3 / seat M4) ena Oe University of Illinois. . « . . : «< 4 % t ‘ 4 ’ ? ’ . “¥ ‘ ° wt OFS ‘ . 4 on 4 . * “4 oy" ANN RSI] y Oe UR i LIE L SRA RY OF THE MEDICAL SCIENCES EMBRACING THE ENTIRE RANGE OF SCIENTIFIC AND PRACTICAL MEDICINE AND ALLIED SCIENCE TEE ONAN A EDM EIT Cam 1 A9 C27 NM bin OSS oS ILLUSTRATED BY CHROMOLITHOGRAPHS AND FINE WOOD ENGRAVINGS Epirep spy ALBERT H. BUCK, M.D. NEw YORK CITY e RSITY < WN" i | VOL UME i Ly | [ 5 3R A RY NEW YORK WILLIAM WOOD & COMPANY 56 & 58 Laraverre Pace 1888. CoPpYRIGHT, 1885, By WILLIAM WOOD & COMPANY TROW’S PRINTING AND BOOKBINDING COMPANY, NEW YORK. LIST OF CONTRIBUTORS TO VOLUME VI. CHARLES W. ALLEN, M.D....New York, N. Y. Visiting Physician, Charity Hospital. BUDO LISSA OEM) een oe le: Sr. Lovurs, Mo. EDMUND ANDREWS, M.D.......... CuicaGo, Int. Professor of Clinical Surgery, Chicago Medical Col- lege ; Visiting Surgeon, Mercy Hospital. bi te aA RCHINARD, Merb). oo. New ORLEANS, LA. Visiting Physician, Nervous Diseases Service, Charity Hospital; Assistant Pathologist to the same ‘hospital. I. EDMONSON ATKINSON, M.D..Bautrworsg, Mp. Professor of Pathology and Clinical Professor of Der- matology, University of Maryland. OA Neo Bw DALRD OND. 258.0625 hece'e ATLANTA, GA. PRANK, BAKER: SM. Diice.. 0. WasuHineton, D. C. Professor of Anatomy, Medical Department of George- town University. HENRY BY BAKER cM. Dooce. oes Lansine, Micu. Secretary of the Michigan State Board of Health. WILLIAM BARNES, M.D.........., DEcaATuR, Iu. MOPAS HH BARTUERY ~ M.D: 3.4. Brookuyn, N. Y. Lecturer on Chemistry, Long Island College Hospital : Chemist to the Brooklyn Board of Health. MeN LGA ETN eM Dye a cigs sly oss St. Lovuts, Mo. Professor of Special Pathology and Therapeutics, St. Louis Medical College. ALBERT N. BLODGETT, M.D........ Boston, Mass. - Professor of Pathology and Therapeutics, Boston Den- tal College. Wet oh OL Minpe isd )s rte es heck ae tees Boston, Mass. Professor of Materia Medica and Botany, Emeritus, at the Massachusetts College of Pharmacy ; Visiting Surgeon, Boston City Hospital. MHADE BOLTON, MD... c.cckl be. BALTIMORE, Mp. Assistant in Bacteriology, Johns Hopkins University. PaPORS ROME Hult NC Ls cor, te anes wletae eee a. Sr. Lours, Mo. BOR SAINSDRLDGE. OE Dace cate as Cuitcaeo, Inu. Professor of Pathology and Adjunct Professor of the Principles and Practice of Medicine, Rush Medical College. EDWARD BENNET BRONSON; M.D..NEw York, ewy Professor of Dermatology, New York ATEN ca Visiting Surgeon, Charity Hospital. BOLD sCINGES TCH VWI ESL), et gate os New York, N. Y. Assistant Surgeon, New York Orthopedic Dispensary and Hospital. Pet erect CeO DoS eer « TORONTO, CANADA. Professor of Chemistry, Ontario Agricultural College ; Secretary of the Provincial Board of Health. L. DUNCAN BULKLEY, A PY Blan at New York, N. Y. Physician to the New York Skin and Cancer Hospital ; Consulting Physician, Manhattan Eye and Ear Hospital. T&S CS WILLIAM N. BULLARD, M.D....... Boston, Mass. Physician to the Nervous ‘Department, Boston Dispen- sary ; Visiting Physician, Carney Hospital. FRANK BULLER, M.D........Monrrean, Canapa. Professor of Ophthalmology and Otology, McGill Uni- versity. J. WELLINGTON BYERS, M.D..CHartorts, N. C. Aly OO ey Gabby MCD) T ade dees Boston, Mass. Attending Surgeon, Massachusetts General Hospital, Boston. DONALD M. CAMMANN, M.D...NEew Yorg, N. Y. Instructor in Diseases of the Chest, New York Poly. © clinic; Visiting Physician, Orphans’ Home and Asylum. WILLIAM H. CARMALT, M.D..NEw Haven, Conn. Professor of Surgery, Yale University ; Visiting Sur- geon, New Haven Hospital. Weare COUNCEUMAN, WDi eure BALTIMORE, Mp. Associate Professor of Pathological pnatomy, Johns Hopkins University. EDWARD CURTIS, MD yes New York, N. Y. Professor Emeritus of Materia Medica and Thera- peutics, College of Physicians and Surgeons, New York. EES TR RIGCU RR LIS ON Aes cre ees Cuicaao, Inu. Professor of Histology, Chicago Medical College ; Vis- iting Physician, Mercy Hospital. CHARLES LOOMIS DANA, M.D..New York, N. Y. Professor of Diseases of the Mind and Nervous Sys- tem, and of Medical Electricity, New York Post- graduate Medical School and Hospital; Visiting Physician, Bellevue Hospital. NP DANDRIDGE IAL Deve cons oe: CINCINNATI, O. Professor of Genito-urinary and Venereal Diseases, Miami Medical College. INNS ean LD Sache s sin eaion ils cate ee CuicaGo, IL. Professor of the Principles and Practice of Medicine and of Clinical Medicine, Chicago Medical College; Visiting Physician, Mercy Hospital. ROBERT H. M. DAWBARN, M.D..NEw Yorks, N. Y. Examiner in Surgery, College of Physicians and Sur- geons, New York; Visiting Physician, Northwestern Dispensary, Department of Diseases of Children. D. BRYSON DELAVAN, M.D....New Yorks, N. Y. Professor of Laryngology and Rhinology, New York Polyclinic; Chief of Clinic, Department of Diseases of the Throat, College of Physicians and Surgeons, New York. W5. DENNETT, A 8d Dee Cee New York, N. Y. Assistant Surgeon, Ophthalmic Department, New York Eye and Ear Infirmary. JAMES H. ETHERIDGE, M.D....... Cuicaao, Inu. Professor of Materia Medica and Medical Jurispru- dence, Rush Medical College. lil LIST OF CONTRIBUTORS TO VOLUME VI. WaltA Here N Tee Dk irs New York, N. Y. Attending Physician, Presbyterian Hospital; Assistant to the Chair of Principles and Practice of Medicine, Bellevue Hospital Medical College. WiGGLAMeHs FORD, “MD... PHILADELPHIA, PA. President of the Philadelphia Board of Health. HU GEN EE OS THR Ma ora. oct. cigeacs AvausTA, GA. President of the Board of Health of Augusta. GEORGE B. FOWLER, M.D....NeEw York, N. Y. Professor of Physiological Chemistry, New York Polyclinic; Visiting Physician, New, York Infant Asylum. SLOLO NeH eA GE: Bist oe ye eer conte Irmaca, N. Y. Assistant Professor of Physiology, and Lecturer on Microscopical Technology, Cornell University. WILLIAM GARDNER, M.D....MonrTREAL, CANADA. Professor of Gynecology, McGill University ; Gyne- cologist to the Montreal General Hospital. GHORGE: Wi GAY, ovaD oe: -oeee Boston, Mass. Visiting Surgeon, Boston City Hospital. BeGRAD GLE MID: See er iret eee, eae CHICAGO, ILL. Professor of Physiology, Chicago Medical College. JAMES BE. GRAHAM, M.D....... TORONTO, CANADA. Lecturer on Diseases of the Integumentary System, Toronto School of Medicine. J OO NAGREEN SMD ors oe caer St. Louis, Mo. Professor of Ophthalmology, St. Louis Medical Col- lege. CHARLES E. HACKLEY, M.D...NeEw York, N. Y. Visiting Physician, New York Hospital. ALLAN McLANE HAMILTON, M.D...NEw York, Visiting Physician, Department of Nervous Diseases, mae a for the Relief of the Ruptured and Crip- pled. ROBERT P. HARRIS, M.D...... PHILADELPHIA, Pa. Member of the American Philosophical Society and of the Philadelphia Obstetrical Society ; Fellow of the College of Physicians of Philadelphia; Correspond- ing Member, Royal Academy of Surgery of Naples. SS HERRICK?) Maye (eee San FRANCISCO, CAL. WIGLVAM SBS DES SMD ees Boston, Mass. Assistant Professor of Chemistry, Harvard Medical School. 7 WH HOW EEL. MDs Sete bee BALTIMORE, Mp. Johns Hopkins University. JAMES NEVINS HYDE, M.D........ CuicaGo, Inu. Professor of Skin and Venereal Diseases, Rush Medi- cal College. EDWARD JACKSON, M.D...... PHILADELPHIA, PA. Professor of Diseases of the Eye, Philadelphia Poly- clinic and College for Graduates in Medicine. LAURENCE JOHNSON, M.D..... New York, N. Y. Professor of Medical Botany, Medical Department of the University of the City of New York. HENRY LEFFMANN, M.D..... PHILADELPHIA, PA. Professor of Clinical Chemistry and Hygiene, Phila- delphia Polyclinic ; Assistant to the Chair of Chemis- try, Jefferson Medical College. ROBERT WEeCOv he ty eh Loe ee Boston, Mass. Assistant in Surgical Out-Patient Department, Boston Children’s Hospital; Late House Surgeon, Boston City Hospital. iv CHARLES SEDGWICK MINOT, M.D..Bostron, Mass. Assistant Professor of Histology and Embryology, Harvard Medical School. ROBERT B. MORRISON, SD as BALTIMORE, Mp. Professor of Dermatology and Syphilis, Baltimore Polyclinic and Post-Graduate Medical School. HH: 7 MUDD; MaDe 4 es eae St. Louis, Mo. Professor of Anatomy and Clinical Surgery, St. Louis Medical College. SAMUEL NICKLES, M.D...v.....0- Crncrnnatr, 0. Professor of Materia Medica, Medical College of Ohio. WILLIAM OLDRIGHT, M.D..... Toronto, CANADA. Lecturer on Sanitary Science, Toronto School of Med- icine ; Chairman Provincial Board of Health. FREDERICK N. OWEN, E.M...New York, N. Y. Civil and Sanitary Engineer. ROSWELL PARKA M.D esos BuFrFrato, N. Y. Professor of the Principles and Practice of Surgery University of Buffalo, N. Y. . THEOPHILUS PARVIN, M.D...PHILADELPHIA, PA. Professor of Obstetrics and Diseases of Women and Children, Jefferson Medical College. ABNER POST, (MA eee eee Boston, Mass. Surgeon to Out-Patients, Boston City Hospital. WILLIAM HENRY POTTER, A.B., D.M.D....Bos- TON, Mass. Demonstrator of Operative Dentistry, Harvard Dental School. T. MITCHELL PRUDDEN, M.D..NEew York, N. Y. ’ Lecturer on Normal Histology, Yale College; Director of the Physiological and Pathological Laboratory. of the Alumni Association, College of Physicians and Surgeons, New York. LEOPOLD: BUTZER, M.D ee... New Yors, N. Y. Visiting Physician, Randall’s Island Hospital. HUNTINGTON RICHARDS, M.Dila..: NEw York, NAY: Aural Surgeon, New York Eye and Ear Infirmary ; Chief of Clinic, Department of the Ear, College of Physicians and Surgeons, New York. THOMAS G. RODDICK, M.D..MontTrea, CANADA. Professor of Clinical Surgery, McGill University ; Vis- iting Surgeon, Montreal General Hospital. J. WEST ROOSEVELT, M.D..... New Yorks, N. Y. Professor of the Principles and Practice of Medicine, in the Medical College of the Woman’s Infirmary, of New York; Visiting Physician to Bellevue and Roosevelt Hospitals. IRVING G.OROSSELO MD: os. o. WASHINGTON, D. C. EDWARD W. SCHAUFFLER, M.D...Kansas Crry, Mo Professor of the Principles and Practice of Medicine, Kansas City Medical College. WILLIAM T. SEDGWICK, Pu.D..... Boston, Mass. Assistant Professor of Biology, Massachusetts Insti- tute of Technology. NS BIC NN NDS DD deer orien MILWAUKEE, WIS. Attending Surgeon, Milwaukee Hospital ; Professor of the Principles and Practice of Surgery and of Clini- cal Surgery in the College of Physicians and Sur- geons, Chicago, II. CHARLES SMART, M.D........ WASHINGTON, D. C. Surgeon, United States Army. STEPHENGS MITA IM Dar cecum. New York, N. Y. Professor of Clinical Surgery, Medical Department of the University of the City of New York; Visiting Surgeon, Bellevue and St. Vincent’s Hospitals. LIST OF CONTRIBUTORS..TO VOLUME VI. M. ALLEN STARR, M.D., Ph.D..New Yorks, N. Y. Clinical Lecturer upon Diseases of the Mind and Ner- vous System, ‘College of Physicians and Surgeons, New York; Attending Physician, Nervous Class, Demilt Dispensary. THOMAS L. STEDMAN, M.D..... New York, N. Y. Late Attending Surgeon, New York Orthopedic Dis- pensary and Hospital. JAMES STEWART, M.D....... MONTREAL, CANADA, Professor of Materia Medica and Therapeutics, McGill University. THOMAS. DAS WIP? MDs... .. 35 New York, N. Y. Visiting Physician, Demilt Dispensary. SAMUEL THEOBALD, M.D........ BALTIMORE, Mp. Attending Surgeon, Baltimore Eye, Ear, and Throat Charity Hospital; Ophthalmic and Aural Surgeon, Saint Joseph’s General Hospital, Baltimore. PITGNYe UPSON COLD Con. «cnet ee CLEVELAND, O. ARTHUR VAN HARLINGEN, M.D..... PHILADEL- PHIA, Pa. Professor of Diseases of the Skin, Philadelphia Poly- clinic and College for Graduates in Medicine: Con- sulting Physician, Dispensary for Skin Diseases. GEORGE L. WALTON, M.D......... Boston, Mass. Assistant in Out Patient Department for Diseases of the Nervous System, Massachusetts General Hospital. RUDOLPH AY WITTHAUS, M.D. New Yorn, N.Y. Professor of Chemistry, Medical Department of the University of New York. LEROY MILTON YALE, M.D..... New York, N. Y. Visiting Surgeon, Presbyterian Hospital. HENRY CRECY YARROW, M.D.....WAsHrINGTON, GEMS, ‘ A. A. Surgeon, United States Army ; Honorary Cura- tor, Department of Reptiles, United States National Museum ; Professor of Dermatology, National Medi- cal College, Columbian University. PHIDCPFARNNER GA Denis oainee cen CINCINNATI, O. Clinical Lecturer upon Diseases of the Nervous System, Medical College of Ohio. iis ay eee ane A REFERENCE HANDBO OF ee ey a a eee ——— al — ad ne PR mera THE iar Nae SiC EEN Oks: PRAIRIE ITCH. This is an affection, or rather a group of affections, met with frequently in the northern and western portions of this country, but seldom seen in the Southern States, which has long been, and still is, a subject of much dispute among practitioners in the re- gions first mentioned, as to its nature, cause, and treat- ment. The literature of the disease is very meagre, and the views of those who have written concerning the affection are so at variance, that it is impossible to avoid the conclusion that they have seen and described differ- ent disorders, which have no other relation to each other than that they are all characterized by the one symptom of itching. The names by which these different forms of pruri- tus have been designated, are almost as numerous as the localities in which they have been observed. Among others may be mentioned, prairie digs, Michigan itch, Texas mange, lumberman’s itch, swamp itch, Ohio scratches, whore’s itch, army itch, winter itch, etc. A general description of the symptoms observed in the majority of these cases, as gathered from the articles on the subject published in various journals, chiefly of the West, is as follows: The affection begins usually rather suddenly, and is not preceded by any premonitory symp- toms. The patient is, apparently without any cause, at- tacked by an intense pruritus, confined usually to the parts covered by the clothing. The itching is worse at night after the sufferer has retired, though he is not en- tirely free during the day. The sensations are described as itching, burning, or tingling. There is said to be, at times, a papular eruption, followed by the appearance of vesicles, pustules, and sometimes urticarial wheals. After a time the evidences of scratching become visible, and most writers, indeed, regard all the lesions as the direct result of this form of irritation, believing that the affection is a pure pruritus, unaccompanied by any pri- mary lesions. Sometimes there are evidences of consid- erable dermatitis, the integument surrounding the lesions being of a bright scarlet hue, while a feeling of tension in the skin is complained of. The disease is said by some to be contagious, and many instances have been reported in which it seems difficult to exclude or explain away this element. On the other hand, others assert with equal confidence that no evidences of contagion are present, but that the pruritus occurs frequently in mem- bers of one family or community, simply because all are exposed to the same climatic conditions. It is said by some to occur only in those regions where the inhabi- tants are exposed to sudden and extensive variations of temperature. Others assert that it is as troublesome in milder climates and during the warmer seasons of the year, as it is in winter and in places where the tempera- ture of the atmosphere is subject to great changes. The affection is, by some, regarded as an eczema papu- losum ; others believe that the great majority of the cases are nothing more than pruritus hiemalis; some, again, look upon it as scabies pure and simple, while still others incline to the opinion that it is a disease sw generis, and due to the presence of a micro-organism in Vou. VI.—1 Prairie Itch. Pregnancy. the layers of the skin. It is very probable that all of these different observers are right, and that there are sev- eral diseases grouped under the one name of prairie itch. Dr. J. N. Hyde, of Chicago, who has made a very care- ful study of pruritus hiemalis, believes that most cases of prairie itch are instances of the first-named disease, though he thinks that some cases of scabies, and pos- sibly of other forms of disease, are included by various observers under this common designation. Dr. J. E. Engsted, of Dakota, has described a parasite which he has found in cases of prairie itch. The organisms ap- pear as flattened cells, of varying lengths, arranged usu- ally in chatas of from five to twenty links, or as oval cells« with from four to twenty hooklets projecting from their sides. The treatment which has been recommended for prai- rie itch naturally varies according to the views that dif- ferent observers hold concerning the nature and cause of the disease. Those who believe that the affection is con- tagious and due to the presence of a parasite, whether animal or vegetable, advise the employment of one or other of the various parasiticides, such as mercurial or sulphur ointments, naphthol, carbolic acid, hyposulphite of soda, etc. The secret of success, they say, is in the persistent and thorough application of these remedies ; internal medication is without avail. Others, who re- ject the parasitic theory, also advise external applications, but of antipruritic rather than of antiparasitic remedies. Alkaline lotions, bismuth or starch powders, various preparations of carbolic acid, one part each of chloral and camphor in eight parts of unguentum aque rose, lead lotions, diachylon ointment, etc., are among the rem- edies of this sort which have been found more or less efficacious in different cases. Hyde insists upon regula- tion of the diet, and the avoidance of all articles of food or medicaments which are capable of exciting cutaneous rashes or of aggravating pruritic symptoms. Of course, strict cleanliness and the avoidance of underclothing made of rough and irritating material are very essen- tial points in the treatment, whatever the cause or the nature of the pruritus may be. During the fall of 1886, many short communications on prairie itch appeared in the medical journals of this country. The reader may find information of value in the issues at that time of the Detroit Medical Age, the Journal of Cutaneous and Venereal Diseases, the New York Medical Record, and other journals, chiefly those of the West. Much assistance in the preparation of this brief sketch has been derived from the several articles in these jour-. nals, and also from a pamphlet on ‘‘ The Affections of the Skin Induced by Temperature Variations in Cold Weather,” by Dr. James Nevins Hyde, of eee . PREGNANCY. Pregnancy is the condition of a woman who has within her the product of conception. It begins with fecundation, and ends with the expulsion or removal of the fecundated ovule, no matter how far 1 ¥ Pregnancy. Pregnancy. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. the process of development has been carried, nor how long after development has ceased the ovum has been retained. The word pregnancy, going back to its Latin etymology in the verb gigno, thence to the Greek yevvaw, and finally to the Sanscrit zan, or gan, carries with it as the essen- tial idea reproduction. But, on the other hand, the usual synonyms merely express one or another phe- nomenon of the pregnant condition. Thus, the English gestation, from the Latin gestatio, the German Schwan- gerschaft, and the Greek xveois, are each derived from a verb signifying in these different languages to carry ; the Latin graviditas, and the Italian gravidanza, indicate the increased weight caused by pregnancy, and the French grossesse the greater size. In normal pregnancy, the only variety which will be considered in this article, the fecundated ovule is developed in the cavity of the uterus—that is, the preg- nancy is uterine, not extra-uterine. The pregnancy is simple, or single, when only one ovum occupies the uterus; but if two or more, it is called multiple, or pluriparous. DURATION OF PREGNANCY.—AS has been indicated, a woman becomes pregnant when conception occurs, that is, if there is an actual union between the ovule and the spermatozoid, but when this occurs is one of nature’s secrets which probably she will never reveal, and hence the actual beginning of pregnancy we cannottell. Preg- nancy, an internal incubation corresponding with the external which occurs in fowls, continues until the foetus is best prepared to live external to the mother, and is usually regarded as lasting from about two hundred and seventy to two hundred and eighty days, or in other words, nine solar or tenlunar months. It is true that a foetus born some weeks earlier than the shorter period stated may live, and therefore is said to be viable, though the chances of living lessen as the normal period of pregnancy is receded from. Obstetricians have, until recently, fixed upon seven months of intra-uterine life as the period when viability begins. But occasional excep- tions have been observed, that is, children born at between six and seven months live; and as recently, by means of the cowveuse and gavage, the number of exceptions is in- creasing, Tarnier suggests that this period should be six months, thus corresponding with the civil law of France, which makes a child legitimate if born at the ex- piration of one hundred and eighty days after the time when impregnation by the husband was possible. CHANGES CAUSED BY PREGNANCY.—Two important series of changes result from pregnancy—the one belong- ing to the impregnated ovule, and the other to the maternal organism. The former changes have been _ presented elsewhere in this work, and therefore there will be considered in this article only those concerning the mother. The maternal alterations consequent upon pregnancy are conveniently divided into local and general. The former belong chiefly to the sexual organs, and will be first presented. Ohanges in the Sexual Organs.—These organs in the female include those of reproduction, and those of lacta- tion, and the alterations in each are to be considered in tracing the history of pregnancy. The most remarkable modifications occur in the organ of gestation, the uterus. It is the home for nine months of the new being, which in its rapid and marvellous development requires ample supply of nutritive material and constantly increasing room. But the uterus, in the earlier months or weeks of pregnancy, increases in size and capacity quite indepen- dently of any mechanical action of the ovum, for the latter is at first too small to produce such effects ; and also, the changes just mentioned are observed when the uterus is quite empty, that is, when the pregnancy is ex- tra-uterine. The first modifications occur in the mucous membrane, which undergoes hypertrophy and hyperplasia, and fur- nishes the external covering of the ovum, the deciduous membrane. This deciduous membrane admits of a three- fold division. First, that upon which the ovule rests, and 2 which contributes to the formation of the placenta; this has been known from the time of John Hunter as the de- cidua serotina, because it was believed to be formed after the other decidue ; second, that arising from the hyper- trophied folds of this tissue between which the ovule is placed, and which uniting over it, make a complete cov- ering, and which was called the decidua reflexa, because it was thought that the impregnated ovule entering. the uterus, pushed away an exudate which was supposed to be formed as a consequence of impregnation, and which completely lined its cavity ; and third, the decidua which occupies the rest of the internal surface of the uterus, but which in the latter part of the third, or early in the fourth, month of pregnancy unites with the decidua im- mediately covering the ovule, and is known as the decidua vera. The peritoneal investment of the uterus undergoes re- markable increase, for without being thinned it still covers the organ enormously increased in size at the end of pregnancy. The muscular tissue of the organ is greatly developed. Not only is there hypertrophy of already existing mus- cular fibres—these fibres becoming ten times longer and. five times broader—but there is an actual hyperplasia, new contractile tissue being formed. Blood-vessels and nerves also increase in size; the veins indeed, in certain parts of the uterine wall, become so enlarged that they are called sinuses ; hypertrophy of the lymphatics is well marked. The increased size of the uterus may, toward the end of pregnancy, result in part from passive stretch- ing of the tissues composing its walls; but early in the pregnant state these walls are thicker than in the unim- pregnated condition, and while the neck becomes greatly stretched and thinned, the fundus at the end of preg- nancy remains thick ; indeed, the entire wall of the body of the uterus may undergo even then no thinning in some cases. The weight of the uterus at the end of pregnancy is thirty-three times that of the nulliparous organ, eighteen times that of the parous. At this time its length is twelve inches and three-fourths, its breadth nine inches and a half, and its antero-posterior measure- ment nine inches, According to the late Sir James Simp- son, the surface of the unimpregnated uterus is five or six Square inches, and its capacity one cubic inch; but at the end of the pregnancy the former is three hundred and fifty square inches, and the latter four hundred cubic inches. Changes in the form and the position of the uterus result from pregnancy. In the virgin the organ is at first pear-shaped, but flattened antero-posteriorly ; the body of the uterus next becomes somewhat spheroidal in form, and finally the ovoidal shape is well marked, especially as the cavity of the neck contributes to the general uterine cavity, or in other words, effacement of the neck takes place ; the larger end of the ovoid is above. At first the impregnated uterus sinks somewhat in the true pelvis, though this generally received statement is disputed by Tarnier ; in the course of the fourth month, however, the increase in size of the organ is so great that there is not sufficient room in the pelvic cavity, and hence the uterus ascends; the process of ascension con- tinues until, at the middle of the ninth month, the fundus reaches as high as the lower portion of the ensiform car- tilage; and then, more especially if the subject be a primigravida, descent occurs, the presenting part of the foetus, still, of course, enclosed in the uterus, enters the ‘pelvic cavity, and the upper part of the womb, while lower than it was, projects more in front, causing a nota- ble change in the form of the abdomen. In a multi- gravida the ascension is never so great, because the re- laxed abdominal walls do not compel so decided a change, nor does the descent toward the end of pregnancy occur so soon—indeed it may not be manifested until labor actually begins. Of course, in case of a mal-presentation, this phenomenon fails. The gravid uterus is seldom found in the median line, but is usually inclined toward one or the other, in the great majority of cases the right, side. So, too, in the development of the uterus there is a tor- sion of the organ, a movement upon its longitudinal axis REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Pregnancy. Pregnancy. by which the left side is thrown more anteriorly, while, ot course, the right recedes; this fact is of importance when auscultating for the purpose of hearing the uterine soufile, for this sound, being most distinct at the sides of the uterus, will be best heard at that side to which the stethoscope can be most readily applied. Uterine torsion is readily explained by reference to the embryological development of the organ. Lateroversion of the uterus, the inclination being usually, as has been stated, toward the right side, should be remembered in performing the Ceesarean section, for after opening the abdominal cavity it is important, in order that incision of the uterus shall be made in the median line, to press the organ from the side to which it is inclined so that it will occupy a cen- tral position. Changes in the properties of the uterus are to be con- sidered. While the walls of the unimpregnated uterus are firm and resisting, with the progress of pregnancy they become yielding and elastic, thus permitting momentary changes in form resulting from foetal move- ments, or from changes of position or other movements of the woman herself, or from external pressure. Fol- lowing these various modifications in shape, as for ex- ample, those caused by foetal movements, the uterus re- covers its normal form, partly as a consequence of its elasticity, and in part from its retractility. The sensibility of the uterus is only apparently, not really, increased ; the size of the organ being so much greater, the latter is more exposed, and then, too, it is liable to certain pathological conditions which are char- acterized by more or less suffering referred to it. The irritability of the uterus is greater in pregnancy ; the or- gan responds more readily to causes which excite the action of its muscular fibres, and in some subjects this reflex excitability is so decided that miscarriage is liable to result from comparatively trivial causes. But, on the other hand, this irritability in others is so slight that the greatest violences may be inflicted upon the subject with- out the pregnancy being interrupted. In consequence of the vast increase in the muscular tissue of the uterus, its contractile power is greatly augmented. This power is manifested first by what are known as the painless con- tractions of pregnancy, these contractions beginning as early as the fifth month, occurring at irregular intervals, and observed throughout the succeeding portion of preg- naney, and finally and chiefly by the contractions of labor, these contractions causing more or less suffering. The painless contractions of pregnancy are of importance in promoting the uterine venous circulation ; they pos- -sibly contribute in slight degree in maintaining the atti- tude of the foetus, as they are a factor in causing its po- sition. In addition to the changes already described, and which relate chiefly or exclusively to the body of the uterus, those occurring in the neck are to be mentioned. The neck of the womb undergoes only slight hypertrophy in pregnancy ; it is less abundantly: supplied with blood than the body is, and is not subjected to a stimulus from the growing ovum. The position of the neck depends upon the position of the body ; thus, if the latter be in- clined to the right side and anteriorly, the former will point to the left and backward. It should be remem- bered, however, especially if the subject be a multi- gravida, and the abdominal wall be greatly relaxed, there is in most cases more or less uterine anteflexion ; this comparatively frequent condition should be borne in mind in those instances in which a bougie is introduced into the uterus for the purpose of bringing on premature labor, or the same object sought by introducing dilators into the cervical canal; for harm may result, or simply difficulty, from the effort to force any of these bodies in that which is the usual direction of the canal in the non- pregnant. Apparent shortening of the neck results from the ascension of the body of the uterus in the abdominal cavity, but actual shortening, it is generally held, does not occur in the majority of cases until the latter part of pregnancy—in many instances, indeed, not until just be- fore the beginning of labor. Early in pregnancy a change in consistence of that part of the intravaginal cervix immediately adjacent to the external os occurs, the superficial tissues becoming softer. This softening advances regularly and slowly in the primigravida, until it involves the entire vaginal por- tion, so that, approximately, one-fourth is affected at four months, one-half at six, three-fourths at seven, and the remaining fourth is also softened at eight months. In the multigravida the process is more rapid, because the vaginal portion is shorter, and because it has once or oftener previously undergone the change. The form of the neck of the womb in the primigravida is at first more distinctly conical, but it soon becomes spindle-shaped from the accumulation of glandular secre- tions in the cervical canal; in the multigravida it is cylindrical, or somewhat expanded at its lower portion, so that it becomes club-shaped. The external orifice of the uterus in the former remains closed until the end of pregnancy ; in only very rare instances it may be more or less permeable by the finger in the latter weeks of pregnancy. In multigravide the external os is not sur- rounded by a uniformly smooth surface, but the border is irregular and fissured, the most distinct of the fissures being found in the majority of cases upon the left side ; the cervical canal is permeable by the finger to a distance directly related to the duration of the pregnancy, the finger readily passing to the middle of it at seven months ; the cavity which the canal presents is funnel-shaped, or we may regard the neck of the womb as a hollow cone with its base below. The vagina is elongated by the as- cension of the uterus; it is swollen, moister, its papille more distinct, and acquires a peculiar violet or purplish hue, arising from the increase of venous blood—this be- ing one of the signs of pregnancy first pointed out by Jacquemin, and the value of which has recently been urged by Chadwick ; greater arterial supply gives origin to the vaginal pulse, a sign of pregnancy which was pointed out by Osiander. The external genital organs are swollen, and have an increased secretion ; the inner surfaces of the vulva may show a similar, though less marked, change of color to that observed in the walls of the vagina ; varicose veins are found in some cases. The ovaries, in consequence of changes in the broad ligaments, ascend in the abdominal cavity, come nearer the uterus, and have an almost vertical direction ; they in- crease, according to Jacquemier, to about twice their: usual size ; ovulation, as a rule, is suspended, but the last corpus luteum undergoes remarkable hypertrophy, and disappears much later than that which follows menstru- ation without impregnation ; indeed, it has been found well marked in women dying during the lying-in period. The broad ligaments open up their peritoneal folds to receive between them the enlarged uterus, and become almost vertical; they increase in length and thickness. The round ligaments become greatly hypertrophied, so that they can be readily felt in thin subjects then, and also during labor. In consequence of the greater increase of the posterior than of the anterior wall of the uterus, their uterine insertion, instead of being median as to the sides of the uterus, is now at the junction of the posterior four-fifths with the anterior fifth of the lateral face of the uterus; their hypertrophy and change of position prepare them for their office during labor, drawing the superior part of the uterus forward and downward, thus causing the uterine axis to be brought in correspondence, during a ‘‘ pain,” with the axis of the pelvic inlet. The development of the round ligaments in pregnancy, one of them being usually larger than the other, may furnish a probable prognosis as to the vigor of uterine contrac- tions, for the greater that development, the greater like- wise is that of the uterine muscular tissue. The oviducts participate in the general hypertrophy, and, like the ovaries, occupy a vertical position. The changes in the mammary glands are very impor- tant and characteristic. In some instances the breasts become larger at the beginning of pregnancy, but in the majority of cases no increase in size occurs until at the time of the first menstrual suppression ; according to Zweifel, this enlargement probably depends upon accu- mulation of fat between the lobules, The breasts may 3 Pregnancy. Pregnancy. be the seat of occasional shooting pains, and there may be increased sensibility of the axillary glands. The super- ficial veins are larger and more distinct, their blue color strikingly contrasting with the whiteness of the skin; if the breasts are greatly enlarged, it is not unusual to ob- serve striz upon them similar to those found upon the abdominal wall. The latter part of the second, or in the third, month the nipple is found more prominent and sensitive, firmer and harder ; then, too, possibly a milk- like fluid may spontaneously escape or be pressed from it, though this phenomenon does not usually occur un- til in the last three months, and, on the other hand, in some instances, has been observed independently of preg- nancy. ‘The changes in the areola surrounding the nip- ple are very characteristic. First an apparently emphy- sematous swelling is observed, then an alteration in color corresponding to that of the hair and of the skin, and hence in blondes simply a deep rose color, and in bru- nettes a brown which grows darker with the progress of pregnancy : change in color is least in those having red rm ! Fi hy f i } ‘. ‘ \ Yo Fre. 3083.—Changes in the Breast caused by Pregnancy. . hair, and in them may even be not apparent. Montgom- ery’s glands, the glandule@ lactifere aberrantes of Henle, notably increase in size, projecting from the sixteenth to the eighteenth of an inch. In addition to the primary areola, which has a radius of about one inch, a secon- dary areola surrounding it appears in the fifth or in the sixth month ; this is lighter in color and flecked with whitish spots, presenting an appearance similar toa piece of dusty-white blotting-paper upon which drops of water have fallen. The illustration given above shows very well the changes that have been described in the nipple, the development of the glands of Montgomery, the appearance of the primary areola, and the formation of the secondary areola. Disorders of urination are commonly observed during pregnancy. In the early weeks, in consequence of the pressure and sinking of the uterus, there usually is vesi- cal irritability, while in the last weeks the descent of the presenting part of the foetus into the pelvic cavity may, by pressure upon the urethra, cause ischuria. Pressure upon the rectum may produce constipation, though this is in many cases quite as frequently the result of the 4 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. more sedentary habits of the woman when pregnant ; partly as the consequence of the hyperzemia of the pel- vic viscera generally, and partly from interruption by the enlarged uterus to venous return, hemorrhoids are not uncommon in the pregnant woman. The chief changes in the abdominal wall, in addition to its great stretching, are pigmentation over the linea alba, so that there is found a linea nigra, the formation of strie, and the ‘alterations in form of the umbilicus. The pigmentation referred to extends from the pubes to the navel, and, in some cases, above the latter, the discolora- tion then either forming a semicircle upon one side, or completely encircling it, before passing up toward the ensiform cartilage ; the distinctness and the depth of the color are in relation to the color of the subject, and hence much more pronounced in the brunette. Abdomi- nal strie, the so-called cicatrices of pregnancy, occupy each side of the abdominal wall below the umbilicus, and are arranged in a series ; they are in almost all cases present in first pregnancies, and it is not uncommon to find new ones in the multigravide. When recent they are a deep rose color, sometimes they are purplish, but after labor they become white or pearl-col- - ored; generally the surface is depressed, but in some cases, as the result of serous effusion from compression of the epigastric vein, it is promi- nent. These strive are the consequences of par- tial or complete atrophy of the lymph-spaces, partial atrophy of the skin, and longitudinal arrangement of the fibres of connective tissue. They may be absent in women who have borne many children, and they may be present in women who have never been pregnant; such instances, however, are exceptional. During the first three months of pregnancy the umbilical depression is slightly increased, or remains unchanged; in the fifth month it is found notably lessened, and at seven months |. has disappeared ; in the last two months there | is more or less protrusion. General Changes caused by Pregnancy.— Among the most important and earliest of the changes in the organism are those affecting the digestive organs. Gastric disturbance occurs in the first months of pregnancy in almost all cases. In some it may be so slight as scarcely to be an indisposition, only a transient discom- fort ; but in others so severe as to be a grave disease. From the fact that the nausea and vomiting are more frequent in the early part of the day—in some cases limited to this time—the condition is commonly called morning-sickness. Generally this disorder disappears after the first four months, but later in pregnancy there may be gastric irritability, caused by pressure of the uterus upon the stomach. Both quantitative and qualitative changes in the blood occur in pregnancy. That there is an actual increase in the quantity of blood is proved by the larger area of the. circulation and by the fulness of the vessels, a fulness which may contribute to the development of varicose veins, or to serous effusion. There is an increase in the watery portion of the blood and of the white cells, but a decrease in the albumen, the red corpuscles, and iron ; the fibrin, normally 3 parts to 1,000, lessens until the sixth month, when it begins to become greater, and at the end of pregnancy is 4.38. Increased work is thrown upon the | heart to send a larger quantity of blood through a larger area, and a consequent hypertrophy, involving especially the left ventricle, occurs.* The ascent of the * Larcher, in 1857, first made known the fact of cardiac hypertrophy in pregnancy. He stated that this hypertrophy occurred chiefly in the left ventricle, its walls becoming one-fourth thicker at least, one-third at most. Ducrest confirmed the inyestigations of Larcher, and Blot further proved that the heart increased more than one-fifth in weight. Lohlein, among others, on the other hand, maintained that the cardiac hypertrophy of pregnancy does not exist. Zweifel states that the thor- ough investigations of Miiller, of Jena, led him to conclude that this hypertrophy does occur, though not to the extent asserted by Larcher and others; and that the cardiac increase corresponds to the general increase of the body, for in every such increase the heart’s muscular mass has a proportional increment, 4 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. diaphragm lessens the pulmonary capacity, so too the antero-posterior measurement of the chest decreases ; but there is a compensating increase in the transverse measure- ment ; nevertheless, it seems doubtful if there be complete compensation, for the pregnant woman, when the uterus interferes most with the descent of the diaphragm, is liable to suffer from hurried breathing, as in rapid walking or in ascending steps. Resulting from the greater quantity of the blood and the greater arterial tension, the quantity of urine secreted increases ; this increase is almost ex- clusively of its watery portion ; all the solid constituents, with the exception of the chlorides, progressively lessen with the advance of the pregnancy. Nauche, in 1881, described what was at first thought to be an organic sub- stance found upon the urine of pregnant women about thirty-six hours after it was passed, and which received the name of kyesteine, since it was regarded as charac- teristic of the pregnant condition; this is a soft, gru- mous, white pellicle, which about the fifth day breaks up and falls to the bottom of the-vessel. So far from being an organic substance, it is chiefly composed of am- monio-magnesian phosphates, vibrions, and monads; it may be found upon the urine of the non-pregnant, as well as upon that of the male. Itis not uncommon for the urine to be albuminous, especially in the latter part of pregnancy ; but if this be slight, and caused by vesi- cal catarrh,-the condition need give no anxiety. Still more rarely, sugar is found in the urine toward the end of pregnancy, and is simply significant of the elimination of milk-sugar ; true diabetes mellitus is rarely seen in pregnant women. According to the observations of Ro- kitansky, 1888, in more than one-half of pregnant women there are bone-like deposits upon the internal table of the cranial bones, and external to the dura mater, which he called osseous neoplasms or osteophytes. Similar de- posits have also been found upon the internal surface of the pelvic bones of women dying in childbed. While these deposits are not exclusively found in connection with pregnancy, for they have also been observed in the tuberculous, yet they are more frequent in the former than in any other condition. The spleen and also the thyroid gland increase in‘size ; it is probable, too, that the kidneys become somewhat larger in pregnancy. Pregnancy causes greater nervous sensibility, and hence various reflex nervous disturbances may occur. Neuralgic affections, especially involving one or more teeth, are not uncommon; often the severe toothache may require, or be thought to require, extraction of the ’ painful organ, and women who have borne many chil- dren will sometimes say that every child has cost them a’ tooth. Many women are despondent and a prey to gloomy thoughts or grave apprehensions of danger, and in some actual insanity occurs; but in the majority of instances of mental derangement hereditary influence is the important factor, pregnancy being merely the exciting cause. A woman’s weight increases about one-thirteenth dur- ing pregnancy, this increase being greatest in the last three months—being from one kilogram anda half totwo kilograms (from 4 to 54 pounds) each month. MuutTipLE PrReGNANCY.—When two or more fecun- dated ovules occupy the uterus, the pregnancy is called multiple, or pluriparous. Twin pregnancy occurs once in 90; triple, once in 7,900 ; and quadruple, once in 870,000—though Neefe, quoted by Zweifel, makes the latter proportion 1 to 560,000 ; quintuple pregnancy is of course exceedingly rare. The frequency of pluriparous births varies in dif- ferent countries, and, contrary to the opinion of Pliny, such births are not more frequent in warm climates ; thus they occur oftener in Denmark and Sweden than -in France and Belgium. The sex of the children is the same in sixty-four per cent., different in thirty-six per cent. ; Multiparity and heredity seem to be the most important factors in the production of multiple pregnancy ; but in addition to these, other causes apparently are great stat- ure, race, and the size of the ovaries. Pregnancy. Pregnancy. _ In pluriparous inferior animals fecundation of ovules is simultaneous, and probably this is the fact in multiple pregnancy in the human female in the majority of cases; nevertheless there are a few instances recorded where the fecundation was successive, so that it may be admit- ted that a woman who has already conceived may, while that product of conception remains, conceive again—in other words super-impregnation may occur. But super- impregnation includes super-fecundation, and super- foetation. By the former is meant the fructification of ovules liberated about the same time, and by the latter the -fructification of ovules escaping at an interval of weeks or even of months, an hypothesis that is generally rejected ; this rejection rests upon physiological and ana- tomical grounds. First, we have reason to believe that ovulation is suspended during pregnancy. Just asthe hen does not lay eggs after she has begun setting, so the human female does not, while the process of internal in- cubation is going on, furnish any new ovules for impreg- nation. Then, too, between the third and fourth months the decidua covering the ovum and that lining the uterus are fused into a single membrane, so that ascen- sion of the spermatozoids to the usual seat of impregna- tion is impossible, and also, entrance of the ovule, im- pregnated or not, into the uterus is for a like reason impossible. Therefore, while that variety of super-im- pregnation known as super-fecundation is admitted, the other, super-foetation, is in the highest degree improbable, and after the fusion of the deciduous membranes, impos- sible. There is not space in the present article to con- sider and to answer the facts adduced in favor of the latter hypothesis. In order that twin conception may occur, there may be, first, two ovules furnished by two ovisacs, both of the latter belonging to one ovary, or one from each ovary ; then there will be two corpora lutea. Second, one ovisac may contain two ovules; this is not a mere hypothesis, for some observers have found an ovisac with even three ovules. Third, there may be two germinal vesicles in a single ovule, or the blastodermic membrane may divide into two. If the twins come from a single ovule, they are of the same sex. In the first variety the twins are enclosed in separate sacs, the walls of which are made each of an amnion and of a chorion; originally each sac had its separate decid- ual investment, but pressure caused absorption of the in- tervening decidual walls, so that then a single decidua covers them. The placentez are completely separate, or united only by a membranous band, but in either case there is no vascular anastomosis. Yet it may also happen that, though the twin conception results from two ovules coming from different ovisacs, there is a common cho- rion, but separate amnions, and the explanation proposed is that originally each had its own chorion, but, as stated in regard to the two decidusze becoming one, the interven- ing double chorion wall has undergone absorption. In these cases the placentze make a single mass, but ordinar- ily the vessels do not anastomose. If the twins originate from a single ovule they are enclosed in a common sac, but of course originally each twin had its own amnion ; for that is a production from the embryo, and the fact of there being a common sac has the same explanation as that which has been given for the presence of a common decidua and acommon chorion. The placentse form a single mass, and the blood-vessels anastomose. Accord- ing to Schatz (Archiv fiir Gyndcol., Band xxxii.), usually there remains but one anastomosis, and that arterial ; sometimes there is also a venous anastomosis, and rarely two of each. The weight and size of twins is usually under the aver- age; very frequently one is larger than the other ; in some cases a twin dies in the course of the pregnancy, while the other reaches complete development ; premature labor is frequently observed in twin pregnancies, still more is it the rule in other varieties of multiple pregnancy. The diagnosis of pluriparous will be considered in connection with that of single pregnancy. DIAGNOSIS OF PREGNANCY.—This is a subject of very great importance with reference to the reputation of the 5 Pregnancy. Pregnancy. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. physician, and hence the honor of medicine, because the two are indissolubly united ; but especially with reference to the reputation of the woman, supposing her to be falsely accused, and it may be with reference to her health, and in some cases her life even is at stake. The physician is liable to be deceived by false statements made by the woman herself ; in some cases she herself is deceived, but in others she means to mislead, either for the purpose of concealing a true pregnancy, or else with the design of extorting money from the alleged father of her unborn offspring, or to secure an interest in an estate. In the study of the signs of pregnancy, attention is first given to those of which the woman may inform us, then to those which we obtain by actual examination, the latter being such as we learn by the eye, by the ear, and by the sense of touch. ‘The former are called subjective and the latter objective ; probability only is given by sub- jective, but certainty by objective, signs. The absence of menstruation, morning-sickness, in- crease in the size of the breasts, occasional pains in them, and their secretion taking place, the abdomen growing larger, and the sensation of quickening—that is, the moth- er’s consciousness of the first foetal movements—and the repetition from time to time of these movements, consti- tute the chief evidences of pregnancy which can be given by the woman herself. But there may be an amenorrhea independently of pregnancy, or a girl may become preg- nant before she has menstruated, or a woman during the temporary and normal absence of the periodic flow, as when she is nursing. On the other hand, there may be, especially in the early months of pregnancy, a bloody discharge from the uterus occurring periodically, which, though not menstruation, but a threatening of miscar- riage, may be mistaken for the former. It should also be borne in mind that under the intense desire to be preg- nant, or, on the other hand, the great fear of such condi- tion, there may be what, from its etiology, has been ap- propriately termed psychical amenorrhcea. Nausea and vomiting, simulating the morning-sickness, may result from other causes, such as gastric disease, or reflex dis- order. Enlargement of the abdomen may occur from neoplasms, or hypertrophies of normal tissues, or from ascitic disease. Some at least of the changes in the breasts that have been mentioned as occurring in preg- nancy, may be the consequences of disease in the pelvis or abdomen, ¢é.g., they may occur in connection with the development of ovarian tumors. So faras the perception of foetal movements by the subject herself is concerned, a womdn may believe she recognizes them and be utterly mistaken, even though she has had the experience of such movements in several pregnancies. It is thus seen that none of these signs are positive proofs of pregnancy ; the combination of two or more will make the event very probable, but even should they all be asserted to be pres- ent, the physician must not rest his diagnosis upon them, especially as certain signs are available. In studying the objective signs of pregnancy we may conveniently divide them into those addressed to the sense of sight, of touch, and of hearing. 1. Inspection.—This includes observing the carriage, countenance, the breasts, the abdomen, and the vagina. The pregnant uterus, especially in multigravide in whom, from the relaxation of the abdominal walls, the enlarged organ falls forward, compels the woman to throw the shoulders farther back to compensate for the increased weight in front, and hence a change in the spinal curve. The face may show pigment deposit upon the forehead and the cheeks, constituting, when great, what has been called the mask of pregnancy. The face may be haggard and anxious, and the fulness of the features lessened, more especially in a pregnant woman who has suffered greatly from nausea and vomiting; but it has not the emaciation, the lines descending from the angles of the mouth, and other manifestations characteristic of the ova- rian face. The breasts may be examined with reference to increased size, the presence of milk and of strive, and the prominence of the nipple; and as to the changes in the areola, its swollen condition, development of Mont- 6 gomery’s glands, and darkened hue; if the fifth month of supposed pregnancy has passed, the secondary areola will be in process of formation. The abdomen may be observed as to increase in size, as to the changes in the umbilicus, the presence of the linea nigra, and of striz, and in regard to the latter as to whether they are old or recent. The chief object in examining the vagina is to ascertain whether it shows the peculiar coloration to which Jacquemin, and more recently Chadwick, have at- tached such importance as an evidence of pregnancy. The latter, who has given much study to the subject, makes the following statement in the ‘‘ Transactions of the American Gynecological Society,” vol. xi.: ‘‘ The color begins as a pale violet in the early months, becomes more bluish as pregnancy advances, until it often assumes finally a dusky, almost black, tint.” He further states in reference to the cases examined by him, ‘‘ that, while in the majority of cases the bluish tinge appeared over the whole vaginal entrance, there was a fair proportion in which the violet tint was confined to the anterior wall of the vagina, just below the urinary meatus, whence it shaded off into the normal pink color laterally. This, when distinctly perceptible, I soon found to be, in my practice, an absolutely sure sign of pregnancy. ‘There were, furthermore, a very few in whom the blue tint was universal, but more accentuated on the posterior wall of the vaginal entrance, which I found was valueless as a sign of pregnancy unless the color was quite deep. The recognition of this peculiar localization of the blue tint on the anterior wall as a sure sign of pregnancy, I feel is the most important new point in this communica- tion.” 2. Touch.—Obstetric touch is usually applied to an ex- amination made with one or more fingers, introduced into the vagina for the purpose of diagnosis. But the term should be given a far wider signification ; we touch, whether the entire hand or only a single finger be em- ployed, and so it is an appeal to the same sense, whether the application be made to the abdominal wall or through one of the canals opening from the lower part of the body—chiefly the vagina, more rarely the rectum, and still more rarely the urethra. To the application of the hand or hands to the abdomen the term external exami- nation, or abdominal palpation, is given; internal and ex- ternal examination may be made at the same time, the one assisting the other, and then the method is sometimes called the combined examination. By abdominal palpa- tion we may recognize the uterus enlarged by pregnancy from its form, from its being the seat of intermittent con- tractions, from its containing within it a mobile body, the mobility being either spontaneous or communicated ; we may distinguish different parts of that body—the feet, the back, the head, and the pelvis.. Palpation is usually done with the woman lying upon her back, the head and shoulders slightly elevated, and the lower limbs moder- ately flexed, so that the abdominal wall is somewhat re- laxed; it is important that the bladder and rectum shall have been recently emptied ; the abdomen should be ex- posed as far down as the mons veneris. The examiner, his hands having been carefully washed and warmed, standing with his back toward the woman’s face, and supposing him to be on the right side of the bed,* applies the left hand upon the hypogastrium, first gently, then presses with some firmness, this pressure being most marked at the ulnar side and made just as he is about to raise the hand to place it a little higher upon the ab- domen. The ascending movement is made, similar press- ure follows, and thus the manipulation is continued un- til the ulnar side suddenly meets with a marked lessening of resistance, so that it sinks, readily depressing the ab- dominal wall at that point, and the hand circumscribes the fundus. Another method of beginning palpation, and by which the lateral boundaries of the uterus are first defined, is to * By some it is advised to begin abdominal palpation by pressure with two hands upon various parts of the abdomen, so as to accustom it to such contact, and prevent contractions of its muscles; but this preliminary manipulation may be omitted in most cases, and direct exploration at ounce made, REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. place the palms of the hands in contact directly in the * median line upon the lower part of the abdomen, as represented in the subjoined cut (Fig. 3085). Then the hands are gradually separated, the ulnar margin pressing downward upon the abdominal wall, until, having reached the sides of the uterus, they readily sink, and include be- tween them this organ. It is not then difficult to have them pass farther and farther upward upon the side of the uterus, until the fundus is reached and can be cir- cumscribed. Dr. Braxton Hicks claims that if the uterus be exam- | \ ok oa i Fie. 8085.—Application of the Hands in the Median Line. if it be firm at first ; each contraction lasts from two to five minutes, and they are seldom separated by so long an interval as thirty minutes: he has found this sign as early as the last of the third month. Pregnancy. Pregnancy. At five months the walls of the uterus have become so elastic and depressible, and the foetus is so developed, that it can be recognized by palpation if the abdominal walls are not too thick. In this examination some parts of the uterine tumor readily yield, while others are resistant, and the latter may in some cases be recognized by con- tinuing the manipulation on one part of the foetus ata time; most probably in the lower part of the abdomen the head may be felt. Passive movements may be given the fcetus, or part of it, and to such movements the term abdominal ballotte- ment is given. Usually, in performing ballottement the woman lies upon her back, and the operator’s hands are placed upon each side of the uterus; one hand is used to press away the foetus toward the opposite side, or motion may be given to a part of the fcetus, as the head, and then the manceuvre is called cephalic ballottement (Fig. 3088). The late Dr. Albert H. Smith gave the following description of his method of performing external biman- ual ballottement : The woman is placed upon the edge of the bed with her clothing removed from the abdomen, and then rolled upon her side so that the anterior abdom- inal wall projects over the edge of the bed; then the rotation of her body is carried still farther, until the enlarged uterus becomes so dependent that it may be supported by the hand placed beneath it, while the other hand makes counter- pressure upon the opposite side of the uterine mass. Thus let the woman be upon her left side, the right side, therefore, being above; the examiner takes his seat with his face toward her head, his left side being toward the pendent abdominal mass, but about opposite the hips. The right hand is then passed far under the uterus as it projects over the bed, the palmar surface being in contact with the abdominal integument and the ulnar edge toward the iliac bone. The left hand is then placed similarly upon the right side of the abdomen, making counter-pressure upon the oppo- site side of the uterine body so as to grasp it between the two palms. This gives a full command of the tumor, and enables the examiner to apprehend the shape and density of the mass, its fluctuating character, the move- ment of a separate body in it, which can be operated upon by manipulation and repercussion. | ! ll Fie. 3086.—Application of the Hands to the Sides of the Uterus. Spontaneous movements of the foetus, which can be readily recognized, are almost certain to occur during abdominal palpation, if the pregnancy has advanced to five months ; these movements may be of the entire body or of a member, and in the latter case they are short, 7 Pregnancy. Pregnancy. quick taps, for the moment causing a projection at that part of the uterine wall against which the blow is given, and hence may be seen as well as felt ; if the entire body - = —— —-_ ZB = i ey, ———$— ——— —— — TR ~ —--—-~-__. Na one seg we N a « ~ — oe oe ce on ee * s Fic. 8087—The Fceetal Head included between the Examiner’s Hands. moves the motion is slow and gliding, and there is no sudden localized change in the form of the uterus. By palpation it is possible in most cases, when the pregnancy has advanced to seven months, to recognize different parts of the foetus, as, for example, the head and the breech with the intermediate back, and also parts of the lower limbs. By the vaginal examination we chiefly seek to learn the form, position, size, and consistence of the vaginal neck, and condition of the external os and cervical canal. It isin almost all cases made with the woman lying upon her back and the lower limbs moderately flexed. The index-finger of the right or of the left hand is generally employed; by using the medius also a gain of a little more than a third of an inch is secured, but the intro- duction of two fingers may in some cases be very pain- ful, and a single finger has a greater facility of move- ment, and also more clearly defined sensation. Softening and some enlargement of the neck of the uterus will be ascertained in case the woman be pregnant, and suppos- ing an antero-lateral inclination of the body of the uterus, the neck is found pointing in an opposite direction. The os in the primigravida is round, instead of being a trans- verse depression ; but in almost all cases the tip of the finger cannot enter it, or if it does, is arrested soon after entrance. On the other hand, the os in the multigravida presents an irregular border, marked by fissures and in- tervening prominences, the fissures being most distinct upon the sides, and the cervical canal is open to a degree in direct relation with the period of pregnancy—the fin- ger, for example, readily passing to the middle of the canal at seven months; the cavity thus entered is funnel- shaped. Vaginal ballottement is performed with the subject ly- ing, or standing. If in the former position, it is well to press upon the hypogastrium with the free hand, so as to force the lower portion nearer the index-finger of the other hand ; or in this case the index and medius may be introduced into the vagina, placed either in front of the cervix or behind it, the latter position being usually preferred ; the finger or fingers are made to press firmly against the uterus and upon the fcetal part resting on 8 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. the latter, and quick pushing upward is made, the move- ment being thus communicated to the foetal part, which is for the moment displaced, but afterward returns to its former position ; the movement of return is less dis- tinct than that of displacement, and possibly may fail to be recognized. If the woman’s shoulders and head be well elevated, the finger may be placed in front of the cervix, the position also selected should she be standing. The latter part of the fifth month is as early as vaginal ballottement can, as a rule, be success- fully made, but this sign becomes most distinct at six or seven months. By combining vaginal touch with abdominal palpation the continuity of a doubtful tu- mor felt in the abdomen with the cervix is proved ; so, too, this pressure upon the uterus through the ab- dominal wall facilitates vaginal examination of the part of the organ accessible to the finger or fingers. Abdominal pressure is also combined with digital examination through the rectum for the recognition of Hegar’s sign, an early softening and relaxation of that portion of the uterus immediately above the attach- ment of the utero-sacral ligaments, or the posterior portion of the lower uterine segment. 3. Obstetric Auscultation.—This is a discovery of the present century. In 1818, Mayor, of Geneva, examining the abdomen of a pregnant woman, first heard the sounds of the feetal heart, and three years later Kergaradec, of Lausanne, ignorant of the prior success of Mayor, made the same discovery. In addition to this sound Kergaradec also heard a bruit to which, having \ ‘> an erroneous hypothesis of its cause, he gave the \ name of placental souffle, a name which some writers still use, in spite of the error long ago disproved, instead of calling it the uterine souffle. In addition to these sounds, others may be heard, such as the funic souffle, and those caused by the movements of the feetus ; but the first two are the most important, and they only will be here considered. The room in which auscultation is made should be \ s \ é , as 1 F1a. 8088.—Cephalic Ballottement. quiet, the woman lying upon her back, a pillow under her head, the lower limbs only slightly flexed, if not ex- REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Pregnancy. Pregnancy. tended, the abdomen naked—though a thin, unstarched muslin or linen covering will in most cases not interfere materially with the examination ; as a rule, a stethoscope should be employed, not only from motives of delicacy, but also for the more certain limitation of the part where certain sounds are heard, and because the ear cannot be readily applied to certain portions of the abdomen where it may be necessary to listen ; nevertheless, the pressure of a stethoscope may in some cases be painful, while the direct application of the ear is readily tolerated, or, again, some may be able to hear more readily without than with -aninstrument. This examination may be made as early as the last of the fourth month, but for the majority of practitioners, probably, the proofs thence derived of preg- nancy will not be distinctly obtained until some time in the fifth month. The part to which the stethoscope should be applied will be determined by the period of pregnancy, and by whether the sounds of the foetal heart or the uterine souffle is sought. Should he seek the former, the pregnancy being only four or five months advanced, he will generally best succeed by placing the instru- A2~, ment, in or near the median line, “8 upon the fundus of the uterus, and Y in a position approximating the Ses GY axis of the pelvic inlet; but if the jg examination be made in the last three months, the uterus having now its ovoidal form, and the long axis of the foetus corre- sponding with that of the organ which it oc- cupies, then he should listen at one of the four points, in order, D, C, A, and B (see Fig. 3089). Obviously, the fcetal heart-sounds will be heard most distinctly through the back of the fetus, for the dorsal plane of the fcetus by its convexity is better adapted to the concavity of the internal uterine wall, and besides, with the superior members folded over the anterior chest, the heart is con- sequently made more remote; and, finally, the lungs being not expand- ed, the heart-sounds are heard posteriorly better than after pulmonary respiration has begun. As in the great majority of cases the head is in the lower part of the uterus, the foetal heart-sounds will be heard most distinctly at some point below a transverse line upon the abdomen passing through the umbilicus. But still more, as in by far the greater number of in- stances the occiput of the foetus is.in the left side of the pelvis, usually directed toward the left ilio-pectineal emi- nence, these sounds are most frequently heard with the greatest distinctness upon the left lower of the four spaces into which the abdomen of the mother is supposed to be Fra. 3089. divided (see Fig. 3089), and usually at a point correspond- . ing to the middle of a line drawn from the umbilicus to the left ilio-pectineal eminence. But if not heard satis- factorily at this place, or in its vicinity, corresponding positions upon the opposite side should be tried. All these failing, the two upper divisions should be examined, for the head, instead of being below, may be above—in other words, there is a pelvic presentation. So much of an explanation seemed necessary, though in consequence of it there is suggested a part of the diagnosis of presen- tation by this means, in regard to the parts of the abdom- inal wall to which the stethoscope should be applied in listening for the fetal heart. The mean frequency of the pulsations of the fetal heart is, according to some, 140, but according to others, 135 ; temporary variations, not only in the frequency, but also in the force, of these pul- sations are common. The sound is double and rhythmic ; the first bruit is the clearer and more distinct ; a brief pause ensues, and the second is heard, which is followed by a longer interval before the double bruit is repeated. The uterine souffle is usually heard best at the lower part of the uterus and at its sides, especially the left, which, for reasons previously given, is brought nearer the anterior abdominal wall. This sound is synchronous with the mother’s pulse, but without shock ; it is some- what similar to the sound heard when the stethoscope is applied to a varicose aneurism, but it varies with the pressure made by the instrument, with uterine contrac- tions, and from one time to another, and with the dif- ferent parts examined, and it is usually not harsh. It may be heard earlier than the sounds of the fcetal heart, in some cases at the beginning of the third month. But it is not a conclusive, only a probable, proof of preg- nancy. This, as well as the fact that the placenta is foreign to its production, is proved by the following Fre. 3090. facts: It may be heard in many cases in which the uterus is greatly increased in size from fibroid disease ; it is also heard, in nine cases out of ten, two to three days after labor. The conclusive proofs of pregnancy are hearing the sounds of the foetal heart, feeling—possibly, also, seeing —fcoetal movements, and recognizing the fetus by pal- pation. Diagnosis of Multiple Pregnancy.—Practically, this dis- cussion may be limited to the diagnosis of twins in the uterus, for the other varieties of pluriparous pregnancy are comparatively very rare. Among the probable signs are greater development of the uterus than in single pregnancy; this development is unsymmetrical, a verti- cal furrow dividing the organ apparently in two parts ; the abdomen appears to be especially distended at the sides ; foetal movements are observed at different parts of the uterus, and, finally, the accidents of pregnancy are more frequently observed. The subjoined illustrations from Budin show how fallacious some of the proofs of twin pregnancy may be. In the first the positions usu- ally occupied by the foetuses are given ; both may pre- sent by the head, or both by the pelvis, or one by the head and the other by the pelvis ; but whatever the pres- entations, the foetuses are usually side by side. But in 9 PLCEEANSY: REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Pregnancy. the second drawing one fetus is in front, and in the | by auscultation will be presented in those cases in which third, one is above the other. the twins occupy the unusual positions as given in The only certain proofs of twin pregnancy are given | Figs. 3091 and 3092. by abdominal palpation and auscultation. Thus, by the Differential Diagnosis of Pregnancy.—It is important to Fra. 3091. former two heads may be felt in different parts of the uterus, and by the latter two fcetal hearts are heard, with Fie. 3093. maxima of intensity in different parts, also, of the organ. These sounds differ in frequency ; the difference may be | refer to some pathological conditions which may be con- founded with pregnancy, and briefly state the means by which error may be avoided. Hamatometra : The en- largement of the uterus is slower, and occurs by sud. Fie. 3092. Fig. 3094, only six or eight, or it may be ten or fifteen, but it is | den, not by gradual, increase, and this sudden increase always present. is at more or less regular intervals. Neither vaginal nor It should be remembered, however, that very great | abdominal ballottement is possible, and obstetric palpa- difficulty in making the diagnosis of twin pregnancy | tion and auscultation give negative results. Uterine 10 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Fibroids : These are slower in development, and the uterus is hard instead of elastic, and generally irregular in form ; menstruation, instead of being absent, is usually abnormal, there being menorrhagia, and there may be likewise metrorrhagia ; by vaginal touch, absence of the changes in the cervix and os characteristic of pregnancy, often, too, some portion of the hard, irregular fibroid, may be felt ; abdominal palpation and auscultation give nega- tive results, except that by the latter the uterine soufHle may in many cases be recognized. Ovarian Tumor: Usually slower in development, and if of considerable size, marked impairment of general health with con- siderable emaciation ; the history of the growth, if it can be obtained, shows that the enlargement, instead of being at first median, was upon one or the other side; men- struation usually not absent unless the health has been greatly deteriorated ; marked fluctuation in most cases when the tumor has attained considerable size ; absence of proofs of pregnancy upon palpation and auscultation ; and vaginal examination will in most cases be able to prove displacement, but no material enlargement of the uterus. Uterus Enlarged by Ohronie Parenchymatous Metritis.— Menstruation may be irregular, but there is not absolute amenorrhea; the uterine wall, though somewhat soft- ened, is not elastic and yielding as in pregnancy, and moreover it is sensitive, pain being caused upon pressure, which is not observed when pressing the gravid organ. Accumulation of fat in the abdominal walls, ascites, tumors of the spleen, need only be mentioned in order that the practitioner may be put upon his guard against error from any of these sources. It should be remembered that in all doubtful cases time is one of the most important elements of diagnosis ; if a woman be pregnant, the fact will become clearer from day to day, for unequivocal signs of the condition will surely come. Therefore he is wisest who waits in such cases until he knows, either by the presence or the absence of these certain proofs, before he gives an opin- ion, and not he who risks a happy guess, or draws a conclusion from an average of probabilities. THE HYGIENE oF PREGNANCY.—This includes atten- tion to diet and the condition of the digestive organs, ex- ercise, rest, clothing, sleep, the care of the breasts, and the condition of the mind. In the early months of preg- nancy, it is not unusual for the irritability of the stom- ach to cause lessened desire for food, or possibly the appetite may crave some unusual article of diet; each condition must be considered and respected in the choice of aliments, and in directing the quantity. In some cases the morning-sickness is lessened by having the patient take her breakfast in bed, and not rise until an hour or two after. Generally, in the fourth month gastric disor- der disappears, and the appetite is good; digestible and nutritious food, both animal and vegetable, may be taken, and, so far as possible, dietetic means used for the prevention of constipation. As in the ascension of the uterus in the latter months it comes to press upon the stomach, the meals should not be so abundant, but more frequent, and especial care should be taken not to eat heartily in the evening. If the constipation is not re- lieved by diet, an evacuation should be secured each day by a Seidlitz powder, Hunyadi, compound licorice pow- der, calcined magnesia, or some similar means. Care must be taken that the clothing does not com- press the abdomen or chest, and it ought to be suitable for the season ; especially ought the pregnant woman to avoid being chilled, lest an annoying bronchitis, for ex- ample, or a serious nephritis with albuminuria, result from sudden suppression of perspiration. Moderate exer- cise will be useful, but that which fatigues or is violent, such as dancing, riding on horseback, or over rough roads, must be avoided. Long journeys by sea or land ought, if possible, to be postponed ; the fatigue, the excitement, the constant jarring for several days consecutively on a railway train, for example, and the possible dangers and accidents belonging to travel in general, present strong arguments in favor of the advice just given. So, too, fresh air is especially necessary for the pregnant woman fere with labor at the normal time, Pregnancy. Pregnancy, —she is breathing for two, and therefore must not be in crowded or badly ventilated rooms. The pregnant wo- man should observe regular hours of sleep, and it is also ‘ well for her to have a brief rest during a part of each day, lying down even if she does not sleep. A warm bath may be taken as usual, but hot baths, especially if frequent and prolonged, may cause abortion ; sea-bathing, unless the water is quite warm, is not advisable, and when such baths are taken they must be without great exercise, as in swimming, and they ought to be brief. The belief held by many philosophers as far back as Plato, and also by many eminent physicians as well as by the public, is becoming stronger, that the condition of the mother’s mind has an important influence upon her unborn child ; not only is it held that certain deformities may result from maternal impressions, but modifications of the intellectual and moral character, as manifested in after years, may have their origin in the mental state of the pregnant woman. Hence the importance of the pro- spective mother preserving an equable condition of mind, and as cheerful a disposition as possible ; she should be carefully guarded against all injurious influences, and exposure to perils and to painful sights, and there ought to be thrown around her all protecting care and thought- ful kindness. Sexual intercourse during pregnancy is utterly unnat- ural; it is a frequent cause of abortions ; it is probably regarded with indifference or abhorrence by most wo- men, and is without any moral justification. Many pagan nations have not only condemned this violation of nat- ural law, but coupled severe punishment with the con- demnation. All compression of the mammary glands must be avoid- ed; the nipples especially should be given ample room for their development, and if retracted they ought to be drawn out by means of the thumb and finger for a few minutes each day, and in the intervals a nipple-shield may be worn over them for atime. It is customary to endeavor to harden the skin, so as to prevent the formation of fis- sures and abrasions from nursing, by washing the nipple each day with alcohol holding in suspension or solution an active astringent. I have for some time protested against this practice, on the ground that the alcohol dis- solves the sebaceous secretion with which nature has so abundantly supplied these organs, and which is their best protection from the injurious contact of fluids ; even if the skin may be hardened by alcohol or an astringent, nature intended it to be soft and pliable, and not harsh and resistant, and consequently much more liable to be tis- sured. Therefore, let me advise, instead of the time-hon- ored applications, scrupulous cleanliness of the nipples, the daily washing to be followed by bathing them gently with cologne or tincture of arnica and water, and at night the application of a little cocoa-butter. Delore suggests daily exposure of the nipple to the air as a means of rendering it less liable to become diseased dur- ing lactation. Certainly, if the exhibition of as much of the mammary glands as is made by some fashionable women at balls or parties has any justification, it would be in the fact that these women are pregnant, and are pre- paring for one of the most important duties of mother- hood. PROFESSIONAL CARE DURING PREGNANCY.—The ob- stetrician should see a woman from time to time during her pregnancy, giving her such instruction and advice as her condition may require. During the last three months, earlier if certain symptoms to be presented hereafter arise, it is important that the state of the renal functions should be learned, more especially as to the presence of albumen in the urine ; once in one or at most in two weeks, the condition of the urine should be ascertained by chemical, and if necessary by microscopical, examina- tion. é‘ It would be better too, if at least an external examina- tion were made when the foetus has become viable, so as to ascertain the position which it occupies in the uterus, and the presence or absence of any neoplasms of the or- gan of gestation, or of organs adjacent, which may inter- Some cases, too, may tl Pregnancy. Pregnancy. require measurements of the pelvis to be made, especially in a primigravida, or in a woman whose previous labors have been difficult, requiring artificial means for the re- moval of the child, or in whom possibly the delivery was spontaneous, the child, however, dying in the labor, from the delay and difficulty of the process. THE PATHOLOGY oF PreGNANCY.—The pathology of pregnancy includes, first, those diseases which are exag- gerations of physiological conditions belonging to the pregnant condition, or caused by it; second, diseases be- ginning before pregnancy, or accidentally occurring dur- ing it, that is intercurrent, and which may be modified by the pregnant state or may affect it, and traumatisms, including injuries and surgical operations ; third, affec- tions of the sexual organs ; and, fourth, maladies of the ovum. These classes will be now briefly considered in their order, omitting, however, from this presentation any of the diseases embraced in this class that are dis- cussed elsewhere in this work. Hyperemesis.—The morning-sickness of pregnancy, in its ordinary form, has been previously mentioned, and Wwe are now concerned with that exaggeration of the dis- order known as hyperemesis, or as the uncontrollable, in- coercible, or pernicious vomiting of pregnancy. In about two-thirds of the cases this disease is first manifested before the end of the third month. Usually there is a gradual transition, from the ordinary nausea and vomit- ing to the grave form of the disorder, when the patient rejects the simplest food or drink, very soon after taking it, and then a part only of the food is vomited; in some cases, however, there is immediate vomiting—for exam- ple, simply a little cold water is thrown up immediately after it is swallowed, but more frequently it is retained until it becomes warm. Apparently the most trivial causes will excite vomiting, such as an attempt to sit up, or changing from one position to another, for example, from the back to the side, or when a reverse movement is made. The patient rapidly emaciates, the urine becomes scanty, may contain albumen, and is high-colored ; there is in some cases an abundant secretion of saliva, and usually anorexia is present—in part probably from the patient’s knowing that taking food will be followed by vomiting. With the continuance of the disorder the symptoms become graver, and that which has been described as the second stage occurs. ‘The emaciation makes rapid prog- ress, and the patient becomes more exhausted, fainting, it may be, upon so slight exertion as sitting up in bed; the gums may be swollen, the teeth covered with sordes, and the breath offensive; the pulse is 120 or more a minute, and the thirst excessive. Older observers, without the proof of thermometric facts, described this stage as febrile, the conclusion being derived from the frequency of the pulse; but some recent observations do not prove a marked increase in the temperature. The third period soon follows. Now the vomiting ceases, but there are disordered vision and hearing, and often intense neuralgic pains ; the pulse may be 140 a minute; mental disorder is shown in hallucination and delirium, and coma closes the scene. The disease is not always steadily progressive, but presents, it may be, from time to time remissions, conse- quent, for example, upon a change of scene, or upon some new article of food or of drink. JI have known one instance in which the vomiting ceased for some days from drinking lager-beer. Cazeaux quotes from Dubois an in- stance of grave vomiting in pregnancy, in which the dis- ease disappeared after a violent attack of diarrhoea, and another in which a powerful mental impression, the hus- band of the patient gravely suffering from strangulated hernia, had a similar effect. Among causes of obstinate vomiting in pregnancy are displacements of the uterus, inflammation of the cervix, adhesions of the membranes at the internal os, rigidity of the muscular fibres of the uterus not permitting ready dilatation, circumscribed inflammation of the organ, and inflammation of structures adjacent to it; Lebert and Rosenthal refer the disorder in some cases to partial man- ifestations of a general nerve inanition. 12 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Post-mortem examinations have shown disease of dif- ferent organs, more especially of the stomach—ulceration and cancer, for example—but, as Tarnier observes, it is impossible to describe the pathological anatomy of the disease, and while actual alterations in certain organs have been found, there is no constancy in these facts, and in some instances no lesion can be discovered. Guéniot found that in 118 cases the recovery took place in 72, and 46 died; of the 72 who recovered, 42 either spontaneously aborted, or else premature labor or abor- tion was induced. Of the 46 who died, 28 did not abort, and 18 had abortion or premature labor induced, or mis- carriage Was spontaneous. The treatment is hygienic, medical, or obstetrical. A change of residence, as from the city to the country, an entirely new diet, especially choosing an article of nour- ishment for which there may be a particular desire. Possibly iced lime-water and milk, or ice-cream may be tolerated and prepare the way for taking other food ; effervescent drinks may be employed. Finally, abso- lute rest may be given the stomach for a time, rectal ali- mentation being employed. ‘The medicines advised are very many, and by their number testify to the fact that results accomplished are quite uncertain. Among these are tincture of nux vomica, oxalate of cerium, dilute hy- drocyanic acid, subnitrate of bismuth, chloroform, or sul- phuric ether, each of the two latter given in doses of a few drops with water, or in perles, the various prepara- tions of pepsine, chloral, bromide of potassium, and opium or one of its liquid forms, or morphia. Inhalations of oxygen have occasionally succeeded, and also the use of electricity ; recently, too, cocaine has been strongly rec- ommended. The application of ether spray to the epi- gastrium has been employed; so, too, have Chapman’s ice- bags to the spine; a small blister to the epigastrium, in some cases followed by the use of morphia endermically, has relieved some. Of course a uterine displacement should be corrected ; cauterization of the cervix, and the application of bel- ladonna to the vaginal portion has been employed with occasional success; Copeman used digital dilatation of the cervical canal, while others have leeched the cervix. The obstetric treatment consists in the induction of abortion, or, if the pregnancy has continued until the child is viable, of premature labor. But this grave step is rarely required, and ought not to be undertaken until the usual means for the arrest of the disease have been vainly tried, and until the condition of the patient is such that her life is in imminent peril from the disease ; it should also be borne in mind, that while in the majority of cases the vomiting ceases when the uterus is emptied, or soon after, there are some in which no such happy re- sult follows; and, on the other hand, that cases now and then are seen in which the disorder is most grave and has persisted notwithstanding well-directed remedies, so that the practitioner despairs of a favorable ending, and yet, with some slight dietetic or medicinal change sudden im- provement takes place and the disease ceases. The re- sponsibility of ending the pregnancy ought to be shared with a reliable confrére. Finally, the induction of abortion is not to be thought of if the patient has passed into the third stage of the disease, for then death is inevitable, and may be hastened by this treatment, bringing reproach alike upon the meth- od and the art. Serous Cacheria or Hydremia.—Among the exaggera- tions of the physiological changes of pregnancy is that condition which Stoltz, and before him, according to Tarnier, Baudelocque, the nephew, and Lasserre, called a serous cachexia ; Kiwisch gave the name of serous ple- thora to those blood changes consisting of increase of the quantity of blood and of its water. Stoltz speaks of the serous cachexia as an exaggerated hydreemia. Patients suffering from this condition may have cedema of the lower limbs only, but frequently the serous effu- sion involves the connective tissue of the external gen- erative organs, the upper limbs, the trunk, and the face ; there may also be effusion of serum in the great serous cavities. If there should be disease of the heart the REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. symptoms are more serious. Nevertheless, notwith- standing this general or localized dropsy, the urine is en- tirely free from, or contains only a trace of, albumen. The treatment should consist in rest, nutritious diet, the administration of tonics, especially of iron, the hot bath, diuretics, and occasional mild derivation to the intestinal canal. Tarnier attaches great importance to milk diet. In some cases punctures of the swollen external genitals or of the cedematous lower limbs may be advisable, but should not be made unless the necessity be urgent, lest gangrene ensue. If there is great accumulation of serum in either the thoracic or the abdominal cavity, thoracen- tesis or abdominal paracentesis may be employed with- out hesitation. Charles has recently recorded in the Journal d@ Accouchements a fatal result in a woman near the close of her pregnancy, in whom the most prominent symptom was this hydremia. Anemia.—Those who suffer from hydremia are ane- mic, but there may be an anemia not marked by serous effusions, or, at least, there is only a moderate oedema, more especially of the lower limbs. Such a condition creates a liability to post-partum hemorrhage, and should be corrected by attention to nutrition, and by the use of tonics, especially of iron preparations. Pernicious Anemia.—In addition to the simple form of anzemia just mentioned, there is a grave manifestation of the disease, occurring comparatively rarely, and known as pernicious or progressive anemia. Twenty-six years ago this disorder was described by Gusserow, but some time before this cases of the disease were reported and many others observed, but not published ; in this coun- try, for example, practitioners, more than thirty years since, met with instances of the disease presenting the grave symptoms which Gusserow and others afterward described, and which, by a sort of general consent, was given the title of puerperal ansemia. The etiology of the affection is obscure ; in some cases those affected have suffered from malaria, or were ex- hausted by rapidly recurring pregnancies, by obstinate vomiting, or by insufficient food ; hemorrhage, profound mental shock, and diarrhea were also considered causes. Nevertheless, cases of the disease have occurred in which none of these factors were present. Generally the disease begins gradually. The skin of the face grows paler and paler, and has a waxy appearance ; in some cases the skin has a yellowish hue, but there is no emaciation, the weight, for a time at least, being re- tained ; but after a time fever occurs, and then there is loss of flesh. Often there is anorexia. The more promi- nent general symptoms are palpitation of the heart, faint- ing, syncope, and headache ; frequently sleeplessness is observed, but in some cases drowsiness. Hmorrhages are not unusual, and the gums may be spongy and swol- len, as in scorbutus. Abortion or premature labor is a common occurrence, and in the latter case the foetus is usually found to be dead. A fatal issue occurred in the majority of cases ob- served, though in some it was delayed for months. In regard to the treatment, remedies addressed to the anemic condition are, of course, indicated, but it is not necessary to enumerate them. A more important ques- tion arises in reference to the induction of abortion or of premature labor. Interruption of pregnancy was advo- cated by Gusserow, has received the indorsement of Charpentier, and more recently of Zweifel, but, on the other hand, is rejected by Kleinwachter, because of its hastening the commonly fatal termination of the disease. Chiara advocates an early induction of premature labor, or even of abortion, as in the obstinate vomiting of preg- nancy. ‘Tarnier observes that the epoch of intervention presents a grave question which is difficult to decide. Varicose Veins.—Varicose veins of the lower limbs, or of the external genitals, or of the vagina, of the rectum and anus, are not very uncommon in pregnancy, though authors widely differ in their statements as to the fre- quency of this accident. For example, Budin asserts that twenty to thirty per cent. of pregnant women suffer from varicose veins, while Cazin makes the number one in twenty-one ; and my own observations, made in the Phil- Pregnancy. Pregnancy, adelphia Hospital, are much more nearly in accord with the latter than with the former statement. Among the alleged causes of varicose veins are in- creased quantity and changed character of the blood, gravitation, greater vascular tension, and pressure upon intra-abdominal veins by the enlarged uterus. Tarnier states that some authors have added to modifications in the circulatory apparatus, in explaining the occurrence of varices, those which take place in the nervous system under the influence of pregnancy. It must be confessed, however, that this etiology is not very obvious. Rupt- ure of a varix in pregnancy may cause a rapidly mortal hemorrhage, while such rupture in a varix of the vulva or vagina, taking place in labor, may result in the for- mation of a thrombus or hematoma, seriously interfer- ing with the delivery of the child. If the varicosities be large, all straining, or lifting heavy weights, taking long walks, and even being for a consid- erable time in the erect position, should be avoided ; the subject must lie down a part of each day; moderate compression with a properly applied flannel bandage to an affected limb, especially if there be much oedema, as there frequently is, will be useful. The patient ought to be taught, in case there is threatened rupture of a varix, how to arrest hemorrhage from it by direct com- pression. Albuminuria.—Albuminuria is probably present in five to ten per cent. of pregnant women, although Du- mas, uniting the statistics of Hippolyte, Abeille, Moricke, and Petit, finds that one in five or six thus suffers ; Tar- nier refers to the results recently published by Negri, Doléris, and Pouey, showing that the proportion of albu- minurics is about five per cent. A woman suffering with albuminuria may become preg- nant, or another, being pregnant, may be attacked with ne- phritis ; but in either case the albuminuria is an accident independent of the pregnancy. On the other hand, how- ever, there may be a nephritis which results from the pregnant state, the urine showing the presence of albu- men, hyaline casts, and renal epithelium ; but the disease disappears after the pregnancy. Various explanations have been given of the nephritis of pregnancy. Among these are the renal disorder which results from the in- creased work thrown upon the kidneys by the pregnant state, the greater vascular tension, pressure upon the renal veins by the enlarged uterus, similar pressure upon the ureters, and finally from reflex irritation, this irritation arising from the uterus and affecting the renal circulation and secretion. Leyden (Zeitschrift fir klin. Med., 1886) maintains that the lesions of the kidneys found in preg- nancy nephritis do not correspond either to venous stasis or to acute nephritis, and attributes great importance in their production to arterial anemia. According to him, this anemia results from hindrance to circulation in the abdomen caused by the enlarged uterus, this hindrance increasing with the greater size of the organ of gesta- tion. The cause acts mechanically by diminishing the quantity of urine, and hence albuminuria, and dynami- cally from lessening the supply of oxygen, and hence fatty degeneration of the kidney. Zweifel (Lehrbuch der Ge- burtshitife, 1887) holds that of the many theories ad- vanced in explanation of the disorder, only two deserve special mention, and yet neither has been proved. ‘The first was proposed by Frerichs, and accepted by Bam- berger, Leitzmann, Rosenstein, Lange, Hohl, Moéricke, and others. According to this theory the renal changes are the result of increased intra-abdominal pressure, pre- venting the escape of the venous blood from the kidney, and thus causing engorgement of the organ. The other theory, that of Halbertsma, explains all the facts as re- sulting from pressure of the enlarged uterus upon the ureters. The former is accepted by Zweifel. : It is unnecessary to state the usual manifestations of albuminuria in pregnancy, nor the means by which a diagnosis is made. The most serious possible result is eclampsia; for while the majority of albuminurics are not eclamptic, it is very rare for eclampsia to occur In pregnancy unless the patient has albuminuria. Winter has recently called attention to premature detachment of 13 Pregnancy. Pregnancy. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. the placenta as a not uncommon accident in nephritic patients. The treatment of albuminuria in pregnancy is gov- erned by the same rules that apply to the management of the disease in the non-pregnant, except, probably, as advised by Tarnier, an absolute milk-diet, if the quantity of albumen in the urine be great, should be strictly en- forced, and in some cases it gives remarkably good re- sults ; in some patients, the induction of premature labor or even of abortion may be clearly indicated. Cardiac Disease.—It has been claimed that disease of the heart may result from pregnancy. Thus, admitting a normal hypertrophy of the organ caused by the preg- nant condition, it is asserted that, as a consequence of rapidly recurring pregnancies, an ordinarily transitory hypertrophy becomes permanent. But this is only hypo- thetical. Further, as stated by Tarnier, Ollivier claims that subacute and chronic endocarditis may originate solely under the influence of pregnancy. However these questions may be decided, the obstetrician is concerned almost exclusively with cardiac disease which was pres- ent when the pregnancy occurred. Undoubtedly the pregnant woman, from the fact of her condition, is more liable to suffering, and even to danger, if she has valvu- lar disease ; the pregnancy becomes a complication in many cases, though not necessarily in all. Budin and others have shown that cardiopathics are peculiarly lia- ble to abortion ; Porak found that in 214 women who had disease of the heart, the pregnancy continued until term in only 126, while 88 aborted, or had premature labor. Whether premature or mature labor, or miscarriage oc- cur, there is an increased liability to post-partum heemor- rhage. The treatment during pregnancy does not ordi- narily differ from that required by cardiac disease in the non-pregnant condition. In some cases the induc- tion of abortion or of premature labor may be indicated by the danger to the life of the mother. ; Relaxation of the Pelvie Joints—Some swelling and softening of the pelvic joints is one of the normal phe- nomena of pregnancy, but should these be excessive the mobility of the pelvic bones may become so great that it is impossible for the patient to walk, and, indeed, any movement of these bones may be attended with great suffering. The joint most liable to be affected by this abnormal relaxation is the pubic. The relaxation usu- ally occurs in the latter half of pregnancy, but Moreau mentioned a case in which it appeared in the second month, and in this ‘patient it continued for more than two years after delivery. Having begun, it usually in- creases until the end of pregnancy, when it gradually lessens and disappears in most cases. The most impor- tant treatment is rest; the more exercise is urged upon the patient, the more miserable she becomes through suffering and aggravation of the disorder. A prolonged rest, too, is required after labor, and when the patient gets up the immobility of the bones should be secured by a suitable apparatus. Barker states that in all cases he has seen this immobility has been effected by a little ingenuity in making and adapting a hip-binder of very strong, coarse cloth. Neuroses.—Different nervous affections may occur in pregnancy, some of them indeed depending upon the pregnant condition, Among the latter may be men- tioned neuralgic disorders, especially of the teeth. HHysteria.—In most cases of hysteria the disease ante- dates the pregnancy, but in a few it seems to originate from it. While in a few cases hysteria has disappeared during pregnancy, in the majority it continues, some- times becomes aggravated, and even insanity may follow labor. An interesting fact, observed by many, is that in some instances there is an almost, or quite, total absence of suffering during childbirth. . The treatment of hysteria in a pregnant woman is the same as if she were not pregnant. Epilepsy.—If an epileptic become pregnant the disease may be mitigated by the pregnancy, but the attacks re- turn with their original severity and frequency of oc- currence subsequently ; probably, however, a temporary favorable modification occurs in the majority of cases. 14 In the rare instances in which the disease begins in preg- nancy, it ceases after labor. Chorea.—This is not a frequent disorder observed in gestation, for Barnes could find but fifty-six cases which had been published, and Fehling, in 1874, was able to add only twelve to this number. The liability to the disease is greater in primigravide than in multi- gravide ; previous attacks of the disease create a predis- position to it; it may recur in several successive preg- nancies, or be present in the first only. It usually begins in the first half of gestation, continues during the en- tire subsequent time, and in rare instances during the puerperal state. Wenzel’s statistics show the mortality of the disease to be 27.3 per cent., and Spiegelberg found 23 deaths in eighty-four cases. The medical treatment need not be stated, for it is the same as when the disease occurs in the non-pregnant condition. The obstetric treatment, if the child be viable and the usual means for relief have been tried without benefit, and if the choreic movements are, violent while the patient’s strength is failing, is the induction of labor. Whether cases occur in which abortion is necessary is an undecided question. Diseases of the Skin.—Duhring calls attention to the fact that in a few cases eczema, herpes, or pruritus may result from the pregnant condition, but they cease as soon as the pregnancy is over, and that chloasma is common ; while, on the other hand, chronic affections, as eczema and, psoriasis, are often observed to be much better during this period. Inrare cases the pruritus is so severe that abortion has occurred. In three patients suffering with the disease who were seen by Cazeaux, the pruritus readily yielded to alkaline baths; Tarnier commends a solution of cocaine. Slocum has reported a case of hirsuties gestationis. The woman had been preg- nant three times, giving birth to three children at term, ‘‘and with each gestation a growth of hair on the sides of the face, and under the chin, started at the begin- ning of the pregnancy and continued until childbirth, growing to the length of oneand a half inch. As the ca- tamenial function returned, the hair fell out, the face as- suming its normal smoothness.”’ Acute Infectious Diseases.—Several observations have been made showing that when the mother suffers from a high temperature, the pulsations of the foetal heart are increased in frequency and lessened in force, and inter- ruption of pregnancy not unseldom occurs. ‘The experi- ments of German observers seemed to prove that this interruption was due to the continued elevation of tem- perature ; but the experiments of Charpentier, Doléris, and F. Doré, proved that if the increase was gradual, pregnant animals did not abort, nor was the life of the foetus in the least compromised. Accepting these results, the conclusion must be, as Charpentier has stated (‘‘ Archives de Toxicologie,” 1887), that hyperthermia does not exercise an important, only a secondary, influ- ence in the production of abortion and the death of the foetus, when the mother suffers with grave pyrexia, variola, scarlatina, rubeola, erysipelas, typhoid fever, etc. The interruption to pregnancy occurring in infectious diseases has also been regarded as resulting from heemor- rhagic endometritis. The investigations of Slavjansky, for example, showed such condition in the cases of pregnant women attacked with cholera. But, on the other hand, Queirel, in his recent studies of the epidemic of cholera at Marseilles, took pains to seek for this endometritis, and he has not found it; he states that hemorrhages have not occurred either in abortions or in labors, though he has frequently met with uterine inertia. Klotz, of the University of Innsbriick, studying the course of measles in pregnant women, in eleven cases of which there was interruption of pregnancy, endeavored to ascertain the causes of foetal death not only in measles but in other infectious diseases, and concluded that hee- morrhagic endometritis was not proved anatomically in this disease, in scarlatina, in variola, in erysipelas, or in typhus. Zweifel gives importance to the action of the ‘‘ fever- ' blood” upon the nerve-centres causing uterine action, REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. great increase of temperature producing, as a rule, uterine contractions. Probably, however, the most important factor in inter- rupting the pregnancy is, as asserted by Charpentier, toxemia, the death of the foetus resulting from this, and then its discharge from the uterus follows. Typhoid fever may occur in pregnancy ; this condition, according to the statement of Murchison, and contrary to the opinion of Rokitansky and Niemeyer, furnished no exemption from the disease. In the great majority of cases, though the pregnancy is interrupted, recovery takes place. Yellow fever is quite as likely to occur, according to Bemiss, in the pregnant as in the non-pregnant, but the liability to the disease is increased by childbed. Still referring to the statements of Bemiss, the liability to death is twice as great in pregnancy and in childbed. pregnant woman recovers from yellow fever, and gesta- tion continues, the child is protected from the disease. The last statement certainly points to and strengthens the assertion previously made, that the usual cause of death in acute infectious diseases is toxeemia, that is to say, the specific poison of the disease passes from the mater- nal to the feetal blood. It is not admitted that there is even a partial exemption from intermittent fever given by pregnancy ; where facts seem to sustain this view, their probable explanation is found in pregnant women not being so much exposed to the malarial poison. It seems to be tolerably well established that the foetus may suffer from malarial poisoning, this condition being man- ifested by regularly recurring paroxysms of convulsive movements; and in some of these cases the child at birth was found to be suffering from enlarged spleen. The administration of quinine is not forbidden by preg- nancy, and if abortion or premature labor occur, the event is not to be attributed to the drug, but to the ma- larial intoxication ; nevertheless, it is possible that in some women there may be such idiosyncrasy that some other antiperiodic should be employed. About sixty per cent. of pregnant women abort or have premature labor if attacked by cholera, though the recent statistics of Queirel, including 67 cases, show that in only 29 the pregnancy was arrested. The statistics just referred to also show that when the ‘pregnancy was interrupted, the mortality was about sixty-six per cent., but if it continued, only fifty per cent. The death of the foetus, probably, is usually due to toxeemia, as pre- vicusly stated, or it may result from asphyxia. Curschman claims that pregnancy causes a certain pre- disposition to variola. In varioloid there is little danger to the mother or to the fcetus, but in variola abortion or premature labor usually occurs, and is followed by the death of the mother. If a pregnant woman has variola, the rule is that the foetus is also affected, and it may pass through all the stages of the disease in the uterus, but in some cases is born with the disease, and in others may be attacked soon after birth ; very rarely an apparently healthy mother gives birth to a child having variola, and the explanation proposed is that the mother had the dis- ease without the eruption, and thus infected the child. In some cases successful vaccination of a pregnant woman has rendered the new-born insusceptible to vac- cination. Hence there is a stronger argument for vacci- nating the pregnant woman if she is liable to be exposed to small-pox. Scarlatina has been rarely observed in pregnancy. It is very liable to interrupt the pregnancy, and is peculiarly fatal. A similar statement may be made as to rubeola. Pneumonia is a more frequent disease of the male than of the female, but in the female it has a one-third greater mortality, and is far more dangerous in pregnancy. The pregnant woman, if attacked with the disease, is liable to abort or to have premature labor; this liability to inter- ruption of the pregnancy is greatest the farther the latter has advanced ; after interruption the patient in most cases dies within two or three days, if recovery does not take place. Some have urged ending the pregnancy by artificial means, but the practice is not generally accepted, most authorities preferring the expectant plan of treatment. If the. Pregnancy. Pregnancy. Pleurisy usually terminates favorably, and does not disturb the pregnancy, but if the disease be double, or if bronchitis be associated with it, abortion or premature labor may result. Thoracentesis has been performed upon the pregnant woman without disturbing the gestation. Jaundice ; Icterus Gravidarum.—This disease may oc- cur in pregnancy in one of two forms—simple or malig- nant. The first, when it appears in the later months, is attributed by Frerichs to pressure of the enlarged uterus or of the colon distended with feces, upon the bile-duct : while Tarnier suggests that there is an icterus peculiar to pregnant women, and Peter regards it as arising from congestion of the liver; Bedford has suggested that the disease may sometimes be in part due to mental emotions. The prognosis is favorable; nevertheless, in rare in- stances that which was apparently the benign form of the affection becomes malignant. The malignant form of the disease, which is seldom seen, is dependent upon acute yellow atrophy of the liver, and usually causes abortion or premature labor, and has a fatal result. There have been occasionally epidemics of jaundice in pregnant women, gestation in many instances being ar- rested, the majority of those affected dying. It has been been advised in malignant jaundice that the uterus should be emptied, but this rule has not been adopted ; certainly, if in a case of benign jaundice its fu- ture malignant character could be foreseen, the practice would be justifiable. So, too, it has been advised that in case of an outbreak of epidemic jaundice, security for pregnant women not yet attacked might be found in a change of residence. Traumattsm.—This includes injuries, and surgical op- erations in pregnancy. Very grave injuries have been received by pregnant women, and important surgical op- erations, such as removal of ovarian tumors, performed, and gestation has continued, while, on the other hand, comparatively trivial injuries have arrested it. Accord- ing to Cohnstein, penetrating wounds of the abdomen usually arrest the pregnancy, though the uterus may not be injured., Operations upon the genital zone are very liable to disturb the pregnancy. A question of some im- portance is as to the repair of fractures in the pregnant woman, and a difference of opinion exists, some contend- ing that this repair takes place as promptly as it would if she were not pregnant, while others, among whom Cazeaux and Tarnier may be mentioned, hold that there may be very great delay—the former narrating an in- stance in which a woman in the second month of preg- nancy fractured the tibia, and consolidation failed to oc- cur until after labor at term. In three cases of gun-shot wounds—one case being re- ported by each of the following, Richard, Staples, and Hays—involving the uterus, the pregnancy was arrested ; in one a living child was born ; all the mothers recovered. The simple rule in regard to operations in pregnancy may be founded upon the statement of Sir James Paget, that it would be mere recklessness to operate on a preg- nant woman without good cause; yet, if good cause for operation exists, she may be treated very successfully. Chronic Infectious Diseases.—The statistics of the late Austin Flint and those of Gaulard show that a large per- centage of women become phthisical during pregnancy or lactation. James, however, claims that pregnancy has a favorable effect, but that labor and lactation are un- doubtedly injurious ; it would seem impossible to isolate the effects of labor from those of its preceding and fol- lowing state, and really the conclusion is without prac- tical value, save that the woman who has tuberculosis ought not to nurse her child, and this rule has been clearly shown by previous observations. Pregnancy in the phthisical is rarely interrupted, even though the woman may be greatly exhausted by the dis- ease ; the disease, when labor is over, usually pursues a more rapid course; as might be expected, the children born of such mothers are in most cases feeble, and gen- erally die early. If the physician is consulted, it is his duty to earnestly advise against the marriage of a phthisical subject, whether maiden or woman. 15 Pregnancy. Pregnancy. Fournier holds that pregnancy is a complication of syphilis, complicating it by adding to it its own peculiar anzemia, its disposition to neuroses, its disorders of nutri- tion, etc. Abortion or premature labor is a very com- mon consequence of the disease ; thus, out of 414 pregnant women at Lourcine, in only 260 did the pregnancy con- tinue until term. The secondary stage of the disease is ‘that which furnishes the greatest liability to interruption of pregnancy, and from the fourth month to the end of the second year is the period during which a pregnancy is most liable to be arrested. It is claimed by some, denied by others, that a syphi- litic father may beget a syphilitic child, the mother re- maining free from disease ; yet, according to Fournier, who admits the possibility of direct paternal infection, the probabilities are that the child will not be infected. The most frequent source of infection is the mother. She may be syphilitic before conception, or she may acquire the disease just before, the fecundating being the infecting coition, or, finally, she may acquire syphilis during the pregnancy. Now, in the two first cases the child may be syphilitic ; but in the third case, the infec- tion taking place during pregnancy, it has been held that if this occurs after the middle of pregnancy the danger is very slight, and almost none if the mother becomes affected toward the end of normal gestation. Yet Tar- nier refers to one instance in which the child was born syphilitic, though the mother did not become infected until the eighth month. The probabilities of the off- spring being syphilitic are greatest in those cases in which both the parents are syphilitic. Should a syphi- litic woman become pregnant, an antisyphilitic treatment must be employed, and so, too, if she becomes syphilitic during her pregnancy. If she is free from the disease, but is impregnated by a syphilitic man, ought this treat- ment to be pursued? The answer generally made is, not unless she has previously had pregnancies arrested pre- sumably from syphilis. Diseases of the Sexual Organs.—Pruritus of the vulva is sometimes met with in pregnant women. The applica- tion of a solution of borax in water, or in rose water to which morphia is added, as recommended by Meigs, or of cloths wrung out of hot water, generally gives relief. Other means are brushing the parts with a solution of muriate of cocaine, or of carbolic acid, or of chloral. Tarnier states that he has, in almost all cases, succeeded in relieving the pruritus by the employment of a solution of corrosive sublimate in the following formula: Corro- sive sublimate, one part; alcohol, five parts; rose water, twenty, and water, two hundred and twenty-five. Vegetations of the vulva may appear during pregnancy, and usually spontaneously disappear when the pregnancy is over. While, probably, in the majority of cases these growths are specific in origin, yet in some they may not be. Unless they are large and occupy so much space that they will interfere with the expulsion of the foetus, active treatment during pregnancy is not advisable, for excision would be attended with considerable hemorrhage, and besides the growths would soon be reproduced. ‘The af- fected surfaces should be, so far as practicable, separated and kept clean ; disinfectant and astringent solutions are to be applied. Tarnier speaks favorably of the applica- tion of a strong mixture of tannin and water, and Char- pentier has seen the growths disappear by isolating the affected parts, and applying compresses dipped in Labar- raque’s solution. Prolapse of the vagina, especially if cystocele be asso- ciated with it, may require the use of astringent injec- tions and wearing an elastic ring pessary ; for the latter, should it cause pain, a tampon of prepared wool to which a String is attached, dipped in a mixture of glycerine and tannin, may be worn during the day and removed when the woman retires. Different forms of vaginitis may affect the pregnant woman, the chief of these being simple, granular, and specific; the two latter may be associated. In simple vaginitis, the most marked symptom of which is a leu- corrheal discharge, bathing, cleanliness, antiseptic and mild astringent injections twice a day, will be useful; 16 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. vaginal injections in pregnancy should be warm or tepid, and the fluid is to be used as a wash, not asa douche. Granular vaginitis, first described by Deville, in 1844, is characterized by the presence upon the surface of the vagina, especially at its upper part, of elevations about the size of a hemp-seed, so that the examining finger touches a rough, grater-like tissue, and by rather a pro- fuse yellowish discharge which irritates the parts with which it comes in contact in passing out of the vagina. In addition to the means applicable to simple vaginitis, every other day a cotton or wool tampon, containing half a teaspoonful of powdered alum and the same quantity of subnitrate of bismuth, may be placed in the vagina ; instead of this dry tampon one made of cotton first dipped in glycerine, and its surface freely covered with boric acid, may be employed ; in either case the tampon is removed after twelve hours. Nitrate of silver injec- tions also prove useful, or the diseased surface being ex- posed by a speculum, and then cleansed, is brushed over with the solution. Gonorrhceal inflammation of the va- gina demands treatment in the interest of the child and of the mother, for the former, during its passage through the vagina may, by the contact of the infectious matter with the conjunctive, subsequently have a specific con- junctivitis, or the latter, from extension of the vaginitis after labor, have a salpingitis. Nitrate of silver injections here, too, are useful, but probably the most valuable remedy is corrosive sublimate, an injection of one part to three thousand of water being used at least twice a day. In 1871 Winckel first described a form of vaginitis characterized by the presence upon the vaginal surface of a large number of transparent cysts, fifteen or twenty often being found upon a part the size of a dollar; most of these cysts contained gas, and when punctured col- lapsed with a sound quite audible; there was usually hypersecretion ; he gave the disease the name of colpohy- perplasia cystica. Painless contractions of the uterus as one of the nor- mal phenomena of pregnancy have been described ; but under certain circumstances these contractions cause more or less severe suffering. If we admit with Wigand the existence of uterine rheumatism, the explanation of such suffering is in many cases quite simple, for it is the same in contractions of the uterine muscle as it is in the exercise of voluntary muscles affected by rheumatism. But most authorities do not regard the existence of uter- ine rheumatism as proved. The hypothesis of uterine neuralgia, or that of a metritis, has been suggested, or else we may say that in some women the gravid uterus is peculiarly sensitive to pressure, whether that be made from within or from without, as caused by foetal move- ments, or by placing the hand upon the abdomen. There is, however, a form of intermittent pain in the gravid uterus resulting from injury, which apparently threat- ens premature labor or abortion, though neither occurs ; and which has not been the subject of special considera- tion ; two cases of this kind I have recently met with, one in hospital, the other in private practice. In the former a multigravida, at the beginning of the seventh month of pregnancy, fell, striking the front part of the abdo- men upon a stove. As painful contractions of the uterus succeeded it was at first supposed labor was at hand, but there was no increased vaginal discharge, no effacement of the uterine neck, and no dilatation of the os. Though the uterine soreness and the painful contractions con- tinued for two or three weeks, the pregnancy went to term, and the labor was normal. In the second case a multigravida, at the beginning of the seventh month, was lying in bed upon her back ; one of her children, aged two years, was in the bed, and in his romping fell so that his head struck one side of the uterus. For several days she suffered severe intermittent pain in the uterus, but this pain, though the entire organ contracted during it, was referred exclusively to the side which had been struck. In each case the explanation of the suffering was that the normal and ordinarily painless contractions of pregnancy became painful because of injury to the organ. The treatment of such cases will be rest, opium, and the ap- REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Pregnancy. Pregnancy. plication of warm compresses to the abdomen ; occasion- ally a mild counter-irritant may be required. Various positional disorders of the gravid uterus may “occur—prolapse, anteversion, anteflexion, retroversion, and retroflexion—the gravest of these being complete Fre. 3095. prolapse and the posterior displacements ; in addition to these there may be hernie of the organ. In prolapse of the uterus the organ may descend to the pelvic floor, and may partially or entirely protrude from the vulvar orifice ; should the latter occur the prolapse is called complete. In most cases the patients are multigra- vide ; in some the accident occurs gradually, in others suddenly, in consequence of a violent effort, as lifting a heavy weight ; and in rare cases impregnation of a pro- lapsed uterus has taken place ; there have been instances where prolapse of the uterus has oc- curred during labor ; in some of these the labor was spontaneous, in others it was artificial, the accident taking place, for example, during ex- traction with the forceps. Visual, digital, and bimanual examination will readily recognize this positional disorder of the uterus and its degree, care being taken to avoid mistaking hypertrophic elongation of the cervix for this displacement. XS The consequences of prolapse of the gravid S uterus may be very serious. There is great liability 7 to interruption of the pregnancy, and in rare in- stances incarceration of the organ occurs, having similar grave results to those which will be referred to in connection with this accident in posterior dis- placements. The question as to whether the pregnancy in a completely prolapsed uterus can continue until term, has received different answers, eminent German authori- ties, such as Schroeder, Gusserow, and Zweifel, asserting that no authentic case of this kind has ever been reported ; while some French authorities, among whom may be mentioned Charpentier and Tarnier, hold the opposite ; the statement of the former seems the more probable. If prolapse occur in pregnancy an effort should be made to restore the uterus to its normal position and to keep it there ; after its restoration the patient ought to remain in the horizontal position until danger of the recurrence of the accident is improbable. If the organ be irreducible, and serious difficulties are present, especially incarcera- tion, there must be no hesitation in producing abortion, Vou. VI.