vesicle, having a soft 
feel. This gradually hardens, until finally 
a little bead-like or pearl-like body is formed, 
presenting a whitish colour as seen through 
the skin. In course of time the cutaneous 
covering may be destroyed, leaving the little 
concretion exposed; or this may even become 
detached and removed, so that only a small 
depression is left. 
5. Symptoms due to Chronic Organic 
Diseases.-In addition to what has been 
stated under the preceding heading, it is only 
necessary to refer here to the renal and 
cardio-vascular changes which are associated 
with gout. Disease of the kidneys is indi- 
cated mainly by the changes in the urine, 
which may be slightly albuminous, or even 
contain a few casts. Other symptoms of 
chronic Bright's disease may be present, but 
they are often very obscure. The cardiac 
lesions are revealed by their respective phy- 
sical signs; and there may be symptoms, 
first of excessive cardiac action from hyper- 
trophy, and subsequently of cardiac failure, as 
well as those of particular valvular diseases. 
The vascular changes are evidenced by ex- 
amination of the arteries; and by their effects 
upon the circulation. It is impossible to 
describe within the limits of this article 
the numerous symptoms resulting from the 
various chronic organic diseases which may 
develop during the progress of gout, and 
which in many cases ultimately produce a 
very complicated clinical picture. 
Diagnosis.-The degree of difficulty expe- 
rienced in arriving at a diagnosis with respect 
to gout is very variable in different cases. 
A distinct gouty diathesis or tendency may 
be present, which it is important to recog- 
nise, while the joints are quite free from 
any apparent mischief. In most cases, how- 
ever, the diagnosis has to deal with the 
nature of an articular affection, and to deter- 
mine whether this is gouty or not. The chief 
diseases from which gout has thus to be dis- 
tinguished are acute or chronic rheumatism, 
rheumatoid arthritis, and possibly gonorrhoeal 
synovitis. The data upon which a conclusion 
has usually to be formed with regard to a first 
attack, are the presence or absence of an here- 
ditary tendency to gout, as well as its in- 
tensity ; the age and sex of the patient; the 
social position, occupation, and previous 
habits; the presence or absence of any ob- 
vious cause for the attack, or of premonitory 
symptoms; the localisation and characters 
of the joint-affection; the general symptoms; 
the characters of the urine; the duration of 
the illness; and the absence of any cardiac 
complication. 
The subsequent progress of gout is impor- 
tant in diagnosis, with its tendency to perio- 
dic recurrence; and if the metatarso-phalan- 
geal joint of the great toe is alone inflamed 
several times in succession, or even if only 
the smaller joints of the feet and hands are 
implicated, the diagnosis of gout is tolerably 
certain. The permanent articular changes 
induced by gout also become evident in time ; 
as well as, perhaps, tophi in other parts, which 
should be carefully searched for in any doubt- 
ful case. Moreover, the urine presents pecu- 
liar changes as the disease progresses, and 
may give evidence of renal mischief. In 
very doubtful cases it might be desirable to 
raise a blister, or even to take a little blood 
from the patient, and endeavour to obtain 
crystals of uric acid from the serum. 
It will here be expedient to offer a few 
remarks as to the diagnosis from gout of the 
diseases with which it is most likely to be 
confounded. 
With regard to acute rheumatism, the ab- 
sence of any hereditary tendency to gout 
in any doubtful case may be in its favour, 
and possibly there may be a family predis- 
position to this complaint. It occurs most 
frequently for the first time in early life, from 
sixteen to twenty years of age, and is not 
uncommon even in young children. Rheu- 
matism, though more common among males, 
often attacks females. It is not favoured by 
the habits which generate or promote gout, 
and affects all classes of persons, but espe- 
cially those who from their occupation are 
liable to be exposed to cold and wet. Such 
exposure, or some other definite cause origi- 
nating 'a cold,' usually accounts for an attack 
of acute rheumatism; and it is not preceded 
by any particular premonitory symptoms. 
The joints involved are the middle-sized or 
the larger ones, several of which are gene- 
rally implicated in succession during the ill- 
ness, the rheumatic inflammation exhibiting 
an erratic character; the local symptoms 
tend to be less severe than in gout; there 
is less marked oedema about the joints, and 
no enlargement of the veins, or subsequent 
desquamation. It must not be overlooked, 
however, that gout may attack the middle- 
sized joints. Pyrexia is high as a rule in 
acute rheumatism, and is often quite out of 
proportion to the extent of the articular 
affection; while profuse acid perspiration is 
almost always a prominent phenomenon. 
The urine is simply febrile. The attack lasts 
a considerable time, perhaps several weeks, 
if it is at all severe; while during its course 
some acute cardiac inflammation is very 
liable to supervene. In addition to other 
differences, chronic rheumatism is at once 
distinguished from gout by the entire ab- 
sence of uratic deposits. 
Rheumatoid arthritis is usually met with 
in females between twenty and forty years 
old. There is neither hereditary taint, nor a 
history of such habits as generate gout, but, 
on the contrary, the patients are generally 
poor, hard worked, and badly fed; all joints 
seem to be equally liable to be affected, both 
large and small, and the local symptoms are 756 
GOUT 
not of a very acute character, though the pain 
may be very severe, but they tend to continue 
for a long period ; the general symptoms are 
mainly those of debility and anaemia, and 
Dr. Kent Spender has drawn attention to 
certain prominent and early symptoms, 
especially cold hands and feet, constant 
dampness of the hands, pigmentation of the 
skin, and a rapid and compressible pulse. 
Rheumatoid arthritis is a disease which tends 
to progress, involving joint after joint, but it 
'presents no periodicity in its attacks, and 
often advances without any intermission, as 
a subacute or chronic disease. Ultimately 
it often causes much deformity and crippling 
of the articulations, which creak and grate 
on movement, but this results from a very 
different pathological change from that which 
takes place in gout, for there is not the 
slightest deposit of urates, either in the joints 
or elsewhere; nor in the most extreme cases 
can any uric acid be obtained from the serum. 
The urine presents no special characters ; 
and the kidneys are not diseased. 
Gonorrhoeal synovitis is distinguished from 
gout by the age of the patient; the distribu- 
tion of the joint-affection ; the absence of any 
tendency to recurrence, except in association 
with a fresh urethral discharge; and the 
different nature of the morbid changes, tophi 
never being formed. 
As exceptional points bearing upon the 
diagnosis of articular gout, the following may 
be mentioned. It has happened that pyaemia 
beginning in the great toe has been mistaken 
for gout, but the progress of the case would 
soon clear up any doubt under such circum- 
stances. Again, articular inflammation from 
injury might resemble gout; and, moreover, 
it must be borne in mind that such an injury 
may really set up gouty inflammation for 
the first time, so that the joint may not re- 
cover properly. In some individuals the ends 
of the phalanges of the fingers are enlarged, 
especially the terminal ones, and cause nodu- 
lations-digitorum nodi-which. resemble 
those of gout, and are by some regarded as 
being of a gouty nature. 
The importance of recognising the signs 
of the gouty diathesis, apart from the joint- 
affection, has already been alluded to. 
Equally important is it to be prepared for 
the acute symptoms in connexion with in- 
ternal organs which occur in this diathesis, 
whether along with or independent of 
articular disease. Lastly, in any gouty case 
the detection of the organic diseases liable 
to be set up in its course is of great moment 
in diagnosis, especially renal and cardio-vas- 
cular changes; and also the association with 
their proper cause of catarrhal affections, 
skin-diseases, and other complaints, when 
these are really of a gouty nature. 
Prognosis.-The first point relating to the 
prognosis of gout which calls for notice refers 
to the immediate dangers in any particular 
case. A simple acute attack of articular 
gout rarely, if ever, kills the patient. When, 
however, internal organs are implicated., the 
matter becomes much more serious, and a 
fatal result may occur, so that the prognosis 
must be a guarded one under such circum- 
stances. The danger then becomes much 
greater if the complaint has been long-estab- 
lished, and if the kidneys or other important 
organs have become structurally diseased. 
Indeed, these diseases of organs are often 
themselves immediately dangerous. Again, 
any acute inflammation occurring in a con- 
firmed gouty subject is the more serious on 
this account; and. the same remark applies 
to injuries and shocks of all kinds. 
In the next place, the future of a gouty 
patient has to be considered, as regards the 
prevention of subsequent attacks, or the cure 
and eradication of the disease. It must 
always be recognised that gout is a recurrent 
affection, and complete immunity can never 
be guaranteed, once the complaint has de- 
clared itself. At the same time undoubtedly 
not a few cases have occurred in which there 
has been but one attack, but this can only 
be expected under certain conditions. In 
giving an opinion on this point, the prognosis 
in any individual case will depend upon :- 
1. The degree of hereditary tendency to gout. 
2. The age of the patient; for the earlier the 
period at which the disease begins, the less 
hopeful is the prospect of a cure. 3. The 
time the complaint has lasted from its com- 
mencement ; and the frequency and duration 
of the gouty fits. If gout has become estab- 
lished, and especially if distinct tophi have 
formed, it is quite impossible to eradicate it. 
4. The habits, mode of living, and occupa- 
tion of the patient. It is only when the 
patient is prepared to adhere strictly to proper 
rules of living that a cure can be hoped for. 
Those who in their occupation are tempted 
to drink much, or who are exposed to cold or 
wet, are much less likely to be cured. It may 
be remarked here that gouty subjects are less 
able than others to resist exposure. 
Another point bearing upon prognosis re- 
fers to the duration of life in gouty persons. 
If the disease comes on late in life, and the 
paroxysms only occur at long intervals, while 
the organs are free from any organic mischief, 
gout may not appreciably shorten life, and the 
patients may even enjoy good health up to 
an extreme old age, provided they are suffi- 
ciently careful in their mode of living, and 
no accidental complications arise. Chronic 
gout does, however, unquestionably tend to 
shorten the duration of life, to a greater or 
less degree in proportion to its severity, and 
more especially to the indications present 
that the kidneys, heart, arteries, or other 
important organs are organically diseased. 
This tendency is now recognised by most life- 
insurance companies. 
It has been affirmed that gout is a pro- GOUT 
757 
tection against certain other diseases, such 
as phthisis and diabetes, and therefore its 
presence has been in some instances re- 
garded as a benefit, but how far there is 
any real foundation for this belief is a matter 
of very considerable doubt. 
Treatment.-It is important at the outset 
to lay stress upon the fact that, although 
there are certain well-defined principles 
applicable to the treatment of gout in its 
various phases, it is a great mistake to follow 
any regular routine method under all circum- 
stances, and every case must be considered 
on its own merits. It will be convenient to 
discuss this part of the subject under cer- 
tain general headings, premising that the 
administration of medicines is often the least 
important part of the treatment, and that the 
habits of life of the patient always need 
thorough supervision in all their details. 
1. Preventive and Curative Treat- 
ment.-In a number of cases the primary 
object which should be aimed at is to prevent 
the development of gout; or to eradicate the 
tendency to subsequent attacks, if it has once 
declared itself. These objects have especially 
to be kept in view in dealing with individuals 
who have a marked hereditary predisposition 
to the complaint; in cases where it has ap- 
peared at a comparatively early period of 
life, or where it is in an early stage; and in 
persons who, from their occupation, known 
habits, or the symptoms they present, are 
likely to become gouty. Moreover, even 
when confirmed gout has been established, 
preventive treatment may diminish the num- 
ber of acute attacks, or possibly even avert 
them altogether; as well as obviate the im- 
plication of organs essential to the well-being 
of the economy. In order to carry out these 
purposes in any particular case, the patient 
must intelligently recognise the fact that 
success in treatment mainly depends upon 
himself, and upon his willingness constantly 
to regulate his mode of living according to 
principles suitable to his condition, which 
need to be more or less strict in different 
instances. The general nature of the rules 
to be adopted will be evident from a con- 
sideration of what has been stated in dis- 
cussing the aetiology and pathology of gout, 
but they require to be briefly noticed here. 
(a) Diet.-Moderation in the quantity of 
food is the first point to be attended to in 
the treatment of the gouty diathesis. It is 
not necessary or desirable to restrict persons 
who are gouty to a very low diet, especially 
if they are in any way weak, but an amount 
sufficient for proper nourishment in each 
individual case must be consumed, and at no 
meal should the stomach be uncomfortably 
filled. The meals must be taken at regular 
times, and not hurriedly, so as to avoid bolt- 
ing of the food. Very late dinners, as well 
■as suppers, should be prohibited, but it suits 
many persons better to dine at six or half- 
past six o'clock than at midday. The nature 
of the food is highly important. It is quite 
unnecessary, and probably Would be in most 
instances injurious, to restrict the patient 
absolutely to a vegetable diet, but a due pro- 
portion of animal and vegetable aliments 
should be allowed. At the same time, in 
persons who have any tendency to gout, an 
essential part of the treatment often consists 
in diminishing the amount of meat which 
they consume, and they should not take it 
more than once a day. Indeed, the aim 
must be to reduce all kinds of nitrogenised 
food, whether animal or vegetable, to such 
an amount as the system can satisfactorily 
dispose of, with due regard to the proper 
nutrition and strength of the body. As re- 
gards the kinds of animal food which are 
suitable for gouty subjects, white fish, chicken 
or fowl, game, tripe, sweetbread, and mutton 
are the best forms. Tender and underdone 
beef may be taken in moderation from time 
to time, if it is readily digested. Pork or 
veal, dried and salted meats, and rich dishes 
of all kinds, should be avoided. Lightly 
boiled or poached eggs may be permitted. 
Vegetables which contain much woody fibre, 
or which create flatulence, must be eschewed; 
and certain articles, such as rhubarb, toma- 
toes, especially when cooked, asparagus, and 
sorrel, are often injurious to the gouty, as 
well as others which contain much acid. On 
the other hand, some special beneficial influ- 
ence has been attributed to celery. Those 
who are subject to gout should either abstain 
altogether from, or only take a very limited 
quantity of, sugar and saccharine articles of 
diet. Hence, although digestible fruits may 
often be taken with advantage in moderation, 
those which are very sweet must be used 
with particular caution. Stewed and baked 
fruits often agree well, but fruit-tarts, and, 
indeed, pastry of all kinds, should be inter- 
dicted. The juice of oranges or lemons 
is considered beneficial for gouty persons. 
Starchy foods are permissible in moderation. 
It may be laid down as a rule to be invari- 
ably followed, that gouty patients should 
limit themselves to simple meals, and not in- 
dulge in a number of courses ; and that they 
should avoid everything which experience 
tells them is, in their case, indigestible. 
(6) Drink.-The question of drink demands 
the most careful consideration and atten- 
tion in every case in which gout is either 
threatened or has become established. No 
stringent rules can be laid down, applicable 
to all cases, but there are certain broad 
principles which have to be borne in mind. 
An abundance of good and pure drinking- 
water is to be commended, but it should 
be taken mainly apart from meals. It is 
a good plan for the subjects of lithiasis to 
take a tumblerful of, either cold or hot, 
water before retiring to rest at night. Effer- 
vescing potass- or lithia-water may be 758 
GOUT 
substituted for ordinary water with advan- 
tage, but not soda-water. Tea and coffee may 
be taken in moderation, provided they do 
not disagree. With reference to alcoholic 
drinks, in a considerable number of instances 
one of the first objects in the treatment of 
the gouty diathesis should be the regulation 
of the use of this class of beverages. This 
indication is obvious enough when the con- 
dition is evidently due mainly to intemper- 
ance ; but even when the patient is temper- 
ate, it may be that in his case the amount 
consumed needs to be reduced or total absti- 
nence enforced, especially if there should be 
a strong hereditary predisposition to gout, or 
if the complaint appears in early life. Some 
patients are undoubtedly better if they take 
no stimulants whatever; others, however, 
can take those of a proper kind, and of good 
quality, in strict moderation, with advantage. 
It may be laid down as a general rule that 
malt liquors and all stronger wines are in- 
jurious, and should be interdicted. Those 
which are most suitable are sound light 
claret, hock, moselle, chablis, or sauterne. 
A small quantity of good dry sherry suits 
some gouty patients very well. A little 
brandy, well diluted, often agrees better than 
any other kind of alcoholic liquor ; in other 
cases whisky or gin answers best. Whatever 
stimulant is selected, it should only be taken 
at meal-times, and the habit of drinking be- 
tween meals is strongly to be deprecated. 
Persons who are distinctly gouty should avoid 
any excess on every occasion; and even if 
they do not absolutely abstain, they may 
find it beneficial to do so from time to time, 
especially if there is a tendency to the de- 
velopment of gouty symptoms. 
(c) General hygiene.-Inadequate exercise 
is a hygienic error which has frequently to 
be rectified in the treatment of the gouty 
state. Sedentary habits must be combated, 
whether due to occupation or indolence; and 
it must be insisted upon that a due amount 
of outdoor exercise is taken daily, but pro- 
longed exertion, tending to cause fatigue and 
exhaustion, must be avoided. Walking and 
horse-exercise are highly beneficial, especi- 
ally in the case of those who live rather too 
freely. Even carriage-exercise is useful, so 
that the patient may have the benefit of the 
fresh air. For those who cannot have much 
regular exercise, lawn-tennis, fencing or 
single-stick, golf, and the like may be ser- 
viceable. As bearing upon the prevention 
of an acute fit of gout, it is an undoubted 
fact that some individuals who are subject 
to the disease seem to be able to ward it off 
by walking, riding, or adopting some other 
form of prolonged and violent exercise on 
the first intimation of a threatened attack. 
Gouty persons should retire to rest and get 
up early. They should as much as possible 
avoid excessive mental labour, or any great 
strain upon the mental faculties, but especi- 
ally worry and anxiety of all kinds. Atten- 
tion must be paid to the cutaneous functions, 
the surface of the body being also protected 
from the injurious effects of cold. Warm 
clothing should be worn, in keeping with the 
weather, and those who can bear it should 
wear flannel next the skin. With regard to 
baths, many gouty persons are decidedly the 
better for using a cold or tepid bath every 
morning, followed by energetic friction; in 
other cases the employment of the warm 
bath at intervals, or even of the Turkish bath, 
answers best. A course of treatment in a 
hydropathic establishment from time to time, 
under due medical supervision, is sometimes 
decidedly beneficial. Climate demands atten- 
tion, whenever the circumstances of the 
patient allow a choice to be madei It may 
be advisable for gouty subjects to reside per- 
manently in some warm and equable climate, 
or at any rate during the winter and early 
spring. In this way attacks may. often be 
warded off, and the disease thus prevented 
from making progress. Those who are obliged 
to remain in this climate during the incle- 
ment seasons should avoid exposure to wet 
and cold, as well as sudden changes of tem- 
perature, and night air. The bedroom should 
be warm and well-ventilated; and in cold 
weather it is desirable to keep a fire burning 
during the night. Unduly heated and badly 
ventilated rooms, as well as crowded places 
of public resort, must be eschewed. 
(d) Medicinal treatment.-There can be 
no doubt but that the judicious use of cer- 
tain medicines may assist materially in 
warding off or mitigating the gouty condi- 
tion, and in preventing the occurrence of 
acute paroxysms. Those which are specially 
called for in cases of established chronic 
gout will be presently considered. In the 
meantime, it may be stated that the digestive 
functions require particular attention, and 
medicines which help these functions are 
often of the greatest service, if they should 
be disordered. A course of alkalis or acids, 
according to the indications in each case, 
may prove most serviceable, combined with 
some simple bitter infusion or tincture. 
Certain alkalis and alkaline earths are also 
valuable on account of their power in pro- 
moting elimination of lithic acid, by forming 
soluble salts with this acid. The careful ob- 
servations of Dr. Haig have shown that alka- 
lis increase the secretion of uric acid, while 
acids decidedly diminish it. The alkalis 
which are most useful are salts of potassium 
and lithium, the urate of lithium being 
the most soluble of all. The bicarbonate of 
potassium, carbonate of lithium, or the 
citrates are the best salts to administer. 
They should be taken well-diluted, and on 
an empty stomach. Magnesia or its car- 
bonate may be given with advantage if there 
is much acidity, and if the bowels are habitu- 
ally constipated. Saline aperients are often GOUT 
759 
of great service, and they may be advantage- 
ously administered in small doses, freely 
diluted, and regularly repeated, when they 
also act on the kidneys. In many cases other 
aperients may be employed at intervals with 
advantage, but strong purgatives must be 
used with particular caution. An occasional 
dose of blue-pill or calomel may be decidedly 
beneficial. The administration of other cho- 
lagogues from time to time may also be of 
service. 
(e) Mineral waters and baths.-Certain 
mineral waters are of great value in the 
treatment of the gouty diathesis, when em- 
ployed under proper medical supervision, 
and they offer the advantage that patients 
will often use them, when they will not 
undergo' a course of regular medicinal treat- 
ment ; while the water thus taken internally 
is itself of service. Space will not permit a 
long discussion of this subject here, and it 
must suffice to mention that in different cases 
the kind of mineral water employed must 
be varied according to the object desired to 
be accomplished, and according to the indi- 
cations presented by the patient, for what 
suits one may be highly injurious to another. 
These waters are employed both internally 
and in the form of baths. Those chiefly 
used in gouty conditions are the waters of 
Bath, Buxton, Cheltenham, Clifton, Harro- 
gate, Leamington, Malvern, and Woodhall 
in this country; Strathpeffer and Moffat in 
Scotland; Llandrindod in Wales; Lisdoon- 
varna and Lucan in Ireland; and Carls- 
bad, Marienbad, Vichy, Wiesbaden, Baden- 
Baden, Ems, Royat, Aix-la-Chapelle, Aix-les- 
Bains, Evian-les-Bains, Contrexeville, Dax, 
La Bourboule, Luchon, Friedrichshall, Hun- 
yadi Janos, Pullna, Schlangenbad, Teplitz, 
Seidlitz, Homburg, Kissingen, Rubinat, Wild- 
bad, Ragatz, Gastein, Elster, Tarasp, Apol- 
linaris, and other continental waters. Some 
of these may be taken regularly or at inter- 
vals, for the purposes which they respectively 
fulfil; or, if circumstances permit, a syste- 
matic course of treatment from time to time, 
at certain of the places mentioned, may be 
recommended. See Mineral Waters. 
Before leaving the subject of the preven- 
tive treatment of gout, it needs to be insisted 
upon that those who are particularly liable 
to this disease, whether from hereditary pre- 
disposition, occupation, or any other cause, 
should pay special attention to preventive 
measures ; and also that those in whom the 
disease has already manifested itself must 
take every precaution to avoid the known 
causes of acute attacks, for each attack tends 
to make matters worse. 
2. Treatment of Acute Gout.-When 
a fit of acute articular gout sets in, it is on 
no account to be permitted to run its course 
unmodified by treatment, else serious mis- 
chief is liable to arise. At the same time it 
is requisite to refrain from adopting too active 
measures. Our objects should be to shorten 
the attack; to restore the affected parts as 
nearly as possible to their normal condition; 
and to relieve symptoms. In the first place, 
particular attention must be paid to the 
diet. The aim should be to make this as 
low as is compatible with the condition of 
the patient, especially if the fit is of a very 
acute and sthenic type. In young and strong 
patients the diet should at first consist of 
milk, farinaceous articles, and abundance 
of water, barley-water, or toast-and-water. 
Those who are advanced in years, weak, or 
broken-down in health, or who have long 
suffered from gout, require a more nutritious 
diet, but it should be easily digestible, con- 
sisting of beef-tea and good soups, milk, eggs 
beaten up, and such articles, the quantities 
being regulated by the requirements of each 
case. As the symptoms subside, the food 
should be gradually improved, white fish, 
fowl, and meat being allowed in succession, 
but in strict moderation; and due care must 
be exercised subsequently. If possible, all 
kinds of alcoholic stimulants should be inter- 
dicted, but it may not be judicious to cut 
them off entirely in some cases, either on 
account of the previous habits or present 
condition of the patient, and then it is best to 
give a definite quantity of brandy or whisky, 
well diluted, with the food. For those who 
cannot take spirits, a little good hock or 
sauterne answers well. 
As regards medicinal agents, colchicum 
has long held the most prominent place in 
the treatment of acute gout, and is commonly 
regarded as a specific. There can be no 
doubt as to the influence of this drug in 
relieving the symptoms and shortening the 
paroxysm of gout, although it is by no means 
settled how it acts. Its effects must be 
watched, however, for it does not agree in 
every case. It has been alleged that col- 
chicum renders the patient more liable to 
subsequent attacks of gout, but for this 
notion there does not seem to be any real 
foundation. The tincture or wine of col- 
chicum may be given in doses of ten to 
twenty or even twenty-five minims every 
four or six hours, and either of these pre- 
parations may be combined with the citrate 
or bicarbonate of potassium or with a salt 
of lithium. 
Salicylates, especially salicylate of sodium, 
have been much recommended in the treat- 
ment of acute gout, and Dr. Haig is strongly 
in favour of them, having found that they ma- 
terially increase the discharge of lithic acid. 
They certainly have proved useful in some 
cases in the writer's experience. Another 
class of drugs employed are antipyrine, anti- 
febrin, and allied agents. A remedy named 
piperazin has been introduced for the treat- 
ment of gout, which is said to be the most 
powerful solvent of uric acid known, but the 
writer has no experience of its practical use. 760 
GOUT 
It is necessary to keep the bowels acting 
freely by means of suitable aperients, and 
saline purgatives are of considerable value 
for this purpose. Other aperients, such as 
compound rhubarb pill, colocynth, podo- 
phyllin, calomel or blue pill, may be em- 
ployed in appropriate cases. Diluents may 
be given freely, in order to promote the 
action of the kidneys; and if the cutaneous 
functions appear to be defective, some mild 
diaphoretic may be administered, or it may 
even be desirable to employ the hot-air or 
vapour bath. Medicines may be needed for 
the relief of symptoms, especially pain and 
sleeplessness, for which Dover's powder or 
other preparations of opium, belladonna, 
chloral hydrate, sulphonal, or bromides may 
be indicated, but they must be used with 
discretion. In very severe cases hypodermic 
injection of morphine is of much service. 
Venesection ought never to be practised in 
the treatment of acute articular gout; for 
although immediate improvement may per- 
haps be thus produced, the ultimate results 
are highly unsatisfactory. Even the local 
removal of blood, by means of leeches applied 
near an affected joint, is dangerous, and had 
better be avoided, on account of the per- 
manent local mischief which such a measure 
is liable to induce. 
Local treatment.-The affected parts in 
acute gout should be kept entirely at rest, 
and placed in a comfortable position, sup- 
ported by pillows, and either horizontal or 
elevated, according to the feelings of the 
patient. In ordinary cases it is sufficient to 
wrap up the joints in flannel, or to surround 
them with cotton-wool completely covered 
with oil-silk or gutta-percha sheeting, accord- 
ing to Garrod's method, by which means a 
kind of local vapour-bath is kept up. If the 
pain is considerable, other local applications 
might be used, of which the most efficient 
are warm fomentations, to which tincture of 
opium or belladonna may be added, poppy 
fomentations, lead and opium lotion, localised 
steaming, belladonna liniment, tincture of 
aconite, oleate of morphine, or a solution 
containing morphine and atropine. Some 
practitioners prefer evaporating lotions con- 
taining alcohol, ether, or chloroform; others 
warm water compresses. A blister in the 
neighbourhood of a gouty joint may be of 
service, if the attack be asthenic, and also 
if effusion or much stiffness persist. During 
recovery, benefit may be derived from care- 
ful friction with some stimulating liniment, 
application of iodine, shampooing, gentle 
passive movements, douching with salt and 
water, or the application of a light bandage 
or elastic support, should there be a ten- 
dency to permanent thickening and stiffness, 
or to oedema and enlargement of the veins. 
The acute forms of irregular gout must be 
treated according to their nature, and here 
it must suffice to offer a few general remarks 
on the subject. If serious internal symptoms 
arise, which are distinctly of a gouty nature, 
and especially if they occur as retrocedent 
phenomena, it is important to try to excite 
inflammation in the joints, by means of local 
heat, friction, and sinapisms. Colchicum 
may be of service in the non-articular, as 
well as in the articular form of gout. In 
painful affections opium or other anodynes 
are called for; and frequently the adminis- 
tration of alcoholic and other stimulants 
is indicated, with antispasmodics, such as 
ammonia, ethers, camphor, musk, or bella- 
donna, especially when the stomach or heart 
is affected. In conditions attended with 
signs of much depression or collapse, external 
heat may be applied over the body, or 
sinapisms to the limbs and over the cardiac 
region. In the treatment of inflammatory 
diseases associated with gout much care is 
required, especially in resorting to depletory 
measures. The existence of the diathesis 
must always be borne in mind. 
3. Treatment of Chronic Gout.- 
When gout becomes an established chronic 
disease, the same general rules of treatment 
are to be observed as in the prevention or 
attempted cure of the complaint, but they 
often need modification in particular cases, 
according to the conditions present. Similar 
medicinal remedies are also indicated, lithium 
salts being particularly valuable, and they 
may even aid in removing gouty deposits; 
but others may be added to the list, which 
are suitable in different cases. Colchicum is 
often of much service, taken habitually or from 
time to time, in the form of one of the extracts 
at night, or a few minims of tincture or wine 
two or three times a day, combined with 
other medicines. Among the many thera- 
peutic agents recommended in the treatment 
of chronic gout under different circumstances 
may be mentioned benzoic acid or benzoate 
of ammonium, phosphate of ammonium or 
of sodium, iodide of potassium, bromide of 
potassium, carbonate of aluminium, lime- 
juice, resin of guaiacum, ammoniacum, and 
tonics, especially quinine, tincture or infusion 
of cinchona, or mild ferruginous preparations. 
Undoubtedly most of these are of use in 
appropriate cases of chronic gout, to serve 
their special purposes, but they must be used 
judiciously, especially iron. Symptoms con- 
nected with various organs frequently call 
for attention in this disease, and they must 
be treated by appropriate remedies. It may 
be remarked that, should diarrhoea set in in 
gouty cases, it must not be hastily arrested, 
as this may be a mode of relief to the sys- 
tem. With regard to the local conditions in 
chronic gout, it is affirmed that the prolonged 
use of some of the mineral waters previously 
mentioned, both internally and in the form 
of baths, such as those of Aix-la-Chapelle, 
Aix-les-Bains, and Baden-Baden, may suc- 
ceed in removing to some extent deposits of GOUT 
GRAVEL 
761 
urates, and in diminishing stiffness and 
thickening of joints. For these purposes 
local measures may also be of service in some 
instances, provided the morbid changes are 
not too far advanced, namely, occasional 
blistering or application of iodine; the pro- 
longed use of wet bandages; friction with 
liniments; shampooing and passive move- 
ments ; or systematic compression by means 
of some non-irritating plaster. Solutions of 
alkalis or alkaline carbonates, and especially 
of carbonate of lithium, have been kept ap- 
plied to gouty joints and other parts for a 
long time, under the belief that deposits of 
urates may be thus dissolved. In the writer's 
experience no such effect has ever been thus 
produced, although the constant application 
of warm moisture may be useful. Superficial 
uratic deposits should not be interfered with 
unless they become troublesome, when it 
may be desirable to puncture the skin, and 
let the contents out. The propriety of re- 
moving large masses by operation may come 
up for consideration, but this should only be 
attempted if there is every probability that 
they can be entirely removed without any 
serious difficulty, and if the patient is in a 
fit state for the operation. When abscesses 
or ulcers form, they come under the treat- 
ment of the surgeon; but it may be observed 
that simple dressings usually answer best in 
these cases, and they may sometimes be 
advantageously dressed with solution of car- 
bonate of potassium or lithium. It must 
not be attempted to heal them up too rapidly, 
as the discharge may be a relief to the 
system, and it may even be necessary to 
enlarge the opening of a gouty abscess. 
Under any treatment it is by no means an 
easy matter to induce lesions of this kind to 
heal in cases of chronic gout. 
The treatment of the various chronic 
organic diseases which are liable to arise in 
the course of gout must always be kept in 
mind, but the reader is referred to other 
appropriate articles for a consideration of 
this part of the subject. 
Frederick T. Roberts. 
GRAHAM'S TOWN, in Cape 
Colony.-See Africa, South. 
GRAND MAL (Fr.)-A term applied 
to epilepsy when it assumes the form of a 
severe convulsive attack. See Epilepsy. 
GRANULAR KIDNEY.-A morbid 
condition of the kidney, in which this organ 
is the seat of fibroid change, and as a result 
becomes contracted, hard, and granular. See 
Bright's Disease. 
GRANULAR LIVER.-A synonym 
for cirrhosis of the liver, in which the organ 
presents a granular appearance, on its sur- 
face and on section. See Liver, Cirrhosis of. 
GRANULATION (granulum, a little 
grain).-In medical pathology, granulation is 
synonymous with tubercle in its isolated 
form, the individual tubercles being called 
' grey ' or ' yellow ' granulations, according 
to their appearance (see Tubercle). In 
surgical pathology, the term ' granulations ' is 
applied to small vascular prominences, con- 
sisting of embryonic tissue, growing on the 
surface of wounds or ulcers, and by which 
the healing process is carried on-whence 
the expression ' healing by granulation.' 
When granulations assume the appearance 
of an exuberant growth they constitute what 
is called ' proud flesh.' See Cicatrisation ; 
and Ulcer and Ulceration. 
GRAVEL.- Definition.- The deposit 
in and escape from the urinary passages of 
gritty particles with the urine. 
Aetiology.-The same causes which pro- 
duce dyspepsia are frequently productive of 
lithic-acid gravel, such as indolent habits, 
excess of food and drink-especially of nitro- 
genous and saccharine articles, and the too 
free indulgence in the use of fermented 
liquors. Endemic causes connected with 
climate and the nature of the drinking-water, 
hereditary predisposition, and many slight 
or serious organic diseases, may explain the 
appearance of gravel in those, and especially 
in women, who commit no dietetic excess, or 
who are total abstainers. See Oxalic-Acid 
Diathesis; Phosphatic Diathesis; and Uric- 
Acid Diathesis. 
Varieties.-Gravel may be composed of 
(1) lithic acid and its compounds; (2) oxalate 
of lime; (3) phosphate of lime; or (4) the 
triple phosphate. By far the most common 
form of gravel, and that which alone need now 
be considered, is lithic acid. This, owing 
chiefly to its great insolubility, is frequently 
deposited in the kidney and bladder, and is 
seen in the newly passed urine in the form 
of the well-known reddish-brown crystals, 
often described as resembling cayenne-pepper 
grains. The supernatant urine is generally 
clear, rather dark in colour, and of a dis- 
tinctly acid reaction. 
Symptoms.-The passage of uric-acid crys- 
tals or gravel frequently causes no subjective 
symptoms, and is consistent with perfect 
health. Sometimes, however, it gives rise 
to, or is accompanied by, both general and 
local disturbance of function. The general 
symptoms are those of dyspepsia-namely, 
flatulence and heartburn after meals, eructa- 
tions, headache, muscular cramp, depression 
of spirits, and a sense of malaise. Locally, 
there is dull aching in the lumbar region, 
not increased by movement; frequent mic- 
turition ; a sense of heat and irritation at the 
neck of the bladder and along the urethra, 
especially during and after voiding water; 
and sometimes the appearance of a faint cloud 
of mucus or a slight tinge of blood in the urine. 762 
GRAVEL 
HEMACYTOMETER 
Treatment.-From what has been said, it 
follows that the most important points in the 
treatment of gravel are strict limitation as to 
the quantity of food; the avoidance of highly 
seasoned, very rich, or sweet dishes; the pre- 
ference for vegetable rather than for animal 
food ; abundant exercise in country air; and 
abstention from or the very sparing use of 
alcoholic liquors. Medicinally there may be 
given diuretics to increase the quantity of the 
urine, and facilitate the escape of gravel; 
pure water, alkalis, and alkaline waters freely 
diluted, to act as solvents of uric acid; and 
saline aperients and saline waters, to promote 
digestion, and assist in ensuring the free 
action of the liver and alimentary canal. 
W. Cadge. 
GRAVES'S DISEASE.-A synonym 
for exophthalmic goitre, to which the late 
Dr. Graves, of Dublin, called special attention. 
See Exophthalmic Goitre. 
GREEN-SICKNESS.-A popular syno- 
nym for chlorosis, applied on account of the 
greenish colour of the skin sometimes present 
in that disease. See Chlorosis. 
GRIPPE (Fr.)-A French synonym for 
influenza. See Influenza. 
GROWTH, Disorders of.-See Atro- 
phy ; Hypertrophy ; and Malformations. 
GRUTUM.-Synon. : Milium, a millet 
seed. 
This name is applied to small globular 
pearly-white bodies seen under the cuticle of 
the face, especially near the eyelids. They 
are about the size of a pin's head, and con- 
sist of distended sebaceous glands, the duct 
of which has been occluded. They should 
be distinguished from comedones, which are 
formed in over-distended follicles. When 
pricked with the point of a lancet, and pressed 
with a large watch-key, a small, perfectly 
globular cast of the sebaceous gland is 
squeezed out, which is quite unlike the long 
cylinder of the comedo. See Comedones. 
Robert Liveing. 
GUINEA-WORM.-See Entozoa. 
GUMBOIL.-See Mouth, Diseases of. 
GUMMA (Lat., gum).-A growth occur- 
ring in syphilis, so named on account of its 
supposed superficial resemblance to gum. 
See Syphilis. 
GUMS, Diseases of.-See Mouth, Dis- 
eases of. 
GURGLING.-A physical sign heard 
on auscultation of the chest or abdomen in 
certain conditions, due to the movement of 
gas and fluid within a cavity, whether nor- 
mal or abnormal. A gurgling sensation may 
also be felt at times in the intestines, as over 
the caecum in typhoid fever. See Physical 
Examination. 
GUTTA ROSEA (gutta, a drop; 
rosea, rosy).-A synonym for acne rosacea. 
See Acne rosacea. 
GYMNASTICS (yvpv6s, naked).-See 
Exercise. 
GYNAECOLOGY (yv^, a woman ; and 
Xoyor, a word).-This term in its literal sense 
means a doctrine or discourse concerning 
women. In modern medical language, it com- 
prehends the study of the diseases peculiar to 
women. See Women, Diseases of. 
HABIT OF BODY.-This expression 
signifies the sum of the physical qualities of 
an individual, and is sometimes used as syno- 
nymous with constitution. We speak of a 
full habit, a spare habit, and an apoplectic 
habit. 
HABITS.-See Disease, Causes of; and 
Personal Health. 
HEMACYTOMETER (a^a, blood; 
kvtos, a cell; and perpov, a measure).-An 
instrument by the aid of which the number 
of corpuscles in a given volume of blood can 
be ascertained. 
Description.-All methods employed for 
this object consist in making a definite dilu- 
tion of a certain quantity of blood, and 
counting the number of blood-corpuscles in 
a certain volume of this dilution. Vierordt, 
who originated the method, drew uniform 
lines of diluted blood upon a slide, and, after 
it was dry, counted the corpuscles in a cer- 
tain length of line. Cramer substituted for 
these lines what may be termed a capillary 
cell; and Potain and Malassez employed a 
capillary tube, and a microscope provided 
with an eyepiece ruled in squares. Hayem 
substituted for the tube a cell, the depth of 
which gave one dimension of the volume of 
dilution, while the lines upon the eyepiece 
furnished the others. The writer's instru- 
ment is an adaptation of Hayem's, with cer- HEMACYTOMETER 
HEMATEMESIS 
763 
tain modifications : the diluting apparatus 
is similar, but of different capacity, and the 
lateral dimensions of the volume of dilution 
examined are obtained, not by a microscope- 
eyepiece, but by lines engraved upon the glass 
slide at the bottom of the cell, on which the 
corpuscles quickly fall. The instrument can 
thus be used with any microscope, an im- 
portant convenience in practical use. The 
alteration in the capacity of the diluting 
measures facilitates the counting, and pro- 
vides a much simpler mode of statement of 
the result. The apparatus, which is made by 
Hawksley, consists of (1) a pipette, graduated 
to 995 cubic millimeters, for measuring the 
diluting solution ; (2) a capillary tube for 
measuring the blood, containing five cubic 
mm.; (3) a small glass jar and stirrer for 
making the dilution ; and (4) the cell for 
counting, '2 mm. deep, and ruled at the 
bottom in squares, each T mm. in length 
and breadth. The slide bearing the cell is 
fixed on a small metal plate, to which two 
springs are attached ; these keep the cover- 
glass in position, and secure uniformity in its 
pressure on the cell, and therefore in the 
depth of the contained liquid. 
Various solutions have been employed for 
making the dilution. That which the writer 
has found to answer best, as differentiating 
most clearly the red and white corpuscles, 
consists of sulphate of sodium, 104 grains ; 
acetic acid, 1 drachm; distilled water, 6 
ounces. 
In using the haemacytometer, a drop of 
the dilution is placed in the centre of the 
cell; the cover-glass and springs are applied; 
and in a few minutes the corpuscles have 
sunk to the bottom of the cell, and are seen 
lying within the squares. The dilution of 
5 c.mm. of blood in 995 c.mm. of solution, is 
1 in 200; each square contains the corpuscles 
from a volume of dilution '2 mm. in one, and 
T mm. in each of the other dimensions- 
that is, 2 cubic T mm., or the '002 part of a 
cubic mm. But the dilution being 1 in 200 
this volume of dilution contains just '00001 
cm. of blood. The number of corpuscles in 
a square, multiplied by 100,000, is thus the 
number in a cubic millimeter of blood-the 
common mode of statement. In order to 
limit error, the number of corpuscles in ten 
squares should be counted, and this number 
multiplied by 10,000 is the number per cubic 
millimeter. The average number in health 
is about 5,000,000. Blood of normal rich- 
ness thus contains about 50 corpuscles per 
haemacytometer square. Therefore, the num- 
ber in two squares of the instrument will 
always represent the proportion of the cor- 
puscular richness compared with that of nor- 
mal blood (= 100)-that is, the percentage 
proportion to normal. It is, therefore, con- 
venient to take the volume of blood repre- 
sented by the two squares ('00002 cubic milli- 
meter) as the standard volume, or ' haemic 
unit.' For instance, it is found that the blood 
diluted presents in ten squares 375 corpuscles 
or 75 in two squares (' haemic unit ')-that is, 
75 per cent, compared with the normal. To 
learn the number per cubic millimeter we have 
only to multiply 375 by 10,000 = 3,750,000. 
In counting the white corpuscles, if they 
are not in considerable excess, it is most con- 
venient first to ascertain the number of red 
corpuscles per square, and note how many 
squares are contained in a field of the micro- 
scope. If, then, the focus is raised, so that 
the corpuscles become indistinct, the white 
ones, from their higher refracting power, will 
appear like bright points, and the number in 
a series of fields can easily be counted. For 
example, the number of red corpuscles per 
square has been found to be 40, and the field 
contains 15 squares, that is, 600 corpuscles per 
field. Ten fields contain 15 white corpuscles; 
the proportion of white to red will, therefore, 
i i . 600 x 10 i 
be 1 to --- = 1 to 400. 
15 
With this apparatus we may readily ascer- 
tain, within a small limit of unavoidable 
error, the corpuscular richness of the blood, 
an important element in many morbid states, 
such as anaemia ; and we can thus ascertain 
the indications for, and observe the effect 
of, therapeutic agents. It is, however, very 
desirable in these cases to ascertain also the 
richness of the corpuscles in haemoglobin (see 
H.emoglobinometer). Both elements being 
ascertained and stated in the same terms 
(percentage), the quality of each corpuscle 
may be expressed in the form of a fraction. 
If the blood contains 60 per cent, of cor- 
puscles and 40 of haemoglobin, the average 
' value ' of each corpuscle = or j the nor- 
mal. 
The haemacytometer may also be employed 
for ascertaining the globular richness of milk 
or other liquids. 
W. R. Gowers. 
H2EMATEMESIS (aqaa, blood; and 
I vomit).-Synon. : Fr. Hcmatemese ; 
Ger. Blutbrechen. 
Definition.-Vomiting of blood, depen- 
dent on a variety of morbid conditions. 
^Etiology and Pathology.-Haemorrhage 
into the stomach may arise : 1. From the 
laying open of an artery. 2. From venous 
or capillary congestion of the mucous mem- 
brane. 3. From causes affecting the blood 
itself, so that it tends to transude through 
the vessels under pressure of the circulation. 
1. The most frequent cause of haemate- 
mesis is an ulcer of the stomach. It occurs, 
according to the late Dr. Brinton, in about 
one-third of all the cases of gastric ulcer that 
come under treatment. The bleeding usually 
takes place shortly after a meal, and the 
quantity rejected varies greatly. In some 
cases, it is so small that it may require care- 
ful examination to discover it; whilst in 764 
ILEMATEMESIS 
others enormous quantities are vomited, and 
often also passed through the bowels. The 
splenic artery is the source whence the bleed- 
ing most frequently proceeds, but it may arise 
from the coronary, the superior pyloric, or, 
more rarely, from the blood-vessels of some 
of the neighbouring organs, such as the pan- 
creas, liver, or spleen, to which the stomach 
has become attached, and which may form 
the base of the ulcer. Although it is most 
apt to occur in chronic cases, instances have 
been recorded in which a large vessel had 
been laid open by an ulcer so small as to 
require careful search for its detection. It 
must be borne in mind that extensive bleed- 
ings may take place without any vomiting, 
and the source of the fatal illness be over- 
looked. Such cases are not of infrequent 
occurrence, and warn the practitioner that 
he should be on the alert whenever signs of 
haemorrhage present themselves, and that he 
should not rely too much on the absence of 
pain and vomiting. In cancer of the stomach 
profuse haemorrhage is less common than in 
simple ulcer ; the larger vessels being prob- 
ably compressed by the new-growth, which 
ordinarily commences in the submucous 
tissue immediately above them. But a con- 
stant oozing of blood is, on the contrary, 
more common than in simple ulceration. 
This blood, acted on by the gastric juice, 
constitutes the ' coffee-ground ' vomiting of 
the older authors. Its occurrence used to 
be looked upon as pathognomonic of malig- 
nant disease, but it is now known that its 
presence only shows that the bleeding has 
taken place slowly and in small quantities 
at a time. Occasionally profuse haemorrhage 
takes place from the rupture of an aneurysm 
into the stomach; and in a case which came 
under the writer's notice at the London 
Hospital, fatal vomiting of blood resulted 
from the perforation of the aorta by a fish- 
bone that had become impacted in the oeso- 
phagus. 
2. Congestion of the portal system is a 
very frequent cause of haematemesis. The 
most marked and fatal cases of this kind 
occur along with plugging of the vena portae 
or its large branches with blood-clots or can- 
cerous matter. Such cases are very rare, 
and vomiting of blood, from venous conges- 
tion, ordinarily results from cirrhosis, chronic 
congestion, and other diseases of the liver, in 
which the portal circulation is obstructed, 
and in which relief is obtained by com- 
munication with varicose oesophageal veins.1 
More rarely the like occurrence is observed 
in persons suffering from diseased heart, 
especially where there is narrowing of the 
mitral orifice. In such cases, there is gene- 
rally a co-existence of chronic catarrhal 
gastritis, and in all probability the bleeding 
takes place from the heemorrhagic erosions 
so common in that condition. In one form 
of this disease enormous quantities of mucus 
are discharged. Sometimes there is con- 
siderable bleeding in these cases, but they 
are distinguishable from ulcer by the absence 
of pain; by the vomiting being only oc- 
casional ; and also by the fact that the blood- 
stained vomit generally follows a profuse 
evacuation of colourless mucus, and is always 
of a dark colour. In females thus affected 
the catamenial discharge is generally pro- 
fuse ; and the attacks of vomiting do not 
neces arily coincide with the menstrual 
periods. It has always been held that 
hiematemesis may replace the menstrual 
discharge. Without denying this, the writer 
has never met with a well-marked case oi 
the kind. Haematemesis due to acute con- 
gestion is also a constant result of irritant 
poisoning. 
3. Hiematemesis also arises from causes 
affecting the blood, and predisposing it to 
ooze through the walls of the veins or capil- 
laries. It occurs in this way in purpura, 
yellow fever, and in some cases of typhus. 
In jaundice, where bleeding from the gums 
and other mucous membranes is so often 
observed, life may be suddenly destroyed by 
haematemesis. Occasionally a haemorrhagic 
tendency manifests itself suddenly, without 
apparent cause, as in a case observed by the 
writer, in which a woman, about fifty years 
of age, was affected with severe bleeding 
from the nose, followed by excessive men- 
strual discharge, on the cessation of which 
profuse haematemesis took place, from which 
she sank. She had no jaundice nor other 
apparent cause for her illness, and after 
death the most careful scrutiny failed to 
detect disease in any organ. To this class 
of causes we should probably refer the haema- 
temesis occurring in acute atrophy of the 
liver, and in pyaemia, as, in all probability, 
the oozing of blood through the vessels arises 
from changes effected in its chemical or 
physical composition. 
Symptoms.-Generally the patient in hae- 
matemesis is suddenly attacked with faint- 
ness, accompanied by a feeling of weight at 
the pit of the stomach ; the countenance is 
pale, the pulse feeble and compressible, and 
in some cases actual syncope occurs. This 
state terminates in vomiting, and a greater 
or less quantity of blood is rejected from the 
stomach. When a large blood-vessel has 
been laid open, and the bleeding has taken 
place rapidly, the blood may be florid; but 
generally the haemorrhage goes on so slowly 
that time is given for the action of the gastric 
juice upon it, and consequently it is of a 
dark colour. It is not often that the stomach 
is completely emptied, or perhaps the bleed- 
ing persists in small quantities after the 
vomiting has ceased, so that the stools are 
generally of a dark or pitchy character, from 
the admixture of blood that has passed into 
1 See an instructive communication by Dr. Stacey 
Wilson, Brit. Med. Journ., vol. ii. 1890.-Editor. HE MATE ME SIS 
HEMATOCELE 
765 
the intestines. The haemorrhage may cease 
soon after the stomach has been emptied, or 
the vomiting of blood may recur from time 
to time, or-and this is very apt to occur in 
gastric ulcer-months or years may elapse 
before it again takes place. 
Diagnosis.-In some cases, when the 
blood has been slowly effused into the sto- 
mach, there may be difficulty in determining 
whether the dark colour arises from bile or 
blood. The microscope or spectroscope will 
be enough to settle this point; or the liquid 
may be boiled with alcohol, and tested for 
the biliary salts. It is not always easy to 
ascertain whether the blood has come from 
the lungs or from the stomach, as the patient 
is sometimes so much alarmed that he can- 
not say whether it was brought up by cough- 
ing or vomiting. As a general rule, the 
blood from the lungs is florid, mixed with 
mucus, alkaline, and frothy; that from the 
stomach of darker colour, acid, intermixed 
with particles of food, and in masses. Again, 
haemoptysis is generally preceded by symp- 
toms referable to heart or lungs, such as 
cough, expectoration, and dyspnoea; haema- 
temesis by the symptoms indicative of gastric 
or hepatic disease, such as those described 
above. 
Prognosis.-As a general rule this is 
favourable in haematemesis, more especially 
in first attacks. Dr. Brinton calculated that 
death resulted from this cause in only 3 to 5 
per cent, of the cases of gastric ulcer; and 
it is still less frequently fatal where it pro- 
ceeds from hepatic congestion or cirrhosis. 
Still, the possibility of the bleeding arising 
from an obstruction of the portal vein, from 
the opening of a large artery, or from the 
bursting of an aneurysm, should be kept in 
view, and the patient carefully watched. 
Treatment.-Where a large quantity of 
blood has been ejected from the stomach, 
the treatment must be prompt and decided. 
The patient should be maintained in a re- 
cumbent posture, and kept perfectly quiet. 
All food must be forbidden, and pieces of 
ice placed in the mouth to suck. If faint- 
ness be present, it is better not to give 
brandy, which almost always brings on 
vomiting, but to apply ammonia to the nos- 
trils ; or, if necessary, an enema containing 
brandy may be given. 
The best styptics are gallic acid, alum, and 
acetate of lead. Ihe gallic acid may be 
given in 10-grain doses, along with 10 or 15 
minims of diluted sulphuric acid, and should 
be repeated frequently. Alum may be pre- 
scribed in infusion of roses ; and the acetate 
of lead in 2-grain doses in the shape of a 
pill, or combined with acetic acid. Oil of 
turpentine is also used. Where the bleeding 
is slight, and there is good reason to believe 
it arises from portal congestion, the best 
treatment is to give a small dose of calomel, 
followed by sulphate of magnesium and 
diluted sulphuric acid in infusion of roses 
every three or four hours, until purging is 
produced. 
For some days after severe haemat emesis 
strict quiet should be maintained. In the 
case of ulcer of the stomach, opium may be 
used. The diet should be most carefully regu- 
lated ; if necessary, nutritive enemata should 
be substituted for food by the mouth, and 
all purgatives avoided. When portal con- 
gestion exists, a free action on the intes- 
tinal canal should be commenced after the 
cessation of the haemorrhage, so as to dim- 
inish the amount of blood in the venous 
system of the alimentary organs. 
S. Fenwick. 
HE MAT HO RAX. - See ILemato- 
TH0RAX. 
HEMATIDROSIS (aqta, blood ; and 
tSpwy, sweat).-Bloody sweat. See Sudori- 
parous Glands, Disorders of. 
HEMATIN.-See Hemoglobin. 
HEMATINURIA.-See Hemoglo- 
binuria. 
HEMATOBIUM (aqta, the blood; and 
Stos, life).-A synonym for haematozoon. 
See Hematozoa. 
HEMATOCELE (alpa,blood; and^Ar?, 
a tumour).-Synon. : Fr. Hematocele; Ger. 
Blutgeschwulst. 
Definition.-A swelling occasioned by 
effusion of blood in the sac of the tunica 
vaginalis, or in a cyst connected with the 
testicle. 
Etiology and Symptoms.-The extrava- 
sation of blood in haematocele may take place 
in a healthy state of the parts, or it may suc- 
ceed or be combined with hydrocele. In both 
cases it may be occasioned by a blow, or by 
violent efforts made in straining, especially 
in old persons, or when the blood-vessels are 
diseased. It may happen also from the 
accidental wound of a vessel in tapping a 
hydrocele; or, without any such wound, a 
haematocele may supervene if the walls of 
the sac are very vascular, and a vessel, lack- 
ing the pressure of the hydrocele fluid, gives 
way. The blood effused, if small in quantity, 
mixes with the fluid of the hydrocele, and 
occasions slight enlargement without dis- 
turbance. If it be large in quantity, coagula 
are formed; inflammation is excited in the 
tunica vaginalis; and plastic exudation oc- 
curs on its inner surface, sometimes forming 
layers, and rendering the sac extremely dense 
and firm. 
The testicle preserves the same relation to 
the remainder of the tumour as in hydrocele, 
being situated at its posterior part. Its po- 
sition, however, is liable to similar alterations 766 
HEMATOCELE 
HEMATOMA AURIS 
as occur in hydrocele, which are very difficult 
of detection, owing to the great thickening of 
the parts. 
Diagnosis.-A haematocele may be distin- 
guished from a hydrocele by the absence of 
transparency; the obscure character of the 
fluctuation; the heavy feel of the tumour 
when balanced in the hand ; and the sudden 
and accidental mode of its occurrence. In 
old chronic cases, in which the tunica vagi- 
nalis and its envelopes have become much 
thickened and indurated, the tumour pos- 
sesses so firm a character, and feels so 
heavy and solid, that it is very liable to be 
mistaken for a chronic enlargement of the 
testicle ; and the diagnosis, at all times diffi- 
cult, in some instances cannot be satisfac- 
torily made out by the most experienced 
hands. The records of surgery furnish many 
cases in which castration has been performed 
owing to a mistaken diagnosis. When doubt 
exists, it should be removed by the introduc- 
tion of a trocar or by an incision before 
any serious operation, such as castration, is 
undertaken. 
Treatment.-When haematocele succeeds 
a hydrocele, the blood, if small in quantity, 
mixes with the fluid of the hydrocele without 
producing irritation. The tinged fluid may 
be removed by tapping, and the operation 
can be repeated afterwards at intervals until 
the fluid is free from discoloration. Even 
when inflammation arises, if the sac be tapped 
and tension removed, and the patient be kept 
at rest, with ice applied to the part, the in- 
flammation may subside. When, however, 
the blood effused is large in quantity, and 
when the inflammation is acute and threatens 
suppuration, the tumour should be punctured 
at its upper part, a director introduced, and 
the sac freely laid open by incision. This 
must be done with care, so as to avoid 
wounding the testicle. A chronic haemato- 
cele with a very thickened sac must be cut 
into in the same way; and lateral portions 
of the sac may be excised, so as to lessen the 
wound for healing. If from old age, or other 
causes, the patient's general condition be 
unfavourable for excision, castration may be 
requisite. The practitioner must bear in 
mind that the testicle is sometimes situated 
in front, as in cases of inversion, and is then 
very liable to injury in the operation of in- 
cision, and even in tapping. 
Encysted Haematocele.-Encystedhae- 
matocele implies an effusion of blood in the 
sac of an encysted hydrocele. The treatment 
is the same as that required for ordinary 
haematocele. 
Haematocele of the Cord.-Blood may 
also be effused in the areolar tissue of the 
spermatic cord, constituting diffused haema- 
tocele of the cord ; or in a cyst in the cord, 
constituting encysted haematocele of the cord. 
Such cases are very rare. 
T. B. Curling. J. McCarthy. 
HJEMATOIDIN.-See Haemoglobin. 
HEMATOMA (aqxardo), I fill with 
blood).-A peculiar form of bloody tumour, 
or a collection of extravasated blood that has 
undergone certain changes. It is observed 
more especially in connexion with the ear, 
the vagina, the scalp, and the meninges. 
See CephalhaEmatoma ; Haematoma Auris ; 
Meninges, Cerebral, Haematoma of; Fun- 
gus HaEmatodes ; and Tumours. 
HEMATOMA AURIS (aiaoroG), I fill 
with blood ; auris, of the ear).-Synon. : The 
Insane Ear; Fr. Othematome; Hematome 
de VOreille des Alienes; Ger. Othamatoma; 
Ohrblutgeschwulst von Geisteskranken. 
Definition. -An affection of the auricle, 
which occurs almost, if not quite exclusively, 
in the insane, and consists in the effusion of 
blood or bloody serum between the cartilage 
and its perichondrium, to such an extent as 
to form a distinct tumour. 
^Etiology.-In most of the few cases of 
haematoma auris which have been published 
to show that this disease may occur in the 
sane, the description given of the patients 
rather points to their insanity than otherwise. 
It is most common in cases of general para- 
lysis and mania (acute and chronic), but also 
occurs in melancholia, dementia, and idiocy. 
It is about four times as frequent in men as 
in women; and more often affects the left 
ear than the right. Sometimes both ears are 
affected, but seldom at the same time. There 
would seem to be, in many or all of the 
insane, a morbid condition of the vessels or 
other tissues of the auricle, which predisposes 
to the occurrence of haematoma. If this 
condition be present to a sufficient degree, 
the disease may arise spontaneously; in 
other cases a very slight injury may be suf- 
ficient to cause it; whilst in others very con- 
siderable violence is necessary for its pro- 
duction. 
Symptoms and Course.-The disease first 
makes itself evident by the appearance of a 
swelling of about the size of a horse-bean ; 
this is almost always upon the anterior sur- 
face of the pinna, and usually in the neigh- 
bourhood of the fossa of the antihelix. The 
skin over the tumour is generally of a reddish 
or bluish-red colour, but may be unaltered at 
first; the temperature of the ear is sensibly 
raised; the swelling is very painful and 
tender; there is no extravasation of blood 
from the cutaneous vessels ; and the tumour 
is not oedematous. At this stage, the effusion 
which has taken place between the cartilage 
and its perichondrium consists of dark-red 
fluid blood. In rare cases the swelling does 
not increase further; the inflammatory symp- 
toms subside after about a week; absorption 
gradually takes place; and only a slight 
thickening remains. More usually the 
tumour increases and may attain the size of HAEMATOMA AURIS 
H^MATOZOA 
767 
a hen's egg; it becomes tense, elastic, dis- 
tinctly fluctuating, and hot; and is often of 
a bright red colour. Its prominent anterior 
wall, consisting of skin, cellular tissue, and 
perichondrium, is felt to be thinner and less 
resisting than the posterior, which contains 
the ear-cartilage. In certain cases, however, 
owing to the brittle cartilage having split up, 
and portions of it having adhered to either 
wall, both walls present irregularly alter- 
nating characters. The time which a haema- 
toma takes to attain its largest size varies 
from a week to a month; it then generally 
involves the whole of the concha, occluding 
the external auditory meatus; the folds of 
the auricle are lost, with the exception of 
the helix (which appears as a band running 
round the tumour) and the dependent lobule. 
The weight of the tumour causes the whole 
ear to fall somewhat forwards and outwards. 
Sometimes, especially in the presence of con- 
stant or repeated irritation, the inflammatory 
stage may last many weeks, and the deformity 
which always results from the affection is 
thereby greatly increased. Unless subjected 
to violence, it very rarely happens that the 
tumour opens spontaneously, although its 
tense and inflamed appearance often seems 
to indicate that such an occurrence is immi- 
nent. If rupture does take place, suppu- 
ration ensues; portions of cartilage come 
away; the cavity closes very slowly; and 
great deformity results. The most common 
course is for the inflammatory symptoms 
gradually to subside. The anterior wall be- 
comes firmer, owing to a new deposit of 
cartilage upon its inner surface; the sense 
of fluctuation is gradually lost; and the 
tumour slowly diminishes in size, often 
yielding a somewhat doughy sensation to 
the touch. Occasionally, at this stage, some 
gaseous contents have been observed in the 
cavity. The colour of the skin over the 
tumour becomes gradually more dusky; it 
then passes into yellow and, later on, into 
an unnatural pallor. As the fluid contents 
become absorbed, the tumour becomes harder 
and smaller; folds again appear in the auricle, 
but do not correspond to the original ones; 
and the pinna remains permanently thick- 
ened, puckered, and often nodular. 
Anatomical Characters.-Many of these 
have been given above in explanation of 
symptoms, and do not require to be repeated. 
A shrivelled auricle, which has previously 
been affected by haematoma, presents, on 
section, two distinct layers of cartilage; 
these are of varying thickness, and sepa- 
rated from each other by vascular fibrous 
tissue, which often contains within it other 
small isolated plates of cartilage, and some- 
times also small portions of bone. The 
fibrous tissue is the organised product of the 
original effusion. The two layers of cartilage 
have been developed upon the inner surfaces 
of the perichondrium. The loose portions of 
cartilage and bone which are occasionally 
seen, are developed from the fibrous tissue. 
It used to be supposed that the bone (which 
is soft, vascular, and contains well-developed 
Haversian systems) resulted from ossification 
of the ear-cartilage; but the writer has shown 
elsewhere (Brit. Med. Journ., Oct. 1873) that 
this is not the case. 
Prognosis.-The local affection is in no 
way dangerous, but it always leaves behind 
it a permanent characteristic deformity of 
the auricle. The sense of hearing is only 
affected by the occlusion of the auditory 
meatus; but this condition very rarely per- 
sists after the acute stage. The occurrence 
of haematoma auris influences the prognosis 
of the mental disease unfavourably, but does 
not necessarily indicate the approach of a 
fatal termination to the case. 
Treatment.-Protection of the part from 
injury is usually all that is necessary. Cool- 
ing applications are useful when the inflam- 
mation is excessive. The tumour should 
not be opened; nor should a portion of the 
anterior wall be removed, as has been recom- 
mended; these procedures only lead to suppu- 
ration. It is useless to empty the cavity by 
aspiration, as it fills again with great rapidity. 
The treatment by pressure is very painful, 
and yields no good result. 
Chas. S. W. Cobbold. 
HJEMATO - PERICARDIUM (alpa, 
blood; jrepi, about; and KapSia, the heart).- 
An extravasation of blood into the sac of the 
pericardium. See Pericardium, Diseases of. 
HJEMATO-THORAX(<up.n,blood; and 
Bmpa^, the chest).-An extravasation of blood 
into the pleural cavity. See Pleura, Diseases 
of. 
HjEMATOZOA (atpa, blood; and {wov, 
an animal).-This term is of general appli- 
cation to all kinds of animal parasites dwell- 
ing in the blood and blood-vessels; but its 
employment is often restricted to certain of 
the nematoid entozoa which display this 
habit in a more marked degree than the 
other parasites are wont to do. All classes 
of helminths are liable, at some time or 
other in the course of their lifetime, to take 
up their residence in the blood, but in the 
case of the Tcenice, or rather of their pro- 
scolices, this period is of very short duration. 
One or two species only of fluke-worms or 
trematodes play a similar role in man, the 
most important being the Bilharzia, which 
gives rise to an endemic hsematuria at the 
Cape, and elsewhere in Africa (see Bilhar- 
zia). Our knowledge of the nematoid hae- 
matozoa dates at least as far back as the 
time of Ruysch (1665), who was acquainted 
with the strongyles which produce aneurysm 
in the horse and other solipeds; whilst more 
than half a century later the subject received 
additions from the writings of Schulze (1725) 768 
HEMATOZOA 
HEMOGLOBIN 
and Chabert (1782); and subsequently from 
the memoir by Rayer (1843). About the 
latter period also the observations by Grube 
and Delafond ' on a verminiferous condition 
of the blood of dogs, caused by a great 
number of haematozoa of the genus Filaria,' 
excited much attention; but until quite re- 
cently it was not so much as suspected that 
similar microscopic filariae infested the human 
body. In 1872 the late Dr. Lewis announced 
the important discovery of the existence of ne- 
matoid worms in the living human subject 
also. See Chyluria; and Filaria Sanguinis 
Hominis. T. S. Cobbold. 
HEMATURIA (alpa, blood; and ovpov, 
urine).-Synon.: Fr. Hematurie; Ger. Blut- 
harnen. 
Description.-Haematuria is a symptom 
of many different morbid conditions of the 
system, and of the urinary tract. The 
quantity of blood discharged in the urine 
varies greatly, and the appearance of the 
urine corresponds. Sometimes it is dark, 
loaded with clots; sometimes it is merely 
smoky, or of a faintly pink hue. It is always 
albuminous, and corpuscles (often altered by 
the action of the urine) may be discovered by 
the microscope, sometimes becoming swollen, 
sometimes shrunken. The following are the 
best tests for detecting the presence of blood 
in the urine : (1) Guaiacum. When equal 
parts of simple tincture of guaiacum and oil 
of turpentine are shaken together to make an 
emulsion, and the urine is cautiously added, 
an intense blue colour is produced if blood 
be present. (2) Spectrum analysis. Very 
minute quantities of blood in the urine show 
absorption-lines between Frauenhofer's lines 
D and E in the yellow and green of the spec- 
trum. See Spectroscope in Medicine. 
The blood in haematuria may be derived 
from the urethra. If so, it precedes the 
stream of urine, sometimes forms a long 
thin clot, and may escape in the intervals of 
micturition. Sometimes it is derived from 
the prostate gland or the bladder. When it 
has lain in the bladder and been poured out 
in considerable quantity, it is often in clots; 
and when the urine is voided, the first part 
is frequently clear, the last loaded with blood. 
Blood may also be derived from the ureter 
or the pelvis of the kidney. Sometimes clots 
in the form of moulds of these structures 
may be recognised. At other times the blood 
is derived from the substance of the kidney, 
and then is intimately mixed up with the 
urine, which frequently exhibits blood casts 
of the tubes. 
AEtiology and Pathology. - Urethral 
haemorrhage is due to local inflammation or 
rupture of vessels or to calculus. Prostatic 
haemorrhage may be due to tumours, malig- 
nant or otherwise, to inflammation, or to 
scrofulous affection of that organ. Vesical 
haemorrhage results from malignant disease, 
from simple villous growth, inflammation, 
ulceration, tubercular disease, or the irrita- 
tion of a calculus. Haemorrhage from the 
ureters or pelvis of the kidney may be due 
to the presence of calculi, or to other causes. 
Haemorrhage from the kidney may be due 
to malignant disease, tubercle, suppurative 
nephritis, or to the irritation of crystals or 
amorphous concretions within the urinifer- 
ous tubules. Haemorrhage occurs also in all 
the forms of Bright's disease, especially in 
the early stage of the inflammatory form, 
and the advanced stage of the cirrhotic. It 
results from over-doses of turpentine, chlorate 
of potassium, and cantharides, and from rup- 
ture of the kidney. Sometimes it is a mani- 
festation of purpura haemorrhagica, more 
rarely of scorbutus; occasionally it occurs 
in the course of, or as a sequel to, eruptive 
or continued fevers. It is also occasionally 
vicarious. Renal haemorrhage occurs in 
Egypt, Mauritius, and other localities, in 
consequence of the existence of a minute 
parasite, the Bilharzia haematobia. See En- 
tozoa ; Chyluria. 
Treatment.-The treatment of haematuria 
must vary according to the lesion to which 
the haemorrhage is due. But where the 
symptom is so urgent as to demand treat- 
ment for itself, the most important points to 
be attended to are rest, free relief of the 
bowels, and the application of ice-bags over 
the source of the haemorrhage ; along with 
the internal administration of astringents, es- 
pecially gallic acid, ergot of rye, perchloride 
or pernitrate of iron, turpentine, or acetate 
of lead, with or without opiums If these do 
not succeed, the subcutaneous injection of 
ergotine is often efficacious. Surgical inter- 
ference may be required for relief of symp- 
toms due to coagula. 
T. Grainger Stewart. 
II2EMIC ASTHMA.-A form of asth- 
ma, dependent upon an abnormal condition 
of the blood. See Asthma. 
H2EMIC MURMUR.-A murmur con 
nected with an abnormal condition of the 
blood, as in anaemia. See Anemia; and 
Physical Examination. 
HJEMUNT.-See Hemoglobin. 
HAEMOGLOBIN (aiua, blood ; and glo- 
bus, a ball).-Synon. : Haematoglobulin.- 
This substance, the most important pigment 
in the body, occurs in the red blood-corpuscles, 
of which, when dried, it forms 90 per cent., 
this representing 13 to 14 per cent, of ordin- 
ary blood. In the corpuscles the haemoglobin 
infiltrates the colourless proteid stroma, from 
which it may be extracted by water, ether, 
chloroform, or bile salts, thus forming a solu- 
tion in the plasma; blood so treated is termed 
'laky.' It is of an extremely complex nature, HEMOGLOBIN 
769 
its percentage composition in the dog being 
estimated at C 53-85, H 7-32, N 16'17, O 21-84, 
S -39, F -43. It is to be regarded as a com- 
pound of a proteid substance-globin, and a 
coloured body-haematin, which contains all 
the iron of the molecule. The former belongs 
to the globulin group, though its exact nature 
is not known; and the latter, as a constituent 
of haemoglobin, appears to differ slightly from 
the separated haematin presently described. 
The precise character of the association of 
these two substances in the compound, 
whether a simple mixture or a chemical 
combination, is as yet undetermined. 
Haemoglobin presents a singular exception 
to the general law of diffusion, inasmuch as, 
though it crystallises, it will scarcely diffuse 
through membrane. A considerable variety 
in the shape of the crystals is met with in 
different animals, and much difference in the 
facility with which it crystallises ; in man 
they occur as elongated prisms, and are 
formed with difficulty. 
The most important property of this com- 
pound is its affinity for oxygen. In some 
obscure manner this gas enters into a loose 
combination with haemoglobin in the lungs, 
forming oxy-hemoglobin, and is then con- 
veyed by the red corpuscles throughout the 
body, separating again from its conveyer in 
the tissues. The haemoglobin thus deprived 
of its oxygen is known as reduced hemo- 
globin, and is of a purplish colour, whilst the 
oxy-haemoglobin is of a scarlet tint. It is 
thus that the difference in colour between 
arterial and venous blood is mainly to be ac- 
counted for. The spectra of these two kinds 
of haemoglobin are characteristic, that of the 
former being distinguished by two absorption 
bands of unequal width and intensity between 
the solar lines D and E (i.e. in the yellow 
and green region of the spectrum), whilst 
the reduced haemoglobin presents but a single 
band occupying a position between the two 
of the oxidised form. It is to be noted that, 
whatever be the nature of the combination 
that exists between the oxygen and its carrier, 
it is such that the gas retains its properties 
as a gas, and the union may be roughly com- 
pared to a mere solution of the gas in a fluid. 
There is reason to believe that the oxygen- 
carrying power is mainly, if not entirely, 
possessed by the haematin constituent, since 
this substance is capable of being oxidised 
and reduced in a manner similar to haemo- 
globin itself; and, further, this capability is 
closely dependent on the presence of the iron 
-iron-free haematin having no such power. 
The 'respiratory pigment' corresponding to 
haemoglobin in some of the invertebrata 
contains copper in place of iron. 
Another compound of this substance with 
oxygen, in which the gas is much more closely 
combined, is termed methemoglobin; and a 
still more stable association takes place be- 
tween haemoglobin and carbonic oxide, which 
thus produces its rapidly poisonous effect 
by preventing the oxygen-carrying power of 
the blood. Nitric oxide behaves in a similar 
fashion. 
Certain variations, both quantitative and 
qualitative, are recognised in disease, but 
our knowledge in this direction is most frag- 
mentary. In anaemia the amount of haemo- 
globin is frequently diminished by a half, 
and in extreme cases to even less than a 
quarter of the normal. 
The haemoglobin may be liberated from the 
stroma of the corpuscles and dissolved in the 
blood-plasma (haemoglobinaemia), finally ap- 
pearing in the urine (haemoglobinuria), though 
chiefly in the form of methaemoglobin. This 
result frequently follows on poisoning by 
arseniuretted hydrogen, phosphorus, carbolic 
and some of the mineral acids ; also in the 
course of typhus fever, pyaemia, and scurvy, 
or after severe burns, and in some cases of 
jaundice. It is probable that coincident 
changes in the vascular endothelium favour 
the diffusion of the pigment. 
It is further stated that, in some septic 
states, pyaemia, cancrum oris, and erysipelas, 
and also in leukaemia, the blood when drawn 
from the body shows a remarkable tendency 
to crystallise, quite contrary to the normal. 
This has been attributed to the presence in 
the blood of some peculiar ferment. 
The chief derivatives of haemoglobin may 
now be briefly referred to. 
(a) Haematin(C32H32N4FeO4).-Ilaematin 
may be obtained from red blood-corpuscles by 
treatment with acids or with strong alkalis. 
It is an amorphous dark-brown powder, in- 
soluble in water, alcohol, or ether, but readily 
soluble in caustic alkalis, in sulphuric or 
acetic acids, and in chloroform. The acid 
and alkaline solutions each give a charac- 
teristic spectrum. The acid haematin is known, 
as haematoin. A solution gives a characteris- 
tic absorption-band in the spectrum, different 
from those produced by haemoglobin. It 
forms a green solution when boiled with 
caustic potash. 
(&) Haemin (C32HuClN4FeO3).-Haemin, 
which may be prepared from dried haemo- 
globin by treatment with glacial acetic acid, 
in the presence of an alkaline chloride, is 
a hydrochloride of haematin. It crystal- 
lises tolerably readily in needle-shaped prisms; 
or rhombic plates, and thus becomes an easy 
means of detecting the presence of blood in 
stains of a doubtful nature. The crystals are 
insoluble in water, alcohol, chloroform, and 
ether, and soluble in caustic alkalis and 
boiling hydrochloric and acetic acids. 
(c) Hsematoidin (C3aH36N4O6). - This 
substance is one of the forms of iron-free 
haematin of natural occurrence as rhombic 
prisms or needles of a red or greenish-red 
colour; a fact which shows that the colour of 
haemoglobin is not dependent on the iron. 
It is of considerable pathological interest,. 770 
HEMOGLOBIN 
HEMOGLOBINURIA 
being frequently found in old clot«, and in the 
cavity of ruptured Graafian follicles. It is 
the cause also of the staining so often seen in 
the neighbourhood of extravasations of blood, 
varying from lemon-yellow up to reddish 
black. 
(tf) Hsematoporphyrin, also containing 
no iron, and probably isomeric with the fore- 
going, may be prepared from haematin by 
heating with fuming hydrochloric acid. 
The relationship of haemoglobin, haematin, 
haematoidin, and haemin to the pigments of 
the body is of the greatest interest. It would 
seem that the haemoglobin is the source of 
all-biliary, urinary, &c. A constant destruc- 
tion of red corpuscles is taking place in the 
spleen, and probably also in the bone-marrow. 
The haemoglobin which is liberated from the 
stroma reaches the liver, where the globin is 
separated, the iron removed, and bilirubin 
formed. Normal urobilin, the chief colouring- 
matter of the urine, is very similar to bilirubin, 
and is derived from that substance or directly 
from haematin or haemoglobin itself. The 
pigments of the bile, faeces, and urine are 
therefore to be regarded as the excreted 
waste of haemoglobin. Bilirubin is closely 
allied to, if not identical with, haematoidin; 
and a play of colours-the result of oxida- 
tion-may be obtained from the latter when 
treated with nitric acid, similar to that pro- 
duced by the bile-pigments under the same 
condition. The injection of haemoglobin into 
the blood is followed by the presence of bile- 
pigments in the urine, and an increase of 
bilirubin in the bile. Melanin, the black pig- 
ment of the retina, hair, and skin, and often 
found in connexion with new-growths, especi- 
ally with those of a malignant character, also 
appears to be directly drawn from haemo- 
globin. The colouring-matter of the blood is 
certainly associated, in some way other than 
that of its oxygen-carrying function, with the 
nutrition of the tissues, in connexion with 
the obscure but unquestionable influence of 
pigments. W. H. Allchin. 
HAEMOGLOBINOMETER (Hemo- 
globin; and perpov, a measure). 
Definition.-An instrument for the clini- 
cal estimation of the amount of hemoglobin 
in blood. 
Description.-The quantity of hemoglobin 
may be ascertained by estimating the amount 
of iron in the blood, or by observing the 
dilution necessary to obscure a certain ab- 
sorption-band in the spectrum (see Spec- 
troscope in Medicine). Neither of these 
methods is, however, available for clinical 
use. Simpler methods have therefore been 
contrived, which depend on a comparison of 
the colour of diluted blood with that of solu- 
tions of carmine and picro-carmine. By 
this combination the tint of blood, and even 
its spectrum, may nearly be obtained (Ma- 
lassez). Coloured discs have been employed 
for the same purpose (Hayem). In these 
methods a given dilution of blood is made, 
and this is compared with the tint of the 
standards. In the haemoglobinometer de- 
signed by the writer (and made by Hawks- 
ley) the blood is progressively diluted until 
it reaches the tint of a standard, the colour 
of which corresponds to a dilution of 1 part 
of healthy blood in 100 of water. The 
degree of dilution necessary to make the 
two correspond represents the amount of 
haemoglobin. The apparatus consists of two 
tubes of exactly equal diameter, and a 
capillary pipette, holding 20 cubic mm., for 
measuring the blood. One tube is filled 
with a standard, consisting of glycerine jelly 
coloured to the required tint. The other is 
graduated, each division being equal to the 
volume of blood taken (20 cubic mm.), so 
that 100 divisions equal 100 times the volume 
of blood. The dilution is made by a pipette 
stopper, and distilled water; the number of 
degrees of dilution necessary to produce cor- 
respondence with the standard indicates the 
percentage proportion of the haemoglobin of 
the blood examined compared with normal 
blood. For example, the blood of a patient, 
being progressively diluted, is found to reach 
the tint of the standard when the amount 
of water added corresponds to 45 degrees of 
dilution; the blood examined therefore con- 
tains 45 per cent, of the normal quantity 
of haemoglobin. The method is no doubt 
'rough,' hut it is quick and easy. With 
care there should not be more than 5 per 
cent, of error. It is well to note not only the 
point at which the tints become similar, but 
the number of degrees of dilution through 
which they appear alike, and to take the 
mean. The result, being a percentage, is 
immediately applicable to that obtained with 
the haemacytometer. See Hemacytometer. 
W. R. Gowers. 
HjEMOGLOBINURI A (Haemoglobin; 
and ovpov, the urine).-Synon. : Haematinuria. 
Definition.-A morbid condition of the 
urine resulting from disintegration of blood- 
corpuscles, characterised by change of colour 
of the secretion, in consequence of the pre- 
sence of granular debris containing a large 
proportion of haemoglobin; sometimes pa- 
roxysmal ; sometimes a result of the action 
of poisons; and sometimes associated with 
other more dangerous symptoms, and tend- 
ing to a fatal result. 
jEtiology.-Haemoglobinuria is not refer- 
able to any structural change in the kidneys. 
It is a result of morbid action in the blood, 
consisting essentially in the disintegration of 
the red corpuscles, whereby the haemoglobin 
is set free. It has been observed in the 
course of fevers, particularly ague and scar- 
latina, also as a result of insolation, and, in 
the paroxysmal cases, as a result of chill. 
Outbreaks of this disease have been described HEMOGLOBINURIA 
771 
as attacking newly bom infants. In that 
described by Winckel of Dresden, in 1879, 
twenty-four cases occurred, and twenty-three 
proved fatal. This was evidently due to the 
action of a specific poison existing in the 
Maternity Hospital at the time. Cohnheim 
also showed that it occurred as a result of 
severe, but not speedily fatal, burns. Trans- 
fusion of the blood of one kind of animal into 
the veins of another may suffice to produce it. 
Moreover, many poisons have been found to 
induce the condition. By far the most im- 
portant of these is chlorate of potassium. In 
the case of children, one to two drachms in 
the twenty-four hours is a dangerous quan- 
tity; in the adult, three drachms or upwards. 
Next to it, but at a long interval, rank car- 
bolic, hydrochloric, sulphuric, and pyrogallic 
acids, and the inhalation of arseniuretted 
hydrogen gas. In what way we are to ex- 
plain the action of these various substances 
upon the blood-discs is as yet far from clear, 
but the fact that they do so act is fully es- 
tablished. 
Morbid Anatomy. - The kidneys are 
throughout of a deep chocolate colour, with 
radiating striae of a darker tint. The sec- 
tions show under a low power dark lines 
corresponding to the tubules, and spots mark- 
ing the Malpighian bodies. With a higher 
power one makes out that the tubules are 
blocked with granular pigment, and that this 
discharge is evidently from the Malpighian 
tufts. There are sometimes alterations in 
the spleen and in the bones, and haemorrhages 
into various tissues. 
Symptoms.-The chief clinical features of 
haemoglobinuria are those referable to the 
urine. It is dark like porter, or like the 
sediment of port-wine ; sometimes brown like 
coffee, or almost black. This colour is due 
mainly to haemoglobin, and usually few, if 
any, blood-corpuscles are present. Tube- 
casts and oxalate-of-lime crystals are often 
present in large numbers. The urine coagu- 
lates on heating, or on the addition of nitric 
acid. Spectroscopically examined, it shows 
the features characteristic of haemoglobin, 
oxyhaemoglobin, and methaemoglobin. Other- 
wise the patient shows tokens of general 
discomfort ; gastro-intestinal disturbance; 
jaundice more or less pronounced ; sometimes 
enlargement of spleen, and subcutaneous 
haemorrhages; weakness of heart; tendency 
to hypostatic congestion in cases of a bad 
type ; with other symptoms of depression or 
even collapse. 
Diagnosis.-The different forms of haemo- 
globinuria have to be diagnosed from each 
other, and from certain diseases which re- 
semble the paroxysmal forms. See Hemo- 
globinuria, Paroxysmal. 
Prognosis.-Cases of this kind rarely 
terminate unfavourably except when haemo- 
globinuria is merely one of many symptoms 
in connexion with blood-poisoning. 
Treatment. - Protection against septic 
processes or other causes is of the first im- 
portance. When the symptom is developed, 
ferruginous tonics and chloride of ammonium 
may be tried. T. Grainger Stewart. 
HEMOGLOBINURIA, PAROX- 
YSMAL.-Synon. : Paroxysmal Haematin- 
uria. 
Definition.-A paroxysmal affection of 
the system; manifesting itself by changes in 
the urine, and particularly the discharge of 
haemoglobin; caused sometimes by malaria, 
and sometimes by other conditions not yet 
determined; consisting in no anatomical 
change as yet recognised; and characterised 
by the occasional occurrence of constitutional 
disturbance, with discharge of dark, blood- 
stained urine. 
Etiology.-The most important extrinsic 
cause of the tendency to this disease is ma- 
larious poison; the most important cause of 
the paroxysm is exposure to cold or wet; 
but the tendency may exist without malarial 
poison, and the attack may occur apart from 
any special exposure. Amongst intrinsic 
causes, sex is .evidently important, for the 
disease is almost confined to males. It may 
occur in children, and may occasionally recur 
during a period of years. 
As in other forms of haemoglobinuria, the 
symptom is traceable to disintegration of 
red corpuscles within the circulating fluid. 
That this may occur locally has been proved 
experimentally by Ehrlich. He tied a liga- 
ture round the finger of a patient who was 
liable to the disease, and then chilled the 
congested part by immersing it for a quarter 
of an hour in ice-cold water, afterwards 
transferring it for alike period to tepid water. 
In this patient it was found that many cor- 
puscles were broken down, while no such 
effect was produced elsewhere in the body or 
in healthy people. It is probable, however, 
that it is chiefly in the liver that the destruc- 
tion of corpuscles ordinarily takes place; 
and it is uncertain whether it results from a 
direct influence operating upon the corpuscles, 
or through the production of some chemical 
substance and its action upon them. 
Anatomical Characters.-The disease 
not being fatal, there is no evidence as to 
the existence of any anatomical change in 
the kidneys, but there is every reason to 
suppose that if the kidneys were examined 
they would show the appearances met with 
in non-paroxysmal haemoglobinuria. 
Symptoms.-This form of haemoglobinuria 
is paroxysmal, but not distinctly periodic. It 
may commence in childhood or during adult 
life. The attacks may occur once, twice, or 
thrice a day, on alternate days, once a week, 
or quite irregularly. The paroxysm may 
commence abruptly without any premonitory 
symptom, but is more commonly ushered 
in by a feeling of uneasiness in the loins and 772 
HEMOGLOBINURIA 
HEMOPHILIA 
limbs, by shivering, and general chilliness. 
Sometimes it is preceded by slight jaundice, 
furred tongue, and other symptoms of gastric 
catarrh; and sometimes albuminuria pre- 
cedes by a few hours or a day the occurrence 
of haemoglobinuria. The more abrupt attacks 
frequently terminate by the discharge of the 
peculiar urine, the uneasy feelings having 
subsided before it recurs ; and the next urine 
is normal, or nearly so. In some cases albu- 
minuria precedes or lingers for a time after 
the discoloration has passed off, and some- 
times it replaces the haemoglobinuria. See 
Bright's Disease. 
The characters of the urine are very pecu- 
liar. Its colour is like porter, or like muddy 
port-wine; its specific gravity ranges from 
1015 to 1035; it is acid, or faintly alkaline; 
it is highly albuminous; sometimes it con- 
tains excess of urea. It throws down a 
copious sediment, which contains very few 
or no blood-corpuscles, but an immense 
amount of granular blood-pigment, with 
numerous tube-casts-hyaline or epithelial, 
often loaded or coated with amorphous 
granular matter, and with minute crystals 
of oxalate of lime. The colour is not due 
to blood-corpuscles, nor to haematin, but to 
haemoglobin. In some cases the urine is less 
affected, being merely albuminous, and not 
depositing pigment. It may be doubted 
whether this condition should be admitted 
to the same category as the disease under 
discussion, but cases which have come under 
the writer's observation seem to show that it 
is entitled so to rank, and it is dealt with in 
the article just referred to. 
A very interesting point in the clinical his- 
tory of haemoglobinuria is its relationship to 
Raynaud's disease. The relationship is neither 
constant nor exclusive, and the precise link 
which connects them is as yet not clearly 
determined. Still the clinical fact remains, 
that when the one disease exists the other is 
not infrequently present. 
Diagnosis.-The only diseases with which 
intermittent haemoglobinuria is likely to be 
confounded are haematuria, and renal calculus 
or gravel. From the former it is distinguished 
by the abundance of the blood-pigment and 
the extreme rarity.of blood-corpuscles; from 
the latter, by the short duration of the attacks, 
the presence of the characteristic deposit, 
with the fact that the pains affect both loins, 
not merely one. It is sometimes important 
to distinguish the milder forms, in which 
merely albuminuria occurs, from congestion 
or from commencing inflammatory Bright's 
disease. It is not always possible to dis- 
tinguish these during the early hours of the 
attack; but the amount of general disturb- 
ance, the state of the tongue, the slight 
jaundice, the suddenness of the onset, and 
the absence of dropsy, generally suffice to 
make the diagnosis clear. 
Prognosis.-The prognosis is good in 
paroxysmal haemoglobinuria, as to the indi- 
vidual paroxysm. The tendency to the dis- 
ease is also not infrequently got rid of. It 
has not proved fatal in any case. But it 
appears sometimes to usher in, or to con- 
stitute an early symptom of, Bright's disease 
-the cirrhotic form. 
Treatment.-With a view to preventing 
the attacks, individuals who are subject to 
paroxysmal haemoglobinuria should carefully 
avoid exposure to cold and over-fatigue of 
every kind. They should take abundance of 
good and easily digested food, should avoid 
free use of alcohol, and should clothe warmly. 
As the paroxysm is spontaneously recovered 
from, little need be done, excepting with the 
view of alleviating the discomfort of the 
patient. He should go to bed and be kept 
warm, and have abundance of warm drinks. 
In respect of diminishing or removing the 
tendency to the malady, various remedies 
have been found useful, among which may 
be mentioned quinine, tincture of cinchona, 
iron, arsenic, and chloride of ammonium. 
Antisyphilitic treatment by means of mercury 
has also been found useful. 
T. Grainger Stewart. 
HEMOPERICARDIUM.-See H^e- 
MATO-PERICARDIUM. 
HEMOPHILIA (aqua, blood; and 0iXta, 
predisposition for). - Synon. : Haemorrha- 
philia ; Haemorrhagic Diathesis ; Bleeders ; 
Fr. Himophilie', Ger. Bluterkrankheit. 
Definition.-A congenital disease, often 
hereditary, characterised by a tendency to 
immoderate bleedings, whether spontaneous 
or traumatic, and to obstinate swellings of 
the joints. 
Etiology.-Men are far more liable than 
women to this disease ; the proportion being 
about eleven to one. Women who suffer 
from haemophilia show much less typical 
specimens of the disease than men, and 
rarely die from haemorrhage, although flood- 
ings and profuse menstruation are com- 
mon. 
The best-ascertained cause of haemophilia 
is hereditary predisposition. No other cause 
is known with anything like certainty. In a 
bleeder family, the disease descends to the 
boys through the mothers, the women re- 
maining quite healthy and apparently free 
from all disease. The fathers do not seem to 
transmit the disease to their sons ; at least, 
instances of this are rare. The women of 
bleeder families are remarkably fertile. Some 
have thought haemophilia to be more common 
in Germany, but this is probably owing to 
the greater attention paid to the disease in 
that country. Cases have been met with in 
the Indian Archipelago, North America, the 
Scandinavian kingdoms, and elsewhere. The 
disease is not limited to the Aryan races, as 
the Jews, a Semitic nation, are singularly 
liable to it. HAEMOPHILIA 
773 
Anatomical Characters.-No morbid ap- 
pearances have yet been found after death 
with any constancy. The blood-vessels are 
apparently unaltered. The condition of the 
blood has not yet been properly investigated. 
It would be important to ascertain whether 
the number of white corpuscles is increased 
or diminished, and whether they are altered 
in character. The swellings of the joints 
appear to be due to the extravasation of blood 
within the articulation. 
Symptoms.-The first signs of haemophilia 
are commonly seen during the first year of 
life; but sometimes they are delayed until 
the beginning of the second dentition. Cases 
on record of a much later appearance of the 
first symptoms are not trustworthy. It is 
very rare for bleedings to be noticed at birth. 
There is nothing about the subjects of 
haemophilia, when not suffering from bleed- 
ing, to distinguish them from ordinary per- 
sons. They look well ; and nothing amiss 
can be discovered by physical examination in 
chest or belly. 
There are three well-marked degrees of 
haemophilia. The first is the most typical 
and characteristic, in which there is a tendency 
to every kind of haemorrhage, traumatic or 
spontaneous, interstitial or superficial. The 
swelling of the joints is well-marked. This 
degree is scarcely ever seen in women ; but 
it is the most common among men. In the 
second degree, spontaneous haemorrhages 
from the mucous membranes only are present. 
The third degree, in which the tendency is 
little marked, is seen only amongst the 
women of bleeder families ; and shows itself 
only by spontaneous ecchymoses. 
Hcemorrhage.-Spontaneous bleedings are 
sometimes preceded by symptoms of unusual 
fulness and plethora. The mucous mem- 
branes supply the blood in this case; in 
childhood bleeding from the nose is the most 
common, and also the most fatal, although 
bleedings from the bowel, mouth, or chest 
may also occur. There is only one known 
instance of death Irom haematuria. The 
traumatic bleedings vary much in intensity, 
even in the same individual. Death has 
followed division of the fraenum of the tongue, 
vaccination, leeching, and the extraction of a 
tooth. This last is a very common cause of 
death. If abscesses be opened, furious bleed- 
ing commonly takes place ; and the same 
occurs if a blood-tumour or extravasation of 
blood be interfered with. 
The bleeding is nearly always capillary, 
and may kill in a few hours or after some 
weeks. The quantity of blood lost is some- 
times enormous. After the bleeding the 
patients are extremely anaemic ; and this 
state may last for months. 
Besides superficial bleedings, interstitial 
haemorrhages,ecchymoses, and blood-tumours 
may be observed, whether spontaneous or 
traumatic. A bruise which a healthy person 
would not feel may fill the connective tissue 
of a limb with blood; or the bleeding may 
be circumscribed, and form a tumour in- 
stead. 
Swelling of the joints.-This chiefly affects 
the larger joints, the knee being most com- 
monly attacked. The joint, most commonly 
after some injury, becomes swollen and pain- 
ful, and apparently filled with fluid ; there is 
fever ; and this state may last for many 
weeks. Relapses are very apt to occur during 
convalescence. 
Diagnosis.-The diagnosis of haemophilia 
is often easy. If a boy have suffered re- 
peatedly from early infancy from abundant 
bleedings-especially traumatic-and from 
joint-affections, there can be no doubt of the 
diagnosis. It is made more certain by the 
existence of hereditary predisposition. In 
women the diagnosis must be made with 
more care, as they are subject to a haemor- 
rhagic disorder which first appears about 
puberty, but which is not hereditary. 
Prognosis.-The prognosis is not so serious 
with respect to life as was formerly thought. 
Treatment.-The treatment of haemophilia 
includes almost the whole subject of the 
treatment of haemorrhage. Surgical inter- 
ference in the way of the ligature of arteries 
is, however, contra-indicated in connexion 
with haemophilia, as the haemorrhage in such 
cases is almost exclusively capillary. For 
the same reason, the administration of ergot, 
with a view to bringing about a contraction 
of the arterioles, would not be likely to prove 
of service. Treatment ought to be directed 
entirely to bringing about an increase in 
(a) the rapidity of coagulation, and (6) in the 
firmness of the resulting clot. In our present 
ignorance on the subject of the pathology of 
haemophilia, treatment must take cognisance 
of every factor which is known to influence 
the coagulability of the blood. The facts 
that have been ascertained in connexion with 
this subject are as follows : A defect in 
coagulability may depend on one or other of 
the following conditions:- 
A Defect in the Inorganic Substratum of 
Fibrin.-This may consist in a diminution of 
the amount of available calcium salts in the 
blood. Defective coagulation arising from 
this cause is to be met by the administration 
of lime-salts, preferably calcium chloride 
(liquor calcii chloridi B.P., 1 oz. to 1| oz. for 
an adult; in | to 1 pint of water). Owing to 
the disagreeable taste of the salt, it is best 
administered in the form of an enema. A 
1 per cent, solution of calcium chloride may 
also be applied as a local styptic. Stronger so- 
lutions are not to be recommended, as coagu- 
lation is retarded after a certain percentage of 
calcium has been exceeded. In view of the 
fact that the action of the lime-salt is not 
instantaneous, the solution must be applied 
on a tampon in such a manner as to hinder 
the flowing away of the blood with which it 774 
HEMOPHILIA 
HEMOPTYSIS 
comes in contact. In all cases the clots 
obtained by the addition of lime to the 
blood are characterised by an extraordinary 
firmness. The coagulative efficacy of a solu- 
tion of lime-salts can be increased by the 
addition of fibrin ferment. This last can 
be obtained by extracting washed fibrin with 
water. 
A Defect in the Organic Substratum of 
Fibrin.-There is little doubt that the coagu- 
lation of the blood is brought about by the 
combination of an element of plasma-fibri- 
nogen with a fibrinoplastic element derived 
from the breaking down of the white cor- 
puscles. This fibrinoplastic element consists 
of the substance which is known as Wool- 
dridge's tissue- or cell-fibrinogen. A diminu- 
tion of the available tissue-fibrinogen in the 
blood leads to a condition of diminished 
coagulability. Its addition to the blood in 
all cases is followed by an immediate in- 
crease of coagulability, and an increased for- 
mation of fibrin. In view of this fact a local 
application of tissue-fibrinogen would appear 
to be indicated when haemorrhage in haemo- 
philia does not yield to the application of 
lime, or lime and fibrin-ferment. Tissue- 
fibrinogen may be obtained in the following 
manner: Procure the thymus gland (the chest- 
sweetbread) or testicle of a calf, lamb, or other 
animal from the butcher's. Mince it fine in 
a mincing-machine, and extract with, say, 
twenty times its volume of water for ten 
minutes to twenty-four hours. Strain through 
fine muslin or through flannel, and add to 
each pint of the strained infusion 1 fluid ounce 
of diluted or 1 fluid drachm of strong acetic 
acid (B.P.). A precipitate of tissue-fibrinogen 
forms almost immediately. Allow it to 
settle, and get rid of the supernatant, fluid by 
decantation, or, better, collect the precipitate 
on a filter-paper. In either case dissolve the 
tissue-fibrinogen thus obtained by the addi- 
tion of a few drops of alkali (dilute carbonate 
or bicarbonate of sodium). Apply the some- 
what viscid solution on a tampon of cotton- 
wool to the bleeding point. Escharotics such 
as ferric chloride are seldom found to be of 
any service in bleeding in haemophilia. 
In cases of severe haemorrhage, transfusion 
may be necessary. 
General Treatment of the Morbid Con- 
dition.-It is impossible in our present igno- 
rance of the pathology of haemophilia to lay 
down a scientific method of treatment. It 
will, however, be evident that any treatment 
directed towards rendering the blood more 
coagulable would be indicated. Thus the 
administration of lime-salts might prove 
useful. Further, the means which are at our 
disposal for increasing the number of white 
corpuscles in the blood might be employed, 
with a view of increasing the amount of 
the fibrinoplastic element, for we have seen 
that tissue- or cell-fibrinogen is contained 
in the white corpuscles. While awaiting 
further information on this subject, the fol- 
lowing therapeutic agents might be brought 
into requisition : (a) The administration of 
aromatic substances, such as camphor and 
turpentine. The administration of these 
substances increases the number of white 
corpuscles in the blood (Binz), and they are 
employed apparently with success in the 
treatment of internal haemorrhages. (6) The 
administration of pilocarpine (Horbaczewski), 
which increases the number of circulating 
white corpuscles, (c) The administration of 
nuclein (Horbaczewski), or nuclein containing 
substances such as tissue-fibrinogen (Wright), 
for these substances increase the number of 
white corpuscles in the blood. They are 
available in the form of yeast, sweetbreads, 
lamb's fry, and kidneys. (?) It has, however, 
not yet been ascertained whether these cell- 
substances lose their efficacy on boiling. 
Almroth E. Wright. 
HEMOPTYSIS (alga, blood; and tttvo), 
I spit).-Synon. : Pneumonorrhagia ; Bron- 
chorrhagia ; Fr. Hemoptysie; Ger. Bluthus- 
ten. 
Definition. - Blood-spitting having its 
source in pulmonary or bronchial haemor- 
rhage. 
The restriction of the term ' haemoptysis,' 
as thus defined, has the sanction of long usage 
and convenience. Haemorrhage from an 
aneurysm opening through the lung or air- 
passages would not strictly be included in 
such a definition. 
Spitting of blood, w'hen it arises from other 
and less important sources, comes under the 
denomination of false or spurious haemo- 
ptysis. For fictitious hcemoptysis, see 
Feigned Diseases. 
Etiology and Pathology.-The causes 
of haemoptysis in the widest sense of the term, 
and having regard to its pathology, may be 
thus enumerated:- 
I. Hsemorrhage from the pulmonary 
artery or its radicles. 
1. Rupture or w'ound of the lung from ex- 
ternal violence. 
2. Active hyperaemia of the lungs-inflam- 
matory, vicarious, or induced by violent 
effort or excitement. The active hyperaemia 
may be primary as regards the lungs ; or 
may supervene or be attendant upon disease 
already present in them. See Lungs. Hae- 
morrhage into ; and Lungs, Inflammation of. 
3. Mechanical hyperaemia of the lungs, 
secondary to heart-disease, or embolism of 
one of the pulmonary branches, or to pressure 
from tumours, such as enlarged bronchial 
glands. See Lungs, Haemorrhage into; 
Bronchial Glands, Diseases of. 
4. Necrotic division of vessels in the course 
of softening of tubercular or other consolida- 
tions in destructive lung-diseases-phthisis, 
tuberculosis, cancer. 
5. Aneurysmal dilatation or simple erosion HEMOPTYSIS 
775 
of branches of the pulmonary artery, exposed 
in the course of excavation of the lung, or 
ulceration of the bronchial mucous mem- 
brane. 
6. Primary atheroma of the pulmonary 
artery within the lung. 