—2 and after this has occurred the restoration of the organ is to be made. ; Anteversion, or anteflexion, of the pregnant uterus is a less frequent, and usually a less grave, accident than the corresponding posterior positional disorders. Should either of the first two accidents occur in the early months of pregnancy, the progress of gestation gradually rectifies it in almost all cases. In the late months of pregnancy there may be in the multigravida, in conse- quence of great relaxation of the abdominal wall, marked projection of the uterus in front, causing the woman more or less inconvenience and discomfort; the relaxa- tion may be so great that the anterior wall rests upon the thighs when the subject is standing. Lying upon the back as much as possible, and, when the woman is up, wearing a suitably applied bandage, constitute the proper treatment of this accident in the latter part of pregnancy. Should incarceration of the gravid anteverted or ante- flexed uterus happen, an accident possible only in the early months, and which has a predisposing cause in increase of the antero-posterior diameters of the pelvis, the fun- dus of the uterus is fixed behind the pubic joint ; but manual reduction can usually be readily effected. For this reduction the patient is placed in a horizontal posi- tion, the hips somewhat higher than the head; then an effort is made, by drawing upon the cervix and pressing upon the anterior wall of the uterus, near the fundus, to restore the organ to its normal position; or pressure may be made with the index and medius introduced into the vagina upon the body of the uterus. ‘‘ Godefroy placed the index of one hand in the vagina, the other in the rec- tum, and effected reduction by pressure in opposite di- rections ; while Moreau drew the neck down by a finger in the vagina, and pushed up the fundus by means of a sound in the bladder.” Posterior version or flexion of the gravid uterus is a more frequent and grave disorder, if it should not be rectified by nature or by art. These names are frequently used synonymously, and indeed it is asserted that a pure retroversion of the gravid uterus is rarely met with, some flexion usually being combined with it. Nevertheless, it Fria. 3096. is probable that a woman whose uterus is retroverted rarely becomes pregnant, and hence, if the gravid uterus is found retroverted the accident almost certainly _oc- curred after impregnation; and on the other hand, a 17 Pregnancy. Pregnancy. woman with retroflexed uterus may become pregnant more frequently than one whose uterus is in normal position, because the deviation is frequently the cause of abortion. In retroversion the axis of the cervix cor- responds with that of the body of the organ, while in retroflexion it forms an angle—acute, right, or obtuse— with the uterine axis. The preceding illustrations, the first of flexion, and the second of version, show the es- sential difference between the two. In regard to retro- version of the gravid uterus, there has been much dis- pute as to whether the deviation is sudden or gradual, and as to whether distention of the bladder is cause or consequence. It may be admitted that each form of de- viation can occur, that is, it may be sudden or gradual, and that distention of the bladder is occasionally a cause, while in all cases it is one of the gravest consequences of the change of position. In the majority of cases of these positional disorders of the gravid uterus, spontaneous rectification occurs in the progress of pregnancy. In very rare instances, how- ever, of retroflexed uterus, as first suggested by Merri- man, and as confirmed by the observations of Oldham and Stillé, pregnancy may go to term or near it, though the uterus remains retroflexed. In some cases, again, spontaneous abortion is not an infrequent result. But should neither spontaneous nor artificial restoration be made, nor abortion occur, incar- ceration follows, for the unusual development of the uterus observed by Oldham and by Stillé is so rare an event that it may be omitted from consideration. When- the uterus remains imprisoned, there will result reten- tion of urine and obstruction of the rectum; uremia and local or general peritonitis may occur; the bladder may rupture, or there may be a simple or a diphtheritic cystitis, and, as a consequence, detachment of the whole or of parts of the vesical mucous membrane. Valenta has reported a case in which retroflexion caused in the fifth month gangrene of the bladder, perforation into the small intestine, and death. In making the diagnosis the bladder should be first emptied by the catheter if possible, but, if this be impos- sible, especially in case there be great accumulation of urine, by the aspirator; if the patient is very sensitive an anesthetic must be employed. Given the probable fact of pregnancy, its certain proof may usually be had from auscultation in case the pregnancy has advanced to four months or more. Then by examination with the finger, both vaginal and rectal, by abdominal palpation, and finally by combining the latter with vaginal touch, the fact of retroversion or retroflexion of the uterus will in most cases be clearly established. The diagnosis of the deviation having been made, the next step is to correct it, and prevent its return. Sup- posing the simplest form of the disorder, a displacement at two or three months being present, and the uterus be mobile, its correction can generally be readily made by the bimanual method, and the return of the disorder be prevented by the application of a suitable pessary, which in most cases ought to be worn until the end of the fourth month. Even if the uterus be almost, or quite immobile, and no grave consequences of the displacement be yet present, its gradual restoration may be possible. In attempting such restoration the patient takes the knee- chest position and then the operator introduces the large blade of a Sims’s speculum, pressing the point of the blade as. far up as possible in the posterior cul-de-sac. By this pressure upon the posterior wall of the uterus, we endeavor to lift up the organ while retracting the peri- neum; the movement of the uterus may be assisted by hooking a tenaculum into the vaginal cervix, which is thus drawn backward and downward. The operation may be repeated for a brief time each day, should no un- favorable symptoms arise; there may be very slight gain each time, but patient perseverance will, in many cases, be rewarded with complete success. If, however, symp- toms of incarceration are manifested, immediate restora- tion must be attempted. In such cases an anesthetic will usually be required, and therefore the knee-chest position cannot be taken while efforts at restoration are made, 18 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Indeed, such position would hinder rather than assist re- turn of the organ to its normal place in some degrees of this displacement ; for example, in case the fundus of the uterus has descended, so as to be near the vaginal outlet, and the cervix is directed above the pubic joint, the or- gan occupying a position corresponding nearly with the axis of the pelvic inlet, the cervix being highest, it is manifest that there would be, so far as the action of grav- ity and atmospheric pressure are concerned, force exerted which would increase rather than lessen the displace- ment. Under such circumstances it is better for the pa- tient to be lying upon her side, or- upon her back. The four fingers of one hand may be introduced into the va- gina to press the organ up, or two fingers applied to the anterior surface of the neck, now its superior, to draw this part downward and backward, while two of the other hand are placed in the rectum and the body of the uterus is by them pushed upward and forward. It is doubtful if the colpeurynter, whether introduced into the vagina or into the rectum, is of much value. If the organ cannot be restored to its normal position, and serious symptoms are present, the only resource is to empty it, that is, produce abortion ; and in those cases in which it was impossible to reach the os, for the introduc- tion of a sound, puncture of the uterus, thus evacuating the amniotic liquor, has been successfully employed. Hernie of the Uterus.—Hernie of the gravid uterus are rare. In some instances protrusion of a part of the organ may take place in an umbilical hernia, or again there may be a ventral hernia, the integrity of the abdom- inal wall having been lost from the distention of a pre- vious pregnancy, or from an injury, the separation usu- ally being between the recti muscles. The conditions which have been mentioned rarely give rise to serious difficulty during pregnancy, or in labor; nevertheless in the latter, if a considerable eventration is present, the uterus thus being withdrawn from the assisting action of the abdominal muscles during the second stage, that stage will be tedious, and an instance of this kind I have known. The comfort of the patient during pregnancy will usually be promoted by a suitable bandage. The only other forms of hernie known are inguinal and crural. Eisenhart states that hernia of the gravid uterus is nearly as rare as that of the non-gravid, and the slight preponderance in number of the former is probably due to the fact that pregnancy directs attention to a condition that would be otherwise unnoticed. In some historical references this writer states that Nicolaus Pol (1581) reported the first case ; Ceesarean section was performed, the mother surviving three days, but the child lived until it was a year and a half old. In 1610 Sennert operated on a case, the mother living twenty days, and the child until it was nine years and a half old. Saxtorph’s and Ledesma’s cases are next given, that of the latter occurring in 1840. Rektorisk reported a case in 1860; the Cesarean operation was done, the -mother died, but the child lived. Inguinal hernia has been frequently observed with uterus bicornis or didelphys. In Winckel’s case, reported. by Eisenhart, the uterus was bicornis ; the hernia, which involved the right horn, occurred suddenly in the fourth month of pregnancy. Scanzoni has reported a case of inguinal hernia in a patient who had two pregnancies in one year, one of these being ended by spontaneous and the other by artificial abortion. In either crural or inguinal hernia, Winckel advises abortion ; but if the foetus be viable, the Czesarean sec- tion should be done at the end of pregnancy, and after the operation the uterus is, if possible, to be restored to the abdominal cavity ; but if this cannot be done it should be extirpated. Structural Diseases of the Uterus.—Two only of these will be considered, benign and malignant growths. Fi- broids, or myomatous tumors of the uterus are compara- tively rarely observed in pregnancy, for such tumors cause a relative sterility ; thus, while the average sterility of wo- men is one in eight, that of those suffering from such neo- plasms is one in three. These tumors usually increase in size and become softer in pregnancy, and after this a par- —— REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Pregnancy. Pregnancy. tial atrophy is frequently observed, more especially in those which have a predominance of muscular tissue in their structure: Stratz (Zectschrift fir Geburtshilfe) has recently report- ed the results of 11 cases of uterine myomata observed in pregnancy. In 4 spontaneous abortion occurred, and in 3 it was induced ; twice the tumor and the uterus were removed, and twice also the tumor only was taken away, once by laparotomy, and once through the vagina, and in the two latter cases only were living children born at term ; all the mothers recovered. On the other hand, of 13 women in whom the tumors were discovered during labor, 7 died, and 8 of the children were saved. Hence he draws the conclusion that intervention during preg- nancy is much more favorable for the mother, while de- lay until labor occurs is more favorable for the child. Rec- ognizing the fact that the mother’s is more valuable than the child’s life, Stratz holds that intervention during preg- nancy ought to be the general rule; that in very many cases abortion should be produced, as the sole rational measure, since myomotomy is yet too recent an operation for its true value to be known. But it should be remem- bered that whether a fibroid is a serious complication of pregnancy depends upon its size and position ; growths of moderate size, unless so situated that they notably lessen the size of the birth-canal or seriously interfere with the expansion of the lower segment of the uterus, may not prevent normal labor ; and such growths, as the experience of most practitioners will testify, are those which are most frequently observed. If the fibroid is situated at the uterine fundus, abortion is very liable to occur. In many instances where the growth was in the lower part of the uterus or in the cervix, and submu- cous, it was successfully extirpated during labor. If the tumor be subserous, and not so large that it prevents the development of the uterus, there is no indication for in- terference; on the other hand, its removal is indicated if it be large, and then, in case it be pedunculated and with- out extensive adhesions, that removal is not difficult, nor likely to-be followed by interruption of the pregnancy. If the fundus of the uterus be affected by cancer or by sarcoma, pregnancy is not at all probable, and should it happen, abortion is inevitable. Malignant disease of the cervix, however, is not so invariable an obstacle to im- pregnation. Nevertheless, it is a comparatively rare oc- currence that a woman who has cancer of the womb becomes pregnant ; the statistics presented by Stratz, op. cit., show that in 1,034 cases conception was observed in only 12. Pregnancy causes the more rapid growth of malignant tumors of the uterus, and extirpation of the diseased structure, although the operation may cause abortion, is plainly indicated. If an ovarian tumor is small it rarely interferes with pregnancy, and, therefore, the statement made by Stratz is too absolute, that the occurrence of pregnancy in a woman having such a growth is a sufficient indication for at once performing ovariotomy. But should the tumor, either by size or position, interfere with the progress of the pregnancy, ovariotomy is indicated, and the earlier in gestation the operation is done the more favorable the prognosis. In fourteen cases of ovarian tumors compli- cating pregnancy, reported by Stratz, ovariotomy was done; all the mothers recovered, and thirteen out of fifteen children were saved, abortion occurring in two cases, and there being one twin pregnancy. These re- sults are very much better than those following the ex- pectant plan, the induction of abortion, or puncturing the cyst. Mastitis, ending in resolution or in suppuration, has occasionally been observed during pregnancy, but the treatment of this affection does not require special con- sideration. There is a normal hypertrophy of the mamime in pregnancy ; but in rare instances this hy- pertrophy becomes very great, transgressing all physio- logical bounds, and in such cases abortion is liable to occur ; usually the hypertrophy is followed by atrophy when the pregnancy is over. Treatment—including the application of support to the enlarged breasts, of iodine, or of cold, and of compression, and the internal admin- istration of the potassic iodide—has rarely proved of not- able value. Tumors of the breast, whether benign or malignant, usually increase rapidly in size during pregnancy ; in a few instances malignant growths begin at this time. If mammary cancer is complicated by pregnancy, or origi- nates during it, extirpation of the growth is indicated. Diseases of the Ovoum.—There will be included in this class anomalies of the amnion, the chorion, the decidue, and of the placenta and cord, diseases of the foetus hav- ing been elsewhere considered in this work. Amniotic Adhesions and Bands.—Adhesions between the amnion and the fcetus and amniotic bands are in some instances met with. These were supposed by some observers to result from inflammation of the amnion, amniotitis ; but the hypothesis now most generally ac- cepted is that adhesions are caused by an arrest of devel- opment, and that bands uniting the skin of the fcetus, or, in some instances, floating in the amniotic liquor, either unattached or attached only at one end, result from stretching the adhesions through an increase of Fre. 3097.,—Amniotic Adhesions and Bands. (Charpentier,) the amniotic liquor. Deformities of the foetus may be caused by these anomalies, and, in some instances, am- putation of a limb, or part of it, may be effected by an amniotic band. Polyhydramnios ; Oligohydramnios.—By the former— commonly called hydramnios—is meant excess, and by the latter deficiency, of the amniotic liquor. Whenever the amniotic liquor is in marked excess of two quarts, there is said to be polyhydramnios ; in some instances this excess is between twenty and thirty quarts. The affec- tion is more frequent in multigravide than in primigra- vide—according to McClintock, 23 to 5; more frequent in twin than in single pregnancies, and generally in the former the twins are of the same sex ; and in some cases there is polyhydramnios in one fetal sac, oligo- hydramnios in the other ; in afew instances polyhydram- nios has been found in extra-uterine pregnancy. The disease has been attributed to amniotis, to persist- ence of the vasa propria of Jungbluth, which usually become obliterated in the last months of pregnancy, to great activity of therenal function of the foetus, to trans- udation of serum of the maternal blood through the feetal membranes, and to transudation from the feetal circula- tion. Two forms of polyhydramnios are met with, the one chronic, the other acute ; the former is much the more frequent. In the chronic affection the dropsical accu- mulation takes place slowly, and is, therefore, better tol- erated ; but in the acute disease the accumulation 1s very rapid, and fever is present. Tarnier distinguishes the last form of the affection as primary or secondary ; by 19 Pregnancy. Pregnancy. the latter is meant an acute form grafted upon the chronic. The most striking characteristics of polyhydramnios are the rapid increase in size of the uterus—the organ at five months, for example, being as large as it should be at the end of pregnancy—and the very distinct fluctua- tion. Besides these we have pressure-accidents relating to respiration and circulation, the former becoming diffi- cult, so that the patient must be erect or sitting; and from interference with the latter there may be general cedema, but there always is cedematous swelling of the lower limbs; the uterine walls, both by abdominal and by vaginal examination, are found tense and resisting, and obstetric palpation and auscultation are difficult, or may even yield negative results so far as clearly estab- lishing the diagnosis of pregnancy ; vaginal examination shows the os high up, and a tense, elastic mass, in some cases giving distinct fluctuation, is found blocking up the pelvic inlet ; the neck may be partially or completely effaced. The induction of labor is clearly indicated if the uter- ine distention be so great that the life of the mother is in peril. The obstetrician must remember that there is great liability to post-partum hemorrhage from uterine atony, and must guard against this accident. Oligohydramnios may, according tosome, cause adhe- sions between the fcetus and the amnion, and the subse- quent formation of amniotic bands by stretching these adhesions when the amniotic liquor becomes abundant: a more probable explanation of these conditions has been given. But it seems not doubtful that in those cases in which this fluid is scanty, the foetus cannot have its normal attitude, and undergoes injurious compression from which deformities may result. Diseases of the Chorion.—Cystie Mole, or Hydatidiform Degeneration of the Chorial Vili. 'This is an affection of Fre@. 3098.-—Cystic Mole. (Charpentier. ) the chorial villi, but whether these are primarily or sec- ondarily involved has been a matter of dispute. Hecker asserted that it arose from failure in the development of the allantois, but this view, though strengthened by the absence of blood-vessels in the walls of the vesicles, is not generally accepted. Lesions of the decidua are pres- 20 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. ent, and these in most cases follow the change in the villi; but sometimes, according to Virchow, endometritis pre- cedes the chorial disease, and may contribute to it. The arguments in favor of the maternal origin of the disease are its frequent recurrence in the same woman—thus De- paul reported the case of one patient who thus suffered in three, and Mayer, one who had the disease in eleven pregnancies—and its occurrence in women advanced in years—for example, Schroeder saw it in one woman fifty years of age, and in another fifty-three years of age. On the other hand, instances of twin pregnancy, in which one ovum was diseased and the other healthy, have been observed, and such facts strongly indicate the fetal ori- gin of the malady. The generally accepted view of the nature of this af- fection is that proposed by Virchow, who believes that it arises from a myxomatous degeneration of the chorial villi. The part affected by this change is converted into a vast number of cyst-like formations—there may be five or six thousand ; these vary in size, some being as large as an almond, others as small as, or smaller than, a currant, and still others scarcely visible to the unaided eye. Depaul states that they vary in size from a pin’s head to a pul- let’s egg ; they have pedicles, but these are not attached to a common stem, as is seen in a bunch of white cur- rants, or of grapes, to which their appearance has been compared, but to other vesicles. The semi-fluid substance in the vesicles is similar to that found in Wharton’s jelly ; it is composed of water, albumen, mucine, salts, chloride of sodium, and phosphoric acid (Fig. 3098). If the disease begins before the formation of the pla- centa, the entire chorial tissue will be involved, but if after, the disease is limited to the placenta chiefly, and in some instances to a part of it. The affection is rare, Madame Boivin having met with but one case in 20,375 deliveries. Depaul has presented three important signs of a cystic mole: 1. A more rapid enlargement of the abdomen than is seen in normal pregnancy. In one of his patients the uterus was four fingers’ breadth above the umbilicus at four months. 2. Attacks of uterine hemorrhage. This symptom has occurred as early as the forty-fifth day, and, on the other hand, has been delayed as late as the four- teenth month. Discharges of blood in some cases alternate with discharges of a watery fluid. 3. The expulsion of separate vesicles, or of clusters ; of course this sign is con- clusive. The danger to the woman is exhaustion from repeated hemorrhages, or a single hemorrhage may be so great as to be fatal. The foetus in almost all cases dies. Nevertheless, there are instances in which an ‘‘ hydatid” mass has been expelled, and the pregnancy continued until term, when a healthy child was born. Such cases were probably examples of a twin pregnancy in which myxomatous degeneration affected one ovum, which was discharged, while the other remained healthy. No active treatment is required until hemorrhage oc- curs. If this be slight, rest, cold acid drinks, and an opiate may be sufficient. Even if the disease be proved by the expulsion of the so-called hydatids, it does not follow that the uterus is to be at once emptied. The dominant fact guiding the treatment is hemorrhage. If this persists, if it is grave, and only temporarily restrained by the tampon, the os uteri should be dilated, the uterine cavity emptied, and hemostasis secured by proper means. Destructive Cystic Mole.—Zweifel describes, under the designation Die destruirende Blasenmole, rare cases, of which only three have been observed—one each by Volk- mann, Waldeyer, and Kriger—in which the chorial villi grow so rapidly into the uterine wall that they reach the peritoneal covering, and hence this wall becomes greatly weakened. The difficulty in removing such a growth, the impossibility of making the removal complete, and the liability of causing rupture of the uterus, are obvi- ous ; but without such removal the hemorrhage cannot be arrested. Two of the three cases that have been re- ported died from hemorrhage, and the third from peri- tonitis. Where interference is necessary, Zweifel advises dilatation of the os by a compressed sponge that has been thoroughly disinfected by hot air ; expression of the REFERENCE HANDBOOK OF THE.MEDICAL SCIENCES. uterine contents may be tried, and if this fails, the hand must be introduced into the uterus and the curette then employed, this operation being followed by washing out with antiseptic injections the parts detached. Myxoma of the Membranes of the Ovum. In addition to the ‘‘ partial hyperplasia of the foetal connective tissue in the chorial villi, the cystic mole, Breslau and Eberth have found a similar hyperplasia in the parts of the chorion without villi. This appears in the form of a soft gelatinous thickening of the membranes, and during labor it feels like the scalp distended by serous infiltration” (Zweifel). Fibrous Myxoma of the Placenta. This degen- ~ eration was first described by Virchow, who gave to it the name of fibrous myxoma of the placenta. The growth is composed of mucous and fibrous tissue ; it is vascular, but there are no vesi- cles as in cystic degeneration of the chorial villi. In some cases there is a single large tumor, as in one reported by Storch, in which the mass was five inches and a half long, and three inches and a half broad ; but in other instances there is a large num- ber of small tumors. Decidual Endometritis.—Four varieties of this affection have been described. 1. Diffuse Decidual Endomeiritis. This Wage usually affects only the uterine decidua, de- 0 cidua vera; there is thickening of the mem- brane from proliferation of the decidual cells, and development of the connective tis- sue; it is also as- serted that the sub- jacent muscular fibres may undergo hyperplasia. 2. Polypoid Decid- ual Hndometritis. This is character- ized by thickening of the decidua vera, and polypoid growths, irregular in form, broad- ae and about three-fourths of an inch in height (Fig. 3100). . Breus states that if polypoid endometritis occurs early, the inflammatory process readily extends to the chorial villi, with consequent atrophy of the ovum and _ abor- tion; upon the aborted ovum there will be found the proofs of diffuse and polypoid decidual endometritis. 3. Cystic Decidual Hndometritis. In this form of the disease not only the decidua vera is involved, but also the glands; obstruction of the gland-ducts results from inflammatory swelling, and cysts are formed—in other words, they are retention-cysts. 4. Catarrhal Decidual Endometritis. The characteris- tic evidence of this disease is the discharge from time to time of a watery fluid, known as hydrorrheea gravidarum. This discharge, which may occur as early as the third month, but usually not until the late months, of preg- nancy, is more frequently observed in multigravide than in primigravide ; it is albuminous, generally yellowish, and may contain blood. Many of the cases of supposed rupture of the membranes and discharge of the amniotic liquor days and even weeks before labor, are really in- stances of hydrorrhcea, a discharge of so-called false waters occurring. Slight pains commonly accompany the discharge ; in most cases it is repeated several times. Pre- mature labor rarely follows hydrorrhcea, but its possible occurrence suggests that the patient, especially if there are uterine contractions, should lie down, and decided pain indicates the use of opium either by rectal injection or by the mouth. The causes of decidual endometritis are not well known. In some cases it is apparently the result of syphilis, and in others of violent bodily effort, or of excessive work ; in others it existed prior to the pregnancy, and in still others follows the death of the cetus., Fie. 3099.—Destructive Cystic Mole. Pregnancy, Pregnancy. _ Decidual Hamorrhage.—Extravasation of blood may take place involving all the deciduous membranes; ‘if the extravasate is situated in the serotine membrane it may extend between the reflexa and the chorion, invagi- nating the latter and the amnion into the cavity of the ovum, and the embryo, if not previously dead, dies from compression ;” sometimes even the cavity of the ovum is ruptured and the effusion penetrates into it. If the ovum is not ruptured the amniotic liquor is absorbed after the death of the embryo, and the latter disappears, the ovum containing only the remains of the cord. If expulsion of the ovum occurs soon after the hemorrhage, the mass is composed chiefly of a large clot of blood, and has been called a blood mole. If, however, the ex- pulsion be delayed, the embryo having prematurely es- caped, or having undergone absorption, the effused blood has become more firm, and regressive metamorphoses hav- ing taken place, the mass is known as the fleshy mole. In either case the pregnancy has been called a false or molar pregnancy, and the mass expelled a blighted ovum (Fig. 3101). Placental Apoplexy.—Jacquemin has described three forms of placental hemorrhage. In the first the blood is infiltrated in one or several lobes of the placenta ; in the second it occupies an irregular cavity which presents projections in different directions ; but in the third there are regular and circumscribed cavities, varying in size from a hemp-seed to a ;pigeon’s egg; these effusions are usually multiple, and at first appear as blood-red extrava- sates, but afterward lose their deep hue and become gray- ish-red, or yellowish-white, fibrin-like masses. Accord- ing to Kleinwachter placentitis is the usual cause of these heemorrhages. When the effusions are multiple or large, they may so seriously interfere with the nutrition of the foetus that its death results. Placentitis.—According to Hegar and Maier, inflamma- tion of the placenta may originate as a cell proliferation of the decidual tissue, or from the larger foetal arteries ; it soon terminates in induration ; in some cases it results in strong adhesions between the placenta and the uterus, requiring at labor manual detachment of the former. The Fia. 3100.—Polypoid Decidual Endometritis. (Charpentier. ) formation of pus is, according to Zweifel, exceedingly rare, and can only be ascertained by the help of the microscope. Caleareous and Fatty Degeneration of the Placenta.— The presence of sand-like grains either upon or in the ma- ternal or the foetal portion of the placenta is not uncom- mon; in some cases the calcareous products may present 21 Pregnancy. Presbyopia. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. the form of needles or of scales. The presence of these for- mations is without importance. Fatty degeneration has been described by Barnes ‘‘ as generally partial, invading one or more cotyledons, or part of them, forming in many cases diseased masses im- bedded in comparatively healthy tissue, thus giving evi- dence that it originated during the life of the foetus. In some instances we find, indeed, a living foetus with a placenta in part affected; in others we find the disease more advanced and the foetus dead, but with some healthy placenta, the vessels still containing blood. To the naked eye the fatty placenta may exhibit masses of a yellowish pale color, more solid than the spongy, healthy tissues surrounding them, and easily friable.” Among the con- sequences of fatty degeneration is abortion. Barnes holds that this change may explain some cases of hemorrhage during gestation which are attributed to placenta previa. Tumors of the Placenta.—Cystic and solid tumors of the placenta are sometimes met with; one variety of the latter has been previously mentioned. Klotz has recently (Archiv fur Gyndk., Band xxviii.) described adenoma of the placenta. This tumor originates in the spongy por- tion of the placenta or in the glandular cavities of the serotine decidua. Adenoma of the placenta causes the Fie, 3101.—Hemorrhagic Mole. CS, blood-clots; HK, hemorrhagic cysts. (Charpentier. ) death and the expulsion of the fetus, and this is followed by retention of the placenta, the retention lasting for weeks, and even months. Syphilis of the Placenta.—The following are the micro- scopical appearances of placentz from syphilitic mothers, as given by Zilles in his valuable monograph, Studien aber Hrkrankungen der Placenta und der Nabelschnur be- dingt durch Syphilis (1885): The placenta is of massive development and of great weight, in comparison with the imperfect development of the fetus. The general color of the organ is pale red, but in the diseased portions yellowish-white. Here and there the tissue is firmer, more resistant, compact, and friable than the normal pla- centa. At various points gummatous nodules are found ; they are wedge-shaped, nodulated, fibrous formations, with their bases in the decidua, but they generally grow smaller as they penetrate more deeply into the fcetal pla- centa ; they vary in size, some being as small as a pin’s head, others as large as a walnut; in some instances they occupy circumscribed portions of the entire thickness of the placenta. The gummata upon section show a struct- ure of concentric lamelle ; the external layers are firmer, more like fibrous tissue, and have a grayish-yellow color, while in the centre there is a yellowish-red, or orange-yel- low, cheese-like, soft or fluid material. Scattered through the peripheral zone are nodules of a cloudy orange-yellow color and cheesy in character, about the size of miliary tubercles. If complete degeneration of the central por- tion has occurred, an irregular cavity is present, its walls 22 being formed of fatty, granular débris, and covered with pus-corpuscles. The decidua at the uterine surface is greatly thickened, cloudy, and presents yellowish-white spots. If the fcetus is affected, nodules, similar to those previously described, are found under the amnion. The umbilical cord is firmer than normal, and upon section a remarkable crescent-shaped thickening of the vessels can be seen with the naked eye. There are also seen the characteristic nodules in the tissue of the cord at some distance from the vessels. Anomalies of the Cord.—Cotls of the Cord about the Fatus or its Members. One or more loops or “‘ circulars” may be around the foetus, or one of its members ; the part most frequently thus encircled is the neck, and in one case that has been reported the cord was wound around the neck eight times. This accident occurs more frequently in multigravide than in primigravide, and is oftener found with the male than with the female fetus. In general no injurious result follows such position of the cord, but in some cases the calibre of the umbilical vessels is materially lessened, and death of the foetus ensues. Knots.,—Accumulation of Wharton’s jelly at particular parts of the cord, causing there a notable projection, is known as a false knot. Buta true knot is formed if the foetus passes through a loop in the cord ; such a knot is met with once in two hundred cases ; the knot is in some cases double, and in others, instead of either one single knot or a double knot being present, there are several sin- gle knots. Depaul, for example, saw a case in which there were five. The knots are recent, or old; in the former, which occur during delivery, the diameter of the cord is normal, there is no lessening of Wharton’s jelly ; but in the latter the knot is smaller, Wharton’s jelly being nota- bly lessened. If the knots are contiguous, and are formed during pregnancy, it is possible, according to some au- thorities, that they may be drawn so tightly that the cir- culation is seriously interfered with and the foetus dies ; but ordinarily the circulation is not interrupted from this cause. Torsions.—The umbilical cord normally presents tor- sions, this twisting being, in by far the larger number of cases, from left to right. But there may be an excessive number of these torsions ; Dohrn saw a case in which there were 85, Meckel 95. They have been more frequently ob- served in the case of the male than in that of the female foetus, the proportion being 8 to 5. Spiegelberg de- scribed them as preemortal, and postmortal; the first are usually caused by the movements of the foetus, but the second by those of the mother. Dancing is mentioned by Kormann as a cause of twists in the cord. ‘Torsions are most numerous near the umbilicus, and next in the vicinity of its placental attachment. In some instances division of the cord has followed torsions, the foetus thus being left free in the uterine cavity ; in rare cases occlu- sion of the vessels or great stenosis has been thus caused, and of course in either condition the foetus dies. Stenoses of the Umbilical Vessels.—Narrowing of the vessels of the cord may occur independently of knots or torsions. ‘These stenoses, first observed by Oedmanson and Winckel, and described by Birch-Hirschfeld, are usu- ally found in the vein near the placenta. The latter also found circumscribed stenoses of the arteries in the vicin- ity of the umbilicus, and also near the placenta; he re- gards them as resulting from syphilis. -Spaeth states that atheromatous changes may occur in the arteries. Hyrtl found stenosis of the umbilical vein consequent upon periphlebitis. Theophilus Parvin. PRESBYOPIA (Pr), from mpéoBus, old, and &y, eye, is ‘‘the condition in which, as the result of the increase of years, the range of accommodation is diminished, and the vision of near objects interfered with.”! The range of accommodation diminishes year by year, from about 15 dioptrics (1/23), at the earliest age (ten years) at which accurate observations have been made, to about 1 diop- tric (7s), at the age of sixty-five or seventy ; at forty it amounts to something less than 5 dioptrics (4), and at forty-five to about 3.3 dioptrics (qs).’ Of the 15 dioptrics of accommodation which the child REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. of ten years can bring into exercise, from two-thirds to © three-fourths (10 to 11 dioptrics) may be lost without greatly incommoding an emmetrope in ordinary near vision. In emmetropia the distance (P2) of the binocular near-point ( 2) is the reciprocal of the number of dioptrics of accommodation ; hence, with a binocular range of ac- commodation of 5 dioptrics, Pz = 4 metre (20 centimetres = 8 inches), at which distance the smallest print in ordi- nary use is easily deciphered by eyes of average visual acuteness ; when the range of accommodation is reduced to 4 dioptrics P. = + metre (25 centimetres = 10 inches), at which distance ordinary newspaper print is still easily read ; with the loss of another dioptric of accommoda- tion (leaving but 3 dioptrics available), Pz = 4 metre (83.3 centimetres = 13.12 inches), and the reading of fine print becomes difficult, except under the favorable conditions of good illumination and normal acuteness of vision. These several values of P2 correspond, in emmetropia, to ages ranging from about thirty-eight to about forty-seven years, and few emmetropes attain the latter age without seeking aid from convex glasses in reading or other fine work ; the adoption of convex glasses by an emmetrope under forty, is generally determined either by the exact- ing nature of the work in which he habitually employs his eyes, or by the fact that his acuteness of vision is somewhat below the normal standard. When at the age of from fifty to fifty-five years the range of accommoda- tion-is reduced to 2 dioptrics, P2 = 4 metre (50 centi- metres = 19.68 inches), and the book must be held at arm’s length, at which distance only exceptionally large print can be read; but, even with this range of accom- modation, a public speaker may be able to read fluently from a plainly written manuscript lying before him upon a reading-desk or table. The diminution of the range of accommodation with advancing years is a strictly physiological change, and is directly related to the progressive increase in the hardness of the crystalline lens, in consequence of which it becomes less and less capable of undergoing the change in curvature required for the adjustment of the eye for near vision. As this hardening of the crystalline occurs in all eyes alike, irrespective of their refractive condi- tion, as determined by the relation of the curvature of the refractive surfaces to the length of the axis of the eyeball, it would be scientifically correct to define pres- byopia as the loss of accommodative power incident to advancing years. Immemorial usage has, however, as- sociated the name with the special condition in which, as a result of increasing age, near vision becomes indistinct while distant vision remains either absolutely or rela- tively unimpaired. As thus defined, presbyopia is an incident in the life-history of all emmetropes and. hyper- metropes, and also of myopes whenever the myopia is of low grade—say, 3 dioptrics or less. In myopia of higher grades, say, of 4 dioptrics or more, the distance of the far-point remains within + metre (25 centimetres = 10 inches) of the eyes, which is somewhat less than the usual reading distance for fine print ; so that the charac- teristic disability of presbyopia, namely, the failure of vision for small near objects, is either never developed or only very late in life.* The apparent antagonism be- tween myopia, in which only near objects are seen dis- tinctly, and presbyopia, in which distant objects are seen clearly, while near objects appear confused, was very early recognized,* and, in the absence of any clear con- ception of the nature of the function of accommodation, presbyopia was, for more than two thousand years, re- garded as the opposite condition to myopia. Hyperme- tropia, the true opposite of myopia, remained confounded with presbyopia until the middle of the present century, when the demonstration of the change in the form of the crystalline lens in accommodation by Cramer* and by Helmholtz,° and the masterly analysis of the phenom- ena of accommodation in its relation to the several anomalies of refraction, by Donders,® dispelled the cloud of obscurity in which the whole subject had been so * That is, in connection with the moderate falling off of the refraction which occurs late in life, see p. 24. Pregnancy. Presbyopia. long enveloped, and through which only momentary glimpses of the truth had been previously enjoyed by a few exceptionally acute observers.’ Premonitory signs of presbyopia may ordinarily be detected in emmetropes before the thirty-fifth year; ex- ceptionally fine print, such as No. 1 of Jaeger’s scale, is no longer read with the same perfect fluency as in youth, especially if the illumination is defective. Within the next five years the finer newspaper print loses something in sharpness of definition, and the finest needle-work be- comes difficult, and perhaps deteriorates somewhat in quality. If the acuteness of vision (V—see Optometry) is normal, and the print is not too fine, relief from the consciously increasing effort inaccommodation may be ob- tained by holding the book or work a little farther from the eyes; but if vision is subnormal, or if the print is bad or very fine, a stronger illumination may be demanded without increasing the reading distance. By the age of forty-five the disability has- generally increased to the point that only fairly large print can be read with ease by ordinary artificial light, and a more powerful lamp is procured, or the book is held nearer to the light ; about this time the probable need of help from glasses com- monly suggests itself, and they are, perhaps, tried and adopted. A hypermetrope habitually wearing neutralizing (con- vex) glasses, or a myope wearing neutralizing (concave) glasses, experiences the disabilities of presbyopic vision at about the same age, and in about the same degree, as the emmetrope ; thus, between the ages of forty and forty- five, the hypermetrope discovers that his convex glasses are no longer quite sufficient in reading, and similarly, the myope discovers that his concave glasses have become something of a hinderance in near vision, although, in both cases, the neutralizing (convex. or concave) glasses continue to serve perfectly for distant vision. A change to stronger convex glasses by the hypermetrope, or to weaker concave glasses (or, perhaps, the temporary re- moval of his glasses) by the myope is the remedy which now suggests itself, and which is, sooner or later, adopted. With the change of glasses reading again becomes easy, but with a corresponding falling off in the distinctness of distant vision; for this reason, an elderly ametrope ordinarily requires two pairs of glasses, the one pair (neu- tralizing) for distance, the other pair (stronger convex or weaker concave) for reading and other near work. A hypermetrope, not wearing convex glasses, experi- ences the disabilities of presbyopia at an earlier age than the emmetrope, after having, perhaps, passed through a more or less protracted stage of suffering from asthen- opia (see Asthenopia). In myopia, on the other hand, if of low grade, the reading-power with the unaided eyes is retained to a more advanced age than in emmetropia ; in the higher grades of myopia the reading-power is re- tained indefinitely. As a result of the very gradual increase in the resist- ance which must be overcome in order to effect such de- gree of accommodative adjustment as is still possible in presbyopia, the relation of the accommodation to the convergence undergoes an important change, the binocu- lar accommodation (A.) associated with convergence for the habitual reading distance of from thirty to thirty-five centimetres (12 to 14 inches) becoming at length nearly equal to the absolute accommodation (A) ; in other words, the binocular near-point (p2) comes to coincide very nearly with the absolute near-point (p). With the use of convex glasses in near work, the distance (P2) of the binocular near-point (2) undergoes a rapid increase, so that such reading-power as may have been retained up to the time of the adoption of the glasses is speedily lost, and reading without glasses becomes inpossible. Hence the common experience of presbyopes, that having once formed the habit of using convex glasses, their continued use has become imperative, and this whether the glasses have been adopted somewhat prematurely, or only after the need of them has become urgent. The too early use of convex glasses is, therefore, to be deprecated, as entailing upon the wearer all the disabilities of presbyopia several years, perhaps, before the normal age ; on the other hand, 23 Presbyopia. Prescription. as there is a definite limit to the absolute range of accom- modation at any given age, the use of convex glasses cannot, as a rule, be deferred by an emmetrope much be- yond forty-five, unless he be content to forego the use of the eyes in reading ordinary print, or in other fine work. The total disuse of the accommodation for a consider- able period, especially if occasioned by protracted and exhausting illness, may lead to the premature develop- ment of presbyopic symptoms, which may then be inter- preted as an indication for the immediate adoption of convex glasses. If glasses are used in such a case, they should be of the least power compatible with the use of the eyes under favorable conditions of illumination, and the patient should be encouraged in the hope that, as the accommodative power increases with use, the glasses may be laid aside. In cases of this kind it is often pos- sible to bring the accommodation again into effective use by the instiliation, once or twice daily for a few weeks, of a weak solution of pilocarpine, and thus to put off the use of glasses for perhaps several years. In addition to the impairment of the accommodation, which is the essential characteristic of presbyopia, the refraction undergoes, in the course of time, a slight but positive diminution, so that ultimately an emmetrope be- comes slightly hypermetropic (H acquisita—see Hyper- metropia), a hypermetrope somewhat more hyperme- tropic, and a myope somewhat less myopic; a very low grade of myopia may thus give place to emmetropia, or may even pass through emmetropia to hypermetropia. A low grade of hypermetropia which, sooner or later, necessarily becomes absolute (H adsoluta), is, in fact, the ultimate normal condition of all emmetropes, so that weak convex glasses come to be required for perfect vi- sion at a distance ; hypermetropes similarly require a moderate increase in the power of their convex glasses and myopes require a corresponding diminution in the power of their concave glasses. This falling off in the refraction is ordinarily scarcely to be detected at the age of forty-five ; at sixty it may amount to perhaps 0.5 diop- tric, at seventy or seventy-five to 1 dioptric, and at eighty to 2 dioptrics or more.® The treatment of presbyopia is necessarily confined to the palliation of the actual disability, by the use of such convex glasses aS may suffice to supplement the failing accommodation and also to correct any existing hyper- metropia, whether original or acquired. A person origi- nally emmetropic may, at the age of seventy, require con- vex glasses of as much as 5 dioptrics power (4), in order to read fairly good print at a distance of from ten to twelve inches; and if the acuteness of vision is somewhat below the normal, it may be necessary to use glasses of 6 or 7, or even 8 dioptrics (4 to 4), in order to admit of reading at the shorter distance of from nine to seven inches. In the case of a person originally hypermetropic, the measure of the required glasses will be increased by a quantity equal to the grade of the hypermetropia ; in myopia the measure of the glasses will be similarly diminished. The glasses first given to a presbyopic emmetrope of from forty to forty-five years of age, should ordinarily not much exceed 1 dioptric (say zy or 3), and, in many cases still weaker glasses (say ¢#y or -#s) are quite suffi- cient, and may be more acceptable to the patient than stronger glasses. These glasses should be used for only such work as is performed with difficulty without glasses (reading fine print by artificial light, etc.), in order that the habit of using the accommodation may not be need- lessly or prematurely abandoned,* and they should not be exchanged for stronger glasses so long as they con- tinue to afford the needed assistance. Subsequent changes should always be made with reference to the glasses ac- tually in use, adding perhaps 0.25 or at most 0.5 dioptric at each change, and it is generally advisable to retain the * The proposal to make use of weak convex glasses somewhat before the appearance of marked presbyopic symptoms, for the alleged purpose of preserving and strengthening the sight, is so irrational as to justify the suspicion that it may have originated in the interest of trade; the only apparent foundation for such a practice is the fact that in hyperme- tropia convex glasses are needed at an earlier age than in emmetropia. 24 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. old glasses for a time, for reading in bright daylight, re- serving the stronger glasses for more exacting work. It follows that a presbyope should always know the power of the glasses which he is using, in order that, in replac- ing a lost pair, he may not be reduced to the necessity of selecting new glasses at random, or after a hasty and in- adequate trial, conducted, perhaps, by an ‘‘ optician” whose knowledge is limited to the trick of selling his wares, A presbyope using glasses suited to his condition, is able to use his eyes in near work freely and without fa- tigue; glasses of insufficient strength fall short of afford- ing the full measure of relief, and glasses of excessive strength compel the hoiding of the book too near the face, thus imposing needless work upon the recti-interni muscles, and so possibly giving rise to muscular asthen- opia * (see Asthenopia). The clinical investigation of any case of presbyopia in- volves, first of all, the careful testing of the eyes for ametropia (hypermetropia, myopia, or astigmatism ; see these titles; see also Optometry). As has been already explained, the measure of any hypermetropia that may be detected must be added to, and the measure of any myopia subtracted from, the value of the glasses ordinar- ily required by an emmetrope of corresponding age, in order to arrive at an approximation to the glasses to be given for reading. These tests are best conducted at a range of at least five metres (about sixteen feet), and only after the satisfactory determination of the state of the refraction, should a trial of reading-glasses, based upon this determination, be made. (The final tests are made in reading fine print (such as Nos. 1 to 5 of Jaeger’s test- types). If astigmatism is present, it should, as a rule, be accurately corrected by having one surface of each glass ground to the appropriate cylindrical curvature (see Astig- matism). A rapid increase in the grade of presbyopia, necessitat- ing frequent and considerable additions to the strength of the reading-glasses, should always be regarded as a suspicious symptom, indicating the possible development of glaucoma. Repeated changes from weaker to stronger glasses, but with a shortening of the reading distance after each change, point to a falling off in the acuteness of vision, oftenest from failure in the perceptive power of the ret- ina, or of the conductive power of the optic nerve. A marked diminution in the apparent grade of presby- opia is occasionally observed rather late in life, and is due to the development of a myopic state of the refrac- tion ; this change, which is popularly known as ‘‘ second sight,” is ordinarily a symptom of incipient cataract. John Green. 1 Donders: On the Anomalies of Accommodation and Refraction of the Eye, p. 210. The New Sydenham Society. London, 1864. 2 Donders: Op. cit., p. 20%. 3 Aristotelian Treatise, tpoBAjpmara, xxxi., 25; cf. Paulus Aegineta. 4 Cramer: Tydschrift der Maatsch. vor Geneeskunde, 1851. 5 Helmholtz : Monatsberichte der Akademie der Wissenschaften, Ber- lin, February, 1853. 6 Donders: Archiv fiir Ophthalmologie, vi., 1860. On the Anomalies of Accommodation and Refraction, 1864. 7 Vide Donders: Op. cit., p. 825, note. 8 Tbid., p. 208. ® Scheffler: Die Theorie der Augenfehler und der Brille. Wien, 1868. PRESCRIPTION-WRITING. 's |. &.q|/Amountof basis to be prescribed in order to yield to the ye jw so half fluidounce the several doses of on ot rey =| of glace Se O}a'n =| re: I gé 8 Five Ten Fifteen Twenty o) ee a grains grains, grains. grains, al D. Sin ke Dj. 3 ss. dij. 2 4 dj. dij. 3]: Dv. | 4 8 dij Div. 3 ij. Dvilj. 6 | 12 3}. Bij. | 3 iij. Z ss, 8 16 Div D viij. Z 8s. DXvj 135 15.24 3 ij. Z 88. avi. 3). III. Toe ExpReEssING OF A PRESCRIPTION.—A pre- scription is an order, dated and signed, to the pharmacist to take certain quantities of certain several substances ; to perform upon them certain pharmaceutical operations ; to label the package with certain directions concerning use, and to address it with the name of the patient. Upon this order the author may also have occasion to set down certain injunctions, such as ‘‘not to be renewed,” or, ‘“not to be shown to the patient,” etc. In form, pre- 27 Prescription- Writing. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. scriptions are commonly written after the following para- digm : [Not renewable without authority. ] For Mr, A. B. Take Of substance A, i Of substance B, quantity /. Of substance C, quantity 2, [ete.] Doso-and-so [with them] -.0 4 ses emer stele coe se duabel- [the package]| 7... >. aides cota bids as eee sie [Signed] C. D.. M.D., No. 1 Blank Street. quantity x. [Dated] November 22, 1886. Instead of a written signature, a very common anda very good plan, followed by many practitioners, is to have prescription-blanks printed for their personal use, bear- ing the imprint of name, address, and office-hours. In such case the imprint is commonly at the head of the pa- per. In language, a prescription is commonly written in part in Latin, and in part in the vernacular. In the United States the use of the Latin is commonly confined to such portion of the prescription as has to do with directions to the pharmacist for the compounding and ‘putting up ” of the medicine ; but in many other coun- tries the directions for use are also written in Latin. This latter foreign custom has nothing to commend itself, but, on the contrary, is intrinsically objectionable on the score of opening an unnecessary doorway for the entry of mis- takes. For such directions must, of necessity, finally ap- pear in the vernacular in the label upon the package which is to serve for the patient’s guidance; so that, to write them in the prescription in Latin is to entail their translation back into the vernacular at the hands of the pharmacist for the purpose of transcription, all at the risk of mistakes. Far better is the American custom, whereby the prescriber can—and always ought—set down, in the vernacular, in fullest necessary detatl, the directions for administration, which directions are then simply to be copied, exactly as written, in the labelling of the package. Another, and quite universal, custom is to express by ab- breviation or by symbol, in the pharmaceutical portion of the prescription, what might be called staple words. Thus, in the foregoing paradigm, take is expressed by the symbol ‘‘ BR,” which, originally the astronomical sign ‘* or,” of the planet Jupiter (symbolical of the prayer to the deity Jove which in ancient times headed prescrip- tions), now bears its present peculiar form in order to do duty also as the initial letter of the Latin word 7eczpe, signifying take thou. Next, titles of denominations of weight or measure are expressed by the commonly em- ployed symbols for such denominations, and numeral adjectives by the so-called Roman numerals in the use of the apothecaries’ system of weight or measure ; but by the ordinary Arabic numerals when the prescription is by metric weight or measure, as is practically a necessity for the expression of the related integral and decimal frac- tions by which metric quantities are signified. Next, the word misce, signifying mix thou—the most commonly oc- curring word expressing requirement of pharmaceutical manipulation, is expressed by its initial letter J7, and similarly, and lastly, the word signa, signifying label thou, by its initial letter S. Other commonly employed abbre- viations are ‘‘ aa” for ana, latinized Greek for the phrase of each ; “no.” for numero, signifying to the number of ; ““q. s.” for quantum sufficiat, signifying as much as may be necessary, and ‘‘p. r. nu.” for pro re natd, signifying ac- cording to need. It thus appears that all of the prescription requiring full dress in Latin is comprised in the titles of substances prescribed, and in the directions for the compounding. And for the correct latinizing of such items a critical knowledge of the Latin language, though, of course, of great advantage, is yet not indispensable. For, so far as relates to the expression of medicine-titles, all that is ne- cessary is to know how to set these titles in proper case ; and, as concerns the expression of pharmaceutical direc- tions, it is to be remembered that, in the great majority of instances, the directions for compounding requiring | specification in prescription-writing, are simple and set, so that their Latin phrasing is easily compassed by the 28 knowledge of a few arbitrary words and phrases. Indeed, for all but seldom occurring exceptional directions, the latinizing can be effected by the words and phrases in the following list, properly coupled with the Latin words sig- nifying forms of medicines, presumably already learned. List oF OpD WoRDS AND PHRASES OF COMMON Oc- CURRENCE IN THE EXPRESSION OF PHARMACEUTICAL DIRECTIONS, IN PRESCRIPTIONS.—1. Verbs, in imperative mood ; ‘‘object” to be in the accusative case (analogue of the English objective) : Adde, add. Cola, strain. Divide, divide. Heténde, spread. Solve, dissolve. Fac, make. Tére, rub. 2. Verbs, in subjunctive mood, taking a subject or a predt- cate, nominative : Billiat, \et [it] boil. Firat, let [tt] be made [into]. Fiant, let [them] be made [into]. 3. Verbal adjective (participle) to agree with its noun in gender, number, and case : Dividéndus (masculine) ; —a (feminine) ; —wm (neuter), to be divided. 4. Prepositions: noun following to be in the accusative case : Filtra, filter. Mécera, macerate. Misce, mix. Ad, to; up to. In, into. Supra, upon. 5. Prepositions : noun following to be in the ablative case : Cum, with. Pro, for. 6. Miscellaneous Words and Phrases: Ana, of each. Guttdtim, by drops. Béne, well, Non, not. Bis, twice. Sémel, once. Déin or deinde, thereupon. Simul, together. Et, and. Stdtem, at once. Gradatim, gradually. Ter, thrice. In the instance of a pharmaceutical operation which cannot be expressed in Latin by the application of the foregoing vocabulary, the wise course, even for the Latin scholar, is to forego elegance and write the direction in the vernacular. Otherwise it might chance that the pre- scription overstep the pharmacist’s capacity for transla- tion, to the obvious defeat of the compounding. As regards the rendering, in proper Latin case, of the titles of the ingredient substances of a prescription, the points are as follows: There are, in Latin, six cases in the declension of nouns and adjectives, but of these cases four only are concerned in the latinizing of medicine- titles. These four are, respectively, as follows: The nominative case, corresponding to the English nominative, is the case in which titular words stand in simple state- ment—by which, in short, names are learned. Thus we recognize prepared chalk by the Latin title Creta prepa- rata, Wherein the two words of the title are in the nomi- native case. Next, the genitive case corresponds to the English objective case after the preposition of, and is the case in which titular words most commonly stand in pre- scription-writing. For, in the first place, compound titles, even in simple statement, commonly afford an instance of the genitive, as in the case of the title tincture of opium. Here the phrase of opiwm is rendered in Latin by the word opium set in the genitive case. Then, in the second place, in prescribing, the order for the ‘‘taking” of a given ingredient is, in the enormous majority of instances, a direction for the taking of a specified quantity of the substance in question. A prescription for a phial of laudanum, that is, will read: ‘‘ Take of tincture of opium one-half fluidounce.” In such case the titular word of the preparation itself—in this instance the word tincture —will have to stand in the genitive, since now it, also, follows the preposition of. With the exception, there- fore, of a few conditions when titular words stand, in prescription-expression, in the accusative, the rule is that all titular nouns and adjectives which, in simple state- ment of the title, stand in the noménative, require, in pre- cription-orders, to be set in the genitive. The third Latin case that concerns the prescriber is REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Prescription- Writing. the accusative, the Latin analogue of the English objective following a transitive verb. Titular nouns and adjectives take the accusative under the two following circum- stances: First, when the order is not the common one to take a certain specified measure or weight of the thing, but to take the thing itself in a conditioned entirety. A common instance of this circumstance is where yolk or white of egg is an ingredient of a prescription. Here by the condition of things it is easiest to measure quantity by the natural measure of the egg-substance itself. Hence, in prescribing yolk the order is commonly to take the yolk of one egg, or of two, or of three eggs, as the case may be; in which case the title-word yolk, standing as the direct object of the transitive verb take, requires to be put in the accusative. Another commonly occurring instance where the accusative must appear, is where the prescriber writes for a certain number of a ready-made medicinal © entity, such as pills or troches, of standard composition, and hence of independent title. Thus, to prescribe the pharmacopeeial compound cathartic pill, the simplest wa is to order directly the desired number of the already made pills, which the pharmacist keeps in stock. Such prescription, therefore, reads: ‘‘ Take compound cathar- tic pills to the number of” so many, and so the word for pills, with its dependent adjectives, appearing as the im- mediate object of the verb take, stands in the accusative. The second circumstance determining the setting in the accusative of titular nouns and adjectives occurs, in one form of writing, in cases where the prescription orders that a given substance be taken wp to the attainment of a certain total bulk or weight. This form of order most com- monly obtains in the prescription of fluid mixtures, where it is often convenient to order in specified quantities the necessary amounts, respectively, of basis or adjuvant ; but, as regards the inert vehicle, to simply direct the compounder to ‘‘ take” the vehicle substance until the whole mixture shall attain the measure of the desired bottleful. In such case the order for the vehicle may be phrased in either of two styles—in the one of which the titular words will appear as usual in the genitive, but, in the other, in the accusative. The phrase in the latter style is according to the model, take so-and-so up to |the measure of | so much. Here the title of the substance ‘‘ taken” is the immediate object of the verb take, and therefore stands in the accu- sative ; the phrase up to the measure of being expressed by the preposition ad. The other style of phrasing the order is after this model: Take of so-and-so as much as may be necessary to attain the measure of so much. Here the title of the medicine once more follows the preposition of, and hence appears in the genitive. In the rendering of the order in this style, the Latin phrase quantum sufficiat ad (commonly abbreviated to g. s. ad) is the translation of the English ‘‘as much as may be necessary to attain the measure of.” The fourth and last Latin case that concerns the pre- scriber is the ablative, a case corresponding to the English objective after certain prepositions. The prepositions governing the ablative that occur in prescription-writing are cum, ‘“‘ with,” and pro, ‘‘for.” The former of these occurs in a few titles, as for instance, Hydrargyrum cum Oretdé, mercury with chalk; Hmplastrum Picis cum Cantharide, pitch plaster with cantharides ; and the lat- ter in the much-used phrase pro re natd, ‘‘ according to need.” But as regards the ablative, the special point ob- tains that the circumstances of prescription-phrasing never require the rendering in the ablative of a title-word which in the title appears in a different case. The few instances of the ablative in medicine-titles are therefore fixed, and the ablatives so occurring are easily learned by rote. The expression of case is, in Latin, effected by modifi- cation of the ending of the word itself which is to be de- clined, and in such modification, adjectives share as well as nouns. Different modifications are employed to sig- nify case in the singular and plural number, respectively, and of such modifications there are, in ordinary, five dis- tinct systems, constituting the five several declensions of nouns and adjectives, besides cases of irregular declension presented by certain pronouns and cardinal numerals, Of the five systematic declensions, one, the fifth, affords but a single example in prescription-Latin, namely, the ablative re of the noun ves in the oft-quoted phrase pro re natdé. Of the other four declensions, examples occur in prescription-writing, of the nominative, genitive, accu- sative and ablative cases, respectively, in the singular number, and of the nominative, genitive, and accusative in the plural. The following table shows the endings for the several cases so enumerated, so far as concerns nouns and adjectives embraced in the prescriber’s vocabulary. Endings for nouns not in such vocabulary are purposely omitted, as are also the irregular declensions of pronouns, In the table the italicised letters m., f., and 7., signify re- spectively, that the case-endings in the columns beneath are those of nouns or adjectives of the masculine, femi- nine, or neuter gender ; for, as appears in the table, case- endings often differ, even in the same declension, accord- ing to the gender of the word. The endings of the first and second declensions, severally, which appear in pa- renthesis, are the endings of certain Greek nouns, adopted into Latin with something of the Greek form retained. The table also gives a list of words of foreign origin ap- plied as drug-titles, which, following the Latin idiom in such case, make no change of ending to signify case—are, in short, éndeclinable. TABLE OF PARTS OF LATIN DECLENSIONS SO FAR AS HXEMPLIFIED BY WorRDS USED IN PRESCRIPTION-WRITING. 1. Regular Declensions of Nouns and Adjectives. 8 of d g 23 ae ee £3 AG 8 § 5 33 ag 29 Hs = 9 ® No ) Fs A = A a Us m.* nN, m. and f. nN. m.t SINGULAR : Nominative .. |-a _(-e) | -us (-os) -um (-on) |(various) (various)} -us Genitive ...... -2e (-eS) -i -is -fis Accusative....| -am (-en) -um (-on) -em (like nom.) | -um Ablative 2)... -a | -O -e PLURAL : Nominative ...| -2 -i -a | -es -a | -us Genitive ...... -arum | -orum -um, -ium -uum Accusative ....| -as -O8 -a | -es -a | -us (Fifth Declension exemplified only in ablative singular re in phrase pro re nati.) * Except juniperus, prunus, sambucus, and ulmus, feminine. + Except cornus and quercus, feminine. 2. Declension of Cardinal Numerals. | Unus, One. Duo, Two. Tres, Three. m. JS. n. | M. if m.|m.andf. n. Nominative. . | un-us -a -um | du-o -22 -o | tr -es ia Genitive .... -ius -orum -arum -orum -ium Accusative...) -um -am -um|— -0os -as -O -eS -ia | All other cardinal numerals are indeclinable. INDECLINABLE DRUG-TITLES—@il neuter. Amyl, Coca, Kino, Azederach, Curare, Matico, Buchu, Elixir, Sago, Cajuputi, Jaborandi, Sassafras, Catechu, Kamala, Sumbul. As appears at a glance from the foregoing table, in the case of any noun or adjective belonging to either of the three declensions numbered as first, second, and fourth, respectively, if the nominative be given, any other case can be at once formed by substituting the proper case- ending for that of the nominative. In words of the third declension, however, this possibility in very many cases does not obtain. For in this declension the nominative often stands apart from the other cases in the way of having the very root, or ‘‘stem,” of the word curtailed or modified in its construction. Thus, the stem anthemid-, giving genitive anthemidis, accusative anthemidem, and ablative anthemide, gives nominative anthemis—a word in which the full stem does not appear. Similarly, the root flor-, giving genitive floris, etc., gives nominative flos ; and root rho-, giving genitive rhois, offers the much modified nominative form rhus. Hence, for the proper 29 Prescription. Pro-Amnion. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. rendering in oblique case of nouns or adjectives of the third declension, it becomes necessary to learn arbitrarily the form of some one of the oblique cases—most. con- veniently the genitive—as well as that of the nominative. A special point concerned in the expression of case ob- tains in the case of adjectives, to the effect that very many of these words form their case-endings after different ones of the declension-models, according to the gender of the noun to which the adjective is attached. In compound drug-titles, therefore, which include an ad- jective, the gender of the noun modified by the adjective becomes necessary to know for the ¢éntelligent, proper rendering of the adjective’s case-ending. Of course, such knowledge is not essential, since the title, adjective and all, can be learned by rote, and then, remembering the nominative form of the adjective, the necessary change to genitive or accusative, to suit the requirement of the prescription-phrase, can be done by rule. But it saves a vast amount of unnecessary memorizing to understand the system, so far as system goes, by which genders of Latin nouns are determined. Reverting, then, to the above declension-table, it appears that all prescription- occurring nouns of the first declension are feminine in gender ; all those of the second declension ending in -wm, or -on, are neuter, and, with a few exceptions, all of the second declension ending in -us, or -os, and all of the fourth declension ending in -ws, are masculine. The exceptions in the two latter instances are nouns in -ws, representing ancient Latin tree-names, which, because of the ancient Latin conception of an inherent feminity in trees as things, take the feminine gender in spite of their etymo- logically masculine nominative ending. In the third declension all genders appear, and, although in nouns of certain nominative-endings the ending carries with it the gender, yet in the case of many other nouns this is not so, and genders must be learned arbitrarily. Happily, however, the number of nouns of the third declension, among drug-titles, which bear an associated adjective, are quite few. From the above analysis it is evident that, in the case of a given nown in the nominative, the rendering of the same in an oblique case can proceed by rule according to the foregoing declension-table, if only the declension of the noun be known ; with the further item, in the instance of a noun of the third declension, that some one oblique case, aS well as the nominative, be known, for the afford- ing of the full stem of the word. Similarly, the proper case-dress of any given adjective can be fixed if the scheme of declension of the adjective itself be known, on the one hand, and, on the other, the gender of the noun to which the adjective is to be affixed—adjectives requiring to agree with their respective nouns in gender, number, and case. This requisite information concerning nouns and adjectives of prescription-use is afforded in the two following tables—the one giving a key to the declensions of nouns, with genders, and also, in the case of nouns of the third declension, genitive endings—and the other showing the schemes of declension of adjectives. TABLE SHOWING DECLENSION AND GENDER OF NOUNS OCCURRING IN TITLES OF U. S. PHARMACOPGIAL MEDICINES AND IN COMMON PRE- SCRIPTION-TERMS, Nominaiive singular ending in -a: All First Declension and Feminine, except (of Greek origin) the fol- lowing in —ma-: : Physosti/gma (physostig’/matis), 8d, | E’nema (ene’matis), 3d, 7. n, Catapla/sma (catapla/smatis), 3d, n. [Aspidospe/rma (aspidospe/rmatis), | Gargari/sma (gargari/smatis), 3d, 3d, n.] nN. Nominative Singular ending in =e: All First Declension, Feminine (Greek nouns). [N.B.—Nouns in-e of Third Declension do not occur in prescription- writing. | Nominative Singular ending in -us: All Second Declension, Masculine, except— Juniperus, 2d, Fru/ctus, 4th, m. . Pru/nus, ‘ Spiritus, ‘ Sambu/cus, ‘‘ Co/rnus, 4th, f. U’Imus, = Que’rcus, ‘* Rhus (rho/is), 3d, f. (‘‘ rhus gla- bra”). 30 Nominative Singular ending in -os: Comprise only the following — Prinos, 2d, m. Bos (bo/vis), 3d, m. or f. Flos (flo/ris), 3d, m. Nominative Singular ending in -um: All Second Declension, Neuter. Nominative Singular ending in -on: Comprise only the following— Eri/geron (erigero/ntis), 3d, 7. Li/mon (limo/nis), 3d, m. Erythro/xylon, 2d, 7. Heemato/xylon, ‘‘ Toxicode’ndron, ‘ Nouns of ali other endings are of Third Declension, and are as follows: Ending in -c: Lac (la/ctis), 2. Ending in -1: (-al) (-ol) Chlo/ral (chlora/lis), Alcohol (alcoho/lis), 7. (-él) Thy’mol (thymo/lis), 72. Fel (fe/llis), 7. Mel (me’llis), 2. [V.B.—Some authorities regara these nouns in -ol as indeclinable. | Ending in -en: Alu/men (alu/minis), 7. | Se’men (se/minis), 7. Ending in -0o: Noy Male) ey (-ago) Confe/ctio (confectio/nis), f. Mucila’go (mucila/ginis), f. Emu/Isio (emulsio/nis), /. Ustila’go (ustila/ginis), Lo/tio (lotio‘nis), 7. (-bo and —po) Po/rtio (portio/nis), /. Ca/rbo (carbo/nis), 772. Tritura/tio (trituratio’nis), f. Pe’po (pepo/nis), 7. Sa/po (sapo/nis), 2. Einding in -Y: -er) (-or) fii/ther (e/theris), m. Li/quor (li’quoris), m. Pi’per (pi’peris), 7. (-ur) Zi/ngiber (zingi/beris), 7. | Su/Iphur (su/lphuris), 22. Ending in -s: (-és, genitive —eris) Pu/lvis (pu/lveris), m. (-és, genitive —is) Ca/nnabis (ca/nnabis), f. Digita/lis (digita/lis), /. Hydra/stis (hydra/stis), / Sina/pis (sina/pis), f. (-as, genitive -atis) Ace/tas (aceta/tis), m. [and all salt-names in —as.] (-as, genitive —adis) Ascle/pias (asclepi/adis), /. (-is, genitive -ztis) A/rsenis (arseni‘tis), 7. [and all salt-names in -is.] (-08, see ante.) : a ees. (-us, see ante.) (-is, genitive —idis) A/nthemis (anthe’midis), 7. Ca/ntharis (cantha/ridis), /. Colocy/nthis (colocy/nthidis), /. —ps Hamame’lis (hamame‘lidis), /. A/deps (a/dipis), m. l’ris (i/ridis), /. (-7rs) Ma/cis (ma/cidis), f. Pars (pa/rtis), f. Ending in -X: (-ax) (-ée) Bo/rax (bora/cis), ™. Pix (pi/cis), 7. Sty’/rax (styra/cis), m, Ra/dix (radi/cis), f. (-ex) Sa/lix (sa/licis), f. Co/rtex (co’rticis), m. and /. (-uz) Ru/mex (ru/micis), /. Nux (nu‘cis), /. —lax Calx (ca/Icis), f. (ns) Ju’glans (jugla/ndis), f. TABLE SHOWING SCHEMES OF DECLENSION AND GENDER OF ADJEC- TIVES OCCURRING IN U. S. PHARMACOPG@IAL MEDICINAL TITLES AND IN PRESCRIPTION-PHRASES. ScHEME, I.—Second and First Declensions Combined. Feminine. Neuter. -a@ [1st dec.] —wm (-o7) [2d dec.} ScHEME II.—Tzrird Decilension, Masculine and Feminine. -is (genitive —is). ScHEME III.—Third Declension, Masculine and Feminine. -ior (genitive -ioris). Masculine. —us [2d dec.] Neuter, -é (genitive —is), Neuter. -ius (genitive —ioris), ScHEME I1V.—Third Decilension. All Genders. -ens (genitive singular —e7tis) ; (genitive plural -entizm). -or (genitive -oris). In commentary upon the declension-schemes of adjec- tives set forth in the foregoing table, it may be stated that Scheme I. embraces by far the greater number of adjec- tives. In this scheme the neuter ending -on, borrowed from the Greek like the same ending among nouns of the second declension, finds among drug-titles but a single example, diachylon. Scheme II. embraces a few adjec- REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. tives only among those occurring in medicine-titles, and affords an example of the nominative-ending -e of the third declension, which does not occur among nouns of pharmacopeeial titles. Scheme III. is a special scheme for the declension of the comparative of adjectives, and affords but a single example from among the adjectives of medicine-titles, namely, the adjective fortior, fortius, “stronger.” Of Scheme IV. pharmacopceial adjectives give but two examples in -ens, namely, effervescens and recens, and but one in -or, namely, tricolor. A survey of the genders marked on the table shows that in every case a distinctive gender, where there is such, can be told from the adjective nominative ending, with the exception that, among adjective nominatives in -uws, one, fortius, is of the third declension neuter, and belonging to the third scheme, whereas all other adjectives of this nominative are of the second declension masculine, and belong to the first scheme. A final point, concerning the expression of a prescrip- tion, is that, having regard to the fact that a slip of the pen on the part of the writer, or a slip of the understanding on the part of the pharmacist-reader of a prescription, may convert what was meant as a missive of mercy into a death-warrant, it most solemnly behooves the prescriber to execute his task deliberately, thoughtfully, and, in chir- ography, legibly, abjuring all dangerous cloak-of-ignorance abbreviation: of medicine-titles ; and, finally, to fail not of that trusty safeguard against error, a review of the paper after the writing. Hdward Curtis. - PRIAPISM. The term priapism is usually understood to signify an unnaturally prolonged erection. The erec- tion may be imperfect, or may even exceed the normal state, and is usually unaccompanied by sexual desire. It can hardly be considered as a distinct disease, but is prob- ably always symptomatic of some abnormal local condi- tion, or of some nervous derangement. A few cases have been reported in which it has followed violent or exces- sive coitus. A case was reported by Mr. Callaway! in 1824. The man was forty-four years of age, and while intoxicated had connection. Priapism continued for six- teen days, when Mr. Callaway ‘‘ made an incision into the left crus penis below the scrotum, and a large quantity of dark grumous blood with small coagula escaped,” and in a few days the man returned to work. Mr. Luke? re- ported a case in which priapism came on after repeated connection, and lasted for about four months. It occurs in connection with inflammations, new-growths, and trau- matisms of the genito-urinary apparatus. Neumann? re- ports a case of carcinoma of the posterior and inferior wall of the bladder, with perforation of the bladder-wall and peritonitis, in which priapism was present for thirty- one days. The disease had invaded the vesicule semi- nales, the vas deferens, and the left ureter. It had com- pressed the vessels and caused inflammation of the corpora cavernosa. In gonorrheeal inflammation of the vesicule erections are frequent and may amount to priapism. In a case at the Boston City Hospital, rupture of the urethra and corpora cavernosa followed a fall upon the perineum. External urethrotomy was done, and an un- successful attempt made to unite the corpora by suture of the fibrous sheath. Partial priapism was present dur- ing the latter portion of the case, but finally disappeared. Priapism occurs in a certain proportion of cases of acute poisoning from cantharides. Priapism is a not uncommon symptom in acute mye- litis. Generally the erection is incomplete, but it often persists for days with slight variations in degree. In- juries of the spine and cord are liable to be followed by continued or recurrent priapism, or by turgescence with- out rigidity. In eighty-two cases of fracture of the spine tabulated from the records of the Boston City Hospital, priapism occurred in eighteen. It is most common in connection with crushing of the cervical portion, rarer with that of the dorsal, and, according to Erb,® never oc- curs with fracture from the third lumbar vertebra down- ward. Priapism has been noted in some cases of tumor or Preseription. Pro-Amnion, other disease of the cerebellum and pons varolii, and is said to occur frequently in hydrophobia and tetanus. The treatment must be directed mainly toward the condition of which priapism is but a symptom, but the patient’s comfort may often be greatly increased by local applications of cold water or evaporating lotions, or by the local use of opium. Suppositories or cold rectal in- jections may give some relief. Internally the bromides are most likely to be of service. Abner Post. 1 London Medical Repository, 1824, p. 286. 2 Lancet, July, 1845. 3 Wien. Med. Jahrb., Heft ii., S. 148, 1883. 4 Burrell: Transactions of the Mass. Medical Society, 1887. 5 Ziemssen’s Cyclopeedia, xiii., p. 313, PRO-AMNION. ‘This convenient term was introduced by Ed. van Beneden to designate that part of the area embryonalis at the sides and in front of the head of the developing embryo, which remains without mesoderm for a considerable period, so that the ectoderm and ento- derm are brought in the region of the pro-amnion into immediate contact. As found in one stage of the rabbit, it has already been figured in this work, vol. ii., p. 308. A later stage in the rabbit, as seen in longitudinal section, is figured by Kélliker in his ‘‘Grundriss d. Entwickelungs- ges.,” 2 Aufl., p. 107. Wefind that it had been observed in the chick by Remak, His, and Kolliker. Strahl -was the first to direct special attention to it. It has since been observed by various writers; van Beneden and Julin have described it in the rabbit, Heape in the mole, and recently its exact history has been admirably worked out in the chick by Ravn. The pro-amnion, then, has been observed in representatives of the classes Reptilia, Aves, and Mammalia; hence, we may conclude that it is common to all Amniota. It will be remembered that the mesoderm grows out in all directions from the blastopore, or hinder end of the primitive streak. In a chick of twenty-seven hours, the front edge of the me- soderm is a somewhat irregular transverse line, which crosses the germinal area about at the front border of the head. This line is well shown in His’s drawings, loc. cit., Pl., xii., Fig. 14. As the mesoderm expands, it does not grow forward in the median line, but does grow for- ward at the sides of the area pellucida in front of the head of the embryo. A space is thus enclosed between the mesoderm on each side ; this space later becomes the pro- amnion ; it contains no mesoderm. Later on, the lateral portions of the mesoderm approach the median line again, some distance in front of the head, so that now the pro- amniotic area is completely surrounded by mesoderm. We see, as the next phase of development, the head amni- otic fold arising in such a position that the pro-amnion is embraced between the arc of this fold and the head of the embryo; the pro-amnion, therefore, constitutes the floor of the pit formed by the upgrowth of the head am- nion. In the chick the pro-amnion never acquires any considerable development, but gradually disappears by encroachments of the mesoderm upon all sides, as has been well described by Ravn, whose Fig. 3, loc. cit., Pl. xxi., will serve to give a clear general notion of the rela- tion of the pro-amnion to the head, and to the true amnion in the chick. The disappearance of the pro-amnion in the chick involves some curious appearances in sections of embryos, which have not been understood hitherto, but which Ravn has correctly and fully elucidated, so far as I can judge. In the rabbit, according to van Beneden and Julin, whose observations have been confirmed to a certain ex- tent by Kélliker and Heape, the réle of the pro-amnion is more considerable. The history of the pro-amnion, as given by van Beneden, may be followed easily by the aid of the accompanying diagrams (Fig. 3102), copied from van Beneden. In A, the pro-amnion, pro.A, is very small, and the allantois, Al, is just growing out. In B, the embryo, which for greater clearness has been shaded with stippling, has grown very much, and the anterior half of its body is bent down at a sharp angle into the yolk-sac. The embryo, however, remains separated from the cavity Y, of the yolk-sac, by the pro-amnion, which forms as it were a hood, pro,A, over the anterior 31 Pro-Amnion. [ses. Professional Neuro- extremity of the embryo. The amnion proper is as yet developed only over the posterior end of theembryo. For the further history of the amnion see Amnion, vol. i. of Reilly i) Neesassayu a THTOTTTHMSHNHHETINEY 2 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. the rabbit—a point just mentioned. It is unlikely that man forms an exception to a rule of such wide applica- tion, in regard to an organ phylogenetically so ancient. y ; Ec, Fie. 3102.—Diagram of the Development of the Foetal Adnexa in the Rabbit. (After van Beneden and Julin.) A, B, C, D, successive stages ; pro.A, pro-amnion ; Av, area vasculosa ; Coe, ceelom; Coe’, Coe’, extra-embryonic portion of the celom ; Hn, entodermic cavity of the embryo; Hnt, ex- tra-embryonic entoderm; Hc, ectoderm; Mes, mesoderm; Api, area placentalis; Al, allantois; 7, terminal sinus of the area vasculosa; Y, yolk- sac; am, amnion; am’, portion of the amnion united with the wall of the allantois; Ch, chorion. this HANDBOOK. The pro-amnion, as can be seen in C and D, retains its importance as a foetal covering for a considerable period, during which the amnion am, and allantois Ad, are rapidly pursuing their development. After the stage shown in Fig. 3102, D, by the expansion of the cavity marked Coe’, the amnion proper, am, en- croaches more and more upon the pro-amnion, pro. A, until at last the embryo is entirely covered by the true amnion, and the pro-amnion is altogether lost. It is to be noted especially that the amnion develops principally over the posterior end of the embryo, and grows forward. To this fact reference will be made again directly. We possess no observations at present, as to the exist- ence of a pro-amnion in man, but from what we know of the early stages, we may conclude that it disappears quite soon after its origin ; for we may assume that it occurs in man, since it has been demonstrated in all classes of am- niota. This deduction renders it improbable to my mind that His’s hypothesis of the formation of the human amnion is quite correct. We see, in fact, that in the amniota generally the principal growth of the amnion is from the allantois or allantois stock, when the allantois is rudimentary. This growth extends far forward, as in 32 It is a well-known rule that the older an organ in the evolutionary series, the less does its mode of development vary in any essential respect from species to species. LITERATURE. Beneden, E. v.: Recherches sur la formation des annexes foetales chez les mammiféres (Lapin et Cheiroptéres), Arch. biol., v., 869-434, 5 Pls., 1884. Heape, Walter: Quart, Journ. Micr, Sci., xxvii., 123-163. His, Wilhelm: Untersuchungen ber die erste Anlage des Wirbel- thieres. Die erste Entwickelung des Hiilmchens im Hi. 4to, pp. 237, Tafn. 12. Leipzig, 1868. K6lliker, Albert: Grundriss der Entwickelungsgeschichte des Men- schen und der hdheren Tiere. Zweite Auflage, S8Svo, pp. viii., 454. Leipzig, 1884. For pro-amnion, see p. 107. Strah], H.: Ueber Entwickelungsvorginge am Vorderende des Em- bryo von Lacerta agilis, Arch, f, Anat. Physiol., Anat. Abth., pp. 41-88, Tafn. iii.—iv., 1884. Ravn, Edward: Ueber die mesodermfreie Stelle in der Keimscheibe des Huhnerembryo, Arch. f, Anat. Physiol., Anat. Abth., 1886; 412-421, Charles Sedgwick Minot. PROFESSIONAL NEUROSES. Synonyms.—Beschaf- tigungsneurosen, Professional Dyskinesize, Nevrose co- ordinatrice professionnelle, Anapeiratic Paralysis, Neural Disorders of Writers and Artisans. DEFINITION.—Under the term professional neuroses is REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. bropmnion. included a class of spasmodic and co-ordinative disturb- ances mainly of functional origin, affecting the groups of muscles used in special kinds of muscular work. While spasm and co-ordinative disturbance are the main and typical features, paresis, sensory disturbances, vaso-motor phenomena, and general nervous symptoms are also present. Forms.—Every class of work, or form of occupation, which calls for continual use of the same groups of mus- cles, furnishes examples of professional neuroses. The upper extremities are, however, naturally the parts chiefly affected. Those professions in which the smaller and more delicately adjusted muscular groups are brought into play, furnish the largest contingent. The list of names for the various forms of professional neuroses increases almost every year, and now includes: Writers’ cramp ; telegraphers’ cramp; milkers’ cramp ; musicians’ cramp, including pianists’, violinists’, flutists’, and elocutionists’ cramp ; tailors’ and seamstresses’ cramp ; blacksmiths’ and carpenters’ cramp, or hammer-cramp; dancers’ cramp ; photographers’ cramp; watchmakers’ cramp ; cigarmak- ers’ cramp ; auctioneers’ cramp ; Swimmers’ cramp ; saw- yers’ cramp. History.—We hear nothing of any of these now nu- merous neuroses until about fifty years ago. Dr. Bern. Ramazini, who in 1746 wrote a work on the diseases of tradesmen, does not describe writers’ cramp, although he speaks of the diseases which come from the sedentary life of the clerk. Ramazini says, that the causes of the ““morbt scriborum” are ‘‘continua sessio, manus perpetua et eodem semper tenore motio, mentis attentio ne libros erroribus conspurcent.”” He cites only one case, that of paresis of the arm, which at all suggests writers’ cramp. ‘The disease, therefore, is undoubtedly a product of the present century. The idea that the Emperor Augustus had writers’ cramp is based merely on a single sentence in Suetonius. The first to refer to the disease was Sir Charles Bell, who gives a brief account of a case of writers’ cramp in his work on the nerves, published in 1830. A year later, a case was reported in Germany by Brick, and at about the same time one by Gierl. In the next four years, a number of German writers reported their observations of the disease. Cazenave, in 1835, was the first French writer upon the subject. In this country Weir Mitchell, Beard, Hammond, and Lewis have writ- ten specially upon it. In the past fifteen years the liter- ature of professional neuroses has been continually en- riched by the contributions of writers from various countries. WRITERS’ Cramp (Syn.: Scriveners’ palsy, mogo- graphia, graphospasm, steel-pen palsy, chorea scrip- torum). Etiology.—As the disease is one of this century, it is most probable that the influences of our present civil- ization, by increasing the neuropathic constitution, furnish a larger material for writers’ cramp. Fora neuropathic history is present in many cases, and all writers, except Beard, agree that it is this class which is peculiarly liable to the disorder. A history of some family nervous affection, such as chorea, epilepsy, or insanity, is obtained in a minor proportion of cases. On the other hand, it is strikingly true that some victims of writers’ cramp are strong and robust in every way. The explanation here is that such persons overwork themselves to a degree ex- ceeding that which nervous and delicate persons can do. Those who write a beautiful hand are more liable to the affection than poor writers, for the reason, chiefly, that poor writers get no position in which they can overuse their writing-muscles. The introduction of steel pens (1820 to 1830) corresponds with the appearance of writers’ cramp, and there is no doubt that the use of steel pens tends to favor this disease, owing doubtless to the rough- ness of the end. Besides this, steel pen-holders continu- ally carry away heat from the fingers, thus tending to lower vitality, and are difficult to grasp firmly. Writers soon learn that wooden, rubber, or cork holders are safer. The introduction of stylographic pens, and espe- cially of type-writers, may lessen the relative amount of writers’ cramp, just as steel pens at one time increased it. Vou. VI.—3 (ses. Professional Neuro=«= Americans ought, theoretically, to be very subject to writers’ cramp. So far as I can learn, however, this is not the case, and, in my opinion, in New York City the disease is a somewhat rare one. Men are much more subject to the disease than wom- en, though the difference is not so great now as formerly, owing to the greater number of women employed in writ- ing. Among thirty-one cases of typical writers’ cramp ob- served by Poore, all were men. Women are more liable to have impairment of the writing-arm from pains and paresis, without having the true professional dyskinesis. The average age in cases collected and observed by Lewis was twenty-seven (26.96) years. Among 64 cases of Berger’s, 24, or nearly one-half, occurred between the ages of twenty and thirty, 12 between thirty and forty, 16 between forty and fifty, 7 between fifty and sixty, 5 between sixty and seventy. On the other hand, Dr. J. Russell Reynolds’s cases were all over thirty, and Dr. Hammond’s cases all over forty. The cases which I have seen have all been a little over thirty. The disease occurs, therefore, very rarely before twenty, and most often at about the age of thirty. The use of alcohol or tobacco in excess, onanism, and other sexual excesses, emotional disturbances, and wor- ry, all predispose to the disease. ; The exciting cause is the abuse of writing. In ordi- nary writing about four motions of flexure, extension, and lateral movement are made for each word. Calculating at the rate of five letters for a word, and twenty words per minute as the rate of writing, this would be two hundred and forty-five thousand muscular contractions in a working day of eight hours. When the speed is increased, and the hours of work lengthened, under the pressure of a desire to earn more or to complete a task, it is easy to understand how the nerve-cells may become exhausted, or refuse to work together. Persons who do copying or routine work are much more liable to the af- fection, but it is largely because they abuse their writing- powers. Persons who write as they compose—authors, literary men, clergymen—are not so subject to the trouble, because they necessarily rest more in their work. Brain-workers are, therefore, as a rule, exempt from writers’ cramp. Berger and Erlenmeyer seem to think that the ‘‘ Amer- ican method” of writing specially tends to produce cramp. Thecontrary is, [ think, true. In the American, or free-hand, mode of writing, as taught in most of our schools, the wrist does not touch the paper, and the hand is just supported by the little finger, the motion being made largely by the whole arm. Debilitating disease may lead to a development of writers’ cramp. Weir Mitchell reports two cases occur- ring in patients who had albuminuria. The symptoms were relieved when the albuminuria was treated. Lead poisoning (Berger), exposure to cold and rheumatic influ- ences, injuries of the arm, tight sleeves, ingrowing nails, the pressure of a sleeve-button on the ulnar nerve, have all been mentioned as exciting causes of the affection. Pathological Anatomy.—Neuritis is undoubtedly present in some forms of writers’ cramp, so-called. It is not present, however, so far as external tests go, in the typical neurosis. Nor are there any post-mortem obser- vations throwing light on the anatomy of the disease. Pathology.— We must believe, therefore, that it is a neurosis, having no appreciable anatomical basis. The act of writing ‘is a very complicated one, calling into play numerous sets of delicately innervated muscles. These muscles are employed: 1, in pen-prehension ; 2, in pen-movement ; 3, in holding the arm and wrist tense. 1. The muscles employed in pen-prehension are the two outer lumbricales, two outer interossei, the adductor muscles of the thumb, the flexor longus pollicis ; to some extent the deep and superficial, short and long flexors, and the extensors of the thumb. These are supplied mostly by the ulnar (interossei, adductor pollicis, inner heads of deep flexor of fingers, and inner head of short flexor of thumb). The rest of the muscles are supplied 33 Professional Neuroses, by the median. (I cannot understand Poore’s state- ment, that the muscles of pen-prehension are innervated by the median and musculo-spiral.) The spinal centre for these muscles, 7.¢., for the intrinsic muscles of the hand, and for the extensors of the thumb and flexors of the fingers, is situated at the level of the eighth cervical and first dorsal nerves, and the cell-groups are probably the anterior and median. 2. In moving the pen, if the writing is done mainly by finger, and not by arm, movements, the muscles brought into play, according to Poore, are the flexor longus pollicis, extensor secundi internodii pollicis, flexor profundus digitorum, extensor communis digitorum, and to some extent the interossei. The musculo-spiral and. ulnar nerves innervate these groups about equally. In moving the pen by the ‘‘ American” or free-hand method, there is a very slight play of the above muscles, while most of the pen movement is done by the muscles of the upper arm and shoulder, viz., the teres major, pectorales, latissimus dorsi, biceps, and triceps. The spinal centres for these muscles are distributed along the fifth, sixth, and seventh cervical segments of the cord. The cells are larger, and situated more super- ficially, in the anterior gray horns. 3. Besides these movements involved in pen-prehen- sion, and in the letter-making, a certain amount of muscular tension is exercised in ‘‘ poising”’ the forearm and hand and steadying the wrist. The biceps and tri- ceps, the supinators and the flexors, and extensors of the hand are here brought into play. From the foregoing it will be seen that the muscles of pen-prehension are most used in all but the free-hand style of writing, since the same groups have a double duty, that of clasping and of moving the instrument. That this prehension group is oftenest affected is shown by the following table, compiled by Poore from a study of thirty-two cases of undoubted writers’ cramp. He found the muscles affected in the following proportions : Interossei (supplied by the ulnar), 18 times; extensors of thumb (supplied by musculo-spiral), 10 times; flexor brevis pollicis (Supplied by median and ulnar), 7 times ; abductor pollicis (supplied by median), 7 times; flexor longus pollicis (supplied by median), 4 times ; adductor pollicis (supplied by ulnar), 3 times; opponens pollicis (supplied by median), 2 times ; all the muscles of fore- arm, more or less, 2 times. While writers’ cramp is often complicated with some neurotic disturbance leading to associated symptoms of pain, paralysis, tenderness over nerves, vaso-motor dis- turbances, etc., there can be no doubt that the lesion in typicai cases is central. Writing is an acquired auto- matic movement, and it must have as its anatomical basis a certain established arrangement of nerve-cell groups in the cervical part of the spinal cord. ‘The nerve impulses generated in the cerebral cortex pass along the pyramidal tracts and set at work those ganglion groups which, in turn, innervate the muscles used in writing with motor impulses. These groups are themselves innervated also sensorially by the nerves of muscle-sense in movement. In writers’ cramp the spinal groups of cells are more or less used up or exhausted, and the motor impulse which naturally would innervate them strikes cells which re- spond unequally, or it overflows to other cell-groups, and hence the spasmodic, irregular movements of the arm. The cerebral centres in the cortex are closely connected with those in the cord, and may be said to form part of the writing-mechanism. It happens in some cases that this centre too is exhausted and discharges its impulses irregularly. In some cases, therefore, the cerebral, and in some the spinal, cell-groups are the more affected, and a diagnosis of the exact condition in each is approxi- mately possible, and may be not without practical impor- tance. Writers’ cramp is a disorder of efferent paths and sta- tions. The muscular sense does not seem to be involved. The pathology of writers’ cramp is that of all the other forms of professional neuroses, and nothing need be said upon this point regarding them when they come to be considered. 34 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Symplomatology.— Writers’ cramp very rarely attacks a person suddenly. The patient first notices a certain amount of stiffness occurring at times in the fingers, or the pen is carried with some uncertainty, and jerky movements are made. He feels a sensation of fatigue in the hand and arm, and this may amount to an actual tired pain. The first symptoms may last for months or even years. The hand is rested as much as possible, new pens or pen-holders, and new modes of holding it, are tried. Often the patient, fearing the onset of the cramp, and as its result loss of employment, becomes anxious, worried, and mentally depressed. Sometimes the trouble is worse when beginning a daily task, and it gradually wears off in afew hours. At other times ex- actly the reverse is the case. When the disease has reached its highest stage, writing becomes almost or entirely impossible. The moment the pen is taken in the hand and an attempt at using it made, spasmodic contractions of some of the fingers, or even of the arm, oc- cur, the pen fiies in any direction, and it is impossible to control or co-ordinate the movements. In a well-marked case, with the history of which I am acquainted, the patient, when called upon to sign a check, was obliged . to make an unintelligible scrawl, which was attested to by witnesses. The rule is that, although writing cannot be done, all other complex movements are performed as wellasever. . Thus the sufferer from writers’ cramp may be able to play the piano, or paint, or thread a needle, or use the hand in any complex movements. Telegraphers, however, who use to some extent the same muscles as in writing, and who also often have to do a great deal of writing, are liable to suffer from both writers’ and tele- graphers’ cramp at the same time. No evidences of actual paralysis are present in the affected muscles, and there is rarely anesthesia, but the arm aches and is sometimes tender. Sensations of numbness and prickling are pres- ent ; in rare cases vaso-motor disturbances are observed ; associated muscular movements of the other arm, or of the neck or face, sometimes occur. The hand may tremble on attempting to write, or fall almost paralyzed when the pen is taken. The various symptoms occur with different degrees of prominence, so that the disease has been classed under the heads of, 1, the spastic; 2, the paralytic, and 3, the tremulous type. To this Dr. Lewis adds, types with 4, sensory, and with 5, vaso-motor symptoms. Such a classification is convenient, but it is to be re- membered that in the majority of cases the forms are mixed. 1. The spastic form is undoubtedly the most common, and it has given to the disease its name. Cramp of some muscle or muscles was present in over half of Berger’s cases of writers’ cramp, and in thirty-one of Lewis’ forty- three cases of telegraphers’ cramp. The muscles of the thumb and first three fingers are oftenest affected, and in some cases the flexors, in some the extensors are chiefly involved. Canstett bases a classification upon this fact. In telegraphers’ cramp it is the extensors, but in writers’ cramp the flexors, that are mainly affected. The thumb, or fore-finger, or the little finger alone may suffer from the spasms. The pronators and supinators are quite often involved, and Berger notes a case in which there was spasm only in the pronator radii teres. Duchenne and Weir Mitchell report cases of ‘‘ lock-cramp,” in which, on attempting to write, the hand closes tightly in strong con- traction, and remains so for a considerable time. This symptom suggests the hypertonia of Thomsen’s disease. As stated, associated spasmodic movements sometimes occur in the neck muscles, or in the other arm. With the spasm, there is also inco-ordination so far as writing movements are concerned, and this fact is quite as important in producing the bad writing as the spasm. The inco-ordination is apparently of the motor, or at least: central, type, and is not due to anesthesia of the muscle-sense, as in locomotor ataxia. 2. The paralytic form, or that type in which muscular feebleness is the dominant symptom, ranks next in fre- quency. In Berger’s 64 cases, 24 were purely spastic, 10 paralytic, 8 tremulous, and 22 mixed. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. In the typical paralytic form the patient, as soon as he begins to write, feels an overpowering sense of weakness and fatigue in the fingers and arm. The fingers them- selves loosen their grip, and the pen may drop from the hand. Powerful impulses of the will and change in the mode of holding the pen, enable the sufferer to continue, but the arm aches, and finally is absolutely painful, and weakness and fatigue compel the writer to desist. Some- times the paretic condition is succeeded by the spastic. Many of the cases of paralytic writers’ cramp are not true examples of the neurosis, but are rather cases of neuritis of a rheumatic or other type. Poore’s tables show that nearly a third of the cases of impaired writing power are really forms of neuritic paresis. In this para- lytic form the muscles of the thumb and the interossei are oftenest affected. The first dorsal interosseus and the abductor pollicis may be independently attacked. The writing, while writing is still possible, is fainter, and the characters larger as well as less perfectly formed. In the true cramp, the hand or arm muscles show no pa- resis, except in the act of writing ; but in the neuritic im- pairment of writing, the paresis is absolute. Duchenne records a case in which the lateral move- ments of the hand and arm along the paper were impos- sible. After writing a few words the patient had to draw the paper from right to left. In this instance the deltoid and infraspinatus were paralyzed. 3. The Tremulous Type. This, though rare, is very characteristic when present. The patient, when attempt- ing to write, observes a tremulous movement of his hand and arm. ‘This ceases when his attempts to write cease. The tremor usually affects most the fingers used in pen- prehension, but it generally spreads to the forearm, and may even involve the entire extremity. An oscillatory or lateral tremor, due to involvement of the pronators and supinators, has been observed by Cazenave. The tremor, as may be seen, is of the character known as ‘‘intention-tremor,” such as is observed in dissem- inated sclerosis. It is much shorter in range and more rapid than the tremor of that disease, and corresponds practically more with the ordinary fatigue tremor often seen after great muscular exertion. General Symptoms.—Writers’ cramp is essentially a motor neurosis, and its leading symptom is the impair- ment of a motor function. Other symptoms, however, both general and local, are always associated with it. These are mainly (1) psychical and (2) sensory, more rarely (8) vaso-motor, and (4) trophic. 1. PsychicalSymptoms. The patient is often nervous, emotional, and mentally depressed at times. He suffers from insomnia and vertigo. Patients are generally unwilling to admit that there is any other trouble than the local one, and only careful examination may bring evidence of constitutional trouble. There are cases of purely mental ‘‘ writers’ cramp.” Thus, Shever gives the history of a man forty-two years of age, who was suddenly attacked with vertigo. Next day he found that he could not write, because an inexplicable feeling of fright seized him when he began to form letters. His condition became ameliorated, so that he could write for a time, when again the fear would seize him. He could write with his eyes closed. ‘There were no other symp- toms. Dr. Morris J. Lewis, who has investigated the subject of telegraphers’ cramp more thoroughly than any- one else in this country (‘‘Pepper’s System of Medi- cine,” vol. v., p. 520), states that telegraph operators who suffer from cramp, are sometimes unable mentally to grasp the proper number of dots and dashes composing certain Morse characters. They also have special diffi- culty in making these characters and of recognizing them by sound. ‘The dot-characters give the most trouble. 2. Sensory Troubles. These consist of pain, sense of fatigue, feelings of numbness, prickling, pressure, weight, tension, constriction, etc. Hyperesthesia, and more rarely anesthesia, are also observed. The most common sensory symptom is that of aching and fatigue, and this is usually confined to thearm. The pain is especially noticed in connection with the para- lytic form (Zuber), and it generally follows the course of Professional Neuroses, the nerves. The radial and median are those chiefly in- volved, while very little pain is ever felt along the ulnar. The arm is tender along the course of the nerves, and there may be tenderness over the cervical vertebrae. Erb had a patient who suffered from a steady pain over the left frontal region, almost exactly, it seems, over the probable writing-centre. M. Meyer calls attention to the presence of pain and tenderness, at times, in the apophyses. Disturbance of the common sensibility of the muscles of the arm has been obServed by Poore. In fine, the involved extremity may be affected with a great variety of subjective sensory disturbances. 8. Vaso-motor, Trophic, and Secretory Disturbances. The condition known as digit? mortut has been observed, coming on paroxysmally. It is a symptom which the general neurasthenic state helps to produce. When the nerves are involved, decided vascular changes may occur, such as passive congestion of the hand and arm, with swelling and turgescence of the fingers, and a sensation of throbbing. In bad cases the fingers will look as if they had chilblains. Local sweating, dryness of the skin, and cracking of the nails, all are conditions which may follow impairment of writing-power from neuritic causes. P Hlectrical Reattions.—The results of observations upon the electrical reactions of the affected parts are somewhat contradictory. Ordinary tests will, as arule, reveal very little change. Sometimes there is a quantitative increase, sometimes a decrease, of irritability to both forms of current. The increase occurs in the earlier stages, the decrease in the later. The contraction formula, Ka C C >An C C, is not changed, unless a decided neuritis com- plicates or causes the trouble. An increase, or modifica- tion, of electro-muscular sensibility has been noted. The electrical examinations, therefore, are only of value in excluding a neuritis, or possibly in determining the stage of the disease. Course and Duration.—Writers’ cramp is a chronic disease. It begins insidiously, and attacks one group of muscles after another, as each is brought into play by new methods of writing. If the left hand is used, that, too, is liable to become affected. The course va- ries, however; for a time progress may be arrested, or improvement set in. When the disease becomes well established, it will most often last a lifetime. For ‘ex- ample, a pianist, while yet a young man, was attacked with pianists’ cramp. He changed his profession, and gave up piano-playing ; yet, at the end of five years, if he attempted to use the piano, the cramp still attacked him. Prognosis.—The prognosis is unfavorable, yet not so much so as has once been thought. Undoubted cases of complete recovery have been reported, and Berger’s statistics place the per cent. as high as eight. I have observed a case of complete cure of telegraphers’ cramp, and one of writers’ cramp. The prognosis is much more favorable if the patient begins treatment early, and before marked spastic symp- toms are present. It is believed that certain modern therapeutical methods, to be referred to later, will also modify the prognosis. Some patients who suffer from a mild form of the trouble manage, by the help of in- struments or special pens, to do their work for years. The more acute the disease, and the more evidently peripheral and neuritic its origin, the better the prog- nosis. Severe sensory disturbances are of more favora- ble omen than severe motor trouble. Perhaps in about one-fourth of the cases, patients who use their sound arm will not be affected in it. The facts stated regarding the cause, physiology, and general symptomatology of writers’ cramp apply to the other forms of functional neuroses. A few special de- tails, however, will be given regarding these. The most common and important are musicians’ cramp and tele- graphers’ cramp. Musicians’ Cramp.—Under this head we include pian- ists’ cramp, violinists’ cramp, flutists’ cramp, and the cramp of clarionet players. Pianists’ cramp occurs usually in young women who are studying to become professionals, or who are espe- 35 Professional Neuroses. cially hard-working and ambitious. The absurd “ Stutt- gart method ” of teaching the piano, in which the mo- tions are confined as much as possible to the fingers, predisposes especially to this disease. The symptoms are those of fatigue, pain, and weakness. The pains are of an aching character. They are felt in the forearm especially, but extend up to the arm and between the shoulders. Spasmodic symptoms are rare. The right hand is oftener affected, but both hands eventually be- come involved. ? Violinist’ cramp may attack the right hand which holds the bow, or the left hand which fingers the strings, but more often the left ferer feels at first a sense of fatigue and uncertainty in the fingers and arm, then pain, and finally some spasmodic movements oc- WCUr, Clarionet players some- times suffer from cramp of the tongue (Striimpell), and of the laryngeal mus- cles (Eichhorst). Flute players, according to observations related to me by Dr. T. H. Kellogg, suffer not very infrequent- ly from slight laryngeal Ve GLEN. co. AS Li Fie. 3103. — Mathieu’s Apparatus. The pen is moved by the thumb and index-finger. spasms. ‘The same observer has noted similar spasms in elocutionists. The term mogophonia is applied to this trouble. Telegraphers’ cramp was first described by Simon, in 1878 (Comptes rendus Soc. de Biol., 6, 92-96). It has been noticed by English and Scotch physicians, and has been exhaustively studied by Dr. Lewis, of Philadelphia (loc. cit.). Dr. Beard also made some studies of it. It affects especially those operators using the Morse system, an in- strument which is still the one most widely in vogue. Contrary to the opinions of,previous writers, Dr. Lewis believes that this neurosis is not a rare one, and is des- tined to become more frequent. Considering that there are perhaps less than thirty thousand telegraph operators in the country, aS against the vast army of clerks, copy- ists, writers, etc., the fact that Dr. Lewis was able to collect forty-three cases of telegraphers’ cramp is signifi- cant. Dr. W. H. McEnroe, of New York City, who has had a largely personal experience with telegraph operators and their diseases, informs me that the cramp is rare, the pro- portion being about one in every two hundred. The technical name, among operators, for the cramp is ‘‘loss of the grip.” In telegraphing, the extensors of the wrist and fingers are called most into play, and hence are most and earliest affected. The symptoms come on very slowly, the thumb and index-finger being first affect- ed. The victim finds that he can- not depress the key on account of spasm in these muscles, and he finds most difficulty in making the dot-characters, such as h (....), OL Dee iy ) Oren Ga ms stay ren the flexors are most affected, the key is depressed with undue force, and a dash is made instead of a dot. Sufferers from the ‘‘loss of Frye. 3104.—Mathieu’s Ap- grip” generally suffer from writ- paratus. The pen is held ers’ crampalso. Most cases occur Hy the index- and middle- between the ages of twenty and sag thirty. Males and females are almost equally affected— perhaps there is a preponderance in favor of females ; and, according to Lewis, the disease attacks them earlier than it does males. While spasm is usually present, the disease may show itself simply in pain, paresis, and in- capacity to co-ordinate the muscles. lo, TIEMANN 8&0. In sewing spasm, which affects tailors, seamstresses, 36 hand isaffected. Thesuf- . REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. and shoemakers, clonic and tonic spasms attack the muscles of the hands on attempting to use them in the regular work. ‘Tailors who sit cross-legged sometimes suffer from a peculiar spasm on assuming this position. It is possible, however, that these are cases of tetany, and not of the functional neurosis under consideration. Smiths’ spasm, crampe des forgerons, hephestic hemi- plegia, appears to have been observed only by Duchenne and Dr. Frank Smith (Dictionnaire encyclop. des Sciences médicales, t. x., p. 775). It occurs in persons engaged in pen-blade manufacturing, saw-straightening, razor-blade striking, scissors-making, file-forging, etc. il) . Y | Wy Yj, In doing this work they have to use a light or heavy hammer, with which strokes are delivered very rapidly and carefully. After a time spasmodic movements occur in the arm used, and the arm falls powerless. As in the cases re- | ported there are gen- erally hemiplegic symptoms, and also neuralgias, vertigo, and other cerebral troubles, the disease can- not be a pure ‘‘ professional” neurosis, Drivers’ spasm has been ob- served in a veterinary surgeon by Dr. Samuel Wilkes (‘‘ Diseases Fig. Baer eee Ar of the Nervous System”). The viofimgor, and thumb are Patient had to drive hard-bitted immobilized. horses for many hours daily. Finally his arms were attacked with cramps whenever he took the reins. Milkers’ spasm is an extremely rare affection, which was first described by Basedow and seems to occur in milkmaids, never in milkmen (Casper’s Wochenschr., 1851). Berger is the only other author who reports a case. Cigarmakers’ cramp must be an exceedingly rare affec- tion. I can find reports upon it by only two observers, O. Berger (Berlin. klin. Woch., 1873, No. 21), and Koster (ibid., 1884). Watchmakers’ cramp (O. Berger, 8. Weir Mitchell) and Photographers’ cramp (H. Napias: Revue d@ Hygiene, i., 927, 1879), are also to be regarded merely as pathological curiosities. Ballet-dancers’ Cramp.—Under this name certain pain- ful and paralytic troubles occurring in ballet-dancers, especially premiéres danseuses, have been described by Schultz, Onimus, and Kraussold. It does not appear that G.TIEMANN & 60. < SG. T/EMANN & C0. Ss Fra. 3106.—Duchenne’s Apparatus. the trouble is really a co-ordinative functional one, but is rather neuralgic, or the result of local strain upon the parts. The list of professional neuroses is made to include, ‘besides those above given, cramps and co-ordinative troubles affecting artificial flower-makers, billiard-play- ers, dentists, hide-dressers, electrical instrument-makers, stampers, turners, Sewing-machine girls, money-counters, weavers, painters, and pedestrians. | REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. In most of these cases there is probably some inflam- matory affection of the nerves, or ligaments, and not a true central neurosis. The Diagnosis of well-marked cases of writers’ cramp presents no difficulty. In the earlier stages, however, it may be confounded with a large number of disorders, viz., post-hemiplegic chorea, hemiataxia, progressive muscular atrophy, progressive locomotor ataxia, various forms of tremor, lead paralysis, rheumatoid arthritis, neuritis, cerebral and nerve tumors, and tenosynovitis. In many of these cases it is only necessary to bear in mind the history of the disease in order at once to reach Fie. 3107.—Cazenave’s Apparatus, Modifieé by Duchenne. a diagnosis, for in writers’, or telegraphers’, or musicians’ cramp the symptoms are localized in asingle, or at most two, extremities. : Dr. Weir Mitchell has called attention to the fact that a person may have avery slight and transient cerebral hemiplegia, followed later by post-hemiplegic disorders of movement, which may be mistaken for writers’ cramp. Such troubles occur either much earlier, or somewhat later, in life than the writers’ cramp, and the motor dis- turbances affect the leg and possibly the face as well as the arm. Dr. Lewis (loc. cit.) cites from Dr. Weir Mitchell’s note-books two cases, illustrating the fact that some cases of slight arm paralysis, due to small lesions affecting the arm-centre of the cortex, may be mistaken for functional paralysis. Some occupations which call into play repeatedly and continuously the same group of muscles, produce in them a gradual atrophy. This has been called ‘‘ pro- fessional muscular atrophy” by Onimus. I have seen it occur in the thenar muscles and deltoid of a butcher, whose work obliged him to handle a cleaver for many hours daily. I have also observed atrophy of the thenar muscles in a lapidary. The act of writing may induce a progres- sive paresis and atrophy of the muscles of pen-prehension. These occupation muscu- lar atrophies are, I believe, myo- pathic in origin; they are not ac- \ aes companied with the central vaso- Rey ox ; motor or secretory disturbances of SYK Ks." true spinal progressive muscular / Z - atrophy, and they are char- acterized by a rapid im- * 5 provement or arrest in pro- Vf ee gress under rest and treat- 4 ment. Dr. Lewis cites some cases to show that in the . earlier stages, or in mild Fie. 3108.—The Pen is Attached to types of multiple sclerosis, 2 Block, which is Grasped by the euivregoler diffuea sclerosis G7. of the brain and cord, mo- , tor disturbances occur which may be mistaken for writ- ers’ cramp. As already stated, the diagnosis of the various ‘‘ cramps” is practically easy when any ordinary care is exercised in examination ; and, after all, the most important point for the physician to determine is the form of impaired writing-power from which the patient suffers. ty . . plese. ee a. Semen” Professional Neuroses, If there is a great deal of pain in the arm, with tender- ness along the course of the nerves; if there is decided change in the electrical reactions; if there are sensations of tingling, numbness, etc.; and if the patient shows an absolute loss of power in the various groups of muscles, with some incapacity for doing other acts besides the one with which he is specially concerned ; then the trouble is undoubtedly peripheral and due largely to an underlying neuritis. The prognosis in these cases is much more favorable. If, on the other hand, the disorder comes on in persons who have not done an excessive amount of writing; if it is associated with nerve-strain; if the electrical reactions are but slightly changed, the sensory symptoms slight, and the motor inco-ordination marked, limited to the special class of work, and not accompanied with absolute paresis, the disorder is central, and needs both a different treatment and prognosis. It is these cases that form writers’ cramp proper, although no doubt neuritic and central forms are associated, or the former may run into the latter. For convenience I append a diagnostic table showing the differential points between central and peripheral writers’ cramp: IMPAIRED WRITING-POWER, ETC., IMPAIRED WRITING-POWER, ETC., MAINLY OF NEURITIC ORIGIN. MAINLY CENTRAL 1N ORIGIN. 1, Caused by excessive writing. 1. May be no marked excess of writ- ing; but a neurotic history is obtained. 2. Marked sensory symptoms of | 2. Sensory symptoms subordinate, tenderness over nerves, General nervousness and men- tal depression are noted. 8. Electrical reactions show in-/| 38, Electrical changes slight. creased irritability, possibly qualitative changes, 4. Paresis of certain groups of | 4. Paresis but little marked or ab- muscles. This may be shown sent. Patient can do all other in inability to do other co- kinds of muscular work easily, ordinate acts. Prophylaxis and Treatment.—Although the amount of writing done at the present day is enormously increased, there is not acorresponding increase in writers’ cramp. This is due to the introduction of gold and stylographic pens, type-writers, and better pen-holders. , Persons who do a great deal of writing, if they find any signs of impending cramp, should use some of these instru- ments as much as possible. Stylo- graphic pens are less liable to lead to trouble in writing, because not so much prehensive power is needed in their use. The same is 4 true to a less extent of gold (Gee pens. The pen- holders |, should have a_ slightly |= roughened surface, of cork or soft rubber. Large-handled pen- holders are held moreeasily. Small, smooth, metal or hard-rubber holders are to beavoided. Pencils are not so good as pens, because they require more prehensive force. ‘The paper written upon should be smooth. The best style of writing is that already referred to as the American, the movements being made both.with the arm and the fingers. Many nervous persons have a bad habit of gripping the pen very tightly, and pressing down on the paper with exces: sive force. Fatigue soon results, and painful sensations develop in the arm. Proper attention should be paid to the position of the paper written upon, the height of the desk, the light, and the sleeves of the coat or dress. The paper should be laid at an oblique angle to the edge of the desk, and not at a right angle as many writing teachers are accustomed to direct. As some cases of “cramp” are undoubtedly cerebral, it is very unwise to attempt any extraordinary exploits in writing, or to work with the ambition to put the writing capacity to the utmost test. Cramp is often dated from days when such extra work is done. Sensations of weariness and 37 Fia. 3109.—Velpeau’s Apparatus. Same principle as the preced- ing, but the block is held ina different grip. Professional Neuro- prrERENCE HANDBOOK OF THE MEDICAL SCIENCES. Prostate, [ses. slight premonitions of cramp should be watched and promptly treated. It seems to be agreed that no modifi- cation of the telegraphers’ key is of much value in pre- venting ‘‘loss of grip.” Telegraphing with : the finger-movement alone, the wrist and fore- ‘arm resting on the table, is a bad method that should be avoided. When thecramp is fully developed, by far the most The hand is fast- The board slides along upon the Fria. 3110.—Apparatus of MM. Charcot and Cazenave. ened to a board, as is also the pen. paper. essential thing is prolonged rest, and the physician should always consider the question whether the patient should not abandon his occupation altogether. If com- plete rest is not attainable, the various methods of getting partial rest are as follows: 1. Getting a new form of pen and pen-holder. Fria. 3111.—Nussbaum’s Apparatus. It consists of a bracelet of hard rubber, upon which the pen can be fastened at any length. In order to hold it firmly, the fingers have to be spread out. A piece of flannel is placed between the hand and the paper. 2. Holding the pen in a different way. 3. Using the unaffected arm. 4, Using some form of mechanical appliance. With regard to 1 and 2, enough has already been said. 3. Asarule, if the unaffected arm is used, it soon be- comes involved also. This is not always the case, how- ever. 4, The mechanicalappliances are splints, rubber bands around the wrist, and various instruments contrived to prevent spasm and throw the work of writing on new and larger groups of muscles. Instruments for writers’ cramp are very numer- ous. The first one was invented by M. Caze- nave, in 1846, and simply fastened together and 0) <, eS) Prostate. Prurigo. than to the sight. The hand when run over the skin feels the minute nodules before the eye can detect them, projecting above the level of the surrounding epidermis, As time goes on, this roughness of the skin to the touch is even more pronounced, so that the hand feels as if it were being rubbed upon coarse sand-paper. After the papules appear, itching commences, and the child is seen to scratch. A drop of clear-colored serum forms a vesicle at the top of the papule, the epidermis becomes thin, is then scatched off, and the serum escapes, while further scratching may rupture the capillaries al- ready dilated, forming a crust of blood and serum. After years of recurring eruption and scratching, the skin be- comes thickened, hardened, brittle, parchment-like, and pigmented. The patients are unable to resist the im- pulse, and spend the greater part of their lives in scratch- ing. Even in sleep there is no cessation. Unconsciously, all night long they are at work, so that the regular grat- ing sound, coming from the beds of long-suffering pru- Sea fifegroeere Saco hed 2.9. bi afeece eee WA sie aM Sis % 8 : AST BN RE ys a9 een ES EC SE CRLF eh Od BbG| n/a BD NS OSes EH UN wos a t rote aha: md 53 NA ome eee \ - neta et 0 as eties BS LLA PSRC! I(, 8 or LID Bee A Pies Six ‘al ae ie * ; fue, ‘ eZ 7 & oe) WT ie Bie Ree) ae + Derk Ss et LL, SA re ei oad 2 Haw Rey ale eat 8: Shek ~p BER 5 i o od Pea am \ a vp obo! se 2s a : aH £e) Ake - ° (?} ‘oe 76 c “f ° 3 ~ + Sie \e* y Fre, 3128.—Prurigo Papule. terms which still to a large extent exists among the older general practitioners. They should not be confounded, for the dermatologist recognizes prurigo as a disease sw? generis, while pruritus is only a symptom. Prurigo is a rare disease in North America. The re- ports of the American Dermatological Association for the last three years give 19 out of a total of 38,320 cases of skin diseases reported by the different members. For- eign dermatologists are incorrect in suggesting that the disease is overlooked in this country. The fact is, it hardly exists here ; and if cases are seen, they are most often in those who have come into the country from abroad, bringing it along with them. As described by Hebra, the disease is divided into pru- rigo simplex seu vulgaris and prurigo agria seu ferox, according to its severity and duration. It always begins in early life, and is generally foreshadowed by the appear- ance, upon the extremities of an infant, of constantly re- curring urticarial wheals. After the second year of life an eruption of small papules, the size of a mustard- or hemp-seed, makes its appearance, and we then have true prurigo. Primarily, the papules are more perceptible to the touch rigo patients at night, is one of the most weird and un- pleasant noises imaginable. It is as regular as their breathing. The disease most generally begins upon the extremi- ties, where it is also most intense. The papules appear first in this situation, and then, in order, upon both sides of the thorax, the abdomen, the back, and the buttocks. They do not appear on the scalp, and seldom in the axilla, the palms, the flexor surface of the knee-joint, or on the genitals. In cases of long standing the lymphatic glands are enlarged. ; Histological investigation of the papule, made by the present writer,! shows that it is formed by an infiltration beginning around the upper layer of vessels of the cori- um ; this infiltration, extending upward, surrounds the papillary vessels and enlarges the papille, thus pushing up the epidermis, which becomes thickened at an early stage above them (see Fig. 3128). Finally, this infiltra- tion, penetrating the epidermis, forms with its layers a small vesicle containing serum, blood, and lymph-cells. The signs of infiltration surrounding the hair-sheaths and sweat-ducts are secondary, and they play no especial part in the process. Their presence in the papule is ac- 53 Prurigo. Psoriasis, REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. cidental, and it is certain that the primary changes in the skin are not in connection with them. The color of the papule at first does not differ from that of the surrounding skin, on account of the depth of the slight infiltration with which it begins. At this stage there is no itching, but later on, when the infiltration has become greater, this symptom begins. Hebra says prurigo is incurable ; the symptoms may be alleviated by proper remedies, but there is no per- manent cure. The therapeutical indications are to re- move the dry, brittle epidermis, to soften the skin, and to allay the itching. Warm baths, continued for hours at a time; stimulating soaps, such as spiritus saponis al- kalinus ; ointments of vaseline, lanolin, or simple cerate, containing zinc, salicylic acid, or sulphur; medicated gelatines, and attention to the general health, are some of the means employed to relieve the sufferer. It is a dis- ease of the poorest, most ill-fed classes—such classes as know no hygienic laws, and have for successive genera- tions beenin the same unhealthy condition. Fortunately, we have as yet no such classes in this country ; hence the rarity of the disease with us. Robert B. Morison. 1 A Contribution to the General Knowledge Concerning the Prurigo- Papule, American Journal of Medical Sciences, October, 1883. PRURITUS. A neurosis of the skin, characterized by local or general itching, without any perceptible primary lesion. Pruritus UNIVERSALIS usually affects larger portions of, or even the entire, surface, and may occur at any age or in either sex. Itis not infrequently accompanied by some disturbance of the abdominal organs, as granular liver, hepatitis, Bright’s disease, etc. In young women, dis- turbance of the menstrual functions and, in older women, pregnancy sometimes occupy a causal relation to general pruritus. In still older persons, and especially in the aged, general pruritus not infrequently occurs in its se- verest and most stubborn form, probably-in connection with the senile changes in the skin, forming a most dis- tressing malady. Pruritus LOcALIs occurs commonly in certain regions by preference. Thus we have pruritus ant, which usually occurs in connection with hemorrhoids or, in children, with seat-worms. The affection usually first shows itself at the muco-cutaneous junction, and spreads forward toward the perineum and backward toward the coccyx. Pruritus ani is usually worse in the evening on undress- ing, and when the patient becomes warm in bed. In the semi-unconsciousness of sleep the parts are rubbed and scraped until an artificial eczema results, and, in fact, more or less eczema is present in most severe cases of pruritus ani. Pruritus genitalium takes on a somewhat variable aspect, according to the sex. In men the scrotum is the usual seat of the disease. Pruritus scroti is a not infre- quent accompaniment of pruritus ani. In the earlier stages of the disease no lesions are perceptible, but after the affection has lasted for some time excoriations and blood-crusts appear as secondary lesions, the result of scratching. Here, too, artificial eczema sooner or later results, although the writer has observed numerous cases where, even after prolonged and severe pruritus, no per- ceptible lesions could be observed upon the scrotum. Pruritus scroti is always a stubborn affection, and some- times becomes chronic, resisting every attempt at relief, and at times driving the patient nearly frantic. Pruritus pudendt muliebris commonly occurs in the mucous membrane about the labia minora and majora, and in the neighboring muco-cutaneous’ surface. Occa- sionally it seems to be confined to the clitoris and its im- mediate surroundings. In children, ascarides are often the cause of the itching; in adult females, uterine dis- ease, leucorrhcea, vaginismus, etc., give rise to the trouble. Not infrequently, however, no known cause can be as- certained, and the affection appears to be purely idio- pathic. European writers often allude to this affection as the cause of onanism and nymphomania. The writer 54 has never observed this result excepting among the in- sane, and is not disposed to regard pruritus pudendi as a frequent cause of these neurotic manifestations in per- sons enjoying the full use of their mental faculties. This form of pruritus is connected at times with diabe- tes mellitus. Pruritus palmaris and plantaris are forms of local pruritus which may be mentioned. ‘They are rarely se- vere or long continued, and are usually more amenable to treatment than the other forms. A form of local pruritus due apparently to changes of temperature is that first described by Duhring as pru- ritus hiemalis, or winter pruritus. This form is com- monly observed upon the lower extremities, particularly the insides of the thighs and the calves, although some- times it may occur upon the upper extremities, and may assume an almost universal form. The peculiarity of pruritus hiemalis is that it leaves its victim free during the summer months, only to return promptly with the frosts of autumn, year after year. During the winter months a spell of clear, bright, frosty weather will bring on a tormenting attack, which will pass away when the weather becomes warm and moist. The itch- © ing comes on when the patient takes off his clothing at night, and seems to be excited by the impact of cold air. In the majority of cases it passes off as the patient grows warm in bed. Severe cases may, however, continue through the entire day, and even torment the patient at night. The diagnosis of pruritus should give rise to no diffi- culty, because, although there are other diseases in which itching is a prominent symptom, these are always charac- terized by primary lesions of some sort. The history of itching as the first symptom, with visible lesions occur- ring only secondarily, if at all, is conclusive. Old cases of pruritus are almost always accompanied by a certain amount of eczema, with scratch-marks, pap- ules, fissures, crusts, pigment-deposit, etc., and it may at times require careful investigation to ascertain the character of the original disease. Of course, the possible presence of parasites must always be considered and ex- cluded (see Pediculosis). The treatment of pruritus is always difficult, and will at times require every therapeutic recourse and the most careful examination and study of the patient’s whole economy. There are few skin diseases in which it is more neces- sary to examine every possible weak point, and yet cases not infrequently occur in which the practitioner must proceed on a basis of pure empiricism, and simply em- ploy one remedy after another until something or some combination is secured which will attain the desired end. As regards drugs, the usual tonic and alterative medi- cines are to be employed. Irregular menstruation must be treated by the judicious use of iron or other remedies, cod-liver oil, etc. Quinine and strychnine are sometimes of use. Recourse may be had to bromide of potassium and chloral, alone or together, in order to subdue general nervous symptoms. Morphia should in no case be used, as it tends to aggravate the itching. External treatment affords great relief, and is to be used in all cases. Hot and cold douches, used alternately, or hot water applied as hot as it can be borne, or plain vapor-baths, are often useful. Medicated baths, contain- ing from three to six ounces of bicarbonate_of sodium, or from two to four ounces of carbonate of potassium or borax, to thirty gallons of water, ‘will at times afford relief. Sulphuret of potassium and sulphur vapor-baths are sometimes used with success. Inunctions with a bland oil, as almond-oil, may be practised after these baths. Lotions of various kinds are the most generally useful - applications in pruritus, and those containing carbolic acid are by far the most generally efficient. Chloroform ; chloroform and alcohol, a drachm to the pint; lead- water; dilute water of ammonia; dilute nitric acid, ten minims to the ounce of water ; vinegar—are all service- able remedies which may be tried singly or in succession REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. in troublesome cases. The following tar-preparation, known as liquor picis alkalinus, and introduced by Bulkley, is generally useful: . Picis liquide, 64 Gm. (Zij.); potasse caustice, 32 Gm. (%j.); aque, 160 Gm. (Zv.). M. This is very strong and must be diluted with from three to ten parts of water. In some localized forms of the disease, ointments are to be used in prefer- ence to lotions. One of carbolic acid, ten to fifteen grains to the ounce of oxide of zinc, is often useful. In pruritus of the female genital organs, water as hot as can be borne, sponged upon the parts, forms an admi- rable anzesthetic and should be used in all cases, whatever other treatment may be added. Following this, carbolic lotions, sulphurous acid—sulphite of sodium, in solution of a drachm to the ounce of water—and lotions contain- ing hydrocyanic acid may be employed. Sometimes an emollient poultice of freshly made almond-meal, which evolves a small quantity of hydrocyanic acid, will be found very soothing. Where the itching is localized, particularly about the clitoris, a ten-per-cent. solution of hydrochlorate of cocaine, painted on, will give an ex- quisite sense of relief for a time, and may even prove curative. Pruritus of the anus is best treated by oils or oint- ments. Carbolized oil, in the strength of twenty per cent., and ointments of belladonna or tar are usually beneficial. Applications. of hot water should precede the use of the medicinal agents. Sometimes a pledget of lint wet with a five-per-cent. solution of hydrochlorate of cocaine will relieve the pruritus like magic. Pruritus of the scrotum is often very intractable, the more so because the skin is thin and not infiltrated and its surface is intact. It is difficult to get any local remedies in direct contact with the diseased parts. The following formula is much used: &. Bismuthi subnitrat., 8 Gm. (3 ij.); acid. hydrocyanic. dil., 8 Gm. (f 3 ij.); mist. amyg- dale, 82 Gm. (f 3 iv.). In the pruritus of jaundices, mercurial ointment is said to be of value ; also, lotions and baths of vinegar, in the proportion of two quarts to an ordinary thirty-gallon bath, or of nitric acid, in the proportion of two to three ounces to the bath. The prognosis of pruritus should be guarded. The disease, as a rule, is obstinate; oftenextremely so. The prognosis often depends largely upon the cause and our ability to remove it. In grave cases melancholic symp- toms may be present. Occurring in the aged, the prospect of ultimate cure is poor. Pruritus hiemalis, though usually less severe, is perhaps even more intractable than the other forms of the dis- ease. Arthur Van Harlingen. PSORIASIS. A chronic affection of the skin, charac- terized by the appearance of reddish, slightly elevated, dry, inflammatory patches, variable as to shape, size, and number, covered with abundant, whitish or grayish mother-of-pearl-colored, imbricated scales. The disease varies greatly in its extent and intensity in different cases, sometimes showing a typical development, in other cases represented by one or two obscure lesions. It possesses, almost invariably, however, certain characters which serve to identify it. The lesions begin as small, reddish spots, scarcely raised above the level of the skin, which almost immediately become covered with whitish scales. They often develop rapidly, reaching the size of coins in afew weeks. At other times the course of the disease is more sluggish. The extent of the eruption varies greatly. A few patches may be all that are present, or the entire surface from head to foot may be involved, with scarcely a clear spot to be found. Commonly the disease shows itself in the form of scaly patches, of vary- ing size, scattered over different parts of the body. The patches are characteristic. They are usually rounded, sharply defined from the surrounding skin, and consist of a mass of imbricated, yellowish-white scales on a red base. When the scales are picked off, a smooth, shiny, reddish surface is shown underneath, on which can be perceived a few drops of blood the size of pin-points. The abundance of the scales is a marked feature in some - Prurigo, Psoriasis, cases. Where they are formed rapidly—that is, in well- developed cases—the patient’s bed may be filled in the morning with a handful of scales which have accumu- lated during the night. When the disease exists about the joints, fissures may show themselves, so deep at times as to make movements of the affected limb painful. There is no watery discharge at any period of the dis- ease. Sometimes the eruption takes on a highly inflam- matory -character, with redness, swelling, and severe burning and itching, while at other times all these symp- toms are much less marked, and; in fact, the patient would hardly be aware of the existence of the disease, did he not see the eruption. Though the individual patches of psoriasis may be, and generally are, small, yet they sometimes coalesce into patches the size of the HE or larger, or may even cover the greater part of a imb. Psoriasis may occur on any part of the body, but is most apt to be seen on the extensor surfaces of the limbs. It is sometimes found on the elbows and knees when it shows itself nowhere else. On the other hand, it may be absent from these localities, although present at many other points. The back is more commonly attacked than the chest, and in women a favorite seat of the eruption is around the waist where the skirts are tied. The scalp is a frequent seat of the disease. In this locality it some- times occurs in patches, but more frequently as a diffuse and abundant scaliness. It is apt to extend a little be- yond the border of the scalp, especially behind the ears and on the forehead, and this is quite characteristic. Psoriasis does not occur upon the mucous membranes. The so-called ‘‘ psoriasis ” of the tongue is probably only a precursory hardening leading to epithelioma. Psori- asis is not contagious. The cause of psoriasis is not known. It is apt to occur in well-nourished, rosy-complexioned, light-haired peo- ple, the ‘‘ picture of health” excepting that they are apt to bea little rheumatic. Now and then, however, it is met with in thin, worn persons who are in poor health. Greenough’s statistical inquiry into this point confirms the writer’s view. Psoriasis is not often encountered in children, though Stelwagon has reported a case where it occurred in achild between three and four years of age, and Greenough’s statistics show of 150 cases 20 which were known to have first occurred under the age of ten. On the other hand, 6 cases out of those observed by Greenough first showed signs of the disease after passing the fif- tieth year. It is the opinion of the writer that psoriasis occurs much more generally than is supposed at an early age, but the disease is not apt to be noticed until it grows with the growth of the individual and becomes more pronounced. Greenough succeeded in obtaining a his- tory of hereditary or family tendency in 31 cases out of 97, but the tendency to hereditary transmission has not been observed by most writers or has been considered rather exceptional. Some cases of psoriasis are worse in winter and disappear almost or entirely in summer ; others are worse in summer. Diet, I believe, has little influence in causing the disease, though in some cases it may influence its course quite markedly. Psoriasis and syphilis are not connected in any way. There isa syphilitic eruption sometimes called ‘‘ syphilitic psoria- sis,” because the lesions resemble those of psoriasis. This most unhappy term has caused much confusion of mind, but it must be remembered that the cause, course, and treatment of syphilis differ 77 toto from those of pso- riasis (see under Syphiloderma). The diagnosis of psoriasis is easy when the affection is well developed and presents its typical appearance. The form and aspect of the lesions, and the history of the case, will usually serve to determine its nature. Scanty and ill-developed eruptions of psoriasis are, however, at times distinguished only with difficulty. Nevertheless, it is an important matter to accurately determine the nat- ure of the disease, for its treatment is widely different from that of the affections with which it is liable to be confounded ; its prognosis is also different, and, in addi- tion, two of the other affections are contagious. Two or three small patches of psoriasis occurring alone 5D Psoriasis. Pterygium. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. upon the arms or legs may be mistaken for eczema. Itch- ing, however, is almost invariably present in eczema, and therefore itching is one sign that an eruption in question is not of this nature, though not a sure sign, since psoriasis also sometimes itches. In the majority of cases of eczema there will be a his- tory of moisture at some time. Psoriasis is always dry and scaly, never moist. The scales of psoriasis are more abundant, larger, and whiter than those of eczema. The patches of psoriasis are usually bold and well defined in outline, while those of eczema fade into the surrounding skin. Syphilis in the form of the papulo-squamous syphilo- derm is very apt to be mistaken for psoriasis, and vice versd. Psoriasis, however, is more apt to be symmetrical in its distribution. It often involves a large portion of the surface at once, or is found in regions remotely sepa- rated, which is rarely the case with the papulo-squamous syphilitic eruption. In psoriasis the lesions seem to be on the surface, so to speak. They are very scaly, but with- out much infiltration. The syphiloderm, on the other hand, is deeply indurated, and is only scantily covered with scales. In psoriasis the knees and elbows are apt to be involved. In syphilis these are not often attacked. Occurring on the palms and soles the disease is almost certain not to be psoriasis, which is very rare in this local- ity. Thecolor, though often deceptive, sometimes aids in diagnosis. It is usually much lighter in psoriasis, while in syphilis it is apt to be a dusky ham-color. The age of the patient and the duration of the disease may give a clew to the diagnosis. Psoriasis generally first shows itself before the age of twenty ; this form of syphilis, later. The history of psoriasis is that of a chronic dis- ease lasting for years, continuously or in an intermittent manner. Syphilis rarely retains one form for any length of time. Other points in the history—infection, the oc- currence of other lesions, etc.—may come into use. Itch- ing is rare in syphilis, common in psoriasis, but too much reliance must not be placed on this symptom. It has been the writer’s misfortune to see several lamentable mistakes made by the exclusion of syphilis based on the presence of itching. Finally, the touchstone of treat- ment may be resorted to in very obscure cases. Tinea circinata and psoriasis are sometimes mistaken for one another, but the patches of tinea are less inflam- matory, red, and infiltrated, and are much more super- ficial. The scales in tinea are larger and lighter, and the patches show no attempt at symmetry. The microscope shows the existence of a fungus in the scales of tinea cir- cinata, which is absent in psoriasis, and a history of con- tagion may often be obtained in the former’ disease, which is absent in the latter. Psoriasis may occasionally be mistaken for seborrhea, -as this disease occurs on the chest and back. A com- parison of the description just given of psoriasis with that of the former disease will show in what points the difference lies, while it may also be kept in mind that seborrhea affects a small patch, the size of the hand, over the sternum in front and the region of the scapule, with the parts between them, behind. From seborrhea capitis and from pityriasis capitis, psoriasis of the scalp is distinguished by the yellow, friable character of its scales and their abundance, the scales of seborrhcea be- ing markedly oily and adherent, while those of pityriasis are gray, thin, and powdery. Psoriasis may occasionally be mistaken for lupus, es- pecially lupus erythematosus ; but in addition to the fact that lupus erythematosus is most likely to be encountered on the face alone, whereas psoriasis is almost always found coincidently in other localities, the more scanty scaliness of lupus and the greater amount of infiltra- tion also serve to distinguish between the two affections. The description of both forms of lupus may be referred to in this connection. It is said that psoriasis may be confounded with lichen ruber. This certainly cannot occur very frequently in this country, the forms of lichen ruber commonly en- countered here being easily distinguishable. Lichen ruber usually occurs upon the extensor surface of the 56 forearms, at. least in the milder cases; the lesions are uniformly of small size, not much larger than a pin-head or small split-pea, while the lesions of psoriasis vary from the size of a pin-head to that of a coin, with occa- sional larger patches. The lesions of lichen ruber have few scales, while the lesions of psoriasis are very scaly. The anatomy of psoriasis has been made the subject of careful study by Robinson, whose description shows the affection to consist in a hyperplasia of the rete and cor- responding structure of the hair-follicles. In a section of a lesion of a few days’ duration the corneous layer is found to be but slightly changed. Prolongations down- ward of the interpapillary portion of the Malpighian layer, which are more extensive in the central, ¢.e., older portions of the lesion, are seen in microscopic sections of older lesions. In the papillze and superficial part of the corium within the psoriasis regions there are seen en- larged blood-vessels and round bodies in varying num-- bers in the surrounding tissues, while in the non-papu- lar region no enlargement of blood-vessels is as a rule observed, and also no white blood-corpuscles. The deeper parts of the cutis appear normal, as well as the se- baceous and sweat-glands. . The increase in the thickness of the Malpighian layer arises from an increase in the number of rete-cells. This increase is sometimes very great. The blood-vessels, also, in the papille are more or less dilated, this dilatation, together with the emigration of white blood-corpuscles, increasing with the duration of the eruption. All the in- flammatory changes, however, in the cutis are secondary to the hyperplasia of the rete. The hair in psoriasis becomes changed at the com- mencement. The external root-sheath, the structure cor responding to the rete, becomes increased in size in the same manner as the latter structure. There is a real hyperplasia, with an extension of the hyperplastic struct- ure into the surrounding cutis. This growth occurs principally at the root of the hair, though it is met with also along the rest of the follicle. During the period of disappearance of the disease there is a gradual return to the normal condition, until the hyperplasia, dilatation of the blood-vessels, and ceil- infiltration have completely disappeared. The Malpig- hian prolongations become smaller and smaller until the layer attains its normal size; the blood-vessels gradually return to their normal diameter, and the round cells and serous exudation to their normal channels. Of these pathological processes, the cell-infiltration and cedema generally disappear first, and the hyperplasia last. Psoriasis may sometimes undergo degenerative changes and become changed into epithelioma, as has been shown by White. The treatment of psoriasis must be in most cases both internal and external. The constitutional treatment of the affection should be based on a careful study of the history and habits of the patient. Attention should be given to the patient’s general health and his condition, whether stout and well nourished or thin and delicate. Regard must be had also to any functional derangement. The history of the eruption itself must be inquired into, as to its acuteness or chronicity, as to local and constitu- tional treatment which may have been previously em- ployed, together with the effects of the same. In ad- dition, inquiry should be made regarding the influence of the seasons, and whether the eruption is apt to dis- appear for a time and then to break out again. Fortified with this knowledge, the medical treatment can be entered into intelligently. In the large majority of cases, arsenic is pre-eminently the remedy. But while arsenic is as near a specific as, in the nature of things, it is possible for any medicine to be, yet it must be em- ployed judiciously if its good effects are to be obtained, or even if we do not wish to do harm. Arsenic should not, as a rule, be administered where there is much gas- tric irritation, and it is hardly necessary to say that it should not be continued, should it disagree even slightly. The patient should be warned of its. possible effects, and should be under the constant watch of the physician ; on the first symptom of indigestion, pain in the stomach or =. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. bowels, or diarrhcea, the dose should be lessened or the use of the medicine suspended. Large or almost toxic doses do not hasten the cure of psoriasis ; they some- times even retard it by upsetting the stomach. Some- times only a minute dose, as half a minim of Fowler’s solution, is borne at first, when, later, tolerance is gained and a full dose may be given. Some persons need and will bear large doses of arsenic, but this idiosyncrasy must be learned by careful tentative increase of the dose, beginning always with a moderate one. Arsenic should not usually be given in acute and inflammatory forms of psoriasis. Arsenic acts slowly. Where in a case of psoriasis it is going to do good, improvement generally begins to be shown after two or three weeks ; but to get the full benefit of the drug it must be given for several months, and its administration should be continued for several months after the eruption has disappeared. The best form in which to administer arsenic is, in the great majority of cases, unquestionably that of ‘‘ Fow- ler’s solution ’—Liquor Potassii Arsenitis—of which five drops contain about one-twentieth of a grain of arseni- ous acid, the average dose. The medicine should never be given in drops, as mistakes are likely to occur. A very good formula, and the one almost always employed by the writer, is the following: K. Liq. potas. arsenit., Gm. 8 (3 ij.) ; vini ferri, ad Gm. 128 (fZiv.). M. Sig.— Teaspoonful three times a day, after meals. The dose here is four minims. The amount may be gradually in- creased, say, every three days, until an effect upon the eruption becomes perceptible, or until the limit of toler- ance is reached. Sometimes it is desirable to give the arsenic in pill- form: &. Pulv. acidi arseniosi, Gm. .14 (gr. ij.) ; pulv. piperis nigra, pulv. glycyrrhize rad., 44 Gm. 3 (9ij.). _ M. et div. in pil. No. xl. Sig.—One, after meals. Or, occasionally, powders may be preferred : B. Pulv. acidi arseniosi, Gm. .14 (gr. ij.); pulv. sacch. lactis, Gm. 10 (gr. cl.). M. in chart No. xl. div. But neither pills nor powders are as effective as Fow- ler’s solution, and the writer rarely prescribes them un- less forced to do so by circumstances. Various other specifics have been recommended for psoriasis at different times ; tar, carbolic acid, turpen- tine, phosphorus, and iodide of potassium may be men- tioned. None of these, however, has stood the test of time. Some cases of psoriasis require, instead of the specific treatment, one directed against the patient’s general con- dition. In debilitated cases, cod-liver oil, iron, the hy- pophosphites, etc., are useful. In thin, worn-out wom- en, as nursing mothers, where the attack has come on during lactation, iron is imperatively called for. Next to iron is cod-liver oil, and these remedies occasionally succeed where arsenic fails. In acute inflammatory cases, diuretics are occasionally of service. Acetate of potassium, in half-drachm doses, may be given three or four times a day, in a wineglass of water. The alkaline mineral waters are also of service. The local treatment of psoriasis is of more or less im- portance, according to the nature of the case. Where the lesions are few, small, and widely disseminated, and there are no disagreeable subjective symptoms, local treat- ment is inconvenient, and need not be employed. Where, however, there are a few large patches, or where the eruption is situated on some conspicuous part of the person, or gives rise to annoying burning or itching, local treatment is required, and will be found advanta- geous. If there are scales, these should first be removed by rubbing with sapo viridis and hot water, or by the use of a hot-water bath. If the patches are few in num- ber, large, and very scaly, the following solution, well rubbed in, will remove the scales readily, and give an opportunity for making healing applications: h. Acid. salicylici, 4 Gm. (3j.); alcoholis, 64 Gm. (f ij.). This is especially useful upon the scalp. After the scales have been cleaned off by this means, or by means of spiritus saponis alkalinus (two parts of sapo viridis dissolved in one part of hot alcohol, and filtered) used as a shampoo, an oil composed of one drachm of oil of Psoriasis. Pterygium, cade to the ounce of oil of almonds or alcohol may be well rubbed in with the aid of a brush. On the edge of the scalp and about the face the best ointment is that of ammoniated mercury, twenty to forty grains to the ounce, vi Where it is desirable to get rid of the scales and patches in the most rapid manner possible, chrysarobin is the best application. An ointment of half a drachm to a drachm to the ounce is very efficient, and will remove a patch in a few days, leaving a white spot of skin surrounded by a purplish areola in its place. There are strong objections to the use of chrysarobin, however. It discolors everything with which it comes in contact, dyes the hair orange-yellow, and spoils the clothes. It cannot be used on the scalp or about the eyes and cheeks, because it induces inflammation there, and it cannot be trusted in the hands of most patients, be- cause, unless used cautiously, it may inflame the skin wherever used. G. H. Fox has suggested the following solution, which is effectual, though decidedly less so than the ointment, and which saves the smearing which renders the chrysarobin ointments so annoying and dis- agreeable: R}. Chrysarobin, 4 Gm. (3j.); stheris et al- coholis, 44 q. s.; collodii, 82 Gm. (%j.). M. Rubupthe chrysarobin with a little alcohol and ether and add to the collodion. It forms a sort of emulsion, which should be shaken before using. By the aid of a camel’s-hair pen- cil in the cork this may be painted over the affected patches after removal of the scales. When it dries it will not come off on the clothes, which is a great advan- tage. Next to chrysarobin in activity comes pyrogallic acid. This may be used in ointment, a drachm to the ounce. It is not so effectual, but ismuch more cleanly, although it leaves a blackish stain. It should not be employed over a very large area at once, for fear of absorption. Preparations of tar have been used from time imme- morial in the treatment of psoriasis. They are particu- larly useful when there is a good deal of itching. Pix liquida and oleum cadinum are the forms most commonly employed, either in ointment or dissolved in alcohol in the proportion of one or two drachms or more to the ounce. The solution known as ‘*‘ Tinctura Saponis cum Pice” is a useft/l application ; it is composed of-equal parts of sapo viridis, pix liquida, and alcohol. Wilkinson’s oint- ment is also useful, owing its virtues partly to the sul- phur which it contains. The formula for it is as fol- lows: RB. Olei cadini, flor. sulphuris, 44 12 Gm. (3 iij.) ; saponis viridis, adipis, a 24 Gm. (3 vj.); crete, 1.7 Gm. (gr. xxvj.). These preparations should be rubbed firmly into the diseased patches, once or twice daily. In very severe or extensive psoriasis, baths, with the inunction of bland oils and fats, are better than any of the applications mentioned. Tar may be used at times, but with caution. The prognosis of psoriasis, so far as the individual at- tack is concerned, is in medium and mild cases usually favorable. But the disease is prone to relapse, and the patient should be warned that while the attack can be cured, the affection is liable to return, and that no treat- ment, however well directed, will surely prevent the dis- ease from coming back. Severe cases especially, when almost the entire surface is covered with the disease, are often rebellious to all treatment. Arthur Van Harlingen. PTERYGIUM (arepvé, a wing). diagnostic of tricuspid stenosis. BIBLIOGRAPHY. Stokes: Diseases of the Heart and Aorta, Amer.-ed., p. 214. Philadel- phia, 1855. Bamberger: Lehrb. d. Krankheiten d. Herzens, p. 99. Wien, 1857; Wiirzburger Med. Zeitsch., Bd. iii., 1863. Friedreich : Deutsches Archiv f. klin. Med., Bd. i., p. 241, 1865. Taylor : On Pulsation of the Liver, Guy’s Hosp. Reports, 1875, p. 37%. Riegel: Deutsches Arch. f. klin. Med., Bd. xxxi.; p. 1, 1852; Sammlung klin. Vortrage, No. 227, 1883. Tripier : Lyon Méd., 1884. No. 42. Bramwell: Dis. of the Heart, etc. New York, 1884, p. 291. G. Baumgarten. 1 Potain : Des mouvements et bruits qui se passent dans les veines ju- gulaires. Soc. méd. des Hép., 24 Mai 1867. 2 Mosso: Die Diagnostik des Pulses, etc. 3 Riegel: Berlin. klin. Wochenschr., 1881. 4 Gottwalt: Arch. f. d. gesammte Physiologie, Bd. xxv., 1881. 5 Chauffard: Revue de Méd., July, 1884; Practitioner, December, 1884, p. 448. PUMPKIN-SEED (Pepo, U. S. Ph.). The seed of Cucurbita pepo Linn., order Cucurbitaceew, the common Pumpkin ; a vine scarcely known in the wild state, but probably of Asiatic origin. It has been cultivated from time immemorial for its edible fruits. Its seeds, as well as those of other species—gourds, squashes, and cucum- bers—have long been considered to have medical proper- ties (les grosses et les petites semences froides), but their Leipzig, 1879, p. 60. Pulse. Punta Rasa, present employment as teenicides is of rather modern origin. The seeds of several species and of numerous varie- ties of pumpkins, squashes, etc., are very similar in ap- pearance, and are probably supplied in the market some- what indiscriminately ; the officinal description will serve to eliminate some of them: ‘‘ About three-quarters of an inch (two centimetres) long, broadly ovate, flat, white or whitish, nearly smooth, with a shallow groove parallel to the edge; containing a short, conical radicle and two flat cotyledons ; inodorous, bland, and oily.” The testa is tough and flexible, and must be removed when the seed is prepared for use; the embryo is exalbuminous and has a pleasant, nutty, sweetish, oily taste. Pumpkin-seed, besides sugar, mucilage, albuminous sub- stances, ferments, and asparagin, contains twenty-five or thirty per cent. of a pale yellow, thickish, almost non- drying, odorless, and tasteless jived oil, composed of glycerides of oleic, palmitic, myristic, etc., acids, and some free acids. The medicinal power is contained in the oil, but has never been separated. Usrt.—This seed is a moderately efficient, agreeable, and entirely safe agent for the destruction of tape-worms. It should be. preceded by the usual preparatory fasting (see Koosso), and be followed by a cathartic. It is not quite so certain as koosso and pelletierine, but is much Climate of Punta Rasa, Fla.—Latitude 26° 36', Longitude 82° 10'.— Period of Observations, September 1, 1871, to June 15, , 1883.—Hlevation of Place of Observation above the Sea-level, 2 feet. A AA B Cc D E EF G H ' oO o bmAd lhe oO Bisabeg EEEHEREE ed g Fi Ee as a> AB a 2 2 aol "Sod eel ion Qa 4 NO o DP [oF af 5 a ga” gles” 8 = . : TS-4 — oO hee a2 a3 Pe Absolute maximum ||Absolute minimum ||..°¢ BS ie zs Mean temperature of months o~ Mean temperature ag ah temperature for temperature for || © of noes at the hours of sr for period of ob-) go ga period. period. BEE! Ot ge servation. Gh E a 2 oe aA v oH == Pease ES =) q q Ber Slas's 25 g 2. SEE BESS c ie s s Sossigoes S S E SPEE|SESS t seats ee see eee 1.688 : Bicarbonate of magnesium). 7c... caleak cece cchake 0.024 Organic matter: ete.) 1.8 ws eee cence eee aa 0.031 Total solide) x. ixiottaceeaeteaectes oe Pee io 10.700 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Pylorus. Quarantine. The amount of free carbonic-acid gas is less than is found in the chalybeate springs. The other saline waters are not drunk, but are used for bathing. A course of treatment at Pyrmont is espe- cially useful in those cases in which both chalybeate and saline waters are indicated, such as various scrofu- lous and nervous affections, diseases of the female sexual organs, catarrhal conditions, and diseases of the diges- tive organs, combined with anemia and debility. The season at Pyrmont is from the middle of May to the middle of October. In addition to the use of the waters, there are facilities for the various forms of “cures,” goat’s-milk, whey, pine-needle, etc., so popular at many of the German spas. Pele 8 PYROGALLIC ACID. ‘‘Pyrogallic acid” is the name in common use for the phenol pyrogallol, CsH3(OH)s. This body is producible by the action of heat on gallic acid, whence the name “‘ pyrogallic acid.” Pyrogallic acid presents itself in long, flattened prisms ; colorless ; bitter to taste ; soluble in two and a half parts of water, in alcohol, and in ether. In solution, exposed, the acid oxidizes, turning brown. Pyrogallic acid possesses the poisonous property, more or less common to the group of phenols, of affecting the blood and bringing about hemoglobinuria. Administered by injection to rabbits, this medicine has speedily caused chill, dyspnea, tre- mor of the extremities coming on in paroxysms, and death. The urine in such cases has shown the charac- teristic features of hemoglobinuria, and the blood has exhibited discoloration and destruction of the red blood- corpuscles. : In rapidly produced death by large doses, the blood has turned black or, in some cases, of a choco- late color and jelly-like consistence. In the human sub- ject death has resulted, in one instance, from the appli- cation, to one-half the body at once, of a ten per cent. pyrogallic-acid ointment. In this case a violent chill, with vomiting and collapse, set in six hours after mak- ing the application of the salve. The patient rallied, but forty hours later a second attack ensued, ending in coma, with great reduction of temperature. Death oc- curred on the fourth day. During the illness the urine was much diminished in quantity, and showed, in high- est degree, the condition of hemoglobinuria, being dark- brown in color and, upon standing, depositing a thick sediment of amorphous, blackish material. The blood was found, post mortem, disintegrated, and the kidneys bluish-black and stuffed with the same material as the urinary sediment. Pyrogallic acid has been used in medicine almost exclusively as a local application for the relief of certain skin diseases, notably psor¢asts—an application often successful when other remedies may have failed. Applied in solution or in ointment, pyro- gallic acid stains the skin somewhat, but the stain speed- ily disappears. Linen clothing, however, may be per- manently injured by the action of the medicine. To avoid this latter effect, a solution of pyrogallic acid in flexible collodion has been proposed (Elliot). Such prep- aration, when dried toa film upon the skin, seems still to exert the therapeutic action of the medicine, but, being dried, is without action upon the clothing. Pyrogallic acid may be applied in ointment or in solution, and strengths are used ranging from five to fifteen per cent. of theremedy. The higher percentages, in ointment cer- tainly, may irritate severely, and should be used with caution. Applications should never be extensive at any one sitting, for fear of enough absorption occurring to bring about constitutional poisoning. Hdward Curtis. QUARANTINE. The ancients during periods of epi- demic pestilence sacrificed to their gods or consulted the oracles on the best means of appeasing the offended de- ities, and in Christian times fasting and prayer have been undertaken as a means of preservation from these ‘‘ visi- tations of Providence.”” But so long ago as the time of Hippocrates more appreciative views of the origin of epi- demics were entertained, for that enlightened authority combated pestilence in Athens and other Grecian towns by directing the citizens to keep great fires burning in the streets, and feed them with herbs and drugs of sweet odor. This implied a recognition of that subtile atmos- pheric cause which even now exists in many lay and some professional minds, finding expression in the phrase epidemic constitution. 'The doctrine of contagion in rela- tion to these diseases appears to have been developed slowly and almost insensibly, for although Livy speaks of the Roman citizens shutting themselves up in their houses and paying attention to nothing except how to preserve themselves from the pestilence, the time of Boc- caccio was reached before systematic efforts were made to exclude contagion from a community. The epidemic which the former describes, devastated Rome B.c. 459, destroying most of the slaves, half of the citizens, many senators, tribunes, and priests, and two successive con- suls. The latter refers in his tales to the attempt made by Florence to preserve her citizens from the plague which overspread Europe in 1348, by denying access to all sick persons. When contagion was recognized in these epidemics— and probably most of them were, from the stand-point of to-day, either directly or indirectly infectious—a grand advance in preservative methods became possible. All European nations enforced laws for limiting the spread of leprosy, and these, which had been handed down from ancient times, had merely to be modified in their applica- tion in order to exercise a controlling influence on the spread of fulminant febrile diseases. The sanitary laws of Moses provided for the segregation of lepers and the fumigation and destruction of infected clothing. Among the Gentile nations these unfortunates were also ostra- cized ; they gathered in small communities in the out- skirts of cities, and ultimately hospitals were built for them. Even at the present day the spread of leprosy is controlled in the same way. In the Sandwich Islands, where two per cent. of the population is affected, the isolation of the disease to special settlements has been enforced since 1865, for contagion is acknowledged, and every leper, whether in the advanced or incipient stage, is looked upon as a dangerous focus of the malady. - When, therefore, contagion was appreciated asa factor in the propagation of wide-spread pestilential epidemics, the attempt to exclude it, as at Florence, naturally fol- lowed. Sanitary cordons were drawn around healthy places to preserve them, and around infected places to prevent the spread of their pestilence. Infected persons were taken out of the city into the fields, there to die or recover, and their attendants were forbidden to associate with anyone for ten days. Ultimately it became recog- nized that these epidemic diseases had their origin in the East—in Asia, Turkey, or Egypt—and entered Eu- rope by the Mediterranean seaports. Hence, in periods of freedom from pestilence, restrictive measures were concentrated at these ports to prevent its introduction. Venice at that time was the commercial metropolis of the world. Her vessels brought the products of the East to the Western nations, and among them, occasionally, the plague. A lazaretto was built for the isolation and treat- ment of infected sailors as early as 1423, but not until about 1484 were laws enacted requiring every vessel from suspected localities to undergo a period of detention and observation prior to the admission of her crew, passen- gers, or cargo. As this period embraced forty days, the term quarantine came to be applied to it and all matters pertaining to it. Lazarettos and quarantine codes were afterward established at other exposed seaports, as at Malta, Ancona, Messina, Leghorn, Genoa, Trieste, Mar- seilles, etc. As the accommodation for suspects was gen- erally insufficient at these quarantine stations, much hardship was inflicted during the period of probation. The full operation of the system was required only occa- sionally, in times of emergency, and as it was rarely equal to the occasion, extemporizations were necessitated ; but these did little to mitigate the evils of the enforced detention of healthy persons in dangerous proximity to those who were infected. Thus quarantine, to its victims, appeared imbued with a spirit of inhumanity, cruelty, and reckless tyranny ; and although its methods at the present time are wholly changed, much of the barbarism 117 Quarantine. Quarantine. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. of former years continues associated with the use of the term. Unfortunately the seaport quarantines, no matter how rigorously enforced, frequently failed in their efforts to exclude the plague and prevent its spread into the inte- rior. In this event, sanitary cordons became the estab- lished method of limiting the progress of the pestilence— they constituted, in fact, a species of inland quarantine ; and, even at the present day, the panic occasioned by an extended prevalence of a deadly epidemic not infre- quently calls into existence a vigorous but unnecessary policy of non-intercourse, known in Europe as the cordon militaire, and in this country as the shot-gun quarantine. Improvements in the sanitary condition of Europe, consequent on the progress of modern civilization, have succeeded in preventing those terrible visitations of the plague against which quarantine was first instituted. London has not suffered since 1665, and although certain sections specially exposed to infection from the East, as Egypt, Turkey, Malta, Italy, and Spain, have been visited during the present century, the disease is now mainly con- fined within the Asiatic boundary and seldom threatens the invasion of Europe. But the necessity for quaran- tine did not cease on the subsidence of this disease, for yellow fever from the West Indies and certain parts of tropical America occasionally ravaged the seaports of Southwestern Europe, and more recently cholera from In- dia has spread epidemically in the pathways of commerce. The former was first imported into Spain from Havana in 1741 ; but its appearance on European soil exercised no modifying influence on quarantine measures—those in use against the plague were applied for the exclusion of this new exotic. The latter made its first progress through Europe in 1830; and as its westward track from its origin in India was well recognized, the quarantines at the Mediterranean ports became considerably relieved and Western civilization protected by the establishment of special quarantine stations for the interception of the disease in the Red Sea and at points on the overland route. About this time the severity of the requirements of quarantine became lessened. The natural history of epi- demic disease was better known, and instead of an arbi- trary detention of so many days the period became based on that of the incubation of the disease to be excluded. Thus in France, in 1847, vessels from infected ports in Turkey and Egypt were admitted without restraint, if ten days had been consumed in the voyage and no dis- ease had appeared on board in the meantime. An im- perial decree, in 1853, admitted such vessels at once into the Atlantic ports of France, and into the Mediterranean ports if eight days had elapsed since leaving the port of departure. Steamers from Alexandria to Marseilles landed their mails at once, however short the voyage, but passengers were detained until the period of eight days had passed. Vessels from infected ports were quaran- tined for ten days after arrival at any of the ports of the empire, and their cargoes for ten days after their removal at the quarantine station. These regulations had regard to plague. With respect to cholera, vessels from infected ports were, in the Mediterranean, subjected to a quaran- tine of five days including the voyage, and in the Atlantic ports to one of three to five days when one or more cases of the disease had occurred on the voyage ; but no quar- antine was imposed on the cargo. Vessels from places infected with yellow fever were quarantined from three to seven days at the Mediterranean ports, but had free entry on the Atlantic coast if no sickness or death had occurred during the last ten days of the voyage. In this country quarantine was instituted against yel- low fever from Barbadoes, and typhus and small-pox from the other side of the Atlantic. Philadelphia suf- fered from the Barbadoes distemper in 1699, and in the following year the Province of Pennsylvania endeavored to secure protection in the future by passing an ‘‘ Act to prevent sickly vessels from coming into this Govern- ment,” which required, under penalty of one hundred pounds, that such vessels should come no nearer than one mile to any of the towns or ports of the province, 118 nor land goods or passengers until they had received a license from the proper authorities. Massachusetts en- acted a quarantine law in 1701 against vessels infected with plague, small-pox, pestilent or malignant fever, or other contagious disease, or coming from places where such maladies prevailed, prohibiting all communication between the infected or suspected vessels and the shore. In 1758 the colonial legislature established quarantine at New York by an act to prevent the bringing in and spreading of infectious diseases in the colony. After the successful passage of the Atlantic by cholera in 1882, this disease became added to the list of exotic pestilences which it was the object of quarantine to exclude. Based originally on the theory of contagion, quarantine measures were directed to the detection and isolation of infected individuals, but the transmission of disease by fomites placed restrictions also upon goods, particularly such as experience had shown to be efficient carriers of the morbific matter. This interference with the liberty of the individual, combined with the financial interests in- volved, raised a continued opposition to quarantine de- tention, which became more outspoken on every fresh demonstration of the inability of this measure to accom- plish its object. Indeed, the burdensome nature of the restrictions led in many instances to their evasion and consequent failure to protect the community. Unfortu- nately there were many such failures in the operation of every quarantine ; and the opposition did not hesitate to affirm that the quarantine system was a barbarous impo- sition of the middle ages, of no value as a protective measure, and operating merely as an impediment to commerce. The reply to this acknowledged the inabil- ity of quarantine to guarantee protection, but claimed that the chances of importation were reduced in propor- tion to the care with which the regulations were enforced. ‘‘Shall we,” as Sir Sherston Baker says, ‘‘ abolish the fire brigade because a row of houses are burned down ? Shall we dismiss the police force because a dozen bur- glaries have occurred? Shall we denounce the system of railway signalling because a false signal has caused a fatal catastrophe ?” The immense importance of her commercial relations to England has made that country a leader in the estab- lishment of a sanitary system which will give adequate protection without imposing the burdensome restraints of former times. Originally her quarantines, directed against the plague, were formulated on those in exist- ence at the Mediterranean seaports; but since cholera became the pestilence specially to be guarded against, a system of sanitary inspection has been urged for adop- tion at the Red Sea stations, and accepted as the only needful measure at her home ports. Quarantine regulations did not take practical shape in Britain until the beginning of the present century. Con- sular officers at foreign ports furnished bills of health to vessels clearing for the United Kingdom. A clean bill implied that no infectious disease existed at the port of departure at the time of sailing, nor had existed for forty days prior to that time. This did not entitle the vessel carrying it to free pratique unless the superintendent of quarantine was satisfied that her crew and cargo were free from suspicion; and, indeed, all vessels laden with cotton from Alexandria were obliged to undergo quaran- tine irrespective of the character of their bills of health. A suspected bill was given to vessels when.the port of de- parture, although free from disease, had commercial rela- tions with infected ports or places. aleicuh Sesion 1.759 DOCLIMMSELD TAGE a crn ersitictetec oie ae! oecceik's elaehee sore 5,-< 0 Mis 0.498 Magnesium sulphate. ............ See. Aa OM 0.307 Magnesium chloride......... Lh oewas eo ateh aes 0.014 Sodimmachlonide.s. saht< ates aces alee Sib evaltls Sie Sisiesa te alates 0.009 CaleimTchioride. sici. = greater than, < = less than, 148 As the process of degeneration advances we first find that the anodal closing contraction is equal to the catho- dal closing, and that the anodal opening contraction is equal to the cathodal opening, but as the degeneration becomes confirmed we find the formula expressed : D: Rie An Cl C.> Ca ClCeraAn.O CAGa Oe Ultimately it is impossible to get any response what- ever, except perhaps a weak anodal closing contraction. When such an advanced degree of degeneration exists the muscle undergoes atrophic changes, and its essential elements, more or less, disappear, while fatty deposit takes place. If the abolition of conductivity is not too extreme, or does not last too long, we find after a time an inverse restoration, the muscle responding feebly at first to an interrupted galvanic current of great strength, the normal reaction being finally attained, and afterward faradic excitability. For the electric diagnosis of the reaction of degeneration we should make use of a milli- ampere metre, and begin with a minimum current which may afterward be increased. If it requires a current of several milliamperes to evolve a response, we may meas- ure the qualitative improvement by the reduction in the required strength and note the same. Small carbon elec- trodes covered by absorbent cotton are the best. I have of late dispensed with cell selectors, and use simply a water rheostat and a milliampére metre. Allan McLane Hamilton. RECOARO, near Valdagno, in Venetia, is a pleasantly situated spa, lying in a sheltered valley at an elevation of about 1,500 feet above the sea. The climate is mild. There are ten or more springs in the place, the most im- portant of which are the Lelia, Amara, Lergna, Giuliana, Civillina, and Virgiliana. The first four of these are the property of the government. The following is the anal- ysis (made by Ragazzini) of two of these springs, com- puted in parts per thousand : Fonte Lelia. Fonte Giuliana. Calchumesuipiate; sae nteat ease sete ee 1.310 trace Calcium ‘carbonate’: 2% 5 o's ssc orm 1.016 0.100 Herrousicarbonates: issue. cence ee oe 0.069 0.063 Magnesium carbonate................ 0.099 - 0.051 Sodium eul phate ce ay ovis. es clic 0.045 0.010 Magnesium sulphate................-- 0.679 0.451 Macnesitimichloride 2. -4e0s..: essen. 0.004 0.003 SiliciGiacid 64 eae Avene eee eer 0.017 0.009 Organic matters) CC. ewes ree 0.022 0.013 Totaliva hoses thee ie cies 6 Gents 8.261 0.700 The waters of Recoaro are given chiefly internally, though baths are also employed to a certain extent. They are recommended in the treatment of ansemia, in con- valescence from typhoid fever and other debilitating diseases, in catarrhal troubles of the digestive and uri- nary systems, and in the visceral congestions following rebellious malarial fevers. The season extends from May to the middle of September. LeeLee RECTO-VAGINAL FISTULA. A communication be- tween the rectum and vagina. In rare instances an opening is established between the vagina and some higher part of the intestine, oftenest the lower part of the ileum. A coil lying in the Douglas pouch may be- come adherent, and ulcerate or rupture into the vaginal cul-de-sac. Symproms.—The escape of feeces and intestinal gases into the vagina and from the vulva. In some cases, when the edges of the fistula are ulcerated or cleanliness is neglected, vaginitis and vulvitis result. Then the pa- tient suffers from itching, soreness, and offensive dis- charge. In sensitive natures this distressing infirmity induces depression of spirits, amounting sometimes to melancholia. The severity of the symptoms depends, however, on the size of the opening and the state of the bowels. If the opening be small, the diet properly reg- ulated, and the parts kept clean, all the symptoms will be greatly mitigated. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. CausEs.—These may be classed under two heads— mechanical violence and disease. Mechanical Violence.—All forms of difficult or instru- mental labor in normal or deformed pelves; the use of forceps and the exercise of undue manual force; cepha- lotripsy ; slipping of blunt hook, or other instrument used in the reduction of the size or extraction of the child ; laceration by splinters of the bones of the fcetus. Contraction or other deformity of the bony pelvis, as from tumors, exostoses, and anchylosis of the coccyx ; and a narrow or indistensible condition of the vagina, strongly predispose to this injury during labor. Certain operations, such as those for the relief of stenosis or atre- sia of the vagina; extirpation of tumors of the uterus or vaginal walls; excision of cancer of the rectum; and perforation of the rectum from rough or unskilful ad- ministration of enemata are occasional causes. Pessaries, when ill-fitting or neglected, sometimes ulcerate into the rectum, though much more rarely than into the bladder. Recto-vaginal fistula following labor are usually the re- sult of lacerations; more rarely they result from pro- longed pressure causing a slough with perforation. . Disease. —Cancerous, syphilitic, or other ulceration not rarely results in perforation of the recto-vaginal septum. Abscesses of the septum, from whatever cause, may rupt- ure into both rectum and vagina. Suppuration of an adherent pelvic dermoid, or other ovarian tumor, or of an extra-uterine gestation-sac, may establish a fistula be- tween rectum and vagina. The latter causes lead espe- cially to the formation of fistulae communicating with the upper part of the vagina. Recto-vaginal fistula is very rare except in adults, but is not unknown even in infants. Bednar relates a case of gangrene of the recto-vaginal septum, resulting in fistula, in an infant of four weeks. This child died of cellulitis of the right arm. Witter relates another in a child of seven months, who had suffered from thrush for several months, when suddenly feces began to escape from the vagina, and an ulcerated opening was found in the recto-vaginal septum. to 345° C. per second, otherwise the an- imal might pass motionless into rigor caloris. Foster (Journal of Anat. and Physiology, vol. viii., p. 45) found that if only the toes were immersed, it was impossible to pass, however slowly, above 35° C. without reaction ; and explained the fact of easier reaction following the immersion of a smaller area by comparing it to the easier stimulation of a nerve through a bit of skin than through the whole nerve-trunk. Fratscher, however, finds it 155 Reflex Actions, Reflex Actions, REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. _ possible to go higher than 35°; indeed, as high as is de- sired even with the smaller area. It has been suggested by Sedgwick (Studies from Biol. Lab. Johns Hopkins Univ., ii., 885) that the greater difficulty of arousing reflexes by thermal stimuli, when larger areas are im- mersed, is due not so much to the stimulation of a large area as to the heating of the whole animal by the circu- lating blood to such an extent that the contrast between the part in the water and that out of it never amounts to enough to constitute a stimulus. That this is very likely true is shown by stopping the circulation at the begin- ning of an experiment ; after which it is found that com- paratively low temperatures produce movements, even when large areas are immersed. The question has been raised whether the reflexes pro- duced by various stimuli are produced through the same end-organs. Tiirck, who first introduced the subject, takes the affirmative. Setschenow (Setschenow und Pas- chutin, ‘‘ Neue Versuche,” etc. Berlin, 1865), and Dani- lewsky (Archiv fir Anat. und Physiologie, 1866, p. 677) take the negative, the latter holding that a difference ex- ists between ‘‘ tactile” and ‘‘ pathic” reflexes. The sub- ject cannot be further treated here, but it may suffice to say that the present tendency appears to be toward the idea of a (limited) number of end-organs, rather than of one kind susceptible to all sorts of stimuli. Hlectrical Stimulation.—The same general statements may be made here as in the other cases of stimulation. The constant current is effective only when of a certain strength ; but summation may occur and give rise to stimulation, in the use of streams so weak as to be ineffec- tive, by making thecurrent interrupted. Induced currents at rather long intervals may be of considerable strength, and yet produce no reactions ; while weaker but more frequent currents may be ‘‘summated” and produce re- actions. This whole subject has been accurately studied by Stirling (‘‘ Berichte der Konigl. Sachs. Gesellschaft der Wissenschaften,” 1874, p. 372), who carried out his investigations in Ludwig’s laboratory, and employed novel and exact apparatus. Reference must be made to his complete paper for the details. THE Nervous MECHANISM OF REFLEXES.—Since the time of Mayow, Hall, Miller, and Grainger (vide supra), there has never been any doubt that the brain acts as a central reflex organ. It does not appear to act as a whole, but the cerebrum and cerebellum seem rather each to include many centres. The spinal cord, how- ever, is the central reflex organ par excellence, not so much from the great number of reflex centres located in it (for it must be remembered that the extreme hind- brain—the medulla oblongata—is very rich in reflex cen- tres), as from the fact that this is probably its most im- portant function, while the brain, including the medulla, is much devoted to other important functions. It must not be forgotten, however, that the hindmost portion of the spinal cord does not act as a central reflex organ, as was first shown by Volkmann (Miiller’s Archiv, 1888, p. 15; 1841, p. 354), and has since been confirmed. Thus Sanders-Ezn (1867) affirms that no reflexes can be obtained from the cord of a frog behind the level of the eighth pair of spinal nerves. Koschewnikoff states that all re- flexes cease upon removal of the cord as far back as the middle of the fifth vertebra. Eckhard finds that even strychnized frogs showed no reflexes with the hindmost portions only of the spinal cord intact. It is no longer held by anyone that reflexes occur ac- cording to the old doctrine of the peripheral anastomoses. ‘When, however, we turn to the question whether or not the sporadic ganglia can serve as reflex centres, we find amass of conflicting testimony, and great difference of opinion. It may be said, meanwhile, that although the possibility that they may so act is granted, no sufficient proof has yet been given that they do or do not. At the same time it cannot be denied that if they do act as reflex centres some evidence of the fact ought to be easily ob- tained ; and, on the other hand, it is not difficult to see the advantages which must accrue to that organism - whose central government is instantly and directly in- formed of changes occurring in its periphery. It is much 156 easier on @ prior? grounds to suppose internal, and, so to speak, domestic affairs, such as the heart-beat, vaso-motor actions, and the like, to be partially self-controlled, auto- matic, or even purely reflex, than more external affairs, such as locomotion, motion, secretion, etc., which are far more irregular and unequal. In the latter the ad- vantage of a central co-ordinating apparatus in direct communication with every part of the body is too evident for debate. That this central system should reserve di- rect reflex authority over the periphery, and surrender to internal machinery the general control of vaso-motor actions, etc., is also quite within the limits of possibility. Studies of the reflex powers of sporadic ganglia have been made upon the cardiac ganglia, the inferior mesen- teric, and the submaxillary ganglion, all of which are macroscopic, besides the microscopic ganglia of the blood-vessels, etc., either known or supposed to exist. Most famous of all is the controversy of which the reflex functions of the submaxillary ganglion form the subject. This ganglion, from its size, its accessibility upon the living animal, and from the ease with which its effects upon salivary secretion can be estimated, is well adapted for use as a ‘‘test case.” It is connected with the sub- — maxillary gland by the chorda tympani, with the tongue by the lingual, and with the brain by both. The debate was begun by Claude Bernard (Comptes Rendus, 1862, ii., 341), who seems to have overlooked the earlier experiments of Grainger (see above), and was taken up by Kiihne (Lehrbuch der Physiol. Chem., 1868, p. 8) and Vulpian (Lecons sur Vapp. vaso-moteur, i., 311, 1875), who supported Bernard, and by Eckhard (Zezt- schrift fiir ration, Med., xxix., 74), Heidenhain (Breslau Studien, 1868), Bidder (Archiv fir Anat. und Physiol., 1867, 1), and Schiff (Moleschoit’s Untersuchungen, x., 1870, p. 423), who opposed him in the theory that the submax- illary ganglion acts as a reflex centre for salivary secre- tion. This celebrated discussion, so important to the student of the physiology of reflex actions, has been ad- mirably reviewed and summed up by Dr. Michael Foster in his well-known ‘‘ Text-book of Physiology,” where he treats of the physiology of secretion in general, and then proceeds as follows : ‘‘In the angle between the lingual and the chorda tympani, where the latter leaves the former to pass to the gland, lies the small submaxillary ganglion, from which branches pass to the lingual on the one hand, and to the chorda on the other; branches may also be traced toward the ducts and glands, and toward the tongue, It has been much debated whether this ganglion can act as a centre of reflex action. ‘‘Bernard found that after he had divided the con- joined lingual and chorda at about one centimetre above the place where the chorda diverges to the gland, stimu- lation of the lingual at about three or four centimetres distance below the ganglion still caused a flow of saliva ; this effect, however, was no longer seen when the branches passing from the ganglion to the lingual had been pre- viously divided. He explained the result by supposing that the impulses generated by the stimulus were con- veyed by afferent fibres in the lingual, along the lingual roots of the ganglion, to the ganglion, and were thence reflected by efferent fibres along the branches from the ganglion to the chorda, and so to the gland. The gan- glion, in fact, acted as a reflex centre. ‘The same appar- ent reflex secretion could also be induced, but less read- ily, by pinching the peripheral branches of the lingual near the tongue, or by dipping them into concentrated salt solution. In this case also the secretion failed to appear if the lingual roots of the ganglion were divided. Such a reflex secretion was very difficult to obtain by stimulating the mucous membrane of the tongue ; but Bernard was successful when he stimulated the tongue directly with a galvanic current, or drew the tongue out and placed ether on its surface. The secretion in all these cases was accompanied by a dilatation of the blood- vessels of the gland, and the effect on the gland was in- deed wholly similar to that of directly stimulating the chorda. Bernard further insisted that in these experi- ments no anesthetics were to be used, and observed that REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Reflex Actions. Reflex Actions. the reflex act was no longer visible when two or three days had elapsed after section of the conjoined lingual and chorda trunks. Both these facts rather militate against his view, since it seems improbable that a spo- radic ganglion should be so susceptible of anesthetics, or that degeneration and functional incapacity of the gan- glion should follow upon section of the conjoined lingual and chorda, so long as the afferent and efferent connec- tions of the ganglion with the gland and tongue were kept up. ‘Eckhard, in repeating Bernard’s experiments, failed to obtain any effect from dipping the endings of the lin- - gual nerve in salt solution, or from placing ether upon the tongue, and he very naturally argued (being support- ed in this by Heidenhain) that the effects seen when gal- vanic stimulation was employed were due to an escape of the current upon the chorda fibres. Schiff did obtain reflex secretion, after section of the conjoined lingual and chorda, by direct galvanic stimulation of the tongue, and by pouring ether on the surface of that organ; but the currents necessary in the first case to produce any effect were so strong that escape must have taken place, and in the second case the secretion appeared even though the lingual was divided close under the tongue, and when, therefore, this nerve could not have been the channel for conveying impulses to the submaxillary ganglion. He further pointed out that in large dogs, at all events, certain fibres of the chorda, after running along the conjoined lingual and chorda, do not leave the lingual with the rest of the fibres going straight to the gland, but continue in the lingual close up to the tongue, then bend round, and, as recurrent fibres, run back and eventually join the nerve going to the gland. He in con- sequence argued that Bernard, in stimulating the lingual below the divergence of the chorda, was in reality stim- ulating not afferent but efferent fibres. But in sucha case these recurrent fibres must pass to the chorda through the ganglion, if Bernard’s result be true that the reflex effect ceases when the lingual roots of the ganglion are divided. Schiff further states that these recurrent fibres degenerate in the retrograde portion of their course when the lingual is divided near the tongue, and that no effect follows upon stimulation of the lingual if the lingual have, some five or six days previously, been divided close to the tongue, so as to cause degeneration of the recurrent fibres; provided that the stimulation be not so strong as to lead to an escape of the current to the main chorda fibres. In small dogs Schiff could not so readily demon- strate these recurrent fibres, and though he says the ap- parent reflex secretion is more easily obtained in large dogs, such as Bernard probably used, than in smaller ones, it is improbable that mere size should make such a difference in nervous distribution ; and if an escape of current can explain the results in the one case, it can also, probably, in the other. ** Bidder’s account of the nerves of the ganglion at first sight offers support to Bernard’s views. In the dog he finds, passing from the ganglion direct to the tongue, medullated nerve-fibres which do not degenerate when the chorda is divided at its exit from the skull. These fibres, accordingly, would seem to take their ori- gin in the ganglion, and to be the afferent nerves required for Bernard’s views. When Bidder divided the con- joined lingual and chorda he found fibres, the chorda fibres, after about three weeks, completely degenerated ; not only those forming the nerve going to the gland, but also those constituting the branches going to the gan- glion, 7.¢., the chorda roots of the ganglion. In the gan- glion and in the branches going from the ganglion to the gland were seen numerous degenerated fibres in the midst of undegenerated (but non-medullated) fibres which seemed to have their origin in the ganglion itself. Thus, after complete degeneration of the true chorda fibres, there still remained intact (1) the ganglion, (2) fibres from the ganglion to the tongue, and (8) fibres from the ganglion to.the gland; in fact, exactly the ner- vous mechanism demanded by Bernard’s view. But Bidder, like Eckhard, failed to obtain a reflex secretion by pouring ether on the tongue after division of the con- joined lingual and chorda, and he found that galvanic stimulation of the nerves going from the ganglion to the tongue was of no effect, provided that errors due to es- cape of current on to the main chorda fibres were avoided by previously inducing, through section, degeneration of the chorda fibres, including the chorda roots of the gan- glion. So that Bidder’s results in the end oppose the view that the ganglion can act as a centre of reflex ac- tion. In fact, such a view must be regarded at present as not proven.” For the discussion of cardiac and other vaso-motor ganglia, etc., as reflex centres, the discussion of which belongs rather to the physiology of automatic actions, reference must be made to the original paper of Eckhard (Bettrage zur Anat. und Physiol., ix.), where, also, the literature may be found 7n extenso. INHIBITION OF REFLEXES.—The actions of the animal body may be physiologically interrupted, postponed, or otherwise modified. Such interruption or postponement is called tnhibition, of which the most striking example, perhaps, is the slowing or total stoppage of the automa- tic heart-beat by stimulation of the pneumogastric nerve. More familiar examples are the voluntary refusal to be tickled, or to sneeze, or to cough when only a strong effort of the will forbids what would otherwise hap- pen; the frequent insensibility to pain when greater pain is being suffered ; and the unsusceptibility to many stimuli, ordinarily effective (absent-mindedness or pre- occupation), induced by ‘‘absorbing” pursuits of work or play. All these phenomena, and more, were well known when, in 1868, Dr. J. Setschenow, professor of physiology in St. Petersburg, published a work upon in- hibition (‘‘ Physiologische Studien iiber die Hemmungs- mechanismen fiir die Reflexthatigkeit,” etc., Berlin, 1863) which immediately drew general attention to the subject. It had been observed already that the reaction-time of a frog is greater before than after decapitation, or, in other words, that reflex actions are more quickly performed in the absence of the brain. Setschenow states, at the be- ginning of his monograph, that there were at that time two possible explanations of this increase of reflex-exci- tability consequent upon decapitation, viz. : first, that since the spread of sensory (afferent) impulses must tend to weaken them according to the area over which they are extended, those which cover the smaller area should give rise to stronger reflexes. Hence, when the head is cut off, because the sensory impulses are more confined the reflex of any given impulse is more intense. Or, second, that the brain normally exerts an inhibitory action-upon the reflex excitability of the spinal cord. This latter the- ory Setschenow accepts and proceeds to verify, regarding it the more worthy of support since ‘‘ Ed. Weber, speak- ing with a certain authority (on account of his celebrated discovery of the inhibitory influence of the vagus upon the heart), had first suggested that the will, whose seat is commonly supposed to be in the brain, is in a position to exert an inhibitory influence upon the reflex functions of the spinal cord” (loc. cit., p. 1). This hypothesis seemed to presuppose the existence of “inhibitory mechanisms,” and to find these Setschenow set to work. By cutting away the hemispheres no marked effect was produced ; but whenever the optic lobes or optic thalami were re- moved, the excitability of the cord rose; whenever they were irritated it was depressed. Setschenow concludes as follows (loc. cét., p. 35): 1. The inhibitory mechanisms for the reflex activity of the spinal cord have their seat, in the frog, in the optic lobes and corpora quadrigemina, and in the medulla ob- longata. 2. These mechanisms must be regarded as nerve-centres in the broadest sense. 3. The afferent nerve-fibres form one (and probably the only) way for the excitation of these inhibitory mechan- isms. ; In the twenty-five years which have gone by since Set- schenow propounded his theory of the existence of special centres for reflex inhibition, it has found numerous ad- herents and opponents. The former have added little enough to the evidence upon which Setschenow’s theory 157 Reflex Actions. Registration. is based, while the latter have made it clear that the hypo- thesis is probably gratuitous, the facts involved being more easily explained otherwise. To give the whole history of this debate would carry us too far into details, and for these we must refer again to Eckhard (Beitrdge zur Anat, und Physiol., ix.). The tendency of physiolo- gists to-day is to look upon the inhibition of reflexes, not as a peculiar function of a special inhibitory centre or centres, but as one phase of inhibition in general, some- what as follows: The central nervous system is a system of centres—automatic as well as reflex—closely bound to- gether by nerve-fibres. The separate centres are to a great extent independent, but by no means entirely so, each being more or less influenced in its activity by others. Into this central system (brain and spinal cord) impulses, recognized or unrecognized by consciousness, are con- tinually flowing from the eye, the ear, the heart, the vis- cera—in short, through every afferent nerve. Within the system itself impulses are started by the automatic cen- tres and sent along its length as well as outward. Each centre, therefore, is always affected more or less by every other, and by afferent impulses arising in the peripheral sensory end-organs. To remove a quantity of these in- ward-bouna impulses is to alter materially the conditions affecting the centres. But to remove the hemispheres of the frog is probably to remove only a very limited and (in the frog) uninfluential group of automatic centres. To take away the optic thalami, optic lobes, and medulla, however, is to remove the most important of all the in- coming impulses, viz., those from the eyes, the ears, and the great pneumogastric, which of all the nerves probably modify most the more purely mechanical functions of the cord. It is not surprising, therefore, that after de- capitation the cord, freed from the interference ordinarily produced by these impulses, should work, from a mechan- ical point of view, more perfectly, passing into an abnor- mally sensitive condition analogous to hyperesthesia. Or, again, to remove the cerebral hemispheres and then stimulate the mid- and hind-brain with salt, after the man- ner of Setschenow, thus producing a depression of reflex activity, is plainly to intensify the impulses passing down into the cord, and to increase interference. That salt does not so readily do this when applied to the cut end of the cord after the brain has been all removed, is probably be- cause in the former case the salt-produced impulses were added to the ordinary impulses going from the hind- brain, while now they are alone; previously they acted upon a cord already normally ‘‘ depressed,” while now they act upon a cord abnormally exalted. On the other hand, stimulation of one sciatic inhibits more or less*per- fectly the reflexes performed by the other; and yet sec- tion of one is said to depress the reflex powers of the other. The fact is, we are not yet in a position to dogma- tize upon the subject of reflex inhibition, and the whole subject urgently demands further elucidation. THE TIME ELEMENT IN REFLEX AcTIons.—Exner has estimated the time required for a stimulus applied to one eyelid to make the other blink. a erect fang, which is situated OES farther. back than that of the i OOS s=— Crotalids. The tail is slender eS es=sse and continuous with the body, * and has norattle. All the culee TR parame age ae a of the body are smooth, not ; keeled as in Crotalus, Figs. 3237 and 3238 represent the head of Hlaps fulvius, the Harlequin Snake. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. The colors of the different species of this genus are generally red for the body tint, with black, red, or yel- low annulations, and their similarity to certain non-venomous snakes makes _ them particularly dangerous, as in- { stances are on record of individuals having suffered in consequence of handling what were supposed to be innocuous serpents, but which really belonged to the genus Hlaps. The genus Heloderma contains but one species, viz., Heloderma suspectum, the ‘‘ Gila Mon- ster,” which may be described as a large stumpy lizard with a short tail, the whole reptile sel- Fie@. 3237.—Elaps Ful- vius. View of head from above. SOFAS dom exceeding eight inches i f WA g eighteen inches in eee length. The head, sub-triangular in ruieene at a .__ Shape, is separated from the body by 1G tho same, & Constricted neck, and the whole of its upper surface is covered with ovoid -tuberculated scales. The color is brownish-black, inter- spersed with yellowish spots. (See Plate XXVIII.) It is of interest because of the peculiar character of the teeth, which somewhat resemble those of poisonous serpents. Dr. Jacob Wortman, who has made a careful study of the dentition of this curious reptile, states as follows: Fie, 3239.—Heloderma Suspectum, as seen from above. “The form of the crown is that of a long, slender, sharp- pointed cone, curved inward and backward. The ante- rior outer surface of each tooth is marked by a well-de- fined groove, extending from the base to the apex. It is somewhat deeper at the base than at the summit, and is most distinct in the teeth of the lower jaw. The intervals between the bases of the teeth allow abundant room for the accommodation of poison-glands, the secretion of which is conveyed down the grooves and thus injected . into the wound which the teeth inflict upon a prey.” Fia. 3240.—The same; side view. Whether true poison-glands actually do exist, has not yet been accurately determined. will convey an excellent idea of the appearance of the head of the Heloderma, seen from above and in profile ; the black line running vertically through the snout, hav- Ing a hook at its lower end, is intended to show the lip drawn up, as under ordinary circumstances the teeth are concealed by the lips. Having thus briefly considered the characteristics of the venomous reptiles, it may be proper to give a de- scription of the mechanism which controls and operates the poison-fang apparatus of all our venomous serpents Figs. 8239 and 38240 : Reptiles. Reptiles, with the exception of Hlaps, the account being substan- tially the same as was published by Dr. Elliot Coues and the writer as a result of their herpetological studies, a few years since, more modern researches having in no wise induced an alteration of the opinions then expressed. In the production of the bite the active instruments are a pair of deciduous fangs, one on each side of the upper jaw, rooted in the maxillary bones, which bear few, if any, other teeth ; but it should be mentioned as a mat- ter of interest that, while in Crotalus confluentus the fangs are generally shed or pushed out of place at vari- able periods of time (probably in twelve months), in Cro- talus atrox, a species common in the Sonoran region, this shedding or loss frequently fails to take place, and it is common to find, generally in the right side of the jaw of this species, two or more fangs in position. In one specimen, in possession of the National Museum, three are to be seen in position, and behind them are others well advanced in growth. The fangs vary in size, being sometimes three-fourths of an inch in length. They are somewhat conical and scythe-shaped, with an extremely fine point ; the convexity looks forward, the point down- ward and backward. The fang is hollow for the trans- mission of the venom, but the construction of the tube is not as if a hole had been bored through a solid tooth. It is in effect a flat tooth, with the edges rolled over to- gether till they meet, converting an exterior surface, first into a groove, finally into a tube. This is shown, on mi- croscopic examination of a section of the tooth, by the arrangement of the dentine. Unlike an ordinary tooth, the fang is movable, and was formerly supposed to be hinged in its socket, since it is susceptible of erection and depression. But the tooth is firmly socketed, and ‘the source of this movement is the maxillary bone itself, which rocks to and fro by a singular contrivance. The maxillary is a small, stout, triangular bone, movably ar- ticulated above with a smaller one, the lachrymal, which is itself hinged upon the frontal. Behind, the maxillary articulates with the palatal and pterygoid, both of which are of rod-like shape, and are acted upon by the spheno- pterygoid muscle, the contraction of which pushes them forward. This forward impulse of the palatal and ptery- goid is communicated to the maxillary, against which they abut, causing the latter to rotate upon the lachry- mal. In this rocking forward of the maxillary, the socket of the fang, and with it the tooth itself, rotates in such manner that the apex of the tooth describes the arc of a circle, and finally points downward instead of back-- ward. This protrusion of the fang is not an automatic motion, consequent upon mere opening of the mouth, as formerly supposed, but a volitional act, as the reverse motion, namely, the folding back of the tooth, also is ; so that, in simply feeding, the fangs are not erected. The folding back is accomplished by the ecto-pterygoid and spheno-palatine muscles, which, arising from the skull behind as a fixed point of action, in contracting draw upon the jaw-bones in such a way that the maxil- lary, and with it of course the fang, are retracted, when the tooth is folded back with an action comparable to the shutting of the blade of a pocket-knife. All the mo- tions of the fangs are controlled by these two sets of an- tagonistic muscles, one of which prepares the fangs for action, while the other stows them away when not wanted. The fangs, when not in use, are further protected by a contrivance for sheathing them, so that they rest like a sword in its scabbard. This is a fold of mucous mem- brane, the vagina dentis, which envelops the tooth like a hood, enwrapping its base, and slipping down over its length, partly as a consequence of its elastic texture, partly on account of its connections. Erection of the fang causes the sheath to slip off, like the finger of a glove, and gather in folds around the base of the tooth. This arrangement can readily be examined without dis- section. The poison-fluid is secreted in a gland which lies against the side of the skull, below and behind the eye, of a flattened oval shape, obtuse behind, tapering in front to a duct that runs to the base of the tooth. Without 167 Reptiles. Reptiles. going into the minute anatomy of the gland, it may be described as a sac, or reservoir, in the walls of which the numerous secretory follicles are imbedded , it is invested with two layers of dense, white, fibrous tissue, the outer of which gives off three strong ligaments that hold it in place. Ina large snake, the entire gland may be nearly an inch long and one-fourth. as wide, weighing, empty, . ten or twelve grains, and having a capacity of ten or fif- teen drops of fluid. There is no special reservoir for the venom, other than the central cavity of the gland. A certain dilatation of one portion of the duct, formerly supposed to be such a store-house, is due to thick- ening of its walls, without corresponding increase of capacity, resulting from muscular fibres which serve as a sphincter to compress the canal and pre- vent wasteful flow of the contents. There is fur- ther provision to this same end. When the tooth is folded back, the duct attached to its root is sub- mitted to some strain, which pushes it against a shoulder of the maxillary bone, and tends to shut off the communication. The injection of the venom, though to all ap- pearance instantaneous, is a complicated process of several rapidly consecutive steps. Forcible voluntary closure of the jaws may always be, if desired, accompanied by a gush of the venom, owing to the arrangement of the muscles which effect such movement of the jaw. These are the temporales, one of the three of which is situated in such relation to the poison-sac that its swelling in contraction presses upon the receptacle and squeezes out the fluid. The force of ejection is seen when the serpent, striking wildly, misses its aim; under such circumstances, the stream has been seen to spirt five or six feet. A blow given in anger is always accompanied by the spirt-of venom, even when the fang fails to engage, from what- ever cause. But since this result does not follow upon mere closure of the mouth, it is probable that the two posterior temporals ordinarily effect this end, the more a (64 © pn 2\ \" Zp z. Fie. 3241.—Head of Crotalus. a, a, Anterior temporal muscle; b, point of insertion in the lower jaw ; c, venom-gland; d, fang, partly erected. powerful action of the anterior temporal (the one which presses upon the poison-sac) being reserved for its special purpose. There is one curious piece of mechanism to be noted here. Since the serpent snaps its jaws together in delivering a blow, the points of the fangs would pene- trate the under jaw itself in case they failed to engage with the object aimed at, were there no contrivance for preventing such disaster to the snake. But there is a certain movement among the loose bones of the skull, perhaps not well made out, the result of which is to spread the points of the fangs apart in closure of the mouth, so that they clear the sides of the under jaw, in- stead of impinging upon it. The complicated mechanism of the act of striking may be thus described: The snake prepares for action by throwing itself into a number of superimposed coils, upon the mass of which the neck and a few inches more lie loosely curved, the head elevated, the tail projecting and rapidly vibrating. At the approach of the intended victim, the serpent, by sudden contraction of. the mus- cles upon the convexity of the curves, straightens out the anterior portion of the body, and thus darts forward the head. At this instant the jaws are widely separated, | and the back of the head fixed firmly upon the neck. With the opening of the mouth the spheno-palatines contract, and the fangs spring into position, throwing off 168 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. the sheath as they leap forward. With delivery of the blow and penetration of the fangs, the lower jaw closes forcibly, the muscle that executes this movement causing simultaneously a gush of venom through the tubular tooth into the wound. There are also some secondary actions, though all occur at the same moment. The mouth fixed at the wound drags upon it with the whole weight of the snake’s body. This dragging motion is accompanied by contraction of the ecto-pterygoid and the spheno-palatine muscles, which ordinarily fold back Fre. 3242.—Naja Tripudians. the digastric ; c, c, the posterior temporal; d, d, the anterior temporal ; e, e, the masseter; 7, the poison-gland covered by masseter and fascia : g, poison-duct; , maxillary bone; 7, neuro-mandibular muscle; J, costo-mandibular muscle. a, Is the trachelo-mastoid muscle ; 0, b, the tooth ; but the fang being at this moment engaged in the flesh, the action of the muscles only causes it to bury itself deeper, and thus enlarge the puncture. The train of action seems to be, the reaching of the object, the blow, the penetration, the injection of the poison, and the enlargement of the wound, These actions completed, the serpent loosens its hold by opening the jaws, and dis- ~ engages itself, sometimes not without difficulty, espe- cially when the bitten part is small and the numerous small teeth have caught. The head is withdrawn, the fangs folded, the mouth closed, and the former coiled at- titude of passive defence is assumed. Fig. 3241, after Mitchell, represents the head of Crota- lus, and shows the relation of the temporal muscles to the venom-gland, and the mode in which the pressure is exerted upon the poison-gland at the proper moment. Fig. 3242, copied from Sir Joseph Fayrer’s admirable work on the Thanatophidia of India, represents the head of Naja tripudians, the Cobra, the cifferent’ muscles in- volved in the movements of the jaws and fangs being carefully delineated. By comparing this cut with Fig. 3241, it will be noticed that the fangs are fixed more an- teriorly in the upper jaw than those of Crotalus, and the arrangement of the temporal muscles differs some- what. The mechanism of the jaw of Hlaps resembles some- what that of the Cobra, both reptiles belonging to the same class of poisonous colubrine serpents, the Elapide ; but in Hlaps the fang is permanently erect, the jaws be- Sr SS nea. Fig, 8243.—Head of Naja Tripudians, as seen from above. ing less dilatable than in most venomous species. This fact explains why it is that the death-dealing power of Hilaps is more restricted than in other species. Figs. 8248 and 3244 represent the head of Naja tripu- dians seen from above and in profile, and shows the characteristic appearance of the heads of the venomous colubrine serpents. GE HANDBOOK ewan” Be J Plate XXVII MEDIGAL SCIENCES. / oNT py . sf a ad gun teyy det. : LINDNER, EDDY & CLAUSS,LITH. N.Y DIAMOND RATTLE-SNAKE./Georacus abaranrevs./ REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. It is acurious fact, that notwithstanding the knowledge possessed for ages regarding the poisonous effect of ser- pent venom, until within the last three centuries no at- tempt was made to study its peculiar physiological Fia. 8244.—The same, as seen in side view. effects, the first writer on the subject being Francisco Redi, an Italian, who in 1664 published, at Florence, a paper upon the venom of the viper, entitled ‘‘ Osserva- zione intorno alle Vipera,” and this was followed, in 1767, by a work which may be considered classic, written by Felix Fontana, entitled ‘‘ Richerche filosofiche sopra il veneno della Vipera,” published in Lucca. In 1845, the naturalist, Prince Lucien Bonaparte, published a paper on the results of his analyses of viper venom, which was really the first scientific chemical study made. A num- ber of other papers appeared from time to time subse- quent to this, but it was not until 1860 that the most im- portant work on serpent venom appeared. This was thre ‘«Study of the Venom of Rattlesnakes,” by Dr. S. Weir Mitchell, of Philadelphia, and appeared as a volume of one hundred and seventeen quarto pages in the Smith- sonian Contributions to Knowledge. In 1868, this dis- tinguished physician supplemented his first paper by one in the New York Medical Journal, and in 1886, in collab- oration with Dr. Edward T. Reichert, the great work entitled, ‘‘ Researches upon the Venoms of Poisonous Serpents,” appeared as No, 647 of the Smithsonian Con- tributions to Knowledge. It should not be forgotten that while our own countrymen were seeking to diffuse knowledge among mankind, the subject of serpent ven- om was being investigated by scientists abroad. In 1872 Sir Joseph Fayrer published a work on the venomous serpents of India; Dr. Lauder Brunton and himself pub- lished in the same year an admirable physiological study of venoms. In 1883, appeared a comparative study of the venoms of the colubrine and viperine snakes of India, by Dr. A. J. Wall; nor should the work on antidotes, by Vincent Richards, be forgotten. The physical appearances of all serpent venom are near- ly alike, varying in color from pale amber to deep yellow when fresh, although it has been stated that occasionally the Cobra venom is colorless ; and this finds its analogy in the venom of our own laps, which has been seen.on one occasion to lack color. In the desiccated condition venom appears as yellow particles, semi-transparent, and remains unchanged for long periods of time. It is equally viru- lent whether dry or preserved in alcohol or glycerine, Dr. Mitchell having in his possession a glycerine solution which was poisonous after twenty years’ preservation. For a full description of the microscopic appearance and the changes which venom undergoes the reader is referred to the admirable study by Mitchell and Reichert already mentioned. So far as the chemistry of venom is con- cerned, the presence of alkaloids and ptomaines has long been suspected, but up to the present time they have been sought for in vain; but Mitchell and Reichert have suc- ceeded in isolating certain principles belonging to two classes, the former termed globulins, the other peptones. To the first belong complex substances which they call water-venom-globuline, copper-venom-globuline, and dialysis- venom-globuline, these names indicating the chemical pro- cesses by which they have been separated. The venom peptone is found in a solution of the poison after boiling, which coagulates the albuminous principles, or it may be prepared by dialysis. In the cobra venom Drs. Mitchell and Reichert have been able to isolate two proteids which are similar in character to those found in the venoms of Crotalus and Ancistrodon, which are a globulin and pep- tone-like principle. From a careful series of analyses it Reptiles. Reptiles. has been found that the venom of Crotalus adamanteus contains 24.6 per cent. of globulins, that of Anctstrodon 7.8 per cent., and that of the cobra 1.75 per cent. Ser- pent venom has been subjected to the action of various agents with a view to determine the effects in reducing its toxic power. Dry and moist heat have little if any effect, but prolonged boiling seems to reduce the poison- ous quality, owing to the fact that the peptone is con- verted into a coagulable albuminoid which is not destruc- tive to life. The addition of a sufficient quantity of caustic potassa to a solution of venom, absolutely de- stroys the toxic power, and caustic soda appears to have the same effect. A number of other substances have been employed, but space will not admit of a further consideration of the results attained ; but it may be stated as a matter of interest that a solution of the permanganate of potassa is said to be an absolute chemical antidote to serpent venom. i Much might be said of the effects of venom, but a brief notice seems all that is necessary, as the subject has been most elaborately discussed by the authors already quoted. Crotalus poison, if swallowed, is harmless, as it is not ab- sorbed by the healthy mucous membrane, or because it undergoes some change in the progress of digestion which makes it harmless ; but Fayrer has found that the inges- tion of cobra poison by mammals does produce death. When venom is applied to serous surfaces absorption takes place most rapidly, and hemorrhagic patches occur with surprising celerity. According to Mitchell, after the hypodermic injection of venom, the following patho- logical appearances may be noticed: ‘‘'There appears a swelling at the point of injection, with intense violet- black discoloration of the skin which gradually extends over an area of several square inches. On making an in- cision into the tissues in the immediate neighborhood of the injection, they are found to be soaked with extrava- sated blood. This is often all that is visible if death has occurred soon, but if it has been postponed for a short time, then, in tissues distant from the place of injection, ° extravasations to a smaller extent are always found. Most pronounced and most frequent are the ecchymoses below serous membranes (subpleural, subperitoneal, and subpericardial) ; in fact the whole organism is deeply af- fected, the tissues being congested and presenting a much darker appearance than normal. The blood does not seem to coagulate readily within cavities or interstices of the body unless death follows almost instantaneously. In cases which live longer the blood remains constantly in a liquid state, or coagulates imperfectly, and then only after being exposed to the air, resembling in this particu- lar the state of that fluid observed in conditions of as- phyxia.” As the valuable work of Mitchell and Reichert is not generally available to the public or practitioners of med- icine, it may be proper to give in their own words a sum- mary of the conclusions arrived at, as a result of their most valuable and careful studies : ‘1, Venoms bear in some respects a strong resem- blance to the saliva of other vertebrates. ‘¢2, The active principles of venom are contained in its liquid. parts only. The solid constituents, such as we observed suspended in the poison, consist of epithelium cells, some minute rod-like animal organisms and micro- cocci, etc., which, when separated from the liquid, fresh venom by means of filtration and well washed by water, are harmless. Micrococci are constantly present in fresh venom, but have nothing to do with its virulence. ‘©3, Venoms may be dried and preserved indefinitely in this condition, with but very slight impairment of their toxicity. In solution in glycerine they will also probably keep for any length of time. ‘‘4, There probably exist in all venoms representatives of two classes of proteids, globulins and peptones, which constitute their toxic elements; the former may be rep- resented by one or more distinct principles. ‘©5,. When venom is taken into the stomach in the in- tervals of digestion, enough of the poison may be ab- sorbed to produce death, especially in the case of those venoms which contain a larger proportion of the more 169 Reptiles, Reptiles, REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. dialysable peptone ; but during active digestion the ven- om undergoes alteration, and is rendered harmless. ‘6. Potassic permanganate, ferric chloride in the form of the liquor or tincture, and tincture of iodine seem to be the most active and promising of the generally available local antidotes. ‘“7, Venom exerts a powerful local effect upon the liv- ing tissues, and induces more rapid necrotic changes than any known organic substance. It causes cedema, swelling, attended with darkening of the parts by in- filtration of incoagulable blood, breaking down of the tissues, putrefaction, and sloughing. “8. It renders the blood incoagulable. ‘‘9. When brought in contact with a vascular tissue of a warm-blooded animal, it produces such a change in the capillary blood-vessels that their walls are un- able to resist the normal blood-pressure, thus allowing the blood-corpuscles to escape into the tissues. These lesions are, however, not analogous to those of inflam- mation, since in the latter process it is principally the white blood-corpuscles which emigrate from the ves- sels, and the blood is highly coagulable, while here the blood exudes en masse, and coagulates with difficulty, if at all. Free access of air (probably of oxygen) ap- pears to lessen the virulent effects. The mesentery ex- posed to air, and on which the venom is merely brushed, endures the venom ionger and in much larger quantities than when the poison is injected into the unopened and uninjured peritoneal cavity, or when directly thrown into the blood. There may be here, also, a question of temperature and other conditions. ‘The following facts, as elicited in these investiga- tions, seem to be sufficient to explain the mechanism of the hemorrhages: The blood-pressure has been shown to play a most important part ; a watery salt solution sub- stituted for the blood does not extravasate, hence blood seems to be necessary ; there always occur molecular changes in the blood-vessel walls from the effect of venom. That blood-pressure is an important factor has been established by the observation that the hemor- rhages, as a rule, occur first in the capillaries which are immediately next to, or nearest, the large blood-ves- sels. The hemorrhages take place soonest where the force of the blood-current is first felt and cannot be sufficiently resisted, and in no case do hemorrhages seem to originate from vessels with strong walls, like the arterioles or veins. Cutting off the circulation of a part, as, for instance, by ligation of the vessel of the mesentery, destroys the blood-pressure, and, as a con- sequence, the hemorrhages are so slight as scarcely to be seen by the naked eye, though venom was freely applied. Finally, the colloid, softened, diffluent condition of the red corpuscles must inevitably facili- tate extravasation. It is impossible to have seen nu- merous cases of venom-poisoning without noting a va- riety of symptoms often abrupt or unexpected. These often are due, as Dr. Mitchell long since pointed out, to accidental hemorrhages into the brain, kidney, and heart tissues. They explain much which might other- wise seem inscrutable, and serve sometimes to give a marked individuality of symptoms to cases which sur- vive long. ‘“10. Among the most remarkable effects of venom is that upon the red blood-corpuscles. These bodies un- dergo substantial modifications, 7.e., they lose their bi- concave shape, become spherical and softened, and fuse together into irregular masses, acting like soft, elastic, colloid material. This jelly-like condition of the cor- puscles is, no doubt, doubly important: in connection with the extravasation of the blood, and in its probable interference with the normal respiratory functions of the blood-cells. “11. The direct action of venom upon the nervous sys- tem, Save as concerns the paralysis of the respiratory centres, is of but little importance. ‘12. The alterations in the pulse-rate are dependent chiefly upon two antagonistic factors which are active at the same time, the one tending to increase the rate, and the other to diminish it. The former is found in the 170 increased activity of the accelerator centres, and the other in a direct action on the heart. When we have the action of the accelerator centres removed by isolation of the heart from any centric influence, we almost inva- riably find a diminution of the heart-beats. Occasionally after this operation the pulsations are increased, but this alteration is attended, as in the case of the diminution of the pulse, by feeble heart-beats, and, accordingly, is but a manifestation in another way of a depressed condition of the heart. ‘13, The variations in arterial pressure are due chiefly to three causes—depression of the vaso-motor centres, depression of the heart, and irritation, and consequent constriction or blocking up, of the capillaries. It seems not improbable that all of these are consentaneously ac- tive, and it therefore follows that such alterations are de- pendent upon the relative degree of power exerted by any one of these factors. Our results indicate that the profound primary fall of arterial pressure is chiefly due to depression of the vaso-motor centres, and is in part cardiac, that the subsequent recovery is capillary, while the final fall is cardiac. The initial fall does not con- tinue, because the constriction of the capillaries is, for a time at least, capable of compensating the depressed ac- tion of the central organ of circulation. 3 ‘14, The respirations are primarily increased and sec- ondarily diminished. Here again we have two antago- nistic factors at work together, one tending to increase and the other to diminish the rate. The former is an irritation of the peripheries of the vagi nerves, and the latter a depression of the respiratory centres ; whether we have an increase followed by a decrease, or a decrease from the first, will depend upon the relative intensity of the action of the venom on these two parts. When the action of the Yenom is sufficient to profoundly depress the centres the excitation of the peripheries may prove futile. ‘15. Death in venom-poisoning may occur through par- alysis of the respiratory centres, paralysis of the heart, hemorrhages in the medulla, or possibly through the in- ability of the profoundly altered red corpuscles to per- form their functions. There can be no question, how- ever, that the respiratory centres are the parts of the system most vulnerable to venom, and that death is com- monly due to their paralysis. ‘‘A general survey of the chief physiological actions of venoms leads us to believe that the most important effects are upon the respiratory and circulatory apparatuses, and that in the production of these results antagonistic fac- tors are at work, so that we sometimes have observations which seem directly contradictory. When it is remem- bered that there are two classes of poisons in venoms, that each class possesses certain distinguishing physical, chemical, and physiological differences, although closely related, it is easy to conceive of the cause of the exist- ence of antagonistic actions and the necessarily varying results. ‘‘ A comparative study of the actions of the globulins and peptones indicates that the globulins produce swell- ing and blackening of the parts by infiltration of inco- agulable blood; they are the more potent in producing | ecchymoses, in destroying the coagulability of the blood, in modifying the red corpuscles, and in the production of molecular changes in the capillary walls; their action on the accelerator centres of the heart is more notable than that of the peptones, hence they are more active in causing the increased pulse-rate ; they exert, too, a more marked action on the vaso-motor centres in producing _ the primary fall of pressure, and are the greater depres- sants of the heart ; they also act more powerfully upon the respiratory centres to paralyze them. The peptones are more active in the production of cedema, in the break- ing down of the tissues, in the production of putrefac- tion and sloughing; they have little power to produce ecchymoses, to prevent coagulation, or modify the capil- lary walls or the blood-corpuscles ; they have less ten- dency to accelerate the pulse ; they tend to increase the blood-pressure by irritating the capillaries, and are the principal factors in exciting the peripheries of the vagi ae REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Reptiles. Reptiles. nerves in the production of the increased respiration- rate. ‘© A knowledge of these peculiarities in the actions of globulins and peptones, coupled with the fact that the two classes exist in different proportions in the various species of venoms is of great importance in explaining the di- verse pathological appearances in cases of poisoning in different kinds of snake-bite, and suggests immediately the cause of the frightful local changes which are seen after the bite of the Crotalide, but scarcely at all in cobra-poisoning. It must not, however, be supposed that the peptones or globulins, for instance, are abso- lutely identical physiologically in every venom, as they are probably modified physiologically as well as chemi- cally, although we do not doubt that on the whole the type of action is carried throughout all species. Cobra venom does not produce the marked lesions of crotalus- poisoning because it is so lacking in globulins ; it is weak in the production of the local swelling and blackening of the parts, of the ecchymoses, of the altered corpuscles, and of the non-coagulability of the blood ; but the effects of cobra venom are closely in accord with the actions peculiar to peptones. The peptone of cobra seems to have a more decided power in producing convulsions than that of the rattlesnake. “The fact that the active principles of venom are pro- teids, and closely related, chemically, to elements nor- mally existing in the blood, renders almost hopeless the search for a chemical antidote which can prove avail- able after the poison has reached the circulation, since it is obvious that we cannot expect to discover any sub- stance which, when placed in the blood, will destroy the principles of venom without inducing a similar destruc- tion of vital components in the circulating fluid. The outlook, then, for an antidote for venom which may be available after the absorption of the poison, lies clearly in the direction of a physiological antagonist, or, in other words, of a substance which will oppose the actions of venom upon the most vulnerable parts of the system. The activities of venoms are, however, manifested in such diverse ways, and so profoundly and rapidly, that it does not seem probable that we shall ever discover an agent which will be capable at the same time of acting efficiently in counteracting all the terrible energies of these poisons.” With regard to the poisonous effects produced by the venom of the Ancistrodons (Moccasins and Copperheads), the reader is referred to an article by the writer which appeared in the American Journal of the Medical Sciences, Philadelphia, April, 1884, in which special attention is called to the recurrence of symptoms of poisoning after snake-bite ; this recurrence seems to be confined to cases in which individuals were bitten by the serpents of the genus named. In the Medical News, Philadelphia, 1887, i., p. 628, the writer, after carefully watching the two cases mentioned in the former paper during a period of nearly three years, published a short paper upon the ‘Recurrence of Symptoms of Poisoning after Snake- bite,” in which the results of the examination of the patients and the recurrent symptoms are fully set forth. : With regard to the poisonous lizard, Heloderma suspec- tum (Gila Monster), there is a mass of conflicting evi- dence as to its toxic power. The Mexicans have long looked upon it as dangerous, but other perfectly harm- less lizards also share in this evil reputation. Surgeon B. J. D. Irwin, U.S. A., experimented many years since, while on duty in New Mexico, with the Gila Monster, and concluded that it‘ was harmless, and a number of persons have been bitten, within the writer’s knowledge, without evil results. In fact, in New Mexico and Ari- zona the reptile is kept. as a domestic pet, and handled with great carelessness. Opposed to the view of its non- dangerous nature are the facts that persons have un- doubtedly perished from its bite, the writer having in his possession the affidavits of two respectable indivi- duals who witnessed a death, and the experiments of Mitchell and Reichert, which conclusively show that the saliva-like fluid from the mouth of the Heloderma, when injected beneath the skin of an animal, produces fatal re- sults with great rapidity. These investigators obtained the fluid by provoking the animal to bite on a saucer edge, and after it had held on for a few moments a thin fluid like saliva was ob- served to issue from the lower jaw. This fluid was dis- tinctly alkaline, differing in this respect from the venom of all serpents, which is acid. The first experiment made by these gentlemen was as follows: ‘‘ About four minims were diluted with one-half cubic centimetre of water, and thrown into the breast-muscles of a large, strong pigeon at 4.23 p.m. In three minutes the pigeon was rocking on its feet and walking unsteadily. At the same time the respiration became rapid and short, and at the fifth minute feeble. At the sixth minute the bird fell in convulsions, with dilated pupils, and was dead before the end of the seventh minute. The first contrast to the effects of venom was shown when the wound made by the hypodermic needle was examined. There was not the least trace of local action, such as is so characteristic of the bites of serpents, and especially the Crotalide. The muscles and nerves responded perfectly to weak in- duced currents, and to mechanical stimuli. The heart was arrested in the fullest diastole, and was full of firm, black clots. The intestines looked congested. The spine was not examined.” Subsequent experiments with rabbits and frogs pro- duced like results, the conclusions of the authors being, ‘“That the poison of Heloderma causes no local injury. That it arrests the heart in diastole, and that the organ afterward contracts slowly—possibly in rapid rigor mor- tis. ‘“That the cardiac muscle loses its irritability to stim- uli at the time it ceases to beat. ‘‘That the other muscles and the nerves respond read- ily to irritants. ‘“That the spinal cord has its power annihilated ab- ruptly, and refuses to respond to the most powerful electrical currents.” It should not be forgotten, however, that Dr. Stern- berg and Professor Gautier have proved that human sa- liva may produce death in rabbits and pigeons, the latter observer considering the venomous properties due to nor- mal ptomaines or animal alkaloids.! It is by no means uncertain that in the near future it may be shown that the saliva of other reptiles possesses poisonous qualities, especially in such genera as Siren, Pseudobranchus, Necturus, Amphiuma, Murenopsis, and Menopoma, which in the Southern States are popularly supposed to be able to destroy life by their bite. The symptoms produced in man by the bites of poi- sonous serpents possess a certain degree of similarity, their gravity depending largely upon the size of the rep- tile and the amount of venom injected into the wound. In case the serpent had repeatedly used its fangs and exhausted the supply of venom, dangerous symptoms would be less pronounced. Briefly, they may be stated as follows: After the puncture, at first the pain is slight in the part ; this gradually increases along the line of the lymphatics, with nausea; bleeding takes place, with rapid tumefaction and discoloration in the vicinity of the wound. The pulse is feeble and fluttering, and in some cases, when an overwhelming dose of the venom has been received, the action of the heart is almost paralyzed. If remedial means are not employed there is exaggera- tion of all the symptoms mentioned, with incontinence of urine and involuntary passage of feces, delirium, coma, and death, which may occur within a few hours. These symptoms may be immediate or delayed, as in the case of the photographer bitten by a copperhead, and reported by the writer, as in this individual several days elapsed before any real suffering commenced, the entire duration of the poisonous symptoms lasting from May 30th until late in August. Regarding the treatment of poisoning by serpent venom, many plans have been suggested, and hundreds of remedies employed with varying success ; but to an in- telligent observer of such an accident the indication would doubtless be to prevent the entrance of the poison 171 Reptiles. Reptiles, into the general circulation by means of a ligature or bandage, which should not be narrow, but quite broad, and applied above the bite or between it and the heart, it being, of course, understood that these remarks, so far as ligatures are concerned, apply to wounds of limbs. The bite or bites should then be laid open by crucial incision, care being taken not to injure blood-vessels, and suc- tion should be made, either by the mouth (in case no abrasions of the mucous surface exist), or by cupping ; this latter procedure may be made by means of sur- gical cups if available, by a small tumbler or wineglass from which the air has been exhausted by burning a small quantity of alcohol or spirits. therein, or by means of an ordinary wide-mouthed bottle or can, in which boiling-hot water should be poured and quickly emptied. Alcoholic stimulants or digitalis should be given by the mouth, or hypodermatically if nausea ex- ists, to keep up the flagging heart, and the band should be loosened fora few moments at atime in order that only a small quantity of the venom shall enter the circu- lation. This process should be repeated, and the pulse - will indicate when the proper amount of stimulation has been reached. It is not necessary to produce drunken- ness, aS it is believed that in some cases, especially of children, death has resulted not from the snake venom, but from lethal doses of alcohol. The mountaineers of the West attach much virtue to the flashing of a quantity of gunpowder over the bite, this, with cataplasms of to- bacco and unlimited whiskey, constituting almost their entire pharmacopceia. Within a few years, however, the attention of those in- terested in the subject of serpent-bite has been called to the elaborate experiments of Dr. J. B. de Lacerda, Di- rector of the Physiological Laboratory of the National Museum of Rio Janeiro—a study followed with most con- scientious care, and one which seems to show that there exists a most potent chemical antidote to serpent venom. His researches commenced in 1872, and in 1881 he an- nounced to the French Academy of Sciences that he had made a valuable discovery. Alluding to the inefficiency of the various so-called antidotes, he stated that he found that a solution of potassium permanganate was an absolute antidote. The venom used was from the Bothrox, a very well known and venomous serpent of Brazil, and it was obtained by forcing the reptile to bite upon cotton-wool. The quantity thus procured was dissolved in eight or ten grammes of distilled water, and a certain amount of the solution was injected into the leg of adog. In afew min- utes after, the same quantity of a filtered one per cent. solution of potassium permanganate was injected into the wound. Next day the animal was perfectly well, with the exception of a slight local irritation. The poison in- jected in other animals, without the subsequent use of the permanganate, produced grave and dangerous symptoms. The venom was also injected into a vein, and the perman- ganate proved equally efficacious in preventing poisonous symptoms ; and in some cases, before using the antidote, the symptoms of poisoning were allowed to continue for quite a lengthy period ; and out of thirty experiments all were successful with but two exceptions. It is proper to add that many of Lacerda’s experiments were per- formed in the presence of the Emperor of Brazil, and other scientific individuals. Lacerda’s experiments with the permanganate of potassa have been repeated by a number of observers with varying results, but in view of the very positive statements made by him it would appear that the permanganate should be given a trial. It should be used in the form of a one per cent. solution in water, and injected into the bites made by the teeth of the ser- pent. The writer, while sojourning among the Moqui Indi- ans of Arizona, at the time of their celebrated ‘‘ snake- dance,” was shown the so-called antidote which they em- ploy in case a dancer is bitten; it is a pale, dirty-green fluid, without odor, and slightly bitter taste, but its com- position could not be ascertained, only two individuals in the tribe knowing how to prepare it. This preparation is used, mixed with saliva and the charcoal of pifion nuts, to smear the bodies of those Indians who are to par- 172 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. ticipate in the dance, and after it is finished copious draughts of it are swallowed, which produce prompt emesis. In case one is bitten, which happens occasion- ally, the wound is immiediately sucked, some of the an- tidote rubbed into the wound, and a large quantity swal- lowed. During the last ten years, in which period five dances have occurred, but one individual has perished from snake-bite; and this is the more surprising when the fact is made known that the salient feature of the dance con- sists in the dancer holding one or two rattlesnakes in the mouth. The writer saw two individuals bitten, both by harmless snakes. Unfortunately for science, no oppor- tunity was afforded to test the permanganate solution, which had been prepared and was on hand for use should occasion offer. After the subsidence of acute symptoms of snake-bite, the others would have to be treated according to the gen- eral indications. Considering the number and wide distribution of ven- omous serpents in the United States, and in view of the fact that no absolutely reliable plan of treatment is known, it is surprising that so few individuals lose their lives from snake-bite. That the rattler is still numerous in cer- tain portions of our country, the following statement will show : In 1876, Lieutenant Morrison, U.S. A., encountered in New Mexico acolony of Crotalus confluentus, of which . not less than from three to five hundred were seen during the occupation of a hill as a topographical station, and of which seventy-nine were killed in less than one hour ; and Professor J. A. Allen reports that during the Yellow- stone Expedition of 1872, not less than two thousand were killed. With reference to the subject of antidotes, mention may be made of a remarkable work, published by Boericke & Tafel in 1872, in which the author endeavors to prove that the galls of serpents are antidotal to their bite. In preparing the gall for use, one drop is added to ten drops of pure alcohol, and the mixture is allowed to stand for a few days, at the expiration of which period the supernatant liquid is poured off and carefully pre- served in a well-corked vial. In ordinary cases of bite, five or ten drops of this tincture are added to half a tumbler of water, and a tablespoonful of the mixture is administered every five, ten, fifteen, or twenty minutes, according to the violence of the symptoms. In addition to the internal use of the gall, a cruciform incision is made over the wound, and a few drops of the prepara- tion are dropped in. Unfortunately the value of this so- called antidote depends entirely upon the statement of its discoverer, and it is believed little credence can be at- tached to his published results, as Sir Joseph Fayrer, following instructions received from the author, failed utterly to neutralize the poisonous effects of the venom of Cobra and Bungarus, using the gall as directed. The popular mind has ascribed to certain serpents properties, venomous and otherwise, which they really do not possess, and it is thought a correction of these er- rors may perhaps serve a useful purpose. In some parts of the United States is found a snake be- longing to the genus Heterodon, which inspires as much fear as the rattlesnake ; in fact, the species known as Hete- rodon niger is called in Virginia the ‘‘ black rattlesnake,” although the want of a rattle should prove the name a misnomer. This reptile has a broad, flat head, with a somewhat constricted neck, a stout body, and a short stumpy tail, and when captured it hisses. fiercely, ex- pands the cervical ribs, and presents a very pugnacious appearance. The coloration of one species is somewhat like Crotalus confluentus, and, if the mouth is examined, in the upper jaw will be found fang-like teeth, which have given origin to the generic name, which means “‘ dif- ferent or dissimilar teeth.”” These teeth are not grooved, and are not connected with anything resembling a poi- son-sac. Notwithstanding its dangerous appearance it is absolutely harmless, and can scarcely be provoked to bite. -Not long since, the writer had forwarded to him, by an intelligent gentleman living in the South, one of these snakes, which was declared to be one of the most poisonous known to the region; it proved to be Hetero- ~ AN HLM ‘Ssnvio ¥ AGda waNGNM oo ie ee ne Spat > alec i | ES a 3 : ee ‘SAONAIOS 1 overs kM wr — 2. rw s t — . " : ase —— volaa | REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. don platyrhinus. The common names for this serpent are ‘‘ puff-adder,” ‘‘ hog-nosed snake,” ‘‘ sand-viper,” etc. Next to the almost universal belief regarding Hetero- don, is a Similar opinion about the so-called water moc- casin, Tropidonotus sipedon, and oneof the old writers, in a history of Virginia, describes this serpent so that no doubt as to its identity can exist, and then gravely states that an Indian was severely bitten by one, but by the ap- plication of proper remedies finally recovered. This serpent, as is well known to naturalists, resembles the poisonous species Ancistrodon piscivorus, and as both are found in and about watery places, it is not surprising that their properties should have been confounded. In addition, Tropidonotusis a very pugnacious individual, and will bite fiercely if opportunity offers, especially if it has not been handled—in fact, even then, if roughly seized. Some time since, the writer had occasion to re- move a small sebaceous tumor from below the angle of the jaw of a fine female Tropidonotus belonging to the National Museum, and after the operation, as it had lost a considerable amount of blood, and seemed very weak, it was placed in the pond of water in the rotunda of the Museum. Desiring to exhibit it toa friend, it was re- moved from the water, when it struck fiercely at the hand, throwing its upper jaw back as the venomous ser- pents are in the habit of doing, and at the third stroke succeeded in fixing its teeth near the base of the thumb. The pain was trifling, and had it not been for the some- what free bleeding, an injury would hardly have been suspected ; no evil consequences resulted, nor have any ever occurred, as the writer has been bitten several times by this species. . The difference in the appearance of the head between the true moccasins and the so-called water moccasin is very marked. In the former the plane surface of the head may be said to roughly resemble a triangle, the snout representing the apex, the angle of the jaws’ the base, the neck being narrow behind. In this species the pit between the eye and nostril is well marked. In the harmless species the head is hardly separated from the body by a constricted neck ; it is rounded, and the ex- panse of the angles of the jaw not so well marked. It has, however, when coiled up, a very vicious appearance, and resembles greatly a venomous snake. One of the most curious myths in regard to serpents is that of the ‘‘hoop-snake”’ or horn-snake, which is thus described by a recent writer: ‘‘ The horned snake is the last of the poisonous serpents, and is a great curiosity. Instead of in the head, it carries its weapon in its tail, which has a horny appearance, is shaped like a cock’s spur, and is from an inch to an inch and a half in length. This tail has a cavity, inclosed in which is a sharp needle- like sting, growing from the extreme point of the tail. The snake puts the end of the tail in the mouth, thus forming a hoop, and rolls forward until within striking distance, when it slips the tail from the mouth and strikes with considerable force ‘tail foremost. The sting produces about the same effect as the sting of the adder. The horned snake is about three feet long when full grown, rather dark in color, and is oviparous. They are very scarce and seldom seen.” What is known as the horned snake in the West and Southwest is the Farancia abacura, of which the head and back are bluish-black above, and which has sub- quadrate red spots on the flanks. Its abdomen is rosy- red, with transverse or alternating bluish-black irregular spots. How or why it should have acquired the unen- viable reputation it possesses, at present is unknown, for it is one of the most harmless and gentle of all snakes. That its tail ends in a horny tip is true, but the ‘“ bull- snake” of California, Pityophis bellona, has a similar horny tip, but neither the one nor the other ever uses it for defensive or offensive purposes. In some of the Southern States the grass lizard, Opheosaurus ventralis, is also called the horn snake. Another serpent about which a curious superstition prevails is the ‘‘coach-whip snake,” and lying at full length in the road it seems worthy of its popular name, Reptiles. Reptiles, To naturalists it is known as Bascanium flagelliforme. The anterior fourth of the body is a deep brownish-black color, which gradually becomes lighter until near the posterior part, where it is of a yellowish-gray. This col- oration, in connection with a peculiar arrangement of the scales, gives it a very whip-like appearance, the dark part of the body being the handle, the lighter the lash. This reptile, in the South, has long been a terror to the col- ored population, and many are the stories related of how drunken and belated negroes have been found dead in the road, whipped to death by the coach-whip snake. Perhaps it would not be unfair to say that it is probable that this tradition was encouraged during ante-bellum days as a wholesome corrective to the night-prowling propensities of the slaves. This serpent is very graceful, and it may be imagined that if held, provoked, or irri- tated, it might, in its efforts to escape, switch fiercely with its long tail and body; but as for its being able to seize a person and whip him to death, the tradition must be consigned to limbo, with others of similar nat- ure. From the somewhat fragile nature of the liga- mentous attachments of the spinal vertebre of the rep- tile, it is more likely that the snake would stand a better chance of breaking its back than of inflicting serious injury. Of all the habitable regions of the globe, the empire of India is without doubt the one in which the greatest de- struction of human life takes place from the bites of venomous serpents, and it may be interesting to briefly consider some of the well-known species which con- tribute to the fearful result. Sir Joseph Fayrer states that the average mortality from serpent-bite is fully twenty thousand annually, and in 1869, care was taken to obtain, officially, returns of cases, which showed that out of a population of 121,000,000, in an area embracing only one-half of the peninsula of Hindostan, the deaths were 11,416, or nearly one in ten thousand. These deaths were caused, as nearly as could be ascertained, as follows : Cobra, 2,690; Krait (Bungarus ceruleus), 359; other snakes 889; unknown snakes, 6,922; no details, 606; total, 11,416. The British government recognizing the im- portance of destroying venomous snakes,-paid a bounty, in 1880, for the enormous number of 212,776, and in 1881, for 254,968. Superior in venomous properties are the Hlapida, of which several genera are common in India; Najzde, or snakes with hoods, or dilatable hoods, or dilatable necks ; and the Hlapide, without hoods. Najid@ contains two genera, Vaja and Ophiophagus, and in Hlapide are Bun- garus, Xenurelaps, and Callophis. The characteristics of the family are a cylindrical body, a rather short and tapering tail, and a lateral nostril. The poison-fang has a mark in its convexity indicating the groove, differing in this respect from the poisonous water-snakes, Hydrophide, in which it is quite open. At the head of the list should be placed the Cobra, or Cobra di capelio, Naja tripu- dians, of which there are a number of well-recognized varieties, all of them possessing most deadly properties. The largest Cobra seen by Fayrer had attained a length of five feet eight inches, and measured six and one-fourth inches in circumference, and a fowl bitten by it perished in one minute. The color of the Cobra varies from dark olive or black, to pale chocolate or yellow, and the mark- ings on the hood vary greatly in the different varieties. All of them possess the hood, and never bite without ex- panding it, and, unlike the rattlesnake, the body is not coiled, the lower two-thirds remaining upon the ground while the anterior third is raised, the head oscillating from side to side with wary caution in preparing to at- tack. They are good climbers and take readily to water, although essentially terrestrial in habits. Ophiophagus elaps is the only representation of its genus, and is prob- ably even more formidable than the Codra, as it attains a length of from twelve to fourteen feet. It has no hood and is exceedingly aggressive. The coloration varies greatly, but the general tint may be described as olive- green above, the scales edged with black, the trunk hav- ing on it numerous alternate black and white bands con- verging toward the head. To the Bengalese it is known 173 Reptiles. Resection. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. as the “shell. breaker,” and its habits are largely arboreal, although it takes to the water. Dr. Carter relates the following anecdote regarding its fierceness: ‘‘ An intel- ligent Burman told me that a friend of his one day stumbled upon a nest of these serpents and immediately retreated, but the old female gave chase. The man fled with all speed over hill and dale, dingle and glade, and terror seemed to add wings to his flight, till reaching a small river he plunged in, hoping he had then escaped his fiery enemy ; but lo! .on reaching the opposite bank up reared the furious Hamadryad, its dilated eyes glistening with rage, ready to bury its fangs in his trembling body, In utter despair he bethought himself of his turban, and in a moment dashed it upon the serpent, which darted upon it like lightning, and for some moments wreaked its vengeance in furious bites; after which it returned quietly to its former haunts.”” This serpent, as its name implies, devours other snakes, but it doubtless also feeds upon birds and small animals. The genus Bungarus contains two Indian species, B. fasciatus and B, ceruleus, known to the natives as Kraits, and these serpents, next to the Cobra, are probably the most destructive to human life in India. The coloration of Bungarus is uniform blackish-brown,. the head being white in young individuals, although as in the other ser- pents there is some variation of tint. In B. fasciatus the triangular shape of the body and sharp dorsal ridge are especially noticeable. Xenurelaps bungarotdes, the only known representative of its genus, resembles greatly the Bungarus ; but little is known as to its habits. The genus Callophis contains a number of species, but from their small size and diminutive fangs they are prob- ably not so dangerous to human life as the other venom- ous serpents. Belonging to the viperine serpents is the terribly venom- ous Daboia russelli, which is of a light chocolate color, with black white-edged rings, and which also shows many variations of tints. It is most justly dreaded, for with its long, movable fangs it produces deep mortal wounds. It is terrestrial in its habits, and lives upon smal] animals. Dr. Imlach states that it is not uncommon to find two fangs.on both sides of the upper jaw. There are a number of other genera of poisonous ser- pents in India, such as Hehis, Trimeresurus, Peliopelor, Halys, and Hypnale, which resemble the North American | Crotalide in having the ante-orbital pit, and are without rattles; but space will not admit of a consideration of their peculiarities. The most interesting of all venomous serpents are probably the sea-snakes, which inhabit the estuaries and tidal streams, and are known to naturalists as the Hydro- phide. They have a wide geographical distribution, being found in the Indian and Pacific Oceans from Mad- agascar to the Isthmus of Panama; Ginther says they are most numerous in the Eastern Archipelago and in the seas between Southern China and North Australia. The sea-snakes vary greatly in form, some of them at- taining a length of five feet; the body is elongated, and in some instances is short and thick, while in others it is very thick toward the tail and much attenuated near the neck, the head being minute in proportion to the size of the individual. The posterior part of the body and the tail are flattened and compressed vertically, like the tail of a fish, and with it they swim with extreme grace. The fangs and jaws of the sea-snakes are gener- ally smaller than those of land-serpents, the venomous teeth having open grooves. That they are venomous is without doubt, as several instances are on record of per- sons losing their lives, and Fayrer found by actual ex- periment the dangerous nature of their venom. Be- longing to this family are seven genera: Platurus, Aipysurus, Disteira, Acalyptus, Hydrophis, Enhydrina, and Pelamis, and of these the latter only is known -to be found occasionally near the Isthmus of Panama. Platurus contains two species ; Hydrophis, twenty-seven ; Enhydrina, two; and Pelamis, one. The coloration of the sea-snakes varies greatly, one of the most beautiful being Pelamis bicolor, the back of which is slaty black, the belly orange. Another very beautiful species is 174 Hydrophis nigrocincta, in which the ground color is fawn, the entire body being partly surrounded with lake-brown circles. In the experiments reported by Fayrer as having been made by Dr. W. P. Stewart, at Pooree, British India, the virulence of the venom of the sea-snakes is abundantly proved. Fayrer’s experiments, which were made upon different sorts of animals, using different: kinds of serpent-venom, led him to the following conclusions. Snake-poison acts with most vigor or the warm-blooded animals ; birds succumb very rapidly ; a vigorous snake can destroy a fowl in a few seconds. The power of resistance is generally in relation to the size of the ani- mal, though not altogether so; cats, for example, resist the influence of the poison almost as long as dogs three or four times their size. Cold-blooded animals also succumb to the poison, but less rapidly. Fish, non-ven- omous snakes, mollusca, all die. After death from co- bra-poison the blood coagulates, but generally remains fluid after the bite of a viperine serpent. With regard to treatment of snake-bites, Fayrer tried every reputed antidote and every plan of treatment, but without success, although he believes that ligature, exci- sion, and general treatment seem to afford some chance. Much, however, needs still to be done in the way of. ex- perimentation.® It would be foreign to the purpose of this article to give an account of all the venomous serpents of the world, but the names of a few may be added to swell the al- ready formidable list. In Europe the most dreaded serpent is the Pelias berus, common viper; in Australia the Hoplocephalus curtus, tiger-snake ; in Africa the different species of Clotho, Megera, etc.; in South America the different species of Craspedocephalus, the Jaracacas and Fer de lance ; while in Costa Rica particularly is found a genus of venomous serpents known as Telewraspis, which are allied to the Cro- talid@, but have no rattles. These snakes are arboreal in habit, and present no less than five color variations, the most beautiful of all being of a golden-yellow color. A peculiarity of the genus is the presence of a series of scales above the eye resembling small horns. It is said that these serpents, which are very venomous, lie at full length along the branches of trees, striking at the faces of passers-by. In Mexico a large Hiaps and the various Crotalide are most justly feared. The illustrations which accompany this article have been drawn with great care by Mr. John Ridgway, of the Bureau of Ethnology, United States National Mu- seum, from certain cuts already shown in the various works on Serpents; in other instances they have been copied from life, and leave nothing to be desired in the way of drawings. The large colored plate of Cro- talus adamanteus has been drawn from a fine specimen owned by the National Museum, and that of Heloderma — suspectum is by Mr. A. Zeno Schindler, copied from a living reptile in the same institution. Acknowledgment is also made to the published works of many authors, the most prominent being those by Mitchell and Reichert, Fletcher, Cope, Garman, Fayrer, Halford, and others. 1 With regard to the very poisonous qualities of the Heloderma saliva recent experiments by the writer would seem to indicate an extremely feeble toxic effect, at least so far as rabbits and fowls are concerned, 2 It is to be regretted that a repetition of Lacerda’s experiments with the permanganate by the writer has not given the resuJts claimed by the distinguished Brazilian. 3 A series of experiments are now being tried to verify what appears to be decided antidotal effects of Jaborandi to Crotalus venom, the writer having succeeded in saving rabbits which had received fourfold lethal doses of the poison. It has no antidotal effect, however, upon fowls. Henry Crécy Yarrow. RESECTION OF JOINTS.—In the strictest sense, the terms resection and excision as,applied to joints are not synonymous. The former involves the primary idea of the removal of a section of a bone, especially of its shaft ; the latter refers more particularly to the removal of the joint as such. As a joint is excised by the resection of the ends of the bones that compose it, the terms in REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Reptiles, Resection, practice become synonyms, and are so found in standard works. It may be noticed that in French and German works the term resection is commonly employed ; in Eng- lish and American writings excision is more in use. In this article they will be used as practically synonymous. The term exsection is also used in the same sense. Resections have been divided into complete and partial, the former meaning operations in which all the compo- nent bony surfaces are removed, the latter op- erations in which the articulating surface of one bone, or of more, in some complex joints, is left. Here again the nomenclature is not always 4 strictly adhered to—as applied to the shoulder J or hip for instance,—and writers seem to be not a at all agreed as to what constitutes a complete a 5 & S excision of some joints, notably the wrist. The term osteoplastic is applied to resection in the performance of which a bone or bony prominence (¢.g., the trochanter major, the ole- cranon, or the patella) is divided and the parts temporarily separated, in order to expose the diseased tissues, and subsequently replaced more or less perfectly in situ. The same term has been applied to operations analogous to those of plastic surgery in which the sawn surfaces of bones not normally in apposition have been brought together after the removal of the inter- vening parts; for example, Mikulicz’s osteo- plastic resection of the tarsus. It is not easy to rl see why such operations are more osteoplastic F!6- 4. than many others in which anchylosis is sought for, ordi- nary resection of the knee, for instance. It is unnecessary to enter upon the history of resec- tions. Scattered through surgical literature are allusions to operations, made to meet emergencies, more or less resembling modern resections. But it is little more than acentury since Henry Park (1783) first formally proposed the removal of the elbow and knee joints for the cure of disease, and Moreau soon after (1786) made the first com- plete operation and became the advocate of it as a defi- nite surgical procedure. Nevertheless resections gained footing with such slowness that their real history belongs to the present century, and chiefly to its second half. Excision of the shoulder, by reason of the ease of the operation and the disabling mutilation it promised to prevent, became an accepted operation earlier than the removal of other joints. The labors of Syme, beginning ‘ about 1831, made the profession acquainted with | the value of elbow-resection, and the authority and teaching of Ferguson in the decade follow- ing 1845 fairly put excisions of the hip, knee, and wrist among recognized procedures, how- ever much surgeons differed as to their real value and applicability. Continental surgeons were also engaged in working out the problems of excision, but the influence of the two British surgeons named was especially powerful. Resection was primarily an attempt to escape the disaster of an amputation. Hodges, in his classical monograph, says: ‘‘ It is only as a sub- stitute for amputation in traumatic lesions, and in certain organic ones, that the proposition of excising joints has been entertained, excepting in those comparatively few cases in which the operation has been undertaken for the cure of deformities or in disease of the hip-joint where it is the sole operative alternative.” It was in the spirit of conservatism that Ferguson in par- ticular urged the resort to excision. To sur- geons of the present day, at least in America— excision seems a radical procedure, and they have difficulty in appreciating the condition of affairs existing thirty or forty years ago. To-day, ina case of joint disease, we choose between resection and a highly perfected plan of treatment by joint-rest and expectancy in its best sense. Then the choice was be- tween amputation, on the one hand, and probable death, or, at least, painful and disabling disease of indefinite duration, on the other. Under such circumstances a pro- SSs2525) Ile Soo 25 aceses: Sarees $2525 S555 oe S525 225 ones S25 ve ose $393 S33 Fa an oOo. Sos esose AZ S52 te. 99 SEFONATIL Fig. 3246. cedure which gave better chances as to life or function was a boon, and truly conservative, even if hidden under ~ the guise of a somewhat complicated surgical operation. To establish the true value of resections, it is necessary to determine, first, whether they are really conservative of life as compared with either amputation or expectant 3S >. : oS SSSSSS OSS SSS SSIS OS PODS AOS Fig. 8247.—Sands’ Periosteotome. treatment, and, second, whether the limb saved is really a useful member and worth the suffering and the risk. With regard to some joints these points are entirely settled ; as to others, there is not yet entire unanimity of opinion. Before the introduction of aseptic surgery, the question of vital conservatism was kept open by the considerable death-rate of excisions, dependent upon prolonged sup- puration and its results. Since the change in surgical Fic, 3248.—Sayre’s ‘*‘ Oyster Knife.” methods has reduced the operation-death-rate in civil practice of both amputations and resections to a much lower figure, the question is no longer very important, except as to the results of operative interference of any kind when compared with those of purely conservative treatment. And it should be noted that asepsis has had its influence not on the greater operations alone, but upon the minor substitutes for them, such as incision and Fie. 38249.—Parker’s Retractor. drainage, as well as upon conservatism pure and simple. The vital prognosis being a matter of less urgent con- sideration, the functional prognosis has taken a propor- tionally more prominent place. There is no doubt that the different estimates at present set upon resection in different countries depend upon the value of its alternatives. In America and in Great Britain, certainly, even before the prevalence of aseptic surgery, resections were almost confined to those classes whose circumstances did not al- low them the best kind of conservative treat- ment. .The same, we think, is at least meas- urably true of other countries, and wherever joint-diseases are very common among the very poor, then operative procedures are not only much more frequently resorted to but are also much more necessary than they would be un- der more fortunate circumstances, The znstruments necessary for resections of joints are essentially the same as those for other operations on bone. For the division of the soft parts and the denudation of the bone are required knives, periosteotomes, and retractors. The knife should be strong and broad-bladed, the handle roughened to assure firmness of grasp (Fig. 3245). It is sometimes convenient to have the handle terminate in a periosteotome (Fig. 3246), but in operative surgery, as in other mechani- cal arts, combination-tools are usually annoy- yy. 3950. ances, and perform no one office really well. Periosteotomes are of very various patterns. The es- sentials of a good one are that it shall be strong enough for its work, its handle sufficiently large and rough, its edge sharp enough to avoid any contusion of tissues, and 175 Resection. Resection, REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. to easily and completely remove the periosteum, while it shall not be so sharp as that of a knife or any instrument intended for cutting the soft parts. Figs. 3247 and 3248 represent tyo patterns much used in DORADA OOOO JU REVMOERS & OL Fie. 3251. this country. The latter is Sayre’s “ oyster-knife,” and when the edge has just the right degree of sharpness, it is a very efficient instrument. Ollier’s periosteotomes re- semble dull chisels and flattened gouges. Retractors may be of thin German silver (Fig. 3249) or Fig, 3252. of steel (Fig. 8250), the latter being made of various pat- terns with sharp or blunt points. Those which give the most certain control of, while doing the least injury to, the parts, are the best. For the removal of the bony parts various forms of saws and of cutting and holding forceps are required. Fie. 3253. The ordinary amputating saw (Fig. 3251) is quite suffi- cient for most operations on the larger joints. Occasion- ally other forms of saw are convenient. The chain-saw (Fig. 3252) is useful where it is desired to sever the bone without raising it from its bed in the tissues ; as, for in- stance, the neck of the femur in excision of the hip. In ~.2 oa WOE Seer ce AM aol LEO THN, <-->? 2. Fia. 3254. some situations the small saw with movable back (Fig. 3258) is very convenient, as is the key-hole saw (Fig. 3254). Butcher’s saw, with its thin rotating blade, or the sim- ilar instrument of Szymanowski (Fig. 3255) is rarely de- manded, although useful where cuts of curved or varied For the division of small directions are to be made. Fra. 3255. bones the cutting forceps, either straight (Fig. 3256) or bent (Fig. 3257), are often handier than any saw. Cut- tant vessels and nerves, and wherever possi- gnawing, or rongeur, forceps (Fig. 3260) are necessary for the removal of the edges of bone and of diseased ee Parts not otherwise acces- tie sible. For this last object gouges, to be used by hand (Fig. 3261) or driven by the mallet (Figs. 38262, . 3263, and 3264), are am very useful. Se, too, Sy are bone-scoops (Figs. Sey 3265 and 3266), and occasionally the chis- el (Fig. 3267). For removing detached pieces of bone, and for steadying the parts, the holding for- ceps (Figs. 3268 and 8269) are needed. For the last-named purpose the “‘ lion- jaw” forceps of Ferguson (Fig. 3270), or that of Farabeuf, are preferable. When the bony parts are to be fastened by gut or wire, drills (Fig. 3271) are necessary to the introduc- tion of the suture, and if nails are to be used for the pur- pose, it is better to make with the drill a preliminary chan- nel to guide them. The elaborately planned and care- fully executed resections of to-day could scarcely have existed previous to the use of anesthetics ; the facil- ity and certainty of their performance have been immensely increased by the Esmarch bandage; and their danger reduced to a minimum by ~ aseptic methods. It is as- ’ sumed in what follows that, wherever necessary, these \ adjuvants to success will be employed. Whatever asep- tic precautions and dressing are used, they should be those in which the operator has faith and with the de- tails of which he is familiar. In the hospitals of this city (New York), in bone-surgery, the favorite method seems to be the bichloride of mercury for douching; iodoform and iodoeform gauze for the wound-application, and iodo- form or bichloride gauze for the envelopes. i It is convenient and efficient. ie | The general law of surgery, to do the least : possible damage to the parts consistent with the full accomplishment of the end sought, emphatically applies to joint-resections. To extirpate the disease or to remove the sources of danger is the surgeon’s first care, to impair the functions of the part as little as possible his next. To the A ied accomplishment of these ends /{ -esov. —_ certain general rules of proced- |) } ure hold good, whatever joint is the seat of | operation. It may save needless repetitions if some of theseare con- a sidered in M\, this place. Incisions. —Al1l inci- , sions should be so made as to avoid impor- Fie. 3256. Fia@. 3257. Fie. 8258. LY ble they should avoid muscles and tendons. *%* eat The latter requirement can usually be accomplished by using the intermuscular spaces as avenues of approach to ting forceps of various shapes (Figs, 3258, 3259), andthe | the bone. When a muscle must be cut, let the incision 176 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Resection, Resection, as far as possible follow the direction of the fibres of that muscle, avoiding its nerve. The situation of an incision is often determined by pre-existing wounds or sinuses. Simple incisions are preferable, but should not be adhered to to the embarrassment of the operator ; broken incisions SS — = =< Fie. 3261. or transverse cuts may sometimes be demanded for con- venience. All incisions should be ample, without being excessive ; if the previous rules are observed a long inci- sion is of no harm. Two or more independent incisions are often convenient. It is often possible to make an in- cision, in a sense exploratory, which will be sufficient for arthrotomy, resection, or amputation, as the condition of the explored parts may demand. Usually the same incision that traverses the overlying parts divides the capsule also. The same rule as regards extent of incision, 7.¢., ample but not excessive, applies to the capsule as to other soft: parts, if it is intended to pre- serve the mobility of the joint. Tendons should be preserved in their entirety, and if possible remain undisturbed in their sheaths, and their insertions carefully dissected away from the bone if the latter is to be re- moved. Or, what in many places is preferable, _asmall piece of bone may be chipped or pried off attached to the tendon. If by accident or through necessity a tendon is divided, suture of it with catgut is desirable; but the fact that sut- ure of tendons is often successful should not be made a ground for unnecessary injury to them. The occasional surprising restoration of a de- stroyed or lacerated tendon, and the success following the interposition of a leash of catgut or a piece of animal’s tendon in the interval when the divided ends could not be approxi- mated, should encourage the surgeon to every endeavor to preserve the functions of tendons. The management of the soft parts during the operation deserves a word. One often sees during an excision the operator or his assistants, intent upon denud- ing and removing the bone, maltreat the soft parts, for- getful of the processes of repair. The tissues are over- strained to make room which could have been more easily obtained by a more generous incision ; they are torn with C.T/EMANN &CO0. Fie. 3262, As sharp retrac- = a | or or ped G.TIEMANN &CO. WW ee, ones, some- Fie. 3263, : times lacerat- ed by the violence with which the bone to be sawn is thrust out, and lastly they are teased and nicked by care- less sawing. Such errors only need to be pointed out to be corrected. How the periostewm shall be dealt with is still an open question among surgeons, Many operators ignore it, or 6. TIEMANN &C Fria. '8264. pay little attention toit. The bone having been reached in an operation, it is neatly cleared of the soft tissues by sharp or blunt dissection, with no especial care to save the periosteum. The advocates of the sub-periosteal method, on the other hand, insist upon the careful preser- vation of this membrane. Against the method it has been urged that it is difficult and tedious in execution, Vou. VI.—12 and that it has not given better results than the other plans (which Ollier styles the parosteal). Further, it has been accused of favoring anchylo- as sis of the excised joint. It is ad- mittedly a slow method, but exci- ° sions are'rarely undertaken upon patients whose condition demands speed in operation. Ollier is perhaps the most ar- dent advocate of the preservation of the periosteum intact, although he has the support of other emi- nent surgeons, prominent among whom are Langenbeck in Ger- many, and Sayre in America. The former claims? for his method that, by going directly to and through the capsule, and then carefully turning back the perios- teum with all its overlying tissues undisturbed, the traumatism is re- duced to a minimum ; that the en- velope left after the removal of the bones, which he styles the perios- teo-capsular sheath, ig at once a a protection to the soft parts and a fa Support to the bones, retaining the # latter in more normal relations @ during the reparative process ; and that the reparative process is itself y much more efficient, and that the f functional results are much better than can be obtained by the other es maintains Fie. 3266. ae ¥ OXVZVH ‘ay _ AN GYOS -1'M‘09 L/ method. He further Fie. 3265, that the method, if time is allowed, = Hebra's is not difficult. Making all allow- ance for enthusiasm, it would seem that these claims are mainly sound. The chief point, namely, that better functional results are obtained, is the very one that is difficult of proof. Excellent results have been obtained G.TIEMANN & CQ Fig. 3267. by both methods. One man’s results can with difficulty be compared with another’s ; the conditions under which they are obtained may also vary exceedingly. It is, however, fair to say, in estimating the value of the sub- periosteal method, that many operations done under that name are so imperfect as to be worth- less as such. The method as employed by Ollier is most care- ful in details, and the after-care is prolonged and remarkably at- ff tentive and painstaking, so that @ one is left in doubt whether the X excellent success in some cases ‘ is due to the operative procedure or the after-treatment. Ollier detaches the periosteum by means of instru- ments (rugines) much sharper than the periosteal eleva- tors ordinarily in use. They are comparable in this Big Fie. 3271. Resection. Resection. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. respect to dull chisels, but are made of various shapes. He maintains that the periosteum should be lifted in its entirety by very careful to-and-fro motions of the tool, and that this can only be accomplished by a rather sharp instrument; a blunt one usually tearing the mem- brane, bringing away its fibrous part more or less lacer- ated and shredded, and often leaving behind the bulk of the osteogenetic layer, which alone is valuable for repro- duction of bone. To make sure of the removal of this layer, the elevator must be sufficiently sharp and strong to chip the bone when necessary, and whenever he en- counters a small prominence or a dimpled surface which is very difficult to enucleate, he slices off a bit of bone with the periosteum, and later on detaches it from within if desirable. Asa rule, however, such pieces of bone, if sound and firmly attached, may be well left as aids in the restorative process. bathed on one side, by the respiratory medium, and on the other by the respiratory blood, which is spread out in a thin, almost continuous sheet in the 198 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. capillaries. This respiratory membrane, in man and the mammals generally, is in the form of two great elastic sacs called lungs, in which the surface is repeatedly folded, thus forming an almost infinite number of second- ary sacs—the pulmonary alveoli, vesicles, air-sacs, or air cells (Figs. 3313 and 3317). The lungs are placed in the o Fig. 3318.—The Trachea, Bronchi, and Ultimate Termination of the Bronchi in the Lungs. (A) Ventral view of the larynx, trachea, and bronchi, and of the lungs in outline and opened so as to show the tree- like branching of the bronchi (Sappey). 1-2, the larynx; 3-38, the trachea; 4, bifurcation of the trachea to form 5 the right, and 6 the left bronchus; %, division extending to the cephalic or superior, 8 to the middle, and 9 to the caudal or inferior lobe of the right lung; 10, bronchial division to the cephalic or superior lobe, and 11 to the caudal or inferior lobe of the left lung ; 12, ultimate ramification of the bron- chi; 13, contour of the lungs; 14, summit; and 15, base of the lungs. (B) Two lobules from the lung of a new-born child, half diagram- matic and magnified twenty-five diameters (Killiker). Three ultimate bronchial tubes or lobular bronchioles are shown, but the terminal lobule is shown on but two of them. a,.@, Lobules; 0,b, alveoli or air-vesicles; c,c, terminal bronchial tubes or Jobular bronchioles. (C) A single lobule in section, magnified (Dalton). a, Terminal bron- chial tube opening into 6, the alveolar or lobular passage ; C,¢,¢,c, air- vesicles or alveoli. The pulmonary capillaries ramify in the shaded partitions between the alveoli. air-tight chest or thorax, and communicate with the ex- terior through the respiratory or air-passages (Fig. 3315). In shape the lungs conform accurately to the cavity left in the thorax by the heart and great vessels ; that is, the costal surface of each lung is convex, while the mesal surface is somewhat concave where it is moulded to the surface of the heart. At the base the lungs rest upon the diaphragm, and from their elasticity follow all its varying shapes (Fig. 3319). At the apex the lungs are REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Respiration, Respiration, bluntly pointed, fitting the corresponding cavity in the cephalic or upper part of the thorax. In man the right lung is divided into three somewhat unequal lobes by two fissures extending from the costal i | ZEW Z By Ae / \ ! SSA Wy Z H \\\i WZ ut \ = ri m . \\> ve Rolls { eM) Um Wa > mall ik (| I ‘an ! | Hy \ lit We NL HN Fic. 8314.—Ventral View of the Lungs, Trachea, Heart, and Great Vessels. (Gray.) The lungs are slightly-inflated, and separated so as to bring into bet- — ie sci The right lung is divided by two fissures into three respiratory medium. ter view the heart, etc. lobes, and the left one by a single fissure into two lobes. surface toward the root of the lung. The left lung is divided into two lobes by a single fissure (Fig. 3314). The so-called root of the lung is at the point of suspension of the lung, and each is composed of a bronchus, the pulmonary blood-vessels, lymphatics, and nerves, and the connective tissue binding these structures together (Figs. 33138 and 3314). Each lung is covered by a se- rous membrane, a reflection of the corresponding pleura, which, commencing at the root, is reflected over the entire surface, entering the fissures and forming a com- plete envelope for the lung. The connective-tissue layer of the pleura covering the lungs is directly continuous with their connective-tissue framework, so that the pul- monary pleura forms an essential part of the lung-struct- ure. The Respiratory or Air-passages are tubes or openings serving to conduct the air to and from the lungs. They are the two nasal passages, sometimes also the mouth, the pharynx, which like the mouth is also common to the alimentary canal, the larynx, trachea, and bronchi (Figs. 3313 and 3314). The bronchi continually divide, like the branches of a tree, without anastomosing, and finally ter- minate in sac-like enlargements which are the true respi- ratory parts of the lungs (Figs. 3313 and 3317). From ‘this arrangement of the true respiratory parts of the lung at the ends of the bronchi the lung is sometimes not considered as composed of a great sac, as stated above, with foldings of the surface and a minute bron- chial twig connected with each minute fold, but it is supposed to consist of a great number of small, inde- pendent sacs closely bound together. On this view, the comparison with a tree, especially one with divided leaves, might be continued, each leaf representing an ultimate lobule of the lung (Figs. 3313 and 3317). The air-passages of the lungs, and the respiratory pas- sages in the nose, are lined with ciliated epithelium. In each case the motion of the cilia produces a current to- ward the pharynx. This current carries dust and mucus into the pharynx, from which they are readily expelled. (See also articles on the Bronchi, vol. i., and the Minute Anatomy of the Lung, vol. iv.) Vascular and Nervous Supply of the Lungs.—The blood going to the lungs is of two kinds and from two sources : (1) The impure or venous blood from the right side of the heart going through the pulmonary artery to the lungs to be purified or arterialized ; and (2) pure or arterial blood from the left side of the heart going through the bronchial arteries to the lungs for the nourishment of their substance. The first, after puri- fication, is returned to the left side of the heart by the pulmonary veins. The second, after serving for the nourishment of the lung-tissue, is returned in part through the bronchial veins to the right side of the heart, and in part through the pulmonary veins to the left side of the heart; in other words, part of the arterial blood of the bronchial arteries is returned as arterial blood directly to the left side of the heart from which it was sent, without first passing in the regular way into the systemic veins and the right side of the heart © 7. ‘‘In their course together through the lung the artery is usually found above and be- hind the bronchial tube, and the vein below and in front.” 7 The bronchial arteries and their branches ramify in the lung-tissue without such definite rela- tions to the bronchi as with the pulmonary vessels. The nerves of the lungs are derived from the vagus and the sympathetic, and form a dense plexus on the dorsal and another on the ventral side of the root of each lung (the so-called anterior and posterior pulmonary plexuses). From these plexuses the nerves ramify in the substance of the lung, following the bronchi. EXTERNAL RESPIRATION.—Under this heading are included the changes which occur in the respiratory blood during its passage through the lungs or gills, and also the changes occurring simultaneously in the According to the view of chemists and physicists, the earth’s atmosphere, or the air, as it is more com- monly called, is a mechanical mixture composed princi- SSS SWQ NOSE 45—-— Tongue a f) ~-~ Réinice Glottictis — — -Trachec eS = cEsophaqus - 4-Yo= : Seat || Cardiac Shhincter -\— Diaphragr -- es e Inteshines — — == C bs \) ue —Pylo PLS Abdominal Muscles hhe Bladtile = \ the Bladcler. Fig. 3815.—Diagrammatic Section of the Body. Sphrerroters_ Avie (Kirkes.) pally of oxygen and nitrogen, with a minute quantity of carbon dioxide and a varying amount of watery vapor. 199 Respiration. Respiration. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. The composition of the air from various parts of the earth’s surface has been found nearly uniform. When dried and reduced to the standard temperature and press- ure (a temperature of zero centigrade and a pressure of 760 mm, of mercury), the composition is about as follows : * OXY 2ONs os seas. +s sc eet eto LEDC LAUGOE Witrogens, 5 6 LE Le eR Carbon dioxide. 0102. ch bickic eels) eee 100.60 per cent. Air coming from the lungs (expired air or breath) of man, or one of the other warm-blooded animals, compared with the inspired or atmospheric air, shows the following changes, due to its sojourn in the lungs: (1) A marked decrease in the amount of oxygen; (2) a great increase in the quantity of carbon dioxide ; (8) slight if any change in the amount of nitrogen ; (4) usually an increase in the “quantity of watery vapor; (5) the temperature is closely approximated to that of the body, being usually warmer than the surrounding air; (6) traces of organic matter have been added ; (7) traces of ammonia are often pres- ent, and sometimes odors from substances taken into the stomach, as alcohol, garlic, etc. The surrounding air is usually at a lower temperature than the body, and is therefore heated by the body when taken into the lungs. In this case it increases in volume, following the law for the expansion of gases by heat. If the temperature of the air is higher than the body, it is cooled by being inspired and diminishes in volume, fol- lowing the same law. But after making allowance for changes in temperature and in the amount of aqueous vapor present, the expired air is usually slightly less in volume than the inspired air, due to the fact that the volume of oxygen absorbed from it is greater than that of the carbon dioxide added to it. This diminution is variously estimated from 1 to 2.5 per cent. of the original volume inspired. Owing to the change in volume, a comparison of the percentage composition of inspired and expired air does not furnish exact information concerning the quantitative changes which the air undergoes in the lungs. These changes can only be determined accurately by comparing the absolute amount of the various constituents of a known volume of ixspired air with the absolute amount of the various constituents of the same air after it is expired.’ + Gases of the Blood.—It was thought by Lavoisier,? and those who followed his teachings, that carbon dioxide was formed in the lungs by an oxidation of the waste materials brought to the lungs by the blood. This view was found untenable by later investigators, who proved that the arterial blood was cooler than the venous. This * While it was formerly supposed that the composition of the atmos- phere in a given place was constant, later investigations have shown that there is considerable variation ; the oxygen has been found to vary from 20.45 to 21.01 per cent., and the carbon dioxide from 0.0206 to 0.0417 per cent,§ + It is apparently assumed by many writers on respiration that, if the percentage composition of inspired air and that of expired air are com- pared, one can determine accurately the changes occurring in the air dur- ing its sojourn in the lungs, thus neglecting the diminution in volume. For example, in the excellent works of Wundt (Physiologie des Menschen, 4th ed., p. 388), and Foster (Text-book of Physiology, 8d ed., p, 841), per- centage compositions of inspired and expired air are given with the state- ment that, when dried and compared at the standard temperature and pressure, the expired air is '/, 9th to !/,)th less in volume than the same air when inspired. Inspired air: Oxygen, 20.81 per cent. ; nitrogen, 79.15 per cent.; car- bon dioxide, 0.04 per cent, Expired air: Oxygen, 16.038 per cent. ; nitrogen, 79.557 per cent. ; car- bon dioxide, 4.88 per cent. ; The loss in oxygen by the air, and its gain in carbon dioxide, are both determined by comparing the percentage differences, without appar- ently taking any account of the diminution of volume. It is further stated by Dr. Foster, with reference to the nitrogen: ‘‘ The quantity of nitrogen in the expired air is sometimes found to be greater, as in the table, but sometimes less, than that of inspired air.” While it is true that the percentage quantity of nitrogen in the expired air is greater, as shown in the table, the absolute amount is less, provided there is the diminution in volume described. Taking the least diminution mentioned, 1/9th or 2 per cent., then 100 c.c. of inspired air would measure but 98 c.c. when expired. If, now, 79.557 per cent. of this is nitrogen, the total nitrogen in the 98 c.c. of expired air would be (98 x 79.557) =77.96586 c.c. ; and as in the 100 c.c. of air originally inspired there were 79.15 c.c, of nitrogen, there has been an actual diminution of (79.15 — 7.96586) = 1.18414 c.c. of nitrogen, instead of an increase as stated by Dr. Foster. 200 could not be the case if oxidation sufficient to produce all the carbon dioxide appearing in the expired air took place in the lungs, It was also shown that, in blood from any part of the body, carbon dioxide and oxygen could be obtained directly without chemical means ; and that more carbon dioxide could be obtained from venous than from arterial, and more oxygen from arterial than from venous, blood. At the present day it is known that the respiratory process occurring in the lungs is an absorp- tion of oxygen from the air by the blood, and a return to the air of carbon dioxide already existing in the blood. The exact office of the blood in respiration could only be determined by discovering the nature and relations of the gases of arterial and venous blood.” * From one hundred volumes of blood about sixty vol- umes of gas may be extracted. This does not diminish the volume of the blood. The gas is composed of oxy- gen, nitrogen, and carbon dioxide, the proportions of these gases varying in the different kinds of blood. In order that the results shall be of the greatest value, the two kinds of blood from which the gases are ex- tracted should be from the same animal, under similar conditions. According to five such double analyses of dog’s blood by Schoeffer,® the following averages were obtained from 100 c.c. of blood: Arterial Blood: Oxygen, 19.2 ¢.c.; nitrogen, 2.7 c.c. ; carbon dioxide, 39.5 c.c. Venous Blood: Oxygen, 11.9 c¢.c.; nitrogen, 1.7 ¢.c. ; carbon dioxide, 45.3 c.c. This table shows that in 100 c.c. of arterial blood there are 7.3 c.c. more oxygen, and 5.8 c.c. less carbon dioxide than in the same volume of venous blood. From nu- merous determinations made by other observers, Zuntz gives as an average, an increase of 8.15 per cent. of oxy- gen and a decrease of 9.2 per cent. of carbon dioxide in 100 c.c. of arterial blood as compared with the same vol- ume of venous blood. According to the very numerous (nearly two hundred) determinations of the gases of ar- terial blood of the dog by Bert and Pfliiger, the gases in 100 c.c. of blood are as follows :* Oxygen, 18 to 20 c.c.; nitrogen, 1 to 2 c.c.; carbon dioxide, 38 to 40 c.c. In hu- man arterial blood the gases were found by Setschenow ® in the following quantities in a single determination : Oxygen, 21.6 ¢.c.; nitrogen, 1.6 c.c.; carbon dioxide, 40.3. So far as this single determination goes, the gases in hu- man blood agree very closely in quantity with those found in dog's blood, and any conclusions drawn from observations on the gases of dog’s blood might probably be legitimately applied to human blood. Arterial blood is of nearly uniform composition through- out the entire body, containing a slightly less percentage of oxygen in the smaller arteries farthest from the heart, due to the diminished number of blood-corpuscles as shown by the lower specific gravity,® and in part, probably, also to the true respiration occurring in the blood itself. The venous blood differs considerably in composition in dif- ferent parts of the body, hence that for the extraction of the blood-gases should be taken from the right heart or the pulmonary artery, where it is mixed, if a general average is sought. A comparison of the gases of arterial and venous blood from any part of the body shows, however, wherein lies the difference between them so far as respiration is concerned, and it is found to be a difference only in the proportions in which oxygen and carbon dioxide are present in the two kinds of blood. Arterial blood may, therefore, be defined as blood con- taining a relatively large percentage of oxygen (eighteen to twenty per cent.), and a relatively small percentage of carbon dioxide (thirty-eight to forty per cent.). Venous blood may be defined as blood containing about eight per cent. less oxygen and six to eight per cent. more carbon dioxide than is present in arterial blood. In ordinary respiration the blood is not saturated with either of the respiratory gases, as is shown by shaking blood * The terms arterial and venous blood are unfortunately used in two senses, viz., in a morphological sense, relating to the kind of blood-vessel containing the blood without regard to its quality, and in a physiological sense, referring solely to its quality without regard to the vessel contain- ing it. The terms are used only in the lattér sense in the present article. — ee REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. with them. If shaken with pure oxygen or with air, blood will take up about twenty-three per cent. of its volume of oxygen, instead of twenty per cent. as in or- dinary respiration, and if it is shaken with pure carbon dioxide the blood will absorb about its own volume of that gas.!° Relations of the Gases in the Blood.—It is believed that but a small amount is in simple solution, but that the greater part is in loose chemical combination. This is supported by the fact that when blood is put under the mercurial pump (Fig. 3316), a small amount of gas is gradually given off, following the Henry-Dalton law for the absorption of gases by liquids; but the larger part of the gas comes off only when the pressure falls to about twenty millimetres of mercury ; then it is sud- denly given off. The oxygen simply dissolved in the blood plasma has been found to exceed but little the amount that water dissolves at the same temperature. It has been proved conclusively that the main part of the oxygen in the blood is combined with the hemoglobin in the red _ blood- corpuscles (see also article Blood, vol. i.). The relations of the carbon dioxide are © not quite so simple, for although the blood contains less carbon dioxide than would be absorbed by water at the same temperature, it does not follow the law for the absorption of gases by liquids; and it is the prevailing belief among physiologists that it is all chemically combined in the plasma of the blood, very little being in the corpuscles. As part of the carbon dioxide is readily re- moved from the blood by the mercurial pump, it is called the ‘‘ loose” carbon di- oxide, and is supposed to be united with the soda of the blood in the form of a bicarbonate ; while the part (‘‘ fixed” carbon dioxide) which cannot be pumped from the blood serum without first add- ing an acid, is supposed to be united to the soda in the form of a carbonate. It has been found by experiment that in removing the blood-gases the hemoglobin acts like an acid, enabling all the carbon dioxide to be pumped out without adding an acid. If the red corpuscles containing the heemo- globin are first removed, only the “‘ loose ” carbon dioxide can be obtained, as stated above, unless an acid is first added.° The nitrogen in the blood seems to be in simple solution. Color of the Blood.—It has been found that hemo- globin containing oxygen (oxyhemoglobin) is of a bright scarlet color, 7@.e., the color of arterial blood, while hemoglobin not containing oxygen (reduced hemoglobin) is of a darker color, that is, the color of venous blood (Fig. 3312). This is true of the hemoglobin in the blood, whether it is in the blood-corpuscles or dissolved in the plasma, and it is entirely independent of the carbon di- oxide that may be present. This is shown by the blood of animals dying of carbon dioxide poisoning in a con- fined atmosphere of pure oxygen, *!!, Under ordinary circumstances, however, the color of the blood is a good test for determining its respiratory quality, as carbon di- oxide escapes at the same time that oxygen is absorbed. But it is truly arterial only when its hemoglobin is nearly saturated with oxygen and the plasma contains a moderate amount of carbon dioxide (see above). Gas-interchange in the Lungs.— When the venous blood reaches the lungs it is spread out in a thin sheet in the pulmonary capillaries and separated from the air on two sides, in many places only by the epithelium of the capillaries and that lining the alveoli of the lungs (Fig. 3317). The blood being thus practically in contact with the air, oxygen passes through the membrane sepa- rating the air from the blood into the blood, in accord- ance with the law for the absorption of gases by liquids ; Respiration. Respiration. but as soon as it reaches the blood-plasma, the reduced hemoglobin combines chemically with it to produce oxy- Ds SIM IAV’ SD: US SSUES VCHAIBSING Fig. 3316. — Diagram of Pfliger’s Mercurial Pump for Extracting Blood- gases. (Landois.) A, blood- bulb; B, froth-chamber ; C, drying chamber; D, tube connecting E and ©, and containing a mano- meter for determining the extent of the exhaustion ; EH, fixed bulb containing mercury; F, open and movable bulb containing mercury; G, heavy rub- ber tube connecting the two bulbs (E and F); H, two-way tock allowing the gases to pass from A, B, C, to E, or from E to H; J, eudiometer filled with mercury; K, section of the two-way cock H, showing the passage from E to H;3 a, a’, stop-cock, opening upward in a, and downward in a/; b, c,d, e, f, stop-cocks; g, connection between the collecting and drying part of the apparatus and the pump; h, glass tube connecting the bulb E with the eudiometer J: i, mercury into which the eudiometer and the tube h dip; v, dish of mercury (pneu- matic trough) ; w, support in which the bulb F is raised and lowered by the ratchet-wheel shown at the right. The following directions for the use of this pump are taken from Landois: The blood-bulb A is first exhausted by means of a mercurial pump, and then carefully weighed. The end ‘of the stop-cock a is tied into a blood-vessel and the cock turned so that the blood flows into the blood-bulb. When a sufficient amount of blood is collected the cock is turned in the position (a/), and after cleaning the outside of the blood-bulb it is again carefully weighed to ascertain the amount of blood that has been collected. The frothi- chamber (B), as its name implies, is to catch the froth formed during the energetic evolution of the blood-gases. It is connected with the other parts of the apparatus, on both sides, by means of stop-cocks, The drying chamber Cis composed of a U-tube filled with pumice stone saturated with sulphuric acid, and at the base of the U-tube is a bulb partly filled with sulphuric acid. The blood-gaves in traversing this chamber are completely dried. In working the pump, the whole ap- paratus is emptied of air by filling the bulb E with mercury, by raising the bulb F, after turning the cock H.in the position K, so that the air in E can pass out through the tube h, which is not yet dipped into the mercury, and then turning the cock H so that it will connect with the rest of the apparatus. All the other cocks except a and b are opened, and the bulb F is lowered until part of the air is exhausted, then the cock H is turned to the position of K and the air is got rid of by raising F, This process is repeated until the manometer in D shows a com- plete vacuum. Then the cock H is turned to the position K, and the bulb F raised until mercury runs out of the tube h, when the cock is turned to the position H, and the tube h is placed in the pneumatic trough v, under the eudiometer J. A vessel of water at about 60° C, is now raised so as to immerse the blood-bulb, and the cocks, except a, are opened and the bulb F lowered. After part of the gas has passed over to E, the cock H is turned to the position K, and the gas 1s forced over through the tube h into the eudiometer J. This process 1s repeated until, as shown by the manometer in D, the gases are all extracted. hemoglobin, leaving the plasma as poor in oxygen as before. The absorption of oxygen by the plasma there- 201 Respiration. Respiration. fore continues until all the reduced hemoglobin is oxi- dized and changed to oxyhemoglobin, and the plasma is Fic. 5817.—Diagram of Part of a Pulmonary Lobule, to Show the Relations of the Various Parts, especially the Blood Capillaries and the Alveoli. A, A, A, Alveolar or lobular passages ; a, a, pulmonary al- veoli, air-vesicles, or air-cells. These open either into the al- veolar passages singly or in groups; B, ultimate bronchial tube or lobular bronchiole. It is lined with ciliated epitheli- um and opens into the alveolar passages on one side and joins other bronchioles on the other ; C, CC, capillary . containing blood - corpuscles. The capil- lary is exposed to the air on two sides, being separated from the air only by the epithelium lining the alveoli. In the act- ual specimen all the partitions are filled with capillaries; I, opening into the alveolar pas- sage of an infundibulum or group of alveoli. saturated with oxygen at the temperature of the blood and the partial pressure or tension of the oxygen in the alveolar air. * This explains why the oxy- gen needed for respiration is obtained by the blood indepen- dently of the partial pressure or tension of the oxygen in the air, provided the tension does not fall too near the point of dissociation of oxy- hemoglobin ; for, according to the law of absorption of gases by liquids, a certain amount of oxygen enters the plasma of the blood whether there is a greater or less amount of oxygen in the air than normal. The reduced hemoglobin combines with the oxygen to produce oxyhee- moglobin independently of the tension of the oxygen. If the air is very rich in oxygen, the hemoglobin of the blood is quickly changed to oxyheemo- globin, fora sufficient amount is rapidly .absorbed by the plasma and thus brought into combining distance of the he- moglobin. If, on the other hand, the tension or partial pressure of the oxygen in the alveolar air is small, the he- moglobin will still combine with the same amount, but it will take a longer time, from the slowness with which the oxygen is absorbed and brought into combining distance by the plasma. At the same time that the oxygen is passing from the alveolar air into the blood, carbon dioxide is passing from the blood to the air ; hence the designation of the process as an exchange of gases. The same principles are sup- posed to govern the exit of carbon dioxide as for the * Partial Pressure, Tension.—Although these subjects belong to phys- ics, a brief consideration of them may not be out of place, since the terms are so often used in discussing the interchange of gases in respi- ration. So far as a mixture of gases, unconnected with liquids, is con- cerned, these two expressions are used interchangeably. The meaning is, that as gases in a mixture exert no pressure upon each other, each exerts such a pressure or has such an expansive force as though it ex- isted alone. This expansive force or pressure is expressed in millimetres of mercury, measured at the standard temperature and pressure (temp., 0° C.; bar., 760 mm. hg.); hence, the partial pressure or tension of a gas in a mixture is obtained by multiplying the atmospheric pressure by the percentage volume of the given gas. Thus, the oxygen of the air forms 20.81 per cent. by volume of the atmosphere; hence its partial pressure or tension is 760) x 20.81 per cent. = 158.156 mm. hg. Know- ing the partial pressure in millimetres of mercury, the corresponding percentage by volume is readily obtained by reversing the above process ; thus, 158.156 + 760 = 20.81, the per cent. by volume desired. When a gas is dissolved in a liquid, the term tension alone is applied to it. This means the force by which the gas tends to escape from the liquid. The tension in this case is also expressed in millimetres of mer- cury or in percentages by volume of the gas. When either of these is known, the other is obtained, as described above for the partial pressure of a gas in a mixture. The tension in millimetres of mercury and the corresponding percentage by volume indicate the amount of the given gas which should be present in an atmosphere overlying the liquid, in order that none of the gas shall escape from the liquid and that no more shall be absorbed, It has no reference to the absolute amount of gas absorbed by aliquid. That varies with each liquid and each gas, In general, in two gases, a gas and a liquid separated or not by a membrane, or in two liquids separated by a membrane, if there is a dif- ference in the tension or partial pressure of the same gas in the two situ- ations, or a difference in the tension of the given gas in the liquids, or in the liquid and the overlying air, there will be a diffusion of gas from the situation in which the given gas is at the higher, to that in which it is at the lower, tension, and this will continue until equilibrium is estab- lished. On the other hand, if the tension is already the same in the two situations, no diffusion of the gas will occur. 202 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. absorption of oxygen—the air in the alveoliof the lungs contains carbon dioxide at a less tension than it possesses in the blood, so that the excess of carbon dioxide tends to pass from the blood to the air to establish equilibrium. The case is not so simple as this, however, for, as the entire amount of carbon dioxide in the blood is in com- bination, it could not be expected ‘to follow the laws of diffusion determined by difference of tension. If it is in true chemical combination it has no tension in the blood. The explanation has been sought in the fact that oxy- hemoglobin acts as an acid in setting free the carbon dioxide, and this action seems to be all the more energetic at the moment when the oxygen is taken up to form the oxyhremoglobin. The pulmonary epithelium covering the alveoli (Fig. 3317) is also supposed to assist by actively excreting carbon dioxide. Finally, as the amount of carbon dioxide in venous blood may be represented by a tension of 41 mm. hg., and the partial pressure or tension of the air in the pulmonary alveoli is only 27 mm. hg.,° it is supposed that this difference in tension is sufficient, with the assistance of the acid-like action of the oxy- hemoglobin, to dissociate the combined carbon dioxide, when it would be subjected to the laws of absorption of gases, and would escape to the air of the alveoli, where the carbon dioxide tension is lower. Certain it is that this transfer is constantly taking place. Equilibrium would, however, soon be established between the gases of the blood and the alveolar air if either or both were stationary ; but both are constantly changing, the one by diffusion and currents, the other by circulation ; hence equilibrium is never established, and the respiratory gas- interchange between the blood and the air in the lungs is continuous throughout the whole of life. INTERNAL OR TissuE RESPIRATION.—The question still remains to be answered : ‘‘ What is the ultimate des- tiny of the oxygen removed from the air, and what is the source of the carbon dioxide added to it?” After it was conclusively shown that the formation of carbon dioxide did not take place in the lungs, it was supposed that its formation took place in the blood in all parts of the body, the oxygen taken up in the lungs serving to oxidize the waste matter poured into the blood. This view was found to be untenable, for very easily oxidiz- able substances, like pyrogallic acid, do not become oxi- dized when placed in the blood of a living animal; and if the arterial blood is followed in its course through- out the body, it is found that while the blood in the ar- teries is of nearly uniform character, as soon as it comes into intimate contact with the tissues in the capillaries the oxygen markedly diminishes, and the carbon dioxide greatly increases, in amount. That the oxygen dimin- ishes in amount during its passage through the tissues may be demonstrated on a living animal by examining the light which traverses some thin membrane like a frog’s web, or the wing of a bat, through a spectroscope. The light will show the two bands characteristic of oxy- hemoglobin (see articles Blood and Blood-Stains, vol. i.). If the leg of the frog, or the wing of the bat, is com- pressed sufficiently to stop the circulation, the single band characteristic of reduced hemoglobin will soon ap- pear, showing that the oxygen has been given up by the oxyhemoglobin. According to Vierordt!® the same may be observed in man by examining through a spectro- scope the light which traverses the crack between two fingers. The two bands of oxyhemoglobin will appear as long as the blood circulates freely ; but if a string be wound tightly around the fingers, thus stopping the cir- culation, the single band of reduced hemoglobin will soon appear. ‘These demonstrations do not show, how- ever, that the waste material was not first poured into the blood of the capillaries and oxidized there. That it is the tissues that take up the oxygen and give out the carbon dioxide, and that the carbon dioxide is not pro- duced in the blood, is definitely proven by the following : If a living tissue, muscle for example, is removed from an animal and deprived of blood, and placed in a va- cuum, or an atmosphere of pure nitrogen or hydrogen, the muscle will continue to produce carbon dioxide, and if irritated will contract, showing that it is alive. If it REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Respiration. Respiration. is placed in an atmosphere of oxygen or in the air, oxygen will be taken up directly, and carbon dioxide be given off directly, as described in the direct respiration of the ameba, etc. If muscle or other living tissue is placed in arterial blood, some of the oxygen will disap- pear, and carbon dioxide will appear in its place. Fi- nally, Oertmann and Pfliiger have shown that in frogs in which the blood had been entirely replaced by normal salt solution, the respiratory changes take place in a nor- mal manner for a considerable time, and are nearly as great as when the blood was present. From the facts just stated, and many others, physiolo- gists feel warranted in asserting that the tissues take up the oxygen and give off the carbon dioxide—that is, the true respiratory process occurs in them, and not in the lungs or in the blood. If the first knowledge concern- ing respiration had been obtained from animals in which \jdaeans ance Sauendatet eekanuacenennanecksocauneaoee sa AT Ahi {mm watery vapor; xX, exit-tube from the respiratory chamber. experiment. the respiration is direct (see above), no respiratory blood or elaborate apparatus being present, it would have been seen from the beginning that respiration is solely for the tissues, no matter how elaborate the appliances for supplying the oxygen and removing the carbon dioxide. 1) %8,9, 12 The laws governing the gas interchange between the blood in the capillaries and the tissues are supposed to be the same as those obtaining in the lungs, viz., the oxygen-tension in the tissues and the lymph bathing them is far lower than in the blood-plasma, hence diffusion toward the tissues occurs. This goes on until the oxygen- tension in the plasma is so low that the dissociation of some of the oxyhemoglobin follows, raising once more the tension in the plasma above the dissociating point ; but as the tissues are continually taking the oxygen and combining it, the oxygen-tension of the plasma soon falls again below the dissociating point, and more oxygen is given off to it by the oxyhemoglobin. This process is continuous, for as fast as the oxygen comes into com- bining distance in the tissues, it is united in a compound more stable than oxyhemoglobin; consequently, no mat- ter how low the oxygen-tension may fall in the lymph Fie. 3318.—Pettenkofer’s Respiration Apparatus, (Landois.) a, opening in the respiration ’ chamber for the entrance of air; b, vessel containing pumice-stone saturated with sulphuric acid, for drying the expired air; C, gas-meter for measuring the air from the respiratory chamber after it is dried ; K, bulb containing sulphuric acid to dry the expired air that is to be analyzed ; M, M, suction apparatus constructed on the principle of Miiller’s mercurial valve, and driven by a steam-engine; n, small tube conducting part of the air from the respiratory chamber to the analyzing apparatus, where its composition is determined; N, apparatus for analyzing the air before it enters the respiratory chamber; P, P, double suc- tion-pump, driven by a steam-engine, for drawing the air through the respiratory chamber ; q, manometer ; R, tube filled with a standard baryta solution, for determining the carbon dioxide ; u, small gas-meter to measure the analyzed air, less the carbon dioxide and the The air from both the top and the bottom of the respiratory chamber is drawn into this tube, so that it shall be of an average quality; Z, respiratory chamber in which the person or animal remains during the surrounding the tissues, the oxygen compounds formed by them are not dissociated, and the oxygen-tension in the tissues outside the blood-vessels is always lower than in the blood ; consequently the diffusion of the oxygen is always away from the blood toward the tissues. - _ The carbon dioxide in the tissues and lymph surround- ing them is at a considerable, and always increasing, ten- sion, while in the blood it has practically no tension, as it is all in combination, and there is a continuous dif- fusion of the carbon dioxide from the position of higher tension in the tissues to that of a lower tension in the blood. The blood itself is a tissue, and all the respiratory processes go on in it as in any other tissue. Relations of the Oxygen in the Tissues.—The changes through which the free oxygen passes after it is taken by the tissues, before reappearing in the car- bon dioxide or other excretory product, belongs, perhaps, more properly to the general subject of nutrition, yet a brief discussion may not be out of place here. The oxygen is probably combined, in some way, with other chemical substances into the highly potential or explosive forms of mat- ter which, in breaking up, give rise to the special form of activity characteristic H p of the special tissue, and leave less po- tential compounds, one of which is in- variably carbon dioxide. This is shown from the fact that if a muscle, for exam- ple, is removed from the body, and freed from blood, it yields no oxygen to the mercurial pump, showing that neither free oxygen nor that loosely combined is present; yet the muscle will contract vigorously when stimulated, and it gives off carbon dioxide continuously—more during the contraction than at rest. As there was no free oxygen present, the car- bon dioxide must have been formed by the breaking up of some compound con- ; taining oxygen previously stored in the & tissue, That this is also true of an entire animal, as well as for the individual tis- sues, was proved by Spallanzani, Ed- wards, and Pfliiger, who kept frogs, at a low. temperature, in an atmosphere of pure nitrogen or hydrogen, for several hours—that is, much longer than the slight amount of oxygen remaining in the air of the lungs or in the blood could, have lasted—yet the animals continued to live and produce carbon dioxide. This could not have been the case if oxy- gen had not been stored in the tissues previous to the experiment. From what was said under the head of Huternal Res- ptration it is evident that the free oxygen disappearing from the air in the lungs is not immediately returned to the same air, combined with carbon, in the form of carbon dioxide, for it has been shown that this combina- tion does not take place in the lungs; so, likewise, the carbon dioxide returned to the blood of the capillaries” does not contain the same oxygen that had been just taken up from the blood by the tissues; but it may have been stored in them, forming part of their living substance for a considerable time. The time interven- ing between the absorption of the oxygen and its re- appearance in the carbon dioxide depends, no doubt, somewhat on the bodily activity of the animal. It is certain that man and the other warm-blooded animals, in which the processes of life are carried on with great vigor, can endure the deprivation of oxygen as well as of other food for a shorter time than the cold-blooded ani- mals, The Respiratory Income and Outgo, and the Circum- stances Affecting Them.—As the oxygen disappearing and the carbon dioxide appearing in respiration have been traced to the tissues, the respiratory activity of 203 Hespiration. Respiration, the tissues can be ascertained by determining the amount of oxygen supplied to them and the carbon dioxide ex- creted. A determination of the total gas-interchange in the lungs will not, however, give the total amount of oxygen absorbed, and of carbon dioxide excreted, as there is a considerable gas-interchange taking place through the skin and through mucous surfaces other than the lungs. The respiratory interchange through the skin, in man and the other animals with a thick and comparatively dry epidermis, is a very small fraction (about 345) of that taking place in the lungs. Accord- ing to the determinations of Aubert and Lange, the average amount of carbon dioxide excreted by the skin in twenty-four hours is about four grams, or 2,000 c.c. This amount is increased by an elevation of tempera- ture in the surrounding air. Part of this carbon diox- ide is not due to respiration, but to decomposition go- ing on at the surface of the skin (Hoppe-Seyler 7°). amount of oxygen absorbed by the skin is less than the carbon dioxide excreted in the proportion of 100 c.c. of REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. with carbon forms but one volume of carbon dioxide gas, The diminished amount of the oxygen appearing in the carbon dioxide is explained from the fact that part of the absorbed oxygen is used in forming compounds other than carbon dioxide. TABLE FROM PETTENKOFER AND VOIT, SHOWING THE TOTAL GAS-EX- CHANGE, THE RESPIRATORY QUOTIENT, AND THE AMOUNT OF WATER EXCRETED IN TWENTY-FOUR Hours BY A MAN UNDER VARIOUS Con- DITIONS OF Foop AND AOTIVITY : !3 —— oxygen to 128 to 610 c.c. of carbon dioxide.*®® It is comparatively easy to determine the amount of respiratory gas-interchange going on in the lungs and through the skin ; but it is difficult or impossible to de- termine directly the change through the mucosa of the nose and that of the alimentary canal from swallowed air; consequently, in determining the total respiratory changes going on in an animal, such a method as that of Pettenkofer’s, in which the entire income and outgo of the animal is ascertained, must be used (Fig. 3318). It is desirable, however, to estimate the part taken in the total gas-exchange by the different organs involved, so that the part played by each may be known. In the method of Pettenkofer the amount of carbon dioxide excreted is determined directly, but the amount of oxygen absorbed is determined indirectly, as follows: To the weight of the person or animal at the beginning of an experiment is added the weight of solid and liquid nourishment taken during the experiment; this sum is then subtracted from the weight of the body at the end of the experiment, plus the solid, liquid, and gaseous excreta. The difference represents the oxygen used by the animal during the experiment. From data furnished in the table in the next column, and by other investigators, the total amount of oxygen taken up by an adult man in 24 hours averages about 750 grams (523,088 c.c.), and the carbon dioxide excreted in the same time averages about 900 grams (456,514 c.c.). The oxygen reappearing in the carbon dioxide is consid- erably less than that absorbed during the same time. This may be readily seen by comparing the volume of the two gases, as one volume of oxygen when united Carbon di- 5 & _ | Oxygen ab- Respiratory} Water ex- Diet, etc. rae mes sorbed. quotient. creted. Grams. Grams, Grams, I. Fasting. day ..... 427 450 Unc 0.69 444 Rest | night 32 ¢ 788 330 { 780 0-4 0-69 385 t 829 (day..... 379 |p 420 | 66 (9 pg | 463 act Rest} int 7 | 16 ¢69 | gag f 748 071 {0-8 oi 814 day ...| 980 922 73) 1,425 14 vom Labor fare . { 1,187 11,072 1194 ¢ 0-81 | 'g59 {1,777 II. Mixed diet. ; ye 533 235 1.75) 344 Resy cone a7} 912 fra ¢ 709 0.58 ¢ 9-80 434 ¢ 88 ay ile 539 469 0.84 534 Rest | OP aos 8 450 5 919 0-65 50-7 ‘5 ¢ 15009 dayit.:: 527 418 | 09 8 eels Rest | ee 403 ¢ 930 | 449 (867 | 92654 9-78 | 514 L957 day ...| 885} 295 2.18 1,095 t. Labor } ne 400 f 1-285 BBO f 905 0-445 0.88 ye { 2,042 day ...| 828 79514 ane | 0.%6 1,035 } Labor } night, 306 ¢ 1184 21] { 1,006 1.06 ¢ 9-82 977 f 412 III. Diet largel nitrogenous. day .... | 580) 632 0.67 ) 696 Rest | nignt..,| 433 ¢ 008 is ¢ 850 rat po-8 414 19110 day ..... 596 566 | 644 Rest | gly 2 Dey: { 1,038 pe | 876 son {0.86 Len 1 1,207 IV. Diet non-ni- trogenous. day ..... 508 523 0.71 566 Rest { G87» 331 839 ae } 808 0:94 ¢ 0-74 ae \ 92s Rest 4 day ...¥% 522 @| 551 0.69 681 Following Pfliiger, most physiologists designate the relation or ratio between the volume of carbon dioxide excreted and the volume of oxygen absorbed in a given CO. om varies considerably with different conditions of the body, as will be seen below and by consulting the table above. The respiratory activity of man is greater than that of animals larger than himself, but less than that of many at least of the warm-blooded animals smaller than himself, as will be seen from the following table. In this table the amounts given represent what each animal, retaining its normal respiratory activity, would show if it weighed one kilogram and the experiment continued one hour :8 time as the respiratory quotient This ratio Name of animal and total weight Oxygen absorbed per | Carbon dioxide excreted merc eay Authori in kilograms, hour and kilogram. per hourand kilogram. Quotient, a uthority. Cubic cen- Cubic cen- Grams. timetres, Grams. timetres. DAS, SOU Se ices eet 28 sa Basins oto t el git eer 0.518 361 0.619 814 0.869 Speck. ORO he tae eae tee oie town idole atc ey eae ae Ai gate 0.437 217 Het Pettenkofer and Voit. Bill Call ell Dees, Pee nc: Soca tek oy vee eee 0.481 336 0.571 290 0.862 Reiset. PCCD MO ie ects yates held te cats [he dee one, San, | 0.490 343 0.671 841 0.994 OY DG, CSUs ioc entten tee tsttee ae cack fics 24 bien page AO 814 1.188 604 0.742 Regnault and Reiset. Rebbity 2. (80 jccwepesenk cee ey. sok we cs eel ees 0.877 618 1.107 563 0.918 E # Bieri, 1280 Fee bo ee hee eee re Fe ot | 1.058 740 1,327 675 0.913 ae es Sparrow, 0,022 | 9.595 6,710 10.492 5,334.5 0.795 wp xt PR POR BE ioe 0. Seas dh Mace nts RA ORLA cei al 0.083 58.8 0.063 44 23 0.741 Ee ee Wockchafersi. ciscaes weotee ey ae ee ont ape ee | 1.076 52 1.1699 594.8 0.791 ee = Conditions Affecting the Respiratory Gas-interchange. —Bodily activity of any form exerts two influences: the absolute amount of oxygen absorbed and of carbon dioxide excreted are both greatly increased. The rela- tive amount of the two gases is more nearly equal during action than at rest. In some cases of activity and appar- ent rest this quotient may approach or even exceed unity, showing that oxygen stored at some previous time is be- ing drawn upon (see table from Pettenkofer and Voit). Sleep and hibernation being conditions of profound re- pose, the respiratory activity is greatly lessened. The 204 relative amount of oxygen absorbed increases in most cases, showing that oxygen is being stored for future use. The respiratory quotient consequently falls considerably below unity. In hibernating animals this quotient may fall below one-half (0.399 to 0.588, Regnault and Reiset). ’ During digestion the respiratory activity is increased, the amount of carbon dioxide approximating more closely to the amount of oxygen absorbed than when fasting. This is especially true if a vegetable diet is taken in which there is considerable starch. In fully-fed animals there appears to be also a slight excretion of nitrogen * REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. through the lungs. In fasting animals nitrogen appears to be absorbed in small quantities in the lungs. The respiratory activity is greater in children than in adults, in boys than in girls, in men than in women. The absolute amount increases with age and body weight in both sexes until puberty. In women it then remains nearly stationary (except during gestation, when it is greatly increased) until the cessation of the menses, when it increases for a few years. In men there is a gradual increase until the thirtieth or thirty-fifth year, then nearly a standstill until about the fiftieth year. Beyond fifty there is in both sexes a gradual decrease in the respiratory activity, following the decrease in general bodily activ- ity.14 TABLE FROM SCHARLING 2? SHOWING THE VARIATION IN RESPIRATORY ACTIVITY IN PERSONS OF DIFFERENT AGE AND SEx. , Carbon diox- a ey Os ideexcreted Age and sex; weight in kilograms. é per hour aL a id’ kilo- four hours. gram. Grams. Grams. _ Man, age, 35 years; weight, 65.5 kilos. ...... 804.72 0.512 Soldier, age, 28 years; weight, 82 kilos ...... 878 .95 0.497 Boy, age, 16 years ; weight 57.75 kilos ....... 822.69 0.594 Woman, age, 19 years; weight, 55.75 kilos .. 608 .22 0.455 Boy, age, 934 years; weight, 22 kilos ........ 488 .14 0.925 Girl, age, 10 years ; weight, 23 kilos ......... 459 .87 0.833 Man and the other air-breathing animals have become so accustomed to the mixture of oxygen and nitrogen found constantly in the air, that this mixture is undoubt- edly the best adapted for health and comfort ; but ow- ing to the fact that the absorption of oxygen and the ex- cretion of carbon dioxide are regulated by the activity of the tissues, and that they are largely chemical processes, the respiration goes on practically unchanged in widely varying conditions of the atmosphere. In an atmosphere of pure oxygen the respiratory processes go on normally. If the amount of oxygen in the air falls considerably be- low the amount normally present, there is a feeling of dis- tress, especially upon muscular activity, as the hemo- globin cannot get the oxygen fast enough, owing to the low oxygen-tension in the air and its consequent slow ab- sorption by the blood-plasma, Thus, in an atmosphere containing less than fourteen per cent. of oxygen dysp- noea occurs upon exertion; if it contains but seven per cent., breathing in repose is difficult; and if it falls to three or four per cent. there is rapid asphyxia, although there is no excess of carbon dioxide. The asphyxia produced by lack of oxygen is accompanied by violent spasms, while that resulting from an excess of carbon dioxide, when plenty of oxygen is present, is not usually accompanied by spasms.§ By a greatly diminished atmospheric pressure the re- spiratory gas-interchange is diminished in rapidity, and by an increased pressure it is increased. If the pressure of the atmosphere falls below two hundred and fifty millimetres of mercury warm-blooded animals soon die, owing in part to the slowness with which the oxygen comes into combining distance with the hemoglobin, and, according to Hoppe-Seyler, in part to the liberation of bubbles of gas in the blood, and the consequent plugging of the blood-vessels. Under an increased atmospheric pressure the oxygen enters the blood-plasma more rapidly, and hence comes into combining distance with the hamo- globin in such quantity that it may be fully saturated, and hence ready to supply the tissues more generously than under ordinary circumstances. If the pressure is too great (ordinary air at a pressure of fifteen atmospheres, pure oxygen under a pressure of three atmospheres) the animal dies of asphyxia, as if no oxygen were present. This is comparable with the non-combustibility of phos- ‘phorus in pure oxygen, and its ready combustibility when the oxygen is diluted with nitrogen, or if it is di- minished in pressure. *® Variations in temperature have a marked effect in changing the respiratory activity. In cold-blooded ani- mals the respiratory activity is in direct proportion to Respiration, Respiration, the rise in temperature up to the maximum not inimical to health. With the warm-blooded animals, in which the body temperature is maintained at a nearly uniform standard, the respiratory activity is lessened with an in- crease of temperature, and increased with a diminution of temperature. WATER, ORGANIC MATTER, ETC., EXCRETED BY THE Lunes.—Strictly considered, the excretion of water and other substances from the Jungs may not properly belong to the subject of respiration ; it is usually so included, however, as the excretion takes place from organs which are primarily organs of respiration, and it is a constant accompaniment of breathing. Under ordinary circum- stances there is given off by the lungs about one litre of water in twenty-four hours. This water is derived from the mucous surface of the lungs and the air-passages. The amount of water required to saturate the breath with moisture depends largely upon the hygrometric conditions of the atmosphere, That is, if the air contains very lit- tle moisture a great deal must be added to it in the lungs to bring it to the point of saturation at the temperature of the body. On the other hand, if the air is warm and nearly saturated with aqueous vapor, only a little will be necessary to complete the saturation. If the air is warmer than the body, and saturated with moisture, it will be cooled in the lungs, and water will be deposited until the point of saturation at the lower temperature is reached. That is, the expired air may be cooler, and contain less watery vapor than the inspired air, but this is uncom- mon. Air containing considerable moisture is more com- fortable to breathe than dry air. If it contains too much moisture there is produced a feeling of closeness, and if too little, the evaporation from the air-passages is so rapid that they become parched. For this reason it is more comfortable to sit in an artificially heated room in which watery vapor is constantly mixed with the heated air. In addition to the watery vapor exhaled, there is con- stantly a smatl amount of organic matter given off with the breath. The exact nature and amount of this or- ganic matter have not been determined, owing to the dif- ficulty of so doing. It is this substance which produces the chief deleterious effects in breathing air over and over. The amount of carbon dioxide present in a room containing several individuals is usually not sufficient to produce any serious effects, as is shown by the continu- ous breathing of air containing a considerable amount of carbon dioxide by men when mining coal. The carbon- dioxide tension in the air of an inhabited room, how- ever, is a good guide as to the wholesomeness of the air, for, if the carbon dioxide was produced in breathing, the air will also be loaded with the more dangerous organic matter, which cannot be so readily estimated. The lungs may also act as excretory organs in eliminating sulphur- etted hydrogen and ammonia from the system, and also alcohol and various essential oils, like turpentine and those giving the odor to garlic, etc., which had been pre- viously taken into the stomach.° MEcHANICS OF RESPIRATION.—Under this heading are included all the movements necessary for the supply of the respiratory organs with pure air and the removal of that which has become vitiated. For this respiratory ventilation, as it is often called, two very definite acts occur—inspiration, or breathing air into the lungs, and expiration, or breathing air out of the lungs. Inspiration.—This is forcing air into the lungs, and is brought about entirely by muscular movement, as fol- lows: The glottis is widely opened, rendering the pas- sage to the lungs free; the diaphragm contracts, thereby flattening its arch and increasing the cavity of the thorax lengthwise (Fig. 3319). At the same time the muscles attached to the curved and sloping ribs contract, rotating and raising the ribs, and thus enlarging the thorax 1n Its two transverse diameters (Fig. 3320). The enlargement of the thoracic cavity lessens the atmospheric pressure within it, and as there is no communication between the thoracic cavity and the air, the air rushes into the elastic lungs through the air-passages; the lungs stretch and completely fill the enlarged cavity in the thorax. Expiration.—This is forcing the air out of the lungs. 205 Respiration. Respiration. In normal breathing it follows inspiration without a pause, and is brought about, in quiet breathing, by the relaxation of the inspiratory muscles, the weight of the elevated ribs and chest-walls, and the elasticity of the cos- tal cartilages; by the elasticity of the abdominal walls Fie. 3319.—View of the Thorax, with the left side removed to show the position of the diaphragm in various phases of inspiration and expi- ration. (Rosenthal.) A, position of the diaphragm in strong expira- tion ; B, its position in moderate, and C, in deep inspiration. and the abdominal organs; and, finally, by the elasticity of the lungs, which were put on the stretch during inspi- ration, Whenever, by any form of bodily activity or any other cause, the lungs cannot be thus sufficiently ventilated, the respiratory movements become more vigorous and the respiration is said to be labored. Whenever this occurs, muscles not employed in quiet inspiration are brought into action, and the expiration is no longer due to gravity and elasticity alone, but is aided by muscular contrac- tion. In the following list are given the muscles which aid directly in inspiration by making the thoracic cav- ity larger, or in expiration by diminishing that cavity ; or they may aid indirectly by furnishing fixed supports for other muscles which can act directly on the thorax with more advantage there- by ; or they may assist by opening more widely the air-passages. This list, which also gives the nerves supplying the muscles, is copied from Landois.§ Ordinary Inspiratory the Skeleton of the Thorax, show- ing the position of the ribs and sternum in expiration (light shad- ing) and in inspiration (dark shad- MMyscles (the muscles in ac- aoe) Boclned.) tion during quiet breath- ing): The diaphragm (nervus phrenicus) ; the Mm. leva- tores costarum longi et breves (Ramzi posteriores, Nn. dorsalium) ; the Mm. intercostales externi et intercartila- ginei (Nn. intercostales). Auatliary Inspiratory Muscles (muscles brought into ac- tion during labored and forced inspiration). (A) The ordinary inspiratory muscles named above. (B) Muscles of the Trunk : The three Mm. scaleni (Ram musculares of the plexus cervicalis et brachialis) ; M. sternocleidomastoideus (Rami externus, N. accessorit) ; M. trapezius (ft. externus, N. accessorii et Ram, musculares 206 »~REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. plexus cervicalis) ; M. pectoralis minor (Nn. thoracici an- ' tertores) ; M. serratus posticus superior (WV. dorsalis scapu- le); Mm. rhomboidei (NV. dorsalis scapule) ; Mm. exten: sores columne vertebralis (Ram. osteriores nervorum dorsalium); Mm. serratus anticus major? (WV. thoracicus longus). (C) Muscles of the Larynx: M. sternohyoideus (Ram. de- scendens hypoglossi); M. sternothyroideus (Ram. descendens hypoglosst) ; M. crico-arytenoideus posticus (WV. laryngeus inferior vagt); M. thyreo-arytenoideus (JV. laryngeus in- Sertor vagi). (D) Muscles of the Face: M. dilator narium anterior et posterior (VV. facialis); M. levator ale nasi (1. facialis) ; in gasping for breath the dilators of the mouth and nares. (E) Muscles of the Pharynz : M. levator veli palatini (1. facials) ; M. azygos uvule (NV. facialis). Muscles in Action during Labored Hapiration: The ab- dominal muscles, including the obliquus externus and internus, and transversalis abdominis (Vn. abdominis in- ternis anteriores e nérvis intercostalibus, 8th to 12th); Mm. intercostales interni, so far as they lie between the osseous ribs,* and the infracostales (Wn. tntercostales) ; M. trian- gularis sterni (Vn. intercostales) ; M. serratus posticus in- ferior (Ram. externt nerv. dorsulium) ; M. quadratus lum- - borum (Ram. musculare e plexu lumbalt). Rate of the Respiratory Movements, Apnea,—According to the numerous observations of Hutchinson,!® Sibson, and others, in quiet breathing there occur in the adult from eighteen to twenty inspirations and expirations per minute, or about one breath for every four heart-beats. The number of respirations, that is, the number of in- spirations and expirations, is greater in children than in adults, and in those in the prime of life than in old age. In small animals, like the rat, the rate is far greater than in man (100 to 200 per minute), while in some at least of the larger animals it is slower than in man (rhinoceros, 6 per minute).® Any circumstance increasing bodily activity in any form causes an increased rapidity of the respiratory movements to supply the extra oxygen demanded, and to remove the extra carbon dioxide formed. If the num- ber and depth of the respirations are increased volunta- rily, the total amount of oxygen absorbed and of carbon dioxide exhaled is not increased beyond what is due to the extra muscular exertion required in so breathing ; for the respiratory gas-interchange is controlled entirely by the tissues, not by the respiratory movements. The expired air will, however, contain less carbon dioxide and more oxygen than usual, as the carbon dioxide ex- creted is more largely diluted by the extra amount of air, and the larger amount of air supplying a definite amount of oxygen is less impoverished than a smaller amount would be. If one breathes deeply and rapidly for a short time, it is easier to hold the breath for a considerable time afterward than when breathing ordinarily. Somewhat similarly, if artificial respiration be performed on an ani- mal—a rabbit, for example—that has been in nowise in- jured, the animal will remain, for a considerable time after the artificial respiration has ceased, without breath- ing ; the respiratory movements will then commence, and gradually increase in vigor until the animal breathes in a normal way as before the artificial respiration. It has been demonstrated, in one case at least, that a human being will show the same phenomena under the influ- ence of artificial respiration after tracheotomy.”! This cessation of breathing has béen designated apnea by Rosenthal.!® It has received three explanations: (1) That of Rosenthal, who supposes that on account of the purity of the air in the lungs produced by the extra ven- tilation, the hemoglobin of the blood becomes entirely saturated with oxygen, and this supply lasts for a consid- erable time before more is needed to keep the blood up to the ordinary standard of purity. (2) That of Gad,° who * The controversy begun by Haller and Hamburger concerning the ac- tion of the internal intercostal muscles is still continued. At present, however, the majority of physiologists agree with Hamburger that the internal intercostal muscles between the bony part of the ribs act as ex- piratory muscles, while those between the costal cartilages act as inspira- tory muscles. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. supposes that on account of the purity of the air in the lungs the blood can get all the oxygen needed, and get rid of its carbon dioxide for a considerable time without further ventilation of the lungs. (38) That of Hoppe- Seyler,'® who thinks the cessation of breathing is due to the exhaustion of the respiratory muscles. This view seems less satisfactory than either of the others, for in the case of the rabbits no muscular exertion was required on their part to exhaust their respiratory muscles, and fur- thermore, muscular activity tends to increase, not dimin- ish, the rapidity of the respiratory movements. Rhythm and Type of the Respiratory Movements.—In normal quiet breathing, beginning with inspiration, in- spiratory movements are rapid and continuous, then ex- piration follows without a pause, but proceeds more slowly than inspiration, the ratio being, inspiration six, expiration seven, for adult men. In women, children, and the aged the ratio is, inspiration six, expiration eight or nine (Sibson). After expiration there is in many Fic, 3321.—Diagrams Showing the Change in Form of the Thorax and Abdomen during Respiration in the Male and the Female. (Hutchinson. ) A, outlines of the male, and B, outlines of the female figure, indicating the different phases of the respiratory movements; @, a, outline of the body in full expiration ; in this condition the lungs contain only the residual air. 6, b, heavy continuous line; the outer margin in- dicates the contour of the body in ordinary inspiration, and the inner margin in ordinary expiration; the thickening of the line over the abdomen in the male, and over the thorax in the female, indicates that the greater movement occurs in the abdomen of the male (abdom- inal type of respiration), and in the thorax of the female (costal type of respiration) ; the entire thickness of the line represents the amount of tidal air; in ordinary inspiration the lungs contain the residual, the reserve, and the tidal air. c, c, dotted line giving the contour in the deepest inspiration ; the thorax is greatly expanded, but the ab- domen is less so than in ordinary expiration; in the deepest inspira- tion the lungs contain the residual, the reserve, the tidal, and the com- plemental air (see below). cases a slight pause (expiration-pause) before the begin- ning of the following inspiration. This pause is not always present, and is always absent except in quiet breathing. The movements of a complete respiration are then, (1) a rapid continuous inspiration, (2) a some- what slower expiration immediately following the in- spiration, (3) in many cases a slight pause before the fol- lowing inspiration. The respiratory movements in some individuals are more especially due to the elevation of the ribs, and in others to the contraction of the diaphragm ; consequently these movements have been divided into two correspond- ing types by Hutchinson,'* viz., costal respiration, in which the enlargement of the chest is due largely to the elevation of the ribs, and abdominal respiration, in which the chest-cavity is enlarged most by the contraction of the diaphragm, with the consequent movements of the abdominal walls. The costal type is most common in women, the abdominal type in men. In children of both sexes there is no marked difference in type, and in the Respiration. Respiration. adult the differences are only noticeable in quiet breath- ing. In labored breathing the movements of the chest are most noticeable in both sexes (Fig. 3321). Two explanations have been offered for the great prev- alence of the costal type in the female: (1) That it is due to the habitual use of tight clothing around the waist ; and (2) that it is a kind of reservation against the period of gestation. Hutchinson found the costal type marked in twenty-four girls, varying from eleven to fourteen years, who had never worn tight clothing around the waist.!6 On the other hand, Mays” found by careful experiments, made according to the graphic method, that in eighty-two North American Indian girls, varying from ten to twenty-two years, the abdominal type of breathing was marked in nearly every case. The experi- ments of Mays would indicate that the primitive and natural type of respiration in the female, as well as in the male, is the abdominal ; but in comparing the obser- vations of Mays and Hutchinson on subjects which had Fie. 3322,—Diagram of Hutchinson’s Spirometer. (Landois.) A, grad- uated cylinder serving as a receiver for the breath ; it is supplied with a stop-cock at the top for the ready expulsion of air, and is balanced by weights passing over pulleys. B, mouth-piece with tube reaching nearly to the top of the graduated receiver (A), when the latter is sunk in the reservoir ready for an experiment; there is a stop-cock in this tube near the first angle to prevent regurgitation of air. C, reservoir for the graduated receiver. In using the spirometer the reservoir and graduated receiver are filled with water, or, to prevent the absorption of carbon dioxide, with a saturated aqueous solution of common salt (Na- Cl.). When ready for an experiment, the stop-cock at the top of the receiver is closed and that in the tube of the mouth-piece opened, and the breath forced into the receiver. The receiver rises as fast as the breath displaces the water. After the breath is forced into the receiver the stop-cock in the tube of the mouth-piece is closed, and the water outside and inside the receiver brought to the same level, so that the air within the receiver shall be at the atmospheric pressure. The amount of breath within the receiver is then read directly from the scale attached to the receiver. For accurate measurement the breath should stand a few minutes to acquire the temperature of the liquid over which it is collected, then the various corrections for aqueous vapor tension, and the variations from the standard temperature and pressure, should be made. been equally free from the effects of tight clothing, it would appear that the type of respiration may differ in the females of different races. Respiratory Ventilation.—In very young children the lungs are nearly emptied at each expiration, so that the ventilation is nearly complete ; but after the first period of infancy a large amount of air remains constantly in the lungs, and only a limited amount of this is changed at each breath. Hutchinson and others have investigated with great assiduity the question as to the total capacity of the lungs, the amount of air in them under various conditions, the amount of air inspired and expired at each breath, etc. When the subject was first studied there were great hopes that it would give valuable aid in discovering and treating disease, but these anticipations were not realized. Its chief value is in hygiene ; for, by 207 Respiration. BRhatany. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. showing how much air is breathed by an individual in an hour, and knowing by analysis the contamination of the air due to being breathed once, data are furnished for the ventilation of rooms and buildings. For determining the various amounts of air expired under various conditions, Hutchinson !* invented a kind of gasometer, called by him a Spirometer (Fig. 3322). In the following table is shown diagrammatically the relative position and amount of the different volumes of air that may be in the lungs at the same time. Complemental air, 1,600 c.c. Breathing or tidal air, 500 c.c. Breathing or vital capacity, | J 3,700 c.c. Reserve air, 1,600 c.c. ae ** Collapse” air, 800 c.c. Residual air, 1,600 c.c. Total capacity of the lungs, 5,300 c.c Stationary air, 3,200 c.c. ‘* Minimal” air, 800 c.c. Complemental air is the amount of air that may be inspired after an ordinary inspiration. Breathing or tidal air is the air inspired and expired at an ordinary breath. Reserve air is that which may be expired after an ordinary expiration. Residual air is that which cannot be expelled from the lungs by the most forcible expiration. It is composed of two nearly equal portions, the ‘‘ Collapse” air, which escapes from the lungs when the chest is freely opened, and ‘‘ Minimal” air; that which remains in the lungs after the thorax is opened. Breathing or vital capacity. 'This is the amount of air which may be forced from the lungs after the deepest possible inspiration. It is the sum of the reserve, the tidal, and the complemental air. Stationary air. 'This is the sum of the reserve and the residual air, and is so named as, under ordinary circum- stances, these two volumes of air remain constantly in the lungs. Many experiments have been tried to determine the amount of change of the air in the lungs by a single breath. From the nature of the problem no method is wholly satisfactory. The one originally proposed by Davy is most used. It consists of inhaling a known volume of pure hydrogen, and then analyzing the expired air. If no mixing of the hydrogen with the air already in the lungs takes place, then the expired gas, like the inspired, would be pure hydrogen. By actual experi- ment it is found that, supposing 500 c.c. of pure hydrogen are inhaled, only 170c.c. of hydrogen are exhaled, the re- maining 330 c.c. being air. That is, 330c.c. of the inhaled hydrogen displace the same amount of air. If, now, it is assumed that in ordinary breathing 500 c.c. of air are inhaled, and the 330 c.c. of this remain as with the hydro- gen, and displace a similar amount of vitiated air, then the amount of renewal must be the ratio between the air in the lungs before the inspiration—that is, the reserve and the residual air (8,200 c.c.), and the fresh air (830 c.c.) re- maining in the lungs after each expiration—#iy5 = 0.103. This has been termed the coefficient of ventilation,® and in the case given shows that only about one-tenth of the air in the lungs is changed at each breath. The inter- mixture of this fresh tidal air with the reserve air in the air-passages is due largely to the currents produced by inspiration, but the residual air in the alveoli and smallest air-passages must depend mostly on diffusion for its purification. itated by the swaying to and fro of the air as the chest alternately expands and contracts, to the jars produced by the heart-beats and the pulsation of the pulmonary arterioles, and also to the ciliary currents in the bronchi. It would seem reasonable to suppose, therefore, that the air in the alveoli remains of a nearly uniform quality, and that it contains a greater percentage of carbon dioxide, and a less percentage of oxygen than the 208 This diffusion is no doubt greatly facil- . expired air. The direct experiments of Wolfberg and others, however, show that there is but little difference in the composition of the alveolar air and that which may be expired by a full expiration. This seems to show that the diffusion in the lungs is very rapid.® Pressure in the Air-passages.—-This varies in inspiration and expiration. It is measured by connecting a manom- eter with the nose or mouth, or, in an animal, with the trachea, and noting the variations in the columns of mercury during inspiration and expiration. In man, when there is a perfectly free entrance for the air to the lungs, the aspiration, suction, or negative pressure during quiet inspiration is about 3 mm. of mercury, and during expiration the positive pressure is from 2 to 8 mm. In forced inspiration the aspiration may reach 57 mm. hg., and in forced expiration the pressure may rise to 87 mm. hg. If the air-passages are closed, so that no air can enter or leave the lungs, then the aspiration or negative pressure is from 30 to 74 mm. hg., when inspiratory efforts are made ; and when expiratory efforts are made the pressure is 62 to 100 mm. hg. The elastic lungs are during life and the complete in- tegrity of the thorax somewhat stretched. If the trachea of a dead person is connected with a manometer and then the thorax freely opened, the elasticity of the lungs will show a pressure of 6mm. hg. If the lungs are fully in- flated, then the pressure due to their elasticity will be measured by about 30 mm. hg. This shows very graph- ically the part played by the elasticity of the lungs in ex- piration.®,!? The respiratory sounds and the interaction of the cir- culatory and respiratory movements have already been treated in this HANDBOOK, the first under Chest, vol. ii., p. 82; the second under Blood-circulation," vol. i., pp. 563, 566. The Respiratory Centre and the Nerves of the Respiratory Apparatus.—As with all the other muscles and organs of the body those belonging to the respiratory apparatus are well supplied with nerves. The names of the nerves sup- plying the respiratory muscles are given above in the list of the muscles. It has further been found that the whole complex mechanism of respiration is under the control of a nerve-centre, termed from its office the respiratory centre ; and from the fact. that an animal invariably dies after its destruction, it is called the vital point (nwud vital). This centre is situated in the medulla, near the origin of the vagus nerve. While it has been known from the time of Le Gallois !® that this centre exists in the medulla, the question whether it is a reflex centre, acting only in accordance with afferent impulses from without, either through special nerves like the vagus, or through those from the entire system, or whether it is an automatic centre acting in accordance with changes going on within itself, was for a long time unknown. It is now quite well established that the centre is automatic, although its action may be greatly modified by afferent impulses. It is a matter of common experience that one’ can cease breathing for a limited time, or can greatly increase the number and depth of the respirations, at will; also that a dash of cold water causes most persons to take a deep breath, and by the application of snuff or dust to the nose a sneeze is produced. So coughing, which is likewise only a modified respiratory act, is induced by an irrita- tion of the glottis, etc. While, therefore, the centre is constantly being influenced from without, the final proof of its automatic action is given by the following experi- ments : In 1879 Flint ® showed that if the thorax of an animal is opened and artificial respiration kept up sufficiently to aerate the blood well, no respiratory efforts are made by the animal; but if the vessels going to the medulla are clamped, cutting off the supply of arterial blood to the re- spiratory centre, violent respiratory movements are made, although all the rest of the body is well supplied with ar- terial blood. On the other hand, if clamps are put on the vessels so that oxygenated blood can go only to the re- spiratory centre, no respiratory movements will be made, although all the rest of the body is suffocating. Anatomically and physiologically, the respiratory cen- REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Respiration. Rhatany. tre is symmetrical, there being one on each side, as is shown by the continuance of the respiratory movements after cutting the medulla longitudinally. If one side of the centre is then destroyed the respiratory move- ments cease on that side, but continue on the other. There are also many reasons for supposing that the res- piratory centre is composed of an inspiratory and an ex- piratory part, the expiratory part being cephalad, or in front of the inspiratory part. ® 1§ The stimulus acting on the respiratory centre to arouse its activity seems to be the blood which circulates in it. If this blood contains too small an amount of oxygen the centre sends out stimuli to the inspiratory muscles, and then, slightly later, to the expiratory muscles. An excess of carbon dioxide seems also to have a stimu- lating effect on the respiratory centre, chiefly the expira- tory part: (Bernstein).'° The lack of oxygen is the more potent factor in arousing the respiratory centre, how- ever, as is shown by the fact that the most violent respi- ratory efforts are made when a deficient supply of ox- ygen is present in the air supplied to the lungs, although there may be no excess of carbon dioxide. If there is plenty of oxygen in the air, and an excess of carbon dioxide, the animal often dies from carbon-dioxide poi- soning, without spasms. Besides the main respiratory centre in the medulla, other centres, called accessary respiratory centres, have been described as present in the myel or spinal cord, and also in the brain; but at present exact informa- tion concerning thesé centres, if they exist, is very meagre. ® REFERENCES. In preparing this article, constant reference has been made to the Eng- lish, French, and German journals of physiology, and to the text-books and larger works on physiology and physiological chemistry. The bib- liography is especially full in Bert, 9; Gamgee, 20 ; Milne-Edwards, 19; Reid, 15; Rosenthal, 18; and Zuntz, 8.- As some of the authors are referred to several times, the pages are given in the order of the refer- ences. 1 Bernard, Cl.: Lecons sur les Phénoménes de la Vie Communs anx Animaux et aux Végétaux. Twovols. Paris, 1878-1879. Vol. ii., pp. 185, 179, 149. : 2 Béclard, J,: Traité Elémentaire de Physiologie, 7th Ed. Paris, 1880. Pp. 336, 337. 3 Bell, F. J.: Comparative Anatomy and Physiology. London and Philadelphia, 1885. P, 210, f 4 Flint. Jr., A.: The Physiology of Man. 5 vols. New York, 1868- 1874) Voli pasoan a, 5 Flint, Jr., A.: A Text-look of Human Physiology. 3d Ed., pp. 154- 166. New York, 1884, (See also N.Y, Med. Jour., November, 1877, and Amer. Jour. of the Med. Sc., July, 1880.) 6 Landois, L. (Translated by Stirling): A Manual of Human Physi- ology, including Histology and Microscopic Anatomy. From the fourth German edition. Philadelphia, 1885. Pp. 222, 58, 260, 265, 264, 257, 268, 277, 234, 878, 247, 876, 877. 7 Quain’s Anatomy, 9th Ed. London and New York, 1882. Vol. ii., p. 52U. 8 Zuntz, N.: Blutgase und respiratorischer Gaswechsel, in Hermann’s Handbuch der Physiologie, Bd. iv., II. Theil. Leipzig, 1882. Pp. 111, 118, 37, 35, 36, 65, 88, 114, 182, 144, 157, 101, 106. ® Bert, Paul: Lecgons sur la Physiologie Comparée de la Respiration. Paris, 1870. Pp. 270, 18, 140, 30, 393. 10 Hermann, L.: Lehrbuch der Physiologie, 8th Ed, Berlin, 1886. Pp. 101, 108, 124. 11 Dalton, J. C.: A Treatise on Human Physiology, 7th Ed. Philadel- phia, 1882. PP. 252. 12 Foster, M.: A Text-book of Physiology, 3d Ed. London and New York, 1880. Pp. 367, 368, 331. 13 Hoppe-Seyler, F.: Physiologische Chemie, III. Theil. Berlin, 1879, Pp. 580, 534, 520. 14 Kirkes’s Handbook of Physiology, revised by Baker and Harris, 11th Ed. London and New York, 1885. P. 193. 15 Reid, John: Article Respiration, Todd’s Cyclopedia of Anatomy and Physiology, vol. iv., pt. i. London, 1847-1849. P. 380. 16 Hutchinson, J.: Article Thorax, Todd’s Cyclopzedia of Anatomy ene Physiology, vol. iv., pt. ii. London, 1849-1852. Pp. 1085, 1080, 64. 17 Martin, H. N.: The Human Body. New York, 1881. P. 367. 18 Rosenthal, J.: Athembewegungen und Innervation derselben, in Hermann’s Handbuch der Physiologie, Bd. iv., II. Theil. Leipzig, 1882. Pp. 264, 242, 244, 19 Milne-Edwards, H.: Lecons sur la Physiologie et l’Anatomie Com- parée de Homme et des Animaux. 14 vols. Paris, 1857-1880. Respi- ration in vol, ii., p. 151. 20 Gamgee, A.: A Text-book of the Physiological Chemistry of the Animal Body. London, 1880. P. 123. 21 Fell, Geo. E.: International Medical Congress, September, 1887. 22 Mays, Thos. J.: Experimental Inquiry into the Chest Movements of the Indian Female. Therapeutic Gazette, May 16, 1587. Simon H. Gage. Vou. VI.—14 RHATANY (Arameria, U. S. Ph.; Kramerie Radix, Br. Ph.; Radix Rhatanie, Ph. G.; Ratanhia, Codex Med.). The roots of some species of Krameria, espe- cially K. triandra Ruiz and Pavon, and K. [zina Linn. (Kk. tomentosa St. Hi- laire), order Polygala- cee (Leguminose, Kra- meri@, Luerssen). Krameria triandra is a low shrub with a thick, dark - colored, woody, branching root, and straggling, slender, branching stems. These latter are from one- third to one metre in length, the longer re- clining or horizontal, the shorter erect ; bark grayish-brown, twigs greenish - gray, silky. Leaves alternate, ses- sile, obovate, lanceo- late, spiculate, silky- hairy. Flowerssolitary, axillary near the ends of the branches, calyx of four scarlet sepals, cruciform, the lateral sepals shorter than the others. Petals four, also scarlet, the two upper erect, spatulate, the two lower short, broad, and glandular. Stamens three, short and thick. Pistil sim- ple; ovulestwo. Fruit spherical, silky, and spiny. ‘This species is indigenous’ to high, sandy slopes in Peru and Bolivia, and is the source of the Red Peru- | vian Rhatany. K, Izina has alarger, smoother, more brown or purplish root, longer leaves, smaller and duller-colored flowers, and five sepals. It grows inthe West Indies, and in Central and South America. Its root, whichis fully as good as the other, is known as Savanilla, New Granada, or Violet Rhatany. There is very good reason for placing this anomalous genus near the sub-order Cesalpine in Leguminose. Rhatany root was noticed by Ruiz in 1784, as used by the women of Huanaco and Lima for the preserva- tion of their teeth, and by him was introduced into Spain a year or two after (Fliickiger), whence it soon became known. Peruvian Rhatany (root) ‘ig about one inch thick, knotty and several-headed above, branched below, the branches long, bark smooth or scaly, deep rust-brown, about one-twelfth of an inch (2 millimetres) thick, very astringent, inodorous; wood pale-brownish, tough, with fine medullary rays, nearly tasteless. The root of Krameria tomentosa (Say- anilla Rhatany) is less knotty and more slender, and has a dark purplish-brown bark about one-eighth of an inch (8 millimetres) thick. Both varieties have essentially the same medicinal 209 Fic, 33823.—Krameria Triandra; flower- ing branch. (Baillon.) Fie. 8824.—Krameria Triandra ; flower. (Baillon.) Rhatany. Rheumatism. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. properties and composition. The most important con- stituent (of the bark—the wood is nearly inert) is Rha- tania-tanniec acid, existing to the extent of about twenty per cent.; a brilliant, deep-red, amorphous mass, soluble in alcohol, incompletely so in water; with perchloride Fie. 3325.—Krameria Triandra; fruit, entire and in section, (Baillon.) of iron it gives a dull-green color. When exposed to the action of diluted acids, and under other circumstances, this tannin is decomposed into sugar and Ithatania red, This substance is much less soluble in water than the tannin, and is also but little soluble in alcohol and ether. AcTIoN AND Use.—Rhatany is a reliable and useful astringent, owing to itslarge per cent. of tannin, and is ee +8) é ° aaoen ute SA See Fie, 3326.—Krameria Triandra ; transverse section of root. (Baillon.) applicable to all the conditions where gallic or tannic acid is useful. The crude drug may be given in powder, but seldom is, as the large amount of woody tissue is a disad- vantage. Dose, one or two grams (gr. xv. ad xxx.). The following officinal preparations are all good: Extract 210 (Hztractum Kramerie) for pills, strength about #; Fluid Extract (Hatractum Kramerie fluidum), strength +; and Tincture (Tinctura Kramerie), strength t. ALLIED PLANTS.—There are a dozen or more South American species of Krameria, all astringent, and several are in use in the countries where they grow. ALLIED Drues.—See NUTGALLS, CATECHU, etc. W. P. Bolles. RHEUMATISM, ACUTE ARTICULAR. Synonyms: Rheumatic Fever, Acute Rheumatism, Acute Rheumatic Polyarthritis. Definition.—Acute articular rheumatism is a specific inflammation which attacks the structures in and around the large joints. Asa rule, two or more articulations are affected, and the inflammation moves from one to an- other. It is scarcely ever followed by suppuration. It is accompanied by severe febrile disturbance. In a large proportion of cases the fibro-serous structures of and about the heart are also affected by the inflammatory process. HMistory.—This disease has doubtless existed from the earliest ages, but the term rheumatism was first applied to it by M. Baillon, who published a treatise on the sub- ject in 1642. The term was afterward applied by many authors to inflammation of the joints generally. We now distinguish under several heads diseases which formerly, by some, were called rheumatic, viz. : 1, Articular rheu- matism ; 2, gout; 8, rheumatoid arthritis ; 4, muscular, and 5, gonorrheeal, rheumatism. Articular rheumatism may conveniently be divided into (a) acute, (0) subacute, and (ce) chronic forms. Morbid Anatomy.