II. Haemorrhage from the bronchial 
capillaries.-Capillary haemorrhage from 
the bronchial mucous membrane. 
III. Haemorrhage from the aorta, or 
one of its great branches.-Aneurysm 
rupturing through the lung or into a bron- 
chus. 
Details respecting the pathology of these 
several forms of haemoptysis will be found 
under the headings of the principal diseases 
giving rise to them. There are a few ad- 
ditional remarks, however, that should be 
introduced here. 
The pathology of haemoptysis occurring in 
early phthisis-of which it is one of the most 
frequent symptoms-is still somewhat ob- 
scure. Besides the active hyperaemia above 
referred to-that is, the inflammatory con- 
gestion that constitutes the first stage of 
some forms of phthisis, and tends to recur 
at different periods of the disease; besides 
also the necrotic division of vessels, or their 
aneurysmal dilatation, which more especially 
account for the haemorrhage occurring in the 
later stages of the disease,-there are other 
conditions present in early phthisis which 
probably have much to do with the occur- 
rence of haemoptysis. The minute blood- 
vessels are importantly concerned in the 
very earliest stage of phthisical lung-disease 
in one or other of three ways:- 
(a) Their walls become the seat of nuclear 
proliferation, and hence become softened; 
and (b) these vessels become more or less 
extensively blocked, not merely as the result 
of the inflammatory stasis which may affect 
their capillaries, but by the pressure of sur- 
rounding tubercular growth, or by tubercular 
thickening of their walls intruding upon their 
calibre, (c) It is very possible that in the 
ill-developed lungs of small-chested people, 
who inherit a tendency to consumption, the 
vessels are also morbidly frail, and are apt 
to give way in any temporary hyperaemia. 
Some persons are remarkably subject to 
irregular distribution of blood; they are 
liable to chills, cold extremities, and tran- 
sient flushings; and a pulmonary blush is 
as conceivable as a temporary flush else- 
where, and would favour the occurrence of 
haemorrhage. 
It has been alleged that the haemoptysis 
occurring in all stages of phthisis frequently 
has its source in haemorrhage from the 
bronchial tubes, and that this bronchial 
haemorrhage may give rise secondarily to 
phthisis, or may, when it occurs in the course 
of that disease, set up fresh centres of mis- 
chief in the lungs by inhalation of blood to 
distant portions. In the entire absence of 
reliable pathological grounds for this view, 
and in the abundance of anatomical evidence, 
clinical experience, and weight of authority 
in favour of the pulmonary origin of haemo- 
ptysis, we are, in the opinion of the writer, 
justified in believing that decided haemoptysis 
originating in haemorrhage from the bronchial 
mucous membrane is exceedingly rare, ex- 
cluding, perhaps, syphilitic ulceration of the 
bronchi. Blood inhaled to distant portions 
of lung may, however, as show'n by Dr. 
Reginald Thompson, undergo changes re- 
sulting in fresh pulmonary destruction. 
Description. - The quantity of blood 
brought up in haemoptysis varies from a 
mere streak to two or three quarts. When 
blood is expectorated in large quantity, it 
is pure and unmixed; and either dark and 
venous, or bright arterial. The first and 
last portions are usually more or less aerated. 
If in small quantity, the blood is most 
generally bright and frothy, it may be only 
a speck or two upon the sputum, or it may 
be in several mouthfuls of pure aerated blood. 
It commonly happens that this mitigated 
and more characteristic haemoptysis precedes 
the rarer attack of profuse haemorrhage that 
may prove instantly fatal. Haemoptysis is 
sometimes scanty, dark, and clotted, usually 
from a small portion of blood having been 
detained in the lung before being expecto- 
rated. 
In decided haemoptysis the shock to the 
system is always great. The patient is 
alarmed and anxious, especially on the first 
attack. The sense of weakness and prostra- 
tion is, indeed, often prolonged after the 
attack-not necessarily a severe one as re- 
gards quantity of blood lost-has ceased. 
The face is often flushed; the extremities 
cold. The temperature is usually depressed; 
after a few hours it biomes normal, and it 
may continue so, or it may rise in the course 
of forty-eight hours or within five days. This 
elevation of temperature may depend (a) upon 
return of the previous fever after being tem- 
porarily checked by haemorrhage and shock ; 
(&) upon the cause which has also produced 
the haemoptysis; or (c) upon the secondary 
consequences of the haemorrhage. It has 
been clearly shown that the inhalation of 
blood into the bronchial tubes and pulmonary 
alveoli sometimes sets up broncho-pneu- 
monia, and thus may give rise to fresh 
centres of phthisical disease; and cases do 
occur in which acute miliary tuberculosis of 
the lungs supervenes upon an haemoptysis 
in a manner suggestive of direct infection. 
The later the rise of temperature up to the 
fifth day, the more reason we have for re- 
garding it as due to secondary pneumonia. 
In the haemoptysis that occasionally arises 
in some forms of heart-disease (chiefly mitral 
stenosis), the amount of blood expelled is 
usually small, darker in colour, less aerated 
than in ordinary haemoptysis, and partially 776 
HEMOPTYSIS 
clotted. This form of haemoptysis is, more- 
over, associated with the signs of heart-disease 
of more or less old standing. See Lungs, Hae- 
morrhage into. 
Anatomical Characters.-These depend 
very much upon the nature of the disease 
which has preceded the haemoptysis In cases 
of death from haemoptysis there are the usual 
appearances of death from haemorrhage - 
pallor of organs, empty and contracted ven- 
tricles, &c. The bronchial tubes of both 
lungs are found to contain clots. The healthy 
portions of lung are found inflated from ob- 
structions in the bronchi, impeding the exit 
of air; they are generally pale, but beauti- 
fully speckled by pink spots, marking the 
lobules into the air-cells of which blood has 
been inhaled. If death take place several 
days after profuse haemoptysis, any blood 
which remains in the bronchi is dark and 
disorganised, and patches of consolidation 
may sometimes be found, having for their 
centres the stained appearance attributable 
to inhaled blood. More or less bronchitis is 
also noticeable. It is rare to find fatal 
haemoptysis without the presence of cavities, 
which are also, more or less, filled with blood- 
clot. In almost every instance of fatal 
haemoptysis in phthisis, sufficient diligence 
will discover either an aneurysm of a pul- 
monary vessel within a cavity, or ulcerative 
erosion or laceration of an exposed vessel. 
The writer has found such a condition in 
fifteen cases at various ages, including one 
infant seven months old. 
Significance of Haemoptysis.-No modifi- 
cation in our views respecting the nature of 
phthisis can lessen the significance of haemo- 
ptysis as being one of its most important 
positive signs. Thus regarded, it is a warning 
that may sometimes save, and very often 
prolong life, by drawing our early attention 
to a condition that might otherwise remain 
too long concealed; but, lightly considered 
and carelessly treated, it is but the precursor 
of destructive disease. 
Diagnosis. - Genuine haemoptysis can 
rarely be mistaken by a skilled observer 
present at the attack. The gurgling in the 
bronchi, the loose cough, and repeated ex- 
pectoration of bright frothy blood are quite 
characteristic. The blood is distinctly ex- 
pectorated with cough, not vomited; and its 
quality is distinctly fresh, not changed. In 
haematemesis, with which haemoptysis is 
sometimes confounded, the blood is brought 
up by vomiting ; is more or less mixed with 
the contents of the stomach ; and, save when 
the haemorrhage is very rapid and abundant, 
presents a dark grumous appearance, owing 
to the action of the gastric fluid upon it (see 
H^matemesis). It may, too, be observed 
that the blood does not come from the nose, 
unless a small quantity be projected through 
the nostrils with the spasmodic cough. If, 
as often happens, no medical attendant is at 
hand at the moment of the attack, the appear- 
ance of the blood is usually sufficient for 
diagnosis; and if the haemoptysis have been 
at all copious, any further expectorations for 
the next few hours are sanguineous. The 
fact of this sanguineous coloration of the 
sputa having existed for some hours, or a 
day or two after an haemoptysis, is positive 
evidence of the haemoptysis having been 
genuine. In cases of very copious haemor- 
rhage from a large pulmonary branch, the 
blood brought up is dark and venous. 
It is very important in investigating the 
cause of haemoptysis to be as gentle as possible 
in physical examination. We can listen to 
the lungs in front and to the heart without 
moving the patient or requiring him to 
breathe deeply; we can make a note of the 
temperature ; and at the time we should do 
no more. 
The throat should always be examined in 
doubtful cases of haemoptysis, as the blood 
will sometimes be found to have issued from 
an ulcerated tonsil, or even from enlarged 
vessels on the posterior wall of the pharynx. 
Spurious hcemoptysis, however, may be de- 
fined as the escape of a blood-stained mucus 
from the throat or gums. In cases of spurious 
haemoptysis there is usually distinct evidence 
of a morbid condition of these parts. The 
mucous membrane of the fauces is relaxed; 
the gums are spongy, and often bleed when 
the teeth are brushed in the morning. Some- 
times this condition of gums arises from 
insufficient attention to the teeth, carious 
stumps and much tartar round the teeth 
causing irritation and sponginess of the 
gums. The patients are usually anaemic and 
short-breathed, and often complain of morn- 
ing cough, but there is no evidence of lung- 
disease. The blood-stained mucus is usually 
ejected in the morning, on waking ; and often 
escapes from the mouth during the night, 
staining the pillow. On examination, it is 
found to be a pink, watery mucus, uniformly 
stained, and containing comparatively few 
blood-corpuscles. 
Treatment.-Absolute rest is the first 
thing to be observed in the treatment of all 
attacks of haemoptysis. The patient should 
lie down with the head and shoulders raised 
by pillows. He should not talk. The room 
should be kept quiet and cool; the bedclothes 
should be light, but sufficient; and warmth 
should be applied to the feet. A little ice in 
the mouth, or some iced water to sip, will 
ease the cough and tend to check haemor- 
rhage. The patient must, if possible, be 
reassured as to the absence of immediate 
danger, and the shock to the system allayed 
without the use of stimulants. Sometimes 
opium may be usefully given for this 
purpose, due regard being had to the habits 
and idiosyncrasies of the patient. In copious 
haemorrhage, attended with shock, a small 
subcutaneous injection of morphine is some- HEMOPTYSIS 
HEMORRHAGE 
777 
times of great value. Astringent medicines 
are not always needed in haemoptysis, es- 
pecially in attacks in which the haemorrhage 
is presumably capillary; they may, however, 
be given in such cases in small doses. To 
be really useful in haemoptysis, astringents 
must be given in full doses. Those most 
used are acetate of lead, four grains, every 
three or four hours; alum, twenty grains, 
with diluted sulphuric acid, thirty minims, 
every four hours; gallic acid, twenty to 
thirty grains every half-hour or hour, for 
two or three doses, followed by ten-grain 
doses every three hours; oil of turpentine, 
thirty minims every two hours in sweetened 
mucilage or in milk, for a couple of doses, 
then in half or third doses; liquid extract of 
ergot in half-drachm or drachm doses, every 
two or three hours; ten- or fifteen-minim 
doses of the pernitrate or persulphate of iron 
solution, or thirty or forty minims of the 
perchloride freely diluted. Of the above- 
mentioned astringent remedies, alum and 
sulphuric acid, gallic acid, and ergot are the 
best in the greater number of cases. Acetate 
of lead is less applicable to cases of lung- 
haemorrhage than in bowel or kidney lesions. 
Ergot is to be preferred in those cases in which 
we infer that a considerable vessel has given 
way. It may also be given in the form of 
ergotin-one-half to two grains hypodermic- 
ally ; but thus given it sometimes causes much 
local inflammation. Oil of turpentine is cer- 
tainly one of the most powerful of astringents 
in pulmonary haemorrhage, and may be use- 
fully held in reserve. When freely adminis- 
tered, the condition of the urine must be care- 
fully noted. Cases of haemoptysis only rarely 
occur in which it is well to give the iron 
astringents. As a rule, they tend to increase 
pulmonary congestion ; but in some cases, in 
which haemoptysis has a tendency to con- 
tinue after the patient has been brought to a 
state of profound anaemia from the first out- 
burst, they may be usefully given, their effect 
being carefully watched. Digitalis is a drug 
sometimes of great value in haemoptysis; it is 
best adapted to those cases in which there is 
much excitement of the circulation. In cases, 
for instance, in which the'haemoptysis has 
been determined by intemperance, or in full- 
blooded people by effort, tincture of digitalis 
in twenty- or thirty-minim doses may be 
given. In such cases, in which the portal 
system is usually congested, sulphate of 
magnesium and diluted sulphuric acid maybe 
combined with the digitalis, and given every 
four or six hours for a couple of days or so. 
In the treatment of haemoptysis it is usually 
necessary to counteract the effect of the 
astringent upon the bowels by purgatives or 
laxatives. An enema may be necessary to 
enable the bowels to act easily and without 
straining. The use of the bed-pan must of 
course be enjoined. 
Counter-irritation is of great value in the 
treatment of many cases of haemoptysis, 
chiefly in those cases in which the haemor- 
rhage is not great, and occurs in the course of 
phthisis, being due either to local pulmonary 
congestion or to active hyperaemia of the 
walls of a cavity. Blisters are, as a rule; 
best avoided in copious haemoptysis during 
the stage of shock. Continuous cold to the 
chest is decidedly to be deprecated. The 
intermittent application of cold may some- 
times be employed, but is a measure of 
doubtful expediency. 
The temperature and pulse of the patient 
should be carefully watched during an attack 
of haemoptysis, and for days afterwards. 
The diet must at first be restricted to cold 
nutritious fluids. The tendency is to keep 
patients suffering from haemoptysis on cold 
slops and cold solids for an unnecessary time. 
In most cases, after forty-eight hours, warm, 
not hot, food may be allowed. Stimulants, 
except in special cases, must be interdicted. 
The treatment of false or spurious hcemo- 
p lysis depends upon its cause. In most 
cases, the cause being anaemia, with a relaxed 
and morbid condition of the mucous mem- 
branes, an acid preparation of iron containing 
some chlorate of potassium and glycerine will 
speedily cure the malady. Tincture of the 
acetate or perchloride of iron, added to a small 
'lemon-squash,' is also an excellent remedy. 
"When the gums are spongy, the addition to a 
chalk or charcoal tooth-powder of finely pow- 
dered kino or catechu, or the addition of some 
glycerine of tannin to the tooth-water, will 
prove efficacious. Astringent gargles will 
suggest themselves in fitting cases; and fruit 
and vegetables must be added to the diet. 
R. Douglas Powell. 
HAEMORRHAGE («qxa, blood ; and 
prjyvvyt, I burst forth).-Synon. : Er. Hemor- 
rhagic ; Ger. Blutfluss. 
Definition.-The escape of blood from 
any part of the circulation, and its discharge 
from the body. 
When blood escapes from any of its natural 
reservoirs, it is either extravasated into the 
neighbouring organs or cavities, or flows from 
one of the surfaces or orifices of the body. 
In the latter case only is the term ' haemor- 
rhage ' strictly applicable (see Extravasa- 
tion). This distinction, however, is not 
always carefully observed ; and such expres- 
sions as 'cerebral haemorrhage,' 'haemorrhage 
into the pericardium,' and ' haemorrhagic 
eruptions ' are employed in connexion with 
what are more correctly called extravasa- 
tions of blood. 
.Etiology.-Haemorrhage is almost always 
due to a solution of continuity of some part 
of the circulatory system, whether by injury 
or by disease. Haemorrhage from the ex- 
ternal surface of the body is, with few excep- 
tions, the result of wounds or otuer form of 
injury ; but ulceration-either simple or 778 
HEMORRHAGE 
malignant-frequently lays open a vein or 
an artery; and aneurysm of the great vessels, 
and even of the heart, may also give rise to 
external bleeding. Haemorrhage from in- 
ternal organs, on the. contrary, is most 
frequently the result of disease, as, for in- 
stance, ulceration or aneurysm, or of circu- 
latory disturbance, such as congestion. Great 
excitement and severe exertion are two of 
the chief determining causes of haemorrhage, 
by producing great or sudden rise of the 
general blood-pressure, whether by cardiac 
disturbance or by obstruction of the terminal 
vessels; they may lead even to the rupture 
of healthy vessels. Local disturbances of the 
blood-pressure give rise in the same way to 
congestion or hyperaemia, and finally to 
haemorrhage. The principal causes of haemor- 
rhages of this class are diseases of the heart, 
of the great vessels, of the respiratory organs, 
and of the liver, and sudden variations in the 
atmospheric pressure or in the temperature; 
and such haemorrhages are also in some in- 
stances undoubtedly of a vicarious nature. 
Certain conditions of the blood are believed 
to predispose to haemorrhage, as, for example, 
in scurvy, purpura, the malignant fevers, 
chronic Bright's disease, and. alcoholism. 
There is, probably, however, a lesion of the 
vessel-walls in some of these diseases. A 
peculiar condition of body is known as the 
hcemorrhagic diathesis or haemophilia; the 
subjects of which exhibit, amongst other 
forms of debility, a remarkable tendency to 
profuse haemorrhage from trivial causes. See 
Hemophilia. 
Seats and Varieties.-Bleeding from the 
surface of the body, whatever its origin, is 
simply called hcemorrhage, and its exact 
source and situation are otherwise defined. 
On the contrary, when blood escapes by 
any of the natural openings of the body, 
and is derived from an internal organ, the 
haemorrhage is described by a special name. 
Haemorrhage from the nose is called epi- 
staxis', from the ear otorrhagia', from the 
stomach hcematemesis ; from the respiratory 
tract hcemoptysis ; and from the urinary 
tract hcematuria. Blood passed per anum, 
after undergoing certain changes to be re- 
ferred to immediately, is called melcena. 
Menorrhagia and metrorrhagia are the 
names given to profuse bleeding from the 
genital organs in the female-at the men- 
strual period and at other times, respectively. 
Description.-The local phenomena which 
characterise haemorrhage from the external 
parts of the body, vary with the source of the 
blood. If it proceed from an artery of con- 
siderable size, it escapes in the form of a jet, 
which is strengthened at each beat of the 
pulse as an active spurt. Blood discharged 
from an opened vein either flows in an 
abundant continuous stream, or wells up 
from the depth of the tissues in which the 
vessel lies. Capillary haemorrhage is gene- 
rally much less profuse, and is most fre- 
quently seen in the form of oozing. Blood 
proceeding from internal organs is variously 
discharged by the several outlets. Some- 
times it is immediately expelled, especially 
if in quantity; or it may escape even when 
in small quantity, owing to gravitation, as in 
haemorrhage from the nose. Most frequently 
the blood is retained for a time, and then, 
acting as a foreign body, is ejected; for 
example, in bleeding from the stomach, 
bowels, or bladder. 
Characters.-Blood flowing from the sur- 
face of the body usually presents its familiar 
characters. The colour of the blood will be 
scarlet when it is derived from an artery; 
purple, with a tendency to become scarlet on 
the surface, when it flows from a vein ; and 
of a tint intermediate between these two 
colours when the haemorrhage is capillary. 
In all cases, the blood coagulates more or 
less abundantly around the seat of haemor- 
rhage. 
In haemorrhage from internal organs, on 
the contrary, the blood is frequently coagu- 
lated ; more or less mixed with the fluids of 
the part; or otherwise altered during its 
transit. The following are the principal 
changes that blood undergoes in its passage 
towards the several outlets of the body:- 
Blood flowing from the external ear, or 
from the anterior nares, is frequently thin 
and watery, if the haemorrhage have lasted 
for any length of time. Blood discharged 
from the posterior nares is often coagulated, 
black, and mixed with thick mucus. In 
haemorrhage from the mouth, the blood may 
be derived from that cavity, from the fauces, 
from the respiratory passages, or from the 
upper portion of the digestive tract-especi- 
ally the stomach. When the blood flows from 
some part of the mouth, such as the gums, 
tongue, palate, or cheeks, it is more or less 
intimately mixed with frothy saliva and 
mucus. In haemorrhage from the respira- 
tory passages, or from the stomach through 
the mouth, the ejected blood varies extremely 
in different instances (see Hemoptysis ; and 
Hematemesis). Haemorrhage from the 
genito-urinary tract is also specially de- 
scribed. Haemorrhage from the bowels is 
not peculiar, if the source of the blood be 
near the anus, or if the bleeding be very 
profuse; taking the form sometimes of a 
gush of fresh, warm blood, at other times 
of a mere red streak upon the faeces. If the 
blood be derived from a higher part of the 
intestines, the appearance of it, when dis- 
charged, will be different. Generally it is so 
far altered by the action of the various in- 
testinal contents, as to be converted into a 
black tarry-looking mass (see Melena). 
Less frequently, the bleeding may be so pro- 
fuse as to fill a considerable portion of the 
bowel, and clots of blood may then be passed, 
as in some cases of haemorrhage in typhoid HAEMORRHAGE 
HAEMORRHOIDS 
779 
fever. The peculiar characters of menstrual 
blood are described elsewhere. Haemorrhage 
from the uterus in large quantity consists of 
unaltered blood, whether coagulated or not. 
Course and Terminations. - Haemor- 
rhages caused by wounds are generally most 
profuse at first; and, unless they prove fatal 
speedily, or are artificially arrested, gradually 
cease. On the contrary, haemorrhages due 
to disease are frequently insignificant at first, 
and increase in amount; or they recur again 
and again in variable quantity. 
Many natural causes contribute to the ar- 
rest of haemorrhage, the most important being 
weakening of the force of the heart by the 
loss of blood; the contraction of the coats of 
the vessels at the seat of lesion; the coagula- 
tion of the blood-first around, and then 
within the open vessel; the pressure of the 
extravasated blood in the surrounding tissues; 
and the increased coagulability of the blood 
after the flow has continued for some time. 
The relief of the local disturbance of pressure 
by the occurrence of the haemorrhage is 
alone sufficient in many instances to arrest 
the flow. 
Effects.-The effects of haemorrhage are 
chiefly exerted upon the system generally; 
and they are therefore remarkably uniform, 
whatever may be its locality. The circum- 
stances that more especially affect the in- 
tensity of the effects or symptoms are two, 
namely, the amount of blood lost, and the 
rapidity of the flow. When haemorrhage is 
at once free and persistent, syncope rapidly 
ensues, probably accompanied by convulsions, 
and ending speedily in death unless the bleed- 
ing either spontaneously cease or be arti- 
ficially arrested (see Syncope). The sudden 
loss of one-half of the total amount of blood 
in the body is believed to be sufficient to 
cause death. On the other hand, enormous 
quantities of blood may be lost without a 
fatal result if the haemorrhage be slow, or 
frequently repeated with considerable inter- 
missions. The condition of the subject of 
the haemorrhage then becomes one of anaemia 
(see Anemia). More moderate bleedings 
frequently repeated produce faintness, and 
may cause a certain degree of pallor, which 
shortly disappears. Moderate haemorrhages 
from certain situations, for example from 
the nose, rectum, or even the lungs, may 
sometimes remove congestion, and be at- 
tended with a feeling of relief and with real 
benefit. 
Local effects do occur in some forms of 
haemorrhage. Haemoptysis is frequently ac- 
companied by inhalation of blood, and may 
lead to inflammation or more complex disease 
of the lungs. Haemorrhage into the urini- 
ferous tubules causes plugging of these, and 
discharge of blood-casts. Blood retained in 
the generative or in the respiratory passages 
occasionally becomes decomposed. The 
special symptoms of the several forms of 
haemorrhage are described under the head 
of each. 
Treatment.-The treatment of haemor- 
rhage from external parts is a subject oi 
purely surgical interest; but it may be said 
that, in cases of emergency, moderate pres- 
sure, with the finger or other means, on the 
seat of the bleeding, is generally practicable 
and successful. Haemorrhage from internal 
parts requires special treatment according to 
the particular organ from which it is pro- 
ceeding. The reader is, therefore, referred to 
the several articles on Epistaxis ; Hemate- 
mesis; Hematuria; Hemoptysis; Melena; 
Menses or Menstruation, Disorders of; 
Hemostatics ; and Styptics. 
J. Mitchell Bruce. 
HEMORRHAGIC (alpa, blood; and 
pgywp.L, I burst forth).-Associated with 
haemorrhage. The word is applied to certain 
inflammatory products or to effusions when 
they contain blood, as in hcemorrhagic peri- 
tonitis ; and to varieties of certain diseases 
in which extravasations or haemorrhages from 
free surfaces occur, for example hcemorrhagic 
small-pox, hcemorrhagic measles, and hcemor- 
rhagic purpura. 
HEMORRHAGIC DIATHESIS. 
See Haemophilia. 
HEMORRHOIDS (ntpa, blood; and 
pew, I flow).-Synon. : Piles; Er. Hemor- 
rhoides; Ger. Hcemorrhoiden. 
Description.-The haemorrhoidal vessels, 
and especially the veins distributed to the 
lower part of the rectum, are very liable to 
become dilated and varicose, giving rise to a 
disease termed hcemorrhoids or piles. When 
the plexus beneath the mucous membrane 
within the external sphincter is thus affected, 
the haemorrhoids are said to be internal. 
"When the veins beneath the integuments 
outside the muscle are enlarged, the haemor- 
rhoids are called external. Internal and ex- 
ternal haemorrhoids very frequently co-exist. 
External Hcemorrhoids.--We may distin- 
guish two kinds of external piles-(1) the 
venous; and (2) the cutaneous. 
(1) The venous tumour consists of a softish 
elevation of the skin near the margin of the 
anus, of a rounded form, and a livid or 
slightly blue tinge. On cutting into it, we 
find it is formed by a dilated vein or veins, 
which after inflammation will be occupied by 
a dark-coloured coagulum. 
(2) The cutaneous excrescence consists of 
a flattened prolongation of skin, due to hyper- 
trophy of the cutaneous layers, and is com- 
monly pedunculated. It is generally the 
result of the first form-a projecting skin tag 
left after absorption of the coagulum having 
undergone some hypertrophy. Often there 
is only a single broad flat excrescence at the 
side of the anus, but sometimes there are two 
-one On each side; and occasionally there are 780 
HEMORRHOIDS 
several encircling the anus. They are apt to 
become inflamed and oedematous. Similar 
excrescences occur as the result of irritating 
discharges from the bowel, and are common in 
stricture and chronic ulceration of the rectum. 
Internal Hemorrhoids.- Internal piles 
may be divided into three classes-(1) the 
venous ; (2) the columnar; (3) the nevoid. 
(1) The venous pile resembles the external 
venous pile, except that it is covered by mu- 
cous membrane and is within the sphincter. 
(2) The columnar pile consists essen- 
tially of hypertrophy of the folds of mucous 
membrane which surround the anal opening 
-the pillars of Glisson. They have a red, 
almost vermilion, colour, an elongated form, 
and contain within them one of the descend- 
ing parallel branches of the superior haemor- 
rhoidal artery ' (Hamilton). This pile is very 
vascular, bleeds copiously, and is made up of 
hypertrophied submucous tissue with many 
dilated arteries and veins. 
(3) The nevoid pile is bright red, spongy 
and villous, and has been well compared in 
aspect to a strawberry. In structure it re- 
sembles a capillary naevus. It may bleed 
almost continuously. 
Internal piles seldom attract attention until 
they have become so developed as to protrude 
at the anus in defecation. They then exhibit 
a remarkable diversity of appearance, ac- 
cording to their number, size, and condition. 
The protrusion may consist of only one large 
pile, found usually towards the perinaeum, 
especially in women. More commonly there 
are three distinct prominent growths, dif- 
fering in size, one at each side of the anus, 
and a third in front-the latter, the perineal, 
being the largest. In old cases they may be 
more numerous-as many as four or five. 
The distinction between them is commonly 
well-marked, but not always, for the piles 
sometimes merge into each other, so that the 
protrusion forms nearly a circular prominence. 
The aspect of extruded piles depends much 
upon their condition, whether congested, in- 
flamed, or constricted by the sphincter. In 
an inactive state, and in a relaxed condition 
of the sphincter, they form softish tumours 
of a granular appearance, presenting just at 
the orifice of the anus; but when protruded 
and congested, they constitute large tense 
tumid swellings, of a deep red colour and 
smooth surface, which readily bleed. When 
haemorrhoids are of large size, the integu- 
ments at the margin of the anus become 
everted, and form a broad band girting the 
base of the tumours. The skin thus everted 
is liable to be mistaken for external piles, 
and to be excised in operations-an error 
very likely to be followed by serious con- 
traction of the anus. 
Aetiology.-Haemorrhoids are a disease of 
middle and advanced age. They rarely occur 
before puberty; and but few persons in after- 
life altogether escape them. All circum- 
stances which determine blood to the rectum, 
or which impede its return from the pelvis, 
tend to produce this disease. There is in 
many persons a natural predisposition to the 
complaint, which may be hereditary. But a 
predisposition is most frequently acquired by 
sedentary habits, indulgences at table, and 
neglect of the bowels. Haemorrhoids, though 
a common disease in both sexes, occur more 
frequently in males than in females. Few 
women bear children without becoming in 
some degree affected by them; but the urinary 
and genital disorders of the other sex, com- 
bined with freer habits of living, leading to 
congestion of the liver, are still more fertile 
sources of piles. It must be remembered that 
piles may be a symptom only in certain 
cardiac, hepatic, or uterine diseases. 
Symptoms.-The symptoms produced both 
by external and internal piles vary greatly 
in different subjects, and in different stages 
of the complaint. 
External piles cause a feeling of heat and 
tingling at the anus. A costive motion is 
followed by a burning sensation, and the 
excrescence becomes swollen and tender on 
pressure, so as to render sitting uneasy. This 
congested state of the pile may pass off; or 
it may lead to inflammation accompanied 
with considerable enlargement of the haemor- 
rhoid, forming an oval tumour, red, tense, 
and extremely tender. In such case phlebitis 
has ensued, anil the pile cavity is occupied by 
a coagulum. The inflammation may subside 
or go on to suppuration. When the matter 
is discharged, the clot of blood escapes with 
it, the abscess closes, and the dilated vein is 
usually obliterated, the pile being reduced to 
a small flap of integument. External piles 
rarely give rise to bleeding. 
Internal piles, when slight, may exist for 
years, causing little inconvenience besides 
slight bleeding after a costive motion; with 
occasionally a feeling of fulness, heat, and 
itching just within the anus. If only small, 
they protrude slightly with the mucous mem- 
brane in defecaton, returning afterwards 
within the sphincter. When of large size, 
the piles always protrude at stool, and re- 
quire to be replaced, the patient usually 
pushing them up with his fingers. In a lax 
state of the sphincters, and in a loose hyper- 
trophied condition of the mucous membrane 
from which they spring, haemorrhoids come 
down, even when the patient stands or walks 
about, so as to prove exceedingly troublesome, 
and to interfere with his taking walking exer- 
cise. In consequence of the irritation from 
pressure and friction to which the protruding 
piles are hable, their mucous surface becomes 
tumid and abraded, and furnishes a free 
mucous discharge tinged with blood, which 
soils the linen. They are often so sore that 
the patient is obliged to keep the recumbent 
posture, the pressure in sitting causing more 
or less uneasiness. HEMORRHOIDS 
781 
Persons subject to piles frequently suffer 
no inconvenience from them until irritated 
by an unusually costive motion, or by a 
smart purgative; or when, under the excite- 
ment of alcohol, the growths become congested 
and inflamed, and cause spasm of the 
sphincter muscle. Then they have what is 
termed an ' attack of piles '-that is to say, 
they experience a sensation of heat, weight, 
and fulness just within the rectum, followed 
by considerable pain at stool, and sometimes 
irritation about the bladder. These symp- 
toms, which are often attended with febrile 
disturbance, arise from inflammation and 
swelling of the piles, which afterwards sub- 
side, but seldom without leaving some en- 
largement of the growths. Anaemia may 
follow upon continued bleeding; and reflex 
pains in the back, groin, and genitals are 
often complained of. 
Strangulation. - When internal piles of 
some size protrude at the anus and are not 
returned, they are liable to be constricted and 
strangulated by the external sphincter. The 
contracted muscle impedes the return of blood, 
and occasions inflammatory swelling of the 
piles, which may become strangulated and 
gangrenous. In this way haemorrhoids of 
large size have been known to slough off, the 
patient being relieved of the annoying com- 
plaint by a sort of natural process. An oc- 
currence of this kind is attended with a 
good deal of pain and suffering, but is free 
from danger. In general, the extremities 
only of one or two of the larger growths 
perish, and the patients, though experiencing 
relief, are by no means cured of the disease. 
Hcemorrhage.-One of the most common 
symptoms of internal haemorrhoids-indeed 
that from which the name of the complaint 
is derived-is haemorrhage, which occurs when 
the bowels are evacuated. The bleeding varies 
greatly in amount. Sometimes the motions 
are merely tinged with a few drops of blood; 
in other instances the quantity lost is con- 
siderable, several ounces being voided at 
stool. The bleeding may be irregular, oc- 
curring only after costive motions, or in 
certain states of health; or it may take place 
daily, going on even within the bowel, and 
producing the usual symptoms of derange- 
ment from continued losses of blood. The 
character of the bleeding also varies with the 
structural character of the pile, being, how- 
ever, usually venous. There are persons 
who are liable to discharges of blood from 
the haemorrhoidal veins, either at regular 
periods, or when, from good living or want of 
exercise, some plethora is induced. In these 
cases from three to six ounces of blood, or 
even more, pass away at stool, following the 
evacuation; and the blood which is voided is 
of a dark colour and evidently venous. Such 
discharges must not be rashly interfered 
with. They relieve congestion of the liver 
and kidneys, help to ward off attacks of gout, 
and prevent fits of apoplexy; so that in 
certain of these plethoric persons they are 
rightly regarded as safety-valves. The bleed- 
ing from internal piles is undoubtedly in 
some cases arterial. Sometimes the blood 
may be observed to escape from the pile in 
jets. This is not evidence that it is arterial, 
but may be due to a regurgitant stream of 
blood forced through a rent in a vein by the 
pressure of the abdominal muscles. That 
bleeding from piles is always good for the 
health is quite a mistaken notion; and it is 
important that the practitioner should dis- 
tinguish the bleeding taking place as a con- 
sequence of local disease, from that which 
arises from plethora, congestion of internal 
organs, or such a disease as cirrhosis of the 
liver. 
Treatment.-When piles are small and 
cause but little inconvenience, the treatment 
is very simple. Persons with this complaint 
should take stimulants in great moderation, 
if at all; and in most instances they would 
do well to abstain entirely from alcohol. 
Many individuals never suffer from piles 
except after taking a glass of spirit-and- 
water, or a few glasses of wine. Such per- 
sons should become water-drinkers. Active 
exercise in the open air should be taken 
daily; and the patient should avoid sitting 
too long at the desk, because it is by pro- 
longed sedentary occupation and the neglect 
of the rules of health that haemorrhoidal 
complaints are encouraged. Chairs with 
cane seats are to be recommended. The 
bowels must be carefully regulated, so as to 
avoid hard and costive motions, as well as 
too frequent action. Irritating the rectum by 
active and repeated purging is more hurtful 
even than constipation. In regulating the 
bowels, a simple enema of half a pint of 
cold water, injected after breakfast, answers 
most admirably, and is more efficacious than 
purgatives. If aperients be needed, prefer- 
ence may be given to confection of senna, 
cascara, or the compound liquorice powder. 
Carlsbad salts, or the foreign mineral waters- 
the Pullna, the Friedrichshall, or the Hunyadi 
J^nos-taken in the morning fasting, answer 
well with many persons, and ensure a com- 
fortable relief. The diet must be simple and 
moderate, and the habits of the patient 
regular. The relief afforded by this pallia- 
tive treatment is often remarkable. 
Ordinary bleeding may be met by injections 
of cold water, or by some astringent injection 
or ointment; among these may be named a 
solution of sulphate of iron (10 grs. to Jj), 
or preparations of tannic acid or rhatany. 
When the bleeding is copious, injections are 
not so successful, and operative treatment 
often becomes necessary. As a local appli- 
cation, the ointment of galls and opium is 
of value, or a combination of morphine and 
tannic acid. 
External piles when large and troublesome, 782 
HEMORRHOIDS 
HAIR 
and internal piles when they protrude at 
stool, and are not easily reduced, or are sub- 
ject to inflammation, ulceration, and frequent 
bleeding, can be removed only by operation. 
It is seldom desirable to operate upon piles 
developed during pregnancy, or upon haemor- 
rhoids symptomatic of grave constitutional 
disease. 
T. B. Curling. Frederick Treves. 
HEMOSTATICS {alga, blood; and 
arards, stopped). 
Definition.-Internal remedies and local 
applications which arrest haemorrhage. 
Enumeration. - The chief haemostatics 
are : the Ligature; Pressure ; Rest; Cold; 
the Actual Cautery; Astringents; and the 
whole class of Styptic drugs. 
Actions and Uses.-When taken in their 
widest sense, it is evident that haemostatics 
must include all the various means which 
have been devised to stop bleeding. Ex- 
ternally we must vary our plan of treatment 
according to circumstances. No surgical 
principles are better founded than those 
which enjoin us to tie a wounded artery, 
and to apply pressure to a vein; and for the 
absolute arrest of haemorrhage from any 
readily accessible part a most powerful aid 
has been provided in Esmarch's elastic 
bandage. When the bleeding depends on 
general capillary oozing, the application of 
ice may often prove effectual; and where 
this fails, recourse must be had to some of 
the numerous articles of the Pharmacopoeia, 
already referred to, which possess styptic 
properties {see Styptics). An example of 
the successful application of a haemostatic is 
the arrest of uterine haemorrhage by means 
of injections of perchloride of iron. In the 
case of undue haemorrhage from a leech-bite, 
if milder remedies, such as pressure, do not 
succeed, we may apply the solid nitrate of 
silver, or include the bleeding point in a loop 
of twisted suture. 
Absolute rest is essential for the successful 
treatment of haemorrhage; and the regula- 
tion of the diet and of the bowels is equally 
to be attended to. For the details of treat- 
ment in each particular form of haemorrhage, 
the reader is referred to Haematemesis ; 
Haemophilia ; Hemoptysis ; Mel^ena ; &c. 
Robert Farquharson. 
HEMOTHORAX. - See Hemato- 
TH0RAX. 
HAIR.-The intimate anatomical rela- 
tions which exist between the hair and the 
cuticle, on the one hand, and the skin-follicles 
on the other, naturally influence or determine 
the diseases to which the hair is liable. 
These diseases may be divided into three 
chief groups: those of nutrition and growth, 
including atrophic, hypertrophic, and pig- 
mentary changes; diseases associated with 
inflammation of the follicles, such as sycosis 
and other forms of folliculitis; and parasitic 
affections. The two latter groups will be 
found described under their respective heads, 
so that in this place we have to deal chiefly 
with the first group. 
Diseases involving the Nutrition 
and Growth of the Hair.-Most of the 
alterations in the growth and colour of the 
hair are atrophic in their nature. The more 
common forms of atrophy produce various 
kinds of baldness ; and in addition we have 
greyness or loss of the natural colour of 
the hair, and certain structural alterations, 
such as those met with in trichorexis nodosa; 
these latter alterations, though not simple 
atrophies, yet belong to the atrophic group. 
Alopecia or Baldness.-Baldness is of two 
kinds-congenital and acquired. Congenital 
alopecia is very rare; it is a malformation 
rather than a disease, and is generally asso- 
ciated with a defective development of the 
teeth. This condition is permanent. 
Acquired baldness arises from many dif- 
ferent causes. It may result (1) from various 
forms of disease; (2) from simple defective 
nutrition and growth ; or (3) from atrophic 
senile changes. 
(1) Baldness from various forms of dis- 
ease.-Different diseases produce baldness in 
different ways, and they may be conveniently 
divided into four groups: acute febrile dis- 
eases ; follicular inflammations ; nervous 
affections of the skin; parasitic diseases. 
The baldness which follows fevers is always 
temporary, though often severe. There is 
apparently an almost sudden death of the 
hair at the time of the fever, and this is 
followed by its falling off some two or three 
months afterwards. Parturition and some 
other illnesses besides fevers produce a 
similar result, though generally more slowly 
and persistently. The falling off of the hair 
which accompanies secondary syphilis is 
apparently produced in a similar way, and 
often occurs without any visible eruption on 
the scalp. 
Folliculitis, or inflammation of the hair- 
follicles, is one of the commonest causes 
of baldness. We meet with it in seborrhoea 
capitis, in sycosis, and in various pustular 
eruptions involving the hair-follicles. When 
produced in this way, alopecia may be tem- 
porary or permanent, according to the nature 
or the severity of the disease. All diseases of 
the skin which leave scars or obliterate the 
follicles lead to permanent alopecia of the 
parts affected. Erythematous lupus, sclero- 
derma, and some forms of syphilis, are 
examples. It is especially these forms of 
alopecia resulting from folliculitis which are 
so much aggravated by the stimulating appli- 
cations almost universally recommended by 
hairdressers, without regard to the cause of 
the malady. 
The changes in the nervous system which 
produce baldness may be general, as in some HAIR 
783 
cases of shock; or local, as in alopecia areata. 
Falling of the hair, which sometimes follows 
a blow or other injury, belongs to this class. 
See Alopecia areata. 
The parasitic diseases which lead to par- 
tial baldness are tinea tonsurans and favus, 
which are fully described under their proper 
headings. 
(2) Baldness from defective nutrition; 
and (3) Senile baldness.-Premature bald- 
ness from defective nutrition differs little 
from senile alopecia, and is often hereditary. 
The changes, however, in these cases are 
said to differ from those due to old age, inas- 
much as there is no thinning or atrophy of 
skin such as we meet with in senile baldness. 
This view is, however, certainly erroneous 
with regard to the great majority of cases, 
which are quite indistinguishable from senile 
baldness, not only in the part of the head 
affected, but also in the atrophic changes 
of the scalp itself. The two cases, in short, 
differ only in degree and not in kind. 
The treatment of this kind of alopecia, as 
might be expected, is not very satisfactory. 
Some good, however, may be done in the 
early stages by stimulating remedies. One 
of the best is a lotion consisting of vinegar 
of cantharides, f. $vi.; glycerine, f. 5j-» spirit 
of rosemary, f. Jij.; rectified spirit, f. 5 V. This 
should be dabbed on the scalp daily with a 
small sponge. Frequent and excessive sweat- 
ing is certainly an exciting cause of prema- 
ture baldness in those predisposed to the 
malady, and hence its frequent occurrence 
in Europeans who live in tropical climates. 
See Baldness. 
Pigmentary changes.-Canities, or grey- 
ness, results from the deficient development 
of the natural pigment of the hair. It may 
be congenital or acquired. The extreme 
form of congenital canities is met with in 
albinos, in whom there is an absence of 
pigment in the skin and choroid as well as 
in the hair. In an irregular form it some- 
times exists as a congenital white lock on 
the scalp or face, the surrounding hair being 
of a normal colour. 
As an acquired alteration in the hair, 
canities is well known as a simple senile 
change. Premature greyness, not differing 
essentially from the senile change, is often 
met with in those suffering from any chronic 
disease, such as phthisis; it is also more or 
less hereditary. In all these cases the grey- 
ness is symmetrical. In an unsymmetrical 
form it is met with in several diseases of 
the skin, especially in area, leucoderma, and 
chronic neuralgia of the scalp. The distri- 
bution of the grey hair and the history of 
the case will serve as a means of differential 
diagnosis. 
In many cases of canities any treatment 
is obviously useless. In those cases which 
admit of rational treatment, cantharides is 
by far the best local stimulant, as it has a 
tendency to excite the natural development 
of colouring matter, as may be often seen in 
the skin where a blister has been applied. 
Arsenic is usually the best form of tonic for 
the same reason. 
Excessive growth of hair.-Writers have 
generally stated that hairs may increase in 
numbers and size. With regard to an in- 
crease in their numbers, the statement can- 
not be accepted. Downy and almost invisible 
hairs may grow into strong and visible ones, 
but there is never any increase in their 
number ; it is really a great increase in their 
size which leads to the erroneous belief that 
they have multiplied. Sometimes the old 
hair is held in the follicle after the new hair 
has grown up, but this is not a true mcrease 
of numbers. An excessive growth of hair is 
not uncommon, and is chiefly inconvenient 
on the face in women. The ordinary de- 
pilatories which are used to get rid of this 
excessive growth are worse than useless. 
See Depilatories. 
Structural change in the hair.-Tricho- 
clasis, or trichorexis nodosa, is the most im- 
portant and best-known change in the struc- 
ture of the hair. The affection was first 
described by the late Erasmus Wilson and 
Beigel. To the naked eye the hairs appear to 
be marked with two, three, or more small 
bulging spots, somewhat resembling nits. 
The hairs very easily break at these points, 
which, examined under the microscope, seem 
to consist of spindle-shaped swellings of the 
shaft of the hair. In a more advanced stage 
this swelling partially bursts near its most 
distended part, and finally the hair breaks 
with a ragged fracture, so that the divided 
hair has the appearance of two brushes, the 
bristles of which are interlocked. When 
the separation is complete, a stumpy hair is 
left with a frayed or brush-like free ex- 
tremity. Trichorexis is chiefly met with in 
the hairs of the face, especially those of the 
chin. 
Lepothrix.-Although this curious affec- 
tion is'a concretion rather than a structural 
change of the hair, yet it has that appear- 
ance to the naked eye, and may be con- 
veniently referred to under this head. The 
hairs affected with this disease are met with 
in the axillae and on the scrotum. Indeed, 
warmth and moisture appear to be essential 
to its development. The concretions, seen 
under the microscope, have usually a rounded 
and nodulated form anparently surrounding 
the shaft of the hair, but not symmetrically. 
Sometimes the concretion extends con- 
tinuously for some distance along the shaft 
of the hair, giving it a feather-like appear- 
ance. The hairs themselves are abnormally 
brittle. The exact nature of these curious 
concretions has not yet been determined, but 
they are associated with a micrococcus. 
See Lepothrix. 
Robert Liveing. 784 
HALL, IN AUSTRIA 
HANGING, DEATH BY 
HALL, in Austria. - Common salt 
waters, with iodine. See Mineral Waters. 
HALLUCINATION (hallucinor, I 
blunder).-A false perception of an organ of 
sense, for which there is no external cause 
or origin (see Illusion) ; as when a man in 
total darkness thinks he sees an object. Hal- 
lucinations of all the senses occur, the most 
frequent being those of sight and hearing. 
They may be found in persons not insane, 
but indicate a disordered state of brain. 
HAMMAM-MELOUAN, in Algiers. 
Thermal muriated saline waters. See Mine- 
ral Waters. 
HAMMAM-MESKOUTINE, in 
Algiers (the Aquce Tibilitince of the 
Romans).-Highly thermal saline springs, 
weakly mineralised. See Mineral Waters. 
HAMMAM-R'HIRA, in Algiers.- 
Highly thermal waters. See Mineral 
Waters. 
HANGING, Death by.-Hanging is 
the effect of suspension of the body by the 
neck by means of a ligature or noose, the 
constricting force being the weight of the 
body, wholly or in part, or the weight multi- 
plied by the distance through which the body 
falls. The mode of death varies according 
to these circumstances. With a long drop, 
the method now usually employed in judicial 
hanging, and particularly if the knot is under 
the chin, death is not infrequently due to 
fracture, or displacement, of the cervical 
vertebra;, and injury to the medulla oblon- 
gata. Death may also occur, without such 
anatomical lesion of the cervical vertebrae, 
from shock or syncope, or, as it is termed by 
Casper, neuro-paralysis. 
When death does not occur in either of 
these ways, it is the result of asphyxia from 
occlusion of the air-passages, or rather of 
asphyxia in combination with coma, caused 
by compression of the cerebral blood-vessels. 
Though compression of the carotids and 
jugulars may be maintained for a consider- 
able time without a fatal result, if the trachea 
is open below the point of constriction- 
whereas death speedily ensues if the air- 
passages are also occluded-yet death may 
result from the disturbance of the cere- 
bral circulation alone; and the two causes 
operate conjointly in every case, in varying 
proportions. 
Phenomena.-When death is not instan- 
taneous, as in cases of injury to the medulla, 
or from neuro-paralysis, convulsive move- 
ments of the type seen in asphyxia may 
continue for some minutes after suspension, 
and the heart may continue to beat for a 
considerable period after all other vital 
movements have ceased. 
Subjects who have been partially hanged 
have described various sensations, more or 
less pleasurable, similar to those of cerebral 
congestion and narcotic stupor. 
Post-mortem Appearances.-The appear- 
ances found after death by hanging are not 
uniform or constant; and there is no single 
sign invariably present diagnostic of this 
mode of death. Indicative of suspension, but 
not necessarily of death so caused, is the 
mark of the cord on the neck. Usually it is 
above the hyoid, passing obliquely upwards 
behind the ears, and losing itself in the occi- 
put. But the position may vary according 
to the tightness of the noose before suspen- 
sion, or the position of the head and direction 
of the pressure. It is generally single, but 
if the cord should have been twisted twice 
round the neck, two marks may be found, 
one circular and the other oblique. The cha- 
racters of the mark differ somewhat accord- 
ing to the texture and thickness of the liga- 
ture. Usually it is a shallow groove or furrow, 
of a whitish or brownish hue and parch- 
menty consistence, occasionally abraded, 
rarely ecchymosed; but it may have livid 
edges or a chocolate tint. The appearances 
may vary in different parts of the same mark. 
The subcutaneous cellular tissue is com- 
pressed and silvery. Occasionally minute 
extravasations are seen in the deeper layers 
of the skin. The middle and internal coats 
of the carotids are sometimes lacerated; and 
where the momentum has been great, lacera- 
tions of the cervical muscles, hemorrhage in 
their vicinity, fracture of the larynx, rupture 
of the thyro-hyoid ligaments and fracture of 
the hyoid bone, and fracture or dislocation 
of the cervical vertebrae, with injury to the 
medulla and effusion into the spinal canal, 
have been found. All the appearances usually 
found in the neck in cases of hanging may 
be produced by suspension of the dead body, 
especially if the legs are pulled forcibly 
downward. 
The face is sometimes, but not commonly, 
distorted and expressive of suffering. Usually 
it is placid and pale, though if the body have 
hung for some time, it becomes very livid. 
The eyes are sometimes very prominent, and 
the pupils are usually dilated. Frothy mucus 
may be found at the mouth and nostrils. 
The tongue is pressed against the teeth and 
indented, or it may be clenched between the 
jaws. The base of the tongue is injected. 
The hands are often tightly clenched, the 
nails even being driven into the palms. 
Erection, or semi-erection, of the penis in 
men, with expulsion of semen or prostatic 
fluid, and vascular turgescence of the genitals 
in females, with sanguinolent effusion, are 
occasionally observed. Expulsion of the con- 
tents of the bladder and rectum is likewise 
common. The condition of the brain varies. 
Congestion of the meninges is sometimes 
pronounced, at other times not very marked. 
The mucous membrane of the larynx and HANGING, DEATH BY 
HAY FEVER 
785 
trachea is congested, and mucous froth is 
present. The lungs are at times pale and 
distended ; at other times collapsed. The 
condition of the heart and venous system 
characteristic of asphyxia is common. Marked 
redness of the mucous membrane of the 
stomach, simulating irritant poisoning, has 
been occasionally noted. The determination 
of the fact of death by hanging depends on a 
consideration of these various phenomena, 
and the absence of other causes of death. 
Accident, Suicide, or Homicide?-Hang- 
ing is rarely homicidal. It signifies great 
disproportion of strength between the assail- 
ant and the victim; and therefore, in the 
absence of this condition, there will be in- 
juries indicative of a struggle. Apart from 
collateral circumstances, homicide can only 
be argued from the presence of such injuries 
as could not have been self-inflicted or caused 
accidentally during the act of suspension. 
Occasionally hanging is accidental, as in 
foolish experiments and insane imitation. It 
is not necessary that the body should be 
entirely off the ground to cause death by 
hanging. Many instances are recorded of 
suicide by hanging in most extraordinary 
positions calculated to throw the greater part 
of the body-weight on the noose. 
Treatment.-This is rarely called for, ex- 
cept in accidents or attempted suicide. The 
body must be cut down, and artificial respi- 
ration employed. Venesection may be had 
recourse to for relieving cerebral congestion. 
See Artificial Respiration ; and Resusci- 
tation. D. Ferrier. 
HARKANY, in Hungary.-Thermal 
sulphur waters. See Mineral Waters. 
HARROGATE, in Yorkshire.- 
Saline, chalybeate, and sulphur waters. See 
Mineral Waters. 
HASTINGS, on the South-East 
Coast of Sussex.-A mild climate. Mean 
winter temperature, 40° F. Exposed to the 
east, but sheltered from the north. See 
Climate, Treatment of Disease by. 
HAUT MAL (Fr.)-A synonym for epi- 
lepsia gravior. See Epilepsy. 
HAY FEVER. - Synon. : Catarrhus 
cestivus ; Bostock's Catarrh ; Hay Asthma ; 
Fr. Asthme d'ete; Ger. Fruhsommercatarrli. 
Definition.-A catarrhal affection of the 
mucous membrane of the eyes, nose, mouth, 
pharynx, larynx, and bronchi, accompanied 
by dyspnoea; induced in persons predis- 
posed to it by the action of the pollen of 
various plants, chiefly of the Graminaceae; 
prevalent during the hay season, but sub- 
siding at its close; and varying in severity 
according to certain atmospheric conditions, 
and the amount of pollen present in the air. 
JEtiology.-Hay fever exists in Europe 
and North America, and it is especially 
common in England, where the number of 
cases is annually double that of any other 
country. The Anglo-Saxon race appears 
more liable to it than other races. It 
prevails more among men than women, 
probably because the former are most ex- 
posed to the atmosphere ; and inhabitants of 
towns visiting the country are more liable to 
attack than the country-people themselves. 
Dr. J. N. Mackenzie of Baltimore assigns 
hay fever to an exalted condition of the 
nasal erectile tissue, and especially the por- 
tion covering the posterior end of the inferior 
turbinated bone and the septum immediately 
opposite, rendering it more sensitive to the 
action of pollen and other irritants; and he 
maintains that destruction of this erectile 
tissue by the galvano-cautery cures the dis- 
ease. 
It has been ascribed by some writers to the 
sun's heat in the summer months, also to 
certain odours, vegetable and animal; but 
the experiments of Mr. C. H. Blackley show 
it to be due to the specific influence on cer- 
tain mucous membranes of the pollen-grains 
of the following natural orders of plants : 
Ranunculaceae, Papaveraceae, Fumariaceae, 
Cruciferae, Violaceae, Caryophyllaceae, Gera- 
niaceae, Leguminosae, Umbelliferae, Rosaceae, 
Liliaceae, Compositae, Graminaceae, and others, 
both exotic and native. Different kinds of 
pollen were applied to the mucous membrane 
of (1) the nares, (2) larynx, trachea, bron- 
chial tubes (by inhalation), (3) conjunctivae, 
(4) tongue, lips, and fauces; and in all these 
cases it produced the symptoms of hay fever, 
the pollen of grasses being most potent. 
Amongst these, secale cereale, or rye, exer- 
cised most marked effects, though greater 
influence is generally attributed to antho- 
xanthum odoratum. 
It has been found that large quantities of 
pollen float in the air during the summer 
months; and that the number of cases of hay 
fever depends on the amount present, which 
increases in warm damp weather, decreases 
when it is very dry and hot, and often nearly 
disappears after heavy rain. Cold weather 
reduces the number of sufferers by checking 
the inflorescence of plants. The higher strata 
of the atmosphere appear to contain more 
than that immediately overlying the soil; 
and Mr. Blackley found the greatest number 
of pollen particles at between 1,000 and 1,500 
feet above the earth's surface, whither they 
are probably carried by aerial currents. The 
number of pollen grains present reaches its 
maximum in June, when Mr. Blackley col- 
lected 880 in a day on a square centimetre 
of glass. The size and forms of the pollen 
grains vary greatly in the different species, 
but this does not seem to influence their 
action, which appears to depend on the 
pollen sac absorbing moisture from the 
contiguous mucous membrane and bursting, 786 
HAY FEVER 
when the minute granules it contains are 
thus extruded, and cause irritation. 
Symptoms.-An attack of hay fever gene- 
rally occurs without any premonitory distur- 
bance, immediately on the application of the 
pollen to the mucous surfaces-for instance, 
when the person enters a hay-field. The first 
symptoms are itching of the parts with which 
the particles come in contact, beginning with 
the hard palate and fauces, and then extend- 
ing to the nostrils, the eyes, and face, though, 
if the wind be strong, the eyes may be first 
attacked. The catarrhal stage follows, marked 
by violent fits of sneezing, and running from 
the eyes and nose, with occasional pains in 
the head and in the frontal sinuses ; then 
the submucous tissue of the nares swells; 
and in a short time both nostrils become 
blocked and impervious to air. A change 
to the recumbent position, however, if the 
patient lies on one side, will often re-open 
the uppermost nostril, while the other, as 
the result of gravity, becomes still more 
occluded. The sneezing will continue with- 
out fresh application of pollen, as at night, 
when the subsidence of the swelling restores, 
or even exaggerates, the sensibility of the 
Schneiderian membrane. The alae nasi be- 
come red and inflamed, and occasionally 
bleed. The discharge after this becomes 
less in quantity, inspissated and puriform, 
and finally subsides. In the eyes, the swell- 
ing of the submucous tissue causes closure of 
the lachrymal canals and nasal ducts; and 
considerable injection of the conjunctival 
capillaries is apparent. Sometimes, but rarely, 
oedema of the eyelids follows. Similar to the 
nose-symptoms are those occurring in the 
throat, some swelling taking place in the 
pharynx, which gives rise to partial closure 
of the Eustachian tubes, and hence to a 
certain degree of deafness. Slight feverish- 
ness is occasionally present, the pulse quick- 
ening to 100, and the temperature slightly 
rising; but in a large number of cases pyrexia 
is entirely absent. The changes which take 
place in the mucous membrane of the air- 
passages give rise to asthmatic symptoms, 
such as tightness of the chest, difficult and 
wheezy breathing, with prolonged expiration, 
and some dry cough, followed, at the close 
of the attack, by expectoration. 
The catarrhal symptoms are, however, 
more characteristic than the asthmatic, 
which are not invariably present. 
The liability to attack lasts generally from 
three to four weeks in summer, but its dura- 
tion depends on the presence of the exciting 
cause, which, if not removed, may cause the 
malady to last for months. A fall of rain will 
diminish the disorder by clearing the air of 
pollen; exercise, which increases the number 
of respirations and, therefore, of pollen grains 
inspired, will render it more severe; while 
each attack makes the individual more sus- 
ceptible to this subtle influence, and conse- 
quently augments the probability of other 
seizures. As a rule, hay fever has no com- 
plications, and passes away completely on 
the removal of the exciting cause. Constant 
recurrence of the attacks has been noticed 
to lead to deafness, owing to catarrh of the 
Eustachian tubes. 
Diagnosis.-The diagnosis of hay fever 
from other affections is easy, as the fact of 
the catarrhal symptoms occurring only in 
summer separates it from an ordinary ' cold 
in the head ' ; while their combination with 
dyspnoea in hay fever prevents it being mis- 
taken for spasmodic asthma arising from other 
causes, in which there is usually no catarrh. 
Prognosis.-The prognosis is favourable 
if the patient be removed from the exciting 
cause, as the asthmatic symptoms seldom, 
if ever, lead to pulmonary emphysema, or to 
any permanent change in the bronchi. 
Treatment.-The most obvious course in 
the treatment of hay fever, but not always 
the most easy one, is to avoid exposure to 
pollen. Mr. Blackley notices that a small 
amount of this material might exist without 
giving rise to hay fever, but if ten particles 
of pollen were detected on the glass slide ex- 
posed to the air for twenty-four hours, symp- 
toms were sure to appear in persons liable 
to it. Sufferers from this complaint should 
avoid hay-fields, hay-ricks, and much ex- 
posure and exertion in the country during 
the hay season, and should remain to a great 
extent within doors; but, where circumstances 
admit, change to the seaside is highly desir- 
able, and it frequently effects a speedy cure. 
Even on the coast some care must be taken 
to select a locality free from vegetation; for 
if the wind blows from the land, and hay- 
grass be flowering at the time, an attack may 
be induced. Choice should be made of a 
seaside place backed by high cliffs, and 
where the prevailing winds are from the sea. 
Another method of avoiding attacks is by sea 
voyages or short yachting cruises, undertaken 
during the hay season, and many sufferers 
enjoy complete exemption in this way. Of 
other localities, high mountain stations, where 
there is more grazing than hay-growing, and 
closely inhabited cities with few parks or 
grassy squares, are to be preferred. Carbolised 
cotton-wool and other available respirators 
are sometimes used with advantage. 
The medicinal treatment consists, first, in 
combating the general predisposition to the 
complaint by tonic measures ; and, secondly, 
in allaying the local irritation. 
The first object is best achieved by shower 
baths, and by such tonics as iron, quinine, 
mix vomica, sulphate of zinc, and arsenic. 
Lotions of sub-acetate of lead or sulphate of 
zinc applied to the eyes and inner surface of 
the nostrils give some relief; but the writer 
has found the most successful results from 
brushing the interior of the nostrils and 
pharynx with a solution of hydrochlorate of HAY FEVER 
HEADACHE 
cocaine (20 per cent.) with a curved brush. 
Sir Andrew Clark strongly recommends the 
application of a combination of glycerine of 
carbolic acid, quinine, and perchloride of mer- 
cury to the floor of the nares and pharynx. 
Various sprays are exceedingly useful, such 
as those of solutions of carbolic acid (eight 
grains to an ounce), sulphurous acid (equal 
parts with water), sulphate of quinine (two 
grains, with acid, to an ounce), and tannic 
acid (four grains to an ounce); but the best 
of all is a solution of cocaine (8 to 10 per 
cent.), which reduces the sensibility of the 
parts affected. The spray may be applied, 
with proper precautions, to all the irritated 
surfaces-eyes, nose, throat, and larynx- 
with great relief. 
C. Theodore Williams. 
HEADACHE.-Synon. : Cephalalgia ; 
Fr. Doulcur de tete; Ger. Kopfschmerz.- 
Pain or uneasiness in the head is very vari- 
able in its nature, and is produced by a great 
number of causes. It is present at some 
period or other in the course of most acute, 
and many chronic diseases; and may be 
associated or not with organic change in the 
brain, or in other organs of the body. 
Symptoms. - Headache presents many 
varieties. It may be slight or most intense ; 
superficial or deep-seated. It may be more 
or less confined to particular parts, as the 
forehead, the temples, the occiput, or vertex. 
Sometimes the pain is limited to one spot, 
producing the sensation as if a nail were 
being driven into the head, when it is called 
clavus. It may extend over one side of the 
head, as in hemicrania, or megrim; or be 
generally diffused. Headache presents every 
variety of character-dull, sharp, cutting, &c. 
Its accession may be sudden or gradual; and 
the paroxysms may be of the shortest possible 
duration, or may extend over hours, days, or 
months. The pain may be simple, or asso- 
ciated with various perverted sensations, such 
as giddiness, tingling in the limbs, disordered 
hearing, or disturbances of vision. 
Varieties.-For practical purposes head- 
aches may be arranged in the following 
order:- 
1. Structural headache, or headache de- 
pendent upon disease within the cranium. 
2. Congestive headache. 
3. Nervous or sick headache-hemicrania 
or megrim. 
4. Toxcemic headache. 
1. Structural headache.-This may be due 
to any of the many forms of disease of the 
brain, or of its membranes, such as menin- 
gitis, cerebral softening, abscess of the brain, 
cerebral tumour, &c.; or it may be premoni- 
tory of cerebral softening. It is nevertheless 
often wanting in these disorders, and the 
locality of the pain, when present, by no 
means corresponds with that of the lesion. 
As a rule, the pain of organic disease is fixed 
and habitual, though sometimes, as in abscess 
or cancerous tumour, it may be of an inter- 
mittent character. If there be sickness asso- 
ciated with it, the sickness occurs without 
any apparent gastric disorder, and the pain 
continues after the sickness ceases. Stooping, 
and even the recumbent posture, aggravates 
the pain, whilst it is lessened by elevating the 
head. If organic disease be suspected, the colla- 
teral symptoms must be carefully scrutinised 
and weighed. It rarely happens that organic 
disease needs to be inferred from pain alone. 
2. Congestive headache.-Many forms of 
headache depend upon a greater or less de- 
gree of congestion of the vessels of the brain ; 
the congestion being either active or passive. 
Active congestion may be caused by hyper- 
trophy of the left ventricle of the heart, 
general plethora, catamenial irregularities, 
mental or emotional excitement, and other 
conditions. The pain in such cases is of an 
obtuse character, affecting the whole or a 
part of the head, particularly the forehead 
and occiput. It is accompanied with a sense 
of pulsation in the ears, flushed face, glitter- 
ing eyes, and giddiness on stooping. 
Passive congestion may be produced by 
dyspnoea, by asthma, by valvular disease of 
the heart, or by disordered action of the liver, 
bowels, and skin; it may be an after-effect 
of drunkenness; or may result from any 
cause which can produce a state of debility 
in the vessels of the brain, such as general 
anaemia, exhaustion from fatigue, loss of 
blood, leucorrhoea, or that following over- 
excitement, mental exertion, or bodily fatigue 
-causes which all favour congestion. When 
the headache is induced by anaemia, debility, 
or indigestion, the pain occurs generally 
across the forehead or at the top of the head. 
3. Nervous or sick, headache, hemicrania 
or megrim.-This disorder is discussed in a 
separate article. See Megrim. 
4. Toxcemic headache.-The headache 
which attends all fevers and inflammatory 
disorders, though due in some measure to 
cerebral congestion, is chiefly caused by the 
action of the blood, altered in character and 
elevated in temperature, on the nervous ele- 
ments of the brain. In uraemia likewise the 
headache, which frequently precedes or ac- 
companies the other symptoms pointing to 
the existence of renal disease, results from 
the morbid condition of the blood. So also, 
in some persons, breathing the impure air of 
a crowded room, or the products of the com- 
bustion of gas, will, by the imperfect decar- 
bonisation of the blood, speedily produce a 
headache. 
Diagnosis.-Besides the above varieties of 
headache, pain about the head external to 
the brain may be produced by rheumatic 
affections of the scalp, with tenderness of 
the skin and rheumatism in other parts ; by 
syphilitic affections of the periosteum or 
bone ; by inflammation of the scalp, com- 
787 788 
mencing erysipelas, &c; and by trigeminal 
and other varieties of neuralgia. Headache 
may be discriminated from neuralgia by its 
mode of accession; by the generally longer 
duration of the attack ; and by the more 
complete intermissions. 
Treatment.-The treatment of headache 
must necessarily depend upon the peculiari- 
ties of each individual case. In organic or 
toxsemic headache, the disease with which it 
is associated, and not the symptom itself, will 
of course be the object of consideration, and 
the treatment will be found discussed in 
connexion with these special morbid states. 
The same remark applies to many forms of 
congestive headache, such as those produced 
by disease of the heart, asthma, &c. If cata- 
menial irregularities or uterine disorders are 
the exciting cause, these must be treated by 
appropriate measures. If anaemia or debility 
be present, then, in the intervals between the 
paroxysms, iron in some form, either alone or 
in combination with quinine or some vege- 
table bitter, must be given. During the 
paroxysms a little sal volatile, a cup of soup 
or strong tea or coffee, or some weak alcoholic 
stimulant, may be of service. Where anaemia 
is not a prominent symptom, or when the 
disorder assumes a periodical or intermittent 
character, quinine alone, in doses of two or 
three grains twice or three times a day, may 
be given; and if this fails to afford relief, 
arsenic. is often of signal service. Great 
benefit is frequently afforded in the latter 
cases by the careful administration of alco- 
hol or other alcoholic stimulant during the 
paroxysm. Except when the headache is 
associated with general plethora or active 
congestion, strong purgatives are to be 
avoided, and the bowels are to be regulated 
by the mildest aperient which will answer 
the purpose. The patient's habits and mode 
of life must also be strictly regulated; and 
care must be enjoined as to diet, sleep, cloth- 
ing, and exercise, especially if the headache 
be associated with dyspepsia. If dyspeptic 
symptoms are prominent, or if the pain be 
connected with a gouty diathesis, then these 
disorders must be treated with their appro- 
priate remedies. 
If during the paroxysms the head be hot 
and the face flushed, warm or cold lotions, 
iced water,or eau-de-Cologne may be applied; 
a warm douching may be useful in some 
cases. Occasionally in severe attacks a few 
leeches may be placed on the temples or 
behind the ears with advantage, or a blister 
to the nape of the neck, but never if the 
face be pale and the pulse feeble. Compres- 
sion of the temporal arteries with a pad, sus- 
tained pressure around the head, or holding 
the arms high above the head, will sometimes 
relieve severe congestive headache. 
The treatment of sick headache is discussed 
under the article Megrim. 
P. W. Latham. 
HEADACHE 
HEALING- SPRINGS, in Bath 
County, Virginia, U.S.A. - Thermal 
waters. See Mineral Waters. 
HEALTH, Maintenance of.-See Dis- 
ease, Causes of; Personal Health ; and 
Public Health. 
HEARING, Disorders of.-These 
disorders may be grouped under three 
classes, namely: (a) Partial or complete 
loss of hearing, or deafness; (i) Exalted 
hearing (so-called) ; (c) Perverted hearing 
or tinnitus. They may be due to various 
conditions quite independent of any actual 
disease of the auditory apparatus, and only 
such causes of disordered hearing will be 
considered in the present article as are not 
due to changes in the conducting portion of 
the ear, which can be demonstrated by the 
different methods of examination, or to 
recognised affections of the nervous appara- 
tus connected with hearing. These w ill be 
found discussed under the article Ear, 
Diseases of. 
(a) Partial or complete loss of hearing.- 
Perhaps the deafness due to accumulations 
of cerumen, which so frequently interfere for 
a time with the hearing of persons whose 
ears are free from disease, should be regarded 
as disordered hearing, rather than as a 
symptom of a pathological condition. As 
nothing more energetic than careful syringing 
is required to remove such obstructions, it 
will be sufficient to observe that in this pro- 
ceeding the nozzle of the syringe should be 
directed along the roof of the external canal. 
Amongst a very large number of people with 
the organs of hearing in an apparently 
healthy state, some few will be found upon 
whom, throughout their lives, certain notes 
produce no response. They will not, for 
example, be able to hear the sounds made 
by grasshoppers, or the singing of some 
birds-the call of a partridge, for instance ; 
and in most persons, as age advances, the 
very high notes are lost. To prove this, it 
is only necessary to blow one of Mr. Galton's 
whistles in a room full of people, when a 
considerable proportion of the assembly will 
fail to catch the high notes, which are dis- 
tinctly heard by the rest; and although this 
failure is also noticeable in many nervous 
affections, all other sounds will perhaps be 
heard quite normally by these individuals. 
Emotional influences play a very large part 
in the destruction or suspension of hearing, 
and this is especially observable in the case 
of women. The unexpected sight of a dead 
husband, hearing of the death of a dear 
friend, the proposal of a severe surgical 
operation on a relative, a quarrel, an alarm 
of thieves, and witnessing a carriage accident, 
have each within the knowledge of the writer 
been followed by intense and sudden deaf- 
ness, which has only been partially recovered 
from. The same effect has been noticed 
HEARING, DISORDERS OF HEARING, DISORDERS OF 
HEART, ABSCESS OF 
789 
with men who have been subjected to pro- 
longed mental strain, in connexion with 
literary work, or during commercial crises. 
It has been recorded that a deaf-and-dumb 
child has suddenly recovered hearing, after 
the discharge from the bowels of eighty- 
seven lumbrici and a large number of oxy- 
urides (Journ. of Med. Soc., 1844). Com- 
plete loss of hearing, extending over seve- 
ral months, was on one occasion followed 
by perfect hearing in a girl of fifteen, on the 
first appearance of menstruation. The tem- 
porary effect of quinine and salicylic acid on 
the hearing is well known, but when quinine 
has been administered in large doses, and 
for a long period, this special sense is not 
unusually injured permanently. Amongst 
the diseases which often induce a lasting 
deafness, without any perceptible local 
change in the conducting portion of the ear, 
may be included mumps, many of the fevers, 
and diphtheria ; for although in the two 
latter instances the middle ear often suffers, 
this is not always the case, and the imme- 
diate cause of the deafness must be sought 
in the products of inflammation which have 
been left within the cranium. The same 
explanation is probably also the correct one 
in those instances where children lose for 
ever all hearing power after cerebral excite- 
ment or congestion. Habitual and obstinate 
constipation is sometimes attended with loss 
of hearing, which returns after the action of 
purgative medicine, A clot of blood within 
the cranium, whilst causing hemiplegia of 
the opposite side, may destroy the hearing 
on the same side as the effusion; and a case 
is on record in which closure of the cerebro- 
spinal foramen gave rise to this symptom. 
(&) Exalted hearing. - What is termed 
' exalted hearing ' will generally, on careful 
examination, be found to be not so much a 
definite change in the capacity of the hear- 
ing apparatus to receive impressions, as an 
inability on the part of the patient to receive 
such impressions without an undue effect on 
the nervous centres being produced. Thus 
in many inflammatory states of the brain 
or its membranes this symptom is often a 
prominent one. It is also not uncommonly 
met with in hysterical and nervous persons. 
(c) Perverted hearing.-Attendant on most 
of the above examples, and closely allied to 
deafness, is the often persistent tinnitus; but 
there are conditions in which this distressing 
symptom is the chief and solitary trouble. 
Thus tinnitus, with a feeling of pulsation in 
the ear, is occasionally the first warning of 
an intracranial aneurysm; whilst a furious 
tinnitus and the hearing of strange noises 
sometimes precede an attack of acute mania. 
Patients who have been the subjects of 
malarial fevers and sunstroke often complain 
of tinnitus ; and as in all cases of disease of 
the ears, when present, it is the most in- 
tractable of symptoms, so it is when the ears 
have not been the seat of any malady or 
injury. 
Treatment.-Since all the above states 
of disordered hearing may strictly be said 
to be due to causes which are in them- 
selves abnormalities of one part or another 
of the organism, it is to these that the 
treatment will naturally be directed rather 
than to alterations in hearing which in truth 
are merely symptoms. See Ear, Diseases 
of; and Tinnitus. W. B. Dalby. 
HEART, Diseases of.-The study of 
this class of diseases has reference to the 
immediate pathological changes wrhich occur 
in the heart itself, and to the consequences 
or results of these changes upon its function, 
that is to say, upon the circulation of the 
blood. The latter portion of the subject will 
be found discussed in the articles which 
have reference to disorders of the special 
organs of circulation; and it will therefore 
be necessary in this place to summarise 
only the morbid changes which affect the 
heart itself, and this merely as an introduc- 
tion to the full description of those changes 
contained in the following articles, or which 
will be found in other parts of this work. 
1. The heart may be displaced, misplaced, 
or malformed. 2. Its various textures, in- 
cluding the coverings, the lining membrane, 
the valves, and the walls, are liable to acute 
and chronic inflammation and their effects. 
3. The organ itself as a whole may be in- 
creased in size, either by general dilatation 
of one or of more of its cavities, or partially, 
as by aneurysm of the walls ; or by an addi- 
tion to its volume, by hypertrophy of its 
muscular structure, of the fatty tissue which 
exists beneath the pericardium, or of the 
connective tissue which binds the muscular 
fibres together. 4. Its volume may be di- 
minished by simple or general atrophy; or 
by the walls of one or more of its cavities 
being wasted and thinned. 5. Its walls are 
liable to various forms of degeneration-more 
especially fatty, granular, calcareous, and 
pigmentary. 6. They may be the seat of 
fibroid disease, and of various morbid 
growths, such as cancer, tubercle, syphi- 
litic formations, or hydatids. 1. Conges- 
tion and hwmorrhage may occur in the 
walls of the heart. 8. These are liable also 
to such injuries as rupture-whether sponta- 
neous or as the result of violence; and to 
various kinds of wounds and their effects. 
9. The nervous apparatus of the heart may 
be affected, as in angina pectoris. 10. And, 
lastly, the reader will find discussed under 
the head of functional disorders of the heart, 
certain disturbances in its action and sensi- 
bility which cannot be clearly referred to 
any distinct lesion. Bichard Quain. 
HEART, Abscess of.- See Heart, 
Inflammation of; and Heart, Pyaemic Ab- 
scess of. 790 
HEART, ANEURYSM OF 
HEART, Aneurysm of.-Definition. 
A simple depression or a sacculus formed in 
the walls of the heart, and communicating by 
an orifice, varying in size, with one or more 
of its cavities. 
The term ' aneurysm of the heart ' has not 
been always used in this sense. It was first 
applied by Lancisi and subsequently by 
Bouilleau to any dilatation of the heart, 
whatever its cause or its character. Cases 
of the disease, as the term is now understood, 
were published by Galeatti and John Hunter 
in 1757. In this country, Dr. Thurnam, Dr. 
Peacock, more recently Dr. Wickham Legg, 
and others have treated the subject fully. 
In France aneurysm of the heart has been 
described specially by Breschet and by Pelvet; 
whilst in Germany, Lobstein, Lbbl, and Hart- 
mann have written upon it at length. A full 
account of the researches of these and several 
other writers will be found in the work of 
M. Pelvet-Fes Anevrysmes du Coeur, Paris, 
1867-and in the Bradshaw Lecture at the 
Boyal College of Physicians by Dr. Wickham 
Legg. 
Aetiology and Pathology.-The essential 
condition which leads to aneurysm of the 
heart is a change in a portion of the heart's 
texture, by which the resisting power of the 
affected part against the pressure of the blood 
from within the cavity is diminished. Under 
such circumstances a simple depression, corre- 
sponding to the weakened spot, may be first 
formed on the inner surface of the heart. 
This gradually extends through the cardiac 
wall towards the external surface, where 
the resistance becomes less, and where a 
pouch or sac is then formed, communicating 
with the cavity of the heart, it may be by a 
neck. The weakened condition referred to is 
attributable in different instances to inflam- 
mation of the substance of the heart, whether 
acute or chronic; to syphilitic or other 
growths; to fibroid and to fatty degenera- 
tion. 
(a) Inflammation of the heart, affecting 
either the endocardium or the substance of 
the heart itself, may lead to softening and 
ulceration; and both conditions have been 
found in connexion with aneurysm. Inflam- 
mation may also lead to the formation of 
pus in the walls of the heart; and cases are 
recorded in which, the contents of the sac 
thus formed having been discharged into the 
circulation, the cavity became converted into 
an aneurysmal pouch (Dr. Wilks, Path. Soc. 
Trans., vol. xii.) Cases of aneurysm of this 
character may be regarded as originating in 
acute inflammation of the heart. 
In a still larger number of cases, in which 
the endocardium and pericardium, as well as 
the muscular walls, are involved, we find a 
development of fibroid tissue-a cirrhosis, as 
it were, of the wall of the heart, as the result 
of chronic inflammatory action, and as some 
writers suppose of disease of the coronary 
arteries. In these cases the fibroid tissue is 
stretched at each systole of the heart, and it 
returns less and less to its former dimensions, 
owing to its want of elasticity. Thus by 
degrees the portion of the heart affected 
yields and is pushed outwards, forming a sac 
of a more or less globular shape. 
(6) Growths in the heart, whether syphi- 
litic or tuberculous, undergoing the process 
of softening, may lead to the formation of 
aneurysm, as in the conditions just described. 
(c) Fatty degeneration may give rise to 
the formation of aneurysm. First, a circum- 
scribed portion of softened tissue m the wall 
of the heart, the result of fatty degeneration, 
yields without rupture to the pressure of the 
blood from within, and thus allows of the 
formation of an aneurysmal pouch. Secondly, 
partial rupture may take place in the muscu- 
lar wall, and, haemorrhage occurring at this 
point, constitutes what is called ' cardiac 
apoplexy ' (see Heart, Haemorrhage into the 
Walls of). The clot thus formed undergoes 
the changes usual in extravasated blood; and 
a cyst results, which may ultimately commu- 
nicate with one of the cavities of the heart. 
Meriedec Laennec, who wrote on aneurysms 
of the heart, believed that this form of dis- 
ease was almost exclusively thus developed. 
With reference to the relative frequency of 
the various causes of cardiac aneurysm just 
enumerated, the writer finds that out of a 
total of 56 cases, the histories of which were 
collected by himself, in 21 the walls had 
undergone fibroid changes, which may have 
occurred before or during the progress of the 
aneurysmal formation; in 6 there was fatty 
degeneration; in 3 the disease was the 
result of ulceration; in 2 cases it appeared 
to have originated in abscess ; and in 24 the 
materials were not sufficient for arriving at 
an accurate conclusion. 
Age.-With regard to the age at which 
this disease occurs, in 62 cases collected by 
the writer the oldest was eighty-two, the 
youngest a child of twelve. Three cases 
occurred between ten and twenty years of 
age, 10 between twenty and thirty, 14 be- 
tween thirty and forty, 10 between forty and 
fifty, 7 between fifty and sixty, 10 between 
sixty and seventy, 6 between seventy and 
eighty, and 2 between eighty and ninety 
years of age.1 
Sex.-Of 62 cases, 45 were males and 17 
were females. 
Anatomical Characters. - Keeping in 
view the several conditions under which 
aneurysm of the heart can occur, we may 
expect to find a corresponding variety of 
morbid appearances. On laying open the 
pericardium in cases in which aneurysm of 
the heart exists, adhesions which are more 
or less universal, or which may be limited 
1 Sacs connected with the cavities of the heart 
have been found at birth occasionally. They must be 
regarded as malformations. HEART, ANEURYSM OF 
791 
to the seat of the disease, are very fre- 
quently found. The heart itself is generally 
enlarged; and where the aneurysm projects ! 
externally it is altered in shape, so much so I 
in some instances that the organ looks like ; 
a double heart. The sac may project from 
the walls as a rounded or conical tumour; 
or, as in an instance that came under the 
notice of the writer, it may assume the 
appearance of an elongated sac winding round 
the base of the aorta. Again, nothing abnor- 
mal may be observed until the heart is laid 
open, when a depression or an opening may 
be discovered in the walls of the ventricle, 
or in the septum. In some instances more 
than a single pouch is formed: there may be 
several, each communicating with the cavity 
of the heart by a separate or by a common 
opening. The size of the tumour may vary 
from that of a bean to that of an average- 
sized cocoa-nut. The opening leading into 
the pouch may be the widest part of the 
sac, the aneurysm being a mere depression ■ 
like a watch-glass or half an egg ; or there 
may exist a constricted or defined neck, 
leading to a tumour bulging from the walls. ! 
The size of the opening may vary from a 
couple of inches across, to one capable of 
admitting only a probe. The neck is, in a 
few cases, described as hard and cartilagi- 
nous ; in others, as being smooth and regular, 
or jagged and irregular. The walls of the 
tumour may be formed by the dilated and 
thin walls of the heart; or by the walls con- 
siderably thicker than natural, and altered in 
texture. A very usual condition to find is 
that the walls of the sac consist, proceeding 
from within outwards, of endocardium; 
of fibroid tissue, with or without portions of 
muscular tissue ; and of pericardium. This 
condition was described as occurring in 11 
cases. In 8 cases the walls were said to 
consist only of the endocardium and pericar- 
dium, with fibroid tissue between; but it was 
found that at the base of the tumour, in all 
these cases, all the layers of the heart-tissue 
were present, and that it was only towards 
the apex of the swelling that the muscular 
layers disappeared. In 3 cases the walls of 
the aneurysm were said to be composed of 
a thin membrane, which appeared to consist 
of endocardium and pericardium only. In 
3 cases the walls were of cartilaginous con- 
sistence, with bony plates interspersed in 
the tissue. The thickness of the walls of 
the sac varied from that of paper to three 
lines or more. In 14 cases the wall of the 
tumour was strengthened .by an adherent 
pericardium. The aneurysmal cavity in the 
majority of cases was lined by smooth mem- 
brane; but in a few instances, apparently 
of acute formation, the walls consisted of 
muscular fibres, torn and separated by the 
blood which had been extravasated amongst 
them. The contents of the sac are generally 
in the form of blood-clots or layers of fibrin, 
the outermost layers of which may be more 
or less organised and adherent to the wall. 
Seat.-Of the 56 cases already alluded to, 
52 were in the left ventricle, 3 in the right 
ventricle, and 1 in the right auricle. Of 
the 52 cases in which the aneurysm was 
situated in the left ventricle, 22 occupied the 
apex, 11 the base, and 17 were in inter- 
mediate situations. Several cases have been 
recorded in which the aneurysm was situated 
in the muscular septum between the ventri- 
cles ; in the ' undefended space ; ' 1 or at the 
base immediately below the aortic valves. A 
case of the last-named form was recorded by 
the writer in the third volume of the Trans- 
actions of the Pathological Society. These 
two last forms are generally associated with 
endocardial inflammation and ulceration. 
Symptoms.-In 13 of the 56 cases referred 
to, the aneurysm was not discovered until 
after death; no mention being made of signs 
or symptoms of its previous existence. In 
the remaining cases, symptoms, more or less 
marked, indicative of heart-disease, were pre- 
sent. These symptoms were chiefly-pain, 
dyspnoea, lividity of the surface, palpitation, 
and irregularity of the pulse. In 10 cases 
murmurs were heard, accompanying or re- 
placing the sounds of the heart. We thus see 
that the symptoms of aneurysm are such as 
may exist in common with other lesions of 
the heart; and it is extremely doubtful, 
except in presence of some special circum- 
stances indicative of this condition, whether 
we have at our command the means of 
diagnosing the existence of cardiac aneurysm. 
The writer not long since saw, with Dr. 
Holman, late of Reigate, a case of grave 
heart-disease, in which extended dulness to 
the left, and below the usual situation of the 
1 apex-beat, with a feeble impulse in the same 
situation, led to a suspicion of the probable 
; existence of cardiac aneurysm. 
Progress, Duration, and Terminations.- 
Pathological testimony fully justifies the 
inference that certain cardiac aneurysms- 
such as those which originate in inflammatory 
softening, ulceration, or the opening of cysts 
into the cavities of the heart-are acute in 
their formation. But the like evidence 
further testifies that the formation of most 
other aneurysms, and the progress of all, are 
of a slow or chronic character. Still it would 
seem to be difficult, if not impossible, to 
determine the duration of the disease in any 
given instance, inasmuch as many cases, for 
example, have been found in the post-mortem 
room, which had not given rise to any special 
symptoms; whilst in other cases the pre- 
existence of heart-disease before the forma- 
tion of aneurysm rendered it equally impossi- 
ble to fix a date for the development of the 
latter special disease. 
| 1 A case of this character, apparently congenital, 
was described by Dr. Angel Money in a child five 
years old. See Path. Soo. Trans., vol.xxxviii. p. 97 792 
HEART, ANEURYSM OF 
HEART, ATROPHY OF 
Death may result from the disturbance of 
the heart's action, induced by the presence and 
the extent of the disease ; from the aneurysm 
opening into the pericardium; or from its 
burrowing in the wall of the heart, and open- 
ing into another cavity of the organ different 
from that in which it originated. Lastly, 
one or two cases are recorded in which a cure 
of the disease had apparently been effected by 
the walls of the sac becoming indurated or 
calcified. 
Diagnosis and Prognosis.-Seeing how 
extremely obscure the clinical history of 
these cases is, it would be impossible to speak 
more definitely either as to the diagnosis or 
the prognosis of the disease than has been 
done under the preceding head. 
Treatment.-The treatment of cardiac 
aneurysm must be such as would be adopted 
in any other form of grave heart-disease, and 
according to the special circumstances of, 
and indications in, each case. We can only 
seek to mitigate the more urgent symptoms, 
whether local in the heart itself, or more 
generally affecting distant organs. 
Richard Quain. 
HEART, Apoplexy of.-See Heart, 
Haemorrhage into the Walls of. 
HEART, Atrophy of.-Definition.- 
A diminution in the size and weight of the 
heart as a whole ; or a diminution in size of 
one part of the heart in relation to the whole 
organ. 
Aetiology.-The causes of atrophy of the 
heart are either general or local. With respect 
to the general causes of atrophy, the heart is 
found reduced in volume together with the 
other organs of the body, in cases of maras- 
mus, of phthisis, of syphilis, cancer, &c. Prob- 
ably one of the smallest hearts on record- 
one which weighed but 3^ ounces-was 
found by Dr. Church in the body of a woman 
aged forty-seven, who died of cancer of the 
pylorus, after an illness characterised by 
' gradual starvation ' of more than seventeen 
months' duration. With reference more 
especially to phthisis, as affecting the size of 
the heart, an analysis of 171 cases, made by 
the writer at the Brompton Hospital, showed 
that this organ was below the average weight 
in 54'4 per cent. Diseases of a sub-acute 
character, such as typhoid fever when pro- 
tracted in its course, may lead likewise to 
wasting of the heart. The heart is also occa- 
sionally congenitally small. 
The local causes of atrophy of the heart are 
chiefly two-namely, (1) pressure by pericar- 
dial adhesions upon the heart, by mediastinal 
tumours, by fatty growth beneath the peri- 
cardium, and other like conditions; and (2) 
interference with the circulation in the 
coronary arteries, as in the conditions just 
enumerated, or as a result of malformation 
or of disease of the vessels themselves. 
Partial atrophy of the heart, when it occurs, 
may be said to be referable to insufficient 
blood-supply from vascular disease or from 
local pressure ; or from fatty infiltration. 
Anatomical Characters.-The heart in 
simple atrophy presents a general uniform 
diminution in size, as regards both its walls 
and its cavities ; and in its weight. In local 
atrophy, a portion of the cardiac wall, more 
or less extensive, or of one of the divisions or 
cavities of the heart, may be found to be 
below the ordinary dimensions. The colour 
of the atrophied heart may be normal; it is 
frequently pale; and it is occasionally of a 
deep reddish-brown. The pericardium, not 
shrinking proportionately with the muscular 
substance, may present a puckered, opaque, 
and cedematous aspect, ' like a withered 
apple ' (Laennec) ; and for the same reason 
the coronary vessels may be tortuous and 
prominent. The consistence of the walls 
is generally firmer than natural; and the 
muscle may be even tougher, except where 
the atrophy is due to the presence of fat, in 
which case the fibres are friable, and on 
microscopical examination present the ap- 
pearances of fatty degeneration. In simple 
atrophy of the heart, the muscular fibres 
undergo diminution in volume; and they 
may also be actually reduced in number. 
Atrophy of individual muscular fibres is also 
found as the result of interstitial fatty or 
fibroid growth ; and this when extensive has 
been somewhat erroneously named ' yellow 
atrophy.' Another variety, which is most 
frequently found in the marasmus of old age, 
is known as brown atrophy of the heart. In 
such cases the muscular tissue is of a dark 
or dirty reddish-brown colour, which proves 
on microscopical examination to be due to 
the presence of numerous shining yellow or 
brown pigment-particles within the muscular 
fibres, and specially abundant either around 
the nuclei or between the ultimate fibrillae. 
Symptoms.-The symptoms and signs of 
atrophy of the heart are those which might 
be expected to result from diminished size 
and power of the organ. The characteristic 
phenomena are those of feeble circulation. 
The physical signs are chiefly diminished 
praecordial dulness; a feeble impulse, the 
apex-beat being within and above the usual 
situation ; diminished area of audible sounds; 
and a small, weak pulse. 
Diagnosis.-The above signs and symp- 
toms, in association with general wasting, 
afford sufficient grounds for the diagnosis 
of atrophied and feeble heart. Emphysema, 
pericardial effusion, and other causes of 
diminished cardiac dulness and weakness of 
impulse, must be excluded by the ordinary 
modes of investigation. There are no special 
means by which partial atrophy of the heart 
can be diagnosed, except, possibly, that the 
presence of this condition may be assumed 
where the functions of the organ are disturbed 
in the absence of valvular or other of the HEART, ATROPHY OF 
HEART, CONGESTION OF 
793 
more common forms of cardiac disease, suffi- 
cient to explain the symptoms. 
Treatment.-The treatment of atrophy of 
the heart is the treatment of the primary 
disease upon which it depends, so far as is 
possible. Richard Quain. 
HEART, Calcification of.-See Heart, 
Degenerations of. 
HEART, Cancer of.-See Heart, Mor- 
bid Growths in. 
HEART, Cirrhosis of.-See Heart, 
Fibroid Disease of. 
HEART, Congenital Misplacement 
of.-Synon. : Ectopia Cordis (Breschet); 
Ectocardia (Alvarenga). 
The heart is occasionally found to occupy 
a wrong position, and such misplacement may 
be either within the cavity of the thorax, or 
external to it. 
1. Of the internal malpositions-ectopia 
cordis intrathoracica or ectocardia intra- 
thoracica-the most common is that io which 
the term dexiocardia has been applied, in 
which the heart is in a very similar position 
on the right side of the chest to that which 
it should occupy on the left. This condition 
may coexist with transposition of the other 
viscera of the body, or it may occur alone. 
Instances of the former kind have long been 
placed on record, cases having been met with 
in Rome in 1643, in Paris in 1650, and in 
London in 1694. When the heart is mis- 
placed, the aorta generally follows an ir- 
regular course, crossing the right bronchus 
and passing down to the right side of the 
bodies of the vertebrae ; and the right carotid 
and subclavian arteries are given off as sepa- 
rate vessels, while the brachio-cephalic trunk 
is situated on the left side. In some in- 
stances, however, the vessels at the arch are 
not transposed; whilst in others the aorta, 
after passing over the right bronchus, crosses 
the spine and follows its usual course to the 
left of the bodies of the vertebrae. In cases 
of transposition the heart itself may be well- 
formed ; or it may be very imperfectly de- 
veloped. 
In another kind of misplacement, meso- 
cardia, the heart is situated more in the 
median line than natural-a position which 
it occupies in the foetus at the earlier periods. 
Cases have also been recorded in which the 
organ occupied a transverse, and an antero- 
posterior direction. 
2. Of the external misplacements, those 
in which the heart is situated external to 
the thoracic cavity-ectopia or ectocardia 
extrathoracica-the most common is that in 
which, from deficiency of some part of the 
sternum, the organ lies in front of the chest 
- ectopia cordis or ectocardia pectoralis. 
In other cases, from deficiency in some por- 
tion of the diaphragm, the heart is placed in 
the abdomen, either lying in the cavity, or, 
if the integuments are partially defective, in 
a sac in the praecordia-ectopia cordis or 
ectocardia abdominalis. In a third form 
the heart lies at the root of the neck - ectopia 
cordis or ectocardia cephalica. Of these 
forms, examples are related or referred to in 
the memoirs of Breschet and Alvarenga, and 
various others have been published since the 
appearance of the memoir by Breschet. 
Symptoms, Duration, and Terminations. 
-When the heart is well-formed, its mal- 
position within the thorax does not neces- 
sarily cause such interference with its func- 
tions as to be productive of symptoms, or 
materially to curtail the duration of life. 
Indeed, cases are on record in which the 
heart and other viscera have been transposed 
in persons who had never presented any 
signs of disorder of the circulation, and who 
lived to very advanced ages. When, how- 
ever, the organ is also defective, and espe- 
cially when the displacement is external to 
the thoracic cavity, life is usually only of 
short duration - though some remarkable 
cases of external displacements are on re- 
cord, in which the patients survived to ad- 
vanced ages. 
Malformation of the Pericardium.- 
Closely allied to the cases of misplacement 
of the heart are those in which the organ, 
though occupying its natural position, is not 
covered by the pericardium, but lies in con- 
tact with the lung in the left pleural cavity. 
Of this form of anomaly various instances 
are recorded-the first undoubted case of the 
kind being probably that represented by Dr. 
Baillie, in 1778. The defect seems to con- 
sist in the pericardium, which is apparently 
reflected from the external coat of the aorta, 
not being prolonged so as to cover the front 
of the heart and become attached to the dia- 
phragm. The imperfectly developed mem- 
brane is represented by a kind of loose fold, 
or pocket, which is found on the right side or 
upper part of the heart. 
Effects.-This condition does not seem 
materially to interfere with the functions of 
the organ. Cases are recorded in which the 
subjects lived to middle age; and the writer 
has himself seen it in a man who died of 
heart-disease at seventy-five. 
T. B. Peacock. 
HEART, Congestion of.-Attention 
was first directed to this morbid condition 
of the heart by Sir William Jenner (Med.- 
Chir. Trans., vol. xliii., p. 199). The 
coronary veins, like the veins of other parts, 
are subject to engorgement when the flow 
of the blood from them into the right 
auricle is interrupted. The most common 
cause of this interruption is dilatation with 
distension of the cavities of the right side of 
the heart, which conditions are themselves 
usually due either to emphysema or to 
valvular ditease of the heart. Disease of the 794 
HEART, CONGESTION OF 
HEART, HYPERTROPHY OF 
trunks of the coronary veins and pressure 
upon them may be regarded as less frequent 
causes of cardiac congestion. 
Post mortem, congestion of the heart is 
recognised, when recent, by fulness of the 
veins on the surface of the organ; by cedema 
of the loose connective tissue at the base; 
and ecchymosis of the pericardium and endo- 
cardium. The pericardial sac contains some 
serous or sero-sanguinolent effusion; and 
the mouth of the coronary sinus may be 
found to be dilated. When the congestion 
is slight, gradually developed, and of long 
standing, the venous fulness gives rise to an 
increased formation of connective tissue in 
the walls of the heart, which become, in con- 
sequence, tough and indurated; whilst the 
dilatation of the cavities, with which the 
congestion is associated, is rendered per- 
manent by the same cause. When divided 
with the knife, the cardiac walls do not fall 
inwards; their substance feels like a piece of 
leather; and the section has a smooth homo- 
geneous appearance. Microscopically, the 
connective tissue seems to be increased in 
quantity; and the muscular fibres are in a 
condition of granular, fatty, and pigmentary 
degeneration. 
Congestion of the heart possesses no direct 
clinical relations; but its existence should 
never be overlooked in estimating the effects 
on the circulation of mechanical congestion, 
which must impair the functional activity 
of the heart in the same way as it impairs 
that of the liver, stomach, and kidneys. 
J. Mitchell Bruce. 
HEART, Connective-Tissue Hyper- 
trophy of.-Synon. : False Hypertrophy. 
Definition. - An excessive development 
of the connective tissue which exists between 
the muscular fibres of the heart, causing an 
increase in the size of the organ. 
Anatomical Characters.-In connective- 
tissue hypertrophy the heart is enlarged more 
or less uniformly as regards the walls of its 
several cavities, and usually to a great extent, 
the organ weighing in some instances as much 
as forty ounces. The thickness of the walls 
is increased, as in simple or true hypertrophy; 
their density and consistence are such as to 
present a firm, tough, leathery character. 
When cut the edges do not collapse, but con- 
tinue stiff and prominent. The colour of a 
heart in this condition may vary from pale 
buff to deep purple, according to the amount 
of connective tissue, and of blood present in 
the vessels. Microscopically there is seen- 
not the usual limited amount of inter- 
muscular fibrillar tissue and connective- 
tissue cells, but a decided hyperplasia of 
these elements, in the form of connective- 
tissue, of which all stages of development 
may sometimes be observed, from the round 
and spindle-shaped cell to the complete 
bundle of fibrillae. Between the individual 
bundles of this tissue lie the muscular fibres, 
which are also hypertrophied, but which are 
more or less compressed, and are occasionally 
in a condition of granular or fatty degene- 
ration (fig. 59). 
There is a certain amount of anatomical 
resemblance, but a very clear pathological 
distinction, between this form of heart-disease 
and the change described by Sir William 
Jenner as fibroid disease of the heart result- 
ing from congestion (see Heart, Congestion 
of). Connective-tissue hypertrophy may also 
to some extent be compared with the fibrosis 
described by Sir William Gull and Dr. Sutton 
as existing in the walls of arteries and other 
tissues. 
^Etiology.-Cases of hypertrophy of the 
heart have been described by several writers 
which were remarkable for the absence of 
disease of the valves, or of the blood-vessels, 
or of the kidneys, which, if present, could 
explain its origin, but which the writer be- 
lieves were due to the morbid change above 
described, and not to hypertrophy of the 
muscular fibres alone. A remarkable speci- 
men is preserved in the museum of St. 
George's Hospital, consisting of a heart 
weighing forty and a-half ounces, which was 
removed from the body of an under-butler, 
in the post-mortem examination of whom 
nothing was found which could satisfactorily 
explain the occurrence of the enlargement. 
Fig. 59.-Connective-tissue Hypertrophy of the 
Heart.-a a, Connective-tissue fibrillae, b b, Mus- 
cular fibres, x 250. 
The writer is indebted to Dr. Whipham for 
an opportunity of examining this specimen, 
which was found by his friend, Dr. Mitchell 
Bruce, to possess the microscopical characters 
above described and figured (fig. 59). This 
and similar cases exhibit no appearance of 
chronic inflammatory action, and thus differ 
altogether from examples of that form of 
fibroid degeneration which is described under 
a separate heading (see Heart, Fibroid Dis- 
ease of). In the cases now described there is 
a simple hyperplasia of connective tissue, the 
origin of which cannot be fully explained. In 
Germany a similar enlargement of the heart HEART, HYPERTROPHY OF 
HEART, DEGENERATIONS OF 
795 
is said to have been found more especially in 
gourmands, and hence it derived a character- 
istic appellation. The existence of connec- 
tix e-tissue growth being thus determined, the 
effect of its presence on the muscular tissue 
is obvious. The connective tissue, surround- 
ing, as it must do, the muscular fibres, inter- 
feres with their free action, to overcome 
which there will be a natural tendency to 
increased action, and consequent hypertrophy 
of the muscular fibres themselves. It is very 
probable that it is to these two processes 
going on simultaneously that the great in- 
crease in the size of the heart is due. 