—Opportunities for making post-mor- tem examinations in cases of acute rheumatism are rare. The synovial membrane is found congested, the inner sur- face being rather dull in appearance, with a serous fluid filling the cavity of the joint. This fluid contains masses of epithelium. Occasionally pus is found in the exuda- tion. The structures around the joint are also inflamed. Sometimes the tendinous structures are filled with a yel- lowish serum. The cartilage often shows signs of inflam- mation. Symptoms.—The onset of the disease is marked by dif- ferent features in different cases. The attack is some- times preceded by a slight chill followed by fever. In many cases there is a premonitory stage, during which wandering pains occur in the joints, and there is observed a peculiar puffy condition about the ankles. Ina few instances the pericardium or endocardium is first attacked. In such cases the patient first notices a sense of oppres- sion, with dull pain, in the chest. When the disease has become established the most prominent symptoms are as follows: Pain and swelling of the larger joints of the body ; elevation of temperature with general febrile dis- turbance; the occurrence of excessive perspiration. The joints most often affected are the knee, elbow, wrist, and the smaller joints of the hands and feet. The hip and shoulder may also be attacked, but the swelling is less apparent in these, owing to their being covered by large muscles. The swelling is often accompanied by some redness and tension. Neither of these latter symptoms is aS prominent as in gout. The pain is more or less acute; it is sometimes dulJl and aching, but more fre- quently it is severe and excruciating. It is increased by the slightest movement ; even the shaking of the bed will make it moreintense. The patient is thus rendered quite helpless, and speaks of having lost the use of his limbs. The pain is more severe at night than during the day. The swelling of the joints varies very much in different cases. In some it is but slightly marked, and is not ac- companied by much redness, or tenderness on pressure. In others, again, the swelling is excessive, so that the ar- ticulation presents a red, shining, tense appearance, very much resembling gout except that the surrounding veins are not enlarged. It is remarkable how quickly the swelling may subside. A joint may present the most severe symptoms on one day, and the next it may have almost resumed its normal condition. The intense in- flammation usually lasts four or five days, and on its disappearance other articulations may become affected. > REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. The same joint may be attacked two or three times dur- ing the illness. The inflammation passes from one joint to another so rapidly that some have considered it an example of metastasis. As a rule, however, the second series of joints are attacked before the first are entirely normal. Pitting on pressure occurs in some delicate pa- tients. Suppurationis a very rare sequence in rheumatism. The presence of excessive perspirations is a very fre- quent symptom. They occur in exacerbations, when the sweat often possesses a peculiar, sour odor. This is due to the presence of an acrid substance rather than to excess of lactic acid. A red, papular eruption, together with sudamina, frequently appears on the skin, the result of profuse sweating. A peculiar erythematous eruption, peliosis rheumatica, has been noticed in some cases of acute rheumatism. The rash does not differ from erythema multiforme, as we now use that term. Urticaria is present in some cases. The temperature during an attack rises to 102° or 104° F.; in some cases of hyperpyrexia it rises to 110° F. The fever is of a remittent rather than a continuous character. The temperature is usually higher in propor- tion to the number of joints attacked. The tongue is coated thickly with a white fur. The saliva, which is normally alkaline, becomes acid. There is lossof appetite with more or less nausea. The bowels are constipated. The urine is scanty, high-colored, and strongly acid in reaction ; its specific gravity is higher, owing to increased quantity of urates and urea; on standing a reddish sedi- ment is formed. Albumen is sometimes found in small quantity during the febrile stage and during convales- cence. The pulse is increased in frequency, often out of proportion to the rise in temperature. This may be due to severe pain or to the onset of cardiac trouble. The respirations are frequent and often shallow. They be- come greatly hurried when there are severe heart-com- plications. The red corpuscles of the blood are much decreased in number, and the amount of fibrin is in- creased. In a large proportion of cases, the fibro-serous struct- ure of the heart is attacked. The endocardium is much more frequently affected than the pericardium, the pro- portion being as six to one. In a few cases the muscular wall is also involved. ' The structures are attacked in the same way as the joints, the result of the elective affinity of the poison. Their involvement is not an instance of metastasis, nor should it be regarded as a complication, but simply as a part, of the disease. Rheumatic inflam- mation of these structures differs from that of the joints in two or three particulars. The exudation contains lymph, often becomes organized, and occasionally degen- erates into pus. Pericarditis is usually accompanied by a dull pain beneath the sternum and a sense of oppres- sion in the chest. By auscultation a friction-sound can be heard most distinctly over the base of the heart. This soon disappears as the serum accumulates in the pericar- dial sac. The presence of the latter is diagnosed by the increased cardiac dulness and diminished cardiac im- pulse. The endocardial inflammation is confined almost altogether to the left side of the heart. Its presence is usu- ally made known by abnormal valvular murmurs, which are heard on auscultation. It may here be stated that one often hears abnormal heart-murmurs, during an at- tack of rheumatism, which disappearin afew days. In some of these cases it is difficult to say whether endocar- ditis was present or not. Two theories have been given to explain such cases: First, that there is a temporary dilatation of the heart ; second, that an endocarditis may exist which undergoes rapid resolution. For further de- tails, see vol. iii., pp. 583 and 584; and vol. v., p. 573 et seq. The duration of acute rheumatism varies much—it may disappear in five or six days, or it may last as many weeks. The average duration is from two to three weeks. The patient is scarcely ever free from pain and fever dur- ing this period, and there are frequently exacerbations, which are followed by periods of comparative relief. There is a strong tendency to relapse, and many: patients are subject to repeated attacks of the disease. Rhatany. Rheumatism, Unusual Events and Complications in the Course of Acute Rheumatism.—A frequent complication is pleurisy of the left side, which is said to occur in ten per cent. of all cases in which the heart is involved. Bronchitis, con- gestion, cedema of the lungs, and catarrhal pneumonia are sometimes concurrent with acute rheumatism. In rare cases inflammation of the meninges of the cord and brain complicates the disease. Delirium, convulsions, and coma have been recorded. Chorea sometimes follows rheumatism in children. Acute delirium occurs in cases of hyperpyrexia. Or- ganic changes of the nerve-centres from embolism are among the possibilities. A few singular cases of rheu- matic hyperpyrexia have been recorded by Ringer, Mac- lagan, and others. In these the temperature rises some- times to 110°. They are marked by the presence of acute delirium, which rapidly passes into coma; such cases are very frequently fatal. They often commence and continue for a few days in the ordinary way, when sud- denly the temperature rises and the patient becomes de- lirious. Ithas been found necessary to reduce the tempera- ture by the application of ice, and some cases have been saved inthatway. Itis probable that the excessively high temperature is due to impairment of the heat-centre in the bulb, and the brain-symptoms result from the effect of heat upon the nerve-substance. SuBACUTE RuHEUMATISM.—Under this head cases have been described in which only two or three of the joints are affected at one time, and the pyrexia is of a mild type, the temperature not rising above 100° F. The duration is usually much longer than in the acute cases, but the joints are not permanently affected and serious heart-trouble does not follow. This subacute variety forms a connecting link between the acute and chronic forms. In a few cases the disease, after attacking two or three joints, finally settles in one articulation. . This is usually the case in the gonorrheeal form, but it also oc- curs sometimes in the acute and subacute varieties. Ettology.—Exposure to dampness and cold has gener- ally been considered the principal factor in the causation of rheumatism. Severe muscular exertion, attended by overheating of the system and followed by chilling of the surface, is a frequent cause. Neither of these will produce rheumatism unless the patient is predisposed to the disease, either from hereditary or acquired taint. An hereditary predisposition, according to Fuller, is present in thirty-four per cent. of all cases. A long residence in adamp and cold climate seems to render the system liable to an attack. Age has a strong influence in predisposing to rheumatism. It does not often attack children under fifteen years of age, nor adults over forty-five. One is more subject to it between the ages of fifteen and thirty than at any other time of life. The heart is not often at- tacked after forty years of age. The same person may suffer from several attacks. The number of males af- fected is somewhat larger than the number of females. The former are more exposed and more frequently en- gaged in severe muscular exercise. Season and climate exert a predisposing influence. It is most prevalent in the cold, moist climate of the temperate zone. On this continent most cases occur in the latter part of the winter or early spring. Occupations which require great mus- cular effort in a warm atmosphere predispose to rheuma- tism. Washerwomen, bakers, maid-servants, moulders, and laborers generally are among those especially liable to the disease. Diet probably exerts some influence ; the ingestion of an excessive amount of saccharine and starchy food increases the tendency to this malady. Cer- tain diseases appear to have an etiological relationship. In the desquamative stage of scarlet fever, a mild form of articular inflammation sometimes presents itself. In dengue, hemophilia, gonorrhcea, and in the puerperal state, a special tendency to inflammation of the joints appears to be present. In some of these latter diseases the polyarthritis is often of a pyeemic form. Pathology.—Rheumatism must be considered as_a gen- eral disease with local manifestations. The febrile con- dition appears to be a primary rather than a secondary element in the process. The inflammatory condition 1s 211 Rheumatism, Rheumatism, of a special character, and is the result of a materies morbi existing in the blood. It has a tendency to attack the fibro-serous structures connected with the locomotor apparatus and with the heart—in other words, those structures subject to movement and strain, 60. of the tumor is principally due to the presence of the hyaline colloid material. In 1882 Fritsch reported that he had found constantly in the rhinoscleroma short bacilli, which he was able to cultivate in aqueous humor. He made inoculations with the cultures, but did not get any results. From the con- Sepa 1,000. stant presence of these bacteria he regarded them as causative of the disease. The best description of the bacteria is given by Cornil and Alvares, from whose drawings the accompanying figure is taken. The bacte- ria are principally found in the large protoplasmic masses 218 SS" a single capsule. The capsule is best seen after staining with aniline water gentian violet, and then decolorizing with iodine. The bacteria present the most striking simi- larity to the Friedlander pneumonia-bacilli, and can be distinguished from these neither by their morphological REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. characters nor by culture. They have recently been made the subject of careful study by Paltauf and Eisel- berg. They made numerous inoculations in various ani- mals, and succeeded in producing in mice the same changes that are produced by the pneumonia-bacilli. It is difficult to say with certainty whether or not these bac- teria are the cause of the growth. They are invariably present, and their situation in the large cells and lymph- atics shows that their presence is not an accidental one. Remarkable as is their resemblance to the Friedlander bacilli is, we are by no means justified in regarding them as identical. The very fact of the extreme rarity of the rhinoscleroma and the frequency with which Friedlander bacilli are found speaks against this view. In addition to this, the rhinoscleroma has a well-defined geographi- cal distribution. Most of the cases have been found in Vienna, which may be regarded as the home of the dis- ease. A few cases have been found elsewhere in Aus- tria, a few in Italy, and one (that of Schulthess) in Switzerland. Nocases have been met within the United States, although several have been seen in Central Am- erica. The diagnosis of the disease is comparatively easy. Hebra has given the following as the most marked char- acteristics: 1, The seat of the disease, which is in the nose or in parts immediately adjacent to it; 2, the peculiar hardness of the part affected ; 3, the extremely slow de- velopment ; 4, the sharp limitation of the growth, and the absence of cedema or of any inflammatory reaction in the surrounding tissues; 5, the absence of retrograde metamorphosis ; 6, the inutility of all internal treatment ; 7, the benign character of the growth as regards the or- ganism, even when it has lasted years; 8, the absence of pain except on pressure. The only affections with which there is any probability of confounding it are syphilis and epithelioma. From the former it may be distinguished by its circumscribed growth, absence of ulceration, and the inutility of specific treatment ; from the latter by absence of ulceration, its painless character, history of slow growth, and absence of infiltration, of the surrounding tissue. The treatment is confined to excision of parts of the growth, when it endangers life by closure of the nares, etc. No medication has been found to be of any avail, and by reason of the extent of the growth complete ex- cision has not been found to be practicable. Frequent operations are necessary, as the portions removed are quickly reproduced. W. T. Councilman. RHINOSCOPY. Inspection of the nasal cavities and retro-pharynx is accomplished by two methods of exam- ination. These are anterior rhinoscopy and posterior rhinoscopy. Preliminary to the investigation of the nasal canals, it is well to observe the exterior of the nose. From the appearance of this, some suggestion may be obtained as to the existence of abnormalities within. Thus, deflec- tion of the nasal septum is often attended with irregular- ity of external contour; the presence of an intra-nasal growth is attended with bulging of the alee or distortion of the nasal bones, causing in extreme cases the appear- ance known as ‘‘ frog face ;” occlusion of the nasal pas- sages and mouth-breathing are associated with the pecul- iar upturning and enlargement of the end of the nose, or, on the other hand, with the pinched, atrophied, and col- lapsed condition of the ale commonly observed in such patients ; chronic catarrh is attended with congestion and thickening of the alee ; and, finally, there may be actual depression of the bridge of the nose from surgical injury or from tertiary syphilis. Although by no means infallible, the above are often useful guides toward a diagnosis. Again, the ease with which the exit of air is effected through one nostril, the question as to whether or not the patient can breathe for any length of time with the mouth closed, the existence of fetor in the expired breath, the quality of the voice, and the condition of the olfactory sense, are points of importance in the examination which are capable in Rhinoscleroma, Rhinoscopy. many cases of conveying information, and which should not be neglected. Inspection of a wide nostril may sometimes be par- tially accomplished by placing the patient opposite a strong light and then forcing upward the tip of the nose. This, however, is unsatisfactory. For the accomplish- ment of a thorough examination it is necessary to use, first, a good light ; and, secondly, something in the way of a speculum by which the nostril can be dilated and the light thrown into the dark and remote passages which are to be examined. Both anterior and pos- terior rhinoscopy may be TT Zia efficiently performed by Zw FS REYNDERS—Co SSN means of sunlight, and in some cases this is to be pre- ferred. In most instances, however, the simplest and most convenient method will be by artificial light, and with the appliances used in the performance of laryngoscopy (see vol. iv., p. 385). For the performance of anterior rhinoscopy many in- genious specula have been devised. Among the differ- ent kinds commonly sold by the instrument-makers, those pictured in the accompanying cuts (Figs. 3380 to 3382) Will be found useful and convenient. A very valuable form of nasal speculum is that of Sig- mund, a tubular instrument made of hard rubber. and shaped like an ear-speculum. | It is particularly useful in the application of the galvano-cautery to the nasal cavi- ties. An excellent substitute for a nasal speculum may be improvised from a common hair-pin by bending both ends of the pin in oppo- site directions, and thus forming a double curve, jy one end of which is held in the operator’s hand and the other pressed outward against the ala of the nose. Among other good varieties may be mentioned Fraenkel’s, Bosworth’s, Cres- well Baber’s, and John N. Mackenzie’s. For the performance of anterior rhinoscopy the patient should be seated as for a laryngoscopic examination, and the arrangement of the light, the head, mirror, etc., should be the same as for the latter (see vol. iv., p. 386). The blades of the speculum should then be introduced into the vestibule of the nose and separated. The vesti- bule itself is lined with integument and furnished with an abundant growth of short, stiff hairs, which, for facil- itating the examination, it is sometimes desirable to cut off. This, however, is seldom necessary. At the poste- rior superior limit of the vestibule is the opening of the anterior nares. Here the integument changes its char- acter and becomes mucous membrane. Professor Wilhelm Meyer, of Copen- hagen, has observed that in cases of chronic catarrhal disease the charac- teristics of the ex- ternal integument are preserved to an unusual distance posteriorly. Upon inspecting the nasal fossa, which is brought into view by the nasal speculum, the patient’s head being bent somewhat forward, the first objects seen will be the an- terior aspect of the inferior turbinated body and the lower part of the cartilaginous portion of the nasal septum. Beyond these may be seen the inferior meatus, the floor of the nose, and the lower border of the inferior turbi- nated body. Tilting the head a little backward, the re- mainder of theinferior and part of the middle turbinated bodies come into view. And, bending the head back- ward still farther, the uppermost part of the middle tur- binated body and the roof of the nasal fossa can be seen. 219 modified, Fie. 3331.—Goodwillie’s Speculum. wy if Up S Fia. 3382.— Jarvis’s Speculum, Rhinoscopy. Rhubarb. The superior turbinated body may sometimes be demon- strated anteriorly, although this is unusual. Under in- spection in the above positions, with the head turned a little to one side, the corresponding parts of the septum can be demonstrated. The color of the nasal mucous membrane varies in different situations. The anterior and inferior border of the inferior turbinated body, and the floor of the fossa, are usually bright red, while the septum and the inferior border of the middle turbinated body are of a paler hue. Fig. 3333.—a, Outer lip of anterior border of middle turbinated body; », angle of middle turbinated body ; c, lower border of middle turbinated body ; d, inferior turbinated body ; e, tubercle of septum ; 7, outer wall of nasal cavity. In diagrams A and B, the margins of the middle tur- binated body, hidden by the tubercle of the septum, are indicated by dotted lines. (Cresswell Baber.) The description of the contour of the parts seen by an- terior rhinoscopy, and their recognition by one not ac- customed to such examinations, are matters of consider- able difficulty. They have been made much more clear and easy by the excellent work of Mr. Cresswell Baber, of Brighton, England, who, through a series of diagrams and illustrations, has sought to depict the real conditions normally present, and to assist the learner in understand- ing the variations in form which may occur in patholog- ical states. The accompanying diagrams, while intended to illustrate the different appearances of the tubercle of the septum, convey an excellent idea of the neighboring parts. As will be seen from these cuts, the extent of view ob- tained of the middle turbinated body will depend largely 7a 4 Fie. 3335, Fias. 3334 and 3385 represent respectively the right anterior rhinoscopic view of a man, aged twenty-four, before and after erection of the an- terior end of the inferior turbinated body. (About twenty minutes elapsed between the times of drawing the two sketches. ) In Fig. 33834, a is the collapsed anterior end of the inferior turbinated body; } is the inner surface of ditto, which leaves a space between it and the septum, through which the palatal movement can be plainly seen. Above, the middle turbinated body c is visible, its neck being hidden by the tubercle d. In Fig. 3835, @ is the erected inferior turbinated body, terminating above in the swollen ‘* neck” 6, which almost entirely conceals the mid- dle turbinated body. The upper parts of the drawing are slightly dia- grammatic. (Cresswell Baber, ) Fia. 3334. upon the prominence of the tubercle of the septum. Undue prominence of this part may be reduced by the application of cocaine. When the erectile tissue of the anterior angle of the inferior turbinated body (a, Fig. 3335) is tumefied, this body appears as a rounded, shin- ing eminence, having a smooth surface, which is in con- tact with or close to the nasal septum. Above, it is pro- longed into a broad neck (Fig. 3335, 5), the inner or free margin of which, if its erection be extreme, is in con- 220 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. tact with the septum, and completely conceals the mid- dle turbinated body. When the soft parts lining the anterior aspect of the in- ferior turbinated body and the lower part of the septum are tumefied, or hypertrophied, the entrance of light to the nasal fossa will be greatly facilitated, as has been sug- gested before, by the use of cocaine. This drug, applied in a solution of from two to four per cent., will cause more or less complete retraction of the projecting tissues, and thus render possible a far more thorough and satis- factory inspection. In the examination of the anterior nares, a short, deli- cate probe will give much assistance, as by its use the appearances conveyed to the eyes can be verified or dis- proved, the consistence of various parts fairly estimated, and, with the aid of a pledget of absorbent cotton, secre- tions which obscure the view may be removed. In all cases in which secretion exists, it must be recognized, and, if too great in amount to be dealt with in the way wy just alluded to, it should be removed by means of atomized spray or the ordinary nasal douche. Of the three methods the spray is likely to do the least injury, and is in a large proportion of cases the best. Posterior rhinoscopy, or inspection of the nasal cavities and the upper pharynx from behind, is accomplished by means of a pow- erful light, a mirror similar to that used in laryngoscopy, only smaller in diameter, and a tongue-depressor. The conditions, as to the illumination and as to the position of the pa- tient, are the same as for the performance of laryngoscopy (see vol. iv., page 386). The simplest and best form of rhinoscopic mirror, and the one in by far the most general use, is illustrated in Fig. 8336. LEY so in benzol, than chrysophanic acid ; to alkaline solutions it gives . acherry-red color. | Several species of Rhamnus | I contain this derivative. heo- O tannic acid is a hygroscopic yellow powder of astringent taste, reducing iron with a greenish-black color; it dis- solves readily in water and spirit, and precipitates mucus and albumen. Pha@oretin, as well as aporetin, erythroretin, is a not very well-defined resinous substance, existing only in minute quantity. The composition of Rhubarb, as at present known, does not give much clew to its quality. AcTION AND Ust.—When chewed Rhubarb stimulates the saliva. In small doses, in the stomach, it seems to act as a digestive stimulant ; in larger ones it appears to be a simple purgative, hastening along the contents of the bowels by increased peristalsis, carrying the liquid contents of the small intestine rapidly down, to soften and force along the more solid mass in the colon and rec- tum, Intestinal secretion is supposed to be less stimu- 223 Fic. 3340.—Leaf of Rheum Pal- matum ; variety, tanguticum. (Baillon.) Rhubarb. Rickets. lated by it than by salines or the cathartic resins. Its coloring matters are absorbed, and may tinge the milk andurine. Really our knowledge of the details of the ac- tion of this, and many other vegetable cathartics, is much more vague than is desirable. Their gross action is evident enough, and the comparative liability to produce nausea, Utes eae vomiting, colic, col- lapse, etc., is pretty well understood ;_ but how much is peristal- sis, how much retarded absorption, how much increased secretion, how much biliary stim- ulation, is known of very few. Rhubarb is mild and pretty certain ; it produces compara- tively little pain, no depression in moderate doses, and its action is not prolonged. The tannin in it is credited with producing some constipation after its use, but the simple emptying of the bowels without irritation of Fra. 3341.—-Piece of Round Chinese Rhu- barb, showing the white lozenge-shaped the mucous membrane reticulation on its surface and the ir. Would be enough to ex- regular medullary rays on the section. plain this result. Rhu- (Baiions barb is given in almost all conditions where simply emptying the bowels is de- sired. ADMINISTRATION. —Rhubarb is offered by the Pharma- copeia in a great variety of forms; it is also found ina good many of the popular proprietary laxative mixtures. It makes a fine, deep-yellow powder which is sometimes given, but not often, on account of its very nauseous taste. Two or three decigrams (gr. iij. ad v.), once or twice a day, would be a very mild tonic-laxative dose; a single dose of a gram (gr. xv.) is mildly, while one of two grams (gr. xxx.) would be severely, cathartic. Rhubarb in substance is frequently taken by chewing and swal- lowing a piece of the root as large as a pea or a bean, once a day or so, preferably after eating ; the taste in oot . - TS ~ ee x a Ft aN OS IN Pyar) Seetne ~ we ae en ESTEE! Ss tes 4 De Be] Se cet “a tans seal ai in a 1S 22% Upoxd WYO I> Te ) & 2. ce) g C O A iy BIEN, aN A. M, (@ q ce Cra MUA Te this way being less nauseous than that of the powder. The tonic, almost carminative, action of Rhubarb upon digestion, has made it widely used in this way. The following are the preparations of the U. 8. Pharmaco- poeia : Extract (Extractum Rhet), made by exhausting with alcohol and water, and evaporating; strength about 3 ; useful for pills and mixing with other pill-masses. 224 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Pluid Extract (Hatractum Rhet Fluidum), strength, 4, less used than the tinctures, is an ingredient of the fol- lowing : Mixture of Rhubarb and Soda (Mistura Rhet et Sode) : Bicarbonate of Soda .......... 30 parts. Fluid Extract of Rhubarb..... 30S Spirit of Peppermint.......... OU ska: Water enough to make........ 1,000 “ It is an excellent laxative for indigestion, or diarrhea with fermenting intestinal contents. Pills (Pilule Rhei): Rhubarb, three parts ; soap, one part ; each pill contains three grains of Rhubarb. Compound Pills of Rhubarb (Pilule Rhet Composite) : Rhubarb, two grains; Purified Aloes, one and a half grain; Myrrh, one grain; Oil of Peppermint, one-tenth of a grain, in each pill. Compound Powder of Rhubarb (Pulvis Rhei Compositus) : Rhubarb, twenty-five parts; Magnesia, sixty-five parts ; Ginger, ten parts. Corresponds to the mixture. Tincture of Rhubarb ( Tinctura Rhet), strength, +2;, with zé0 Of Cardamom. Aromatic Tincture (Tinctura Rhet Aromatica) contains : RbUbarbk wn ot eee ene murt rte ae eee ace Cinnamon goose oe eas kemien cae lice a ClO VES 5). semugelsic: Se erte icy a sta eet tene 4 * NULMEP Wh cloacae ee Tae mai Sone Diluted Alcohol enough to make one hundred parts. The most desirable preparation as a general cathartic. Sweet Tincture (Tinctura Rhet Dulcis) : Rhubarb 4 7iek eae ces eats ere ATES. Glycyrrhiza ie ier ia ci eae Anise 240%. Si icah eee rele. eras Cardamom sh 27 tee errant eld ae Diluted Alcohol enough to make one hundred parts. A desirable preparation for children, as the licorice masks somewhat the disagreeable taste. Wine (Vinum Rhet), strengh +5, with 745 of calamus in sherry wine, a duplicate of the tincture. Syrup (Syrupus Rhet): Rigibarbies tes yee OP i ARE tras UR eG roe CDNA ORAS Rie ey Socio cats Wace ase ae, Carbonate of Potassium......... 6 ‘ SUCHE terri. ee a Shs vies pte aU Water enough to make one thousand parts. Like the sweet tincture, the sirup is a very popular cathartic for infants and children. ALLIED PLaANtTs.—The genus contains about twenty species, most of whose roots have qualities similar to the above. Several of these, R. Rhaponticum, and others, are cultivated in Austria and elsewhere in Europe for this Fic. 3343.—European Rhubarb. (Fliickiger. ) (Fliickiger.) purpose, and the European product is trimmed and pre- pared so as to closely imitate the Chinese. It can gener- ally be told by its duller color, more spongy texture, ab- sence of gritty crystals when chewed, and the more regular arrangement of its medullary rays; the stellate rT oe REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Rhubarb, HRickets, spots are absent. The foliage of Rhubarbs is bitter and sour; by cultivation the above and several other species have developed very large and pleasantly acid petioles, which, especially if partially blanched or shaded, make a Malic and oxalic delicious vegetable for tarts and stews. acids and their salts, and ni- trate of potassium, are among their constituents. The order contains besides : Bistort, Polyganum Bistorta Tourn; Buckwheat, Hagopy- rum esculentum Monch; Docks and Sorrels, Rumex sp. var. These latter (docks) resemble Rhubarb somewhat in the composition of their roots, but as their tannic matters are in excess of their laxative ones, they are not cathartic. ALLIED Drues.—The dif- ferent species of Rhamnus (Buckthorn, Cascara Sagrada, SUS Frangula, etc.) appear, in their ELS Sag ah At a tea ead action on the bowels, and, IML. (Fifckiver.) Le Labia) some respects, In composition, to be more like Rhubarb than most cathartics. Senna, Wahoo, Blue Flag, and Podophyllin in small doses may also be mentioned, as well as perhaps Castor-oil. Aloes acts more upon the large intestine, the drastics and sa- lines are more depressing, hydragogue, and violent. Sul- phur and Magnesia are less active, but not dissimilar in kind to Rhubarb. None of them has the later astringent effect of the one under consideration. The following list of substances used to increase the movements of the bowels, partly from Brunton, appears to be very well arranged : Laxatives: Honey, Molasses (and food made with it), Manna, Cassia Fistula, Tamarinds, Figs, Prunes, Stewed Apples, Sulphur, Magnesia. Simple Purgatives: Aloes (?), Rhubarb, Senna, Fran- gula U.S., Cascara Sagrada, Castor-oil, etc.; also Calomel (single dose). Drastics: Elaterin, Colocynth, Jalap, Scammony, Gam- boge, Podophyllin, Croton-oil. ; Salines: Sulphate of Soda, Sulphate of Magnesia, Phosphate of Soda, Tartrate of Potassium, Bitartrate of | Potassium (very mild), Citrate of Magnesium. Cholagogues : Aloes, Rhubarb, Mercury (various prep- arations), Enonymin, Iridin, Podophylin. W. P. Bolles. RICE (Azz, Codex Med.). The grain of Oriza sativa Linn., Order, Graminee. A water- or swamp-grass originally from India, cultivated there for ages, early introduced into Southern Europe and the warmer parts of America, and forming the principal food-product of many tropical races of men. It has been divided into numerous garden varieties differing in the length of its glumes, color, size, and shape of its grains, etc. For use, the grains are deprived of their husks and pericarps by beating, rubbing, or passing between rollers, by which means the embryo also is shelled, or rubbed out. The prepared grain, consisting entirely of the peri- sperm, needs no description. It hasa smaller amount of mineral and albumi- nous constituents than other cereals, and a larger amount of starch (eighty- five to ninety per cent.). Rice starch Fig. 3346.—Flower of is also a commercial product ; it con- Rice. (Baillon.)~ gists of exceedingly minute polyhedral granules. (See STARCH.) # Rice has no medicinal properties, it is simply an almost pure farinaceous food, and is neutral and unirritating to Vou. VI.—15 the bowels ; on this latter account it is often given in dysentery and diarrhoea. Rice-water, made like barley- water, by boiling whole rice in a large proportion of water and pouring off the clear liquid, contains a little soluble starch, and is employed as a demulcent drink. ALLIED PLANTS, etc., see STARCH. W. P. Bolles. RICHFIELD SPRINGS, Location and Post-office, Rich- field Springs, Otsego County, N. Y. AccEss.—By the New York Central & Hudgon River, the New York, West Shore & Buffalo, and the Delaware & Lackawanna Railroads. ANALYysI8 (Professor C, F, Chandler).—One gallon contains : Grains. Hydrosulphatelof sodium’, 92. ie... eee eee soe. 1.7189 Hydrosulphate of calcium...............2-..+000- 0.0908 Sul phabeyoipMOtassaescmcs a lee el enn abort 1.6656 Bulplate of lime ec ed. ec eeor a ae a 112.3379 Sulphate: OLstroutiane ns. caer oe ae une eee 0.0105 SUlP RACE LOfbaritia 1 Gael eee ener een nny Mane D trace SipMalerotemagnesinn ao) me sa alee a ste ene 5.1498 My drosnlphite OMeoGa see enact ae cities ae seein 0.3801 Bicarbonate of magnesia ........ See eee Breast ee 31.7408 Bicanponateol Tron tas cen eee eet ce oabe eh trace Phosphiateronelimeteny setum ois ene mee aise epee a 0.0067 Chilorid esomesOcu yt sane cet see oes eee eee ene 0.5249 OhionideroL hthinmre. sao we cence ete 0.0165 BATTEN TIER PR Ep ema Ua hers, ARS RPT EE MERC ATT CUE KES UN RO Me, trace SILT Ge ae eee nel hl Pes ae, Poteet are a tem emits, Welabay be 0.6415 DOU Nee a eee ce ree ee wee eh apna NO Biss Gas. Cubic inches, Hulphunertedsiydroceneenn ne eee wee cece ate 14.206 The above analysis is of the water of ‘‘The Great White Sulphur Spring.” THERAPEUTIC PROPERTIES.—These well-known sul- phur waters are among the best of their class. The pict- uresque situation and classical associations add materi- ally to the popularity of the resort. The diseases for which these waters are famous are chronic catarrhs, rheumatism, and skin affections. Richfield Springs is situated about sixty miles west from Albany, on Canaderaga Lake, at an altitude of seventeen hundred feet. The surrounding country is devoted to farming, and affords many beautiful drives, especially about Otsego Lake, five miles distant, famous as the scene of some of Cooper’s ‘‘ Leather-stocking Tales.” The hotel accommodations are first-class and ample. Of late years Richfield has become a favorite and popular summer resort. George B. Fowler. RICKETS. Syn.: Rachitis; Fr., Nouwre, Rachi- tisme, Ger., Hnglische Krankheit. A disease of child- hood, arising from perverted nutrition, affecting nearly every tissue of the body, but chiefly and most con- stantly characterized by a softening of the bones, with resulting deformities. It occurs most frequently in chil- dren under three years of age, the greater number of cases apparently originating during the second year of life, at the period when weaning is usually accomplished ; and though the bone symptoms may make their appear- ance at a later period than the end of the third year, care- ful inquiry will generally establish the fact of the oc- currence of some of the manifestations of the disease in earlier life. The etiology of rickets is obscure. It is usually sup- posed to be due to insufficient or improper food and im- pure air. Yet, though of undoubted importance, these are not the sole factors in the causation of this disease ; for of the thousands of children living in the crowded tenements of our cities, constantly inhaling a vitiated at- mosphere, and seldom receiving proper nourishment, but few, comparatively, are the subjects of rickets. On the other hand, the children of well-to-do parents, living un- der vastly better hygienic conditions, are by no means exempt. Parrot advanced the theory that rachitis is a develop- ment of hereditary syphilis ; but he stood almost alone in this view, and since his death the theory has had few supporters. Fournier, indeed, asserts that rachitis is so frequent among children the subjects of hereditary syph- ilis, that there must be some relation between the two 225 Rickets, Rickets. affections. He believes that syphilis may act indirectly as a cause by producing malnutrition. But this is very different from the theory of Parrot, who believed that hereditary syphilis was the sole cause of rickets; that rickets, indeed, was hereditary syphilis. In the ‘* Report of the Collective Investigation Committee of the Norwe- gian Medical Association” (Christiania, 1887) it is stated that, out of two hundred and forty-two cases of rickets, it was possible to find some evidences of syphilis in the parents in only nine instances. Oppenheimer assumes the disease to be a manifesta- tion of malarial poisoning, basing his belief upon the periodicity that has been frequently observed in some of the symptoms. He states that rickets occurs chiefly in localities in which malaria is most prevalent ; but this assertion is not borne out by observation, for the disease is of greatest frequency in cities, where malaria is weak- est, and is very rare in tropical regions, where the most pernicious forms of malaria prevail. It has been asserted that the children of young par- ents are more often rachitic than those of older parents, but the writer has been unable to verify this assertion by a study of the statistics at his command. The influence of heredity has been denied. It is an undeniable fact that the mothers of rachitic children often themselves show evident traces of the disease, but this may possibly be ascribed to the fact that they were brought up under similar conditions. That there is, however, at least a racial predisposition to rachitis, is a fact of daily observation. In this country the disease is seen for the most part in children of parents born in European coun- tries, with the exception possibly of the Irish, among whom it would seem to be for some reason less common than among those of the Anglo-Saxon and Latin races. The children of white native Americans are compara- tively seldom attacked, but negroes are almost without exception rachitic. This predisposition to rickets in the colored race would seem to be an acquired one, for it is said that native Africans seldom, if ever, show any evi- dences of the disease. The first symptoms are often developed during conva- lescence from whooping-cough or some other of the de- bilitating diseases of childhood. In the present state of our knowledge the most that can be said is that rickets is a disease occurring in children predisposed by heredi- tary or racial influences, in whom the assimilative func- tions have become impaired by poor food, bad air, absence of sunlight, or the influence of debilitating disease. Pathology.—Of the pathology of rickets even less is known definitely than of its etiology. Numerous theories have been advanced, most of which are, however, based solely upon the changes observed in the bony structures, leaving out of consideration the pathological processes occurring in other tissues. The urine in this disease contains an excess of phos- phates, while the bones are markedly deficient in earthy constituents ; and upon this fact is based the theory of an increased formation of acid in the system, whereby the earthy materials are dissolved out of the osseous structures. The nature of this acid, however, has never been determined, and its existence even remains a matter of conjecture only. The changes occurring in the bones are much too com- plicated and varied to admit of a purely chemical ex- planation. The new bone formed beneath the periosteum is soft and deficient in earthy matter, and the animal matter seems also to be abnormal, as it has been found by some observers not to yield gelatine on boiling. The epiphyses are enlarged, and ossification at these points proceeds slowly and with great irregularity. The border of ossification does not present a clearly defined, straight line, aS in normal bone, but is serrated, the new bone shooting far up into the cartilage in some places, while at other points streaks of unossified cartilage are observed extending for some distance along the shaft of the bone. The medullary cavity is advanced beyond the border of ossification, and is filled with a reddish pulpy matter. The jamella of bone are loosely imposed one upon the other, so that sometimes, in fresh specimens, they may be peeled 226 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. off like the layers of an onion. Spontaneous incomplete fractures not infrequently occur, giving rise to much of the deformity usually attributed to a simple bending of the bone. Separation at the epiphysis (diastasis) may also take place, and when occurring at the hip may simulate congenital dislocation. Ossification in the flat bones proceeds in the same ir- regular manner. In the cranium the fontanelles remain open for a long time, the sutures are not firmly united, and are apparently depressed, owing to an elevation along the borders of the bones similar to the enlarged epiphyses of the long bones. The earthy matter is not deposited regularly, but here and there soft spots may be felt in which the osseous formation is wanting. This deficiency is most common in the occipital bone, and constitutes the condition known as craniotabes. The liver, spleen, and lymphatic glands are frequently enlarged and harder than normal. The brain is often hypertrophied, the change involving chiefly the white substance. The muscles are flabby, poorly developed, and on section seem to be paler than normal. The liga- ments are nearly always relaxed. Symptoms.—The earliest stage of rickets is character- ized by no pathognomonic signs, and may readily escape recognition. The only symptoms are those of imperfect nutrition. The appetite is good, but the child does not seem to thrive. It is a little peevish and out of sorts, and the usual means resorted to by the mother or nurse to restore good nature are unavailing. It is most con- tented when alone, and resents any playful overtures, especially objecting to being tossed in the air or trotted upon the knee, sports which perhaps occasioned delight at an earlier period of its existence. Growth is retarded, the rounded cheeks and plump limbs lose their chubby outlines, and the child looks puny and wizened. Occa- sional attacks of diarrhoea may alternate with obstinate constipation. Now the disease is established and its true character becomes revealed. The desire to be let alone becomes more positive, and is due to a hyperesthesia of the skin, so that even a light touch may cause actual pain. The little patient will lie quietly for hours in its crib if undisturbed, but cries and betrays apprehension upon the mere approach of anyone who, it fears, is about to lift it. The weight of the bedclothes even seems to cause pain or discomfort, and, perhaps in consequence of this, the child is found uncovered as often as it is visited by the mother or nurse. There is profuse sweating, espe- cially about the head, to such a degree oftentimes that the pillow is soaked by the perspiration. The action of the bowels is irregular, and attacks of diarrhoea with very offensive stools frequently occur. The muscles become soft and flabby. Some writers speak of a rachitic paralysis, but this is incorrect; the . muscles are weak and often atrophied, but the atrophy is rather that of disuse, and no real paralysis exists. The ligaments are relaxed, and the joints are in consequence abnormally movable. The child makes no attempts to walk or stand, but cries if placed upon its feet. Some- times it is even unable to sit up; the back is bowed, and the head lolls from side to side, the patient having no power to steady it. The teeth appear late and at irregular intervals; they are poorly formed, and early become carious. There is but little, if any, elevation of temperature. The appetite usually is good, sometimes excessive, and thirst is a fairly constant symptom. The picture here presented is that of the early stage of typical severe rachitis, prior to, and during the com- mencement of, the stage of softening of the osseous tis- sues. The symptoms vary greatly in severity, sometimes being so slight as to escape remark by the mother ; but careful questioning will usually elicit the admission that the child was noticed to perspire freely, and that it had a habit of constantly throwing off the bedclothes. The most painstaking investigation will not seldom fail to develop any fuller history than this. The second stage is that of softening of the bones, through which ™any of the characteristic deformities of iw REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. rickets are produced. All the bones of the body are sub- ject to this change, though, in mild cases, the deformity is chiefly confined to the lower extremities, which become bent under the weight of the body. It is probable, also, that the muscles have some part in the production of the deformity in the long bones. But the more common oc- currence of distortion in the lower extremities is seem- ingly due to the fact that these members have to bear the weight of the body. ‘The upper extremities are less often bent, and when they are curved to any extent it is gen- erally because the child has been allowed to crawl, thus throwing some of the weight on the arms. During this period the symptoms of the first stage usually continue, though with decreasing severity ; or, in the milder cases, a marked amelioration may take place ; the muscles regain their strength, the ligaments grow less yielding, the out- lines of the limbs become rounded, and the child gains rapidly in weight. But this improvement in the general health has its disadvantage in causing increased deformity of the lower extremities, by forcing them to sustain a greater weight while the bones are still more or less yielding. The head, in a typical case of rachitis, is elongated, and flattened upon the top and at the sides, the occiput is projecting, and the frontal bosses are prominent, thus giving to the head, when viewed from above, a rec- tangular appearance (déte carrée, caput quadratum). The features are small, and the cranium in consequence ap- pears to be greatly enlarged, when it really may be smaller than. normal. Dr. Henry N. Read (New York Medical Journal, August 29, 1885) states that the ratio of the greatest antero-posterior diameter to the base-line of the cranium is altered. Normally this should be, as pointed out by Dr. Samuel Gee, as 6:5. But in rickets Dr. Read has found that the antero-posterior diameter of the cranium is always lengthened in proportion to the base-line ; in a case reported of not very marked rachitis this ratio was as 7+:5. There is sometimes an actual increase in size, due to hydrocephalus. The fontanelles are open, the sutures loosely knit, and lying in a groove caused by the prominent edges of the bones on either side. The soft spots in the occipital bone, due to imper- fect ossification, may sometimes be felt. This condition (craniotabes) is said to be one of the earliest and most constant anatomical features of rachitis. The writer has not, however, found it with anything approaching the constancy asserted of it by most authors. The ligaments and muscles of the spine are weak, the bodies and intervertebral cartilages are soft, and the con- sequent deformity is a posterior curve (kyphosis) in the dorsal region, with at times compensatory lordosis of the cervical and lumbar portions; usually, however, the kyphosis is complete and involves the entire length of the spinal column. Lateral curvature, or scoliosis, due to rickets, is a much less common deformity than kyphosis, though it is by no means rare. The scapula usually suffers but little change; some- times it is thickened, but more often is smaller than normal. The clavicle is thickened, its articular ends are enlarged, and it presents an exaggeration of its normal curves. Deformity of the arm and forearm, when at all pronounced, is found generally in children who cannot walk, but crawl upon their hands and knees. The curve of the humerus is outward, with its greatest convexity at the point of insertion of the deltoid muscle. The convex- ity of the curve of the forearm shows itself on the dorsal aspect. A very constant sign of rachitis, even in slightly marked cases, is the enlargement of the epiphyses at the wrist, the swelling being the more readily appreciated here because of its superficial location. The softening of the ribs, when marked, is a constant source of danger, owing to the impediment thereby of- fered to free respiration. The heart is also very con- stantly hypertrophied in marked cases, in which the soft- ening of the chest-walls is pronounced. The thorax is bulging at the sides, but the ribs recede before uniting with their cartilages, forming a groove running from above downward and inward on each side of the anterior wall of the chest. Each rib is enlarged at its junction with the Rickets. Ricketts, cartilage, forming a row of knobs just anterior to the depressed line, and which has been called the rachitic rosary. The sternum projects forward in fancied resem- blance to the keel of a ship, or the breast-bone of a fowl (pectus carinatum, chicken-breast). The lower ribs are flaring, being pushed out by the enlarged liver and spleen. The abdomen is swollen from the same cause, and also from flatulent distention of the bowels, which occasions much suffering to the little patient. The deformity of the pelvis in the female may prove a serious obstacle to parturition in later life. The sacrum projects forward, and the acetabula are pushed in by the weight of the trunk; a horizontal section of the true pel- vis thus presents the appearance of a trefoil. The neck of the femur forms a more nearly right angle with the shaft than is normal; the latter is bowed out- ward and forward. The deformity sometimes consists of a sharp curve, with the concavity looking outward, at the lower end of the femur, producing one form of knock- knee ; the tibia also sometimes presents a bend at its up- per part, similar to that of the lower end of the femur, which contributes to produce the same deformity. Bow- legs is caused by an outward curve of the tibia, or of the tibia and femur, associated usually with a relaxed condi- tion of the lateral and crucial ligaments of the knee. The tibia not infrequently presents an anterior curve at its lower third. The fibula usually follows the curve of the tibia, though in rare cases it may remain straight, in which case the external malleolus will project too low down and cause pain and difficulty in walking. The malleoli are enlarged and prominent. Flat foot (talipes valgus) frequently results from stretching of the plantar fascia, with consequent breaking down of the arch of the foot, and also from softening of the bones of the tarsus. The chief cause of the deformities in rickets is the weight of the body acting upon the long bones of the extremities and causing them to bend or break ; not in- frequently the curves are due to a green-stick fracture rather than to a simple bowing. Muscular action is, however, a frequent, and sometimes the sole, factor in the production of deformity. The misshapen thorax is aresult of atmospheric pressure and muscular contrac- tion combined. The last stage of rickets is the stage of cure. The con- stitutional disturbances, in cases in which they have con- tinued through the second stage, now subside, and the child seems again to enjoy the perfect performance of all the animal functions. The bones become firm from a deposition of the earthy constituents, but there is nota simple restoration of the osseous structures to the nor- mal; for, with the irregularity peculiar to rickets, in which the balance-wheel of the animal machine seems to be wanting, there is an excess of action ; the process of ossification, so long delayed, now runs wild, and the soft animal matter becomes converted into ivory rather than bone. Any deformities which have been overtaken by this process, called eburnation, while still uncorrected, become fixed and incapable of cure by other than opera- tive measures. Sometimes a spontaneous straightening of the bowed limbs occurs during this stage. This occurrence is diffi- cult of explanation, but it is possibly due to an increased growth on the concave side of the bone. A child who has been profoundly affected with rickets never attains the full stature which he would have reached had he remained free from the disease. In a given family, the children who have suffered from rick- ets, even though they be free from deformity, are always shorter than their unaffected brothers and sisters. The prognosis of rachitis, apart from its complications, is favorable as regards life; very few children die from rickets alone, but many succumb to bronchitis and laryn- gismus stridulus, appearing as complications of the dis- ease. A simple bronchitis, which would pass almost un- noticed in a healthy child, becomes a most serious disease in one affected with rickets, in whom the ribs are soft and yielding. The elasticity of the thoracic walls 1s impaired, the lungs can neither receive nor expel a normal amount of air, and when a further impediment is added to respl- 227 Ricketts. Roanoke Springs. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. ration by the presence of inflammatory secretions, the condition of the child becomes precarious indeed. Another complication, through which the life of the child is jeopardized, is laryngismus stridulus. This af- fection is stated by some writers to occur only as a con- sequence of rickets, the origin of each attack being attri- buted to cerebral pressure from the weight of the softened cranium resting upon the brain. It certainly occurs most frequently, if not solely, in rachitic children. The prognosis, as regards deformity, if mechanical treatment be neglected, is unfavorable. The curved bones, it is true, do at times straighten themselves as the disease subsides, but such a favorable result is doubtful, and can seldom be predicated in any individual case. But little can be done by way of prevention of the pelvic deformity, the consequences of which in after-life, in females, are often most serious. A spontaneous rectifi- cation of this deformity seldom, if ever, occurs. Fortu- nately it is of rare occurrence, except in the most severe forms of the disease. The treatment of rachitis is twofold, viz., the treatment of the disease, and the prevention or correction of de- formity. All measures which tend to improve nutrition are beneficial. Light and airy sleeping apartments, easily digestible and not too watery food, pure mountain or sea air, plenty of sunlight, perfect cleanliness, all are of the utmost importance. A change should always be sought ; if the child live near the sea, mountain air is more likely to be of benefit, and conversely, those from inland towns should be taken to the sea-shore. Salt-water baths, in moderation, sometimes prove in the highest degree bene- ficial. Unfortunately, the children of the poor, living in the crowded quarters of large cities, are seldom able to avail themselves of such treatment. Yet much may be done, even here, by a more careful observance of some of the simplest rules of hygiene, to give instruction in which is the first duty of the medical attendant. The child may be taken every day, or every other day, to the parks or outskirts of the city ; or, if the town is by a river, to the water’s edge or upon a ferry-boat. If the parents live on the first floor of a tenement-house, they should seek rooms on the upper floors, where the air is presum- ably less impure. Great care should be taken in guard- ing against the sudden changes of our climate, since even a slight bronchitis is liable to prove fatal. As these chil- dren always lie uncovered, in spite of the most watchful care, they should sleep in flannel garments which cannot be thrown off. Cod-liver oil and the compound syrup of the hypophosphites are useful when they are not rejected by the stomach ; they may be administered in combina- tion, or the oil may be given in winter, and the hypo- phosphites in summer. Eucalyptus globulus, in doses of ten to forty minims of the tincture, three or four times a day, is said to be often very beneficial. Much has been written of late years for and against the use of phosphorus, as recommended by Kassowitz, in the treatment of rachitis. Many regard this drug as a real specific in rickets, while others, after a long experience, condemn it as useless, if not harmful. The writer’s ex- perience with it has not been sufficiently extensive to warrant him in expressing a positive opinion. But in some dozen cases in which he has tried it, it has seemed to be of service. dose is 3} to zh grain twice or three times a day. The phosphorus should not'be given dissolved in cod-liver oil, as recommended by some, for such a mixture is not per- manent, and soon becomes inert. The ethereal solution and the solution in bisulphide of carbon are probably the best forms in which to administer it. The latter may be prepared after Hasterlik’s formula as follows: BR. Phosphori...... ae as ee 0.01 (gr. 4). Carbonei bisulphidi ,....... 0.25 (gr. iv.). = A Gur destillate:? 2.2202: 100.00 ( 2 iij.). The dose of this is half a teaspoonful, which may be given in syrup, or, preferably, with an equal amount of cod-liver oil. The solution should be kept in a well- stoppered bottle away from the light. 228 No bad effects were observed. The Treatment of the deformities should be instituted early, before the bones become hard, and should be persevered in without intermission. The mechanical treatment of rachitis is no less important than the hygienic and med- icinal, and in no case should it ever be neglected under the idea that the deformities will correct themselves. No child who has received intelligent instrumental treat- ment need grow up with crooked legs or a crooked spine as a result of rickets, and every adult who suffers from such misfortune is a living witness of parental or medical neglect. For the management of the special deformities, see under their respective headings. Thomas L. Stedman. RIO DE JANEIRO. The accompaning chart, repre- senting the climate of the city of Rio de Janeiro, Brazil, is likely to interest some of the readers of the REFER- ENCE HANDBOOK, as giving them a fairly typical show- ing of a truly tropical climate (although, to be sure, not an extreme example of this class), and also as conveying more accurate information than is generally possessed re- specting the climate of the largest commercial city of the South American continent. - As a health-resort proper, Rio de Janeiro is not for a moment to be considered ; but as a temporary halting-place for invalids undertaking a long sea voyage it is worthy of consideration. > > Seas tase __ 5.96680 AHOLT TI townie Ae. SARA RG ane CICR OOOO Oy OnIeCnact 27.66877 Cubic inches of gas per gallon : 12.40 Carbonioanhydride. 2... 6,-5.5. - = ec ese se ee en Sulphuretted hydrogen .........eee+eeeeereeeee ) 229 Roanoke Springs. Rocky Mt. Springs. THERAPEUTIC PROPERTIES.—These are excellent al- kaline, chalybeate, sulphur waters, of a mild and agree- able type. The springs are situated in the southeastern part of Virginia, at an altitude of over two thousand feet above sea-level. The country is mountainous, with forests of pine, and there are many natural objects of interest within driving distance. The hotel and cottages fur- nish ample accommodations for two hundred and fifty guests. GEED AGE. ROCHEFORT is an important town in France, situ- ated on the Charente River, near its mouth. There is an artesian well here, the water of which, issuing at a tem- perature of 105° F., is employed, both internally and externally, for therapeutic purposes. The following is REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. its composition, according to an analysis of M. Roux. One litre contains : Grammes Sodiumuisulphatews.a-nn hese etie cee eine aiaihisietele are Sines 2.590 Caleium sulphate a. os sc ce awics eee oe ace vee eC ner: 1.8238 Marnesium:sulphates. oe .ca: soos eeu cnc ce teen 0.504 Sodiumichloride ss, Witelede cee ete Reece ae 0.754 Magnesium" chlorides. Sivecccmeacn cease asec eenter 0.023 Oalcinm chloride tie. ncac sede wee tae ee ee 0.0384 Calcinm'carbonatéyi.. o. cco. osc tec cect ee eee ores 0.313 Magnesium, carbonate nn eee ciao ree ee ere eee 0.033 Berrous,carbonater’. Useanscne eerie ee oo eee 0.085 CAV 111 Soe) toce case Hiss oi coils earn eae teas ie ee «an oe One 0.005 Pel D Ret, Nevin ao. Aenea ie rer RA Bia a 8 EES A re Be 0.017 Iodine, bromine, organic matter, etc ................ 0.083 TOGA Fe a cieise es ee ns ee ciole Ie ieee cap etane Meee 5.714 There are also traces of manganese and arsenic. This water is employed in the treatment of engorged Climate of Rochester, N. Y¥Y.—Latitude 48° 8', Longitude 77° 42’.—Period of Observations, November 1, 1870, to December 31, 1883.—Hlevation of Place of Observation above the Sea-level, 500 feet. | A AA B Cc D E F Gi ‘ o oO b> A 1 , 3 5 5 PEeL|EEES 4 a se 5 se ~ Ed 5 5 Se Ae Eo As Shy © ® “Sok|"aoe 6a i= =) ap avlohad, Be 5 g ea" alse” & om Pod P=) ce, ae Tp o/T-4 On 2 } 5 Absolute maximum ||/Absolute minimum ||,,4 =| 2 Mean temperature of months go wo eae ee eh temperature for temperature for S BS Si CFSE at the hours of || a g red eiie ae a a =e period. period. Bee z Bgee $6 eS | 38 Eaesleaes & Sercleses alk 8 AS a|R5° 8 ae & & geeb|eee2 ee = = SLeS|S2es cob) eassiegwsa 5; > > Segoe sss = < <4. Gans |e aa TAM, 3 P.M. 11 P.M, Highest. | Lowest. | Highest. | Lowest. || Highest. | Lowest. Degrees. | Degrees. | Degrees. || Degrees, || Degrees. | Degrees. || Degrees, | Degrees. |, Degrees. | Degrees. || Degrees. | Degrees. | January....| 22.9 26.4 24.4 36.5 18.2 30.9 16.9 69.0 39.0 15.0 | —12.0 21 29 February...| 22.6 28.2 25.1 32.6 14:8 34/1 18.5 63.0 46.0 10.0. | 12.0 21 19 arch teste 28.2 34.4 30.1 40.1 22.2 39.4 24.9 69.0 47.0 16.0 7.0 25 28 April ?.25 40.1 47.5 42.9 52.5 35.5 51.4 35.1 83.5 61.0 35.0 11.0. oped 28 May «acne 53.7 62.7 56.8 64.2 50.1 65.7 46.9 90.0 73.0 34.0 28.0 28 27 June typ tcr 63.3 rier 65.9 69.8 61.0 74.1 55.1 94.0 85.0 48.0 36.0 20 19 Jalyee 68.0 77.0 70.9 W4.1 68.2 80.0 62.1 96.0 86.0 54.0 48.0 20 17 August..... 65.9 13.7 69.4 73.3 67.1 78.6 60.6 96.0 85.0 54.0 47.0 19 21 September..| 58.6 67.6 61.8 71.2 56.2 42.8 55.2 98.0 78.0 46.0) 34:0 25 17 October... 47.3 55.3 50.4 57.6 45.6 61.0 44.0 87.0 73.0 36.0 19.0 20 21 November..} 34.4 39.4 36.2 40.6 26.6 45.0 31.5 71.0 54.0 25.0 1:0 20 16 December..| 26.4 29.6 27.8 36.1 19.5 35.4 23.6 70.0 42.0 26.0 2 et10 20 25 SACRA AS Se: 43.2 49.5 38.7 eee eee ap ha cil aie dectk 68.7 iiog 66.5 : as. eR ae be ae ons bce Gaeasiaee 49.4 54.5 44.9 ; ite eee aA ac Wn, neces 25.7 32.6 20.4 i Bee ade hes oe betel sage el al monroe 46.8 49.6 43.9 se pein te al tee Se ro Oe K |L/| M N Oink. Ss : : : ee ae Teaetsaet eke Be Tid a: ent here introduced for convenience of reference. Be | b28 | United States, the city itself standing but seven miles aie 8 OS a. 5 Bick ay distant from the southern shore of Lake Ontario. A ref- Inches.) From erence has already been made to the winter cloudiness Taney BO Oly Be Se 8 a eet) echareverizing athemcli lee gotetiis ster Ote (seem unter February...| 75.0 | 76.9 | 10.8] 38.3 | 14.1 | 2:68 W. 11.3 5 : March...... 76.0 | 75.7 | 11.0} 3.9 | 14.9 | 38.41 W. 11.6 Portland, Me., on page 782 of vol. v.). A compari- gic Ba) et ws] ge | are | Bet |W | 8 | son of columns K, L, ML, N, and O in this Rochester June. «eos... 58.0) 65.7 | 12.6| 7.6 | 20.2 | 3.16 W. 8.3 chart, with the like columns in the chart for New York Aususie2| 49:0 | 67s |is7| 10l | str | $05 | sw. | @9 | City, will demonstrate the decidedly greater cloudiness Beptember..| 64.0) 69.6.) 13.3) 8.8 | 21.1 )02.35 | Swe) Bt and relative humidity during the winter season at Roch- Novernber.,| 70:0 | 75:5 | 9:3; 29 | 122 | x01 | Sw" | 103 | ester. The rainfall, which at New York is seen to be December..| 81.0 | 79.9 | 6.8] 0.9 7.7 | 3.07 W. 10.8 least in winter, is, at Rochester, least in autumn ; but Spring ti, 97.0 68.2 84.0 20.4 544 9.36 W. 10.5 throughout the year the Vaan of the rainfall is more ummer.. ! 6. 4t. cena 9.73 W. 4.6 i j . j Autumn...| 970| "0 | 323 is2 | s07 | ses | sw. | os | evenly distributed at the latter than at the former place, Winter ..... 82.0/ 79.0 |258| 5.7 | 81.5 | 9.06 | WwW, 11.1 winter not being that comparatively rainless season at ‘Sede ona Mie eae 2) Die ah be beeen oie Ww. 9.6 | Rochester which it is at New York, although the winter | conditions of the abdominal organs, in anemia, and in debility during convalescence from acute diseases. Ex- ternally it is used to promote the healing of indolent ulcers, to stimulate granulations, and hasten cicatriza- tion. Danis, ROCHESTER. The accompanying chart, represent- ing the climate of the city of Rochester, N. Y., and ob- tained from the Chief Signal Office, at Washington, is 230 rainfall of the two places is very nearly the same, and is, in fact, slightly greater at New York than at Rochester. On the other hand, during the six months, April to September, inclusive, the relative humidity of the atmos- phere is markedly lower at Rochester than at New York, and the cloudiness is nearly the same at the two places ; during the mid-summer months actually less at the for- mer than at the latter. Thus, during the winter season Rochester is decidedly damper and more cloudy than New York ; during the summer season, and especially REFERENCE HANDBOOK OF THE MEDICAL SCIENCES, Foaneke Springs. the mid-summer season, New York is markedly damper and a trifle more cloudy than Rochester. Hoh, ROCKBRIDGE ALUM SPRINGS. Location and Post- ofice, Rockbridge Alum Springs, Rockbridge County, 2. AccEss.—By the Chesapeake & Ohio Railway to Go- shen, eight miles from the Springs. ANALYsISs.—One pint contains : | | = a a S =| ig ag +g SOLIDS. a ae ray yaes| Ay pagel < < < < < < Grains Grains. Grains Chloride of sodium............. 0.053 0.126 0.055 Sulphate/of potassay.. eee esi ae ee oa Lanes ieee ek Sulphate of magnesia..... ..... 0.135 0.220 0.552 Sulphatevof limes ese: 0.180 0.408 0.413 Protoxige ol sren. 5.69.2 aes. oe 0.460 0.608 0.587 Alimindseree teen eae eter fee 1.846 2.238 3.011 Crenate of ammonia........... 0.175 0.088 0.1538 Bilicateso£, sOdaiesivne cece sine CG) peaks), Mei > pee eo © ln) eae Sulphuric acid (free).........-. | 24347 1.908 0.689 Silicievacid (iree)@un nesses ss see) tn 0.355 0.213 Organicemattersces ee ee cele ee) | fines dees 0.127 A Wat Ns eee Se». Soe Ome 5.514 6.167 5.800 GAS. Cubic in. Cubic in. Cubic in, Carbonic) acid te. tei. ts ossks ss ORG 1.9 ee THERAPEUTIC PROPERTIES.—There are here nine alum springs and one pure chalybeate, and their remedial value is attested by the decided cures effected in many in- stances. The alum waters are tonic and astringent. Their taste is astringent, and their temperature averages about 50° F. They cure catarrhal diseases of the alimentary and genito-urinary tract, and are famed for their bene- ficial influence upon chronic skin diseases, glandular en- largements, chronic ulcers, and, in fact, all scrofulous de- generations. An experienced physician resides at the Springs, and directs the use of the waters. The situation of these Springs is in the northwestern part of Virginia, in a glen at the base of North Mountain on the south and Mill Mountain on the north, amid the beautiful scenery of this section. The lawn, of about fifty acres, is partially surrounded by several fine hotels and cottages, affording accommodations for seven hun- dred guests. Geo, B. Fowler. ROCKBRIDGE BATHS. Location and Post-office, Rockbridge Baths, Rockbridge County, Va. Accress.—By the Baltimore & Ohio (Harper’s Ferry & Valley Branch) Railroad to Timber Ridge Station, thence by stage to the baths, four and one-half miles. THERAPEUTIC PROPERTIES.—These waters are princi- pally employed as baths. They contain iron, lime, soda, magnesia, potassa, and iodine. The springs are beautifully situated on the banks of the North James River, on the old stage road, passing through the celebrated Goshen Pass, from Goshen to Lexington, about ten miles from either place, amid some of the most picturesque scenery in Virginia. There are hotel accommodations at the baths. GaBAL. ROCK CASTLE SPRINGS. Location and Post-office, Rock Castle Springs, Pulaski County, Ky. Accress.—By the Louisville & Nashville Railroad (Knoxville & Bardstown Branch) to London, thence by stage to the Springs, eighteen miles. THERAPEUTIC PROPERTIES.—This is one of the waters which should prove beneficial in disorders of digestion and allied complaints, simply from its purity; as the writer holds that the imbibition of pure water (in excess in disease) is one of the greatest aids in treatment. Rocky Mt. Springs. ANALysIs (Dr. Peters).—Composition in 1,000 parts : Grains. Carhonate Ofaronerse cette raat ec rcie one ee ee .0045 Carhonate‘ol limear.. ces sce sti eels sens nn oe eee ome ne .0488 Carbonate of macnesiaiis. nei ack oe ddch coceccy ohn 0148 (Held in solution by carbonic acid.) Silpbateror NM yen ees ec es here la ate Cole 0029 Sulphate Ol mar wesian css. caste wemeraen a iene 008 STU MALE/ Oly BOG Ger essen ci erstettante 4% rubbed and beaten to a smooth mass, suitable for pills ; Fluid Extract (Hetractum Rose Fluidum); Honey (Mel Rose), strength, +§>; Syrup (Syrupus Rose), strength, -jy. It is also employed in making the Pills of Aloes and Mastich. Red Rose petals are collected in England, France, and Belgium. Rosa centifolia Linn., possibly a variety of the above, is the parent stock of numerous fragrant, very full-flow- ered varieties. It has large, hooked prickles, and droop- ing, generally double, pale-colored flowers. Sts DEIN SG at eke oie 0.210 SUICA posctise sehr were ieiee ae cosas fait plesiotote teres olen 30.400 Organic matters....:.:... 5 an Sle esas ora levahe teat a(o apetae Sake 8.103 TOSS SIGS OE Sas cee htitstee Merete ca tiers Sone eee aan e aie 2.700 OLA archer ecttiols huasiete cee clei re cements 100.000 The waters of the springs, which are used for drink- ing, contain sulphates of calcium, sodium, and magne- sium, carbonates of calcium and magnesium, chlorides of sodium and magnesium, and silicic acid. No use is made of the water for bathing purposes. Saint-Amand is recommended chiefly for the relief of chronic and sub- acute rheumatic affections, of certain forms of neuralgia, and of lameness and disability following sprains or re- maining as sequele of fractures and dislocations. Men eae or Mean temperature of months Servet or _ at the hours of duced from Column A. Average mean temperature de- | > Cc D E ¥ G Hi sce) Slt by 5 E ges jess 2 oe) es Diss g g Ags |azg o ® no | g| 2 5 Bg 2 & mPa | Peck ce a sé Bee | OG S3 ” ~ ° Mao! dan! g ge Absolute maximum |Absolute minimum bates Ft Oat F 3 mS a9 temperature for] temperature for|| , BSa/ 2S I go = period. period, Bee aeoR “A oy at bal +2 | 5 RS | 8s Foo. fs5g g | Reo8|See Ss o (0) pan§ie g no ac oo MS ee S Cc ie FS S SobG Pores S @ SYLE| So wee a < CEB hloae Highest.| Lowest. | Highest.) Lowest. Degrees.| Degrees.| Degrees.| Degrees.| Degrees.| Degrees. 38.7 22.9 72.0 48.0 eT) —16.0 24 31 45.5 28.4 73.2 61.0 27.0 —3.0 21 22 53.5 36.7 82.0 62.0 34.0 8.0 25 26 65.8 47.5 87.5 78.0 » 43.0 22.0 18 18 73.4 56.7 93.0 84.0 45.0 32.0 25 25 83.0 65.2 99.0 90.0 64.0 48.0 16 19 88.2 70.0 104.0 93.0 70.0 57.0 22 21 87.4 68.3 106.4 7.0 63.0 55.0 25 22 79.2 60.0 101.5 85.0 51.0 40.0 25 19 63.4 51.2 90.0 80.0 42.8 25.0 23 21 Heid 36.6 82.0 61,0 31.0 5.0 24 23 43.4 29.0 74.0 53.0 21.0 —17.0 22 24 TAM. 3P.M. | 11.P.M. Highest.| Lowest. Degrees. |Degrees. | Degrees.|| Degrees.|| Degrees.) Degrees. January... : 27.8 36.2 Stel SL.7 45.7 ale February...) 31.1 41.3 36.0 36.1 43.9 26.0 March ..... 37.2 49.2 42.9 43.1 53.9 37.8 April Wears... 48.9 62.2 54.4 55.1 61.3 47.6 AY Sees se sis 60.6 73.0 64,8 66.1 70.8 59.5 June... 69.6 81.1 93.4 G47 "9.7 71.9 J tlyeeee 3 73.7 85.3 WA 78.8 81.7 73.8 August..... 71.0 84.0 75.7 76.9 82.5 72.8 September . 61.5 75.7 67.0 68.0 75.3 64.9 October .... 51.2 65.0 56.4 57.5 62.3 52.0 November. . 37.7 47.7 42.0 42.4 49.6 31.9 December .. 30.3 38.4 34.1 34.2 47.9 24.9 SHEN pea. week aca Agor 54.7 60.1 51.9 Summer.... AO Nae AoC 76.8 79.5 73.6 Autumn.,... eres cade sa00 55.9 60.0 50.9 Winter...... aero see wet 84.0 41.9 26.4 Nearer vosa | ees Rea erat 55.3 57.5 53.6 J K L M N 6) Ss sits ! by be bi hy =| } bo Poe ee leetepas he Ol BR es Be | 2 ds | 2 | se | 3 se ik S244 ar | 63 | ag H of oS Ps, eh Se oe oH o& on & ovs om | BB | oy | &s | os, | wo | BS [eas oe D RG £S Peay gas) fd Se |£E x. go | Sq |-fs | be | Sel fs | &S l[esk ae. Ce eo ee h(a pte ha January...| 88:0 Deceit LS 8.8 20.1 Zl e ay oss 10.2 February..| ‘6.2 69.5 10.5 8.5 19.0 3 100e > 8. 10.3 March..... 74.0 66.0 11.9 EE 19.6 3.04 N. W. | 11.6 Ayu) gh ee SS 65.5 59.7 11.8 9.4 ieee SraD 8. 10.7 LAV ee ose: 61.0 64.2 15 9.8 21.3 | 3.86 Ss. 9.7 June..:.... 51.0 68.2 14.4 8.0 22.4 4.82 bd. 8.9 Jiihyeescerer 47.0 67.9 12.$ 11.4 24.3 4.36 Ss. "7 August....| 51.4 66.1 13.2 14.1 27.3 2.56 Ss. v4 September.! 61.5 64.7 10.9 13.9 24.8 2.55 s. 8.5 October....| 65.0 64.9 11.8 12.8 PEN a ly Ss. 9.5 November.| 77.0 67.9 12.2 ed 19.9 2.19 s. 10.6 December .| 91.0 (2.0 11.2 V2 18.4 | 2.19 Bs 10.2 Spring..... 85.0 63.3 35.2 26.9 62.1 | 10.25 Ss: 10.7 Summer. 53.4 67.4 40.5 33.5 74.0 | 11.74 Ss. 8 0 Autumn. 96.5 65.8 34.9 34.4 69.3 8.12 s. 9.5 W interes | ol. 0 70.9 33.0 24,5 Deo) 7.48 Ss. 10.2 Yearseoe 123.4 66.8 | 143.6 | 119.3 | 262.9 | 87.59 Ss. 9.6 March alone interfering to change the direction from S. to N.W. Vee wee SAINT MORITZ. The climate of Saint Moritz, con- sidered as.a winter health-station, has already been suffi- ciently described in the article entitled Engadine. In the present article a few words will be said concerning the summer climate of this celebrated resort of the High Alps, and concerning its valuable mineral springs. The wood- cuts on page 246 (Figs. 3361 and 3362), copied from Woldemar Kaden’s ‘‘ Baths of St. Moritz,” are pre- sented to the reader as illustrations of the descriptive passages in the Engadine article, where they would have been more properly introduced had they been available to the writer when that article was prepared for press. These illustrations will be especially interesting to a reader of Dr. Yeo’s work on ‘‘ Climate and Health-re- sorts,” and if studied.in connection with the lengthy and interesting descriptions of scenery therein given, will con- vey to the mind a very accurate impression of the topog- raphy and scenery of the Upper Engadine. In studying the illustrations it should be borne in mind that the direction of the Upper Engadine valley is from southwest to northeast. The view in Fig. 3361 is taken from an elevated point on the eastern side of the valley, just south of the St. Moritz bathing establishment, and shows the valley as seen on looking north from this point. In the foreground are seen the Kurhaus, bathing establishments, and hotels constituting St. Moritz Bad, or the Baths of St. Moritz. Near the centre of the picture is seen the village of St. Moritz, built upon the northern slope of the valley, at an elevation of some two to three hundred feet above the lake of the same name. The mountains which close in the view to the north are a portion of the range of the Albula and Bindner Alps, the lofty serrated peak seen directly in line with the village of St. Moritz and tower- ing above all other summits visible in the picture being the Piz Kesch (11,211 feet high above sea-level; 5,411 feet above St. Moritz Lake). In Fig. 3362 the view is taken from an elevated point on the western side of the valley, just north of the village of Campfer; probably from the ‘‘summer restaurant known as the Alpina,” mentioned by Dr. Yeo (op. c?t., p. 192). In this view we are looking up the valley, instead of down the valley as in Fig. 3361. The baths of St. Moritz are behind us on the left: and not very far dis- tant either ; for Dr. Yeo, in describing Campfer, tells us that ‘‘it is a convenient abode for those visitors to the Baths of St. Moritz who would be at St. Moritz, but not of St. Moritz,” being ‘‘as near the Kurhaus and the baths as the village of St. Moritz itself.” It isthe village of Campfer that is seen in the immediate foreground of this picture. The little village standing in the distance is that of Silva Plana. The lake in the foreground is that of Campfer, the one in the background beyond Silva Plana is the lake of Silva Plana. The lake of Sils, the village of Sils, and the Maloja we do not see; they are hidden behind the mountain-shoulder which rises behind Silva Plana; but the great snow-covered alp which closes in the view to the southwest is the Piz Margna, one of the three Bernina mountains whose slopes are said by Dr. A. T. Tucker Wise to abut on the lake of Sils and on the eastern side of the Maloja plateau (‘‘ The Alpine Winter Cure,” p. 66). The elevation of the Piz Margna above sea-level is 10,355 feet. A reader of Dr. Yeo’s book will easily recognize another prominent ob- ject in this picture, namely, the location of ‘* the restaur- ant and summer house called Crest-alta, which is finely situated on the top of a wooded promontory which pro- jects in the most picturesque manner from the south side of the valley into the Campfer lake.” This promontory is seen just to the left of the centre in our illustration. SumMMER CrimaTE.—The following tables, taken from Woldemar Kaden’s interesting pamphlet, will serve 245 Saint Moritz. ms ; Saint Paul. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. itl Fic. 3361.—Baths and Village of St. Moritz, (From *“ The Baths of St. Moritz.” by Woldemar Kaden, ) Fic. 3362.—Campfer, near the Baths of St. Moritz, and Piz La Margna, (From ‘** The Baths of St. Moritz,” by Woldemar Kaden.) 246 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. sufficiently to illustrate the summer climate of Saint Moritz: TABLE A.—Mean Temperatures of the Summer Months and of the Season during the Ten Years 1856-1865, ac- cording to Professor O. Brugger. (‘‘ The Baths of Saint Moritz.’’) | j . Mean daily hee oe Month. 5aM. 1p.m,|9pP.m.| tempera-| uation o ture, tem pera- ture. JUNG 4s). Minas area 41.57 | 57.27 | 44.74 49.55 15.69 (?)* TUulypE te ewe Gee tenes 43.55 | 61,28 | 49,35 52.46 49.67 ANIGUBER arse si-.5 0 Hoje ages oh 42.98 | 60.62 | 48.70 51.67 49.64 Heptember Foc.e cece 38.64 | 54,23 | 43.16 45.60 47.48 Season (June 21st to Sep- tember 20th) 2.2. os. 42.31 | 59.43 | 44.07 50.63 49.01 TaBLE B.—Mean Temperatures of the Summer Months and of the Season during the Seven Years 1867-1873 (Dr. Husemann, from Candrian’s Daily Observations). (‘* The Baths of Saint Moritz.’’) Daily fluc- Mean daily | aS f Month. 7 aM.|1P.M.|9P.M.| te mpera- ae cai five. em pera- ture.* June ee: ....| 45.95 | 55.61] 44.74] 48.74 43.89 DULY pee a rereion Het sacaena | 50.79 | 62.43 | 47.57 54 57 45.39 PGi eee Gln RE Per wae eee 46.92 | 59.50 | 48.11 51.51 45.86 Septentberc o's. Wes se cs 40.88 | 54.96 | 44.00 46.45 47.33 Season (June 21st to Sep- | tember 20th).<........ 47.31 | 59.77 | 48.30 51.80 45.89 * Whether the figures in this column represent the mean, or the ex- treme daily, fluctuations I do not know.—H. R. TABLE C.— Average of the Weather Conditions for the Summer Months and the Season during the Fourteen Years 1860-1873 (Dr. Husemann, from Candrian’s Observations). (‘‘ The Baths of Saint Moritz.’’) = we | 8 § 5 5 6 se| be af eb 3 | Ba Month. 3 a a qs > e ms a Se} et | wo | as ev) sc rn Be cs fa Gi = PUNCH artes cle tre cetera ee 1G9 a1 2.1 1.4 7.2 | 0.93 | 1.4 ed UL Ware teesreferctareiais: ere! opereteve ss otarsts in eis 21.9 shal 3,3 Ome Osta leuk AMIE UBbier tte te ce steetele siete eerie ® 21.5 9.5 3.38 7.4 | 0.86 | 2.2 Sepbember con «cj 4oc cristal aes 21.4 8.6 5.4 6. | £36.) 0.8 Season (June 21st to Septem- ber! 20th) ea es tec ea Gamiwes te lOsSaieelA el 57 5 i6 Mr. Kaden states that July and August are the best months for a summer stay at Saint Moritz, and that April and May, being the snow-melting months, are the very worst season of the year in the Engadine. MINERAL WATERS. — There are two chief mineral springs at the baths of Saint Moritz, known respectively as the ‘‘ Alte-Quelle” and the ‘‘ Paracelsus-Quelle ;” of these the latter appears to be a trifle the richer in mineral ingredients, but the two are very similar one to the other. A very full analysis of the two waters may be found on pages 58 and 59 of Mr. Kaden’s pamphlet. Dr. Yeo (op. eit., p. 160) also gives an analysis of the Saint Moritz wa- ters. He sums up the characteristics of the waters as follows: ‘‘ Practically these waters may be regarded as containing a small quantity of iron, about three grains of the carbonate in a gallon of the stronger source, and a considerable amount of carbonate of lime, about eighty grains in a gallon, held in solution by an abundance of carbonic acid. The presence of this large amount of car- bonate of lime in the absence of any appreciable amount of aperient saline constituents, interferes somewhat with the usefulness of this water in many cases where the use of a chalybeate is indicated.” ‘The duration of the course of treatment by baths, etc., usually recommended, is from three to eight weeks. For full information con- cerning the proper use of the waters and the class of mal- adies ameliorable by such proper use, as well as the type of disease and of constitution indicating the propriety of recourse to this ‘‘ high altitude” bathing-station, and the class of invalids and type of constitution which should / Saint Moritz. Saint Paul, be forbidden to resort thither, see Dr. Yeo’s book and Mr. Kaden’s pamphlet, in both of which works (the former especially) these matters are treated ably and at very considerable length. For general indications see articles ‘‘ Health-resorts” and ‘‘ Mountain Resorts.” Huntington Richards. SAINT-OLAFSBAD is a health-resort in Sweden, not far from the city of Christiania, which is visited to some extent by foreigners on account of its iron-spring. This water contains 0.114 Gr. of mineral constituents, about fifty per cent. of which is ferrous carbonate, in each litre. There are various other ‘‘ cures”? made use of, such as pine-needle baths, mountain climbing, frictions with peat, milk and whey cures, ete. The affections for the relief of which Saint-Olafsbad is visited are anemia, chronic bronchitis, chronic rheuma- tism, debility attending tedious convalescence from acute diseases, etc. The place is well protected against the north winds, and the climate is more mild than in other places in the vicinity. The season for guests lasts from about the end of May to the first of September. Lidia: SAINT PAUL. The accompanying chart, represent- ing the climate of the city of Saint Paul, Minn., and ob- tained from the Chief Signal Office at Washington, is here introduced for convenience of reference. | 55 See égvaise § | es Beuahees ceeseee® 1] one 4 “ ere 5 2 rs Mean temperatureof months ||) @9 Mean temperature : = a 5 iB Absolute maximum) | Absolute minimum = ED 5 ® BS 5 at the hours of Ne ai g for period of ob-| §& a a temperature for|| temperature for||@ g~ g/28 es eo servation. ky asks ee period. period. a aga = aye OH 8.C Banc} ea Be as Gs fg : 5 as 8)a6"8 oo © o eparpivy > ae a tn) eae od begs o | 8 3 Swse Sass > 1 Pa > Q9ano Pages ee |< 4 owed oaad TAM. | 8P.M. | 11 P.M. Highest.) Lowest. \| Highest. Lowest. || Highest.| Lowest. Degrees. | Degrees. | Degrees. || Degrees.|| Degrees. Degrees.| Degrees.| Degrees. || Degrees. | Degrees.| | Degrees, | Degrees. January....| 8.8 UW BS 12.4 Rey Weer ebue tel 0.8 24.3 4.8 49.0 23.0 —11,.0 —31.0 27 26 February...; 12.8 24.7 17.8 18.4 31.8 629° i -220"4 9.4 59.0 24.0 5.0 —32.0 21 3 March tain a1 22.6 34.7 28.3 28.5 44.3 Pe On Pelemclae 22.2 68.0 46.0 21.0 —22.5 20 30 ADIN teow | 93%.9 51.8 43.7 44.4 50.9 36.9 58.3 36.9 82.0 63.0 30.0 7.0 19 21 May ie cceny 53.1 66.1 57.2 | 58.8 63.8 52.2 68.7 48.3 94.0 75.0 40.0 24.0 24 25 Abitsbnodante 61.5 73.7 65.1 66.7 43.0 | 63:8 78.1 ate) 94.0 85.0 | $2.0 39.0 17 20 JULY tee eek 65.9 79.6 69.9 eS A eo} 74.6 66.6 82.8 62.7 100.6 91.0 57.0 46.0 26 21 August..... 63.5 17.8 68.0 feeO Se 42.9 66.1 82.0 61.5 98.0 §8.0 54.0 43.0 ai 24 September... 52.2 66.2 57.0 | 58.4 64.1 GBM Ns CEE 50.7 94.0 76.0 41.0 30.0 23 19 October..... 41.9 53.5 45.3 46.9 heeo6z9 a2 D0 i) r.6 41.0 7.0 67.0 32.5 15.0 22 19 November.. 26.4 34.8 29.3 eis VAN 39.6 22.2 | 40.2 23.8 72.0 47.5 15.0 —24.5 20 24 December .. 15.2 22.8 18.1 fot setts! 33.6 Seer ily eS.2 12.2 56.0 36.0 10.0 —39.0 at 30 Spring et ec.f wee tenet Moseees viene te | 43.9 47.1 SOA, gcc sene me ae ehhh tee GREY Magenta Cis ae SOULE CI a= nie esters aunote.| lie cacone | 69.4 71.3 (Care APs |) Roane SAP doses.) jl” aencos ASN Macsane. eater ATTN Feet Bee ote cic emma Miecis ¢ Siotln |e avers inte je a5eL0 siege o. 6 5 os eee acon Wl oreo. HEC ad Snooe al) Goans Ber old ericnn ye 1k Bec Winter...... Me Bisa pian gacic, Hill G datigos 16.6 || . 29.2 Se a ippemaccre | Ole ompsso NNN Geecwl, uh epoods voi Sw hate ee oe 4 YVear:t). 2328; ee ee 43.7 48.2 BOS 8 p's ns sieve. cally ee sie. e eeu a motets een Onl emretme pile, son! |N iste ardor lh ts pheetaty | | | eye J'K LF mM! N Oo | F_ S_4 the composition of the waters, after analyses made by at ae fut as bg Filhol and Byasson. In 1,000 parts of water there are of | | pan oO 2 23) 4 ny FS ot Es f Vises ig 3a Source Source SE iy ac = be E 8 | Sc P| m8 | os des Bains. de Hontalade. Se BS) ae) Ae ae 3 eee | PA Sodium eiphate.+ 47. aemen 0.0400 0.0213 SE | Bo | ek] oF | ox i BS | oF 5 Calcium ‘sulphate. ..0 ia. -2 teers eee ee 0.0572 Ase aa | oo | fee ep rt ae Meg ee Magnesium sulphate! ... ) We os eee 0.0087 }gsi1 8 | 33 | oy Bie 5 on ie g Sodium sulphides, iva. a: it nee 0.0218 0.0197 aes 4 a SE A aia Sodium hyposulphite., sieccs- ave ees ee 0.0028 Eo (Be Tip, RMP Rn caer db) VACA OA Ba teres AB Sodium ichloride..g7.4 8; Acasa Sa ee 0.0695 0.0600 | | Inches.| From Miles. Sodiumsilica tessa eee eee See 0.0704 0.0896 January....; 80.0; 72.1 | 18.0; 8.@ | 21.0 1.07 | N.W. 7.8 Calcium silicate... .cc eee eee nee 0.0062 0.0076 poorer y is] ae a 4S | ee an Of | an ae Magnesium silicate...........0....... O00ST > Sin a ee ane aes 9. Ae “ 20. . cons : Aluminiumasilicates seme set eee 0.0070 Aprils eee 75.0 | 60.38 | 12.0° S528] 2052) 2209 NW 9.6 P| aoe See Bite go VETS co Re PM Bony OM CL tine 215 May wie. 20.0 60.5 14.2 | 8:8 23.0 8.72 8.E. 8:6 Oreaniceumatterac.mevscs.se oe eee see 0.0820 0.0215 UNE res D. 68.0 | 15.% Py de ray. : Hi. : oa lUnY ss taeties | 54.0 | 69.9 | 15.8} 10.6 | 26.4 | 8.22 | S.E. 7.2 LOtAl so... see os oe ae tests 0.2500 0.2884 August..... hOl0- ae pele) teh 5 25.3 3.83 | S.E. 7.3 res ;. ° September.! 64.0 | 70.7 | 18.8) 91 | 22.9 | 8.26 | S.E. 8.2 There are traces of iodine and boracic acid. The S pamene cael Ih aR lata h eet eet cas ith eee waters issue at a temperature of 94° and 71° F., respect- December. .| 95.0 |) 74:8 | 12.8.) ° 8.8 | 21.6°|° 1.28 ) NW. 1 75 ively. Spring's... 116.5 | 63.3 | 98.2| 25.3 | 63.5 | 7.45 | NW. 95 The indications for a course of treatment at Saint- Summer... 61.0 | 69.9 | 45.8 | 29.3 | 5.1 | 12.18 S.H. ee Sauveur are stated to be catarrh of the bladder, gravel, ee ee te See tee Mk ees ee ney gastralgia, chronic diarrhcea, menstrual disturbances, Near Sos: 139.0 69.1 1159.9 | 106.2 | 266.1 | 29.9% | SH. 8.4 certain uterine affections, pulmonary phthisis, and irri- It is in the matter of temperature that we find the chief difference between the climates of the two places. The mean temperature of November at St. Paul is the same as that of January at New York City ; while the mean temperature of the four months, December, January, February, and March is at New York 32.8° F., at St. Paul only 19.6° F. Steady cold in winter, involving exemption from thaws, is the chief cause of the popularity formerly enjoyed by Minnesota as a resort for phthisical patients, and is the leading factor in its climate (combined with relative windlessness and cloudlessness, and its inland location, involving freedom from the perpetual changes from land to sea air, and from sea air to land air, common along the Atlantic coast), which renders the truly and purely continental climate of that State more favorable to weak lungs than is the climate of any of the larger seaboard cities of the Northern United States. Reig i % SAINT-SAUVEUR is a little hamlet in the Départe- ment des Hautes-Pyrénées, France, lying at an elevation of 2,500 feet above the sea. The valley in which the village lies is exposed to the north and south winds, but the climate is nevertheless equable and mild. There are two principal springs—the Source des Bains or des Dames, and the Source de Hontalade. The following is 248 table conditions of the nervous system. The therapeutic means employed are baths, both general and local, douches, and the internal use of the water. The season extends from about the first of June to the middle of September. A single course of treatment generally oc- cupies about four weeks. 7 S. SALEP, Codex Med. (Tudera Salep, Ph. G.). The corms of several European and Asiatic Orchidaceous plants, es- pecially of Orchis mascula Linn., O. Moris Linn., 0, militaris Linn., O. varvegata Linn., etc., dried by means of artificial heat. It is in the form of small round, oval, or irregular tubers of a yellowish color and rather trans- lucent texture. Salep is tough and hard to pulverize ; it has a mucilaginous taste and very little odor ; consists of a small quantity of starch and a good deal of bassorin- like gum, with no more active ingredients, and is simply a not very nutritious food, devoid of physiological or therapeutic value. ALLIED PLANTS.—See VANILLA. ALLIED DrRuGs.—See TRAGACANTH ; STARCH. W. P. Bolles. SALICYLIC ACID AND SALICYLATES. Salicylic acid, chemically ortho-orybenzoic acid, HC;H;QOs, takes its name from the principle salicin, found in willow-bark, from which substance it is possible to make salicylic REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Saint Paul. acid by fusion with potassic hydrate. Salicylic acid in the condition of the ethereal salt, methyl salicylate, con- stitutes about ninety per cent. of oil of gaultheria (wintergreen), and occurs also in other plants. Salicylic acid can be made from oil of gaultheria, but at present almost all the acid used in medicine is made by the pro- cess of Kolbe, from carbolic acid. The principle of this process consists in the forcing upon the molecule of car- bolic acid a molecule of carbon dioxide, an addition which just converts one molecule of the phenol intg one of salicylic acid. By the process, carbolic acid and a concentrated solution of soda are first evaporated to dry- ness, and over the product, heated, a stream of dry car- bon dioxide is made to pass. As a result, one half of the phenol used is converted into salicylic acid in condition of sodic salicylate, which salt, on decomposition by treat- ment of its aqueous solution with hydrochloric acid, yields salicylic acid under its own form. Kolbe’s pro- cess, by reason of its cheapness, has practically super- seded all others for the procurement of salicylic acid. Salicylic acid is officinal in the U. §8. Pharmacopceia under the title Actdum Salicylicum, Salicylic Acid. It presents itself as ‘‘ fine, white, light, prismatic, needle- shaped crystals, permanent in the air, free from odor of carbolic acid, but sometimes having a slight aromatic odor, of a sweetish and slightly acrid taste, and an acid reaction. Soluble in 450 parts of water, and in 2.5 parts of alcohol at 15° C, (59° F.); in 14 parts of boiling water ; very soluble in boiling alcohol; also soluble in 2 parts of ether, in 2 parts of absolute alcohol, in 3.5 parts of amylic alcohol, and in 80 parts of chloroform. When heated to about 175° C. (847° F.) the crystals melt, and at about 200° C. (892° F.) they begin to sublime; at a higher temperature they are volatilized and decomposed with odor of carbolic acid. The aqueous solution is colored intensely violet-red by test-solution of ferric chloride” [one part of ferric chloride dissolved in ten parts of distilled water] (U.S. Ph.). Although salicylic acid is but feebly soluble in cold water, it dissolves freely in many saline solutions. Thus the pharmacopceial solution of acetate of ammonia will dissolve twenty-five per cent. of salicylic acid ; a twelve and a half per cent. aqueous solution of potassic acetate will dissolve twelve _ and a half per cent. of the acid ; a twelve and a half per cent. solution of potassic citrate in equal volumes of glycerin and water will dissolve six per cent. All of these solutions possess the sharp stinging taste of the un- combined acid. A serviceable and permanent solution of the acid, and one that instead of being sharp to the taste has a pure bitter flavor only, can be made as follows: Dissolve two parts of borax in twelve of glycerin by the aid of heat ; add one part of salicylic acid, continue the heat, and stir until the acid dissolves. Almost all solu- tions of salicylic acid, either immediately or after a while, turn of a reddish or of a smoky color resembling that of solutions of carbolic acid. Salicylic acid, taken into the mouth, has not much taste, proper, but speedily and quite suddenly after the tasting a sharp stinging seizes the throat, often severe enough to bring tears to the eyes. Similarly, a little of the dry acid snuffed up the nostrils will sting quite strongly. The acid brings sharp pain to cuts and abra- sions, but, swallowed, is much less irritant to the stom- ach than its effects on the throat would lead to suppose. Large doses, so taken, may upset digestion and cause a strong sensation of heat, and even actual burning pain, but no serious or lasting results follow. The acid is rapidly absorbed from the stomach into the circulation, presumably in saline combination, and thereupon exerts the peculiar influence characteristic of the salicylates (see Salicylates, below). Salicylic acid was at first used as an internal medicine for the procurement of the therapeutic effects of the salicylates; but now, and very properly, salicylates themselves, because of their freedom from the locally irritant action of the uncombined acid, have superseded the acid for this purpose. The present medicinal appli- cation of the acid is for local purposes as a deodorant, detergent, or so-called antiseptic—purposes which sali- cylic acid fulfils by reason of its possession of a fairly potent germ-sterilizing faculty. (See Salicylic Acid in article Germicides.) For general local use, the solution of the acid in a glycerin solution of borax is convenient, this solution bearing any necessary dilution with either water or alcohol without precipitation. A. dilution rep- resenting a two per cent. solution of acid is one very commonly employed. For other salicylic preparations for local use, see Salicylic Acid in article Antiseptics. SALICYLATES.—In saline combination, whether with metallic or ethereal bases, the local pungency of free salicylic acid disappears while yet the faculty for consti- tutional action remains. As already said, it is probable that the acid, when taken as an internal medicine, enters the circulation only after conversion into a salicylate, so that, as a matter of fact, what is commonly called the constitutional action of salicylic acid is, so far as we know, the action of a salicylate. The constitutional ef- fects in question are as follows: After a full dose a non- pyrexial subject experiences, in about fifteen minutes, a moderate reddening of the face with a sense of fulness of the head, or perhaps even a pronounced headache, and with a buzzing or roaring in the ears precisely similar to what occurs in cinchonism, Almost simultaneously free perspiration begins, and, according to dose, there is more or less tendency to a reduction of pulse-rate, of respiration- rate, and of body-temperature. Tests for salicylic acid will reveal the presence of the substance in the urine, the saliva, and the sweat. The urine will furthermore be dis- colored, appearing brown by reflected, and green by trans- mitted, light. It will also contain a something that will reduce copper salts in copper test-solutions (Brunton). In overdoses, salicylates readily irritate the kidneys, set- ting up albuminuria ; may derange the cerebral faculties, causing hallucinations and delirium; and may danger- ously or even fatally depress the functions of heart and lungs, determining collapse or death by failure of respi- ration. These several untoward effects vary a great deal in readiness of occurrence, and, according to Squibb, in ‘‘a very large proportion” of instances are determined, not by the salicylic acid, but by a contaminating acid very commonly present in market samples of salicylic acid, and hence in salicylates derived therefrom. The medicinally valuable constitutional effects of salicylates do not appear in experimentation with a subject in health. They consist, in general, in a reduction of fever-tempera- tures, and, in particular, in an abatement of pains in fibrous tissues, notably the pain of affected parts in acute articular rheumatism ; and in an occasionally seen abate- ment of the glycosuria in saccharine diabetes. The anti- pyretic power of salicylates is second to none, in all the three elements of quickness, degree, and duration of re- duction of temperature. For a full antipyretic effect, however, considerable dosage is necessary—considerable enough to cause disagreeable sweating, ténnitus aurium, depression of pulse and respiration-rate, and, every now and then, actual toxic symptoms. The antirheumatic faculty of salicylates is unapproached by any other known medicine, so that, as is well known, salicylates constitute a standard set of medicines for the treatment of acute rheumatism. Various opinions have been held concern- ing the efficacy of salicylates to accomplish more in this disease than the obvious reduction of temperature and abatement of pain. Some maintain that these effects are all that can properly be ascribed to the medicine ; while others consider statistics to show for salicylate treatment a shortening of the duration of the rheumatic attack and a lessening of the frequency of cardiac complications. The antidiabetic power of salicylates, as is the case with the same faculty shown by other medicines, is very vari- ably manifest in different cases of glycosuria. Some- times the effect is n¢/, while in other cases the sugar may, for a while at least, totally disappear from the urine as the direct result of salicylate treatment—the diet remain- ing as before during the period of the observation. For decided results full dosage is necessary, and full doses are often exceedingly well borne in diabetes, the subject hardly experiencing any obvious derangement from the medicine. 249 Salicylic Acid. Salivation. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. The salicylates in common medical use for the purpose of salicylate medication are the salicylates, respectively, of sodium, lithiwm, and methyi—the last named in the shape of the volatile ot of gaultherta, which consists of ninety per cent. of methyl salicylate. The salicylates, respectively, of physostigmine, quinine, and other alka- loids, are used for the sake of the medicinal action of the respective bases only. Sodice Salicylate, 2NaC;H;03.H2O. The salt. is offici- nal in the United States Pharmacopeeia under the title Sodii Salicylas, Salicylate of Sodium. It is thus de- scribed : ‘‘ Small, white, crystalline plates, or a crystal- line powder, permanent in the air, odorless, having a sweetish, saline, and mildly alkaline taste, and a feebly acid reaction. Soluble in 1.5 parts of water, and in 6 parts of alcohol at 15° C, (59° F.); very soluble in boil- ing water and in boiling alcohol. When heated, the salt gives off inflammable vapors, and leaves an alkaline resi- due amounting to between thirty and thirty-one per cent. of the original weight, which effervesces with acids, and imparts to a non-luminous flame an intense yellow color, not appearing more than transiently red when observed through a blue glass. On supersaturating the aqueous solution with sulphuric acid, a bulky, white precipitate is obtained, which is soluble in boiling water, from which it crystallizes on cooling ; also soluble in ether, and striking an intense violet color with ferric salts ” (U.S. Ph.). Sodic salicylate is the most commonly used salicylate, and is a very important medicine. It is easily made 7 solution by mixing salicylic acid and a sodic carbonate in the presence of water, whereupon sodic sa- licylate results, and remains in solution, and carbon di- oxide gas escapes in effervescence. From this solution the salt can be obtained by evaporation to dryness, care- fully conducted. Extemporaneous preparation of the medicine 27 solution being easy, Squibb points out an advantage of such extemporaneous making of the salt in all cases where the prescriber or the dispenser may not be certain of the purity of the market article. The point is that the purity of a given sample of sodic salicylate is not easy of establishment except by an elaborate chemi- cal analysis, whereas a good sample of salicylic acid is immediately recognizable by the simple fact of its crys- talline condition. Hence, in making one’s own sodic salicylate from a selected well-crystallized sample of salicylic acid, purity is assured. And in the instance of this salt purity is important, since, as above said, there is probably good reason to lay many of the untoward effects of salicylates to the door of the contaminating acid of salicylic acid. Squibb recommends the follow- ing formula for the preparation of a solution of sodic salicylate of a strength convenient for use as a medicine: ‘Take of salicylic acid, well crystallized, 437 grains = 28.32 grammes ; bicarbonate of sodium, 270 grains = 17.5 grammes ; water, free from iron, a sufficient quan- tity. Put the acid into a vessel of the capacity of a pint, add 4 fluidounces = 120 c.c. of water, stir well together, and then add the bicarbonate of sodium in portions with stirring, until the whole is added and the effervescence is finished. Filter the solution, and wash the filter through with water until the filtered solution measures 6 fluidounces, or 180 e¢.c. This solution contains 10 grains (= 0.65 grammes) of the medicinal salicylate of sodium in each fluidrachm (= 3.75 c.c.).. If made from good materials, the solution before filtration is of a pale, amber color, but as most ordinary filtering paper con- tains traces of iron, the filtered solution is often of a deeper tint.” The proportions of the ingredients for this solution are estimated so that the solution shall be neu- tral, but, ‘‘ owing to the varying proportions of hygro- metric moisture in the materials,” the neutrality may not always be absolute. According to Squibb, a well- made sample of sodic salicylate, prepared by use of a well-crystallized sample of acid, is always, when evap- orated to dryness, ewhite, and is free from all odor of car- bolic acid, unless it have been shut up for a long while in a bottle. Even then, however, the odor should be but very faint—only perceptible on close examination, and should disappear upon exposure of the sample to air, 250 Solutions of sodic salicylate of good quality should have none of the carbolic acid smell. Sodic salicylate is used almost exclusively as an inter- nal medicine, being commonly held to be lacking in the germ-sterilizing faculty which gives salicylic acid, as such, its applicability as a local antiseptic. For the pur- poses of internal salicylate-medication, as set forth above, the salt is thoroughly effective, and, if made from a well crystallized and therefore fairly pure sample.of salicylic acid,. rarely produces untoward effects in reasonable doses. So large a quantity as 5.00 Gm. (about seventy- seven grains) has been given at a single dose in rheuma- tism without producing serious derangement, but the ordinary dosage for an antipyretic or antirheumatic ef- fect does not exceed 1.30 Gm. (twenty grains) repeated every two hours, for three or four doses, or until a dis- tinct impression is produced, followed by doses of half the quantity every hour or two thereafter, as long as the influence of the medicine may be required. In diabetes, doses of 1.30 Gm. (twenty grains) three or four times daily may be required, and can often be borne without derangement of the stomach or an unpleasant degree of ringing in the ears. The medicine is readily enough taken in simple aqueous solution, but if the faint, mawk- ish taste of the salt be objected to, the addition of twenty _ per cent. of glycerin and the flavoring with a drop or two of oil of gaultheria will render the mixture perfectly palatable. Lithic Salicylate, 2LiC;H;O3.H.O. The salt is offici- nal in the United States Pharmacopeeia under the title Lithti Salicylas, Salicylate of Lithium. It is thus de- scribed : ‘‘ A white powder, deliquescent on exposure to air, odorless or nearly so, having a sweetish taste, and a faintly acid reaction. Very soluble in water and in al- cohol. When strongly heated, the salt chars, emits in- flammable vapors, and finally leaves a black residue having an alkaline reaction, and imparting a crimson color to a non-luminous flame. On supersaturating the dilute aqueous solution with hydrochloric acid, a bulky, white precipitate is obtained, which is soluble in boiling water, from which it crystallizes on cooling ; also solu- ble in ether ; and producing an intense violet color with ferric salts” (U. 8. Ph.). The effects of this salt are similar to those of sodic salicylate, with the possible super-addition of medicinal virtues, in rheumatic or gouty cases, derived from the basic element. The dose is similar to that of the sodic salt. Methylic Salicylate, as already said, is used only as it occurs as the main ingredient of the volatile oil of gaul- theria. See Wintergreen. Hdward Curtis. SALIES-DE-BEARN is situated in a well-protected valley in the Département des Basses-Pyrénées, France. There are several springs here, all strongly saline, the most important of which is the Source du Baillat. The following is the composition of this water, according to the analysis of Henry. One litre contains: Grammes Sodium chloridene haces). share tk ets eae ota sere bipewielas 216.020 Potassium chioride whine cent woe cnc ciciuee oe nore 2.080 Sodium sulphate ) Magnesium sulphate t ES, Glee See otha la ce rele ee 9.750 Calcium sulphate Potassium sulphate J Magnesium and calcium bicarbonate nes Se etd 5.500 Ferrous oxide, organic matter SUICAANG SUMING, wcoetiocaee + sete ia= were cele eatin eee ae 1.056 TT OLA eee olers wereiais mei Oo ice oretsia siete teeters 234.406 There are traces also of iodine and bromine, The waters are used externally and internally in the treatment of so-called scrofulous affections of the glands, bones, and articular structures, of subacute and chronic rheumatism, and of anemia following hemorrhage, or induced by long-continued suppuration. Ea SALINS is a small village in the Département du Jura, France, lying at an elevation of about a thousand feet above sea-level. The climate is subject to considerable changes of temperature, the days often being quite warm while the mornings and evenings are cool. There are REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. several mineral springs, the most important of which is known as the Puits 4 Muire (Grotto A). The following is the analysis made by Réveil. One litre contains: Grammes. SOGiMUMEHCHIOTIGS ase. e Sel ceriacce en Sieee ohne keene 22.74516 IMatnIGsItinn GHIOTIGGI ewe cs ve cis ciece niet ce totus 0.87018 ‘Potasnimncnloridere. cease ts cceeek oft, pee ae 0.25652 POTASSIUM DIOTDIUG Ase mc leik le retain teauie coo nen 0.03065 Walotum sal phates week on ccc cae oh ok arte oe ee 1.41667 POCASSIUT TAU PIRLe secs scs fcs cea teetccnee eo. 0.68080 Bsc Tien Lares eter ate ciate © re ochre tate wie tle aiccret baees 25.99993 There are traces also of sodium iodide and of calcium and magnesium carbonates. M When employed for bathing purposes this water is sometimes strengthened by the addition of a brine con- taining about 320 Gm. of saline constituents to the litre. The waters are used internally and, in the form of baths, douches, and local compresses, externally. Like other waters of this group, they are employed chiefly in the treatment of rheumatic troubles, anzemia, and the so- called scrofulous affections. i Sd Pk SALIVATION. The term salivation is used to denote a superabundant secretion and flow of saliva, This use of the word has been objected to on the ground that sali- vation should properly signify a physiological act, in an- alogy, perhaps, with such words as urination, defecation, lactation, and the like. But the Latin word saldvatio is derived from the transitive verb salivo (from saliva), which means to salivate, to produce an excessive flow of saliva. The synonym ptyalism would, perhaps, be less liable to ambiguous construction. The term sialorrhea, while in- dicating an abnormal flow, does not necessarily imply abnormal secretion. It often happens that saliva accu- mulates in the mouth or drools from the lips, through failure in the act of deglutition, even when not produced in abnormal quantity. Thus in sleep, especially in cer- tain conditions of debility, and when the head is in a de- pendent position, the saliva may escape from the mouth because the muscles or nerves of deglutition are inactive, as it does habitually from a similar cause in the case of imbeciles. Similarly, when, in consequence of inflamma- tion of the throat, as in acute tonsillitis, the act of swal- lowing is instinctively avoided or rendered impossible through tumefaction of the parts, the saliva often ap- pears to be in excess; but this is due rather to passive accumulation than to any excess of secretion from reflex irritation. _ As to the exact amount of secretion necessary to con- stitute a superabundance, it is difficult to speak definitely. Normally, the quantity of the secretion varies from two to three pints in the twenty-four hours. In salivation it is often increased to from three to four pints, and may reach six or eight pints or more in the day. In the simplest cases it may only be sufficient to cause moderate discomfort from the frequent necessity of swallowing or spitting; in the most aggravated cases, on the other hand, salivation becomes a fatal malady, partly through the prolonged and excessive drain upon the economy by the loss of the solids contained in the salivary discharge, and partly through the intensity of the concomitant sto- matitis and the interference with nutrition consequent upon the inability to swallow the necessary food. In addition to the increase in quantity, there is also more or less alteration in the character of the secretion. The proportion of water may be either increased or di- minished—the latter more particularly in inflammatory conditions, when the solid ingredients are augmented. The saliva is then cloudy in appearance, and often con- tains gray or blackish flocculi. In certain nervous forms of salivation albumen may be present in the secretion. ‘The ptyaline is usually diminished in quantity. The re- action is commonly neutral or alkaline, and but rarely acid ; in the latter case the acidity is said to be due to the buccal mucus. In cases accompanied with stomatitis the salivation is attended with a fetid and characteristic odor. The association of stomatitis with salivation, while very common, is by no means necessary. Very often Salicylic Acid. Salivation. = the buccal inflammation is the primary and more essen- tial disease, the ptyalism being secondary to it and the result of irritation reflected from the mucous membrane of the mouth to the salivary glands. In other cases both the ptyalism and the stomatitis are more or less the di- rect effects of a common cause. But there is no evidence that ptyalism, as such, can be the cause of stomatitis. A very common cause of salivation is a reflex irritation of the glands, which has its starting-point in the buccal mucous membrane. The irritation is conveyed by the centripetal nerves to the medulla, and thence transmitted through the secretory filaments of the chorda tympani to the salivary glands. This irritation may be excited by the'so-called ‘‘ topical” sialagogues—strong acids and al- kalies, ethereal substances and the various masticatories, such as pyrethrum, horseradish, ginger, mezereon, to- bacco, cubebs, and the like. Again, the irritation may proceed from the teeth, as in dentition or dental caries. Erythematous stomatitis, aphthee, buccal ulceration, ul- cero-membranous stomatitis, gangrene, and cancer of the mouth are likewise all attended with salivation in greater or less degree. In the mercurial and scorbutic forms of salivation, gingivitis or more extensive inflammation is an almost invariable accompaniment, and the latter com- monly precedes the ptyalism. In many of these cases, however, when the flux first appears, the swelling and redness of the mucous membrane are concealed by thick- ening and opacity of the epithelium, so that the presence of the stomatitis might easily be overlooked. So far as the scorbutic form is concerned, the sialorrheea is doubt- less dependent solely upon the buccal inflammation. Again, irritation may be transmitted to the salivary glands in a similar manner from regions more remote than the mouth. Nausea is commonly attended with ab- normal flow of saliva, as are various forms of disease of the stomach, or even the presence of food, the irritation being communicated to the medulla through the vagus and thence to the salivary glands. Frerichs found that the saliva was secreted abundantly so soon as food was introduced into the stomach through a gastric fistula. It is said also that irritation of the splanchnic nerve, whether by means of an electric current or through intestinal dis- ease, may produce salivation. Ptyalism may be asso- ciated with the presence of intestinal worms. The salivation that sometimes occurs as a symptom of pregnancy has been attributed directly to irritation of the uterine nerves, but not improbably it is the nausea that usually attends this condition, and the consequent irritation of the pneumogastric, which is the more direct cause of the ptyalism. According to Dewees, in all pregnant women there is more or less excess in the secre- tion of saliva. When the salivation is marked the sali- vary glands are usually swollen and tender, and there is a certain degree of swelling and congestion of the buccal mucous membrane. The gums, however, do not become sore, spongy, or ulcerated, and there is no fetor from the mouth. The amount of saliva secreted varies, but may reach as high as three or four quarts in the twenty-four hours (Tanner). The affection generally begins at an early period of gestation, coincidently with the period of the so-called ‘‘ morning sickness,” disappearing generally by the end of the third month; though it may persist during the entire course of pregnancy, and, in some rare instances, for one or two months after parturition. It is stated that menstrual troubles also may give rise to ptyalism. A ‘‘nervous” form of salivation may be the result either of transitory impressions on the sensorium or of neuropathic conditions of the nerves or nerve-centres. Of the former a common example is the so-called ‘‘ water- ing of the mouth,” at the sight or suggestion of certain kinds of food. ‘‘Frothing” of the mouth, another form of sialorrhcea, may be the result of mental emotion. Mental disease (acute mania, melancholia, hypochondria) may also be accompanied with ptyalism. The same affection may occur as a symptom of facial neuralgia, or of disease of the medulla, brain, or spinal cord. It is observed in connection with certain forms of partial or general paralysis, and with progressive muscular atrophy; 251 Salivation. Salivation. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES, also in hystero-epilepsy and in rabies... In some of these cases it is possible that a condition of atony of the sub- maxillary ganglion may account for the salivation. Ac- cording to Claude Bernard, this ganglion has a moderating or inhibiting action upon the secretory function of the salivary glands, and when its influence is withdrawn, the secretory filaments of the chorda are free to act without restraint. Sometimes salivation, occurring in connection with cer- tain fevers, has the character of a ‘‘ critical” flux. Ithas been observed in pneumonia, typhoid fever, dysentery, and other acute febrile diseases. This form, however, is rare. It remains to speak of the ptyalism that is the result of the systemic or toxic action of certain medicaments, These, in contradistinction to the sialagogues that owe their effect solely to topical irritation of the buccal mu- cous membrane, are known as “‘ general” or “‘ remote ” sialagogues. Such are jaborandi, physostigma, musca- rin (obtained from bitter orange), tobacco, mercury and its compounds, the compounds of iodine, gold, and cop- per, and also the so-called nauseants. The last-named doubtless produce this effect upon the salivary glands re- flexly, through the gastric division of the vagus. With regard to the others, the mode of action has been too lit- tle studied to justify positive conclusions, It is quite possible that in some instances the effect is due to a toxic irritation of the medulla, whence the stimulus is con- veyed to the salivary glands through the chorda tympani. Many of these drugs are eliminated with the saliva, and in some this elimination is attended with stomatitis. In the latter case the ptyalism may be secondary to the buc- cal affection. Jaborandi, which salivates within half an hour, and sometimes by the end of two minutes, causes no inflammation of the mucous membrane of the mouth, and doubtless acts directly upon the salivary glands. That it does not act through the nerves has been demon- strated by experiment. Salivation occurs after injecting pilocarpine into the blood, even when the nerves supply- ing the salivary glands have been previously divided. The same is said to be true of muscarin, physostigmine, and nicotine. Gold does not cause stomatitis, it is said, and it probably acts in a similar manner to the above. On the other hand, the salivation from mercury and cop- per is almost invariably accompanied with more or less inflammation of the mouth. Of all forms of salivation, the one most frequently ob- served is that which occurs as a toxic manifestation of the constitutional action of mercury. That the stoma- titis, which so commonly attends this form, plays a very important part in the etiology of the ptyalism, does not admit of doubt. As to the question whether it is the sole cause of the latter—whether without the stomatitis there would be no ptyalism, a number of well-authenti- cated cases, in which salivation occurred without any signs whatever of buccal inflammation, give a pretty defi- nite answer. Hallopeau mentions a case observed by Fournier, in which salivation was produced by mercurial inunctions without the gums showing the least trace of inflammation. Similar cases have been observed by Fournier and others. Von Mering several times saw salivation produced in cats in five minutes after a hypo- dermic mercurial injection. The opinion has been held that mercurial salivation is a dynamic effect of the mercury acting upon the general system, while others have maintained that it was due to an impression produced upon the sympathetic ganglia. The most rational explanation, however, is that it is the direct effect of the mercury contained in, and eliminated by, the saliva. That mercury is eliminated by the saliva there can no longer be any room for doubt. It has been verified repeatedly, and Bernatski has even succeeded in finding the metal in the saliva coming directly from Steno’s duct. Doubtless both the ptyalism and the stomatitis may be due to the same irritating cause con- tained in the saliva, although the former would naturally be aggravated by the existence of the latter. All the facts seem to point to the presence of a corrosive poison in the secretion. 252 According to Ricord, the starting-point of this form of stomatitis is an area of inflammation just behind the last molar tooth, on the side on which the patient habitual- ly sleeps, and this observation has also been repeatedly verified by Fournier. The natural inference is that the trouble begins where the saliva collects, and where the poison would therefore become concentrated. The well- known influence of the teeth in the production of mer- curial gingivitis has an important bearing here. Eden- tulous individuals, such as infants and toothless old men, do not have inflammation of the gums when mer- curialized. It would seem, therefore, that it is the col- lection and concentration of the poisoned: saliva about the teeth that excites inflammation in the gums. Itisa noteworthy fact, true as well of those who are exposed to the action of mercury by the nature of their occupa- tion as of those who take it medicinally, that when par- ticular attention is paid to the teeth, when they are often and carefully brushed, the individual most frequently escapes mercurial stomatitis. Indeed, it is a matter of every-day experience that patients undergoing mercurial treatment who are careful to keep the teeth clean, rarely show any oral effects whatever. Hutchinson says,! with regard to the so-called ‘‘mercurial teeth,” that ‘‘ the effects produced by mercury concern chiefly the enamel, although when severe, they affect the dentine also. The enamel is usually deficient, and the surface of the teeth is in varying degrees rugged, pitted, and dirty. The in- cisors and canines are usually affected, and not infre- quently we see the enamel deficient on them all, below a line which crosses them at the same level. The appear- ance produced is much as if a line had been stretched horizontally across these teeth at about their middle.” ‘‘The first molars” are ‘‘ almost invariably affected ” also. These appearances point pretty clearly to a cor- rosive effect, to which the teeth were subjected at an early age through the administration of mercury. The ‘‘line” of defective enamel mentioned corresponded, doubtless, in early childhood to the line of the gums, and to the part where the secretions and impurities of the mouth would be most apt to collect. Furthermore, it should be noted that of all modes of administration, that which brings the mercurial in direct contact with the mouth is most likely to cause stomatitis. Overbeck attributed the peculiar liability of calomel to produce salivation to the fact that, of all preparations, it was most apt to leave traces of the dose in the buccal cavity, where it would act topically after solution in the salivary fluid. In this connection we recall the observation of John Hunter, that every mercurial, when held long in the mouth, becomes sapid, showing that a solution takes place. The inference seems unavoidable that the mercurial stomatitis, and to a certain extent also the ptyalism, are due to the elimination of the mercurial, which becomes corrosive immediately upon its escape from its organic connections. While circulating in the fluids of the body it is in intimate combination with the albumen, forming an albuminoid compound which almost assumes the character of the homogeneous substances of the body. But at the moment of elimination a noxious inorganic chemical substance is set free to work its deleterious ef- fects. To account for the severity of these effects it must be remembered that there is a continual irrigation of the parts with the solution, and not a single applica- tion. And, furthermore, this solution will become more concentrated where the secretions are apt to collect, 7.e., at the borders of the teeth. Of the conditions which are favorable to mercurial salivation, the most important depend upon the mode in which the mercury is introduced into the system. Gen- erally speaking, those methods by which the drug is most rapidly introduced and absorbed are most likely to cause salivation. It is stated that it is oftenest observed after inunctions, fumigations, and the administration of calo- mel. It has been erroneously claimed that it was com- paratively infrequent among workers in mercury. But, according to Kussmaul, though seldom so severe among them as when the drug is given therapeutically, it is REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Salivation. Salivation. nevertheless always the most common of the symptoms of hydrargyrism. In the professional form of mercu- rialism the amount of mercury received into the economy is much smaller than when it is administered as a drug, and it is introduced more gradually. Hence acute toxic manifestations, such as ptyalism and stomatitis, are not often severe, while the constitutional disturbances are commonly more marked than in patients who are mer- curialized therapeutically. The dose necessary to produce mercurial salivation varies according to individual predisposition. Some in- dividuals are singularly susceptible. Ricord speaks of a patient in whom one grain of calomel was sufficient to cause salivation. Trousseau saw a violent case follow a single vaginal injection of a solution of corrosive subli- mate 3 parts in 5,000 parts of warm water. Breschet observed a similar effect in a woman the morning after the vaginal portion of the cervix had been cauterized with the acid nitrate of mercury. Gubler saw severe stomatitis result from a single mercurial friction to the abdomen of a woman suffering with puerperal peritonitis. Christison reported cases in which salivation followed, in one instance the administration of two grains of calo- mel, and in another the inunction of two drachms of mer- curial ointment. On the other hand, cases are met with where prolonged exhibition of mercury in considerable doses fails to produce the slightest effect in the mouth. Hallopeau refers to a case in which a patient, who had been treated for months with mercurial inunctions with- out salivation, afterward had a stomatitis in consequence of a single local application of mercurial ointment for pediculi pubis. Asarule, women are more susceptible than men, and pregnant women are especially liable to it. Exposure to cold, when the system is under the in- fluence of mercury, will often provoke or precipitate an attack of salivation. The influence of disease of, or neglect in cleansing, the teeth has already been referred to. The fact that a patient has previously been salivated appears to render the person more susceptible to a sub- sequent attack, perhaps for the reason that a certain amount of mercury still lingers in the system. Under certain provocations this residual mercury may give rise to ptyalism long after the use of mercury has been stopped. Kussmaul cites the case of a woman who had a sudden attack of salivation, without stomatitis, in con- nection with a severe frontal headache. The woman was pregnant, and her condition may have had something to do with the causation of the salivary flux ; but it was dis- covered that at this time both the saliva and the urine contained mercury, though it was known that shortly before the attack the drug was not present. The patient had been a worker in quicksilver four years before, and had suffered severely during her employment from mer- curialism with stomatitis. Other observers also have testified to the fact that salivation may occur at long in- tervals after exposure to mercury, whether profession- ally or medicinally ; sometimes after exposure to cold ; occasionally after the administration of certain drugs (especially the iodide of potassium), in connection with commencing gestation or with some nervous affection. Thanks to the more conservative and rational treat- ment of syphilis now generally pursued, mercurial sali- vation is far from being the common malady it was in former times. Instead of being regarded as a necessary accompaniment of the cure in every case of syphilis, it has now, among the best practitioners, become an accident of exceptional occurrence. How important was the role that salivation formerly played in the treatment of syph- ilis appears from the following aphorisms of Boerhaave : ‘1468. To procure it, drench the patients for several days with large quantities of ptisan. ‘1469. Next give a small dose of calomel every two hours. . ‘©1470. When the breath begins to be fetid, the gums are painful, the teeth seem to grow longer, examine whether it be proper to continue, to stop, or to check the symptoms, : ‘©1471. A salivation of three or four pounds a day is enough. ‘1472. If less, it must be excited by mercury. ‘1473. If more abundant, it must be restrained by emollient clysters, purges, sudorifics. ‘1476. This treatment should be kept up till the symp- toms have entirely ceased, usually thirty-six days. ~ “1477. Afterward, for thirty-six days more, give only very moderate doses of mercury, to maintain a slight salivation.” When a patient is about to be salivated with mercury the first thing noticed usually is a sense of dryness and a disagreeable metallic taste in the mouth. If the teeth are clashed together the patient is aware of a little tender- ness. The gums have a grayish appearance, or are slight- ly reddened and swollen, and if pressed upon a little pus wells up between their border and the teeth. There is emitted from the mouth a more or less fetid odor. Soon the gums begin to recede from the teeth, and when the tongue touches the latter it seems to the patient as though they were elongated. The tenderness increases and is accompanied with some pain in the jaws. Meantime the saliva increases in quantity, collects in the mouth, and, bécause of its disagreeable taste, the patient is often im- pelled to spit. The inflammation increases and extends to the lips, cheeks, and tongue. Their surfaces are cov- ered with a whitish or yellowish coating, and exhibit the prints of the teeth. The saliva becomes more copious, and, if the case is severe, dribbles from the mouth. The mucous membrane becomes ulcerated, and the ulcers are covered with pseudo-membrane. The ulceration extends superficially rather thanin depth. The teeth become loose. The mouth is kept continually open, with the swollen tongue protruding, and over the lips and chin flows a con- stant stream of stringy saliva, sometimes tinged with blood. The quantity may become enormous. The stench becomes horrible, tainting the air of the whole apartment in which the patient is. The condition of the patient, if the malady is not arrested, grows more and more distress- ing. The teeth drop out; the swelling and pain, which may extend to the face and neck, continue to augment till the patient can neither masticate nor swallow ; speech becomes impossible, and even respiration may be greatly impaired. Sometimes deep gangrenous ulcers form and the mucous membrane separates in large sloughs. Oc- casionally there is suppuration of the parotid or cervical glands; sometimes phlegmon of the cheeks or roof of the mouth occurs, or there is gangrenous inflammation of the tongue; finally cicatricial deformities may result, unless the patient, worn out by the intensity of the disease and the impairment of nutrition, sinks into a fatal collapse. Cases of such intensity as this are fortunately very rare. The recovery in most severe cases is slow. The swelling gradually diminishes, the ulcers slowly heal, and the teeth regain their solidity. For a long time, however, the mu- cous membrane of the mouth remains vulnerable, and slight irritations, such as may arise from the use of sharp or pungent articles of food and the like, will suttice to reawaken the stomatitis and produce again some degree of sialorrhcea with more or less fetor of the breath. The first indication for treatment in all cases of sali- vation is to remove, if possible, the offending cause. If the ptyalism be the result of a reflex irritation originat- ing in the buccal cavity, in the stomach, or in regions still more remote, the surest way to relieve the secondary affection is to allay the primary irritation. Where this is impracticable, as, for example, in pregnancy, we may avail ourselves of certain drugs, such as belladonna or duboisia, which have a controlling influence over the salivary secretion. In other cases the offending cause is located in the salivary glands or contained in the saliva. In salivation from mercury the ptyalism is doubtless partly due to the direct action of a corrosive mercurial upon the salivary glands, but chiefly to the stomatitis which is the effect of the same corrosive poison in the mouth. 5 As already intimated, mercurial salivation is at the present time regarded as an exceptional occurrence In the treatment of syphilis, and is usually the result either of neglect of proper precautions, or of an idiosyncrasy on the part of the patient. If the mercury is judiciously 253 Salivation. San Antonio. ‘ REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. administered, the teeth properly attended to, and expo- sure to sudden changes of temperature avoided, the pa- tient will rarely complain of ptyalism or stomatitis, ex- cept in their incipient stages. So soon as signs appear indicating that the gums are ‘‘touched,” the mercury should be suspended. Unfor- tunately there are cases in which this does not suffice to arrest the progress of the malady. The mercury accu- mulated in the system continues for some time to be eliminated in the saliva in sufficient quantity to maintain or augment the local irritation. Therefore, when the latter does not quickly subside, measures should be taken both to hasten elimination and to divert it to other emunctory channels. At the beginning, a brisk purge is to be given, followed by a series of hot baths and the administration of diuretics. 'To the same end iodine or the iodide of potassium may be given, bearing in mind, however, that the first effect of these remedies, some- times, is to aggravate the trouble, though they are after- ward beueficial in limiting its duration. The use of iodine to arrest salivation was first recommended by Knod. It is given in doses of ten centigrammes (one and a half grain) per day, gradually increased to twice that amount, as in the following formula : BO ie, Be wee to eee ete caaions 0.25 (gr. iijss.). PB ICODO A sae cane acs ee ee 8.00 (3 ij.). Dissolve and add cinnamon WALD ches stain avers Bees wosar are . 80.00 ( 3 ijss.). LID DIO SVT Diet cisctag ase vicie cee 16.00 (3 ij.). M. Dose, two to four teaspoonfuls. To check the flow of saliva one one-hundredth of a grain of atropia may be injected hypodermically, and repeated according to the effect. The inflammation of the mouth must be combated by astringent or disinfectant washes, and by the local and internal use of the chlorate of pot- ash. Mouth-washes of borax, alum, or tannin in honey or glycerine and water (seven or eight grains to the ounce), or tincture of myrrh (3 ij.-iv.) in water or infu- sion of cinchona (3 iv.), serve a good purpose. The chlo- rate of potash may be used as a mouth-wash, dissolved in cold tea or in infusion of flaxseed, to which a small portion of dilute hydrocyanic acid or spirits of chlo- sesgang,. roform may be added. “S8&s It should also be ad- ministered internally in doses of two or ( 0 three grains every hour ortwo. Should ulceration or gan- grene supervene, mouth- washes con- taining carbolic acid, Labarraque’s solu- tion, or the perman- ganate of potash are re- quired. Edward Bennet Bronson. 1 Tilustrations of Clinical Surgery, p. 54. London, 1878. SALIX (U. 8. Ph., Saule blanc, Codex Med.). Wil .3* low ; ‘‘The bark of Salix alba Linn. and of other species of Salix.” SALIcrn (Salicinum, U. 8. Ph.), a crystalline, bitter, neutral substance, obtained from the bark of various species of Salix. Salix alba Linn., the white willow, is a large tree with, when old, often a very thick, irregular trunk, dividing near the ground into several great limbs ; branches numerous, ascending, rather close; twigs slender, brittle, with a light yellow or yellow-green bark, and white, rather brit- tle, soft wood; young shoots, buds, and the under sur- 254 Fic. 3863.—Salix Alba; Stami- nate Branch. (Baillon.) face of the leaves silky ; leaves numerous, alternate, with minute stipules and short petioles ; blade lanceolate, nar- ; : row, and very acute at the apex, white beneath, bor- g der finely serrate ; flowers h ~early, dicecious, in slen- 7 der, weak spikes, each Ag flower in the axil of a / small bract; staminate fy flowers consist of two sta- jae mens, the pistillate of one one-celled, many-ovuled ovary; fruit dehiscent ; two-valved, seeds silky. This willow has a very wide natural range, cover- ing most of the temperate belt of the Old World; it has been also introduced into North Am- erica, where it is firmly natural- ized. The bark of the small branches is officinal, and is col- lected with that of some other willows of similar appearance and properties. Willow bark is ‘‘in frag- ments or quills, from one- twenty-fifth to one-twelfth of an inch (one to two millimetres) thick, smooth; outer surface somewhat glossy, brownish or yellowish, more or less finely warty; under the corky layer green; inner surface brownish- white, smooth, the fibres sepa- rating in thin layers; inodor- ous ; bitter, and astringent.” Willow is an old tonic and febrifuge, formerly official abroad, but dropped from most pharmacopeceias since the easy preparation of salicin, which in a great measure took its place ; neither is much used at present. Composition.—The bitter, crystal- line, neutral principle, salicin, is the characteristic derivative of all the willows. It is easily prepared by ex- hausting the bark with water, pre- cipitating tannin, etc., with litharge, evaporating and crystallizing out the salicin, which is then purified by re- solution and the same process again. Salicin is colorless, odorless, but very bitter; it crystallizes in scales and needles ; is permanent in the air; melts at 198° C. (388.4° F.); dissolves in twenty-eight parts of water and thirty of alcohol ; sublimes and is entirely dis- sipated by heat; with concentrated sul- phuric acid it forms a red solution. It is a glucoside; treated with diluted sul- phuric or hydrochloric acid, or with a powerful galvanic current, it is decom- posed, and saligenin and glucose are formed ; by other methods of handling many interesting derivatives have been obtained ; salicylous and salicylic acids, saliretin, helicin, helicoidin, etc. It has also been formed synthetically. AcTIon AND Use.—As salicin is the only active principle, whatever value this bark has is due to it. Salicin itself, it must be confessed, is far from an energetic remedy—between two and three ounces have been taken with no marked effect. It appears to be decomposed in the blood Fia. 3366.—Salix into saligenine, salicylic acid, etc., and is iaattty eliminated from the kidneys as one or ; more of these products. Salicin has un- doubted antipyretic power, although less than quinine or salicylic acid, its antiperiodic action is much less than Fic. 3364.—Salix Alba, Pistil- late Branch. (Baillon.) Fig. 3865.—Salix Alba, Fruit. (Paillon.) REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Salivation. San Antonio. that of either of them; as a remedy in rheumatism, sali- cin has also been obliged to yield to the more useful sali- cylic acid. Asa tonic, in small doses, it is occasionally used, but is far inferior to gentian or quinine. Four or five grams(3j. ad 3 jss.) may be given as a dose, and re- peated every three hours; as a tonic one or two deci- grams (gr. jss. ad ilj.) is sufficient. ALLIED PLANTS.—The genus comprises a hundred and sixty species ; from twenty or more this substance has been obtained. The allied genus Populus has some sali- cin-yielding species, and others containing populin, which latter can be made to yield salicin itself by decomposi- tion. The order, in its narrow sense, contains but these two genera. ALLIED DruGcs.—A number of plants in different or- ders yield also a little salicin, but not enough to make it their characteristic principle. The various tonics, of which Gentian, Columbo, Cinchona, etc., are examples, are also related, and the latter is doubly so as an anti- periodic. Other glucosides of mild or tonic qualities are hesperidin, from orange peel; phloridzin, from apple bark ; arbutin, from several Hricacew; esculin, from the horse-chestnuts, etc. W. P. Bolles. SALOL. Under the titles salol and salicylate of phenol, there has been recently proposed, for medicinal use, a body compounded of salicylic acid and carbolic acid (phenol), representing in its composition sixty per cent. of salicylic acid and forty per cent. of carbolic. Salol is a white crystalline powder, melting at 48° C. (110° F.) into a colorless, oily fluid. It is nearly insoluble in water, but dissolves in alcohol, ether, and fixed oils. From its insolubility in aqueous fluids it is practically tasteless in powder, but it has a faint aromatic smell. Salol has been proposed as a substitute for the com- monly used salicylate salts, on the grounds that it is equally, at least, effective as a medicine, while at the same time, in medicinal doses, it is much less deranging to digestion on the one hand, and less productive of con- stitutional toxic effects on the other. It is said of this substance that it is insoluble in the fluids present in the stomach—whence the lack of gastric derangement in its employment—but suffers solution by chemical decompo- _ sition in the small intestine through the action of the pancreatic juice, resolving into salicylic acid and car- bolic acid (phenol). Constitutionally, so far as reported, salol, in ordinary dosage, has produced little disturbance beyond an occasional and trifling ringing intheears. In experimenting, however, with a dosage exceeding 6.00 Gm. (about a drachm and a half) distributed over the twenty-four hours, toxic symptoms have been observed. Salol, taken internally, imparts to the urine of the sub- ject the peculiar coloration seen after ingestion of car- bolic acid, a phenomenon that may persist for several days after discontinuance of the medicine. The average medicinal dose of salol for an antirheumatic or anti- pyretic effect is 2.00 Gm. (about thirty grains), given twice, or possibly thrice, daily. A dosage reaching 8.00 Gm. (about two drachms), in the course of a day, was fol- lowed, in one instance, by severe vomiting, gastralgia, and tinnitus. Salol may be taken dry upon the tongue, in powder, the dose to be washed down with a little water, or may be conveniently administered in pill-form. Hdward Curtis. SALT SULPHUR SPRINGS. Location and Post-office, Salt Sulphur Springs, Monroe County, W. Va. Accrss.—By the Chesapeake & Ohio Railway to Fort Spring, two hundred and forty-four miles west from Richmond, Va., thence by stage fifteen miles south to the springs. Stages meet the C. & O, Railway trains at Fort Spring. THERAPEUTIC PROPERTIES.—The name Salt Sulphur would imply the presence of an appreciable amount of sodium chloride. This is not the case, so that the name is not appropriate. They are rather alkaline sulphur wa- ters, purgative and alterative. Taken internally or em- ployed as baths, they are effective in chronic diseases of the digestive organs, bladder, liver, and kidneys, and I am informed of their utility in chronic neuralgias. The iodine spring is indicated in syphilitic and scrofulous dis- orders. ANALYSIS.—One pint contains: Old Spring, Iodine Spring, 49° F. to 56° F. 561g° F, Prof. W. B. Rogers, D. Stewart, M.D, Grains. * Grains. Carbonate of potassa ............ ...... 0.291 Carbonate Of soda... sence ee. eee 1.350 Carbonate of magnesia .......... 0.414 0.875 Carbonate of lime... ........ 62. 1.283 4.125 Chloride of sodium.............. 0.197 0.188 Chloride of magnesium.......... 0.083 0.085 Chioride of calctum,........2.-. 0.007 0.070 Sulphateofsodas aon oe eke oe 2.195 3.000 Sulphate of magnesia.........., 2.276 2.500 Sulpbateof limes... 0 ..006 282. 10.613 8.500 Peroxideiobarons. 22. eee 0.012 0.1383 EGdINer As ae nets ieee trace. 0.079 IBYOMTINES, A eaeke cistsie’s cee Ree ee 0.081 Silicic Acideoeir aan. oe eee ed ee 0.220 ANUINING SAP on act oh ck ced ae, 0.0238 Earthy phosphates (soda and Lithia: event cs eeeptics th ire ee trace. 0.091 Organic matter (with sulphur)... 1.155 = «...., Motalass saves dss cae’ 18.%85 21.561 Gases. Cub. in Cub. in Carbonicl acidic eee ee 1.66 4.32 Sulphuretted hydrogen.......... 0.43 2.39 This resort, possessing the Iodine, Salt Sulphur, and Sweet Sulphur Springs, is beautifully situated in a val- ley north of Peter’s Mountains, Alleghany range, on the banks of Indian Creek, at an elevation of 2,000 feet above sea-level. The surrounding views of mountains and hills are charming, and the climate is delightful. The hotel buildings are built principally of brick and stone, the largest containing seventy-two rooms, with wide piazzas, and surrounded by a beautiful lawn. An elegant ball- ‘room, a billiard-room, tennis courts, bowling alleys, etc., furnish amusement for the guests. Gopal SALZUNGEN is a spa in Sachsen-Meiningen, Thiirin- gen, lying in the valley of the Werra, at an altitude of about 820 feet above the level of the sea. There are sev- eral salt-wells here, the composition of one of which, the Bernhardsbrunnen, is as follows. One litre contains : Grammes., Sodiumchloride ae 40.0 sara. cL cee eee 260.76419 Potassitumpechlorideywer neds cae: ee es 0.32566 Magnesium chlorides: s S28.6.. eee ae 0.20179 Calcium chloride eern8 (eercnk chee ee 0.78266 Magnesium brontid cir. secs arse ae ee 0.01218 Sodium sul phatensrae: ake aie cae ee ee ee 1.25679 Calciumysulighatess.-mp oe succes aoc Paha he Coke OF 3.340138 Mapnesiine sulphate ce ays. eect cee ae oe 0.19408 Calcium. cCarbonatemsar ae ecces. ce eee ae ee 0.05199 IM a ONeSTU IR CArb OME Le mnie atta renee ae eae 0.00188 Herrous CAT Doreteyeenmcntats set ie oe tii noes 0.01318 Silicic: acid eee ah ete et eens ees oh oe ae ae 6.00259 DOtaleew ta ecreretesih stones aaicc scares dhe eles 266.94712 There are also traces of iodine, lithium, aluminium, and manganese. There is some carbonic acid gas. When employed internally, the water is usually diluted with milk or whey. Baths, douches, local compresses, and inhalations are made use of. These waters are employed in the treatment of catarrhal troubles of the respiratory mucous membranes, anzemia, and scrofulous affections of the joints, bones, glands, and skin. The season extends from the middle of May to October. A. course of treatment lasts from two to three weeks. By TRS SAN ANTONIO. The accompanying chart, obtained from the Chief Signal Office, represents the climate of the city of San Antonio, Tex., a town of twenty thousand inhabitants, lying at an elevation of six hundred and fifty- six feet above sea-level, and situated two hundred and forty-five miles to the north of Brownsville, and one hundred and thirty miles from the coast of the Gulf of Mexico. Its climate may be regarded as typical of that of the inland and moderately elevated portion of Southern 255 San Antonio. Sandefjord. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Climate of San Antonio, Tex.—Latitude 29° 28'; Longitude 98° 22'.—Period of Observations, March 1, 1877, to June 15, 1883.—EHlevation of Place of Observation above the Sea-level, 656 feet. A AA B C D E FE G H 1 o o bBLadlmadag as] 3 Boe ECPEILEEE = ~~ rs : § Fa Ko RS Ao RS pa & & sg o 3 odo 3 ea g g Bas Qi) me 5 s] 5 g z . is ory g g Be =3 he SAEs aes o ° = + r ini oH io) ° Mean temperature Ses Pay Absolute maximum Absolute minimum ||\S 224 og cee ee haces ate es for period of ob-|| ¢ Ey as, temperature for| temperature for| #2353) 4 Pa 5 2 || servation. BS ly period. period. 2 nH} 2 9 g $F as = Be} Segelaaak ea ae a= BESS GSEs a | Bo, Alas rt | ie ea Se 43 = Be | ea) a5 s ss CHES VobS 5 5 5 Sbee Suse S > > DPaBS|D RS < < < Oa Bala aad 7 A.M. 3 P.M. 11 P.M. Highest. | Lowest. Highest. | Lowest. | Highest.| Lowest. | Degrees. Degrees. | Degrees. || Degrees.|| Degrees.| Degrees.|| Degrees. Degrees,| Degrees. | Degrees. | Degrees.| Degrees. January....| 45.4 58.8 51.8 51.8 61. 43.4 61.4 41.1 80.0 75.0 38.0 14.0 26 27 February... 48.8 63.1 55.2 55.7 60.7 53.0 66.0 44.9 88.0 77.0 36.0 17.0 18 20 March ..... | 57.1 72.3 63.3 64.2 70.2 60.7 5.3 53.8 92.0 83.0 41.0 7.0 18 26 Atpril <0. 26 | 68.1 79.0 68.8 70.3 1.2 68.4 82.0 59.5 96.0 87.0 47.0 36.0 15 20 May. sacri. | 69.6 84.4 74.5 76.1 79.9 13.5 87.1 66.5 104:0 93.0 61.0 49.0 22 24 ORE, a ich | 5.6 90.2 80.6 82.1 84.5 79.8 92.4 "3.0 103.0 97.0 68.0 53.0 14 28 July. t0.53 i ewud 91.7 82.5 83.5 87.3 81.6 95.7 73.7 104.0 98.0 71.0 58.0 19 24 August.....| 75.2 90.6 80.9 82.2 85.0 78.7 93.4 72.2 108.0 95.0 69.0 60.0 20 28 September... 70.3 86.6 75.9 77.6 80.3 74.4 89.2 67.7 100.0 93.0 59.0 53.0 22 22 October ....| 63.6 79.3 68.8 70.5 2.7 65.1 81.3 60.8 99.0 87.0 46.0 41.0 22 21 November..| 51.8 66.2 56.7 58.2 65.4 48.6 68.7 47.9 88.0 75.0 32.0 21.0 25 23 December..| 47.4 61.2 52.8 53.8 59.0 49.0 64.0 43.4 82.0 75.0 32.0 10.0 28 | 88 Soritig Riss itd lacey tate Meee: 70.2 73.8 68.8 i hea. al Dia werte ot YEA le « aeagsleh as a cn Ramee ot as tenes ¥ SULIMAEL yi) ioe sen el iat len crereiely meet ste.s 82.6 84.3 S152. ailisaceas ooh | reseies, UM vee sas cmmm Maneler stron MMi emtsta\soe stoner incteige'om | [reersttere eave VQoaocvesee ie Meaaos || capace. | aga 68.7 71.7 C52 We ORS We ies dart Mes este Mh Mss arm ste chee ane Mere ote lcim mn temetela:s eta itebeiare Winters! Ja laucdee | aessaseeeed Bae ae 53.7 58.8 AO A eae ese La ke toig oh Jeai'e Sens AU nahin SG? en Ee sees: wes Vicar yo. 2s0hs (bse cotes MIM a mic eee 68.8 71.2 ei Wye) | Rha tee J ocetsee | teeeet | sees | seetee [cette [T eeeeee Be sie J |K| L y Oo . : : eu i s Santalum album Linn., order Santalacer, is a small as | os > iy Se | q & me East Indian tree, whose fragrant wood has made it a ae eS oe a4 | BS eee Pe highly esteemed plant from the most remote time. It Saye dg aS | #3 | 3 "4 Sa has a slender habit, with opposite branches, and smooth, wi | 83 Oi apogee of | #8 | ocd light-green, opposite, lanceolate leaves; inflorescence ee | “E as | go | ae oo ag cate small, close, pyramidal, paniculate cymes; flowers a8 3 2 23 SH 2 eS ere minute, perfect ; the perianth is single, bell-shaped, four- Clea) MM . a |S = a rahe) 4 ay <4 or five-lobed, at first yellow, afterward purplish ; sta- ne | nh mens opposite, arising from the throat of the corolla, January....| 66.0 | 72.3] 8.2 | 10.0 | 18.2 | 1.50 | N. 48 and separated by a series of alternate scales ; pistil one, February... 71.0 | 87.6 Ee Bauer te pose piece tat 5.6 ovary one-celled, with central placentze and three or four Bear sstes| Dee EY roel Gee elegans ae ae naked, pendulous ovules; fruit one-seeded, about as May «1.1... 55.0 68.8 oe 6. i a8 8.25 SE. 4.8 large as acurrant. This tree is a native of India, and of July. 2222) | 46:0 | @2.6 | 13:9 938 | 3:7 | 398 | SE 46 some of the islands of the Indian Archipelago. It is also August.....| 48.0 | 67.0 | 17.7 B52 ae 2509 ets Ovens. Er 3.8 ultivated, the property of th vernment or protected September..| 47.0 | 69.0 12.4 11.3 ont 5.05 S.E. 4.2 ‘ 2 1 re ie ioe : leg : ° her ey October ....| 58.0 | 69.7 | 10.2 | 12:5 | .92°7 | 2:73 | SE 4°93 y the authorities, in most localities ; in others it has been November..| 67.0 | 69.3} 11.0 10.0 21.0 1.93 N. 4.9 exterminated. December..| 72.0 | 69.5 | 9.5 9. 19. 04 é 4.8 ; aN 3 Ue a = CoLLECTION.—The logs are felled, cut into short Spring...... 77.0 | 66.3 | 87.2 | 25.8 |- 68.0 | 8.30 | S.E. 4.9 £ : Pee 4 Meno | 30k Cocco sae a ee aH lengths, and then left on the ground for several months, Autumn “9.0 | 69.3 | 33.6 | 38.8 |. 67.4 | 9.76 | S.E. 44 while the white ants gnaw away the alburnum, or white Winter...... 78.0 | 69.8 | 23.9 | 29.8 | 58.2 | 5.40 | N. 5.1 i ; . : Neat Acc, 98:0 | 67.8 | 145.1 | 113.4 | 25815 | 92.55 | SE. | 4:7 outside zone, and leave the valuable heart-wood perfectly cleaned. This is then cut and made into various articles of cabinet work or convenience, the chips and coarser Texas. What this climate is may be seen fairly well | portions being put into the still for the extraction of the from a study of the chart (an explanation of which will be found on pages 189-191 of vol. ii.). The reader’s at- tention is especially called to the general mildness of temperature during the winter season, which, so far as shown by the figures of Column AA, is seen to be nearly as warm as the autumn at New York City. Columns E, F, and J show, however, a great range of possible ex- tremes at San Antonio, and Table F, in the article entitled Colorado Springs (vol. ii., p. 238), shows that the average daily range of temperature is thirty-three per cent. higher at San Antonio than at- New York City. Asarule the atmosphere is remarkably still at San Antonio, and in this respect this station even surpasses that of Little Rock, Ark.; but San Antonio is a Texan town, and Texas, with its ill-famed ‘‘northers,” is that part of the United States which is most liable to great and very sud- den falls of temperature upon the supervention in winter of a northerly wind. Column K shows us that the San Antonio climate is moderately dry ; column O, that the winter rainfall is very light. Hf, fi. SANDAL WOOD, OIL OF (Olewm Santali, U. 8. Ph.; Br. Ph.; Santal citrin, Codex Med.; yellow (or white) sandal wood). 256 oil. A considerable amount of the wood is exported to England and Germany, where a high grade of oil is dis- tilled. The root is also dug up and used. This is a compact, heavy, porous wood, of pleasant aromatic odor, pungent, astringent taste, and yellowish- brown, variegated color. The oi, of which it contains from one to three per cent., isa thickish, pale yellow liquid of agreeable, aromatic odor, pungent, spicy taste, neutral reaction, and specific gravity of 0.945. As a perfume, etc., but not generally as a medicine, sandal wood has been used for more than a thousand years. It was known in Europe some eight hundred years ago, and it has always been a costly perfume. Its modern employment in gonorrhea, etc., is not more than a generation old. Of the different trade varieties, that from the East Indies is most highly prized, that of the West Indies and South America the least. There may not be so very much difference in their medical properties. AcTION AND UsE.—Sandal wood oil resembles copaiba in many respects, as well as the terebinthinous oils in general. It is readily absorbed and pretty promptly eliminated, appearing both in the urine and in the exha- lation from the lungs. It is slightly astringent, and fre- REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. San Antonio, Sandefjord, quently followed by discomfort in the stomach and dry- ness of the throat ; occasionally it causes vomiting and colic. Disagreeable eructations and its taste are com- plained of by some patients, but on the whole it is less unpleasant than copaiba. Its elimination by the kidneys, which is sometimes accompanied by a feeling of tension there, changes the odor of the urine, and causes it to become cloudy with acid, in the same way as co- paiba; alcohol, by clearing up this cloudiness, fwhich is caused by a resinous precipitate, will dis- tinguish it from albumen. ucts in the urine exert a beneficial action upon vesical, and especially gonorrhceal, inflamma- ‘tions, equal to, if not better than, that of co- a paiba or cubebs, for which it is an efficient (fg and rather more elegant substitute. It is es- pecially serviceable in recent acute cases with considerable discharge. ADMINISTRATION.—This is simple enough. Dropped upon sugar, or shaken with mucilage, it can be easily taken by those who do not mind its disagreeable taste, but probably more than nine-tenths of it is given in gelatine cap- sules, where it is often mixed with copaiba or cubebs. Dose, from five to twenty drops —ten is a good average— four or five times a day. It should be continued F a week or so after the S244 symptoms have disap- of} “i peared. ALLIED PLANTS. —There are eight known species of Santalum, all close- ly related. They are inhabitants of India, Australia, and of many of the Pacific Islands; all are fragrant, and _ perhaps others than 8. album may con- tribute to the ield of East ndian sandal wood. 8S. Yast Seem, of the Fiji Islands, S. Freycinetia- num Gaudich, and S. Pyruy- lartum Gray, of the Sand- wich Islands, and several species in Aus- 4 A. O77 ths bry Wa Ye, a fp) Re f / tralia, furnish Ge A; both wood and GY Fi iyjuk * “YY iy yy oil. The order jlttttleddll isarather small one, compris- ing some two hundred spe- cies, mostly shrubs or trees, and often root-parasites. The source of West Indian and South American ‘‘ Oil of Sandai” is not known. It resembles in its odor and taste the Kast Indian oil, but is cruder and less agreeable. It is very much cheaper, and is the kind usually dispensed for medi- cine, the other being reserved for perfumery. ALLIED Droues. —From a medical point of view Co- PAIBA and CuBEsBs are most nearly related to the subject of this article. As an astringent of the intestinal and urinary mucous membranes it may be compared with Vou. VI.—17 A The sandal wood prod- = Fic. 336%7.—Flowering Branch of Sandal Wood Tree, about Natural Size, (Baillon. ) Vey. AY ‘ TURPENTINE, to which it is inferior; as an alterative to bronchial secretion, for which purpose it is sometimes given, GRINDELIA is superior ; in cystitis, etc., it is com- parable with the balsams, as well as Bucuu, Uva Urst, etc. The red saunders, or red sandal wood, resembles this product only in name. W. P. Bolles. ay SANDARAC (Sandaraque, Codex Med.) A a BN very brittle resin obtained in tears in North- PPh “OG ern Africa from Callitris quadrivalvis Vent. Vd (2 (Thuja articulata Shaw), a member of the 5 \ £2 Cypress division of the order Conifere, Sandarac exudes spontaneously from S the trunk and branches, and dries ( in rounded or irregular drops averaging the size of small peas, but sometimes larger and long. The tears are dull on the surface and covered with a white powder produced by attrition. Fracture glassy, interior transparent. Upon being chewed the tears crum- ble to a fine powder in the mouth, while Mastic, which closely resembles it in ap- pearance, softens. Powdered Sandarac, which is non-adhe- sive and white, with a pleas- ant resinous odor, and a re- sinous and_ bitter taste, bejeceash he ‘*Pounce,” and was formerly used to rub over the sur- face of paper where an eras- ure had been made, to pre- vent the ink from running when it was written over Wee again. Sanda- 2. TR G rac 1s not used » LEN at present in medicine. This resin is a com- pound one, con- sisting of at least two, hav- ing different degrees of solu- bility in alco- hol, ether, etc. Asie bl Rep Puants, ETc. —See TURPEN- TINE. W. P. Bolles. SANDE - FJORD is a Norwegian healt h-resort, pleasantly situ- ated on a fjord at a short distance from the sea. In addition to the sea-bathing, therapeutic use is made of the several min- eral springs here found. Sea-mud, containing sulphur, iron, and common salt, is used in the form of baths, poultices, and as a local application applied with fric- tion. Sandefjord enjoys considerable reputation as a resort for those suffering from chronic rheumatism, neuralgia, nervous prostration, chronic joint diseases and other so- called scrofulous affections. The season extends over 257 >. Sandefjord. San Francisco, REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. the months of June, July, and August. A course of treatment occupies the usual time of three or four weeks. The following is the composition of the three principal springs, computed in grammes per litre : } Ba bo ela ges Ed @ op Hed bh a8 2 ) asi rm ont - 2 | mM cS 18 us a Fes Bee | B83 gOS qp09 | 2a gas oh ee Wi ABA Sodium ‘chloride FL. Ny. -Gaea me ee eee eee 3.9066 | 16.3877 Lithium chloride 302. 2ssjccseice ane eee trace). | aan eee Calciumecnloride ie o...4.0 60s ae ee ee O22) > Sie botassinm chloridety~ 002 cee cee in ieee oe OL0632 5 eee ae Povassium wromiders Ja) l 4) see eee tee 020005) area. - Maenesium chlonidesc.c-0. seaesee eee O01 87 a acres 2.2149 Macnesinmubromidens .nr ei eens a) meee | ees 0.0639 Calcium sulpaate. nee eee 0.7582 0.0248 0.5821 Macnesium sulphate).ces: onsets I O.46B00 Ot ss tersee ep ees Sodium jsulphate 2275 4) ee eee een. OAL aor Oieoeee rae ee Potassium sulphates wet ianna eee 0,03881°- |" seeee 0.5282 Herrous Sulphate osm os oe oe er CD Rie tie. IN. Gerry 6 Ferric sulphate. ste ccsmre eee ee ne 1:0542 4) (Saen 5 he a eee Aluminium! sulphateg=2..- eee eee oe 0.8467 0.0009 0.0068 Caleiani carbonater c.ccvcwe ceo ce te cline eatote 0.0832 0.5446 Macnesium. carbonates dan cme se ae cll seer 0.1806 0.6814 Berrous.carponatert. 5 oes a nea tase: cleats 0.0016 0.04166 Manganous carbonate................. RAS, AIR Aare oe 0.0080 Dilicic Acid Fishes ee Oe Sete 0.0642 0.0167 0.0274 Organic matters eee meee eee OL0010 55 | aeeee 0.2271 Total takctain re: een ee es 3.6117 4.4002 21.8187 The composition of the sea-mud, used for bathing and local applications, is as follows. In 1,000 parts there are of: Clay ‘and sand 2. teenies ces cc See eeiaee 728.0 g Organicumatters so Si sageaes cies s tlocig ane as coe ee 99.2 Sodium (chloride Siva: csicee cee cack coe eee ene 41.8 Sulphuric acids i.e Gas sea cist ele ee ee eee 20.5 Potassimmit) ede ee eee pee eee ee eee 7.8 Ma pinvesiinr Ys... cracls ascii cue 5) Seectensl oer ee tere ee rakiove 11.3 TPOD 2 3 oe oe vues coe Ba oe De ee ele Soe RO EC seioe ces 41.5 Callens co's s je kee Stic seuss AEE So Ee eee ee eee 13.1 AMIN a TAOS: Soins See orate eee eR en aes eee re 12.5 Silica ese i. cays one tats eae Tee eccienetios wate heels sints 13.9 TLiO88° og Sacks ded ee eee ksiete cee OReeT is: ein ee oth weet ete 0.4 Yes Piers A SAN DIEGO. [For a detailed explanation of the ac- companying chart and suggestions as to the best method of using it, see the general article on Climate. | The city of San Diego, California, lies upon the slop- ing northeast shore of a land-locked bay five and a half miles long, twenty square miles in area, and twenty-three feet deep on its bar at low water, constituting a harbor which, by competent authority, has been pronounced to be, ‘‘ with the single exception of San Francisco, perhaps the best from Callao to Puget Sound” (General Emory, of U. S. Engineers, quoted by a writer in the New York Times of May 9, 1886). The town is the most southerly of any in California, lying in the extreme southwestern corner of the State, only fifteen miles distant from the Mexican border, ‘and its latitude is almost precisely the same as that of Yuma, Arizona, from which it is distant about one hundred and fifty miles in a westerly direc- tion. From San Francisco it is distant nearly five hundred miles in a direction 8.E. by 8. The popu- lation in 1880 was less than three thousand; it is now (1887) estimated at about seven thousand. The slope of the hill upon which the town is built is three hun- dred feet to the mile; hence the natural facilities for drainage must be good. Concerning the soil, I possess no information save that the writer in the New York Times, already cited, states that ‘‘ there is little mud and - the ground dries in a few hours after the heaviest rain.” The water-supply of the town was formerly deficient, but Dr. Chamberlain, in a paper read before the New York Academy of Medicine in October, 1886, says of this defect that it is one which he believes is soon to be remedied. There are good hotels at San Diego, As may be seen from the chart opposite, the winter climate of San Diego, so far aS mean temperature is concerned, is about the same as that of Los Angeles, but the daily range is much less than at Los Angeles, and a decidedly greater 258 equability of temperature throughout the year is found at San Diego, on the coast, than at Los Angeles, among the hills and seventeen miles back from the coast. San Diego has a less rainfall, but a more cloudy sky and markedly more humid atmosphere than has Los Angeles. In point of windiness the two places are almost precisely alike in winter; very similar, indeed, throughout the year. In regard to the frequency of occurrence of fogs at San Diego, I find two contradictory statements: that of the writer in Appleton’s ‘‘ Handbook of Winter Re- sorts” (1886-1887), who says of San Diego that ‘‘ there is no fog, as in Santa Barbara and more northern latitudes, and very little moisture in the air,” and that of Dr. Chamberlain (loc. cit.), who tells us that the local climate’ of San Diego is ‘‘ unsurpassed in the matter of tempera- ture,” but is damp; for while the ‘‘ rains are few,” the ‘‘fogs are frequent.” Dr. Chamberlain also speaks of the fogs at Santa Barbara. Dr. H.S. Orme, president of the California State Board of Health, in his interesting pamphlet entitled ‘‘ The Climatology and Diseases of Southern California,” tells us that ‘‘ from the time of the first rains the belt of country next the coast is bathed in an atmosphere which is tolerably moist,” and that ‘‘at a distance of a few miles inland the relative humidity in- creases, not because there is more moisture, but because the temperature is apt to range lower.” In this belt, he tells us, ‘‘ the fogs are heaviest and the deposition of dew is greatest ;’’ while beyond it, ‘‘as the distance from the coast increases, the relative humidity decreases until, at the crest which separates the Pacific slope from the Great Basin the air throughout the year is dry, pure, and in- vigorating.” The limits of the belt of country character- ized by an especially frequent occurrence of fogs, and by greater relative humidity than elsewhere throughout the Southern California region, cannot be very accurately de- fined ; but to the seaward it is in general bounded and defined by a line drawn parallel to and at a distance of five miles back from the coast. Probably it is only close to its seaward border that this district is damper than the coast belt itself. Its inland border I can by no means determine, for while Dr. Lindley (see his paper quoted in article Los Angeles and Pasadena) speaks of an ele- vation of one thousand feet as the inland limit of the re- gion wherein fogs ‘sometimes come in from the sea,” and the atmosphere ‘‘ during the winter months is some- what moist,” we see from the chart of Los Angeles, a point only seventeen miles back from the sea, and 283 feet above its level, that the relative humidity in winter is decidedly less than in summer ; while a comparison of column J in the Los Angeles chart with the same col- umn in the San Diego chart shows that, month by month throughout the entire year, the relative humidity of Los _ Angeles is very markedly less than that of San Diego, a place not lying within this belt of especially great hu- midity, frequent fogs, and heavy dewfall, but upon the coast which, according to Dr. Orme, is drier and less liable to fogs than this belt, beginning ‘‘ at a distance of a few miles inland.” The paramount importance of a careful study of each ‘‘climat de localité” in Southern California has already been urged in the article on Los Angeles and Pasadena, is well recognized by all authorities on this subject whom I have consulted, and is probably exemplified before the eyes of the reader who has followed us through what has just been said respecting the somewhat misty limits of this belt of winter dampness and spring fogs. A brief and necessarily general discussion of the clim- ate of Southern California taken as a whole, and of its undoubtedly great adaptation to the purpose of a health region for the resort of phthisical and other invalids dur- ing the winter season, or during the entire year, has al- ready been presented in the article entitled ‘‘ Los Angeles and Pasadena.” To what is said in that article, and in particular at its close (page 582 of vol. iv.), I have noth- ing to add, merely repeating here, in slightly different form, what I have said before, viz., that for many in- valids Southern California is not only a good winter resi- dence, but is a health-giving and health-restoring home for residence all the year round; and this in no small REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Sandefjord. San Francisco, Olimate of San Diego, Cal.—Latitude 32° 43', Longitude 117° 10'.—Period of Observations, November 1, 1871, to De- A [AA ie cember 31, 1883.—Hlevation of Place of Observation above Sea-level, 49 Jeet. 2 | ? B C D DD E F ' Y 2 bay 2 | by ure s Bo PHOS gos | g65 24 ee ey Seg.| S885 B'_g x a, Oo - woe | oo ae & oq PAH! hag o I 5 = mo ies | mo ep 25 (83 | 23 | 3E ogee | ogee Soa atagn ¢ t ae Slog : ‘4 we | GD Meant { iS) ean temperature || ¢ ga - ||Absolute maximum | Absolute minimum || os °38.| S¢0a op eeeateotmpnths S5 for period of ob- || By Be aS temperature for | temperature for || 4 ae A) & a a5 servation. = ga” | ee period. period. 2OBL | S508 oo q5 | 55 | &s Ga2n| gao¢g | Sis a" | 3" | ms aees| Fegs o Fe A'S Borg | 8§o%eq os on op a? Paad | epsex ao | as Sobek | SoBe : Pete ere a SaeH| $uge < ee 2s GaSe) GAbw 7 AM. 3 P.M. 11 P.M. De- || Highest. | Lowest. || De- | De- | De- || Highest.| Lowest. | Highest. | Lowest. Degrees. | Degrees. | Degrees. | grees.|| Degrees, | Degrees, \grees, |grees, |prees,|| Degrees.| Degrees. | Degrees. | Degrees, January ...| 48.0 60.4 52.6 || 58.6 || 57.4 50.4 || 61.8 | 44.5 | 17.3 78.0 64.0 44.0 32.0 22 24 February ..| 49.1 60.3 53.5 54.3 || 57.9 50.8 || 61.6 | 46.3 | 15.3 || 82.6 63.0 45.0 35.0 25 17 March ..... 50.8 61.3 54.9 55.6 || 58.9 52.1 || 62.8 | 49.0 | 18.8 99.9 63.0 || 48.0 38.0 27 19 April... ;..s. 52.5 63.6 57.0 57.7 || 60.8 56.0 || 65.8 | 51.2 | 14.1 87.0 67.0 51.0 39.0 18 20 eee ee 56.6 66.2 60.0 60.9 || 62.6 60.0 || 68.5. | 55.3 | 13.5 94.0 68.0 52.0 45.4 23 21 June.:.\a.. 60.5 69.6 63.2 64.4 || 66.6 62.7 FTL B81) 12.8 94.0 73.0 || 58.0 51.0 17 21 False... dea: 63.5 72.2 65.6 67.1 68.7 63.4. || 73.5 | 61.9 | 11.6 || 86.0 73.0 62.0 54.0 26 24 August... 65.0 eRe 67.4 68.7 Fg) 65.8 74.9 | 63.1 | 11.8 || 86.0 78.0 || 64.0 54.0 27 26 September.| 62.7 eee 65.6 66.8 69.7 63.1 74.5 | 60.4 | 14:1 || 101.0 73.0 59.0 49.5 26 17 October ....| 58.1 69.1 61.4 62.8 || 67.2 61.2 70.2 | 55.0 | 15.2 92.0 12.5 53.0 44.0) 20 16 November..| 52.5 65.7 56.6 58.2 60.6 56.2 || 66.8 | 48.7 | 18.1 85.0 75.0 50.0 33.0 22 23 December..| 50.0 62.7 54.1 55.6 57.5 58.3 || 64.5 | 49.0 | 15.5 82.0 68.0 44.0 82.0 24 15 rey TMI 2 Le Ny Sion cai ee lee a Rel, ae 58.0 || 59.2 86.44 ||"). laren On ee iia Eh A SUI OTe welenercer tm | eetostaeee siete thax 66.7 68.1 64.1 ; He Opi aueeteieas) iil MMvaee NS ill |Meracas rte ik care se MU UM ont tosene a [sc soer) lth es ss ns 62.6 65.1 60.2 Ube tl eka i) genset “NM Gator fea imeceeee Ld a den 9 Ayes ae ds aR 545 57.4 52.2) || PeOUN Mec sae sy | Pacer cA Ops tee Vedra Bers ar ANN fy ae n steam ocd | 60.4 62.1 | 58.5 ET |e seis ee Ge ef eee a J K L MI N oO R Ss . ; bp rss ates pacts 1 During the year 1880 the thermometer at San Diego rose 2.2 S B | ss camila se By | to 90° F. only six times, while at Los Angeles this tem- emake &, | 86 | Be 4 ad | 82 perature was reached fourteen times (Dr. Orme, op. cit.). g3 BB Er ES FE 4 aE ey The general healthfulness of Southern California has es BE ae ae s ibe oS been alluded to in the account of Los Angeles (vol. iv.), = fal rt a= . Go| a 28 ao aeg| @ #8 a5 and a table printed on pages 10 and 11 of Dr. Orme’s cel é 2 pe | S38 | © ef | gs | pamphlet, which shows the prevalence at each of twenty- ms PN cu ee poy ie Oe es ee four towns of the diseases occurring throughout this Taeheaih Brom i aries. caeale in the yea oe owen the fact that San January ...| 46.0} 71.2 | 11.2 | 11.3 | 22.5 | 1.85 | NE. | 5.1 lego compared very tavorably with any of the other February ../ 47.6 | 74.8 | 11.3 | 9:0 | 20.3 | 2:07 | NW. | 6.0 points specified. For phthisical invalids it is probably ee a ya al to ae esos HL ea not quite so suitable a winter residence as are Pasadena May... 35: | 48.6 | %8.0 | 12.1 SH OO te 86 We.) 6.7 and other inland points. Huntington Richards. JUNE. os. | 43.0 3.8 15.2 6.7 21.9 0.05 Ww. 6.3 lye | $2, 76. A 2 ‘ 0) : i Sewtember..| 3 | wed | as9 | tz | one | oe | Nw. | Si SAN FRANCISCO. The chart on next page, ob- October rae 48.0 i15 12:6 12:8 25.4 0. 49 NW. Bu pe aa ie ee Bia Office, in Nig nee sg ovember..| 47. 6. ‘ : 23. G00 oN We | Ssh resents the climatic conditions prevailing at the city o ae ele ih cea ee ay Soo ee Ot San Francisco, Cal. (For a detailed explanation of the Spring een 61.0 | - 73.6 36.7 26.9 63.6 1.91 WwW. 6.6 chart and suggestions as to the best meth j j Summer..../ 68.0 | 75.8 |° 48.2 | 24.3 | 72.5 | 0.30 | W. 6.2 ve J] Clos fable L - 189 ae eo Uane 1 ie al Os | Be | Bo aes | aa | Ree | SE | rece uaay be the ndveniagen of inter .....| 8 70. 33.7 : 2 é : d } Yr meg ages j > clims Near: on. DEVO Sth asslie trash 7B hog We 15.9 Pua NE Tila ia Cate ACW ana e ee 0 eae tet eninate | at San Francisco when compared with that found at degree by reason of the very considerable varieties of cli- mate which are therein to be found comprised within a -comparatively limited area of territory. In conclusion, and as emphasizing the equability of the climate of San Diego, the place now under our special consideration, and, as illustrating its immunity from even occasional extremes of heat and of cold, I quote the fol- lowing data, derived from Appleton’s ‘‘ Handbook of Winter Resorts,” from Dr. Orme’s pamphlet, and from the letter to the New York Times of May 9, 1886, already quoted above. During the ten years 1876 to 1885 the mercury at San Diego rose above 80° F. on only one hun- dred and twenty days (¢.e., on an average but twelve times in each year); and it went above 95° F. on only six days. During the same period it fell below 40° F. on only ninety-three days, an average of but nine days in each winter ; and on no day did it remain below 40° F. more than two or three hours, and this between midnight and daylight. It fell below 35° F. on six occasions only throughout the whole period of ten years, and never once fell below 32° F, Says the Times correspondent, com- menting upon these figures: ‘‘ There is therefore no such difference between summer and winter, or between day and night, as to prevent one from wearing the same cloth- ing and, sleeping under the same cover all the year round.” places of corresponding latitude in the eastern and cen- tral portions of the United States, it is very much less mild than that found at points lying further south in the same State, and particularly at such as lie to the south of the Tehachipi and Santa Ynez mountain ranges, in. what is known as Southern California. As for the sum- mer climate, it is by very common consent pronounced to be exceptionally disagreeable ; and is by no means suited to the benefit of invalids affected with any form of pulmonary disease. The situation of San Francisco, at the mouth of a gap through which the cool air lying over the surface of the Pacific is sucked up to supply the place of the heated air radiated from the great inland basin comprising the Sac- ramento and San Joaquin Valleys, is the cause of its pe- culiar, and to most persons very disagreeable, summer climate. The hotter it is at this season in the interior, * the colder and more windy will it be in San Francisco, a fact which is well corroborated by the data in the accom- panying chart. The windiness of the summer season, as compared with other parts of the year, is plainly to be seen in the data of Column 8. The direction of the pre- vailing wind at this season, the high relative humidity of July, August, and September, the low absolute and aver- age daily maxima, and the small mean daily range of July and August as compared with those of June and 259 San Francisco. Sanitary Inspectn, REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Climate of San Francisco, Cal.—Latitude 87° 48', Longitude 122° 26'.—Period of Observations, March 8, 1871, to De- cember 31, 1883.—Hlevation of Place of Observation above the Sea-level, 13 feet. A AA B c |p |DD E F G H n . pb St oe 1 ; $ Apa ay get gees | E96 2d 2 3 ey i es ES _ ss 4 be ra = | om Ss | So "Zs B S 5, 5. fis neg o ws 2 2 gE | SI sl rae a Ras g ee 9 a0 2 4 Absolute maximum ||Absolute minimum ia: BS eS bes Mean temperature of months go Bee eer oe 55 | EE on temperature for temperature for Pas a at the hours of F 5 servation. Eo nee | Ea period: period BS se le S me : zeae Ee es0e | be (oP) | ro] AO aS © © i) fo | ‘ac BAEb | peee of on & | eo QRES mee SS es) 3 ° RZoss Cords mB = ta as ahs | 596% w ) © (ag S ws Es casa > > > | S38 Seso] Sau9 < < PO | BY > RS bao | manner. 1e mercury falls suddenly, and long before a =| < qo°- Ay oe : ECs , ee eke “ eb See ME 4 Pld EPA, Be re _ | sunset fixes itself within a few degrees of 50°, where it Inches. From remains pertinaciously till next morning, often not mov- Forbert 355 re 1033 06 19:9 305 W. ce ing a hair’s breadth fortwelve hours. . . . The mist March ne 55.0 2.8 Hy ‘ 11.8 aes 2.88 W. 83 often increases toward evening, and when the wind falls Drilveeeeees F : b 2. : : : ; es A : May 41.0 | 72.0 | 102| 15.0 | 25:2 | om | w. | 13 | Yemains all night in the shape of a heavy fog. Some- June........ 41.2 3.8 He 2.6 | 3.8 (ah BW. ee times, when the sun has been shining brightly, the mist August.....| 39:0 | 80:0 | 144} 9'7 | 341 | 0101 | Siw: | 19:1 | Comes in from the ocean in one great wave and suddenly September..| 42.0 | 77.5 | 13.1) 12.4 | 25.5 | 0.15 | 8.W. 9.9 submerges the landscape. In short, there is no conceiv- October.....| 39.0 (ea | 11.4 15.4 26.8 1.18 Ss. W. %.8 - bl d * t f ° 1 d t ] d f d hi November..| 37.0 | 71:1 | 914| 15:0 | 24:4 | 2:70 | N.w. | 61 | able admixture of wind, dust,{ cloud, fog, and sunshine December..| 34.0 | 76.0 | 9.6 | 18.2 | 22.7 | 4.72 N. 6.4 | that is not constantly on hand during the summer at San Spring...... 47.0 | 2.0 | 92.9) 30.2 | 1 | 5.99 | We | 101 Francisco.” ummer.... : (KG il. 30. gt : 3.W. , i r . . Autumn 2/30 | a6 | 389 | 28 | wea | sas | Siw. | ao | , Lhis fog, we are told by Mr. Blodget, does not blow Winter... 86.5 | 74.0 | 295 | 84.7 | 64.2 | 18.77 N. 7.0 | in from the sea, but is formed on the spot by contact of Neat Nines 61.2! 74.8 '187.6 | 146.7 | 984.3 | 28.32 S.W. 9.4 the cold sea-air with the naturally warmer land-air. The sea-breeze in summer is a more or less cold breeze, he tells us, all the way down the coast as far as the ex- tremity of the peninsula of Lower California, at Cape St. Lucas ; but at San Francisco its coldness is most marked, because the indraught of air at that point is vastly’ stronger than elsewhere, for reasons which will be found fully explained in his work, and which have been al- ready briefly referred to in this article. San Rafael, a town of some three thousand inhabi- tants (population in 1880, 2,276) lying twelve miles north of San Francisco, about three miles from the shore of San Pablo Bay (a subdivision of the great gulf compris- ing San Francisco, San Pablo, and Suisun Bays, which is entered through the Golden Gate), is a place much better sheltered from the direct influence of the sea- winds than is San Francisco, and on this account pos- sesses a much more agreeable climate. ‘‘ The scenery about San Rafael and in the approaches to it is extremely fine . . . and the air is pure and bracing, and, though. hardly warm enough for consumptives in ad- vanced stages of the disease, is admirably adapted for September, all point in the same direction, and receive their full explanation in the following passages, which are taken from Blodget’s ‘‘ Climatology of the United States,” and are quoted by the author of that work from the writings of Dr. Gibbons, of San Francisco. The first of these passages discusses the increase in the force and frequency of the sea-winds during the summer sea- son. ‘‘ Whatever may be the direction of the wind in the forenoon in the spring, summer, and autumn months, it almost invariably works around to the west in the after- noon. So constant is this phenomenon that in the seven months from April to October, inclusive, there were but three days on which it failed to do so, and these were rainy. ‘The sea-winds are moderate until May, when they begin to give trouble. In June they increase in force, reaching their greatest violence at the beginning of July. In August they decline in force, but not in constancy ; in September they continue steady, though moderate ; and_in October they lose their annoying quali- ties, and become gentle and agreeable.” What these ‘“‘ annoying qualities” are will appear from the second passage quoted from Dr. Gibbons, wherein he describes the course of a summer day at San Francisco : ‘The sun shines forth with genial warmth, the mer- cury rising generally from 50° at sunrise, to 60° or 65° at * Blodget’s Climatology was published in 1857. Dr. Gibbons’s meteoro- logical observations at San Francisco covered the period of sixteen months, from December, 1850, through March, 1852, + The dust is less troublesome now than at the time when this account was written, more than thirty years ago, the streets of the city being kept carefully watered. a ee Dee Ss SS ee eS SS eee 260 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. San Francisco, Sanitary Inspeec’n, such as are in the preliminary stages, and only need a dry and tonic climate inviting to an out-door life” (Ap- pleton’s ‘‘ Handbook of Winter Resorts,” 1886-87). The hills which lie close about San Rafael on its western as- pect, that is, on the side toward the ocean, are quite high (1,500 feet according to a writer in the New York Daily Graphic of January 22, 1885), and, moreover, the dis- tance -in a direct line to the sea-coast is, in a southwest- erly direction ten miles, in a westerly direction twenty miles. I have no data to illustrate the superiority of San Rafael over San Francisco in point of climate. Monte- rey, a small town lying directly upon the Pacific coast, at the southern extremity of the Bay of Monterey, and Monterey Temperature and Rainfall. at a distance of about one hundred miles from San Fran- cisco in a SSE. direction, has acquired some reputation during late years as a pleasure and health-resort, and a large hotel has been built there by the Southern Pacific Railway. Through the kindness of Dr. C. B. Currier, of San Francisco, I received, some two years ago, a printed table showing the absolute monthly maximum and minimum temperatures, the mean daily temperature, and the total rainfall for each of the fifty-four months, July, 1880, to December, 1884, inclusive. The observa- tions of which these data are the record were taken at the HN just mentioned ; the hours of observation I do not now. AA B T V E ¥F 1) Month as 3 PP aie (le Le aR tes pS os FE Absolute maximum | Absolute minimum ea of 3 3 a f p ure, 3 ar 8 as temperature, temperature. Sees 455 qm | 288 qs Highest. | Lowest. Highest. | Lowest. | Highest. | Lowest JARUATY q clea slave cus sie tcte ne cee ce aibiere 49.55 53.67 46.75 63.33 35.41 70.00 57.00 | 45.00 27.00 2.38 MEDITIALYE co evpeenr. islea eek set cee. 52.30 56.28 50.60 69.33 37.66 82.00 58.66 52.00 28. 00 3.03 ERECT To's cn Ohinaike's's ees eo 8 oo0.c.0e be 55.41 56.82 54.29 70.383 45.16 84.00 60.66 49.66 40.00 4.73 PANEL aretetete a clot heseic'eieieinie Ze ss e'a see 58.45 62.26 56.83 67,58 50.41 71.00 63.33 58.00 45.00 2.03 WER Vcmeisten acer iin ot v0.0 © fol e-tace ee 60.73 62.74 59.68 74,75 53.33 87.00 66.00 58.00 50.00 - 0.42 SUNG ree ate ointitacie Aaioave 6° a eGiaweis 63.13 64.92 61.13 72.83 58.41 87.00 67.00 62.66 55.00 0.52 JOIN FS Unniberac bac Sh Ucar eane tare 64.21 66.42 61.01 73.63 59.02 84.00 67.50 63.33 53.00 0.00 PSPS eRe eicercte tae wis hts te. aioli 62.89 64.85 61.09 70.99 56.59 77.00 66.66 61.33 50.00 0.01 BepremlDereem staves sacs cee eo ae 61.46 63.26 57.52 74.06 53.73 85.60 66.66 60.00 44.00 0.11 Octoberwee apace ss heise ceteces canes 57.17 bY 54.39 68.53 47.40 77.00 60.66 55.00 37.00 1.19 INDVEMDERT reas sas Bieincien takes 51.79 52.58 51.13 64.79 40 73 71.00 58.66 46.00 82.00 0.82 OCEM DEL M c kis ecisis: se eecicees ets 52.16 53.87 50.81 - 64.26 40.80 73.00 58,33 49.33 80.00 2.99 From this table, sent by Dr. Currier, I have deduced by calculation the data standing in columns AA, T, V, and O of the chart herewith presented ; the figures in the remaining columns (B, E, and F) are copied directly from the table, but are differently arranged. The col- umns of this chart may be compared with corresponding columns of the San Francisco chart (and of other Signal Office charts), but in doing so the reader should bear in ‘mind that the period of observations at Monterey was a very short one, the hours of observation perhaps different from those adopted by the Signal Service, and the method of taking maximum and minimum observations unknown tome. A careful study of the chart not only shows that Monterey possesses a mild winter and a cool summer cli- mate, but also reveals facts which bear out the observations made by Mr. Blodget, to the effect that the peculiarity al- ready noticed in the summer climate of San Francisco ex- ists also at other points upon the coast, but that it is very much less marked at places lying to the south of San Francisco than it is at San Francisco itself. Columns T and V by no means correspond to columns C and D of the Signal Office charts ; the former give the average of monthly, the latter of dazly, maxima and minima. Huntington Richards. SANICLE, Codex Med., Sanicula europea Linn., order Umbellifere. A small European perennial with palmate orreniform, five-lobed leaves, unisexual flowers, and ovoid spiny fruits. It contains tannin, bitter extractive, and resin. Sanicle is a household herb of Europe, and used both internally and externally in numerous condi- tions. It probably has no value. W. P. Bolles. SANITARY INSPECTION, PRINCIPLES OF. This is a comprehensive subject, as it relates to inquiries into all influences affecting or tending to affect injuriously the health of a locality. It involves a knowledge of the importance of perfect purity and cleanliness of air, water, food, and soil as the fundamental and paramount condi- tions of health, and seeks to discover and guard against or counteract those influences which are liable to render impure these essentials to the maintenance of healthy life. It is through this important public service that the local health authority is kept informed of those condi- * Observations of five years. For the other months the observations covered only four years. tions which tend to endanger the health of the inhabitants, and that knowledge is obtained with regard to the sani- tary state of the people, and the preventable causes of sickness and death, which forms the basis of all intelli- gent and efficient sanitary legislation and administration. Sanitary inspection is not restricted in its objects sim- ply to the collection of information which is indispensable to the application of the provisions of the public health laws ; it also includes the execution of the provisions of such laws whenever the circumstances of the case may justify and require it. An executive service is the nat- ural and necessary complement of an inspection service, inasmuch as the purpose of the latter, in detecting all such influences as are injurious to the public health, is to suggest and make possible the proper steps for their removal. The causes of disease with which public hygiene is con- cerned, such as affect the mode of life of masses of popu- lation, operate through a great variety of channels, and their discovery and removal require the exercise of knowl- | edge affecting the various conditions under which people live, whether in the city, town, or hamlet. Such knowl- edge relates to the natural and acquired features of the locality, its meteorological peculiarities, and the social and sanitary state of. its population ; the character of the soil, ground-water, wells, and springs; the water-sup- ply ; plans of drainage and sewerage ; the distribution of buildings and of open spaces, whether paved or unpaved ; the sanitary arrangements of houses, especially those of the poorer classes; the management of burial-grounds and the arrangements for the burial of the dead; the nat- ure of manufacturing and other industrial establish- ments ; the housing of the poor, and the facilities afforded for bathing, washing, etc. ; the conduct of slaughter- houses and all establishments where food-supplies are prepared ; the examination of foods with respect to their wholesomeness ; the sanitary inspection of schools and school children ; the regulations for cleansing the public ways and markets, and for the removal and disposal of domestic and trade refuse ; the examination of persons and houses with the object of restricting or suppressing contagious or infectious diseases of local origin, and of vessels and passenger-trains in order to prevent the in- troduction of such diseases from without. 261 Sanitary Inspection. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. While the intelligent exercise of the functions of the sanitary inspector requires a familiarity with these vari- ous subjects, a high degree of efficiency is more surely attained by a division of labor according to special branches of inquiry, a plan which yields the advantages of more matured experience and greater precision of knowledge. Besides the ordinary nuisance inspectors and inspectors of quarantine, it is becoming more and more customary to appoint officers fitted for particular lines of work by special education and training. In or- der to prevent the sale of adulterated and unwholesome foods and drugs, it is necessary to have officers who, in addition to other qualifications, shall possess a knowledge of chemical analysis and microscopical examination. The sanitary inspection of school buildings and the supervi- sion of the heaith of the children are wisely entrusted to men who have had a medical training. The sanitary su- pervision of house-drainage and plumbing required under the laws recently established in many American cities, imposes upon the local health boards the duty of employ- ing experts skilled in the technics of this art. The ex- amination of immigrants and travellers, with the object of preventing the introduction and spread of dangerous communicable diseases, is another special branch of sani- tary inspection which none but a medical officer is quali- fied to conduct. QUALIFICATIONS OF SANITARY INSPECTORS.—FEfficient sanitary inspection depends primarily upon an adequate knowledge of the various subjects relating to hygiene and public health, and the officers employed in it should be fitted for the work by special and sufficient education. As many of these subjects relate to diseases, their causes, mode of propagation, and the means of their suppression, a medical knowledge becomes an essential qualification of at least a portion of the force employed as sanitary inspectors by a board of health. Under the English health laws the officer of health, whose duties are largely those of an inspecting officer, must be qualified by law to practise medicine or surgery, though such qualifica- tion is not made necessary in the case of inspectors of nuisances, Intelligent sanitary inspection rests upon a knowledge of the following subjects : 1. The principles of chemistry, particularly with re- gard to the methods of analysis (including microscopical investigation). Such knowledge is indispensable in forming accurate judgment as to impurities of air and water, injurious impregnations of the soil, harmful ad- mixtures in food, and also in the proper use of disinfect- ants. An acquaintance with chemical physics, includ- ing the chief phenomena of light, heat, and electricity, is also advantageous. 2. Natural philosophy, which should embrace a thor- ough knowledge of the principles of pneumatics, hydro- statics, and hydraulics, with special reference to venti- lation, water-supply, drainage, construction of dwellings, and sanitary engineering in general. The laws of nat- ural philosophy will be of great aid in tracing nuisances, in determining questions of ventilation and of over- crowding, and in studying atmospheric changes; and, in conjunction with chemistry, will be of the greatest service in the investigation of industries and trades al- leged to be prejudicial to health, and in devising meas- ures for the abatement of the evils associated with them. 3. A knowledge of the laws relating to public health. 4. The, sanitary construction and arrangements of dwellings, including soil, structure, materials, internal decoration, lighting, ventilation and warming, water- supply, house and soil drainage, and disposal of refuse. 5. A knowledge of the effects of overcrowding, vitiat- ed air, impure water, bad or insufficient food, unhealthy occupations, and of the diseases they produce ; the char- acter of nuisances injurious to health, the disposal of sewage, and the effects of soil, season, and climate upon the health of localities. 6. A knowledge of the causes, propagation, and pre- vention of contagious and infectious diseases. In addi- tion to a familiarity with the above subjects, there should be the further qualifications of methodical and industri- 262 ous habits, competent powers of observation, sound judgment, and conscientiousness in the investigation and statement of facts. It may be objected that the qualifications outlined above are too comprehensive, and that the knowledge deemed essential for the performance of the duties of sanitary inspector is such as should only be required of a professional expert. But it should be remembered that sanitary inspection is pre-eminently the service by which information is obtained of the numerous and vari- ous conditions which operate against the health of a locality, and constitutes a large and important part of the work of sanitary government. In order to recognize and intelligently investigate these conditions, and advise as to the means of their amelioration or removal, a com- prehensive knowledge of the principles and laws of science involved in their consideration is indispensable. Efficient sanitary inspection requires skilled or expert labor, which can only be secured by special knowledge and experience. SANITARY SuRVEyY.—A systematic sanitary survey of a locality isthe true basis of measures for its sanitary improvement. Such a survey embraces an investigation of the natural and artificial or acquired conditions affect- ing the health of the inhabitants in the district. The natural conditions affecting the health of a district comprise the geological and topographical characteristics of the locality, the climate, water-supply, etc. The causes of many of the most common diseases arise from conditions connected with the earth’s surface and under- lying structure, as well as with the soil polluted by the act of man. The influence exerted upon human health by the drainage of a locality, by the moisture in the soil, the ground-water, and telluric emanations, has long been recognized, but the exact effects of these conditions can- not be rightly understood without a knowledge of the physical characteristics of the soil, studied in their rela- tions to the records of diseases in their geographical dis- tribution and local history. These two series of facts, studied side by side, lead to the interpretation of the laws governing the relations of the earth’s features to health and disease. Detailed and exact records of the configu- ration of the earth’s surface and its underlying structure, illustrated so far as possible by means of maps and dia- grams, form the basis of correct knowledge of sanitary geography and local hygienic history. It is only by the aid of these facts that the health of a town or district and the records of prevalent diseases can receive their proper explanation. The influences of climatic conditions upon health are also to be investigated in connection with the natural local conditions. The daily temperature and rainfall, the force and direction of the wind, the barometric press- ure, degree of humidity, etc., should be subjects of care- ful observation and record. In many places these data can now be obtained from the Signal Service Bureau of the Government. In districts where such observations are not recorded, arrangements should be made for ob- taining the necessary information. The meteorological fluctuations exert a powerful influence on health and disease, and though they are beyond the control of man, a knowledge of their effects will be most useful in the investigation of other local conditions more amenable to human effort, and in assigning to them their proper share of hurtful influence. The quantity and quality of the water-supply of a dis- trict depend mainly on its geographical and topograph- ical characteristics, which must be studied in their rela- tions to this important fact. The quality of water is necessarily affected by the character of the soil through which it flows and by the surface upon which it is col- lected. A water may become so thoroughly impregnated with mineral or vegetable matters contained in the soil, or with organic matter upon its surface, as to be unfit for domestic use. A wholesome water may become polluted by the transmission of impurities through the porous structure of the ground. In locating wells the physical characteristics of the soil should be taken into considera- tion with reference to the risks of pollution of the supply. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Sanitary Soil moisture and the state of the ground-water play an important role in the causation of disease. These natu- ral characteristics of the soil depend on certain combi- nations of geological and topographical structure, which must be investigated in every locality before improve- ments necessary to secure healthfulness can be intelli- gently undertaken. Before drying and aerating the soil one must have a knowledge of its natural drainage and physical conditions. No plans of artificial drainage or of sewerage can be satisfactorily accomplished without a thorough comprehension of the natural drainage system of the district. The acquired conditions affecting health relate to the habitations of the population, the water-supply, the drain- age and sewerage, removal of refuse matters, public ways and places, gas and lighting, slaughter-houses and abat- toirs, markets, food-supplies, manufactures and trades, public school buildings, hospitals and public charities, police and prisons, fire establishments, cemeteries and burial, the arrest of contagious and infectious diseases, etc. Tanks Are there side windows therefrom into courts or outer air?, ....; Are on roof, SIZOle wes 3 Overflow discharges...... E p transom windows into hall kept open?.. ... ; Bedrooms, how lighted Heating and Lighting.—Stove...... ; Damper in pipe?...... ; Does and ventilated ?...... ; Are there any transom windows over doors be- chimney smoke?...... ; Is coal-gas noticed ?...... ; Light shafts, how tween rooms?........ 4 cop ae Seleade S, ote ve £ 2 indole Size. Material. Location. | Condition. | i | 43 How connected. Opening where. a ve es AEP ae B3/a2! "6 ais eeles|23 = -— S Lamed 3 Si cw House Drain. csi... 5... Sol?Pipesee. cee etd | Waste. Pines cr ccc ciclo. +.c sre Rain) Weader tise ects. s-e's REMARKS, Soe ae r Bs ag : Poe eae [= ,) £6 | 8e P d ig |3 oo re eke g ol ae o9 a¢d a= fo) | |o © a} $ ee lS Sater ig © Se ae Be lacie. fg ISOS] aw 5 ul Stlnwexineeie Sew seats ma = g |2 S| e244 Be lee Git ‘ be AS) eh iy hae A Oo | o's =. eeic# q 3.8 © > he 3 ag ht ESE TF opal aoe bo Sea | Sc 5 eS |i 5 4 + Ee = 2 3 ES, (Sp) GSy i) o a Se | BS 3) ae @lg 2 |o# = ® cel Gt tie, at adie ho Ve et O86 Z oD jo. |o a 4e} Oo al | ca ar | — FLOOR b Ne crete ren See ree | Bae cients eles eters stele CRE II She 58 is Deiat ociae baa coke | Total, . PLOOHMIMOR EEN MiT ira lo. (ict Meee) i | OEE DES is a 2 eC re Di henna A sees | CoRR cn teee. cris © Dinars sede on stab se | Total, | FLOOR Riser! ink | rey Adama stacias. args toy Les aonb ca eee Sf a Ben Boece eee | D.. Niiahe clit ewes 0%) Sls whee | | 5 Total, | FLOOR | | +3 DN ri ate AE, dean Ae Bi Cheese sinas shoes Ce Matte aie eee Sec Dy Woes, « eae eiese sere: | Total, FLOOR ar | | US. Cio Geta Sa ence | Bade sie a ow eens | | Cree eta nisnteserais | | 1 8) cer Pinan | Total, | FLOOR E ARE ASCE scree oleate Biasiniek eee tee (oes eh Aq Ane pene 1D Ae aA Sapo os Total, Summary.—Total ocecupants...... ; Adults..... 3 Ghveren ite es fle. per litre. The climate is mild, and the air is delightfully of beggars recorded? ..... ; No. of saloons on block front...... ; Any ure and invigorating. The indications for the employ- i 8 : bE Meet, ; Any sleeping in Pp 8 e: L JO1 Hay aaa rae! ek ae Reet ot ment of these waters are said to be chronic inflammatory Frederick N. Owen. SAN PELLEGRINO is a thermal station near Bergamo, in Lombardy, Italy, lying at an elevation of about four- teen hundred feet above the sea. The water of the springs issues at a temperature of 81° F., and contains 1.6 Gm. of saline constituents in a litre. The solids are chiefly chlorides and sulphates, with 0.022 Gm. of sodium iodide troubles of the liver, spleen, intestinal tract, bladder, and female sexual organs, gout, syphilis, and the so-called scrofulous diseases of the joints, glands, and skin. San Pellegrino is a favorite summer resort for families in which there are delicate ‘‘scrofulous” children. The waters are employed medicinally both internally and in the form of baths. Teds 279 Santa Barbara. Santa Barbara. SANTA BARBARA. The town of Santa Barbara, Cal., lies in a valley among the foothills of the Santa Ynez Mountains, close to the shore of the Pacific Ocean. The main street of the town runs down to the beach, but its thickly settled portion lies about a mile back from the beach and at an elevation of from twenty to one hundred feet above sea-level. The latitude of Santa Barbara is 34° 28’ N. ; two degrees farther south than Algiers ; less than two degrees farther north than Madeira. The mildness of its winter climate is, however, due only in part to the comparatively low latitude, being chiefly de- pendent upon its situation on the western rather than the eastern coast of the North American Continent, and also in great measure upon the trend of the coast-line at this point, and to the protection against northerly winds af- forded by the Santa Ynez range of mountains. From Point Concepcion to Carpenteria, a distance of about sixty miles, the California coast-line runs nearly due east and west, a chain of the Coast Range Mountains, bear- ing the name of the Santa Ynez Range, running parallel to the coast-line, its chief peaks lying some twenty miles back from the shore and rising to an elevation of three or four thousand feet above sea-level. In fact, we have along this part of the California coast a counterpart of the Genoese Riviera; less extensive by half than the lat- ‘ter and backed by mountains less elevated and farther re- moved from the coast-line, so that the term ‘‘ cornice ” (La Cornice), which is applied to the Genoese Riviera, would hardly be applicable to this far wider Riviera, or coast country, of California. Protection alone gives to the Cornice a mildness of winter climate to which by its latitude it is not entitled ; less perfect shelter against northerly winds along the California Riviera is but an adjunct of low latitude and proximity to the warm water of the Pacific in causing the swpertor mildness of its win- ter climate. Santa Barbara is the largest town in this part of Califor- nia (population, about five thousand), and as it is beauti- fully located, and is one of the most attractive places—per- haps the most attractive place—in all Southern California, it is doubtless destined to increase greatly in size so soon as the chief obstacle to such growth, lack of direct rail- road communication, is removed. The water-supply is ‘‘abundant and excellent” (Dr. W. M. Chamberlain in New York Medical Record, October 80, 1886); of the drainage [ find no specific mention. There are excellent hotels, and we are told by a recent writer on Southern California (Wolfred Nelson, C.M., M.D., in the Planet of January 15, 1884) that living expenses are moderate. Many of those who resort to Santa Barbara very wisely follow the plan of living in their own cottages rather than at either of the large hotels; boarding-houses also exist for such as prefer them. Dr. Nelson speaks of still a fourth method of living which is adopted by some per- sons, viz., the renting of furnished rooms near a hotel and taking one’s meals at the hotel. Riding is the most popular form of amusement at Santa Barbara; fishing, hunting, boating, and bathing are also in vogue; and the beach is not only a good one for this latter form of recreation, but is so hard as to be likewise available for riding and driving. As to bathing, it may be practised at all seasons of the year, as the sea-water is never very cold; but the season proper begins in May. The mean temperature of the sea-water for each month of the year is given by Dr. Nelson, on the authority of Mr. John P. Stearns, as follows: January ....60° April ....... 619 JULY Pee ee 64° October..... 68° February, ...61°° Mays... ..:; 61° August ..... 65° November. .. 61° March? oc. 7 Glos Funes see 620° September ..66° December... .60° This would give a mean for the five months, Novem- ber to March, of 60.6°, a temperature 3.5° higher than the mean surface-temperature of the Mediterranean during the same season at Cannes, as quoted by Dr. Sparks from a paper of Dr. Tripe’s (see Sparks’s ‘‘ Riviera,” p. 7). CuIMATE.—The chief objections to the Santa Barbara climate appear to be that it is less dry than that of inland and higher-lying stations in Southern California, is liable to fogs, and is rather exceptionally windy—exceptionally, 280 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. that is, for a South California station. Dr. H. S. Orme, president of the California State Board of Health, speaks of the land- and sea-breezes as ‘‘ nearly always to be found ” along the coast of this part of the State, and as be- ing ‘‘ very noticeable at Santa Barbara, Santa Monica, and San Pedro; perhaps less so at San Diego” (‘‘ The Clima- tology and Diseases of Southern California”). I have no data showing the force of the winds at Santa Barbara, but at San Diego we see, from column § of the chart published under that heading, that the mean ve- locity of the wind is remarkably small. From column K of the accompanying chart it would appear that Santa Barbara possesses a drier atmosphere than San Diego; yet hardly so dry as to warrant the assumption that it is what can be rightly termed a dry place, and Dr. W. M. Chamberlain (doc. cit.) evidently regards it as very infe- rior in this respect to the inland California resorts, ‘‘ Like San Diego,” he tells us, ‘‘it is very damp, as the moss- covered roofs and lichen-encrusted fences indicate. More than San Diego it is windy, for it lies in a trough be- tween the hills opening to the southeast and northwest ; up this valley the fogs roll in the early hours of the day, and whatever winds there may be are compressed and accelerated to an unusual force.” In other respects, the Santa Barbara climate appears to be all but ideally per- fect—warm, sunny, and equable ; and, lest what has just been said concerning its liability to fogs and comparative liability to winds should produce an unduly dark impres- sion of its claims as a health-resort, I introduce the fol- lowing passage, quoted from Appleton’s ‘‘ Handbook of Winter Resorts” (1886-87). The ‘‘only serious draw- back” to the climate of Santa Barbara, according to the writer in this guide-book, is the fog which ‘‘ sometimes comes in from the sea.” Such a fog occurs, on the aver- age, perhaps twice a week between May and September, he tells us, but he adds that these fogs ‘‘ disperse at nine in the morning, and the succeeding weather is delight- ful.” * ‘Mr. Nordhoff,” he says, ‘‘expresses the opin- ion that there were but ‘five days, either in Santa Bar- bara or San Diego, in December, January, and February of this year (1871), in which the tenderest invalid could not pass the greater part of the day out of doors with pleasure and profit. In Santa Barbara there were not a dozen days during the whole winter in which a baby I know did not play on the sea-beach.’”’ The following ‘‘record of the weather at Santa Bar- bara for one year, kept by , an invalid with ad- vanced pulmonary disease,” is quoted from Dr. Nelson’s paper already cited.{ According to the observations of the gentleman in question, made during a leap year (366 days), there were ‘‘ 310 pleasant days, so that an invalid could be out of doors five or six hours with safety and comfort ; 29 cloudy days, upon over twenty of which an invalid could be out of doors; 12 showery days, upon seven of which an invalid could be out an hour at a time several times on each day ; 10 windy days, confining the invalid to the house all day ; and 5 rainy days, also con- fining the invalid to the house during the whole of that time.” Santa Barbara not being a station of the United States Signal Service, I am obliged to rely on the reported ob- servations of various volunteer observers for the data quoted in this article and presented in the accompanying chart. All the figures of the chart are either copied from or calculated from those given in Dr. Nelson’s article. The headings of the various columns of the chart suffi- ciently indicate the value of the data in each as an index of the habitual weather, or climate, of Santa Barbara. One of Dr. Nelson’s tables shows the temperature ob- served at 7 A.M., 2 P.M., and 9 P.m. of every day during the year 1879, and the average daily temperature at the hours specified during each month of that year, the ob- servations having been taken by Dr. L. N. Dimmick. Another of Dr. Nelson’s tables gives the highest, lowest, * How frequently these morning fogs occur during the months between September and May we are not told. + Dr. Nelson gives the name of the gentleman who kept this record, which name I omit, not having asked permission to publish it in the HANDBOOK, REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Santa Barbara. Santa Barbara. * Calculations made according to the Smithsonian formula \% (7 A.M. + 2P.M. + 9P.M. + 9P.M ** Figures evidently calculated according to the formula 4 (7A.M. + 2 P.M. + 9 P.M.). Deduced from Dr. N.’s figures. tt Winter of 1877-78. t Winter of 1874-75. and average temperatures for each month and year from January 1, 1871, to December 31, 1879. A correspond- ence which exists between the maximum and minimum temperatures of the year 1879 in this table, and the figures of Dr. Dimmick in the table first mentioned, shows that 7 9 P.M. the averages are derived by the formula 4%+??-+°?™: and that the maxima and minima are such as were noted at the regular tri-daily hours of observation ; not such as would have been recorded from self-registering instru- ments. Hence I assume that the same is true of the averages and the maximum and minimum figures of each of the other eight years, 1871-78. The figures of Column K, showing the mean relative humidity for one year, are quoted by Dr. Nelson on the authority of Dr. J. B. Shaw, M.R.C.S., of Santa Barbara. Those of Column O and of Column OO are based on a table pre- sented by Dr. Nelson, which is quoted from records of Drs. Shaw and Tebbetts. This table shows the actual total rainfall of each month and of each year from Jan- uary, 1867, through December, 1878. b>! : ore ©: al ad at Absolute maxi- | Absolut ini- Mean temperature during the|| 25 84 £2 ieee pec aed piety Be | 3 mum tempera- mum tempera- year 1879 at the hours of eq Bb a of vara 1871279, oe R - a ture at 2P.M., ture at 7 A.M. BS | gf | && bales a has i Sea el al 1871-79. or 9 P.M., 1871- eo | as | os ehh | ay 79. Bs Be ae Om On Be S + & 3s e 2 ¢ s os} Sek ares eae S = a < < 7AM. 2 P.M. 9 P.M. De- De- De- Highest. | Lowest. De- De- ||Highest.| Lowest. | Highest. | Lowest. Degrees. | Degrees.| Degrees. || grees. | grees. | grees. || Degrees.| Degrees.|| grees. | grees. || Degrees. | Degrees.) Degrees. /Degrees. JAMUANY, | .-.| tremesofrainfall inches ; and during the third it was only 3.85 inches. In HH | ote | 1867-78 (twelve | the case of this last winter season, the excessively small da | ees |. rere). | rainfall of D ry, and Feb Belles s, total rainfall o ecember, January, an ebruary was S < no doubt, in great measure, compensated by the very ex- —- ca pe Pane ceptionally heavy rainfall of the preceding November 1gnest. owest. “| a . 1 ehea lt aches fi labhon (November, 1875), which was no less than 6.53 inches. January co. eae eee oe Bee re 14.84 0.25 But in neither of the other two cases of winter drought ene Beara eicabincicleasiys gmeiseian eis ie at ee He do we find any compensation. The combined rainfall of Ape Ge, APM Rt tee, Sel Teach: OT 0.88 2.44 0.00 October and November, 1869, was only 0.95 inch, while ey se teeeeee Steen eee en ee er eens eeee neers 2 Ae hee 03 during the nine months of March, April, May, June, aly; eeeweee HNeedeisences| 12 0.00 0:00 | 0.00 July, August, September, October, and November, 1870, rea een settee eee esate teen nee nee ey ane Deng eke ee the total rainfall amounted to only 3.72 inches. In other OeDber ha anor RA gicks |) TO 0.31 1.91 | 0.00 words, a winter drought (4.35 inches of rain) was pre- ) ‘ : . . UW Deaalte SCRE en any Pec are on Pipa (a npes iti ie ceded by a rainfall of only 0.95 inch in two months, and cig is followed by a rainfall of only 3.72 inches in nine months. Saat a a ee ee geet Way Nae The winter drought of 1870-71 (5.75 inches of rain) was AMOUMMN os sseeeeeseeeseeereeeeeese tee 69.3 | 1.63 | 6.58 0.90 preceded by a rainfall of 1.81 inch in October and No- Year III coats’ 15:6? | S683 | tuo | “vember, 1870, followed by nine months, March to No- vember, 1871, having a total rainfall of 4.04 inches. From March 1, 1869, to December 1, 1871—a period of thirty-three months—the total rainfall was only 21.44 inches. On the other hand, in the single month of De- cember, 1871, there fell 6.56 inches of rain ; and in Jan- uary, 1874, there fell 14.84 inches! These facts abun- dantly establish the truth of what is said concerning the irregularity of the winter rains of California in Blodget’s ‘*Climatology of the United States.” ‘‘They are some- times much later or much earlier than their average,” he tells us, ‘‘and sometimes in great excess as well as in great deficiency.” As tothe rainlessness of the summer season, that is a never-failing phenomenon, as may be seen from the data set down in Column OO. The most extreme case of summer rainlessness recorded in Dr. Nelson’s table was that occurring in 1872, when between March 1st and December 1st—a period of nine months—there fell only 0.05 inch of rain. It is not possible to establish any accurate comparison between the climate of Santa Barbara and that of San Diego or of Los Angeles, based upon the data of the charts for these places, because of the different hours of observation adopted at Santa Barbara, and the shortness of the period of observations upon which some of the data are based. In Dr. Orme’s pamphlet we find a brief table (op. cit., p. 7) giving the mean summer and winter temperatures of each of these three places for a period of four years ; from which it would appear that, both in winter and in summer, Santa Barbara is the warmest of 281 Santa Barbara. Saratoga Springs. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. the three. Column F of the chart presented in the pres- ent article, shows an absence of frost and of very low temperatures at Santa Barbara throughout nine success- ive winters. But neither this column nor column E can fairly be compared with corresponding columns of the San Diego and Los Angeles charts, because in these lat- ter self-registering instruments supplied the data; in the former such does not appear to have been the case. Dr. Nelson gives an interesting and practically useful table, showing throughout the course of seven years the num- ber of days on which the mercury was observed to fall below 48° (probably either at 7 A.M. or 9 P.M.), and the number of days on which it was observed to rise above 83° (probably at 2 p.m.). This table is presented below. 1873. | 1874. | 1875. | 1876. | 1877. | 1878. | 1879. IBCLOW Aso ee eee eee Fi 9 4 AiG 15 23 13 MADOVE! GBC vce oon ce 1 6 22 4 10 8 15 Average below 43° F., 12 days ; above 83° F., 94 days. The figure 13 in the year 1879 is very likely a misprint, for on referring to his table for 1879, based on Dr. Dim- mick’s observations, we find that the 7 A.M. observations of January in that year gave a temperature of 41° F. on two occasions, of 40° F. on three occasions, of 39° F. on two occasions, and of 88° F. on one occasion ; in Febru- ary of that year we find three 7 A.M. minima under 48° F. (viz., 42° F., 40° F., and 89° F.); in November two such minima (42° F. on two occasions) ; and in Decem- ber of the same year, 7.¢., the first month of the following winter season, seven such (viz., 42° F. on two occasions, 38° F. on one occasion, 87° F. once, 85° F. once, and 33° F. twice). That is, we get the figure 20 instead of the figure 13 representing the total number of days having a minimum under 43° F, As tothe figure 15, showing the number of days, in 1879, having a maximum at 2 P.M. above 83° F., a careful examination of Dr. Dim- mick’s figures verifies its accuracy. The actual figures for the fifteen days in question were as follows: March, 89° F. once, 84° F. once; May, 92° F. once; June, 97° F. once, 95° F. once, 90° F. once; August, 85° F. once, 84° F. once ; September, 86° F. once; October, 90° F. twice, 89° F. once, 88° F. once, 87° F. once, and 86° F. once, We have now presented all the data at our command which are likely to help the reader toward an accurate understanding of the Santa Barbara climate, at least so far as it has been possible to do so within the just limits of the present article ; and the sum and substance of all recorded observations appears to be a demonstration of the fact that Santa Barbara possesses a winter climate as mild in temperature as any in Southern California, per- haps the mildest of all; and that it has (like all other stations lying to the west of the Coast Range Mountains) a very moderate degree of heat in summer, with cool nights, and with temperatures, even at mid-day, which are usually much below those found at that season in the eastern and central portions of the United States. Fogs and winds are the chief blemishes in its winter climate, and it is at that season unsuited for residence by those having a tendency to rheumatism, and is less suitable for most phthisical patients than are the inland stations. The upper part of the town is the best for residence by those desiring to avoid dampness, and at El] Montecito, a suburb two or three miles to the east, there is said to be better shelter against the sea-breeze than at Santa Barbara itself. THE Osat VALLEY.—About thirty miles east of Santa Barbara is the Valley of the Ojai, which, according to Dr. Orme (op. cit.), is sheltered from ocean winds and fogs. The little town of Nordhoff in this valley has an elevation above sea-level of about 1,500 feet, and stands fifteen miles back from the coast. The Ojai Valley is a resort which seems likely to become one of the most popular in Southern California. ~ Interesting views. of Santa Barbara, and rather attractive (although far less instructive) views taken in the Ojai Valley, may be found in Harper’s New Monthly Magazine for November, 1887. Huntington Richards. SANTA FE. [For a detailed explanation of the ac- companying chart and suggestions as to the best method of using it see article ‘‘ Climate,” vol. ii., pp. 189-191. ] Santa Fé, the capital of New Mexico, and the largest town in that Territory, lies at an elevation of seven thousand feet above sea-level, upon the western slope of the Rocky Mountains, the eastern slope of the Valley of the Rio Grande, and, roughly speaking, at a point equi-distant from the crest of the mountain chain and the river. The little river Santa Fé, one of the chief branches of the Rio Grande among those running into the latter from the east, bisects the town. The distance from Santa Fé to the Rio Grande in a ‘‘ bee line” is about seventeen miles ; in a southwesterly direction to the point of junc- tion between the Santa Fé River and the Rio Grande, it Climate of Sante Fé, N. Mex.—Latitude 35° 41’, Longitude 106° 10'.—Pertod of Observations, December 1, 1871, to June 15, 1883.—Hievation of Place of Observation above the Sea-level, 7,055 feet. A B = > ® as} 2, Ba ge 2.5 § 9° Mean temperature of months go Mean temperature at the hours of a g for period of ob- ae servation. OH =fee) o or gc oO > _ | 7 AM. 3 P.M 11 P.M. || Highest.| Lowest. Degrees. | Degrees. | Degrees. || Degrees.) Degrees.) Degrees. ganuary....| 21,1 36.2 26.9 28.0 b Meero aac February...| 24.7 40.5 381.0 82.0 | 87.0 24,2 March...... 30.3 49.6 38.5 39.4 We 2475 32.4 ACO YT Peis ee 36.2 55.8 44.3 45.4 | 51.2 Ait: i, ee ee 46.7 66.3 54.8 55.9 | 60.0 52.0 dine re... 56.6 76.0 63.6 65.4 || 68.6 62.2 PUL ese 60.4 GTA 66.2 68lOe e708 64.0 MUS Stic. at | 988.2 75.1 64.5 65.9 1. 168.2 64.3 September..| 49.8 69.7 57.5 59.0 62.5 56.8 October..... 40.4 60.1 47.8 49.4 52.8 45.7 November.. 29.2 45.8 34.9 36.6 42.7 29.6 December .. 23.3 39.5 28.7 30.5 33.0 26.4 | floaters, eas He asioaoe i asada. || eceriac 46.9 | 51.8 44.2 SQMMIOr, FI Cees scte | leiswte vel | renee ue 66.4 68.2 65.2 AACE. ea icicte aot til mae atte WHE Ol eats 48.3 50.8 44.0 Wanter.. Go iets do's ala sis ay S coil ees caities 30.1 32.8 27.2 VORP Cee, ool wrerteete | Feereasleme [5 ea grote ft!) 50.2 45.4 Cc D E F G H o © Sia gi mddo Pa 4 a B 3 Bg Ss/S8S8 Sasha So Pe Fs Be” Aiton & o vo J 5, Beg sies sa = = SeP Sacha Be & ||Absolute maximum] |Absolute miniraum||° 2g 8|° 235 9 8, 5 a temperature for|| temperature for||3 5° 5 Se°R tale c= period, period. Bo aR Oo ag as 5S Eada sca k + he BERS See : © a Ba g » f softs po ea ier g e goFe goes 2 g SMES SHES < < Sane oad Highest.; Lowest. |} Highest.; Lowest. Degrees.| Degrees. || Degrees. | Degrees. || Degrees. | Degrees. 89.5 15.0 76.0 46.0 6.8 —13.0 18 ° 44.9 20.7 75.0 48.0 19.0 —3.0 28 23 54.8 28.3 82.0 66.0 25.0 Zero 81 31 58.0 34.3 84.0 7.0 23.0 11.0 24 24 71.3 43.0 890). 975.0 34.0 24.0 24 28 81.0 51.3 92.0 85.0 53.0 33.0 21 22 83.2 56.5 95.5 86.0 53.0 46.0 22 29 80.7 Dok 97.0 $1.0 | 53.0 40.0 17 29 74.5 46.6 90.0 74.0 42.0 27.0 28 25 63.5 ities! 85.0 69.0 29.0 16.0 25 27 49.4 24.6 77.0 56.0 25.0 —11.0 24 27 41.5 17.0 65.0 52.0 10.0 —13.0 18 18 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 3|Kiu| m|wn oO R S oot to 5 i oa ‘ Pe 25 a 4 g| oe 5 = 3 ‘og g aI £ ° ta - 5 e So a 3.8 5 g S92 /32)acg| gt | ke 5 aoe pa. we | SS Bs u Ss Far ous ea | OF OF Se £3 oH © Be Yo) ots Po ae |] ae a YS ai oo aq ES aedis do | oo | OR! £ Fo a doje |2 | 2° |ee3| £ |) gF | 38 : ays ce ar ar 2 Inches.| From January..../ 89.0 | 51.7 | 11.2) 15.8 | 26.5 | 0.52 N. 6.9 February ..| 78.0 | 54.0 | 12.5 ins 23.8 0.64 N. ee! March...... 82.0 | 42.9 | 13.8 1255 26.3 0.51 S.W. 8.1 A DTT eke 73.0 | 35.0 | 14.7 Hb 26.2 0.57 S.W. 8.8 Maya cnces 69.07 1630-4 |- 15.2 12.4 27.6 0.85 |E.&S.W. 8.5 June, ......} 59.0 | 30.5 | 18.9 13.7 27.6 114 S.W. 7.5 dhyana ce 49.5 | 46.5 | 18.4 Gl 25.5 3.41 E. 6.7 August..... 57.0 | 50.9 | 18.0 WES al 3.01 EK. 6.1 September.| 63.0 | 48.5 | 12.7 14.9 27.6 E25 E. 5.9 October....| 69.0. | 41.9 9.9 18.8 28.7 1.02 EK. 6.6 November..| 88.0 | 49.2 | 10.9 15.4 26.3 0.91 N. 6.5 December..! 78.0 | 50.7 | 10.8 | 15.6 26.4 0.65 N. 6.3 Spring .....| SOO 36.1 || 43.7 36.4 86.1 1.93 S.W. 8.5 Summer ...| 64.0 | 42.6 | 50.3 28.3 78.6 7.56 EK. 6.8 Autumn ...!101.0 | 44.9 | 33.5 49.1 82.6 3.18 EK. 6.3 Winter..... 89.0) 52.1 | 34.5 42.2 76.7 1.81 N. 6.8 Year): ee. 110.0 |! 43.9 1162.0 | 156.0 318.0 14.48 E. tee is about twenty-three miles. The main chain of the Rocky Mountains near Santa Fé attains a very consider- able elevation, and less than thirty miles to the northeast of the town are peaks between twelve and thirteen thou- sand feet high. Santa Fé does not lie in a valley, but upon a great plateau ; ‘“‘in a wide plain surrounded by mountains,” are the words used to describe its location by the writer in the ‘‘ Encyclopedia Britannica ;” while the authors of an army circular, quoted by Dr. W. Thornton Parker in his interesting pamphlet ‘‘ Concerning the Cli- mate of New Mexico,” say that the town is ‘‘ pleasantly situated on an extensive plateau,” etc. We are told by the authors just cited, that although ‘‘large pines and cedars are found on the hills toward the mountains : the country for miles about Santa Fé is,” never- theless; ‘‘ destitute of trees,” 7.e., of trees of any consid- erable size, although ‘‘ stunted cedars and pines are very common.” They add that ‘‘this want of vegetation de- tracts much from the natural beauties of the town and vicinity.” Of the water-supply they say: ‘‘ The river water is very extensively used for drinking purposes, and is excellent ; good water, but a little impregnated with lime, may be obtained by wells at a depth of from ten to forty feet.” Of the matter of drainage they remark that although ‘“‘ the natural drainage of Santa Fé is excellent, ind is materially assisted by an extensive system of ace- quias or canals around the town, still little attention is paid to the subject, and many of the narrow streets and lanes of the city are excessively filthy.” The soil about Santa Fé they describe as ‘‘ dry, light, and sandy, and yet very fruitful.” I shall attempt no discussion in this place of the claims of Santa Fé as a health-resort. The reader desirous of particular information on this point is referred to Dr. Parker’s pamphiet just mentioned. A general discussion of the climate of New Mexico, considered from a sanitary point of view, may be found in the article entitled New Mexico, and in particular toward the close of that arti- cle, vol. v., p. 182. In Dr. J. Hilgard Tyndale’s papers on ‘‘ The Climate of New Mexico” (see boston Med. and Surg. Journal, 1888, vol. i., pp. 265 and 818) may be found various tables and data illustrative of the climate of Santa Fé; but the figures presented in the accom- panying chart, together with such as stand in Tables A, B, F, and H in the New Mexico article (of which Table F is quoted from Dr. Tyndale), and the data given in the table on page 238 of vol. ii. of this REFERENCE HAND- BOOK, will doubtless suffice to convey an abundantly ac- curate idea of the local climate of this town. i, i. SARANAC LAKE. Saranac Lake lies in the north- west portion of the Adirondack region of New York State, at an elevation of 1,539 feet above the sea-level. Having at command no special climatic data for this resort, and having no comment to make upon its claims as a health-station other than what may be found un- Santa Barbara, Saratoga Springs. der the title Adirondacks, in vol. i. of the HANDBOOK, the writer will confine himself in this article to a brief mention of the institution known as the ‘ Adiron- dack Cottage Sanitarium,” which was established near Saranac Lake three or four years ago. This institu- tion, intended for such phthisical patients as, in the opinion of its medical staff, would be likely to derive benefit from a sojourn in the Adirondack country, pro- vides good accommodations and medical supervision, at the exceedingly moderate price of five dollars a week, being supported chiefly by voluntary contributions, and with the object of providing a chance for climatic treat- ment to persons in moderate or reduced circumstances. The plan wisely adopted in building this institution is the cottage plan, each cottage accommodating from two to four persons, and intended for use simply as a dor- mitory ; the dining-room, general “ sitting-room,” kitch- en, etc., being in the main building, about which the cot- tages are grouped. This main building is described as ‘‘ a quaint, irregular, red cottage, with unexpected corners, delightfully original and ample windows, a deep piazza, and a range of offices and store-rooms at the rear.” (‘The Adirondacks as a Health-resort,” by Joseph W. Stickler, M.S8., M.D.) The custodian’s apartments and four bedrooms for patients are on the second floor of this building. The site for this institution was admirably well chosen, being a shelf-like plateau ‘‘on the shoulder of ‘a hill which overhangs the valley of the Saranac River,”—a “natural terrace on the spur of the hill, with a steep de- scent of about one hundred feet to the Saranac River in front, and an equally sharp and still higher rise to the crest of the ridge in the rear.” (Op. cit.) The exposure is toward the southeast. The little plateau commands a fine view of the higher peaks of the Adirondacks, some fif- teen miles distant toward the east and southeast. The steep wooded hill-side behind the terrace protects it from the storm-bearing winds of the region. The soil is sandy ; the natural drainage facilities are of course excel- lent. It is much to be desired that similar institutions should be established at other leading sanatoria of the United States. SARATOGA SPRINGS. Location and Post-office, Sara- toga Springs, Saratoga County, New York. AccEess.—To Albany, N. Y., by the various railroads centring there, thence to the springs by the Saratoga & Champlain Division of the Delaware & Hudson Canal Company’s Railroad, extending from Albany north to Montreal, Canada. THERAPEUTIC PROPERTIES.—The characteristic ingre- dients of the waters of this famous resort are common salt and alkaline carbonates. They are therefore classed as alkaline-saline. The proportion of contained carbonic- acid gas is unusually great, and the waters in great meas- ure owe their popularity to their sparkling appearance and agreeable taste. Altogether there are about thirty springs, six of them spouting. The High Rock, Con- gress, Washington, Hathorn, Geyser, Empire, and Star springs can be taken as types of the Saratoga waters. Some are cathartic, some contain iron, sulphur, and iodine. The tonic and cathartic properties of these wa- ters have made them the most popular in America of all adapted to the treatment of catarrhal diseases of the di- gestive and urinary organs, gall-stones, urinary calculi, jaundice, torpid liver, ete. Saratoga is situated in the northeastern part of New York State, thirty-two miles north of Albany.. Its per- manent population is about ten thousand, but this num- ber during the ‘‘season”’ is quadrupled. The streets are wide, well graded, and bordered by large elm-trees. Ho- tels and boarding-houses abound, and there are many handsome residences. Probably nowhere in the world are there caravansaries constructed upon such a scale as to size and comfort. The attractions at Saratoga are few besides the interest connected with observing the ever Changing multitude of fashionable visitors, and lis- tening to the fine music provided at the leading hotels and in Congress Park. é 283 Saratoga Springs. Sarcoma. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. ANALYsIs.—One gallon contains : Champion | Colum- | Gongress,| Crystal. | Empire. | Eureka. | Excelsior.| Geyser. | Hathorn.| High | spouting. bian. /Prof. C. F.| Prof. C. F. |Prof. C. F./R. L. Al-/R. L. Al-|Prof. C. F, Prof. C. F. Rock. Prof. C. F.| Prof. E. | Ghandler.|) Chandler. | Chandler.| len, M.D. | len, M.D. | Chandler.| Chandler. |Prof. C. F. Chandler.| Emmons. | Chandler. Grains. Grains Grains, Grains. Grains. Grains. Grains. Grains. Grains. Grains. Bicarbonate of lithia.............. C24 eee ee 4.761 4.326 2.080 Wi GS oe eee 7.004 200, lee ee Bicarbonate of soda.............-- 17.624 15.40 10.775 10.064 9.022 S!750 aes ee wAsooe 17.685 34.888 Bicarbonate of magnesia .......... 193.912 46.71 121.757 75.161 42.953 29340 FAY eos 149.343 130.555 54.924 Bicarbonate of lime............ -» > PHOAV EUS Eb pas ear 143.899 101.881 109.656 A1 G21 Tile ee es 170.392 147.226 131.789 Bicarbonate of strontia ........... OCS 25 tees cee trace trace tracesy i Mist cele ee 0.425 trace trace Bicarbonate of baryta............. 2083 MR eck or 0.928 0.726 0, OF 0 re terete an nee ee 2.014 0.972 trace BICaArHDONALG OILON eho. eae O64 ti eee ee 0.340 2.038 0793 Sh) ee ee cet mee eet core 0.979 0.853 ° 1.478 Oarbonaterton mew cee ck Pilly revatio Hebe g ie ate Pe en tke ec Sem |) tema ata s (oO baal) fo ereeret mtn | et enete ee LOCOS ee on : E inp ee, Ol atte eee @hloride‘of sodium... cen veuee 702.239 267.00 400.444 328.468 506.630 166.811 370.642 562.08 478.722 390.127 Ghioride!of potassium... 7.3.26... A446 ol 0 Ber. cts 8.049 8.327 4: 202 78 1 aa eereee Wl mesieaees. fio 24.684 82.859 8.497 OChiloride’of magnesium :2%.6.6..58 50. lad irk een] Re EAE Se Ty AUS oc ci clan 00 Mucccwaire Cicatercll at Nm Mena a ie sor uiag Nees SCO kad Lc ae ee ee CO) sV erm hroy merece) 1204s eS Ser he a ie A a Se i sac WN porenny lee st cek. IP kseke yt pig sse oe he cer eel Poe Ohloride of lithium 3). Sos es hoe ic Re Meee oe ayes Pe ere ET Hp Nee scat ote Taal! areca 0h a eae | ea) Re Mees Al ee pct Sulphate of potassa.. ...........- 05252 sree 0.889 2.158 269 Oe nn diaries 28d 0.318 | trace 1.608 Sulphate Of Masnesialvec class we.ce cll heres Heel eee tec, © (Mme ete tet reuman laMeratetetore, Mea EeMartayela cere 2.146 Tol Beene mall oe a Were ok aad Meteors Sulphate of Boda :.b 0 dacs cece wcekladd | Wystee cee amid la beste: coke) LOL daie ee’ ctene all SOc a tercy ete saue MME sc teues ae as Oia tot cere SQ Soe cote, lr ieee ce ah mettre Sulphate of strombiagy 25 20 cco mk ose tl Sota ee ok ee orto cn er he i | aaa tones hres or (re ne noe EXYACE™ Ell ites. Wl atisaclee GaMILa Sistine peje § 6) ft; 0 cian Mil ba6)> eae re PRM ire gener Mere ee MC ee ee aes tio rade Os dinars il aabdoels, | Godlee | saben Fi resstabehl| | Matias oO ees Phosphate ofisodayyivse. oeieeste ee OO103 eee 0.016 0.009 OLU28 CIT | ee saroe an meets ee trace OS OL Ole mae Phosphate. of Times. 0. s-f.c5.s clersce cM Saree Sar Ab uherewtee ) E Ua en setehen WL, (ies oo ots MIM MDUNEtere crete cM Cay cen) So a ee ee oe ee trace Biborate ofisoda so see een. an eee tEACE) Tce ee trace trace trace) uh sb eee ieee trace TYACOW UNGMAE S os Bromideoft sodiumu. eae 3:5 (ON Mae ee 8.559 0.414 0.206, 21a ee er aes 2.212 3.644 0.731 Bromide of potaselwm yo cesiscre es Hs eee IN ete ee eeSTemn lecP deceisecce rem en nieSTO ct 20 een Poe 1.566 LFACCS Bi Ouitcee ah eile merecaeke Seemel ware eRe Jodiderof sodium sey see eee tee 022340 ret 0.188 0.066 0.006 4.666 4,235 ().248 0.115 0.086 Fluoride of c#leiumir. pees eee pagevetey Vill)” aa kt ke trace trace ALTACE, hl hed. Je. eee! meres trace trace trace Fluoride of lithium, .5 62/20 03.62 a5 | Sea geews Ul See cee Od eee Se etise U| Tipcteceiesecell aces ee ric anita coerce) ane Erg tee O Hydriodatetor soda hens ssecetit all meee Psi eo ne Poe cies Pry wl eeepc inks car Et el el hae Las, NI else f Alumina Ces qadeh Meee ee Ler weer cees OLB pence trace 0.805 0.418 Oi 2571 Cain tee ape trace 0.258 1.223 Silicate of potasea fey seas casicis lates ec ML pect MMB WD ae ctor lice cus ro os ret O00) Shot eee ee eae Bln, eee Silicate Of BOM 1.5 saicre chi eceareee cha BEh Meets el eee oT aac olathe s Sean Garda re coe maieccs: tc enn meu ete faye UM see AQOU |e cRe eat Clk Win. heme eee mele Silica f/tavike oot lee eee ite ete 0.699 2.05 0.840 3.213 1.458 O:5 82) Miers 0.665 0.700 2.260 Organic imattermiieen seen one ee tTAce: Wile cew ste TieaeeAt Te ee trace traces 3 04.52 2. Cling eee trace trace WW ne. totes) a nr ik A ane aaa ll abeeae ee eer fe Bieta ae ik Carre oe ol Suck Wl Mies Ase We oagand! bof eoce sc BOracic ACid 07.22 un8 wee oe cence el Loren ceteel ae no tarrete byes Wi eee ead GW inmates ile emp etas WMA seen Bi” MN Uaioe pine) Malt ay eas opts CR eames MOtala ye cee re eee 1195.582 407.30 700.895 537.156 680.436 258.365 514.746 991.546 820.844 627.561 Gas Cub. in. | Cub. in. | Cuh. in. Cub. in. Cub. in. | Cub. in. | Cub. in. | Cub, in. Cub. in. | Oub. in. Oarbonic:acid. = Set eeeecm ances 465.458 272.060 | 392.289 317.452 344.669 239.000 250.000 454.082 375.747 409.458 Kissingen.| Pavilion. Red. (Saratoga A.| Seltzer, Star. Union. United | Vichy. Washing- J. R. Nich- Prof. C. F.|Prof. J. H.|J. G. Phole,| Prof. C. F.|Prof. C. F.|Prof. C, F.|_ States. | Prof. ¢.F.|_ ton. — ols & Co. | Chandler.) Appleton. M.D. Chandler.| Chandler.) Chandler.|Prof. C. F.. Chandler, J- R. Chil- Chandler. ton. Grains. Grains. Grains. Grains, Grains. Grains Grains. Grains. Grains. Grains. Bicarbonate of Lithia va): sees 5.129 9.486 () 1042) PATE 08 SS Salt os Pete yee ee 2.605 4.847 . T(60 ane Bicarbonate of soda..............- 67.617 3.764 15.327 6.752 29.428 12.662 17.010 4.666 82.873 8.474 Bicarbonate of magnesia .......... %0.470 16.267 | 42.413 20.480 40.339 61.912 109.685 72.883 41.503 65.973 Bicarbonate of lime ............... 40.260 120.169 101.256 56.852 89.869 124.459 96.703 93.119 95.522 84.096 Bicarbonate of strontia ........... trace trace sp Seae ee Milter se ets ols trace Pavceer trace 0.018 trace, oases Bicarbonate of baryta............. 0.992 OSS ae ete AP eerste tpg Pore lh We me gene 1.703 0.909 0593 S|" Se iBicarpouate-ol tron ess ene 1.557 2: DO ilpereerce 1.724 1.703 1.2138 0.269 0.714 0.052 3.800 Ontoride orsodiuins + -eor cue sence. 238.500 459.903 83.530 565.300 234.291 378.962 458.299 141.872 128.689 182.733 Chloride of potassium............. 16.980 7.660 6.857 0.857 1.385 9.229 8.733 8.624 TALS ieee Chloride of marnesium teh ge. cos hie toe |e. ee ea ene eee trace: 2) CC. LER Sorin OR Re NEP ter Fela ROR all ee ore tat 0.680 Chiorvide oficalcium Fs. 7.c sesceecell| bem ceteec | Meeeie se en ee one EYACOE | sli Pes Renee “efi Oke eles taal Reta c coe POR ID tnre eee eel lee eens 0.203 OhloridevoL bthivim |. :Gee fees cose catches, eects or aned I tna ete en mm 0562 clans ARCA aes Shah an ia soe Oconee gee || eee ee Sulphate of potassa ..........--00 trace 2032 Cale geek 0.370 0.557 5.400 OLS ub ene cies LTACET br luber eee Stilphate- of maanesia. leit... ip bivohepe cia oll ntti aes Seatposts ot Ree te ec eee re ALUMINA Ce, aath citos staieees cece trace 0.3829 2.100 * 0.880 OSTA Bie Manes se 0.824 0.094 0.473 trace Silicate of POtASBA 7. 6 siss'eisievels.edies os), “isterut alee ct soahbr fh cS od cereale eetepe tee MRT: Mine Pet ern wh Oty nti (ura eres Fe a | a ger Or | Sica terorsoda sekiincs ate sicwse esc brews eee Mere rar! fey st) | aagke MeN oete aie oouuae| cake Wt ya gelsts’ “MS esaeise Siljcn Maceo. heen Net eee ook 1.280 3.155 3.250 2a ee 2.561 1.288 2.653 3.184 DATOS Nil ae ete OLranicaMaLLerine acta cece: tokeis trace trace ')) Si cU.F 0 Re Pee een nmerereyetares alll Sirona reeee trace trace UWACOT EH ceria MILICIG: BOLdae 12, By eee wie sicvectevs Chicabolitl mee shire. esumecuen iene habe arne ans LAGOA earth e enters & Bacal ete cra eee, Ree 1.500 BOraGicracld eS aare slaslee nee eee Ce ol dee oc bine tmhll ieeeleieca sce Tl ca htc -5 Reale ee ERACON Eph Wie serail ul Sc ciseaten sain |i enue teeter ore tenee co am | en camer LOCAL UE Sethe wth. let cite: 444.627 687.275 255.680 656.911 401.680 615.685 701.174 381.8387 367.326 350.227 __ Gas Cub, in. | Cub. in. | Cub. in. | Cub. in. | Cub. in. | Cub. in. | Cub. in. | Cub, in. | Cub. in. | Cub. in. OCarbonic'acid so. wean ede ee acces 432.634 EP AACN hg Gay fae 212.000 824.080 407.550 384.969 245.784 383.071 363.770 284 * Alumina and sesquioxide of iron. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES, — Saratoga Springs. Sarcoma. The High Rock is the oldest spring, its medicinal qual- ities having been known to the Indians, and by them shown to the whites as early as 1585. Derick Scowton built the first log-cabin here in 1778, and in 1784 General Schuyler erected the first frame-house and made cther improvements toward rendering the place more accessi- ble and providing for visitors. The season extends from the middle of June to Sep- tember. During July and August the weather is apt to be excessively hot. Yet the air is pure and is generally acknowledged to be tonic. Shade-trees on the streets, in the park, and in the extensive and attractive courtyards of the leading hotels, in a great measure temper the at- mosphere and compensate for the absence of a cooler climate. Geo. B. Fowler. SARCOMA. In defining the various tumors of which we have treated in this work, it was possible to compare them with some normal tissue, either in the character or in the arrangement of the cellular elements. We come now to the consideration of a tumor most forms of which do not agree, either in structure or in the character and arrangement of the cells, with any of the tissues of the adult body. The sarcoma has most similarity in struct- ure to the connective tissue, and its affinity to this is still more clearly shown by the fact that it always origi- nates in this tissue. ‘The chief difference between the sarcoma and the other connective-tissue tumors is that the connective tissue which forms the type of the sar- coma is represented, not by the adult, but by the em- bryonic form of this tissue. The different varieties of sarcoma may be said in a general way to represent the different phases which the embryonic connective tissue passes through in the course of development. This dif- ference between the embryonic and the adult connective tissue is chiefly found in the greater abundance of cells in comparison to the formed material, the intercellular substance; and a similar difference exists between the sarcoma and the fibroma. In the fibroma we have a tu- mor composed of a tissue which in nowise differs from the adult connective tissue, and which cannot be distin- guished from it, macro- or microscopically. The same -is true of the osteoma and chondroma. The tumors are typical. The sarcoma may not differ from the fibroma, save in the number of its cells, nor from the osteoma or chondroma, save in the fact that the bone or cartilage in the tumor is atypical, as compared with the adult tissues, and resembles that formed in the first stages of the evolu- tion of the skeleton. We may have different species of sarcoma, which are more unlike each other than two tu- mors of wholly different names. The tumors which are now included under the term sarcoma were formerly known under a great variety of names. The name sarcoma is a very old one, and was used to describe all manner of fleshy growths (cdpé, flesh). Galen described under this name fleshy polypi of the na- sal cavity, and afterward all sorts of fleshy growths ; and later. authors used the term to describe all growths which had the appearance and consistency of muscular tissue. Still later the conception was extended until, at the beginning of the present century, it came to include every sort of tumor which had not a cystic struct- ure, or was not extremely hard, or had not an especial tendency toward ulceration. The influence of Abernethy was felt in this ; he proposed to make a very large group of tumors, which received the general name sarcoma, and which was further subdivided, according to general appearances and clinical course, into a number of species. Only the cystic tumors, the exostoses, and cancers were left out. As soon, however, as the tumors began to be studied histologically, those for whose tissue a type could be found in some one of the adult tissues were separated from what had been known generally as sarcomas, and an attempt was made to abolish this name. Still, it was found that many tumors did not agree exactly with the forms of connective tissue, though they were evidently derived from it. Lebert, in France, designated the most common of the sarcomas, and the one most frequently taken as a type of the tumor, the spindle-cell sarcoma, fibro-plastic tumor. Robin separated from the general group certain tumors which, though having much anal- ogy with the fibro-plastic tumors, yet in their structure more nearly approached that of the embryonic tissues, and to these he gave the name embryo-plastic. In Eng- land, Paget, studying the tumors more from a clinical than a histological stand-point, found certain tumors which, though similar in appearance to the fibromas, dif- fered from these by their greater malignity, as shown by a tendency to return after removal. To these he gave the name of recurrent fibroid. Paget named other tu- mors, from the similarity of their structure to the marrow of bones, myeloid tumors. We owe to Virchow the first scientific classification of these tumors; and his views, as expressed in his ‘‘ Geschwiilste”’ (1864), have since then undergone but slight modifications. We will first consider the sarcoma as a single tumor, then under separate heads the various varieties. The sarcoma, in general, is distinguished from all other tu- mors by the abundance of its cells; and the diagnosis of the particular species is in great part made from the character of these cells. In the case of the simple tu- mors of the histoid group, as the fibroma, myxoma, etc., the diagnosis is made, not so much from the character of the cells as from the tissue which they produce, In the carcinoma and other tumors of the epithelial type, the diagnosis is made, not only from the character-of the cells but by their grouping. The great strength of Vir- chow’s description of the sarcoma lies in his comparison of the tumor to embryonic tissue. JBillroth does not agree with him in this, hut considers the sarcoma-tissue as most similar to embryonic muscular tissue. This ap- plies especially to that variety of sarcoma which is com- posed of spindle-cells. The type of the sarcoma-tissue may also be found in the adult tissues, in some patholog- ical conditions. The tissue covering the floor of an ul- cer, the granulation-tissue wherever found, is similar to the tissue of some of the sarcomas. This granulation- tissue passes through the same steps in the formation of connective tissue as does the embryonic tissue. In its earliest form it is composed almost entirely of cells which present some differences of form, and whose general character is represented by a round cell about the size of a leucocyte, with a relatively large nucleus. Not infre- quently large protoplasmic masses, containing many nu- clei, may be found in this tissue. The blood-vessels are peculiar in that, in many cases, they appear to represent nothing but channels surrounded by cells, and are alto- gether lacking in a supporting meshwork of connective tissue. Granulation-tissue varies in some degree in the various tissues in which it arises; that coming from the marrow of bones, as in cases of fracture, etc., is similar to the embryonic marrow. We may have represented by it not only the general type of the sarcoma, but also some of its distinct species. The difference between the sarcoma and the inflammatory granulation-tissue is to be found, not in the histological character of each but in the termination to which each tends. When the granulation- tissue is produced in consequence of a wound or a chronic disease of the bone or articulation, it never passes beyond a certain point of growth, tends to the production of a typical tissue, and ceases to be when the conditions which favored its development no longer exist. In all cases a tendency to, or a beginning production of, a typical formed tissue can be seen in some part of the granula- tions. In the sarcoma, on the other hand, there is no such tendency to the production of tissue, but the cells simply increase in numbers. The character of the cells of a sarcoma is but slightly influenced by its seat ; every variety of cell may be found in tumors arising from the subcutaneous cellular tissue. The close connection of the sarcoma with the typical connective-tissue tumors is further shown by the forma- tion of mixed forms with these. In a fibroma the whole tumor, or certain parts of it, may contain more cells than can be regarded as typical for fibrous tissue; In other words, it approaches the type of connective tissue found in the embryo. This connection with sarcoma 1s expressed by the compound name fibro-sarcoma, myxo- 285 Sarcoma. Sarcoma, REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. sarcoma, etc. Virchow says that a tumor may also rep- resent a mixed form between the sarcoma and carcino- ma, in which certain parts are sarcomatous and others carcinomatous. Such tumors he has named sarcoma carcinomatosum, and he ascribes to them the malignity of both the sarcoma and the carcinoma. He does not think that in such cases the tissue of the sarcoma passes over into that of the carcinoma, but that they both develop simultaneously from the same tissue, growing like two branches of the same stem. When we regard the carci- noma as a pure epithelial tumor, and the sarcoma as a connective-tissue tumor, such combined forms must seem extremely improbable, and the tumors in which such a combination appears to exist will be found, on careful examination, to be either carcinomas with a stroma very rich in cells, or sarcomas in which the arrangement of the cellular elements resembles somewhat the alveolar structure of the carcinoma, the alveolar sarcoma of Bill- roth. Regarding, then, the sarcoma as a pure connective- tissue tumor always arising in this, it will be seen that it holds the same relation to this tissue that the carcino- ma holds to the epithelial tissue. Both are atypical tu- mors, the sarcoma showing this departure from the regu- lar type of connective tissue by the abundance of its cellular elements, and the carcinoma showing its depart- ure from the type of epithelial tissue by the number and arrangement of its cells. Hach may begin as a typical tumor. The sarcoma may first appear as a fibroma, and then, by an excessive development of cells, without any further development of formed tissue, become a sarcoma. The carcinoma may in like manner begin as an adenoma, and become atypical by the epithelial cells forming solid cylinders and growing into the connective tissue. There may be the mixed form of adeno-carcinoma, just as there may be the mixed form of fibro-sarcoma. The sarcoma bears the same relation to the fibroma that the carcinoma bears to the adenoma, but between the sarcoma and the carcinoma we have not only a morphological, but a histo- genetic, difference. No one sort of cell can be regarded as typical of the sarcoma. Almost every variety of cells may be met with, and even in the same tumor there may be found round cells similar to the granulation-tissue, spindle- shaped, and giant cells. The form of the cells, in great part, depends upon the physical conditions to which they are subjected in the tumor. When the intercellular sub- stance is relatively abundant, and fluid or semifluid, the cells are subjected to the same pressure in all directions, and they are then round. When the intercellular sub- stance exists in but small amount and is more or less solid, the cells are then pressed against one another, and they take various shapes. If the pressure is exerted laterally they become elongated and spindle-shaped. On such cells facets can often be seen, caused by the pressure of oppos- ing surfaces. The different characters of the cells may best be studied on small pieces of the tumor which have been macerated for along time in one-third water and two-thirds alcohol, as recommended by Ranvier, or in Miller’s fluid. The latter method gives in many cases excellent results. Spindle-cells are found more often than any other sort of cells in sarcomas. These are long cells terminating in long pointed extremities. In the middle the cell is swollen and contains a single nucleus, and rarely more than one. The nucleus is more refractive than the re- mainder of the cell, and often contains a bright nucleo- lus. In’some cases more than one process is given off from an extremity, giving the cell something of a stellate appearance. ‘These cells may vary a good deal in char- acter in the different tumors. In many cases cells are found which present a spindle appearance only when viewed in profile; on the side they appear as flattened epithelial scales. These cells are formed by pressure on the sides. Stellate cells are often found with long, branched processes, which may communicate with neigh- boring cells. The round cells vary much in size and general character ; some are found which are about the size of white blood-corpuscles, and contain a nucleus 286 which is very large in comparison with the cell. In other tumors large oval cells, closely resembling epithe- lial cells, are found, and between these two extremes there may be numerous other varieties. Whatever may be the character of the sarcoma-cells, they are always in the closest connection with the con- nective tissue. Even in those tumors which are richest in cells there is always a certain amount of intercellular substance between the cells, and there is not the same sharp contrast between the cells and the stroma which carries the blood-vessels, that exists in the epithelial tu- mors. In these the cells are arranged in groups like the glandular organs, with the stroma surrounding the groups of cells, but not entering into them. This isa diagnostic point of the greatest importance between the sarcoma and the carcinoma. Even in the case of the al- veolar sarcoma the separation of the cells into alveoli is only apparent, and on closer examination it will be found that small masses of connective tissue, and even blood-vessels, enter into the alveoli. Of late numerous growths, which were formerly con- sidered under the sarcomas, have been removed from the list of true tumors. This is the case with the pearly nod- ules which are found on the serous surfaces of cattle, and which Virchow placed among the sarcomas. They have been shown to be identical with tubercle-nodules, and to be due to the specific virus of tuberculosis. The same thing is true of actinomycosis. Before it was known that this disease was caused by a definite organism, the large tumor-like masses which it produces in the jaws of cattle were classed with the sarcomas, as a species of osteo- sarcoma, anditis probable that there may be other tumors, now classed with the sarcomas, which will be shown to be due to a specific virus. All sarcomas are very vascular, and, as a rule, only the larger vessels have any considerable amount of connec- tive tissue around them. The smaller vessels are in di- rect contact with the cells, they are more voluminous than vessels of a similar character in normal tissues, and their walls are composed of cells which in many cases are similar to those of the tumor. On section they ap- pear simply as spaces surrounded by the tumor-cells. They are similar to the vessels found in granulation-tis- sue. The close connection between the cells of the tumor and the blood-vessels is of great importance, and explains the course taken in the formation of metastases, In forming a classification of sarcomas, the only basis that we have is the character of the cells. As said be- fore, there may be different forms of cells in the same tumor, but one type will be found to be dominant. When divided into different species in this way, it will be found that, though there are a good many points of similarity in histological character, a study of the clinical features of each species will make these differences in structure still more evident. Some of the forms into which they may be divided will be found to be of much more clin- ical importance than others. The classification which we have adopted, one based principally on the character of the cells, is as follows: 1. Round-cell sarcoma syn. ; granulation-sarcoma, sar- come encephaloide, lympho-sarcoma, embryo-plastic tu- mor. A tumor composed of a tissue similar to that of the upper layer of granulations. The cells are round, and there is a very small amount of intercellular sub- stance between them. 2. Spindle-cell sarcoma; syn., sarcome fasciculé, fibro- plastic tumor, recurrent fibroid. A tumor composed of spindle-cells which are generally arranged in bundles. The intercellular substance is small in amount. 