Symptoms and Diagnosis.-In a remark- 
able case recorded by the late Dr. Hyde 
Salter, which the writer believes to have 
been of the nature here described, acute or 
severe cardiac dyspnoea and haemoptysis, from 
which the patient had suffered for several 
weeks, were the most prominent symptoms. 
The heart-sounds were natural, except that 
the first was dull and defective. The pulse 
was 84. The symptoms increased in severity, 
and were aggravated by excessive epistaxis. 
The patient died after being in hospital for 
fourteen days. At the post-mortem examina- 
tion the heart was found to be of great size, 
and there was no disease either of the valves 
or of the vessels or of the kidneys to account 
for this. In the case of the butler in St. 
George's Hospital, it is recorded that he con- 
tinued going about until within a few days of 
his death. These and some like cases indi- 
cate that we can do little in the way of 
diagnosis beyond recognising the presence of 
cardiac hypertrophy by the usual signs; and 
if the hypertrophy be considerable, and if 
there be no valvular disease and no kidney- 
disease, we might not be far wrong in con- 
sidering that the hypertrophy was caused by 
increase of some other element as well as 
that of the muscular fibres. 
Treatment.-If the opinion be correct that 
this form of disease finds its origin in exces- 
sive alimentation, it would be well to place 
the patient in such circumstances as would 
prevent this, giving attention at the same 
time to other hygienic conditions. The more 
aggravated symptoms of cardiac disease must 
be treated on general principles. 
Richard Quain. 
HEART, Coverings of, Diseases of. 
See Pericardium, Diseases of. 
HEART, Degenerations of.-The de- 
generations that affect the heart may be 
enumerated as follows : (1) Fatty; (2) Paren- 
chymatous ; (3) Albuminoid; (4) Pigmentary; 
(5) Cartilaginous; (6) Calcareous ; and (7) Vit- 
reous. The condition which has been called 
'fibroid degeneration' of the heart is described 
under the heads of Heart, Fibroid Disease 
of; and Heart, Syphilitic Disease of. 
1. Fatty.-This form of degeneration of 
the heart being of special importance is 
discussed in a separate article. See Heart.. 
Fatty Degeneration of. 
2. Parenchymatous.-Synon. : Granu- 
lar Degeneration; Cloudy Swelling; ? Paren- 
chymatous Inflammation. 
Aetiology.-This form of degeneration of 
the heart is generally met with in the acute 
specific fevers, especially typhus, and typhoid 
fever, diphtheria, and septicaemia; and is 
probably referable to the action either of the 
poison or of the high temperature attending 
the disease-process upon the muscular sub- 
stance. See Degeneration. 
Anatomical Characters. - The disease 
generally attacks the heart as a whole. The 
organ appears somewhat enlarged, extremely 
soft-flabby as well as friable, and of a dirty 
greyish-red colour. The pericardium is 
ecchymosed, dull, and swollen, and the 
epicardial fat has more or less completely 
disappeared. Microscopically, the muscular 
fibres are found to be dull and granular, 
swollen, and variously ruptured; their stria- 
tions are indistinct; and the addition of acetic 
acid removes many of the granules from the 
fibres, whilst it brings more distinctly into 
view a few fatty globules, and frequently an 
increased number of pigment-particles. 
Symptoms.-Inasmuch as parenchymatous 
degeneration of the heart is usually but a 
complication of some acute specific disease, 
the condition of the patient is one of great 
febrile prostration with cardiac asthenia. 
The physical signs, which are regarded as 
more distinct evidence than the symptoms 
of the condition of the heart, are-feebleness, 
advancing to complete absence, of the apex- 
impulse, or more rarely palpitation; and pro- 
gressive weakening, and. finally loss of the 
first sound. The pulse has been described 
as corresponding with the condition of the 
heart, indeed in some cases it is imperceptible 
although associated with cardiac palpitation. 
Course and Terminations.-The course 
and terminations of granular degeneration of 
the heart are inseparable from those of the 
primary disease. In typhus the average date 
of the appearance of the symptoms and signs 
just described is the sixth day of the fever; 
and they usually cease on the fourteenth day, 
but a large proportion of cases prove fatal 
before that time. 
Prognosis.-The existence of this kind of 
degeneration of the heart adds seriously to 
the gravity of a case of fever; and the danger 
increases with the rate and weakness of the 
pulse, and the feebleness of the cardiac im- 
pulse and first sound. The re-appearance of 
the first sound under observation justifies a 
favourable prognosis. 
Treatment.-The treatment of parenchy- 
matous degeneration of the heart is in no 
respect different from that of the fever in 
which this condition originates. The ap- 
pearance of the chaiasteristic symptoms and 
signs of the cardiac affection is, however, to 796 
HEART, DEGENERATIONS OF 
be regarded as an important indication for 
the use of alcoholic stimulants, which are, as 
a rule, well borne in such cases, and act very 
beneficially. 
3. Albuminoid.-This kind of degenera- 
tion has been said, with a certain amount of 
possibility, to have been found in the heart. 
It is certainly excessively rare. 
4. Pigmentary.- Pigment-granules, in 
the form of shining yellow particles, are 
almost invariably found in the muscular 
fibres of the heart in chronic cardiac disease. 
In certain cases of atrophy known as ' brown 
atrophy,' as well as in the granular degenera- 
tion just described, these pigment-particles are 
decidedly increased in number, and collected 
towards the axis of the fibres. A somewhat 
similar appearance is seen in the heart in 
jaundice. 
The condition is of purely pathological 
interest. 
5. Cartilaginous.-Portions of the myo- 
cardium have frequently been described as 
' cartilaginous ' or ' fibro-cartilaginous,' but 
it would appear that in these instances the 
muscular tissue was replaced by dense firm 
fibroid tissue only. See Heart, Fibroid 
Disease of. 
6. Calcareous. - Calcification of peri- 
cardial adhesions is not very rare ; and in 
some of the recorded instances of this con- 
dition, plates of the same material have been 
found projecting into the substance of the 
heart, appearing as if formed within the 
myocardium. Besides this class of cases, 
instances of true deposit of calcareous par- 
ticles within the individual muscular fibres 
have been described. The change appears 
in the form of small, pale, gritty deposits, 
taking the place of the normal muscular 
tissue on the surface. On microscopical ex- 
amination, the muscular fibres are found to 
have become solid and opaque, whilst hydro- 
chloric acid or sulphuric acid removes the 
opacity with the evolution of gas, the addi- 
tion of the latter acid also producing gypsum 
crystals. It is probable that, in other in- 
stances, the calcareous particles are situated 
outside the muscular fibres, and may be pro- 
ducts of a caseous nodule, whether syphilitic 
or ' tubercular ' in origin. 
This form of disease appears to possess no 
special clinical relations. 
7. Vitreous.-Vitreous, waxy, or colloid 
degeneration, as described by Zenker, occurs 
in the myocardium, as it does in the voluntary 
muscles. J. Mitchell Bruce. 
HEART, Dilatation of.-Definition. 
Dilatation of the heart may occur in two 
forms. In the one it involves only a limited 
portion of the cardiac walls and constitutes 
an aneurysm ; in the other there is uniform 
enlargement of one or more of the heart's 
cavities, and dilatation in the usual accepta- 
tion of the word is present. To this latter 
condition, however, the names ' aneurysm ' 
and ' passive aneurysm ' of the heart were 
formerly applied. Dilatation is probably 
always associated with hypertrophy. 
Etiology.-The occurrence of dilatation 
implies that the walls of the heart which 
yield are too weak to resist successfully the 
internal pressure to which they are exposed. 
This defective relation may be due either 
to actual enfeeblement of the heart's walls, 
which renders them unequal to the task 
normally devolving on them ; or to excessive 
blood-pressure, which even the healthily 
constituted walls are unable to withstand. 
The enfeeblement of the heart may be a 
consequence of fatty or other degeneration ; 
or, as is probably more frequently the case, 
may be inherent but unconnected with 
visible textural disease. The excessive blood- 
pressure may be dependent on actual ob- 
struction to the circulation, which the heart 
is called upon to surmount; or on undue 
rapidity of action, which (other things being 
equal) implies an unwonted expenditure of 
force. As a matter of fact, however, dilata- 
tion and hypertrophy are generally if not 
always associated ; and the processes by 
which these combined conditions are at- 
tained are more complicated than the fore- 
going statement might lead one to suppose. 
It will be convenient, therefore, to consider 
certain cases seriatim. 
1. In obstructive disease at the aortic 
orifice ; in general stricture of the minute 
systemic arteries, such as occurs in con- 
nexion with contracted granular kidneys; 
and indeed in all cases in which resistance 
is offered to the free discharge of blood from 
the left ventricle, progressive hypertrophy 
of the walls of that ventricle takes place. 
But the hypertrophy is complicated even 
from the beginning with dilatation. The 
hypertrophy, at any rate at first, is simply 
compensatory, and may be taken as a 
measure of the excess of resistance which 
the heart is called upon to overcome. The 
dilatation, however, is in no sense com- 
pensatory, and is probably to be regarded as 
a measure of the inability of the walls to 
cope successfully with the extra work re- 
quired of them. It is, moreover, obvious 
that the occurrence of dilatation, by increasing 
the area of resistance to the endo-ventricular 
blood-pressure, increases pro tanto the mus- 
cular effort requisite for the propulsion of 
the blood into the aorta; and by enlarging 
the capacity of the ventricular cavity and 
consequently the amount of blood to be dis- 
charged from it, on that account also throws 
additional labour on the muscular walls of 
the ventricle. Thus the hypertrophy and 
dilatation react on one another; and the 
hypertrophy, which was probably at first 
simply compensatory of the mechanical 
obstacle to the discharge of the normal con- 
tents of the ventricle, ends by becoming-or 
HEART, DILATATION OF HEART, DILATATION OF 
797 
rather striving to become-compensatory not 
only of this but of the virtual weakness of 
the heart which dilatation entails. 
2. In regurgitant disease at the aortic 
orifice, hypertrophy and dilatation of the left 
ventricle also take place. But in this case, 
while the hypertrophy probably reaches a 
higher degree of development than in simple 
obstruction, dilatation preponderates from 
first to last; and the ventricle attains larger 
dimensions than in perhaps any other form 
of disease. But to what are the hypertrophy 
and dilatation due in this case ? There is 
no impediment to the escape of blood through 
the aortic orifice, and therefore prima facie 
no need for compensative hypertrophy. 
There is no doubt that here hypertrophy 
■waits on dilatation. The immediate effects 
of regurgitation are, that during diastole the 
ventricle becomes more rapidly and com- 
pletely filled with blood than it does under 
other circumstances; that hence the subse- 
quent contraction of the auricle tends to dis- 
tend it unnaturally with blood; and that 
during the whole of this period the walls have 
also to sustain the backward pressure of the 
systemic arterial blood. The result is that, 
on the principles above enunciated, the walls 
of the ventricle have to encounter a larger 
area of pressure, and to expel a larger 
amount of blood, than natural, and hence 
are called upon to make excessive effort, and 
hypertrophy ensues. Thus the tendency to 
lilatation causes the tendency to hyper- 
trophy ; and both, acting continuously, pro- 
mote the progressive increase in the capacity 
of the ventricular cavity and in the thickness 
of the ventricular walls. 
It is probable in both cases, but more es- 
pecially in the latter of them, that ere long 
the ventricle fails to expel the whole of its 
contents into the aorta at each contraction, 
and that the retention of this residual blood 
becomes an important factor in promoting 
dilatation. 
3. The effects of continued violent action 
of the heart, whether caused by nervous in- 
fluence or by muscular effort, are much the 
same as those of obstructive disease. For 
both increased rapidity of contraction and 
increased amount of blood to be expelled at 
each beat (other things being equal) imply 
increased expenditure of force ; and the per- 
sistence of either or both of these conditions, 
therefore, the supervention of hypertrophy 
and dilatation. 
4. The above discussion relates especially 
to dilatation and hypertrophy of the left 
ventricle. But, mutatis mutandis, it applies 
with equal force to dilatation and hyper- 
trophy of the other sections of the heart. 
Thus, in mitral valve disease, the left auricle 
undergoes hypertrophy and dilatation-the 
dilatation preponderating in regurgitant dis- 
ease of the valve, the hypertrophy prepon- 
derating in obstructive disease. 
5. In pulmonic valve disease the right 
ventricle becomes hypertrophied and dilated 
-the dilatation being greatest where there 
is pulmonic regurgitation, the hypertrophy 
being greatest where the disease is obstruc- 
tive. 
6. In tricuspid valve disease the right 
auricle suffers, becoming chiefly dilated in 
the presence of tricuspid regurgitation, 
chiefly hypertrophied when there is obstruc- 
tion. And thus, also, just as when the sys- 
temic circulation is impeded the left side of 
the heart suffers, so when the pulmonic cir- 
culation is obstructed, the right side of the 
heart undergoes enlargement. 
In all cases, therefore, hypertrophy and 
dilatation seem to result concurrently ; but 
whether the one or the other condition pre- 
ponderates, depends partly on the particular 
nature of the cause to which the hyper- 
trophy and dilatation are due, partly on the 
inherent strength or weakness of the cardiac 
walls. In all cases, too, the other cavities of 
the heart, besides that primarily and directly 
implicated, suffer according to their position 
from the effects of the greater or less work 
which sooner or later is cast upon them. It 
may particularly be pointed out, that cavities 
situated behind the one primarily implicated 
tend sooner or later to share in its hypertrophy 
and dilatation, and that in cases of obstruc- 
tive disease of either of the auriculo-ventri- 
cular orifices the corresponding ventricle, 
in consequence of receiving less than its 
due amount of blood, and of thus having 
less work thrown upon it, tends to undergo 
atrophy. 
The temporary dilatation which is de- 
scribed as occurring in acute febrile dis- 
orders, such as typhus, is due mainly to en- 
feeblement of the cardiac walls. 
Anatomical Characters.-In dilatation 
of the heart, the cardiac walls may be either 
thinner or thicker than natural, or may 
retain their normal thickness. It is a ques- 
tion, however, whether, excepting in the case 
of partial dilatation or aneurysm, dilatation 
ever takes place independently of hyper- 
trophy ; for even as regards the auricles, 
where dilatation with attenuation is chiefly 
observed, there is reason to believe that the 
attenuation is not commensurate with the 
extension which accompanies it, and conse- 
quently that the total bulk of muscular 
tissue is increased. When dilatation is as- 
sociated with no apparent change in the 
thickness of the walls, hypertrophy is of 
course present. 
It must be mentioned, however, that it 
is often very difficult to determine on post- 
mortem examination the true relation be- 
tween the thickness of the cardiac walls and 
the capacity of the cardiac cavities. For 
their apparent relation is largely dependent 
on the condition of the cavities as to systole 
or diastole at the moment of death; and 798 
HEART, DILATATION OF 
on the state 'of the heart as to cadaveric 
changes at the time of post-mortem examina- 
tion. 
The form which the heart assumes in dila- 
tation is the same as that which it assumes 
in hypertrophy ; and indeed, as the two con- 
ditions are probably always associated, it is 
needless to endeavour to establish any dis- 
tinction between them in this respect. If the 
dilatation be general, the form of the heart 
remains unchanged, but its size is uniformly 
augmented. If the left ventricle be mainly 
affected, the heart appears not only enlarged 
but elongated, the left ventricle taking more 
than its due share in the formation of the 
cardiac apex. If the right ventricle be speci- 
ally implicated, the heart becomes enlarged 
in its transverse diameter; it is more rounded 
in its contour as seen from the front than it 
should be; and its apex is obtuse, and either 
bifid, from the fact that the apices of both 
ventricles take an equal share in the forma- 
tion of the cardiac apex, or formed wholly by 
the right ventricle. If the auricles be dilated, 
they constitute large masses on both sides of 
the root of the aorta and pulmonary artery. 
The walls of the dilated heart vary not 
only in thickness, but also in quality. Thus 
they may be preternaturally firm or preter- 
naturally soft; they may be healthy in struc- 
ture, or may present more or less degenera- 
tive change. 
Consequences of Dilatation.-Dilatation 
of the ventricles, especially if it be consider- 
able, is apt to disarrange the mechanism of 
the auriculo-ventricular valves. It was shown 
many years ago by Mr. Wilkinson King that 
even in mere temporary distension of the 
right ventricle a kind of safety-valve action 
of the tricuspid valve took place, in conse- 
quence of which regurgitation of blood was 
permitted from the ventricle into the auricle. 
And since his time it has been clearly demon- 
strated, both by clinical and by post-mor tern 
evidence, that established dilatation of the 
right or left ventricle is liable to be attended 
with persistent regurgitation of blood through 
the corresponding auriculo-ventricular orifice. 
The defaulting valve under these circum- 
stances has a natural aspect; but careful 
examination shows either that the orifice 
has undergone dilatation in company with 
the ventricle-the valve itself presenting no 
corresponding increase ; or that there is a 
want of relation between the size of the 
musculi papillares and chords® tendineae on 
the one hand, and the capacity of the ventricle 
on the other, which interferes with the due 
closure of the valve. 
It is obvious that if regurgitation becomes 
established, the usual consequences of regur- 
gitation will presently ensue-namely, in 
connexion with affection of the left side of 
the heart, dilatation and hypertrophy of the 
left auricle, and subsequently congestion of 
the lungs and pulmonary apoplexy; and in 
connexion with affection of the right side of 
the heart, dilatation and hypertrophy of the 
right auricle, fulness of the systemic veins, 
anasarca, nutmeg liver, and congested, indu- 
rated kidneys. It is also obvious that, even 
if no regurgitant condition be developed, 
dilatation of heart, which implies feebleness 
of heart and imperfect circulation, must 
ultimately induce the ordinary remote con- 
sequences of heart-disease. A further con- 
sequence of dilatation and other cardiac 
affections attended with feeble circulation 
is the formation of thrombi during life, both 
in the heart itself and in other parts of the 
vascular system. Mr. "Wilkinson King has 
demonstrated that dilatation of the left 
auricle may cause compression of the left 
bronchus. 
Symptoms.- Since dilatation of the heart 
rarely, if ever, exists alone, but is associated 
with hypertrophy, valve-disease, degenera- 
tions, and other conditions, it is almost im- 
possible to make any definite statement with 
regard to the signs and symptoms by which 
its presence may be recognised. Still there 
is no doubt that dilatation is one of the most 
important factors of heart-disease, clinically 
considered; and that its supervention materi- 
ally affects the patient's condition, and pro- 
spect of life. Dilatation implies weakness, 
and as a rule over-distension of the implicated 
cavities with blood, which probably never 
becomes wholly expelled. 
The physical signs of dilatation are neces- 
sat ily m many respects the same as those of 
hypertrophy. The praecordial dulness is in- 
creased in area-the extent and form of this 
area, and the situation of the apex-beat, 
being determined by the general size of the 
heart, and the relative dimensions of its 
component parts. In proportion, however, 
as dilatation preponderates over hypertrophy, 
the impulse of the heart becomes weak, and 
possibly to some extent diffused. In extreme 
dilatation, as in extreme weakness from other 
causes, the sounds of the heart, and especially 
the first sound, are enfeebled. And it may 
be asserted that generally the tendency of 
dilatation is to shorten the first sound, and 
to give it the characters of the second sound. 
It has nevertheless been observed over and 
over again that it is in the concurrence of 
hypertrophy and dilatation that the cardiac 
sounds are apt to attain their greatest in- 
tensity. The feebleness of the heart's action 
is generally attended before long by more or 
less irregularity; and even in the absence of 
valve-disease, a mitral or tricuspid systolic 
murmur, implying regurgitation, is apt to be 
established. 
The symptoms of dilatation are to a large 
extent those of cardiac obstruction, and more 
especially of mitral disease. The patient 
complains of weight, oppression or uneasi- 
ness in the cardiac region, with probably a 
sense of fluttering there, and of a tendency HEART, DILATATION OF 
HEART, DISPLACEMENTS OF 
799 
to sighing respiration. He becomes short- 
breathed, and may have extreme dyspnoea. 
His face is apt to become livid; his surface 
pale or ghastly; his extremities cold and 
blue ; and his pulse weak and irregular. 
Dilatation of the systemic veins arises sooner 
or later ; and subsequently general anasarca, 
pulsation of the veins in the neck, epigastric 
pulsation, and pulsation of the liver, together 
with the other usual consequences of heart- 
disease. The chief of these are-congestion 
of the lungs, with pulmonary apoplexy, 
cough, and expectoration of blood ; con- 
gestion, enlargement, and tenderness of the 
liver, with jaundice; and congestion of the 
kidneys, attended with the discharge of 
scanty, high-coloured, heavy urine, contain- 
ing albumen and possibly blood. Other 
symptoms referable to the nervous and 
digestive organs, which -need not be enu- 
merated here, are also liable to supervene. 
The symptoms will vary, of course, ac- 
cording as the left or the right ventricle is 
mainly affected. In the former case we are 
liable to have at first irregularity and feeble- 
ness of pulse with tendency to faint; then 
pulmonary complications ; and at a later 
period, symptoms referable to the systemic 
venous circulation. The latter case is one 
of considerable interest; because in a large 
number of instances it is, in its most marked 
form, a consequence of emphysema of the 
lungs, or of other analogous conditions, and 
moreover is apt to come on very rapidly. 
Under these circumstances, there is neces- 
sarily much dyspnoea, but the systemic 
venous and capillary systems speedily be- 
come over-loaded; extreme cyanosis often 
develops rapidly; and, before long, all the 
other symptoms referable to disease of the 
right side of the heart become established: 
namely, pulsation of the veins in the neck, 
epigastric pulsation, pulsation of the liver; 
general anasarca, with perhaps petechial 
extravasations, jaundice from nutmeg liver, 
and albuminuria from congestion of the 
kidneys. 
Prognosis.-There is no doubt that some 
degree of dilatation of the heart, and more 
especially of the right ventricle, may arise 
either from over-exertion, or from functional 
disturbances, and in connexion with pul- 
monary disorders. But such dilatation is 
for the most part temporary or remediable; 
and only by continuance of its cause becomes 
established and a matter of serious import- 
ance. In the same way there is no doubt 
that the dilatation which comes on in the 
course of organic disease of the heart or 
lungs, or of other organic diseases which in- 
fluence the action of the heart, is remediable 
within certain limits by due attention to the 
conditions under which it arises. Neverthe- 
less it is certain that the presence of dilata- 
tion of the heart in connexion with other 
diseases, more especially those of the heart 
itself, lungs, or kidneys, is a grave source of 
danger; and that in the great majority of 
cases it is of fatal omen, aggravating the 
patient's cardiac symptoms, and hastening 
his death. 
Treatment.-The treatment of dilatation 
of the heart merges in that of the other 
cardiac conditions with which it is associated, 
and in that of other diseases in the course of 
which it may have supervened. It may be 
stated, generally, however, that the treat- 
ment is that of cardiac debility, and of dis- 
tension of the heart with blood. 
The chief indications, therefore, are rest 
of mind and body; avoidance of exposure 
to cold and wet ; the exhibition of ample, 
nutritious, and readily digestible food; due 
attention to the action of the bowels, kidneys, 
and skin ; and the employment of medicines 
likely to regulate and strengthen the action 
of the heart. For the last purpose digitalis 
in small doses is universally acknowledged 
to be of great value. And it is in many cases 
desirable to combine the digitalis with iron, 
or some vegetable tonic. Ammonia and 
other diffusible stimulants are often called 
for, and are of great service. In cases where 
there is much lividity, and evidence of stag- 
nation of blood in the right side of the heart, 
removal of blood by venesection will often 
prove of great service. 
When the dilatation is due to pulmonary 
disease, this of course requires primary and 
especial treatment. J. S. Bristowe. 
HEART, Displacements of.-Besides 
the displacements of the heart that occur as the 
result of disease, there are certain changes of 
position which this organ undergoes in health. 
The most important of these physiological 
displacements of the heart are-first, its ver- 
tical movements in respiration ; and, second, 
the alterations in its situation corresponding 
with changes in the bodily posture. The 
present article, however, will deal only with 
the former class, or abnormal displacements 
of the heart. 
^Etiology.-The heart may be congenitally 
displaced-a condition which is described 
under the head of Heart, Congenital Mis- 
placement of. These cases being excepted, 
the causes of displacement of the heart may 
be arranged in two classes-namely, (1) con- 
ditions that exert pressure, and (2) conditions 
that exercise traction, upon the heart. 
1. The heart is pressed or pushed out of 
position by effusions of fluid-inflammatory, 
serous, or bloody-into either pleural cavity ; 
by pneumothorax of either side; by intra- 
thoracic tumours-whether mediastinal (in- 
cluding aneurysm and abscess), pulmonary, 
or parietal; by hypertrophous emphysema, 
or other causes of enlargement of the lungs ; 
by extensive pneumonic consolidation ; or by 
abundant pericardial effusion of any kind. 
Certain conditions of the abdominal contents 800 
HEART, DISPLACEMENTS OF 
produce a similar effect-for example: gaseous 
distension of the stomach and intestines; 
enlargement of the liver and other solid or- 
gans ; abdominal tumours of all kinds; the 
pregnant uterus; and ascites, when consider- 
able. Hernia of the abdominal viscera through 
the diaphragm, and abscesses connected with 
the diaphragm, also cause displacement of 
the heart. 
2. The heart suffers traction, or is drawn 
out of position, during absorption of pleuritic 
effusion with imperfect expansion of the lung, 
on either side ; by the contraction of pleuro- 
pericardial adhesions, of pulmonary cirrhosis, 
or of cavities in phthisis; in collapse of either 
lung from pressure on the main bronchus; 
and in some forms of deformity of the chest 
from curvature of the spine. 
Mechanism of Displacement.-The causes 
just enumerated constitute in each instance 
what may be called the displacing force. 
When this force belongs to the first or pres- 
sure class, it acts against the surface of the 
pericardium and heart that is opposed to it, 
and presses or pushes it, a tergo, away from 
its own seat, in the direction of least resist- 
ance. Thus the heart is, speaking broadly, 
pushed towards the left by effusion into the 
right pleural cavity; towards the right by 
similar disease on the left side ; downwards 
by tumours in the region of the base; and 
upwards by gaseous distension of the stomach. 
On the other hand, when the displacing 
force is of the nature of traction, the heart is 
drawn a fronte, that is, towards the seat of 
the force. Thus, when a cavity in a phthisi- 
cal lung is contracting, the pericardium and 
heart, as well as the walls of the chest, are 
displaced towards the healing area. It must 
be observed, however, that in this class of 
cases, actual traction, in the strict sense, is 
rare, and that the ordinary displacing force 
is, in reality, the atmospheric pressure; the 
heart and the other organs being ' sucked ' 
towards the potential vacuum, in the same 
way as water is ' drawn ' into a syringe. 
Still, in a very small number of cases, the 
pericardium does actually become involved 
in a healing process in the lungs; and it 
and the heart are dragged towards the cica- 
trix. 
Besides the displacing force, there are at 
work in dislocation of the heart certain other 
agencies, which contribute to the result, 
whether their effect be to increase or to 
diminish that of the chief cause :- 
(a) The weight of the heart manifestly 
favours displacement in different directions, 
according to the posture. Thus, in the erect 
posture, it favours downward, and limits up- 
ward displacement. However, the effect of 
the weight of the heart is comparatively insig- 
nificant, and may be practically disregarded. 
(6) The resistance, positive or negative, of 
neighbouring parts must be taken into ac- 
count. The heart when disturbed from its 
position will move in the direction of least 
resistance. Thus it cannot be displaced to 
any extent either forwards or backwards; 
but is moved with comparative ease towards 
either pleural cavity. The resistance inferiorly 
is greater under the right half of the dia- 
phragm than under the left. On the other 
hand, the resistance around may become 
negative ; for example, in left pleural effusion 
the corresponding half of the diaphragm is 
pushed downwards, and the accompanying 
downward displacement of the cardiac apex 
is thus increased. 
(c) The heart is attached at its root; and, 
speaking broadly, this is a fixed point, at the 
right and upper extremity of the long cardiac 
axis. This attachment will limit and other- 
wise modify displacements of the heart in 
all directions, especially downwards. Round 
this point as a centre, and with the long axis 
as the radius, the apex of the heart would de- 
scribe an arc of a circle, cutting the surface 
of the chest in the left axilla, the left sub- 
mammary region, the epigastrium, the right 
submammary region, and the right axilla. 
{d) The tendency that the heart has to 
rotate or roll on one or other of its axes is 
also affected by its attachment at the root. 
If the heart lay free in the pericardial cavity, 
there would be no limit to such rotation under 
the influence of pressure or of traction. The 
base being fixed, rotation is greatly limited, 
and does not occur to any extent except 
around the longitudinal axis; the left ven- 
tricle, for example, being rotated more for- 
wards or more backwards, as the case may 
be. Rotation round the transverse-hori- 
zontal and the antero-posterior-horizontal 
axes is very limited. 
Anatomical Characters and Effects.- 
The only essential change that the heart is 
found to have undergone in displacement is 
an alteration of its relations to the surround- 
ing parts. The softer parts of the cardiac 
wall, however, such as the auricles, are some- 
times compressed to a moderate degree. The 
pericardium is partly dislocated and partly 
stretched. The great vessels at the base of 
the heart and at the root of the neck may be 
elongated, shortened, twisted, or bent, accord- 
ing to the particular form of displacement; 
and the circulation within them impeded. The 
neighbouring organs are variously displaced 
and compressed. One of the effects often seen 
after displacement is permanent fixation of 
the pericardium and heart in their new posi- 
tion, for example, in the pleural cavity, on 
the disappearance of the original cause. 
The effects of displacement of the heart 
upon its functions differ greatly in the two 
classes of dislocation to which we have 
referred :- 
In displacement due to pressure, the heart 
is compressed between the displacing force 
and the resistance in other directions, and 
the dislocation is generally rapid. For- HEART, DISPLACEMENTS OF 
801 
innately, in most cases of such displacement 
the resistance is slight; and the heart, if 
healthy, suffers little or no real compression 
of its substance or cavities between the two 
forces, the mobile and compressible lung 
especially yielding before it. But if the 
heart be diseased-and especially if its walls 
be weak, degenerated, or dilated-moderate 
compression, as in flatulence, may cause 
embarrassment of the cardiac action and 
even fatal paralysis; and the rapidity or 
even suddenness with which displacement 
generally occurs when due to pressure-for 
example, in pneumothorax-is another and 
perhaps the principal cause of this embar- 
rassment. 
On the other hand, when the heart is 
drawn out of its normal situation towards 
a phthisical cavity, or towards either pleural 
cavity from which an inflammatory effusion 
is being absorbed, the displacement occurs, 
not because there is want of space, but 
because there is excess of space within the 
thorax. The process is also very gradual. 
The effects, therefore, upon the functional 
activity of the heart may be said to be few, 
though the unusual pulsation may be a 
source of inconvenience, and even of anxiety, 
to the patient. In very rare cases, the heart 
and pericardium, when thus displaced, may 
be involved in the fibrotic process going on 
in the lung or pleura, and the adhesions thus 
established may ultimately interfere with the 
cardiac action. 
Symptoms.-In displacement of the heart, 
special symptoms are frequently slight or 
altogether wanting; or they are inseparable 
from the symptoms of the original cause. 
This may be said to be almost invariably the 
case when the displacement is due to gradual 
traction, as in phthisis. In the pressure 
class of cases, on the contrary, there are 
frequently developed, and that rapidly or 
suddenly, symptoms due to compression of 
the heart, such as a sense of distress, stifling, 
and pain over the prsecordia or at the epi- 
gastrium, or even true angina; dyspnoea, 
perhaps amounting to orthopnoea; palpita- 
tion ; blueness of the surface; and irregularity 
and feebleness of the pulse. When the dis- 
placement is due to upward pressure from 
gaseous distension of the stomach and in- 
testines, the above symptoms may be asso- 
ciated with flatulence or ' spasms,' and are 
relieved by the erect posture, eructation, 
vomiting, and the administration of carmi- 
native and absorbent remedies. If this con- 
dition be not removed within a short time, it 
may become aggravated, pass into a state of 
collapse, and end in death. 
Varieties and Physical Signs. - The 
varieties of cardiac displacement, according 
to the direction in which the dislocation 
occurs, may, for clinical purposes, be said 
to be as follows : towards the left, towards 
the right, downwards, upwards, backwards, 
and forwards. It must be observed, how- 
ever, that this is only a broad general classi- 
fication, and that the heart is very rarely 
displaced in an absolutely horizontal, or in 
an absolutely vertical plane. The exact 
direction taken in each variety will now be 
described, as well as its special causes, and 
the physical signs by which it may he 
recognised. 
1. Displacement towards the Left.-- 
This, the most common variety of marked 
cardiac dislocation, is most frequently caused 
by contraction of the left lung from any of 
the conditions already enumerated, and effu- 
sions into the right pleural cavity. Right 
pneumothorax, and tumours connected with 
the right side of the chest, with the medi- 
astinum, or with the right lobe of the liver, 
are less common conditions leading to the 
same result. The distance towards the left 
to which the heart is dislocated varies, the 
extreme limit being probably the vertical 
axillary line. During its progress towards 
the left, the heart is rotated around its 
longitudinal axis, so that the right ventricle 
is more exposed anteriorly ; and the apex is 
moved, at first somewhat downwards, and 
afterwards upwards. 
The visible and palpable impulse is found 
to the left of its normal situation, and either 
lower or higher than it, or on the same level 
with it, according to the degree of displace- 
ment. In some cases due to contraction of 
the left lung, the impulse may be found in 
any one or in all of the left intercostal spaces 
from the base to the apex of the heart, and 
of different rhythm in the different spaces. 
If the displaced heart be the seat of valvular 
disease, thrill may be felt in an unusual 
situation, for example, in the left axilla. 
The area of percussion-dulness is altered 
in outline, being invaded on the right side 
either by the dulness due to effusion there, 
or by resonance due to pneumothorax or to 
encroachment of the right lung-border; whilst 
it is either transposed towards the left axilla, 
or blended with unnatural dulness over the 
left lung. The cardiac sounds are reduced 
in loudness over the normal praecordia, whilst 
they are unnaturally loud towards the left 
axilla and up the left front. Structural 
murmurs if present are similarly transposed, 
as regards the seat of their greatest intensity 
and the lines of their convexion. A systolic 
murmur may be developed at the base of the 
heart from distortion of the great vessels. 
2. Displacement towards the Right. 
This form of dislocation of the heart is the 
result of effusion into the left pleural cavity; 
of contracting processes connected with the 
right lung or pleura ; of left pneumothorax ; 
and of tumours of the left side of the chest 
or in the mediastinum. The heart may be 
displaced towards the right side until the 
impulse is found in the axillary region, the 
true apex at the same time being depressed 802 
HEART, DISPLACEMENTS OF 
towards the epigastrium. During its lateral 
movement, the heart is rotated on its longi- 
tudinal axis in such a manner that the left 
ventricle is more exposed. 
•The physical signs correspond closely with 
those enumerated under left displacement- 
the two sides being, of course, exactly re- 
versed. The cardiac impulse is most fre- 
quently transferred to the epigastrium. New 
areas of pulsation are developed in the region 
of the right nipple, and in the second and 
third right interspaces, close to the sternum; 
ihey indicate the displaced position of the 
right auricle, if praesystolic, or of the aorta, 
if systolic and followed by palpable shock in 
diastole. The description of the auscultatory 
phenomena, as regards both sounds and 
murmurs, does not require to be repeated. 
3. Displacement Downwards.-This 
is an exceedingly common form of cardiac 
displacement, though seldom extreme in de- 
gree. It is the constant result of hypertro- 
phous emphysema of the lungs; and may 
also be caused by the downward pressure of 
tumours at the base of the heart, such as 
aneurysm, and by collapse of the stomach 
and intestines. Displacement of the heart 
downwards is limited by the diaphragm, and 
by the attachment of the pericardium and 
great vessels at the root of the heart. At 
the same time the apex may either move 
somewhat towards the left in its descent if 
the downward pressure be uniform, as in 
emphysema; or it may ascend somewhat 
towards the left if the pressure be exerted 
chiefly upon the base. 
The ordinary cardiac impulse is generally 
quite imperceptible in this form of displace- 
ment, on account of enlargement of the lungs; 
or it is greatly weakened, and situated in the 
sixth left space, or lower, to the left of its 
normal position. A new area of systolic 
pulsation is perceptible in <;he epigastrium, 
generally well marked, and connected with 
the right ventricle. The praecordial dulness 
is usually completely replaced by pulmonary 
resonance ; or, more rarely, confused by the 
dulness of some form of mediastinal tumour. 
The cardiac sounds are feeble, or absent, 
over their usual seat; and are heard, instead, 
over the epigastric triangle and the lower 
left cartilages. 
4. Displacement Upwards.-Themany 
abdominal causes of this form have been al- 
ready mentioned ; so have the symptoms due 
to compression of the heart which charac- 
terise it when so produced. The heart, as 
a whole, is moved upwards in the chest, and 
at the same time the apex passes more or less 
towards the left, and the right ventricle may 
become somewhat more exposed anteriorly. 
The cardiac impulse is elevated until it is 
found on the nipple-level, or even higher ; or 
it is lost, along with the area of percussion- 
dulness, behind the inferior border of the left 
lung. The sounds of the heart are transposed 
upwards, and weakened. The displacement 
of the cardiac apex towards the left axilla in 
pericardial effusion is described elsewhere. 
See Pericardium, Diseases of. 
5. Displacement Backwards. - This 
variety of displacement of the heart is very 
uncommon; and when it does occur, is 
generally referable either to abundant peri- 
cardial effusion, or to backward curvature of 
the spine (kyphosis) in the dorsal region. A 
certain amount of backward displacement is, 
however, not so rare in extensive excavation 
of the left lung, in association with other 
forms of dislocation. The base of the heart 
is then the part most transposed into the left 
paraspinal groove, and the apex is tilted 
somewhat forwards as well as elevated. 
The physical signs of backward displace- 
ment are those of the cause of the malposition 
rather than any that can be referred to the 
condition itself. 
6. Displacement Forwards. - Dis- 
placement forwards is also very rare, al- 
though it is frequently simulated by bulging 
of the prsecordia in enlargement of the heart. 
The chief cause of it is the presence of a 
tumour in the mediastinum - especially 
aneurysm of the descending aorta, or en- 
largement of the bronchial glands. The 
amount of actual transposition is necessarily 
exceedingly small, the anterior border of the 
lungs being compressed or pushed aside, but 
the further progress of the heart forwards 
being arrested by the anterior wall of the 
chest. 
The physical signs are, therefore-increase 
of the area and strength of pulsation and of 
percussion-dulness over the prsecordia; bulg- 
ing of the same in young subjects; and in- 
creased loudness of the cardiac sounds in 
that situation. 
7. Complex Displacements.-It has 
already been indicated that displacements of 
the heart, strictly speaking, occur almost 
without exception in more than one of the 
directions described; and they may all, there- 
fore, be said to be generally more or less 
complex. Dislocation at once upwards and 
towards either side is especially common, 
as the result of contracting processes in the 
apex of the lung. 
Diagnosis.-After the full account that 
has been given of the several forms of dis- 
placement of the heart, there ought to be no 
great difficulty in diagnosing them from each 
other, as well as from the conditions which 
simulate them. These must be carefully re- 
membered. The chief of them are: (1) Phy- 
siological displacements, already referred to ; 
(2) cardiac enlargement, especially when 
attended with bulging of the praecordia ; (3) 
pulsating tumours of the chest and abdomen, 
particularly aneurysm of the aorta; (4) adhe- 
sion of the pericardium; and (5) atrophy of 
the lungs from any cause. 
Treatment. - The rational treatment of HEART, DISPLACEMENTS OF; AND FATTY DEGENERATION OF 
803 
displacement of the heart would be to remove 
its cause; but when the cause is of the nature 
of traction, treatment is very rarely called 
for, even if it were possible. In displace- 
ment due to pressure, on the contrary, treat- 
ment is often urgently indicated, perfectly 
practicable, and highly successful. The un- 
pleasant sensation of pulsation complained, 
of in some instances of displacement-for 
example, in phthisis-is frequently relieved 
by an assurance on the part of the physician 
that the palpitation is of no import; and by 
the application of a simple plaster, contain- 
ing iron, belladonna, or opium. 
J. Mitchell Bruce. 
HEART, Embolism of.-See Embo- 
lism ; and Heart, Thrombosis of. 
HEART, Fatty Degeneration of.- 
Synon. : Fr. Degenerescence graisseuse du 
Coeur; Ger. Fettige Metamorphose des Her- 
zens. 
Definition.-The process by w'hich the 
muscular fibres of the heart are converted 
into a granular fatty matter. The term is 
also used to express the state of the heart in 
which this change has been accomplished. 
^Etiology and Pathology.-The process 
by which the protein elements of animal 
bodies, including muscular fibre, are con- 
verted into granular fatty matter, as well as 
the circumstances under which this change 
occurs, have been already so fully discussed 
under the head of Fatty Degeneration, that 
it is unnecessary to repeat the information 
which will be found there. It will suffice to 
say here, that when the process of nutrition 
is interfered with in the tissue of the heart, 
this change takes place, and is best illustrated 
in the local or limited form of disease, which 
occurs when the coronary circulation is ob- 
structed. This is seen in cases in which the 
orifice of the coronary arteries is contracted 
or where there is thickening or calcification 
of one of the trunks, or of the branches of 
these vessels, and is more marked by reason 
of the fact that the coronary arteries do not 
anastomose as freely by their primary and 
secondary branches as do arteries in other 
situations. Still, as Dr. Samuel West has 
well shown (Lancet, vol. i. 1883), there does 
exist free communication. The fatty change 
is found to occur in the more diffused or gene- 
ral form in those diseases in which the vital 
powers are lowered, as in certain forms of 
chronic cachectic disease, especially in cases of 
pernicious anaemia, as described by Dr. Sidney 
Coupland (Brit. Med. Journ., vol. i. 1881), in 
poisoning by phosphorus, or after loss of 
blood. In certain other conditions, such as 
acute specific fevers, the tissue of the heart 
becomes softened, and under the microscope 
presents a granular appearance, which is be- 
lieved by some pathologists to be an inci- 
pient stage of fatty degeneration. We might 
also refer to the more or less diffused form of 
fatty degeneration which takes place in cases 
of enlarged heart, the result, not, as Roki- 
tansky supposed, of a disturbance of the ner- 
vous functions, but of the fact that these en- 
larged hearts require a larger supply of the 
materials for nutrition than can be furnished 
to them by the coronary arteries, which in 
such cases are frequently themselves diseased, 
both at their origin and in their course. 
Lastly, fatty degeneration of the heart is 
found to occur after delivery in some in- 
stances, in which the organ had become en- 
larged during pregnancy, thus explaining cer- 
tain cases of sudden death after parturition. 
Dr. Bedford Fenwick has described (Lancet, 
vol. i. 1888) fatty degeneration occurring in 
consequence of the pressure exercised by the 
presence of large ovarian tumours; and he 
accounts for the collapse which sometimes 
occurs after operation for the removal of 
these tumours by the presence of this lesion 
of the heart's texture.1 
Certain other circumstances connected with 
the origin of the disease require to be men- 
tioned here. In reference to sex, the disease 
is more frequent in males, in the proportion 
of nearly two to one. With respect to age, 
in his original memoir on this subject the 
writer found that nearly one-half of all the 
cases observed were over sixty years of age. 
In the late Dr. Hayden's valuable work on 
Diseases of the Heart, the proportion stated 
of cases under sixty years of age shows a 
larger number of young persons whose hearts 
have undergone this change as a result of 
wasting disease-a result which is evidently 
due to the greater care with which micro- 
scopical examinations of the heart have been 
made in recent times. As regards social 
position, of thirty-three cases formerly noted 
by the writer, the subjects of the disease are 
stated to have belonged to the higher ranks 
in nine cases; to the middle class in eight 
cases; and to the lower class in sixteen cases. 
This enumeration contrasts with the propor- 
tion in which fatty growth appears on the 
heart; seven of fifteen cases belonging to the 
first class; six to the second ; and only two 
to the third. Fatty degeneration and fatty 
growth on the heart are thus seen to occur 
under markedly different conditions. The 
latter is the result of the accumulation in the 
blood of the elements of fat; the former is 
the result of decay and disintegration of 
tissues. 
Anatomical Characters.-In fatty de- 
generation the heart was found to be enlarged 
in about two-thirds of the cases recorded 
both by Dr. Hayden and the present writer. 
It is not infrequently simply dilated. To 
find a heart thus affected of an average size, 
1 For much very instructive and valuable infor- 
mation, see an article, by Dr. F. W. Mott, on ' Cardio- 
vascular Nutrition and its Relation to Sudden 
Death,' in the Practitioner, vol. xli. p. 161. 804 
HEART, FATTY DEGENERATION OF 
or even occasionally below it, is not an 
exceptional occurrence. The colour of the 
heart's substance is pale, sometimes as pale 
as ' a dead leaf,' but more generally it is of 
a yellowish-brown or buff, or muddy pink 
colour. This discoloration is generally seen 
in spots or in patches; and though the whole 
heart may be pale, the spots, being still paler 
when seen beneath the endocardium, give 
the tissue a mottled look. The same appear- 
ance may be observed beneath the pericardium, 
and in the substance of the heart. With the 
progress of disease the spots run together, 
giving portions of the walls a uniform buff- 
coloured character, whilst the rest of the 
organ retains its ordinary aspect. The con- 
sistence also varies from that of mere flabbi- 
ness or softness, to such a condition as per- 
mits of the tissue being torn like wet brown 
paper. The organ then feels like a piece of 
wet chamois leather, or a wet glove. In 
other cases the heart retains in appearance 
much of its ordinary solidity, but the tissue 
breaks down on pressure, as does a lung 
consolidated by pneumonia. This is a state 
which occurs more frequently in hearts which 
are hypertrophied. In addition to these 
changes in size, colour, and consistence, others 
have to be noted. The fibrous character of the 
heart's structure, even to the naked eye, dis- 
appears ; in some cases the tissue resembles 
that of a fatty or a boiled liver. In other in- 
stances the cut or torn surface has a granular 
appearance, not unlike that of the lung in an 
early stage of grey hepatisation. These dif- 
ferent appearances may in a great measure 
be due to the greater or less fluidity of the 
oily matter present, as well as to the extent 
and degree to which the disease has ad- 
vanced. Further varieties in appearance 
may be caused by the presence of a larger or 
smaller quantity of blood, or of its colouring 
matter, in the heart's texture or in its cavi- 
ties, by which the lining membrane may 
so fully described under the head Fatty De- 
generation, that it is needless here to do 
more than refer the reader to that article, 
and to the annexed figure (GO), in which these 
characters are well seen. 
All parts of the heart are subject to fatty 
degeneration, but not equally so. It is most 
frequently found in the left ventricle; next 
in the right ventricle; then in the right 
auricle; and least frequently in the left 
auricle. It is generally more evident in the 
columnae carnese, and in the inner layers of 
the muscular walls, than elsewhere. 
Effects.-Of the structural lesions which 
occur in the heart when it is the seat of fatty 
change, one of the most important is rupture, 
which was found in twenty-five out of sixty- 
eight cases of fatty or softened heart, the his- 
tories of which were collected by the writer. 
Partial rupture, leading to some effusion of 
blood in the tissue and the formation of 
what has been called cardiac apoplexy, is 
another condition which has been described. 
The clot in such cases, if it lose its colour, 
may produce the appearance of an encysted 
abscess; and a consecutive false aneurysm 
of the walls of the heart may be thus formed, 
as well as by the simple yielding of a portion 
of the softened cardiac wall. The involvement 
of the columnae carneae may lead to imperfect 
action of the valves. Valvular disease itself 
is not often present in connexion with fatty 
heart. Dr. Henry Kennedy, in a late in- 
teresting work on this subject, pointed out 
that the valves are affected only about once 
in nine cases; and he further shows that, 
when the valves are affected, it is chiefly the 
aortic valves that are involved. 
Of the effects of fatty degeneration upon 
the functions of the heart, the most promi- 
nent are those which exhibit the weakened 
powers of the organ. Coma, preceded or not 
by giddiness, has been described by several 
writers in connexion with feeble powers of 
the circulation. The late Dr. Adams of Dub- 
lin has mentioned as many as twenty attacks 
in one of his cases of fat heart; and the 
writer has noticed the occurrence of even 
more frequent seizures. Syncope-' cardiac 
syncope '-is a term very frequently used by 
the older writers; and it is a term which 
may be well applied to the condition of faint- 
ness which is frequently found in connexion 
with fatty heart. In some cases the feeling 
of syncope amounts to little more than a 
simple sense of faintness-that the patient 
must fall if he do not lay hold of something. 
In other instances this symptom is accom- 
panied by a feeling of impending death ; and 
such patients do frequently die. In the cases 
collected by the writer, thirteen out of thirty- 
three died of what he proposed to call syncope 
lethalis, or ' fatal syncope ; ' and it would be 
possible, no doubt, now greatly to extend the 
number of cases that have proved fatal in 
this way. Death may result in such cases 
Fio. 60.-Fatty Degeneration of the Heart, 
x 400 diam. 
in the latter case be dyed of a deep purple 
colour. 
Microscopical characters.-The microsco- 
pical characters of this disease will be found from cardiac failure, as indicated after death 
by a flabby heart containing blood in the left 
ventricle ; or, where there is a less amount of 
degeneration, death may result from irregular 
action or spasm, and the ventricles may be 
found empty. 
Pain is also an effect of degeneration. It 
may occur independently of syncope; or, 
being associated with syncope, constitutes 
what is named syncope anginosa. See Angina 
Pectoris. 
The respiration is always affected in cases 
of fatty degeneration, and we find either 
simple breathlessness, even on slight exer- 
tion, or that peculiar form which has been 
called Cheyne-Stokes respiration. 
Symptoms and Diagnosis.-There is no 
doubt that many cases occur in which fatty 
degeneration is found in the heart after 
death, without its presence during life having 
been suspected. This result is found more 
especially in those instances of exhausting 
disease in which the heart participates. In 
such cases the requirements of the system 
may not be out of proportion to the powers 
of the heart; and death may come on slowly 
and insidiously without our attention being 
attracted to the state of this organ. In a 
second class of cases, in which the heart suf- 
fers from some local cause, as, for example, 
from disease of the coronary arteries, whilst 
the system generally maintains its powers 
more or less fully, the balance between the 
system and the function of the heart is lost, 
and diagnostic evidence of the change that has 
occurred in the central organ, sufficiently clear 
and pointed, may be traced without difficulty. 
Amongst the symptoms of the disease we 
then observe various modifications of the 
phenomena of drowsiness and coma; faint- 
ness and syncope ; disordered respiration; 
pain in the region of the heart; and disturbed 
pulsation. For example, the patient com- 
plains in the earlier stages of being easily 
exhausted, particularly by mounting ascents; 
he feels, he says, faint on reaching the top 
of a flight of stairs; though not giddy, he 
feels he must fall; though not breathless or 
fainting, he sighs deeply and seeks the air. 
Any unusual excitement, or a heated or a 
close atmosphere, produces the like effects. 
At the same time there is often experienced 
an uncomfortable feeling of choking or ful- 
ness in the chest. In the intervals the in- 
dividual may be fairly well. 
As the disease advances, the attacks, of 
whatever kind, become more frequent and 
severe, and often disturb and distress the 
patient at night. The temper is observed 
to become irritable. The expression of the 
features frequently appears anxious, and the 
countenance sallow. Copious perspiration 
from very slight causes, sometimes coldness 
of the extremities and swelling of the ankles, 
appear amongst the incidents of the disease. 
The pulse is generally affected; but how 
HEART, FATTY DEGENERATION OF 
must no doubt depend in a great measure 
upon the part of the heart affected, and on 
the extent and degree of the disease. In 
the writer's opinion, intermittence and irre- 
gularity are the more frequent alterations; 
weakness is another; and slowness-often 
remarkable-is a third. Quickness of the 
pulse, more especially when it increases with 
age, has been dwelt upon by Dr. Kennedy 
as a symptom deserving of attention in the 
diagnosis of fatty degeneration. The irregu- 
larity may be constant, or it may appear and 
disappear. The writer has seen it present 
during the slight disturbances above de- 
scribed; and he has seen it disappear alto- 
gether when the patient was in tolerable 
health, to return as the effect of any depress- 
ing cause, the more marked because that 
cause may be far too inefficient to affect a 
sound heart. The frequency with which the 
pulse is affected in cases of dyspepsia, more 
especially in those in which there exists a 
gouty diathesis, should not be overlooked in 
the diagnosis of fatty heart. 
The breathing is always more or less af- 
fected in cases of fatty degeneration of the 
heart. In some instances the disturbance is 
represented as a sense of choking or suffoca- 
tion; the person feels as if he were breathing 
through a sponge. The difficulty in some in- 
stances is so slight as scarcely to be regarded; 
in others so severe that the smallest effort, par- 
ticularly in mounting ascents, is most painful. 
A peculiarity sometimes observed is that the 
ascent of a gentle height is distressing, while 
the person can read aloud without inconve- 
nience. A character of the respiration first 
described by Dr. Cheyne of Dublin, and after- 
wards by Dr. Stokes, is by some regarded as 
diagnostic of fatty degeneration of the heart. 
It is thus described by Dr. Stokes : ' A form 
of respiratory distress peculiar to this affec- 
tion (fatty degeneration of the heart), con- 
sisting of a period of apparently perfect 
apnoea, succeeded by feeble and short inspi- 
rations, which gradually increase in strength 
and depth until the respiratory act is carried 
to the highest pitch of which it seems capable, 
when the respirations, pursuing a descending 
scale, regularly diminish until the commence- 
ment of another apnoeal period.' Dr. Hayden, 
in writing on this subject, mentions a case 
in which during the period of apnoea there 
was no change in the heart's action; a second 
case in which the action of the heart and the 
pulse underwent no change during the period 
of apnoea and dyspnoea ; whilst in a third 
case, during the paroxysm of dyspnoea, the 
heart's action was remarkably irregular. It 
should be stated with regard to this symptom 
that, though frequently present, it is by no 
means characteristic of fatty degeneration 
only. It is by some said to be more fre- 
quently associated with disease of the aorta. 
Various explanations of this phenomenon 
have been given. Dr. Little (Dublin Journ.. 
805 806 
HEART, FATTY DEGENERATION OF 
of Med. Sci., No. 91) believes that it is due 
to derangement of the dynamic adjustment 
between the right and left ventricles of the 
heart. Dr. Hayden (op. cit.) connects it with 
atheromatous or calcareous change with dila- 
tation of the arch of the aorta, involving loss 
of elasticity in its walls. The late Professor 
Laycock thought (Dublin Journ. of Med. 
Sci., July 1873) that this phenomenon de- 
pended upon ' sentient palsy of the respiratory 
centre,' or ' a paresis of reflex sensibility of 
the mucous membrane of the lung.' This 
respiratory action, though suggestive of some 
grave and serious source, may pass away. 
See Respiration, Disorders of. 
Another phenomenon, said to be diagnostic 
of fatty degeneration of the heart, is arcus 
senilis-a pearly crescentic opacity of the 
upper and lower portions of the circumference 
of the cornea, which must be distinguished 
from an opaque annulus which occasionally 
surrounds the entire cornea, and which is not 
the result of fatty degeneration. The late Mr. 
Canton was the first to describe the nature 
of this change as fatty degeneration. It is 
quite true that when fatty degeneration is 
present in the cornea it may possibly be 
found in the muscular fibres of the heart and 
in the arteries. Still it by no means follows 
that the degeneration must exist in any other 
particular part or organ, and therefore this 
appearance in the cornea cannot be at all 
regarded as pathognomonic of fatty degenera- 
tion of the heart. 
As the disease progresses the symptoms 
become more marked; the various effects of 
feeble and languid circulation further show 
themselves; angina may perhaps become 
fully developed; or the patient may be cut 
off suddenly by one or other of the effects 
connected either immediately or remotely 
with the lesion itself. Of eighty-three cases 
of ' fatty disease ' of the heart collected by 
the writer, sixty-eight had died suddenly. 
Physical Signs.-The physical signs that 
characterise fatty disease are neither many 
nor marked. They are-a feeble impulse of 
the heart, proportionate to the extent and the 
degree of the disease; a feeble muffled first 
sound, under like conditions, sometimes 
scarcely audible. When the heart is en- 
larged, the impulse, though weak, will be 
found extended, and so likewise will be the 
dulness on percussion. A murmur may be 
present, as suggested by Rokitansky, from 
degeneration of the columnse carneae. The 
second sound is often distinct and clearly 
accentuated, as compared with the first. 
Diagnosis.-The diagnosis of the presence 
of this degenerative change, in the absence of 
any alteration in the size of the heart, must 
be founded upon a consideration of the symp- 
toms and physical signs above described. 
When the heart is hypertrophied or dilated 
only, the presence of fatty degeneration is 
more difficult of diagnosis by its physical 
signs. We must then seek to trace how far 
the usually well-marked signs of hypertrophy 
of the organ are modified by those we have 
described as being present in, and character- 
istic of, fatty degeneration. The same ob- 
servations will apply to dilatation or thinning 
of the walls. This special condition has its 
own well-marked phenomena, which will be 
found described elsewhere (see Heart, Dila- 
tation of). These signs will be more or less 
modified in proportion to the degree and 
extent of any fatty change that may be pre- 
sent. They must be carefully studied so that 
they be not confused with like conditions ori- 
ginating in disordered state of other organs, 
as the lungs, the liver, &c. 
Progress, Duration, and Terminations.- 
It is impossible to determine the duration of 
a disease the date of origin of which is in 
most cases very obscure. Still there are 
grounds for believing that persons with a 
certain amount of degenerated tissues in 
their hearts have gone on living during 
periods extending over many years. On the 
other hand, death has occurred from fatty 
degeneration of the heart, determined post 
mortem, in which the entire absence of symp- 
toms until a few months before the fatal 
event justified the opinion that the duration 
of the disease had not much exceeded the 
period just mentioned. When fatty degene- 
ration occurs as the result of phosphorus- 
poisoning, or of certain exhausting diseases, 
the progress of the change, which can then 
be determined, is rapid. In such cases, the 
morbid process is not confined to the heart 
alone, and therefore when death occurs, it 
cannot well be attributed solely to the con- 
dition of this organ. 
Death is frequently sudden, the proportion 
being as five to one compared with other 
modes of death from fatty disease of the 
heart. The immediate modes of death in 
these cases are those which have been 
already alluded to when treating of the 
effects of the disease, namely, by syncope, 
angina, coma, and rupture of the heart; the 
first and last of these contributing nearly 
the whole number of those who die sud- 
denly. Such facts indicate very strongly 
the necessity of avoiding any mental excite- 
ment or physical exertion which might lead 
to these results. Here it might also be well 
to remember, with reference, to the adminis- 
tration of anaesthetics, that chloroform has 
an especially depressing effect on the heart's 
action; and that when the heart's power is 
enfeebled by the disease which we are here 
describing, a very small dose of this anaes- 
thetic, which w'ould have little or no effect 
on a healthy heart, may prove fatal. This 
opinion was first expressed by the writer 
many years ago, in 1850, and it has been fully 
confirmed by numerous cases of death which 
have since occurred during the administration 
of chloroform. HEART, FATTY DEGENERATION OF 
HEART, FATTY GROWTH ON 
807 
Prognosis and Treatment. - The pro- 
gnosis of fatty degeneration of the heart must 
depend in a great measure upon a knowledge 
of its cause a id its extent. In cases where 
the disease originates in constitutional causes, 
such as in phosphorus-poisoning, and in cases 
where it is of the nature of involution-for 
example, after parturition-there is good 
ground for believing that, the cause being 
removed, the effect will cease, and a fairly 
healthy condition of the organ be restored. 
On the other hand, when the coronary arteries 
are obstructed, and degeneration is thereby 
set up, or when nutrition generally is im- 
paired, and all the tissues are more or less 
undergoing this change, the prognosis must 
be in the highest degree unfavourable, more 
especially so if in the latter case the patient 
cannot be placed in a condition by which 
this degenerative tendency may be counter- 
acted. 
The treatment consists in the adoption 
of all the measures calculated to improve 
the general health-such as pure fresh air, 
wholesome food, and temperance, together 
with moderate exercise (either carriage, 
riding, or walking), if it can be accomplished 
without causing pain or breathlessness. 
Everything which may tend to lay stress on 
the heart's action, such as walking uphill 
or making efforts, or any mental excitement, 
should be avoided. With reference to drugs, 
such tonics as can be best tolerated by the 
patient might be given. We may mention 
iron-especially dialysed iron-phosphorus in 
small doses, and strychnine. Special attention 
must be paid to the condition of the excretory 
organs, such as the kidneys and liver, which 
are liable to become congested when the 
cardiac action is feeble. Lastly, it may be 
said that in cases of syncope, in addition to 
the administration of the usual stimulants, 
galvanism applied from the back of the neck 
to the praecordia by the interrupted current, 
has in a few instances been known by the 
writer to be useful. 
For further information on the subject of 
Fatty Degeneration of the Heart the reader 
may consult the complete and very valuable 
article by the 'ate Dr. Hayden in his work on 
Diseases of the Heart ; and a memoir by 
the writer in the 33rd vol. of the Med.-Chir. 
Trans. (1850). Richard Quain. 
HEART, Fatty Growth on.-Synon.: 
Fr. Hypertrophie graisseuse du Coeur ; Ger. 
Fettige Infiltration des Herzens. 
Definition.-The growth of fat on the 
surface and in the substance of the heart, in 
quantity sufficient to interfere with its func- 
tions, and thus to constitute a disease. 
^Etiology.-In our inquiries concerning 
the cause of this condition, we are met with 
the problem, still to be solved, Why are cer- 
tain individuals, and certain parts of the body, 
more prone to the formation of fat than other 
persons and other parts ? We can ascertain 
with some degree of certainty the circum- 
stances which promote the formation of fat 
in general; and observations collected by the 
writer and others show that when fat is thus 
formed throughout the system, the heart is 
likely to partake largely of the accumulation. 
We may accordingly refer to the article 
Obesity, in which the causes of fatty growth 
in general will be found discussed. 
Of fifteen cases of extreme fatty growth on 
the heart collected by the writer, eleven oc- 
curred in very fat individuals, and only one 
in a person who was described as being ' thin.' 
Age seems to exert a decided influence upon 
the formation of fat upon the heart. It is 
very scanty in infancy, and is rarely present 
in any quantity before the thirtieth year. 
Corvisart, however, quotes from Kercking 
the case of a child whose heart seemed want- 
ing, so great was the quantity of fat in which 
it was embedded. Of the fifteen cases just 
referred to, thirteen were above fifty years, 
and one only under that age. Males, accord- 
ing to the same data, are more liable to 
accumulation of fat on the heart than females, 
the respective numbers being as twelve to 
three. 
Anatomical and Pathological Cha- 
racters.- A certain amount of fat-tissue, 
which is not inconsistent with health, 
occupies a definite position in the structure 
of the heart. It is seen most abundantly in 
the groove between the auricles and the 
ventricles ; and as the distribution of this 
tissue bears a relation here, as in other parts, 
to that of the blood-vessels, it first appears in 
the course of the primary branches of the 
coronary arteries; then in the course of the 
secondary branches-that is, in the groove 
over the septum, which marks the boundary 
between the ventricles; and, lastly, it follows 
the distribution of the small lateral branches. 
These branches are more superficial over the 
right ventricle than over the left; hence the 
former is found always and more abundantly 
covered with fat. A fringe of fat is also found 
at the apex of the heart; and frequently around 
the margins of the auricles. A mass of 
superabundant fat will of itself be sufficient 
to press on and embarrass the action of the 
heart; but fat rarely exists in this abundance 
on the surface of the organ without insinuat- 
ing itself between, and encroaching on, the 
muscular fibres. In this way the muscular 
portions of the walls of the organ become 
thinner and thinner, until the columnae carneae 
may appear to arise from a mass of fat. This 
state constitutes what was once regarded as 
fatty degeneration of the heart, and which 
has also been called ' fatty metamorphosis ; ' 
but it is in many cases nothing more in reality 
than a simple hypertrophy of fat. In parts 
of hearts which are less affected, that is, where 
fat is not very abundant, simple striae of 
yellow tissue will be observed lying amongst 808 
HEART, FATTY GROWTH ON 
the muscular fibres-an appearance often 
found in the auricles. 
Microscopical appearances.-When a por- 
tion of heart suffering from fatty growth in a 
high degree is examined with the microscope, 
it will be found that where the growth is 
most advanced, that is, towards the external 
surface, very few muscular fibres can be seen, 
and that the very wide intervals between 
them are occupied by fat-cells (see fig. 61). 
Proceeding inwards, the muscular fibres be- 
come more evident; the fat-cells become 
fewer; and, finally, we reach the muscular 
fibres beneath the endocardium, with a few 
fat-cells lying here and there amongst them. 
It is worthy of note that the fibres, though 
overwhelmed by fat, may still retain their 
organisation. In all cases, however, the 
course and direction of the fibres are more 
or less modified and distorted. The fact that 
the fibres still exist, though concealed, affords 
an explanation of the persistence of the heart's 
action in those instances in which the mus- 
cular walls appear to a greater or less extent 
replaced by fat. It might also be mentioned 
that small masses of fatty tissue sometimes 
pectoris; it may be death. Rupture of the 
heart sometimes results. Such an enumera- 
tion of evils, in which there is no evidence of 
any other lesion of the heart's texture, save 
an accumulation of fat, would suffice to render 
this condition a source of very grave import; 
but we cannot always be quite clear on the 
subject, because in the particular cases quoted 
it is possible that some degeneration of the 
muscular fibres may co-exist. It would be 
well, therefore, not to dwell too much on 
such effects as proceeding from and depen- 
dent on fatty growth alone. 
Diagnosis.-The presence of an excessive 
deposit of fat about the heart must, in a great 
measure, be a matter of inference during life. 
Where one or more of the effects mentioned 
above as having been noticed in cases of this 
kind are present; when the pulse is small 
and weak ; when the first sound of the heart 
is feeble, and the impulse weak ; when the 
extent of dulness on percussion is increased ; 
and when these phenomena occur in a fat 
person, it may be inferred that the heart is 
too fat.1 But, on the other hand, it must not 
be overlooked that these symptoms and signs 
may be found in cases of fatty degeneration 
of the walls of the heart, in cases where the 
amount of fat-tissue is but moderate. Nay, 
more, as already stated, both conditions are 
often present in the same heart, thus render- 
ing distinctive diagnosis impossible. It is 
said that the presence of water in the peri- 
cardium may be confounded with the presence 
of fat upon the heart; but the history and 
general features of the case in the former 
condition should be sufficient to prevent all 
difficulty in the diagnosis. See Pericardium, 
Diseases of. 
Treatment.-The treatment of fatty ac- 
cumulation on the heart is so intimately 
associated with the subject of the formation 
of fat in general, that this point can be dis- 
cussed with more advantage in its wider 
relations (see Obesity). Whilst the treat- 
ment directed to this point is being carried 
out, we can do little more for the heart itself 
than aim at giving strength to the portion df 
its texture still available for duty-by tonics, 
Fig. 61.-Fatty Growth in the substance 
of the Heart, x 400 diam. 
appear beneath the endocardium, varying in 
«ize from that of a pin's head to that of a pea. 
The writer has seen these little fatty tumours 
in cases where there was a considerable, but 
not an excessive, amount of fat upon the sur- 
face of the heart. 
Effects.-The fat accumulated on the 
heart and in its substance may be supposed to 
act mechanically; and by its pressure upon 
the muscular fibres, on the nerves, and on 
the blood-vessels, to impede the function of 
the organ, embarrass its nutrition, and pro- 
duce those effects which may be briefly 
enumerated as-a languid and feeble condi- 
tion of the circulation, with a sense of un- 
easiness and oppression in the chest; em- 
barrassment and distress in breathing, drow- 
siness, even coma; syncope ; perhaps angina 
1 Dr. Henry Kennedy, of Dublin, in a lately 
published special monograph on Fatty Heart, states 
that the points upon which the diagnosis of fatty 
growth on the heart mainly turn are the follow- 
ing : ' First, a large full pulse, beating at the 
natural standard of frequency; secondly, evidence 
derived from percussion of the heart's dulness being 
more extended than natural; thirdly, the possible 
presence of a soft systolic murmur over the aortic 
orifice, occupying the first sound of the heart only, 
and leaving the second normal; and, lastly, the con- 
dition of the individual as to his being fat or other- 
wise ' (p. 39). The present writer hesitates to agree 
with Dr Kennedy as to the condition of the pulse 
generally, and certainly this description will not 
apply in the cases of those persons of small frame, 
with small arteries, who often become obese and 
present symptoms of fat-heart after the middle 
period of life. HEART, FATTY GROWTH ON 
HEART, FIBROID DISEASE OF 
809 
steel, quinine, phosphorus, &c.; secondly, by 
lightening as far as possible the work which 
the heart has to do; and thirdly, by attending 
to the excreting organs, so as to prevent con- 
gestion there, and consequently embarrass- 
ment to the weak heart. 
Richard Quain. 
HEART, Fibroid Disease of.-Synon.: 
Chronic Myocarditis. 
Definition.-A morbid condition in which 
the muscular fibres of a portion of the walls 
of the heart are replaced by fibroid tissue. 
^Etiology.-Fibroid disease of the heart 
is met with most frequently in middle-aged 
male subjects. The disease is supposed to 
be occasionally nothing more than an ex- 
tension between the muscular bundles of a 
chronic process that has commenced with 
endocarditis or pericarditis. The cause of 
this, which is generally rheumatism, is then 
regarded as the cause of the fibroid growth; 
but in reality it is more probable that in 
such cases the serous inflammation is the 
result, not the cause, of the fibroid change. 
Fibrosis is sometimes the consequence of 
acute interstitial myocarditis. In a con- 
siderable number of cases of fibroid disease, 
and in most of the cases of so-called ' fibrinous 
deposit,' the change is probably syphilitic in 
its nature. In other instances it is asso- 
ciated with degenerative changes in the ves- 
sels, and even infarction, or with disease of 
the kidneys. Increase of fibrous tissue in 
the myocardium may also be the result of 
prolonged moderate congestion of the coro- 
nary veins (see Heart, Congestion of). 
Very frequently no evident cause of the 
disease can be discovered. 
Anatomical Characters.-Our knowledge 
of the pathology of this disease is in a great 
measure due to the remarkable number of 
cases which have been described in the 
Transactions of the Pathological Society, 
since the first specimen was presented by 
Sir Richard Quain in the year 1850. Fibroid 
disease of the heart occurs most frequently in 
the walls of the ventricles. It is met with 
under several different forms. In rare in- 
stances, which might be described as cases 
of connective tissue hypertrophy of the heart, 
there is an uniform increase of fibrous tissue 
between the muscular fibres throughout the 
whole organ (see Heart, Connective-Tissue 
Hypertrophy of). In other instances, the 
disease appears as a local thickening of the 
connective tissue underneath an opacity of 
the endocardium or of the pericardium, 
whence septa run outwards or inwards be- 
tween the muscular bundles. Most fre- 
quently, however, it presents the appearance 
of a fibroid patch, generally situated near 
the apex of the heart, replacing the muscular 
substance throughout its whole thickness, 
and over a greater or less extent of surface 
-possibly even a considerable portion of 
one ventricle, and consisting of dense, firm, 
inelastic, greyish-white fibrous tissue. Smaller 
patches, nodules, scars and streaks may be 
found in the deeper parts of the myocardium. 
The apices of the papillary muscles, again, 
may become fibroid, especially in chronic 
valvular disease. Polypoid tumours, com- 
posed of fibrous tissue, have been met with 
on the endocardial surface of the heart, that 
is, projecting into one of the cavities ; more 
especially into the left auricle. Possibly the 
detachment of such a polypus may be one 
mode of origin of the 'fibrinous balls' or 
' concretions ' occasionally found lying free 
in the auricular cavities. Fibroid and ' fib- 
rinous ' formations due to syphilis are de- 
scribed in the article Heart, Syphilitic 
Disease of. 
Microscopically, fibroid disease of • the 
myocardium presents a concomitant increase 
of the connective-tissue elements, and de- 
crease by atrophy of the muscular fibres. 
Occasionally, in an early stage, as well as at 
the margins of the older patches, round and 
spindle-shaped cells and bundles of young 
fibrillae have been observed. The latter in- 
crease in size and in number, press upon the 
intervening muscular fibres, and finally unite 
and form bands or patches of ordinary fibroid 
tissue. Meanwhile, the muscular fibres 
gradually become attenuated, granular, or 
fatty; and at last they disappear by absorp- 
tion, or patches of them may be imprisoned 
within the fibroid growth. 
The effects upon the heart of fibroid 
changes in its walls vary with their situation 
and extent. If a large portion of the wall of 
one cavity is fibrotic, irregular patchy dilata- 
tion of the chamber ensues. Localised fib- 
rosis, especially if it commence beneath the 
endocardium, gives rise to aneurysm of the 
heart, by the yielding of the diseased area to 
the intra-ventricular pressure (see Heart, 
Aneurysm of). Deeper or more limited 
patches or lines of cirrhosis cause irregularity 
or puckering of the cardiac walls; and 
valvular insufficiency may result from this, 
or from fibrosis and functional disturbance 
of the papillary muscles. Lastly, fibroid 
disease occasionally involves the conus 
arteriosus in an annular form, giving rise to 
constriction and the formation of so-called 
' cardiac stenosis.' 
Symptoms. - The symptoms of fibroid 
disease of the heart vary greatly in different 
instances, according to the extent, situation, 
and other conditions of the growth. When 
the fibrosis is very limited, few symptoms 
can be expected to be present. In the 
majority of cases in which a considerable 
portion of the cardiac wall has been found 
diseased, the symptoms have been described 
as those of ' ordinary heart-disease,' namely, 
dyspnoea on exertion; praecordial pain or dis- 
tress ; occasional palpitation; a small, weak, 
or irregular pulse ; dropsy; and visceral 810 
HEART, FIBROID DISEASE OF 
HEART, FUNCTIONAL DISORDERS OF 
complications. As a rule, no endocardial 
murmur has been present; but fibrosis of 
the papillary muscles may sometimes give 
rise to the signs of incompetence of the 
auriculo-ventricular valves. The symptoms 
of cardiac aneurysm and of syphilitic disease 
of the heart, as well as those of connective - 
tissue hypertrophy, are separately described. 
Course and Terminations.-The course 
of fibroid disease of the heart is generally 
chronic, although urgent symptoms are 
sometimes observed a short time only be- 
fore death. Attacks of pain, palpitation, and 
dyspnoea may occur aiid subside long previous 
to the last fatal illness. The development of 
cardiac aneurysm, and its possible termina- 
tions, will modify the course of the disease. 
Sudden death may occur, with or without 
previous cardiac symptoms, and must be re- 
garded as a special mode of termination of 
fibroid disease of the heart. Otherwise the 
cases generally end by pulmonary complica- 
tions, dropsy, and exhaustion. 
Diagnosis.-Fibroid disease of the myo- 
cardium has to be diagnosed from chronic 
valvular disease; from enlargement due to 
extracardiac causes, such as renal disease, 
gout, or emphysema; and from fatty de- 
generation. Under all circumstances, an 
accurate diagnosis is extremely difficult, if 
not impossible. The presence of a murmur 
does not exclude fibrosis, as the valves may 
become secondarily involved; and valvular 
disease is not always attended by a murmur. 
The other cardiac lesions mentioned must be 
excluded in the ordinary way. 
Prognosis.-When fibroid disease of the 
heart is attended with sympto'ms sufficient 
to establish a diagnosis, the prognosis is un- 
favourable as regards life, although it may 
not be immediately so. 
Treatment.-This consists in relieving 
and supporting the heart by every possible 
means, especially by rest and cardiac stimu- 
lants, such as alcohol and ether. Iodide cf 
potassium may be given with benefit in seme 
cases, particularly if there be a history of 
syphilis. Digitalis will have to be adminis- 
tered with great circumspection. 
J. Mitchell Bruce. 
HEART, Functional Disorders of. 
Definition. - A disturbance in the func- 
tions of the heart, with or without pain; 
having origin in causes other than inflam- 
mation or organic diseases of the heart 
itself. 
This definition comprises various disorders 
in the dynamical functions and sensibility of 
the heart, from the slightest disturbance of 
only momentary duration, to urgent symp- 
toms of considerable persistence. The fre- 
quency of the occurrence of functional 
disorders of the heart, and the similarity of 
many of the symptoms exhibited to those 
met with in organic diseases, as well as the 
fact that these functional disorders may 
co-exist with organic disease, thus greatly 
exaggerating the apparent gravity of the 
latter, render it important to accurately de- 
termine how much of the disturbance may 
be due to the one or to the other of these 
causes. Here, however, functional disorder, 
uncomplicated with organic lesion, will only 
be referred to. 
^Etiology.-To estimate the immediate or 
proximate cause of functional disturbance of 
the heart, regard must be had to its structure, 
and how this is nourished and its motions 
regulated. For adequate and equable dy- 
namical movement, the primary requirement 
is a healthy development of muscular struc- 
ture. Weak muscular fibre, apart from 
degenerations by disease, becomes a pre- 
disposing cause of feeble and irregular action. 
But as the regular recurrence of the muscular 
contraction and expansion must, moreover, 
be ascribed to the agency of the cardiac 
ganglia, the vagus nerve, and the nerves and 
ganglia of the sympathetic system, all nour- 
ished and excited by the blood, any abnormal 
conditions of these have also their effect: 
the contractions of the heart being inhibited 
by impressions made on the terminations of 
the vagus, and accelerated by such as may 
be made upon those of the sympathetic. 
Through the medium of these impressions, 
afferent and efferent, the heart's action is 
remotely regulated by the cardiac centre in 
the medulla. Interference with the functions 
of these several nerves may so modify the 
action of the heart as to cause deficiencies 
of power of every variety and extent, giving 
rise to illustrations of abnormal contractility 
and irritability, which the heart exhibits in 
common with all other muscles. The heart 
further possesses the distinguishing feature 
of rhythmical action : and this action is also 
shown by experiment to be immediately 
dependent on the blood, whether venous or 
arterial ; for without a supply of blood 
rhythmical action ceases. There are cogent 
grounds for the belief that this is not only 
thus due to the intrinsic ganglionic system 
cf nerves ; but, as errors of rhythm are cer- 
tainly induced by such causes as improper 
diet, dyspepsia, the presence of worms, con- 
stipation, injuries or deformities of the chest, 
and diseases of the lungs, there can be no 
doubt that the heart is also liable to reflex 
irritation of the pneumogastric and sympa- 
thetic nerves. The healthy action of the 
heart, and the controlling energy of its 
nerves, greatly, if not entirely, depend on 
the supply of healthy blood; and any ab- 
normal condition of the supply, whether in 
quantity or quality, shows itself by dis- 
turbance not only in the functions of the 
heart, but in the substitution of haemic 
murmurs for the normal sounds. Morbid 
conditions of the general arterial and venous 
systems have also their influences ; thus HEART, FUNCTIONAL DISORDERS OF 
811 
the force and frequency of the pulse, and, 
more especially, the amount of the peri- 
pheral resistance, causing in their tubes 
dilatation or constriction through the vaso- 
motor or dilator nerves, and, indirectly, the 
compensation and relief afforded by the 
abstraction of fluid through activity in the 
Malpighian tufts of the kidneys, are to be 
duly considered. Moreover, the muscular 
substance of the heart itself is nourished by 
the blood circulating in the coronary arteries, 
and thus becomes susceptible to the quality 
and condition of the blood so distributed; 
hence, a blood too rich in fibrin or red 
globules, and thereby inducing plethora, 
frequently causes over-action of the heart 
and palpitation, whilst in anaemia a deficient 
amount of blood induces a weak and often 
excited and irregular action. The predis- 
posing causes, in addition to those already 
named, may, therefore, be classed thus: 
(1) Those conditions acting through or upon 
the nervous system, such as the general 
exhaustion of the nervous system, all forms 
of reflex irritation, venereal excesses, vain 
longings, purposeless occupations and amuse- 
ments, protracted mental exercise, abstinence 
from adequate repose, &c. To these must 
be added the special temperament and per- 
sonal peculiarities of the individual, a con- 
genital or superimposed want of vigour, 
general debility, deformities of the ribs and 
spinal column, a small weak heart, uterine 
irritation, hysteria, adynamic fevers, and the 
special sanitary influences under which the 
individual is placed. (2) Those conditions 
acting upon the general blood-supply of the 
body, and consequently affecting the special 
blood-supply of the heart, such as the turgid 
a?id plethoric states of gross feeders, depraved 
states caused by bad and deficient diet, and 
all forms of blood-disorder, as amemia, gout, 
scurvy, &c. Amongst the immediately ex- 
citing causes may be named mental shock or 
distress; protracted and unusual physical 
exertion; various articles of diet, as tea, 
coffee, &c.; tobacco in excess; many medi- 
cines, as aconite and digitalis; as also pro- 
longed abstinence, exposure to cold, and 
notably blows on the epigastrium. 
Symptoms.-An increased impulse, indi- 
cating a state of general plethora or sur- 
charged circulation, is usually associated 
with a series of well-marked symptoms, 
when rapidity of action is superadded-such 
as flushing of the face ; heat and pain of the 
head, with a sensation of a whizzing, or 
rushing upwards of the sounds of the heart; 
dimness of vision, with photophobia ; and a 
tendency to syncope, and to clammy perspi- 
rations, with cold shivering. In some rare 
cases the voluntary muscles, more especially 
of the lower extremities, may refuse to act, 
so that the gait becomes tottering, or the 
patient grasps adjacent objects to steady 
himself, yet there is neither paralysis nor 
vertigo. The respiration, though not gene- 
rally embarrassed, may become irregular 
and oppressed, presenting the phenomena of 
a short inspiration with a prolonged expira- 
tion ; but should the right heart be congested, 
independently of any frequency of cardiac 
impulse, the breathing may be accelerated 
and accompanied with dyspnoea, or even 
apnoea, and a short dry cough. Illustrations 
of this class of symptoms often occur in 
those of sanguine and nervous temperaments; 
and may be the result of violent and too 
protracted exercise, of emotional excitements, 
or of the over-indulgence in stimulants or 
food when associated with lives of idleness 
and inactivity. Should the increased im- 
pulse be associated with rhythmical dis- 
turbance, there is for the most part con- 
sciousness of the existence of such states, 
more especially on the first ingress of the 
attack, so that it becomes a source of much 
anxiety and even of terror, inducing the self- 
conviction of the existence of organic disease. 
The head-symptoms also become more 
marked, and associated with local pains and 
tinnitus aurium; whilst the breathing is 
marked by sighing, and often becomes les- 
sened in frequency. The irregular form of 
nervous palpitating heart is often associated 
also with hsemic diseases, and with nervous 
affections, as chorea, disturbances due to 
masturbation, &c. When such diseases as 
scurvy or chlorosis exist, the attacks become 
more persistent ; there is an increase of 
pectoral complication, even to dyspnoea; the 
headache is sometimes so bewildering that 
the mind becomes alarmed with vague ap- 
prehensions of danger, which give rise to 
general restlessness; the integuments over 
the region of the heart, as well as of the face, 
and even of the extremities, may become 
puffy and cedematous, especially in cases of 
extreme chlorosis, with enlargement of the 
thyroid gland and exophthalmos, where the 
morbid conditions inducing these may also 
possibly cause the irregular palpitation. 
When functional disorder occurs with a 
diminished impulse, the general symptoms 
group themselves under anxiety and lowness 
of spirits, or actual despondency, with mental 
and bodily incapacity for exertion; flati lent 
dyspepsia, with cold clammy extremities; 
anorexia, or, may be, depraved appetite ; ex- 
haustion, with tendency to faintness; and, 
should irregularity of cardiac action be very 
marked, there may be a sensation of prae- 
cordial pain. Males are more subject to this 
form of functional disorder than females, and 
it chiefly occurs in persons having a normally 
small and feeble heart, or where a state of 
general nervous debility is superimposed. 
When the distinctive feature of functional 
disorder is rhythmical error, and this is ap- 
preciable to the patient, the special symptom 
is that of extreme anxiety, even to the fear 
of impending death; occasionally a single 812 
HEART, FUNCTIONAL DISORDERS OF 
intermission is so prolonged as to induce the 
impression that escape has only occurred by 
a miracle. These alarms often induce a pal- 
pitation not belonging to the rhythmical dis- 
order. But if the rhythmical error be as- 
sociated with a deficiency of systolic force, 
temporary paralysis of the heart's action or 
syncope may be induced, and in some extreme 
cases the functions may be weakened even to 
extinction. Such forms of disorder occur in 
those having normal but weak hearts; in the 
dyspeptic; in those subject to gout, especially 
if an attack is impending; and in those whose 
habits and occupations involve exhaustion of 
the nervous system. They are a characteristic 
of advanced age, but may be sympathetically 
induced in the young; and may be observed 
in the course of many diseases, such as tuber- 
culosis, rheumatism, liver affections, or when 
malignant disease is making its ravages. 
Functional disorders of the heart are not 
infrequently associated with pain. This may 
have its origin in the structural relations of 
the heart, though the heart itself be in a 
normal condition; or its seat may be confined 
to the pros cordial regions. When occurring 
in the former, its primary source may be 
in gastric injury or irritations, or caused by 
other foreign disease transmitting its influ- 
ences through the sympathetic system ; or it 
may be due to mental distress, in which case 
the vagus, probably the depressor nerve, pro- 
ceeding therefrom, and the ganglion of Remac 
are the immediate causes of spasm. Fainting 
from emotion is admitted to be due to reflex 
inhibition of the heart, the afferent impulses 
reaching the medulla through the vagus ; and 
it may be concluded that this is also the case 
when pain is the result. In some rare cases, 
pain thus occurring may be the indication of 
urgent, or even of fatal, disorder ; this is evi- 
denced by the well-known effect of a severe 
blow in the epigastrium, or in cases of sudden 
mental shock. These are illustrations of 
purely functional angina pectoris; but for 
the most part this symptom has its origin 
in structural lesion of the heart itself. See 
Angina Pectoris. 
Praecordial pain is by no means an unusual 
symptom accompanying functional affections 
of the heart; it may aggravate the urgency 
of these disorders, yet appears to be little 
influenced by them. The pain does not 
march pari passu with the irregularity or 
strength of the impulse. The pain may be 
persistent, while the associated disorder is in 
abeyance ; and in this respect it differs from 
prcecordial anxiety, which is essentially only 
temporary, though often persistent in its 
duration, and acquires urgency from the 
symptoms with which it may be associated. 
Physical Signs.-The physical signs re- 
ferring to the cardiac action may be con- 
veniently separated into the following groups, 
al though in practice they will be found mingled 
or associated with each other : (1) Increased 
or diminished impulse, connected or uncon- 
nected with increased rapidity or rhythmical 
irregularity ; (2) rhythmical disturbance, 
with intermissions, the impulse being normal 
or diminished; (3) increased or diminished 
frequency, the rhythm and force being nor- 
mal ; (4) hcemic murmurs, both of the left 
and right sides. 
(1) The cases in which an increased im- 
pulse is the distinctive feature of the heart's 
disturbance present many varieties, chiefly 
referable to force and regularity; but to the 
simple forms of increased and accelerated 
impulse there is so very frequently added 
rhythmical disturbance, that this complica- 
tion is perhaps the one most usually occur- 
ring. The rhythmical disturbance may occur 
both in the force and the rapidity of the 
systolic contractions, or it may result in a 
true intermittence, or occasionally the irregu- 
larities thus induced maybe so great as to defy 
definite appreciation, save as a tumultuous 
whole. On palpation, the impulse, abrupt 
in stroke, presents the characteristic of a 
sudden bound, now strong, now failing, some- 
times so rapid as to communicate the impres- 
sion of a fremitus or agitation, then a pause 
or true intermittence followed by hurry or 
more evident irregularity; but amid all this 
irregularity the pulse preserves, in an un- 
broken surface-wave, the characteristics of 
efficient valves. On auscultation, the sounds 
are more difficult of appreciation than in 
simple palpitation; they are loud and clear, 
and sometimes so exaggerated and pronounced 
as to be audible both in the mammary and 
epigastric regions. But whether the exagge- 
rations of sound and impulse be more or less, 
they will be found to act in unison with each 
other; the impulse and sounds increase to- 
gether and diminish together. When there 
is an unusual amount of irregular functional 
excitement in systole, there maybe occasion- 
ally heard, as a passing, but not persistent 
occurrence, a reduplication of the second 
sound, very rarely of the first; and usually 
the first portion of the divided or cleft sound 
is the most accentuated. This reduplication, 
though it may be met with in active inflam- 
matory diseases, is chiefly the concomitant of 
functional disorders of the nervous heart. 
The pulse is generally sharp and jerking; it 
does not always beat in unison with the sys- 
tole of the heart; if there be plethora, it has 
a force and fulness not otherwise observable; 
and if there exist congestion of the right 
ventricle, it becomes contracted and dimin- 
ished in force. 
In cases where the impulse is diminished 
in effort, the special characters are somewhat 
negative; the impulse and sounds being 
feeble, but otherwise normal, unless the 
systole be excited by mental shock or any 
undue bodily exertion, when irregularity and 
increase of impulse, with some slight sharp- 
ness of the sounds, take place. The first HEART, FUNCTIONAL DISORDERS OF 
813 
sound may suggest, rather than have, a 
sharp ringing tone ; while the second is pro- 
longed. 
(2) With respect to errors in rhythmical 
action, separately considered, it must here 
be noted that the chief and characteristic 
errors may be classified under the distinct 
heads of irregularity and intermittence. 
Irregularity may be in the force or in the 
frequency of one or more beats, and presents 
the many varieties which a want of normal 
uniformity may suggest; the minute and 
particular enumeration of these is rather 
satisfying to curiosity than instructive. It 
is sufficient to say that every variety of 
irregular frequency may occur ; while, with 
certain beats, force may be increased or 
diminished. Sometimes there appears to be 
a kind of order in rhythmical disorders-that 
is, short series of varying irregularities may 
regularly succeed each other ; there may be 
a fluttering or trembling, or that vibratory or 
vermicular motion to which the term ' thrill ' 
has been given. True intermittence is not 
so frequent as irregularity; but when inter- 
mittence does occur, it is generally associated 
with irregularity. These disturbances may 
be only momentary or of long duration, 
slight or considerable; but, however this may 
be, their character is determined by the 
irregularity in the recurrence of the systole, 
and the consequent prolongation or retarding 
of the period of intermission in the systole. 
The physical examination of this form of 
functional disorder shows no marked peculi- 
arities, excepting those of systolic irregularity. 
To the ear is revealed irregularity in the re- 
currence and duration of the sounds, from 
the slightest appreciable pause to the most 
rapid and confused trembling, with very 
manifest alterations in tone and pitch. The 
sounds generally are intensified, the first 
sound being sometimes heightened to the 
extent of a sharp knock; whilst the second, 
save in intensity, is not materially altered. 
In extreme cases there may be so much ven- 
tricular irregularity as to induce in place of 
sounds an ill-defined fremitus ; and so much 
force as to produce a metallic ringing, with 
a rubbing murmur on the systole. Thus the 
impulse of the heart, which in health is 
rarely appreciable, and its friction never, 
respectively become so to the touch and to 
the ear ; and the abnormal sounds may exist 
to such an extent as to entirely obscure the 
normal first sound. 
Occasionally there is met with an appre- 
ciable rhythmical disturbance in the pulse, 
which is not found to exist in the heart - 
false intermittence. The heart only indicates 
irregularity of power; and as there is occa- 
sional failure of force in the already weak 
systolic contractions, the impulse is not com- 
municated to the artery at the wrist. These 
false intermissions accompanying irregularity 
most frequently occur when the heart is op- 
pressed by flatus in the neighbouring viscera, 
or is excited by injurious articles of diet, 
as tea, or by the use of tobacco. The sensa- 
tion communicated to the patient is that of a 
disagreeable flutter or ' tumbling over ' of the 
heart, which tends to alarm, although habit 
may to a certain extent ameliorate the terror, 
Rhythmical irregularity occasionally ap- 
pears as a normal condition, having a life- 
long existence. Some cases are marked by 
an extension of the pause, with unsteadiness 
of the systolic impulse; others by its apparent 
extinction, so that there exists a rapidity of 
beats defying all analysis-tachycardia; but 
tachycardia also occurs either as an habitual 
state, or in paroxysms (see Tachycardia). 
There is in these cases usually a small weak 
heart, with systolic impulse devoid of energy. 
Both these classes of cases present the re- 
markable feature of losing much of their dis- 
tinctive irregularity when under the influence 
of a febrile attack; the slow pulse becomes 
quicker and more steady, the rapid one less 
frequent and more distinct; but the sensa- 
tion to the individual is, nevertheless, not so 
comfortable as when the heart's action is in 
its state of normal irregularity. 
(8) Functional disorder occasionally as- 
sumes the form of either increased or of 
diminished frequency, while the force and 
rhythm remain normal. Each of these 
conditions may be congenital and proper to 
the individual, or may be the result of ab- 
normal influences. The functionally fast 
beat is generally induced by other diseases, 
as fever, diabetes, tuberculosis, &c., and is 
indicative of injury to normal innervation. 
The slow and drawling beat is generally met 
with where the nerve-power is healthy, but 
the heart itself is weak or fatty; or there is 
a perverted innervation under the influence 
of digitalis, aconite, or injury to the ganglionic 
system-a blow in the epigastrium offering 
a familiar example. 
(4) Inorganic murmurs are frequently 
heard in functional disorders of the heart, 
and more especially in those cases of haemic 
disorder where the systolic impulse is in- 
creased, with rhythmical irregularity. These 
murmurs have the special characters usually 
attached to such sounds. They are systolic, 
basic, with conduction in the course of the 
great vessels. There is no apex-murmur; 
but at the apex, synchronously with the basic 
murmur, the first sound is clearly defined, 
with a metallic ringing second sound. The 
tone of these murmurs is musical, cooing, soft, 
of low pitch. The seat is in the aortic valves, 
and, as a rule, they are always accompanied 
with palpitation: this palpitation may be 
persistent, while the murmurs are not so. 
The murmurs in chlorosis and spaneemia, 
and, when they occur, in ichorrhsemia and 
leukaemia, have their seat for the most part 
in the pulmonary valves, and are not trace- 
able in the course of the larger arteries ; they 814 
HEART, FUNCTIONAL DISORDERS OF 
are also generally associated with the venous 
hum to be heard in the jugular veins. It is 
remarkable how large may be the amounts of 
blood drained from the system, and the fre- 
quency of the discharges, provided there be 
no diseased condition of the blood itself, with- 
out inducing the presence of a murmur. But 
under these circumstances, though there be 
no murmur, the first sound is usually flap- 
ping in character, and the second ringing in 
tone. 
Complic.a hons and Sequels.-The several 
functional disorders of the heart are often 
complicated with other diseases-many ex- 
ternal to the heart, and some of the heart 
itself. The more prominent of the former 
are disorders of the nervous system and of 
the blood. Many of these have been already 
referred to. For the most part, those asso- 
ciated with a perverted innervation are 
examples of irritability, and exhibit rhyth- 
mical disorder, with pain. Haemic diseases 
induce the simpler forms of palpitation: 
anaemia, gout, and dyspepsia induce palpita- 
tion with rhythmical disorder; spanaemia 
and chlorosis induce all these disorders, with 
murmurs superadded. The diseases of the 
heart with which symptoms of functional 
disorder, though only occasionally occurring, 
may be complicated, are mainly degenerations 
of the walls and valvular lesions. In all 
these cases the amount and urgency of the 
functional disturbance of the heart are no 
indication of the urgency of the disease with 
which it may be complicated. 
Are there any distinct morbid states or 
other sequelae traceable to functional dis- 
order of the heart ? To answer this question 
dogmatically may be difficult. Doubtless 
frequent and prolonged attacks of functional 
disorder are seen to occur without inducing 
any such. On the other hand, the long con- 
tinuance of functional disorder is often 
marked by a depreciation of mental and 
bodily vigour. More specific organic changes 
are generally found to be due to some one or 
other of the diseases with which the func- 
tional disorder has been in its course asso- 
ciated. 
Diagnosis.-In order to make a correct 
diagnosis, the first consideration is to ascer- 
tain the entire absence of structural disease; 
or, should it be present, whether it be 
adequate to cause the full amount of the 
symptoms exhibited. Supposing this to have 
been done, if the agitation of the heart is 
not only excessive, sudden, and apparently 
increased in strength, even to violence, but 
presents the features of spasm rather than 
the calmness of rhythmical order; if the 
sounds are pari passu increased in sharpness 
and intensity, and diffused over a larger area 
than is proper to them; and if the pulse does 
not partake of the simulated force of the 
heart-the presence of an excited functional 
impulse may be assumed. The concurrence 
of some symptoms usually associated with or- 
ganic disease, such as dyspnoea or even apnoea 
and oedema, may, as has been shown, be duo 
to the presence of chlorosis. So also where 
there is a deficient impulse, if the heart have 
its normal position and dimensions ; if the 
sounds though weak be natural in tone and 
quality-it may be concluded that the cause 
is functional only, in the absence of any ab- 
normal physical disease. The same may be 
said of rhythmical irregularities. When any 
of these symptoms are associated with haemic 
murmurs, the character of the murmur, its 
seat, and its persistency must be considered 
in connexion with the absence or the presence 
of haemic diseases. The symptoms of each 
of these several forms of functional disorder 
have been so fully described that there is no 
need to repeat them here. It must, however, 
be always borne in mind that the absence of 
the physical signs of disease is not always 
conclusive of there being no structural lesion, 
for there may be lesions, and important ones 
too, that do not yield evidence of their 
existence. The occurrence of the secondary 
changes, the immediate result of various 
congestions, is often an indication that the 
heart-symptoms are due to the presence of 
structural disease; still it is not always so, 
for congestions of the lungs and liver, and 
oedema, may be the consequence of spanaemia 
or of other morbid conditions of the blood. 
Hence, when these are present, the symp- 
toms exhibited by a disordered heart may 
not be due to structural disease; and the 
same may be said of the effects of muscular 
exercise and of position, for either or both of 
these may distress if there be present any 
anaemic condition or an intercostal neuralgia. 
Nor, on the other hand, does the occasional 
subsidence of urgent symptoms, so frequently 
the' case in functional disorder, absolutely 
affirm the conclusion that there is no struc- 
tural lesion ; for occasionally in the latter the 
normal rhythm and force of the heart may 
reassert themselves; but then in these cases 
there remain the other characteristics of the 
organic affection. Repeated examination and 
an accomplished experience will generally 
lead to a just diagnosis. 
Prognosis.-The prognosis of functional 
disorders of the heart, for the most part, is 
favourable. Where there are baneful con- 
stitutional tendencies, or complications with 
other diseases, the prognosis must not, how- 
ever. be always so considered. In the leuco- 
phlegmatic temperament the symptoms may 
be severe and abiding, and generally dis- 
tressing to the nervous system. If the dis- 
ordered condition be so. urgent as to distend 
the right heart, the liver may become loaded, 
and dropsy thence ensue. In this tempera- 
ment mental shocks may induce palpitation, 
irregularity, and syncope, whence may ensue 
not only persistent disorders, having reference 
to these symptoms, and eventually disease, HEART, FUNCTIONAL DISORDERS OF 
815 
but even immediate death. When functional 
disorder is the concomitant of scurvy or 
anaemia, the prognosis is not always favour- 
able. Still in the young and middle-aged 
there is good chance of ultimate recovery ; 
for if these diseases be subdued the functional 
disorder subsides. When occurring in the 
aged, or in those having a constitutional 
tendency to hypochondriasis, or when asso- 
ciated with structural diseases, or excited by 
inflammations of the endocardium, a less 
favourable prognosis must be given. Func- 
tional rhythmical irregularity, for the most 
part, does not indicate danger, but it may do 
so if associated with some obscure structural 
lesion. Nevertheless, cases of simple func- 
tional disorder, so severe as apparently to 
indicate an immediately fatal termination, 
prove, for the most part, manageable, and re- 
sult in a restoration to health. The freedom 
of the heart from all agitation and other 
indications of disease, before and after an 
attack, is due to its being a normal and un- 
injured organ; and though liable during an 
attack to the morbid influences of spasms 
and congestive loading, it still may be a 
healthy organ. This holds whether the 
periods of disorder be short or prolonged, oc- 
curring rarely or frequently recurring. They 
are distressing but not dangerous. 
Treatment.-The treatment of functional 
disorders of the heart should have reference 
primarily to the mitigation of the symptoms; 
and, secondly, to the prevention of their re- 
currence by avoidance or cure of the exciting 
causes. 
Treatment during the paroxysms.-Func- 
tional disorder with increased impulse ac- 
companied by accentuation of the second 
sound is to be met mainly by depletory 
measures. If the symptoms present an 
aspect of urgency, venesection is called for; 
but otherwise the promotion generally of the 
secretory and excretory functions, especially 
through the portal and renal systems, and 
the enforcement of a regulated, unstimulating 
dietary, are the measures to be resorted to. 
The medicines thus indicated are the alkaline 
diuretics and the saline aperients, and either 
colchicum or mercurials in occasional alter- 
ative doses. When rapidity of action is super- 
added, there are two classes of remedies to be 
resorted to-either sedatives, or the excitants 
of the inhibitory nervous influences of the 
vagus. Of the former, aconite, bromide of 
potassium, diluted hydrocyanic acid, and 
lobelia are types; of the latter, digitalis and 
strophanthus are the most reliable; but 
convallamarin, adonidin, and scillain are 
members of the same group. When there is 
diminished impulse or malnutrition of muscle, 
the causation, as in spanaemia or scurvy, must 
be met, and the remedies to be adopted are 
either the sedatives with stimulant action, 
such as bromide of ammonium or camphor, 
or the nervine stimulants, such as sumbul, 
valerian, or castor. Functional aortic 
murmurs, generally assumed to be indicative 
of spanaemia, are to be met by blood tonics, 
of which iron is the type; but sometimes they 
would appear to be strictly neurotic in origin, 
as in some forms of chlorosis, when the 
nervine tonics, represented by arsenic, zinc, 
or phosphorus, are preferable. The cause of 
intermittence is often to be found in the 
abuse of tea (the tasting habit), and of 
tobacco; otherwise it is generally to be viewed 
as a nerve failure, to be remedied by tonics, 
especially the simple bitters combined with 
ammonia and stimulants. When irregularity, 
on the other hand, whether with increased or 
diminished impulse, is more than probably 
due to an irritable state of the sympathetic or 
intrinsic cardiac ganglia, arising in some in- 
stances (as in gout) from irritative causes 
within the blood, sedatives, and especially 
the alkaline sedatives, are called for. If 
it be induced by a temporary paresis of 
the inhibitory centres, whether of the vagus 
or the ganglion of Ludwig, stimulants are 
needed. The abuse of digitalis and the like 
produces irregularity, firstly of the pulse, then 
of the heart. This becomes, therefore, the 
warning note in the administration of digi- 
talis ; belladonna, on the contrary, excites 
the action of the heart through the motor 
ganglia, and can partly annul the inhibitory 
nervous power when this is not influenced 
from the medullary centre. 
Treatment between the paroxysms.-The 
paroxysm being allayed, it is then well to ex- 
amine carefully into the state of the health, 
so as to ascertain if there be any of those dis- 
ordered conditions which may probably have 
been its exciting cause. Dyspepsia is to be re- 
lieved, the liver is to be set right, the uterine 
functions are to be restored to regularity, 
loaded bowels relieved, plethora subdued; 
spanaemia and chlorosis strengthened into 
health; exhaustion compensated for, and de- 
bility counteracted; and the overworked must 
seek renovation in travel and cheerful recrea- 
tion. In persons prone to these disorders many 
precautions should be observed. The young 
and the plethoric must avoid extremes of 
diet and exercise; the food should be mode- 
rate in quantity and unstimulating in quality ; 
and exercise should be unfatiguing, and 
chiefly taken in the open air. Hot and ill- 
ventilated rooms, and the postponement of 
sleep by late hours, should be especially 
avoided. A careful mental discipline should 
be observed; and this must be sought in 
a healthy exercise of the brain, and restrain- 
ing, by a well-ordered intellectual culture, the 
tendency to vain imaginings and emotional 
passions. The constitutionally nervous and 
irritable in mind must sedulously avoid ex- 
citing situations, as well as exhaustion by 
overwork. The sluggish and hypochondriacal 
must resist the temptations to inaction, 
seeking to overcome these tendencies by 816 
HEART, HEMORRHAGE INTO 
HEART, HYDATID DISEASE OF 
exercise, healthy mental occupation, and 
cheerful companionship; by cold bathing, 
more especially by means of the shower- 
bath ; and, if the bowels be confined, by the 
judicious use of aperients. As all the varieties 
of functional disorder of the heart are peculiarly 
under the influence of a morbid will, it be- 
comes of the first importance that the medical 
attendant should generally encourage and 
cheer; and as soon as careful investigation 
has satisfied the requirements of a just 
prognosis, further investigations by the 
stethoscope should be avoided. Repeated 
investigations tend to prolong the disordered 
action, and perhaps so to impress the imagin- 
ation as to forbid recovery. 
Thomas Shapter. 
HEART, Haemorrhage into the 
Walls of.-Synon. : Cardiac Apoplexy. 
Definition.-Extravasation of blood into 
the substance of the heart. 
^Etiology and Pathology.-Blood is ex- 
travasated into the substance of the heart in 
various pathological conditions, but as these 
are described under their respective headings, 
it will not be necessary in this place to do 
more than refer to them. 
Rupture of the heart is the most frequent 
origin of haemorrhage into the walls of the 
organ. The blood in these cases may be 
derived from the cavity of the ventricle, and 
forced between the muscular fibres at each 
contraction. More rarely, a partial rupture 
of the wall may occur, unconnected with the 
cavities, and haemorrhage take place into the 
seat of the lesion from one of the coronary 
vessels or their branches, constituting what 
has been called ' cardiac apoplexy.' In both 
classes fatty degeneration is generally the 
cause of the rupture. 
The formation of false consecutive aneur- 
ysm of the heart may be attended with 
haemorrhage into the walls; an abscess, 
blood-cyst, hydatid-cyst, or gumma having 
burst or made its way into one of the cavities. 
The coronary arteries may be the source 
of the haemorrhage : for instance, in rupture 
of a coronary aneurysm ; in cases of can- 
cerous ulceration of their walls; and in em- 
bolism or thrombosis of their lumen, leading 
to infarction. 
Ecchymosis of the heart is' a form of 
haemorrhage belonging to a different cate- 
gory. It is generally met with in associa- 
tion with parenchymatous degeneration of 
the heart, for example in the acute specific 
fevers ; with that form of fatty degeneration 
which is produced by certain poisons, such 
as phosphorus and arsenic; and with other 
pathological states in which ecchymoses 
occur in the viscera generally, as in purpura 
and scurvy, and especially in cardiac and 
pulmonary disease. 
In cases of non-fatal haemorrhage into the 
walls of the heart, the blood undergoes the 
changes usual in extravasations, and gives 
rise to the collections of pigment-particles 
which are sometimes found between and 
upon the muscular fibres; to blood-cysts ; or 
to collections of puriform matter. 
Haemorrhage into the myocardium, what- 
ever its pathology may be, possesses no 
special clinical relations. 
J. Mitchell Bruce. 
HEART, Hydatid Disease of.-A 
considerable number of cases have been 
recorded, in which hydatids, in the wider 
sense of the term, have been found in the 
human heart. According to the late Dr. 
Cobbold, 3'5 per cent, of all cases of hydatids 
in man occur in this situation. 
Anatomical Characters.-Hydatid cysts 
of the heart are either simple or multiple, 
the latter being the more common of the 
two forms. They are situated in the myo- 
cardium of either side of the heart; but tend 
naturally by enlargement to project either 
into the pericardial sac, or into one of the 
cardiac cavities, in the form of a prominent 
cystic tumour. In this condition they have 
generally been found post mortem; but it is 
probable that in other cases the parasite may 
undergo degenerative changes in the heart, 
as in other organs, without its existence 
being suspected during life or discovered 
after death. In still other instances the 
hydatids rupture or are dislodged from their 
seat in the cardiac wall-either inwards or 
outwards or in both directions at once. In 
the first event, the parasite or its contents 
or fragments becomes impacted in the cardiac 
cavities or orifices, or give rise to embolism 
of the great vessels or of a distant branch. 
Rupture of a cyst into the pericardial sac 
causes pericarditis ; and rupture both inter- 
nally and externally has given rise to haemato- 
pericardium. 
Hydatids of the heart are frequently asso- 
ciated with the same disease in other viscera. 
The appearance and structure of the para- 
site do not require to be described here. 
See Entozoa. 
Symptoms.-In several cases of this disease, 
the subjects have died suddenly during ex- 
ertion ; or, as in a case recorded by Dr. 
Wilks, after a hearty meal. These persons 
were not known to have suffered previously 
from symptoms referable to the heart. In 
other instances the ordinary phenomena of 
chronic cardiac disease were present, in- 
cluding endocardial murmurs ; but it is not 
certain that these were always due to the 
presence of the hydatids in the heart. A 
sudden fatal termination w'ill be the result 
of internal rupture and embolism, or of 
haemato-pericardium, as described above. 
Diagnosis.-Hydatid disease of the heart 
does not appear to have ever been suspected 
during life. Cardiac symptoms and signs, 
or sudden death, occurring in an individual HEART, HYDATID DISEASE OF 
HEART, HYPERTROPHY OF 
817 
known to be suffering from hydatids of 
other viscera, would suggest that the heart 
was possibly also affected. 
Treatment.-The disease cannot be said 
to have any special interest therapeutically. 
J. Mitchell Bruce. 
HEART, Hypertrophy of.-Synon. : 
Fr. Hypertrophic du Coeur ; Ger. Hypertro- 
phic des Herzens. 
Definition.-An excessive growth of one 
or more of the tissues of which the heart is 
composed, the result of which is an abnormal 
increase in the weight and bulk of the organ. 
The walls of the heart are composed of 
muscular tissue, connective tissue, and fat ; 
and an increase may occur in any one of 
these elements. Here we have to deal with 
hypertrophy of the muscular tissue. Increase 
of the fat and of the connective tissue will 
be found described under Heart, Fatty 
Growth on; and Heart, Connective-Tissue 
Hypertrophy of, respectively. 
Anatomical Characters.-The most im- 
portant anatomical change in cardiac hyper- 
trophy is an increase of the proper muscular 
tissue of the heart. There is no growth of 
new tissue different from the normal heart- 
muscle : there is an increase in the number 
and it may be in the size of the muscular 
fibres. There may be hypertrophy of only 
one part of the cardiac walls, abnormal 
thinning being found in other parts. The 
organ may be greatly enlarged from general 
dilatation, without any notable thickening of 
the walls ; but the capacity of the chambers 
should always be carefully noted in estimat- 
ing the degree of hypertrophy, as there may 
be a greatly augmented extent of wall, al- 
though its actual thickness seems normal. 
Simple hypertrophy is very frequently the 
first condition, preceding hypertrophy with 
dilatation. See Heart, Dilatation of. 
The increase of weight and bulk may be 
due to (1) augmentation of the size of the 
muscular fibrillae, which may become more 
than double that of the normal; (2) the 
formation of new muscular fibres ; (3) in- 
creased development of blood-vessels; (4) 
augmentation of connective tissue; and (5) 
fatty accumulation. In the course of time 
the hypertrophied tissue may unduly press 
upon the blood-vessels and contribute to in- 
duce degeneration, whilst the continuance or 
increase of the primary cause of obstruction 
may lead to dilatation of the cavity (auricle 
or ventricle), the work of which is obstructed. 
General Considerations.-The weight of 
the heart of the infant at birth becomes more 
than doubled at the age of two years. Be- 
tween seven and fourteen years of age it is 
about eight times the weight at birth ; from 
fourteen to twenty the increase is such that 
the weight is again nearly doubled. There 
is, speaking generally, progressive augmenta- 
tion even to old age. Wilhelm Muller, how- 
ever, has shown that the progressive increase 
of weight with age is due rather to the 
augmentation in the weight of the great 
vessels within the pericardium than to that 
of the heart-substance itself. There has been 
a general consensus amongst observers that 
the heart of the male is, as a rule, heavier 
than the heart of the female. W. Muller has 
shown, however, that this is only because the 
weight of the heart is proportionate to that 
of the body. Up to the body-weight of 44 
lbs. the heart is relatively heavy as compared 
with the body, whilst from 44 to 176 lbs. its 
proportional weight diminishes. Witness the 
extremes as following : Proportion of weight 
of heart to that of body, ages 1 to 10, male 
*0059; ages 80 to 90, female '0028. 
The average weight of the female being 
less than that of the male, the heart of the 
former is of course less. It will be readily 
seen that, as the weight of the heart varies 
with that of the individual, one cannot ex- 
press with exactitude any figure as the normal 
weight. We may roughly say that the heart 
of the adult should we^gh about lOt oz. One 
that weighs 12 oz. is hypertrophied. The 
weight of a hypertrophied heart may vary 
between this and the enormous figure of 
60 oz., which has been recorded; not un- 
commonly it reaches 27 to 30 oz. In taking 
the thickness of the muscular walls of the 
ventricles as a standard, we may regard a 
left ventricle of an adult as hypertrophied 
when the breadth of the thickest portion sur- 
passes six-tenths of an inch, and a right 
ventricle as hypertrophied which measures 
over a quarter of an inch. In hypertrophy 
the thickness of the left ventricular wall and 
of the septum has been found as great as 30 
and even 40 millimetres (1| inch and If inch). 
The columnae carneae may be greatly en- 
larged in hypertrophy, but the hypertrophy 
chiefly tells upon the walls of the ventricle. 
The walls of the auricle may be considered 
as hypertrophied when the thickness exceeds 
4 millimetres (about one-eighth of an inch). 
Varieties of Hypertrophy.-Bertin in 
1811 described three forms, which most suc- 
ceeding writers have referred to, namely : 
(1) simple hypertrophy, in which the pa- 
rietes of the compartments are thickened, the 
cavities retaining their natural dimensions;; 
(2) hypertrophy with dilatation {eccentric- 
hypertrophy), in which the cavities are in- 
creased in capacity, while the parietes are 
either of natural or of augmented thickness; 
(3) the so-called concentric hypertrophy, or 
hypertrophy with diminished cavities, in 
which new material was supposed to be 
added, chiefly in the interior of the ventri- 
cular walls. Cruveilhier and Budd pointed 
out that the condition called concentric hy- 
pertrophy is the result, not of hypertrophy, 
but of a powerful contraction of the organ 
suddenly arrested, as it were, by death. Budd 
found that the hearts of persons who had 818 
HEART, HYPERTROPHY OF 
died a violent death presented this so-called 
concentric hypertrophy; but that such hearts 
became relaxed, and showed the normal 
size of cavities and thickness of walls after 
maceration. Bokitansky and Bamberger 
acknowledge the rarity of concentric hyper- 
trophy, but think it does sometimes occur. 
There can be little doubt that concentric 
hypertrophy of the ventricles has no real 
existence. The appearances which have 
given origin to the term are due, in the 
great majority of instances, to the occurrence 
of rigor mortis in the muscle of the ventricle, 
which has caused firm contraction and thus 
diminution, to almost obliteration, of the 
cavity. If a heart presenting such signs be 
soaked for some hours in warm water a 
gentle dilatation with the finger will restore 
the ventricle to its normal dimensions. The 
left ventricle may simulate concentric hyper- 
trophy in some cases of mitral stenosis when 
the disease has developed in early childhood. 
The ventricle has not received its normal 
blood-contents, and development has pro- 
ceeded disproportionately in the right cham- 
bers and the left auricle. The cavity of the 
left ventricle has thus been left relatively 
small till the time of death. In like manner, 
in congenital stenosis of the pulmonary 
artery the right ventricle, hypertrophied in 
intra-uterine life, may so continue, and its 
cavity never become dilated to the normal 
extent. The ventricles are much more fre- 
quently hypertrophied than the auricles, and 
the left ventricle more frequently than the 
right; but the right auricle more frequently 
than the left auricle-which last shows the 
change very seldom. 
I. Hypertrophy of the left ventricle. 
Anatomical Characters.-The whole heart 
appears to be elongated, and the apex-portion 
of the left ventricle especially prolonged. 
The walls of the left ventricle and the inter- 
ventricular septum are thicker and firmer 
than in the normal: the septum may bulge 
into the right ventricle, diminishing its 
capacity and even producing actual ob- 
struction of its conus (Coats). In transverse 
section the thickening and bulging of the 
septum are very manifest, the right ven- 
tricular cavity presenting the appearance of 
a crescentic appendage to the left chamber. 
^Etiology and Pathology.-Sir Richard 
Quain (Lumleian Lectures, 1872) has classi- 
fied the exciting causes of hypertrophy under 
three heads-nervous, mechanical, and nu- 
tritive. 
(1) Amongst nervous causes are prolonged 
mental excitement or strain, and those emo- 
tional conditions which produce frequent pal- 
pitation. The immoderate use of strong 
coffee, tea, or spirituous liquors might come 
under this head. It is not in all cases that 
a heart which beats for long periods at an 
abnormal rate of rapidity becomes hyper- 
trophied, inasmuch as the general nutritive 
processes may be feeble or imperfect in some 
persons, active or vigorous in others. In cases 
of rapid heart (tachycardia) the writer found 
evidences of enlargement in three only out 
of seventy-five cases; in some the heart 
seemed even smaller than the normal. In 
Graves's disease, when there has been ab- 
normal rapidity of heart, persistent or par- 
oxysmal, for several years, the cardiac area 
has been sometimes found not larger than 
under conditions of health, and in many cases 
the post-mortem examination has demon- 
strated no morbid change. The just con- 
clusion, therefore, seems to be that for the 
production of hypertrophy of the left ven- 
tricle in cases of nervous excitation there 
must be an additional factor to rapidity- 
either a thickening of the arteries, or a vaso- 
motor irritation causing contraction of their 
muscular walls, whereby the intra-arterial 
tension is increased, or a quantity or quality 
of blood affording better nutrition. If the 
blood-pressure be at or below the normal, 
the rapidly beating heart does not tend to 
hypertrophy. 
(2) Amongst mechanical or physical causes 
are all those obstructive conditions to be 
specially examined presently. Violent and 
long-continued athletic or other exercises, 
which notably accelerate the contractions of 
the heart, or produce excessive blood-pres- 
sure, may be mentioned here. It has been 
pointed out that great muscular exertion 
with the arms is specially prone to cause 
hypertrophy, as in the case of hammer-men, 
&c. Prolonged working in a bent or con- 
strained position is also mentioned as a cause. 
In some callings and conditions in which 
muscular effort is severe, hypertrophy of the 
left ventricle is prone to occur-e.g. Cornish 
miners (Peacock), dwellers in hilly regions, 
especially those accustomed to carry heavy 
loads (Miinzinger, Allbutt), stonemasons, 
slaughterers (Leyden). In many cases it is 
probable that the two factors just mentioned 
-nervous excitation and muscular over- 
strain-combine to produce the hypertrophy. 
So may be best explained the signs and 
symptoms in the cases of ' irritable heart ' of 
soldiers during the American Civil war (Da 
Costa), those in our own Foot Guards who 
carried heavy accoutrements (Myers), and 
those in the Franco-German war (Fraentzel) 
(see Exercise). The excitement of a soldier's 
life co-operates as a cause with the muscular 
effort, which may be excessive and either pro- 
longed or violent and fitful. It is a signifi- 
cant observation of Hirsch that there has 
been a notable increase in the proportion 
of heart-diseases in a community at times 
of great political and social excitement. This 
was observed in France during the great Re- 
volution and after the political agitation of 
1830, in Rome after 1848, in Sicily in 1860, 
and in the Argentine States after the political 
confusion and civil war. HEART, HYPERTROPHY OF 
819 
(3) Diseases of the valvular apparatus- 
aortic and mitral-induce hypertrophy of 
the left ventricle by causing an obstruction 
to the outflow of blood or an abnormal blood- 
pressure within the cavity from regurgitation, 
(a) Stenosis of the aortic orifice is a com- 
mon cause of hypertrophy of the left ven- 
tricle. The opening is not only narrowed, 
but is also rendered more rigid, and thus 
increased force is necessary to propel the 
blood. Along with the valvular lesion there 
may also be, especially in advanced life, 
a loss of elasticity and a roughening of the 
inner coat of the aorta from degenerative 
changes - conditions which increase the 
mechanical strain upon the left ventricle. 
(b) Aortic regurgitation often induces so great 
enlargement of the left ventricle, from hyper- 
trophy and dilatation, that the heart in such 
cases merits the name cor bovinum. The 
back-flow of blood increases the intra-ven- 
tricular pressure, tends to dilate the cavity, 
and calls forth augmented efforts of ven- 
tricular contraction. In some cases of injury 
and rupture of the aortic valves it has been 
possible approximately to estimate the rate 
of hypertrophy. In two cases, related by Dr. 
Stone, of injury to these valves by blows 
upon the chest, assuming that the heart was 
healthy previous to the injury, there must 
have been an increase of nearly an ounce a 
week during the four or five weeks that 
elapsed before death, (c) Mitral regurgitation. 
Insufficiency of the valve at the left auriculo- 
ventricular orifice of necessity causes the 
left ventricle to be subject to abnormal pres- 
sure, with the result that it becomes hyper- 
trophied as well as dilated. 
(4) Aneurysm of the aorta.-There has 
been much difference of opinion on the ques- 
tion whether aneurysm of the thoracic aorta 
is a cause of hypertrophy of the left ventricle. 
The divergence is capable of explanation. 
When the situation of the aneurysm is at the 
commencement of the aorta, where it in- 
volves the semilunar valves, hypertrophy is 
the rule. When the aneurysm is so situated 
as not to involve the valves, hypertrophy is 
a rare exception. This is proved to demon- 
stration by the following figures, deduced 
from the records of the London Hospital, 
the cases being collected by Dr. F. J. Smith, 
medical registrar. Of forty-one cases of 
aneurysm of the thoracic aorta in which the 
valves were not implicated, enlargement of 
the left ventricle was evidenced in only nine 
instances, and in three of these the hyper- 
trophy was recorded as only slight. In forty- 
one cases in which the valves were involved, 
hypertrophy and dilatation were manifested 
in thirty-five. 
(5) lienal disease.-Hypertrophy of the left 
ventricle may occur in all forms of Bright's 
disease, the lardaceous form excepted. Of 
these chronic Bright's disease (contracted 
kidney) is a very important cause, the hyper- 
trophy being often of the purest type, with- 
out dilatation. This change is the result of 
the great increase of blood-tension produced 
by the resistance offered to the blood in the 
small arteries through the whole body, as 
well as in the kidneys. 
(6) Pregnancy.-It has been shown by 
many observers that the left ventricle tends 
to become hypertrophied and the arterial 
tension augmented during pregnancy. The 
hypertrophy may continue for a considerable 
portion of the period of suckling, and then the 
heart, like the uterus, undergoes a process of 
involution. According to Duroziez, the ven- 
tricle tends, after many pregnancies, to re- 
main hypertrophied. 
(7) Excess of food.-With regard to the ali- 
mentary causes of hypertrophy of the heart, 
the state of the local nutrition and the 
nutritive quality of the blood have both to 
be taken into account. Bich nitrogenous 
food, and the use of ferruginous medicines, 
will favour hypertrophic changes. With the 
increase of the muscular structure there is 
proportional enlargement of the coronary 
arteries, so that the hypertrophied organ has 
an increased blood-supply. 
Physical Signs of Hypertrophy of the 
Left Ventricle.-In simple hypertrophy 
(e.g. when occurring in athletic persons, or 
in relation with chronic renal disease in the 
earlier periods) the wall of the chest on in- 
spection may be observed in the neighbour- 
hood of the apex to be raised with each 
ventricular systole. Pulsation, also, of the 
carotid arteries in the neck may be observed, 
such pulsation being rather prolonged, and 
not sudden (as in aortic regurgitation), unless 
there be concurrent fever. On palpation 
the fingers are lifted by the apex, the impulse 
of which is prolonged and heaving. The 
duration of the heaving impulse is in propor- 
tion to the degree of hypertrophy. The im- 
pulse is often strong enough to visibly move 
the bedclothes, and even to raise the head 
of the auscultator by the impact against 
the stethoscope. Of course a larger portion 
than usual of the heart's surface impinges 
against the chest-wall. The outline of the 
apex-portion of the heart, as obtained by 
percussion, is acutely triangular, its acute 
angle pointing downwards and to the left. 
This becomes broader and more rounded as 
dilatation preponderates over hypertrophy. 
In simple hypertrophy the heaving apex 
may be in the sixth or seventh, rarely in 
the eighth, left intercostal space; but in 
dilatation with hypertrophy the area down- 
wards and towards the left axilla is greatly 
increased. On auscultation the first sound 
at the apex is found to be dull and prolonged. 
It is the sound of muscular contraction that 
the ear in the greatest degree appreciates, 
the element of valve-tension being muffled 
by the thick wall of the ventricle. Over the 
second right costal cartilage the second sound 820 
HEART, HYPERTROPHY OF 
is loud, and may have a ringing character; it 
may sometimes be the only one of the two 
normal sounds audible. In this situation it 
is much louder than over the second left 
interspace (the commencement of the pul- 
monary artery) unless the ventricular hyper- 
trophy is accompanied by mitral insufficiency. 
If with evidence of powerful left ventricle 
and firm arteries the aortic second sound is 
not loud, but dull and ill-pronounced, there 
is strong probability that the aortic cusps are 
swollen or thickened from disease. In later 
stages of hypertrophy, when the muscular 
tone of the left ventricle is impaired, the 
sounds of the heart may have a triple rhythm, 
resembling the cantering of a horse-the bruit 
de galop, carefully studied by Potain. This is 
especially observed in the hypertrophy asso- 
ciated with renal disease, and in the hyper- 
trophy with dilatation accompanying gastro- 
hepatic derangement. 
The radial pulse is felt to be prolonged; 
the artery is firm and resisting, and its coats 
may be thickened. In the hypertrophy re- 
sulting from muscular overstrain the pulse 
is large and full, the first wave is prolonged, 
and there is no dicrotism. In chronic renal 
disease, as the arterial coats become thick- 
ened the amplitude of the pulse is mani- 
fested in less degree, the vessel being felt 
hard, resisting, and full between the beats. 
In some cases the fullest force exerted by 
the finger may fail to entirely obliterate the 
pulse, and on the distal side of the point 
compressed the wall of the artery may be 
felt cylindrical and firm. In the hyper- 
trophy associated with aortic stenosis the 
pulse is somewhat narrow and gradual both 
in its rise and fall. In that manifested 
with aortic incompetency it is sudden and 
powerful in its impact against the finger, but 
rapidly receding, so that the artery seems 
empty between the beats-it is the collapsing 
or water-hammer pulse. 
Symptoms of Cardiac Hypertrophy.-It 
must not be forgotten that simple hyper- 
trophy may exist without producing symp- 
toms attracting the attention of the patient, 
and that there is a natural tendency to some 
degree of cardiac hypertrophy with the 
advance of age. Dyspnoea.-In moderate 
hypertrophy without complication, there is 
usually easy and natural breathing when the 
patient's body and mind are at rest. But 
mental excitement or bodily effort at once 
induces more or less of temporary dyspnoea. 
In some cases the due expansion of the lungs 
may be mechanically impeded by the in- 
creased volume of the heart. In eccentric 
hypertrophy with dilatation, more especially 
when the right cavities are thus affected, 
pulmonary congestion and oedema are usually 
present, and then marked dyspnoea is a pro- 
minent and distressing symptom. Cough.- 
In simple hypertrophy there may be an occa- 
sional dry, irritating cough, and in young 
plethoric women a wheezing cough may be 
complained of. In right-side enlargements, 
when pulmonary obstruction and dropsical 
effusions supervene, cough is, in most cases, 
a very frequent and painful addition to the 
other sources of discomfort to the patient. 
Hcemoptysis and other hcemorrhages.- 
Haemoptysis from capillary engorgement is 
common, being generally active and sudden. 
Niemeyer points out that, in left-heart hyper- 
trophy, there is often active distension, and 
sometimes rupture, of the branches of the 
bronchial arteries. In left hypertrophy, too, 
the cerebral arteries are specially liable to 
give way. In right-side enlargement with 
pulmonary obstruction, the blockage may in- 
fluence the vessels of the liver and the portal 
system generally, so as to produce hsema- 
temesis or mel®na. Epistaxis may also be 
due to cardiac enlargement. Palpitation is 
a common symptom in all organic diseases 
of the heart, and is often very marked in 
cardiac enlargements. The least excitement, 
bodily or mental, may induce a greater or less 
degree of this symptom. Especially in eccen- 
tric hypertrophy with dilatation, most dis- 
tressing paroxysms of palpitation are apt to 
occur from time to time. Besides bodily and 
mental excitement, other conditions, such 
as indigestion, flatulence, or an overloaded 
stomach, readily call forth this symptom. 
When there is much dilatation, the palpita- 
tion may be irregular and intermittent, and 
is then more particularly a very alarming 
symptom. 
The renal and urinary derangements are 
very important. In the hypertrophy of the 
left ventricle, associated with chronic Bright's 
disease, there will be found the copious 
excretion of a pale urine of low specific 
gravity. Albumen may be found in small 
quantity, and may sometimes be absent. In 
the hypertrophy associated with gastro- 
hepatic disturbance, the urine will be scanty, 
of high specific gravity, often thick with 
urates, containing much urea, and dark with 
the colouring-matter of the urine, of the bile, 
or of both. 
Certain cerebral symptoms ought to be 
mentioned in connexion with the other more 
direct signs of cardiac hypertrophy. A feel- 
ing of fulness, or perhaps of throbbing, may 
be felt in the head after great muscular 
exertion or mental excitement. In pro- 
nounced cases there may be headache, ring- 
ing in the ears, vertigo, muse® volitantes, 
and disturbing dreams. The bright and 
shining, or perhaps bloodshot, condition of 
the eyes is an indication of the hyper®mia of 
the cerebral vessels. 
II. Hypertrophy of the right ven- 
tricle.-The normal weight of the right 
ventricle is probably less than half that of 
the left (average in men: left ventricle 173 
grammes, right 72; in women: left ven- 
tricle 150. right ventricle 62. Du Castel). HEART, HYPERTROPHY OF 
821 
The capacity of the right ventricle is gene- 
rally greater than that of the left-according 
to recent researches in the proportions of 
about seven to six. The walls are from a 
quarter to one-third the thickness of those 
of the left. ' 
In the great majority of cases the right 
ventricle becomes hypertrophied only in 
association with a morbid change in the left, 
and when such hypertrophy occurs it is 
nearly always accompanied by dilatation. 
There are exceptions to this rule, as will be 
presently seen. 
The right ventricular wall may be thick- 
ened to the extent of one inch, instead of the 
normal two and a-half lines; its greatest 
thickness is at its base. The column® ear- 
ner of the right ventricle are even more 
liable to hypertrophy than the wall. In 
dilatation with hypertrophy the column® 
carneae become stretched and attenuated. 
The substance of the hypertrophied left ven- 
tricle can generally be torn with ease, whilst 
that of the hypertrophied right ventricle is 
usually tough and leathery. 
^Etiology and Pathology.-The right ven- 
tricle may be observed in a state of simple 
hypertrophy in- 
(1) Congenital anomalies of the heart.- 
Chief of these is stenosis of the pulmonary 
artery, which in the majority of cases 
results from foetal endocarditis. The ob- 
struction may be below the valves, the conus 
of the right ventricle being narrowed. In 
each case the right ventricle becomes hyper- 
trophied in consequence of the obstruction in 
front, and there is no dilatation of the cavity. 
(2) In emphysema, fibrosis, and consoli- 
dated or compressed conditions of the lungs, 
the impediment to the pulmonary circu- 
lation induces hypertrophy with dilatation 
of the right ventricle. 
(3) In the subjects of curvature of the 
spine the capacity of the thorax is nearly 
always diminished; the lungs are emphy- 
sematous, and often suffer other pathological 
changes. The two branches of the pulmonary 
artery may be unequal, owing to the differ- 
ences of development of the two lungs. The 
right ventricle is dilated as well as hyper- 
trophied. 
(4) Endocarditis affecting the tricuspid 
valve.-It is rarely that endocarditis attacks 
the valvular apparatus of the right side of 
the heart without that of the left side par- 
ticipating in still greater degree, except in 
intra-uterine life. Byrom Bramwell has 
shown the great probability that when endo- 
carditis affects the valves of the left side it 
frequently involves also the right, though 
the inflammatory changes in the latter may 
be evanescent. Such cause may co-operate 
to impair the muscle of the right heart and 
hasten dilatation. In some cases (and these 
not very infrequently) the result of endo- 
carditis is stenosis of the tricuspid orifice, in 
which case the right ventricle tends to hyper- 
trophy rather than to dilatation, whilst the 
right auricle becomes greatly dilated. 
(5) The most common cause of hypertrophy 
with dilatation of the right ventricle is val- 
vular disease of the left side of the heart. 
Whether there be mitral stenosis or regur- 
gitation, the consequences are hypertrophy 
of the right ventricle to antagonise the oppo- 
sing forces, and dilatation on account of the 
persistent overstrain. 
Signs and Symptoms of Hypertrophy of 
the Right Ventricle. - In enlargements 
of this ventricle, inspection may reveal a 
rounded smoothness of the epigastrium, with 
perhaps some bulging of the ensiform and 
lower left costal cartilages. The apex-beat 
may be seen to be very diffused, extending 
towards the tip of the ensiform cartilage. 
Facial lividity is frequently seen; and jugular 
pulsation may be observed when there is 
tricuspid regurgitation. Palpation over the 
lower part of the sternum detects an impulse, 
which feels as if immediately under the hand, 
and usually wants the heaving character of 
the impulse of a hypertrophied left ventricle. 
Epigastric pulsation is often very pronounced. 
The liver-pulsation in such cases may result 
either from venous regurgitation or from 
right systolic action exerted through the 
diaphragm. On percussion, the inferior line 
of dulness is found to extend lower down 
and farther towards the right than normal, 
sometimes reaching an inch or more beyond 
the right sternal edge. On auscultation, the 
second sound over the pulmonary valves is 
found to be louder than over the aortic. The 
accentuation of the pulmonic second sound, 
however, is not so marked as in cases of well- 
compensated stenosis or insufficiency at the 
mitral orifice. The aortic second sound is 
weak, and though palpation may detect a 
forcible impulse at the apex of the heart, the 
radial pulse may be felt small and contracted. 
In some cases a triple sound-the bruit de 
galop-may be heard over the right ventricle. 
The radial pulse in hypertrophy of the 
right ventricle is usually small and resis- 
tant. There is a difficulty in the passage 
of blood through the pulmonary circuit, and 
the supply to the left chambers is reduced in 
amount; moreover, the blood is imperfectly 
oxygenated and, containing an undue propor- 
tion of carbon dioxide, it stimulates the vaso- 
motor influences and augments the intra- 
arterial tension. 
III. Hypertrophy of both ventri- 
cles.-Complications and Sequels.- Sim- 
ple hypertrophy of the heart may go on quietly 
for a long time, just balancing the obstruc- 
tive influence, and giving rise to no other 
form of disease. But when dilatation co- 
exists with hypertrophy, palpitation, dyspnoea, 
venous congestion, and serous effusions are 
the ordinary results. Diseased conditions of 
the arteries may occur simultaneously, or 822 
HEART, HYPERTROPHY OF 
may be induced by the long-continued addi- 
tional strain put upon them by a hypertro- 
phied heart. Cerebral haemorrhage often 
occurs in connexion with a hypertrophied 
left ventricle, as in Bright's disease; although 
there are always perhaps other factors, be- 
sides the mere excessive propulsive power 
of the heart, in the production of apoplexy. 
Pulmonary and general congestion and 
(edema are the usual attendants of mitral 
lesions with right-side enlargements. Pul- 
monary haemorrhagic infarction (the so-called 
' pulmonary apoplexy') generally results from 
engorgement of the branches of the pulmo- 
nary vessels, and takes place in connexion 
with right-heart enlargement. Sanguineous 
exudation in the tract of the bronchial mucous 
membrane may occur in left-heart hyper- 
trophy. Persons suffering from cardiac 
hypertrophy are apt to be gravely affected 
by acute febrile diseases, because the re- 
sultant acceleration of the heart's action 
increases the embarrassment of the organ. 
Of course, hypertrophied cardiac walls are 
subject to the fatty degenerative changes 
described elsewhere. 
IV. Hypertrophy of the auricles.- 
Hypertrophy of the right auricle is scarcely 
ever met with except in association with dila- 
tation of the cavity. Simple hypertrophy is 
only possible in the case of tricuspid stenosis 
occurring in infant life. Hypertrophy and 
dilatation are marked in cases of mitral 
disease, both regurgitant and obstructive. 
The hypertrophy is in greater degree in the 
obstructive lesion. In both, but especially 
the latter, the auricle may be sufficiently 
powerful to cause a back-flow into the venous 
channels by its systole, and thus a venous 
pulsation, presystolic in time, in the veins of 
the neck. Hypertrophy of the left auricle 
occurs in greatest degree in mitral stenosis. 
One of the writers has found in such case, in a 
boy of nine, a left auricle varying in thickness 
from one-eighth to one-quarter of an inch- 
i.e. the thickness in some parts being nearly 
that of the right ventricle of an adult. In 
some cases-in children-the hypertrophied 
auricle may be observed to cause a distinct 
presystolic pulsation in the third left inter- 
costal space at the outer portion of the, 
cardiac dulness. As the case progresses, 
dilatation occurs, and the muscular wall be- 
comes thin. An increase of dulness to the 
left over the situation of the left auricle is 
often manifested on percussion in cases of 
mitral stenosis. 
V. Hypertrophy of the whole heart. 
This is manifested in the highest degree in 
cases of combined aortic and mitral disease; 
either when a rheumatic lesion has induced 
mitral and aortic regurgitation coincidentally, 
or when the initial lesion has been aortic 
regurgitation, and mitral inadequacy has 
resulted from the abnormal intra-ventricular 
pressure. In mitral disease, however, when 
the aortic valves are intact, the hypertrophy 
and dilatation of both ventricles may be very 
considerable. Differences of opinion have 
been expressed as to the influence of peri- 
cardial adhesions in determining hypertrophy 
of the heart. It can scarcely be doubted that 
pericarditis is a potent factor of hypertrophy 
during the period of childhood. A heart 
presenting signs of almost universal peri- 
cardial adhesion will be often found to evi- 
dence a far greater degree of hypertrophy 
than could be ascribed to any coexisting 
valvular imperfection. When the period of 
heart-growth has ceased, in fully adult life, 
the consequences may be different, and no 
hypertrophy, but, on the contrary, wasting, 
may ensue. 
Pathology.-True muscular hypertrophy 
of the heart is compensatory, or conserva- 
tive. The heart obeys the law that muscle 
tends to increase in force and in develop- 
ment when an obstacle is imposed to its 
normal working (see Hypertrophy ; and 
Heart, Valves and Orifices of, Diseases of). 
We have just seen what the obstacles are in 
hypertrophy of the different parts of the 
heart. Some obstacles are direct, such as 
stenoses; and hence by this change the heart 
is enabled to overcome deficient valvular 
action or obstruction to the blood-current, 
the increased peripheral resistance of Bright's 
disease and of emphysema. Other lesions 
are indirect or relative obstacles, particu- 
larly valvular incompetence, which permits 
over-filling of the cavities, and demands 
a corresponding increase of vigour in the 
systolic discharge, which leads to hyper- 
trophy. 
Diagnosis.-An extended area of dulness, 
displacement of the apex-beat downwards 
and to the left, and a slow, heaving systolic 
action, with augmented force of impulse, 
are the chief diagnostic physical signs of 
cardiac hypertrophy. In young and thin 
people the last of these signs may seem to 
be present, but the accompanying conditions 
readily exclude hypertrophy, especially the 
non-extension of the cardiac dulness. An 
emphysematous left lung may mask hyper- 
trophy when present; and lung-consolidation 
might, though only for a moment, suggest it 
when absent. In pericardial effusion the 
triangular shape of the area of dulness, with 
the apex of the triangle upwards, is a dis- 
tinctive feature; there would, moreover, be 
the history of an acute disease, with lancina- 
ting pain, dyspnoea or suffocative sensations, 
and other symptoms not found in mere en- 
largement of the heart. Pleuritic effusion 
or aneurysm would be still more readily 
discriminated. The differential diagnosis 
between left-heart and right-heart enlarge- 
ments has been sufficiently discussed in 
speaking of the symptoms and signs. Dila- 
tation, as distinguished from hypertrophy, is 
characterised by the feebleness and diffuse- HEART, HYPERTROPHY OF 
HEART, INFLAMMATION OF 
823 
ness of the apex-beat, which may even be 
quite imperceptible; by the great irregularity 
and intermittency of the heart's action; and 
by the general signs and symptoms of a 
feeble circulation. 
Prognosis.-Simple, uncomplicated hyper- 
trophy, as in the young and in athletes, is 
not incompatible with long life, if the cause 
be removed in time. According to the extent 
and degree of complication, whether in the 
form of valvular lesions or co-existent pul- 
monary disease, the prognosis will be un- 
favourable. When the cardiac change is 
itself producing secondary lesions, as de- 
generation of the arterial coats, when dila- 
tation is advancing, and when there is 
Bright's disease, the prognosis becomes very 
unfavourable. 
Treatment.-Hypertrophy being in itself 
a conservative change, protective from worse 
results, the primary object is to remove, if 
possible, the cause of the hypertrophy. To 
aim merely at reducing the hypertrophy, 
irrespectively of its cause, as by lowering the 
nutrition, would gravely favour the worse 
evil of dilatation. General therapeutic prin- 
ciples, and the morbid conditions accom- 
panying the hypertrophy, must therefore 
be carefully attended to. All mental and 
bodily exertion which excites the circulation 
must be scrupulously avoided. Alcoholic 
stimulants should be taken sparingly, and 
no more wine allowed than such as may 
seem to benefit digestion. The diet should 
be carefully selected, nitrogenous food being 
generally necessary. The digestive organs 
must be sedulously looked after, not only 
because good nutrition is very important, 
but also because flatulence and dyspepsia 
directly embarrass the heart's action. Mild 
saline and aloetic aperients with alteratives 
should be given. Diuretics will be neces- 
sary if there is a tendency to dropsy, and 
in all cases great attention must be paid to 
the removal of congestion when it affects 
important organs, and the restoration of 
their functions when affected, more espe- 
cially of the liver and the kidneys. When 
there is great excess of cardiac action, direct 
cardiac sedatives, as aconite, diluted hydro- 
cyanic acid, conium, and perhaps the local 
application of ice, may be called for. When 
there is dilatation or feebleness of texture 
with the hypertrophy, iron and digitalis are 
the chief remedial drugs. 
J. R. Wardell. A. E. Sansom. 
HEART, Inflammation of.-Inflam- 
mation of the heart may affect either the 
lining membrane, or the substance or walls 
of the organ ; and the subject will be best 
discussed under the separate heads of endo- 
carditis and myocarditis. Inflammation of 
the investing membrane of the heart is de- 
scribed in the article Pericardium, Dis- 
eases of. 
I. Endocarditis.- Synon. : Fr. Endo- 
cardite; Ger. Endocarditis. 
Definition.-Inflammation of the lining 
membrane of the heart. 
Three forms of endocarditis are commonly 
described: (1) Simple endocarditis; (2) Ul- 
cerative endocarditis ; and (3) Chronic endo- 
carditis. Only the two first forms will be 
discussed here ; chronic endocarditis is re- 
ferred to under the head of Heart, Valves 
and Orifices of, Diseases of. 
1. Simple Endocarditis.-.Etiology. 
Endocarditis generally occurs in association 
with acute rheumatism ; less frequently 
with other acute specific febrile diseases, 
such as scarlet fever, measles, tonsillitis, 
erythema, pyaemia, and septicaemia-includ- 
ing puerperal fever ; much more rarely with 
typhoid fever and variola. It may be ob- 
served in the course of pregnancy, and after 
parturition; in acute and chronic Bright's 
disease; and in syphilis. Injuries of the 
heart, such as rupture of the valves, may 
also lead to endocarditis; and local endo- 
carditis is frequently the result of the un- 
natural contact of one part of it with another 
during the cardiac revolution, as, for ex- 
ample, by growths from the walls or valves, 
or by unnatural blood-currents. It is also 
common in chorea. Possibly it may be 
idiopathic. 
Age is an important predisposing factor in 
the fetiology of acute endocarditis, the occur- 
rence of which as a complication of acute 
rheumatism is certainly most frequent in 
young subjects, and declines as age advances. 
Women also are more subject to rheumatic 
endocarditis than men. 
The localisation of the endocardial inflam- 
mation appears to be determined chiefly by 
pressure and tension, rather than by any 
peculiarity of the membrane itself, or of the 
blood in contact with it. Thus the left ven- 
tricle is almost the sole seat of the disease 
(at all events of readily recognisable degree) 
in the adult, and the right ventricle in the 
fcetus; whilst endocarditis is rarely seen be- 
yond the boundaries of the valves, that is, 
the parts most subjected to strain. In the 
same way, chronic endocarditis is usually 
due to increased pressure within the heart, 
as in chronic Bright's disease, and in con- 
ditions that entail prolonged severe strain 
upon the valves during exertion. A similar 
cause is at work in pregnancy. 
Anatomical Characters.-Inflammation 
of the endocardium affects chiefly the valves 
and the chordae tendineae, and especially the 
lines of contact or the surfaces of the valves 
exposed to the force of the blood-current. 
The endocardium of these parts at first 
appears slightly swollen, velvety, soft, and 
of various shades of red ; whilst the lines or 
points of contact of the valves present warty 
enlargements of a similar character, which 
are known as ' vegetations.' As the process 824 
HEART, INFLAMMATION OF 
advances, the inflamed areas become more 
opaque and firm; and a fibrinous deposit is 
entangled with their surface. When the 
endocarditis has gone thus far, resolution is 
probably rare ; and the most common result 
is what is known as ' chronic valvular disease,' 
that is, that the affected parts are left opaque, 
puckered, and thickened by growth of con- 
nective tissue, whilst the vegetations develop 
into firm fibroid or even cartilaginous-like 
bodies. As a consequence of these changes, 
the valves may become much altered in size 
and shape, and the ostia contracted and ir- 
regular, so that the mutual adaptation of the 
parts is greatly disturbed. Other results of 
inflammation are not uncommon in the pro- 
gress of endocarditis, such as adhesions be- 
tween the neighbouring structures, and ossi- 
fication or calcification of the altered tissues. 
Laceration of the valves and rupture of the 
chordae tendineae during the stage of dimin- 
ished resistance, ulceration, suppuration, and 
the formation of aneurysm are rarer events. 
The microscopical appearances of inflam- 
mation of the endocardium correspond with 
the naked-eye characters. In the early 
stages, the proper tissue of the endocardium 
is swollen by hyperaemia, oedema, and the 
appearance between its fibres of a number 
of leucocytes; the latter rapidly multiply to 
form the bulk of the vegetations; and the 
surface presents various thicknesses of de- 
posited fibrin, which in its turn may become 
organised. The further development of con- 
nective tissue gives rise to the opacity, thick- 
ening, and puckering of the valves, and to 
the formation of permanent vegetations. 
The effects of these changes upon the func- 
tions of the valves and their appendages are 
described in the article Heart, Valves and 
Orifices of, Diseases of. Particles of fibrin, 
and even of the vegetations, are occasionally 
detached from the endocardium, and give rise 
to embolism. 
Symptoms.-The symptoms of endocarditis 
are inseparable from the symptoms of the 
disease with which it is associated, and the 
diagnosis of it is made almost entirely from 
the presence of physical signs. Thus fever 
probably precedes the advent of endocarditis 
in every case; and it cannot be said that the 
simple uncomplicated disease in any respect 
affects either the pyrexia or any other ele- 
ment of the same. Local symptoms are 
almost equally rare, unless the endocarditis 
leads to serious lesion of the cardiac valves. 
As long as these remain sound, and the 
disease is acute and does not involve deeper 
structures, pain in the heart, praecordial dis- 
tress, syncope, shortness of breath, and other 
symptoms of heart-disease cannot be said to 
occur at all frequently in endocarditis. The 
cardiac contractions are necessarily increased 
in frequency; and palpitation and dyspnoea 
may occur on movement. It is otherwise 
when the inflammation has lasted so long 
as to render the valves incompetent, or to 
obstruct the orifices; or when the myocardium 
is attacked, and dilatation ensues. The 
symptoms just enumerated then make their 
appearance. In children, rheumatic endo- 
carditis is peculiarly latent, and also danger- 
ously progressive or recurrent. See Rheu- 
matism, Acute. 
Physical Signs.-The physical signs of 
acute endocarditis are-increased extent and 
frequency, with variable strength, of the 
visible and palpable impulse; moderate in- 
crease in the area of praecordial dulness; and 
various alterations in the cardiac sounds. At 
the beginning of endocarditis, the first sound 
at the left apex is frequently heard prolonged 
and hollow, or mufiled; and, as the process 
advances, this alteration of character may 
gradually pass into a murmur, which is at 
first indistinct, but afterwards well-formed. 
If the aortic valves are affected, the second 
sound may similarly lose its characters, be- 
come dull, and finally be converted into, or 
be complicated with, a murmur. The most 
frequent murmur in acute endocarditis is 
mitral systolic; aortic murmurs are decidedly 
less common; and mitral praesystolic murmur 
is very rare. Various murmurs, inorganic 
or organic, may also appear and disappear 
during the course of the disease. 
Complications.-Endocarditis is itself al- 
ways a complication of the diseases previously 
mentioned. Myocarditis and pericarditis may 
be correctly regarded as complications of 
endocarditis, when the inflammation begins 
in the lining membrane of the heart. Ac- 
cording to some authorities, clots may form 
in the heart in endocarditis, and give rise to 
very urgent symptoms (see Heart, Throm- 
bosis of). Embolism may arise from detach- 
ment of fragments of coagula or vegetations. 
Congestion or inflammation of the lungs 
frequently occurs in association with endo- 
carditis, and so may albuminuria. 
Course, Terminations, and Sequel®.- 
The course of simple endocarditis is very 
uncertain, and varies with the course of the 
original disease with which it is associated, 
as well as with the complications. If acute 
rheumatism be quickly checked, inflamma- 
tion of the endocardium will be also arrested; 
but the two diseases may recur together. In 
a considerable number of cases, however, 
endocarditis passes on to chronic valvular 
disease. The late Dr. Sibson found that 
seventeen out of seventy cases of endocar- 
ditis with mitral systolic murmur ended in 
established valvular disease, and less than a 
half of the cases with diastolic basic murmur. 
Simple endocarditis very rarely proves 
fatal, But, being by far the most common 
cause of valvular disease of the heart, it 
leads indirectly to much suffering, and in 
such cases as a rule ultimately to death. 
Diagnosis.-The diagnosis of endocarditis 
depends upon the discovery of the develop- HEART, INFLAMMATION OF 
825 
ment of an endocardial bruit of organic origin 
during the course of one of the diseases 
already named. From functional murmurs 
the bruits of valvular inflammation may be 
diagnosed under different circumstances- 
first, by their locality, which is most fre- 
quently the mitral area; secondly, by their 
time, diastolic or praesystolic murmurs being 
always organic; and, thirdly, by their associa- 
tion with pericardial friction. The special 
characters of inorganic murmurs are described 
elsewhere. Chronic valvular disease may be 
diagnosed from acute endocarditis by the 
presence of cardiac enlargement and many 
w'ell-known signs; of marked cardiac symp- 
toms-especially pain and dyspnoea; of cer- 
tain lesions-mitral stenosis, for instance, 
being very rarely an acute lesion; and of 
visceral complications. Much more difficult 
of diagnosis is acute endocarditis occurring 
in the course of chronic valvular disease. 
Change of the character of the murmur, if 
this have been previously known, may lead 
to the suspicion of fresh inflammation but 
cannot positively establish the diagnosis of its 
existence. Acute endocarditis is most fre- 
quently overlooked when the primary dis- 
ease is ' latent '-particularly rheumatism in 
children. 
Prognosis.-The immediate prognosis of 
acute endocarditis is generally favourable, 
and may be safely estimated by the absence 
of local symptoms. The remote prognosis, 
on the other hand, as regards both life and 
health, is bad, inasmuch as endocarditis so 
frequently ends in chronic valvular disease. 
This result is very often difficult or impossible 
to forecast. A feeble, soft, and smooth 
murmur, or a feeble and grave murmur, is 
much more likely to disappear than a loud, 
extensive, well-defined bruit. The probability 
of the disappearance of diastolic basic 
murmurs is very small ; it may be best 
estimated by the absence of the effects pro- 
duced by aortic incompetence upon the heart 
and vessels. Murmurs referable to endo- 
carditis disappear more often in young sub- 
jects than in adults. 
Treatment.-The treatment of acute endo- 
carditis has to be discussed under three heads 
- namely, first, preventive ; secondly, imme- 
diate ; and, thirdly, subsequent treatment. 
(a) Preventive treatment.-When a patient 
is suffering from any disease which may be- 
come complicated with endocarditis, and 
especially if he be suffering from acute 
rheumatism, every means must be adopted 
to prevent, as far as possible, the occurrence 
of inflammation of the heart. Thus, in acute 
rheumatism it is all-important to check at once 
the intensity of the disease by recourse to one 
or other of the salicyl compounds or other 
means; for experience shows that endocar- 
ditis, when it does occur in acute rheumatism, 
generally makes its appearance within the 
first week. Again, the duration of the pri- 
mary disease must be curtailed if possible, 
inasmuch as endocarditis, although it gene- 
rally appears early, may possibly occur at 
any period of the disease. Thus the medi- 
cinal preventive treatment of endocarditis in 
these cases resolves itself into the medicinal 
treatment of acute rheumatism. Another 
point of equal importance in the prevention 
of endocarditis is diminution of the cardiac 
activity. We have seen that the pressure 
within the heart is an important factor in 
the causation of endocarditis; and this pres- 
sure must be reduced by diminishing the 
work to be done by the heart, without lower- 
ing the cardiac power. Rest must therefore 
be enforced in the recumbent posture-an 
end which is usually already secured by the 
presence of acute rheumatism of the joints. 
Excitement of every kind has to be strictly 
interdicted. The personal comfort of the 
patient must be zealously attended to, and 
pain relieved, so that restlessness and irri- 
tabilitymay be avoided; and for this purpose 
carefully selected anodynes may be necessary. 
Stimulants must be cautiously ordered; the 
bowels regularly and fully moved; and the 
various secretions kept as active as possible. 
(6) Treatment during an attack.-When 
endocarditis has actually made its appear- 
ance, the various means just insisted upon 
must be enforced as rigorously as before, so 
as to diminish the intensity of the inflamma- 
tion, and to limit the extent of surface in- 
volved. Rest is still of the first importance, 
mental as well as bodily. The medicinal 
treatment of the original disease-especially 
of acute rheumatism-must be persevered 
in. Local applications to the praecordia, such 
as cataplasms, or leeching, in cases of sthenic 
inflammation, are often of great service. The 
administration of stimulants will require the 
greatest care; excitement of the heart, on the 
one hand, being avoided, and, on the other 
hand, digitalis, ammonia, or alcohol being 
employed if symptoms of cardiac distress 
supervene. Equal caution is demanded in 
the use of anodynes which may be indicated 
to relieve distress connected with the joints; 
and local applications, such as cotton-wool, 
poultices, aconite, and belladonna, should be 
employed in preference to opium, chloral, and 
other cardiac depressants. 
(c) Treatment after an attack.-When the 
primary disease, such as rheumatism, has 
subsided, and the restoration of the various 
functions indicates that convalescence has 
commenced, the physician must not forget 
the state of the endocardium which has 
recently been inflamed, and which is still 
in a condition of great physical weakness, 
and the seat of new cell-growth. Instead of 
urging the patient to sit up and walk about 
under these circumstances, as must have 
been frequently done under the 'rival me- 
thods ' of treating acute rheumatism, we 
should recommend a very gradual return to 826 
HEART, INFLAMMATION OF 
exercise, and the most jealous avoidance of 
actual exertion. There can be no question 
that, at this stage, rest for several weeks is 
of more importance than medicinal treat- 
ment. At the same time various tonic and 
other remedies should be employed. 
2. Ulcerative Endocarditis.-Synon.: 
Malignant Endocarditis; Diphtheritic En- 
docarditis ; Er. Endocardite Vlcereuse; Ger. 
Infectiose, Maligne Endocarditis. 
Definition.-An acute, subacute, or chronic 
infective disease, characterised by ulceration 
of the endocardium or by vegetative growth 
upon it. 
.(Etiology.-Ulcerative endocarditis occurs 
most frequently between the ages of twenty 
and forty, but is not uncommon in children. 
More women suffer than men, in conse- 
quence of its frequent origin in puerperal 
disease. Previous valvular disease distinctly 
predisposes to it. 
An exciting cause sometimes cannot be 
discovered. In most instances, however, 
ulcerative endocarditis is but part of a gene- 
ral septic or pyaemic process. The common 
sources of infection are septic wounds, puer- 
peral thrombosis, pylephlebitis, otitis media 
with thrombosis of the associated sinuses, 
acute osteomyelitis, gonorrhoea, injuries and 
ulceration of the urethra and prostate-in 
connexion, for instance, with stricture and 
catheterism; also acute pneumonia and pul- 
monary gangrene, acute rheumatism, and 
other acute specific diseases. The primary 
lesion may be so slight as to escape observation. 
Anatomical Characters.-Malignant en- 
docarditis, as the name is commonly em- 
ployed, comprehends a variety of morbid 
conditions in connexion with the heart. 
Two of these are fairly distinctive, the ulce- 
rative and the vegetative, and they may be 
conveniently selected for description as being 
the most diverse types between which there 
lie a number of intermediate forms. 
In the ulcerative form, the endocardium 
presents small areas where the proper tissue 
has disappeared, leaving behind it shallow 
ragged erosions. This change occurs most 
frequently in connexion with the mitral 
valves and opening, including the auricular 
aspect of the curtains and the line of attach- 
ment of the valves - particularly the two 
commissures of the segments, and the an- 
terior aspect of the anterior segment; also the 
aortic cusps; parts of the septum and general 
endocardial surface; and the papillary mus- 
cles and chordae tendineae. The endocardium 
of the right ventricle is relatively more fre- 
quently involved in malignant than in simple 
endocarditis. 
The earliest stage of the morbid process 
may sometimes be observed as small yel- 
lowish opacities of the endocardium. But 
as a rule the surface is found already eroded, 
presenting a small, irregular, oval, circular 
or linear ulcer; its ragged grey base covered 
with a loose friable thrombus; its edges 
fringed with vegetations, swollen, indurated, 
and undermined. Such an ulcer increases 
but slowly in area, but it readily advances 
into the depth of the tissue. A variety of 
secondary changes may then occur-acute 
valvular aneurysm, complete perforation of 
the valves, abundant vegetative or fungating 
growths, and suppuration, which ends in 
acute cardiac aneurysm or in complete per- 
foration of the parietes. 
The vegetative form of malignant endo- 
carditis is readily recognised post mortem by 
a prominent and possibly extensive growth 
of polypoidal vegetations, in connexion usu- 
ally with the auriculo-ventricular opening, 
the neighbouring surface of the left auricle, 
and the auricular aspect of the mitral seg- 
ments. Less frequently the aortic valves 
are involved. In either situation the vege- 
tations form a large mass of soft growth, 
almost choking the mitral or aortic opening, 
whilst portions of it must have floated and 
waved in the blood-current, and by their 
contact or impact during the cardiac move- 
ments have injured the neighbouring or op- 
posed surfaces of the endocardium, there set- 
ting up fresh disease of the same kind. The 
surfaces of these vegetations are sometimes 
calcified. 
In both forms of malignant endocarditis it 
is obvious that during life portions of the 
diseased endocardium and thrombi, as well 
as their fluid products, whether on a small 
or on a large scale, must have been readily 
detached or washed off, and carried as emboli 
into other parts of the circulation. 
In addition to the lesions just described, 
the heart may present a variety of morbid 
changes. It is in at least 75 per cent, of 
cases (Sansom) the seat of chronic valvular 
disease and associated enlargement; some- 
times of congenital malformation. The myo- 
cardium may be swollen and in a state of 
granular degeneration like other visceral 
structures; or it presents a number of small 
embolic, haemorrhagic, inflamed, or fattily 
degenerated areas. Pericarditis is sometimes 
associated. 
Embolism is one of the essential anato- 
mical characters of ulcerative endocarditis. 
It occurs most often in the spleen, kidneys, 
and heart, but may be almost universal. In 
the vegetative form of the disease the emboli 
may be so large as to be arrested even in 
the abdominal aorta; the tibial, brachial, and 
other vessels of the limbs are often occluded, 
as well as the splenic, renal, mesenteric, 
cerebral, and a variety of arteries in other 
parts of the body. In the purely ulcerative 
type of the disease the emboli are much 
smaller, and their effects are only recognised 
post mortem by infarcts in various conditions 
of change. Sometimes these secondary foci 
proceed to abscess-suppurative meningitis 
is fairly common. The skin and mucous HEART, INFLAMMATION OF 
827 
membranes, the serous membranes, the 
vessel walls, and the retina are also favourite 
seats of minute embolism and haemorrhage. 
The lungs are specially affected in some 
cases: pulmonary embolism and infarction 
accompany ulcerative endocarditis of the 
right chambers; in other instances acute 
pneumonia appears to be the primary lesion, 
in which the endocarditis of the left chambers 
of the heart has originated. The local effects 
of infective embolism occur very extensively 
in ulcerative endocarditis, namely, haemor- 
rhage, softening, and acute aneurysm ending 
in fatal rupture. See Embolism. 
In a considerable proportion of cases of 
ulcerative endocarditis micro-organisms are 
found both in the valvular lesion and in the 
emboli and infarcts. No less than ten dif- 
ferent kinds of organisms have been de- 
scribed in this connexion, the chief of these 
being Staphylococcus pyogenes, aureus and 
albus; Streptococcus pyogenes; Diplococcus 
pneumoniae ; and Bacillus tuberculosis. 
Micrococci have also been found in the 
circulating blood. See Micro-organisms. 
Symptoms.-In its climcai characters ma- 
lignant endocarditis is either (a) an acute, 
severe, and fatal malady with markedly 
typhoidal features; or (&) a disease of sub- 
acute, possibly chronic, course, pyaemic in 
character, occasionally ending in recovery. 
These two forms call for separate description. 
(a) Acute Typhoidal Malignant 
Endocarditis.-In this variety of the 
disease, the patient is seized with a rigor 
when apparently in good health, or during 
convalescence from an acute illness-particu- 
larly rheumatism; in other instances the 
invasion is more gradual. Pyrexia and the 
other phenomena of severe fever are quickly 
developed, and the patient complains of 
malaise, debility, and cardiac distress; but 
for the first two days the medical attendant 
probably fails to make a complete diagnosis. 
By the end of this time, the patient's con- 
dition having become steadily worse, the 
cardiac sounds are found to be impure; they 
shortly become murmurish; and probably on 
the next day an endocardial murmur is de- 
veloped, systolic or diastolic, still changeful 
in its characters. The general symptoms 
now begin to assume a typhoid type. The 
patient lies helplessly on his back ; the tem- 
perature rises to 104J; the tongue, at first 
furred, becomes dry and brown ; sordes form; 
the respiration becomes hurried, possibly 
with thoracic pains and haemorrhagic sputa; 
and somnolence sets in, broken by low 
muttering delirium, jactitations and sub- 
sultus. The spleen is enlarged and tender, 
suggesting infarction. The bowels may be 
relaxed. The skin is visited by heavy sweats, 
and may become covered with a peculiar 
petechial eruption. The urine, passed natu- 
rally or incontinently, or withdrawn with 
the catheter, is found to contain blood, albu- 
men, and various micro-organisms. The 
ophthalmoscope reveals retinal and other 
intraocular haemorrhages. Bleeding takes 
place from the bowel. Less frequent symp- 
toms are parotitis, arthritis, pericarditis, and 
jaundice. Meningitis, associated with head- 
ache and delirium, and ending in coma, is 
more common, and gives a new or different 
aspect to the case. 
Malignant endocarditis of this severe type 
may be said to always terminate in death 
after a duration of less than fourteen days; 
it Jias been known to end fatally in two 
days. The course which the disease pur- 
sues is one of steadily increasing gravity, 
broken only by equally ominous complica- 
tions in the form of meningitis, haemorrhages, 
or sudden paralysis referable to cerebral 
haemorrhage. Very rarely the disease passes 
into the subacute or chronic form. 
The pyrexia belongs to the continued type, 
the maximum rise being 104° or 105° F., with 
a daily remission of about one degree. In 
some instances it may not exceed 101°, or 
even keep close to normal. With the fever 
may be associated repeated rigors, followed 
by increased prostration and stupor. The 
physical signs connected with the heart have 
already been referred to. The endocardial 
murmur is usually systolic and mitral. It 
develops under observation, changes in loud- 
ness and quality day by day, and may be 
reinforced by a second murmur over another 
part of the praacordia. If traced to the right 
side of the heart, it is of special significance. 
Occasionally the murmur is absent, suggest- 
ing a parietal lesion. The radial pulse pre- 
sents all the characters of the typhoid 
state with increasing prostration, rather than 
those of any particular form of valvular 
disease. The so-called skin ' eruption ' con- 
sists of fine reddish spots, with paler centre 
representing the seat of a minute embolus. 
The signs of pleurisy, pulmonary infarction 
or gangrene, or even of pyo-pneumothorax, 
are sometimes to be determined. 
(&) Subacute and Chronic Malignant 
Endocarditis.-This variety of the disease 
bears but little superficial resemblance in its 
clinical characters to the severe form just 
described. Its general features are those of 
subacute or chronic cardiac disease accom- 
panied with pyrexia and multiple embolism. 
Heart-disease is the central fact, on which 
are superadded the phenomena of general 
infection. There is no prostration until 
the last; no typhoidal aspect. The patient 
is anaemic, sallow, poorly, and he wastes 
steadily ; but he sits up in bed, reads, en- 
gages in conversation intelligently and cheer- 
fully, and may even resent strict treatment. 
The physical signs connected with the 
heart consist mainly of a well-developed 
endocardial murmur, possibly referable to a 
previous valvular lesion, but changing its cha- 
racters from time to time under observation. 828 
HEART, INFLAMMATION OF 
It is usually systolic and mitral; occasion- 
ally aortic systolic or diastolic, or mitral 
presystolic; and it may be suddenly altered 
or complicated by the development of a fresh 
lesion in the heart, such as rupture or per- 
foration. The pulse varies greatly. 
The type of pyrexia in fully developed 
cases of malignant endocarditis of subacute 
course is markedly remittent, or even inter- 
mittent. Three, four, or even six degrees F. 
of a rise and tail (between 98° and 102° to 
104°) may be recorded daily for weeks on end. 
In other instances the disturbance of tem- 
perature takes the form of irregular bouts of 
pyrexia complicating the downward course 
of a severe case of valvular disease. Some 
patients suffer from repeated rigors, unex- 
pected and irregular, followed by profuse 
sweats and prostration. 
The other phenomena of general infection 
are mainly significant of embolism : pain 
and the proper physical signs of infarction of 
the spleen and lungs, blood in the urine, loss 
of pulsation in the arteries of the limbs, 
the development of acute aneurysm with 
subsequent rupture, and even gangrene of 
the extremities. This element of the disease 
gives it a peculiarly uncertain and protean 
character, its course being, for instance, sud- 
denly interrupted by the development of 
severe haemorrhage into the peritoneal cavity, 
or possibly into the brain, with paralysis and 
coma ending in rapid death. 
The duration of this disease is almost in- 
definite. It extends from six or eight to 
twelve or sixteen weeks; in one case of Dr. T. 
Henry Green's it lasted eighteen months. The 
progress is very striking. The patient steadily 
but ahnost imperceptibly loses strength, flesh, 
and colour. With very few exceptions, the 
disease terminates in death, and such patients 
as have recovered were left with permanent 
heart-disease. 
Pathology.-In the less severe type of 
ulcerative endocarditis (as in the more 
familiar ulcers of the integuments) portions 
of the ill-nourished, degenerated, or lowly 
organised fibroid tissue of chronic valvular 
lesions break down in serious impairment of 
the general health, in acute disease, and in 
other unfavourable constitutional states (see 
Ulcer and Ulceration). Subjected to con- 
stant strain and impact, the ulcerous surfaces 
extend rather than heal, establish on and 
around them an increasing growth of vegeta- 
tions, and these become the source of mul- 
tiple embolisms. In cases of this kind no 
morbific micro-organisms are present; the 
disease runs a comparatively slow course; 
and recovery may occur. In the acute 
typhoidal type of the disease it appears that 
true contagia, derived from some obvious 
source (the ' primary lesion '), or entering the 
blood through some unknown channel (' idio- 
pathic '), settle on the endocardium whether 
previously diseased or injured-possibly even 
when intact. The organisms flourish on this 
soil, shed their products into the circulation, 
and plant embolic colonies of their own kind 
as multiple foci of disease throughout the 
body. This process is necessarily associated 
with a septicasmia of a more or less severe 
kind, according to the nature of the organisms 
and emboli. Some authorities deny that 
the organisms are the essential cause of the 
morbid process, and it must be acknowledged 
that the full and complete proof of this con- 
nexion is not yet established. 
Diagnosis.-Now that malignant endo- 
carditis has been so carefully investigated, 
its recognition ought not to be attended with 
much difficulty. The acute form has to be 
diagnosed from typhoid fever, acute tuber- 
culosis, and other infective diseases belonging 
to its own type. The diagnosis usually turns 
on its association with some primary disease, 
and on the result of a physical examination 
of the heart and the correct interpretation of 
any murmur that may be discovered. When 
no murmur is developed, ulcerative endo- 
carditis may escape recognition. Repeated 
rigors, the type of pyrexia, the character 
of the spots, and the occurrence of retinal 
haemorrhages will further serve to exclude 
typhoid fever and tuberculosis. When de- 
lirium and other cerebral symptoms are 
urgent, ulcerative endocarditis has been mis- 
taken for ' cerebral rheumatism ' and simple 
meningitis. 
The subacute and chronic forms are spe- 
cially liable to be confounded with a number 
of diseases which present a similar type of 
pyrexia, particularly the many pathological 
conditions which underlie obscure persistent 
pyrexia, such as latent tuberculosis; lymph- 
oma ; chronic suppuration in connexion with 
the liver, prostate, bowel, kidney, internal 
ear, lymphatic glands, and connective tissues; 
and also syphilis. The existence and change- 
ful character of the murmur, the sudden em- 
bolisms, and the absence of other local signs, 
all indicate the cardiac seat of the disease. 
From malaria it can be distinguished by the 
history, by the absence of periodicity in the 
rigors and fever, as well as by the cardiac 
murmur. 
Some of the gravest complications of this 
form may, for a moment, be misleading, such 
as violent headache ending in coma, refer- 
able to the development and. rupture of em- 
bolic intracranial aneurysm. Experience 
teaches us to be prepared for every possible 
variety of symptom in a disease of which a 
striking feature is visceral embolism. 
Prognosis.-The prognosis of acute malig- 
nant endocarditis is practically hopeless. In 
the subacute form the prospect is but little 
better. However confident and cheerful the 
patient may be at first, the disease will surely, 
if slowly, exhaust the strength, and may at 
any period rapidly prove fatal by some com- 
plication. If the temperature fall and become HEART, INFLAMMATION OF 
829 
less remittent, if the rigors cease, and par- 
ticularly if weight and strength increase, 
hope may begin to rise that the case will 
prove one of the very few exceptions and 
ultimately recover. But the practitioner 
must not forget the precarious nature of such 
improvement, and the incompleteness of the 
recovery at the best. 
Treatment.-The failure of every means 
of cure hitherto employed in acute malignant 
endocarditis serves to impress on us the 
importance of preventive treatment. Dr. 
Sansom urges the necessity of protecting the 
subjects of chronic valvular lesions against 
zymotic diseases, and also of attending in 
them with special care to the treatment of 
suppuration. When ulceration has com- 
menced, the case must be managed on me 
general principles applicable to all acute 
specific fevers, the best possible nursing, 
abundance of food, and a free supply of 
stimulants being provided. Fresh air is es- 
sential ; and if the disease be traced to some 
error of sanitation, it may be advisable to 
take the risk involved in changing the room, 
or even the house, in which the patient is 
lying. 
A great variety of drugs have been tried 
in both forms of this disease, unhappily with 
little benefit, including mercurials, quinine 
and other antipyretics, and the essential oils 
of eucalyptus, turpentine, and their allies. 
Two methods are reported to have been at- 
tended with success in a few instances of the 
chronic form: the sulphocarbolates of sodium 
introduced by Dr. Sansom in 30-grain doses 
four times a day, and quinine in 15-grain 
doses three times a day with a free allowance 
of alcohol (in the form most agreeable to the 
patient), which is recommended by Professor 
Fraentzel of Berlin. 
II. Myocarditis.-Synon. : Carditis; Fr. 
Myocardite; Ger. Myocarditis. 
Definition.-Inflammation of the walls of 
the heart. 
This disease may be either acute or 
chronic; but the latter form, which is at- 
tended with the formation of fibroid tissue 
in the myocardium, is described under the 
head of Heart, Fibroid Disease of. Pysemic 
inflammation of the substance of the heart 
also constitutes so special a form of disease 
that it is treated separately (see Heart, 
Pysemic Abscess of). Aeute myocarditis 
alone, therefore, has to be considered in the 
present article. 
JStiology.-A certain amount of myocar- 
ditis is sometimes associated with acute en- 
docarditis and pericarditis, and depends upon 
the same causes; the most frequent being 
acute rheumatism. In a small proportion 
of cases, rheumatic myocarditis appears to 
occur independently of inflammation of the 
lining or of the covering membrane. In the 
great majority of recorded cases of localised 
myocarditis ending in abscess, the cause of 
the disease was altogether obscure. It has 
been observed most frequently in males, and 
before the twenty-fifth year of life. Exposure 
to cold, severe exertion, and local injury are 
mentioned amongst exciting causes, but with 
questionable correctness. 
Anatomical Characters.-Acute inflam- 
mation of the myocardium generally in- 
volves the connective tissue as well as the 
muscular fibres; but in a few instances the 
latter alone have been found affected, con- 
stituting so-called parenchymatous myocar- 
ditis. 
The ordinary form of the disease is cha- 
racterised by the appearance of leucocytes 
between the muscular fibres of the heart. 
In one class of cases, the inflammation is 
moderate in intensity but diffused in extent, 
affecting one or more layers of muscle under- 
lying the endocardium or the pericardium, 
which is also inflamed; in another class of 
cases, the inflammation is more active, and 
proceeds to the formation of abscess, whilst it 
is, as a rule, comparatively localised. 
In the first or diffused form, the myo- 
cardium, as it is seen through its inflamed 
covering, appears of a mottled opaque 
buffy colour, and is somewhat swollen and 
softened. The microscopical characters con- 
sist chiefly in the appearance of leucocytes 
and inflammatory effusion in the intermus- 
cular connective tissue; swelling, opacity, 
nuclear proliferation, and rupture of the 
muscular fibres, followed by fatty degenera- 
tion and atrophy of the same; and the ordi- 
nary inflammatory changes of the vessels of 
the part. Beyond this stage, unless the case 
prove fatal, the diffused form of myocarditis 
passes into a chronic condition; and it ends 
either in fibroid disease with a moderate 
amount of atrophy, by development of the 
inflammatory products and compression of 
the affected fibres; in fatty degeneration; in 
calcification; or in cardiac aneurysm. 
Suppuration of the heart, on the other 
hand, generally takes the form of swollen 
yellowish-white patches or abscesses, sur- 
rounded by dirty-red or ecchymosed tissue, 
boggy or pulpy to the finger, and containing 
on section a small quantity of variously 
coloured puriform matter, consisting of pus 
and muscular debris. In the same cases a 
great part of the walls of the heart may be 
in a condition of parenchymatous degenera- 
tion; and in some recorded instances the 
whole of the cardiac tissue is described as in- 
filtrated with pus. Abscesses resulting from 
acute localised myocarditis are generally very 
small, varying from the size of a pea to that 
of a nut. They may either burst externally 
into the pericardial sac, or internally into 
one of the cavities or through one of the 
valves, leading to pyaemia, and to the forma- 
tion of an acute cardiac aneurysm; or the 
pus may make its way both externally and 
internally, and lead to fatal haemorrhage into 830 
HEART, INFLAMMATION OF 
the pericardium. In other cases the pus 
undergoes the usual changes, and becomes 
inspissated or cheesy; or calcification takes 
place. 
In both forms of interstitial myocarditis 
the left ventricle is most frequently the seat 
of inflammation. 
Symptoms.-The principal symptoms of 
acute rheumatic myocarditis are restlessness 
and urgent dyspnoea; severe pain and dis- 
tress referred to the praecordia; and palpita- 
tion, which gradually passes into irregularity 
and greatly increased frequency, and finally 
into complete cardiac failure. The pulse 
corresponds. The countenance is anxious, 
and either pale or cyanosed. The mind is 
fearful and distressed at first; and delirium 
frequently supervenes before death, especially 
in young subjects. Vomitiug is not un- 
common. 
The physical signs are generally associated 
with those of endo- and peri-carditis. When 
uncomplicated, they may be described as con- 
sisting of violent cardiac impulse at first, 
which rapidly loses in strength and regu- 
larity while it increases in frequency ; a 
somewhat increased area of cardiac dulness; 
and short sharp sounds, afterwards becoming 
duller and more feeble. 
When these symptoms and signs make 
their appearance, they generally run their 
course rapidly, and end in death. In a small 
number of cases they as rapidly disappear. 
The symptoms of localised suppurative 
myocarditis leading to abscess are not unlike 
those just recorded. There are the same 
distressing symptoms locally, with restless- 
ness and anxiety, passing on to delirium and 
ending in collapse. Rigors have been ob- 
served in some cases ; and a peculiar 
pustular eruption on the skin in other cases. 
The physical signs also are not special; 
excepting that a murmur may be suddenly 
developed by rupture or perforation of part 
of the wall or of a valve. 
The majority of cases of abscess of the 
heart prove fatal by asthenia; but the other 
terminations of abscess mentioned above 
will be attended by their respective symp- 
toms, and the possibility of sudden death is 
especially to be noted. 
Diffuse parenchymatous myocarditis is 
clinically known only as a cause of sudden 
death. 
Complications. - The complications of 
acute myocarditis have already been suffi- 
ciently indicated, such as, first, aetiologically, 
pericarditis, endocarditis, acute rheumatism, 
and other causes of these forms of inflamma- 
tion ; and secondly, pathologically, rupture 
of the cardiac walls or valves, acute cardiac 
aneurysm, haemato-pericardium, embolism, 
and septicaemia. 
Course and Terminations.-The course 
of acute interstitial myocarditis, as already 
stated, is generally rapid, extending from a 
few hours to eight days in different cases. 
Death occurs, in the great majority of cases, 
from the effects of cardiac failure, if the in- 
flammation be extensive or proceed to sup- 
puration. The formation of acute aneurysm 
by internal rupture, the production of peri- 
carditis by external rupture, and other com- 
plications will variously modify the progress 
and termination of cardiac abscess. Simul- 
taneous rupture both externally and inter- 
nally causes sudden death. 
Diagnosis.-The diagnosis of acute myo- 
carditis is extremely difficult. Occurring in 
connexion with acute rheumatism, it has to 
be distinguished from endo- and peri-carditis. 
The absence of murmur and of the charac- 
teristic signs of pericarditis, along with 
symptoms of cardiac failure and severe local 
phenomena, such as pain, distress, dyspnoea, 
and finally collapse, should generally serve 
to establish the diagnosis of inflammation of 
the walls of the heart. It cannot be said 
that cardiac abscess has ever yet been 
diagnosed; but the careful consideration of 
all the points in the case, including the sudden 
development of a murmur indicative of rup- 
ture of a portion of the wall, or of a valve, may 
hereafter ensure greater success. In the 
event of the development of the last-named 
sign, and of septicaemia or embolism, cardiac 
suppuration would have to be carefully 
diagnosed from ulcerative endocarditis. In 
children, the delirium of acute myocarditis 
has to be distinguished from acute meningeal 
inflammation, an object which maybe effected 
by the careful observation of the signs and 
symptoms connected with the heart. 
Prognosis.-The prognosis of myocarditis, 
when it is either so extensive or so intense 
as to give rise to unequivocal symptoms, is 
extremely unfavourable. 
Treatment.-The two principal indica- 
tions of treatment in acute inflammation of 
the substance of the heart are to rest and 
sustain that organ, and to relieve the pain 
and distress. Local anodynes, especially in 
the form of the preparations of belladonna 
and poultices; and stimulating ' counter- 
irritants,' such as mustard cataplasms, will 
conduce to fulfil the second indication. Such 
relief is the first essential, if rest is to be 
secured. The patient must be spared the 
very smallest exertion. Food must be given 
in small quantities, and be easily digestible 
and highly nutritious ; the bowels must be 
kept open; and the flow of urine should be 
as free as possible. Alcoholic stimulants 
will be urgently called for, but must be em- 
ployed with great discrimination; and pal- 
pitation, as much as weakness of the im- 
pulse, is to be regarded as an indication of 
the necessity for these. At the same time, 
digitalis, ammonia, and other cardiac stimu- 
lants should be given cautiously, so as to 
sustain the cardiac action. 
J. Mitchell Bruce. HEART, MALFORMATIONS OF 
831 
HEART, Malformations of.-Synon. : 
Fr. Affections Congenitales du Coeur; Ger. 
Missbildungen des Herzens. 
Classification and Description.-The 
cardiac anomalies of development may be 
classed as follows:- 
I. Those dependent on arrest of the process 
of development at an early period of foetal 
life, so that the organ retains its most rudi- 
mentary form, the auricular and ventricular 
cavities being still single or presenting only 
slight indications of division, and the primitive 
arterial trunk being retained, or the aorta 
and pulmonary artery being very imperfectly 
evolved. 
II. Those in which the defective conforma- 
tion occurs at a more advanced period, when 
the auricular and ventricular partitions are 
already partly formed, and the aorta and 
pulmonary artery more or less completely 
developed. Such are the cases in which, with 
imperfect separation of the ventricles and 
auricles, the arterial or auriculo-ventricular 
passages are constricted or obliterated, and 
the origins of the aorta and pulmonary artery 
are misplaced. 
III. Cases in which the development of 
the organ has progressed regularly till the 
later periods of foetal life, so that the 
auricular and ventricular septa are complete, 
and the primary vessels have their natural 
connexions, but in which there are defects 
which prevent the heart undergoing the 
changes which should ensue after birth. Such 
are the premature closure of the foramen 
ovale, the non-development of the ductus 
arteriosus, and the occurrence of slighter 
sources of obstruction at the arterial or 
auriculo-ventricular passages or in the course 
of the aorta. 
IV. Cases in which there is some irregu- 
larity in the formation of the valves, or in 
the connexions with the vessels, or in the 
vessels themselves, which, though not im- 
mediate sources of obstruction, may become 
so during the progress of life, so as to lay 
the foundations of subsequent disease. 
I. Cases of the first class are of very in- 
frequent occurrence, and are the more rare 
according to the extent of the imperfection. 
The first case of simply biloculate heart was 
placed on record by Mr. Wilson, in the 
Philosophical Transactions, in 1788, and the 
specimen is preserved in Dr. Baillie's museum, 
in the possession of the Royal College of 
Physicians. The anomaly was found in the 
body of a child, which survived for seven 
days. From defect in the diaphragm, the 
heart lay in a sac on the upper surface of the 
liver ; and the organ was found to consist of 
an undivided auricle and ventricle, and a 
single artery, evidently the primitive arterial 
trunk, which first gave off a vessel that 
furnished the branches to the lungs, and the 
vessels to the head and upper extremities. 
The coronary arteries arose by a common 
trunk from the aorta before its final division. 
Since the publication of this case, others have 
been placed on record, illustrating the gradual 
advancement from the simple to the more 
complicated forms-the ventricle becoming 
more completely divided, the septum of the 
ventricles being more fully developed, and 
there being two vessels given off from the 
ventricle, though in some cases one of these 
may be abortive, or if there be only a single 
vessel, that being shown by the origin of the 
coronary arteries from its commencement to 
be really the aorta. 
II. Of the second class, the examples which 
have been described are much more numerous. 
In cases of this kind the auricles and ventri- 
cles are fully formed, though the septa which 
divide them are incomplete, and there is 
usually more or less displacement of the 
origins of the primary vessels, so that the 
aorta more especially may come to arise 
partly or almost entirely from the right 
ventricle; or the points of origin of the vessels 
may be transposed, the aorta arising from 
the right ventricle, and the pulmonary artery 
from the left. Cases of the former descrip- 
tion, in which the septum of the ventricles is 
incomplete, and the aorta misplaced to the 
right, are almost always found to coexist with 
some obstruction to the passage of the blood 
from the right ventricle, either (1) from 
smallness of the pulmonary artery; (2) from 
imperfection of the valves; (3) from constric- 
tion at the outlet of the right ventricle, or at 
the end of the conus arteriosus or infundibular 
portion of the ventricle; or (4) from constric- 
tion at the commencement of the conus or 
point of union between that portion of the 
ventricle and the sinus. A case of the second 
description was published by Sandifort, in 
1777, and one occurred to Dr. Hunter in 
1761, but was not published till 1763. The 
fourth form of obstruction, or that occasioned 
by constriction between the sinus and the 
infundibular portion of the right ventricle, 
has only recently been explained, though 
cases of the kind have for some years been 
placed on record. It is indeed probable that 
the existence of a very decided partition in 
this situation led to the idea entertained by 
some of the older pathologists, that the heart 
occasionally had three ventricular cavities. 
The abnormal septum is partly formed by 
hypertrophy of the muscular structure, and 
partly by the endocardium becoming thick- 
ened ; and in some cases very decided ob- 
struction is so caused. The defect is gene- 
rally developed at an early period of fcetal 
life. The septum of the ventricles is there- 
fore incomplete, the defect being at the pos- 
terior part, so that the aorta comes to arise 
from the sinus of the right ventricle, while 
the pulmonary artery takes its origin from 
the infundibular portion, which seems to 
constitute a distinct cavity. The heart thus, 
as pointed out by Mr. Grainger, bears an 832 
HEART, MALFORMATIONS OF 
almost exact resemblance to the condition of 
the organ in the turtle. In the turtle there 
are two aortic ventricles and one pulmonic 
ventricle; the right aortic and the pulmonic 
ventricle being the analogues of the sinus 
and infundibular portion of the right ventricle, 
and being in connexion, while the left aortic 
ventricle is distinct. 
Much more rarely there has been found 
an entire obliteration of the orifice or trunk 
of the pulmonary artery, the first case of this 
description of anomaly having also been 
published by Dr. Hunter at the same time 
as the former case. Much more rarely, also, 
the defect in the ventricle has been found in 
connexion with obstruction or obliteration 
of the right auriculo-ventricular, the left 
auriculo-ventricular, or the aortic aperture. 
Where the septum of the ventricles is in- 
complete, the defect generally exists at the 
base, at the part which has been termed the 
undefended space-the space which inter- 
venes between the contiguous sides of the 
left and posterior semilunar segments, where 
on the left side the muscle is naturally de- 
ficient ; and in this wray a connexion may 
exist between the left ventricle and right 
auricle or ventricle, either immediately above 
or below the right auriculo-ventricular open- 
ing. More rarely the septum between the 
left ventricle and the conus arteriosus of the 
right ventricle is defective; and still more 
rarely an aperture exists at a lower part of 
the septum. The portion of the septum 
dividing the left ventricle from the sinus of 
the right is termed by Rokitansky the pos- 
terior-that between the left ventricle and 
conus arteriosus, the anterior septum. With 
the defects now mentioned, the auricular 
septum may also be incomplete, or the fora- 
men ovale may be still open, or the ductus 
arteriosus pervious. Indeed, when the pul- 
monary artery is much contracted or im- 
pervious, one or other of the former conditions 
necessarily exists, and the ductus arteriosus 
becomes the means by which the blood is 
conveyed to the lungs, though occasionally 
there are compensatory branches derived 
from the aorta or one of the large vessels also 
distributed to the lungs. 
The transposition of the aorta and pul- 
monary artery also occurs at an early period 
of foetal life. The first case of the kind re- 
corded was related by Dr. Baillie in 1797; 
the specimen is figured in his plates, and 
still exists in the museum in the possession 
of the Royal College of Physicians. In this 
anomaly the septum of the ventricles is gene- 
rally defective, and the two foetal passages 
open, and the organ may indeed be very de- 
fective in conformation. The heart also is 
often misplaced in the chest. Another form 
of defect is that in which the descending 
aorta is given off from the pulmonary artery 
through the ductus arteriosus. This condi- 
tion is apparently the result of imperfect de- 
velopment of the isthmus aorta? between the 
origin of the left subclavian artery and the 
point of entrance of the duct, so that an 
adequate supply of blood cannot be conveyed 
from the ascending into the descending aorta. 
Generally the condition coexists with defect 
of the septum of the ventricles, as in two 
cases formerly in the possession of Sir Astley 
Cooper, and now contained in the museum 
of St. Thomas's Hospital, described by Dr. 
Farre in 1814. In some instances of this 
kind the portion of aorta between the left 
subclavian artery and the duct is imperfo- 
rate, and yet in others, as in a case related 
by Steidelle and referred to by Hein in 1816, 
there is no connexion between the two por- 
tions of the aorta, the ascending part giving 
off the vessels to the head and upper extre- 
mities, the descending portion being wholly 
derived from the pulmonary artery. This 
form of defect is closely allied to the cases 
which are occasionally seen in after-life, in 
which there is constriction or obliteration 
of the isthmus aortse beyond the left sub- 
clavian artery, the circulation being main- 
tained through collateral channels. 
III. The third class of cases consists in 
the premature closure of the foramen ovale; 
or the non-development or disappearance, at 
an early period of fcetal life, of the- ductus 
arteriosus; or in diseased conditions of the 
valves, which prevent the heart undergoing 
the changes which should ensue after birth. 
The first condition is of very rare occur- 
rence The first instance recorded was related 
by Vieussens in 1715. In these cases, the 
blood during foetal life being all transmitted 
through the right cavities and the pulmonary 
artery and duct, those portions of the heart 
are unduly developed, while the left side of 
the organ becomes atrophied. In the second 
class of cases the heart is defectively deve- 
loped, and the right ventricle gives origin to 
the aorta, and often also vessels are distri- 
buted from the aorta to the lungs, while the 
ordinary pulmonary artery may be very small 
in size, or may be entirely absent. In a case 
of this kind, described by Dr. Ramsbotham, 
the pulmonary artery is said not to exist; 
but by examination of the specimen preserved 
in the London Hospital Museum, the writer 
has ascertained that this is not correct. The 
artery exists as a very small vessel, but the 
scanty supply of blood to the lungs which it 
furnished was complemented by small vessels 
from the aorta. In cases which are not of 
uncommon occurrence, and may be classified 
with the malformations now spoken of, but 
which are closely allied to the next class, 
there exists some source of obstruction to the 
transmission of the blood from or into the 
right ventricle, which determines the imper- 
fect closure of the foramen ovale, or the 
patency of the ductus arteriosus. The ob- 
struction in these cases generally depends on 
disease of the pulmonic valves, or obstruction HEART, MALFORMATIONS OF 
833 
at the end or beginning of the conus arteri- 
osus, or at the right auriculo-ventricular 
aperture. 
IV. The fourth class of malformations 
consists of defects, of a slighter description, 
of the valves, or narrowing of the orifices or 
of the isthmus aortae. 
The semilunar valves may be excessive 
or defective in number. The former con- 
dition probably does not materially interfere 
with the functions of the heart-the latter 
often does so, and especially when, as is very 
frequently the case, the valves become the 
seat of disease in after-life. If there be only 
two valves, one of them imperfectly repre- 
senting two distinct segments, there is great 
liability to incompetence. If there be only 
one valve, representing three imperfect seg- 
ments, obstruction is almost necessarily oc- 
casioned. 
It is probable that the cases in which the 
tricuspid valve is found represented by a 
kind of membranous diaphragm, stretched 
across the orifice and perforated in the centre, 
and some of the so-called cases of button- 
hole mitral, are also of congenital origin. 
It is not considered necessary in this 
article to refer to many examples of these 
different forms of malformation, or to allude 
to other of the less important deviations from 
the natural conformation of the heart. The 
subject will be found more fully treated of 
in the works of Dr. Farre,1 of Gintrac,2 of 
Freidberg,3 in the papers of Dr. Chevers,4 
and in the writer's own work.5 The more 
recently published cases also are abstracted 
in the treatise of Taruffi,6 and numerous 
examples of different forms of malformation 
are given by Rokitansky.7 
Mode of Formation.-It is probable that 
all the different forms of irregularity in the 
development of the heart are due to arrest oi 
development, occurring at different periods 
of evolution, so that the heart retains the 
forms proper to it at such stages. The cause 
to which this arrest is to be ascribed can 
rarely, however, be traced in cases where the 
defect is great, such as those of biloculate 
heart, or where the vessels are transposed 
with or without very marked imperfection in 
the organ itself. These defects must be as- 
cribed to the imperfect evolution of the 
double set of cavil ips, and of the pulmonary 
artery and aorta from the primitive trunk 
and branchial arches. In the less marked 
defects, however, the irregularity can often 
be traced to a source of obstruction to the 
transmission of the blood through one or 
other of the apertures or vessels. Such 
obstruction is much the most common in 
connexion with the right ventricle and pul- 
monary artery. In cases of this kind the 
septum of the ventricles is deficient, so that 
the aorta arises wholly or in part from the 
right ventricle. Dr. Hunter, in the paper 
before referred to, when describing a case of 
obstruction of the pulmonic orifice with de- 
fect in the septum of the ventricles, suggested 
that the imperfection in the septum was 
probably caused by the pulmonic obstruction. 
Meckel, however, adopted the view that the 
primary defect was in the septum of the 
ventricles, and that the pulmonary artery 
became more or less abortive from being 
thrown out of the course of the circulation 
by the ready outlet afforded for the blood 
from the right ventricle into the aorta. The 
former view seems, however, to afford the 
more satisfactory explanation, and is in ac- 
cordance with the almost constant occurrence 
of disease of the valves in these cases. Ac- 
cording to the view of Meckel, the pulmonary 
artery should simply be small, as when the 
ductus arteriosus is absent, like the case of 
Dr. Ramsbotham's before referred to, but such 
a condition is very rarely found. The excess 
in the number of the semilunar valves might 
seem to afford an example of redundant de- 
velopment, but this condition also probably 
depends on arrest of development; though, 
as we do not clearly understand the mode in 
which these valves are developed, it is im- 
possible to express a very decided opinion as 
to the cause of the apparent excess. 
Symptoms and Diagnosis.-There can- 
not generally be much difficulty in recognising 
a case of malformation of the heart during 
life. Not only in cases of a very marked 
kind is there generally a complete history of 
the condition of the subject during its short 
life, but the symptoms are also very charac- 
teristic. The child is very markedly cyanotic; 
the cheeks, lips, hands, and feet are exces- 
sively livid; the fingers and toes are clubbed ; 
the nails are incurved; and the patient is 
liable on any excitement, or on exposure to 
cold, to attacks of dyspnoea, often followed 
by convulsions. There are also often present 
difficulty of breathing, cough, and expectora- 
tion of blood; with cardiac palpitation, and 
pulsation of the vessels of the neck. If also 
there be any obstruction at or near the pul- 
monary orifice, there will be a harsh systolic 
murmur heard in the course of the pulmonary 
artery; and if there be a defect in the septum 
of the ventricles, the murmur will be heard 
probably also in the course of the aorta. 
Often there are unhealthy ulcerations about 
1 On Malformations of the Human Heart. 
London, 1814. 
2 Observations et Becherches sur la Cyanose, 
ou Maladie Bleue. Paris, 1824. 
3 Die angebornen Krankheiten des Herzens, etc. 
Leipzig, 1844. 
4 Collection of facts illustrative of Morbid Con- 
ditions of the Pulmonary Artery. London, 1851, 
and Medical Gazette, 1845 to 185i. 
5 Malformations of the Human Heart. Second 
edition, 1866. 
6 Sulle Malattie congenite, etc., del Cuore. 
Bologna, 1875. 
7 Die Defecte der Scheidewdnde des Herzens. 
Wien, 1875. 834 
HEART, MALFORMATIONS OF 
the fingers, toes, and anus or vulva. If the 
case do not attract notice till later in life, there 
will probably be less marked signs of obstruc- 
tion to the circulation, and possibly they 
may be entirely absent, and there may be no 
history of the patient's previous condition. 
In cases of this kind the probability will be 
that if there is a murmur at the pulmonary 
artery there is some defect at or near the 
orifice of that vessel, with or without an 
aperture in the septum of the ventricles or 
an open state of the ductus arteriosus. The 
former condition is so rare as the result of 
disease in after-life, that if the signs point 
to pulmonic valvular disease, its congenital 
origin may safely be surmised. The open 
foramen ovale and ductus arteriosus could 
probably not be diagnosed with any certainty, 
though cases have occurred in which peculiar 
murmurs noticed during life were believed 
to be so produced. It might be supposed 
that when so small a proportion of the blood 
is subjected to the influence of the air as in 
some of these cases, the temperature of the 
patient would not reach the natural standard; 
but the most careful observation of the tem- 
perature of children labouring under con- 
genital cardiac cyanosis has generally failed 
to detect any marked difference in this respect 
between them and other children of about the 
same age. 
Cyanosis.-There are few subjects which 
have excited more discussion than the causes 
of cyanosis or morbus cceruleus. Morgagni, 
in 1761, when describing the case of a girl 
who had obstruction at the orifice of the 
pulmonary artery with an unclosed foramen 
ovale, expressed the opinion that the general 
congestion was probably the cause of the re- 
markable lividity which had been noticed 
during life; and. Dr. Hunter, in 1783, in 
describing a case of pulmonic obstruction 
with imperfection in the septum of the 
ventricles, ascribed the lividity to the inter- 
mixture of the venous and arterial currents of 
blood. These two views have since received 
support from various writers. The view of 
Morgagni has been maintained by Louis, and 
that of Hunter by Gintrac. It has been very 
fully shown that there is no just and constant 
relation between the intensity of the cyanosis 
and the amount of intermixture, and indeed 
that very marked cyanosis may exist without 
any intermixture ; while on the other hand 
in all cases of marked cyanosis there are 
present causes capable of producing great 
venous congestion. The writer is, therefore, 
of opinion that the evidence is very greatly 
in favour of the correctness of the views of 
Morgagni and Louis, that the cyanosis results 
from stasis of the blood, though probably 
other causes conduce to the intensity and 
peculiarity of discoloration. Thus, probably, 
the defect must be congenital, or, at least, of 
very long duration, so that the smaller vessels 
may become greatly dilated; the integu- 
ments must be thin, so as to allow the colour 
of the blood more readily to be seen; and 
lastly-probably also from the very small 
portion of the blood which can be subjected 
to the influence of the air-the whole mass 
of the blood is of an unusually dark colour, 
and so the intensity of the lividity is in- 
creased. 
Duration and Terminations.-The dura- 
tion of life in the subjects of the different 
forms of malformation varies greatly, accord- 
ing to the degree of the defect in the heart. 
In cases in which the organ presents a very 
rudimentary condition, life can only be pro- 
longed for a few hours or days; while in the 
slighter forms of defect the patient may sur- 
vive to puberty or to manhood or womanhood, 
or even to more advanced age. Thus, in 
cases of contraction of the pulmonary artery, 
without other defect in the organ, cases are 
on record in which patients lived to 44 and 
03 ; when, with the pulmonic disease, the 
foramen ovale was unclosed, the subjects 
have reached 40 and 57. Where the septum 
of the ventricles was deficient, a few patients 
are stated to have lived to between 20 and 
30. Where the ductus arteriosus was still 
open, patients lived to 13^ and 19 years; but 
of course these ages are the extremes, and 
by far the largest proportion of the subjects 
die much younger. When the pulmonic 
orifice or artery is impervious, but few 
patients survive for more than two years, 
but cases are on record in which 9 and 12 
years of age were attained; the age' being 
greater according to the facility afforded for 
the transmission of the blood from the right 
side of the heart, as when the septum of 
the ventricles was imperfect, than when the 
ventricles were completely separated by a 
fully developed septum. 
Transposition of the aorta and pulmonary 
artery is a defect incompatible in any of its 
forms with the prolongation of life for any 
lengthened period. Four cases are, however, 
on record in which the patient survived to 
between 2 and 3 years of age-the imperfec- 
tion of the septum of the ventricles tending 
in these cases also to the prolongation of 
Efe. 
The most common causes of death in cases 
of malformation of the heart are affections of 
the brain and lungs, haemoptysis, &c.; and, 
if the patient survive for a sufficient period, 
tuberculous affections. Notwithstanding the 
very great obstruction to the circulation, 
dropsical symptoms do not generally arise to 
any marked degree. 
Treatment.-It is scarcely necessary to 
speak of the treatment of these cases. It 
must consist in protection against cold; in 
the maintenance of bodily and mental quiet; 
and in the use of a nutritious and easily 
digestible diet. Their special liability to 
tuberculosis must not be forgotten. 
T. B. Peacock. HEART, MORBID GROWTHS IN 
HEART, PALPITATION OF 
835 
HEART, Morbid Growths in.-The 
various forms of morbid growth that have 
been met with in the heart may be thus 
enumerated in the order of their frequency: 
(1) Malignant disease; (2) Lymphomatous or 
lymphadenomatous growths; (3) Non-malig- 
nant tumours; and (4) Cysts. Fibroid 
growths, syphilitic gummata, and tubercle, 
as well as hydatids affecting the heart, are 
discussed separately under their respective 
heads. Calcareous, cartilaginous, and 
osseous changes of the myocardium are 
noticed in the article Heart, Degenera- 
tions of. 
1. Malignant Disease of the Heart.- 
Cancer, although the most common of the 
new formations found in the heart, is still 
very rare in this situation, and is a subject 
chiefly of pathological interest. 
.Etiology.-Malignant disease of the 
heart is, with very few exceptions, always 
secondary; and the primary growth may 
have its seat in any part whatever of the 
body. Occasionally the heart becomes in- 
volved by continuity, the lungs and medi- 
astinum being the seat of the primary 
disease. Cases have occurred at all periods 
of life, from infancy to old age; but at least 
one-half of the subjects have been in the 
middle period of life. The disease has been 
most frequently found in males. 