3. Myeloid sarcoma. A tumor composed of cells simi- lar to those in the bone-marrow, and among these large multinuclear, protoplasmic masses known as giant-cells. 4, Osteo-sarcoma. A tumor somewhat resembling the myeloid sarcoma, but in which there is a tendency for the embryonic tissue to organize and form more or ‘less complete bony masses. 5. Melano-sarcoma. A tumor whose cells contain a dark-brown or black pigment, which differs from the pig- ment formed from blood-extravasations. j REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. SARCauS Sarcoma. 6. Alveolar sarcoma. A tumor composed of cells often | cells are large and have more the appearance of epithe- resembling epithelium, and having, in the arrangement | lial cells, the malignant course is not so pronounced. of the cells into alveoli, some similarity to the carcino- | Most of the tumors known as encephaloid come under ma, but with the difference that the separation of the | the head of round-cell sarcomas. The term encephaloid tissue into cell-masses and connective tissue is not abso- | refers simply to the pulpy, brain-like character of the lute as in the carcinoma. tumor, due to the number of the cells and the softness of 7. Angio-sarcoma. A tumor which combines an ex- | the material between them. tensive new formation of blood-vessels with an active The spindle-cell sarcoma is more frequently met with growth of the cells forming their walls. than any other form, and this tumor has been generally Some authors. have subdivided the sarcomas still fur- | regarded as the type of the sarcoma. The tissue of the ther, making twelve or more species. The division here | tumor is arranged in fasciculi, and this is so evident given will embrace most of the forms of sarcoma. The | that it has given rise to many of the names which the mixed forms, with other tumors, have already been | tumor bears. This arrangement into fasciculi can best treated of. See Fibroma, Myxoma, etc. Any classifica- | be studied by roughly tearing apart tumors which have tion that can be made, either from the histological or | been hardened in alcohol. The trabeculae are composed from the clinical features, is at best an artificial one, and | of spindle-cells and fibrils, all running in the same direc- cases are often found in which it is difficult to say to | tion. Often several of these fasciculi seem to arise from which one of the species mentioned it belongs. the same point, and take a more or less spiral course. Round-cell sarcoma. The cells of which this tumor | They run through the tumor in every direction, and are is composed may be very small, resembling those found | sharply separated from one another. Sections made in granulations, with a nucleus almost entirely filling the ' through the tumor cut them in every plane. When the body of the cell, or may be section cuts one of them at a larger, similar to some epithe- : pare right angle, it no longer ap- lial cells. They are round and pears aS a spindle, but as a surrounded by an inter-cellular round? "cell? aA substance which is very soft or blood-vessel gen- semi-fluid. On section of the erally traverses fresh tumor a small amount of the centre of one juice, more transparent than of these bands, that which comes from a carci- and in its walls noma, escapes; but after the every transition tumor has been kept for between the thin from twelve to twenty- wall of a capillary four hours, and the inter- and the thicker cellular substance has wall of an artery been softened by cada- or vein can be veric changes, this seen. The smaller juice is more abun- of them consist of dant. It is prob- é endothelial tubes, able that the inter- £ the cells compos- cellular substance 7 ing which can be is not naturally seen without treat- ‘fluid, but of a ment with nitrate of jelly-like consis- silver. Besides these tency; or if fluid, it is held in the vessels passing through meshes of the tissue just as the fluid is the bundles, others will retained in dropsical tissues. When be found which surround the fresh fluid is examined large num- them like a long spiral. bers of cells will be found init. In Both the cells and the nuclei many cases the amount of fibrillar of the endothelium are much connective tissue is so small, that it larger than in normal vessels. is only by careful shaking and brush- Their nuclei, especially, are ing the section that it becomes visible. te eo pee apt PU le Some of this connective tissue is un- a eee above the level of the cells, anc doubtedly newly formed, but part is ot Silat eae igetensinin ach gore are seen in the lumen of the tube the old connective tissue of the place Fluid. x 300. as slight elevations, As a rule, of origin of the tumor, simply pushed : these blood-vessels are much wider apart by the rapidly-growing cells. Some spindle-shaped | than vessels ofa corresponding structure in normal tis- cells are always seen, either around the larger groups of sues. Either the entire vessel may be wider, or there may round cells or along bands of connective tissue. When | be dilatations at intervals, which may reach a considera- a thin section has been shaken for a long time in a test- | ble size. The spindle- or oat-shaped cells, of which the tube with water, most of the cells will be washed away, | tumor is principally composed, early attracted attention and if the section has been examined before this, one | when the histological structure of tumors began to be will be surprised at the amount of connective tissue | the subject of systematic study. For a long time they which is now visible. There may be an almost perfect | were considered as characteristic of the sarcomas and of reticulum, which can surround every cell in much the | the malignant tumors In general. These cells are not al- same way as in a lymphatic gland. The blood-vessels are | ways pure spindles in shape, but often show various tran- always very large and abundant. They seldom have nor- | sitions approaching the stellate form. They consist of an mal vascular walls, and on section appear as spaces be- elongated mass of protoplasm, which at each extremity tween the cells. Only the larger ones are surrounded by | runs out intoa long, thin process. Sometimes two or more any connective tissue. Along these vessels, and gener- | processes are given off from a single extremity, and these ally throughout the tumor, blood extravasations are com- | 1n turn may have lateral processes. The surface of the mon. The connection of the tumor with the surrounding | cell is rarely perfectly round and smooth, but is indented tissues is a very close one, and it is often difficult to say in various ways, and may be flattened into a ae just where the tumor ends. The most striking resem- | nous form. The protoplasm of the cellis finely granular, blance between this tumor and an inflammatory focus is | and more refractive than that of the white blood-cor- often seen. These round-cell sarcomas are very malig- | puscle. Occasionally one or more fat drops are outs i nant; they grow rapidly and diffusely, invading the sur- | a cell. The nuclei are ordinarily visible EA. the fhe rounding tissues, and produce metastases. When the | of acetic acid or any coloring agent. They lie in 287 f Sarcoma, Sarcoma. middle of the cells and occupy the entire body of the cell at this point. Rarely more than one nucleus is found in a single cell. The cells are not always of the same size, even in the same tumor. The smallest of them are about 15 w long and 5. broad, while in other cases they are 100 w long and 15 to 380 broad. This difference in the size of the cells has led to a division of the tumor into large and small spindle-cell forms. In general the cells are smaller in those tumors which have the most rapid growth, or in those parts of a tumor where the growth is most recent. The cells all lie in the same direction in the bundles, dovetailed into one another, with the largest part of one cell in contact with the smallest part of its neighbor. In a perfectly fresh tumor it is difficult to separate the cells from each other. A certain amount of fibrous tissue is always to be found in these tumors, and even in the bundles where the cells Jie thickest careful observation will show some fibrils between the cells. These fibrils often appear to be in direct continuity with the cells. The name fibro-plastic was given to this tumor on account of the supposed tendency of the spindle-cells to form fibres. Bands of connective tissue in which the cells are very numerous, are sometimes found between the larger cell-bundles. The slower the growth of the tumor, the more connective tissue is found in it. The spindle-cell sarcomas vary much in density, but are al- ways much firmer than the round-cell form. Some of them are fully as hard as a myoma, and on section re- semble this very much. The firmness of the tumor de- pends upon the amount and character of the intercellular substance. In the fresh state the cells are difficult to isolate, and on scraping the cut surface a clear, trans- parent fluid, containing but few cells or fragments of cells, will be obtained. The myeloid sarcomas are soft tumors whose tissue is similar to that of the embryonic bone marrow. The cells lie in close relation with each other, and the inter- cellular substance is small in amount and more or less fluid. Some of the cells are small and spherical, like those of embryonic bone marrow, and like the early em- bryonic cells in general. They have little protoplasm in comparison to the size of the nucleus, and are similar to those described in the encephaloid sarcoma. Sometimes numerous spindle-cells are found, but these have not the definite arrangement into bundles that is found in the spindle-cell sarcoma, and their processes are not so long. There are other cells, which though sometimes met with in other species of sarcoma, more properly belong here. These are large protoplasmic masses containing a great number of nuclei, frequently one hundred or more, and have received the name of giant cells. They are found in considerable numbers in embryonic bone marrow, but never reach the size that is met with in tumors. They may be round, or oblong, or irregular in shape, and pro- vided with numerous processes. The nuclei are some- times arranged at one or both ends of the cell, or may be packed closely together in the middle. They are rarely scattered evenly through the cell-substance. The typical arrangement of the nuclei along the periphery of the cell, with their long axes pointing to the centre, which is so often found in giant cells elsewhere, notably in tu- bercles, is seldom found here. These cells may fall from their places in sections, and the empty spaces which were occupied by them may give the tissue an alveolar appear- ance. It is not uncommon to find them in great num- bers in one part of the tumor, while other parts may not contain them at all, or only isolated examples scattered here and there in the tissue. The nuclei of these cells are large and refractive, and in most cases can be seen without the aid of any reagent. The cell-substance itself is composed of a thick, finely granular material, which frequently has a slight yellowish or greenish tinge; in these cases the cell may be so dense that the nuclei only appear when the protoplasm has been rendered more transparent by acid. ‘The size which these cells fre- quently attain fully justifies their name. They may reach a diameter of one-fifteenth to one-tenth of a milli- metre or more, and can be seen with the unaided eye. Although most frequently found in the myeloid sarcoma, 288 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. they are often found in the other varieties also, especial- ly in the spindle-cell sarcoma. The myeloid sarcomas are almost always seated in a bone, and originate in the marrow. They gradually destroy the bone, but as the tumor grows a new capsule of bone is formed around it. Osteo-sarcoma. See Osteoma. Alveolar sarcoma. This name was first used by Bill- roth to designate certain sarcomas whose histological structure somewhat resembled the carcinomas, in that the cells were grouped together into alveoli. So striking is the similarity to carcinoma, that Billroth himself says that in many cases he is unable to make the dif- ferential diagnosis, It has been contended by many pa- thologists that the term was a misnomer, and that any tumor of such a structure must be a carcinoma. How. ever similar the structure of the two tumors may be, a careful investigation will always show points of differ- ence. In the strictest sense, no sarcoma has the alveolar structure of the carcinoma. Still, tumors which cer- tainly originate in the connective tissues, and which, from their general structure, must be regarded as con- nective-tissue tumors, are occasionally met with, which, on a superficial examination, appear to have an identi- cal structure with carcinoma. The cells are round or irregular in shape, are very similar to epithelial cells, and are arranged in groups which are surrounded by connective tissue. These groups of cells may be smaller or larger in the different tumors, and the connective tis- sue also varies in amount. In all cases the tissue around the groups of cells is richer in cells than ordinary con- nective tissue, and may be composed of spindle-cells. On closer examination it will be found that the connec- tion between these groups of cells and the tissue around them is much closer than is the case in carcinoma. When thin sections are made of carcinomas which have been hardened in alcohol, it will be found that in many cases the groups of cells have fallen out in the manipula- tion of the specimen, or have shrunken, leaving the con- nective tissue around them as a sharp, clear line. On shaking such sections in a test-tube with water, or care- fully brushing them, it is possible to remove all the groups of cells, leaving the connective-tissue framework intact. In specimens which have been injected, it is never possible to follow a blood-vessel into an alveolus. In the alveolar sarcoma the case is different. It is never possible to remove the cells as completely and easily as can be done in acarcinoma. After brushing the speci- men to remove as many of the cells as possible, it will be found that fine filaments of connective tissue enter into the apparent alveolus, and in some cases every cell is enclosed in a delicate meshwork. This is much bet- ter seen when the section is examined in water, as the fine fibrils are more refractive in this than in any other medium. The difference between the two tumors is also apparent from a careful macroscopic examination. On scraping or squeezing the cut surface of an alveolar sar- coma, a juice will be obtained which is never so abun- dant as that which comes from a carcinoma so treated, and on microscopic examination of this juice, numer- ous cells of various shapes and sizes will be found in it, The compact groups of cells so often found on exami- nation of the juice from a carcinoma, and which evi- dently represent the contents of an alveolus, will not be found. These tumors are very vascular, the connective tissue between the alveoli contains numerous large blood- vessels, and fine capillaries given off from these pene- trate the alveoli. ‘The tumor is frequently found in the testicle, and the soft and rapidly growing tumors of this organ generally belong to this variety. The most malignant of the sarcomas, and in many re- spects the most malignant tumor that is met with, is the pigmented sarcoma, the melano-sarcoma. This is char- acterized by the presence of a dark pigment, similar to that in the choroid of the eye, in the cells. The melan- otic sarcomas, as a rule, appear only in places where some pigment in the connective tissue is normally pres- ent, as in the choroid of the eye and in the skin ; they have also been seen in the lymphatic glands. Other sar- comas containing pigment may be mistaken for these REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Sarcoma. Sarcoma. tumors. Heemorrhages are common in every variety of sarcoma, and the blood-pigment which results from this and is taken up by the cells may be mistaken for the es- sential melanotic pigment. In these cases, besides the pigment in the cells, some will be found free. This free pigment either results from the breaking down of cells which contained it, or it is formed by a metamorphosis of the blood-pigment which has taken place, not in the cells, but in the interstitial tissue. In both this accidental and the essential autochthonous pigmentation, the pigment- granules may be brown or dark-brown, and in some cases it is not easy to decide, except by a careful examination, what the nature of this pigment is. In the melanotic sarcoma in course of development, all of the cells are not impregnated with pigment, and in no case do all the cells of the tumor contain this pigment in equal amount. As arule, asection of such a tumor will show various zones of coloration, the color being deeper in those por- tions of the tumor which must be regarded as the old- est. The oldest portions are black, and the younger por- tions on the edge of the growth may be only brown- \ Y) >) * aah ; ) Pl/ ; is zs \ Dea 5 f w¥i -3,' SF eX AN eS // fy j ONO ig ‘ PITS lire qT ish or not pig- mented at all. Although this partial pig-: mentation is the rule, some tumors are found which are black in their whole extent. The pigment- granules are most often disposed around the nucle- us, but they may fill up the entire cell. No pigment is ever found in the nucleus. The pig- ment which results from a meta- morphosis of blood coloring matter usually has a reddish tinge, which is absent in the true melanotic pigment. The cells of these tumors have no particular arrangement or form. The tumor may present the most typical appearance of a spindle-cell sarcoma, but as a rule they belong to other of the Testicle. forms, the arrangement of the cells into alveoli being | especially frequent. When such tumors are scraped a blackish, often inky, fluid is obtained, which contains many pigmented cells, but also free pigment-granules In great numbers. These free granules have an active molecular movement. The source of this pigment Isa subject which has for a long time occupied the attention of pathologists. In the consideration of this question, the fact that the tumor rarely originates in tissues except those in which pigment is normally present, is of the first importance. As we have said before, the favorite places of origin are the choroid of the eye and the skin. It _Vou. VI.—19 Fig. 337%7.—Section of an Alveolar Sarcoma x 400. does not appear primarily in the other pigmented tissues of the body, as in the liver, the supra-renal capsules, and the seminal vesicles. The pigment is very similar to that found in the connective-tissue cells of the corium in the negro race. -Virchow believes that the pigment is formed in the cells themselves as the result of their own metabolism. This view is the one in favor of which most facts speak, and is the view most generally ac- cepted. Gussenbauer, on the other hand, believes that the pigment is formed directly from the blood-pigment, and calls attention to the frequency with which hemor- rhages are found in such tumors. Most strongly against this view speaks the fact that the secondary tumors ak ways show the same sort of pigmentation as do the pri- mary. Inno tumors are such minute metastases found as in these, some of the secondary growths being com- posed of but a few dozen cells, and being evidently of such a recent date that sufficient time would pelos not have been given Li LL for the formation : x of pigment from blood extravasa- tion, even were extravasation present. Be- sides this, blood extra- vasations cannot be said to be more common in the mel- anotic sarco- ma than in any other. Akerman, in his interesting monograph on sarcoma, has called attention to the situation of the pigment in Ad- dison’s disease, and of the pigment which is often found in the skin of certain parts of the body of dark-skinned people. These pigment-cells lie in the neighborhood of the small vessels of the skin, are of long spindle shape, and contain a diffuse or granular brown coloring matter. He supposes that these pigment-cells are specific and have no connection with the ordinary cells of the connective tissue, and that the melanotic tu- mor may arise from a proliferation of these cells. In the skin the tumor most often originates from small, congen- ital, pigmented nevi. Many of these, which are to all purposes perfectly benign, show on section the most typical sarcomatous structure. In connection with these tumors, Virchow calls attention to the melano-sarcomas in horses. It is a well-known fact that white and gray horses are especially subject to these tumors, which ap- pear principally on the tail or around the anus. The tu- mors have not the malignant course that similar tumors have in man, and ordinarily do not reappear after com- 289 Sarcoma. Sarsaparilla. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. plete excision. A tendency to the development of these tumors is transmissible in high degree, especially by the stud; the offspring, both male and female, especially those of a whitish color, being liable to it. Virchow sees in the absence of color in such horses a weakness or lack of resistance in the skin. The angio-sarcoma is a tumor formed by an extensive development of blood-vessels and a sarcomatous growth of their walls. The tumor appears to be made up of long filaments, which are loosely attached to each other and may be isolated for considerable distances. ach fila- ment contains a blood-vessel in its centre, and around this an extensive formation of cells. There is no distinct wall to the vessel, save that formed by the tumor cells. The cells are distinctly epithelial in appearance, and are divided into groups by the formation of capillaries. This tumor may develop in any part of the body, grows rap- idly, reaches a large size, and is very malignant. The metastases which result from it have the same general structure as the primary tumor, but the arrangement of the blood-vessels with the cells surrounding them is not so well marked. After this description of the histological structure of the different forms of sarcoma, we will consider the tu- mor more as a whole, especially its macroscopic clarac- ters, most frequent seat, clinical course, etc. The growth and the general clinical characters of the sarcoma are so different in the several forms that we can find in this group of tumors representatives of completely benign as well as of the most malignant growths. Beyond doubt, in this regard, the separate varieties of the tumor have individual characteristics. The pigmented sarcomas may be regarded as the most malignant of tumors, not only on account of their local destructiveness, and rapid and un- limited growth, but also from their tendency to form me- tastases. The small-cell encephaloid varieties are but lit- tle behind these in malignity. The osteo-sarcomas come next, and the spindle-cell and myxo-sarcomas are in gen- eral only malignant locally. The spindle-cell sarcoma is the more malignant the smaller are its cells, and the more numerous they are in proportion to the amount of intercellular substance. Asa rule, it does not form me- tastases, but cases in which extensive secondary growths appear arenot uncommon. When the sarcomas are com- pared with the other tumors of the connective-tissue type, it is evident that they have a much greater malignity, and this is shown in all by their tendency to return after extir- pation. This tendency to local return, even in’ cases in which the entire tumor and much of the surrounding apparently healthy tissue have been removed, shows that the sarcoma is not a sharply circumscribed growth: The microscopic investigation of the periphery of sarcomatous tumors will often show that the tumor-cells have entered much more deeply into the surrounding tissue-spaces than is apparent on a mere macroscopic examination. The cells not only have an extreme degree of proliferative energy, but the tissue of the sarcoma, which is so much looser than that of any typical connective-tissue tumor, favors this outward growth of the cells. In addition to this direct outgrowth of the cells into the tissues, it is very probable that the cells of many sarcomas have the power of amceboid movements. This would explain the pres- ence of small foci separated by a greater or less interval from the parent tumor. Virchow advances the view that the sarcoma cells can excite the cells of the tissues with which they come in contact to a similar growth. This can take place both about the original tumor and in those places where the cells may be carried by the blood and lymph currents. Most of the recent authors do not ac- cept this view as to the mode of formation of secondary tumors, but believe that these result from a direct growth of the cells or collections of cells which have been carried from the tumor and deposited in distant organs. The power of the sarcomas to produce secondary metastatic nodules in the most different organs is not confined to any special species, though some show a much more de- cided tendency in this direction than others. In some cases the secondary nodules are of such small size, and appear in so many places in the body, that the condition 290 is known as sarcomatosis. These nodules, from their very small size, may be mistaken for miliary tubercles. The path of the metastases is almost always along the blood-vessels, the sarcoma in this again contrasting with the carcinoma, in which metastases follow the lymphatics. Although this mode of infection is most common in sar- coma, there are exceptions in which the lymph-glands are early infected. This is notably the case in sarcoma of the bones. The course that the metastasis usually takes is easily explained, when we consider how intimate the relation is between the cells of the tumor and the blood- vessels, the latter being in many cases without essential walls, and representing little more than channels be- tween the tumor-cells. It is by no means rare to finda sarcoma growing directly into a large vein, and it may extend in this for a considerable distance as a long, fleshy polypus, moving freely in the blood-stream, and appar- ently nourished by the surrounding blood. Billroth mentions a case in which a sarcoma of the testicle grew into the spermatic veins, some of its cells being carried thence through the inferior cava into the heart, and pro- ducing numerous metastases inthe lungs. As we should suppose, metastases are most commonly found in the lungs, and next in the order of frequency come the spleen, the kidneys, and the liver. Infection of these organs is generally secondary to infection of the lungs. The metastases are often much larger than the primary tumor, and are the most frequent cause of death. The clinical importance of a sarcoma does not depend altogether upon the histological structure. The seat of the tumor is of great importance, for it is evident that, when seated in an organ whose functional activity is necessary for the life of the individual, the tumor may be very dan- gerous, even when it does not show any special tendency to the formation of metastases. The glio-sarcomas of the brain are malignant, though they are always confined to this organ. It is also well known that the mediastinal tumors are dangerous in consequence of the pressure on the great blood-vessels which they exert. This primary danger of the tumor in great part depends upon the ra- pidity of its growth. In general, it may be said that the growth is most rapid, and the tendency to metastases strongest, in those tumors in which the cells are smallest and most abundant. This growth may be restricted in various ways by the local relations of the tumor. The sarcomas of the bone grow slowly, and do not produce metastases as long as they are surrounded by the bone ; but when the surrounding osseous tissue is broken through, they show a very rapid growth and produce metastases. Although, from what has been said, it is seen that the’ sarcomas have a greater clinical malignity than the other tumors of the connective-tissue type, still, in comparison with the carcinomas, they may almost be considered be- nign. This is shown, apart from the lesser tendency of the sarcoma to metastases, in the influence which the two types of tumors respectively exert on the general consti- tution. A condition known as the cancerous cachexia is the ordinary result of a carcinoma, even when it is con- fined to a single organ, while an enormous sarcoma will not ordinarily produce such a condition. This difference is in great part due to the lesser tendency of a sarcoma to ‘ulceration, and to the fact that the degree of pain expe- rienced from the sarcoma cannot compare with that pro- duced by the carcinoma. ‘This lesser tendency to ulcera- tion may be explained by the abundant vascularization of the sarcoma, and by the slight tendency of its cells to degeneration. In still another way is the minor malig- nity of the sarcoma, in comparison with the carcinoma, manifest. Even those sarcomas which are shown to be very malignant in their later course by a general exten- sion in the body, have a primary period when they may almost be regarded as benign. The carcinoma, on the other hand, from the moment it first appears and can be recognized as being such, is malignant, and shows this by the early infection. of those lymphatic glands which stand in relationship to it. The sarcoma in its beginning may be a perfectly circumscribed tumor, but the carci- noma never is. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Sarcoma, Sarsaparilla. The benign period of the growth of a sarcoma is shown by its slow and circumscribed growth. In this early be- nign period the entire tumor is often enclosed by a con- nective-tissue capsule, and in those developing in bone this connective-tissue capsule may be substituted by an osseous capsule. The rapidity of the primary local growth varies in the different species of sarcoma. In many cases the growth is so rapid that we are reminded more of the extension of an inflammatory process than of the growth of atumor. The tumor itself, in these cases of primary rapid growth, is generally a round-cell, en- cephaloid sarcoma, and may be very similar, even in its histological structure, to an inflammatory focus. This primary benign period that a sarcoma passes through is of great clinical importance, and shows that the tumor should be removed as early as possible. In this removal care should be taken not only to remove all of the tumorthatisapparent, fA but a considerable amount of the surrounding tissue as well. Even when this appears to be f. unaffected, it may contain, at a f} *: comparatively early period in the }} history of the tumor, long pro- longations of tissue extending from the tumor. Any of this tissue left behind will serve as a point of departure for a return- ing growth. The known: ten- dency of the sarcoma to return, after appar- ently complete extirpation, is only to be explained by imperfection of its removal. When a sarcoma is seated in the marrow of bone, it is impossible to say how high up the marrow is affected, and in this case disarticulation ‘is a better operation than amputation. The seat of the sar- coma is most often found in the skin and subcutaneous tissue. In the in- termuscular and muscular connec- tive tissue, in the fascia, and _ espe- cially in the perios- teum, the spindle-cell sar- coma is a very common tumor. Other varieties of the sarcoma show an es- pecial predilection for cer- tain tissues, as the melano- sarcoma for the eye. The alveolar sarcoma is most often found in the testicle. Among the most interest- ing sarcomas, from a histo- logical point of view, are those which develop in glands. These almost al- -ways include some of the glandular elements, which undergo various changes of form. In general, glandu- lar structures show a comparative immunity from the development of sarcoma, though there are exceptions to this rule. The female breast is often attacked by sarco- ma, which forms here large, round, lobulated growths, often very elastic to the touch. The tumor grows slowly, causes little or no pain, and is separated from the remain- der of the gland. On section, small fissures are seen in the tumor, and often a mass of tumor-tissue will project like a polypus into one of these fissures, and be almost surrounded by it. On microscopic examination these fis- sures are found to be lined with epithelium, and are cer- tainly formed by the dilated and flattened glandular ducts. The entire tumor may be enclosed in one of these fissures. Fic. 8378.—Smilax Officinalis, H. B. K., the origin of Jamaica sarsaparilla; male in plant. Cysts formed both by degenerative processes in the tumor, and by an accumulation of secretion in gland-ducts, may be met with. The growth of these tumors is a very slow one, and is painless except when they attain a very large size. Many of them have the peculiarity of swelling up and becoming more painful during the menstrual period. Return after extirpation is not to be feared in young pa- tients, but it may occur in patients thirty or forty years of age or older. Sarcomas also appear in the salivary glands, especially in the parotid, and here they are accom- panied by a growth of the epithelium. The inner surface of the dura mater, and the substance of the brain or spi- nal cord, may be the seat of sarcoma. In the cord they may be multiple, one case having been seen oh by the writer in which four tumors, which varied in size from a small pea to a bean, were found at various places along the cord. The largest, which reached the size of a bean, was found in the cervi- cal swelling, completely en- closed by the cord. Concerning the etiology of sarco- ma, what little there is to be said will be found in the articleon Growths, It is an interesting fact that those tumors whose structure is most like very early embryonic tis- sue are most malignant. W. T. Councilman. vA SARSAPARILLA, U. SAMS. Ph. (Sarse Radia, le Br. Ph.; Radia Sarsa- Eger MINS VW pardiile, Ph. G.; Salse- ay" \< hf = pareiile, Codex Med.). The long, cylindrical roots of several Central and South American or Mexican species of Smi- lax; order, Liliaceae (tribe, Smilacee). The Smilax- es are perennials, with SY, woody, often very long and _= slender \ roots, and generally \ with tough, woody \j (rarely herbaceous), climbing or wander- \f ing stems. These | are generally green and smooth, or “Sq pubescent, round, ‘ square, or several- angled, and armed with strong, flat- tened, recurved, sharp prickles. The leaves are alternate, generally two-rank- ed, petiolate, with, uae most species, bene a long, strong ten- dril, arising on each side of the petiole below the middle. Blade usually oval, ovate, or heart-shaped, from ¢hree- to five-nerved, reticulate between the principal nerves ; often coriaceous, and evergreen. Flowers small, greenish-white, in axillary umbels, dicecious or polygamous ; perianth three- to six-parted (or more). Stamens in the male flower usually six, attached to the bases of the sepals ; anthers introrse, apparently one-celled ; pistil rudimen- tary—in the female flower, pistil three-celled, with two (or one) ovules in each cell ; staminodes six, three, or variable. Fruit, a one- or two-seeded berry. _The genus contains toward two hundred species of tropical or tem- perate plants, some of which make the most impenetrable 291 Sarsaparilla. Sassafras. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. underbrush. Some are not spiny, a few are not climbers, and a smaller number have herbaceous, annual stems. The genus is well represented in the United States by toward a score of species, among which S. rotundifolia Linn., the common Greenbrier, and S. herbacea, the Car- rion Flower, with its horribly fetid odor when in bloom, are familiar examples. The former is a very good rep- resentative in appearance and habit of the medicinal Smi- laxes. Of these, it is surprising how little exact knowl- edge we have; specimens have been collected of most of them, but never in bloom, and the botanical details are therefore wanting, so that how much the different varie- ties of the drug owe to difference in species, and how much to difference in climate or cultivation, cannot in all cases be said. 1. S. officinalis, a large, coarse, woody climber, with a short, thickened rhizome, whence are given off numer- ous long, cylindrical, horizontal roots, and several or many round, erect stems, soon becoming more or less angled, and branching into quadrangular, very long, flexuose, climbing branches, armed with stout, sharp prickles. Leaves very large, or smaller on the upper portions of the plant, round, heart-shaped, ovate, or broadly lanceolate ; in short, it is like a gigantic green- brier. It is a native of New Granada, and appears to be the plant introduced into the West Indies. It probably yields ‘‘ Jamaica Sarsaparilla.” Female flowers and fruit not seen. 2. S. medica Cham and Schl., a large climber, with mostly unarmed angular branches, and frequently auri- culate or lobed leaves. It grows in Mexico, and supplies the Mexican variety. S. papyracea Poiret, with a many-angled stem ; flow- ers unknown ; of Guiana and Brazil ; may be the source of Para Sarsaparilla, etc. Of several other imperfectly known species there is a suspicion of probable connec- tion with the drug, but no certain knowledge. Sarsaparilla was first carried to Europe about 1536-45, and first or early employed as a cure for the same disease with which it has been since most generally associated, and for which another smilax, ‘‘ China,” had previously been used. The use in numerous other slow diseases, especially in eruptions and as a ‘‘ blood-purifier” in gen- eral, followed, and has continued extensive until the present time. Although now it has been nearly discarded as a serious medicine by physicians, it is still a much- prized popular remedy. CoLLECTION.—This has been observed several times, and consists in selecting clumps where numerous stems indicate plenty of roots, clearing away the dirt and other roots around them, and carefully digging up the long, whip-like sarsaparilla ; the crowns and remnants are then covered with dirt and leaves, and left to sprout again, or in some countries collected with the roots. The collected roots are simply dried and packed in more or less char- acteristic bundles. DESCRIPTION.—Sarsaparilla comes in long, simple, or sometimes forked, longitudinally wrinkled (when dry), flexible, slender, rope-like roots, in some varieties thicker in the middle than at either end, often one or two metres in length, and from two to five or more centimetres in diameter ; surface light or dark brown, with scattered fine roots, and sometimes short, velvety hairs. The rhi- zome—a dark, irregular, woody ‘‘chump”’”—is present in some varieties. ‘The roots vary considerably in their plumpness, owing to a very variable amount of starch in their tissues, which fact has given rise to their division into two general groups: a, Starchy, or mealy—Hon- duras, Guatemala, Brazilian, Para, etc.; 6, non-starchy— Jamaica, Mexican, Guayaquil, etc. There is no import- ant difference in their medicinal qualities, but the non- mealy varieties are darker and rather stronger-tasting. These varieties are more easily told sometimes by their mode of packing than by their individual appearance. Honduras Sarsapariiia is pretty plump and smooth, with more or less ‘‘ beard.” Near the middle the roots contain a thick zone of white, starch-laden tissue. They are packed in hanks seventy or eighty centimetres long, wound with a flexible root, and bound in bales with 292 hide. Guatemala Sarsapariila is yellowish, with a brittle bark. Brazilian comes in very large, long, closely wound bundles, cut smooth at either end. ‘‘ Jamaica Sarsaparilla” (the most esteemed in England, and from Central America, instead of Jamaica), isin short bundles, half a metre or so long, rather carelessly done up, wound like the others by a long, flexible root of the same ; it is a slender, deeply furrowed, dark root, brown within as well as without. Mezican is pale, not made into bundles, and often contains also the chumps and bases of stems. Guayaquil comes loose in large bales. It has a large, coarse-looking root, accompanied also by the rhizomes and some stem-bases.* The histology of Smilax roots has been studied with more care and detail than their unimportance deserves. (See Berg’s ‘‘Atlas zur Pharm. Waarenkunde.”) The (endogenous) woody portion is collected in a cen- tral core, and surrounded with a false bark of thin- walled, parenchymatous, starch-laden cells, of varying, often considerable, thickness. The woody column con- oo args eR Raneacean ECA TALES RLS ON epee HRA TE BN Hee Sra xX XS ee racer ®, iS soa RNS TE Fre. 3379.—Root of Smilax Officinalis, Enlarged Section. (Baillon. ) sists of a parenchymatous centre of thin-walled cells, sur- rounded by a progressively increasing number of scat- tered woody and vascular bundles, compacted into a hard, porous wood near the circumference of the column. ComposITion.—Most earnest attempts have been made to find a tangible and useful active principle in Sarsapa- rilla, with only partial success. Starch in most varieties is abundant, but unimportant. Hssential oil in minute quantity, a little resin, ‘‘ extractive,” etc., may have some value, but the most characteristic substance is parillin, of which about two per cent. may be obtained. It erys- tallizes in white scales or needles, permanent in the air, neutral, odorless, at first tasteless, but afterward bitter and acrid ; but little soluble in either cold water or alco- hol, freely so in hot. It is more soluble than in either alone in a mixture of alcohol and water. Parillin is a glucoside, yielding parigenin and sugar if treated by di- lute mineral acids (Fliickiger). Parillin is, as yet, of doubtful composition, but is nearly related to saponin. AcTION AND UsEe.—This paragraph will seem short compared with the preceding descriptions. Parillin, in doses of half a gram or so, produces nausea, vomiting, and retardation of the pulse; in larger doses, constriction in the throat, weakness, sweating. It has been tried to a slight extent in syphilis, without marked results (Huse- mann). Sarsaparilla itself, in large doses, only produces ee * Hanbury and Fluckiger. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Sarsaparilla, Sassafras, gastric disturbance, so from the physiological action of this remedy little therapeutic value can be predicated, and it probably has not much. Yet, on the other hand, not only this, but other products of Smilax (China, East- cyrrhiza, 2; Mezereum, 1; water enough to make 100; strength because used as a vehicle. ale » 109 and the Syrup, more used than the others, It is composed as follows: ern Sarsaparilla, etc.) are used the world over for syphi- nie Se AE cys re tates get ce sl Party litic and scrofulous diseases, in the United States perhaps Pak Seepage ONE a Raa ae ee . PP less seriously than elsewhere. It does seem possible GI ‘ shite Sih Be ONS Te a Daa tes a vote that Sarsaparilla in fair doses is beneficial in some cases g AAR eee A os er aaa “e 2 « of dyspepsia or mal-assimilation arising from winter diet Siege a OIE 2S any Go or improper food, and hence its popularity in ‘‘ Spring pee Hen ORG Race Coane itr medicines ;” but the bitters in general, and some laxatives Gaulth tps Tee Woe. te Py Sane Becca Sa (Gentian, Dandelion, Frangula, etc.), are equally or more g ree EGMONT RE 600 ¢ efficacious. Its use in ‘‘scrofula” is diminishing. In tions Bet Bop baee syphilis it is still a good deal prescribed, especially in England, India, etc. ADMINISTRATION, —Smilax is never given in substance, but the theoretical dose may be stated as from four to eight grams (3 j.-3ij.). The best preparations are the Fluid oe es (ie FSFE $ a Chay | ed <= wes 3 a S etl S82 Ife ek S20. Bao on (fa BY fmm. es. e aa Yee pc (ee ae | cs vi Se > = IK fe i f) Os Me FA eos & se = eer ok a We AIA «i SOR jex Se 0) 0 | ©. y (2) ay! Cyr az) wos 228 _ oo a_>. we) IS aw a BSE: LAE el Sy z ai. p>, a otal <<) ‘o> Ara ws Se AE! : a) CA € ry ° SS te c (e= = a oo 5 IVYoreaSe HAN ON reg PESSy fo (eH Sey, f oO Fie, 3380.—Magnified Section of One-half Diameter of Root of Smilax Officinalis. (Baillon. ) Extract (Hzxtractum Sarsaparille FPluidum, U. 8. Ph.), strength, +; the Compound Fluid Extract (Ha. Sarsa- partile Comp. Fluid., U. 8. Ph.): Sarsa., 75; Glycyr- rhiza, 12; Sassafras, 10; Mezereum, 3; Glycerin, 10; alcohol and water enough to make 100; strength, #; the Compound Decoction (Decoctum Sarsaparilla Comp., U. S. Ph.): Sarsa., 10; Sassafras, 2; Guaiacum, 2; Gly- Water and diluted alcohol enoug The Infusion and Fluid Extract are the best forms where full doses are to be given. to make 1,000 parts. ALLIED PLANTS.—The suborder Smilacew forms a rath- er distinct division of the great modern group collected under the name Liliacee ; it includes but little more than the great genus Smilax described above. China Root, from Smilax China Linn., in large, Jalap-like tubers, is used in the East for the same purposes as sarsaparilla. For the order, see SQUILL. ALLIED Drues.—In the treatment of syphilis and scrofula, and many of the conditions for which Sarsaparilla was once highly esteemed, Mercury, Iron, and Iodine have long since taken the principal place. There is, however, a long list of dubious remedies from the vegetable king- dom, which have a reputation, mostly local, as ‘‘alteratives,” or anti-scrofulous and anti-syphi- litic substances; few of them are more than household drugs. China, just mentioned, He- midesinus or Indian Sarsaparilla, our False Sar- saparilla, are among them. Guaiacum, Mezere- um, etc., are more generally used ; Colchicum, Stillingia, Sanguinaria, Chelidonium, Dulcama- ra, and Arsenic also help to fill up this hetero- geneous collection. W. P. Bolles. SARSAPARILLA, FALSE, Arvalia nudicaulis Linn., order Araliacee. This little plant, gen- erally known among country-folks and herb- gatherers as ‘‘sarsaparilla,” has no botanical relation whatever to the preceding drug ; in taste and in the shape and size of the roots there is a little similarity. It consists of a long, slender, perennial root, about as large as a pipe-stem, and two or thred metres in length, with a light- brown surface and soft, flexible texture. It has a rather pleasant, aromatic odor, and an aro- matic, somewhat sharp taste. The stems, which arise at intervals of from twenty to fifty centimetres, are only one or two centimetres long, barely emerging from the ground, and give rise, each. to one twice ternately or qui- nately compound leaf, and one three-branched scape supporting three globular umbels of small greenish-white flowers. This Aralia is common in moist places over most of the United States, and is in some popular demand for the same complaints that sarsaparilla is reputed to bene- fit. Dose indefinite. Composition not known. ALLIED PLANTSs.—The genus contains thirty species, mostly Asiatic, of herbs, or rather shrubs, of mild, indefinite medical properties. A. racemosa Linn., American Spikenard, and A. quingvefolia D. & P., American Ginseng, are other native species employed in popular medicine. The Ivy (Hedera Helix) also belongs in the family. ALLIED DruGs.—See SARSAPARILLA. W. P. Bolles. SASSAFRAS, U.S. Ph. ; Codex Med. (Sassafras [a- dix, Br. Ph.; Lignum Sassafras, Ph. G.). officinale Nees, one of the very few plants of the Laurel family growing wild in this country, is a medium- or Sassafras 293 Sassafras, Scabies, good-sized tree, or, near the northern boundary, a shrub or small tree, with irregular, spreading, brittle branches, covered like the trunk with rough, furrowed bark, gray without, fawn-colored or pinkish when freshly cut, with- in, Wood light-colored, with darker heart. Twigs and smaller branches _ bright green, glossy; pith large, very mucilaginous. Leaves bright-green, smooth, oval, pointed at each end or blunt at the apex, entire, or else, especially those coming later in the sea- son, deeply three- lobed ; bet ween these shapes are various intermediate ones, lobed on one side, and not on the other, or merely auriculate on one or both sides. Both kinds of leaves are usually seen on the same tree. Flowers vernal, appearing with the leaves, in small ra- cemes; small, regular, dicecious, yellow. Perianth six-parted. Stamens nine; the three inner ones glandular at the base; anthers four-celled, each opening by means of a little valve. Pistil one, one- celled, with one pendant ovule. In the staminate flowers the .pistil is rudimentary ; in the pistillate ones there are six sterile stamens. Fruit a blue berry, on a reddish, cup- shaped receptacle. All parts of the tree are fragrant, es- pecially the bark of the root; the growing parts contain also considerable mucilage. Sassafras has a wide rangé over tlie United States, ex- tending slightly into parts of Canada, etc. In many re- gions it is very abundant, New Jersey, Pennsylvania, Maryland, and Virginia supplying large quantities both of the bark and oil. It has been valued since the settle- ment of the country, and is said to have been used by the aborigines even before. Although its reputation as a medicine is a thing of the past, as an agreeable flavor and cheap perfume it is in steady demand. There is very lit- tle call for the whole root in this country, excepting what is used on the spot in the manufacture of the oil; but considerable is exported to Great Britain and the Conti- nent, the Bark of the Root (technically called Sassafras, U.S. Ph.), being preferred. The officinal description is as follows: ‘‘In irregular fragments, deprived of the gray, corky layer; bright rust-brown, soft, fragile, with a short, corky fracture ; strongly fragrant, sweetish, aro- matic, and somewhat astringent.” Sassafras Pith (Sassa- Sras Medulla) is ‘‘in slender cylindrical pieces, often curved or coiled, light, spongy, white, inodorous, insipid. Macerated in water it forms a mucilaginous liquid, which is not precipitated on the addition of alcohol.” Composrrion.—Of the wood and bark : The most im- portant constituent here is the essential oil (Olewm Sassa- Fras, U.S. Ph.), of which the wood contains perhaps one per cent., the bark of the root from two to four per cent. It is a heavy (sp. gr. 1.087+-), white, or by age yellow, and then reddish-brown, very fragrant liquid, of an agreeable aromatic taste and a neutral reaction. Soluble freely in alcohol. By the action of cold, or upon standing, it can be separated into Safrol, or sassafras camphor, which comprises its principal portion, and safrene, a hydrocar- bon; both have the same odor. Both bark and wood contain also a little tannin, and the bark contains a red coloring matter, perhaps derived from the tannin. — Fie. 3381.—One of the Three- lobed Leaves of Sassafras. (Baillon.) 294 _ Krameria, etc. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Sassafras Pith contains a peculiar non-adhesive muczi- age. ; Ratton AND Us8.—Sassafras, like Cinnamon, to which it is related, is an aromatic tonic and carminative, with little or no peculiarity of action to distinguish it from others of its class. It is said to be a stimulating diapho- retic, but probably is not more so than-most aromatics, or essential oils, when given in hot ‘‘ teas.” It is, however, of an agreeable flavor, and for this quality it is freely used as an adjuvant in medicine, and asa flavor for confec- tions, soaps, and other household luxuries. The mucil- age of the Pith (Mucilago Sussafras Medulle, U.S. Ph., +35) is used rarely as an eye-wash, or asa gargle or de- mulcent drink for pharyngitis. ADMINISTRATION.—Oil of Sassafras may be given in doses of from five to ten drops or more on sugar, or in emulsion with mucilage, or otherwise, for the same pur- poses as oil of Cinnamon or Checker-berry, or an infusion may be made of the bark. Sassafras Bark is an ingre- dient of the Compound Extract, the Compound Decoction, and the Compound Syrup of Sarsaparilla. ALLIED PLANTS, ETC.—See CINNAMON. W. P. Bolles, SASSY BARK, Mancona Bark. The bark of Erythroph- leum quinense Don.; order, Leguminose (Cesalpiniea), a good-sized, acacia-like tree, growing in tropical Africa, and employed by the tribes of the west side like Calabar Beans, as an ordeal. It was made known in Europe and America about forty years ago, and was revived as a medicine about ten years since. It is atponderous bark, heavier than water, of a dull red color, a fissured exter- nal surface, and a short fracture. Odor slight, taste as- tringent. The active principle of Sassy Bark is Hry- throphiwine, a crystalline alkaloid, first obtained by Gallois and Hardy. It is an active heart-poison of the digitalis kind, producing slowing of the pulse, increase of blood- pressure, and in experiments upon animals death, with the heart in systolic contraction: ‘The powdered drug is a powerful sternutatory. But little use has been found for this potent medicine. It is said to be employed at home in dysentery, etc., with benefit, as well as in inter- mittent and other fevers. In full doses it is nauseating and emetic, as well as somewhat narcotic. ALLIED PLANTS, ETC.—See SENNA. W. P. Bolles. SAUNDERS, RED (Santalum Rubrum, U.S. Ph.; Pter- ocarpt Lignum, Br. Ph. ; Santal Rouge, Codex Med.). The heart-wood of Pterocarpus sanialinus Linn., or- der Leguminose (Dalbergiew). A small tree with red wood, alternate trifoliate leaves, small yellow, papilli- onaceous flowers on axillary racemes, diadelphous stamens, and a flat, orbicular, wing-margined, one- or two-seeded, stalked, indehiscent fruit. It is a native of the Madras Presidency, but not common, and is now be- ing cultivated. Red Saunders is imported in billets three or four feet in length, and from two to eight or nine inches in di- ameter, the bark and sapwood being removed. It is of a bright blood-red color within, but darker upon the surface, becoming sometimes nearly black with age and exposure. For pharmaceutical use it is usually cut into chips or powder. There is a slight astringent taste, but little or no odor. Alcohol and ether extract its constitu- ents, but not so with water, which it scarcely colors. The important principle is Santalin, or Santalic acid, discovered by Pelletier. It crystallizes in minute red prisms, which are soluble as above, and in alkaline solu- tions and a few essential oils. Besides this, a number of less important or ill-defined substances are described. Saunders is essentially a dye-stuff. In medicine it has no employment, excepting as a harmless coloring agent. The Compound Tincture of Lavender contains eight parts in the thousand. ALLIED PLANTS.—KINO ; see also SENNA. | ALLIED Druas.—Saffron, Annato, Cochineal, etc.; also the red coloring matter of Kino, Red Cinchona, W. P. Bolles. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Sassafras. Scabies, SAVINE (Sabina, U. 8. Ph.; Sabine Cacumina, Br. Ph.; Summitatis Sabine, Ph. G.; Sabine, Codex Med.). The leaves and young twigs of the European Juniperus Sabina Linn., order Conifere. This is acompact, horizon- tally spreading, evergreen shrub or small tree, resembling our common juniper on a small scale, and bearing similar berries. It is widely dis- tributed through the north temperate zone of the Old World, and is also met within the North- ern United States (in the Great Lake re- gion) and in Can- ada. The medical supply comes from Europe, in ‘short, thin, sub-quadran- gular branchlets, leaves in four rows, opposite, scale-like, ovate lanceolate, (edu more or less acute, Oe RS appressed ; imbri- cated,on the back with a shallow groove containing an oblong or roundish gland ; odor peculiar, terebinthinate; taste nauseous and bitter.” The odor and taste of Savine are mostly due to from one to two per cent. of essential otl (Oleuwm Sabi- ne, U.S. Ph.), a pale yellow, terebinthinous liquid, becom- ing thicker and darker by age, colorless if redistilled, of a spe- cific gravity of about 0.910. It has the odor of Savine, a sharp, bitter, camphoraceous taste, and is more rubefacient and irritating to the skin than others of its class. Tannin and resin are less im- portant constituents of Savine. AcTION AND Usr.—Savine and its oil are essentially like, but more intense than, oil of turpentine in physio- logical and therapeutical properties; irritating to the skin and mucous membranes, to the urinary apparatus by which they are eliminated, and to the uterus, which they may cause to abort. Besides these effects, convulsions and coma may follow. Vomiting, diarrhcea, gastro-intestinal inflammation, strangury, with or without convulsions or unconsciousness, these are the usual symptoms of Savine- poisoning ; abortion may or may not take place. This potent drug is not much employed. It has been given as an emmenagogue, also as a hemostatic, for leucorrhcea and other purposes mostly connected with the uterus. It is not infrequently used with criminal intent to pro- duce abortion, usually without success, unlessit nearly or quite kills the mother also; externally it is the basis of some moderately useful stimulating ointments, liniments, and ‘‘ hair-restorers.”’ In this country the Oil of Juniper, which is milder, is perhaps generally substituted for Oil of Savine. The dose of Savine (leaves) is about half a gram (0.5 Gm. = gr. viij.); of the oil, from one to four or five drops. A Fluid Extract of the former (Hz. Sabine Fluidum, U. S. Ph.) is an eligible preparation and the basis of the Cerate (Ceratum Sabine, U.S. Ph., strength about 45 Savine), ALLIED PLANTs.—See TURPENTINE ; also JUNIPER. ALLIED Druas.—Tansy, Ruz, TURPENTINE, CAM- PHOR, CAJEPUT, etc. W. P. Bolles. SAVORY, SUMMER (Sarriette, Codex Med.). The herb of Satureia hortensis Linn., order Labiate, a well- known European mint, now cultivated everywhere as a ~~ Fig, 3882.— Savine, Fertile Branch. (Baillon.) flavoring herb for soups and sauces. It has no proper- ties not common to other mints and aromatics in gen- eral, and is only employed for its agreeable odor and taste. ALLIED PLANTS, ETC.—Hyssop, Thyme, Patchouly, Lavender, etc. See PEPPERMINT. W. P. Bolles. SCABIES (Latin, scabies, an itching eruption, from scabo, I scratch). Synonyms: The Itch; German, Krdtze ; French, Gale. Scabies is a contagious disease of the skin, wholly local in character, due to the pres- ence in, and upon, the skin of an animal parasite, the acarus or sarcoptes scabtet (see vol. i., p. 84). The erup- tion present may vary from the smallest amount imagin- able, a few papules, up to the most severe development of inflammatory lesions, even such as to render the pa- tient helpless; the subjective sensations may vary from a slight pruritus, which is described as not unpleasant when relieved by scratching, up to an itching which is almost unendurable, causing restless nights and distress- ing days. The most common sites for the lesions of scabies are the hands, especially about the wrists, in the soft skin between the fingers, and on the sides of the hands. But in many cases the eruption is entirely absent from this locality and is well marked elsewhere. In males the penis seldom escapes, and in females the region of the nipples is very apt to be affected; the anterior fold of the axilla is a very common seat of the lesions, and the elbows and extensor surface of the forearms are some- times most severely affected. In those who sit a great deal the buttocks often present an abundant eruption. In infants and children the softer parts of the feet and ankles generally exhibit lesions. It may be said that the head is never affected by scabies. The eruption of scabies exhibits the greatest variety of lesions, from the smallest papules and vesicles to large pustules, often ecthymatous in character, and in weakly children pustular bulle may form on the hands. The bulk of the lesions is papular, although small vesicles can generally be seen on tender portions of the skin dur- ing some period of the disease. Mingled with these pri- mary lesions there are generally found the results of scratching, abraded surfaces, and those covered with crusts. The only single pathognomonic sign of scabies is the cuniculus, furrow, or burrow (German, Milbengang ; French, Sillon), which is caused by the penetration of the female beneath the epidermal layer of the skin in the search of a place to lay her eggs; the male seldom, if ever, goes beneath the skin. This cuniculus consists of a minute dark-colored line, generally somewhat beaded in appearance and curved, appearing much as if a bit of dark sewing-silk had been run beneath the surface, rarely as long as a fourth of an inch, more often half that length ; this may generally be seen to terminate at one end in an inflamed papule or vesicle, or sometimes to run over a pustule. The female insect will be found at that end of the furrow, and the dark line is her track, which is found to be filled with eggs in various stages of development, and, among them, black particles of feces. If the skin is washed these dark lines, instead of being removed, become more apparent; but in recent vases, or in individuals who are very cleanly or have un- dergone treatment, it is often impossible to discover any of these cuniculi, although the disease may still exist, and, if left alone, will increase and may be communicated to others. Scabies is not a very frequent disease in this country, forming only about 1.5 per cent. of a large number of skin cases analyzed. In other countries it is more com- mon, and in Glasgow it formed twenty-five per cent. of ten thousand cases analyzed by McCall Anderson. DiaGnosis.—Considerable care is often required to diagnose a mild or unusual case of scabies, and cases sometimes go unrecognized for some time. The disease most commonly confounded with it is eczema, which may present almost identical appearances, except that there are no cuniculi; when these latter are positively 295 Scapula. senbion: REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. found the diagnosis is certain. The location and distri- | times an artificial: eruption is excited by the treatment, bution of the eruption, the history of contagion, and the | when soothing remedies are required. The clothing multiform character of the lesions are generally suffi- | should always be treated ; the underclothes should be cient to establish the diagnosis. Scabies may also be | boiled a long time and very thoroughly ironed ; the outer confounded with lichen, pityriasis, prurigo, pruritus, garments may be baked or very thoroughly ironed on and urticaria papulosa. the wrong side. Patients should be more or less iso- ErroLtocy.—There is but one cause of scabies, the lated, although when they are under treatment the presence of the parasite, acarus or sarcoptes scabiei (see chances of communicating the disease are very small, article Acari in vol. i. of this HANDBOOK), whose re- Proenosis.—The prognosis is, of course, favora- moval or destruction is followed by the cessation of ble ; there can never be the slightest harm in curing the disease. It often occurs, however, that the treat- even the most inveterate or severe cases of scabies. ment employed may occasion an amount of artificial In the hospitals abroad it is claimed that a cure is eruption or dermatitis which may mask the true \ effected in a few hours, but it is questionable if, in affection, and may even remain after the real cause \VE the large majority of cases, the relief is more than of the disease has been destroyed; this second Mi temporary, a portion only of the parasites being eruption may require a very different treatment, killed. Practically, cases require treatment for a of a soothing character. number of days, or even weeks, to make the cure PatnHo.tocy.—The only pathological lesions, certain ; when the skin is delicate the active aside from the presence of the cuniculus, which parasitic treatment may have to be inter- is a channel beneath the epidermis and just rupted, owing to the dermatitis excited, and above the papilla, filled with the female acarus, occasionally it will be found difficult to use its eggs, and feces, are those connected with remedies strong enough to effect a cure. inflammation of the skin (see article Derma- L. Duncan Bulkley. titis). The lesions are simply inflammatory masses of greater or less size, caused either SCABIOUS (Scadbieuse, Codex Med.); Morsus Diaboli, Succisa pratensis Monch, by the direct irritation of the burrowing in- sect, or by the scratching or other measures order, Dipsaceew (Scabiosa succisa Linn.), A European herb, whose roots, leaves, employed for the relief of the itching, or and heads were formerly in vogue as a both. When the local irritation is re- remedy for leucorrhea, diabetes, throat moved the eruption ceases; if the acari could all be removed mechanically, affections, and skin diseases. It is now obsolete. picked out, there would be no eruption. ALLIED PLANTS, ETC. — Dipsacus In patients who are paralyzed on one | Fullonum Uinn., in the same family, side, or who have been unable to . scratch, there is very little eruption on is the teazle used by woollen weavers. “Sweet Scabious” (Hrigeron) is an the portions of the skin which are out entirely different plant. W. P. B. of reach. TREATMENT. — The treatment of scabies is purely local, and consists SCAMMONY (Scammonium, U.S. in such measures as destroy the life Ph., Br. Ph. ; Seammonée ad’ Alep, of the parasitic insects and their Codex Med.; also Scammonie Ra- eggs. The patient first takes a diz, Br. Ph.). The impure resin warm bath, using plenty of strong obtained from the root of Convol- soap, rather alkaline in charac- vulus Scammonia, order Convolou- ter, such as the sapo viridis or lacee, This is a perennial with a the common laundry soap, rub- long, thick, cylindrical, several- bing the affected parts so as to headed, but otherwise usually break the furrows as much as simple, milky-juiced root, and numerous hollow, herbaceous, slender, smooth, twining stems, possible. After drying, the affected parts, or even much two or three metres long. The root, which is an article of of the body, should be well rubbed with an ointment of English trade, is up to a me- tre in length, and a decime- which sulphur is a chief in- gredient. The ordinary sul- phur ointment diluted once, tre in diameter at the crown, with the addition of a light brownish-yellow with- drachm of liquid storax out, white within, fleshy, and resinous. The leaves are in- frequent, alternate, to the ounce, answers as long-petioled, triangu- well as anything. After thorough friction with this for at least half an hour, the patient puts on underclothes, which are to remain on night and day until the end of treatment. The oint- ment should be freshly rubbed in twice daily for several days, and a bath is to be taken on the third day, the oint- ment being again rubbed in and afresh suit of un- lar, halberd- or arrow- shaped, pointed at the apex, with one or two obtuse dentations near the cordate base. Flow- ers five or six centime- tres across, pale yellow, solitary or in cymes of three, on long two- bracted peduncles. Calyx five-parted ; co- rolla conduplicate in the bud, broadly fun- Fia. 3383.—Scammony-plant in Blossom, (Baillon.) derclothes put on. After three days more of treatment 1 nel-shaped when open, with an indistinctly five-parted another bath may be taken, and it is then to be expected | border. . Stamens five, attached to the corolla tube, pis- that the cure is complete. But frequently some of the | til two-celled, four-seeded. cuniculi will be found to have escaped being broken, or This pretty plant is a native of the Levant—Greece, new infection may come from the clothing or elsewhere, | Asia Minor, Syria, etc. It is also cultivated in botanic and in such case the treatment must be repeated. Some- gardens. The resin is collected by cutting off the root 296 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Scabies, Scapula,. at the crown, and either scraping off the exudation as it appears or putting a shell or some receptacle at the lower side to receive it as it runs down. It is then dried at once, constituting a very high grade of the drug, or more usually the separate collections are laid aside until enough is accumulated to make a ‘“‘ cake,” when it is all moistened and kneaded together. In this way the bubbles and sour odor are developed, and what is known as ‘‘ Virgin Scammony ” is produced. Scammony is in ‘“‘irregular, angular pieces, or circu- lar cakes, greenish-gray or blackish, internally porous, and of a resinous lustre, breaking with an angular fract- ure ; odor peculiar, somewhat cheese-like ; taste slightly acrid; powder gray or greenish-gray.” The porous, bubbly texture, and the sour, cheesy smell are results of fermentation during the process of drying. It is soluble to the extent of three-fourths in ether. The costliness and opaque color of Scammony render it especially lia- ble to adulteration. Lime, flour, ashes, gum, etc., are among the common admixtures. The proportion of resin is the best test of purity. This resin (Resina Scammonit, U. 8. Ph.) is obtained by digesting the drug with alcohol and evaporating the tincture so obtained, or by treating the root in the same way. It is a brown, translucent, brittle resin, with a sweet, fragrant odor if obtained from the root ; but, as usually seen, from crude Scammony, it is more greenish and dirty in color, and has the odor of Scammony itself. The action and value of the two products are about the same. CompositTion.—The peculiar resin of Scammony, un- fortunately called jalapin, first obtained in a state of purity by Johnston, in 1840, differs from the convoloulin of jalap by its solubility in ether. When purified it is a colorless, translucent, brittle, non-crystalline resin, tasteless and odorless, of nearly neutral reaction, and freely soluble in ether. It is a glucoside, and resolv- able into jalapinolic acid, a crystalline substance, and sugar. Good Scammony contains eighty or ninety per cent. of this resin. ACTION AND UsE.—Scammony and its resin are to be counted among the very active drastics, excelled only by croton-oil and elaterium. Their action is similar to that _of jalap, but considerably more intense. They are used as derivatives and hydragogue cathartics in cases of cardiac and renal .troubles associated with dropsy. Scammony resembles the action of jalap, but is more intense. Aromatics and carminatives are appropriate adjuvants. Dose, of good Scammony, half a gramme or so; of the Resin, three or four decigrammes. The compound Extract of Colocynth contains fourteen per cent. of Resin of Scammony. ALLIED PLANTS, ETC.—See JALAP. W. P. Bolles. SCAPULA: DISEASES AND INJURIES OF THE CORACOID PROCESS. The coracoid process (Syn.: Processus Cornicularis, Hawk-bill Process) is usually described as a short, thick, curved process of bone, rather more than one inch in length, which arises by a broad base, and projects beneath the outer end of the clavicle from the anterior part of the upper margin of the scapula. It is first directed upward and inward, then, becoming smaller, it changes its direction and passes forward and outward. The horizontal portion is irregular and flattened from above downward, the under surface is smooth, while the internal and external bor- ders are roughened for the attachment of ligaments and muscles. The ligaments are—the origins and insertions corre- sponding to the situations named—the coraco-clavicu- lar, coraco-acromial, and coraco-humeral. The muscu- lar attachments are the short head of the biceps, and the tendons of the coraco-brachialis and pectoralis mi- nor muscles. In position the coracoid process is almost unique, being uncommonly well protected by the cir- cumjacent bony and muscular structures. The clavicle is arched above, the head of the humerus protects it from external injuries, and the deltoid and pectoral mus- cles complete the defence with a buffer-like elasticity, shielding it from all assaults directed from either above or below. ‘The development of this process takes place from two centres of ossification, one in the body and the other near its base. It remains as an epiphysis until near the twenty-fifth year, a portion at birth being carti- laginous. Allen (‘‘ Human Anatomy,” sec. 11, p. 171), says: ‘‘ This process is homologous with the coracoid bone of batrachian reptiles and birds; as seen in these animals, the coracoid bone extends between the sternum and scapula very much after the manner of the clavicle in the human subject.”” In persons of moderate muscular and adipose development this process can be felt just be- neath the mesial portion of the outer third of the clavicle, a short distance to the inner aspect of the head of the hu- merus. The hand should grasp the shoulder, the fingers at the same time steadying and pushing the scapula for- ward against the back of the chest; it can then, ordinar- ily, be recognized, by the thumb being pressed in front, as a bulbous protuberance about the size of a large bean. The arm during the manipulations should be extended and rotated outward, which, by producing traction upon the accessory ligament, brings the process forward and facilitates its detection. There is one fact which de- serves to be specially mentioned because of its importance in regard to diagnosis. In the normal subject, where no disease nor injury is suspected, the coracoid will fre- quently be found intolerant of rude manipulation or pressure ; therefore, it should be impressed upon the ob- server, when making examinations in this region, that a precipitate diagnosis should not be made from the mere presence of pain uncorroborated by other morbid indica- tions. DisEASES.—The literature of this class of affections is very meagre. Nothing seems to have been recorded that would demand any special therapeutic measures, beyond what is usuall comprehended by ordinary estab- lished rules, and such as are appli- cable to bone dis- ease situated in analogous struct- ures elsewhere. It may be worthy of mention here— rather as a matter of curiosity—that the coracoid pro- cess is sometimes thought to become the seat of reflex neuralgic mani- f ions, du tee rs g My Fie,’ 8884.—Fracture of the Coracoid Process, Some inde ae € showing action of muscles in its displace- disturbances 1n_ ment. the abdominal vis- cera. Pain felt in the right process has been attributed to vague hepatic derangement, while that of the left side is supposed to be connected with morbid conditions operating in the spleen. How far these are to be cred- ited as demonstrations of disorder in these organs can- not at this time be determined; but it would be wise to regard these relations as extremely conjectural, and as such quite insufficient to warrant much serious con- sideration. Periosteitis, simple and tubercular osteitis, caries, and syphilitic necrosis have occasionally been observed in this process. It may be also said of these that the principles governing the management of such common forms of disease will be found the same here as elsewhere. It will, therefore, be amply sufficient for all purposes to limit our observations here to osteitis alone, this being in the common run of cases the form of disease most likely to be met with. ‘“‘QOsteitis of this process occurs with greatest fre- quency in the period of adolescence, before the epiphyses have consolidated, and is liable to be confounded with scapulalgia, osteitis of the head of the humerus, or even cervical Pott’s disease. The diagnosis may be made by 297 Scapula. Scapula,. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. the location of the pain on pressure, and by the presence of tumefaction, or of an abscess. The latter is found usu- ally in the subclavicular region rather than in the scapu- lo-humeral, or on the internal aspect of the arm, the pus following the sheath of the coraco-brachialis muscle, or the short head of the biceps. ‘* Treatment.—This consists of resection of the process by means of a T-shaped incision. In case of tubercular osteitis union by first intention cannot be hoped for, and it will be necessary to provide for free drainage ” (Pon- cet, Lyons Bull. Gén. de Thérapeutique). Fracrures.—Injuries of this class involving the cora- coid process have always been considered as remarkably rare, the ordinary surgical authorities and text-books enumerating not above a dozen examples, which are generally accepted as constituting the entire list of authentic cases. These statistics are, however, mis- leading, and sufficient data are not wanting, as will be shown in the tables below, to prove that the lesion is much more common than is usually believed. Writers have seemed to be possessed with the idea that this process is so well protected that fracture is wellnigh impossible without the infliction at the same time of such an extensive injury to the surround- ing structures as to overshadow the coracoid trouble. This @ priort reason- ing has in time become dogmatic asser- tion. Experience, however, has shown that this process is not disproportionally ex- empt from simple fractures. The rarity of fracture of the cora- coid process has been greatly exaggerated in the past, and there can be no doubt that a careful investiga- tion, at any time dur- ing the past century, would have shown that very many ana- tomical collections contained specimens of this injury. The result of sucha study would have been to prevent the emphatic and misleading lan- guage of Lizars, which is as follows: ‘The coracoid is said to be broken off, but this I question very much; it must be along with the glenoid cavity, or there must be a fract- ure of the neck of the scapula.” No less pronounced are the remarks of the eminent Malgaigne. ‘This fracture is ex- cessively rare, and does not occur except in company with other serious inju- ries.”” Holmes, Erich- sen, South, and Bry- ant bear similar testi- mony, regarding it either as highly improbable or ex- ceedingly rare, unless accompanied by marked complica- tions, rendering it a very serious accident. Varéeties.—There are three principal forms of this fract- ure that have been observed, ‘The first of these, which Fic. 3885.—Green-stick Fracture of Cora- coid Process, with Multiple Fracture of Scapula. 298 \ is the most frequent of any, may be defined to embrace all fractures limited to the process proper in which the line of fracture is simple and complete. ‘The second va- riety is denominated partial green-stick, or incomplete, fracture, an example of which is shown in Fig. 3385, taken from a case the dissection of which was reported by Bennett, of Dublin, to the Academy of Medi- cine of Ireland. This may be pronounced the most unique of speci- mens, and probably is the only case of the kind ever verified by. an autopsy. An ex- amination of the cora- coid shows two fract- ures, one at the apex and another at the base; the latter break runs from the junction of the process with the glenoid cavity, on through the entire concave surface which is related to -the subscapularis muscle. On looking at the supra- spinous fossa (Fig. 8885), there is no trace whatever of the fracture visible. The scapula came from a man who died a few hours after being crushed by a quantity of falling masonry. The third division of these in- juries is that known as the intra-articular or compli- cated. This is a fracture in which the break is not con- fined entirely to the process, but continues into, or runs through, the glenoid cavity or the subscapular fossa. (This is also seen in Fig. 3385.) Those of the latter class belong more properly to the subject of fractures of the scapula, and the reader is referred to the article Fractures, in vol. iii. of. this HANbBOooK, for more thorough. information upon the subject. From the foregoing arrangement it will be seen that fractures of this process correspond to the ordinary types of a like injury occurring in the other bones of the body. History.—It will not be deemed necessary to sacrifice ‘space to enter into a detailed history of this fracture. Du Verney, more than a century ago, called attention to its existence, and, only a few years later, among the first in this country to describe it was William Gibson, of Philadelphia. The latter recognized its importance in his ‘Treatise on Surgery ” (vol. i., p. 258, 1885 edition), and mentioned two cases as having come under his own obser- vation, in which this was the diagnosis arrived at. He records the first of his cases as occurring in the person of the famous Charles Carroll, of Carrollton, who, while rid- ing in the carriage of the British Minister, Bagot, was upset, and by a violent fall upon the shoulder this pro- cess was broken off. Gibson remarks, ‘‘The subject being a remarkably thin one, I was able to distinctly feel and move the fragments one upon the other.” Of his second case he makes no further mention than to say it was in the person of a sailor. The following reports of cases, though not arranged to illustrate any particular feature of these injuries, will be found to describe this fracture when resulting principally from falls and vio- lence imparted to the humerus and the shoulder-joint as a Whole. As an apology for entering the reports of cases REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Scapula. Scapula, in a work like this, it can be said to best justify the general purpose of it, which is to present reliable infor- mation lucidly and briefly. Case I.—A milk-woman, aged thirty years, fell from a cart upon her right side into the street. The motions of the arm were not impaired, she could raise her hand to her head without any difficulty. The clavicle, hume- rus, and acromion were entire, there was neither deformity nor flattening ; but on attempting to grasp the coracoid process while the arm was freely moved up and down, a looseness and crepitus could be distinctly felt, and a grating was also perceptible in the axilla. The arm was secured to the side by means of a sling and bandage, and fomentations were applied. There was very little swell- ing, but the woman complained of pain which was in- creased by motion. (London Lancet, 1840-41.) Case II1.—Male, aged forty-five years, very thin and spare, fell down a steep flight of stairs feet foremost, striking heavily upon his left elbow, which was thrown backward in an effort to protect himself. Examination showed the arm shortened, elbow carried a little back- ward and slightly separated from the body ; motion, es- pecially forward, greatly restricted. To the inner side of the acromion was felt a prominence, which was the head of the humerus, dislocated but easily reducible. Crepitus was obtained by making traction upon the arm and carrying it outward and forward ; this crepitus was felt by the thumb when placed upon the coracoid pro- cess, and was plainly marked, though consisting of but a single click. Pain was localized at the point of crepi- tus. (Taken from Streeter’s case, Medical Record, 1887.) Case III.—Male, aged twenty-four years, fell down an open hatchway of a vessel, some twenty feet. The right hand at the time of the fall was in the pocket of his trousers. The injuries were fatal, and a dissection dis- closed a fracture of the coracoid process. The line of fracture ran obliquely from the inner and upper bor- der of the process, just beyond the attachment of the coraco-clavicular ligament, downward and outward to- ward the tip, and terminated on the external border, a fourth of an inch from its summit. There was no dis- placement of the fragment, the head of the humerus was dislocated forward, and at the moment of its passage from the glenoid cavity the upper portion had fractured the process by pushing against its under surface. (Ben- nett: Dublin Journal of Medical Science, 1878.) Case IV.—Male, aged seventy-six years, fell, striking his right shoulder against a projecting board. . . . The right arm was powerless, the shoulder somewhat swollen, and there was a contusion one and a half inch below the acromion, and slightly to the posterior side of the humerus. Movement was very painful, and occa- sional crepitus could be distinctly felt when the arm was rotated. The head of the humerus was thrown a little forward and inward, but readily answered to all move- ments imparted at the elbow. No pain or crepitus was found over the clavicle, the acromion was intact, and there was no break about the glenoid cavity. There was unmistakable bone crepitus, and pain was felt over the coracoid process. (Johnson: Medical News, 1885.) Case V.—Elderly woman, who slipped down in a narrow alleyway and struck her elbow, driving the head of the humerus forward. The symptoms were loss of function of the coraco-brachialis and pectoralis minor muscles, tenderness, and crepitus on pressure of the cor- acoid process. (Packard : Charleston Medical and Surgical Journal, 1859.) Case VI.—Male, aged thirty-three years, slender build, scanty adipose tissues, bony landmarks prominent. The patient had recently undergone an amputation of the forearm a few inches below the elbow, the stump re- maining unhealed and tender. He was found supporting his stump with the opposite right hand, nervous, pale, and evidently suffering intense pain. : The information was that, while endeavoring to avoid the wheels of a vehicle in the street, he had lost his footing and fallen backward into the gutter; in doing so he had, to use his own words, ‘‘ knocked his shoulder out of joint.” Further questioning as to the exact manner of the accident elicited the fact that, while falling, he had struggled to recover his lost equilibrium, and, as a consequence, landed heavily and awkwardly upon his left shoulder. The arm, it was ascertained, had been raised above the head and thrown outward, possibly instinctively as it were, to protect the sensitive stump, and in this position the bulk of the traumatism from the fall was sustained by that portion of the shoulder corresponding to the space between the deltoid insertion of the humerus and the dorsal aspect of the acromion. Upon exposing the limb for inspection it was found to hang lower than its opposite fellow, the elbow being held away from, and slightly to the front of, the body. The hand, in passing carefully along the clavicle, acromion, scapular spine, and head of the humerus, then into the axilla and the space corresponding to the coracoid process, detected no anomaly, excepting a slight subluxation forward of the head of the humerus. A little extension reduced this to position, and, the parts presenting their normal con- tour, the patient was assured that everything was in its place and nothing broken. Notwithstanding this assur- ance he continued, with considerable misgivings, to complain of severe pain. In order to convince him, the arm was immediately put through several brisk manipu- lations, as if nothing was the matter ; while carrying the limb outward and rotating, distinct crepitus was heard, which the patient was quick to notice, and remarked that he ‘‘felt it grate, and something must be broken.” A careful repetition of these movements, with the fingers pressed gently into the coracoid space, revealed the ir- regularity there. Any increased pressure from the fin- gers while the limb was moved, caused crepitus, and so augmented the pain that the patient energetically pro- tested against its being repeated, flinching each time the process was touched. He was then directed to shrug the shoulder, and was unable to do so. This peculiar movement of shrugging the shoulders (Hawsser les épaules) has not been before alluded to by writers when discuss- ing this injury; it is, however, of considerable value as an element in diagnosis. It will be recalled that the pectoralis minor muscle draws the scapula forward and downward, and at the same time causes it to execute a rotating motion, by virtue of which the inferior angle is carried backward and the anterior depressed ; if the arm be fixed the coraco-brachialis assists these movements, and in order to perform them it is necessary that the en- tire set of ligaments of this process should be in an in- tact condition. Ifafracture be present in which there is separation of the fragments, with an alteration in the position of the ligaments, these combined movements cannot take place. In this case the arm was elevated and abducted ; the force was severe, the whole weight of the body striking the curbing, and the head of the humerus, in partial dislocation, was directed against the process. There were localized pain and crepitus, with swelling and a suspension of the function of the muscles corresponding to the parts. (Byers: ‘‘Coracoid Fract- ures,” pamph., 1885.) There is little doubt, in this case, that when the head of the humerus was driven forward it pressed forcibly against the process, and caused rupture of the coraco- acromial ligament, the fracture being produced by one bone striking against the other. Allen says: ‘‘ The coracoid process acts as a check to this inward movement of the head of the humerus, and, unless it be broken off, subclavicular dislocation can scarcely occur.” Rotation of the head of the humerus outward, in a great many of the cases reported, produces crepitus, and appears at the same time to effect a reduc- tion of the piece broken off. The mechanism of this crepitus and restoration of the fragment has not been sat- isfactorily explained. The late Dr. Hamilton, upon one occasion, saw an instance in which the apex could be replaced, but how and upon what principle he confessed his inability to state, unless perhaps it was by drawing upon the muscle attached to the process. The most plausible explanation, however, would appear to reside in another and entirely different source, namely, trac- tion exerted by the accessory ligament. This arises from 299 scapula. Scapula. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. the outer border of the coracoid and passes over across the capsular ligament—being partially blended with its fibres—and is inserted into the greater tuberosity of the humerus. It can now be seen that tension upon this lig- ament, caused by outward rotation, will produce results directly opposite to the ordinary action of the muscles mentioned. The action of the muscles is to displace downward, while traction exerted upon the accessory ligament lifts and carries the process outward. The foregoing cases are found to illustrate this fract- ure chiefly when it occurs as the result of violence im- parted to the humerus, this being by its displacement the principal factor in its production. Some cases will now be presented to show how it may be a consequence of violence applied to the process directly from the front. These two causes are found to be the most important ones in a large number of these accidents. The opinion has been entertained that force applied to any portion of the scapula, and especially from the front, would cause it to rebound upon its muscular supports, and that this would so mitigate the force as to render it virtually incapable of fracture. Agnew is of the opinion that the head of the humerus alone is capable of fracturing even the glenoid cavity when forcibly driven against it. That the hypoth- esis of its being protected by the muscles is not consist- ent with experience, will be seen from a study of the cases that follow : Case I.—Male, aged twenty-seven, fell in the dark, striking his shoulder against the edge of a door standing ajar. The pain was excessive, so much so as to render him unconscious for some little time. Upon a careful examination of the part no objective signs of the injury were at first evident. There was inability to place the hand upon the head, and also extreme tenderness on pressure, limited to a space just inside of the acromial end of the clavicle and just below it. No crepitus was at this time present, nor was there deformity. Next day there was tumescence, circumscribed to the injured spot, with impairment of the functions of the muscles attached to the process, and crepitus was now plainly perceptible over the seat of the injury. (Huse: Chicago Medical Hx- aminer, 1879.) Case II.—Male, aged sixty-six, while walking along the street was struck full on the right shoulder by a run- away horse, lifting him bodily off his feet and violently throwing him against an iron column, Upon making an examination, pain was found about the shoulder, very severe, the patient complaining that his arm was broken. But no false point of motion was found until the cora- coid process was reached. Manipulation here caused ex- quisite pain; some crepitation was made out, and there was a slight degree of displacement. (Borcheim, in At- lanta Medical Journal, 1886.) Case III.—Male, aged fifty-six, stout farmer, thrown down by a colt and kicked badly. Examination showed no displacement nor fracture, until by chance crepitus was noticed at a point in front of the right shoulder. The humerus was in place, and every motion of the arm could be made passively, the spine of the scapula and clavicle were entire, the crepitus being strictly localized to a point internal to the shoulder-joint and beneath the clavicle. (Higgins: Philadelphia Medical News, 1885.) Case IV.—Male, laborer, of intemperate habits, was struck by a plank falling from a great height, the point striking him full upon the tip of the shoulder. The arm hung helpless by the side of the body. The adjacent bones were all entire, crepitus was felt by manipulating the arm, and motion of a loose fragment could be de- tected on examination through the axilla; the line of fracture probably extended into the glenoid cavity. (S. W. Smith, N. Y., unpublished case.) Agnew and Hamilton have each observed cases in which violence, as a blow in front, was a cause. Diagnosis.—The detection of this injury may at times be a matter of difficulty, especially when the presence of other complications more important, such as swelling, dislocation, and other fractures, masks it. The history, with a knowledge of the kind and direction of the force, will frequently be of material service in its recognition. 300 Crepitus can usually be produced by outward rotation of the arm, and mobility of the fragment is occasionally seen and felt ; localized pain and tumefaction, with an inability to shrug the shoulder, and an absence of other injuries capable of producing analogous symptoms, are further aids to diagnosis. These will usually lead to a correct solution of the difficulty, should any be presented. Holden, in his valuable ‘‘ Landmarks,” says: ‘‘On the front surface of the clavicle, not far from the acromial end, there is, in many persons of mature age, a spine-like projection of bone. This is liable to be confounded with the coracoid, and it would be well to ex- amine the opposite side to see if there is a corre- sponding projection also, in order to clear up any possibil- ity of error from this source. Prognosis, — This will in most cases depend much upon complications, if there be such; if there be none, the final result as regards the use- 2 fulness of the limb will be F16-3386.—Neill Specimen, show- ing Process Reunited by Two good, and assurances may be parallel Fibrous Bands. generally given to this effect. The exact seat of the fracture, as compared with its ligamentous arrangement, will be a matter to be deter- mined, if it is desired to obtain perfect union. If the fracture is in immediate proximity to the base, and if the acromial and clavicular ligaments are also ruptured, we certainly shall expect to find very marked displacement of the broken fragment. This will be evidenced by an un- usual degree of passive mobility, and by a more or less total suspension of the functions of the corresponding muscles. The union, as a consequence, will necessarily here be by an intervening fibrous band, since no sort of retentive apparatus is capable of acting as a perfect splint in these circumstances. Again, if the break be anterior or between the ligaments, and if their clavicular and acro- mial attachments escape rupture, the area of displacement will be materially abridged. If the process be broken in such a manner as to hinder or prevent its easy reposition and retention—as when the base is drawn down and tilted forward, or when there are spasms of the muscles—the union will be fibrous, and there will doubtless also be a permanently movable pro- cess. This con- dition is shown in Fig. 3386, and s the common sequence in a ma- jority of cases. Hamilton mentions sev- eral examples in which the process could be moved months after the accident. ‘These mova- ble processes will occur in all those cases where the bones have been widely separated, and where there has been a failure to retain the surfaces in proper apposition dur- ing the reparative effort. How- ever, this fibrous or ligamentous union does not mar the ultimate usefulness of the process, the Fig. 3387.—Specimen show- shoulder usually presenting noth- ing Partial Osseous De- ing yncommon excepting, at times, posit. (Warren Anatomi- cal Museum, Boston. ) an awkwardness observable solely by the patient. Many of the spe- cimens contained in museums show ligamentous union as a result, but very few manifest anything like an at- tempt at genuine osseous deposit, this being rare. Fig. 3387 is taken from a photographic plate in the possession of Marcy, of Boston. The specimen is to be found in the pe: 2 44 mee 2 ee) a ee a REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Sex. Male, Male. Male. Male. Male. Male. Female. Male, Male. Male. Male. Male. Female, © Male. a aceoe eee nee Pee wees Male. Female. Male. Female. Male. Male. Male. Male. Age, 45 years. 66 years. 33 years. 56 years. Adult. Adult. Elderly. Adult. Adult. 55 years, Adult. 14 years. Adult. ereees er ec eee ee aeseee eee eee aeeeee eee eee eee eee Adult. 16 years. 35 years, Adult. 32 years. 27 years, 15 years. 76 years. Adult. 38 years. Adult, Cause. Fall backward. Thrown bodily against an iron column. Fall backward. Kicked’ by a horse. Patient crushed by falling ma- sonry. a ee ary Fall upon elbow. Unknown. Gunshot. Fall upon shoul- der. Struck by aniron bar. se ae ee ere wees a ee Muscular action. Fall forward. ee ee ey ee ey ee ey er sere ccc e tts ose ee ee ee Pe ee ey Pe ce) ey ee ee | moka venniel @@).d) lene) o.6ne Fall. Plank falling up- on shoulder. Fall, Fall forward, Fall, Fall. Struck board. by a Struck by an iron rod. Fall forward. Evidence. Pain, crepitus, swelling, and mo- bility of process. Pain, crepitus, and mobility of pro- cess, Pain, crepitus, mo- bility, and loss of function. Crepitus, pain, and mobility of pro- cess. Post-mortem dis- section. Post-mortem dis- section, Pain, crepitus, and loss of function. Post-mortem. Post-mortem dis- section. Pain, crepitus, and mobility. Pain, prominence of process. Post-mortem dis- section, Mobility and crep- itus. Post-mortem dis- section, Post-mortem dis- section. Post-mortem dis- section, Post-mortem dis- section. Post-mortem dis- section. Post-mortem dis- section, Post-mortem dis- section. Post-mortem dis- section. Post-mortem dis- section. Post-mortem dis- section. Post-mortem dis- section. Crepitus, displace- ment, mobility of process. eee ree ne teen rose Post-mortem dis- section. Post-mortem dis- section. Crepitus, pain, and displacement. Post-mortem dis- section, Pain, crepitus, loss of function. Pain, crepitus, and loss of function. Pain, crepitus, and loss of function, Mobility and crep- itus. Crepitus, pain, and impaired func- tion. Preternatural mo- bility 8 months after injury. Crepitus and dis- placement. Mobility and crep- itus. Scapula. Scapula,. Complication, Reference. There was some, but not stated. There was some, but not stated. Subluxation forward of | head of humerus, Not stated. See illustration of green- stick fracture, Fig. 3385, Tip seen suspended by the clavicle ligament. Head of humerus dislo- cated forward and up- ward, Fragment hangs loose. Peewee rene rees see ersees Dislocation of head of humerus. Fracture of glenoid and base of acromion. eC a i a | ee ee re ee ee Not stated Dislocation of humerus, clavicle fractured. Dislocation of humerus, Fract. acromion and hu- merus. Broken twice and gle- noid involved. See Fig. 3387. Severe damage to the soft parts. Ce ee ee i Cs ee ee cs eee e reer ere sr sees - seers ee ee ee Horizontal fracture of scapula. Unreduced dislocation of humerus forward. er ee ee Dislocation of the head of the humerus, Supposed fract. of gle- noid cavity. Wounds of face. Loss of consciousness. Dislocation of the clav- icle. Humerus subluxated for- ward. Dislocation of the outer end of the clavicle. Paralysis of arms and hand. Pe ee Record, vol. i., 1887. | Dr. L. E. Borcheim, At- lanta, Ga., Med. and Surgical Journal, 1886, Dr. J. Wellington Byers, pamphlet, 1885. Dr. F. W. Higgins, Phila. Med. News, Dec., 1885. Bennett, Trans, Academy Med., Ireland, 1883. Wood’s Museum, Specimen 455, Dr. J. H. Packard, Charles- ton Med. Journal and Re- view, 1859. Wood’s Museum, N. Y., Specimen 475. Army Med. Museum, Wash- ington, D. C. aN, Vids Gibson’s Surgery, edit. 1836, vol. i., p. 258. Agnew’s Surgery, vol. i. Erichsen’s Surgery, vol. i. 9 Paule’s case, Bryant’s Sur- gery, 4th edit. Neill specimen, see Fig. 3886; also Agnew’s Sur- gery, vol. i, p. 876. Gibson, Agnew’s Surgery, vol. i., p. 876. Lancet, London, 1873. Holmes’ Surgery, vol. i. London Med. and Surg. Re- view, 1840. Hamilton, Fractures, edit. Cooper, Fract. and Disloca- tion. Hamilton, Fract. and Dis- location, 7th edit. Marcey, Trans. Am. Med. 7th Ass., 1885. Archives Générales de Méd., 1840. Malgaigne, Fract., Pack- ard’s Trans. Malgaigne, Fract., Pack- ard’s Trans. Army Med. Museum, Wash- ington, D. C. Gibson's Surg., vol. i., 1836. Bennett, Dub., case not pub- lished. Fergusson’s Surg., p. 231. Malgaigne, Fract. and Dis- location. Phila. Med. News, No. 671, Nov., 1885. Med. and Surg. Trans., vol. xli., p. 447. Dr. T. E. Little, Dub. Jour. Med. Sci., 1879. Notes by Dr. R.W. Smith, of Dub., case not published. Bryant’s Surg., third Am. edit., p. 829. Bennett, Dub. Jour. Med. Sci., 1873. Dr. S. W. Smith, of New York (Case IV., on p. 800). London Lancet, 1840-41. Huse, Chicago Med. Jour., August, 1879. Hamilton, Fract. and Dis- location, 7th edit. Dr. R. W. Johnson, Phila. Med, News, 1885. Hamilton, Fract. and Dis- location, 7th edit. Hamilton, loc. cit. Holmes, System Surg.,vol. i. Dr. F. B.. Streeter, Med. Results. Not stated. Not stated. Ligamentous un- ion. Union by liga- ments. i ee i er ey pair. es No attempt at re- pair. Osteitis, with spontaneous separation, ion. er ee sare eeeree Ligamentous un- ion. Union by liga- ment. Union ment. by liga- ey union. Ligamentous un- ion. Ligamentous un- ion. No effort at re- pair. Osseous union by unbroken peri- osteum., i ee ie a ee ee ay Bony union (doubtful). Ligamentous un- ion, Ligamentous un- ion. Ak ey Py Ce i ee ee oe tere sere seen ee Se ee ee eee e cee reecece ion, ee os fe oe eeeere se eeee eee eee sere ee ee eoee es Partially osseous e@oeoee eersae eecene cee see ere ee eeeese eee nee aeretee were oe serene a sooner Scapula. Scarlet Fever. Warren Museum of the same city, and is catalogued as No. 988, deposited by Warren, 1847. An examination of it shows that the edge of the fracture, which extends into the glenoid cavity, has undergone no effort at repair, yet, upon the superior border of the neck, there is an abun- dant formation of new bone, filling the suprascapular notch, and extending along a fissure running nearly the whole extent of the supraspinous fossa. Bennett men- tions a case in which the result was osseous union and unbroken periosteum, as was shown at the post-mortem examination. Two other cases, by Drs. Alan Smith and R. W. Johnson, of Baltimore, have been reported, but not confirmed, however, by autopsies. Treatment.—This can be set forth briefly and in a ver few sentences. The indications, in the light of what has been already stated, are plain. Usually we should en- deavor to restore the part broken off to as near its origi- nal position as is possible, and to retain it there by means of suitable apparatus. This can best be accomplished and the requisite indications fulfilled by first relaxing the muscles causing displacements. To effect this the forearm should be flexed, and rotated outward, bringing the fragment back to its normal position ; then the arm, still flexed, should be carried across the chest and se- cured there by means of a Fox apparatus, a Velpeau, or a four-tailed bandage. It is advisable to combat the inflammation that some- times follows in the loose cellular tissue by anodyne lotions. The effusions are abundant when they take place, frequently reaching to the elbow. . The appara- tus should be worn for six weeks, when osseous union may be expected. At first the muscles should be used carefully. ftemarks.—To summarize these reports of cases and the tables that are shown on preceding page, it will be seen that in all those which were not fatal there were associated with the fracture changes in the head of the humerus. Pain and crepitus are the most frequent symptoms met with. One-half of all the cases tabu- lated were verified by post-mortem dissections, these being principally reported by the older authorities ; whereas nearly all of the recent cases were diagnosed and clearly illustrated by the symptoms during the life of the subject. Of those not terminating fatally, seventy per cent. were the result of falls. No particular manner of falling seems essential for the production of this injury, since it is seen to occur while the arm is elevated, ab- ducted, thrown backward, or by the side, the body fall- ing either backward, forward, or sideways. Flower saw two cases in which the hands were stretched forward during the fall. Twenty-five per cent. of the cases oc- curred in adult males, five were women and young girls, the sex of the remainder being undetermined. The ages will be found to extend from fourteen to seventy-six years, a large per cent. certainly occurring after a con- solidation of the epiphyses ; the only cases showing any liability toward criticism from this source are those of Bryant, Paule, and one of Hamilton. The Neill speci- men has been objected to on account of this, but the scapula is large, well-developed, and doubtless came from an adult. As to this fracture being confounded with separation of the epiphyses, this term is only ap- plicable when the line of fracture is identical with the remaining interosseous cartilage, which during the years of adolescence merges into the bone of the scapula proper. Separations of this bone are only possible prior to the twenty-fifth year, unless, as a result of some malforma- tion or disease, the cartilaginous medium has persisted later in life. Therefore the attempt of some to pronounce all these injuries as merely separations of the epiphyses, rather than true fractures, is unwarrantable. As to direct violence being the principal cause of this injury, as is generally taught, an examination of fifty examples shows that this was the means in only six cases. Two cases are reported as the result of muscular action, but these, it is fair to assume, were associated with osteomalacia or other diseases. Gurlt’s ‘‘ Knockenbriicher” is said to contain a description of about twenty cases of coracoid fracture. 302 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. BIBLIOGRAPHY. London Lancet: University Hospital Reports, 1840-41. Dublin Jour. Med. Sciences, 1878, vol. lvi., p. 345. Atlanta Med. Jour., May, 1586, Dr. L. E. Borcheim. Bul. Gén. de Thérapeutique, 1885, Poncet. Chicago Med. Jour., August, 1879, Dr. E. C. Huse. Coracoid Fract., Pamph., 1885, Dr. J. Wellington Byers. Dub. Med. Jour. Sci., 1879, Dr. E. H. Bennett. Gurlt’s Knockenbriicher, edit. 1862-64. London Lancet, 1878, vol. ii., Hulme. Med. News, Philadelphia, 1885, Dr. R. W. Johnson. Med. News, Philadelphia, 1885, Dr. F. W. Higgins. Med. Record, Dr. F. B. Streeter, vol. i., 1887. Trans. Am. Med. Ass., 1880, Dr. H. O. Marcey. Trans. Academy Med., Ireland, 1883, Dr. E. H. Bennett. Charleston Med. Jour., 1859, Dr. J. H. Packard. J. Wellington Byers. SCARBOROUGH, a city of about thirty-five thousand inhabitants, on the east coast of Yorkshire, is one of the best known and most popular of English watering-places. There are two mineral springs here, which are known as the North Well, or iron spring, and the South Well, or saline spring. The following are the analyses of these two springs, made by Phillips (Rotureau). In 1,000 parts of water there are of North Well. South Well, Sodium chloridG yaw ses seeresce erotics. 2.016 3.140 Petrous bicarbonate. - oe 44seee-se 0.210 0.192 CalciumPbicarbonaleseseeee see eee 5.517 5.066 Calcium sulphate....... RASA Saeed 11.877 11.713 Magnesium sulphate................. 19,734 23.884 Total. -.v5 oc Weak eee eee a oe 59.854 43.995 The waters of Scarborough are used to some extent in therapeutics for the same purposes as are other saline and ferrnginous springs, being prescribed especially for those suffering from anemia who are also troubled with con- stipation, But the visitors are, as a rule, attracted more by the fine sea-bathing than they are by the spree 4 SCARLET FEVER. Synonyms: Scarlatina (English and Italian); Scharlach (German) ; Scarlatine (French) ; Escarlatina (Spanish). DEFINITION.—Scarlet fever is an eruptive contagious fever. Its incubative period is brief, rarely less than twenty-four hours, usually lasting from four to six days, and not often exceeding this duration. This period is succeeded by a period of invasion which is ushered in by fever, usually of considerable intensity, and by sore throat. A scarlet eruption begins to appear before the end of the second day, and marks the end of the prodromal, and the beginning of the eruptive, period. The eruption rapidly becomes general, and the tongue becomes stripped of its coating and assumes a raspberry-red color. The eruption slowly fades after the first few days. The fever persists until the sixth, seventh, or eighth day, or longer. As the eruption fades, desquamation begins and con- tinues for from eight to fourteen days or more. It is peculiar in being lamellar, sometimes occurring in very large shreds and exfoliations. During the attack, and for weeks subsequently, there is an especial predisposi- tion to renal inflammation. Scarlet fever attacks chil- dren more especially. It usually affects an individual but once. Histrory.—Scarlet fever is probably a disease of very ancient origin, though until three centuries ago medical writers had not recognized it; indeed, definite knowl- edge of it as a specific, independent affection dates back hardly two hundred years, although as early as 1589 an epidemic, which we now presume to have been scarlet fever, was described as having occurred in Sicily in 1543 (Paulus Restiva).’ It was not until 1676 that Syden- ham definitely separated this malady, as ‘‘ feb77s scarlatt- na,’ from measles, and gave it an established position. The observations of writers had already been leading them toward similar views, and within a few years scar- latina became recognized all over Europe. Although its place of origin can never be known, it is probably of European birth ; for it isa remarkable fact that scarlet fever has never succeeded in gaining a firm foothold in Asia or Africa. According to Hirsch, in whose most REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Scapula. Scarlet Fever. valuable work these facts have been recorded, the coast of Asia Minor is the only Asiatic district which is fre- quently visited with scarlatina in its severe forms. In nearly all other parts of Asia it occurs not at all, or only sporadically. Wernich, in 1871, declared the disease to be quite unknown there. In Africa, Hirsch states that it is only in Algiers and in the Azores that it is at all common. Following the carefully recorded data of Hirsch, scarlet fever appeared first in America, in New England, in 1785. It extended as far south as Philadel- phia in 1746, and penetrated to Ohio in 1791. Not un- til 1851 was it seen in California. In 1880 it began to be generally observed in South America. In the West In- dies it was first observed in 1802, in Martinique, asa mild epidemic. Greenland has heretofore escaped with but a solitary case. Australia and Polynesia appear to have escaped until 1848. In the Polynesian islands, except Tahiti, scarlatina has not been known. It is unques- tionable that scarlet fever has never occurred in some localities only because the inhabitants have not been ex- posed to its influence; but there can be no doubt that in other countries influences prevail that oppose the devel- opment of the disease. Whether these are climatic or racial, or due to other causes, is at present unknown. The American Indian is not exempt from its ravages, nor can any different degree of susceptibility be observed in the negro race in the United States. Frick,’ how- ever, noted a somewhat more pronounced tendency in the negro to scarlet fever. In the epidemic in Balti- more, between the years 1850 and 1854, of every ten thousand inhabitants 13.8 whites and 10.8 negroes died. This would indicate a relatively greater predisposition in the negro, as in the total population the whites were largely in the majority. Frick’s observations were too limited to secure an unhesitating acceptance of his con- clusions. It must be noted, however, that in this coun- try the negro is rarely of unmixed African descent. He may have inherited from white progenitors some of their -especial liabilities to disease. Drake and others have . Shown that scarlet fever prevails less in the Southern - than in the Northern States. It is also probably true that the disease is more frequent in cold than in hot countries. Yet it cannot be determined that the differ- ences depend upon temperature; Greenland has re- - mained without an epidemic, while Algiers has experi- enced them frequently. Scarlet.fever at once shows differences from small-pox and measles in not Sweeping over localities in great peri- odic waves. It may, it is true, sometimes invade very wide areas of territory with astonishing rapidity, but the intervals between epidemics are often very great. With- out obeying any well-defined periodic law, measles is often known to prevail with noticeable violence every third or fourth year, frequently disappearing completely in the interim: so, too, small-pox usually exhibits un- wonted activity at intervals of from five to ten years, or as soon as popular neglect of vaccination renders a large portion of a community susceptible to it. It is not thus with scarlatina. Hirsch has collected very valuable in- formation upon this point. At Miinster fifty years elapsed without the disease appearing. At Ulm there was only one small epidemic in seventeen years. At Tutt- lingen scarlet fever had not been seen for thirty-five years previous to the epidemic of 1862-63.. A number of writers, however, have observed an epidemic cycle in scarlet fever. Thus Fleischmann,’ at St. Joseph’s Hos- pital, in Vienna, observed one of four years. In Dres- den, according to Gerhart, there is an epidemic cycle of from four to five years ; in Munich, according to Ranke, of three years, On the other hand, scarlet fever often pre- vails sporadically for a long time in a locality, finally to dis- appear or to spread suddenly far and wide. Mayr‘ states that in Vienna the register shows that scarlatina has never absolutely died out in fifty years. Scarlet fever is remarkable in the varying intensity of cases occurring during a given epidemic, and in the differing severity of epidemics. At one time it was regarded as an insignifi- cant disorder, almost never proving perilous to life. Even now epidemics of an exceedingly mild type are fre- quent. Graves has told how, between 1800 and 1834 whenever scarlet fever prevailed in Dublin, it was so uniformly mild that medical men attributed the bad re- sults of their predecessors to improper methods of treat- ment, and flattered themselves upon their superior skill, until a change in type brought their death-rate quite up to that of former times. ErroLtocy.—It is certain that scarlet fever has for its essence some active specific principle, which, conveyed by the atmosphere, or by fluids, or by mediate or imme- diate contact from one person to another, excites a pe- culiar morbid train of phenomena. Although, even re- cently, there have been those who maintain that it may be autochthonous, contemporary writers are unanimous in adopting the theory of a contagium vivum in its patho- genesis. The tendency of recent investigation has been to direct attention to certain low forms of vegetable life, belonging to the schizomycetes. or bacteria, as the probable cause of this elass of specific diseases. It is altogether probable that they maintain a similar rela- tionship to scarlet fever. As yet, however, they have not been identified with certainty. Carpenter, who claimed that the disease may arise de novo, asserted that it then ‘results from germs of organic matter which have been given off from vertebrate blood in a particular state of decomposition, and that the decomposition of blood in slaughter-houses is a frequent source of scarlatina. This view has not been successfully maintained. Coze and Feltz® detected in scarlatinous blood diplococci (sphero- bacteria), and produced in rabbits by inoculation of this blood a fever-like disease. Riess* has had similar ex- perience. Recently Léoffler’ has described chain-shaped cocci in the membrane of scarlatinal diphtheria. He claims that if these be introduced into a joint, inflam- mation soon develops ; if simply beneath the skin, an in- flammation like erysipelas results. Hallier® found in the blood of three patients a greater mass of micrococci than he has ever seen in any other infectious disorder. They were more numerous than blood-corpuscles, swimming free in masses united by a gelatinous envelope, in or on the corpuscles. Exceptionally the white cells, which were unusually numerous, were pervaded with micrococci. Hallier made culture experiments, and concluded that the blood of scarlatina patients contains a micrococcus of unknown nature, and proposed for it the name Tvdletia scarlatinosa. Eklund ® recognizes as the cause of scarla- tina. a micrococeus which he calls plax scindens. He finds it in the urine of scarlatinous patients, and de: scribes it minutely. He has not found it in the urine of those who have not had scarlet fever, but has dis- covered it in the soil, on damp walls, on the margins of swamps, and in other places. Inoculations with plazx scindens have not been performed, and, indeed, we can only wonder that anyone could be convinced by such in- sufficient evidence. More recently, Mr. George F’. Cooke! has described a bacillus found in the nasal discharge and in the sero-purulent exudation from the inflamed lym- phatic tissue of the neck in cases of scarlet fever. It oc- curred in leptothrix-like filaments. Pohl-Pincus!! and Klamann ?? discovered micrococci in the scaling epider- mis after scarlatina. Klein, in investigating the very im- portant relations between scarlatina and a certain disorder in milch-cows, occurring at Hendon under the observa- tion of Mr. Power (vzde infra), discovered in the ulcers of the teats of affected cows a streptococcus which he was able to cultivate, and with it to successfully inoculate calves, producing a like affection. This streptococcus he also found in some condensed milk which was sus- pected to have caused an outbreak of scarlatina, He also succeeded in raising some colonies of the streptococcus in nutritive gelatine, etc., inoculated with human scarla- tina.'? Klein’s investigations were of a highly meritorious character, and seemed to lead to the identification of the true micro-organism of scarlatina, but doubts of their ac- curacy have recently been raised by the results obtained by Jamieson and Edington, in Edinburgh, whose conclusions by no means tally with those of Klein. These authors," after experiments and cultures performed under the strictest precautions and with the greatest care, describe 303 Searlet Fever. Scarlet Fever. . : | a number of organisms, of which diplococcus scarlatine | REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Fleischmann’s figures give 8 deaths of children under sanguinis and bacillus scarlatine deserve especial atten- | one year of age; 304 from one to four years of age; and tion. The former was found in forty-five per cent. of the cultures made from the desquamation, and in thirty per cent. of those made from scarlatinal blood. The specific cause of scarlet fever, however, is considered to be, by these writers, baczllus scarlatine. It was discovered ‘‘in every case but one of the tubes made from the desqua- mation, if taken after the termination of the third week, but never before this.” It also occurred in every tube made from scarlatinal blood, if taken before the third day of the fever. While these various observations are of the greatest interest, they are so little in accord that one can hardly admit as yet that the pathogenetic organism of scarlatina has been definitely determined. While we assume the exciting cause of the disease to be an, as yet, undetermined germ, in the presence of which alone scarlatina is possible, the question of the predisposing causes is a much wider one and demands careful consideration. There is a widespread impression that scarlet fever prevails more especially during the fall and winter months. There is, indeed, some difference in favor of these seasons, but by no means to the extent that is gen- erally supposed. Hirsch has tabulated the records of 435 epidemics. These prevailed 178 times in the winter ; 157 times in spring; 173 times in summer; and 213 times inautumn. ‘The same relative prevalence is shown in his tables of deaths from scarlatina. Of more than fifty-five thousand deaths from scarlet fever in London, from 1888 to 1853, 32.1 per cent. occurred in autumn ; 20.2 per cent. in summer; 24.6 per cent. in winter ; 22.1 per cent in spring. These figures, however, cannot be accepted with perfect confidence, as they must have been influenced by the mildness or severity of the several epidemics. Hirsch’s data show also the season of preva- lence and the severity of type for two hundred and sixty- five epidemics. Of 77 winter epidemics ¢,..5. foe aeeene j pa A eA i severe, Of/b0 spring epidemicszy.2.. hanes e eee ee } - i * eee Of 66 summer epidemics’... ...2..6secse sees ie id ; ; ae ss Of %2 autumn’ epidemics’. 22)... 2 -sseee ee. { a : j - ue The maxima of malignancy fall in winter and summer ; but, as Hirsch remarks, the difference is unimportant. It may be concluded, however, that in the spring epi- demics are usually less frequent and milder. Scarlet fever attacks nearly all of those who are ex- posed to its influence for the first time. It is chiefly observed in young persons, because older people are gen- erally protected by a former attack. Nevertheless, adults who have never had scarlet fever are less liable to take it than children similarly circumstanced. This is not at- tributable to differences of age, but to feeble individual susceptibility, which probably held as well during the childhood of these persons. It is certain that a not very small percentage of persons successfully resist exposure to the scarlet-fever contagion throughout life. While, then, it is not difficult to understand why adults seldom take scarlet fever, it is more difficult to account for feeble predisposition observed during the early months of life. Infants less than a year old are rarely attacked, and often escape even when exposed directly and frequently. Ac- cording to J. Lewis Smith, infants less than four months of age almost possess immunity. Murchison tabulated the ages of 148,829 fatal cases of scarlatina occurring in Eng- land and Wales, as follows, viz.: Wesths unders vear ence, ass cote cictenecre s os ‘* between 1 yearand 2 years...... ack 14.0 SS a 2 Maes ee eae Ry ge ek RS 16, ce s 4 Stes des ae ake ete Aa: 15:15 sues oa uh 2 Oa APA Te era ty i ees ON 11.9 ve oe ss Bete ue U ee sen nee 25.9 Be Ss pear UAT ese AGE MY ges ie me 1 5.8 e a eel br 10 MG i taeeO: | Agcy etd eho be ede 2.6 ot ch SP OM ls Lele OO) Be ent ie oe are 0.8 we POMPE TOVOR, POD seitclic -etinie tte cates ale soon eae 0.8 4 304 206 from five to twelve years of age. J. Lewis Smith added 58 cases reported by Octerlony to 145 of his own, a total of 203 cases, from which he framed the subjoined table : 1 year of age. 25 + ty OELONIM ee eaheee ote ee lto 2 years of age. 43 * v6 a REED A ey ee eee 2 ets AP ee ee ‘ste ‘ad ay RAs he ers ately te ro 53. OS ve LR ee ee ee 5 ** 10 ‘ Kr tsar a eebtp an th act abate ft By Ae I) Conta) 7 Ge i 3 & ve (0G siete Rares 155720 ff. . qs es enh ey dey aoe fee 20 ** 30 a, ty Bebe Ot ee Sethe eee tes ae ae BO RE 40a eee Children less than one year of age, therefore, possess no absolute immunity ; indeed, scarlatina during foetal life has been reported. Leale observed such acase, as did also Tourtual. Thomas records several cases occurring in the practice of others. Veit noted scarlet fever in a child four- teen days of age. Numerous similar observations, more or less trustworthy, have been recorded. On the other hand, Murchison saw two new-born infants remain healthy while their mothers suffered from scarlet fever. New-born children are so subject to cutaneous and other disorders that may readily be mistaken for scarlatina, that we may well demand the most definite testimony. Scientific exactness should require that a new-born child must be proven either to have served as the medium of contagion for others, or to have developed characteristic symptoms in the midst of predisposing surroundings. The third year is the one during which the most cases are probably encountered. Nearly ninety per centwm of all cases of scarlet fever occur before the completion of the tenth year. Although the disease is rare in advanced life, it sometimes occurs. In Murchison’s tables there are recorded ten deaths of persons over eighty-five years of age. Barthez and Rilliet thought that boys were more often affected than girls. They were probably correct, though the difference is not great. Of 472 cases in St. Joseph’s Hospital, in Vienna, Fleischmann states that 263 were boys and 209 girls. Barthez and Rilliet observed that scarlet fever rarely attacks tuberculous children. (Gri- solle believed the same rule to prevail for the adult.) The predisposition to scarlet fever is much less uni- versal than that to measles and small-pox. While the two latter diseases will almost certainly attack all unpro- tected persons exposed to their contagion, scarlet fever often leaves unscathed persons who have been brought into the most intimate personal relations with it. It is consequently much easier to practise isolation with the hope of success. ~However, the immunity possessed by an individual, as shown by repeated exposures, may not prove perpetual, and well-marked, even fatal, scarlatina may follow a final exposure. A degree of immunity from scarlatina is sometimes exhibited in families, the members of which escape altogether, or have only light | attacks. Unfortunately, on the other hand, a decided family predisposition to the disease is occasionally en- countered, one member after another falling a victim to its virulence. Careful observation has failed to show that predispo- sition to scarlet fever is especially favored by the nature of the soil or the state of the weather; neither can it be proven that the type of the disease is especially influ- enced by any ordinary surroundings, further than that conditions of life prejudicial to the maintenance of good health diminish the powers of resistance to the onset of the disease. It is important to remember that in the ab- sence of the contagious principle no degree of filth, de- privation, dampness, bad ventilation or drainage, or ex- posure, no matter how injurious to general healthfulness, can serve as the starting-point for scarlet fever. Indeed, it is remarkable, considering the bad hygienic environ- ment of the poorer classes, that between them and the rich there should be so small a difference in the degree of predisposition to, and in the relative mortality from, scarlatina. | To develop scarlatina an individual must, of necessity, REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Scarlet Fever. Scarlet Fever. receive into his body the materies morbi derived from one who has, or who has had, the disease. In all cases the contagion must be communicated by the air, or in solids or fluids received into the body. It is probable that physical contact occurs but rarely between infected and unprotected persons, and that when it does occur, the danger of infection is due rather to the increased liability of intercepting emanations from the body. Scarlet fever appears to be not contagious at the very beginning. In this respect it differs markedly from small-pox and measles. In the prodromal stage the contagion is probably not set free as readily as at a later period. Girard, however, has asserted that it is contagious only on the first day. This hardly needs a refutation. Longhurst !