Anatomical Characters.-Carcinoma, epi- 
thelioma, and sarcoma, including colloid 
cancer and melanosis, have all been found 
in the heart in different instances. Any 
part of the organ may be affected, and the 
right side appears to be more frequently 
invaded than the left; but the disease is 
generally multiple. The morbid growth 
usually presents itself upon either of the 
surfaces of the heart, rather than in the 
substance of the myocardium. In these situa- 
tions there may appear one or more masses 
of malignant disease, which as a rule are 
easily distinguished from the cardiac tissue 
around, and which possess the ordinary 
characters of such formations, according to 
their respective kinds, encephaloid being 
the most common, and epithelioma by far 
the most rare. Any difficulty in the recog- 
nition of the disease is removed by section 
and microscopical examination. The extent 
of cardiac wall involved by the growth is 
sometimes great. When the masses of 
malignant disease project externally, they 
are frequently associated with pericarditis, 
either local or general. Prominent nodules 
in the interior of the heart may cause local 
endocarditis; and in other instances the 
valves and their appendages may be so in- 
volved that incompetence results. In very 
rare cases malignant disease of the heart 
proceeds to ulceration. 
Symptoms.-Of thirty-six cases of malig- 
nant disease of the heart, the histories of 
which were collected by Sir Richard Quain 
(Lumleian Lectures'), in thirty no symptoms 
were present, or they were not recorded. In 
one of the remaining six cases, the subject of 
the disease-a man of thirty-seven, in whose 
heart a single large mass of encephaloid cancer 
was found post mortem-had been subject to 
attacks of excruciating pain in the praecordial 
region, dyspnoea, palpitation, and vomiting; 
and death occurred suddenly. Pain in the 
chest and oppression, not referable to other 
causes, are recorded in two other cases; in 
the fourth case there were anginal seizures. 
In cancer of the heart spreading from the 
mediastinum or lungs, dyspnoea, cough, and 
pain are necessarily frequent symptoms. 
"With respect to the physical signs of 
malignant disease of the heart, tenderness 
on percussion over the priecordia (in associa- 
tion with local pain), pericardial friction- 
and endocardial murmurs due to involve- 
ment of the valvular apparatus in the new- 
growth, appear to be the only phenomena 
that have been specially observed. 
Course.-The disease naturally ends in 
death; and in more than one instance this 
termination was sudden, and perhaps 
directly due to the affection of the heart. 
Diagnosis.-This condition has probably 
never been diagnosed during life. The ap- 
pearance of true cardiac pain, or of any of 
the physical signs just mentioned, in the 
course of a case of cancer, would, however, 
be strong evidence that the heart was 
secondarily involved. 
Treatment.- The treatment of malignant 
disease of the heart is necessarily limited to 
the relief of any symptoms that may be 
present, and does not differ from the treat- 
ment of cardiac distress from other causes. 
2. Lymphoma of the Heart.-Lym- 
phomatous or lymphadenomatous growths 
have been met with in the heart in several 
cases in which the disease was general, but 
this affection of the organ cannot be said to 
have any clinical importance. 
3. Non-Malignant Tumours of the 
Heart.-These growths are also of purely 
pathological interest, and are amongst the 
very rarest of morbid appearances in con- 
nexion with the heart. Myomata have 
been recorded as instances of this class of 
diseases. Lipomata lying under the endo- 
cardium are referred to in the article Heart. 
Fatty Growth on. 
4. Cysts of the Heart.-The occur- 
rence of true cysts in the myocardium 
(hydatids, abscesses, haematomata, and soft- 
ening gummata being excluded) is doubtful. 
J. Mitchell Bruce. 
HEART, Palpitation of.-Synon. : Fr. 
Palpitation du Coeur; Ger. Her zklopfen. 
Definition.-Abnormal movement of the 
heart, without appreciable structural lesion; 
the movement, frequent or tumultuous, vary- 
ing in tone and force. 836 
HEART, PALPITATION OF 
^Etiology.-The immediate or proximate 
cause of palpitation is an over-stimulation of 
the excitability of the muscular structure of 
the heart, induced by functional errors of the 
cardiac ganglia and of the vagus, more es- 
pecially the depressor nerve proceeding 
from its trunk, or of those other nerves which, 
proceeding from the ganglia of the great sym- 
pathetic, supply the heart; it being borne in 
mind that the cardiac centre in the medulla 
is subject to impressions co-existent with the 
whole nervous system, and that these are 
transmitted by the vagus or sympathetic to the 
heart. It is therefore a true neurosis. The 
disordered action of these nerves may be in- 
duced either directly by dynamic or adynamic 
causes, or by reflex action; but in either case 
the phenomena as regards the heart are the 
same-namely, the morbid activity or irregu- 
larity in a normal function, and which must 
be here considered as independent of any 
accompanying organic lesion. In dynamic 
and reflex palpitation the general blood pres- 
sure thus resulting is influenced, partly by 
peripheral resistance, but mainly by the 
tumultuous increase in the heart's action. 
The lessened duration of the diastole ad- 
versely determines, first, the period of rest; 
secondly, the recruiting of the nerve-power 
of the lieart, by lessening the nourishment 
afforded to its general structure through the 
coronaries; and, thirdly, the stimulus afforded, 
by a deficiency in the due amount of blood 
supplied to the ventricles. As the variableness 
of this duration is measured by the recurrence 
of the systole (defined and uniform as regards 
time), the relative frequency, force, and tone of 
the pulse-stroke become important elements 
in the appreciation of these forms of func- 
tional disturbance. In the adynamic form 
the palpitation is mainly influenced by an 
increase in the peripheral resistance effected 
by morbid action of the vaso-motor system, 
and evidenced by a marked deficiency of tone 
and force in the beat. 
The predisposing and exciting causes of 
palpitation of the heart are various. The 
chief predisposing causes are to be found in 
the nervous and excitable temperaments; 
general debility; inanition ; physical depres- 
sion ; exhaustion, whether bodily or mental; 
early age; hysteria; venereal excesses; and 
in deterioration of the blood, as occurs in 
gout, scurvy, chlorosis, or spanaemia. Amongst 
the exciting causes may be classed violent 
exercise; mental shock, emotion, and all 
forms of sudden excitement of the nervous 
system; exposure to too low a temperature ; 
dissipation ; injurious articles of diet; and 
dyspepsia. 
Symptoms.-In the dynamic and reflex 
forms of simple palpitation there may occur 
(1) a single action; or (2) a series of actions, 
which may become prolonged, and of such 
a character as to be esteemed chronic. The 
single abnormal beat not infrequently occurs 
during a first sleep, and the patient is wakened 
by a consciousness of it. Sleep may then 
return, and the attack subside without other 
inconvenience ; or it may be associated with 
a feeling of weight, fulness, anxiety, sinking, 
or even pain of the praecordia. More fre- 
quently, however, the attacks are prolonged 
and recurrent, returning with an accelerated 
and uncertain frequency. To the patient the 
act of palpitation causes various and widely 
different sensations. There may be a mere 
occasional flutter, or a slightly increased 
action continuing for a time; or there may 
be increased action attended with great 
rapidity, and such violence, that the heart 
appears forcibly to strike the chest-walls, dif- 
fusing its influence over the whole sternal 
region, and even at times agitating the whole 
body (a phenomenon probably due to an 
associated general nervous agitation) ; or the 
heart, again, may seem to the sufferer to rise, 
as it were, into the throat. With these 
several symptoms there may be the accom- 
panying disturbances of choking-the globus 
hystericus ; vertigo; tinnitus aurium ; im- 
paired vision, with a feeling of distension 
of the eyeballs: a copious secretion of pale 
limpid urine; a clammy coldness of the ex- 
tremities ; fear of death ; partial unconscious- 
ness ; or actual syncope. These attacks may 
be preceded by a somewhat prolonged state 
of cerebral disturbance, as evidenced by heat 
of brow and vertex, headache, and an in- 
aptitude to think or regulate the thoughts; 
and as there is generally a self-consciousness of 
the abnormal action of the heart, the anxiety 
on this account serves to impress the mind 
with so much fear and inquietude as to tend 
to increase and prolong the disorder that has 
induced them. In the adynamic form there 
is usually increased frequency with failure of 
systolic power, so that the pulse becomes de- 
ficient in tone, force, and rhythm, and may 
be even reduced to a mere flutter. The 
patient is painfully sensible of the disturbance, 
which induces a feeling of restless anxiety; 
relief is sought, but not easily obtained, 
either by moving about or in repose. When 
this adynamic form of palpitation has its 
causation primarily from undue depression 
of temperature, in the peripheral circulation 
and subsequently in the venous system and 
right heart, these symptoms become more 
urgent -may be to the extinction of life ; the 
vaso-dilators of the arteries are paralysed; the 
systemic current fails, and hence the ceiebral 
vessels and the nutrient vessels of the heart 
itself are unfilled, the immediate result being 
syncope and death. This is probably the 
frequent course of events in drowning. It is 
certainly so in those cases of death from the 
injudicious use of the cold bath, taken when 
physical exhaustion or other circumstances 
interfere with the necessary reaction from 
the shock. 
Physical Signs.-The physical examina- HEART, PALPITATION OF 
HEART, PYEMIC ABSCESS OF 
837 
tion of the heart in the dynamic and reflex 
forms of simple palpitation, shows the apex- 
beat to be normal in position, but diffused 
and much exaggerated in force. The area of 
dulness, a? a rule, is not enlarged upwards, 
but it may be temporarily enlarged, under 
certain circumstances, towards the right side. 
The sounds, always exaggerated, at times 
become very much so, and usually with a 
sharp metallic ring. Occasionally a kind of 
remitting humming sound is superadded, and 
may be heard even by the patient; but this 
is never constant. Sometimes the sounds are 
heard over a great extent of surface ; but this 
extent is no measure of their intensity, for 
they may not be loud, but abnormally clear 
and distinct only. Occasionally there is a 
pericardial rubbing accompanying the mitral 
apex-shock, simulating the friction-sound of 
pericarditis; but there is never true friction- 
sound. The basic second sound, more fre- 
quently than the first, presents the metallic 
ring. Sometimes it becomes lower-pitched 
and less clicking than in an ordinary attack 
of palpitation; and may even, as also the first 
sound, so lose sharpness and abruptness as to 
assume somewhat of the character of a soft 
murmur. The aorta, carotids, and large 
arteries also throb, and have an excited im- 
pulse. The smaller arteries are not sensibly 
affected. The pulse at the wrist is thus often 
an uncertain indicator of the amount of action 
exhibited by the heart. Sometimes it has 
the character of being sharp and jerking, 
without force ; or, should the right side of 
the heart become loaded with blood, it may be 
small and soft, and weak. This is markedly 
the case in the adynamic form; the im- 
pulse may be weak even to extinction, and 
the sounds so feeble as scarcely to be appre- 
ciable, while there are indications of a loaded 
state of the right heart. The symptoms may 
be summed up as indicative of depressed 
irritability, even to suppression, with venous 
congestion. On the subsidence of an attack, 
the ventricular impulse may return to its 
natural force and frequency, and the sounds 
be unaccompanied by any exaggerations. 
Nevertheless, though the attack may have 
subsided, there may be slight irregularity of 
the heart's action perceptible for some short 
time afterwards. 
Diagnosis.-Though the diagnosis of pal- 
pitation of the heart in some cases may 
present difficulty, yet, in the absence of 
evidence of structural lesion, an increased 
impulse presenting the above distinctive 
characters may be assumed to be functional 
in its origin, and not dependent on any or- 
ganic disease of the heart itself. We have, 
in fact, to do with an exaggeration, some- 
times highly marked, of the natural nervous 
susceptibilities of the heart; and this nervous 
increase of impulse, even when only slight, 
is usually more appreciated by the patient, 
more painful, and more a source of anxiety 
than is that attending organic disease, es- 
pecially in its earliest stages. 
Treatment.-Palpitation, in reference to 
treatment, may be briefly viewed as dynamic, 
reflex, and adymic. Reflex palpitation, as 
irritative in its centripetal origin, is, for the 
most part, dynamic in character; and there- 
fore its occurrence with the dynamic forms 
is to be temporarily met by corresponding 
remedial agents. Those sedatives which 
combine sedation with diffusible stimulation 
are in practice very generally selected, be- 
cause a rapidly acting heart is not necessarily 
distributing the blood evenly through the 
vessels; in fact, the pulse may be no guide 
to the action of the heart, this being in- 
fluenced by other causes. These remedies 
include ether, camphor dissolved in spirit of 
nitrous ether, ethereal tincture of lobelia, and 
bromide of ammonium, sedatives combined 
with ammonia, and carminative volatile oils. 
The rational treatment, however, even during 
the attack, is rather to strengthen those 
measures which before and after are to be 
used to counteract the cause, and to lessen 
vascular tension, as well as to quell inordi- 
nate cardiac action. Aconite, diluted hydro- 
cyanic acid, or the green hellebore, are there- 
fore especially indicated; or the inhibitory 
action of digitalis and its allies may be called 
for. In adynamic palpitation the sedative 
action is not required, but stimulation, either 
through the nerves or upon the heart itself, 
is mainly to be relied on. Thus, sumbul, 
castor, valerian, or alcohol, and ammonia, 
or compound tincture of lavender, and allied 
medicines may temporarily relieve the 
attack. Of all stimulants to an enfeebled 
and impeded circulation and adynamic in- 
ordinately acting heart, nitroglycerine or 
trinitrin is the most reliable and most 
powerful; and the allied remedies are to 
be found in amyl nitrite and the alkaline 
nitrites. It is important, however, to observe 
that the action must be maintained in a 
properly regulated dose, for this should not 
involve any depressing influence on the 
nervous system, as cannot generally be 
avoided when amyl nitrite is given by in- 
halation ; and the dose of trinitrin cannot be 
measured by a fixed standard of one minim 
of a 1 per cent, alcoholic solution, for in 
some cases half the standard dose will be 
sufficient; in other cases double the amount 
will be required to produce the requisite de- 
gree of stimulant action. T. Shafter. 
HEART, Pyaemic Abscess of.-Defi- 
nition.-Abscess of the heart occurring in 
pyaemia. 
./Etiology.-Abscess of the heart has been 
most frequently observed in cases of pyaemia 
following acute necrosis of bone or diffuse 
periostitis; less frequently after phlebitis, 
chronic or acute arthritis, urethral stricture, 
chronic abscess, and cancerous ulceration. 838 
HEART, PYEMIC ABSCESS OF 
HEART, RUPTURE OF 
In eleven out of fourteen cases, the histories 
of which were collected by Sir Richard 
Quain (Lumleian Lectures'), the age of the 
patients was seventeen years or under; and 
twelve out of the same fourteen cases were 
males. In other words, pyaemic abscess of 
the heart has been most frequently found 
in cases following injury to a bone or to a 
joint in boys. In older subjects it has been 
associated with pyaemia secondary to one or 
other of the diseases just mentioned. In a 
few cases no primary disease was discovered. 
Anatomical Characters.-Pyaemic disease 
of the walls of the heart most commonly 
affects the left ventricle-towards the base 
and in the papillary muscles. Pericarditis 
co-exists in the great majority of cases, and 
very frequently endocardial inflammation 
pericarditis. The physical signs found in 
these cases are chiefly those of acute peri- 
carditis. Sometimes an endocardial bellows- 
murmur may be heard, due either to val- 
vular lesion, or to the formation of an acute 
aneurysm of the cardiac wall. 
Course and Terminations.-The cases of 
pyaemia in which the heart has been found 
post mortem to be involved, have generally 
proved rapidly fatal, the patients dying from 
exhaustion. Rupture of the abscess in either 
direction may tend to accelerate the fatal 
termination; but complete rupture of the 
wall in both directions, with sudden death 
from haemato-pericardium, as in non-pyaemic 
abscess of the heart, does not appear to be 
on record. 
Diagnosis.-In every case of pyaemia the 
physical condition of the heart should be 
regularly investigated ; and there should no 
longer be any risk of acute inflammation of 
the heart or pericarditis being mistaken for 
meningitis or simple delirium. Pyaemia 
with multiple arthritis and involvement of 
the heart is more difficult of diagnosis from 
ordinary acute rheumatism with cardiac 
inflammation; and mistakes in such cases 
have not infrequently occurred. The history 
of the case, including the evidence of a 
definite injury, however slight, is of the 
greatest value; but a careful consideration 
of all the facts of the case alone can prevent 
mistakes. The only difficulty that remains 
in the diagnosis of pyaemic abscess of the 
heart is the determination of its existence in 
the presence of pericarditis, which is rarely 
absent. For this purpose the facts of the 
aetiology of the case are more important than 
the symptoms ; and especially the occurrence 
of an injury to the periosteum of a youthful 
subject as the original cause of the pyaemia. 
As a matter of fact, the symptoms, either 
general or local, appear never to have sug- 
gested the diagnosis of pyaemic abscess of 
the heart. 
Prognosis.-If a diagnosis of abscess of 
the heart can be made in pyaemia, the only 
possible prognosis that can be given is one 
of speedy death. 
Treatment.-The treatment of pyaemia 
affecting the heart cannot be said to differ in 
any important respect from that of ordinary 
cases of the disease (see Pyaemia). The 
accompanying pericarditis will call for local 
treatment. 
J. Mitchell Bruce. 
HEART, Rupture of.-The heart is 
liable to rupture from external injuries, and 
from causes acting from within. The latter 
are called spontaneous ruptures, and these 
only will be considered here. Spontaneous 
ruptures may affect either the walls or the 
valves. The latter form of lesion will be 
found discussed under the head of Heart 
Valves and Orifices of, Diseases of. 
also. The pyaemic foci are generally mul- 
tiple, and vary in size from a pea to a pin's 
head. They appear at first as small, slightly 
elevated, yellowish or buff-coloured, softened 
patches, projecting either on the external or 
on the internal surface of the heart, and 
covered with inflammatory deposit. On 
section, these patches either present an ap- 
pearance of diffused yellowish softening, or 
contain one or more collections of dark dirty 
puriform matter, with ragged, ill-defined 
boundaries, as if formed by destruction of 
the discoloured tissue around. 
Microscopically examined, the yellowish 
patches prove to be portions of the myocar- 
dium which are infiltrated with pus and 
granular matter; the muscular tissue itself 
being in a condition of granular or fatty de- 
generation. The puriform material repre- 
sents an advanced stage of the same change, 
consisting of granular matter and other mus- 
cular debris, blood, various micro-organisms, 
and frequently pus-corpuscles. The several 
stages of the pyaemic process have been 
found side by side in some cases; and em- 
boli have been discovered in the branches 
of the coronary arteries, where they may 
have served as the foci of the abscesses. The 
walls of the heart are sometimes in a con- 
dition of softening throughout. Pyaemic ab- 
scess of the heart occasionally bursts; and the 
contents make their way either into the left 
ventricle-producing cardiac aneurysm, and 
perhaps giving rise to further embolism and 
pyaemic disease-or into the pericardial sac. 
Symptoms.-"Whatever the symptoms of 
pyaemic abscess of the heart may be, they 
have in recorded cases been completely ob- 
scured by the general symptoms of pyaemia, 
and by the local symptoms and signs of 
pericarditis. Thus, the patients are de- 
scribed as presenting a febrile, typhoid, or 
pyaemic appearance, an anxious look, dys- 
pnoea, and praecordial pains; and pericardial 
friction has generally been discovered over 
the heart. Delirium probably occurs more 
frequently than in ordinary cases of pyaemia, 
but may be referable to the accompanying HEART, RUPTURE OF 
839 
.Etiology.-Rupture of the walls may be 
said never to occur spontaneously when the 
heart is healthy. The following have been 
enumerated by different writers as the 
diseased ^conditions of the heart's walls that 
predispose to rupture :-A thin or atrophied 
condition, simple softening, a ' gelatiniform ' 
condition of the walls, apoplectic or haemor- 
rhagic effusion into the walls, abscess, ulcera- 
tion, and fatty degeneration. The writer 
finds from a table of 100 cases of rupture, 
the histories of which he has collected from 
different sources, that the heart had under- 
gone fatty degeneration in 77 ; in 6 the walls 
were described simply as being softened; in 
1 there was rupture of an aneurysmal dilata- 
tion ; in 1 there was bursting of an abscess ; 
in 12 the heart is said to have been healthy 
in texture, or not to have been examined; 
but in most of these latter cases mention is 
made of the previous existence of endocar- 
ditis, or of changes in the coronary arteries, 
fully justifying the impression that there was 
disease of the texture of the heart. 
The influence of age in relation to rupture 
of the heart can be distinctly traced. For 
example, of the 100 cases just referred to, 63 
were above the age of sixty years. Arranged 
in decades, the cases stand thus:-2 were 
between ten and twenty; 1 between twenty 
and thirty; 3 between thirty and forty; 6 
between forty and fifty; 13 between fifty and 
sixty; 33 between sixty and seventy; 24 
between seventy and eighty ; 6 were over 
eighty; and in 2 the age is not stated. With 
respect to sex, of 98 out of 100 cases in which 
it is mentioned, 54 were males and 44 females. 
The exciting cause of rupture of the heart 
is usually some mental excitement or physical 
effort; but the accident may occur when the 
subject of it is at rest, or pursuing the ordinary 
avocations of life. 
Anatomical Characters.-Seat. In 76 
cases out of the 100 to which we have already 
alluded, the left ventricle was the seat of the 
rupture; and in 43 of these cases the lesion 
was in the anterior wall. The right ventricle 
was found ruptured thirteen times, nine in- 
stances occurring in its anterior wall. The 
right auricle was ruptured seven times; the 
left auricle twice; and a rupture was found in 
the septum four times. These results corre- 
spond remarkably with those of other writers 
on the subject. Elleaume (Mon. des Hopit., 
1858) in 55 cases found the rupture 43 times 
in the left ventricle, seven times in the right 
ventricle, three times in the right auricle, and 
twice in the left auricle. 
On examining a heart in which rupture 
has occurred, the torn part is found to pre- 
sent different characters in different cases. 
The lesion may be complete, causing perfora- 
tion of the walls; or it may be incomplete. 
In complete rupture the opening is sometimes 
barely sufficient to admit a probe, whilst in 
other instances it may be two or three inches 
in length. The rent is sometimes longer ex- 
ternally, and sometimes it is longer inter- 
nally. There may be but one, or there may 
be more than one, rupture; and in the latter 
case the ruptures may or may not communi- 
cate with one another. In incomplete rup- 
ture the injury may be confined to the 
internal surface, or to the external surface, 
or it may occur in the substance of the walls. 
The edges of the rent are ragged, irregular, 
and sometimes ecchymosed. The irregularity 
of the edges is due to the manner in which 
the muscular fibres are torn, whether across 
or split longitudinally. This description 
refers more correctly to rupture in a heart 
that is the subject of fatty degeneration. 
The appearances are different when the rup- 
ture is secondary to an abscess, or to ulcera- 
tion, or to certain other causes presently to 
be described. In such cases the lesion has 
been described as a rent, tear, ulceration, or 
perforation. The condition of the heart in 
the majority of cases of rupture has been 
already referred to under the head of etio- 
logy. Ecchymoses are sometimes found in 
the vicinity of the lesion. The pericardium 
generally contains an effusion of blood, which 
often surrounds the heart with coagulum, 
leaving the sac filled with serum, to the 
amount, it may be, of thirty ounces, as in 
an instance which came under the writer's 
notice. 
Mechanism. - Rupture of the heart is 
doubtless nearly always the result of a strain 
or of pressure acting upon the muscular 
walls. The walls of the healthy heart are 
sufficiently strong to resist any ordinary 
force to which they are exposed. But when 
they are softened by degeneration, or are 
very thin, as is sometimes the case in the 
auricles or the right ventricle, they may give 
way before the pressure to which they are 
exposed during muscular efforts or strains, 
or even in the ordinary action of the organ. 
Thus, when a part of the wall of the heart is 
weakened by softening or other cause, this 
spot may be, as it were, torn across by the 
contraction of the healthy fibres among which 
it is situated. Or again, when the walls of 
the heart are thick, it may be that the outer 
surface, being strained over the contents of a 
distended ventricle, as would be the outer 
surface of an overbent hoop, gives way, tears, 
and the opening gradually extends from 
without inwards. These facts enable us to 
understand why rupture is more frequent in 
the left than in the right ventricle. A further 
explanation is to be found in the fact that 
the left ventricle is more frequently than the 
right the seat of fatty degeneration, from 
causes elsewhere alluded to (see Heart, Fatty 
Degeneration of). There is yet another way 
in which softening leads to rupture. A soft- 
ened spot occurs in the substance of the 
heart, and into it haemorrhage takes place, 
constituting what is termed apoplexy of the 840 
HEART, RUPTURE OF 
HEART, SOFTENING OF 
heart. At times this haemorrhagic softening 
may yield either externally or internally, and 
give rise to rupture. Lastly, the writer has 
seen more than once a small spot of softening 
with loss of substance occurring on the in- 
ternal surface of the ventricular wall, most 
frequently in the left; this softening and 
breaking down of tissue gradually insinuates 
itself amongst the muscular fibres, until 
finally perforation of the outer wall of the 
heart occurs. 
Symptoms.-The symptoms of rupture of 
the heart may be described as those which 
are premonitory; and those which occur at 
the time of the accident. The former are 
such as indicate a diseased condition of the 
organ-namely, breathlessness on exertion, 
palpitation, more or less irregularity of pulse, 
and faintness. In some instances recorded 
these symptoms were so slight as hardly to 
attract attention; in others so severe as to 
cause intense suffering. In the majority of 
the cases noted in the table referred to, no 
mention is made of any preceding symptoms, 
death being sudden. In several cases it is 
distinctly stated that no symptoms preceded 
the fatal attack. 
The occurrence of the lesion itself, when 
the patient has lived long enough to describe 
his sensations, has always been marked by 
intense cardiac suffering, more or less distress 
in breathing, restlessness, rapid and irregular 
pulse, faintness, pallor, coldness of the skin, 
sometimes vomiting, and by various nervous 
symptoms. When life is prolonged beyond 
a few minutes, there may be more or less 
intermission in the progress of these symp- 
toms ; but the whole attack is marked by 
anguish more or less severe. The duration of 
the attack itself from the first fatal seizure 
varies remarkably. In 71 out of the 100 
cases alluded to, death was sudden, occur- 
ring within one or two minutes. One patient, 
however, lived eight days, 1 six days, 1 three 
days; 5 lived over forty-eight hours, 3 lived 
under twenty-four hours, and 19 under twelve 
hours. 
The special symptoms indicative of a fatal 
seizure are, in addition to those already 
mentioned, severe praecordial pain, dyspnoea, 
vomiting, cyanosis, pallor, loss of conscious- 
ness, and convulsions. These symptoms, or 
some of them, were noted in 44 out of the 
100 cases; and in 24 of these the patient lived 
for more than five minutes after seizure, and 
in some of the cases for more than twelve 
hours. These cases, doubtless, are instances 
in which the muscular fibres are torn apart ' 
layer by layer successively. In the other 20 
cases the patient was seized with severe pain, 
and then expired; or with dyspnoea and some 
of the other symptoms mentioned above, and । 
lived but a few seconds. 
The physical signs of complete rupture 
having occurred, so far as can be ascertained, 
are merely a greater or less amount of dul- 
ness in the region of the heart; the impulse 
diminished; the sounds muffled, distant, or 
imperfectly developed; and the pulse weak 
and intermittent. 
Course and Terminations.-The difference 
in the progress of the fatal malady depends 
much upon the seat of the rupture, on the 
size of the opening, and on the rapidity with 
which the extension of the laceration takes 
place. In the cases in which the septum is 
torn, there is no external haemorrhage, and 
life is prolonged until the patient dies from 
disturbance in the functions of such an im- 
portant organ as the heart. (See a case re- 
ported by Dr. Peacock, Path. Trans, vol. v.) 
The progress of the symptoms is also influ- 
enced by the direction and course of the rup- 
ture. If the torn fibres overlap from the 
inside or from the outside, the injury pene- 
trates slowly through the cardiac wall, and 
the fatal progress is also slow. (See cases 
recorded by the writer in the Path. Trans. 
vol. iii., and also in vol. xii.; and a case by 
Dr. Peacock in vol. xvii. of the same Trans.) 
Prognosis.-As far as is known, rupture 
of the heart is always fatal. Still it is pos- 
sible that such an accident, owing to the 
small size of the opening, its incomplete cha- 
racter, and its occlusion by a coagulum, may 
not prove fatal. Numerous instances are re- 
corded of severe wounds of the heart, the 
subjects of which have survived. Ollivier 
has collected 29 such cases, only two of which 
proved fatal within forty-eight hours, the 
others living from four to eight days. Cases 
are recorded in which persons have survived 
many years severe wounds of this important 
organ. These cases, however, differ from 
those of rupture in this particular, that they 
occur in the healthy organ, whilst sponta- 
neous rupture occurs in the heart when it is 
seriously diseased. See Heart, Wounds of. 
Treatment.-In the way of treatment of 
rupture of the heart little can be done. The 
patient's sufferings may perhaps be relieved 
by the hypodermic injection of morphine, or 
by tbe use of sedatives or antispasmodics. 
Perfect rest sh:uld, if possible, be maintained. 
Richard Quain. 
HEART, Softening of.-This term was 
formerly applied to several conditions of the 
heart in which the consistence of the cardiac 
tissue was diminished, whilst the process to 
which it was due was obscure or anomalous. It 
is probable that under the name of softening of 
the heart there were especially included in- 
stances of acute myocarditis, parenchymatous 
degeneration, and fatty degeneration. In the 
present more advanced state of cardiac patho- 
logy, it seems desirable that the expression 
' softening,' while retained to express a fami- 
liar physical condition, should cease to be 
employed as a classifying term-that is, to 
designate any specific morbid state. 
J. Mitchell Bruce. HEART, SYPHILITIC DISEASE OF 
841 
HEART, Syphilitic Disease of.- 
Syphilitic disease of the heart is by no 
means a rare condition, having been found 
in a large number of instances in which the 
specific nature of the lesion was determined 
with certainty; whilst, in another series of 
cases, similar anatomical appearances were 
present, although the existence of syphilis 
was not ascertained. Syphilitic disease of 
the heart is therefore of much pathological 
interest; but it cannot be said that a great 
deal is known as yet with respect to its 
clinical history. 
^Etiology.-There appears to be nothing 
of importance known as to the causes of the 
location of syphilis in the heart. The con- 
genital as well as the acquired form of the 
disease has been met with. 
Anatomical Characters.-This morbid 
condition presents two leading appearances 
post mortem. The first is the well-marked 
syphilitic gumma, which closely resembles 
the same form of growth as it is met with, 
for example, in the liver and testicles. 
Gummata of the heart appear as pale yellow 
patches in the cardiac wall, or as yellowish 
nodules which are found on section. They 
present a variety of appearances, according 
to their age. When young they are firm or 
even scirrhoid, elastic, and homogeneous; 
creak on section; and are very slightly 
succulent : when older, they become soft 
and cheesy, like a mass of ' yellow tubercle.' 
In either firm the masses are not isolated, 
but pass continuously into the myocardium, 
either directly, or through the medium of 
soft vascular connective tissue, so that they 
were formerly described in this country as 
'infiltrations' or 'fibrinous deposits.' The 
superjacent endocardium or pericardium is 
vasctdarised and dull in the early stage of the 
nodules; opaque and thickened in the more 
advanced stage. The masses or nodules occur 
in various numbers in different instances, but 
are generally multiple. They may be found 
in any part of the heart. Gummata most 
frequently become caseous in the centre, as 
described; and they may then soften more 
completely and discharge inwards, leading 
to acute cardiac aneurysm and ulcer of the 
wall; but more frequently the cheesy pro- 
ducts are in a great measure absorbed, 
leaving a puckered fibroid patch behind. 
The second form of syphilitic disease of 
rhe heart is the fibroid patch. This is 
sometimes well-defined and localised, and 
in such instances it represents the stage of 
full development of an area of ordinary 
syphilitic interstitial inflammation. In other 
specimens, the fibroid patches appear as 
irregular masses of indurated fibroid tissue, 
occupying part of the wall of the heart, and 
sending septa into the depth of the myocar- 
dium, whilst the endocardium and pericar- 
dium that correspond to them are opaque, 
thickened, and puckered. The syphilitic 
nature of such patches may be determined 
by the presence of specific lesions in other 
viscera. 
A form of the disease intermediate between 
the two forms just described is one in which 
the outer zone of the gumma has undergone 
development into fibroid tissue, and the 
caseous centre remains as a ' fibrinous ' 
mass. 
The microscopical characters of syphilitic 
growths do not require to be described here. 
In the heart, the primary seat of the disease 
is the intermuscular tissue; the muscular 
fibres lying imbedded in the gummatous 
products or in the fibroid growth being 
either healthy in appearance, or fattily de- 
generated and broken up. 
Syphilitic endarteritis (obliterans) may 
also occur in the vessels of the myocardium, 
and give rise to infarction of the walls of 
the heart. 
Amongst the occasional effects of syphilitic 
disease of the heart are chronic aneurysm of 
the walls; distortion of the ostia and of the 
valves and their appendages; and, more 
frequently, adhesion of the pericardium. 
Some of the other viscera present, as a rule, 
evidence of syphilitic disease. 
Symptoms.-The subjects of syphilis of the 
heart may, from a clinical point of view, be 
divided into three classes. The first class 
of patients suffer from some one or other of 
the ordinary symptoms of chronic cardiac 
disease, such as dyspnoea, cardiac distress, 
palpitation, pulmonary complications, and 
general dropsy; whilst the physical signs 
are those of cardiac enlargement, and per- 
haps of valvular incompetence. Praecordial 
uneasiness, syncopal attacks, and remarkable 
infrequency of the pulse, have been promi- 
nent features in several recorded cases. 
The second class of subjects of this disease 
die suddenly, after few if any complaints re- 
ferable to the heart. 
The third class die of syphilitic marasmus, 
and may or may not present some evidence 
-by physical signs or otherwise-that the 
heart is not sound. 
In many of the cases, other symptoms of 
visceral syphilis have been prominent-for 
example, phenomena connected with the 
brain and nervous system. 
Diagnosis.-Well-defined symptoms or 
physical signs connected with the heart, 
such as those just mentioned, occurring in 
a syphilitic subject, would furnish consider- 
able grounds for the diagnosis of specific car- 
diac disease, in the absence of other more 
probable causes-such as a history of endo- 
carditis, strain, or Bright's disease. 
Prognosis.-If such a diagnosis were 
positively made, the prognosis would be 
more favourable than it is perhaps in any 
other form of chronic heart-disease, inas- 
much as the condition might be successfully 
removed by treatment. 842 
HEART, SYPHILITIC DISEASE OF 
HEART, THROMBOSIS OF 
Treatment.-Anti-syphilitic remedies, es- 
pecially iodide of potassium, should be freely 
tried, along with the other remedies indi- 
cated on general principles. 
J. Mitchell Bruce. 
HEART, Thrombosis of. - Synon. : 
Heart-clotting; Fr. Thrombose Cardiaque] 
Ger. Gerinnungen im Herzen] Herzpoly- 
pen. 
Definition.- Coagulation of the blood 
within the cavities of the heart during life. 
.Etiology.-Thrombosis of the heart is 
most frequently due to local arrest of the 
movements of the blood, comparatively or 
absolutely, within its cavities. Such arrest 
is itself generally referable to weakness of 
the cardiac contractions, whether associated 
with dilatation secondary to valvular, renal, 
or pulmonary disease, or due to some 
primary affection of the muscular walls. 
The peculiar saccular condition of the ex- 
tremities of the auricular appendages, and 
the trabecular arrangement of the columnae 
carneae of the ventricles, as well as the dis- 
tance of the same parts from the main blood- 
currents, determine the favourite localisation 
of the thrombosis. Roughening of the en- 
docardium is another cause of thrombosis, 
but one which is to be considered less 
common than the causes already mentioned, 
unless the fibrinous coagula of endocarditis, 
or vegetations, be regarded as thrombi, 
which, in the strict sense of the term, they 
partly are. Possibly certain conditions of 
the blood may contribute to the occurrence 
of cardiac thrombosis. Finally, thrombi 
once formed tend to promote the further 
progress of the condition. 
Anatomical Characters.-Coagula found 
within the heart are of two kinds, which 
have been termed active and passive, ac- 
cording as they are formed during life, or 
at or after death, respectively; and the 
characters of the former, with which alone 
we are here concerned, cannot be understood 
until those of the latter have been briefly 
described. 
Passive coagula are found in the heart in 
most necropsies, occupying the track of the 
principal blood-currents. Frequently they 
appear as black or red blood-clots, occupy- 
ing the auricles principally, and moulded in 
their cavities. In other cases they take the 
form of masses of firm whitish fibrin, 
cleaving with some tenacity to the endo- 
cardium, but not truly adherent; matted 
with the chordae tendineae and columnae 
carneae; and projecting some distance into 
the pulmonary artery. Or, thirdly, passive 
coagula may be a combination of the two 
previous forms, the upper part (according to 
the position of the body) being decolorised 
or fibrinous, and the deeper part resembling 
more an ordinary blood-clot. In certain 
cases these passive clots are peculiar. In 
phthisis and other diseases proving fatal by 
very slow exhaustion, they are remarkably 
firm and fibrinous, and closely matted 
amongst the chordae tendineae-appearances 
which seem to indicate that coagulation 
was slowly proceeding for some time before 
the heart had finally ceased to beat. In 
anaemia they are jelly-like and translucent. 
In leukaemia they are soft and creamy in 
appearance, and yield, when broken up, a 
puriform fluid. In the acute exanthemata 
these passive clots are soft and friable ; and 
in many cases of these and of other forms 
of acute disease and of sudden death, no 
coagula are found in the heart, which con- 
tains only fluid blood. 
Active coagula-the result of thrombosis 
of the heart-are, on the contrary, situated 
in the saccular appendages of the auricles, 
at the apex of the ventricles, and in the re- 
cesses behind and between the columnae 
carneae-in other words, as far as possible 
from the track of active blood-currents. In 
these situations they may be seen projecting 
in the form of fleshy knobs or globes, with 
their free surface smooth and rounded. 
Their deep surface is adherent to the endo- 
cardium, from which, however, it can 
generally be separated without much diffi- 
culty, leaving behind it a discoloured mark. 
If the thrombus be incised, it will be found 
to be laminated in structure, somewhat 
after the fashion of an onion, the colour of 
the section being greyish-brown or yellowish, 
with irregular patches of red and black. In 
most instances the centre is less firm than 
the periphery; and usually it is of a fluid 
consistence, in the form of a foul, sanious, 
puriform substance. 
If the process of thrombosis have been 
proceeding for some time, these formations 
may extend in all directions, embrace the 
columnae carneae, coalesce in front of them, 
and finally may fill up a considerable portion 
of one, or even of more than one, cavity. 
The thrombi are generally friable; but some- 
times they gain in firmness by the deposit of 
lime-salts within them; and at other times 
it is possible that they become detached and 
form into the ' fibrinous balls ' which have 
been found lying free in the cavities of the 
auricles. Cardiac thrombi may, in part at 
least, be reabsorbed. They frequently give 
way during life; and portions of them, as 
well as of their puriform contents, are con- 
veyed into the circulation, causing embolism 
and pyaemia. 
Cardiac Embolism.-It may be adde I 
that embolism of the heart has frequently 
been found-thrombi or simple clots, some- 
times of remarkable size, having been carried 
from the veins, and arrested in the heart or 
in the mouth of the pulmonary artery. 
Symptoms.-The clinical phenomena asso- 
ciated with true cardiac thrombosis may be 
best described as those of the last stage of HEART, THROMBOSIS OF 
HEART, VALVES, DISEASES OF 
843 
chronic disease of the heart. Praecordial 
distress and restlessness; irregularity and 
feebleness of the pulse ; oedema and coldness 
of the extremities; pulmonary congestion, 
infarction, and oedema; dulness of expression, 
and sopor, broken by low weak delirium; 
with other symptoms, as well as with the 
signs of cardiac failure and imperfect empty- 
ing of the cavities in systole-all these phe- 
nomena are associated with the process of 
active coagulation within the heart. It 
would not, however, be correct to describe 
these phenomena as symptoms directly re- 
ferable to the thrombosis. All that can be 
said is, that in such a case thrombosis is 
probably going on and increasing the em- 
barrassment and the gravity of the condition. 
An unusual degree of cyanosis appears in 
some instances. The symptoms of arterial 
embolism may suddenly make their appear- 
ance from detachment of particles of the 
clots; and, if the puriform contents find 
their way into the circulation, septicaemia 
may result. 
Cardiac embolism.-The dislodgment en 
masse of a large venous thrombosis, and the 
impaction of the same, or of a ' fibrinous 
ball,' in one of the ostia of the heart have 
frequently caused rapid death. See Pul- 
monary Vessels, Diseases of. 
Passive coagulation.-It should be added 
that the appearance of the ' passive ' form of 
coagulation within the heart, which has been 
already referred to as a post-mortem process, 
or one occurring in articulo mortis, has been 
otherwise interpreted by some authorities, 
who regard passive coagula as formed ante 
mortem, and as giving rise to severe symp- 
toms by the embarrassment which they pro- 
duce in the circulation. The symptoms 
caused by this condition are said to be - 
great praecordial pain and distress; tumul- 
tuous action of the heart, passing on to ir- 
regularity, flickering, and finally arrest, whilst 
the pulse is very feeble ; urgent dyspnoea; 
cyanosis; haemoptysis; coldness of the ex- 
tremities ; deepening stupor; and coma end- 
ing in death-in short, the congeries of 
symptoms which would be referred by most 
authorities to failure of the muscular walls 
of the heart, the coagulation being regarded 
as only another result of the same condition. 
Diagnosis.-In the presence of the very 
serious and complex conditions with which 
cardiac thrombosis is usually associated, the 
question of its existence can hardly be said 
to occur to the physician as a point of great 
importance. An unusual degree of cyanosis, 
especially if it be progressive, favours the 
recognition of this state; and in the absence 
of valvular disease, the occurrence of embo- 
lism or pyaemia would tend to confirm it. 
Treatment.-The treatment of cardiac 
thrombosis consists in the treatment of its 
cause; and nothing is demanded or can be 
done for the former which is not indicated 
for the relief of the latter. Those authorities 
who see in ' passive ' coagula the evidence of 
rapid ante-mortem thrombosis, recommend 
the use of stimulants, and even of certain 
drugs which are supposed to have a solvent 
effect on fibrinous formations, especially am- 
monia. 
The treatment of embolism of the pul- 
monary artery is described separately. 
J. Mitchell Bruce. 
HEART, Tuberculosis of.-Indepen- 
dently of the pericardium, the heart itself is 
believed to be rarely the seat of tubercular 
disease. Grey miliary tubercles have been 
found in the connective tissue of the wall of 
the heart, in some cases of acute general tuber- 
culosis. Tubercle bacilli occasionally occur on 
endocardial ulcers. In other instances the 
' tubercle ' has been of the yellow or cheesy 
kind, in the form of small nodules lying at 
various depths in the muscular tissue be- 
neath the pericardium; the latter also being 
frequently affected, as well as the lungs, in- 
testines, and other organs. 
There appears to be no evidence that 
tuberculosis of the myocardium gives rise to 
definite svmptoms, or that it can be recog- 
nised during life. 
J. Mitchell Bruce. 
HEART, Valves and Orifices of, 
Diseases of. - Classification.-The dis- 
eases of the valves and orifices of the heart 
which produce mechanical disorders of the 
circulation, by establishing abnormal rela- 
tions between those parts, are of two kinds- 
obstructive and regurgitant. Valvular dis- 
ease, on the one hand, is said to be obstruc- 
tive when narrowing of an orifice presents an 
obstacle to the passage of the blood-current- 
a condition better named stenosis. On the 
other hand, when the blood regurgitates or 
flows back through an orifice, in consequence 
of imperfect closure of the valves, due either 
to valvular changes or to widening of the 
orifice, the condition is called regurgitation 
or insufficiency. 
Aneurysm, of the valves of the he?"t is 
discussed separately. See Heart, Valves of, 
Aneurysm of. 
.Etiology.-Each of the orifices may be 
affected with one or both forms of disease, but 
the frequency with which the several orifices 
are attacked varies. The results of organic 
disease are chiefly met with in the left side 
of the heart, and are due to local inflamma- 
tion-endocarditis and its consequences; or 
to chronic degenerative changes, such as 
atheroma. In adult life the valves of the 
left side are more frequently affected than 
those of the right, because they have to bear 
a much greater pressure; but in foetal life, 
when the pressure is reversed, the right 
valves suffer more. Endocarditis is com- 
monly of rheumatic origin, and attacks the 844 
HEART, VALVES AND ORIFICES OF, DISEASES OF 
mitral more frequently than the aortic valves; 
the former having to sustain tho full force of 
the ventricular systole, while the latter only 
bear the force of the aortic recoil. In ad- 
dition to rheumatic fever, the chief diseases 
which tend to develop endocarditis are 
pyaemia, puerperal fever, the exanthemata, 
diphtheria, chorea, typhoid, tuberculosis, 
chronic renal disease, and syphilis. The 
aortic valves and orifice are more commonly 
affected than the mitral by chronic end- 
arteritis extending from the aorta, the chief 
causes of which are gout, old age, syphilis, 
and the abuse of alcohol. These facts explain 
why mitral affections (commonly rheumatic) 
occur mostly in early life, and aortic affections 
in later life. Valvular lesions are more com- 
mon in men than in women, from the strain 
of the heart incidental to more laborious 
occupations. Strain helps to swell the greater 
proportion of disease of the aortic valves, 
which are liable to rupture from effort; but 
similar accidents may occur to the mitral 
valve and its tendinous cords. Valvular de- 
fects are also due in some cases to congenital 
malformations. 
Anatomical Characters. - The patho- 
logical changes in the valves and orifices of 
the heart, which cause valvular diseases, are 
mostly the results of acute or chronic endo- 
carditis. In the acute form, the valvular 
lesion is caused by the growth of vegetations 
which interfere with the action of the valve- 
segments ; or by softening and ulceration of 
the valve-structure, which lead to valvular 
aneurysm and perforation, or to loss of sub- 
stance and consequent insufficiency. The 
mere chronic form of inflammation produces 
thickening of the valves from overgrowth of 
the connective tissue, with subsequent cal- 
careous degeneration, and retraction from 
shrinking of the hyperplastic connective 
tissue; or adhesion of the valve-segments 
causing stenosis. 
Aortic stenosis is generally the result of 
thickening and calcareous degeneration of the 
valves, or of deformity of the valves from 
vegetative growths which obstruct the free 
passage of the blood from the ventricle. 
Sometimes it is due to adhesion of the 
valves preventing their elevation, and caus- 
ing them to form a diaphragm with a narrow 
central aperture. More rarely it is caused 
by thickening and contraction of the fibrous 
ring of the aortic orifice, gradually involving 
the valves; or by endocardial thickening pro- 
ducing contraction immediately beneath the 
aortic ring. 
Mitral stenosis results most frequently 
from a leather-like thickening and rigidity 
of the valves, which contract all round the 
mitral orifice, so as to narrow the outlet, 
and form a diaphragm between the auricle 
and the ventricle. This diaphragm is in 
some cases funnel-shaped, while in others the 
mitral orifice is transformed into a button- 
hole aperture, or narrowed to the size ol 
a goose-quill. The tendinous cords of the 
valve are shortened, and their muscles 
thickened. In some cases the valves are 
smooth and thin ; in others they are thick- 
ened, studded with vegetations, rough and 
calcareous. This latter state may cause 
stenosis, without any funnel-formation, as 
may also fibrinous clots or polypi obstructing 
the orifice. In many cases of mitral stenosis 
the valves are also insufficient. Mitral stenosis 
is mostly observed in young females, as a 
result of mild rheumatic attacks or chorea. 
It is sometimes called congenital in cases in 
which it can be referred to no acute illness. 
Aortic insufficiency sometimes depends on 
dilatation of the aortic orifice, due to soften- 
ing of the aortic coats, with little or no change 
in the valves, which are incapable of closing 
the enlarged orifice. This may be called 
relative insufficiency. Vegetations, thicken- 
ing, retraction, calcareous degeneration, ad- 
hesions, perforations, loss of substance, and 
rupture of the valve-segments by effort are all 
causes of aortic insufficiency. In rupture of 
the valves, a full description of which was first 
given by Sir Richard Quain (Edin. Monthly 
Journ. 1846), the valve-segment is torn from 
its angle of attachment, and its free edge 
retroverted towards the ventricle. This 
accident happens more frequently in cases 
where the valves were previously diseased 
by chronic inflammatory changes connected 
with the strain of very laborious occupations, 
and in such cases further laceration may 
subsequently occur. 
Mitral insufficiency is due to thickening, 
retraction, or deformity from vegetations of 
the valve-curtains ; adhesion of the curtains 
to each other or to the ventricular wall; and 
calcareous degeneration. In some instances, 
one of the valves is perforated or torn ; and 
sometimes the tendinous cords are shortened 
and thickened, or ruptured as the result oi 
degeneration, preventing the normal action 
of the valve-curtains. In rarer cases asso- 
ciated with dilated ventricle, the papillary 
muscles are so weakened by degeneration 
that they can no longer aid in the closure oi 
the orifice. Dilatation of the left auriculo- 
ventricular orifice is also a cause of relative 
mitral insufficiency. This form is uncon- 
nected with structural valve changes, and is 
due to defective muscular contraction, such 
as occurs in anaemia, typhoid fever, and the 
failing systole of the later stages of aortic 
insufficiency. 
Valvular defects on the right side of the 
heart are due to similar changes. They 
arise chiefly during foetal life, when the right 
cavities have to bear greater pressure. In 
adult life these defects are generally asso- 
ciated with diseases of the lungs, which cause 
increased tension in the right cavities, and 
lead to their dilatation. 
Combined valvular lesions are not infre- HEART, VALVES AND ORIFICES OF, DISEASES OF 
845 
quent. The most common are stenosis and 
insufficiency of the aortic valves, and the 
same morbid changes of the mitral valves. 
In the last stages of both forms of aortic 
valve-disease, the mitral valve becomes in- 
sufficient, either from chronic endocarditis, 
or from dilatation of the ventricle and of the 
auriculo-ventricular orifice. Mitral stenosis 
is not infrequently associated with aortic 
insufficiency, but is more commonly con- 
nected with some degree of narrowing at 
the aortic orifice. Tricuspid insufficiency is 
usually met with in the last stages of diseases 
of the left heart; and tricuspid stenosis is 
met with in connexion with a similar nar- 
rowing of the mitral orifice. 
Symptoms,-Valvular diseases of the heart 
produce a series of morbid phenomena, which 
are connected together by a necessary se- 
quence. Each and every form of valvular 
defect impairs the perfection of the heart as 
a pumping machine, and disturbs the normal 
relations between the contents of the arteries 
and of the veins. Wherever the valve-mis- 
chief is, and whatever its nature, it robs the 
arterial circulation and enriches the venous. 
In front of the lesion there is less blood ; 
behind it there is more. In aortic valvular 
diseases, the first effects are increase of the 
blood-pressure in the left ventricle, and 
lessened blood-pressure in the aorta; next, 
from the difficulty which the left auricle has 
in emptying all its contents into an over-full 
ventricle, there is produced increased pressure 
in the left auricle and pulmonary veins. 
Mitral valve-lesions cause similar results: 
fii st, increased pressure in the left auricle, 
less pressure in the left ventricle, and con- 
sequently lessened pressure in the aorta; 
with a gradual increase of pressure extending 
from the left auricle to the pulmonary veins. 
Aortic affections thus act first on the arterial, 
and secondly on the pulmonary circulation; 
while mitral lesions affect the pulmonary 
vessels more immediately. The final results 
of the two forms are, however, identical, and 
may be stated in the form of a law-namely, 
that all valvular diseases of the heart tend 
to lessen the quantity of blood in the arterial 
system, and to produce increased fulness and 
stasis in the veins. From the action of this law, 
various associated visceral disorders follow 
as consequences. These disorders, however, 
vary greatly in the period of their occurrence, 
and in the intensity of their manifestations. 
This variation is due to the more or less 
perfect way in which the original valvular 
defect has been compensated for, by changes 
in the power of the cardiac muscle and in 
the capacity of the cardiac cavities. These 
changes often suffice to maintain fairly the 
normal balance between the arterial and 
venous contents, thus compensating for the 
valve lesion ; and the process by which this 
is effected demands careful consideration. 
Compensation.-Compensation is effected 
differently, according to the form of disease. 
It may be stated, generally, that it consists 
in hypertrophy of the cavity immediately 
behind the defect. Now hypertrophy means 
increased contractile power, and this means 
better filling of the arteries, and consequently 
increased arterial tension. Thus it makes 
up for the valvular incompetency, which 
tends to lessen arterial tension. When the 
increased power of the ventricle exactly 
balances the effects of the valvular mischief, 
the compensation is complete. 
In aortic stenosis, hypertrophy of the left 
ventricle is the mode in which compensation 
is effected ; the obstacle to the blood-current 
is overcome by the increased muscular 
power. 
In aortic insufficiency there is some dila- 
tation of the ventricle as the primary result 
of the lesion. This is counterbalanced by 
greater hypertrophy; and as long as the dila- 
tation does not progress, the insufficiency is 
compensated for. A sufficient excess of blood 
is thrown into the aorta at each systole to 
allow for the regurgitation during each 
diastole; and thus the balance is maintained, 
though not always equably. 
In mitral lesions the left auricle is dilated 
as the primary consequence of the condition 
of the valves; hypertrophy follows, but is 
insufficient to prevent increased fulness of 
the pulmonary veins. This impedes the 
circulation in the lungs ; and increased ten- 
sion in the pulmonary artery soon begets the 
necessary hypertrophy of the right ventricle. 
It is by means of this increased power of the 
right ventricle that the blood is driven through 
the lungs in spite of the defect in the left 
heart, and pulmonary stasis is prevented; 
and the blood entering the left auricle under 
greater vis a tergo, the compensation of the 
valvular defect is effected. The compensa- 
tion, from the nature of the means on which 
it depends, is manifestly less perfect than in 
aortic lesions. 
On the right side of the heart similar 
modes of compensation are observed. 
The basis of the salutary changes just de- 
scribed is increased cardiac nutrition; and, 
consequently, a free coronary circulation is a 
necessity. Conditions which interfere with 
this prevent compensation, and so diminish 
the duration of life. Wherever the compen- 
sation begins to fail, dilatation of the cavities 
and vessels behind the lesion commences. 
This may, how'ever, be checked, and the 
power of the heart restored for a time. 
Sooner or later, however, changes in the 
nutrition of the cardiac muscle, in the 
vessels, and in the general nutrition, bring 
on failure of compensation. The cardinal 
symptom in such cases is weakened contrac- 
tile power of the heart, or asystolie (Beau). 
In this state, the cavity chiefly affected has 
no longer power to expel its contents fully 
into the vessels, and consequently becomes 846 
HEART, VALVES AND ORIFICES OF, DISEASES OF 
gradually and increasingly distended. Fail- 
ing compensation in aortic valve-disease 
manifests itself by dilatation of the left 
ventricle, and the development of secondary 
mitral insufficiency. Similar retro-dilatation 
marks the failure in mitral cases, only here 
it is the right ventricle which dilates, and 
tricuspid insufficiency and general venous 
stasis are added to the pre-existing pul- 
monary engorgement. 
The earliest symptoms of failing compen- 
sation are attacks of palpitation from very 
slight exertion or excitement, or during 
sleep. Irregularity of the pulse soon follows, 
if it have not previously existed. This is 
especially the case in mitral disease. The 
irregularity is due not so much to true car- 
diac intermission as to abortive contractions, 
which do not reach the wrist; or to contrac- 
tions unequal in force, or in the quantity of 
blood expelled. The pulse is small, unequal, 
irregular, and compressible. In aortic val- 
vular disease true intermissions occur, and 
are of grave import. With failing cardiac 
power there usually supervene cardiac op- 
pression, anginous attacks from distension of 
the cavities of the heart, and faintness and 
giddiness from cerebral anaemia. 
Visceral complications.-The most im- 
portant of the associated disorders of chronic 
valvular disease, depending on defective con- 
traction of the heart, are the visceral conges- 
tions. 
In the lungs, the habitual engorgement of 
mitral diseases produces a hyper-secretion of 
mucus and a state of chronic catarrh. The 
blood-vessels also undergo changes from the 
excessive intravascular pressure, and become 
dilated, varicose, and atheromatous ; whence 
oedema and haemorrhage arise. In mitral 
stenosis especially, grave and frequent 
attacks of haemorrhage, with laceration of 
the pulmonary substance, are liable to occur; 
these attacks are called pulmonary apoplexy, 
and the lung-condition splenisation. The 
lungs, from long-continued congestion and 
oedema, undergo brown induration. The 
varicose condition of the vessels in the 
alveoli interferes with oxidation, both by 
favouring stasis and by mechanically nar- 
rowing the alveoli, and so aids in the dete- 
rioration of blood, which the other visceral 
congestions favour. 
In the liver, the general venous stasis is 
felt by the obstruction to the passage of 
blood from the hepatic veins into the in- 
ferior cava. Passive congestion ensues, and 
' nutmeg liver ' results. This term ' nutmeg 
liver ' refers to the rough changes in the 
viscus, the dark congested centre of each 
lobule being surrounded by a paler area. In 
course of time the compression of the central 
cells of each lobule by the distended veins 
leads to atrophy, and the growth of a hyaline 
fibroid tissue, which causes the toughness; 
the liver, from being large, shrinks in 
very chronic cases to half its size; and the 
condition may, like true cirrhosis, lead to 
ascites. The passive congestion in the liver, 
as in the lung, causes catarrh of the tubes, 
and may thus be productive of jaundice. 
Amongst other symptoms associated with 
the hepatic congestion may be mentioned 
haemorrhoids and epistaxis. 
The spleen is a very easily distended organ, 
and suffers like the liver, but frequently 
before it; and this may partly account for 
the pain in the early stages, which is com- 
plained of beneath the left ribs. In long- 
standing cases the spleen becomes tougher, 
and the capsule opaque and thickened; while 
haemorrhagic infarcts are common. 
From the hepatic congestion there natu- 
rally follows distension of all the other radicles 
of the portal vein ; hence the congestion and 
chronic catarrh of the stomach and intestines, 
which impede digestion and assimilation, and 
so reinforce the other causes producing the 
cachexia of chronic valvular disease. 
In all cases of valvular disease, when the 
mechanical effects extend to the general cir- 
culation, the function of the kidneys is more 
or less disordered. The first stage of general 
circulatory trouble is lessened arterial ten- 
sion ; this makes itself felt in lessened pres- 
sure in the Malpighian tufts, and is manifested 
by scanty, dense, high-coloured urine. When 
the more advanced circulatory trouble- 
namely, general venous stasis-is developed, 
a further change takes place in the urine. 
The arterial anaemia keeps it still scanty and 
dense, but the venous stasis in the kidney 
leads to the transudation of serum-a dropsy 
of the kidney, as it were; and consequently 
albumen appears in the urine. Long-con- 
tinued venous congestion ends in structural 
changes, which, as elsewhere, consist in con- 
nective-tissue hyperplasia and degenerative 
(rarely fatty) changes in the tubules. These 
renal changes sometimes add uraemia to the 
patient's ailments. 
In the brain decided alterations are not 
found, except when a detached vegetation 
produces embolism and its special pheno- 
mena. The brain-substance is, however, 
generally cedematous, and the membranes 
are thickened. Delirium is an occasional 
symptom in heart-disease, and when present 
to any great degree is of evil import. The 
blood-vessels of the general circulation are 
frequently affected with atheroma in hyper- 
trophy of the left ventricle, and it is these 
degenerative changes, as well as embolic 
aneurysm, which favour the occurrence of 
apoplexy. 
General dropsy.-The mechanical impedi- 
ments to the circulation which produce these 
several visceral congestions, also manifest 
themselves in the general dropsy which is 
common in the last stages of heart-disease. 
The dropsy begins as a puffiness of the ankles, 
especially the left, at bedtime. The general HEART, VALVES AND ORIFICES OF, DISEASES OF 
847 
venous stasis, thus first indicated, advances 
slowly and surely, if not checked, to general 
anasarca, and even to dropsy of the serous 
cavities. The increased venous tension, and 
the hydraemia of blood deterioration, are the 
causes of this serous transudation, which 
shows itself first in the feet, the most depen- 
dent portions of the body, where the pressure 
of the blood-column is naturally greatest. 
The horizontal posture, by distributing the 
pressure, is sufficient at first to disperse the 
oedema of the ankles. General anasarca is 
much more frequent in mitral, especially the 
regurgitant form, than in aortic lesions. 
In some cases a solid form of oedema is 
observed. This occurs mostly in the last 
stages of valvular affections, and is due to 
thrombosis of venous trunks, in which, the 
circulation being much impeded, coagulation 
easily takes place. The termination of the 
external jugulars is a common site for such 
thrombosis; and the left innominate vein, 
from its transverse position, and from its 
emptying almost at right angles to the 
current in the superior vena cava, is, in the 
writer's experience, more commonly ob- 
structed than the right. Solid oedema is 
consequently seen more frequently on the 
left side of the head and neck and in the left 
arm, than on the right side. 
Defective compensation.-The phenomena 
just described are associated with valvular 
diseases of the heart, as the consequences 
of partial or defective compensation. These 
conditions are more or less developed ac- 
cording to the individual case, and conse- 
quently give rise to symptoms in varying 
degrees. These symptoms will now be 
described. 
Palpitation is intimately related to the 
state of cardiac nutrition and innervation, 
and has no special connexion with any form 
of valvular disease. Cardiac pain, varying 
in intensity from mere uneasiness to the 
agony of angina, is most common in aortic 
cases, and is associated with endarteritis, 
particularly at the root of the aorta, or with 
dilatation of the left ventricle, or is a neur- 
algia of the cardiac plexus. In mitral affec- 
tions, pain arises from over-distension of 
the left auricle, and its pressure on neigh- 
bouring parts, and later on from dilatation 
of the right ventricle. Dyspnoea may be 
present in any form of valvular disease, but 
it is often absent from the earlier history of 
aortic cases, while some dyspnoea is always 
present in mitral cases. This difference is 
due to the absence of pulmonary congestion 
in aortic affections, whilst it is more or less 
present from the first in mitral affections. 
The dyspnoea is a breathlessness rather than 
a difficulty of breathing. It is panting and 
gasping in its character, with acceleration of 
the rate. It is aggravated by any movement, 
and often compels the patient to sit upright 
(orthopnoea). Headache, vertigo, dreaming, 
night-frights, and sleeplessness are other 
symptoms, which depend on disordered cere- 
bral circulation. Sleeplessness is one of the 
most distressing of all symptoms, and can 
only be relieved when the dyspnoea is les- 
sened. Other more special symptoms will 
be found in certain cases, and will be trace- 
able to the disturbances in the circulation, 
which the particular form of valvular disease 
has engendered. 
Physical signs.-The physical signs asso- 
ciated with valvular affections may be said 
to be-first, those of alteration in the size of 
the heart; and, secondly, those of mechanical 
disorders of the circulation; together with 
one or more endocardial murmurs. The per- 
sistence of a murmur is the cardinal sign, 
and if the murmur be either diastolic or 
praesystolic in its rhythm it is of absolute 
value. A systolic murmur may be caused 
by poverty of blood-anaemia, especially at 
the base of the heart. But in such a case- 
that is, in haemic murmur-there is no car- 
diac hypertrophy, as indicated by increased 
cardiac dulness, though there is often nervous 
over-action of the heart. There is no ac- 
centuation of the pulmonary second sound, 
inasmuch as there is no extra-fulness of the 
pulmonary blood-vessels from obstructed 
circulation. The pulse in anaemia is generally 
quick, ample, and compressible, but, withal, 
jerky; while with an organic systolic murmur 
it is generally slow, rising gradually under 
the finger, and not very compressible (aortic 
stenosis), or small, irregular, and unequal 
(mitral insufficiency). The clinical methods 
of investigating valvular lesions are mainly 
inspection, palpation, percussion, and auscul- 
tation. The signs of each form of valve - 
disease are stated below; and on these the 
special diagnosis rests. 
Diagnosis.-In Aortic stenosis there is 
often some prominence of the prsecordial 
region, and a steady forcible impulse is per- 
ceived below and to the left of its normal 
position. A thrill, systolic in time, may 
often be felt at the base of the heart. On 
auscultation, a loud, frequently rough, rasp- 
ing, sometimes musical, murmur is heard 
with the first sound at mid-sternum, and 
also at the second right intercostal space. 
The murmur, commencing with the first 
sound, extends to the succeeding second 
sound, which is often not very distinct. In 
relative stenosis with a dilated aorta, the 
murmur is softer, and the second sound 
sometimes louder than normal. The mur- 
mur of aortic stenosis is audible all over the 
upper part of the thorax, especially on the 
right side; is conducted along the great 
vessels to the left vertebral groove, and it 
may be even to the lower dorsal vertebrae ; 
and is occasionally heard at the apex of the 
heart. The pulse is regular, slow, retarded 
by the narrowing of the aortic orifice, and 
slowly developed under the finger. The 848 
HEART, VALVES AND ORIFICES OF, DISEASES OF 
sphygmogram (see fig. 62) shows the line of 
ascent to be oblique or broken, instead of 
nearly vertical; the summit is generally 
blunt; and the line of de- 
scent shows small or no 
secondary waves, and ill- 
developed dicrotism. Aortic 
stenosis when moderate, 
requiring only hypertrophy 
of the left ventricle for 
its compensation, is often 
very perfectly remedied by 
this change, and produces little or no dis- 
order of the circulation. This is also 
true of cases in which roughness of the 
valves or vegetations are the cause of even 
a loud murmur. The amount of hyper- 
trophy of the left ventricle is the surest 
guide to the gravity of the condition. "When 
the stenosis is very great, epileptiform and 
syncopal attacks may occur, and lead to 
sudden death. "When the compensation fails, 
the mitral valve often yields from the dila- 
tation of the left ventricle, and degeneration 
of the papillary muscles. Then the pul- 
monary second sound becomes accentuated ; 
the pulmonic circulation is embarrassed; 
and dyspnoea, bronchial catarrh, pulmonary 
haemorrhage, oedema, and cyanosis supervene. 
In Aortic insufficiency, inspection dis- 
covers a more forcible and diffused impulse, 
lower than natural, sometimes as low as the 
seventh intercostal space, and outside the 
nipple line. The praecordial region may be 
bulging from the violent action of the heart; 
pulsation may be seen in the upper inter- 
costal spaces at the right edge of the sternum; 
and a thrill may sometimes be felt there, and 
occasionally as low down as the heart apex. 
The great vessels of the neck pulsate visibly. 
The area of cardiac dulness is increased in 
all directions, but mainly vertically. On 
auscultation, a murmur is heard, replacing 
and following the second sound, of a blowing 
or hissing character, rarely rough, and les- 
sening in loudness towards its end. It is 
usually loudest at mid-sternum and in the 
second right intercostal space; and it is con- 
ducted upwards to the right clavicle, but 
mainly downwards to the xiphoid cartilage. 
It is not heard at the back of the chest. It 
may be conducted to the apex of the heart 
rather than to the ensiform cartilage; and 
this occurs, in the writer's opinion, when 
the posterior or mitral segment of the aortic 
valves is the incompetent one, as the re- 
gurgitant current then falls on the mitral 
valve, and the murmur is thus conducted to 
the apex. The second sound may be wholly 
lost at the base of the heart, being replaced 
by the murmur; but in some cases it is 
audible-this being due either to normal 
closure of one or two aortic segments, or to 
the propagated pulmonic second sound. If 
audible in the carotids, the second sound is 
aortic, and is of some value as indicating 
partial competency of the valves. The 
second sound is often audible at the apex. 
The first sound at the base is almost always 
modified, being generally murmurish and 
often obscured by a systolic murmur, due to 
slight obstruction from thickening of the 
valve-segments, or to relative stenosis and 
the vigour of the ventricular systole. In 
some cases there is no distinct first sound 
audible at base or apex ; its absence being 
possibly due to noiseless closure of the mitral 
valve by the intra-ventricular blood-pressure 
before the systole occurs. Thus in cases of 
free regurgitation, both first and second sound 
may be absent over the left heart; but on lis- 
tening over the femoral artery with a binaural 
stethoscope lightly applied, the two sounds of 
the heart can sometimes be heard. In the 
majority of cases the insufficiency is no doubt 
associated with some stenosis, and the mur- 
mur is double-a short rough systolic portion, 
with a softer, longer, and more hissing dia- 
stolic portion. This double murmur might 
be well called the up and down murmur of 
aortic valve-disease : the two descriptive 
words indicating the length, and, to some 
extent, the characters of its component parts. 
The signs connected with the pulse in aortic 
insufficiency are very significant. As the 
pulsations of the aorta are visible to the right 
of the sternum, so the arteries often beat 
visibly all over the body, even to the radial, 
temporal, and dorsal arteries of the foot. 
The ophthalmoscope has shown the same 
phenomenon in the central artery of the 
retina. This remarkable movement of the 
arteries is due to two causes-first, to the 
hypertrophy and dilatation of the left ven- 
tricle, which throws an excessive quantity of 
blood into the vessels at each systole; and, 
secondly, to the sudden collapse of the arte- 
ries, due to the aortic regurgitation. The 
arterial recoil during the ventricular diastole 
is not opposed, as in health, by the resistance 
of the perfectly closed aortic valves, and, con- 
sequently, the blood-column is not sustained, 
and the arteries collapse. These locomotive 
features in the pulse are generally increased 
by elevating the arm. The pulse is sudden, 
short, large, regular, rapidly collapsing, and 
vibratory. The sphygmographic tracing brings 
out these characters: the line of ascent is 
vertical and lofty; the summit is sharp and 
pointed; the line of descent falls rapidly, 
and is broken by a series of secondary waves 
due to vibratory conditions, but has an ill- 
developed dicrotism. The post-dicrotic por- 
tion of the tracing falls rapidly, from the 
absence of a sustained blood-column. The 
longer and more oblique this portion of the 
tracing, cceteris paribus, the less copious the 
regurgitation (see fig. 63). 
Aortic insufficiency often lasts for many 
years without producing any obvious disturb- 
ance of the systemic and pulmonic circula- 
tions ; hence the absence of dyspnoea and 
Fig. 62.-Pulse- 
tracing in Aor- 
tic Stenosis. HEART, VALVES AND ORIFICES OF, DISEASES OF 
849 
cedema. The hypertrophy and dilatation of 
the left ventricle, which form the compen- 
sation, suffice to prevent ill effects. At each 
last part of the diastole; it runs up to the first 
sound, and ends abruptly in it. The position 
in which the murmur is best heard in its 
typical prsesystolic form is limited to the left 
apex itself or a little above-that is, lower 
than a mitral regurgitant murmur. The 
funnel-like shape of the mitral valve-curtains 
in these cases accounts for this, as the button- 
hole aperture through which the blood passes 
is closer to the apex. 
This murmur is soft and puffing, but may 
be harsh. It commonly fills only the last 
part of the diastolic period. In some cases, 
with greater roughening and deformity of the 
valves, the murmur is longer, rougher, more 
rolling or grinding, and ends abruptly with 
the first sound, which is very flapping in tone, 
and might easily be mistaken for the second 
sound conducted. The careful observation of 
the impulse or of the carotid pulse with the 
finger while auscultating, is necessary in 
order to avoid the error. Mitral stenosis de- 
velops three murmurs under different con- 
ditions of the valves : (1) A short, softish puff 
(sounding like vodt) immediately preceding 
the first sound; (2) a short, rough, grinding 
murmur (rrrb) ; and (3) a long murmur 
filling nearly all the diastole, offen rough, 
but varying in tone in some cases. These 
several murmurs increase in intensity up to, 
and end abruptly with, the first sound. The 
soft, hissing diastolic murmur, occasionally 
heard at the apex, which lessens in intensity, 
and ends before the first sound, is a conducted 
aortic (or pulmonic) murmur. 
A special peculiarity of the praesystolic 
murmur is its variability: it is the only 
organic murmur which disappears and re- 
appears as the heart-conditions change. For 
instance, a murmur, inaudible while the 
patient is at rest, is developed by a little 
exercise; or, again, an irregular tumultuous 
action of the heart masks all murmur, which 
becomes distinct as the heart steadies down 
under the action of digitalis. In other cases 
there is no distinct murmur, but only a 
slightly prolonged and rough or grinding first 
sound, while the murmur is often lost as the 
heart-failure advances. In cases of mitral 
stenosis there is accentuation of the pul- 
monary second sound, from the greatly in- 
creased. tension in the lesser circulation; 
there may also be a doubling or reduplication 
of the second sound at the base. This re- 
duplication is a sign of great value in cases 
in which the prolonged or grinding first 
sound is the only sign. The reduplication 
of the second sound is due to a want of syn- 
chronous closure of the pulmonic and aortic 
valves, from their altered relative tension. 
A doubling of the first sound is sometimes 
noticed, probably due to retarded closure of 
the mitral valve, from lessened fulness of the 
left ventricle. 
The rhythm of the heart is frequently 
greatly disordered in mitral stenosis, and 
systole the dilated ventricle throws sufficient 
blood into the aorta to allow for the reflux, 
and to maintain a fair arterial tension. Thus 
the compensation is perfect. In many cases, 
however, if the reflux is free, and the coronary 
segments of the aortic valves are affected, 
the coronary arteries, which are partly filled 
by the arterial recoil, are deprived of the full 
force of the blood-wave, and the nutrition of 
the heart consequently suffers. This is the 
great source of failing compensation, and the 
malnutrition of the cardiac muscle soon 
leads to dilatation of the ventricle, secondary 
mitral insufficiency, and atrophy. 
When the hypertrophy is excessive (over- 
compensation), as it is in some cases, there 
are flushings of the head and face, headache, 
vertigo, and violent arterial action all over 
the body. 
In Mitral stenosis there is rarely any 
prominence of the praecordial region; and in 
its earlier stages neither increase of the 
cardiac dulness, nor alteration in the position 
of the impulse. The impulse, when regular, 
is fairly distinct, but it is often very irregular, 
and is associated with a thrill, which pre- 
cedes, runs up to, and terminates in the 
impulse. In advanced cases, the area of 
cardiac dulness is increased laterally; the 
impulse is diffused, and may be seen in the 
epigastrium ; this indicates hypertrophy of 
the right ventricle, which sometimes obscures 
the left ventricular impulse and gives rise 
to epigastric and liver pulsation. The left 
auricular systole may occasionally be noticed, 
if the chest be thin, in the third left inter- 
costal space. The sounds heard on auscul- 
tation in this lesion vary. The pathogno- 
monic sign is a murmur preceding the systole, 
and ending with its commencement. This is 
best called the prcesijstolic murmur (also 
' auricular systolic '); and is produced when 
the contracting auricle forces blood under 
high pressure into the ventricle. It is the 
passage of a stream of blood in a state of 
high tension into blood already in the ven- 
tricle which causes the murmur. The first 
portion of the blood passes from the auricle 
into the ventricle noiselessly; and it is only 
when a stream of higher tension is forced 
into it by the true auricular systole that the 
murmur is developed. The murmur is, there- 
fore, short in most instances, occupying the 
Fig. C3.-Pulse-tracing in Aortic Insufficiency. HEART, VALVES AND ORIFICES OF, DISEASES OF 
850 
also in mitral insufficiency. A few beats 
occur regularly, or nearly so, and then a 
series of very small hurried ones follows, to 
be again succeeded by stronger and better 
pulsations. These irregularities are referable 
to the varying charges of blood on which the 
ventricle contracts. The over-distended right 
cavities and the left auricle contract rapidly 
to expel their contents, but the narrowed 
mitral orifice does not allow a full charge to 
pass into the ventricle; the diastole is too 
short for this purpose ; and the wave of con- 
traction passes on to the ventricle from the 
auricle, producing a series of small ineffec- 
tive pulse-beats, each representing the small 
charge sent into the aorta. When the series 
of ineffective contractions ceases, the next 
diastole is longer; and the succeeding systole 
sends, as the sphygmograph shows, a fuller 
charge into the arteries. During the small 
irregular beats the praesystolic murmur is 
often indistinguishable, but it is again heard 
with the succeeding slower and more effective 
beats. This irregularity in the heart's rhythm, 
however, is not present in all cases of mitral 
in the left vertebral groove. If not audible 
posteriorly the murmur signifies regurgitation 
through a narrowed but patent mitral orifice; 
and may indicate mitral stenosis, in the 
absence of either a pr®systolic or diastolic 
murmur. The mitral systolic murmur asso- 
ciated with dilated left ventricle or enfeebled 
muscle is not usually heard posteriorly. The 
murmur is usually loud, blowing, and distinct 
in its character, keeping the same tone 
throughout. The true first sound is generally 
obscured by it, but in some cases may be 
heard through it, and is then due to the 
partial closure of the mitral, or to the action 
of the right auriculo-ventricular valves. The 
pulmonic second sound is commonly accen- 
tuated. The pulmonic first sound has in 
some cases a murmurish character, probably 
due to hypertrophy and dilatation of the right 
ventricle, and relative stenosis of the pulmonic 
orifice. 
The radial pulse in cases of fairly perfect 
compensation is regular, but quick, small, 
weak, and easily compressible; and the 
sphygmograph shows low tension, and an 
Fig. 64.-Pulse-tracing in Mitral Stenosis. 
Fig. 65.-Pulse-tracing in Mitral Insufficiency. 
stenosis. In some instances the heart's action 
and the pulse are regular. The sphygmo- 
graph in such cases records a small pulse of 
low tension, with a little inequality in the 
volume of the beats ; this inequality is often 
increased by exercise. In other cases the 
pulse-tracing i^ small, irregular, and unequal 
in its pulsations, and marked by true and 
false intermissions (see fig. 64). 
In the earlier stages of mitral stenosis the 
face may be pale, and the congestive symp- 
toms which mark mitral insufficiency are 
absent till the later stages. This form of 
valvular lesion gives rise more commonly 
than mitral insufficiency to haemorrhagic 
infarction in the lungs; but in other respects 
the pulmonary and systemic circulations 
suffer in the same way as described in the 
other form of mitral disease. 
In Mitral insufficiency inspection discovers 
some slight prominence of the prsecordial 
region, with increased impulse, the apex often 
beating to the left of the nipple line. The 
area of cardiac dulness is augmented mainly 
in a lateral direction, from the hypertrophy 
of the right ventricle. On auscultation, a 
murmur is heard with the first sound, and 
following it; loudest at the apex ; loud along 
the left edge of the heart; but absent or not 
so distinct over the right heart and at the 
base. The murmur is propagated towards 
the left axilla, and is audible in most cases 
inequality in the size of the pulsations. In 
cases of less perfect compensation, it becomes 
irregular and intermittent. In all cases the 
pulse-beat is weak in comparison with the 
vigour of the ventricular systole (see fig. 65). 
There is no unusual fulness of the super- 
ficial veins in the earlier stages of mitral in- 
sufficiency. Later, when the right cavities 
become over-distended, the veins of the neck 
become full and may even pulsate. This is 
very distinct when the tricuspid valve gives 
way. In all cases slight exertion is sufficient 
to induce dyspnoea; and there is an ever- 
present tendency to bronchial catarrh, from 
the congested state of the lungs. When 
asystole comes on, the murmur becomes less 
distinct; the heart's action is rapid, irregular, 
and tumultuous; the accentuation of the 
pulmonary second sound is lost; dyspnoea 
becomes orthopnoea; and cyanosis, oedema, 
and haemorrhagic infarction of the lungs, 
with general and visceral dropsy, close the 
case. 
Many cases of mitral regurgitation obtain 
fairly perfect compensation ; but the disease, 
like mitral stenosis, of necessity entails some 
dyspnoea on exertion, and keeps up con- 
stantly an engorged state of the pulmonary 
vessels. 
Valvular affections of the right heart, 
arising from disease, are rare. Those of the 
pulmonic valves are rare; cases are on re- 
cord, however, of pulmonary stenosis, and HEART, VALVES AND ORIFICES OF, DISEASES OF 
851 
a few of pulmonary insufficiency. In the 
first case the systolic murmur is loud and 
superficial, and is heard loudest at the third 
left costal cartilage close to the sternum, and 
in the second left intercostal space; it is not 
usually conducted across the sternum, nor 
upwards to the right clavicle, as is an aortic 
murmur. A diastolic pulmonic murmur is 
soft and blowing; and is heard loudest in the 
same situations, and downwards towards the 
ensiform cartilage. 
The tricuspid valves are more frequently 
affected. Tricuspid insufficiency is indeed a 
common sequence of disease of the left side 
of the heart. Structural changes in these 
valves are, however, rare. Tricuspid insuf- 
ficiency does not always produce a murmur; 
when present this is soft and short, and is 
heard nearer the middle line than a mitral 
murmur, at the base of the ensiform carti- 
lage. The pulsations of the cervical veins 
may indicate the lesion when the murmur 
is absent. 
Tricuspid stenosis causes a praesystolic 
murmur, harsh in character, loudest at the 
base of the ensiform cartilage and towards 
the left edge of the sternum, not propagated 
towards the left heart, and not audible at 
the back of the chest, though faintly con- 
ducted along the sternum to the base of the 
heart. A praesystolic thrill may be present. 
Mitral stenosis has been observed in associ- 
ation with this lesion, and two praesystolic 
murmurs may be made out in such cases. 
The physical signs and the diagnosis of 
combined valve-lesions remain to be described. 
The mitral and aortic valves may each be 
affected with stenosis and insufficiency, from 
a single attack of endocarditis, or from one 
lesion arising as a consequence of the other. 
The double aortic murmur, already described, 
indicates the aortic combination; but it 
must be always remarked that the systolic 
murmur in these cases may exist with little 
or no actual stenosis. 
In the double form of mitral disease, either 
defect may exist alone at first, and after- 
wards be associated with the signs of the 
second. In some cases the praesystolic 
murmur may fail to be heard, and a systolic 
murmur may alone be audible; in other 
cases, there is a prolonged apex-murmur 
which slightly changes tone; in other cases, 
again, a short grinding praesystolic murmur 
is followed, occasionally at an interval, by a 
soft, blowing, systolic one. The combination 
of aortic with mitral disease may be recog- 
nised by the presence of their special 
murmurs. 
Prognosis.-It is very difficult to state 
general rules of prognosis in valvular affec- 
tions of the heart, as so much depends on 
the peculiarities of each case. There are, 
nevertheless, certain broad rules. As regards 
origin, rheumatic inflammation is less serious 
than degenerative change, which occurs later 
in life, and is necessarily progressive. Acci- 
dental rupture is the gravest form of origin. 
The valve affected is also a prognostic 
element; but any attempt to arrange cases 
in order, according to the seat of the valvular 
defect, must be open to so many exceptions 
that it must not be too much trusted. 
Speaking generally, however, tricuspid 
lesions are gravest, mitral less so, and aortic 
-especially aortic stenosis-probably least 
so. When the heart fails, and asystole 
supervenes, the prognosis is worse, however, 
in aortic cases than in mitral. 
Aortic cases are often free for years from 
any grave symptoms. When the murmur is 
conducted to the left apex, the prognosis is 
more favourable, as, the aortic segment 
affected being non-coronary, the muscle of 
the heart is not robbed of its blood. The 
presence of the second sound over the caro- 
tids is favourable. The pulse-tracing also 
affords valuable aid in prognosis, as it gives, 
by the size of the dicrotic wave and the ob- 
liquity of the line of descent, a rough 
measure of the amount of insufficiency. 
There is much more risk of sudden death 
in aortic cases than in mitral. 
In mitral lesions the dangers arise from 
the pulmonary complications; embolism is 
more common than in aortic affections. 
Mitral cases can be rescued from asystole 
more frequently, and die of advanced cardiac 
cachexia, generally with dropsy. Under 
favourable conditions of life, requiring little 
physical exercise and causing no emotional 
excitement, both forms of mitral disease are 
compatible with many years of life. When 
they are conjoined, the prognosis is more 
unfavourable. In cases of sudden insuffi- 
ciency, produced by rupture of the valve- 
curtains or of the tendinous cords, death 
may occur very rapidly from the disturbance 
of the circulation. 
The whole question of prognosis turns 
principally on the state of the myocardium. 
So long as this is sound, compensation may 
be maintained; the moment degeneration 
sets in, asystoly and all its evil train of 
symptoms come on. Thus asystoly coming 
on gradually, without any previous over- 
strain of the heart, is always most grave. 
Each successive attack becomes graver, and 
the visceral congestions which accompany 
it more stubborn. Albuminuria is a marked 
index of the gravity of the congestion, and 
is serious in proportion to the frequency 
with which it has occurred. In some cases 
a copious flow of limpid urine is a very grave 
symptom. Dropsy of the extremities, and 
of the cavities more especially, is bad, as 
indicating failure in the peripheral circula- 
tion. Next to the cardiac muscle, the state 
of the peripheral vessels is most important; 
thus, petechiae are bad signs ; while atheroma 
and other conditions, such as febrile attacks, 
add to the danger by interfering with the 852 
circulation. The general nutrition of the 
patient suffering from valvular disease also 
enters into the prognostic problem. There 
is a cachexia proper to the end of heart- 
cases, which is due to the gradual deterior- 
ation of the nutritive fluids by the long- 
continued visceral congestions which hinder 
assimilation and excretion. Blood is less 
perfectly made and less perfectly purified ; 
lienee the steady deterioration of cardiac 
cachexia, which is always of evil import as 
regards duration of life. Valvular diseases 
are, however, in numerous instances com- 
patible with many years of life-aortic in 
fairly active, mitral in sedentary persons. 
In some the healthy expectation of life may 
be attained; and, in many, years of com- 
paratively active life are enjoyed. In the 
poor, the prognosis, as to duration, is not 
favourable; but in the well-to-do, all ob- 
servers see many cases extending over a 
great number of years. 
Treatment.-Valvular affections of the 
heart, whether the result of rheumatic in- 
flammation or of degenerative change, are, 
as a rule, incurable. Some few cases of 
rheumatic origin lose the signs of valvular 
disease, and are practically restored by the 
after-processes (for example, contraction) in 
the inflamed valve ; and some few cases also 
of mitral insufficiency, associated with di- 
lated left ventricle and softened muscle, are 
cured by treatment. These exceptions are, 
however, few ; and as we cannot repair the 
valve-mischief, in the vast majority of cases, 
our treatment must be directed to aid the 
compensatory hypertrophy, and to check (he 
development of the consequences of the 
defect. The maintenance of the nutrition of 
the substance of the heart is, therefore, the 
main object of treatment; just as the state 
of the nutrition of the heart is the key to 
the prognosis. On this account the general 
regimen of heart-cases is very important. 
General regimen.-The diet should in all 
cases of valvular disease of the heart be 
unstimulating but sustaining, consisting of a 
good proportion of albuminous food (under- 
done meat, eggs, poultry, and fish), with wine 
in moderate quantity, and some chalybeate 
water. There should be no unnecessary ex- 
citement of the heart, either by exercise or 
emotion. All athletics and violent efforts 
should be avoided by the young, especially 
in mitral cases. In aortic cases, steady 
exercise without strain is beneficial. The 
residence should be so situated as to avoid 
the necessity of exertion, sudden changes 
of temperature, cold, and damp. The chief 
object of the regimen should be to prevent 
anaemia; hence plenty of fresh air is essen- 
tial. Tobacco is injurious. In early life over- 
exertion and exposure to cold-in adult life, 
emotional, sensual, and dietetic excesses are 
the chief dangers. The propriety of marriage 
must be considered in each case on its merits. 
HEART, VALVES AND ORIFICES OF, DISEASES OF 
Women, as a rule, should not marry; when 
affected with mitral disease they are often 
barren. To men marriage is more generally 
permissible. 
Medicinal treatment.-The therapeutical 
treatment varies according to the stage of the 
cardiac disease. The mechanical defect of a 
valve first makes itself felt by palpitation and 
praecordial pain ; these symptoms pass away 
when compensation is effected, but till then 
require treatment. In cases of mitral dis- 
ease, tincture of digitalis (1T[ x doses) relieves 
the palpitation ; chloric ether is also a use- 
ful adjunct. In aortic cases, ether, diffusible 
stimulants, small doses of opium and bella- 
donna, with the local application of bella- 
donna to the praecordial region, are valuable 
remedies. 
The praecordial pain, mostly retro-sternal, 
may, when severe, require a few leeches or 
cupping, but generally yields to mild counter- 
irritants, such as turpentine, iodine, or mus- 
tard. Internally the bromides are useful; 
when the pain occurs paroxysmally, ethereal 
preparations and ammonia act well. 
When the compensatory changes in the 
heart are effected, the palpitation and pain 
decline, and the chief indication is to keep 
up the nutrition of the heart by the hygienic 
rules above given, and by the administration 
of preparations of iron, combined with 
arsenic, strychnine, quinine, and mineral 
acids. Chalybeate waters are also useful 
adjuncts. The syrup, infusion, and tincture 
of the prunus virginica, are preparations of 
value in some cases after the use of digitalis. 
The secretions should be carefully watched, 
and the bowels opened freely every day, so 
as to avoid straining, and to relieve the 
portal circulation. The quantity of urine 
should be daily noticed, as it is a capital 
index of the state of arterial tension. 
Patients in whom the most perfect compen- 
sation exists are, nevertheless, in a state of 
imminent trouble, for an exaggeration of a 
physiological act or emotion may disturb the 
unstable equilibrium of their health. In most 
cases the compensation breaks down sooner 
or later; and then begin the symptoms de- 
pending on pulmonary congestion and general 
visceral engorgement, with the consequent 
impoverishment of the blood. Dyspnoea 
marks the beginning of these troubles; 
anaemia and dropsy the close. The pul- 
monary congestion soon manifests itself by 
bronchial catarrh, which requires expec- 
torants in various combinations, while fric- 
tion, poultices, and counter-irritation are 
applied to the chest-walls. In capillary 
bronchitis with rapid pulmonary congestion, 
it is sometimes necessary to bleed from the 
arm to relieve the over-distended cavities of 
the right side of the heart. Nauseating doses 
of ipecacuanha, or actual emetics of sulphate 
of zinc, are sometimes very useful. 
For the general visceral congestions our HEART, VALVES AND ORIFICES OF, DISEASES OF 
853 
chief remedies are, firstly, diuretics; and, 
failing these, hydragogue cathartics. Of 
diuretics, the salts of potassium, digitalis, 
squill, broom, chimaphila, spirit of nitrous 
ether, and juniper are the most useful. The 
hydragogue cathartics, which relieve the 
over-distended portal vessels primarily, and 
the general circulation secondarily, are also 
most valuable: of these the compound 
powders of scammony and jalap in 20- to 
40-grain doses; bitartrate of potassium in 
electuary, one to two drachms, every morn- 
ing ; sulphate of magnesium; compound 
scammony pill; elaterin; senna; and gam- 
boge are the most trustworthy. By the 
judicious use of an occasional purgative, and 
the administration of a suitable diuretic, 
aided by cupping, poultices, and sometimes 
a small blister over the loins, combined with 
rest and stimulants, the worst cases of dropsy 
from cardiac failure are often saved. 
For the dyspnoea and the insomnia, two of 
the worst symptoms, we have a remedy of 
great power in the subcutaneous injection 
of morphine in doses of one-sixth of a grain 
upwards. This remedy acts often like a 
charm, and may be used even in the worst 
cases of both mitral and aortic disease, but 
always with caution. Albumen in the urine 
does not necessarily contra-indicate its use. 
In some cases chloral hydrate and bromide 
of potassium, alone or in combination, are 
valuable remedies for the insomnia ; of new 
remedies, urethan and sulphonal are the 
best; paraldehyde is also useful; but they 
must all be given cautiously. The bromides 
may be prescribed with other sedatives such 
as nitroglycerine for the dyspnoea. The 
compressed-air bath also relieves the last 
symptom. 
Dropsy, like the visceral congestions with 
which it is associated, requires the use of 
diuretics and hydragogue cathartics. When 
these fail, the swollen limbs may be punc- 
tured with benefit. Continued friction of 
the limbs, by stimulating the vessels, will 
often cause considerable anasarca to dis- 
appear. The drug on wdiich main reliance 
must be placed when general dropsy super- 
venes is digitalis. It is par excellence the 
cardiac tonic. Convallaria, strophanthus, 
casca, caffeine, and adonis vernalis are other 
drugs having similar action-strengthening, 
but slowing, heart-beat. They are all less 
trustworthy than digitalis. Caffeine is a 
good diuretic, and so occasionally is conval- 
laria, even when digitalis has failed. Stro- 
phanthus is generally the most useful. Digi- 
talis has so great a share in the therapeutics 
of heart-disease, and a knowledge of its action 
is so important, that it must be discussed 
separately and last. Whatever views may be 
held as to its physiological action, its greatest 
triumphs are seen clinically in the treatment 
of valvular diseases, when cyanosis, distended 
jugulars, dyspnoea, congested viscera, dropsi- 
cal limbs, scanty urine, tumultuous heart- 
action, and quick, irregular, and failing 
pulse, indicate asystole. This assemblage of 
symptoms is mostly seen in mitral cases, 
and it is precisely in this class that the drug 
is most valuable. Under its use 'the pulse 
grows in force, fulness, and regularity; the 
arterial tension rises; the pulmonary con- 
gestion diminishes; the kidneys, before in- 
active, wake up to their work; and the 
advancing dropsy recognises its master and 
beats a sullen retreat.' In mitral stenosis 
these good results are due not only to the 
increased vigour given by the drug to the 
contractile power of the heart, but also to the 
fact that by its slowing action the diastolic 
period of each revolution is lengthened, and 
the time thus increased during which the 
distended auricle can force its contents 
through the narrowed mitral orifice into 
the left ventricle. Digitalis here not only 
obtains a better filling of the ventricle, but a 
more effective discharge of its contents when 
filled : and thus, under its use, beat by beat, 
the general and pulmonary venous conges- 
tion is relieved. In mitral insufficiency it is 
almost equally potent. In both forms certain 
of its good effects would seem to be due to 
some influence, probably through the pneumo - 
gastric nerves, in producing contraction of the 
pulmonary blood-vessels. It is perhaps this 
property which makes it valuable in pul- 
monary haemorrhages, independent of heart - 
disease. 
In aortic valvular diseases digitalis is not 
so valuable a remedy. In these cases the 
assemblage of symptoms mentioned above is 
not met with, except sometimes in the later 
stages, when the mitral valve is secondarily 
affected, and the case is not one of pure 
aortic disease. In these compound cases 
the drug is valuable, especially in combina- 
tion with stimulants. In aortic insufficiency 
alone, the slowing action of the digitalis 
produces evil by increasing the length of the 
diastolic period of each revolution, during 
which the regurgitation takes place. The 
force it may give to the systole is no gain in 
the face of this slowing action, inasmuch as 
the aortic recoil gains in the same proportion 
as the ventricular systole, and thus forces 
blood back into the ventricle with increased 
vigour during the lengthened diastole. It is 
important in aortic insufficiency to maintain 
the frequency of the cardiac action; hence 
these cases are so constantly the better for 
bodily activity; and so, when the toning 
effects of digitalis are required, it should 
always be given in combination with ether 
and ammonia, to keep up quick action of the 
heart, and to prevent the vertigo and syncope 
which may otherwise occur. When there is 
excessive hypertrophy in cases of aortic in- 
sufficiency, digitalis is useful sometimes in 
quieting palpitation, reducing excessive fre- 
quency, and lessening headache and vascular  HEART, VALVES, ANEURYSM OF 
854 
HEART, WOUNDS OF 
excitement. Caffeine given with senega, aco- 
nite in small doses, and veratrum viride also 
relieve these symptoms ; but a few drops of 
nitrite of amyl inhaled from cotton-wool, or 
nitroglycerine tablets, are more rapidly and 
surely beneficial than any other remedy. In 
aortic stenosis digitalis is rarely required. 
The simple mode of compensation makes 
these cases require little treatment. Digi- 
talis is sometimes useful in combination with 
stimulants to give vigour to the myocardium, 
and check the tendency to dilatation. If it 
slows the action of the heart notably, its effect 
becomes hurtful. Nux vomica often prevents 
this. 
In combined valvular lesions, the pre- 
dominant lesion must be the guide in the 
use of digitalis; but it may be given advan- 
tageously whenever the general signs of 
venous stasis are present. The diuretic 
power of the drug is one of the best tests of 
its beneficial action. Relying on this test, 
the writer often gives digitalis for weeks, 
nay, months at a time, and obtains improve- 
ment in the nutrition of the heart which 
lasts long after its discontinuance. Digitalis 
effects this improvement by increasing the 
vigour of the coronary circulation, and thus 
builds up new heart-muscle to compensate a 
valvular defect. In aortic cases the nutrition 
of the muscle must be kept up by iron, 
arsenic, quinine, strychnine, and stimulants. 
The preparations of digitalis which may 
be used are, the powder in | to 1 grain; the 
tincture in 11) v to xxx ; and the infusion in 
5j 5vj doses. As a diuretic in cases of 
dropsy, the old combination of squill, digi- 
talis, and blue pill is invaluable. 
B. Walter Foster. 
HEART, Valves of, Aneurysm of.- 
Definition.-A valvular aneurysm is a cir- 
cumscribed pouching or sacculation of one of 
the valve-segments. 
Description.-Two forms of aneurysm of 
the valves of the heart are met with. In 
the one, the whole thickness of the valve is 
dilated by the blood-pressure to form the 
pouch; in the other, one of the lamellae being 
ulcerated by endocarditis, the blood pushes 
the remaining lamella before it to form a 
sac. The second form, which is sometimes 
called ' acute valvular aneurysm,' occurs 
most commonly in ulcerative endocarditis. 
Valvular aneurysms vary in size from a pea 
up to a pigeon's egg. The orifice is almost 
invariably towards the greatest blood-pres- 
sure-those on the mitral valve opening 
towards the left ventricle, those on the 
aortic valves towards the aorta. They are 
usually rounded in shape, but may have 
irregular prolongations between the lamellae 
of the valves. Valvular aneurysms are some- 
times multiple. The valves of the right side 
of the heart are seldom affected. The mitral 
valves are the seat of the larger aneurysms, 
and are twice as often aneurysmal as the 
aortic valves. 
Valvular aneurysms terminate commonly 
by early rupture, giving rise to perforation 
and consequent insufficiency of the valve, 
and often leading to considerable laceration. 
Rupture occurs more rapidly in aneurysm of 
the aortic valves. Mitral aneurysms occa- 
sionally become chronic, and filled with 
coagulum; and aortic valve aneurysm may 
also be found filled with solid clot. 
Symptoms. - The clinical history of this 
form of disease is defective. When seated 
on the mitral valve, aneurysms usually give 
rise to no signs until the perforation and 
laceration of the valve suddenly develop the 
murmur of mitral insufficiency. An aneurysm 
of one of the aortic segments causes a soft 
systolic murmur oi er the valves, which one 
day, as the sac ruptures, is supplemented by 
a diastolic murmur, and accompanied by the 
symptoms of aortic insufficiency. The phe- 
nomena of this accident are similar to those 
of sudden rupture of an aortic valve. 
B. Walter Foster. 
HEART, Wounds of.-Synon. : Fr. 
Blessures du Coeur', Ger. Herzwunden. 
The subject of wounds and other injuries 
of the heart belongs more properly to the 
domain of Surgery, but, being in several 
respects of much medical interest, it requires 
to be briefly discussed here. 
^Etiology and Anatomical Characters.- 
Wounds of the heart may be punctured, in- 
cised, or lacerated; and inflicted with a 
variety of weapons or other sharp bodies, 
as well as with projectiles, especially bullets. 
Traumatic ruptures and contusions form 
another considerable class of injuries of the 
heart, which chiefly result from falls, crush- 
ing accidents (for example, being ' run over '), 
kicks, and blows. Injuries of the heart due 
to the entrance of foreign bodies, such as a 
needle or a bone, may be inflicted in some rare 
cases from the interior of the oesophagus or 
stomach; the most remarkable case of this 
kind being one of wound of the pericardium 
from behind by the point of a sword which 
a juggler had attempted to ' swallow.' 
Post mortem, the chest-wall generally 
presents evidence of the wound that has been 
inflicted. The pericardium rarely escapes 
injury. Its sac is found to contain blood in 
recent cases, or effused lymph or pus when 
life has been preserved for a few days or 
more. The walls of the heart at the seat of 
injury present different appearances, accord- 
ing to the precise nature of the lesion. 
Punctured and incised wounds may be of all 
sizes ; may take either a direct or an oblique 
direction through the muscular fibres; and 
are generally penetrating. Bullet-wounds 
cut away a portion of the heart, whether at 
the borders or from the thickness of the 
organ. Traumatic ruptures present special «haracters (see Heart, Rupture of). In all 
the varieties of injury of the heart, the wound 
is found plugged with blood-clot, the edges 
being either infiltrated or ecchymosed and 
torn. In cases that do not prove rapidly 
fatal, the usual signs of inflammation, or 
healing, and even cicatrisation, are found in 
the heart; or aneurysm of the cardiac walls 
may be developed as a result of the latter. 
The valves and their appendages are fre- 
quently incised or otherwise injured. In 
some cases a portion of the weapon, pro- 
jectile, or foreign body may be found in the 
heart. The ventricles-and especially the 
right ventricle -are the parts of the heart 
most commonly injured. The great vessels, 
lungs, and the arteries of the chest-wall, may 
also be wounded in different instances. 
It must be observed that a blow over 
the heart has proved instantly fatal with- 
out leaving any lesion discoverable post 
mortem. 
From these results it is evident that wounds 
of the heart may prove rapidly fatal by loss 
of blood, by compression of the heart result- 
ing from haemorrhage into the pericardium, 
or by shock; whilst, at a later stage, peri- 
carditis, myocarditis, and secondary haemor- 
rhage may be expected to supervene. 
Symptoms, Course, and Terminations.- 
In about one-third of recorded cases of injury 
of the heart, either death is immediate- 
fainting, convulsions, and the other symp- 
toms of syncope, as well as those of shock, 
being the prominent phenomena, along with 
external haemorrhage; or the patient drops 
dead after a few moments, during which 
time he may have undergone considerable 
exertion. In a second class of cases, the 
symptoms of syncope or of shock occur im- 
mediately, but death does not ensue at once. 
The patient then lies in a state either of un- 
consciousness or of complete prostration. In 
the latter event he complains of a sense of 
great debility, praecordial oppression, dys- 
pnoea, and suffocation; the surface is cold, 
pallid, and trembling; vomiting may occur ; 
and there is usually haemorrhage from the 
region of the heart. Death occurs after 
minutes or hours, either from exhaustion 
due chiefly to continued or repeated loss of 
blood, or from compression of the heart. In 
a third series of cases, the course is more 
protracted. The patient, after suffering from 
the symptoms just enumerated, but in a less 
degree, passes through the various phases of 
constitutional disturbance commonly observed 
in severe wounds, complicated, however, 
with pericarditis, myocarditis, and repeated 
haemorrhage; and dies of exhaustion after 
an illness of weeks or months. Lastly, in a 
small proportion of cases, the patient survives 
the various accidents and complications just 
described, and the wound of the heart heals; 
but it sometimes happens that symptoms of 
aneurysm of the cardiac walls, or of incom- 
HEART, WOUNDS OF 
petence of the valvular apparatus, are de- 
veloped as the result of the lesion. 
Diagnosis.-Wounds of the heart can 
usually be diagnosed without difficulty by 
the situation of the external injury, and the 
severity of the symptoms. Similar symp- 
toms may, however, follow injuries of the 
great vessels in the neighbourhood of the 
heart, or of the arteries of the walls of the 
chest, if the haemorrhage be profuse; still, 
unless there be almost complete certainty 
that a vessel within reach is the only seat 
of the bleeding, the diagnosis should be left 
undecided, and all dangerous interference 
avoided. 
Prognosis.-Injury of the heart is gene- 
rally to be regarded as certain to end in 
death; but it should not be forgotten that as 
many as 12 per cent, of recorded cases are 
said to have recovered. Some very remark- 
able instances have occurred of recovery after 
very severe injury to this organ; for example, 
a case in which a bullet was lodged in the 
substance of the heart for twenty years 
(Brit. Med. Journ., March 23, 1867). The 
prognosis may be broadly estimated by 
the severity of the immediate symptoms. 
Traumatic rupture of the heart is said to 
have invariably proved fatal. 
Treatment.-In wounds of the heart, the 
haemorrhage must be at once arrested by the 
usual surgical means; immediate death must 
be prevented by cautious stimulation; and 
the patient must be kept in such a condition 
that, whilst life is preserved, the danger of 
inflammatory reaction in the region of the 
heart, and of fresh haemorrhage, is reduced 
to a minimum. It is on this account that 
restorative measures are to be ' guardedly 
employed at first, and resorted to in the 
further progress of the case only when 
urgently indicated. Absolute rest of body 
and mind is indispensable. Nervine and 
cardiac sedatives, such as bromide of potas- 
sium, morphine, chloral-hydrate, and bella- 
donna, may be of great service when used 
with judgment. 
J. Mitchell Bruce. 
HEARTBURN.-Synon. : Cardialgia.- 
Heartburn is a hot or scalding sensation, 
usually referred to the cardiac orifice of the 
stomach, but in some cases diffused over the 
whole abdomen. It is a marked symptom 
of indigestion, and is frequently accompanied 
by eructations of a very acid character ; and 
the fluid rejected from the stomach produces 
a sensation of scalding in the throat and 
cesophagus. 
^Etiology.-Heartburn exists in a very 
marked degree in dilatation of the stomach, 
being produced by the decomposition of in- 
digestible food retained in this organ. It 
constantly accompanies chronic catarrhal 
gastritis, the retained mucus enclosing 
particles of food in a state of decomposition, 
HEARTBURN 
855 856 
which set up fermentation in the materials 
of each meal as soon as it is swallowed. 
Heartburn is common in the later period of 
pregnancy, probably because the stomach is 
so displaced that it is unable properly to 
expel its contents. 
Treatment.-This sensation is best treated 
by antacids, such as chalk, magnesia, alkalis, 
and alkaline waters. Aperients and altera- 
tives may be necessary. In some cases 
powdered charcoal relieves it. The diet also 
requires careful regulation. All articles of 
food containing much fat, sugar, or starch, 
should be avoided. The use of tobacco 
should be interdicted; the writer has fre- 
quently seen obstinate cases kept up by 
smoking and chewing. Alcoholic stimulants 
should be used very sparingly, the least likely 
to do harm being brandy mixed with Vichy 
or potass water. The writer has obtained 
good results by substituting gluten bread for 
the ordinary baker's bread; and, where this 
could not be taken, has found advantage from 
the use of aerated or some other kind of un- 
fermented bread. Some women who suffer 
severely from heartburn when pregnant find 
relief from eating lettuce. S. Fenwick. 
HEART-CLOTS.-See Heart, Throm- 
bosis of. 
HEAT, JEtiology of. - See Disease, 
Causes of; and the following article. 
HEAT, Effects of Severe or Ex- 
treme.-(A) Constitutional Effects of 
Severe Heat acting generally.-The 
constitutional or general effects of exposure 
of the whole body to high temperatures vary 
with the source and degree of heat, the slow- 
ness or rapidity of transition from lower 
temperatures, and the length of exposure, 
as well, as with the age, constitution, habit 
and health of the body; and they are liable 
to be more or less modified or obscured by 
various concomitant circumstances and con- 
ditions, such as the barometric pressure, the 
hygrometric state, and the purity or impurity 
of the atmosphere. 
The range of temperature within the limits 
of which life can be maintained appears to be 
greater in the case of man than in that of 
most of the lower animals, in virtue of 
greater power of accommodation to external 
influences, without undue elevation or lower- 
ing of the temperature of the body. But in 
every case any such combination of external 
circumstances as causes the temperature of 
the body to rise 10° to 15° above the normal 
standard speedily proves fatal. 
1. Artificial heat.-Numerous observa- 
tions and experiments show that in dry air 
exposure to very high temperatures can be 
borne, during periods varying with circum- 
stances, without danger or even serious in- 
convenience, the temperature of the body 
being kept down within safe limits by evapo- 
HEARTBURN 
ration from the surface and from the lungs. 
Thus, in Dobson's experiments, a temperature 
of 210° was sustained during twenty minutes; 
Blagden exposed himself during eight minutes 
to a temperature of 260°; Chantrey's work- 
men were accustomed to enter a drying oven 
in which the thermometer stood at 350° ; and 
Chabert, the ' Fire King,' is said to have fre- 
quently exposed himself to a temperature 
of from 400° to 600°. Glass-workers, metal- 
founders, gas-stokers, engineers in steam- 
boats-especially in the tropics-bakers' 
oven-builders, and others constantly carry 
on their work in temperatures of from 120° 
to 160° or even higher-to say nothing oi 
the blasts of radiant heat to which some are 
from time to time exposed. In moist air, 
evaporation from the surface and its cooling 
influence being diminished or prevented, 
much lower temperatures speedily become 
insupportable. Berger was unable to remain 
in a vapour bath the temperature of which 
had risen from 100° to 120°, although he had 
easily borne a temperature of 230° in dry air 
for five minutes. When the natural loss or 
heat is prevented by the moisture of a hot 
atmosphere-as in a vapour bath, or by im- 
mersion in a hot-water bath, or otherwise-- 
the temperature of the body rises. It has 
been found, taken in the rectum, to rise as 
high as 103° in eight minutes, and even to 
107° (?) in thirty minutes in a vapour bath 
of 127° (Bartels); and in a hot-water bath ot 
104° to 111° the temperature taken in the 
mouth has been found to rise to 101'6° 
(Mosier).1 
Dr. Fleming2 found that exposure in the 
Turkish bath during an hour to a tempe- 
rature commencing at 170° and gradually 
lowered to about 130°, caused the tempera- 
ture of his body (taken by a specially 
devised thermometer in the mouth) to rise 
rapidly during the first ten minutes from 
a normal average of 97'65° to 99'2° (a rise 
of 1'55°) ; and then more slowly until the 
end of fifty minutes, when the highest 
point, 101'3° (a rise of 3'65°) was reached. 
His pulse rose during the first ten minutes 
from 78 to 91 beats in the minute, and like 
the temperature attained its maximum, 115, 
at the end of fifty minutes. His breathing 
first diminished in rapidity from 22'5 to 20'8, 
and then increased to 25'4 in actual rapidity, 
but maintained a diminished ratio to the 
pulse. The arterial tension seemed to be 
increased by the greater rapidity of the 
heart's action, combined with the gorged 
state of the capillary circulation. The 
quantity of material eliminated during the 
hour amounted to forty-four ounces. The 
proportion of chlorides in the urine passed 
after the bath (3'65 in the 1,000) was little 
HEAT, EFFECTS OF 
1 Leichtenstein. General Balneotherapeutics. 
Smith, Elder & Co., 1885. 
2 Journal of Anatomy and Physiology, Tulj 
1879. HEAT, EFFECTS OF SEVERE OR EXTREME 
857 
more than half that in the sweat (6*05) col- 
lected during the bath, and much less than 
in the urine previously passed (5'68). The 
proportion of urea in the urine was slightly 
increased, and the sweat contained 1'55 in 
the 1,000. 
The effects felt by those exposed to great 
heat vary with the temperature, the length 
of exposure, and collateral circumstances, 
such as impure atmosphere, physical exer- 
tion, &c. A sensation of warmth, at first 
agreeable, is succeeded by one of oppressive 
and then painful heat, until this is again 
relieved by the establishment of copious 
evaporation from the surface. Pleasant 
stimulation, and some degree of excitement 
of the nervous and muscular systems, are 
quickly followed by languor, lassitude, list- 
lessness, feelings of exhaustion, indisposition 
to mental effort or muscular exertion, dizzi- 
ness, tendency to sleep, faintness and uncon- 
sciousness, sometimes accompanied or pre- 
ceded by convulsions. If relief is not afforded 
death ensues. If timely relief is afforded, 
more or less speedy and complete recovery 
may be brought about. 
If the symptoms have been severe and 
persistent, or if the sufferer has been exposed 
to repeated attacks, permanent damage to 
the health, and especially to the nervous 
system, almost certainly results, in spite of 
apparent temporary recovery. In many cases 
general debility and deterioration, in some 
cardiac troubles, and in others insanity, have 
been recorded as the persistent after-effects. 
Symptoms and conditions closely or exactly 
resembling those of sunstroke, may be pro- 
duced by exposure to an artificially heated 
atmosphere, or to blasts of radiant heat from 
fires or furnaces. See Sunstroke. 
Bernard, Delaroche, and others have shown 
that animals exposed to temperatures of from 
130° or lower, to 150° and upwards, quickly 
die. 
The post-mortem' examination of animals 
so killed showed that the heart had entirely 
ceased to beat at the moment of death, and 
that neither it nor the muscular coat of the 
intestines could by any means be stimulated 
to contract again. The muscular fibres of 
the heart examined microscopically appeared 
rigid and coagulated (Kithne and Ranvier). 
Further, the blood in both arteries and veins 
was dark coloured. Rigor mortis set in very 
early, and general decomposition very speedily 
commenced. It would thus appear that 
(apart from sudden shock to the system gene- 
rally) the cause of death from exposure to 
high temperatures is to be found in the effect 
produced on the muscular system of organic 
life, and especially on the heart. The cardiac 
myosin coagulates at 115° ; and at a temper- 
ature considerably short of this its condition 
must be seriously affected. 
Anatomical Characters. - The post- 
mortem appearances met with in the human 
subject in cases in which death has been 
attributed to the general effect^ of heat have 
not been uniform, probably because there 
has been in most cases simultaneous exposure 
to other deleterious influences. The follow- 
ing case, however, recorded by C. Speck1 is 
noteworthy. A girl, aet. fourteen, the subject 
of chronic disease of many of her joints, was, 
on the advice of a quack, wrapped in a sheep- 
skin warm from the carcass, laid in bed, 
surrounded with hot loaves fresh from the 
oven, and covered by the clothes. In about 
an hour she complained of pains, especially 
in one arm. She soon feel asleep. It was 
noticed that her chest rose and fell strongly. 
She perspired freely, and the sweat was fre- 
quently wiped off. She became very pale, 
and about three hours after the commence- 
ment of the treatment she expired, without 
having recovered, or at any rate manifested, 
consciousness. On post mortem examina- 
tion the next day (the weather being cool 
and dry) advanced decomposition was found; 
the blood being black and fluid, and the 
blood-vessels, cavities, and tissues generally 
full of gas. The heat of loaves fresh from 
the oven, such as were put round the child, 
was found to be 185°. 
Treatment.-The immediate treatment to 
be adopted in the case of those suffering 
from exposure of the whole body to heat 
consists essentially in removal into a cooler 
and purer atmosphere; quiet rest in the 
recumbent position; fanning; cool or even 
cold affusions or sponging, especially over 
the head and spine-the effect, however, 
being carefully watched; and the adminis- 
tration of cool or lukewarm fluid in small 
quantity at a time, with some stimulant. 
Copious draughts of cold water in a highly 
heated state of body are liable to give rise to 
dangerous or even fatal results. Bleeding is 
not to be recommended. 
The after-treatment vcmsi be conducted on 
general principles, and determined by the 
condition of the patient, and the indications 
afforded in the particular case. 
2. Climatic and Solar Heat.-ThS 
effects of climatic heat experienced on tran- 
sition from temperate to tropical regions are 
as follows: 1st. The average temperature 
of the body rises -5° to 1° according to Davy 
and Crombie, or to a somewhat greater ex- 
tent according to others. The daily fluctua- 
tions of bodily temperature in health in 
India correspond to those in England. The 
normal temperature of native Indians is 
about half a degree higher than that of Euro- 
peans (Crombie). 2nd. The pulse is quick- 
ened according to most observers, but Rattray 
says this is incorrect. 3rd. The breathing 
becomes slower and less deep, falling from 
about sixteen to about twelve or thirteen per 
minute. Less carbonic acid and less water 
1 Vierteljahrschrift fur gerichtliche Medicin. 
1874, p. 249. 858 
HEAT, EFFECTS OF SEVERE OR EXTREME 
are thus exhaled. 4th. The skin acts much 
more freely, its excretion being increased by 
about 24 per cent. (Rattray). The continued 
hyperaemia and over-action of the skin, how- 
ever, are liable to be followed by congestion 
and obstruction of the sweat follicles, giving 
rise to 'prickly heat.' 5th. The urine is 
diminished in quantity, and in amount of 
urea and chlorides. The experiments of 
Becher (confirmed by those of Forbes Wat- 
son) showed a constant relation between the 
temperature, and the urea and chloride of 
sodium got rid of by the kidneys. As the 
temperature rose from 50° to 70°, an increase 
was found ; but with a further rise from 70° 
to 90°, an almost equally constant diminution 
occurred. 6th. The appetite, especially for 
animal food, is diminished, and the digestive 
powers seem lowered. 7th. Lassitude, lan- 
guor, want of vigour, indisposition to exer- 
tion, and a sense of exhaustion of mind and 
body are experienced in degrees varying with 
circumstances; the depressing effects being 
most felt when the heat is not only great but 
continuous day and night, and when the 
atmosphere is moist. 
The effects of the radiant heat of the sun, 
as distinguished from those of atmospheric 
heat, are not well made out. It would ap- 
pear probable, however, that a physiological 
effect adverse to perspiration is produced by 
the direct rays (Parkes), and that thus, as 
well as from rapid evaporation, the skin 
becomes dry, and liable to certain struc- 
tural changes, such as the formation of 
pigment. 
Exposure to the direct rays of the sun, or 
to great or continued heat in the shade, 
especially under unfavourable atmospheric 
and general conditions, may give rise to 
heat-fever, heat-apoplexy, or one or other of 
the forms of sunstroke. See Sunstroke. 
(B) Local Effects of Severe Artificial 
Heat: Burns and Scalds.-The local 
effects of heat vary with the degree, the 
length of exposure, the medium of applica- 
tion, and the part acted upon. Burns result 
from ' dry,' Scalds from ' moist ' heat. 
Signs and Symptoms.-First: a compara- 
tively slight degree of heat causes vascular 
turgescence, redness, tingling, pain, and ten- 
derness, which soon subside. Desquamation 
of the epidermis may follow, but no perma- 
nent trace of injury is left. Secondly: a 
higher degree causes severe burning pain, 
and great redness of surface, followed by 
effusion of serum beneath the cuticle (vesica- 
tion). Complete restoration without scar is 
usually effected. Thirdly: still higher degrees 
of heat or longer exposure cause intense pain, 
and immediate destruction, or consecutive 
destructive inflammation, of the true skin to 
a greater or less depth. Sloughing and sup- 
puration follow, and permanent scarring re- 
sults. Fourthly: violent heat and prolonged 
exposure cause complete disintegration and 
charring of the structures especially acted 
upon, followed by destructive inflammation 
and sloughing of others to a still greater 
depth and. extent. Loss of parts and more 
or less serious deformity and scarring neces- 
sarily result. 
The separation of sloughs, and the pro- 
cesses of repair after severe burns, take place 
slowly; and as a rule the patient suffers 
much more acutely, and during a much 
longer period, than after other forms of in- 
jury involving equally extensive destruction 
of tissue. 
The constitutional symptoms and effects 
associated with burns and scalds vary with 
the superficial extent and situation, rather 
than with the depth of the injury. Thus an 
extensive burn or scald over the abdomen 
affecting only the skin is much more likely 
to prove fatal than a deep burn of one of the 
extremities, penetrating even to the bone, but 
of comparatively small superficial area; and 
burns over the front of the abdomen or chest 
are more likely to prove fatal than those of 
similar extent over the back. If more than 
half the surface of the body is affected the 
sufferer rarely recovers. 
In severe cases death may result from shock 
to the system, either immediately on receipt 
of the injury, or after a period of from two or 
three to forty-eight hours or more. During 
such time the sufferer remains in a state of 
collapse or prostration, with pallor of com- 
plexion, lowness of temperature (dependent 
probably on decreased production of heat), 
coolness of breath, small or imperceptible 
pulse, dryness of tongue and mouth, and 
sometimes delirium, rigors, or convulsions. 
In about half the fatal cases of burns death 
is attributable to shock. In such cases, post- 
mortem examination shows only congestion 
of the viscera, and especially of the brain. 
In some instances, however, characterised 
by painfully laboured and frequent efforts at 
respiration, tumultuous, irregular, feeble, and 
very frequent action of the heart, and great 
praecordial distress, death would appear to be 
due to cardiac thrombosis, rather than to 
simple nervous shock (Brown). In many 
severe cases the blood has been found on 
microscopical examination changed in ap- 
pearance, the red corpuscles being altered in 
form, or separated into ' numerous little bits ' 
(Ponfick and Schmidt). And it is readily 
conceivable that such destruction of corpus- 
cles may cause thrombosis and stasis in 
various organs, especially in the smaller 
branches of the pulmonary artery (Silber- 
mann), and so give rise to severe symptoms, 
and even lead on to death. 
In about forty-eight hours, more or less, if 
the immediate effects of the injury have been 
survived, the stage of reaction and inflamma- 
tion sets in. The patient revives, and some 
degree of general pyrexia becomes manifest. 
The pulse becomes quicker and fuller; the HEAT, EFFECTS OF SEVERE OR EXTREME 
859 
temperature rises ; and the burnt part begins 
to discharge pus, usually of an offensive 
odour. Thirst, with dry red tongue, want of 
appetite, vomiting and constipation, followed 
by diarrhoea-sometimes with blood in the 
evacuations - are commonly experienced 
during the ensuing period; and inflammation 
of internal parts often occurs, although the 
special signs and symptoms afforded may be 
obscure. The pleurae and lungs, the perito- 
neum, and the gastro-intestinal mucous 
membrane (particularly that of the duode- 
num) are especially liable to be affected. 
Evidence of inflammation of one or more of 
these parts, and not uncommonly of ulcera- 
tion of the duodenum, is afforded on post- 
mortem examination in cases in which death 
has occurred during this period. It has been 
suggested that capillary embolism, from the 
presence of disintegrated blood in the ves- 
sels, may cause in some cases the lesions 
of the internal organs (Brown). During this 
period, and from the causes indicated, death 
occurs in about 30 per cent, of the fatal 
cases. 
In the course of about a fortnight or so 
under appropriate treatment, as a general 
rule, the acute symptoms will have subsided, 
the sloughs will have separated, and granu- 
lation and suppuration will have become 
established and healing will gradually take 
place. But a low form of chronic inflam- 
matory mischief in the internal organs may 
still be going on, and lead to a fatal result 
sooner or later; or the patient may sink, 
worn out by suffering, and exhausted by the 
profuse discharge from the suppurating sur- 
face, or by persistent diarrhoea, accompanied 
or not by blood in the motions. Sometimes 
the kidneys are affected, and blood or bloody 
casts may be found in the urine. Pyaemia, 
erysipelas, or tetanus may occur and cause 
death; but there would not appear to be any 
special liability to these diseases after burns 
or scalds. 
Treatment. - Local treatment. - Slight 
superficial burns of small extent require 
little in the way of treatment. Immersion 
in cold water according to some, in hot 
water according to others, or exposure be- 
fore the fire, affords the readiest means of 
obtaining immediate relief. Afterwards the 
part may be covered with flour, starch, 
oxide of zinc, bismuth, or collodion, and 
wrapped round with cotton-wool to protect 
it from the air and from accidental irritation. 
In cases in which there is vesication, the 
blisters should be pricked, the serum eva- 
cuated, and the cuticle left to form a natural 
protective covering, which may be advan- 
tageously strengthened and kept in position 
by a layer of collodion. But the punctures 
should be left open. Lint soaked in oil, or 
smeared with vaseline or some such mate- 
rial, should be applied, and the whole covered 
with cotton-wool. A mixture of chalk or 
whitening and vinegar, of the consistence of 
thick cream, is said to form an excellent 
application in such cases, speedily relieving 
pain, and helping to constitute a good pro- 
tective covering. 
Severe and extensive burns and scalds 
demand in their treatment the most careful 
management, and the greatest possible pa- 
tience, gentleness, and firmness; for even if 
life be preserved, the most pitiable disfigure- 
ments and deformities are liable to result 
from cicatricial contractions, unless proper 
preventive measures are perseveringly carried 
out. 
So soon as may be after the injury, the 
clothes should be removed from the patient 
with the greatest care - being cut away 
piecemeal if needful, and not removed in 
such way as to tear off epidermis or scorched 
or charred parts. The whole burnt surface, 
having been cleansed as seems needful by 
some antiseptic wash or spray, should then 
be covered as quickly as possible with the 
dressing considered best, and enveloped in 
thick layers of antiseptic cotton-wool lightly 
bandaged on. For cleansing wash or spray 
solutions of borax or carbolic acid (weak), 
with the addition or previous application of 
cocaine, are perhaps best. Different dress- 
ings have been advocated from time to 
time. One seems to suit best in some cases, 
another in others. But antiseptics should 
always be used. Among the applications 
variously recommended may be mentioned 
the old-fashioned favourite in hospital prac- 
tice-Carron oil, a mixture in equal parts 
of linseed oil and lime water. Almond oil 
or olive oil may be substituted for the lin- 
seed oil, and iodoform or a little carbolic 
acid added with advantage. White lead, 
putty made thin by addition of oil, calamine 
ointment, carbolised oil, solution of carbonal e 
of sodium, carbolic lotion, flour, and starch, 
are among the other materials that have 
been recommended. Among the best prob- 
ably may be recommended a combination 
of boric acid and iodoform with vaseline, 
or glycerine and oil, as a basis. What- 
ever the material selected, it should be 
slightly warmed, and applied very thickly 
spread on separate strips of lint in such way 
as to facilitate future dressing bit by bit, and 
so as to avoid extensive exposure of raw 
surface. The first dressing should be allowed 
to remain undisturbed as long as possible- 
until, indeed, the offensiveness of the dis- 
charge, or the discomfort of the patient 
indicates the necessity for its removal. The 
earlier dressings, however gently carried out, 
occasion so much suffering to the patient 
that-in the case of children especially-it 
is often desirable to administer chloroform 
or to spray the parts with a 5 per cent, 
solution of cocaine. Poultices are sometimes 
useful in aiding the separation of sloughs. 
In such case boracic lint soaked with warm 860 
HEAT, EFFECTS OF 
HEAT, THERAPEUTICS OF 
water forms an excellent substitute for the 
old linseed-meal poultice. Any needful 
washing or cleansing is best done by aid of 
the steam spray-producer, a weak solution 
of carbolic acid or of borax being used. 
When suppuration is established, and the 
surface clean, the application may be varied 
according to the indications afforded. Cala- 
mine or zinc or lead ointment, with or 
without the addition of some anodyne; and 
lotions of lead, morphine, and glycerine, or 
of sulphate of zinc, are amongst those com- 
monly employed. Iodoform, with extract of 
hemlock and spermaceti ointment, has been 
strongly recommended as tending to soothe 
pain, to deodorise the discharge, and favour 
healing. Exuberant granulations may be 
treated with nitrate of silver in solution, or 
by the application of the solid stick. When 
the granulating surface is in a healthy state, 
cicatrisation may be very materially expe- 
dited by skin grafting; and in cases in which 
there is extensive healthy granulating sur- 
face, by transplantation of large portions of 
healthy skin from some adjoining part. 
During cicatrisation, and even for some 
time afterwards, it is of the greatest import- 
ance to keep all parts in such position as 
that there shall be as little deformity as 
possible from growing together of surfaces, 
and contraction of scars. This is to be 
effected or attempted by position, by me- 
chanical apparatus, and by the application 
of strips of adhesive plaster and bandages 
in manner determined by the circumstances 
and conditions in each particular case. 
Constitutional treatment.-In the early 
stages, alcoholic stimulants, or ammonia, 
and. external warmth are especially requisite, 
and such light nourishment as can be taken. 
Opiates or other anodynes, as chloral or 
bromide of potassium, are to be administered 
according to the indications afforded, for the 
purpose of allaying pain and soothing the 
nervous system. When suppuration is es- 
tablished, a full allowance of good nourishing 
food, with some alcoholic stimulant, should 
be given, and such tonics as seem most 
suitable. Small doses of opium at regular 
intervals often prove very beneficial. The 
complications that may arise, such as affec- 
tions of the internal organs, &c., must be 
treated in accordance with general princi- 
ples, but all depressing medicines as a rule 
should be avoided, and if there should be 
indications of intestinal inflammation great 
care should be exercised in the administra- 
tion of aperients. 
(C) Local Effects of Severe Solar 
Heat: Sunburn. See Sunburn. 
Arthur E. Durham. 
HEAT, Therapeutics of.-Principles. 
The primary effect of external heat applied 
locally to the animal body is that of an ex- 
citant or stimulant. There occurs redness, 
with turgescence of the small vessels, in the 
part to which the heat is applied, along with 
slight augmentation of temperature, and pain. 
Increased beyond a certain degree, heat 
ceases to be a stimulant, its prolonged action 
causing greater pain, exhaustion, and depres- 
sion; and, if the action be very intense, it 
becomes an escharotic. 
Experiments have shown that by increased 
heat the electric currents in the nerves are 
destroyed. It may therefore be assumed that 
the nerves become less able to conduct im- 
pressions either to or from the brain, and that 
heat may act as a sedative to painful nerves. 
The action of medicines on the system ap- 
pears to be influenced by temperature. Ringer 
found that a small dose of veratrine greatly 
affects the ventricle at a high temperature, 
but at a low one produces no effect. Brunton 
and Cash found that the roots of the vagus in 
the medulla are paralysed by a high tem- 
perature. This may explain the observation 
of Thomas as to the failure of digitalis to act 
on the pulse in pneumonia with high tem- 
perature. 
Heat applied generally-that is, to the 
whole body-produces a number of impor- 
tant physiological effects which are de- 
scribed in the preceding article ; and in that 
on Baths. 
Applications and Uses.-Heat is employed 
in the treatment of disease as a general or 
local stimulant, a local depressant, a caustic, 
or a counter-irritant; and that in the form 
either of dry or of moist heat. 
Dry heat.-The primary exciting and 
stimulating action of heat may be made 
available to rouse the nervous and vascular 
systems. The use of the hot-air bath (Turkish 
bath) and that of the sand bath are discussed 
in the article on Baths. In some parts of 
the South of France, baths of hot sand (arena 
calida) are used in the treatment of rheu- 
matism, paralysis, and spasm; the sand 
acting as a stimulant and sudorific. Bottles 
of hot water are placed in the axillae, and 
against the feet and thighs, to restore the 
circulation, in cases of collapse of the system 
with coldness of the extremities and great 
failure of circulation, as in the treatment of 
collapse from the shock of an injury, or from 
such diseases as cholera, or of the apparently 
drowned. 
Dry heat may also be applied to the abdo- 
men, in the form of tins or bottles of hot 
water, or bags of heated salt or sand, to 
relieve painful spasm and colic. Hot water 
enclosed in an indiarubber bag is sometimes 
of service to allay undue irritability of the 
spinal nerves. The therapeutical applica- 
tion of heat as a counter-irritant will be 
found described elsewhere. See Counter- 
irritants. 
Moist heat.-Heat and moisture together 
tend to cause relaxation of the tissues, thus 
removing the tension and pain due to inflam- HEAT, THERAPEUTICS OF 
HELMINTHS 
861 
mation. Moist heat is employed locally in 
the form of the local vapour bath, fomenta- 
tions, and poultices. See Fomentations ; 
and Poultices. 
Moist heat is applied to the surface of the 
body generally, chiefly in the form of the 
vapour bath. See Baths. 
John C. Thorowgood. 
HEAT-STROKE.-A synonym for sun- 
stroke. See Sunstroke. 
HECTIC FEVER ((ktikos, habitual).- 
Synon. : Fr. Hectique; Ger. Hectisch. 
Aetiology.-The variety of fever thus 
named has long received special recognition, 
inasmuch as it presents certain prominent 
and peculiar features, as regards its course 
and attendant phenomena. It usually occurs 
in association with some wasting and ex- 
hausting disease, especially when this is 
accompanied by a profuse and constant drain 
from the system, and more particularly when 
there is chronic suppuration, with an abun- 
dant discharge of pus. Hectic fever is most 
frequently noticed in cases of pulmonary 
phthisis, in a large proportion of which it 
appears in various degrees during some part 
of their course, chiefly in the advanced 
stages. Other conditions deserving of men- 
tion in connexion with which it may super- 
vene are empyema, especially if there is an 
external fistula, tubercular ulceration of the 
intestines, chronic purulent discharge from 
the kidneys, hepatic abscess, chronic dysentery, 
and any form of external chronic abscess 
attended with an abundant formation of pus. 
Fever of a hectic type sometimes occurs in 
cases of acute inflammation ; and it is occa- 
sionally observed in chronic affections un- 
attended with suppuration, such as cancer 
and lymphadenoma. 
Symptoms.-Hectic fever is usually estab- 
lished gradually, becoming more and more 
distinct, until it assumes its typical characters. 
It is more or less paroxysmal, being at first 
indicated by slight pyrexia towards evening 
and during the night, the temperature being 
a little raised, and the pulse hurried. During 
the day there is no fever at this time, but as 
the case progresses it becomes constant, 
though exacerbations occur at night, and, it 
may be, also in the morning, the paroxysms 
thus occurring either once or twice within 
the twenty-four hours, and the pyrexia being 
remittent. In typical hectic there is a com- 
plete febrile cycle, beginning with chills or 
even a distinct rigor, followed by considerable 
heat of skin, the temperature continuing to 
rise, and ending in more or less profuse per- 
spiration, especially about the head and chest, 
sometimes so abundant as to saturate the 
bedclothes or even the bedding. Patients 
often feel subjectively very hot, the palms of 
the hands and soles of the feet having a 
burning sensation. The pulse tends to be- 
come very frequent and quick, and is easily 
hurried and excited, being at the same time 
weak, soft, and compressible. Not uncom- 
monly a bright red or pink spot appears on 
each cheek during the paroxysm, known as 
the hectic flush, and this may contrast 
markedly with the general pallor of the face, 
the eyes being also bright, clear, and spark- 
ling. The mind is unaffected, and the mental 
faculties may be unusually cheerful and vivid. 
After a febrile exacerbation the urine may 
present excess of lithates. Hectic fever does 
not always show all its typical features, and 
even in the same case variations are noticed 
in the precise characters of the paroxysms. 
It is usually accompanied with other symp- 
toms due to the disease with which it is 
associated; while it itself tends to cause 
wasting and debility, as well as a sense of 
much exhaustion after each attack. In most 
instances a fatal termination ultimately en- 
sues, but if the condition upon which hectic 
fever depends is curable, recovery will gene- 
rally take place. 
Treatment.-The first principle in the 
treatment of hectic fever is to attend to, and 
cure, if possible, the condition with which it 
is associated, and especially to diminish or 
check suppuration, to prevent retention of 
unhealthy pus, or to employ antiseptic ap- 
plications. General tonic treatment will also 
help in preventing the attacks. These may 
be directly checked in appropriate cases by 
full doses of quinine, salicine, salicylates, or 
other antipyretics, given before the usual 
time for their occurrence. Sponging the skin 
freely may also prove of service in some in- 
stances. The treatment of hectic in phthisis 
runs into that of night-sweats, and can be 
more conveniently discussed under that 
disease. See Fever ; and Phthisis. 
Frederick T. Roberts. 
HELIOSIS (^Xioco, I expose to the sun). 
A method of treatment for certain diseases, 
which consists in exposing the patient to the 
rays of the sun. The term is also employed 
as a synonym for sunstroke. See Sunstroke. 
HELMINTHIASIS a worm). 
The condition of system upon which the 
development of worms in any part of the 
body depends. The term is also applied to 
diseases characterised by the presence of 
worms. 
HELMINTHICS a worm).- 
Of or belonging to worms. A synonym for 
anthelmintics. See Anthelmintics. 
HELMINTHS (eX^s, a worm).-This 
term is often employed in preference to one 
or other of the various synonyms with which 
it is regarded as equivalent (worms, intes- 
tinal worms, vermes, entozoa, internal para- 
sites, and so forth). Thus, von Siebold (who 
speaks of the Helminths as forming a class 
of animals, nearly all of whose members are 862 
HELMINTHS 
HEMIANOPIA 
parasitic) admits that the only character 
common to the greater part of the whole 
group is their peculiar mode of life. The 
study of the helminths forms what is often 
called the science of Helminthology. It has 
been thought desirable, in the present work, 
to speak of the helminths as constituting 
part of the class Entozoa, under which head- 
ing, therefore, more detailed references are 
given. T. S. Cobbold. 
HELOUAN, near Cairo, Egypt.- 
Thermal sulphurous muriated saline waters. 
See Mineral Waters. 
HEMERALOPIA.-Definition.-Day 
blindness : a disorder of vision in which ob- 
ects cannot be seen well or comfortably in 
ordinary daylight or by strong artificial light, 
but are seen more clearly or more comfort- 
ably in shade or in twilight. 
Most modern authors use the term in the 
opposite sense of night blindness, regarding 
it as derived from gpdpa, the day, and dty, the 
eye or sight. In this work it has, from the 
first, been used in the sense given above, the 
al being regarded as representing alpha 
privativa, or as a contraction of dXad?, blind. 
This meaning has since been adopted in the 
Nomenclature of Diseases of the Royal Col- 
lege of Physicians. The word 'hemeralopia' 
does not occur in any of the genuine ancient 
Greek or Latin medical writings. It is once 
mentioned, without being defined, in the 
pseudo-Galenic treatise,Introductio seuMedi- 
cus (ed. Kuhn, xiv. 768). It has, however, 
long been used as the antonym of nyctalopia. 
See Nyctalopia. 
Causes. - Day blindness is a symptom 
rather than an idiopathic affection, and is 
sometimes the effect of mere intolerance of 
light (photophobia), dependent upon irrita- 
tion or inflammation of the cornea, &c. The 
various causes may be grouped as follows:- 
1. Opacity in some of the refractive media, 
such as central nebula or leucoma of the 
cornea, or circumscribed opacities occupy- 
ing the pupillary region of the lens or the 
vitreous. In such cases, vision is obscured 
when the pupil is contracted, but becomes 
clearer when the pupil dilates in shade. 
2. Irritation or inflammation of the parts of 
the eye innervated by the sensory fibres of 
tlie fifth nerve-the lids, the conjunctiva, the 
cornea, or the iris; neuropathic affections 
of these textures ; and reflex irritation from 
nose, teeth, uterus, &c. 3. Hypersesthesia 
of the retina, which may be due to reflex 
irritation, or (rarely) to inflammation of the 
retina, the optic nerve, or the choroid, to 
insufficient pigmentation of the ocular fundus 
as in albinism, to dazzling from coloboma of 
the iris or preternatural dilatation .of the 
iris from any cause, to exposure to bright 
lights or glare of any kind, to prolonged 
seclusion in darkness or dimly lighted places. 
A transient physiological form of hemeralopia 
occurs whenever the eyes suddenly pass 
from darkness into bright light. 
Treatment.-The treatment of hemeral- 
opia should follow the special indications. 
Impairment of sight due to central opacity 
in any of the refractive media may often be 
relieved by dilatation of the pupil with a 
weak solution (gr. to gr. | to an ounce) 
of atropine or other mydriatic, or by making 
an artificial pupil. Inflammations of the 
various textures of the eye and reflex irrita- 
tions are to be treated by appropriate means. 
The eyes should be protected by a shade or 
by neutral-tinted glasses. The general treat- 
ment must be adapted to the associated local 
and constitutional conditions. 
John Tweedy. 
HEMIANJESTHESIA (i^i-, half; d, 
priv.; and alaOdvopai, I feel).-Paralysis of 
sensation, affecting one side of the body. See 
Sensation, Disorders of. 
HEMIAN ALGESIA tfm-, half; a, 
priv.; and dXyos, pain).-Insensibility to pain- 
ful impressions, affecting one side of the body. 
See Sensation, Disorders of. 
HEMIANOPIA (^u-, half; a, priv.; 
and afi, sight).-The term 'hemiopia' is now 
generally taken to mean loss of perceptive 
power in one lateral or vertical half of the 
retina; while by hemianopia is understood 
obscuration of vision on one lateral or ver- 
tical half of the visual field. Thus, owing 
to the fact that rays of light cross within 
the eye, right lateral hemianopia is produced 
where left lateral hemiopia exists, as a result 
of intracranial disease of one or other kind. 
It is well known that in the lower verte- 
brate animals the optic nerves undergo a 
complete decussation at the optic chiasma, 
so that all impressions from each eye go 
to the opposite optic lobe. Some believe, 
even to the present day, that a similarly 
complete decussation of the optic nerve- 
fibres takes place at the chiasma in man; 
others (constituting a large majority) alto- 
gether reject this notion, and adopt the view 
originally propounded by Newton and rein- 
forced by Wollaston, that at the optic chiasma 
there occurs a semi-decussation only. Neither 
view can be said to be definitely proved to 
the exclusion of the other; and it seems quite 
possible that these discrepancies in doctrine 
may be in part dependent upon the fact that 
the course of the optic fibres is not the same 
in all men. There may, in fact, be variations 
in the degree of completeness of the decussa- 
tion of the optic nerve-fibres at the chiasma, 
just as, from the researches of Flechsig, we 
now know that not infrequently considerable 
variations occur in the amount of decussation 
of motor fibres in the anterior pyramids of 
the medulla. 
The effects resulting from congenital or HEMIANOPIA 
863 
early blindness of one eye supply us with 
some information bearing upon this point. 
Where a semi decussation exists, the effects 
of the atrophy of the optic fibres proceeding 
from the affected eye should, beyond the 
chiasma,be pretty equally distributed, so that, 
though in such a case the two optic nerves 
will be very dissimilar in size, the optic 
tracts ought to be of equal bulk ; and this is 
what is most commonly met with. On the 
other hand, it is undoubtedly the fact that in 
some of silch cases the optic tract on the 
opposite side is found to be notably atrophied, 
while that on the same side as the atrophied 
optic nerve presents a healthy appearance- 
signs which betoken a pretty complete decus- 
sation of the optic fibres at the chiasma. 
Different forms of Hemianopia and their 
causes.-In the cases where the common 
arrangement obtains-that is, the semi-de- 
cussation-it seems to be the inner fibres 
that cross one another, whilst the outer 
fibres of each nerve are continued on into 
the outer part of the corresponding optic 
tract. The result of this arrangement would 
be that the fibres from the right half of each 
retina would proceed to the right optic tract, 
while those from the left side of each retina 
would go to the left optic tract; so that if the 
image of any object should fall simultane- 
ously either on the right side of the two 
retinae, or on the left side of the two retinae, 
the impressions in either case will be trans- 
mitted along one and the same tractus 
opticus-the right or the left, as the case 
may be. Therefore it seems clear that, in all 
cases in which the semi-decussation of the 
optic fibres obtains, any intracranial lesion 
which either destroys, seriously presses upon, 
or disturbs the nutrition of the optic tract on 
one side, will give rise to an opposite lateral 
hemianopia. If the decussation had chanced 
to be total there would, on the contrary, have 
been produced a ' crossed amblyopia.' The 
optic tract is apt to be involved in some part 
of its course between the chiasma and the 
geniculate bodies by different kinds of lesions. 
Thus, we may have tumours originating in 
parts of the tract itself; or the tract may 
become involved secondarily, or pressed upon, 
by some tumour or haemorrhage occurring in 
the crus cerebri or in the posterior tubercle 
(pulvinar) of the thalamus, or by a tumour 
originating in the inner and under part of 
the temporal lobe, or from the bone itself in 
the middle fossa of the skull. 
Two other, much rarer, forms of hemianopia 
require to be mentioned, which are produced 
by lesions affecting different parts of the 
chiasma. One of these is double temporal 
hemianopia, which may be produced by a 
lesion pressing upon the anterior median 
portion of the chiasma. Any lesion capable 
of doing this would probably be a tumour, 
and it would produce the same effects whether 
there is a total or a semi-decussation in the 
chiasma. The lesion would involve the de- 
cussating fibres that come from the inner half 
of the retina on the two sides, and thus would 
lead to double temporal hemianopia. The other 
form is known as nasal hemianopia, and where 
semi-decussation of the optic fibres exists it 
would be produced by a tumour or an aneur- 
ysm causing an injurious amount of pressure 
upon either outer angle of the chiasma, since 
there would then be paralysis of the fibres 
emanating from the outer part of the retina, 
and consequently the suppression of the inner 
part of the visual field of the corresponding 
eye. It is only with extreme rarity that 
this form of hemianopia is double. 
We have now to turn to another side of 
the question. It is natural to ask whether 
the lateral hemianopia that develops as a 
consequence of disease of the optic tract will 
also result from a lesion which involves the 
optic fibres beyond the corpora yeniculata- 
that is, in their deep intracerebral course. 
This was the view put forward by von 
Graefe in 1860, and which was very com- 
monly accepted till it was challenged by 
Charcot some few years since. Relying ap- 
parently upon the paucity of cases on record 
in which lateral hemianopia had resulted 
from lesions of the cerebral hemispheres 
themselves, and upon the many cases that 
had come under his own observation in 
which ' crossed amblyopia ' had been produced 
by functional or structural lesions involving 
the posterior or sensory segment of the in- 
ternal capsule, he came to the theoretical 
conclusion that all the optic nerve-fibres 
from each eye went to the opposite cerebral 
hemisphere, owing to the supposed fact that 
those fibres which had not decussated at the 
chiasma did decussate somewhere in the 
corpora quadrigemina. These views he em- 
bodied in a well-known diagram. The sub- 
sequent progress of knowledge has, however, 
not been compatible with this theory. Thus 
Munk's original statement has been confirmed 
by Schafer and S. Brown, to the effect that 
removal of one occipital lobe in the monkey 
produces, not crossed amblyopia, but opposite 
lateral hemianopia (Brain, Jan. 1888, p. 367). 
Again, Seguin, in a valuable memoir (Journ. 
of Nerv. and Ment. Dis., vol. xiii. Jan. 1886), 
has shown that opposite lateral hemianopia 
is more especially produced by lesions in 
that inner portion of the occipital lobe known 
as the ' cuneus,' a region supplied by a rather 
large branch of the posterior cerebral artery 
which passes along the calcarine fissure. 
Still it would appear that lesions anywhere 
in the posterior parietal, temporal, or occi- 
pital region of the hemisphere, when they im- 
plicate the ' optic radiations ' of Gratiolet (i.e. 
fibres passing backwards from the corpora 
quadrigemina and geniculata to the occipital 
cortex), are also capable of producing an op- 
posite hemianopia in man of a permanent 
character. In the lower animals (monkey, 864 
HEMIANOPIA 
dog, &c.), for the production of a similar 
defect the removal of the occipital lobe 
must be complete, and even then the defect 
is of a comparatively brief duration-two or 
three weeks at most. 
There is at present an apparent contradic- 
tion between these well-attested facts, as to 
the production of lateral hemianopia from 
disease of the occipital lobe (implying as they 
do that the semi decussation persists even to 
the cortical termini of the optic fibres), and 
the fact of the existence of a ' crossed am- 
blyopia in association with functional or 
structural disease of the hinder portion of 
the internal capsule. A solution of this diffi- 
culty cannot as yet be readily found. Ferrier 
still maintains that crossed amblyopia is pro- 
duced by destruction of one angular gyrus. 
He asserts, indeed, that ' the angular gyri 
are more particularly the centres for clear 
vision, each mainly for the eye of the opposite 
side ' (Brit. Med. Journ., June 21, 1890, 
p. 1415). 
Diagnosis.-Under this head reference has 
to be made to different sides of the problem. 
The first point to be considered is the mode 
of recognition of the different varieties of 
hemianopia. In some cases, where the defect 
is well marked, and the patient is intelligent, 
he will himself call the observer's attention 
to it; very frequently, however, such defects 
are only discovered by being specially looked 
for. This subject will be referred to under 
Vision, Defects of. Here it must suffice to 
say that for all accurate observation an 
instrument named a ' perimeter ' is required, 
by the aid of which the exact nature and 
extent of the limitation of the visual field can 
be discovered; but, for a first rough examina- 
tion, the following simple method will suffice 
for the detection of any great narrowing of 
the visual field in particular directions. The 
patient stands with his back to the light, and, 
covering one eye, looks steadily from a dis- 
tance of eighteen inches at the nose or eye 
of the observer, who then moves his forefinger 
about in different parts of the field of vision, 
and notes any part where the patient says it 
is invisible or badly seen. Anything like a 
hemianopic defect, of either variety, may be 
easily appreciated in this manner. 
The fact of the existence of hemianopia 
having thus been established, we must next 
seek to determine the site of the lesion by 
which it has been caused. The problems of 
regional and of pathological diagnosis are in 
these cases often intimately related to one 
another. With respect to the latter problem 
some hints have already been given. 
For purposes of regional diagnosis the first 
thing is to determine whether the case before 
us belongs to one or the other of two main 
categories into which cases of hemianopia are 
divisible-that is, whether it is a case of tract 
or of central hemianopia ; and this may be 
determined by a delicate test first used by 
"Wernicke. This test is based upon the fact 
that, in the case of lesions in the primary 
optic centres of one side (the corpus geni- 
culatum and one anterior quadrigeminal 
body), or of their afferent fibres, there is an 
interference not only with visual impressions, 
but also with the path for impressions that 
excite pupillary contractions through these 
oculo-motor centres; whereas in the case 
of deeper lesions, situated in parts of the 
cerebral hemisphere involving either the 
optic radiations or the occipital cortex, the 
pupillary reflex would not be at all inter- 
fered with. Thus in cases of ' tract hemi- 
anopia ' there exists what has been termed 
hemiopic pupillary inaction; while in cases 
of ' central hemianopia ' this sign does not 
exist. The sign itself is searched for by 
throwing a pencil of light obliquely (at an 
angle of 40°-G0°), by means of an ophthal- 
moscope mirror, on to the blind side of the 
retinae, so as to see whether contraction of 
the pupil is, or is not, produced. If carefully 
performed, no reaction of the pupil occurs in 
cases of tract hemianopia-that is, where the 
defect is due either to disease of the afferent 
fibres, or of the primary optic centre itself. 
But where the hemianopia is caused by 
disease in the cerebral hemisphere itself 
(central variety) the contraction of the pupil 
occurs equally well whether the light be 
thrown upon the blind or upon the unaffected 
half of the retina. 
From the point of view of a regional dia- 
gnosis, we may enumerate four fairly marked 
types of central hemianopia. 
1. There are cases in which hemianopia 
exists alone, or as the most prominent symp- 
tom, or in association with certain general 
signs indicative of the existence of tumor 
cerebri. Such are the cases where the occi- 
pital lobe is affected in or about the region of 
the cuneus. 
2. Cases in which hemianopia coexists 
with hemianaesthesia and choreiform or 
ataxic movements of one half of the body, 
without marked hemiplegia. These are prob- 
ably due to a lesion of the caudo-lateral part 
of the thalamus, or of the caudal division of 
the internal capsule, on the side of the brain 
opposite to the dark half-fields and the 
hemiansesthesia. 
3. Cases of hemianopia with complete 
hemiplegia and hemianaesthesia are probably 
caused by an extensive lesion of the internal 
capsule in its knee and caudal part. 
4. Cases of hemianopia with aphasia and 
hemiplegia, with or without hemianaesthesia, 
are probably due to an extensive superficial 
lesion of the area supplied by the left middle 
cerebral artery, such as may be brought 
about by its plugging either from thrombosis 
or embolism. 
In all these cases the pupillary reaction 
would not be interfered with, and there would 
be no atrophy of the optic nerves unless as a HEMIANOPIA 
HEPATOCELE 
sequence of choked disc. In addition to these 
forms, five types of tract hemianopia may be 
enumerated. 
1. The first type of tract hemianopia would 
be caused by lesions in the primary optic 
centres on one side (the corpus genicu- 
latum and one anterior quadrigeminal body). 
Little or nothing is known of lesions thus 
limited, which are excessively rare. Still, 
such parts may be involved, primarily or 
secondarily, by a tumour ; when amongst a 
varying group of symptoms we might have, 
as results of the lesion in the parts specified, 
lateral hemianopia, hemiopic pupillary inac- 
tion, together with early atrophy of the optic 
nerves. 
2. In other cases where disease involves 
the optic tract and the crus cerebri, we may 
have hemianopia coexisting with some form 
of cross-paralysis. A probable combination 
would be paralysis of the third, fourth, and 
sixth cranial nerves on the side of the lesion 
(some one or all of these nerves), together 
with partial hemiplegia (without anaesthesia), 
and hemianopia on the opposite side. In 
some cases choked discs would appear early, 
without interfering with the hemiopic symp- 
toms until optic atrophy with complete blind- 
ness had become established. 
3. In cases where the optic tract is involved 
more anteriorly, other symptoms coexisting 
with the hemianopia may be very vague and 
uncertain; but the hemiopic pupillary inaction 
should be marked, and there should be early 
partial atrophy of the optic nerves. These 
latter signs suffice to distinguish this group 
of cases from those belonging to the first 
category of ' central hemianopia,' with which 
otherwise they might be confounded. 
4. Cases of bitemporal hemianopia due to 
lesions pressing upon the anterior part of the 
chiasma. 
5. Cases of nasal hemianopia, mostly single, 
due to a lesion involving the outer part of the 
chiasma. 
The only other forms of monocular hemi- 
anopia are also very rare, and are due to 
lesions of the optic nerve itself in front of 
the chiasma. 
Other very rare forms of hemianopia affect 
the superior or inferior, rather than the lateral, 
segments of the field of vision. As Seguin 
points out, when these forms exist with a 
very irregular demarcation line, they are 
probably still more peripheral in their origin 
and due to embolism or thrombosis of the 
central artery of the retina. 
In another class of cases, instead of a 
definite hemiopic defect of sight, we meet 
with partial, quadrant, or sector-like defects 
in the upper or lower halves of the visual 
fields. Little or nothing is known as to 
the causation of such defects. They might 
conceivably be caused by disease in certain 
limited portions of the occipital cortex, or 
of some only of the fibres constituting the 
optic radiations. Again, they might be due 
to a localised damage to some of the fibres 
of one crus or one optic nerve ; or to degene- 
ration of the retina caused by the plugging 
of some one branch of its central artery. 
Prognosis and Treatment. - Nothing 
special can be said under these heads con- 
cerning the hemianopia itself. Both the 
prognosis and the treatment of this defect 
are absolutely dependent upon the causative 
conditions, and the nature and severity of the 
collateral symptoms with which it is asso- 
ciated. We must, in fact, always seek to 
mitigate or remove the underlying causal 
conditions, and upon our chance of being 
able to do this the prognosis in any given 
case entirely depends. 
H. Charlton Bastian. 
HEMICRANIA (7/u-, half; and Kpaviov, 
the head).-Pain limited to one side of the 
head. The term is, however, generally used 
as synonymous with megrim. See Megrim. 
HEMIOPIA ) . 
HEMIOESIA J and <*Y> 
sight).-A loss of perceptive power in one 
lateral or vertical half of the retina. See 
Hemianopia ; and Vision, Disorders of. 
HEMIPLEGIA (^u-, half; and 
I strike).-Paralysis of motion of one side 
of the body; sometimes applied to loss 
both of motion and of sensation. See Para- 
lysis. 
HEPATALGIA (frrap, the liver ; and 
nXyos, pain).-Strictly this word signifies 
pain in connexion with the liver. It has, 
however, been specially applied to a supposed 
neuralgic pain referred, to this organ, coming 
on in paroxysms, and said to be of a severe 
character in some instances, so as to simulate 
hepatic colic. Whether there is any such 
affection is exceedingly doubtful; and prob- 
ably in cases of supposed hepatalgia the 
neuralgia is either superficial, or there is 
some tangible but undiscovered cause for the 
pain, connected with the hepatic apparatus 
or some neighbouring structure. 
Frederick T. Roberts. 
HEPATISATION (^rap, the liver).- 
A term applied to the condition produced by 
acute inflammation of the lung, in which the 
pulmonary substance becomes solid and fri- 
able, resembling somewhat the liver in its 
physical characters. See Lungs, Inflamma- 
tion of. 
HEPATITIS (>]nap, the liver).-Inflam- 
mation of the liver. See Liver, Inflamma- 
tion of. 
HEPATOCELE (rprap, the liver; and 
KTjXp, a tumour).-Hernia of the liver. See 
Liver, Displacements of. 
865  HERCULESBAD 
866 
HERCULESBAD (HERCULES- 
FURDO), in Hungary.-Thermal sul- 
phur and muriated saline waters. See 
Mineral Waters. 
HEREDITY.-By heredity is meant 
that special property through which the 
characters and qualities of organisms are 
transmitted to their descendants throughout 
successive generations, so that the offspring 
in their main features resemble their parents. 
The transmission of parental characters to 
offspring is a subject for scientific inquiry. It 
has long been known that a young organism 
is derived from an ovum formed within the 
body of the female parent, so that a descent 
from the mother and a direct continuity 
through the egg with her structure was ap- 
parent. But it is within a comparatively re- 
cent period that the direct participation of the 
male parent in the production of the offspring 
has been traced. The older writers thought 
that the semen evolved a vapour or spirit, 
which influenced the ovum, or that the fluid 
part of the semen penetrated the vitelline 
membrane, and induced germinative changes, 
which resulted in the production of a young 
organism, without the male contributing any 
definite structure in the process. The dis- 
covery, in 184'2, by Dr. Martin Barry, of the 
penetration of the vitelline membrane by the 
spermatozoon put the subject on a more 
definite basis, and the researches of Biitschli, 
Auerbach, Fol, Strasburger, Flemming, 
Hertwig, E. van Beneden, and others, have 
given greater precision and completeness to 
our conceptions of the process of impregna- 
tion. It has now been demonstrated that 
the young organism arises within the egg 
by the incorporation, or conjugation, of an 
extremely minute particle derived from the 
male parent with an almost equally minute 
particle derived from the female parent. The 
particle derived from the male is the head of 
the spermatozoon, which, after it has pene- 
trated within the ovum, is called the male 
pronucleus. The particle derived from the 
female is a portion of the germinal vesicle, 
which has remained included within the egg, 
and is called the female pronucleus. The 
male and female pronuclei gradually ap- 
proximate, touch, and then become incor- 
porated with each other, and form what is 
called the segmentation-nucleus. The seg- 
mentation-nucleus consists of chromatin 
fibres and nucleoplasm, which are derived 
both from the nucleus of a male sperm cell, 
i.e. the head of a spermatozoon, and from the 
nucleus of a female germ cell, i.e. the germinal 
vesicle. The segmentation-nucleus is there- 
fore a composite or hermaphrodite nucleus, 
and consists of matter derived from both 
parents. This composite nucleus then rapidly 
divides and subdivides within the ovum, so 
as to produce daughter-nuclei, and the proto- 
plasm of the yelk undergoes a corresponding 
process of division. Each of the daughter- 
nuclei becomes surrounded by a layer of 
protoplasm, and numerous new cells are 
produced. The nucleus of each of these new 
cells contains chromatin fibres derived from 
the segmentation-nucleus, and through it 
from the corresponding fibres of the nucleus 
of the male sperm cell and of the female 
germ cell. It is believed that the male and 
female chromatin fibres enter in equal pro- 
portions into the structure of the nuclei 
derived by division from the segmentation- 
nucleus, so that each of the nuclei of the new 
cells, like the segmentation-nucleus, is com- 
posite or hermaphrodite, i.e. represents both 
parents. The cells produced by the division 
of the segmentation-nucleus and its envelope 
of yelk-protoplasm form the blastodermic 
membrane. In man and the higher organisms 
this membrane consists of three layers of 
cells, named epiblast, mesoblast, and hypo- 
blast. From these layers, by a continuous 
process of division and subdivision of the 
nuclei of their constituent cells, accompanied 
by a differentiation of the protoplasm, all the 
tissues and organs of the body are descended. 
As the nuclei of all the cells in the body are 
derived by continuous descent from the 
nucleated cells of the blastoderm, and as these 
again are the descendants of the segmentation- 
nucleus, one may infer that the nucleus of 
each cell is composite or hermaphrodite and 
represents both parents. 
The changes which take place in a nucleus 
during its division constitute the process of 
karyokinesis or karyomitosis. They consist 
at first in an enlargement and rearrangement 
of the chromatin fibres of the nucleus, and 
then in a splitting of each fibre into two 
daughter-threads, so that each daughter- 
thread divides itself equally between the two 
daughter-nuclei which are formed by the 
splitting of the parent nucleus. As this 
process goes on throughout the whole period 
of cell-multiplication, there is an actual trans- 
mission of structure from the segmentation- 
nucleus to the nuclei of all the cells derived 
both directly and indirectly from it. Now, 
as this descent in structure is in all probability 
associated with a power of transmitting 
properties, and as the segmentation-nucleus 
consists of material derived from both parents, 
a structural medium is provided for the 
transmission of the characters of the parents 
to their offspring, and the phenomena of here- 
dity may be said to rest on a physical basis. 
The material which forms the structure of the 
male and female pronuclei and the segmenta- 
tion-nucleus has been termed by Weismann 
the germ-plaem. He believes that in each 
individual produced by sexual generation, a 
portion of the germ-plasm derived from both 
parents is not employed in the construction 
of the nuclei'of the cells and tissues of the 
soma or personal structure of the individual, 
but is set aside unchanged for the formation 
HEREDITY HEREDITY 
867 
of the germ cells of the succeeding generation. 
According to this theory there is a direct 
continuity of germ-plasm from one generation 
to another, which acts as the conveyer of 
hereditary characters. Weismann main- 
tains that the germ-plasm is not modified 
by the habits and mode of life of the indivi- 
dual, and he conceives it to be transmitted 
from one generation to another uninfluenced 
by the conditions of life in which the indivi- 
dual is placed. He assumes that the repro- 
ductive cells which contain the germ-plasm 
are not acted on by the organs and tissues of 
the body in which they are situated, except in 
so far as they may be affected by general con- 
ditions of growth and nutrition. Hence, he 
concludes that characters acquired by indivi- 
duals during their lifetime from any external 
cause, which modify the persona or soma, 
cannot be transmitted to their offspring. 
Several arguments may, however, be 
advanced in opposition to Weismann's con- 
clusion, which seems to require for its con- 
firmation that the germ-plasm of the repro- 
ductive cells should, from the commence- 
ment of the development of the embryo, be 
isolated from the cells from which the other 
organs of the body are derived. But both 
reproductive cells and soma cells are formed 
in the fertilised ovum by the segmentation 
of the nucleus, and the reproductive cells in 
man and other vertebrates do not appear as 
isolated organs until after the rudiments of 
all the great organic systems have been 
mapped out. Hence, before they are set 
aside as germ cells or sperm cells, the germ- 
plasm has apparently been in a stage of 
diffusion, and under precisely the same 
influences as those which in the embryo 
affect the formative cells of the body 
generally, so that the conditions which 
would secure the germ-plasm and the soma 
cells from mutual interaction are not com- 
plied with. 
Further, there is experimental evidence to 
show that in placental mammals an inter- 
change of material takes place during gesta- 
tion in opposite directions from foetus to 
mother, as well as from mother to foetus. A 
character derived by a foetus by descent from 
its male parent may thus be acquired by the 
mother from the foetus, and influence the 
germ-plasm of her reproductive cells so as to 
be transmitted to her future offspring, even 
though they may not have the same male 
parent. Hence, it is an axiom with those 
engaged in the breeding of particular kinds 
of stock, that, if they wish to keep the strain 
pure, the mother must not at any time be 
allowed to beget offspring by sires of another 
blood. 
The hereditary transmission of characters 
from parents to offspring is not limited to 
such as are normal and physiological, and of 
service in the perpetuation of the species 
and of the race. Characters which are of no 
service, and, indeed, are detrimental to the 
individuals in whom they occur, may also be 
transmitted, and it is from this point of view 
that the subject of Heredity requires to be 
considered in this place. The study of those 
modifications in the structure of the body, 
which pathologists group together under the 
name of Congenital Malformations, has fur- 
nished numerous illustrations of the descent 
in families of variations from the normal 
structure. Familiar examples are furnished 
in the presence of supernumerary digits on 
the hands or feet in some families, or a 
diminution in their number in others. But 
modifications or variations in structure that 
can be transmitted from parents to offspring 
are by no means limited to changes which 
can be recognised by the naked eye. They 
are sometimes so minute as to be determined 
rather by the modifications which they occa- 
sion in the functions of an organ than by the 
ready recognition of structural variations. 
One might adduce as an example Daltonism, 
or colour-blindness, which has distinctly been 
shown to be hereditary, and which is due 
apparently to a minute structural defect in 
the development of the retina, or the optic 
nerve, or the brain itself, occurring in par- 
ticular families. 
But there are certain diseases which 
occur in some families more than in others, 
and which are regarded as hereditary. Some 
of these are discussed in the article Predis- 
position to Disease, but in addition to the 
examples there given, it may be stated that 
in some families there is a strong tendency 
to the production of cataract in successive 
generations, and in other families an equally 
strong predisposition to the haemorrhagic 
diathesis. When we speak of tendencies, 
susceptibilities, proclivities, or predisposition 
to the transmission of characters,whether they 
be those of health or of disease, we employ 
terms which undoubtedly have a certain 
vagueness. We are quite unable to recognise, 
even with the highest powers of the micro- 
scope, any structural difference in the germ- 
plasm in different persons which would 
enable us to say that in one family a particu- 
lar feature should have one form, in another 
family a different form ; or that in one 
family there should be a tendency or sus- 
ceptibility to one kind of disease, whilst 
another family should display a special 
capacity for transmitting another form of 
disease. We can only determine that such a 
sequence will take place by tracing the life- 
history of the individuals belonging to these 
families. Though, as we have said, these 
terms have a certain vagueness, and are 
wanting in scientific precision, yet it is not 
the less true that they express a something 
of the importance of which we are all con- 
scious, though we may not be able to formu- 
late it in a precise definition. 
William Turner. 868 
HERMAPHRODITE 
HERNIA 
HERMAPHRODITE (Epgris, Mer- 
cury ; and ' A^poSi-rr), Venus).-A term applied 
to an individual in whom the formation of 
the sexual organs is such as to give rise to 
the impression that both the male and the 
female organs are present. See Malforma- 
tions. 
HERNIA (hernia, a rupture).-Synon. : 
Fr. Hernie; Ger. Bruch. 
Definition.-This word is used in surgery 
to express the protrusion of any viscus from 
the cavity in which it is naturally placed. 
In this article, however, the observations are 
exclusively restricted to protrusions of the 
viscera of the abdomen through the walls of 
that cavity, and it is only intended to give a 
mere outline of the subject, its full discussion 
being beyond the scope of this work, as it is 
mainly connected with surgery. 
General Remarks. - Hernial displace- 
ments take place in both sexes and at all 
ages. The most striking objective sign of the 
existence of a hernia is a fulness or swelling 
in one or other of those regions of the abdo- 
men where, from the anatomical construction 
of its walls, the tissues are weakest. When 
the parietes are defective, in consequence of 
local disease or injury, visceral protrusions 
jiiay occur at those spots; and also as the 
result of congenital malformation in both 
sexes, a fruitful cause of hernia being the 
non-closure of the vaginal process of the 
peritoneum at birth, or a patulous state of 
the umbilical aperture. Such a protruded 
viscus forms a hernial swelling or tumour. 
The tumour is composed of a sac, its contents, 
and the tissues outside the sac. The sac is 
composed of a prolongation of the peritoneum 
in most cases; and its orifice, neck, or ab- 
dominal aperture, constitutes, with the tissues 
around it, a frequent cause of impediment 
to replacement or ' reduction ' of the hernia. 
The hernia may be a part of any abdominal 
viscus, but those most mobile are usually dis- 
placed. Thus, in the majority of cases, either 
the omentum or small intestines, together or 
singly, form the hernia. The tissues outside 
the sac are those which exist in the region 
where the tumour is formed, and they are 
frequently described as the coverings of the 
sac. 
Every hernial tumour possesses a neck, 
body, and fundus. 
The first or earliest objective symptom of 
a hernial protrusion is an unusual fulness, as, 
for example, in the groin in a case of inguinal 
hernia. This swelling is transient, appearing 
and disappearing in relation to the actions 
or posture of the individual. When pressed 
with the finger the swelling disappears; but 
it is readily reproduced if the patient contracts 
the abdominal muscles, and then with the 
finger an impulse is felt, produced by the 
protruding viscus. By slow degrees the bulk 
of the swelling increases, until, if no support 
or * truss ' be used, very large tumours are 
formed. 
Classification.-The most practical classi- 
fication of hernial protrusions is based upon 
the usual triple division of the abdomen into 
regions-namely, the epigastrium, meso- 
gastrium, and hypogastrium. 
1. Protrusions in the epigastric region are 
very rare. They are (a) diaphragmatic; and 
(6) epigastric. 
Diaphragmatic hernia is due either to re- 
laxation of the tissue of the diaphragm muscle, 
or to its laceration. In some cases congenital 
deficiency of the muscle is the primary cause; 
in others the natural openings in the muscle 
become dilated. Signs of this hernia are 
very obscure; but when the protrusion de- 
pends upon laceration of the muscle, the oc- 
currence of a recent injury may excite sus- 
picion, if associated with abnormal sounds 
in the thorax. 
Epigastric hernia escapes at the region 
formed by the cartilages of the false ribs on 
either side of the linea alba. It is very rare, 
and, as the abdominal orifice of the sac is 
usually large, the hernia is easily reduced. 
2. The hernias in the mesogastrium are 
(a) ventral', (&) umbilical', and (c) lumbar. 
The term ventral is given to any hernial 
protrusions escaping through abnormal open- 
ings in the walls of the abdomen to which 
no special name is given. They are seen in 
the region of the linea alba, above the um- 
bilicus, but most frequently below it; in the 
line of the linea semilunaris; and even op- 
posite the muscular walls. Commonly of 
traumatic origin, their nature is clearly 
shown by the ready manner in which the 
protruded viscus can be pressed back into the 
abdomen. They sometimes ensue upon the 
weakening of the walls after distension, or 
upon the loss of tissue following abscess. 
Umbilical hernia is met with at all ages 
and in both sexes. It forms a tumour at the 
site of the umbilicus in the first instance, 
and gradually descends over the linea alba 
as its bulk increases. Very soon after birth 
this variety of hernia appears. The pro- 
trusion takes place at the umbilical ring, and, 
pushing before it the peritoneum, an acquired 
hernial sac is formed. To prevent, therefore, 
the development of the sac in infancy, and to 
assist the closure of the ring in the linea alba, 
a slightly convex disc of cork, enclosed in 
washleather, should be strapped over the 
umbilical aperture. The prognosis of in- 
fantile umbilical hernia is favourable, for 
the aperture closes with age, and the tissues 
continue firm. 
In adult life this kind of hernia is frequent 
in fat individuals. The tumour often acquires 
enormous proportions. Its contents consist 
of small intestine and omentum, with not 
uncommonly a portion of the transverse 
colon. Accumulations of faecal matter therein 
often give rise to obstruction, and the symp- HERNIA 
869 
toms arising in consequence of this state 
more or less resemble those of strangulated 
small intestine. A correct diagnosis of their 
cause may usually, however, be arrived at 
from the history of the attack, the com- 
parative mildness of the malady, and the 
alleviation of the symptoms by exciting the 
action of the bowels. The contents of this 
form of hernia, when of long standing, often 
become adherent or bound by bands to the 
sac, in which state they remain permanently 
irreducible. 
When the protruded viscus can be entirely 
reduced within the abdominal cavity, a suit- 
able well-fitting truss should be worn con- 
stantly ; if irreducible, one adapted to the 
circumstances of the case must be used. 
Lumbar hernia takes place in the loins. 
It is a very rare variety, and usually occurs 
as the result of an injury. 
3. The herniae in the hypogastrium are 
the most numerous and the most common. 
They include (a) inguino-scrotal or inguino- 
labial, above Poupart's ligament; (b) femoral, 
below Poupart's ligament; (c) protrusions 
through the apertures of the pelvis in front, 
beneath the horizontal ramus of the pubes- 
obturator ; (d) beneath the arch of the pubes 
-perineal, pudendal, vaginal', and be- 
hind, through the ischiatic notch-ischiatic. 
(a) Inguinal hernia is seen at all ages and 
in both sexes. The following varieties are 
described : the obligue or external; and the 
direct or internal. In the first, the orifice 
of the sac is outside the course of the internal 
epigastric artery; in the second it is internal 
to the same vessel. When the protrusion 
forming an inguinal hernia does not descend 
below the inguinal canal it is termed a 
bubonocele', but when it occupies the scro- 
tum or labium it forms an inguino-scrotal 
or inguino-labial tumour. The essential 
difference between the inguinal hernia of 
youth and of middle age is due to the con- 
stitution of the sac which encloses the pro- 
trusion. From infancy to early adult life, 
protruding viscera escape from the abdomen 
into a serous sheath continuous with the 
parietal peritoneum, namely, the vaginal pro- 
cess of that membrane which extends into 
the scrotum or labium. In middle life and 
afterwards, the parietal peritoneum is thrust 
through the apertures or weak points in the 
abdominal walls by the protruding viscus. In 
this way two distinct kinds of hernial sac are 
formed: the first being due to a congenital 
defect; the second, to a mechanical and ac- 
quired cause. In practice, it is very impor- 
tant to bear these distinctions in mind. In 
the first kind a truss is applied to prevent the 
passage of the viscus into the sheath, in the 
hope that by this means its walls may unite 
and its orifice contract-in fact, to assist 
nature in accomplishing that condition, the 
failure of which permits the protrusion to 
take place. But, in the second, a truss is 
used to prevent the protruding viscus pushing 
the peritoneum before it, and so forming for 
itself a sac. Thus, if the development of the 
sac be arrested, there can be no hernial 
tumour. 
Inguinal herniae occupy the inguinal canal, 
and are therefore in relation with the sper- 
matic cord of the male and the round liga- 
ment of the female. They escape from the 
canal through the external abdominal ring 
into the scrotum or labium. The neck of the 
tumour is always therefore above Poupart's 
ligament, and to the inner side of the ex- 
ternal pillar of the external abdominal ring. 
This anatomical fact constitutes the main dis- 
tinction between inguinal and femoral hernia. 
(&) Femoral hernia forms a tumour at the 
inner and upper part of the thigh, imme- 
diately below the pubic attachments of 
Poupart's ligament. These structures are 
in immediate relation with the neck of the 
sac. The protrusion escapes at the femoral 
aperture, the site of the entrance of the 
lymphatic vessels of the thigh to the abdo- 
minal cavity. The neck of the sac is there- 
fore to the inner side of the sheath of the 
femoral vessels; although, in proportion to 
the bulk of the tumour, its body may overlie 
it, and even extend upwards above Poupart's 
ligament, and outwards towards the crest of 
the ilium. The sac of a femoral hernia is 
always an acquired formation. Hence the 
importance of wearing a truss after observing 
the slightest indication of a femoral protru- 
sion. For if the yielding, relaxed, parietal 
peritoneum be supported at the crural aper- 
ture by a well-adjusted pad, a visceral hernia 
must be avoided, as there will be no sac into 
which it can escape. In other words, arrest 
the development of the sac and there can be 
no hernia. 
To discriminate between a femoral and an 
inguinal hernia, place the index finger upon 
the spinous process of the pubes; if the neck 
of the tumour is to its outer side, and the 
whole length of Poupart's ligament can be 
traced above it, a femora' hernia exists. 
Should precisely the reverse conditions be 
ascertained, the tumour will depend upon 
an inguinal protrusion. Another method for 
diagnosis is the direct and careful examina- 
tion of the site of the femoral aperture. If 
it is clearly and distinctly tangible and well- 
defined, it cannot be occupied by a hernial 
protrusion. 
Femoral hernia is most common in the 
adult female. It has been developed before ten 
years of age; is rare between that age and 
twenty; but is very frequent in persons be- 
tween twenty and forty years old. Prolific 
women are more frequently the subjects of 
this hernia than the single and sterile. 
(c) Obturator hernia escapes from the pel- 
vis through the thyroid foramen, and traverses 
the canal normally occupied by the obturator 
nerve and vessels. It is rarely met with. A 870 
HERNIA 
fulness, rather than a tumour, is produced by 
the protrusion at the inner or pubic region of 
the thigh, beneath the pectineus muscle, and 
accompanied by a peculiar numbness and 
pain, which may be traced to the distribution 
of the filaments of the obturator nerve. The 
lives of patients have been lost in conse- 
quence of overlooking these herniae ; the cause 
of death being only ascertained post mortem. 
(d) Perineal, pudendal, vaginal, and (e) 
ischiatic hernias are very rarely seen. The 
name assigned to each indicates the locality in 
which the tumour is formed; and for a special 
description of them the reader must be re- 
ferred to monographs on the subject of this 
article. 
Effects and Treatment.-We must next, 
as briefly as possible, describe generally the 
various morbid conditions which the hernia 
itself may undergo, and the means by which 
serious consequences from such conditions 
may be averted. 
All hernial protrusions are either reducible 
or irreducible-that is, they can either be re- 
stored to their normal situation, or they may 
be permanently confined to the region in 
which they are protruded. 
The treatment of all reducible herniae con- 
sists in the employment of means to prevent 
the escape of the protrusion. To effect this 
object various kinds of bandages or trusses 
have been devised. Each kind of hernia 
requires its special form of truss, and every 
individual should, as far as practicable, obtain 
a truss well fitted to his or her configuration. 
The essentials of a good truss consist in the 
spring having sufficient power to support the 
hernia and prevent its escape, while it should 
not be so strong as to injure the structures 
about the abdominal rings. The pad should 
be firm, of a shape suitable to the case, and 
of $ size not inconvenient to the wearer. 
The irreducibility of a hernia depends on 
its bulk, adhesions, and special anatomical 
conditions. Under such circumstances special 
bandages must be employed. 
But other much more important morbid 
states of the protruded viscus than the above 
cause impediments to the reduction of a 
hernia, namely: (1) constriction by the tis- 
sues around the orifice of the sac ; (2) accu- 
mulation of fecal matter in the protruded 
viscus ; (3) inflammation of the hernia ; and 
(4) strangulation, when a part of the alimen- 
tary canal forms the hernia. 
(1) Those hernfe-for example, the in- 
guinal-which pass through openings in the 
muscular walls of the abdomen, are liable to 
constriction from contraction of the muscular 
tissue. Inguinal herniae of long standing, 
and more than ordinary bulk, are very prone 
to become irreducible in consequence of 
muscular contraction. Such cases are well 
adapted to illustrate the effects of anaes- 
thetics, and their influence on muscular 
irritability. If the patient be placed under 
the full influence of chloroform, the abdo- 
minal muscles become relaxed, and the hernia 
is quickly reduced. 
(2) Hernial protrusions formed of large 
intestine, such as occur at the umbilicus, 
frequently become irreducible from fecal 
accumulations. In these cases enemata, and 
even purgative medicines cautiously pre- 
scribed, frequently relieve the symptoms. 
(3) Inflammation- excited in an omental 
protrusion may cause temporary and even 
permanent irreducibility. Local and con- 
stitutional symptoms of a rather severe type 
sometimes attend such cases. The usual 
methods adopted to induce resolution must 
be employed. 
(4) A morbid state of the protruded bowel 
termed strangulation has next to be de- 
scribed. A patient the subject of this state 
remains in the greatest danger to life so long 
as the exciting cause, the constriction of the 
bowel, exists. Hour by hour that danger 
increases; and, although rare instances of 
recovery might be quoted after the con- 
tinuance of strangulation for many hours, 
the majority of patients die because the 
intestine was not liberated early enough. A 
hernia is described as strangulated when 
subject to a constriction which at first im- 
pedes, and sooner or later arrests, the cir- 
culation of the blood in its capillary vessels. 
The passage of the intestinal contents is 
necessarily stopped. The local and consti- 
tutional symptoms are strikingly charac- 
teristic. Very frequently the first symptom 
is vomiting, unaccompanied by any alvine 
evacuation. The vomiting continues, and is 
excited by ingesta. This state is probably 
due to mere obstruction of the alimentary 
canal, but it ought always to excite the 
anxious solicitude of the medical attendant 
to ascertain whether the patient has any 
outward signs of a hernial tumour. He 
must examine those regions at which pro- 
trusions commonly occur, and never rest 
content with the statements of the sufferer. 
At first the pulse is not affected in a very 
marked way, but as vomiting continues the 
heart beats more rapidly, whilst the pulse 
becomes weaker and contracted. The surface, 
especially that of the extremities, becomes 
cold; the countenance aged and anxious; the 
visage, lips, and hands shrivelled and bluish; 
the prostration extreme. The tumour is pain- 
ful when touched, and it may have increased 
in size and become tense. All these facts 
indicate progressive morbid changes in the 
tissues of the strangulated bowel, as well as 
in that part of the alimentary canal above 
the hernia. Besides the mere act of vomiting 
all ingesta, the characters of the fluid vomited 
must be carefully noted. Usually, at first, 
it is the food last swallowed, more or less 
digested and mingled with bile; in the 
second stage it becomes yellowish and green- 
ish ; and at last it is stercoraceous-that is, HERNIA 
HERPES 
871 
offensive to smell, of a brownish colour and 
frothy, and often in great quantity. Now 
the only treatment of these urgent symptoms 
consists in the liberation of the bowel by 
surgical means. In the meantime palliatives 
may be employed, opium administered by the 
mouth, enemata injected, local applications 
of ice used, and gentle taxis applied. 
John Birkett. 
HERNIA CEREBRI. - See Brain, 
Malformations of; and Skull, Diseases and 
Deformities of. 
HERPES (eprco, to creep).-Synon.: Fr. 
Dartre; Ger. Herpes, Blaschenflechte. 
The name ' herpes ' was formerly applied 
to a large group of skin affections, which 
were associated together on account of a 
supposed similarity in the eruption, although 
they bore very little real relation to each 
other. Thus we had herpes iris, herpes 
circinatus, and herpes gestationis, diseases 
which are perfectly distinct from any kind 
of true herpes. At present only three forms 
of herpes are recognised: herpes facialis, 
herpes progenitalis, and herpes zoster; all of 
which resemble each other not only in the 
character of the eruption, but also in running 
an acute and definite course, and in having a 
neurotic origin. As, however, herpes zoster 
differs considerably from the other two, it 
is conveniently distinguished by the name 
zona. This nomenclature has the merit of 
simplicity, and is that of the College of 
Physicians. 
1. Herpes Facialis.-Synon. : Herpes 
febrilis; Herpes labialis. 
Herpes facialis consists of a small group, 
or groups, of vesicles on a red base. The 
eruption is associated with some swelling of 
the skin or mucous membrane, and with a 
sensation of very slight pain and stiffness of 
the part affected. It is most commonly met 
with on the lips, but occasionally on the alae 
of the nose, the ear, or the cheek. It is also not 
uncommon on the buccal mucous membrane, 
and on that of the soft palate and uvula. 
It is generally, but by no means always, 
confined to one side, and this is more ob- 
servable on the face or ear than on the lips, 
where it often extends 'to both sides of the 
middle line. The eruption is 'frequently 
associated with catarrh of the air-passages, 
and, though quite unimportant, is apt to 
recur. No treatment is required, as the 
eruption disappears in a few days, but a lotion 
of carbolic acid may be usefully applied. 
2. Herpes Progenitalis.-This disease 
differs but little from herpes facialis except 
in the part affected; it is, however, very apt 
to be troublesome, especially when irritated 
by rubbing or injudicious treatment. The 
eruption is met with in both sexes, but is 
more common in the male than in the 
female. In men it appears on the prepuce 
or glans penis; in women on the labia or ad- 
jacent mucous membrane. When irritated, 
it is apt to form small ulcers, which are diffi- 
cult to heal, and which lead to enlargement 
of the inguinal glands. Under these circum- 
stances herpes has often been mistaken for 
syphilis. 
Treatment.-This should be always of the 
most soothing kind, such as the application 
of water dressing or a very weak boric acid 
or lead lotion, with mild aperients. 
3. Zona.-Synon. : Herpes zoster; Shin- 
gles. 
Definition.-An acute inflammatory dis- 
ease of the skin, running a definite course, 
consisting of groups of vesicles on an in- 
flamed base, and distributed irregularly along 
the course of cutaneous nerves. The erup- 
tion is usually unilateral, and is apt to pro- 
duce scars. 
Symptoms.-Zona is by far the most im- 
portant form of herpes. It is met with 
most commonly on the trunk, where it fol- 
lows the course of some of the intercostal 
or lumbar nerves, and often in the gouty 
diathesis. It is also not very uncommon in 
the supra-orbital region, and is occasionally 
met with following the course of some 
cutaneous nerves down the arm or leg. It 
is said to be more common on the right 
than on the left side of the body. The 
eruption is preceded by a very considerable 
amount of neuralgic pain and discomfort, 
which may even last for days before the 
eruption appears, and has often been mis- 
taken for the pain of pleurisy. The first 
appearance of the eruption is a bright-red 
patch or patches, on which are then deve- 
loped groups of vesicles of rather large size, 
sometimes even amounting to blebs. The 
contents of the vesicles become puriform; 
and they ultimately dry up and leave scabs, 
which generally fall off without producing 
permanent scars. Occasionally, however, 
troublesome ulcers form, leaving behind deep 
depressed scars. Mild cases of zona are very 
apt to abort, the eruption hardly developing 
into true vesicles; this imperfect develop- 
ment may also be seen in the outlying 
groups of the eruption in well-developed 
cases. As a rule the eruption of zona runs 
a definite course of about a fortnight; there 
are, however, not a few exceptions in which 
the period of development is prolonged beyond 
the normal time. The disease is not very 
apt to recur, and in this respect it differs 
from herpes labialis and preputialis. When 
zona occurs in the neighbourhood of lym- 
phatic glands, these almost always become 
enlarged during the attack. 
Prognosis.-There are two points con- 
nected with zona that require especial notice. 
(1) The gravity of the disease, apart from the 
amount of eruption, is, broadly speaking, in 
proportion to the age of the patient. In chil- 
dren and young adults, as soon as the sores 
have healed the patient is generally quite 872 
HERPES 
HICCUP 
well, and no trace of the disease is left except 
perhaps a few small scars and a slight 
tenderness of the skin. In the middle aged, 
and still more in elderly people, this is not 
the case: the eruption is almost always 
followed by some form of nerve disturbance, 
generally of a severe neuralgic kind, which 
may last for months ; in other cases, attacks 
of a kind of vertigo follow the zona. In very 
old people an attack of zona is a serious 
matter from which they seldom entirely 
recover. (2) It must be always borne in mind 
that supra-orbital zona is very apt to leave 
deep depressed scars. The patient should 
invariably be warned of this in the first 
instance, otherwise the formation of the scars 
may be attributed to neglect or injudicious 
treatment. Sometimes the eye itself is in- 
volved in the eruption; and cases of blind- 
ness are not unknown as the result of a 
severe attack of zona. 
Treatment.-The treatment of this erup- 
tion is very simple. It should be protected 
from the pressure of the clothes as far as 
possible. This may be done with a good pad 
of cotton wool. Lotions should generally be 
avoided; and simple powders, such as oxide 
of zinc or starch, should be well dusted on 
several times daily. The treatment of the 
neuralgia which follows zona is most diffi- 
cult. The pain is often of the most violent 
darting kind, and not amenable to treat- 
ment. All the ordinary remedies used in 
neuralgia may be tried, including hypodermic 
injections of morphine and quinine. See 
Neuralgia. Robert Liveing. 
HETEROLOGOUS (ertpos, other; and 
Ady os, nature).-A word used to characterise 
any morbid product, whether fluid or solid, 
which is different in composition or structure 
from the normal fluids or solids of the body. 
HETEROMORPHOUS (erepos, other; 
and poptyr), form).-Applied to new-forma- 
tions which are different in form and struc- 
ture from the normal tissues. 
HETEROTOPOUS (ertpos, other; and 
rdnos, a place).-Misplaced. A term applied 
to the appearance either of a normal tissue 
in an unnatural situation-for example, of 
hairs on mucous surfaces; or of morbid 
growths in unusual places-for instance, of 
epithelioma in nervous tissue. 
HICCUP or HICCOUGH.-Synon. : 
Singultus; Fr. Hoquet-, Ger. der Schlucken. 
Description.-Hiccup, according to phy- 
siologists, is a sudden spasmodic descent of 
the diaphragm accompanied by a spasmodic 
closure of the glottis, the characteristic noise 
being caused by the incoming column of air 
striking against the partially closed glottis. 
The assumption of a spasmodic closure of 
the glottis in hiccup seems scarcely warrant- 
able. Normally the descent of the diaphragm 
in each respiratory act is accompanied by a 
contraction of the posterior crico-arytaenoid 
muscles, which causes an outward rotation of 
the aryteenoid cartilages, and a dilatation of 
the glottic aperture. The diaphragmatic and 
the laryngeal acts keep time together, and in 
health the rhythm of sixteen or eighteen to 
the minute is maintained. If, however, the 
diaphragm give a sudden descending jerk 
irrespective of any respiratory need, as is the 
case in hiccup, and this jerk occur at a time 
when the dilators of the glottis are not acting, 
a noise will be produced by the rush of air 
through the insufficiently widened glottic 
aperture. It seems certainly possible to 
account for the noise of hiccup by the mere 
fact of the descent of the diaphragm occurring 
when the glottis is not properly open. The 
noise is not a constant phenomenon, and 
during an attack of hiccup it never occurs 
during ordinary inspiration, or without the 
spasmodic action of the diaphragm, although 
the latter phenomenon may occur without 
the former. 
/Etiology and Diagnosis.-Hiccup may 
be produced by any irritation of the phrenic 
nerve-its origin, its course, or the ultimate 
twigs which are distributed to the under-sur- 
face of the diaphragm. Undue distension of 
the stomach, by being overfilled with food or 
drink, or by an accumulation of wind due to 
faulty digestion, is the most common cause 
of hiccup. Its occurrence from this cause i« 
far more common in children than in adults. 
Convulsions and muscular spasms generally 
are more easily caused in the young, and 
hiccup in this respect follows the ordinary 
rule. Hiccup is produced by direct or by 
reflex irritation. With many persons the 
introduction of hot spiced or peppery foods 
into the stomach immediately produces hic- 
cup, and the writer knows one or two persons 
in whom hiccup is produced by the passage 
of hot fluids through the pharynx. It is a 
frequent symptom in peritonitis when the 
peritoneal covering of the diaphragm becomes 
affected. It sometimes occurs in cases of 
cancer of the stomach; occasionally, perhaps, 
from over-distension of the organ, but more 
often from an extension of the cancerous 
disease to the peritoneal surface of the 
stomach. It is occasionally a troublesome 
symptom Suring convalescence in cholera, 
and is often accompanied by eructations of 
wind, and sometimes by vomiting. If hiccup 
occur with any persistency in the course of 
typhoid fever, it is often an indication of per- 
foration and the onset of general peritonitis. 
Although most frequently a symptom of gas- 
tric or abdominal disturbance, hiccup occa- 
sionally occurs as a true neurosis. It may 
accompany hydrocephalus or meningitis, and 
is then due probably to an implication of the 
cerebral origin of the phrenic nerve. Cases 
of obstinate hiccuping in hysterical subjects 
have been recorded, and cases of paroxysmal 
hiccup have been observed by Liveing, HICCUP 
HORNS 
873 
Prichard, and others, which have been re- 
garded as instances of modified epilepsy. 
Treatment.-The treatment of hiccup will 
depend upon the cause. An emetic to empty 
the stomach, or a stimulant to increase its 
natural peristaltic action, will often give relief. 
If we can manage to produce a forcible 
action of the diaphragm, we may often suc- 
ceed in curing it, as it were, of the trick of 
spasmodic action. Attempts to count a hun- 
dred without drawing breath, or to hold the 
breath for a minute, are familiar remedies 
for hiccup; and, by producing a feeling of 
suffocation, and necessitating a violent de- 
scent of the diaphragm, they are often suc- 
cessful. Warm applications or counter-irri- 
tation applied to the diaphragmatic region or 
over the cervical spine, may occasionally give 
relief. Pressure upon the trunk of the phrenic 
nerve by means of the finger applied over the 
scalenus anticus muscle, is said also to have 
given relief occasionally in obstinate cases. 
Amongst the drugs which have been recom- 
mended for the relief of hiccup are chloro- 
form (administered internally), either alone 
or combined with opium; camphor in the 
form of a spirit solution, in doses of twenty 
drops and upwards; valerianate of zinc, bella- 
donna, bromide of potassium, musk, or ant- 
acids ; and, in very severe cases, morphine 
administered hypodermically. 
G. V. Poore. 
HIPPURIA (ittttos, a horse; and ovpov, 
urine).-The condition of the urine in which 
it contains hippuric acid in excess. See 
Urine, Morbid Conditions of. 
HISTRIONIC SPASM (histrio, an 
actor).-A synonym for facial spasm, so 
called on account of the contortions of the 
face to which this affection gives rise. See 
Facial Spasm. 
HIVES.-A popular term for chicken- 
pox. See Chicken-pox. 
HOARSENESS (Sax., has, having a 
rough voice).-Roughness of the voice, due 
to disease or disorder connected with the 
larynx. See Voice, Disorders of. 
HOBNAIL LIVER.-A name given to 
a cirrhotic liver, when it presents small pro- 
minences on its surface, somewhat resembling 
hobnails. See Liver, Cirrhosis of. 
HODGKIN'S DISEASE. -A syno- 
nym for lymphadenoma or lymphoma. See 
Lymphadenoma. 
HOMBURG, in Germany.-Common 
salt waters. See Mineral Waters. 
HOMICIDAL INSANITY. - See 
Crime, Irresponsibility for; and Insanity, 
Impulsive. 
HOMOLOGOUS (6/ios, like ; and Adyos, 
nature).-In pathology this term is applied to 
new-growths presenting the same structure 
as normal tissues, such as fatty or fibrous 
tumours. 
HOOPING-COUGH.-See Whooping- 
cough. 
HORDEOLUM {hordeum, a barley- 
corn).-A synonym for stye. See Stye. 
HORN-POX.-A popular term for a 
variety of chicken-pox. See Chicken-pox. 
HORNS. - Synon. : Cornua. - Defini- 
tion.-Horns are epidermic and epithelial 
formations, consequent on hypertrophy of the 
horny product of the integument. 
Description. - Horns generally occur 
singly. Sometimes they attain a size of 
several inches in length and in circumfer- 
ence. They have been met with on all parts 
of the body, more particularly on the scalp, 
the face, the glans penis, and the glans clito- 
ridis. 
Pathology.-When the inspissated pro- 
duct of the follicles of the skin, consisting of 
laminated epithelium and sebaceous matter, 
is exposed to the air, it dries, becomes hard 
and transparent, and is in fact converted 
into a mass having most of the properties of 
horn. This is the principal source of the 
horns of the integument-an accumulation 
of the contents of a follicle ; the protrusion 
of that substance through the dilated aper- 
ture of the follicle, sometimes through a large 
opening resulting from atrophy or ulceration; 
its desiccation by the atmosphere; and its 
growth by continued additions to its base. 
Being essentially the protrusion of a soft 
substance through a constricted aperture, 
the surface of the horn will be modelled in 
figure by the shape of that aperture ; in con- 
sequence of desiccation, its shaft will be 
smaller than its base; and it will be liable 
to be bent or twisted in the operation of pro- 
trusion. Hence these horns are generally 
curved or twisted, and have been compared 
to the beak of a bird, or the horn of the goat. 
A section of the horn affords similar evidence 
of its manner of formation and growth, it 
being always laminated in structure. 
Another kind of horn is sometimes met 
with on the glans penis and clitoridis, and is 
the product of hypertrophy of the papillae. 
This form of growth is fibrous in structure, 
like a wart, which in fact it closely resembles; 
whilst in the same situation concreted masses 
are occasionally formed, constituted by a com- 
bination of both processes-namely, papillary 
hypertrophy and accumulation of follicular 
substance. There is, however, an important 
difference between the two kinds of horn, 
the sebaceous and the epidermic-namely, 
that the former is the mere result of increased 874 
HORNS 
HOSPITALISM 
activity of function, whilst the latter is the 
consequence of hypersemia or inflammation. 
Treatment.-Horny matter being sus- 
ceptible of disintegration by moisture, the 
sebaceous horn may be so thoroughly soft- 
ened by envelopment in a waterproof cover- 
ing, or by a poultice, as to be easily broken 
away at its base. The follicular bed from 
which it has been removed may then be 
cleared by a small scoop, when the sac will 
contract and close. Sometimes it may be 
thought desirable to sponge the surface with 
a solution of chloride of zinc or sulphate of 
copper; but operation by the knife seems 
quite uncalled for. In the instances of epi- 
dermic and epithelial horn, however, it will 
be necessary to have recourse to caustics, 
especially potassa fusa; and when the case 
evinces great obstinacy, or where an epithe- 
liomatous degeneration is suspected, the use 
of the knife becomes essential. 
Erasmus Wilson. 
HORRIPILATION (horreo, I bristle 
up; and pilus, a hair).-A sensation of chilli- 
ness and creeping, the hairs of the general 
surface of the skin appearing to stand on 
end. See Rigor. 
HOSPITALISM.-The term 'Hospital- 
ism ' was introduced into medical literature 
by Sir James Simpson (Edinburgh Medical 
Journal, March 1869), but, as far as the 
writer can see, no exact definition of it was 
given by its author. It, however, was evi- 
dently intended to signify ' the hygienic evils 
which the system of huge and colossal hos- 
pital edifices has hitherto been made to 
involve'-to use Sir James Simpson's own 
words. These evils appeared to him so evi- 
dent, and so necessarily connected with the 
size of the hospital, that he taught (and in fact 
the sole object of his papers was to teach) that 
our system ought to be revolutionised-' hos- 
pitals changed from being crowded palaces, 
with a layer of sick on each flat, into villages 
or cottages, with one, or at most two, patients 
in each room-the village constructed of iron 
instead of brick or stone, and taken down and 
rebuilt every few years.' 
Mr. Erichsen has, to some extent, accepted 
the teaching of Sir J ames Simpson, though he 
allows that some of it is very questionable. 
His tract on the subject of Hospitalism has 
the advantage of being written in a more 
sober style than Sir James Simpson's, and 
also of putting the question in a clearer light. 
By the term, he says, ' is meant a general 
morbid condition of the building, or of its 
atmosphere, productive of disease. . . . 
Doubtless,' says Mr. Erichsen, ' all the 
septic diseases that are met with in hospitals 
may be encountered in the practice of sur- 
geons out of these institutions, but they are 
unquestionably infinitely more common in 
hospital than in private practice, and their 
causes are certainly different.'1 The writer 
believes, on the contrary, that, if a hospital 
be properly managed, there is no general 
morbid condition of the building-that there 
is no reason for thinking that septic diseases 
are more common relatively in hospitals than 
out of them-and that their causes are iden- 
tical wherever they occur. 
And if the term ' Hospitalism ' is to be 
taken in the sense in which Sir James Simp- 
son evidently intended-that is, as mean- 
ing to convey the idea that there is an in- 
evitable tendency to the generation of septic 
disease in large hospitals, that that ten- 
dency becomes greater as the size of the 
hospital is increased, and that it increases 
as the hospital grows older-the writer has 
no hesitation in saying that there is no 
such thing as Hospitalism. No doubt the 
aggregation of the sick and wounded in hos- 
pitals is a cause of danger, and much care 
and vigilance are required to keep hospitals 
healthy. But the dangers are in no sense 
peculiar to hospitals. The surgical affections 
which spring up in hospitals-erysipelas, 
phagedsena, pyaemia, and allied affections- 
all of them prevail in private practice, and, 
as far as has been shown, prevail equally.2 
Further, although the perfect publicity of 
our hospital practice enables us to obtain 
tolerably accurate data for a comparison of 
the experience of the smaller and larger 
hospitals of this and other towns, no one 
has ever seen the least reason for believing 
that the smaller are in any respect healthier 
than the larger; while several of the hospitals 
that have been longest built are renowned 
for their healthy condition, and in many 
large hospitals, parts of which are ancient 
and other parts modern, the former, if equally 
well or better constructed, are (under similar 
conditions of cases and management) as 
healthy or more healthy than the parts more 
recently built. 
The subject is not one which can be passed 
over as dealing with an insignificant ques- 
tion, or one of verbal interest only. The 
doctrines which Sir James Simpson taught led 
him to deprecate altogether the construction 
of any hospital of considerable size, and to 
advocate the extravagant proposal above 
quoted for substituting small detached tem- 
porary sheds for our present permanent hos- 
pitals. The same views led Mr. Erichsen to 
say that when a hospital had become, as he 
1 On Hospitalism, p. 37. 
2 It is not, of course, meant that pyaemia, for in- 
stance, is seen as often in private as in hospital 
practice, because its causes are less often met with 
in the former than the latter ; but, if due allowance 
be made for this obvious consideration, there is 
much reason to acquiesce in the conclusion to which 
Sir James Paget's ample experience has led him, that 
pyaemia is just as frequent in private as in hospital 
practice (Clin. Soc. Trans., vol. vii. p. Ivi.) Ery- 
sipelas seems to be more frequent and more fatal in 
private practice than in hospitals. HOSPITALISM 
875 
phrased it, ' pyaemia-stricken,' it ought to be 
destroyed,1 while similar ideashave led others, 
such as the late Dr. Farr and Miss Nightin- 
gale, to question whether hospitals had not 
destroyed more lives than they had saved. 
Such doctrines should not be passed over in 
silence, since they exercise a great influence 
on the public, on whose co-operation the effi- 
ciency of our hospital system is to a great ex- 
tent based. And certainly a theory which has 
received the support, however qualified, of so 
eminent a hospital surgeon as Mr. Erichsen, 
cannot be considered as of no importance. 
It is therefore necessary to point out to 
the reader that the theory, as so stated (and 
stated quite correctly after Sir James Simp- 
son's writings), is utterly disproved by the ex- 
perience of all well-managed hospitals, both 
before and after the introduction of the anti- 
septic method of dressing wounds. It must 
be noticed, in the first place, that the basis 
of the theory was entirely what is called 
' statistics '-that is, a hasty inference from 
figures, showing the results of a large num- 
ber of cases on either side. Now nothing is 
more dangerous than to draw conclusions 
from such figures, which are quite unsup- 
ported by any histories of the cases on which 
they are founded.3 The success of a surgical 
operation depends more on the antecedents 
of the operation than on its consequents, and 
the healthiness of hospitals depends far more 
on other circumstances than on their con- 
struction, size, or age. Nay, more, the suc- 
cess of surgical operations does not neces- 
sarily vary with the healthiness of the hos- 
pital. In the healthiest hospital a careless 
surgeon, house-surgeon, or nurse may make 
havoc of the major operations while all is 
going on well with the general run of patients. 
For all these reasons, any one of which 
would be sufficient, the conclusions of Sir 
James Simpson are to be repudiated, and 
to be considered the more mischievous be- 
cause, while they allege imaginary causes of 
danger, they thereby conceal those which are 
real and certain, and necessarily induce sur- 
geons and managers of hospitals to overlook 
details, attention to which is always followed 
by success in the treatment of grave surgical 
cases. With such attention, a hospital may 
be brought into a condition not inferior to 
the best circumstances under which private 
practice is carried on. 
The writer must not be misunderstood, 
as if he thought the details of hospital-con- 
struction unimportant. The principles of 
construction which are now accepted for 
the building of a hospital will be found 
at page 879; but it has been shown to 
demonstration that, provided wards be well, 
but not excessively, ventilated, and kept 
perfectly clean, and provided also that the 
beds are far enough apart, the precise ground 
plan of the hospital matters little-that the 
doctrines so much insisted on by the French 
writers on hospitals as to the superiority of 
the ' pavilion plan,' as to the unhealthiness 
of upper storeys and so on, and which have 
been adopted as if they were unquestionable 
truths by many writers on the subject, have 
led to much waste of money on buildings too 
scattered for hospital service, which have 
turned out to be no healthier than the more 
compact and convenient structures which 
they superseded. But we ought not, in re- 
action from these exaggerations, to under- 
value the importance of good ventilation, 
good aeration, proper isolation of beds, and, 
above all, scrupulous cleanliness in hospital 
wards. These essentials being secured, the 
writer is persuaded that a hospital may be 
just as healthy with thirty wards as with 
three, with twenty patients in each ward as 
with two, and with five storeys as with one. 
Far more important, and far too little thought 
of, till within the last few years, is the amount 
of attention given to the personal care of the 
patients. This is particularly the case in the 
treatment of open wounds. Everyone who 
has been much in hospitals must have often 
seen, and especially abroad, surgeons, dressers, 
and nurses hurry from one patient to another, 
hardly washing or wiping their instruments, 
still less their hands, and using the same 
dressing materials for one case after another. 
Surgical practice cannot be safely carried on 
in this way, however healthy in itself the 
hospital may be. The first care of a surgeon 
in charge of hospital-wards ought to be to 
impress upon all his assistants, and never 
to forget in his own person, that the suc- 
cess of surgical practice depends more upon 
minute care in the dressing of cases than on 
all other matters put together. Our surgical 
wards have become far more healthy since 
the introduction of antiseptic surgery; and 
that this must be largely due to the increased 
care in the minutiae of surgical treatment 
which has followed on the discussion of this 
method is proved by the fact that the im- 
provement is as conspicuous in the practice 
of some of those who reject, as those who 
follow, Sir Joseph Lister's teaching.1 
If it were not true that the septic diseases, 
or erysipelatous diseases, which interfere so 
much with the success of operations in our 
hospitals, depend in a very large proportion 
of cases on the method of dressing the wound 
and not on matters conveyed by the atmo- 
sphere, how could the success of the so-called 
1 On Hospitalism, p. 98. 
2 The writer lays less stress on the total absence 
of any guarantee for the accuracy of Sir James Simp- 
son's table of cases in private practice, and is willing, 
for the sake of argument, to assume that the figures 
are correct. 
1 The late Mr. Callender stated it as his deliberate 
opinion that the great surgical operations were ten 
times more successful in hospitals than they used 
to be in the past generation. This was before the 
general use of Lister's method. 876 
HOSPITALISM 
' open method ' of dressing wounds be ex- 
plained ? In this method the wound is left 
freely exposed to that hospital air which is, 
we are told, charged with deadly miasma. 
But care is taken to see that the wound is 
well drained of all putrefiable discharges, and 
kept perfectly clean. If Sir James Simpson's 
theory were true, we ought to have an in- 
creased mortality following on the freer ex- 
posure to this deadly atmosphere. On the 
contrary, the perfect drainage of the wound, 
and the care taken to keep it free from all 
putrefying matters, are followed by results 
which can hardly be surpassed. Thus Dr. 
James Wood, of the Bellevue Hospital, New 
York, relates, that in wards which had been 
recently vacated on account of an outbreak 
of puerperal fever, he treated fourteen suc- 
cessive cases of unselected amputation of the 
limbs successfully, by merely leaving the 
flaps ununited, the raw surfaces exposed to 
the air, but carefully drained, and all putres- 
cible matters continually removed;1 and 
this is only one of many proofs which have 
recently been given of the fact that there 
are many other plans of treating wounds 
besides that which is specially designated 
* antiseptic,' under which, conjoined with 
proper construction and general manage- 
ment, a hospital may be as healthy as a 
private house. 
This statement, which is made after long 
experience, and with a conscientious con- 
viction of its truth, by no means asserts 
that it is as easy to keep a hospital healthy 
as a private sick-room; or, in other words, 
that the aggregation of the sick and wounded 
involves no dangers. Such a doctrine would 
be absurd ; but the dangers are the same in 
kind, and the precautions required are the 
same, with a single exception. Hospitals, 
like private houses, must be kept well-aired, 
well-drained, scrupulously clean, properly, 
but not excessively, lighted,2 and so forth. 
The great difference in the precautions re- 
quired to ensure the salubrity of hospitals 
and private houses is, in one word, to guard 
against direct infection, and this may occur 
in two ways. Surgically, infection is carried 
directly by careless dressing-and every hos- 
pital surgeon must have remarked that as he 
himself is more watchful and careful, and as 
he has the good fortune to be surrounded by 
more careful assistants, his cases do better ; 
and in the present healthy condition of most 
of our large London hospitals, such precau- 
tions of themselves suffice to raise the suc- 
cess of surgical practice to a level probably 
higher than it reaches in private houses. 
The second way in which infection may be 
carried is by direct proximity or contact. 
This is more important in medical cases, and 
the obvious danger of the spread of infectious 
fevers has led the managers of most of our 
general hospitals to exclude such diseases from 
their wards as small-pox, scarlet fever, and 
typhus, while other affections are admitted, 
which, though contagious, are so in a less de- 
gree, as typhoid fever, erysipelas, diphtheria, 
&c. Enough, or more than enough, has been 
done in this direction-that is, the public 
safety might be as well consulted if typhus 
and scarlet fever cases were still admitted 
(as before the institution of special hospitals 
for such cases they used to be) into the wards 
of our general hospitals in small numbers, 
and under strict precautions. Anyhow, it 
appears that there is little if any evidence 
of spread of disease from such cases reputed 
to be infectious as are still to be found in our 
general hospitals. Hearing that some dis- 
tinguished surgeons teach confidently that 
pyaemia and erysipelas are usually propa- 
gated by contagion, the writer has often 
watched the progress of such cases when 
originating in hospital or admitted from 
without, but has never been able to verify 
any spread of the disease from them, though 
he does not deny the possibility of such an 
occurrence. 
To sum up the whole matter-the writer 
would define the term ' Hospitalism ' as ex- 
pressing the danger which exists in hospitals 
of contamination from the aggregation of 
patients-and would add that the extent to 
which such contamination prevails has been 
greatly exaggerated by theoretical writers; 
that, as far as the general atmosphere of the 
ward is concerned, the danger may be, and 
appears in all well-managed hospitals really 
to be, obviated by ventilation and cleanli- 
ness ; and the more immediate danger from 
the contiguity of patients cannot be shown 
to produce any appreciable effect, while the 
danger of contamination of wounds by putre- 
fying materials demands constant vigilance 
to counteract it; but with such vigilance 
seems to be so far counteracted that hospital 
practice is probably more successful than 
private practice in similar cases. In support 
of this assertion the following facts are sub- 
mitted. 
Phagedaena, pyaemia, and erysipelas, ori- 
ginating in the hospital, are the affections uni- 
versally admitted as tests of the healthiness 
of the wards, or (to use Sir James Simpson's 
words) of the existence of Hospitalism. In 
reviewing, a short time ago, his own career as 
assistant-surgeon and surgeon to St. George's 
Hospital, the writer had occasion to examine 
the past and present records of its practice 
-records, he may say, more perfect and 
more available than exist, as far as he 
knows, at any other hospital; for detailed 
notes are preserved of every case, and are so 
1 New York Med. Joum., Jan. 1876. 
2 Most of our hospitals are too light, and too de- 
stitute of the means of excluding the light. No 
doubt a flood of light in the ward is very useful 
in detecting dirt, but it sadly interferes with the 
repose which many medical and surgical cases 
require. HOSPITALISM 
HOSPITALS, ADMINISTRATION OF 
877 
tabulated as to be immediately accessible. 
First, with regard to phagedaena, whether in 
the milder form, to which the name is often 
restricted, or in the more formidable slough- 
ing variety spoken of as ' hospital gangrene,' 
the affection is now unknown ; only three 
cases having been admitted with venereal 
phagedaena, and none having broken out in 
the wards, during a period of five years. 
Next, with regard to pyaemia, there had 
been fifteen cases in the wards during three 
years, eight of which were admitted with the 
disease. Of the seven cases occurring in the 
hospital, one was puerperal in a patient ad- 
mitted for another cause; three after sup- 
purative affections-viz. carbuncular abscess, 
acute periostitis, and diffuse cellulitis-i.e. 
after various forms of blood-poisoning which 
had preceded admission; and three only 
after surgical operations of all kinds, and in 
one of these (who was under the writer's 
own care) the diagnosis was doubtful-the 
man recovered. One of the other cases was 
an operation for stricture and perineal ab- 
scess, where the wound could not be kept 
aseptic. The last was after an amputation 
in which the surgeon (who was again the 
present writer) had probably amputated too 
near the suppurating tissues. As to ery- 
sipelas, a large number of cases of phleg- 
monous erysipelas were admitted; but there 
was no record of the outbreak of this disease 
in the hospital. Cutaneous erysipelas was 
freely admitted into the ordinary wards, and 
a few sporadic cases originated in the wards, 
but almost always of a very mild type. 
During the two last complete years included 
in this survey, there had been thirty-one 
cases on the whole-twenty-three admitted 
and eight originating in tlie wards. Only 
one death occurred out of the whole thirty- 
one, in a drunkard admitted with scalp- 
wound. Delirium tremens and erysipelas 
supervened, and he died in a few days, 
whether of the delirium or the erysipelas 
could not be determined. 
There is no reason to believe that other 
hospitals are in any respect inferior to St. 
George's, so that there seems fair cause for 
saying that ' Hospitalism ' has no existence 
in the institutions of the present day in this 
country, if we are to understand by that 
term any condition cf the hospital which 
exposes a patient to greater risk after injury 
or operation than he would run if treated at 
home. T. Holmes. 
HOSPITALS, Administration of.- 
The administration of a hospital should be so 
framed as to enforce the necessary economy 
consistent with the due supply of the require- 
ments for the sick. 
Governing Body.-The form of govern- 
ment depends to some extent upon the au- 
thority under which the hospital is placed; 
that is to say, whether the hospital is a 
foundation or subscription hospital; a hospital 
established by a municipality or corporation; 
or a military or naval hospital under the 
Government. 
But there are certain general principles 
which must in all cases be observed, without 
which proper discipline throughout the seve- 
ral branches of the administration will not 
be secured. 
The government may be by means of a 
governor, or by a committee, on which the 
professional element should be represented. 
It provides for the general supervision and 
discipline of the establishment, and for the 
financial arrangements. It controls the ap- 
pointment and removal of all members of 
the staff of the hospital. It makes all general 
regulations, after consultation with the pro- 
fessional department, as to internal economy, 
admission and discharge of patients, distri- 
bution of beds, dietary, and other matters. 
It regulates the expenditure. In hospitals 
supported by subscription, it raises the funds 
for supporting the institution. 
Governor or Treasurer.-In large founda- 
tion or subscription hospitals, and in military 
and naval hospitals, there is a resident repre- 
sentative of the governing body, generally 
termed Governor or Treasurer, who exercises 
a general supervision over the structure and 
the discipline of the establishment. 
Secretary or Steward.-The chief execu- 
tive officer immediately under the governing 
body is called the Steward, or sometimes 
the Secretary. He has the control of all 
servants not included in the nursing staff- 
such as porters, ambulance-men, engine- 
man, bath-assistants, and other male attend- 
ants. He sees that all structural appliances 
are in good order, and that cleanliness and 
discipline are maintained throughout the 
building. He controls the issue of all orders 
for the supply of goods, provisions, fuel, &c., 
and watches that they are used with a due 
regard to economy. He countersigns all 
orders for payment after they are passed by 
the treasurer, and is responsible for the hos- 
pital accounts. He sees that the records of 
admission, discharge, and death are duly kept 
by the professional staff. He is responsible 
for the safe custody of clothing, money, and 
property brought in by the patients, till their 
discharge. He has charge of the correspon- 
dence. 
Cleric or Assistant Steward.-The secre- 
tary or steward is assisted by an assistant or 
clerk. This latter receives all provisions and 
stores, sees that they are correctly delivered, 
and is responsible for their safe custody until 
distributed to an authorised person. He sees 
that the diet-tables are prepared from the 
prescription-papers, and that the articles of 
food supplied to patients are strictly in ac- 
cordance with the diet-tables, or else specially 
ordered by the physician or surgeon. 
Professional Staff.-The professional staff 878 
HOSPITALS, ADMINISTRATION OF 
directs the proceedings to be taken for the 
well-being and cure of the patients. It con- 
sists of the consulting and visiting physicians 
and surgeons; the assistant physicians and 
surgeons; and the resident and house physi- 
cians and surgeons, and assistants continually 
present in the hospital. 
Medical Committee. - The professional 
staff forms a medical committee with a speci- 
fied quorum. This committee is consultative 
only, and should be consulted by the governing 
body on all matters concerning the medical 
and surgical departments of the hospital, 
the admission and discharge of patients, the 
distribution of beds, the dispensary, the in- 
patients, the out-patients' department, and the 
students. The medical committee, more- 
over, puts forward recommendations for the 
purchase of instruments, apparatus, and 
medicines. The committee provides for a 
descriptive record of cases admitted into the 
hospital, and for the efficient instruction of 
students. 
Physiciansand Surgeons.-The physicians, 
surgeons, assistant physicians, and assistant 
surgeons undertake the charge of the wards 
and out-patients' departments,.and attend at 
the hospital at fixed times. The physicians 
and surgeons order the diet of the patients; 
and no article of diet which does not appear 
in the diet-tables is supplied unless specially 
ordered by them. 
Resident Medical Officers.-The resident 
medical officers control the treatment of 
patients in the absence of the physicians 
and surgeons ; and have a disciplinary con- 
trol over the dressers and clinical clerks. 
They decide on the admissibility or other- 
wise of applicants for relief, when not ad- 
mitted directly by the physicians and sur- 
geons, as well as on the wards in which the 
in-patients are to be placed, and are respon- 
sible for their care until seen by the physi- 
cians and surgeons. They visit the wards 
and dispensary, according to the regulations, 
to see that the patients are duly attended 
to. They superintend the conduct of the 
assistants of the medical officers, and of the 
dispenser and his assistants, of pupils (if any), 
and of patients; give notice of any misconduct 
of the nurses and servants to the matron or 
lady superintendent; and inform the gover- 
nor or secretary, the physician, surgeon, and 
governing body, of any matter requiring their 
attention. They are responsible that the 
records of cases are properly made out. In 
most cases, however, this duty is now per- 
formed by registrars. 
Dispenser.-The dispenser acts under the 
resident medical officer, subject to regulations 
laid down by the governing body. 
Nztrsing Department.-The nursing de- 
partment is under a trained matron, who 
should be lady superintendent of the training 
school, and head of all the women employed 
in the hospital. 
Matron or Lady Superintendent.-The 
whole responsibility for nursing, internal 
management, care of linen and housekeep- 
ing, and the discipline and training of nurses 
is vested in the trained female head of the 
nursing staff, by whatever title she be called. 
To the governing body of the hospital she is 
responsible for the conduct, discipline, and 
duties of her nurses. To the governing body 
and the physicians and surgeons in charge 
of wards she is responsible for the care and 
cleanliness of the wards, for the care and 
cleanliness of the sick, and for the linen. 
She is responsible to the medical officers 
that their orders about the treatment of the 
sick are strictly carried out. .To fulfil these 
responsibilities, she has the power of en- 
gaging, appointing, and dismissing all nurses, 
female servants, and probationers, subject, of 
course, to the general control of the govern- 
ing body. The nursing establishment cannot 
be made responsible on the side of discipline 
to the medical officers, or the governor of 
a hospital. Simplicity of rules, placing the 
nurses in all matters regarding management 
of the sick absolutely under the orders of the 
medical staff, and in all disciplinary matters 
absolutely under the lady superintendent or 
matron, to whom the medical officers should 
refer all cases of neglect, is essential to due 
discipline and efficiency. Any remissness or 
neglect of duty is as much a breach of disci- 
pline as drunkenness or other bad conduct, 
and can only be dealt with to any good pur- 
pose by report to the matron. But neither 
the medical officer nor any other male head 
should ever have power to punish for dis- 
obedience. His duty should end with report- 
ing the case to the female head, who is re- 
sponsible to the governing authority of the 
hospital, as all her nurses and servants, in 
the performance of their duties, are imme- 
diately responsible to the matron only. If 
the matron or lady superintendent does not 
exercise the authority entrusted to her with 
judgment and discretion, it is then the legi- 
timate province of the governing body to 
interfere and to remove her. 
The matron resides in the hospital where 
her nurses and probationers are at work. 
In a hospital of, say, above 300 beds, and 
with a training school of, say, above twenty 
probationers (which all such hospitals ought 
to include), the trained matron should have 
three trained representatives or assistants- 
one in the training school as mistress of 
probationers or home-sister ; and two in the 
hospital-one by day as assistant matron (or 
superintendent), and one by night as night 
superintendent of nurses ; and of these two 
the night representative is the more impor- 
tant. Besides the trained assistant matron 
(superintendent), who should have such in- 
spection of the wards as the matron may 
commit to her, the matron will require one 
linen-assistant and housekeeper, who might HOSPITALS, ADMINISTRATION OF; AND CONSTRUCTION OF 
879 
also have the charge and inspection of the 
nurses' rooms, if the trained assistant matron 
has not time. She should ' mother ' the ward- 
maids, and have some ' gathering ' for them. 
Nurses and Servants.-Under the matron 
there should be distinct grades of nurses, and 
distinct duties for each grade: 1. Trained 
chief nurses (ward-sisters'). 2. Trained nurses 
(day). 3. Trained nurses (night), at least 
equal in pay and status to the day-nurses. 
4. Probationers in training. 5. Ward-maids, 
and nursemaids for children's wards. 6. 
Dormitory and stairs women. 7. Female 
cook, and her assistants under the house- 
keeper. The hospital cook in a large hospital 
would probably be a man, and under the 
steward. The sisters, nurses, and proba- 
tioners would require a female cook, under 
the matron. All women employed in the 
hospital should reside in the institution. 
Night Superintendent. - The (trained) 
night superintendent of nurses should be in 
charge of the night-nursing, in communica- 
tion with the ward-sisters, as well as of the 
night-nurses, and should see that the venti- 
lation and temperature of the wards is main- 
tained, as directed by the medical staff. She 
must be one qualified not only to have charge 
of nurses and have some ' gathering ' for 
night-nurses by day, but to train probationers 
told off to accompany her at night, to their 
own benefit and hers. 
Assistant Matron.-The assistant matron 
is to have special charge over the nurses' 
rooms, to see that the nurses rise in time to 
wash themselves, strip their beds, empty 
their slops, and have breakfast, before going 
on duty; that later they make their beds and 
put their rooms in order; that they never 
wash their own clothes in their own rooms 
(for all nurses' washing should be done for 
them); that they go quietly to bed at night, 
and lights be put out at a certain hour; that 
their rooms are always clean, in order, whole- 
some, and cheerful. Without this constant 
supervision, what is necessary for the nurses' 
health is not done; the same for night-nurses 
is yet more important. Nurses' meals should 
always be presided over by some such autho- 
rity. 
The hospital night-nurses should have two 
hot meals in the common dining-room-it 
might be in the probationers' home-say, at 
9.30 a.m. and 9.30 p.m., ready and prepared 
for them. And sisters, staff-nurses, and 
ward-maids should have, though at different 
hours-as all cannot be absent from the 
wards at once-dinner and supper, each set 
together in a common dining-room, away 
from the ward air. No nurse should have to 
prepare her meals for herself. 
Laundry- In small and moderate-sized 
hospitals, when there is a laundry attached 
to the hospital, the supervision should be 
under the lady superintendent or matron. 
In large hospitals, it would be advisable for 
the laundry, which should in all cases be in 
a building entirely detached, to be worked 
independently, under the general supervision 
of the governor or secretary. 
Chaplain.-The religious care of the 
patients is generally provided for by the 
appointment of one or more permanent 
chaplains, or by visits and religious services 
of other ministers whom the patients may 
desire to attend them; subject, however, to 
the opinion of the medical attendant, as to 
how far the state of health of the patient will 
admit of such visits, and to the visits being 
made at such times as do not interfere with 
the discipline of the hospital. 
Douglas Galton. 
HOSPITALS, Construction of.'-A 
hospital or infirmary is a building intended 
for the reception and treatment of sick and 
injured persons, under conditions favourable 
for their recovery. 
A hospital must be so constructed and 
arranged as to enable a limited staff of 
medical men, nurses, and assistants to minis- 
ter to the necessities of a large number of 
sick, and to promote their speedy restoration. 
The conditions essential for such objects are 
as follows:- 
(1) Pure air. There should be no appre- 
ciable difference in purity between the air 
inside the wards and that outside the build- 
ing. 
(2) The air supplied should be capable of 
being warmed to any required extent. 
(3) Pure water should be supplied for 
internal use, and sufficient also to ensure the 
removal of impurities to a distance from the 
hospital. 
(4) The most perfect cleanliness within 
and around the building should be enforced. 
These conditions depend on- 
(1) The site of the proposed hospital. 
(2) The form of the rooms or wards in 
which the sick are to be placed, so as to en- 
sure purity of air and convenience of nursing; 
these rooms forming the principal units of 
hospital-construction. 
(3) The distribution of these units, and of 
the other accessories which, combined, con- 
stitute the hospital. 
1. Sites of Hospitals.-The local cli- 
mate should be healthy, and there should 
be a free circulation of air over the district. 
Town sites should be avoided as far as pos- 
sible. When necessarily placed in a town, a 
space free from buildings should be reserved 
on all sides. There should be no nuisances, 
damp ravines, muddy creeks, undrained or 
marshy ground, near the site, or in such a 
position that the prevailing winds would blow 
effluvia arising from them over the hospital. 
1 This article has reference more especially to 
permanent general hospitals. The principles apply 
equally to special temporary field or other institu- 
tions for ' the cure of the sick.' 880 
HOSPITALS, CONSTRUCTION OF 
The site selected for a hospital should not 
receive the drainage of higher ground, and 
the natural drainage outlets should be suffi- 
cient. There should, if possible, be no build- 
ings near a hospital except those connected 
with its object. The number of sick to be 
allowed per acre will depend practically upon 
the arrangement of the buildings in which 
they are lodged. 
2. Form and Distribution of the 
Pai'ts of a Hospital.-The structural 
arrangements of a hospital should be such 
as to secure free circulation of air. 
The Ward.-The basis upon which the 
structural arrangements rest is the ward. 
The administration, means of access, and 
discipline must be made subsidiary to the 
question as to how the sick are to get well 
in the shortest possible time, and at the 
least expense; and this, so far as the struc- 
ture is concerned, is mainly determined by 
the form of the wards. 
Size.-1The size of a ward depends upon 
the number of patients who are to occupy 
it, and upon the cubic space and floor 
space which should be allotted to each 
patient. The disciplinary and economical 
dispositions in a hospital require that each 
head-nurse should have the patients allotted 
to her placed under her immediate eye. 
Economy of labour requires that the hospital 
should be so laid out as to enable the largest 
number of patients to be nursed by a given 
number of nurses. The number to be placed 
in a ward therefore depends upon the number 
which can be efficiently nursed; and the 
form of the ward must be as much calculated 
to facilitate nursing, as to ensure free circu- 
lation and change of air. From twenty to 
thirty-two beds have been taken as the unit 
for ward-construction. In hospitals where 
cases of more than ordinary severity are 
likely to be received, it would be necessary 
to diminish the size of the wards on grounds 
of health. Small wards containing one or 
more beds are also required for isolating 
certain cases or for various necessary objects. 
Conditions regulating ward-construction. 
The general form of ward-construction is 
mainly governed by the question of the re- 
newal of air. The air within an inhabited 
space, enclosed on all sides, is vitiated by 
the emanations proceeding from the bodies 
of those who inhabit it, and especially by 
the effect on it of their respiration. In all 
sickness, and all surgical cases, wounds with 
discharge, or sores, these emanations are 
greater in quantity, and more poisonous in 
quality, than from persons in health ; whilst, 
at the same time, most cases-medical and 
surgical-are more susceptible to these ema- 
nations. Stagnation in the movement of 
the air leads to rapid decomposition of these 
emanations. If they diffused themselves 
uniformly throughout the space, which in 
fact they do not, ventilation would be com- 
paratively simple, and, whatever the cubic 
space, the air would attain a permanent 
degree of purity, or rather impurity, theo- 
retically dependent upon the rate at which 
emanations are produced, and the rate at 
which fresh air is admitted. Hence the 
same supply of air would equally well 
ventilate any space ; but the larger the cubic 
space, the longer it will be before the air in 
it attains its permanent condition of im- 
purity, and the more easily will the supply 
of fresh air be brought in without altering 
the temperature, and causing injurious 
draughts. The amount of air which should 
be removed, and its place supplied with fresh 
air, is at least 3,000 cubic feet per patient 
per hour; but this must depend to some 
extent upon the emanations of the patients, 
which vary with the diseases or injuries they 
are suffering from. The ventilation of each 
ward should be kept independent of other 
wards or rooms. 
Means of ventilation.-The change of air 
may be effected in various ways. For in- 
stance, the air may be drawn out by a fan ; 
or it may be removed by a shaft, whose 
action depends on the difference of the tem- 
perature of the air in the shaft and that in 
the outer atmosphere. Of this the ordinary 
fireplace is one example ; a caldron of water 
kept boiling for the use of the hospital by a 
steam pipe is another; a sunlight is a further 
example ; and a heated shaft connected with 
flues led from holes in the wall near the 
patients' beds, through each of which air is 
drawn into the shaft, is another method. 
Theoretically it is thus quite possible so to 
arrange the ventilation mechanically that a 
specified quantity of air at a fixed tempera- 
ture shall be brought into the ward by day 
and by night. Practically, however, hos- 
pitals dependent upon such means alone for 
ventilation require an attention which they 
can rarely or never receive, and, except under 
favourable circumstances, are not healthy. 
The emanations from the body do not 
uniformly diffuse themselves; they hang 
about as the smoke of tobacco may be said 
to do. In wards into which a fixed quantity 
of air is forced, there is not even a uniform 
degree of impurity ; consequently it is neces- 
sary, in order to ensure the purity of the air 
of a ward, that means should exist for abso- 
lutely sweeping out at intervals all the 
impure air from it, and starting afresh with 
pure air. This is best effected by the direct 
action of currents of fresh air brought in by 
open windows placed on opposite sides of 
the wards. The distance between windows 
for this purpose must not be too great to 
prevent their efficient action in moving the 
air. Twenty-four feet is a good width, but 
opposite windows for such an object should 
in no case be more than from thirty to 
thirty-five feet apart. The space between 
the windows should not be obstructed by HOSPITALS, CONSTRUCTION OF 
881 
walls or partitions. The number of patients 
■-that is to say, the sources of impure ema- 
nations-placed between opposite windows, 
should be limited to two rows. In the day- 
time, and when the weather admits of open 
windows, a ward with windows opening on 
both sides can easily be kept fresh ; but for 
other seasons it is necessary to provide 
openings for the escape of impure air, and 
for the admission of fresh air which shall 
not cause draughts. 
For the purpose of removal of air, shafts 
carried up from near the ceiling-level to 
above the roof are convenient, the lower 
ends being louvered to prevent patients feel- 
ing down-draughts which may occasionally 
prevail. The most powerful engine of venti- 
lation for drawing out the air is an open 
fireplace. 
In order to prevent the temperature of the 
ward from being lowered by the extraction 
of air, that is, to maintain an equable tem- 
perature and to prevent draughts, air 
warmed to a moderate degree should replace 
that removed by the fireplace or by other 
openings. Means for the admission of air in 
an upward current should be provided direct 
from the open air, independently of the win- 
dows and doors; for this purpose tubes with 
bends, which favour the collection of dirt, 
are objectionable. Sherringham's ventilators, 
which are easily cleaned, placed between 
the windows near the ceiling, answer well; 
they admit the air without perceptible 
draught, and also frequently act as outlets 
when open on the leeward side of a ward. 
The external air may be warmed as it enters 
by being made to pass over hot-water or 
steam tubes. Openings, if placed close to 
the floor under the beds, should be capable 
of being easily and securely closed. All 
openings for the admission of fresh air 
should be so placed as to be easily examined 
and cleaned throughout their whole length, 
and this should be done at least once a year. 
Superficial area.-The next most impor- 
tant element in the question of ward-con- 
struction is the superficial area to be allotted 
to the patients, which is even more important 
than cubic space, for on this depends the 
distance of the sick from each other, the 
facility of moving round the sick, shifting 
beds, cleanliness, and other points of nursing. 
In connexion with this it is convenient to 
allude to the question of circular wards. The 
circle affords a maximum of area in propor- 
tion to the perimeter, whilst the rectangular 
form affords a large perimeter in proportion 
to the area. Therefore, with a given floor- 
space the rectangle affords a large wall-space 
for the beds, whereas the circular form affords 
a small wall-space, and the beds must con- 
sequently be placed close together, whilst the 
large part of the area enclosed is in the 
centre of the ward, away from the beds, 
which is a disadvantage. If there be a medi- 
cal school attached to the hospital, the ques- 
tion of area has to be considered with reference 
to affording the largest amount of accommo- 
dation practicable for the teacher and his 
pupils, without their breathing up the patients' 
air. A ward with windows improperly placed, 
so as not to give sufficient light, or where the 
beds are so placed that the nurse must neces- 
sarily obstruct the light in attending to her 
patients, will require a large floor-space, be- 
cause the bed-space must be so arranged, and 
of such dimensions, as to allow of sufficient 
light falling on the beds. In well-constructed 
wards with opposite windows, the greatest 
economy of surface-area can be effected, be- 
cause the area can be best allotted with refer- 
ence both to light and to room for work. In 
a ward 24 feet in width, with a window for 
every bed or every two beds, a 7 ft. 6 in. bed- 
space along the walls would probably be 
sufficient for nursing purposes. This would 
give 90 square feet per bed, and there should 
be as little reduction as possible below this 
amount for average cases of sickness; but 
this space is much too small for surgical, 
fever, or lying-in wards, which should also 
be for a much smaller number. The Herbert 
Hospital, without a medical school, has 99 
superficial feet per bed; St. Thomas' Hospital, 
with a medical school, has 120 superficial feet 
per bed. The bed-space should be larger if 
the locality is less healthy. 
The area allotted to patients practically 
settles the cubic space, because wards should 
not be less than 12 feet high, though as 
a rule they need not exceed 14 feet in 
height. 
In a good situation, and for ordinary cases 
of disease, those spaces which are enough for 
nursing and for ward-administration would, 
with good ventilation, be sufficient for all 
sanitary purposes; but for such cases as 
typhus or other infectious diseases, opera- 
tions, and bad surgical diseases, a larger 
space and area would be required. When 
severe cases of this class come into an ordin- 
ary hospital, the simplest plan is to leave the 
bed vacant adjacent to that occupied by the 
patient. 
Lying-in wards should never contain more 
than from one to four beds. In recent French 
hospitals these wards contain one bed each, 
and the only access to them is from an open 
verandah and through a small ante-room. 
Ovariotomy, and other operations of the 
like risk, should be performed in a one-bed 
ward. When space permits, a room may be 
provided for the use of patients when con- 
valescent, and able to be temporarily absent 
from the wards. The same observation ap- 
plies to grounds for outdoor exercise. But 
separate convalescent hospitals or homes are 
better, both for health and discipline. If 
hospitals are provided for special infectious 
diseases, every patient should be placed 
in a separate hut-ward. Cleanliness and 882 
HOSPITALS, CONSTRUCTION OF 
abundance of fresh air is the best safeguard 
against infection. 
Materials.-With a view to economise heat 
in winter, and to keep the rooms cool in 
summer, the walls should be hollow, and all 
wards should be ceiled, unless the roof is 
constructed of a good non-conducting mate- 
rial. The best lining for a hospital- ward is 
an impervious polished surface, which on 
being washed with soap and water, and dried, 
would be made quite clean. Plaster, wood, 
paint, and varnish all absorb the organic 
impurities given off by the body. Parian 
cement polished is the best material at pre- 
sent known for walls, but it is costly, and it 
can only be applied on brick or stone walls, 
and not on woodwork, because, being inelastic, 
it is liable to crack. Cracks in a hospital 
ward are inadmissible, as they get filled with 
impurities, and harbour insects. The numer- 
ous joints required for glazed bricks, or tiles, 
render the use of these questionable for wards. 
In default of Parian cement, the safest arrange- 
ment is plaster lime-whited or painted, which 
should be periodically scraped, and be then 
again lime-whited or painted. 
The floor should be as non-absorbent as 
possible, and for the'sake of warmth to the 
feet it must in this country be of wood. Oak, 
or other close hard wood, with close joints, 
oiled and beeswaxed, and rubbed to a polish, 
makes a very good floor, and absorbs little 
moisture. The joints should be like those 
of the best parqueterie, affording no inlet for 
dirt. There should be no sawdust, or other 
organic matter subject to decay, under the 
floor. "When a ward is placed over another, 
it is essential that the floor should be non- 
conducting of sound, and that it should be so 
formed as to prevent emanations from patients 
in the lower ward passing into the upper 
wards. Practically, with care, a well-laid 
oak floor, with a good beeswaxed surface, 
can always be kept clean by rubbing. 
There should be as little woodwork as 
possible in a ward, besides the floor; and 
what woodwork there is should be varnished, 
so as to admit of easy washing and drying. 
The cleanest and most durable material is 
varnished light-coloured wainscot oak or 
teak. 
The form of the windows must be con- 
sidered, in their aspect of affording light as 
a necessary means of promoting health, of 
affording ventilation, of facilitating nursing, 
and of enabling the patients to read in bed. 
Light can always be modified for individual 
patients. In order to give cheerfulness to 
the wards, and to renew the air easily, the 
windows should extend from within 2 feet or 
2 feet 6 inches from the floor-so that the 
patients can see out-to within 1 foot from 
the ceiling. An end window to a long ward 
is an element of cheerfulness, and materially 
assists the renewal of the air at night. It is 
essential to cleanliness that every part of the 
ward should be light. One superficial foot of 
window-space to from 50 to 55 cubic feet of 
space, will afford a light and cheerful room, 
but this depends much on aspect and upon 
the walls being light-coloured. To economise 
heat in wards, it is desirable to make the 
windows of plate glass; double windows of 
ordinary glass would secure the same object 
and facilitate ventilation,but they are trouble- 
some to clean, and give a gloomy appearan je 
to a room. The best form of sash for ventila- 
tion in this climate is the ordinary sash, 
opening at top and bottom ; but windows 
made in three or four sections, each of which 
falls inwards from an axis at the bottom of 
the section possess many advantages for 
hospitals. 
Ward-offices.-The ward-offices are of two 
kinds:- 
(1) Those which are necessary for facilita- 
ting the nursing and administration of the 
wards, as the head-nurse's room and ward- 
scullery. 
(2) Those which are required for the direct 
use of the sick, so as to prevent any unneces- 
sary processes of the patients taking place in 
the ward; as, for instance, the ablution-room, 
the bath-room, the water-closets, urinals, and 
sinks for emptying slops. There ought to be, 
in addition to the bath-room here mentioned, 
a general bathing-establishment attached to 
every hospital, with hot, cold, vapour, sul- 
phur, medicated, shower, and douche baths. 
Hot and cold water should be laid on to all 
ward-offices in which the use of either is 
required, because of the economy of labour 
in the working of the hospital. For the 
same reason, when the wards are on two or 
more floors, lifts should be provided to carry 
up coals, trays, and patients. The ward- 
offices should have ample window-space. 
There should be no dark corners or closed 
spaces under sinks. Nothing should be kept 
in these offices which is not in constant use, 
and everything in use should be open to 
inspection. All fittings should be light- 
coloured, so as to show dirt. 
(1) The head-nurse or sister's room should 
be sufficiently large to contain her bed and 
to be also her sitting-room. It should be 
light, airy, and well-ventilated. It is neces- 
sary to discipline that it should be close to 
the ward-door, and that it should when prac- 
ticable have a window looking into the ward. 
If the head-nurse has two wards to supervise, 
her room should be placed between the two, 
with a window opening into each. 
There should be a ward-scullery to each 
ward, and so situated as to be under the 
head-nurse's eye. The scullery should be 
supplied with efficient simple apparatus for 
its purposes : there should be a small range 
for ward-cooking, so that the nurse can 
warm the drinks, prepare fomentations, &c. 
Shelves or racks should be provided. There 
should also be a small larder, with free cir- HOSPITALS, CONSTRUCTION OF 
883 
culation of air, for temporarily keeping pro- 
visions fresh. In the scullery, or adjacent to 
it, a hot closet should be provided for airing 
clean towels and sheets. Foul linen should 
not be retained near the wards, or in the 
hospital building. It should all be placed in 
baskets, on wheels, and conveyed as soon as 
possible to the laundry. Ward sweepings 
and refuse should similarly be placed in 
movable receptacles, and taken out of the 
building with as little delay as possible; 
structural provision for the retention of these 
in or near the hospital is undesirable. 
(2) The ablution-room, water-closets, <&c., 
ought to be as near as possible to the ward, 
but cut off from it by a lobby, with windows 
on each side, having its ventilation and 
warming distinct from that of the ward and 
that of the ward-offices, so as to prevent the 
possibility of foul air passing from the ward- 
offices into the wards. The ward-offices will 
be most conveniently placed at the end of 
the ward farthest from the entrance and 
nurse's room; and distributed at each side, 
so as to enable the ward to have an end 
window. In this arrangement the ab]ution- 
room would be on one side of the ward, and 
should contain a small bath-room with a 
fixed bath of copper, supplied with hot and 
cold water. A lavatory-table of impervious 
material, such as slate or common marble, 
with a row of sunk porcelain basins with 
outlet tubes and plugs, each basin supplied 
with hot and cold water, should be placed in 
the same compartment as the bath, but sepa- 
rated from it by a partition and door. There 
should also be room for a portable bath for 
each ward; and there should be a sink on the 
floor-level for running off the water from the 
bath after it has been used. 
On the other side of the end window of 
the ward would be placed the water-closets. 
These should never be against the inner wall, 
but always against the outer wall of the com- 
partment in which they are placed. A pan 
of a hemispherical shape, never of a conical 
shape, with a syphon, abundantly supplied 
with water to flush it out all round with a 
large forcible stream, is the best contrivance 
for the water-closet of a hospital. The urinal 
should be of a shape to be easily cleaned. 
The sink for slops, bed-pans, expectoration- 
cups, &c., which should have a compartment 
of its own adjoining the water-closets, should 
be a large, deep, round, pierced basin of 
earthenware, with a cock extending far 
enough over the sink for the stream of 
water to fall directly into the vessel to be 
cleaned, and with an ample supply of water 
in a full stream; this sink should be so ar- 
ranged as to be flushed out like a water- 
closet pan, and it should be so placed as to 
make it unnecessary for male patients to pass 
the nurse on their way to the w.c. There 
should be a special receptacle near the sink, 
ventilated to the outer air, for keeping cham- 
ber utensils, &c., for the examination of the 
medical officer. 
Walls of ablution-rooms and water-closets 
should be covered with white glazed tile, 
slate (enamelled or plain), or Parian cement; 
plaster is not a good covering for them on 
account of their liability to be splashed, and 
of the necessity for their being frequently 
washed down. There should be separate 
private water-closets for the nurses; and also 
water-closets for the patients when in day- 
rooms or recreation-grounds. The ablution- 
room and water-closets should be supplied 
with plenty of fresh air, warmed when neces- 
sary, and abundance of light, so as to ensure 
there being no dark corners. Three water- 
closets per ward will suffice for a ward of 
thirty-two beds, but two at least will be 
required for even a twelve-bed ward. 
The water-supply should provide, in ad- 
dition to pure water for general consumption, 
a service of distilled water for dressings and 
such-like purposes. 
3. Aggregation of Ward-Units in 
the Construction of a Hospital.-The 
principles upon which these units of hospital- 
construction, or, as they are generally termed, 
pavilions, when so constructed, should be 
aggregated, are as follows :- 
(1) There should be free circulation of air 
between the pavilions. 
(2) The space between them should be ex- 
posed to sunshine, and the sunshine should 
fall on the windows, for which purpose it is 
desirable that the pavilions should be placed 
on a north and south line. 
(3) The distance between adjacent pavili- 
ons should not be less than twice the height 
of the pavilion reckoned from the floors of 
the ground-floor ward. This is the smallest 
width between pavilions which will prevent 
the lower wards from being gloomy in this 
climate ; where there is not a free movement 
of air round the buildings, this distance 
should be increased. 
(4) The arrangement of the pavilions should 
be such as to allow of convenient covered 
communication between the wards, without 
interfering with the light and ventilation, 
and therefore the top of the covered corridor 
uniting the ends of pavilions should not be 
carried above the ceiling of the ground-floor 
wards. Each block of wards-that is, each 
pavilion-should have its own staircase. 
(5) No ward should be so placed as to form 
a passage-room to other wards. 
(6) As a general rule, there should not be 
more than two floors of wards in a pavilion. 
If there are three floors or more, the distances 
between the pavilions become very consider- 
able because of the rule already mentioned, 
which ought to be absolutely observed, which 
regulates the distance at which the pavilions 
must be kept apart. Besides, when two wards 
open into a common staircase, there is, with 
every care, to some extent a community of ventilation; this will prevail even if the stair- 
case be furnished with permanent openings 
to the outer air. When there are as many as 
four wards one over the other, the staircase 
becomes a powerful shaft for drawing up to 
its upper part, and thence into the ward, the 
impure air of the lower wards. Similarly, 
heated impure air from the windows of the 
lower wards has occasionally a tendency to 
pass into the windows of the wards above. 
For the same reason the upper floor over 
the wards should not be used as a dormi- 
tory for nurses. Similarly, if there is a base- 
ment under sick wards, it should not be used 
for any purpose, such as cooking, or for the 
reception of perishable stores, from which 
smells could penetrate into the wards; and it 
is best not to continue the staircase into the 
basement, for with every care the basement 
will always form a receptacle for ground air, 
which should be kept out of the hospital if 
possible. 
There is a limit to the numbers which 
should be congregated under one roof. This 
limit will depend very much on the nature 
of the cases. In town hospitals, a double 
pavilion should not contain above 80 to 100 
beds. 
The size of any given hospital ought not 
to be determined by increasing the number 
of beds in any one building, but by increasing 
the number of units or wards. So far as the 
sick are concerned, they would be better 
placed in single detached wards ; or, for con- 
venience of administration, in wards all on 
one floor-opening out of a common corridor. 
But on town sites the cost of land makes it 
absolutely essential to build hospitals as com- 
pactly as possible; moreover, economy in the 
current expenses will be best secured by a 
building with wards on two or more floors, 
provided with lifts and other labour-saving 
appliances. 
In addition to the larger wards, it is neces- 
sary, as already stated, to have a few wards 
of one or two beds each for special cases. 
Corridors should connect the pavilions on 
the level of the lower floor of wards only. 
They should be kept as low as possible, so as 
not to impede the circulation of air between 
the pavilions; they should be lighted by 
windows on both sides, opening widely, or 
removable in warm weather ; and they should 
be provided with ample means of ventilation, 
and with fresh warmed air in cold weather, 
so as to prevent draughts. 
The staircases should be treated similarly 
as to light and ventilation, and it is desirable 
to cut off the connecting corridors from ad- 
jacent staircases by swing-doors. These 
arrangements prevent draughts, and cause 
the passages and staircases effectually to cut 
off the ventilation of one pavilion from that 
of another. 
The staircases for patients should be 
broad and easy; the rise of each step should 
884 
HOSPITALS, CONSTRUCTION OF 
not exceed four inches in height, and the 
tread should be at least one foot in width ; 
there should be a handrail on each side, and 
a landing after every six or eight steps pro- 
vided with seats. The patients in their beds 
may be wheeled on to the roof of the corri- 
dors between the pavilions, or on to a broad 
balcony outside the end window of the ward, 
in fine weather. 
4. Administrative Buildings.-The 
necessary subsidiary accommodation may be 
briefly described. 
Operating-rooms, dispensary, and school. 
These should include examining-room, sur- 
gery, drug-store, and operating-theatre ; the 
latter having roof-light from the north, and 
being of easy access to the surgical wards; 
there being one theatre for male, and one 
for female patients. Special wards for such 
cases as ovariotomy should contain but one 
bed. A dead-house and post-mortem room, 
with ample means of cleanliness, should be 
provided, quite outside, and detached from 
the hospital. Where a school is to be estab- 
lished, the necessary lecture-rooms, labora- 
tories, dissecting-rooms, &c., should be kept 
entirely separate from the building for the 
sick. 
All rooms should be plain, and without 
projections or ornaments, which form a rest- 
ing-place for dust. 
Officers' quarters.-Apartments for the 
resident physicians and surgeons, matron, 
nurses, and servants should not, if practic- 
able, be placed under the same roof with the 
sick. All the rooms should be light and 
airy. The resident physicians and surgeons 
should have each a bedroom and sitting- 
room, with proper convenience adjacent; and 
a dining-room for joint use. 
The dispenser, if resident, requires a bed- 
room and sitting-room. An office is required 
for the steward (purveyor or financial officer), 
and a room for meetings,of the governing 
body. Each ordinary nurse should have a 
separate bedroom-neither bare,' tarnished, 
nor dismal; where she may obtain pure air 
while she sleeps-the night nurses' bed- 
rooms being apart, where they may not be 
disturbed by noise. There should be bath 
and closet accommodation near; but each 
woman should be allowed a washstand and 
foot-bath in her own room. The head-nurse 
or 'sister' sleeps in her own room, over- 
looking her ward; but if there is no common- 
room, she would have better health if a small 
sitting-room, as well as bedroom, could be 
given her off her ward. The head-nurses or 
' sisters ' should have a dining-room, and also 
a comfortable, well-furnished sitting-room. 
They will work better in their wards if they 
themselves are made comfortable. For 
sisters and nurses nowadays are, or ought 
to be, educated women. It is most undesir- 
able that they should seek necessary amuse- 
ment all out of doors. Nurses should dine HOSPITALS, CONSTRUCTION OF 
HYDRAGOGUES 
885 
in the sisters' dining-room, but at a different 
hour; and in a large hospital there would 
probably be required an additional dining- 
room for ward-assistants. In hospitals with 
an establishment for training nurses, which 
every large hospital ought to have, the pro- 
bationers or pupil-nurses (in a proportion not 
exceeding one to every ten or twelve patients) 
would live in a 4 Home ' under the hospital 
roof, and under the direction of the hospital 
matron. 
The 4 Home ' should consist of-(1) Class- 
room and nurses' library, large, airy, and 
convenient. (2) One or two dining-rooms, 
in which sisters and nurses might also dine, 
and pantry adjoining. (3) Two rooms and an 
office for the 4 home sister ' (class mistress). 
(4) One separate bedroom for each proba- 
tioner, sufficient to contain press, table, chair, 
bookshelf, washstand, bedstead, and arm- 
chair. 
Each floor should have a bath-room and 
other conveniences. Bedrooms for proba- 
tioners on night duty should be cut off from 
the noise of the 4 Home.' There should also 
be provided-one sick room; one visitors' 
room ; and servants' offices and bedrooms 
for cook and other necessary servants. 
Stores for bedding and linen, kitchen and 
provision stores- The kitchen and all those 
stores between which and the wards there is 
a constant movement, should be as central 
as possible, so as to save labour; but the 
kitchen should be carefully cut off from the 
corridor connecting the pavilions. Attached 
to the kitchen should be a good scullery, 
larder, and serving conveniences. There 
should be a large, well-aired, well-lighted, 
well-warmed, well-arranged linenry and 
mending-room. The hospital laundry should 
be detached from the hospital. Special care 
should be taken to make the laundry build- 
ings airy and very light, with ample means 
of ventilation for removing the steam, which 
is heavily charged with organic impurity, 
and with ample space for the washers. They 
should have separate drying and ironing 
rooms. 
Out-patients' department.-Those hospitals 
which afford outdoor relief require a dispen- 
sary for outdoor sick. This should always 
have an entrance separate from the hospital, 
and should never be under or near a ward, or 
in the space between adjacent wards. It is 
placed in proximity to the hospital, for the 
convenience of the medical men, and medical 
school (if any), and in order to be near the 
drug-store and apothecary's shop; but it 
should be entirely detached, with a free air- 
space between, and no direct communication 
be possible. 
The out-patients' department requires a 
large airy waiting-room, with separation of 
sexes, and separate closet accommodation 
for males and females, which, without great 
care, may (even when detached) become a 
nuisance to the sick-wards; a consulting- 
room for each of the physicians and surgeons, 
to which should be attached a small lavatory, 
and all necessary convenience for the com- 
plete examination of patients. The out- 
patients' department of children's hospitals 
requires more care, and more ample space 
in waiting-rooms, because each patient is 
brought by its nurse. The entrance and exit 
should be through different doors. 
In every large hospital should be provided 
a well-ventilated chapel, capable of being 
well warmed. 
The position and general construction of 
the administrative buildings should be made 
quite subservient to the accommodation for 
the sick, and to the broad general principle 
that these buildings should not interfere with 
the circulation of the air around, or the light 
of, the wards. Douglas Galton. 
HOT SPRINGS, in Bath County, 
Virginia, U.S.A.-Thermal waters. See 
Mineral Waters. 
HOT SPRINGS, in Garland County, 
Arkansas, U.S.A.-Thermal waters. See 
Mineral Waters. 
HOWICK, in Natal. - See Africa, 
South. 
HUM, VENOUS.-A continuous mur- 
mur heard in the veins, generally observed in 
castes of anaemia. See Anaemia ; and Physi- 
cal Examination. 
HUMID (humidus, moist).-Moist: in 
contradistinction to dry. Applied to rales 
(see Physical Examination) ; to characterise 
a variety of asthma attended with expectora- 
tion (see Asthma) ; and also to particular 
climates. . See Climate, The Treatment of 
Disease by. 
HUMORAL (humor, a humour).-Of or 
relating to the humours. Chiefly used as a 
term for a pathological doctrine-the humoral 
pathology-which associates all diseases with 
morbid states of the fluids of the body (see 
Blood-disease). The word is also sometimes 
employed as synonymous with humid, when 
applied to asthma. 
HUNYADI JANOS, in Hungary. 
Sulphated waters. See Mineral Waters. 
HYDATIDS.-See Entozoa. 
HYDATIDS, UTERINE. -See Mole. 
Molar Pregnancy. 
HYDR2EMIA (vba>p,water; andaqm,the 
blood).-A watery condition of the blood. See 
Anaemia ; and Blood, Morbid Conditions of. 
HYDRAGOGUES (v8«>p, water; and 
ayw, I drive).-Synon. : Fr. Hydragogues; 
Ger. Wassertreibende Mittel. 
Definition.-Purgative medicines which 
cause a copious watery discharge. 886 
HYDRAGOGUES 
HYDROCELE 
Enumeration.-Hydragogue purgatives 
include : -Bitartrate of Potassium, Buck- 
thorn, Colchicum, Colocynth, Croton Oil, 
Elaterin, Gamboge, Hellebore, Jalap, Podo- 
phyllin, and Scammony. The two most im- 
portant are Compound Jalap Powder and 
Elaterin. 
Action.-It has been supposed by some 
writers that the action of the drugs included 
in the present class is due only to the in- 
creased peristaltic action which they pro- 
duce. This, however, is not the case, as 
certainly some, if not all, of those just enu- 
merated induce a free secretion of fluid by 
the intestinal mucous membrane, while at 
the same time they stimulate the peristaltic 
action of the bowel, and cause the evacuation 
of this watery fluid. 
Uses.-Hydragogues are chiefly employed 
for the removal of fluid from the body, in 
cases either of general anasarca or of drop- 
sical effusion in serous cavities. They may 
be employed to assist the action of the kid- 
neys when this is insufficient; and it has 
been observed not infrequently, when the 
secretion of urine has previously been de- 
ficient, that it becomes greatly increased 
after a free discharge of fluid has taken place 
from the bowels, in consequence of the ad- 
ministration of a hydragogue cathartic. See 
Purgatives. T. Lauder Brunton. 
HYDRARGYRIASIS {hydrargyrum, 
mercury).-The state produced by the intro- 
duction of mercury into the system. See 
Mercury, Poisoning by. 
HYDRARTHROSIS {v^p, water; and 
apdpov, a joint).-Effusion of a serous fluid 
into a joint. See Joints, Diseases of. 
HYDROA.-Synon. : Fr. Hydroa bul- 
leux ; Pemphigus pruriginosus ; Herpes 
gestationis. 
The term ' hydroa ' was applied by Bazin 
to three different eruptions which he called 
respectively, vesicular hydroa, bullous hy- 
droa, and vacciniform hydroa; the last of 
these has not been recognised by any other 
writer. Vesicular hydroa is now known to 
be identical with erythema iris, in w'hich 
vesicles or small blebs are developed (see 
Erythema). Therefore hydroa is at present 
limited to the hydroa bulleux of Bazin. 
Symptoms.-The disease is a severe and 
rare one ; it is attended with much eruption, 
great itching, and more or less constitutional 
disturbance. Pregnancy seems in some way 
to favour its development-hence the name, 
herpes gestationis. The eruption consists 
of blebs, mixed with pruriginous papules, 
somewhat resembling those of prurigo. The 
blebs resemble those of pemphigus, but their 
average size is smaller and more variable 
than in the latter disease; the resemblance, 
however, induced Hardy to name the disease 
pemphigus pruriginosus. 
Differential Diagnosis.-Hydroa should 
be distinguished from pemphigus, prurigo, 
and erythema iris. From pemphigus it is 
distinguished (1) by the relatively small and 
unequal size of the blebs; (2) by the presence 
of pruriginous papules, and the intense 
pruritus which is often present; (3) by the 
constitutional symptoms, which, though 
sometimes severe, are less than in cases of 
pemphigus attended with equal amount of 
eruption ; (4) by the disease not being amen- 
able to arseni< al treatment to anything like 
the same extent as pemphigus. 
It is only when the blebs are absent or but 
little developed that hydroa could be mis- 
taken for prurigo. The relatively acute nature 
of the disease, and the history of the case 
would greatly aid the differential diagnosis. 
Erythema iris with blebs is probably the 
disease which is most nearly allied to hydroa; 
but in the latter the blebs are a chief and 
characteristic feature, whereas in erythema 
iris they are, so to speak, accidental and 
ephemeral. The pruriginous papules and 
intense pruritus are, moreover, not present 
in erythema. Altogether, hydroa is a much 
more severe disease. 
Treatment.-Alterative aperient reme- 
dies may be required ; and attention should 
be given to diet. Arsenic has not been found 
generally useful, though cases are occasion- 
ally met with in which it appears to do some 
good. Quinine is certainly a more useful 
tonic. Various local remedies, such as 
linimentum calcis made with almond oil, 
or carbolised oil and zinc ointment, may be 
tried to relieve the irritation of the skin. 
Robert Liveing. 
HYDROCARDIA (v3a>p, water; and 
KapSia, the heart).-An effusion of serous fluid 
into the pericardial sac. See Pericardium, 
Diseases of. 
HYDROCELE (ybap, water; and *17X7, 
a tumour).-Synon. : Fr. Hydrocele-, Ger. 
Wasserbruch. 
Definition.-A swelling produced by a 
collection of fluid in connexion with (A) the 
testicle, or (B) the spermatic cord. 
A. Hydrocele of the Testicle.-The 
principal forms of hydrocele of the testicle 
are (1) the vaginal, (2) the congenital, and 
(3) the encysted; (4) chylous, (5) bilobular, 
and (6) diverticular hydrocele will also be 
noticed. 
1. Vaginal Hydrocele.-Description. 
This is a chronic dropsical effusion into the 
sac of the tunica vaginalis. The fluid is a 
pale-yellowish serum, which in old cases is 
often loaded with cholesterine. The quantity 
varies, but seldom exceeds twenty ounces. 
The writer (T. B. C.) has removed as many 
as forty-eight ounces. The testicle is usually 
situated at the back part and rather below 
the centre of the sac; but its position may be 
altered by adhesions ; and, in cases of con- HYDROCELE 
887 
genital inversion, the tetsicle is in front of 
the sac. In old hydroceles the sac is often 
greatly thickened by deposition of lymph on 
the tunica vaginalis, and its conversion into 
fibrous tissue, which is sometimes the seat 
of calcareous deposits. It is generally single, 
but often occurs on both sides. Vaginal 
hydrocele f rms an oval or pyriform swelling, 
which fluctuates; has a smooth, even surface; 
and commences at the lower part of the 
scrotum, very gradually and without pain. 
When examined by transmitted light it is 
found to be translucent, except at the back 
part, where the testicle is situated. Owing 
to the tunica vaginalis remaining unobliter- 
ated for some distance along the cord, tbe 
swelling occasionally assumes an elongated 
form, and extends up towards the inguinal 
canal. A hydrocele sometimes varies in size, 
becoming larger and more tense during the 
day than when the patient first rises in the 
morning. 
^Etiology. - Hydrocele is a common 
disease, especially in warm climates; and 
occurs at all periods of life, but is most com- 
mon in middle age. 
Diagnosis.-The circumstances-that the 
swelling commences below; that the sper- 
matic cord can be detected above the tumour ; 
that the testicle cannot be felt; and that the 
tumour receives no impulse on coughing and 
does not vary in size on pressure-are signs 
distinguishing a hydrocele from an inguinal 
rupture. When the sac is much thickened, 
so as to obscure fluctuation, and prevent the 
passage of rays of light, the tumour may be 
mistaken f> r a haematocele, or disease of the 
testicle, and the diagnosis is difficult. 
Treatment.-In infants, vaginal hydrocele 
usually disappears under the application of 
■weak tincture of iodine or, as this may irri- 
tate the skin, of some evaporating lotion. 
Acupuncture, causing the fluid to escape into 
the areolar tissue of the scrotum, is the only 
operation that is required. 
In the adult external remedies are of no 
use. It is usual to resort at once to operative 
treatment, palliative or radical. The pal- 
liative operation consists in puncturing the 
tumour with a trocar, and evacuating the 
fluid accumulated in the tunica vaginalis. 
The hydrocele usually returns in the course 
of two or three months, and then the opera- 
tion must be repeated, or the patient must 
undergo radical treatment. This may be 
effected by incision or excision of the sac; by 
the passage of a seton ; or by injection of the 
sac with a stimulating fluid. The latter is 
the plan commonly resorted to ; and the fluid 
almost invariably employed is the tincture of 
iodine. The only apparatus required, in 
addition to a medium-sized trocar, is a glass 
syringe. The surgeon generally injects about 
a drachm of strong tincture, which he leaves 
in the sac. The Pharmacopceial preparation 
is not sufficiently strong. Half a drachm of 
iodide of potassium, and 40 grains of iodine, 
dissolved in one fluid ounce of rectified 
spirit, as an injection, is generally success- 
ful. It causes considerable pain, extend- 
ing to the loins; but all suffering may be 
prevented by ether or chloroform inhalation. 
The iodine acts as a stimulant, stirring up 
mild inflammation, and causing a rapid re- 
turn of swelling, which gradually subsides 
until the patient is cured. Instead of this 
solution, 30 to 60 minims of pure carbolic 
acid liquefied with 10 per cent, of glycerine 
have been injected with a successful result, 
but a permanent cure has not been obtained 
in all cases where this agent has been em- 
ployed. Compression with strapping helps 
the absorption. In double hydrocele, injec- 
tion may be performed on both sides at the 
same time. Injection rarely fails to cure the 
hydrocele. If it does not succeed, the injec- 
tion may be repeated, and very often proves 
effectual, but if not, recourse can be had to 
the seton; or, in cases of thickened sac, to 
incision or excision. 
2. Congenital Hydrocele.-In chil- 
dren, the original communication between the 
cavities of the peritoneum and of the tunica 
vaginalis sometimes fails to be obliterated; 
and fluid accumulated in the sac constitutes 
the variety termed congenital hydrocele. 
The communication is usually small in size. 
Diagnosis.-Congenital hydrocele is easily 
distinguished from ordinary hydrocele by the 
absence of a defined boundary on the upper 
part of the tumour ; by the impulse received 
on coughing; and by pressure causing the 
disappearance of the swelling, and rendering 
the testicle perceptible. It is distinguished 
from a reducible hernia by the fluctuation 
and transparency of the swelling; by the 
absence of gurgling accompanying its dis- 
appearance on pressure; and by the slow 
return of the swelling on the patient assum- 
ing the erect posture. 
Treatment. - Congenital hydrocele is 
readily cured by the gentle pressure of a 
truss on the inguinal canal, so as to occasion 
obliteration of the neck of the sac, after 
which the fluid usually becomes absorbed. 
3. Encysted. Hydrocele.-In this form 
of hydrocele fluid is effused into an adventi- 
tious cyst distinct from the vaginal sac, deve- 
loped in the areolar tissue beneath the visceral 
portion of the tunica vaginalis investing the 
head of the epididymis. There may be two 
or even more such cysts. As the cyst en- 
larges, the epididymis becomes flattened and 
displaced to one side, whilst the testicle is 
found either in front or at the bottom of the 
cyst. The fluid contained in the sac differs 
from that of vaginal hydrocele in being less 
in quantity, perfectly limpid and colourless, 
and nearly free from albumen. The fluid 
sometimes contains spermatozoa in great 
abundance, rendering it opaque and milky- 
looking. Their presence may be owing to tha 888 
HYDROCELE 
rupture of one of the tubes of the epididymis, 
and the escape of semen into the sac of the 
hydrocele. More probably, the spermatozoa- 
containing cysts are due to dilatation of one 
or more of the vasa efferentiain consequence 
of stricture; and those that contain limpid 
fluid may be developed from the organ of 
Giraldes. 
Diagnosis.-An encysted hydrocele is dis- 
tinguished from vaginal hydrocele by the 
position of the testicle at the bottom of the 
tumour; and generally by the colourless 
character of the fluid evacuated. 
Treatment.-When large in size, so as to 
be inconvenient, encysted hydrocele may be 
treated in the same way as vaginal hydrocele, 
and injection is attended with the same 
success. 
4. Chylous Hydrocele.-Synon. : Chy- 
locele ; Galactocele; Liparocele; Fr. Hydro- 
cele laiteuse ou graisseuse. 
Description.-Chylous hydrocele may be 
bilateral or unilateral. It is seldom met with 
in temperate climates. The writer (J. McC.) 
has seen only one case. It was unilateral, and 
the patient had lived for many years in India. 
It occurs more frequently in tropical coun- 
tries, where it is sometimes associated with 
elephantiasis of the scrotum. It is not 
translucent, but it otherwise resembles an or- 
dinary hydrocele. When it is tapped, a fluid 
resembling milk is evacuated, which, ex- 
amined microscopically, proved in the writer's 
(J. McC.) case to be a very fine emulsion with- 
out any formed elements. In other cases a 
few blood-corpuscles, coloured and colourless, 
have also been seen. The fluid is neutral, 
and sometimes coagulates spontaneously. 
The occasional association of chylous hy- 
drocele with elephantiasis of the scrotum, 
and the discovery in many cases of the 
filaria sanguinis hominis in the fluid, indicate 
that it is due to this parasite. Blocking of the 
lymphatic glands and vessels connected with 
the testicle by this worm is easily conceivable, 
but no demonstration would appear to have 
yet been made of a communication with the 
chyliferous vessels. See Filaria Sanguinis 
Hominis. 
Two of the recorded cases of chylous 
hydrocele appear to have resulted from in- 
jury, but in the great majority of cases there 
has been no history of traumatism, and the 
fluid most probably transudes as in ordinary 
hydrocele. 
Treatment.-Tapping is merely palliative, 
as the fluid soon re-accumulates. In one case, 
at the third tapping the fluid was of the ordi- 
nary serous nature, but this result appears to 
be unique. Inj ection with solution of iodine 
is usually successful. If it fail, incision, with 
drainage, or excision of the sac may be per- 
formed. 
5. Bilobular Hydrocele. - Synon. : 
Hydrocele en bissa c (French surgeons). 
Description.-This disease may be alto- 
gether outside, or partly inside and partly 
outside, the abdomen. The formation of the 
former variety is easily explicable. The 
processus vaginalis may be closed com- 
pletely at the internal abdominal ring, and 
partially at its connexion with the tunica 
vaginalis propria, the intervening part re- 
maining open. If in such a condition a 
hydrocele develop, it will form two sacs, 
continuous internally, and marked at their 
junction externally by a constriction, the 
depth of which will vary inversely with the 
size of the opening between the sacs. It will 
be a combination of a funicular and a 
vaginal hydrocele, with a communication 
between the sacs. The diagnosis cannot 
present any difficulty, and the symptoms, 
possible results, and treatment will not differ 
from those of an ordinary hydrocele of the 
tunica vaginalis propria. 
For the formation of the other variety, 
where one sac is inside and the other outside 
the abdomen, two hypotheses are possible. 
It may result from some congenital mal- 
formation of the processus vaginalis, or this 
process may be closed at the internal abdo- 
minal ring, and, if a hydrocele subsequently 
develop, a diverticulum may be formed at the 
upper part of the process, and experience 
less resistance to its extension in the sub- 
peritoneal tissue than in the inguinal canal 
or the tunica vaginalis communis. 
This form of bilobular hydrocele has been 
observed at birth, and the great majority of 
recorded cases have been in patients under 
forty years of age; but it may develop or 
become manifest at a later age. Some cases 
have been complicated with retention of the 
testicle within the abdomen or in the inguinal 
canal, but in others the gland has been in its 
normal position. The intra-abdominal sac 
may vary greatly in size. In one case it was 
not larger than a hazel-nut; in another it ex- 
tended above the level of the umbilicus and 
beyond the median line of the abdomen. It 
is usually situated between the peritoneum 
and the iliac fascia, but in one case it was 
between the peritoneum and the fascia 
transversalis. The external sac may also 
vary in size. Sometimes it is small, and 
limited to the processtis vaginalis ; but when 
the tunica vaginalis propria is also involved, 
the sac may be very large. When the con- 
tents of the sac are serous, the patient does 
not experience any greater inconvenience 
than with an ordinary hydrocele. But there 
appears to be in these cases a great tendency 
to the formation of a haematocele, and the 
intimate relation of the internal sac with 
the peritoneum may then become very im- 
portant. 
Diagnosis.-When the intra-abdominal 
sac is large and causes a projection of the 
abdominal wall, attention cannot fail to be 
directed to it, and pressure over the abdo- 
minal swelling will produce increased tension HYDROCELE 
HYDROCEPHALOID DISEASE 
889 
of the external sac, and vice versa. But if 
the intra-abdominal sac be small, or lodged 
deeply in the iliac fossa, or extend into the 
pelvis, it may escape notice; but the reduci- 
bility, partial or complete, of the contents of 
the external sac and the immediate re- 
appearance of the swelling when the pressure 
has been removed, ought to suggest the pos- 
sibility of an intra-abdominal sac. Careful 
palpation, when the patient has been 
anaesthetised, will detect some fulness in the 
iliac fossa; and if the sac has extended into 
the pelvis, digital exploration through the 
rectum will aid the diagnosis. 
Treatment.-The treatment will depend 
upon the size of the communication between 
the sacs, the nature of their contents, and 
their walls. If the communication be free, 
the contents serous, and the walls thin, 
tapping the external sac will empty the 
internal sac also, and injection of iodine 
solution or carbolic acid in glycerine will 
probably effect a cure. But if the communi- 
cation be very narrow, tortuous or valvular, 
if extravasation of blood has occurred, or if 
the walls of the sacs be thick, operative 
treatment varying with the nature of the 
case will be requisite. 
6. Diverticular Hydrocele. - This 
variety of hydrocele is also bilobular, but is 
altogether scrotal. It was first described by 
Beraud in 1856, who showed by dissection 
that the tunica vaginalis propria sometimes 
has very small diverticula. If a hydrocele 
form, one of these diverticula may become 
larger and protrude through some accidental 
rupture or inherently weak part of the 
tunica vaginalis communis. This protrusion 
might subsequently become so distended as 
to form the chief part of the swelling. 
The diagnosis of this condition during life 
must be very uncertain. The form might be 
unusual, and the coverings would be very 
thin, so that translucency would be very 
marked. If the hydrocele be not tense, it is 
said that pressure will convey to the hand of 
the observer a sensation of fluid passing from 
the diverticulum into the parent sac. It is 
practically unimportant, for the treatment is 
similar to that of ordinary hydrocele. 
B. Hydrocele of the Cord.-Hydrocele 
occurs in the spermatic cord in two forms-• 
diffused and encysted. 
The diffused, which is very rare, is simply 
an oedema of the areolar tissue of the cord 
Encysted hydrocele of the cord arisesfrom 
a collection of fluid in the unobliterated funi- 
cular process of peritoneum, which is carried 
down in the natural transition of the testicle. 
It produces a small swelling in the cord, of 
an oval form, above and distinct from the 
testicle, more or less transparent, and quite 
movable. The swelling, when small, is of 
no importance; and it seldom requires treat- 
ment. See Testes, Diseases of. 
T. B. Curling. Jeremiah McCarthy. 
HYDROCEPHALOID DISEASE.- 
This term is one which has been applied 
to a set of symptoms, ill-defined in their 
mode of grouping, occasionally met with in 
delicate children soon after they have been 
weaned. The symptoms may in some cases 
have been due to reflex disturbance of the 
nervous system induced by improper food; 
they may appear as the sequence of some 
exhausting disease, such as a prolonged 
diarrhoea ; or they may be concomitants of a 
pneumonia in its initial stages. In each of 
these, as well as in other allied conditions, 
there may be a febrile elevation of tempera- 
ture ; combined, in the first place, with undue 
irritability and extreme restlessness, whilst 
later on signs of mental sluggishness and 
stupor may supervene. Such symptoms are 
apt to be met with where, in addition to a 
depression of the vital powers, there is a 
reflex disturbance of brain-functions. The 
condition was specially described by Marshall 
Hall, by whom the above name was given. 
It may be well, therefore, to quote from his 
own description :- 
' This affection may be divided into two 
stages-the first that of irritability; the 
second that of torpor. In the former there 
appears to be a feeble attempt at reaction; 
in tbe latter the powers appear to be more 
prostrate. These two stages resemble in 
many of their symptoms the first and second 
stages of [acute] hydrocephalus respectively. 
' In the first stage the infant becornes 
irritable, restless, and feverish; the face 
flushed, the surface hot, and the pulse fre- 
quent ; there is an undue sensitiveness of the 
nerves of feeling, and the little patient starts 
on being touched or on hearing any sudden 
noise ; there are sighing and moaning during 
sleep, and screaming; the bowels are flatu- 
lent and loose, and the evacuations are 
mucous and disordered. 
' If, through an erroneous notion as to the 
nature of this affection, nourishment and 
cordials be not given, or if the diarrhoea con- 
tinue, either spontaneously or from the 
administration of medicine, the exhaustion 
which ensues is apt to lead to a very differ- 
ent train of symptoms. The countenance be- 
comes pale, and the cheeks cool or cold; the 
eyelids are half-closed, the eyes are unfixed and 
unattracted by any object placed before them, 
the pupils unmoved on the approach of light; 
the breathing, from being quick, becomes 
irregular and effected by sighs; the voice 
becomes husky, and there is sometimes a 
husky, teasing cough; and eventually, if the 
strength of the little patient continue to 
decline, there is a crepitus or rattling in the 
breathing. The evacuations are usually 
green; the feet are apt to be cold.' 
But in such groups of symptoms there is 
nothing distinctive ; and the term ' hydro- 
cephaloid,' which is now seldom heard, might 
be discarded. Its use can only be justified 890 
HYDROCEPHALOID DISEASE 
HYDROCEPHALUS, CHRONIC 
on the ground that the symptoms met 
with under such conditions are apt to be 
occasionally confounded with those which 
usher in the commencement of acute hydro- 
cephalus. We do not diminish the difficul- 
ties - already sufficiently pronounced - 
besetting the early diagnosis of this latter 
affection, by endeavouring to group together 
under one name a set of symptoms which, on 
different occasions, have no other common 
bond than that they are apt to occur in 
delicate children, the tone of whose nervous 
system has been lowered, and thereby 
rendered more irritable than natural. We 
should be really better without such a name, 
especially now that bleeding and lowering 
treatment are no longer in vogue for the 
amelioration of the grave organic affection 
with which the states in question may occa- 
sionally be confounded. 
H. Charlton Bastian. 
HYDROCEPHALUS, Acute (y^p, 
water; and KtcpaXr],the head).-A synonym for 
tubercular meningitis. Tuberculosis plus a 
meningeal inflammation is the generating 
condition; and acute hydrocephalus is only the 
occasional, though very frequent, concomi- 
tant. See Meninges, Cerebral, Diseases of. 
HYDROCEPHALUS, Chronic. - 
Synon. : Water on the Brain; Hydrops 
Capitis ; Fr. Hydrocevhale ; Hydropisie du 
Cerveau} Ger. Her Wasserkopf; Hirnwas- 
sersucht. 
Definition.-A gradual accumulation of 
serous fluid within the lateral and third ven- 
tricles of the brain, causing them to become 
more or less distended, and the head en- 
larged ; occurring principally in infants or 
very young children; and leading to restless- 
ness, irritability, or convulsions, followed by 
dulness, drowsiness, motor weakness or actual 
paralysis, together with failure of mind and 
of the special senses. 
The essential condition in this malady is 
the intra-ventricular effusion. The cases in 
which the fluid has been found outside the 
brain and within the arachnoid sac are, in all 
probability, merely examples of the disease 
in which, intra-ventricular effusion having 
previously been well-marked, the distended 
corpus callosum, or, it may be, the floor of 
the third ventricle, has given way, and allowed 
the fluid to pass beneath the arachnoid. The 
so-called extra-ventricular form of the disease 
is therefore, in the majority of cases, merely 
a secondary and altogether accidental con- 
dition. 
As a sequence of a large arachnoid haemor- 
rhage, serous fluid may also be found within 
the arachnoid cavity; this, however, is a con- 
dition which has no real title to be mentioned 
under the head of chronic hydrocephalus, as 
some writers have done. And the same re- 
mark applies to those accumulations of serous 
fluid which take place beneath the arachnoid, 
as a sequence of wasting or atrophy of the 
cerebral hemispheres, one or both. The col- 
lection of fluid in such cases is to be regarded 
as a simple sequence of the atrophy, and is 
of itself unproductive of morbid symptoms. 
Etiology.-Two principal groups of causes 
are appealed to as productive of chronic 
hydrocephalus. In certain cases the affection 
is believed to be idiopa thic, due to an ' essen- 
tial dropsy,' occasioned by an inflamma- 
tory affection of the lining membrane of the 
ventricles. In other patients, however, this 
affection is distinctly secondary or symp- 
tomatic, and then may be caused by one or 
other of two principal sets of conditions. 
Thus (1) it is often occasioned, as writers of 
the last century pointed out, by the pressure 
of scrofulous or other tumours upon the 
' straight sinus,' producing mechanical con- 
gestion of the great veins of Galen as well as 
of their radicles on the walls of the lateral 
ventricles, and, as a consequence, an increas- 
ing dropsical condition of the ventricles 
themselves. (2) Much more rarely it is said 
to be produced as a sequence of an attack of 
acute hydrocephalus. This latter mode of 
origin is admitted by some authors, and denied 
by others. It is at least a possible mode of 
origin, although one which is difficult to be 
established with certainty. By far the largest 
percentage of cases probably belong to the 
first set of the ' symptomatic ' category. 
The disease is sometimes congenital, and 
may be so far developed during uterine life 
as to cause great difficulties in parturition- 
frequently necessitating the sacrifice of the 
life of the child. At other times the enlarge- 
ment of the head begins to show itself soon 
after birth, or at some period before the end 
of the first or second year. Or it may reveal 
itself later still in childhood; much more 
rarely during adolescence; and more rarely 
still in adult life. 
Congenital ' microcephalism ' must not be 
confounded with hydrocephalus. It is true 
that in certain small-headed infants, having 
the cranium malformed and the sutures ossi- 
fied, an excess of fluid may be found within 
the head; but then the fluid in these cases is 
situated outside the atrophied brain, and not 
within the ventricles. The two conditions 
are, in fact, totally opposite in nature. 
Anatomical Characters. -Three different 
states, in regard to size of head, have been 
described as existing in this affection- 
(1) where the head is smaller than natural; 
(2) where the head is of natural size; and 
(3) where the head is more or less consider- 
ably enlarged. 
Those of the first category ought not to 
be included at all. They are the cases of 
'microcephalism' above referred to. Those of 
the second category could never be diagnosed 
with any degree of positiveness during life; 
and it may, indeed, be questioned whether 
such cases exist to any large extent, except as HYDROCEPHALUS, CHRONIC 
891 
more or less transitory stages of instances 
of the disease pertaining to the third of the 
above categories. 
Even the cases in which the head is dis- 
tinctly enlarged differ amongst themselves, 
since in some of them (a) both sutures and 
fontanelles are widely open ; while in others 
(6) the sutures, and perhaps the fontanelles, 
are completely closed. It seems probable 
that the latter may represent conditions into 
which some of the former pass, when the 
disease lapses into a chronic and stationary 
condition. 
Owing to the separation of the cranial 
bones in young infants, this disease, when it 
occurs in them, soon becomes associated with 
an actual enlargement of the head, which 
increases rapidly. In consequence of the 
distending pressure from within, caused by 
the increasing size and fulness of the ven- 
tricles, the bones entering into the formation 
of the vault of the cranium become separated 
from one another, though the bones of the 
face remain unaltered. The frontal, parietal, 
the superior part of the occipital, and a small 
part of the squamous portion of the temporal 
bones become expanded and thinner than 
natural, at the same time that they are sepa- 
rated from one another-especially in the 
regions of the anterior and posterior fonta- 
nelles, and of the sagittal suture. 
The crania] bones are often very thin, but 
occasionally they may be unusually thick 
throughout-even in young children. 
The circumference of the head, though that 
of a young child, may in hydrocephalus easily 
reach 24 to 30 inches, or more. The size 
attained by the head in certain cases has 
been comparatively enormous; thus, in an 
altogether exceptional case, recorded by 
Cruikshank, it is said to have measured, in 
a child sixteen months old, no less than 52 
inches in circumference, and the amount of 
fluid contained within the cranium was found 
to weigh as much as twenty-seven pounds. 
The fluid is generally slightly albuminous; 
possesses some saline constituents; and has 
a specific gravity ranging from 1006 to 1014. 
Its composition agrees pretty closely with 
that of dropsical fluids generally. 
In the great majority of cases, as already 
stated, the fluid is contained within the more 
or less distended lateral and third ventricles 
of the brain. The upper and lateral parts of 
the cerebral hemispheres, as well as the cor- 
pus callosum, become thinned and distended, 
so as to resemble a mere bag, the walls of 
which are represented externally by pale 
unfolded and much flattened convolutional 
matter, and internally-next the fluid itself 
-by the lining membrane of the ventricles. 
This latter has become much thicker and 
tougher than natural; it may also be more 
or less granular on the surface ; and often 
shows an increased number of distended 
vessels. These appearances are, however, 
not to be taken as an indication of the in- 
flammatory origin of the malady, as some 
observers seem to suppose. They may be 
found, as the writer has seen, well-marked, 
in cases where the effusion and distension 
have been the result of a mere mechanical 
congestion, produced by pressure upon the 
commencement of the straight sinus, owing 
to a tumour in the middle lobe of the cere- 
bellum. On the other hand, some years ago 
the writer examined the head of a hydro- 
cephalic child who died in University College 
Hospital, in whom the most careful search 
revealed nothing that could have produced 
mechanical congestion, and in which there 
was, moreover, no sign of anything like an 
inflammatory condition of the walls of the 
greatly distended lateral ventricles. To fall 
back upon the hypothesis of an ' essential 
dropsy ' was felt to be far from satisfactory. 
Such a phrase cannot indeed be regarded as 
conveying any real explanation of the con- 
dition in question. 
The shape of the ventricles and of the 
compressed ganglia about the base is, of 
course, greatly altered. The foramen of 
Munro may be half an inch or more in 
diameter. The optic and olfactory tracts 
and lobes are also often much altered by 
pressure. . 
The brain-substance may be even tougher 
than natural, because the long-continued 
mechanical congestion, which exists in so 
many cases, favours the overgrowth of the 
neuroglia; and, indeed, it would appear prob- 
able that in some instances the overgrowth 
of this mere connective substance is well- 
marked. For, notwithstanding all the pres- 
sure upon and distension of the brain-sub- 
stance, this rarely shows signs of atrophy. 
It is rather the reverse. The mere brain 
alone of a hydrocephalic child, after the fluid 
has been evacuated, commonly weighs more 
than the brain of a healthy child of the same 
age. Thus, in an instance that came under 
the writer's notice, the brain of a child five 
years of age weighed rather more than 52 oz. 
In those cases in which during life the 
fluid has escaped from the ventricles through 
a rupture in the corpus callosum, the brain 
has been found more or less flattened and 
collapsed in the lower part of the enlarged 
cranium, whilst the escaped fluid occupies 
the arachnoid cavity above it. 
Symptoms.-Chronic hydrocephalus begins 
to manifest itself in various ways, and also, 
as above stated, at various ages. The great 
bulk of the cases are either congenital, or 
commence before the fifth month. But, in 
certain rare instances, the head may begin 
to enlarge long after the union of the 
sutures, in early adult life, or even beyond 
middle age. 
As to modes of commencement, at least 
four, pretty distinct from one another, may 
be encountered. (1) The disease may be 892 
HYDROCEPHALUS, CHRONIC 
ushered in by a period of fretfulness and 
irritability, with or without the occurrence 
of convulsions and strabismus, before any 
enlargement of the head is detected. Or 
(2) slow enlargement of the head may be 
noticed as the first event. In some cases, 
this enlargement not only sets in, but may 
continue for months, till notable increase in 
size has taken place, and yet the child may 
exhibit no morbid symptom whatever. The 
writer has seen a well-marked instance of 
this in a child whose head had been en- 
larging for eighteen months (the process 
beginning when it was a year old), and in 
whom, though the head was twenty-four 
inches in circumference, no other morbid 
signs or symptoms presented themselves. 
(3) Chronic hydrocephalus may supervene 
in a child after a fall, through the inter- 
mediation of cerebellar disease. The writer 
had under his care a little girl four years 
old, who, after falling from a table and 
striking the occiput severely, suffered for 
from twelve to eighteen months from symp- 
toms indicative of cerebellar disease, after 
which the head began to enlarge, and hydro- 
cephalus became the apparently dominant 
condition. Complete blindness ensued, then 
convulsions set in, and in the midst of one 
of these the patient died. A tumour of the 
middle lobe of the cerebellum was found, 
plus all the signs of a well-marked hydro- 
cephalus. (4) The disease may occur as a 
sequence of an attack resembling acute 
hydrocephalus (tubercular meningitis); that 
is to say, a child appears to suffer for a 
time from what is regarded as tubercular 
meningitis; the symptoms then undergo 
some mitigation; they become more or less 
chronic; and ultimately the head begins to 
enlarge, as it does in chronic hydrocephalus. 
There is some doubt about the real nature 
of the starting-point in this mode of origin. 
The initial symptoms may not in reality 
have been those of tubercular meningitis. 
The chronic disease and its symptoms may 
occasionally be initiated in an acute manner. 
It may be easily imagined that the subse- 
quent course of the symptoms in persons 
suffering from chronic hydrocephalus, begin- 
ning in these various ways, may also be 
subject to great variations. 
As the head enlarges, or as the pressure 
within increases, sensations of weight or pain 
may be experienced. The child may show 
increased fretfulness and irritability; or its 
manner may become more dull and heavy 
than natural. At other times there is no 
noticeable change in these respects. 
In the ' symptomatic ' forms associated 
with tumours, there is apt to be vomiting of 
a very obstinate and paroxysmal character, 
together with continuous pain, marked by 
exacerbations. Convulsions, either unilateral 
or general, may also occur, as well as para- 
lysis of one or other of the ocular muscles. 
In such cases, too, in comparatively early 
stages, ophthalmoscopic examination will 
frequently reveal optic neuritis, which has 
a tendency to go on to white atrophy, with 
the production of more or less complete 
blindness. 
In later stages of the' disease mental action 
becomes increasingly impaired; there is loss 
of memory, dulness, and a great tendency to 
sleep during the day. There may be marked 
weakness or actual paralysis of limbs. Chil- 
dren affected to this extent often keep to the 
recumbent position, having at last no power 
of sitting up, or even of raising their head 
from the pillow. Where the enlargement 
becomes extreme the weight of the head is 
so great that it cannot be maintained in the 
upright position. It has to be supported by 
the hand or some artificial prop ; or else the 
child does not attempt to rise from the re- 
cumbent position. A sense of fluctuation is 
often recognisable. The forehead becomes 
prominent and overhanging, while the eye- 
balls are depressed ; and as the face remains 
unaltered or even becomes emaciated, it 
seems altogether unnaturally small, and thus 
contributes to produce a most characteristic 
appearance ('facies hydrocephalica'), which 
is often intensified by the old-looking, and 
more or less blank, expressionless aspect of 
the face. The appetite sometimes remains 
good; at other times it becomes much im- 
paired, and a gradual emaciation ensues. 
Blindness, more rarely deafness, loss of 
smell, and impairment of other senses tend 
gradually to reveal themselves after a time. 
Complications.-In all cases where the 
hydrocephalus is itself symptomatic of some 
primary intracranial disease, interfering with 
the proper return of blood from the ventricles 
and central portions of the brain, the symp- 
toms resulting from this latter state of things 
are necessarily complicated with others im- 
mediately produced by the original morbid 
condition. Hence the very great variations 
encountered in the grouping of symptoms in 
different cases. 
Diagnosis.-Where the head becomes dis- 
tinctly enlarged, with widely separated sutures 
and open fontanelles, there can be scarcely 
any room for doubt about the diagnosis. But 
before the head is distinctly enlarged, the 
diagnosis of chronic hydrocephalus with any 
degree of certainty is impossible. In many 
cases also where the head is only slightly 
enlarged, and the sutures are not opened, it 
may be very difficult, for a time, to pro- 
nounce an opinion as to whether or not an 
infant or young child is hydrocephalic. 
| Natural variations in the size of the head 
are considerable; and it may also be en- 
larged from rickets, or from that very rare 
condition known as ' hypertrophy of the 
brain.' Even great thickenings of the bones 
of the head have occasionally given rise to 
uncertainties in regard to diagnosis. But in HYDROCEPHALUS, CHRONIC 
HYDRONEPHROSIS 
893 
all these cases, in order to enable the prac- 
titioner to arrive at a trustworthy opinion, 
the particular form of the head has to be 
considered, together with the sum-total of the 
various symptoms which may have preceded 
or accompanied its increase. 
Whether we have to do with an instance 
of ' idiopathic ' or of ' symptomatic ' hydro- 
cephalus in any particular case often cannot 
be settled ; but in others it can be decided 
by the existence of symptoms distinctly 
pointing to the presence of an intracranial 
new-growth. 
Course and Terminations.-Hydrocepha- 
lus often proves fatal in the course of a 
few months; or it may be less rapid, entail- 
ing death only after a year or two. Its pro- 
gress is variable, however. Remissions and 
stationary conditions are apt to occur, with 
occasionally distinct exacerbations of all the 
symptoms. 
Occasionally one of these stationary condi- 
tions becomes prolonged, and the individual 
may live for years. Some hydrocephalic 
subjects have subsequently lived on to the 
age of twenty, thirty, or even forty years. 
In a few exceptional cases a cure seems to 
have been effected, either naturally or under 
the influence of remedial agencies. 
Death may take place in convulsions; from 
slow exhaustion with emaciation; or from 
intercurrent pneumonia or some other acute 
disease. 
Treatment.-Very little, unfortunately, 
can be done, in the majority of cases, to pro- 
duce decided or lasting improvement. This 
is especially so in those instances-only too 
numerous-in which the hydrocephalus is 
due to some scrofulous or other tumour inter- 
fering with the return of blood from the ven- 
tricles. 
Blistering the scalp, with mercurial in- 
unctions, formerly much lauded, may do a 
great deal more harm than good; and the 
same may be said in reference to pressure of 
the enlarged head by strapping or bandages. 
This latter is a barbarously coarse method of 
treatment, which has happily fallen into dis- 
use. Blistering may do good in some cases, 
but it should be cautiously employed. 
The general health of the child must be 
maintained as much as possible, by the aid, 
if necessary, of tonics and cod-liver oil. Pur- 
gation and diuretics may also be had recourse 
to. Iodide of potassium may be given inter- 
nally in gradually increasing doses, as even 
young children bear this remedy well. Bro- 
mide of potassium will also help, perhaps, to 
mitigate vomiting and convulsions, when 
these are urgent symptoms. 
It may be worth while in suitable cases 
to try the effect of greatly diminishing the 
amount of fluids taken, so as to reduce the 
fulness of the vascular system. The writer 
has had reason to believe that this method 
is well worthy of being tried, where other 
means have failed, and where there is any 
chance of being able to carry it out. 
Puncture of the head has been much 
lauded, and practised by many, but with an 
amount of failure and fatality that has caused 
the method to have almost fallen into disuse. 
If in any given case we could be reasonably 
certain that the hydrocephalus belonged to 
the ' idiopathic ' variety (if there really are 
such cases), the method might be had recourse 
to with much more chance of success than 
if it were occasioned by some mechanical 
pressure, which persists, and prevents the 
return of blood from the central parts of the 
brain. Puncture of the head can scarcely be 
compared with puncture of the chest, because 
(even apart from the greater risks attaching 
to the former operation) a puncture of the 
chest in a case of pleurisy has a fair chance 
of being actually curative, while puncture of 
the head in hydrocephalus, in the majority 
of cases and for the reason above indicated, 
could only be palliative. Still the cases of 
this disease are so grave that where the 
sutures are opened, where the patient's con- 
dition is rapidly getting worse, and death 
seems otherwise inevitable, the question of 
performing the operation, at least once, ought 
to be entertained as a possible means of 
affording relief. 
H. Charlton Bastian. 
HYDROMETRA (vS^p, water; and 
prjrpa, the womb).-Dropsy of the womb. 
See Womb, Diseases of. 
HYDRONEPHROSIS (v^p, water; 
and vecppos, the kidney).-Synon. : Dropsy 
of the Kidney; Fr. Hydronephrose; Ger. 
Hydronephrose. 
Definition.-A chronic disease of the kid- 
ney, caused by obstruction of the ureter; 
which leads to dilatation of the pelvis, and 
commonly of the ureter, with more or less 
extensive atrophy of the substance of the 
organ; usually affecting one kidney, some- 
times both; characterised clinically by the 
presence of a soft fluctuating tumour in the 
renal region, but most distinctively by sudden 
discharge of urine with collapse of the 
tumour; and resulting, if not relieved, in 
complete destruction of the kidney. 
A3tiology.-Among the most common 
causes of hydronephrosis are obstruction of 
the ureter at its lowest part, in consequence 
of pressure by new formations, such as car- 
cinoma of the uterus or tumour of the ovary 
in females, and the impaction of calculi of 
various kinds. More rarely it is induced by 
new formations in the bladder; stricture of 
the urethra; the pressure of the pregnant, 
prolapsed, or retroflexed uterus. Exception- 
ally it is met with without apparent cause; 
in such cases it is to be referred to some 
contraction, due to inflammation or other 
cause, which has disappeared. The con- 
dition is also sometimes congenital, being 894 
HYDRONEPHROSIS 
HYDROPHOBIA 
due to malformations, such as impermeable 
ureter, or valve-like obstruction to the pas- 
sage of the urine downwards. From what- 
ever cause the obstruction springs, accumu- 
lation of urine takes place behind it, leading 
to gradual distension of the organ. See 
Ureters, Diseases of. 
Anatomical Characters.-In the earlier 
stage of hydronephrosis there is simple dila- 
tation of the pelvis of the kidney. As the 
disease advances, the dilatation increases, 
the organ becomes more and more distended, 
and the ureter often becomes so dilated or 
elongated as to present the appearance of a 
bluish-white tube, as large as or even larger 
than the inferior vena cava. Coincidently 
with this distension and pressure the sub- 
stance of the kidney atrophies. At first the 
apices of the cones become flattened and 
wasted, but gradually the renal substance 
becomes more involved, until at length, in 
old-standing cases, scarcely any trace of it 
remains, and the kidney is represented by 
a large lobulated bag, the fibrous walls of 
which are distended by clear fluid. Com- 
monly one kidney only is affected, especially 
when extreme dilatation exists, but in some 
instances both kidneys are involved. There 
is a case on record where the whole abdomi- 
nal cavity was occupied by an enormous sac, 
containing sixty pounds of fluid. 
Symptoms.-In the slighter cases of hydro- 
nephrosis there are no symptoms of such 
a kind as to attract attention. This con- 
dition is often an unimportant complication 
of other serious diseases. In the more 
severe cases there are no constitutional 
symptoms, but the local changes are well- 
marked. There is a tumour situated in the 
lumbar region, extending upwards, down- 
wards into adjacent regions, or forwards 
towards the anterior abdominal wall. The 
colon is usually in front of the tumour, and 
always displaced and compressed, so that 
constipation frequently coexists with hydro- 
nephrosis. The mass is often lobulated, 
always undulating in character; and fre- 
quently fluctuation may be detected. The 
most conclusive evidence of the condition is 
afforded by the discharge of a large quantity 
of urine, generally of low specific gravity, 
and often containing mucus, coincidently 
with the disappearance or diminution of the 
tumour. It sometimes happens that the 
obstruction is permanently removed, and 
dilatation alone remains as evidence of the 
old obstruction. Hydronephrosis, when 
double, sooner or later proves fatal by sup- 
pression of urine or uraemia. When only 
existing on one side, it has proved fatal by 
pressure upon neighbouring pacts; by the 
supervention of impaction of a stone in the 
kidney of the opposite side ; or from other 
causes.1 
Diagnosis.-The distinction of hydrone- 
phrosis from ascites may be sometimes 
difficult when the disease affects both sides. 
The diagnosis is partly to be made by ob- 
serving the effects of change of posture, 
hydronephrosis being much less influenced 
thereby than ascites. The history and mode 
of origin of the affection also afford indi- 
cations. From hydatids of the kidney it is 
sometimes impossible to discriminate hydro- 
nephrosis, but the history of the case and 
the characters of the urine often afford a 
clue. If there be tumour on both sides, it 
is extremely unlikely to be hydatid. From 
ovarian tumour the diagnosis is to be made 
by the history of the case, the position ot 
the mass, and its relations to the colon; and 
by vaginal and rectal examination. From 
perinephric abscess hydronephrosis is distin- 
guished by its being less hard, and by the 
absence of pain and fever. 
Prognosis.-The prognosis is always seri- 
ous ; but if one of the kidneys be sound, 
it becomes enlarged, and does double work; 
and so long as this condition continues, the 
patient may suffer little inconvenience. 
Treatment.-Careful manipulation of the 
tumour is often useful in extreme conditions. 
Tapping with the aspirator may be employed, 
and the further aid of the surgeon may be 
required. T. Grainger Stewart. 
HYDROPATHY (y8a>p, water; and 
7rd0os, a disease).-A synonym for hydro- 
therapeutics. See Hydrotherapeutics. 
HYDROPERICARDIUM (v^p, 
water; nepi, about; and Kap8ia, the heart).-An 
accumulation of serum in the pericardium, 
either dropsical or inflammatory. See Peri- 
cardium, Diseases of. 
HYDROPHOBIA (v3wp, water; and 
(fidSoi, fear).-Synon.: Rabies; Dog-madness; 
Fr. Lyssa ; la Rage ; Ger. Hundswuth; 
Wasserscheu. 
Definition.- An acute disease, produced 
by the inoculation of a specific animal 
poison; manifesting itself by symptoms due 
to disturbance of the central nervous system; 
and almost invariably proving fatal. The 
name ' hydrophobia ' is really that of a single 
symptom, which, though very common, is 
not invariable. 
Etiology.-Never spontaneous in man, 
the disease is always due to inoculation with 
the poison from a rabid animal, almost in- 
variably with the saliva, and commonly by a 
bite. In about nine-tenths of the cases, the 
malady is contracted from dogs; in most of 
the remainder from cats ; in very few cases 
from foxes or wolves, but a larger proportion 
is due to wolf-bites in countries where these 
animals are numerous. It has also been 
acquired through a wound received during 
1 In one case, which occurred some years ago, the 
cyst, in collapsing after being tapped, carried with it 
the sigmoid flexure, which being thus turned on 
itself caused fatal obstruction.-Editor. HYDROPHOBIA 
895 
the dissection of a rabid animal. Inoculation 
with the blood of a rabid animal will probably 
(but not certainly) produce the disease. The 
poison is not known to be present in any 
other secretion than the saliva, but it is 
abundant, after death, in the central nervous 
system. Commencing decomposition is said 
to destroy its activity, but it sometimes 
resists this for many days. The dried saliva 
retains its virulence for some days, but in the 
dried nerve-centres the virus gradually loses 
its activity, and becomes inert in about ten 
days. 
Inoculation by a bite takes place more 
certainly if this is on an uncovered part of 
the body, as on the hands and face, than 
when inflicted through the clothes, by which 
the teeth may be cleansed. But it may occur 
without an actual bite, as by a lick upon an 
abrasion. It has followed the scratch of a 
cat, probably by the animal's saliva being 
thus inoculated. A healthy dog has com- 
municated the disease by a bite given imme- 
diately after it had been fighting with a rabid 
animal, the saliva of which, no doubt, was 
hanging about its jaws. The disease has 
resulted from the teeth being used to loosen 
a knot upon a rope with which a rabid dog 
had been tied. 
It has been asserted that the disease may 
arise from the bite of a healthy dog, but this 
is most improbable. Cases are on record, 
however, in which the disease has followed 
the bite of a dog, which did not at the time, 
or for several weeks afterwards, present the 
recognised symptoms of the disorder. It 
is probable that, in such cases, rabies has 
occurred as a mild and insignificant malady, 
since it is certain that a dog may recover 
even after communicating fatal rabies. 
When no preventive measures are adopted, 
at least half, perhaps two-thirds, of persons 
bitten escape. The immunity may be due 
partly to the bites being inflicted through 
clothes, but probably a fallacy underlies the 
estimate, owing to the inclusion of many 
bites from dogs not really rabid. A certain 
diagnosis can only be made by inoculation, 
but the preventive treatment of Pasteur has, 
fortunately, made it now impossible to obtain 
statistics on the point. 
More males than females suffer, the pro- 
portion being three to one. The largest 
number of cases occur in the middle period 
of life, doubtless from greater exposure to 
the cause. Children, however, are prone to 
suffer, being often badly birten on the face. 
Most cases are contracted from straying dogs, 
or from pet dogs that have been bitten in 
some street fight. 
The period of incubation is longer than 
that of any other acute specific disease, and 
is singularly variable. It is rarely less than 
a month, the shortest on record having been 
about twelve days. The average period is 
six or seven weeks. In about half the cases 
it is between one and three months. In some 
cases it is longer, reaching six, nine, or 
twelve months. Cases have been recorded 
in which two, three, five, and even ten years 
intervened. Most authorities believe that 
such cases were either not true hydrophobia, 
or were due to a second unknown infection. 
Although it is as hard to explain an incuba- 
tion period of one year as of five years, it is 
certain that the lick of a strange dog on a 
scratched hand is more likely to be forgotten 
than remembered, and an unnoted later in- 
fection is, on the whole, the most probable 
explanation of these cases. 
Anatomical Characters.-General fluidity 
of the blood, such as is met with after death 
from acute septic diseases; redness of the 
throat and pharynx, and occasionally of the 
salivary glands ; together with, in some 
cases, evidence of congestion of the brain 
and spinal cord, constitute the chief morbid 
appearances visible to the naked eye. The 
microscope has shown that there is evidence 
of inflammation (congestion and leucocytal 
infiltration) in the salivary glands (Coats); 
and that minute changes in the nerve-centres 
are almost constantly to be found (Clifford 
Allbutt, Hammond, Benedikt, Coats, and the 
writer). Of nine cases examined by the 
writer, the microscopic changes in seven were 
distinct, and in character and position so far 
characteristic, that, given the fact of an acute 
disease, ^post-mortem diagnosis might, in this 
proportion of cases, be made with certainty 
by the microscope. The essential change 
consists in the accumulation of leucocytes 
around the vessels, and their infiltration into 
the adjacent tissue ; this change having a 
special distribution, being either confined to, 
or most intense in, the region of the medulla 
which is contiguous to the lower part of the 
fourth ventricle, that is, the neighbourhood 
of the respiratory centre. Here we have also 
the centre for deglutition. The change is 
most intense in the hypoglossal, glosso- 
pharyngeal, and vagal nuclei and their 
neighbourhood. There is little or no change 
in the upper part of the medulla, corpora 
quadrigemina, cerebellum, or basal ganglia. 
In the convolutions a similar but slighter 
alteration is present in some cases. It is, 
however, often very marked in the spinal 
co^d. In the most affected regions, traces of 
ante-mortem clots and even of inflammation 
of the walls of the minute vessels may be 
found in some cases. Perivascular areas of 
disintegration are common ; but such fre- 
quently occur apart from hydrophobia or any 
other disease. Minute extravasations are 
common, partly mechanical. The only 
change in the nerve-elements themselves 
consists in a granular degeneration of the 
ganglion-cells of the regions chiefly diseased. 
In the dog the changes are quite similar in 
characters and distribution. 
Symptoms.-During the period of incuba- 896 
HYDROPHOBIA 
tion of hydrophobia there are commonly no 
symptoms. Vesicles under the tongue were 
formerly described, but their occurrence has 
not been confirmed. Occasionally pain and 
discomfort have been felt in the seat of the 
wound, explicable, in part, by the attention 
directed to it, but sometimes too pronounced 
to be thus explained, especially during the 
week or two preceding the onset. Mental 
depression has been noted, also probably due 
to anxiety regarding the possible consequence 
of the bite. 
The onset of the acute symptoms is com- 
monly attended by no local disturbance, al- 
though sometimes by pain, rarely by actual 
inflammation, in the wound. The first evi- 
dence of the impending disorder is usually 
malaise, mental depression, disturbed sleep, 
and some discomfort about the throat, with 
a difficulty in swallowing, especially liquids. 
The attempt occasions some spasm in the 
throat, which soon, if not at first, involves the 
muscles of respiration, causing a short, quick 
inspiration, a ' catch in the breath,' resem- 
bling that due to an affusion of cold water. 
In a few hours this increases to a strong 
inspiratory effort, in which the extraordinary 
muscles of respiration take more part than 
the diaphragm; the shoulders are raised, and 
the angles of the mouth are drawn outwards. 
The saliva, which is abundant and viscid, 
cannot be swallowed. It hangs about the 
mouth, and the patient is annoyed by his 
efforts to get rid of it. As the intensity of 
the spasm increases, so does the readiness 
with which it is excited. The mere contact 
of water with the lips, or cutaneous impres- 
sions, as a draught of air, will bring on a 
paroxysm, owing to the intense reflex ex- 
citability. The distress thus occasioned leads 
to a mental state, which is due to disturbance 
of the cortex, but increases the readiness 
with which the spasm is produced. The 
intense excitability of the sensory centres 
may be such that mere sight of water, or 
the sound of dropping water, will cause the 
spasm, and even analogous visual impres- 
sions, as a sudden light or the reflection 
from a looking-glass. Thus the respiratory 
spasm excited by swallowing liquids, which 
is, as it were, the keynote of the disease, 
extends on the one hand to widely spread 
muscular spasm, and on the other to mental 
disturbance. In each of these directions the 
symptoms develop. The early reflex excess 
involves the spinal cord, the knee-jerk is 
increased, and reflex action in the legs may 
be great. While this over-action increases, 
the spasm, from being limited to the muscles 
of respiration, may become general and con- 
vulsive in character, though still excited by 
the same causes. The mental distress passes 
into disturbance, in which the balance of rea- 
son is lost, continuously or during the parox- 
ysms. In the frenzy, the horror of the dis- 
tress is transferred to the attendants by whom 
any discomfort may have been occasioned, 
and during the paroxysms the patient may 
attempt to bite them, and even others. Con- 
sciousness may so far remain that in the 
intervals he may beg those whom he regards 
to keep away. The saliva is ejected with 
force, and the patient hawks it up with a 
noise 'like a dog.' The sight of a dog 
has been known greatly to intensify the 
disturbance ; and this, strangely enough, 
in cases in which the sufferer had no sus- 
picion of the nature of his affection. The 
delirium may, in some cases, be continuous 
and violent. As the mental disturbance in- 
creases, the respiratory spasm and convulsion 
may lessen, or the latter may persist to the 
end. 
Vomiting is common, and is often an 
early symptom, a greenish-brown liquid being 
ejected. Priapism or nymphomania occa- 
sionally occurs. The temperature is usually 
raised two or three degrees. Albumen is 
often present in the urine; and sometimes 
sugar is found. 
Duration and Terminations.-The dura- 
tion of hydrophobia is usually from one to 
four days ; sometimes it lasts six, eight, or 
ten days. In the rare cases which have re- 
covered, the duration of the acute affection 
has been from four to ten days, although 
slight spasmodic symptoms have lasted for 
a longer time, as does the spasm of whooping- 
cough. 
The common cause of death is exhaustion 
due to the attacks of fury and convulsion, often 
aided by manifest cardiac failure, which may 
occur early, and be out of proportion to the 
general asthenia. Sometimes the patient has 
died asphyxiated in a paroxysm of respira- 
tory spasm; partly, perhaps, from spasm of 
the glottis. 
Varieties.-The relative degree of the 
above-described symptoms varies in different 
cases. The mental disturbance, or the gene- 
ral muscular spasm, may, respectively, pre- 
dominate over the respiratory throat-spasm, 
even in the early stages, and may impress a 
special character on the attack, so that it 
resembles in the one case a primary mental 
affection, in the other a general convulsive 
affection, as tetanus. 
Pathology.-We cannot doubt that the 
virus of hydrophobia is a micro-organism, 
although this has not yet been clearly de- 
tected. It is supposed that the organisms or 
their germs, frequently at least, remain in the 
tissues near the wound, and only become dis- 
lodged at a later period, to reach the nerve- 
centres and there develop (Pasteur). The 
symptoms indicate a primary influence on the 
nerve-centres, especially on the respiratory 
region of the medulla, spreading more widely 
in its ultimate action, both in the medulla 
and to the brain and cord. The vascular 
changes, from their variability and occasional 
absence, are probably secondary effects of the HYDROPHOBIA 
897 
disturbed action of the nerve-structures, pro- 
duced by the poison carried by the blood. 
The virus has been thought to ascend by the 
nerves, but this is not likely, although germs 
may simultaneously enter the peripheral 
nerves and develop there, since the virus has 
been found to be abundant in them (Dowdes- 
well). 
The first effect of the poison is probably 
to lessen the ' resistance ' of the medul- 
lary centres. Their action becomes spas- 
modic, and is excited with undue readiness. 
The excessive action of the medulla and spinal 
cord finds its counterpart in the cortex and 
the delirium which results. At a later 
stage this gives place to depressed activity, 
which may end in paralysis and coma, when 
general, but is sometimes unequal in its dis- 
tribution. The secondary vascular changes 
may have their own effects. They are, as 
in other functional diseases, somewhat ran- 
dom in distribution within the affected area. 
By the infiltration of leucocytes, the tissue 
may be broken up, and what are practically 
minute points of suppuration may result. If 
the part damaged is important, grave con- 
sequences may ensue. The nucleus of the 
pneumogastric is often so damaged, and from 
this, or the late depression, we can under- 
stand the occurrence of cardiac failure. The 
changes in the convolutions and the spinal 
cord are probably proportioned to the mental 
or tetanoid (and paralytic) symptoms respec- 
tively. The mental excitement no doubt 
acts upon and increases the irritability of the 
medulla (Putnam). Conversely, the disturb- 
ance of the latter may help to determine the 
character of the mental disturbance due to 
the poison of hydrophobia. 
Diagnosis.-The symptom of greatest 
diagnostic value is the respiratory spasm 
excited by attempts to swallow, increasing 
until it resembles a convulsive action, and 
accompanied after a time by mental disturb- 
ance. The diagnosis is generally aided by 
the history of a suspicious bite, but it must 
be remembered that such a history some- 
times misleads, especially when the mind of 
the patient has dwelt much on the possible 
consequences, and he has made himself 
acquainted with the symptoms of the disease. 
In certain diseases of the throat and chest, 
especially oesophagitis and pericarditis, a 
reflex throat-spasm may occur, but in such 
cases there are commonly pain and other ob- 
trusive signs of the local affection. When 
the mental disturbance occurs early, the 
affection may be confounded with acute 
mania : the association with slight respira- 
tory spasm is still the most important dia- 
gnostic indication. In cases (if such occur) in 
which this symptom is absent, the diagnosis 
is a matter of great difficulty, and can only be 
made by the history of the antecedent bite, 
by the rapid course of the disease, and by its 
association with other convulsive phenomena 
and with salivation. From tetanus, hydro- 
phobia is distinguished by the late period 
after the bite at which the symptoms develop; 
by the absence of trismus and of continuous 
spasm; and by the presence of paroxysmal 
respiratory spasm, of aversion to liquids, and 
of mental disturbance. Too much weight 
must not be given to the general character 
of the convulsive symptoms, if other signs of 
the disease are present, since there is prob- 
ably a tetanoid form of hydrophobia; but in 
this the spasm is excited by attempts at de- 
glutition, and there is no trismus. Organic 
brain-diseases accompanied by delirium and 
convulsions, occurring after a bite, have been 
mistaken for hydrophobia, as in one case in 
which the nature of the disease was only dis- 
covered when, after exhumation, meningeal 
haemorrhage was found. Here also the 
respiratory spasm was absent. 
Mere mental excitement, directed to the 
symptoms of the disease, may determine 
dysphagia simulating that of the genuine 
disease-' spurious hydrophobia ' as it has 
been termed, often accompanied by delirious 
excitement. The spasm, however, is not of 
the respiratory character of true hydro- 
phobia. Recovery commonly ensues on the 
mind being tranquillised, or by the applica- 
tion of some remedy in which the patient has 
confidence. It must be remembered that in 
some cases of genuine hydrophobia the in- 
fluence of the patient's mental state has been 
very clearly traceable even in the early 
symptoms, and it is probable that many true 
cases have been regarded as spurious, and 
even published as such. It is doubtful 
whether death has ever resulted except from 
the genuine disease. 
Prognosis.-Hydrophobia is practically 
fatal, but not certainly so. Recovery has cer- 
tainly occurred in the dog and probably in 
man. Every patient should unquestionably 
receive the ' benefit of the doubt.' Cases 
differ in the intensity and rapidity of their 
course; and the less rapidly the symptoms 
are evolved, the greater is the hope, slight 
though it still is, that an exception to the 
common fatality may be obtained. The 
prognosis is better the longer the spasm re- 
mains limited; it is worse if there are gene- 
ral convulsions, mental disturbance, and signs 
of exhaustion or of disproportionate heart- 
failure. 
Treatment.-Adequate measures against 
the spread of rabies would undoubtedly les- 
sen, perhaps entirely prevent, the occurrence 
of hydrophobia in man; but the discussion 
of these is beyond the scope of this article 
(see Rabies). When a person has been bitten 
by a suspicious animal, the circulation in the 
part should, if possible, be at once arrested 
by a tight ligature above the place; the 
wound should be washed; and then it should 
be allowed to bleed freely. It may probably 
be sucked with impunity if the mouth is 898 
HYDROPHOBIA 
rinsed with water or, better still, with vine- 
gar and water, after each act, especially if 
there are no abrasions in the mucous mem- 
brane. The act has been supposed to be 
dangerous; but all experience is opposed to 
this. Poisons have to remain for some 
minutes in contact with a mucous membrane 
before they are absorbed, and during the act 
of sucking there is a flow from the mucous 
membrane into the mouth, which must be 
opposed to absorption. The wound should be 
cauterised as soon as possible, and before cir- 
culation through the part is again permitted. 
Of chemical caustics, nitrate of silver, 
freely applied at once, is probably effectual. 
If any time have elapsed, nitric acid or 
liquid carbolic acid is preferable. The actual 
cautery, applied deeply and freely, is an 
efficient and ready means. If practicable, 
free excision of the bitten part is wise, and 
should not be neglected, even though the 
cautery has before been used, especially if 
there is any doubt as to the thoroughness of 
the application. Without arrest of the cir- 
culation, cauterisation after ten minutes has 
often failed. 
Next in time, but first in importance, is 
the prophylactic treatment of Pasteur, 
employed as soon as possible after the bite. 
The dried spinal cord of a rabbit contains 
less and less of the virus, up to the tenth 
day of drying, when it fails to produce the 
disease. If an emulsion of such a cord is 
first injected, then, on successive days, that 
of cords dried for a shorter time may be 
employed, until a strength of cord-virus is 
injected that would otherwise cause the dis- 
ease. Not only does this fail to do so, but 
it prevents the occurrence of rabies from the 
virus inoculated by the preceding bite, and 
thus confers immunity even against the past 
inoculation. It is believed that the organ- 
isms of the virus produce a material, prob- 
ably chemical, destructive to them, incom- 
patible with their development, and that 
this is not destroyed by the drying in the 
same degree as the virus. Being injected in 
larger and larger quantities from cords dried 
for a shorter time, it effectually protects both 
from the virus injected with it and from 
that which was already in the system. Facts 
show that this result, though not absolutely 
certain, generally follows, and that the mor- 
tality from bites by certainly rabid animals 
is reduced to about 1 per cent. The most 
careful estimate shows that, during the last 
five years Pasteur has thus saved at least 
1,000 lives. (For a detailed account of the 
treatment, see Buffer, Brit. Med.Journ. 1889.) 
The methods adopted for the treatment of 
the developed disease have been numerous, 
but, for the most part, quite ineffectual. 
All so-called ' specifics ' have been proved to 
be useless. An attempt has been made to 
neutralise the poison by administering large 
doses of mercury, and to eliminate it by dia- 
phoresis. The two have been combined in 
the mercurial vapour-bath. Two or three 
cases are on record in which mercury has 
appeared successful; many in which it has 
been powerless. Of late it has been but little 
tried; nevertheless, there are facts which 
suggest that the apparent influence of mer- 
cury has been real, and that in it we have 
probably a more promising means of coun- 
teracting the virus than in any other agent. 
The vapour-bath treatment has been abun- 
dantly proved to be entirely useless, although 
its supposed value is, from time to time, re- 
affirmed by lay advocates whose energy is 
proportioned to their ignorance. 
Other agents employed have been designed 
to counteract, not the virus, but its conse- 
quences, and so to prevent or postpone 
death, possibly until the malady has run its 
course. One of these is curara, first recom- 
mended half a century ago by an English- 
man (Sewell); it was tried in small doses 
and failed. Niemeyer suggested larger doses, 
and in a case by Offenburg it was apparently 
successful; and since then another case, in 
America, has recovered under its use. In 
many cases it has failed-in all cases in this 
country up to the present time. It is recom- 
mended that it should be used in injections 
of from to of a grain, repeated every 
quarter or half an hour, until the severity of 
the paroxysms is lessened. This point may 
not, however, be reached until general mus- 
cular paralysis is imminent or produced, and 
then artificial respiration may be necessary 
until the effect has passed away. As often 
as this is the case, and the spasms recur, 
another injection must be given. In hydro- 
phobia there is remarkable tolerance of the 
drug, poisonous doses (one grain repeated) of 
active curara having in one case been with- 
out any effect (Curtis). This is, perhaps, a 
hopeful fact, as it indicates that curara has 
an action to which the changes in the central 
nervous system are opposed. 
Ordinary sedatives have been the remedies 
commonly employed, and of these the best 
are chloral and morphine. One case (probably 
genuine), in which morphine and Calabar bean 
were used, recovered (Nicholls); and one in 
which chloral was employed lived for ten 
days (Sansom). The effect of the two on the 
respiratory centre in animals suggests their 
joint use. The morphine should be given by 
hypodermic, the chloral by rectal injection. 
Chloroform is useful in moderating the 
paroxysms, but appears somewhat inferior 
to chloral. Other sedatives-Indian hemp, 
&c.-have appeared of inferior value. 
Cold affusions to the cervical spine and 
head were used in India in two cases which 
recovered, the throat and spine being blistered 
with nitrate of silver, and chloroform ad- 
ministered. Ice to the spine has been tried 
without effect. Tracheotomy was recom- 
mended by Marshall Hall in one case. Death HYDROPHOBIA 
HYDROTHERAPEUTICS 
899 
from laryngeal spasm is, however, too rare 
to justify the measure. 
In all cases tranquillity is of the greatest 
importance. Every excitant of spasm should 
be avoided; the patient being kept in a dim 
still room, and friends as much as possible 
excluded. Next in importance is nourish- 
ment, which should be given by the rectum, 
if spasm is excited by the attempt to swallow. 
Restraint, which may be necessary, should 
be as little as possible, but it should be 
effectual. 
The saliva of persons suffering from 
hydrophobia has been proved to be capable 
of communicating the disease to animals. 
Hence the attendants should be cautioned to 
have no uncovered abrasion on the hands, 
and to wash from the eyes or face any saliva 
which may have been spit on them; and if 
they are bitten by the patient, the wound 
should be treated as if it had been inflicted 
by a rabid animal. These precautions remove 
all danger; and any anxiety the subjects may 
feel may be relieved by the assurance that, of 
the thousands of persons who have attended 
on patients with hydrophobia, no authentic 
instance has ever been recorded in which the 
disease was contracted, either by attendance 
during life, or inspection after death. 
W. R. Gowers. 
HYDROPS (vSwp, water).-A synonym 
for dropsy. See Dropsy. 
HYDRORHACHIS (JSwp, water; and 
pax1?, the spine).-A collection of fluid in the 
spinal canal. The term is commonly used 
as a synonym for spina bifida. See Spina 
BIFIDA. 
HYDROTHERAPEUTICS (uScop, 
water ; and OepaTrevm, I treat). - Synon. : 
Water-cure ; Hydropathy ; Fr. Hydrothera- 
peutique; Ger. Wasserheilkunde. 
It would be out of place were we to enter 
here into a description of the sources and 
the composition of the numerous varieties 
of water used for hygienic and dietetic pur- 
poses; but we may refer to Dr. Parkes' 
instructive Manual of Practical Hygiene. 
We intend to divide this article into (1) a 
short sketch of the history of the water-cure 
or hydrotherapeutics; (2) notes on the in- 
ternal use of water, and on the more common 
hydrotherapeutic procedures; and (3) a con- 
sideration of the morbid conditions suitable 
for hydrotherapeutic treatment. 
History of the W ater-cure.-Although 
the old Greek and Roman physicians occa- 
sionally employed water internally and ex- 
ternally in the treatment of disease, the 
systematic water-treatment seems to have 
gained ground for the first time in the fifteenth 
and in the beginning of the sixteenth century 
in Italy and France, and again after a period 
of oblivion in the seventeenth century, especi- 
ally in England (Floyer, T. Smith), and in 
the beginning of the eighteenth century in 
Germany (F. Hoffmann). The next impor- 
tant scientific application we owe to J. G. 
and J. S. Hahn, who, towards the middle of 
the eighteenth century, treated febrile dis- 
eases with cold sponging, and were so con- 
vinced of the beneficial result, that one of 
them when attacked with typhoid fever 
subjected himself to this treatment. It 
fell, however, again into neglect, until to- 
wards the latter part of the eighteenth cen- 
tury, when Wm. Wright, James Currie, W. 
Jackson, and others resuscitated the cold- 
water treatment in fevers, and strengthened 
their reasoning by thermometric observations. 
In spite of the results obtained, not only in 
England but also in Germany, amongst others 
by Reuss, Frohlich, Brandis, and Horn, the 
method was again falling into disuse when, 
soon after 1820, a small farmer, Vincent 
Priessnitz, of Graefenberg, in Silesia, began 
to treat every kind of ailment, chronic as 
well as acute, with various hydrotherapeutic 
procedures, and added to the external ap- 
plications the abundant internal use of 
water, combined with active exercise, and 
a very simple diet; prohibiting at the same 
time all alcoholic beverages, and also tea 
and coffee. Priessnitz gradually made con- 
siderable changes in his method of treatment. 
For the original packing during several hours 
in dry woollen blankets covered with feather- 
beds, and followed by cold affusions, he sub- 
stituted packing in wet linen sheets during 
several hours, followed by a full bath or a 
douche ; and at a still later period he fre- 
quently employed cold wet packing of orly 
fifteen or twenty minutes' duration, repeated 
several times on the same day; he introduced 
also the method of rubbing the whole body 
with a cold wet or dripping sheet instead of 
the full bath, and made extensive use of 
partial baths, as hip or sitz baths, baths for 
the hands, the arms, the feet, wet abdominal 
belts, and wet compresses over different parts 
of the body. Priessnitz seemed to search for 
a universal method applicable to all cases. 
One of the guiding ideas was that disease of 
the most different nature was caused by an 
acrid humour in the blood, and that the skin 
was the organ through which this humour 
was to be removed. 
Though the success of such treatment, 
combined with active exercise in a healthy 
mountainous country, and simple diet, was 
considerable in many cases, the indiscrimin- 
ate, too energetic, and protracted use often 
led to unfavourable results, and the system 
was beginning to be regarded as a species of 
quackery, when, about fifty-five years ago, 
some establishments were placed under the 
superintendence of regularly educated physi- 
cians, who studied the physiological effects 
of the different forms of bathing, and modi- 
fied them with regard to duration, tempera- 
ture, &c., according to the requirements of 900 
individual cases, combining pharmaceutical 
remedies with hydrotherapeutic procedures 
when required. Thus a more or less modi- 
fied water-cure has now become a branch of 
rational medicine, at least in France and 
Germany; and a new impulse has been 
given to it during the last thirty years, by 
the employment of various forms of baths 
in the treatment of fevers. In this country 
there is as yet very little systematised rela- 
tion between the special hydrotherapeutic 
and the general medical treatment; and the 
experience gained at hydrotherapeutic estab- 
lishments is not communicated and discussed 
in our medical societies, and scarcely ever in 
the general medical journals. This is much 
to be regretted, for there can be no doubt 
that hydrotherapeutic measures might be 
more widely introduced with great advantage 
into our hospitals, as well as into our private 
practice ; but this is not likely to be the case 
so long as the medical profession has not 
fuller opportunities for studying the effects 
of water-treatment. The fault may lie to 
some degree in the nature of most of the 
establishments for the water-cure; but this 
might be remedied if more establishments 
were to be erected under the guidance of 
superior members of the profession-estab- 
lishments where the usual medical, dietetic, 
and hygienic treatment, as well as massage 
and gymnastics, would in suitable cases go 
hand in hand with hydrotherapeutic manage- 
ment adapted to the individuality of each 
case. 
Internal Therapeutic Use of Water, 
and the more Common External Hy- 
drotherapeutic Procedures.-The diet- 
etic necessity of water is well known; life 
cannot exist without it; all our tissues con- 
tain an indispensable proportion of water; 
we constantly lose a large amount by respira- 
tion, and by all excretions; all the internal 
functions of tissue-change are dependent on 
a certain quantity of water. This want is 
supplied by the solid and fluid food which 
we take, water included: while temporary 
excess of supply leads to increased discharge 
by the excretions, and temporary deficiency 
to a diminution of the water of the excretions. 
An increased ingestion of water further leads, 
for a time at least, to an increased removal 
of the products of retrogressive tissue-change; 
the tissues and the blood itself are, so to 
speak, washed out by it; and, as the conse- 
quence of the increased removal of the used- 
up material, the body is enabled to take in a 
larger amount of new substance, and hence 
we observe not rarely increase of weight as 
the effect of plentiful water-drinking, if not 
carried to excess as regards quantity and 
time; the secretions of the urine, bile, saliva, 
and pancreatic juice appear to be increased 
by the abundant internal use of water, as 
well as the perspiration; though the latter 
to some degree requires the concomitant in- 
HYDROTHERAPEUTICS 
fluence of high external temperature or bodily 
exercise. 
Water has also an important share in all 
internal courses of mineral waters. Used by 
itself, it can exercise some good influence in 
cases of gout and gravel, in hsemorrhoidal 
complaints, imperfect secretion of bile, and 
constipation from sluggish peristaltic action. 
As, however, excessive water-drinking, ac- 
cording to Priessnitz's original plan, is apt 
to cause dyspeptic troubles, water is now, in 
general, used internally only either for diet- 
etic purposes, or to assist in other courses of 
treatment. 
The external use of cold water admits of 
a very great variety of applications, and a 
corresponding variety of effects on the body. 
The two main effects of the different forms 
of cold baths are abstraction of heat, with 
its further influences on the functions of the 
body; and stimulation of the cutaneous 
nerves, and through these of the nerve-cen- 
tres. The two effects are usually combined, 
but in some forms of bath the stimulation 
or the exciting effect preponderates; in others 
the abstraction of heat, with its calming or 
depressing influence. Hence the different 
forms of baths, or rather hydro therapeutic 
procedures, may be divided into stimulating 
and calming, but it is to be borne in mind 
that there is no strict line of distinction. 
With this limitation we may regard as stimu- 
lating-the full cold bath of short duration, 
the stimulating action of which is increased 
by motion of the water, be it natural or 
artificially imparted; the rapid wash-down, 
either by means of a large sponge, or a 
wet sheet, with or without friction; the spout- 
ing of the back, and the pail-douche; the 
needle-bath or circular shower-bath; the 
different forms of the rain-bath, and the 
usual shower-bath ; the great variety of other 
douches; and the running or flowing sitz- 
bath. The immediate effects of these stimu- 
lating forms, in a constitution endowed with 
a certain amount of reactive power, are 
exhilaration, increased activity of circulation 
and muscular force, and improved appetite 
and digestive power. By altering the dura- 
tion of the bath and the temperature of the 
water, the effects may be considerably modi- 
fied, and thus adapted to different conditions. 
In adult, as well as young persons, most 
beneficial effects are often produced by the 
combination of warm baths with cold douches 
on the spine. 
The more calming forms are-the wet 
sheet-envelope, entire or partial; the im- 
permeable wet compresses; the full cold bath 
of long duration and without motion ; the 
sitz, the shallow, and foot baths without 
motion ; and the full bath of higher tempera- 
ture. Depression through abstraction of heat 
exceeds the stimulation in these forms: 
diminution of nervous irritability, of sensa- 
tion and mental activity, and of the frequency HYDROTHERAPEUTICS 
901 
of the pulse and energy of circulation; a 
feeling of lassitude; and a tendency to sleep, 
are the principal effects. These forms can, 
however, be modified, and the effects vary in 
proportion. Thus the wet sheet-envelope 
allows ample variation by using warm or 
cold water, by using the sheet dripping or 
wrung out, by making it fit tightly round 
the neck, by moving it to and fro, by fre- 
quently changing it, &c. The calming and 
stimulating form may be further combined 
by using, first, the wet sheet-envelope, or 
the woollen blanket-envelope, for a suffi- 
cient period to produce perspiration ; and 
then a more or less cold bath or shower- 
bath of short duration. The physician has, 
indeed, infinite varieties of application at 
his disposal, to be used according to neces- 
sity. 
Powerful and most important hydrothera- 
peutic helps are the different vapour and hot 
air-baths (Russian, Roman, Turkish baths), 
combined with douches and baths of various 
temperatures. These kinds of baths are, 
however, treated of in another article. See 
Baths. 
A plain nourishing diet, without or with 
only a limited amount of stimulants; out- 
door exercise in proportion to the strength of 
the individual; and in some cases massage, 
in others active or passive gymnastics, are 
likewise to be regarded as valuable adjuvants 
in the hydrotherapeutic treatment of chronic 
diseases. For massage and muscular exercise 
mean not only increased action, oxidation, 
excretion, and development of muscle, but 
also increased general circulation and respi- 
ration, increased inhalation of oxygen, and 
increased production of heat, so necessary in 
the cold water-cure. There is also no reason 
whatever why suitable pharmaceutical reme- 
dies should not be combined with the water- 
cure treatment-a method which, as already 
mentioned, is frequently adopted in the best 
establishments. 
Therapeutic Effects, and Morbid 
Conditions Suitable for Hydrothera- 
peutie Treatment.-The principal results 
of well-adapted courses of cold-water treat- 
ment are : improved nutrition and action of 
the skin; increased tone of the nerve-centres; 
regulation of the circulation; amelioration of 
the sanguification and nutrition; and accelera- 
tion of the retrogressive tissue-changes. It 
is essential for such successful results that 
the organism be able to stand a certain 
amount of abstraction of heat; that it be 
capable of more or less energetic reaction; 
and that the digestive and assimilative organs 
be able to take up a fair amount of nourish- 
ing material, which is required by the in- 
creased demand on the body. 
Acute febrile diseases.-Amongst the oldest 
therapeutic uses of the cold bath, though it 
has only lately been more extensively revived, 
is the employment of different forms of cold 
baths in acute febrile diseases, attended with 
a high degree of pyrexia. The moderately 
cold or the cooled-down bath, as proposed 
by Dr. von Ziemssen of Munich, is the form 
principally employed ; but cold affusions, the 
shower-bath, the wet envelope frequently 
changed, cold compresses, the application of 
ice in substance, washing with iced water, 
and iced enemas, are likewise applicable ; and 
the liberal internal allowance of cold water 
forms an important part of the dietetic 
management of this class of diseases. 
Typhoid fever.-Typhoid fever is the dis- 
ease in which this treatment, with numer- 
ous modifications, has been most generally 
adopted. As soon as the temperature of 
the patient reaches 102-2° to 103° F., he is 
placed in a bath of about 90° F., and the 
temperature is gradually cooled down, by 
the addition of cold water, to 80° or 60° 
F., according to the patient's power of re- 
action. The patient is kept in the bath 
generally from 10 to 15 or 20 minutes, when 
slight shivering often manifests itself. The 
patient's temperature, measured in the rec- 
tum, is usually reduced by this procedure 
about 1|° to 5° F., not immediately, but 
within the first hour after the bath. As 
often as the temperature may again reach 
102'2° to 103°, the patient is again placed in 
the bath. Thus, during the height of the 
pyrexia three to five baths may be required 
in twenty-four hours, while later on about 
two are usually sufficient, and often only 
one. Instead of the bath gradually cooled 
down, a bath of a temperature between 60° 
and 90° F., may be given, according to the 
condition of the individual patient. The 
frequent and careful use of the thermometer 
is an essential element in this method of 
treatment, which may be, as it often is, 
advantageously combined with the adminis- 
tration of alcohol, quinine, and other reme- 
dies. The earlier the baths are commenced, 
the greater seems to be their influence in 
mitigating the severity of the disease and its 
sequelae, and in shortening its duration. In 
the numerous accounts of German physicians 
(Brand, Ziemssen, Zimmermann, Jurgensen, 
Liebermeister, &c.) it is claimed that the 
mortality is considerably less with this than 
with the expectant or any of the other usual 
modes of treatment. 
Hyperpyrexia. -A still bolder use may be 
made of the cold-water treatment in those 
rarer cases of hyperpyrexia occasionally oc- 
curring in the course of rheumatic fever, 
when the temperature rises to 108° F. 
and more ; and where very cold and pro- 
longed baths, the application of ice-bags, &c., 
appear to be the only means of saving life. 
The same treatment is likely to be useful 
in some forms of sunstroke ; and also in 
some cases of hyperpyrexia arising from 
other acute disease than rheumatic fever. 
(See the late Dr. Wilson Fox's Treatment 902 
HYDROTIIERAPEUTICS 
of Hyperpyrexia; the writer's case in the 
Clinical Society's Transactions, vol. v.; and 
several other papers in the Clinical Society's 
Transactions.) 
Scarlet fever.-In scarlet fever the writer 
has found warmer baths (80° to 98° F.) more 
generally applicable than quite cold or cooled- 
down baths, though in cases attended by a 
high degree of pyrexia and brain-symptoms 
these are preferable. 
Hectic fever.-In hectic fever, connected 
with various chronic diseases, the effect of 
hydrotherapeutic treatment is less decided, 
and not yet sufficiently tested. 
Digestive derangements of the most differ- 
ent kind, associated with sluggish venous 
circulation in the abdominal organs-condi- 
tions which may be grouped together under 
the term abdominal venosity, tendency to 
haemorrhoids, to hypochondriasis, &c., are 
often the objects of the water-cure, which 
may be useful by stimulating the physical 
and psychical energy of the nervous system, 
as well as the nutrition and tissue-change, 
by invigorating the skin. Habitual constipa- 
tion from this cause is often relieved by the 
hydrotherapeutic belt. In this class of cases 
the common salt waters, and the alkaline 
sulphated waters are more frequently used, 
and are often preferable ; they may, however, 
be advantageously combined with judicious 
hydrotherapeutic treatment. 
Chronic metallic poisoning may be treated 
in some cases with equal benefit, if there is 
sufficient reactive power, at cold-water estab- 
lishments, as at the thermal sulphur and 
simple thermal spas. The external hydro- 
therapeutic procedures, aiming at increased 
perspiration and tissue-change, are in this 
class aided by the abundant internal use of 
water, in order to wash out the tissues, and 
especially the liver. 
Skin- weakness or atony of the skin is often 
the cause of frequently recurring attacks of 
diarrhoea with neuralgic pains, of tendency 
to catarrh of the respiratory mucous mem- 
brane, and of rheumatism. Gently stimula- 
ting hydrotherapeutic appliances, with gradu- 
ally increasing energy, are here mostly useful, 
unless, as in impeded convalescence, the re- 
active power is so reduced that the gaseous 
thermal salt-baths and mountain-air are pre- 
ferable, while in other cases sea-air and sea- 
baths are successful competitors of the water- 
cure. 
Hysteria.-In hysteria and hysterical af- 
fections the water-cure has obtained many 
good results, not by the internal use of water, 
but by the milder forms of baths. Func- 
tional hyperaesthesia and anaesthesia, hemi- 
crania, spinal irritation, intercostal neuralgia, 
and other forms of neuralgia depending on 
imperfect nutrition and tissue-change, are 
likewise often benefited. 
Organic diseases of the nerve-centres are 
not suitable for treatment in cold-water 
establishments, excepting occasionally for 
palliative purposes. 
Rheumatism and gout.-In muscular 
rheumatism the original supporters of the 
water-cure considered their plan as infallible, 
but this is by no means the case. The dia- 
phoretic methods, namely, the woollen blan- 
ket-pack and the wet sheet-envelope, often 
prove useful; but we know also of many 
failures in even good establishments. The 
exposure to all weathers during the cure 
ought certainly not to be imitated by such 
invalids, and the access of cold air to the 
wet body is to be more carefully avoided than 
it often is. The course must not be pro- 
longed too much at one time, but may be 
repeated after an interval of months, which 
may be spent with advantage at sheltered 
seaside localities, at moderate elevations, with 
the help of pine-leaf Laths, or at one of the 
gaseous thermal saline spas. 
Rheumatic and gouty swellings of joints 
require great care in their management. The 
enfeebled invalid is rarely a fit object for the 
ordinary water-cure; but the stimulating 
local compress, more or less impermeable, 
is a useful element in the treatment of such 
cases. 
Milder cases of gout may expect benefit 
from the usual hydrotherapeutic treatment, 
in so far as it aims at increased retrogressive 
tissue-change, and invigoration of the nervous 
system, especially if this treatment is asso- 
ciated with great moderation in the use of 
stimulants, and also of food in general; 
but local packing not rarely causes fits of 
gout. The more serious forms of gout are 
too much complicated with various defects of 
constitution to encourage us in recommend- 
ing cold-water treatment. 
Chronic affections of the skin.-In some 
diseases of this kind, such as prurigo, urti- 
caria, eczema, and local perspirations, a more 
or less modified hydrotherapeutic treatment 
is an important adjuvant. 
Syphilis.-The favourable results obtained 
in syphilis, or rather in the often complicated 
conditions of lues, have greatly contributed 
to the reputation of the water-cure ; but the 
latter is only an excellent adjuvant to medi- 
cinal treatment in these cases, in a similar 
way as the sulphur waters are; and many of 
the cures of so-called lues may be regarded 
as cures of mercurialism. 
Catamenial irregularities are not rarely 
treated at hydrotherapeutic establishments. 
Profuse menstruation is often checked by the 
regular use of the cold hip-bath of short 
duration, namely, three to five minutes ; in 
insufficient menses, on the other hand, warm 
hip-baths of ten to fifteen minutes' duration 
are frequently useful, combined in some 
cases with the wet sheet-envelope ; and dys- 
menorrhcea is likewise occasionally treated 
with advantage by the partial wet sheet- 
envelope. HYDROTHERAPEUTICS 
HYPERTROPHY 
903 
This list of morbid conditions which may 
be more or less benefited might easily be 
increased. This is not astonishing if it is 
considered that hydrotherapeutic treatment 
can be infinitely modified and adapted to the 
powers of the constitution; and that it may 
be assisted by varying hygienic, climatic, 
dietetic, and medicinal influences. For we 
must reiterate that there does not exist 
any antagonism between hydrotherapeutic 
and other rational treatment, the former 
being, in fact, only part of the latter. 
Hence, however, it is also evident that the 
treatment in well-arranged hydrotherapeu- 
tic establishments ought to be under the 
guidance of the most intelligent physicians, 
just as is the case at all the best spas. 
Indeed the physician to such an establish- 
ment ought to be of a high class, possess- 
ing in a more than usual degree the gift of 
recognising all the individual peculiarities 
of the constitution, especially the amount 
of reacting power, adapting the principal 
remedy to every individual case, and com- 
bining other elements of treatment with 
hydrotherapeutic management wherever this 
is necessary. In the same way as we de- 
mand in suitable cases the administration 
of other remedies together with water-treat- 
ment in hydrotherapeutic establishments, so 
we must also express a wish that, apart from 
such establishments, hydrotherapeutic ele- 
ments should be more generally combined 
with the usual medical treatment. For this 
purpose it is to be desired that well-conducted 
establishments should be in or near large 
towns, in order that persons following their 
usual occupations might undergo certain 
kinds of treatment at such establishments, 
or that attendants from such establishments 
might be sent to the houses of invalids. 
Hermann Weber. 
HYDROTHORAX (y^iwp, water; and 
0G>pa$, the chest).-Dropsy of the pleura. 
See Pleura, Diseases of. 
HYDRURIA (y8wp, water; and ovpov, 
urine).-A profuse flow of watery urine. See 
Urine, Morbid Conditions of. 
HYERES, France.-Town three miles 
from the sea. Mean winter temperature, 
55° F. Well sheltered; little rainfall. See 
Climate, Treatment of Disease by. 
HYGIENE (yyleia, health).-The science 
and art which relate to the preservation of 
health. See Personal Health ; and Public 
Health. 
HYPEMIA (v7to,under; and alga, blood). 
Deficiency of blood in a part; a synonym for 
local anaemia. See Circulation, Disorders 
of. 
HYPESTHESIA (v™', under; and 
aiadgats, sensation).-Diminished sensibility 
of a part. See Sensation, Disorders of. 
HYPEREMIA (ynep, over or excessive; 
and alga, blood).-Excess of blood in a part. 
See Circulation, Disorders of. 
HYPERESTHESIA over; and 
nurdz/o-ij, sensation).-Increased sensibility of 
a part. See Sensation, Disorders of. 
HYPERALGESIA (vnep, over; and 
akyor, pain).-Undue sensibility of a part to 
painful impressions. See Sensation, Dis- 
orders of. 
HYPERIDROSIS (inp, excessive; and 
iSpwj, sweat).-Excessive perspiration; also 
termed idrosis, ephidrosis, and sudatoria. 
See Perspiration, Disorders of. 
HYPERINOSIS (ynip, over; and ik, 
cvos, flesh).-Excess of fibrin in the blood. 
See Blood, Morbid Conditions of. 
HYPERMETROPIA (yrrepytTpos, be- 
yond measure; and sight).--A con- 
genital or acquired error of refraction of the 
eye, in which, owing to low refractive power 
of the dioptric media, or too little convexity 
of the refracting surfaces, or unnatural short- 
ness of the antero-posterior axis of the 
eyeball, parallel rays of light do not, while 
the accommodation is in repose, converge to 
a focus on the layer of rods and cones of the 
retina, as in the normal or emmetropic eye, 
but to an imaginary point somewhere behind. 
It is the opposite of myopia, and is sometimes 
called hyperopia or hyperpresbyopia. See 
Vision, Disorders of. 
HYPEROPIA {ynep, above; and 
sight).-See Hypermetropia. 
HYPERPLASIA (wp, over; and 
rrXaaau, I mould or form).-An excessive 
growth of normal tissue-elements, which ma) 
lead to hypertrophy, or to the formation of 
distinct tumours. See Hypertrophy ; and 
Tumours. 
HYPERPRESBYOPIA (vnep, above; 
npeaSvs, old; and sight).-See Hyper- 
metropia. 
HYPERPYREXIA (vn-ep, excessive; 
and irvpe^ia, fever).-Excessive pyrexia. See 
Fever ; and Temperature. 
HYPERTROPHY (vnep, over ; and 
rpocpg, nourishment). 
Definition.-The word 'hypertrophy' sig- 
nifies excessive nourishment, but is in prac- 
tice used to designate the result of excessive 
nourishment-that is, excessive growth. It 
must be carefully distinguished from mere 
enlargement, and only spoken of where there 
is a real increase in a part, or, at least, in a 
tissue, without alteration of quality. Hyper- 
trophy may be general or partial. 
I. General Hypertrophy. - General 904 
HYPERTROPHY 
hypertrophy, though a remarkable condition, 
is of little practical importance. It is knowm 
only in those individuals of enormous size 
who are called 1 giants.' The production of 
giants depends on causes entirely unknown, 
since it is noticeable that this condition com- 
monly affects only one in a family, and is in 
its most conspicuous forms not hereditary. 
Giants are usually of feeble constitution, and 
deficient in procreative power. The name 
macrosomatia has been given to a condition 
equally unexplained, in which the whole 
body becomes enlarged in a monstrous de- 
gree. This condition has been observed to 
he in some instances congenital, or, at least, 
to begin in very early life. True general 
hypertrophy does not appear to be capable of 
being produced by any artificial means, since 
excessive feeding either produces hypertrophy 
almost confined to one tissue-namely, fat - 
or else fails to produce any enlargement at 
all. 
II. Partial Hypertrophy.-By this is 
meant (a) excessive increase of any part of 
the body during the period of natural growth, 
either in intra-uterine or extra-uterine life; 
or (&) increase of a part already completely 
formed. According to this distinction hyper- 
trophy may be classified as either (1) con- 
genital or (2) acquired. 
1. Congenital Hypertrophy.-Congenital 
hypertrophy is that condition in which some 
part of the body begins from the first to 
grow so rapidly as to attain a size far be- 
yond the normal. This condition has been 
seen to affect one side of the body, or one 
limb only, which thus becomes much larger 
than its fellow on the other side. Such a 
condition might be in theory difficult to dis- 
tinguish from atrophy of the opposite side, 
or of the other limh-that is, from hemi- 
atrophy (see Atrophy) ; but in general the 
hypertrophic side is so far beyond the nor- 
mal size as to prevent ambiguity. One re- 
markable case is on record in which one leg 
and arm assumed the proportions of those 
of a giant, whilst the other remained un- 
altered. Sometimes a congenital hyper- 
trophy occurs without this unilateral cha- 
racter, as in the case reported by Mr. Curling 
of a girl aged fifteen, who had several fingers 
of both hands enlarged in an extraordinary 
degree without any assignable cause, the 
equality of the two sides being nevertheless 
preserved. Such instances, although unex- 
plained, must, it would seem, be put into the 
same class as the gigantic growth of the 
whole of the body. Hypertrophy of special 
tissues is also sometimes congenital, as of 
the skin in ichthyosis. Hypertrophies simi- 
lar to those here called congenital may occur, 
though rarely, in adult life. The enlarged 
part is found to be highly vascular, to have 
an increased temperature, and to preserve 
its normal proportions. The cause is in 
these cases equally unknown. 
2. Acquired Hypertrophy.-Acquired hy- 
pertrophies may be classified as follows :- 
(a) Recuperative, consequent on increased 
work. 
(b) Defensive, arising from pressure or 
inflammation. 
(c) Nutritive, from increased supplies of 
food. 
(cZ) Apparently spontaneous or of un- 
known cause. 
(a) Recuperative.-Some organs and tis- 
sues are so constructed that increased func- 
tional activity causes hypertrophy. This is 
especially the case with the muscles. It is 
a matter of familiar observation that volun- 
tary muscles increase in size when much 
employed, as is seen in the often-mentioned 
arm of the blacksmith or the leg of the 
ballet-dancer. In order to produce this in- 
crease, the exercise must be of a certain 
degree of intensity, but not excessive. It 
must be frequently repeated, with intervals 
of rest; and at the same time the nutrition 
of the whole body must be good. In the 
absence of these conditions, exercise is more 
likely to produce wasting. The explanation 
of this familiar process is still obscure. 
Hypertrophy of the heart occurs in cases 
where that organ is. made to work at a 
higher tension than the normal, and this 
higher tension can only result from increased 
resistance to the flow of blood, either at one of 
the orifices of the heart, or in the peripheral 
vessels. Hence the conditions most com- 
monly giving rise to it are valvular disease, 
especially stenosis; and obstruction of the 
arteries, either by the thickening of their 
walls, or by contraction of their muscular 
coats. The right side of the heart will also 
become hypertrophied when any condition 
whatever hinders the passage of blood through 
the lungs. Disease of the kidneys is a fre- 
quent cause of enlargement of the left 
ventricle of the heart, though in what way 
is still a matter of discussion. It is only 
quite clear that the kidney-disease in some 
way increases the resistance in the smaller 
arteries and capillaries of the body generally. 
Hypertrophy of the smooth or involuntary 
muscular fibres also occurs whenever that 
tissue has to contract for a long period under 
a higher tension than the normal. Thus the 
walls of the bladder become thickened in 
cases where, from obstruction of the passages, 
the evacuation of urine is effected with more 
difficulty, and under a higher pressure, than 
usual. In the same way the walls of the 
stomach, the oesophagus, and the intestines 
become hypertrophied in cases of obstruc- 
tion to the passage of food through the ali- 
mentary canal. 
The explanation commonly given of these 
cases of hypertrophy in the contractile organs 
is, that in consequence of obstruction the 
organ has to contract with greater force than 
usual, and thus becomes hypertrophied in HYPERTROPHY 
905 
the same manner as a voluntary muscle 
which is frequently exercised. It is, how- 
ever, clear that this so-called explanation 
does not account for the connexion between 
obstruction and more powerful contraction. 
The only explanation that can be given is 
that in these cases pressure or tension on 
the organ itself is the stimulus to contrac- 
tion, and that the force of contraction ap- 
pears to depend roughly upon the strength 
of the tension which produces it. 
There is less evidence that nervous or 
glandular structures undergo hypertrophy in 
consequence of their increased use ; but if 
one kidney be destroyed the other is gene- 
rally found enlarged; and some authorities 
believe in an increase in the size of the 
brain from mental activity. 
(6) Defensive hypertrophy is the natural 
reaction of certain tissues against slight injury 
or irritation, whereby they become increased 
and serve the purpose of protection. But if 
the injury be excessive, atrophy or destruction 
of tissue results. 
Pressure, which is a mild form of irrita- 
tion, produces, when moderate and intermit- 
tent, hypertrophy of the external integu- 
ment ; but some regions of the skin are 
much more affected, by this cause than 
others. Besides the epidermis, the coverings 
of certain internal organs sometimes show 
the same phenomenon, as the capsule of the 
liver from pressure of a belt, and certain 
parts of the pericardium where friction oc- 
curs. The defensive character of these pro- 
cesses is obvious. 
Inflammation does not cause hypertrophy 
of organs generally, but only of tissues, and 
among these only of the connective tis- 
sues. In most tissues, e.g. muscular, ner- 
vous, glandular, the only result of inflamma- 
tion is atrophy or destruction, with loss of 
functional power. But it seems to be a 
general law that moderate inflammation, 
chronic or intermittent, of connective tissue 
causes it to increase. Purely fibrous struc- 
tures, such as serous membranes, become 
thickened by chronic or repeated inflamma- 
tion of moderate intensity, especially if sup- 
puration be not produced, but this increase 
is not always permanent. In periostitis the 
formation of new bony tissue causes the in- 
crease to be permanent, and thus hyper- 
trophy of bone is a frequent consequence of 
inflammation. The increase of connective 
tissue from irritation is obviously a conser- 
vative or defensive process, placing a barrier 
to the extension of injurious agents; and 
forming a capsule round foreign bodies. 
Increase of connective tissue is also con- 
stantly present in chronic interstitial inflam- 
mation of solid organs, where indeed it is often 
impossible to draw the line between inflam- 
mation and fibrous overgrowth. These 
changes, being produced by some irritation 
or injury, illustrate the law of the depend- 
ence of increase of connective tissue upon 
such causes; but since there is generally 
simultaneous or consequent atrophy of the 
other tissues of the organ, there is likely to 
be rather a diminution than an increase in 
the size of the organ or part generally. 
(c) Nutritive hypertrophy.-D must be 
regarded as doubtful whether increased 
nourishment alone is capable of producing 
enlargement of any part of the body. It 
certainly does not necessarily do so, as is 
shown by the case of experimental hyperaemia. 
When this condition is produced, for instance, 
by section of the cervical sympathetic nerve, 
in one side of the face and head of an animal, 
hypertrophy is only a rare and occasional 
consequence. When, however, the increased 
supply of nutrition in the form of blood is 
combined with some irritation or functional 
stimulus, we often find hypertrophy result. 
Thus, for instance, reflex hyperaemia of the 
skin of the face, or blushing, which is pro- 
duced by numerous internal causes, such as 
gastric or uterine derangement, may subsist 
for years and reach a very high degree with- 
out altering the nutrition of the part. But 
if there should be in addition some disturb- 
ance or inflammation of the glands of the 
skin, we have the conditions called acne 
rosacea, &c., in which hypertrophy is an im- 
portant element. Almost the only instance 
that can be quoted of hypertrophy from in- 
crease of blood-supply alone is that of the 
corpus luteum during pregnancy, when the 
ovary participates in the functional hyper- 
aemia of the uterus. The well-known experi- 
ment of Hunter should also not be forgotten, 
in which he transplanted the spur of a cock 
from its foot to its head, and found it to in- 
crease in size. 
It is, however, important to remember that 
hypertrophy, however produced, is always 
accompanied by an increased supply of blood, 
and enlargement of the vessels. 
Special nutrition.-It is well known that 
abundant supplies of amylaceous and fatty 
food, especially with a full allowance of 
water, cause hypertrophy of the adipose 
tissue. It is also said that small doses of 
phosphorus favour the growth of bone in 
young animals. But there is no other in- 
stance in which it is known that any special 
food causes hypertrophy of any special tissue. 
(d) Apparently spontaneous or physio- 
logical hypertrophy.-Physiological hyper- 
trophies form an important class. One of 
the best instances is that of the enlargement 
of the uterus during pregnancy. This en- 
largement is clearly not the consequence of 
hyperaemia alone, nor of increase of the func- 
tional activity in the muscular walls, though 
both these conditions are present; but must 
proceed from some direct physiological 
stimulus like that which determines the 
growth of the embryo itself. The hyper- 
trophy affects all parts, of the organ-its 906 
HYPERTROPHY 
HYPOCHONDRIAC REGION 
mucous and serous coats, as well as the 
muscular walls. Enlargement of the mamm® 
appears to arise from similar causes; and it 
is even probable that swelling of the thyroid 
may, through some obscure connexion with 
the sexual organs, be caused in the same 
way. Some instances of hypertrophy we 
cannot in any way explain, such as the ap- 
parently spontaneous enlargements of the 
tonsils, spleen, and thymus gland which are 
sometimes observed. These changes have 
been explained by a supposed derangement 
of the so-called trophic nerves, but this 
explanation only puts the difficulty a little 
further back. 
Process of Hypertrophy.-It has been 
a question whether hypertrophy depends 
upon the increase in the size of the minute 
elements of an organ, or only on increase of 
their number. There can be no doubt that 
the former change often occurs. Thus, in 
the pregnant uterus the muscular fibres have 
been found from seven to eleven times as 
long as natural, and from twice to seven 
times as wide. In a remarkable case of en- 
largement of the nerves, described by the late 
Dr. Moxon, the nerve-fibres were found to be 
on an average three times and some of them 
even forty times as large as normal. "When 
enlargement of one kidney takes place as a 
consequence of destruction of the other, the 
tubules and Malpighian tufts are found greatly 
increased in size. In hypertrophy of the 
heart, the muscular bundles are found to be 
thickened, though the fibrillae are unchanged; 
but in most cases multiplication of the tissue- 
elements is the chief cause of the increase in 
size. To this latter process Virchow gives 
the name of hyperplasia, and it is important 
to remember that, though constantly occur- 
ring in hypertrophy of organs, it does not 
necessarily lead to the latter change. 
' False ' Hypertrophy.-The termfalse 
hypertrophy is sometimes used for a process 
in which an organ becomes outwardly in- 
creased in size, owing to the deposition 
within it of some foreign material, or to mere 
distension. Thus in a fatty liver the real 
liver-tissue is wasted, but is replaced by fat. 
An emphysematous lung appears to be in- 
creased in size, but has actually suffered 
atrophy. The substance of the brain in 
hydrocephalus may be greatly reduced in 
volume, though the head appears of enormous 
size. The very remarkable disease called 
' Duchenne's paralysis ' is an instance of ap- 
parent hypertrophy of the muscles, through 
deposition of fat between the fibres, but the 
term is hardly needed, except as a caution. 
Treatment.-It is obvious that no general 
rules can be laid down for the treatment of 
hypertrophy. When it is connected with in- 
creased functional activity, it is usually a 
favourable rather than a hurtful condition, 
though in some cases it may appear that the 
hypertrophy more than compensates the de- 
ficiency or irregularity by which it is pro- 
duced. But even if this be so, the cure of 
excessive hypertrophy is not within our 
powers. The utmost that can be done is to 
endeavour, if possible, to check the process 
by which the hypertrophy is produced. It 
is, however, well to point out that when 
functional hypertrophy has resulted from 
some obstacle or undue resistance, it may 
entirely subside when that resistance is re- 
moved. Thus if the uterus have enlarged 
around a fibrous tumour, it may regain its 
normal bulk when the tumour is removed; 
and we sometimes see a sensible diminution 
in the size of a hypertrophied heart when 
the derangements which produce it no longer 
act. Moreover, hypertrophy may be com- 
pletely reduced by a general lowering of the 
nutrition of the body. Thus, in early stages 
of pulmonary phthisis, the heart may be 
hypertrophied; but when death occurs in a 
late period of the disease, the organ is rarely 
found enlarged, and is even wasted ; though, 
according to Dr. Peacock's tables, less so 
than in other wasting diseases. 
J. F. Payne. 
HYPINOSIS (vn-o, under; and w, Ivos, 
flesh). - Deficiency of fibrin in the blood. 
See Blood, Morbid Conditions of. 
HYPNOTICS (yrrvos, sleep).-Measures 
or agents employed to induce sleep. See 
Narcotics. 
HYPNOTISM (yrrvos, sleep).- A. syno- 
nym for Braidism. See Braidism ; and 
Mesmerism. 
HYPOCHONDRIAC REGION (M, 
under; and xovSpos, a cartilage).-This region 
is double, right and left, occupying the upper 
part of the abdomen on either side of the 
epigastrium, and partly corresponding to the 
lower regions of the chest, being almost, and 
in some cases entirely, covered in by the ribs 
and their cartilages. Each hypochondrium 
is bounded below by a horizontal line at the 
level of the ninth costal cartilage ; and in- 
ternally by a vertical line from the eighth 
cartilage downwards. The organs situated 
in the right hypochondrium are the liver and 
gall-bladder mainly ; with, more deeply, the 
pyloric end of the stomach, part of the duo- 
denum, and the hepatic flexure of the colon. 
In the corresponding left region lie the spleen, 
a small portion of the left lobe of the liver, 
the fundus of the stomach, the tail of the 
pancreas, and the splenic flexure of the colon. 
The gastro-splenic fold of peritoneum, with 
its vessels, passes from the stomach to the 
spleen. 
Clinical Investigation.-It must be borne 
in mind that morbid conditions within the 
chest not uncommonly originate clinical phe- 
nomena, both subjective and objective, in 
connexion with one or other hypochondriac 
region, and these must always be taken into 
consideration when investigating any parti- HYPOCHONDRIAC REGION 
HYPOCHONDRIASIS 
907 
cular case. In making a diagnosis, no reli- 
ance whatever can be placed on mere sensa- 
tions referred to these regions, but physical 
examination is in every instance required, 
in order to determine the conditions present, 
and especially palpation and percussion. 
Moreover, it must be remembered that dis- 
ease of an important and serious nature may 
arise without the occurrence of any unusual 
feelings. Pain of various kinds is often com- 
plained of, and when referred to the right 
hypochondrium is usually supposed to be 
connected with the liver ; but it may depend 
upon affections of the superficial structures ; 
peritonitis ; right pleurisy or pneumonia ; or 
conditions associated with the gall-bladder, 
pylorus, duodenum, or colon. A character- 
istic pain starting from this region is that of 
hepatic colic, usually due to the passage of a 
gall-stone along the ducts. Persons who are 
hypochondriacal not uncommonly refer some 
abnormal sensation to their right hypochon- 
drium, for which there is really no obvious 
cause. In the left hypochondrium pain may 
also be due to affections of the walls, or of 
structures within the thorax; of the cardiac 
end of the stomach; of the colon; or, in 
exceptional cases, of the spleen. 
The morbid conditions which are capable 
of originating abnormal physical signs in the 
hypochondriac region may also be either 
thoracic or abdominal. Of the former, pleu- 
ritic effusion is the most frequent; and on 
the right side this condition may cause 
marked depression of the liver, as also may 
pneumothorax. In exceptional instances the 
heart is so enlarged as to reach the left 
hypochondrium; and the writer has met with 
a case in which a large thoracic aneurysm 
presented in this region. As regards ab- 
dominal diseases occupying the right hypo- 
chondrium, abnormal physical signs are usu- 
ally associated with the liver, which is 
altered in position, shape, size, or physical 
characters. Occasionally they are connected 
with the abdominal walls; the gall-bladder; 
or the stomach, duodenum, or colon. On 
the left side enlargement of the spleen is the 
main condition discovered by physical ex- 
amination ; but the stomach may also give 
signs of distension in this direction, or of 
organic disease of its walls. Exceptionally 
the colon may present abnormal physical 
signs. Growths may originate here in con- 
nexion with the peritoneum ; and the writer 
has met with a case in which a growth 
started from the left hypochondrium, prob- 
ably of a malignant nature, and involving 
more than one structure, but it was im- 
possible to say where it commenced. Of 
course the hypochondria are involved along 
with other regions in general enlargement of 
the abdomen; and organs from other regions 
may so increase in size in certain diseases as 
to extend into one or both of these regions. 
Frederick T. Roberts. 
HYPOCHONDRIASIS (yni, under; 
and xo^Spos, a cartilage).-Synon. : Fr. Hypo- 
chondrie; Ger. Hypochondrie. 
Description.-The term ' hypochondriasis ' 
is derived from an ancient hypothesis that 
the symptoms of this disorder were due to 
perturbations of natural force generated in 
the liver and pylorus, to which idea the fre- 
quent prevalence of flatulence in the disorder 
conduced. The condition thus called is really 
a disease of the nervous system. It is a form 
of mental unsoundness closely allied to melan- 
cholia, of which, indeed, it often forms the 
initiatory stage. It is characterised by a 
morbid anxiety, either without any, or having 
only very slight, foundations, relative to the 
state of physical health. The patient thinks 
about his health unduly, observing himself 
with restless care, examining especially the 
characteristics of his secretions, translating 
into evidence of progressive organic mischief 
every trivial departure from perfect action of 
his organs, and becoming more and more 
absorbed in precautions against the malady 
with which he believes himself affected. No- 
thing that happens tends to the side of re- 
assurance. If his sleep be disturbed, the 
symptom may be portentous, he thinks, of 
brain-softening; if it be sound, the patient, 
instead of being comforted, fears apoplexy. 
Constipation of the bowels signifies obstruc- 
tion ; a slight diarrhoea implies coming ex- 
haustion. Everything which he reads or 
hears in reference to disease, the patient 
applies to his own case, examining himself 
on every point thus presented to his mind, 
and rarely failing to find something which 
dovetails with symptoms of his own. For 
he recognises only the points of resemblance; 
the features of difference are unconsciously 
ignored. In some cases the patient is con- 
stant in referring his troubles to one particular 
organ. Year after year his story is the same: 
it is his stomach, liver, brain, or some other 
organ, which is in fault; but always the same. 
In other instances there is a vacillation quite 
as remarkable. Routed, perhaps, by the con- 
vincing arguments of his adviser, he is forced 
to yield the position which he had assumed, 
but only to take an equally strong one in 
reference to some other part of his frame. 
These diversities strongly recall the fixed and 
shifting delusions of insanity. The patient is 
prone to wander from one doctor to another, 
often carrying with him a bundle of prescrip- 
tions and a long written list of questions, 
which must receive categorical answers. Ap- 
parently satisfied at the time, he speedily 
recollects some point upon which he has not 
received assurance, and this he conceives 
vitiates the whole of the explanation and ad- 
vice which have been given to him, and he 
is plunged again into his previous state of 
anxiety and doubt. Where circumstances do 
not involve forced labour for existence, the 
patient passes his time in chasing his health, 908 
HYPOCHONDRIASIS 
HYPODERMIC MEDICATION 
which is always contriving to elude his grasp. 
If he holds an appointment, he will resign it 
in order to have full opportunity for studying 
himself; and his occupation once gone, he 
finds too late that it was his best friend, and 
he then ascribes to his forced idleness all the 
ills which had induced him to seek retire- 
ment. 
In many cases the most careful examina- 
tion can discover no signs of disease, and the 
patient wears the aspect of health; or there 
may be a worn, anxious look. In others 
there may be, especially in the digestive or- 
gans, slight deviations from perfect integrity, 
which explain some of the symptoms, but 
not the exaggerated apprehensions to which 
they give rise. 
Hypochondriasis is a chronic disorder. It 
may continue, and this most frequently, as a 
harmless peculiarity attached to a life which 
is not perceptibly shortened in length, though 
often sadly diminished in utility and happi- 
ness, by its symptoms. Or there may be an 
improvement practically amounting to a cure, 
which will endure for a longer or shorter 
period. In the decline of life, however, 
there is very apt to be a return of symptoms. 
Or hypochondriasis may pass into true melan- 
cholia, and then the bodily health, previously 
the constant object of solicitude, improves 
wonderfully. Indeed, nothing more is heard 
about it. 
/Etiology.-Hypochondriasis is very much 
more common in the male than in the female 
sex. The period of life most prone to it is 
from 20 to 40 years of age. It is apt to occur 
in those who inherit a tendency to insanity, 
and the disease in its own peculiar form is 
often hereditary. Excesses of various kinds, 
especially on the side of the sexual system, 
will precipitate the appearance and intensify 
the symptoms of the affection, but it is doubt- 
ful whether they can altogether originate it. 
The same may be said of gout, which is apt 
to be associated with the condition and to 
complicate its symptoms. Depressing moral 
circumstances also are not without influence 
in determining an onset of hypochondriasis 
in those predisposed to it. This is especially 
true of mental strain. The frequent occur- 
rence of some deviation from healthy condi- 
tion in the liver, stomach, or bowels, which 
is noted in these cases, would suggest that, 
probably through an interruption to the per- 
fect nutrition of the body, diseases of these 
viscera bear their part in the causation of 
hypochondriasis. The intercurrence of in- 
ternal haemorrhoids with bleeding is very 
common, and this would manifestly tend to 
keep up, if it did not originate, the disease. 
Stricture and chronic ulcer of the intestines 
are occasionally associations which probably 
also influence the appearance of hypochon- 
driasis. 
Anatomical Characters.-There are no 
anatomical characters peculiar to the disease. 
Diagnosis.-When careful examination, 
which must never be omitted, has disproved 
the existence of organic disease tending to 
produce the symptoms described by the 
patient, it sometimes becomes a question 
whether the case is one of hypochondriasis 
or of melancholia. 
In the former there is no tendency to 
suicide; on the contrary, a strong desire to 
live pervades the sufferer's mind, and impels 
him to endless search for the cure of his ail- 
ments. He delights in consulting medical 
men and entering into the minutest details 
which he thinks can aid them in helping 
him. Up to a certain point his story is fre- 
quently characterised by a logical accuracy, 
which fails him, however, in some point of 
great importance, by which the conclusions 
are invalidated. The melancholic patient, on 
the other hand, is often suicidal and always 
despairs of any relief to his condition, the 
description of which, as given by him, is con- 
fused, frequently incoherent, and unintelli- 
gible. 
Prognosis.-Early and marked hypochon- 
driasis occurring in a person with a strong 
hereditary taint of insanity, without any 
definite cause of mental depression, is of ill 
omen. Such a case very often drifts into 
melancholia. 
The prognosis is more favourable, perhaps, 
the less strongly marked the hereditary pre- 
disposition and the more evident and adequate 
the immediate causes to which the patient 
has been exposed, the most potent of which 
are sexual or alcoholic excesses, mental strain 
or shock, or the sudden change from a life of 
activity to one of forced and, as the sequel 
shows, uncongenial leisure. 
Treatment.-Moral treatment is alone of 
any influence in a large majority of cases. 
Where there is, however, manifest anaemia, a 
history of syphilis, evidences of gouty mal- 
assimilation, accumulation of faeces, catarrh 
of the intestinal canal, or haemorrhoids, the 
therapeutics proper to these conditions should 
be employed. Alcoholic stimulants should be 
avoided. Travel, especially under judicious 
companionship, and the encouragement of 
regular, definite, and useful employment for 
the attention and the physical powers, are the 
most potent means of treatment, by which 
the disease may be often much ameliorated, 
and sometimes cured. Ridicule of the pa- 
tient's sufferings will rarely or never be of 
service, but at the same time a habit of pre- 
scribing for all the symptoms as they arise 
must be avoided. T. Buzzard. 
HYPODERMIC MEDICATION 
(vtto, under; and Seppa, the skin).-Fr. La Me- 
thode Hypodermique or Sous-cutanee; Ger. 
Subcutane Arzneiapplication', Hypoderma- 
tische Injection der Arzneimittel. 
The introduction, by means of a sharp- 
pointed hollow needle, of alkaloids and HYPODERMIC MEDICATION 
909 
other agents into the subcutaneous cellular 
tissue. 
History.-Hypodermic injections were 
first employed by physiologists in experi- 
mental researches. John Hunter appears to 
have used them in this way, and they were 
certainly so employed as far back as 1819 by 
Magendie. Valleix made a crude attempt to 
apply sedatives subcutaneously in the treat- 
ment of neuralgia by means of acupuncture- 
needles ; but, according to Bartholow, it was 
not till 1839 that the method was regularly 
employed in the treatment of disease, when 
Taylor and Washington in America made 
use of it, the idea being suggested to their 
minds by Lafargue's method of inoculation. 
Sieveking claims that Kurzak of Vienna was 
really the discoverer of hypodermic medica- 
tion ; but, be this as it may, it was undoubt- 
edly the late Dr. Alexander Wood of Edin- 
burgh who brought this method of treatment 
into general use. 
Method of Application.-This is a matter 
of great importance. With due precaution, 
the pain in most instances is insignificant. 
In the case of some drugs, such as ergotine, 
more or less pain is inevitable, but by careful 
manipulation the unpleasant effects may be 
reduced to a minimum. The needle, which 
must be sharp and smooth at its point, is 
attached to the nozzle of the syringe, and the 
latter is charged with the drug to be em- 
ployed. If a tabloid is used, it is dissolved 
in a syringeful, or less, of warmish water ; if, 
on the other hand, a solution of the drug is 
used, the syringe should be completely filled, 
and the quantity to be injected accurately 
gauged by moving the button down to the 
required mark on the piston. By either 
plan the possibility of overdosage is guarded 
against. A fold of skin is pinched up be- 
tween the left thumb and index finger, and 
the needle is pushed firmly and sharply into 
the cellular tissue. The barrel of the syringe 
is then steadied between the right index and 
middle fingers, and the fluid slowly and 
steadily injected by pressure with the right 
thumb on the end of the piston. As the 
needle is withdrawn, the left index finger 
should be applied to the point of puncture 
for a few seconds. In the case of ergotine 
and a few other irritating drugs it is well to 
modify this mode of procedure by making 
the injection directly into the muscular 
tissue: in uterine haemorrhage, into the 
gluteal muscles. 
To prevent any chance of sepsis, some 
recommend that the needle before being used 
should be dipped into carbolised oil. Local 
ill effects consist chiefly in pain, phlegmo- 
nous swellings and consequent abscess, slight 
bleeding, or ecchymosis; but with proper 
precautions most of these accidents may be 
avoided, and in nearly all cases the pain is 
both trifling and evanescent. Certain parts 
of the body should always, if possible, be 
avoided in making hypodermic injections- 
e.g. regions where the subcutaneous cellular 
tissue is scanty, such as the skin over the 
tibiae, parts such as the cheeks, forehead, 
ears, &c. It is well also to avoid the neigh- 
bourhood of large vessels. General ill effects 
may easily be produced from injections, es- 
pecially of narcotics, in diabetics, alcoholics, 
and patients suffering from renal disease. 
Solutions should be made with vehicles 
which fulfil the following conditions: (1) 
They should have as high a solvent power as 
possible. (Some substances, such as calomel, 
can only be injected in a state of suspen- 
sion.) (2) They should, as far as possible, 
be permanent, not deteriorating by keeping. 
(8) They should be unirritating. Cherry-laurel 
water, carbolic acid, boric acid, camphor, 
and other substances, may in some cases be 
used to prevent the development of organisms. 
Paroleine (one of the petroleum series) is the 
best vehicle for the injection of antiseptics, 
such as carbolic acid, eucalyptol, iodoform, 
turpentine, &c. Tabloids and gelatine discs 
are convenient forms for use in preparing 
solutions. 
Instruments.-For ordinary hypodermic 
use a simply constructed and accurately gra- 
duated instrument is requisite. The capacity 
of the barrel should be twenty minims. The 
syringe may conveniently be had in a small 
case, with two needles, and a supply of silver 
wires to keep their canals clear. The needles 
are best made of golden platinum, which is 
both tough and non-corrosible. It is of great 
consequence that the points should be sharp 
and with smooth edges. The nozzle of the 
syringe, on which the needle is fitted when 
required for use by a simple sliding motion 
(not by a screw), should always be provided 
with a metal cap. This prevents drying and 
shrinking of the piston packing. The pack- 
ing should consist of leather or wash-leather: 
and if by any chance it does not fit tightly, 
the top of the syringe should be unscrewed 
and removed, with the piston, and the pack- 
ing is then to be well soaked in paroleine. 
The metal parts must not be attached to the 
barrel by cement, as this material is de- 
stroyed by ether and other fluids, and the 
syringe is consequently rendered utterly use- 
less. The minims are best marked on the 
piston, which should have a screw-thread on 
which a button runs: by this means the 
dose is gauged accurately before the injection 
is made, and. there is, therefore, no possibility 
of injecting more than was intended. The 
piston should have a simple sliding, and not 
a screw, action. It is terminated at the top 
by a flat knob, which is pressed with the 
thumb when the injection is made. For 
the injection of ether, alcohol, antiseptics, 
nutrients, saline solutions, &c., much larger 
syringes may be used to avoid multiple in- 
jections ; such syringes are usually of a 
capacity of eighty to one hundred minims. 910 
HYPODERMIC MEDICATION 
It is almost superfluous to add that hypo- 
dermic syringes must be kept scrupulously 
clean. After use, tepid water, to which an 
antiseptic may with advantage be added, 
should be drawn into the syringe and ejected 
through the needle. The latter should then 
be blown through, to expel any remaining 
fluid, and a silver wire is then passed through 
and left in its canal to keep it clear. The 
barrel of the syringe should consist of glass. 
Celluloid has been employed for this purpose, 
but it is soluble in ether and alcohol, and 
should therefore be avoided. The cap, 
nozzle, and piston should consist of nickelled 
metal or silver. 
Advantages.-The advantages of the hy- 
podermic method are numerous, and difficult 
to over-estimate; but it must be remem- 
bered that it has its limitations. There is, 
for instance, no useful end gained by the 
hypodermic injection of such drugs as Epsom 
salts, or of such powerfully irritating and 
depressing principles as colchicine and can- 
tharidine. It is further important to point 
out that the hypodermic administration of 
such drugs especially as morphine and 
cocaine should be under the direct control of 
the medical man, and should in no case be 
entrusted to the patient. The advantages of 
the hypodermic, as contrasted with other 
methods of administering drugs, may be 
briefly summed up as follows: (1) There is 
greater rapidity of absorption, and conse- 
quently more speedy effect. (2) A rapid 
local as well as general effect can be more 
easily obtained. (3) Drugs can be adminis- 
tered in this way when other methods are 
impossible-e.g. in cases of vomiting, nausea, 
and other conditions originating in an irri- 
table or diseased stomach; where there is 
mechanical difficulty in deglutition ; and in 
certain cases of delirium, mania, or coma. 
(4) According to Eulenburg, drugs are less 
liable to produce a cumulative effect when 
injected subcutaneously than when adminis- 
tered by the mouth. (5) In cases of narcotic 
or other forms of poisoning, emetics hypo- 
dermically injected often produce a rapid and 
certain effect, when administration by the 
mouth is inadmissible. 
Remedies used Hypodermically, and 
Diseases for which they are Em- 
ployed. 
Acidum Arseniosum-Arsenious Acid. See 
Arsen ium. 
Acidum Benzoicum-Benzoic Acid. Ben- 
zoic acid 10 grains; alcohol up to 112 
minims. Dose, from 8 to 16 minims. Used 
in chest-diseases to stimulate the respiratory 
centre, and in the collapse of acute fevers and 
uraemia. The solution should be slightly 
warmed before injection. 
Acidum Carbolicum-Carbolic Acid. Pure 
carbolic acid 1 or 2 grains ; paroleine, or 
water, up to 112 minims. Dose, 8, 16, or 24 
minims. Has been used in erysipelas, ma- 
lignant pustule, and other infective diseases. 
Acidum Scleroticum-Sclerotic Acid (ob- 
tained from ergot). The solution easily de- 
composes, and should be made as required. 
Twenty minims of a 4 per cent, solution, 
twice or thrice in the twenty-four hours, 
recommended by Ziemssen in haemoptysis. 
Tabloids of | to 1 grain are convenient for 
administration. The indications for the use 
of sclerotic acid are the same as those for 
ergotinin. 
Aconitina-Aconitine. There are various 
aconitines, and these are of various strengths. 
Morson's is of uniform strength, and should 
be prescribed. The dose ranges from 553 to 
- of a grain. For a first dose the quan- 
tity should never' exceed of a grain: 
aconitine (English) 1 grain; diluted sulphu- 
ric acid q.s.; distilled water to $ ounce. Dose, 
1 to 4 minims (Martindale and Westcott). 
Tabloids (^ and j|5 grain) may also be used. 
Uses : In various forms of neuralgia, espe- 
cially of the trigeminal. It has also been 
employed in cardiac hypertrophy, angina 
pectoris, intermittent and puerperal fevers; 
but in such cases it is preferable, as a gene- 
ral rule, to administer the tincture by the 
mouth. 
AEther-Ether. Sulphuric ether is gene- 
rally used for hypodermic purposes, but 
acetic ether may also be so used. Ether 
may also be injected in combination with 
alcohol; or camphor, 1 to 2 parts dissolved in 
sulphuric ether 10 parts, may be administered. 
Dose of sulphuric ether 20 to 40 minims, 
repeated as required (see remarks on 
Syringes). Uses : In collapse of any kind, 
in the exhaustion of typhus and other fevers, 
pneumonia, &c. 
Alcohol in the form of brandy is very 
useful hypodermically in cases of collapse. 
Doses of half a fluid drachm to a drachm 
may thus be given at a time and repeated 
as required. It causes little pain. 
Ammonite Liquor-Solution of Ammo- 
nia. Dose, 2 to 5 minims hypodermically 
or intravenously. The latter method is of 
service in syncope from any cause, and in 
threatened death from embolism. 
Amyl Nitris-Nitrite of Amyl. Nitrite 
of amyl 1 part; alcohol 9 parts. Dose, 8 to 
12 minims. Used in threatened death during 
chloroform anaesthesia, in puerperal convul- 
sions, and in irregular (hour-glass) uterine 
contractions. Also in strychnine poisoning; 
and, especially, in angina pectoris. 
Apocodeine Hydrochlor ate. Eecommended 
by Dujardin-Beaumetz as an emetic. Dose, 
| to g of a grain in 16 minims of distilled 
water. 
Apomorphince Hydrochloras-Apomor- 
phine Hydrochlorate. Dose, tabloids to 
- grain; or 2 to 8 minims of the pharma- 
copceial 2 per cent, solution in camphor water 
may be given. An over-dose may kill by HYPODERMIC MEDICATION 
911 
causing profuse bronchial secretion (Brun- 
ton). Used in various forms of poisoning as 
an emetic. 
Aqua-Water. Large hypodermic injec- 
tions of water, or of water with chloride and 
bicarbonate of sodium in solution, have been 
used in cholera, but intraperitoneal injections 
have been recommended in preference. Iced 
water has been used hypodermically to cure 
sciatica, and also in pyrexia. Hot water is 
sometimes useful in this way as an analgesic. 
Arsenium-Arsenic, and its preparations. 
Arsenic causes slight local irritation. It may 
be used in the form of Fowler's solution (1 
part to 2 parts of distilled water). It is of 
service in various nervous diseases-paralysis 
agitans, chorea, neuralgia, epilepsy, &c.; in 
skin diseases-lichen ruber, psoriasis, chronic 
eczema; in septic diseases-puerperal and 
typhoid fevers; in lymphoma, in various 
psychoses, and other diseases. 
Atropina-Atropine. The neutral sulphate 
is the best salt. The solution used should be 
recent. Neutral sulphate of atropine 1 grain; 
distilled water up to 2 ounces, 160 minims 
(sixteenminims = grain). It is well to begin 
with grain. The prepared tabloids T|5, 
and ~ grain are useful. Used, in neural- 
gia, asthma (when the mucous membrane is 
not dry), enuresis, spermatorrhoea, intestinal 
obstruction, epilepsy, tetanus, for the relief of 
pain generally, as an antisudorific (especially 
in phthisical sweats), and as an antisiala- 
gogue. Is of great service in combination 
with morphine. See Morphine, p. 912. 
Auri Chloridum-Chloride of Gold. 
Dose, jg grain in 20 minims of distilled 
water. Used in hysterical anaesthesia, and 
in syphilitic affections. 
Caffeina-Caffeine. Caffeine 20 grains ; 
salicylate of sodium 171 grains; distilled 
water to 1 drachm (3 minims = 1 grain). 
Dose, 1 to 6 minims (Martindale and West- 
cott). Tabloids of caffeine sodio-salicylate 
= | grain, may also be used. Used in ma- 
larial neuralgia and rheumatism, megrim, 
insomnia, chronic alcoholism, hysteria, car- 
diac dropsy (on account of its diuretic action), 
asthma, and in poisoning by opium and its 
alkaloids and compounds, alcohol, and co- 
caine. 
Calabarina, Physostigmatis Extractum- 
Calabarine, and Extract of Calabar Bean. 
Calabarine is not used hypodermically, but 
eserine (physostigmine) and the extract have 
been so employed. The best preparation is 
that of Martindale and Westcott. Extract 
of Calabar bean 10 grains; rectified spirit 
10 minims; rub together till smooth, and 
add gum acacia 10 grains; mix, and add 
gradually distilled water to | ounce. Dose, 
3 to 12 minims. Used in tetanus, trismus 
neonatorum, strychnine poisoning, enuresis, 
&c. 
Calomel.-See Hydrargyrum. 
Camphor.-See .Ether. 
Chlor of or mum-Chloroform. Has been 
injected pure, in doses of 10 to 20 minims 
and upwards, as a substitute for morphine in 
neuralgia, lumbago, colic, cancer, &c. 
Cocaina-Cocaine. One of the best, if not 
the best, of local anaesthetics. Injected hypo- 
dermically renders operations for haemor- 
rhoids, small tumours, &c., painless. To ob- 
viate toxic effects the re-crystallised salt 
should alone be used. The solution decom- 
poses rapidly, and it should therefore be 
freshly prepared when required. Tabloids of 
5, and | grain are convenient. In addi- 
tion to its use as a local sedative, cocaine 
has been employed in hemicrania and melan- 
cholia, to overcome the craving for morphine 
and alcohol, and to relieve various forms of 
neuralgia. 
Codeina-Codeine. The hydrochlorate is 
the best salt for hypodermic use. Dose, | 
grain to 1| grain. Codeine hydrochlorate 
1 grain; distilled water up to 128 minims 
(16 minims = £ grain). Used in diabetes 
mellitus ; also in gastrodynia, insomnia, 
cancer, and asthma. 
Conina-Conine, and its salts. Hydro- 
bromate of conine 1 grain; distilled water 
20 minims. Dose, 1 to 3 minims. Used in 
asthma, angina pectoris, pertussis, laryngis- 
mus stridulus, tic-douloureux, chorea, mania 
(Crichton Browne). Useless in tetanus and 
strychnine poisoning. 
Curara- Curare. Is best given hypoder- 
mically. Dose, ~ grain in 1 per cent, filtered 
aqueous solution, or a tabloid (- grain). 
Used to control the spasms of tetanus and 
hydrophobia. 
Daturina, Extractum Stramonii-Datu- 
rine and Extract of Stramonium. Dose, of 
daturine, grain; of stramonium extract, 
~ to 1 grain. Used in emphysema, neuralgiar, 
tetanus, and tremor (paralysis agitans). 
DigitaUnum-Digitalin. Must only be 
used in crystalline form ; all other forms are 
impure and unreliable. Dose, ~ grain 
tabloid. Used only exceptionally subcutane- 
ously, in aconite poisoning, heart-diseases, 
spermatorrhoea, and exophthalmic goitre 
(B artholo w). 
Duboisina-Duboisine. Dose, grain. 
Used in exophthalmic goitre (Dujardin- 
Beaumetz), phthisical sweats (Gubler and 
others), and asthma. 
Ergotinina-Ergotinine. Ergotin is the 
watery extract of ergot. Ergotinine is the 
crystalline alkaloid. Dose, of Bonjean's ergo- 
tin 2 to 4 grains in glycerine and distilled 
water up to 20 minims ; of ergotinine in tab- 
loid ~ or T~ grain. Used because of its 
action on involuntary muscular fibre-(1) to 
contract the uterus; (2) to constringe blood- 
vessels in haemoptysis and other forms of 
bleeding. Should always be deeply injected. 
Ferrum-Iron. The pyrophosphate of 
iron with citrate of sodium (2 grains in 20 
minims), and ammonio-citrate of iron in 912 
HYPODERMIC MEDICATION 
2-grain doses and upwards, have both been 
strongly advocated for hypodermic use in 
anaemia. Very rarely resorted to. 
Homatropina-Homatropine hypodermi- 
cally is less efficacious than atropine. Dose, 
in tabloid, grain. Used to relieve cough, 
expectoration, and insomnia; also as an anti- 
dote to pilocarpine. 
Hydrargyrum-Mercury, and its salts. 
The injection of the salts of mercury should 
only very exceptionally be resorted to, as the 
process is always painful and, without ex- 
treme care, is apt to result in inflammation 
and abscess. Where administration by mouth 
is, for any reason, undesirable, the endermic 
method by inunction with the oleates, or the 
oleates in combination with lanolin, is prefer- 
able to subcutaneous injection. The salts 
available for hypodermic use are the per- 
chloride, the biniodide, the peptonate of mer- 
cury and ammonium, and calomel. If the 
perchloride is used, discs (= grain of sub- 
limate) or tabloids (= /6 and ~ grain of sub- 
limate) are most convenient. If a solution is 
desired, the following formula may be used: 
Perchloride of mercury 3 grains; chloride of 
sodium and hydrochlorate of cocaine, of each 
1 grain; distilled water up to 336 minims 
(16 minims = | grain of mercuric chloride). 
The best solution of the biniodide is that 
of Martindale and Westcott: Injectio hydrar- 
gyri iodidi rubri, 1 in 64. Dose, 2 to 6 
minims. 
Calomel may be injected in doses of 1 or 
1| grain suspended in pure liquid vaseline 
or paroleine, or Neisser's formula (modified) 
may be used : Calomel and sodium chloride, 
of each Jiv.; mucilage of tragacanth jij.; 
distilled water Jj ss. 
Hyoscina-Hyoscine, and its salts. The 
effects of hyoscine are best produced by hy- 
podermic use. The dose ranges from ~ to 
A grain. Tabloids contain and ~ grain. 
The best solution is : Hyoscine 1 grain; dis- 
tilled water 200 minims. Used in the treat- 
ment of delirium, excitement, and insomnia 
due to insanity and other diseases. Has 
been of service in the treatment of epilepsy 
and chorea. Of no use as an analgesic. 
Injectiones Hypodermicce Nutrientes- 
Nutrient injections are of very limited ap- 
plicability. Almond, olive, and cod-liver oil 
may be thus employed. Sugar solution, egg 
albumen (alone or mixed with the yolk), 
milk, and defibrinated blood have all been 
injected subcutaneously, with more or less 
success. Blood-serum and salines have also 
been used. Milk has been injected intra- 
venously, and sodium chloride intraperito- 
neally. 
Iodoform may be given in solution in oil 
or ether, in doses of 1 grain and upwards. 
Iodoform 3 grains; sulphuric ether 15 
minims; castor oil up to 32 minims. Used 
in scrofula, goitre, rickets, phthisis, &c. 
Morphina-Morphine, and its salts. The 
following salts are all more or less adapted 
for hypodermic use-acetate, tartrate, sul- 
phate, hydrochlorate, and bimeconate. The 
pharmacopceial preparation contains the ace- 
tate. Morphine may be combined with co- 
caine or atropine : Cocaine hydrochlorate 3 
grains; morphine hydrochlorate 1 grain; 
distilled water up to 224 minims-sixteen 
minims = grain of morphine and 1 grain of 
cocaine. Atropine sulphate 2 grains ; mor- 
phine acetate 40 grains; acetic acid 
4 minims; water up to 1 ounce-twelve 
minims = 1 grain of morphine and grain 
of atropine-Talfourd Jones. Morphine is 
used to relieve pain (as of neuralgia, gall- 
stones, renal calculus, &c.), to relieve insom- 
nia, to arrest nervous vomiting, in the treat- 
ment of diabetes, &c. It must be used with 
the utmost caution, and its administration 
should on no account be trusted to the pa- 
tient. Small doses (of not more than | or 
£ of a grain) should, as a general rule, be 
commenced with. Great care must be taken 
to avoid inducing the morphine habit (mor- 
phinomania). 
Muscarina-Muscarine has been used by 
Ringer in doses of | to f of a grain. It may 
be employed in the night-sweats of phthisis, 
as an antagonist to atropine, and to arrest 
the secretion of milk. Its action is similar 
to that of pilocarpine, over which salt it 
possesses no advantages. 
N itroglycerinum - Nitroglycerine, or 
Trinitrin. Alcoholic solution of nitrogly- 
cerine (1 per cent.) 25 minims ; cherry-laurel 
water up to 160 minims. Dose, 2 minims, 
repeated as required. Injections should be 
made deeply into the thighs or gluteal 
regions. Used in angina pectoris, asthma, 
megrim, Meniere's disease, sea-sickness, 
puerperal convulsions, &c. 
Phenazone. Doses of 2 grains and upwards 
dissolved in distilled water may be injected 
in pyrexia. The drug has also been used 
hypodermically in various neuralgiae, lum- 
bago, neuritis, megrim, and sea-sickness. 
It should be deeply injected. 
Piero toxinum- Piero toxine. Dose, A 
to g- grain. Used with great benefit in the 
night-sweats of phthisis. Administered at 
intervals of two to ten days. According to 
Gubler, useful in labio-glosso-laryngeal para- 
lysis. 
Pilocarpina-Pilocarpine, and its salts. 
Nitrate of pilocarpine 1 grain; distilled 
water 20 minims. Dose, 2 to 6 minims 
(Martindale and Westcott). Antidote, atro- 
pine. Used as a powerful diaphoretic in 
uraemia, asthma, puerperal convulsions, tabes 
spinalis, polyuria, &c. 
Quinina-Quinine. The hydrobromate 
is the most useful salt for hypodermic pur- 
poses. Quinine hydrobromate 15 grains; 
distilled water 80 minims. Sixteen minims 
(= 3 grains) thrice daily. Tabloids contain- 
ing | grain may also be used. Used as an HYPODERMIC MEDICATION 
HYPOGASTRIC REGION 
913 
antipyretic in phthisis, fever, and as an anti- 
periodic in ague. 
Solanine, Hydrochlorate of. This alka- 
loid belongs to the same class of poisons 
as eserine, pilocarpine, and atropine. The 
hydrochlorate is a gelatinous body readily 
soluble in water. The dose is 1 to 3 grains 
per diem. It has been used with marked 
benefit by Geneuil in sciatica, rheumatic 
neuralgia, prurigo, cystitis, and other ail- 
ments in which nervous symptoms prepon- 
derate. In children it is said to be a safe 
and useful substitute for morphine. 
Sparteine, Sulphate of (an alkaloid ob- 
tained from the Cytisus scoparius). Dose, 
to | grain. Used at first as a diuretic. 
Has since been strongly advocated by Dr. 
Oscar Jennings to overcome the morphine 
craving, alcoholism, &c. 
Strophanthin (the active principle of Stro- 
phanthus hispidus'). Tabloids ( = 5^0 grain) 
are the most convenient form for hypodermic 
use. Used in all forms of weak heart, in 
granular kidney, and other forms of Bright's 
disease, and in asthma due to cardiac and 
renal troubles. 
Strychnine, and its salts. For hypodermic 
purposes the sulphate, nitrate, or hydro- 
chlorate may be used. Discs (= grain) or 
tabloids (= and grain) are convenient. 
Strychnine hypodermically has also been used 
with great advantage in various forms of 
paralysis-e.g. of the vocal cords, in some 
forms of hemiplegia and paraplegia, also in 
urinary incontinence, tabetic pains, diph- 
theritic paralysis, &c. Drs. Lauder Brunton 
and Cash have shown that strychnine has a 
powerful action on the cardiac ganglia, and 
on the vaso-motor and respiratory centres. 
Hypodermic injections of the drug are of 
great value in feeble cardiac action, especially 
when due to acute pulmonary disease, in 
renal coma, and in threatened cardiac failure 
from shock or exhaustion. They are also of 
undoubted service in failing respiratory action 
due to opium poisoning. The best antidote 
to strychnine poisoning is chloral hydrate by 
mouth, or amyl nitrite hypodermically. 
Urethan is useful in cases of simple in- 
somnia and in that due to mental disease. 
Hypodermic injections cause trifling pain, 
and doses of from 2 to 5 grains may be given 
by this method. 
Vaseline and other petroleum products, 
such as paroleine, are specially useful as 
vehicles for the hypodermic injection of anti- 
septics. Eucalyptol, turpentine, carbolic acid, 
iodoform, iodine, and camphor may be in- 
jected in this form without giving rise to local 
irritation. Andrew S. Currie. 
HYPOGASTRIC REGION (M, 
under; and yair^p, the belly).-The hypo- 
gastric region is conventionally described as 
lying between the right and left inguinal, 
below the umbilical, and above the pubic 
regions. 
Anatomical Relations.-The surface of 
the hypogastric region in ordinary persons 
is flat, showing the muscular reliefs ; it is 
rounded in children; and in some individuals, 
much emaciated from disease, it becomes 
concave. 
The median furroiv disappears below the 
umbilicus, owing to the approximation of the 
recti muscles. In women the furrow is rarely 
pronounced-a point of importance in ovario- 
tomy. 
The integument is very elastic and mov- 
able, especially at the sides. 
The superficial fascia consists of two 
laminae, between which lie the subcutaneous 
vessels; but in the middle line these laminae 
are blended. It is strengthened at its lower 
part by the triangular fascia. 
The aponeuroses of the external and inter- 
nal oblique muscles are united in the linea alba, 
and form a portion of the sheath of the rectus. 
The recti muscles themselves have their 
inferior attachments in this region, along the 
line extending between the spine and the 
symphysis of the pubes; their outer edges 
curve outwards, and become straight as they 
enter the sheaths. 
The pyramidales, two small triangular 
muscles, arise from the pubes, lie in the 
same sheaths as the recti, and assist in 
closing in the abdominal parietes anteriorly 
and below. 
Immediately beneath the recti is the fascia 
transver satis, with a little loose areolar tissue 
and fat, the fascia being tolerably adherent 
along the central line. Beneath the fascia 
transversalis there is a considerable amount 
of loose areolar tissue, between it and the 
parietal peritoneum, which in this region is 
very loosely attached, and reflected off the 
bladder on to the fascia transversalis. En- 
closed in folds of the peritoneum lie, on 
either side, passing upwards to the umbilicus, 
the remains of the hypogastric arteries; and 
from the apex of the bladder in the middle 
line, passing to the umbilicus, is the oblite- 
rated urachus, which acts as the superior 
ligament of the bladder. 
The viscera corresponding to the hypo- 
gastric region are-the bladder when full; 
and the small intestine, covered by the great 
omentum. When the bladder is full, the 
intestines are pushed aside, and the former 
then lies against the pubes and recti. In 
children, the bladder, being an abdominal 
rather than a pelvic viscus, always lies in 
this region. During pregnancy the uterus 
also corresponds with the hypogastric region. 
The vessels are the deep epigastric, with 
the veins which pass obliquely inwards from 
the internal iliac. They lie between the peri- 
toneum and the transversalis fascia. 
The nerves are derived from the lower 
intercostals and lumbar. The lymphatics 
pass into the inguinal, superficial pubic, and 
lumbar glands. 914 
HYPOGASTRIC REGION 
HYPOGLOSSAL NERVE 
Clinical Relations.-The hypogastric re- 
gion is of clinical importance chiefly from 
an operative point of view. It is in the 
median furrow (usually a brown mark, which 
sufficiently indicates to the operator bis 
whereabouts) of-this region that the opera- 
tion of tapping in ascites is usually per- 
formed ; and that the principal incision is 
made in ovariotomy, laparotomy for intes- 
tinal obstruction, and the Caesarian section, 
supra-pubic lithotomy, and the many recent 
abdominal explorations and operations. The 
bladder is occasionally tapped above the 
pubes. The presence of the distended bladder 
or of the pregnant uterus, forming a tumour 
in the hypogastrium, has been already re- 
ferred to. Enlargements here from these 
causes have to be diagnosed from pelvic 
tumours of various kinds, which, in growing 
upwards into the abdomen, occasionally 
occupy the middle region instead of either 
groin. Amongst the morbid conditions of 
the abdominal parietes in the hypogastric 
region that require special mention, are ab- 
scesses connected with disease of the lumbar 
spine, which occasionally point above the 
pubes, on either side of the middle line. 
The pus in such a case is normally situated 
between the peritoneum and the fascia trans- 
versalis. The anatomical conditions bearing 
on the operations for internal herniae, &c., 
must be most carefully considered; as a rule, 
the mesial line is or should be selected for 
abdominal exploration. 
Edward Bellamy. 
HYPOGLOSSAL NERVE, Dis- 
orders of.-The hypoglossal nerve is the 
motor nerve for the tongue, and for most of 
the other muscles which are attached to the 
hyoid bone, the exceptions being the stylo- 
hyoid, the mylo-hyoid, and the middle con- 
strictor of the pharynx. It also supplies the 
sterno-thyroid muscle. 
1. Paralysis.-Paralysis of this nerve is 
shown chiefly by the resulting interference 
with the movement of the tongue-' glosso- 
plegia.' 
^Etiology.-The hypoglossal nerve may 
be damaged in any part of its course by the 
growth of tumours, even outside the skull; 
but is most commonly affected at its origin 
from the medulla, by pressure, meningitis, 
syphilitic processes, or by caries of the upper 
cervical vertebrae. The tongue is also para- 
lysed by disease of the nucleus of origin of 
the hypoglossal fibres, but its paralysis is 
then associated with that of the lips, and 
commonly also of the palate, pharynx, and 
glottis (see Labio-Glosso-Laryngeal Para- 
lysis). Such paralysis may be sudden, from 
local softening, or gradual, from nuclear de- 
generation. The latter form is often part of 
progressive muscular atrophy. Disease of 
the motor tract above the nucleus also causes 
paralysis of the tongue, together with the 
face, arm, and leg of the same side. The 
loss of voluntary power of protrusion is much 
greater when the paralysis is on the right 
side, than when on the left, but probably 
only when the disease is in the cortex, and 
aphasia is associated with the hemiplegia. 
Bilateral glossoplegia commonly results from 
disease of the nucleus or its neighbourhood, 
rarely from symmetrical disease of the cortex 
in 'pseudo-bulbar paralysis.' Unilateral para- 
lysis, when isolated, is generally due to dis- 
ease of the fibres of the nerve within or 
outside the medulla. 
Symptoms.-In unilateral paralysis, the 
tongue at rest is in its normal position in 
the mouth, but its root is higher up on the 
paralysed than on the normal side, in conse- 
quence of the loss of the tonic, or voluntary, 
contraction of the posterior fibres of the 
hyo-glossus. Within the mouth, the tongue 
is moved freely to the healthy side, but is 
not moved to the paralysed side. When 
protruded, it deviates towards the paralysed 
side, because the protrusion is the result of 
the action of the fibres of the gemo-glossus, 
and the tongue is pushed over towards the 
weaker side. In bilateral paralysis the 
tongue lies in the mouth behind the teeth, 
and cannot be protruded. If the loss of 
power is complete, the tongue cannot be 
projected over the lower teeth. It is broad 
and flabby, if there is no atrophy, and some- 
times when atrophy is associated with fatty 
overgrowth. When there is wasting, as is 
generally the case when the nerve or nucleus 
is diseased, the tongue is shrunken and its 
surface is wrinkled, on one side or both. 
The faradic irritability of the muscular fibres 
is then lost. In unilateral paralysis, articu- 
lation and deglutition are little impaired. 
The pronunciation of labials and the produc- 
tion of falsetto notes may, however, be diffi- 
cult. In bilateral paralysis, articulation is 
impossible. Phonation is not impaired, un- 
less the larynx is also paralysed. Mastication 
is impeded, because the food cannot be moved 
about in the mouth. Deglutition is also in- 
terfered with, because the food cannot be 
rolled into the fauces; and soft foods, when 
they reach the pharynx, may be driven again 
into the mouth, in consequence of the ab- 
sence of the natural supporting movement 
of the tongue. Taste is not primarily affected, 
but may be somewhat dulled, because the 
patient is unable to move sapid substances 
over the surface of the tongue. 
Diagnosis.-The position of the lesion is 
indicated by the associations of the paralysis. 
If the disease is in the motor tract above the 
nucleus (pons, crus, or hemisphere), there is 
hemiplegic weakness on the side of the 
paralysis of the tongue. In disease of the 
nucleus the paralysis is commonly bilateral, 
is associated with paralysis of the lips and 
throat, and there is usually wasting. Disease 
of the fibres of origin within the medulla may HYPOGLOSSAL NERVE 
HYPOSTASIS 
915 
be associated with paralysis of the opposite 
limbs, so that the tongue deviates from the 
paralysed side. When the disease is at the 
surface of the medulla, the paralysis is com- 
monly associated with that of the correspond- 
ing half of the palate and vocal cord, from 
disease of the adjacent spinal accessory. In 
all these cases there is commonly wasting. 
The diagnosis of the pathological cause of the 
paralysis rests on the course of the affection, 
and on the presence of any causal and asso- 
ciated condition. The chief sources of error in 
diagnosis arise from the fact that in hysteria 
the tongue is often voluntarily but persis- 
tently protruded towards one side ; the cause 
is recognised by the freedom of movement 
within the mouth. In facial paralysis, 
with lateral deviation of the orifice of the 
mouth, the t mgue may be protruded, con- 
sensually, in the middle of this, and therefore 
to one side of the middle line of the face. A 
knowledge of the fact will prevent error. See 
Facial Paralysis. 
Prognosis.-This is usually unfavourable, 
on account of the gravity of the disease 
which damages the nerve or centre. Even 
in syphilitic cases, recovery is often incom- 
plete unless early and energetic treatment 
can be adopted. 
Treatment.-The treatment of paralysis 
of the hypoglossal nerve is that of the causal 
disease. Tonics, counter-irritation, iodide of 
potassium and mercury, with the application 
of electricity to the tongue if there is reason 
to anticipate recovery of some nerve-fibres, 
are the most important remedies to be 
employed, according to the aetiological indi- 
cation. The most convenient method of 
applying electricity is by means of a tongue 
depressor in a wooden handle, the blade being 
insulated by a coating of sealing-wax where 
it comes in contact with the lips. 
2. Spasm.-Spasm in the parts supplied 
by the hypoglossal nerve is rare. The tongue 
participates in the convulsive movements 
in epilepsy, is jerked between the champing 
jaws, and thus becomes bitten. It is often 
the seat of tonic persistent spasm in hysteria. 
Cases have been met with in which the 
tongue is affected with a ' functional spasm ' 
in speaking, analogous to ' writer's cramp,' 
but these are so rare as scarcely to need 
detailed description. W. R. Gowers. 
HYPOSPADIAS (yno, under; and 
orTj-dw, I draw, or tear).-A malformation of 
the penis in which the orifice of the urethra 
is underneath or behind the glans. See 
Penis, Diseases of. 
HYPOSTASIS under; and ardais, 
standing, settlement). - Definition. - This 
term is applied to that condition of the ves- 
sels of a part which consists in an overfulness, 
with a diminution in the rate of flow of the 
contained fluid, caused rather by a failure in 
the propelling forces of the venous circulation 
than by an actual increase in the resistance 
ahead, as occurs in mechanical congestion. 
Among such causes, gravity, as exerted in the 
dependent position, is probably the most po- 
tent, especially when associated with lowered 
arterial tension. 
Pathology.-The entire conditions of the 
venous circulation are such as to readily 
favour a stasis or stagnation of the blood- 
flow ; and a trifling cause, such as would in 
no way affect the arterial flow, may easily 
impede the venous current. The veins also 
are, as a rule, less firmly supported by the 
surrounding tissues than the arteries; and 
this, with their thinner coats, slighter elasti- 
city and resistance, render them easily liable 
to distension by the blood in congestion. If 
a dependent position be added to these con- 
ditions, thereby offering a resistance to the 
return flow of the blood, whilst it favours 
the circulation in the arteries, a combination 
of circumstances exists to which the term 
hypostatic congestion is applied. The lia- 
bility of the veins of the leg to become con- 
gested, leading to a varicose condition and 
its results, is an example of this state. If, 
in addition to all these factors, the heart be 
enfeebled and the arterial tone be diminished, 
together with an impaired vis a fronte from 
weak inspiration, obviously another cause for 
stagnation is introduced, which of necessity 
will manifest itself most in those situations 
predisposed to stasis. Such a state is seen 
in the hypostatic