* also claims that it is most con- tagious during the pre-eruptive stage, and not at all during desquamation. These and similar opinions of individuals are negatived by the almost universal experi- ence of observers. Scarlet fever develops its highest properties of contagion during its period of eruption, and, still unlike measles, retains its contagiousness until desquamation is far advanced. Two children, at the Netherfields Institution at Liverpool, were believed to have been centres of contagion six and a half weeks after the beginning of their illness.'7 Cameron ?® reports a case in which, nearly nine weeks after the beginning of her own attack, a child communicated the disease to her sister by contact. It seems probable that the power of communicating scarlet fever is retained, gradually dimin- ishing in intensity, until the end of desquamation, which may not be completed for six, eight, even ten weeks. Thomas mentions cases where children, even after the completion of desquamation, while suffering from scarlati- nal dropsy, probably served as centres of contagion. The agency of the atmosphere as a contagion-bearer does not seem to extend beyond.a few yards. Thus, it often hap- pens that the disease does not spread beyond the sick- room, provided mediate contact can be avoided. Possi- bly the contagion is of too great gravity to be wafted for any distance. Yet it is certainly, under certain con- ditions, very tenacious of life, and may be conveyed long distances and preserve its properties for prolonged peri- ods. It has often been carried by a healthy person, who has been exposed to the malady, to persons at a distance. There are authentic accounts of physicians, nurses, at- tendants, and visitors serving thus to carry infection. Such unfortunate occurrences are not very common, and probably only happen when the carrier of contagion passes directly from the sick-bed to the unprotected person, without due regard to the proper disinfection of the person and clothing. A pernicious custom is the habit of putting on over-clothing and wraps over the dress in which the patient has been visited, without proper exposure to the free circulation of fresh air. The tenacity with which the contagion clings to inanimate substances is most remarkable. Articles of clothing, _ bed-linen, furniture, wall-paper, hangings, and the like, frequently serve to communicate the disease, and often after almost incredibly long intervals. Richardson gives an example of this. Four children lived with their parents in a thatched cottage. One child was taken with scarlet fever, and the others were sent away. After three weeks one of these was permitted to return. It took the disease on the first day and died. The walls of the cot- tage were now cleaned and whitewashed ; everything was thoroughly scrubbed, and all wearing apparel was washed or destroyed. After four months another child returned. The next day he was seized with the disease and died. Here the thatch was thought to have retained the conta- gion. The germs of the disease may be shut up in a let- ter and conveyed a long distance. Woollen clothing, put away and brought out after many months, pillows, cush- ions, toys, books, have all been known to preserve the contagion in full vigor. The dissemination of the virus in the atmosphere has been stated to be very limited, but the same cannot be said so confidently concerning the agency of fluids. The spread of scarlet fever has never been directly traced to the water-supply, but there is abundant reason to attribute its occasional extension to Vou. VI.—20 the medium of milk. Thomas quotes two examples of this. -One, reported by Bell, leaves it an open question whether the milk, its receptacle, or the boy who carried it, was the medium. The other came under the observa- tion of Taylor, who noticed ‘‘ that one of the first severe cases which initiated an epidemic occurred in the house of a milkman whose wife milked the cows, the milk being supplied to about twelve families in the city. In six of these scarlatina occurred in rapid succession, at a time when the disease was not epidemic, and without any communication having taken place between those who were affected and the person who brought the milk. It is very probable that in this instance the milk was the carrier of the contagion, as, previous to its distribution, it had stood in a kitchen which had been used as a hos- pital for scarlatina patients.” More recently, Airy, in eighteen families, consisting of thirty-five persons, report- ed twenty-four of these sick with scarlatina within thirty- six hours. Every one of these patients received milk from the same source. Neighbors who had milk from other ‘sources were not attacked. It was found that a person who milked the cows lived with a child in full desquamation from scarlatina. Several observations of this kind make it hardly doubtful that milk may serve as the vehicle for the scarlatina virus, and that it, indeed, may be considered a favorable culture-fluid for it. But until recently it has not appeared that the virus-bearing milk received its contamination otherwise than through human sources. Later investigations seem to throw much light upon the possible origin of scarlatina in man, and upon one of the paths for its dissemination previously unrecognized. A recent outbreak of scarlatina among persons who received their milk-supply from a dairy in Hendon, in England, seemed to be traceable directly toa disease of the cow. The cows of this farm were affected with a peculiar affection, among the symptoms of which were a shedding of the hair and the formation of vesicles and ulcers upon the teats and udders. This is an inocu- lable disease among cows.* In this connection it is an important fact that inoculation of cows, especially when in milk, with the virus of scarlatina, results in the pro- duction of definite symptoms. The reports upon these observations by Mr. Power, Dr. Cameron, and Dr. Klein will go far toward establishing the prevalence of a scar- latina in cows, and its fruitfulness as a cause of the spread of scarlatina to mankind. Further information upon this most important subject will, doubtless, be soon forthcoming. The scarlatinal virus gains access to the blood through the respiratory tract, and is also conveyed in solid and liquid food to the stomach, whence it is absorbed. Though itis unlikely that absorption can occur through the sound skin, the disease is said to have been inoculated by arti- ficial deposition of contagion-bearing material upon the abraded cutis. Miguel d’Amobise claimed to have in- oculated children successfully with blood taken from scarlatinous patches. Stoel and Harwood have been re- ported as having conducted successful inoculations. On the other hand, Petit-Radel failed in his experiments. New observations upon this point are required. The contagion probably resides in the epidermis, and becomes diffused as this is exfoliated ; also in the buccal and fau- cial mucous membranes, and probably in the secretions, in the lymph, and in the blood. In the absence of reli- able inoculation experiments we have no fixed knowledge upon these points. Some writers deny that the exfoli- ated epidermis contains any virus whatever. CLINICAL History.—J/neubation.—Scarlet fever has a shorter and much less definite period of incubation than the other eruptive fevers. In determining the interval between infection and the outbreak of symptoms, it is much easier to reach correct conclusions when the fever has followed a single exposure than when the exposures have been repeated or prolonged. There is abundant evi- dence to show that the period of incubation may be less than twenty-four hours. On the other hand, it has been * The existence of scarlatina among animals has been ably upheld. Salmon’s and Peters’ papers upon equine scarlatina are very important. 305 Scarlet Fever. Scarlet Fever. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. claimed that four or five weeks may elapse before the dis- ease manifests itself. Most cases of scarlatina have an in- cubation period of from four to seven days. Even this wide limit, differing markedly from that of the other eruptive fevers, is subject to very many exceptions, and the literature teems. with examples of scarlet fever de- veloping a few hours after exposure, or only after many days, even weeks. Murchison believed the incubation period to be more often less than forty-eight hours in duration. The shortest authentic stage of incubation was in the case of Richardson, who after auscultating a scarlet-fever patient immediately became nauseated and chilly. He was conveyed home in the carriage of a friend, and dated an attack of scarlatina from that hour. Incubative periods of not more than twenty-four hours have been reported by many writers.!% In 20 cases Dukes found the duration to vary from one to nine days, in 10 cases it was less than five days. Murchison reported, in the ‘‘ Transactions of the Clinical Society,” *° the incubative periods of 75 cases, none of which ex- ceeded ten days. He considered a person safe from con- tagion who is not attacked within a week after exposure. Thomas?! thinks that from four to seven days is the most frequent interval ; Kaposi considers it to be about eight days; Gee thinks that seven days are rarely exceeded ; Lewis Smith, that it is ordinarily less than six days. Longer intervals, however, are not infrequently noted. In one case Hagenbach* determined it to be eleven days; in another, fourteen days. Intervals of twelve days or more have been recorded by Veit, Paasch, Bon- ing, Lewis Smith, and others. From the rather untrust- worthy results of inoculation, seven days would seem to have been the incubative period. Barthez and Rilliet, Gee, and others thought they had observed cases where the incubative period covered several weeks, and, indeed, in delicate children, especially those with rickets or other neuroses, it. may be much prolonged (Mayr). There is, however, a growing belief that the incubation of scarlet fever lasts less than six days, and, without attempting to be more accurate, we accept that as the common dura- tion. It is very often less than this, and but very seldom more. In this, as in most other features, scarlet fever shows great variability, and, if the term be allowable, a felyee ete contrasting strongly with the other specific evers. Period of Invasion.—For convenience of description it will be proper to describe scarlatina as following an or- dinary or mild, and a graver, course. The course is very often irregular, from the absence of characteristic symp- toms, or from the undue prominence of one or several of them, or from the presence of complications. In fact, scarlet fever may vary from an insignificant, even an un- appreciable, disturbance of health, to a malady pursuing its fatal course with lightning-like rapidity ; and although the type of the prevailing epidemic may be mild, severe, or malignant, individual cases can only in a measure conform to the standard, from which they will invariably differ to a greater or less extent. Milder Forms.—Ordinary Course.—Prodromal Period. At the end of incubation the active symptoms of scarlet fever usually develop suddenly ; rarely they appear more gradually. In most cases fever is the first symptom ob- served. In larger children and adults an initiatory chill is often noted. Convulsions may occur at the outset ; usu- ally, however, they usher in graver forms of the affection. The fever develops during the night, or during the day the child loses its playfulness and in a few hours is found to have a high temperature, in most cases not exceeding 103° F. (39.5° C.), but occasionally reaching 104° to 105° F’, (40° to 40.8° C.). At the same time the pulse will be full and frequent, beating from 120 to 140 times in the minute very commonly. The rapidly rising temperature and great acceleration of pulse are characteristic, and under favoring conditions should excite suspicions of scarlatina. The face becomes flushed, the eyes bright and injected. There is much thirst, but almost complete anorexia. Nausea and vomiting are so frequent that J. Lewis Smith attaches some diagnostic importance to the symptom. Of 214 patients it was present in 162. 306 Jenner thought that severe vomiting is apt to precede severe throat symptoms. Diarrhoea sometimes occurs, especially in graver cases. The tongue may be only slightly coated ; frequently it is covered with a white, creamy fur, but remains red at the edges. Already the little patient complains of sore throat (indeed this may be the first symptom to attract attention), and upon inspec- tion the mucous membrane of the pharynx will be found to be swollen and dry, and of a bright or dusky-red hue, and often spotted with small areas of duskier redness. At this stage no curdy nor diphtheritic deposit will be observed. The nasal mucous membrane sometimes par- ticipates in the hyperemia, and a nasal catarrh is in- duced. There will now be difficulty in deglutition, and already there may be some enlargement of the submaxil- lary and cervical glands. There is often headache and also delirium, sometimes of an active kind. As the fever in- creases in severity the patient becomes dull, listless, and drowsy, and various symptoms of cerebral disorder are common in graver cases. In very many cases, however, all the symptoms will be mild. There may be little fe- ver, no noticeable disturbance of the various functions, not even sore throat. Beyond slight peevishness and ir- ritability the child may not seem to be unwell. In nota few cases there may be no prodromal period at all, the eruption first attracting notice. During the prodromal stage the urine is rather scanty, acid, and high-colored. According to Gee, the urine is diminished in quantity ; urea is not necessarily increased ; chloride of sodium is diminished, sometimes decidedly, the diminution gener- ally ceasing suddenly on the fourth, fifth, or sixth day ; phosphoric acid, at first normal, is notably diminished on the fourth or fifth day, remaining for four days from one- third to one-half the normal quantity, and then returning to the healthy standard ; uric acid is greatly diminished on the second and third days, becoming excessive on the fifth day, and then normal. Even at the earliest observation albuminuria may be observed. Boning, who denies a prodromal stage, and always encounters the eruption on the first day simultaneously with the chill, has found blood-corpuscles, renal epithelium, and albumen in the urine from the very start. The respiratory movements quicken in proportion to the rapidity of the pulse. Nearly all cases will begin to show the eruption within twenty-four hours, many within twelve hours, a few during the second day. When the eruption appears later, an abnormal or unusually severe form of the dis- ease often follows. Stage of Hruption.—The eruption first appears upon the sides of the face, upon the neck and submaxillary region, and on the front of the chest, in the clavicular region, as small, pale-red points, closely aggregated although at first discrete, and very slightly elevated. It rapidly ex- tends over the chest (where it becomes most intense), upper and lower extremities, and attains its full distribution by the end of the second day, acquiring a bright red or scar- let color. It occasionally happens that the eruption be- gins on other parts than those mentioned, or may never become general. Rarely it spreads more slowly, even fading in some localities before the lower extremities are invaded. It is especially apt to affect the flexures of the joints. In mild cases the spots remain discrete over most of the body, and may resemble a fine ‘‘ prickly heat,” densely arranged and of minute size. At times the erup- tion consists of dark-red points, surrounding hair-folli- cles, separated from each other by less intensely red areas (Henoch). In cases of greater intensity it is coalescent almost universally, and presents a continuous brilliant scarlet surface, like the shell of a boiled crab or lobster. The intensity of coloration varies somewhat, even in the same patient, depending much upon the degree of heat ; becoming paler when the surface is cooled, more scarlet when this is protected by heavy covering, etc. It is, however, not perfectly smooth, but shows the tiny pap- ules upon the reddened base, and communicates to the hand passed over it a sensation of roughness and of dry and pupgent heat. Upon the legs and arms the eruption very often becomes more scattered, assuming the form of separate tiny points ; rarely it is distributed over distinct REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Scarlet. Fever. Searlet Fever, areas of the trunk and extremities, with intervals of faintly erythematous redness (scarlatina variegata). This form, however, is apt to appear in severecomplicated cases. It must be remembered, however, that, unlike measles, scar- let fever affects the face less than other parts. Never very intensely developed over the forehead, temples, or chin, the eruption entirely spares an area around the mouth, including the upper and lower lips and some dis- tance beyond the angles of the mouth, and often extend- ing upward to include the nose. This area contrasts with the surrounding parts by its remarkable pallor. It has been asserted that the cheeks are also spared by the erup- tion. This is not true. The cheeks do not show the pointed redness of the early eruption elsewhere, but at once assume a scarlet or crimson redness that is deeper than the color induced by fever. The lips are often dry and cracked, and may bleed. The face becomes consid- erably swollen, especially in the loose tissue about the orbits. The ears are also swollen and of a bright red color. The eruption does not spare the scalp. Upon the backs of the hands and feet the eruption is discrete, and is arranged in groups the size of a lentil, while upon the palmar surfaces of the hands and fingers, and upon the soles of the feet, a bright, diffused redness, with swelling, is seen. At times the eruption will be partial, develop- ing upon the trunk alone, or on the extremities, or in isolated patches about the body. These cases may not be abnormal in other respects. The skin over the joints is especially prone to be affected. The lesions may be more or less disseminated spots, varying from the size of a pin-head to that of the finger-nail, or a half-dollar, or even larger. It has been asserted that the erup- tion constantly consists of a papulated rash upon a red- dened base, even when universally diffused. This is not invariably so, and one may encounter a smooth, uni- form redness inappreciable to the touch. Where the eruption is very intense, small hemorrhagic spots, or petechiz may appear. When thus occurring, their oc- casional presence is not of serious importance. In warm weather especially, and in children too warmly covered with bedclothes, the surface, particularly of the neck, chest, and belly, is sometimes plentifully sprinkled with -an eruption of sudamina. In some epidemics these are more often observed than in others. It is not impossible that the ‘‘ miliary fevers” that formerly occasionally pre- vailed in Europe, were, in reality, forms of scarlatina. Mayr has said that the eruption of scarlet fever often spares the skin of paralyzed limbs; but Kaposi asserts that it may be unusually intense upon these parts. In dark-skinned races the eruption undergoes some moditi- cations, which are greatest in those of full negro blood. In mulattoes and negroes it becomes often exceedingly -difficult to distinguish the eruption. Of course the scarlet color is absent, a tinge of red will often struggle through the darkly pigmented skin, especially of the cheeks and abdomen. The true character of the eruption may often be revealed by a finely papular condition, the tiny papules of the size of a pin-point being made apparent by their acuminated summits, which give, against the dark back- ground, a resemblance to a sprinkling of the surface with a fine dust. The hand passed over them can perceive the little asperities. These are closely aggregated. In many cases it is impossible to recognize the eruption, and the diagnosis must rest upon the concomitant symptoms, which will not be peculiarly modified. While the eruption—which attains its height by the end of forty-eight hours in mild cases, later in severe ones— is developing, the other symptoms become pronounced. The faucial mucous membrane is uniformly redder, or, occasionally, shows numerous red macules; the uvula, tonsils, and buccal mucous membrane are reddened and swollen, and pain in deglutition increases. As the erup- tion reaches its height, the tongue parts with its coating in patches, exposing areas of intense redness. By the third day it acquires a uniformly brilliant red color, with enlarged papillae scattered numerously over its general surface, and presents the characteristic ‘‘ strawberry ”” or ‘raspberry ” appearance. Exceptionally, this exfoliation of the lingual epithelium does not occur, and the creamy deposit persists. In many mild cases there is slight nasal catarrh, with a thin discharge from the nostrils. A muco- purulent discharge from the nostrils is associated with the throat complications of the graver forms. During this period the fever continues to increase until the completion of the eruption, or the prodromal temperature remains unchanged. In the type of cases we are considering 105° F. (40.5° C.) is not often exceeded. Should the fever continue to increase after the third day, grave solicitude as to the result will be justifiable. The other symptoms continue with undiminished vigor—di- gestive disorder, nausea, vomiting, complete anorexia, rarely diarrhoea, persist. The skin burns or itches more or lessintensely. Nervous symptoms, restlessness, stupor, headache, delirium, usually diminish, but may continue unabated ; or active delirium may occur. Convulsions at this time are very ominous. The sore throat becomes distressing, and the cervical and submaxillary glands en- large and become painful.. Bronchial and pulmonary inflammation only occur as complications. After the fourth or fifth day nearly all of these symptoms cease to increase, and it becomes evident, ceterds paribus, that the course of the disease is to be favorable. The eruption, after persisting in full development for a day or two, be- comes duller and slowly fades, first in the parts earliest affected, latest from the back of the hands. The color, which at first completely faded, now leaves a yellowish stain when the finger compresses the skin. It is not, however, until after four, five, or six days, that the skin loses its scarlet color. This may last longer. Jenner *’ has known it to persist for from fourteen to sixteen days. The fever slowly declines, until it ceases about the sixth, sev- enth, or eighth day, or later, and not before the eruption has entirely disappeared. Sometimes, from unknown reasons, it persists for days after all local symptoms have ceased to be active. On the other hand, fever, in some very mild cases, will hardly be noticed, or will endure but a few hours. The throat manifestations, or the super- vention of complications, may protract the fever for many days. The sore throat, unlike the other symptoms, often fails to show signs of amelioration after the height of the eruption. The swelling and redness may increase, and white or yellowish curdy deposits form upon the tonsils and uvula, or the posterior wall of the pharynx may be bathed in a thick muco-purulent discharge from the pos- terior nares. True diphtheritic membrane is not apt to form in these cases, but the neighboring lymphatic glands may become highly inflamed and suppurate. It is prob- able that renal catarrh and nephritis occur more fre- quently during this period than is commonly supposed. Frerichs, Reinhardt, Eisenschitz, Boning, Begbie, New- bigging, Holder, and others, consider the renal symp- toms as essential in scarlatina. This is, however, not true. Thomas* practised microscopic examinations of the urine in twenty-five of eighty patients, and in twenty of these daily. In the prodromal and eruptive stages he found slight albuminuria only rarely and transitorily. Decided alterations in the renal tract were most uncom- mon. Mild catarrh was more often seen. Only the more severe forms he considered to depend upon a specific scarlatinal influence. Fleischmann,” in 472 cases of scar- latina, reported dropsy during the first week in 9 cases. Not enough, certainly, to bear out the sweeping asser- tions just quoted, but sufficient to direct attention con- stantly to the condition of the kidneys in scarlatina. Many cases of mild scarlatina fail to exhibit all the symptoms enumerated. The prodromal stage may be ab- sent, sore throat may be insignificant, or absent through- out. The tongue may never assume the ‘‘ strawberry ” appearance. The fever may be of feeble intensity. Fi- nally, the rash may be faint and not widely distributed. It may be limited to a few reddish or pinkish punctate spots upon the neck or chest ; or it may only affect the flanks or the flexures of the joints; or it may be so transitory as to escape observation or to be noted only during a few hours; or, finaliy, it may fail altogether to appear. On the other hand, sore throat may be the only active evidence of the disease. Cases that have been ex- posed to the contagion sometimes develop sore throat 307 Scarlet Fever. Scarlet Fever. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. only. These may subsequently become dropsical from nephritis, or they may desquamate more or less abun- dantly, or even communicate scarlet fever to others. An interesting feature is a tendency, often shown by those exposed to contagion, to suffer from_a mild attack of pharyngitis after every exposure. Many physicians, nurses, etc., experience this. Finally, the eruption may fail to appear, knowledge that scarlatina was present being acquired through the occurrence of desquamation or dropsy. Cases of this kind have been designated ‘ Backer,** Dornig,®?7 Lewis Smith,®? Mur- chison,®®? and many others. The combinations and the order of occurrence have been noted as follows, viz.: Scarlatina and measles. Measles and scarlatina. Scarlatina and small-pox. Small-pox and scarlatina. Scarlatina and vaccinia. Scarlatina and varicella. Varicella and scarlatina. Scarlatina and typhoid fever. Concurrence of scarlatina and Rotheln has not been re- ported. A probable source of fallacy is the scarlatini- form rash that is often observed in small-pox, and oc- casionally in typhoid fever ; indeed, Simon asserts that Fleischmann has even made this very error. The possi- bility of these rashes should always be held in mind when questions of concurrence are under consideration. When scarlet fever develops after small-pox the eruption in- volves the parts of the skin left free by the lesions of small-pox, more especially about the chest and abdomen. When the two exanthems appear simultaneously, their course is shortened ; ‘‘the second mitigates the first and becomes shortened itself,” excepting, according to Fleisch- mann, when severe small-pox occurs in connection with scarlatina, when death usually results. The same author asserts that if scarlatina appear at the period of matura- tion of small-pox, the latter, in mild cases, is shortened and mitigated. When scarlatina complicates measles, the latter is shortened, but the scarlatina thus occurring may be mild or severe. Barthez and Rilliet noted that in scarlatina-measles, when the former malady predomi- nates, bronchitis is more marked; but when measles is most severe, faucial angina‘is worse. All of these state- ments lack such evidence as would entitle them to un- qualified acceptation. Very often neither disease is well developed, and the true condition may be very difficult of recognition. In America these concurrences are more uncommon than they seem to be abroad. Whooping-cough has been known to complicate scarla- tina, and a number of non-specific affections may occur simultaneously with it. These coincidences are purely accidental and present no peculiar interest. Biart ® has reported psoriasis as following scarlatina. Barthez and Rilliet assert that tuberculous children very rarely have scarlatina. Some chronic affections partially or entirely disappear during an attack of scarlatina. Among these may be especially mentioned certain cutaneous affections, eczema, psoriasis, etc., but they usually reappear upon the establishment of convalescence. SURGICAL SCARLATINA.—Sir James Paget, in 1864, and again in 1875, declared that patients who have under- gone surgical operations are peculiarly susceptible to the 313 Scarlet Fever. Scarlet Fever. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. action of the scarlet-fever poison. This question has at- tracted a great deal of attention. In France, Trelat was the first to accept this view, though scarlatinoid rashes had been observed by Civiale, Germain Sée, Tremblay, and others. Similar rashes were reported by Hutchin- son. Hilton, Bryant, Lee, Moore, Stirling, and others. They had generally been considered as of septicamic origin. In 1879 Paley and Goodhart ® and House*® re- ported observations of endemics of scarlatina in the Evel- ina Hospital for Sick Children and in Guy’s Hospital. The first-named authors based their report upon twenty- five cases of scarlatina occurring in surgical patients. Of these nineteen were known to have been exposed to scarlatina, and all the rest, save one, were known to have had possible sources of infection. House’s paper was based upon four cases of surgical scarlatina. The epidemic tendencies ceased upon the establishment of isolation, and one cannot doubt their scarlatinal origin. These writers were careful not to assert that add such red rashes should be attributed to scarlatina, or that there is not ‘‘ such a thing as a rose rash in a typical case of septi- cemia ;” but they believe that when occurring in groups they may nearly always rightly be attributed to scarla- tina. Riedinger and Howard Marsh also agreed that there exists in wounded persons a predisposition to scarlatina. While Holmes coincided with these views, he, however, declared that many cases of ‘‘ surgical scarlet fever” are really due to pyzemia and other causes. Most recent writers incline to the opinion that these eruptions are due to true scarlatina. When any epidemic tendency is shown, everyone will agree with such conclusions. This cannot be granted of rashes occurring in isolated cases. Of 25 cases reported in Paley and Goodhart’s paper, scar- let fever attacked 17 after operations ; 7 were without any wound whatever, and 1 had only an old sinus. In many of the cases reported by other writers there was no open wound. These reporters, unfortunately, most rarely note whether their patients had ever previously had scarlatina. Most children, when first exposed to the contagion of this disease, become infected. Is it remarkable that they are unable to withstand it when it attacks them, weakened by injury or surgical operation ? Apart from epidemic in- fluences, it is probable that scarlatiniform eruptions in the wounded may justly, ina large proportion of cases, oc- cur quite independently of scarlatina. Rashes of septi- czmic origin are well known to occur. Various fugitive eruptions often result from emotional and nervous irri- tations, or from the ingestion of certain articles of food or medicines. It must be admitted that scarlatiniform septicemic rashes are uncommon. But there is excel- lent evidence that they occur. Attempts have been made to establish a differential diagnosis for the surgical scarlatiniform rash. Cheadle,® for example, claimed that it has specific characters in not often being universal, and in being confined to the body and parts covered by the clothing ; that it rarely lasts twenty-four hours, and that it never desquamates. He also asserted that there is no tonsillar swelling, nor glandular enlargement, nor the peculiar ‘‘ strawberry tongue.” Such points of differen- tiation do not appear to be well founded. Scarlatiniform eruptions also occasionally follow the ingestion of certain drugs. They may be evoked by belladonna, copaiba, opium, chloral, mercury, and other drugs, but, above all, by cinchona bark and its derivatives. These eruptions are much more common than is generally supposed. The quinine eruptions are only beginning to receive due at- tention. The drug is frequently given to those who have been injured or submitted to surgical operations, and beyond question eruptions evoked by it are often at- tributed to other causes. A number of eruptive forms are observed, but the one of especial moment is the scarlatiniform rash. At the onset it often cannot be dis- ‘tinguished from scarlatina. Beginning with high fever, and often with sore throat, the eruption appears upon the face, chest, and neck, and within twenty-four hours the entire surface may present a bright scarlet aspect. At the end of this period the resemblance may be made perfect by the ‘‘ strawberry tongue.” Up to this point the diagnosis may be impossible. Rarely it remains so 314 throughout the attack, especially when the ingestion of the cinchona preparation is continued. Usually, how- ever, after thirty-six or forty-eight hours the type of nor- mal scarlatina is departed from. The fever rapidly de- creases, the angina disappears, and the rash either fades or acquires features unlike those of true scarlatina. It be- comes duller, more papular, and often tends to form miliary vesicles. Eventually it may resemble ordinary ‘‘ prickly heat.” Sometimes, however, the scarlatinal features are preserved throughout. In either case a co- pious desquamation is sure to follow. This is usually lamellar. Even albuminuria has been known to add to the embarrassment of the diagnostician. These medicinal and septiczemic rashes occur in isolated instances, and may at times baffle the keenest diagnostic powers. We may conclude that unprotected persons who have suf- fered injury, or who have undergone surgical operations, are rather more liable to scarlatina than the unprotected healthy. Scarlet fever is more apt than the other ex- anthemata to attack such persons, because its symptoms vary within such wide limits that it often escapes the at- tention of those who readily detect other infectious dis- orders and provide against them. When an epidemic tendency of the symptoms we have been considering is shown to prevail, it may be confidently concluded that true scarlatina is present. Septiceemia is occasionally accompanied by a scarlatiniform rash which does not depend upon the scarlatinal poison. These rashes are often attributed to scarlatina, ScCARLATINA PUERPERALIS.—While pregnant women seem to enjoy a remarkable immunity from the specific eruptive fevers, it is well known that during the puerpe- rium they are especially subject to them after exposure, and that the disease is then apt to pursue a grave and often fatal course. Not only scarlatina, but measles and small-pox may affect the lying-in woman with such ma- lignity that the symptoms may not acquire the features of the maladies to which they belong, but become indis- tinguishable from those of malignant septicemia. Scar- latina is especially liable to attack the lying-in woman. It may assume the virulence referred to, or it may pursue a course in which it is difficult to determine whether its symptoms are septic or really scarlatinal, or, finally, it may appear with typical and unmistakable features, Not a few writers have thought that the scarlatinal virus may produce in the puerperal woman septicemia, pure and simple. This view is maintained by Playfair, Brax- ton Hicks, Leishman, and others. They assert that in these women, after exposure to the specific contagium, symptoms of acute blood-poisoning may be developed, and not those of scarlatina. On the other hand, just as in septic conditions, independent of puerperal causes, an erythematous rash and other scarlatinal symptoms may be observed in which true scarlatina has no part, so must one guard against assigning to scarlatina every scarlatiniform rash occurring in obstetrical cases. It may be septic in origin, or it may be a medicinal eruption. When a septic, or medicinal, or other form of erythema can be excluded, and when exposure to scarlatinal influence is followed by any degree of the symptoms we are considering, are we in atypical cases to look upon the results of the infection as distinctly scarlatinal ? More recent writers regard the scarlatinal nature of the disorder as preserved, and as capable of further dissemination. It has not been deter- mined to what extent women who have already had scar- latina preserve an immunity from further attacks during their lying-in period. It would appear that the intensi- fied predisposition of the childbed carries with it an in- creased liability to second or third attacks. Busey °° has related a case in which the patient had already had scarlet fever. Other such cases are upon record.* In all probability the scarlet-fever contagium evokes scarlet fever, and not septic disorder, in the puerperal woman, whose systemic condition affords peculiar sus- ceptibility to its influence, and predisposes her to a viru- lence of its activity that often leads to disastrous results. The less remote the date of delivery, the graver the course of the malady is apt to be. If the symptoms do not ap- pear before the seventh day, their development is no REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Scarlet Fever. Scarlet Fever. longer to be feared. Olshausen ® collected from the lit- erature 141 cases, of which the scarlatina attacked, during pregnancy, 7; in 8 it immediately followed delivery ; in 62 it occurred on the first and second days ; in 27 on the third day ; in 22 after the third day. After the fifth day none was attacked. While the puerperal woman shows intense susceptibility to scarlatina, the pregnant woman enjoys a marked immunity from it. Olshausen thinks, however, that the period of incubation may last for months during pregnancy, but only a few days during childbed. ‘This opinion he rests upon no solid basis. Primipare are more often attacked than multiparee. The mortality in puerperal scarlatina is high. In the series just alluded to it was forty-eight per cent. (3 cases during pregnancy and 64 in childbed). In the recorded cases studied by McClintock ® the mortality was over sixty-six per cent. In 34 cases at the Lying-in Hospital the death-rate was thirty per cent. Of 10 deaths at this hospital, 8 occurred when scarlatina had developed within thirty-six hours after delivery. Of 18 patients attacked on the first or second day, 8died. Of those attacked on or after the third day (16 in number), all but 2 recovered. McClintock also quotes Dr. Halahan’s cases, as follows, viz.: 3 patients, ill of scarlatina at the moment of delivery, died ; of 5 attacked during the first twenty-four hours, but 1 re- covered; of 10 attacked during the second day, but 1 recovered ; of 4 attacked during the third day, but 1 re- covered. The remaining 3, attacked on or after the fifth day, recovered. Braxton Hicks’” contributions to this subject have been most important. He believed that in one-half of the cases the usual symptoms of scarlatina are manifested, and that the disease almost always com- mences after the third day after delivery. The death- rate will be greater, the earlier after labor the symp- toms develop. Though lying-in women are peculiarly liable to scarlatina, they are frequently exposed to its influence without detriment. Women have not seldom been confined in the room, even in the bed, occupied at the same time by scarlet-fever patients, without experi- encing the slightest interruption of their normal con- valescence ; a result that is not astonishing in protected persons if the scarlatinal virus only transmits scarlatina, but which would not be expected were the virus equally competent to communicate septicemia in these cases. While a large proportion of cases pursue a grave and anomalous course, there are many others in which a per- fectly typical scarlatina is observed, without seriously endangering life. Secondary inflammations are not un- known. Metritis, cellulitis, peritonitis, or pyamia may be developed, but whether these are direct results of scarlatina or of the puerperal condition is undetermined. RELAPSES AND RECURRENCES. —There are recorded nu- merous instances of relapse, of scarlet fever within a short period after the original attack, and second or even third attacks after a more or less prolonged interval are well known to occur. By a relapse is meant a second attack of scarlatina that is evidently due to the persistent activ- ity of the influences that excited the first attack. Within a short period (three days after deflorescence in a case of Woldberg’s”) after the original attack all the symptoms are repeated ; the initial disturbances, the fever, the erup- tion, the angina, and other phenomena, with ensuing des- quamation, are developed. It is held that the second attack is but the completion of the first, that it occurs after an incomplete primary attack, and that it tends to be severe in proportion to the mildness of the first, and often to affect in eruption only those parts which were originally spared,” imparting thus to the second eruption the appearance of scarlatina variegata. The relapse may be accompanied by complications of throat, kidney, and other disorders, that were not present in the earlier dis- order, and vice versa. These relapses are usually very rare, but seem to be more frequent in certain epidemics. Thomas applies the. term pseudo-relapse, or reve7'svo eruptionis, to those cases in which the exanthem returns be- fore the disorder has entirely completed its course. ‘Tru- jawsky found the interval between the two attacks to be from seven to ten days, with an average of eight and five- eighths days. The intermissions are completely afebrile. These relapses have been explained by, (1) a recrudescence of the original contagion, and (2) the action of a newly acquired contagion from a source different from the orig- inal one. The prognosis is often graver than in the pri- mary attacks. Recurrences or attacks of scarlet fever occurring after a more or less protracted interval, are more common, and are due to fresh infection. They may occur at almost any period. Trujawsky ™ noted, in 300 cases of scarlatina, 18 patients who had had a former at- tack. Of these 4 were under ten years of age ; 10 were over ten years, and 3 were adults. The interval between the attacks varied from one and a half to seven years. Thomas had personal knowledge of a case in which a second attack occurred. Willan never saw one. Many years may elapse between the two attacks, as when a mother who had the disease during childhood again de- velops it by contagion from her child. Heyfelder him- self had a second attack twenty-seven years after the first one. Trujawsky thought that immunity is greater against contagion originating at the home or in the neighborhood of the patient than when it is brought from a distance. A third attack in the same individual may be observed (as in Richardson’s case), and there are reports of repeated attacks of scarlet fever. Bernouilli,”* for ex- ample, mentions the case of a woman, fifty years of age, who experienced in rapid succession six attacks of an ex- anthem indistinguishable from scarlatina. Other similar cases are on record, but their consideration suggests that they may rather have been forms of medicinal eruption. Acute exfoliative dermatitis may also be mistaken for scarlet fever, and may attack repeatedly the same per- son. Rashes resembling scarlatina may occur in va- rious other affections, such as typhoid fever, small- pox, ete. © Hallopeau and Tuffier” saw a scarlatiniform eruption in acute rheumatism, in which there were two relapses with intense erythema, followed by copious des- quamation. The possibility of all such cases being mis- taken for scarlatina should be remembered. It is a rather singular fact that many persons suffer from an- gina whenever they are brought into close personal rela- tionship with those who have scarlet fever. This is com- monly mild, but may occasion serious discomfort. Those who suffer thus from exposure to the scarlatinal influ- ence do not communicate scarlatina to unprotected per- sons. Mild desquamation is said to have been noted in some such cases. This, however, would indicate a true scarlatinal infection. PATHOLOGICAL ANATOMY.—In most fatal cases every trace of eruption disappears after death. After a very in- tense exanthem, more or less redness may remain. After malignant cases blood extravasations may present the only post-mortem discoloration. Remy and Neumann” have lately investigated the histology of the skin in scar- latina. Remy found the capillaries of the papillary layer dilated and hyperemic, and filled with leucocytes which were enlarged and of different sizes, but not so large as in leukemia. The vascular wall was not altered. The epidermis was thickened by increase of its cylinder-cell layer. The horny layer, sebaceous glands, and_ hairs were unchanged. The sweat-glands were empty and shrunken. Neumann found the cells of the rete swollen. In many specimens the prickle-cells were elongated, and here and there formed interspaces in which exudation- cells were imbedded, and into which small blood extrav- asations often occurred. Exudation-cells extended abun- dantly as far as the horny layer, and at the orifices of the follicles they were very numerous. The corium was swollen, the fibres thickened, partly separated by prolif- eration, partly by enormously dilated vessels that were at times bulbous. It is this exudation into the epidermal layers that causes the loosening of the horny layer from its bed, and the characteristic desquamation. Léschner and Fenwick have also noted this infiltration of the rete. The latter writer found the basement membrane of the sweat-glands also thickened, and the lining membrane gone in places, but in other places it was increased so as to occlude the sweat-glands. The deeper layers were normal throughout. The scarlet-fever exanthem, then, 315 Scarlet Fever. Scarlet Fever. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. consists of hyperemia with exudation. Remy found the changes he describes, regularly and uniformly dis- tributed. The throat symptoms, as constant as are those of the skin, are due to lesions that are always recognizable after death. The milder alterations offer nothing character- istic ; they are identical with those of pharyngeal ca- tarrhal inflammation. In more intense degree follicular inflammation, with suppuration and ulceration, is super- added, and cedema becomes more prominent. The in- flammatory changes extend beyond the pharynx into the buccal and nasal cavities, while parenchymatous tonsil- litis and inflammation of the cellular tissues of the throat and neck develop, with, sometimes, extensive gangrene. According to Harlin (Thomas), scarlatinous angina is specific, and is marked by ‘‘a deep, bluish-red injection of the mucous membrane of the tonsils and neighbor- hood, of the uvula, of the posterior portion of the tongue in the neighborhood of the highly swollen papille, of the posterior portion of the region of the cricoid cartilage, and of that portion of the pharynx which includes these different parts, and measures about two inches in breadth.” This coloring is said to be sharply outlined in the direc- tion of its transverse diameter. A point of the highest importance is the nature of the diphtheritic membrane so often formed in scarlatinous angina. By most writers it is assumed to be pathogenetically identical with primary diphtheria. Now, while there can be no doubt that pri- mary diphtheria may and does complicate scarlatina, it is almost equally certain that in many cases the mem- brane is simply a result of the intensity of the inflamma- tion evoked by the action of the scarlatinous virus. In the one case the scarlatinal, in the other a true diphthe- ritic, poison acting upon the vascular tissues of the throat, causes a coagulation-necrosis that results in the produc- tion of the membrane. The lesions of the two processes are identical. They only differ etiologically and in their results. The membrane sometimes extends to the nasal cavity, the larynx, and the trachea. Lewis Smith has seen, in four cases, the diphtheria become dissociated from scarlet fever, and attack other members of a family as idiopathic diphtheria. On the other hand, there is very satisfactory reason to believe that the diphtheritic mem- brane is most often without the specific nature of primary idiopathic diphtheria. Heubner concludes that scarla- tinal diphtheria differs from primary diphtheria clini- cally and histologically. It begins with a simple catarrhal affection ; the change from catarrhal to diphtheritic com- monly occurs on the fourth day. Henoch likewise de- nies that the affection is primary diphtheria. Koven™ gives some remarkable figures that go to prove the non- identity of the two affections. His report includes 426 cases. He shows that while it is most uncommon for two infectious diseases to coexist, of 426 cases 125 had necrosis faucium, while at the very time there was not a single case of idiopathic diphtheria in Christiania. More- over, diphtheritic paralysis was not once observed. Scar- latinal diphtheria, also, much more rarely than primary diphtheria, extends to the larynx and trachea. Kipnrys.—Friedlander ™’ describes three forms of renal inflammation with scarlatina. These are: 1, Initial ca- tarrhal nephritis, the early form; 2, the big, flabby hem- orrhagic kidney, interstitial septic nephritis; 3, glomerulo- nephritis, nephritis post-scarlatinosa. The first, he asserts, appears at the beginning of the exanthem, or a few days later, and disappears in a few days or weeks. It rarely excites oedema, and hardly ever kills. It is analogous to the alterations productive of the febrile albuminuria of many infectious diseases. Cloudy swelling and _ prolif- eration of the tubular epithelium, and, later fatty degen- eration, are shown. Within the tubular lumen are hya- line and granular cylinders, round cells, and desquamated epithelium. In the interstitial tissue are scattered round cells. _Bowman’s capsule is thickened, and there may be a small quantity of albuminous fluid between the capsule and the glomerule. Micrococci are sometimes found in the capillaries and tubules. The large, flabby hamor- rhagic kidney was found in 12 of the 229 scarlatinal ne- cropsies made by Friedlander. It was found especially 316 where the scarlatina had been complicated with diph- theria, abscess, etc. It is not characteristic of scarlatina, but is also seen in primary idiopathic diphtheria. The kidneys are enlarged and soft, and show pronounced cor- tical changes. The cortex is invaded by small extravasa- tions and larger blood infiltrations. The epithelium is only slightly altered, but the interstitial tissue is thick- ened and abundantly infiltrated with round cells. Em- boli of micrococci are commonly present. It develops between the first and fourth weeks, and proves fatal so rapidly that cedema does not develop. It is an especially severe form of septic nephritis. Glomerulo-nephritis, Friedlander holds to be the only characteristic scarlatinal nephritis. Here the kidneys are firm, often hyperemic, and resemble the cyanotic kidney, except that the glom- eruli do not appear red upon section, but gray and anzem- ic, ‘They are enlarged and prominent. Alterations are almost limited to them. Their nuclei are enlarged, their coils empty of blood, their walls thickened, their lu- mina contracted or obliterated. Bowman’s capsule is not much thickened. There are also slight interstitial cell infiltration, fatty degeneration of epithelial cells, and hyaline formation in the arteries. The alterations in the glomeruli account for the anuria and uremia, as well as the rapid hypertrophy of the left ventricle by the ob- struction of the renal arteries, as nearly all of the renal arterial blood has first to pass through the glomeruli. Klein,® who has given the subject especial attention, in a series of 23 necropsies did not observe the identical glom- erulo-nephritis as described by Klebs.*' Klein’s cases had died at various periods between the second and forty- fourth day. Their ages were between two and thirty- six years, the largest number being under twelve years of age. Changes resembling the glomerulo-nephritis of Klebs were observed, but they’ were only characteris- tic of the early stages of scarlet fever. A sharp defini- tion betweén the early and late changes is not practicable. The first set of changes are chiefly limited to the cortex. They are: 1. Increase of nuclei (probably epithelial) cov- ering the glomeruli. 2. Hyaline degeneration of the elas- tic intima of minute arteries, especially of the afferent arterioles of the Malpighian tufts. The intima of these vessels is swoilen here and there into spindle-shaped hyaline masses, causing narrowness of the lumen. There is similar hyaline degeneration of the capillaries of the glomeruli, rendering them often impermeable. These de- generated parts become fibrous in appearance, and Bow- man’s capsule becomes thickened. 3. A third change is multiplication of the nuclei of the muscularis of the mi- nute arteries, with increased thickness of their walls. This is greatest at the point of entrance into the glomeruli, but is also distinct in other arteries of the cortex and in the base of the pyramids. There are also swelling of the epi- thelia of the convoluted tubules and proliferation of their nuclei, especially of the tubules close to the afferent arte- rioles of the glomeruli. . In some cases the epithelium of the large tubules of the pyramids is detached. Klein’s observations, 1, that the hyaline changes readily affect the arteries near their point of branching, and, 2, that the hyaline substance is of the nature of elastic tissue, agree with the conclusions of Neilson concerning the arteries in various cerebral disorders and in many infectious diseases. He does not think that the anuria and uremic poisoning in scarlatina, when the kidney does not show conspicuous change, are due to compression of the vessels of the glom- erulus by the nuclear germination, as claimed by Klebs, but rather to the changed state of the arterioles, and suggests that the increased formation of arterial mus- cular fibres, under the stimulus supplied by the disease, may cause a contractility that obliterates the calibre of the arterioles and shuts out the glomerulus from the cir- culation, and thus, so far as it operates, suppresses the secretion of urine. The parenchymatous changes found in the early stages are slight and difficult to detect, the cloudy swelling and granular degeneration being limited to small portions of convoluted tubules. The second or- der of changes begins about the ninth or tenth day. They are interstitial as well as parenchymatous. Round cells are found around the larger vascular trunks, spreading REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Scarlet Fever, ‘Scarlet Fever. into the bases of the pyramids and into the cortex. This process begins about the end of the first week, and gradu- ally increases until portions of the cortex, rarely portions of the bases of the pyramids, are converted into pale, firm, round-cell tissue, in which the tubules become compressed and obliterated. The parenchymatous element of the ne- phritis consists in crowding of urinary tubules with lym- phoid cells and various kinds of tube-casts, and fatty de- generation of the epithelium of the tubules. This grows more marked with the advance of interstitial changes. The round-cell infiltration of the cortex begins at the roots of the interlobular vessels, spreading rapidly toward the capsule of the kidney, and laterally among the con- voluted tubes around the glomeruli, att first’ between the medullary rays, later it encroaches upon them. Por- tions of the cortex may be converted into firm, pale, bloodless cellular masses in which Malpighian tufts and urinary tubules become more or less destroyed. In one case renal embolism was encountered ; both interstitial and parenchymatous inflammation was very intense. The kidney was markedly enlarged. Klein also noted deposi- tion of lime in the epithelium and lumina of the tubules, first of the cortex and then of the pyramids, at an early stage of scarlatina, when only slight changes are other- wise shown. Heconcludes that cases of scarlatina which die after the ninth or tenth day usually show more or less well-marked interstitial nephritis. LYMPHATIC GLANDs.— Peculiar changes have been noted in the lymphatic glands by Klein. In addition to the ordinary inflammatory infiltrations which he describes as occurring in the lymphatic follicles connected with the organs of the throat and in the glands of the neck, the ordinary uninuclear lymph-cells are greatly diminished in number, and are replaced by large granular cells con- taining numbers of germinating nuclei. Liver.—This viscus becomes slightly enlarged from cloudy swelling. In one case Klein noticed, after two days’ illness, acute interstitial hepatitis. The middle and internal coats of some arteries show the same alterations as in the kidneys. Wagner observed lymphoid new for- mations and numerous collections of cells and nuclei, _ especially in the interacinous connective tissue. SPLEEN.—In the spleen the changes are uniform and constant. They are: 1. Enlargement of the Malpighian corpuscles. 2. Hyaline degeneration of the intima of the arteries. 3. Proliferation of the nuclei of the muscular coat of the ultimate arterioles, with increased thickness of their walls. 4. Hyaline swelling and degeneration of the adenoid tissue around the degenerated arteries. 5. In the central parts of the Malpighian corpuscles the or- dinary nuclei of the lymph-cells disappear, and in their stead are found large hydropic cells containing pigment (Klein). Other writers assert that there is no uniform- ity in the splenic changes, beyond a slight enlargement. Biermer has observed enormous enlargement of the Mal- pighian bodies. Disorders of the alimentary canal are not frequent in scarlatina, and when they occur it is usually in grave cases. They then not infrequently constitute the prin- cipal complicating lesion. In the cases of Fleischmann, diphtheritic enteritis was the most common sequel, The peculiar ‘‘shaved-beard appearance” of Peyer’s patches has been at times observed, and at times these patches and the solitary glands are prominent, reddened, and in- flamed, with associated tumefaction of the mesenteric glands (Harley). Barthez and Rilliet show, however, that in cases where the typhoid-like lesions have been discovered, the symptoms shown during life did not re- semble those of typhoid fever ; and conversely, cases of typhoid scarlatina cannot be expected to reveal these le- sions after death. Enteritis is more often catarrhal in nature. It has been asserted that in scarlatina the exan- them invades the mucous membrane to the same degree as the skin. Post-mortem evidence of this, however, is by no means constant. The glands throughout the ali- mentary tract are sometimes swollen, and sometimes form small ulcers and extravasations. Meningitis is rarely the cause of even the most intense cerebral symptoms. Hypereemia of the brain and me- ninges, with great venous engorgement, is often seen, but signs of pronounced change are extremely uncommon. _ Periosteitis and osteitis occur in connection with affec- tions of the joints, of the nose, of the pharyngeal and aural cavities, and of other parts, but afford nothing characteristic. Neither do the general serous surfaces show peculiar lesions. The condition of the blood and blood-vessels after certain rapidly fatal cases is important. Sometimes the blood is very fluid and black. At other times clots are abundant and firm ; again, it may have become diffused throughout the tissues. Remy has seen all the vessels of the papillary layer of the skin filled with coagulated blood. Thrombosis of the sinuses has been noted after scarlatinal diphtheria (Thomas). Fatty degeneration of the heart following cloudy swelling, with dilatation, occurring particularly in the walls of the right ventricle, is a frequent result of scarlatina, as it is of other infectious disorders. Draenosis.—Scarlet fever must be distinguished from measles, rubella (Rotheln), roseola variolosa, scarlatini- form rashes of septic or medicinal origin, certain idio- pathic erythemata, and diphtheria. From measles it dif- fers in its shorter incubative stage, and in the characters of its prodromes. In the former affection there are symptoms of coryza and bronchitis, with photophobia, sneezing, and coughing, while in scarlatina the prodromal symptoms especially involve the throat. In scarlatina the eruption begins to appear during the first or sec- cond day; in measles during the third or fourth day. During the course of scarlatina there is an absence of catarrhal symptoms for the most part. There are the characteristic sore throat, the peculiar ‘‘ strawberry tongue” (after the first two or three days), the well-de- fined eruption, the more protracted fever, the pronounced desquamation, and the tendency toward renal complica- tions. The eruptions differ both in their development and distribution in the two affections. In scarlatina the face is characteristically invaded by the eruption, which entirely spares the area about the mouth, and is no- where copiously developed in this region; while in measles the eruption is, probably, most intense upon the face. The macules in measles are large, irregular, and mostly papular. In scarlatina the eruption is punctate and more regularly distributed, not elevated ; it is scar- let in color, and generally coalescent, while in measles it is more discrete, elevated, arranged very extensively in forms of crescents and segments of circles, with greater or smaller areas of healthy skin between the le- sions, and is of a darker raspberry color. In measles the stage of eruption lasts from three to four days, and begins to decline as soon as the eruption upon the lower extrem- ities becomes complete. It occupies about thirty-six hours in attaining its acme. In scarlatina this stage lasts from two to six daysormore. It attains its acme in about eighteen hours. In measles there is a rapid return to a normal temperature in uncomplicated cases, while in scarlatina both eruption and fever decline more slowly. The conjunctival, nasal, and bronchial catarrh of measles is absent in scarlatina. In measles the tongue remains coated throughout. Sore throat is constant in scarlatina, quite uncommon in measles, and when present is almost invariably only catarrhal. The fever in scarlatina is at once more intense and more protracted. The desquama- tion of scarlatina is pronounced and lamellar; that of measles insignificant and branny. Scarlatina is frequent- ly complicated by diphtheritic pharyngitis and renal in- flammation, measles by inflammations of the respiratory apparatus. ; The eruption of rubella (Rétheln) more closely resem- bles that of scarlatina. It is paler, more discrete, and its lesions are larger and more distinctly papular. It is more transitory, and fades almost without desquama- tion, which, when present, is branny. Rotheln, more- over, has a longer incubation, almost no prodromal stage, sometimes marked catarrh, and but slight elevation of temperature. It is feebly contagious, of much shorter duration, and is hardly ever followed by nephritis and dropsy. The diagnosis is difficult only when the erup- tion of rubella becomes confluent. Here, however, the 317 Scarlet Fever. Scarlet Fever. confluence involves certain areas. It is sharply circum- scribed by normal integument, and shows in contrast the outlying characteristic lesions. It is of a pale rose-red, and not of a scarlet color, and is accompanied by the pe- culiar symptoms of rubella, and rarely lasts more than thirty-six hours. Both measles and rubella may at times closely resemble the milder forms of scarlatina, and from the eruption alone the diagnosis may be difficult; but a consideration of all the symptoms will usually lead to correct conclusions. Roseola variolosa should only ex- cite embarrassment when it occurs before the peculiar eruption of small-pox has appeared. It is less general, is more like a simple diffuse erythema than is scarlatina, and is so speedily followed by the characteristic vesicular eruption that doubt will soon be dissipated. Its coexist- ence with the essential eruption may excite suspicions of a concurrence of scarlatina and small-pox. Such an error may readily occur. Obstetrical and surgical scar- latina have already received attention. When erythema begins near a wound and becomes scarlatiniform in spreading, a septic origin must usually be allowed, though instances of scarlatina thus beginning have been reported ; otherwise, septic erythema is more circum- scribed and irregular. Scarlatina in the wounded and in_ lying-in women may be perfectly typical. Medicinal eruptions have unquestionably been at the bottom of many errors of diagnosis. It has been shown that many drugs may excite eruptions and general symptoms very like those of scarlatina; but for the most part they are simple active hyperemias, such as are produced by the action of belladonna upon the cutaneous arterioles. Such eruptions differ from that of scarlatina in the absence of prodromes, and, usually, of fever. They are also mostly partial and without the history, course, or results of scar- latina ; but at times, and especially when they follow the ingestion of preparations of cinchona, the whole complex of scarlatinal symptoms may be accurately simulated. The conditions for diagnosis have already been pointed out. In second or repeated attacks of so-called scarla- tina, due consideration of the possible influence of drugs as an etiological factor will, doubtless, convert some very puzzling cases into very simple ones. Acute exfoliative dermatitis and desquamative scarlatiniform erythema ® may well be mistaken for scarlatina upon their first ap- pearance. Therash is more protracted than in the essen- tial fever, and is less abrupt in its onset. The local symptoms are very marked, while the constitutional phe- nomena are usually insignificant. The desquamation may begin while the eruption is in full florescence. These affections are not contagious and have no specific se- quele. An erysipelatous eruption may be like that of scarlatina. It, however, differs markedly in its distri- bution, its evolution, and course, being never universal, always progressive, and of indefinite duration. The sub- jective symptoms are quite different in the two affec- tions ; the erysipelatous eruption is painful both spon- taneously and on pressure. Much cedema accompanies the latter eruption. Diphtheria may complicate scarla- tina, and the intensity of the local inflammation may in- duce a coagulation-necrosis exactly corresponding to the membranous formations.of diphtheria. Idiopathic diphtheria may especially resemble scarlet fever when it is accompanied by the erythematous exanthem that is sometimes developed, either early in the disorder, or later, in cases of blood-poisoning. At first it may not be possible to arrive at a correct diagnosis. According to Robinson,* in the early diphtheritic erythema there is no marked elevation of temperature. The rash may be- gin in any region, and rarely extends to the whole sur- face. The tongue is not affected, and there may be no special general disturbance. Desquamation does not oc- cur. The late diphtheritic erythema is septic. When the eruption of scarlatina is imperfectly developed, or when it does not appear at all, and when sore throat and fever are the only symptoms to attract attention, the diagnosis must rest upon the history of the patient and his surroundings, and upon the course of his illness. In not a few cases a retrospective diagnosis of scarlatina must be made, after the occurrence of desquamation or 318 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. the supervention of nephritis and dropsy under condi- tions that indicate their scarlatinal origin. Proenosis.—The mortality from scarlet fever varies widely in different epidemics. From the affection that in Sydenham’s time ‘‘ hardly deserved the name of dis- ease,” to a pestilence of intense malignity, all degrees of fatality have been, and continue to be, observed. Epi- demics have been recorded in which no deaths have oc- curred, Recently Whitla*+ has recorded but a single death in 133 cases of scarlatina treated in hospital. Such results are, unhappily, exceptional. The mortality has been known to reach thirty and forty per cent. An ex- cessively high rate of mortality is, in great part, attrib- utable to epidemic tendencies toward grave complications, diphtheria, nephritis, etc. In private practice the death- rate will not often exceed ten per cent. In hospitals the percentage of deaths is usually much higher, the result being due to the fact that milder cases are kept at home for the most part, and not to differences in social condi- tion, except in so far as neglect and exposure previous to admission may have aggravated an attack or have excited a complication. The death-rate will be high or low in accordance with the type of the prevailing epidemic, and the average mortality of the disease should always be considered with reference to this. Neither season nor at- mospheric condition appears to exert any influence upon the epidemic type. Likewise, telluric conditions do not modify it. Benign and malignant epidemics follow each other without evident cause. The mortality at the begin- ning and during the height of an epidemic is greater than during its decline. Barring the effects of extreme pov- erty and exposure, scarlet fever affects the rich and poor impartially. The sexes are almost equally attacked, but age exerts a striking influence upon the result. Children under one year of age, though less apt to be attacked, are especially liable to fatal forms of the disease. According to Fleischmann, the mortality at St. Joseph’s Hospital was: Under one year of age, seventy-five per cent. (8 cases, 6 deaths); from one to four years of age, forty- three per cent. ; from five to twelve years of age, 19.6 per cent. ; the total mortality being ten per cent. The majority of deaths occur under the sixth year of age; with increasing years the prognosis becomes more favor- able. Fleischmann’s records show a higher mortality than those of some other writers. For example, Kraus gives 4 deaths in 13 cases less than one year of age ; 29 deaths in 118 cases from the close of the first to the close of the fifth year of life ; 10 deaths in 106 cases from the end of the fifth to the close of the twelfth year of age; and 2 deaths in 40 cases from the twelfth to the twentieth year of age. Voit reported 1 death in 5 cases less than one year of age ; 24 deaths in 166 cases from the first to the close of the sixth year of age ; 10 deaths in 109 cases from the sixth to the twelfth year of age. Roset reported 16 deaths in 43 cases less than one year of age; 31 deaths in 156 cases from the first to the close of the fifth year of age; and 3 deaths in 88 cases over five years of age. An ex- ception must be noted to the favorableness of the prog- nosis in persons of maturer years, in the case of puer- peral women, in whom scarlatina has already been shown to be especially malignant. No case can appear to be so mild as to justify a prognosis unqualifiedly favorable. From the beginning until the termination in recovery there is no period when a sudden change may not place the life of the patient in jeopardy, whether by an aggra- vation of the essential symptoms of the disease, or by the supervention of complications. The prognosis, however, is generally favorable if the disease pursue a regular course ; if the eruption follows a brief prodromal stage, and is regularly developed ; if the fever, more or less in- tense from the first, does not exceed at the height of the eruption 40° C. (104° F.), and, steadily falling, reaches the normal on the sixth, seventh, or eighth day; if the angina do not assume a diphtheritic character, and is not complicated by parenchymatous tonsillitis, retro- pharyngeal abscess, or cellulitis of the throat or neck ; if the kidneys remain unaffected or show only slight evi- dences of disorder. On the other hand, the prognosis is more grave when the eruption appears after a prolonged REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Scarlet Fever, Searlet Kever,. prodromal stage, or when the attack is ushered in by con- vulsions or other profound nervous disturbance ; or when the temperature reaches a high degree, 40.6° to 41° C. (105° to 106° F.), at once ; or when intractable vomiting is present ; or when diarrhcea is a prominent feature ; or when the pulse beats more than one hundred and twenty times to the minute, and is feeble, unequal, and irregu- lar ; or when the throat is ulcerated and develops diph- theritic inflammation ; or when suppurative, parenchy- matous, or gangrenous inflammation of the tonsils, or retro-pharyngeal abscess supervene ; or when the neck becomes swollen, brawny, and livid from glandular, peri-glandular, and diffuse cellular inflammation. Ap- prehension should always be excited if the eruption come out imperfectly or irregularly while the fever is intense ; or if, once fully developed, it suddenly fade; or if the eruption assume a livid color ora distinctly hemorrhagic character. A coppery hue of the eruption is unfavor- able, as is also a livid coloration of parts not invaded b the eruption. Small, scattered petechize in the midst of an otherwise normal eruption are unimportant. Miliary vesicles, developing in the ordinary course of the fever are insignificant ; occurring later, during an attack of un- usual severity, they are often the forerunners of death. Convulsions first occurring after the height of the fever, are more ominous than if occurring earlier. Should the eruption, and especially the fever, continue unabated after the usual period, dangerous complications are to be apprehended. Coma is of grave augury, as indicat- ing uremia, cdema of the brain, or even meningitis. Nephritis is more serious the earlier it is developed. It occasionally happens that scarlet fever at first shows the symptoms of a mild attack, but before the completion of the eruption assumes a malignant character. If symp- toms of malignancy occur after the completion of the eruption, they are usually attributable to complications. On the other hand, all the signs of malignant scarlatina may be present at the outset. High fever, rapid pulse, convulsions or coma, protracted vomiting, intense erup- tion, may all yield after the second or third day, the disease thenceforward pursuing a mild course; again, symptoms of malignancy may disappear upon the super- vention of a delayed eruption. Mayer *® observed a tem- perature of 48° C. (109.4° F.) on the evening of the second day. The temperature subsequently varied slightly until the fourth day, when, upon the appearance of the erup- tion, it subsided. The occurrence of scarlatinal diph- ‘theria always increases the danger of death. Heubner regards its sudden extension to the soft palate and to the portals of the cesophagus and trachea as certainly to be followed by death within from twenty-four to forty-eight hours, the fatal issue occurring either through gradual progress of gangrene, by inflammation of the lymphatic glands and connective tissue of the throat and neck, or by edema glottidis. When circumscribed spots are in- vaded and the lateral portion of one tonsil shows the first patch, from which the membrane gradually spreads, re- covery may occur. Diarrhoea persisting during the at- tack greatly increases the danger. Nephritis is always a serious complication, though terminating favorably in most cases. The danger is usually proportionate to the earliness of its occurrence. Death may occur as in or- dinary nephritic inflammation. Scarlatinal nephritis most rarely becomes chronic. Inflammation of the or- gans of hearing, while rarely imperilling life, often re- sults in partial or complete deafness. This, according to Burkhardt-Merian,*" depends upon croupous-diphtheritic inflammation primary in the throat. The prognosis is more unfavorable if the process be allowed to go un- treated. Rheumatic and rheumatoid inflammations are not commonly dangerous complications. Endo- and peri-carditis, pleurisy, peritonitis, meningitis, pneumonia, dysentery, parenchymatous degeneration of the heart, etc., are all complications of extreme danger. Purulent inflammations of pyemic origin usually constitute se- quelee of scarlatina, and are of the gravest Importance. TREATMENT.—Mild cases of scarlatina require little more than good nursing. As soon as the nature of the disease has been recognized, the patient should be re- moved toa clean, well-ventilated room, supplied with only such furniture as is indispensable. Only the attendants of the patient should be admitted to the sick-room. All superfluous articles of clothing should be discarded. As far as practicable, woollen outer garments should not be worn. In summer the windows should be kept open sufficiently to secure free movement of air and agreeable temperature ; in winter an open wood or coal fire should, if possible, be kept constantly burning. The tempera- ture of the room should not exceed 21° C. (70° F.), nor fall below 18° C. (65° F.). The patient, unless an infant, should be kept in bed even during the mildest attack. The bed-covering should be sufficient to secure comfort, nothing more. The diet should consist in easily assimi- lable food ; the nearer this approaches a pure milk diet the better. Cold drinks may be allowed ; cold water, lemonade, raspberry vinegar properly diluted, soda-wa- ter agreeably flavored, are grateful to the patient and preferable to warm and mucilaginous drinks. Though milk should form the principal article of food, light broths and soups, beef-tea, chicken-jelly, and, especially during convalescence, the various appetizing and whole- some preparations of food now so abundantly supplied, may be given. Clothing and bed-clothing may be fre- quently changed under precautions providing for appro- priate disinfection. In such cases internal medication may be held in reserve, a careful observation of all symp- toms being meanwhile maintained ; the condition of the kidneys being systematically ascertained by daily obser- vation. For the angina, if this does not exceed a simple hyperemia, soothing gargles of flaxseed, sage, or chamo- mile tea, or of decoction of quince-seed, will prove effi- cacious. Should the throat develop the whitish curdy deposits of follicular inflammation and the erosions that so often accompany acute catarrhal pharyngitis, a mildly antiseptic gargle will act beneficially and will correct fetor of breath, and, to some extent, disinfect the secre- tions and exhalations. For this purpose one of the sub- joined gargles may be employed : Foe CIC, CATDOUCHCEV Sb... ara chs maces 2 88, CEIVCODENG co Neale werd ec sle uate nines rac DCCL SUL sila. 6 okt man a euetsie ats Q. $aa0 fay M. Sig.—Gargle. Or, Bae linctsfertl colorids s...arteete marae seb Potases chloraty . 0s tec seieas acta eens 3 Ss. GUY Cerin Woitds ott centers hae eee os {3 j. A ee CLESU Lie. cts gletetetara: celts q. s. ad f % viij. M. Sig.—Gargle. External applications to the throat are often useful. A favorite domestic remedy is a strip of bacon-rind ap- plied to the skin of the throat. It produces a slight ve- sicular eczema, and is probably of some advantage as a counter-irritant. Obviously, such applications are inad- missible when diphtheritic inflammation is present. Mildly stimulating liniments are more handy and ele- gant, and quite as efficacious. The itching and burning of the eruption will be greatly alleviated by inunctions with camphorated oil, cold cream, vaseline, or lard. This practice is especially commended as restricting the spread of contagious particles. Tepid bathing or spong- ing under the bed-covering is refreshing to the skin and nervous system, contributes greatly to bodily comfort, and may be practised several times daily. Although every case demands constant watchfulness, when the temperature does not exceed 39° C. (102.5° F.) medica- tion beyond that mentioned will not be called for, un- less complications develop. When the degree indicated is exceeded, marked benefit will be derived from anti- pyretic remedies. These may be administered inter- nally or externally. Of internal antipyretic remedies, until recently, the most popular was quinine. The sul- phate may be prescribed in capsules, in doses of from three to five grains to a child five years of age, at intervals of two hours, for two or three doses. It must be con- fessed, however, that in scarlatinal hyperpyrexia quinine is at best an uncertain and feeble remedy. In severe cases there is often intractable vomiting, and quinine 1s 319 Scarlet Fever. Searlet Fever. especially apt to be rejected almost as soon as swallowed. It is better, therefore, to give it in solution by the rec- tum or hypodermically. By the latter method a solution containing four grains of the hydrobromate of quinine in twenty minims of water, or of the muriate of quinine with urea,* may be injected once or twice daily. Other agents occasionally used for the reduction of fever are aconite and veratrum viride. In mild cases, however, they are unnecessary, and in severe ones they are both unsatisfactory and unsafe. Salicylate of sodium pos- sesses positive antipyretic properties, and may be used in scarlatina with frequent benefit. The synthetically prepared alkaloids of the aromatic series of carbon com- pounds, of which thallin, antipyrin, and antifebrin may be considered the most reliable and safest for the reduc- tion of temperature, are probably the most valuable rem- edies by the internal administration of which exalted temperature may be reduced. These drugs, which prom- ise to hold a firm position in therapeutics, will most prob- ably serve a very useful purpose in the treatment of scar- latinal hyperpyrexia. At present, however, observation has not been sufficiently extended to justify definite con- clusions. Antipyrin acts well with children, and seldom produces objectionable diaphoresis or eruptions. Argu- tinsky recommends the following minimal doses of this agent : For children under one year of age, three grains thrice daily, at intervals of three hours ; for those of from one to three years, five grains; for children between this age and five years, from five to six grains three times daily, at intervals of two hours; for children of from six to eight years, from eight to ten grains daily, at intervals of two hours; and for children of ten or twelve years, from ten to twelve grains thrice daily; at intervals of one hour. Thallin may also be used to effect the same purpose. The dose of thallin is about one-fourth of that of antipy- rin. There is a somewhat greater tendency to collapse after thallin than after antipyrin, and, therefore, the ear- lier doses should be given very cautiously. Antifebrin affords advantages over either of these agents. Vomiting ost rarely occurs after its use. The dose is one-half of that of antipyrin, though its full action is produced more slowly. Neither is sweating quite so constantly pro- duced, though a pronounced cyanosis of the cheeks and mucous membrane and of the extremities is often ob- served. These agents are also active when administered by enema. During the administration of these drugs the ther- mometer should be constantly employed, care being taken to avoid collapse. After afew hours the influence of the dose fails and recourse must be had to them repeatedly. By far the safest and surest agent for reducing tempera- ture in scarlatina is cold water. This may be applied in various ways. The simplest method is by frequent spongings with cold or tepid water under cover of the bedclothes. At the same time cold wet-cloths may be applied to the head, and the patient may be permitted to suck small pieces of ice. In most cases it is better that the water be warm. The spongings may be repeated frequently during the day and night. In cases where, with an elevated temperature, the eruption develops in- completely, or is much delayed in appearance, the body may be immersed in water somewhat cooler than its nor- mal temperature. A cool bath (27° C.= 80° F.) has been extolled as of singular virtue in such cases, and at times it is of the highest value. The tepid, even the warm bath, is probably of equal benefit in most cases. Recent writers have denied that efforts to ‘‘ bring out” an im- perfect or delayed scarlatinal eruption are of any avail. Therescan be no doubt, however, that treatment with * This salt, which is also called “ quinia bimuriatica carbamidata,” is prepared by Andrews & Thompson, of Baltimore, as follows: Muriate of quinine, 793 grains; muriatic acid (specific gravity 1.070), 500 grains; pure urea, 120 grains. Mix the muriate of quinine in the Hcl in a por- celain capsule, and when it is dissolved add the urea and heat carefully over a water-bath until sufficiently concentrated to form crystals (evapo- ration to dryness under a low temperature may be practised). ‘T'o pre- pare the solution for hypodermic use, take of muriate of quinine and urea, 3ij.; of distilled water, f3j. Dissolve and filter. Twenty minims of this solution contain five grains of muriate of quinine. I'or hypoder- mic use this solution leaves nothing to be desired, 320 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. this object in view is often successful. The hot bath, even with the addition of mustard, by exciting cutaneous hyperemia, will often relieve the congestion of internal parts. Warm and hot drinks made from various vege- table substances were formerly much employed to “ bring out” the eruption. They were given copiously, and of- ten in combination with such diaphoretics as spiritus mindereri, spirits of nitrous ether, etc. This plan of treatment is not much practised to-day. The cold bath, which should be of a temperature not lower than from 24° to 27° C. (75° to 80° F.), should be reserved for cases whose temperature exceeds 40° C, (104° F.). The body should be immersed but for an instant, the benefit of the plunge consisting largely in the dilatation of the vessels of the skin through reaction. The cold pack is also of value in these cases. When the temperature steadily rises to an alarming degree, or when hyperpyrexia is de- veloped almost at the outset; when, with or without well-developed exanthem, stupor or coma, or other grave nervous disorder, arises, and when the pulse becomes very rapid, feeble, and irregular, the maintenance of life depends upon the reduction of temperature. Here it is impossible to give hard and fast rules for conduct. Water below the normal temperature of the body still remains our most efficient means of reducing the exces- sive heat. The lower the temperature of the bath, the more rapidly is this result attained, but the shock of the sudden contact with the cold water may exert a depress- ing effect that may not speedily pass off. The body cannot remain in very cold water longer than a minute or so without exciting chattering of the teeth, lividity about the mouth, and a pinched appearance of the feat-. ures and of the surface. Cold affusions may often be most profitably employed. They were strongly com- mended by Currie. The affusion may be practised by pouring from a pitcher, from a moderate height, cold water upon the head of the patient, until the necessary fall of the temperature has been achieved. The warm bath (82° to 35° C.= 90° to 95° F.) has been highly ex- tolled as favorably influencing the course of scarlet fever when used at the very beginning. Thompson em- ployed it thus constantly, and never lost a case treated in this manner. In a bath of from 27° to 30° C. (80° to 85° F.) the patient may remain for five or ten minutes. These baths should be repeated as often as the tempera- ture of the body becomes as high as 39.5° to 40° C. (103° to 104° F.). To avoid alarming the little patient, the bath-tub may be covered with a sheet or blanket. Plac- ing him upon this, he may slowly be lowered into the water. Upon removal from the bath the patient should be wrapped in a dry blanket. As the body soon dries under the protection afforded, rubbing with towels may be avoided. The skin should now be anointed with oil or other agreeable fatty substance. Refreshing quiet and sleep often follow this bath. In using the wet pack, a blanket may be spread upon a hard couch or bed cov- ered with oil-cloth ; upon this a sheet wrung out in cold water is laid. The naked patient is stretched upon this sheet, which along with the blanket is wrapped about him snugly. The brief sensation of chilliness is soon replaced by one of warmth, and after a few moments the body breaks out into copious perspiration. This may be encouraged by hot drinks, and hot bottles to the surface. The patient should not remain too long in the pack, otherwise hyperpyrexia may rather be increased than diminished. In the intervals of the baths, in ex- treme cases, an ice-cap may be worn, and cloths wrung out in iced water may be applied to the epigastrium. , Nothing can exceed the efficacy of the above-described method of treating scarlet fever with high temperature ; but to secure its full influence, it must be pursued sys- tematically and intelligently. The thermometer must constantly direct the actions of the physician. The prejudices of friends and attendants against the immer- sion of the fevered body in ice-cold water will not ex- tend to the use of tepid and cool baths, from which, in- deed, equally good results may be obtained. The baths may have to be repeated at intervals of two or three hours for days before the fever begins to yield; or they REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Searlet Fever. Scarlet Fever. may unhappily altogether fail to control the irresistible intensity of the disease. On the other hand, they fre- quently exert a most gratifying influence upon the course of the malady, the temperature becoming per- manently reduced, the pulse quieter, fuller, and regular ; jactitation, delirium, and coma being replaced by com- posure, consciousness, or natural sleep. Often an at- tack that appeared about to pursue a malignant course, under the influence of the bath becomes benign and ter- minates favorably. While exalted temperature that threatens to destroy life can, in the manner indicated, often be reduced, the course of the disease itself cannot be aborted. No remedy is known that can be said to exert a specific influence over it. Vaunted specifics have not withstood the test of experience. Bennett claimed to have never lost a case of malignant scarlet fever, a result that he attributed to the administration of fresh yeast,in one or two tablespoonful doses, several times daily. One no longer hears of Schneemann’s plan of rubbing the surface with bacon, and of Deline’s oil inunctions as curative, though the value of such adju- vant treatment is universally recognized. Recently Hay- ward ®* reported several cases of malignant scarlatina successfully treated with crotalus. The agent was ap- plied to the denuded surface of the throat, and was also given internally. The mineral acids, though highly ex- tolled by authors, do not confer any signal advantage in the ‘treatment of scarlatina. Acetic acid has been sup- posed to exert a favorable influence over the disease, and is a favorite remedy. Probably the most popular routine treatment of ordinary scarlet fever is that of carbonate of ammonia. By many it is considered to have a speci- fic influence. When in cases of very elevated tempera- ture the heart-action flags, the pulse becoming rapid, feeble, and unequal, when delirium or stupor appears, the preparations of ammonia are demanded. The carbonate, in doses of one to three grains to a child five years of age, may be given every third hour in aqueous solution with milk, which in a great measure destroys the pungent, disagreeable taste ; or it may be given in solution of the acetate of ammonia, a most commendable combination. The aromatic spirits of ammonia may be employed for the same purpose. Hoffman’s anodyne, whiskey, or brandy is especially indicated when the nervous system shows alarming signs of perturbation, delirium, jacti- tation, stupor, etc. Purgation, which should usually be avoided, may at times become necessary. Small doses of calomel (one-sixth to one-fourth grain) repeated every hour, until the bowels are moved, generally act well. Castor-oil is a harmless and safe, but nauseous, agent. . Rhubarb and scammony are also efficient cathartics. Either may be given in doses of five grains to a child six years of age. The taste of scammony resin is not unpleasant, but its difficult miscibility with water is an objection to its use. Ringer recommends as a purgative for children a few drops of a solution of one grain of podophyllin in a fluid drachm of alcohol given in syrup. When depression is profound, reliance should be placed on enemata in preference to active cathartics. During the progress of the disease the expectant plan of treat- ment is most to be recommended. The daily bath or sponging should be continued. It is probable that renal complications are thus frequently avoided. As the fever and eruption decline, a more liberal, but always easily assimilable, diet should be allowed. The patient should be jealously guarded from draughts and dampness, and even the mildest cases should be kept in bed for at least ten days after the cessation of fever ; nor should the pa- tient be allowed to leave his room before the expiration of the third week. Out-of-door exercise cannot be re- sumed in disregard of season, or of barometric and ther- mometric variations. In midsummer, when windows and doors must remain open, the question of out-of-door ex- ercise is rather one of danger to others than of personal risk ; while in spring, autumn, and winter the risks of exposure are especially great. During these seasons the patient should not venture into the open air before the sixth or seventh week of perfectly normal scarlatina. During convalescence the daily baths should be contin- Vou. VI.—21 ued until desquamation is completed, and daily inunc- tions with oil both expedite this process and minimize the dangers of contagion. No further medication, or at most a ferruginous tonic, will be required. Unfortunately, during the course of scarlatina there constantly arise complications frequently demanding more energetic treatment than the original malady. Of these the most common (indeed, in its milder degrees it is essential) is pharyngeal inflammation. The milder grades of this will require no more active treatment than that already described. Where the inflammation is more se- vere, and accompanied by more or less superficial ulcer- ation, applications should be made with a probang or camel’s-hair pencil, or by means of the spray. When the surface is foul and covered with offensive exudation, an excellent application is the following, first recom- mended by J. Lewis Smith : By eAcid,, carbolic.. 1.22 BRACE Bis 4 oe eae gr. iij.-vj. Liquor ferri subsulphat............ £5 1 Glycerin prt. tj dks bi. ahd £3 vj. S.—Apply with a brush three or four times daily. Or the following : dp LINCUMLOCIDIT ae toy ve tet saia: eer Lae f CVcerl niet eee oe ne tah wees ie Ly age Or, HAA CIGs boraciews SiMe Pe ee Pee. 3.88.-3 ij CLE CCRCLL ST Gere et ee ae ee feive M. 8.—Apply with a brush, with the atomizer. This may also be used Most therapeutic agents may be profitably given through the hand-atomizers in the case of children intelligent enough to assist by inhalation. Subjoined are suitable formule : Hoa Linct, fetmrirCnlovigd.. <4. os. us cate tee wieGe Olas. CULOL ALG ima as seere ae meee ce ca NCICB LULOS cr access Ser doe ae Lai f: Dpiserviti amaliice te ery kee wea te £2): GLY Cert te attr cedtite Sean ohio ae f Z ss. ENC ACBS ELL Ses a itn cna eben Ce iG tiene: M. FEMA Qh LOK Tarp rne thie Sa SU) oe eg Oe f 2 ss; Aquidestik. Dest CR au.We ies sete ees f% vss M. The various carbolized sprays are most extensively em- ployed. Diphtheritic inflammation calls for the same treatment as idiopathic inflammation.* Cauterization with silver nitrate, acid nitrate of mercury, chromic acid, or other agent, should not be practised. Asa gargle in diphtheritis faucium permanganate of potash is valuable. R. Potass. permanganat..... greene aL ae 1 ee Any destil. sa. ng en Gn wakes ne 12 1yi. M. Tracheotomy should never be performed. A case of scarlatinal diphtheria which presents the symptoms that demand this operation, in the idiopathic disorder, is be- yond the resources of surgical art. Inflammation of the lymphatic glands of the neck and of the adjacent connec- tive tissue may be treated first by inunction of oil or cerate. In severer forms, cold wet applications, and where sup- puration threatens, flaxseed, or cornmeal, or hop poul- tices should be applied. Suppurating points should be incised early and freely to prevent burrowing. Gangren- ous inflammation may sometimes be arrested by strong caustics. Iron, quinine, stimulants, and nourishing and supporting food should be administered in these condi- tions with a free hand. Nasal catarrh will not usually require treatment. When diphtheria extends to the nasal passages, similar applications to those made in throat * Dusting powders of subnitrate of bismuth and salicylic acid, and, under proper precautions, of iodoform, is often most useful. 321 Searlet Fever. Scarlet Fever. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. diphtheria should be made through a nasal syringe. Scarlatinal aural inflammation calls for more special treat- ment; the nasal douche should be used and _ the diphthe- ritic pharyngeal and nasal cavities should be repeatedly syringed with antiseptic solutions, for it is by the exten- sion of the inflammation along the Eustachian tube, that the severer forms originate. When the aural inflamma- tion is established, inunctions of mercurial ointment, or of the oleate of mercury, or of iodoform ointment, should be made about the ear several times daily. When the tym- panic membrane becomes strongly injected and bulges outward, paracentesis for the release of the pent-up exu- dation should be performed. Timely tapping of this membrane will often preserve the imperilled sense of hear- ing. This operation is especially commended by Buck and Olshausen. It is simple and very easily performed. The sensitiveness of the membrane may be obtunded by the instillation of a four per cent. solution of muriate of cocaine. Pomeroy’s directions for performing the opera- tion are as follows: ‘‘ A good-sized speculum is intro- duced into the meatus. Then an ordinary broad needle, about one line in diameter, with a shank of about two inches, such as oculists use for puncturing the cornea, should be held between the thumb and fingers, lightly pressed so as not to dull delicate tactile sensibility. The part being well under light, the most bulging portion of the membrane should be lightly and quickly punctured with a very slight amount of force. The posterior and superior portion of the membrane is most likely to bulge. The chorda tympani nerve usually lies too high up to be wounded. The ossicles are avoided by selecting a pos- terior portion of the membrane. After puncture the ear should be inflated by an ear-bag whose nozzle is inserted into a nostril, both nostrils being closed, so as to force the fluid from the tympanum. The puncture may need to be repeated at intervals of a day or two, provided that the pain and bulging return.”*? When pain and tender- ness only are present, hot fomentations to the external ear, and to the parotid and mastoid regions, are very soothing. Laudanum and sweet oil, or a two to four per cent. solution of sulphate of atropia instilled warm into the external meatus, often give relief. Frequently renewed solutions of cocaine are very efficacious. Bags of hot table salt, or of heated flowers of hops, are well- known domestic remedies. When perforation occurs spontaneously the hearing may be preserved, but partial deafness is often permanently established, and sometimes the sense of hearing is totally abolished. In such cases the ear should be frequently syringed with warm water, or warm solutions of boracic acid. Jodoform, however, is by far the most effective application in chronic aural inflammation with perforation, with or without necrosis of the bones of the aural cavity. Its disagreeable odor may be masked by adding to the phial a drop or two of some essential oil (cloves, citronella, cinnamon, etc.). Granulations and polypi developing in the course of chronic otitis may be benefited and even cured by as- tringent powders and washes. Surgical interference will at times be necessary. When nephritis arises in the course of scarlet fever, or as a sequel, prompt measures for its relief must be adopted. Where it forms a feature of rapidly fatal ma- lignant scarlatina, it may have no time to develop symp- toms, or these may escape detection, or the virulence of the disease may throw the renal disorder into the back- ground, or render attempts to treat it futile. In milder cases, and later, during the latter part of the first or dur- ing the second or third week, especial attention may be devoted to the treatment of nephritis. Slight albuminuria will occur, according to Mahomed, during convalescence, associated with constipation and a hard pulse, indicative of high arterial tension, without subjective symptoms, and remediable by a brisk purge. This author also as- serts that a slight chilling of the surface is sufficient to cause transitory albuminuria. The patient should there- fore be carefully protected, in the manner already indi- cated. Dietary management will go far toward prevent- ing renal complications. to 74a Of a grain daily ; or the tincture of belladonna (which is usually employed) may be given. The dose of the tincture should be one drop for each year of the child, administered once or twice daily. It has been claimed that to obtain the desired protection the characteristic effects of bella- donna should be produced in the throat and upon the skin. J. Lewis Smith. believes that boracic acid, regu- larly administered, exerts a favorable influence over the course of the disease, and in great measure confers im- munity upon those who take it for purposes of prophy- laxis. Fordyce Barker®! claims that salicylic acid pos- sesses prophylactic properties. A few drops of a weak solution in alcohol and warm glycerin should be given once or twice daily. At one time it was hoped that inoculation with scarla- tinous virus might afford a protection from scarlatina similar to that derived from small-pox by inoculation, In the few rather questionable cases in which this has been attempted, the resultant scarlatina appeared to be unmodified. The asserted prevalence of scarlet fever among dogs and cats,® and in horses * (Peters), has recently again stimulated the hope that protection to the human family may be obtained by a process similar to vaccination. Strickler“! made a very interesting set of observations, which, however, have not as yet received confirmation. He inoculated rabbits with the nasal se- cretions of a horse supposed to be suffering from scar- latina. Symptoms of what Strickler considered to be modified scarlatina followed. Later these animals were inoculated with scarlatinal human blood without notice- able result. Again, he inoculated twelve children with matter from ‘‘scarlatinous” horses. This was followed 323 Scarlet Fever. Schizomycetes. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. by light eruption, etc. Subsequently these children were inoculated with human scarlatinous blood without effect. Strickler concluded : 1. The subcutaneous injec- tion of scarlatinous virus from horses is without danger. 2. After its injection under the human skin a circum- scribed eruption like mild scarlatina appears. 3. After horse-virus inoculation the organism remains resistant to inoculation with scarlatinous virus. It is to be hoped that further investigation will confirm these observations. I, EH. Atkinson. 1 Historisch-Geograph. Pathol., vol. i. New Sydenham Soc. Trans- lation, p. 172. 2 Amer. Journal of the Medical Sciences, October, 1855. 3 Jahrbuch f. Kinderheilk., 1870. 4 Hebra: Diseases of the Skin. p. 218. 5 Maladies Infect. 6 Reichert’s Archiv, 1872. 7 Berliner klin. Wochenschr., November 3, 1884. 8 Archiv f. Kinderheilk., 1869, 2. ® Annales de Dermatol. et de Syph., 1882, p. 405. 10 Lancet, 1888, i., p. 557. 11 Gentralbl. f. d. Med. Wissensch., 1883, 36. 12 Allgem, Med. Zeitschr., lii., 1349. Berlin, 1883. 13 Righteenth Annual Report of the Local Government Board, 1885- 86; Proceedings Royal Society, vol. xlii., 1887. 14 British Medical Journal, 1887, i., 1262. 15 Pepper's System of Medicine, vol. i., p. 509. 16 Tancet, 1883, i., 194. ‘17 Thid., 1885, i., 854. 18 Tbid., 1883, i., 685. 19 Rehm: Jahrb. f, Kinderheilk., 1869, 4. 20 Vol. xi., 1878. 21 Ziemssen’s Cyclop., vol. ii., p. 169. 22 Jahrbuch fur Kinderheilk.. 1875, viii. 23 Lancet, 1870. 24 Jahrb. f. Kinderheilk., i., 1870. 25 Loc. cit. 26 Jahrbuch. f. Kinderheilk., 1879, xiv., 1. 27 Vierteljahr, f. Dermatol. u. Syph., viii., 522. 28 Albuminuria, p. 820. 29 Jahrbuch f. Kinderheilk, 1870, 411. 30 Gazette des H4pitaux, 1885, lviii., 418. 31 Berlin. klin. Wochenschr., 27, 1882. 32 Tbid., 50, 1873. 33 Correspondenzbl. f. Schweizer Aerzte, No. 8, 1876. 34 Berlin. klin. Wochenschr., 8, 1882. 35 Burkhardt-Merian: Volkmann’s klin. Vortrige, 128, 1884. 36 Boston Med. and Surg. Journal, cx., 228, 37 Gundrun: Med. News, 1882, xli., p. 231. 38 Baader: Loc. cit. Hynes: Lancet, ii., 1870. 39 Deutsche Med. Woch., x., 37-40. 40 Berlin. klin. Wochenschr., 1868, No. 2. 42 Jahrbuch. f. Kinderheilk., 1872, v., 324. 43 The Practitioner, 1875, xvi., p. 21. 45 Charité Annalen, 1876, iii., p. 538. 46 British Medical Journal, No. 498, 1870. 47 Robuske: Deutsche Med. Woch., October 8, 1881. Mitchell : Edin- burgh Med. Journ., February, 1882. 48 Deutsche Med.-Wochenschr., 31, 1883. 49 Jahrbuch f. Kinderheilk., N. F. 1., p. 434. 50 Tbid., viii., H. 2, p. 15. 51 Tbid., N. F., 4, 1870. 52 Thid., iv., 166. 53 T’Union Médicale, April 80, 1882. 54 Wiener Med. Wochenschr., 39, 1877. 55 [bid., 43, 1877. 55 Deutsch. Med. Wochenschr., 31, 1883. 57 Berlin. klin. Wochenschr., 43, 1883. 58 A Treatise on the Diseases of Infancy and Childbirth. Philadel- phia, H. C. Lea. 59 Med. Record, ii., 1859. 69 Journal of Cutan, and Venereal+* Diseases, vol. i., 1883. 61 Clinical Lectures and Essays. 62 Guy’s Hospital Reports, 1879. 63 Tbid. 64 Konetschke: Wien. Med. Presse, 1882, xxiii., 1483; Ffolliott: Brit. Med. Journal, i., 1879. 65 British Med. Journal, 1879, ii., p. ‘75. 66 Amer. Journal of the Med. Sci., ixxxvii., 1884. 67 Page: Lancet, 1885, i., 887. ‘68 Archiv f. Gynakologie, ix., B. 2, 1876. 6) Dublin Journal Med. Sciences, February, 1866. 79 Obstetrical Transactions, 1871, vol. xii., p. 58. 71 Berlin. Klin. Wochenschr., 47, 1872. See also Smith: Med. Times and Gaz., 1870, ii, 10538. Schwarz: Wien. Med. Wochenschr., 42, 1871. Broadbent: Brit. M. J., April 1, 1876. Barrs: Lancet, 1883, ii., p. 102. Farrar: Lancet, 1875, i., p. 109. 72 Trojanowsky: Dorpat. Med. Zeitschr., i., 1871, 73 Dorpat Med. Zeitschr., iii., 1873. 74 Correspondenzbl. f. Schweiz. Aerzte, No. 5.1876. 75 T/Union Médicale, &, 1883. 76 Progrés Médical, 1880, 47. 77 Wiener Med. Jahrb,, 2 H., 1882. 78 Norsk Magazin for Ligervidenskaben, 1880; Viertelj. f. Dermatol. u. Syph., viii., 522. 79 Fortschritte d. Med., Nc. 3, 1888, p. 81. 80 Transact. Patholog. Spc., London, 1877, xxviii., p. 435. 81 Handbuch der Path. Anat. 82 Broeq: Journ. Cutan. and Venereal Dis., August. 1885. 83 Journal Cutan. and Venereal Diseases, April, 1883, 84 Dublin Jour. Med. Sci., March, 1885. 85 J., Lewis Smith: Pepper’s System, vol. i., p. 534. 86 Ann. de Médecine @’Anvers. London Med. Rec.. 1882, 52. 87 Volkmann’s Sammlung klin. Vortriige, No. 128, 1880. 88 Lancet, 1883, ii., 54. 8° J. Lewis Smith: Pepper’s System of Medicine, vol. i., p. 548. 80 British Med. Journal, 1886, ii., p. 813. #1 New York Med. Journal, No. 2, 1879. ENING: x e.0-48.4y [ifoh 93 Journ. Compar. Med. and Surg., New York, v., 134. 94 New York Med. Record, March 24, 1883. New Syden. Soc. Translation, vol. i., 1872. 41 Ibid., 1868, No. 9. 44 Lancct, 1885, ii., p. 795. SCHINZNACH is a Swiss spa, in Canton Aargau, or Argovie, lying at an elevation of 1,150 feet above the level of the sea. It is protected against the cold winds, 324 yet the climate is somewhat changeable ; the average temperature of the summer months is 62.6° F. An anal- ysis of the spring here situated, made by Bolley and Schweizer, gives the following results (Rotureau). A litre of water contains : Grammes Sodium ‘sulphate 250. and tissues of the body. Even where ° the lesion is at first local, the organisms usually get into the blood and are conveyed to all parts of the body. The mould fungi, on the other hand, become lodged in the internal organs, especially in the kidneys, and the mycelia grow out and form distinct foci. The Pathogenic Aspergilli.—Three species of aspergillé have pathogenic properties when injected into the veins of various animals. Inhalations of the spores produce mycosis in the lungs of birds. Animals have been found suffering from an infection without intentional inocula- tion. The aspergilli are widely distributed, and are found upon mouldy bread, etc. . Aspergillus fumigatus.— Greenish. Conidia- bearers short and swollen into hemispheres, 8-12 » in diameter, very thickly set with awl-shaped sterigmata. Conidia round, smooth, show no membrane, and are generally colorless, 2.5-3 « in diameter. Sclerotia are unknown. Grows best at 87°-40° C. Possesses more powerful pathogenic properties than the other two. Aspergillus niger.—Brownish-black. Fruit-bearers are exactly globular. Sterigmata, 20-100 uw long and branch- ing. Conidia round and brownish-black at maturity, and 3.5-5 « in diameter. Sclerotia size of rape-seed, and brownish-red. Optimum temperature about 85° C. Does not seem to have any very great malignant power. Aspergillus flavus or flavescens.— Green or greenish- brown. ' Conidia yellow or brown, with a finely nodular surface, 5-7 wu in diameter. Sclerotia very small and black. Grows best at about 28° C. Stands next to A. Sumigatus in pathogenic power. The most common of all fungi is the Penicillium glau- cum. In the family to which this belongs, penicillium, the conidian fructification is alone met with, except under very extraordinary conditions of nutrition. In the latter case the penicillium occasionally produces a small protuberance, about the Penicil- lium. * The accompanying figures were not drawn from actual observation with the microscope, except Figs. 3895 and 3396 (p. 383). Some of them are modified copies from Fliigge’s Die Micro-organismen (see p. 348). 328 size of a grain of sand, upon a mycelium, and this protu- berance behaves like a thick-walled sclerotium. Still, as a rule, the fruit-hyphe ‘are branched, and have a cluster of conidia upon the end of each branch. As is shown in the ac- companying cut (Fig. 3390), the conidia are formed in rows upon the finger-like terminal branches of the hyphe. Penicillium has no interest aside from its frequent occurrence. The O¢dia form sum- mer and winter spores. Witt ee ge ee The former are es Patna sas 2007: Ti a Rade wee Mane Mildew, Simple conidia separated in a Fie. 8390.—Two Fruit-bearing Hyphe row from the ends of the of a Penicillium. > 170. long, straight mycelia. The winter spores are formed in perithecia, which develop secondarily upon the same mycelia from which the summer spores were given off. The winter spores require a state of rest, 7.e., through the winter, before they germinate. The oidia cause the so-called ‘‘ mil- dew.” A scurf of the comb and gills of poultry, and favus of mice, and perhaps favus and herpes ton- surans in the human being, are caused by the growth of oidia. Some of the members of the Basidiomycetes and Phycomycetes ing Four Sporangia. gre parasites of plants, but as none eee of them have been found to cause disease in animals they may be omitted without descrip- tion. The Zygomycetes order has among its families the Mu- corinee, to which the mucors belong. In the Mucorinez the organs of copulation blend to form a zygo- spore. Spores are also formed without copu- lation in the interior of sporangia (Fig, 3391), by the di- vision of the protoplasm into small unicellular spores (Fig. 3392), which are liberated by the dissolution of the membrane of the sporangium in water. This mem- brane is at first: colorless, but after- ward becomes black. The fruit-bear- ing hyphe grow up perpendicularly. Pathogenic Mucors.—Two mucors have pathogenic properties when in- jected into the blood. Rabbits die in forty-eight to seventy-two hours after injections of the spores of M. rhizo- podiformis and of M. corymbifer. The mycelia are found upon post- mortem examination chiefly in the kidneys, but also in the mesenteric glands and Peyer’s patches. B. The Saccharomycetes, belonging to the order Blastomycetes, grow by budding. The parent cell Yeast becomes enlarged at some Fic. 3392.—A Sporangi- Fie. 3891.—Mucor, show- Mucors. ede point into a protuberance joy eee ea which grows larger, and either sepa- with Spores. < 1240. rates or remains attached, and be- comes in turn a mother-cell (see Fig. 3393, 6). The for- mation of ascospores hag also been observed. No pathogenic saccharomycetes have as yet been dis- covered, but they are of great interest because many of them cause the alcoholic fermentation of sugar. _ This function, however, is not peculiar to the saccharomycetes, for mucor racemosus also causes the same fermentation. It is even probable that all the saccharomycetes are merely a form of mould fungus, since this same mucor racemosus assumes the budding growth if it is immersed in a solution of sugar. The CO, which is liberated in the fermentation buoys the mucor, which has for the time become a budding fungus, up to the surface, where it again sends out hyphe. C. The Schizomycetes, or Bacteria, are very minute uni- REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Schizomycetes, Schizomycetes. cellular organisms, They play an exceedingly important role in pathology and hygiene. Some members of this group cause many of the most terrible maladies of animals and plants, they constitute the con- tagium vivum of many infectious diseases ; others are of the greatest use in preparing dead vegetable and animal matter for assimilation by the higher plants; Bacteria. : 3 dp others, again, are con- _* se Aye cerned in fermenta- % vias tion. 4 A bacterium con- . sists of protoplasm “.°"" Se ® chr 1G: * ese rif Bo# cq enveloped in a cell- a, 3 aro membrane. The cell 2 Bi wy is generally colorless ; +43 in some rare species % 7 6 it contains chlorophyll or other coloring mat- Fie. 3893.—1, Staphylococci. 2, Strepto- cocci, showing in two places larger forms, to signify arthrospores. 3, Micrococci tetrageni. 4, Sarcine. 5, Diplococci. The four diplococci to the right, colored black throughout, are called biscuit- shaped (see Chicken Cholera and Gonor- rhoea, below), and are also regarded by many as bacilli. 6, Saccharomycetes. ter. The protoplasm may also contain mi- nute granules of sul- phur, and sometimes refractive oily parti- cles. It is sometimes granular. Some bac- teria give the blue iodine reaction, which is especially marked just before the formation of spores. Under un- favorable conditions of growth the protoplasm becomes cloudy and breaks up into granules. The cells have no nu- clei. The cell-membrane is sometimes colored, and some- times is surrounded by a gelatinous envelope or capsule, which can be occasionally brought out by staining. It is sufficient for our purpose to divide bacteria into micrococc?, bacilit, and spirilla. Micrococci are spherical Classifica. OF Slightly oval, and bacilli are rod-shaped. It tion of bac- is evident that the individual bacteria may lie teria. separated from one another after cell division, or they. may hang together and form chains, threads, irregular clumps, ete. Now, an organism which grows so as to form chains always retains this tendency ; it does not form chains in one generation and clumps in another. This property of organisms has been used as an important means of diagnosis, especially of the cocci. Micrococci which always tend to form chains are called streptococct ; those forming irregular clumps staphylococct. Micrococci which grow so as to form tetrads are called tetragont. If they hang together in all three dimensions of space, they resemble packets bound tightly around with two cords at right angles, and are called sarcine. Although bacilli also form chains and clumps, no such distinction is made as in the micrococci, except that bacilli in chains are some- ieee times called leptothrix. 7 Very short bacilli were for- (i) we es merly called bacteria, but red — c> the latter name has y come to be univer- LY RP 0 pies sally adopted for the QA ee eo schizomycetes in © crs ue) general, Some —sFe~ a es) of the distinc- “a C=) tions of the ae varieties of bac- PEE 2 teria are very fo slight, and are only apparent Gis to the practised eye. Thus, clostridia (Fig. 3394, 1) are bacilli of a spindle shape, and bacilli with a constric- tion in the middle are called dumb- bell or figure -of-8 Shaped (Fig. 3394, 3), and rods with parallel sides may have rounded, square, or even concave, ends. Bacilli that are curved on the long axis are called commas, or comma- bacilli (Fig. 3394, 4), anda chain of them constitutes a spirobactertum or spirillwm. But there are also spirilla, or long spiral threads, which show no division into Fig. 8394.—1, Bacilli of various shapes. 2, Bacilli in the process of forming spores. 3, Bacilli en- closed in capsules and figure-of- 8 bacilli. 4, Comma bacilli and spirilla, 5, Forms of involution, < 70. ; commas (Fig. 3394, 4). The bacteria never branch as do the mycelia of the mould fungi. The schizomycetes multiply by fission, the cells simply grow larger and divide, and afterward separate or hang together as already explained. Micrococci show no variation, they simply form micrococci from one genera- tion to the next, but the other members of this order are subject to quite decided changes of form, owing to vari- ous conditions. Under favorable conditions bacteria continue to repro- duce vegetative cells indefinitely, and under unfavorable conditions they either form spores or undergo a retrograde metamorphosis-—ti-the latter case they degenerate into what is known a$\fotmsyef-involu- tion (Fig. 3394, 5). The cellsyjbecome swolleniand have irregular protuberances on them, and are often so dis= torted as to bear no resemblaiice to the wormal*ells. Involution. even requiring an abundant supply of nutrition, etc., for their production. Indeed, the life-history of the fungi is incomplete without the formation of spores. But it is comparatively rare in the bacteria, and all the conditions which tend to bring it about are not yet known. It is not the result of copulation. Bacteria are said to form two kinds of spores, endo- genie spores and arthrospores. Both kinds survive the action of agents which would kill vegetative cells, but endogenic spores are more resistant than arthrospores. The latter have been but little studied. They possibly are present in all sorts of bacteria, and are generally not distinguishable in appearance from the other cells, though sometimes they are larger and have a higher refractive index, etc. (see Fig. 3393, 2). The term, therefore, merely means that certain individual bacteria have a higher re- sisting power than the ordinary vegetative cells, but are not as resistant as endogenic spores, and may or may not be distinguishable under the microscope. But the endogenic Charac- Spores have very marked characteristics. They teristics of are very highly refractive, and appear as round pperee: or oval bodies lying in and among the vegeta- tive cells (see Fig. 3394, 2). Their resisting power is very great ; the endogenic spores of some bacteria survive even the temperature of boiling water several minutes (see p. 825). As we shall see presently, the vegetative cells are readily stained with aniline dyes, but the endo- genic spores are not stained under ordinary circum- stances. ‘They are only found in bacilli, and possibly in spiro-bacteria. Micrococci are restricted to the forma- tion of arthrospores. In the following the word spore is meant to refer to endogenic spores. Spores represent a state of suspended activity, and they may remain inactive for months and years, till they Germina- 2re removed from the medium in which they tion of the have been formed and are placed under proper spores of conditions for germination. Under suitable bacilli. conditions of temperature, moisture, etc., the clear globular mass in which each spore is embedded becomes ovoid and gradually elongates into a rod, the spore in the meantime becoming less and less refractive, and finally disappearing (Koch). Or, the spore swells and loses its refractive power, its dark contour, and its transparent capsule. Germination then takes place, either in the direction of the long axis of the spore or at right angles to it. In the latter case there appears a dark cres- centic shadow at each pole of the spore, and a papilla grows out from one side and increases in length till it becomes a rod. In the other case, the cell-membrane of the spore becomes uniformly thickened, and the bacillus is liberated by growing out and breaking through at one of the poles (Prazmowski and Brefeld). The membrane 329 Schizomycetes. Schizomycetes. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. of the spore which has been thus abandoned by the ba- cillus remains for some time lying near the latter. Many of the bacilli and spiro-bacteria are endowed with the power of independent motion ; the micrococci reepen have no motion of their own. If bacteria are dent motion examined in water, there is always more or less of bacilli agitation, due to unintentional movement of aan toeia, the microscope, and currents caused by evap- andthefor. Oration, etc., but this is the so-called Bruno- mation of nian molecular motion, and has nothing to do zovglea. with the independent motion of some bacteria. Bacilli thus endowed dart about in all directions, with a wriggling motion, always end foremost, never sideways. The spirilla have also a twisting motion. The motion in some cases is due to the vibration of a flagellum or fine thread at the ends of the rods. When bacteria accumu- late into masses they cease to move, and the masses are called zodglea. Although the individual bacteria are so minute, their multiplication is so rapid that, starting from an invisible number, they may form macroscopic masses in one or two days in solid media. ‘These masses, whether they are macroscopic or microscopic, are called colonies, and we shall see farther on that they are characterized in each species by color, contour, etc. CONDITIONS OF THE GROWTH OF ORGANISMS.—Some of the conditions of growth have been already mentioned, but in order to understand the laws of nutrition more clearly, the following chemical analysis is not without value. The analyses of the mould fungi and saccharo- mycetes have been reserved for this place, in order to compare them with that of the schizomycetes. Colonies of bacteria. UNDRIED. WATER DRIVEN OFF. Water. Albumen. Cellulose. Fat. Ash. Per cent, Per cent. Per cent. Mould Hume tss.\isercet corte o oie cieteteie o alate hie sie eae ee cre titotelc aataiee eee ate eee 88 29 50 Appreciable. | Appreciable. Saccharomycetes............ Ce ee Clee diclnars oreo ae ye Soe 40-80 4Q 37 Appreciable. | Appreciable. Schizomycetes Jos.00 acts ce oie een eee aie eid ns ck mrpeie taba cee eet cir 88-85 84-87 None. Appreciable. | Appreciable. The composition of the ash is as follows : z : : Oxide of Phosphoric ae ty Hydrochloric Sulphuric Potash. Soda. Lime. | Magnesia, iron anid Silicic acid. acid: doid. Per cent. | Per cent. | Per cent. | Per cent. Per cent. Per cent. Mould Funpis..-e 50 1.5 af 2 1 30 Small amount. Small amount. | Variable. Saccharomycetes.... 28-39 eS 3 1-4 GB FA Fete 53-59 _ Sometimes a trace? i Gaeta oe eee Schizomycetes.* * Probably the same as for the Saccharomycetes. The above analysis of the ash of the mould fungi is really the mean of a number of analyses of the ash of the higher fungi, but is probably approximately correct for the lower fungi. From the foregoing it will be seen that water en- ters largely into the composition of all three classes. The schizomycetes contain the largest amount of albu- men, and the mould fungi the least. The mould fungi have the largest amount of cellulose, and the schizomy- cetes none at all. Potassium and phosphoric acid are the principal ingredients of the ash of all three. It is evident that these organisms require carbon, ni- trogen, oxygen, and hydrogen in some form. As bacteria are, with very rare exceptions, devoid of chlorophyll, they cannot utilize the carbon in the CO, of the air, and are therefore compelled to have more elaborate molecules, such as are supplied by plants and animals. Double molecules of car- bon, or C in combination with N or O, are unsuited, but C in combination with H (CH; and CH.) are readily as- similated. Thus the sugars constitute a very good source of carbon, whereas cyanogen cannot be used. Nitrogen is, preferably, derived from albuminous mat- ter and peptone, but NH, and NH compounds may also serve as a source. Nitrates are also available, but cyanogen is not. The hydrogen and oxygen are supplied by the nitro- Sources gen and carbon compounds, and also by water. of hydrogen The above is true for the mould fungi, and and oxygen. saccharomycetes as well, except that the latter are not capable of assimilating the ammonium salts or the nitrates. Furthermore, the mould fungi require free oxygen for their normal growth. The saccharomycetes are capable of growing without it, they are facultative anaérobic organisms. The schizomycetes, as we have seen, vary in their behavior toward oxygen; some of them are aérobic, some anaérobic, some both. The mould fungi grow best in slightly acid media, whereas the other two classes prefer neutral or slightly alkaline substances ; some of the latter refuse to grow in the pres- ence of even a trace of free acid. The water organisms seem to defy all the laws of nutrition above laid down. Other bacteria require at 330 Sources of carbon. Sources of nitrogen. least an appreciable amount of nitrogen and carbon com- ver y pounds and salts, whereas the aquatic cocci ppleaig ee and bacilli find nutrition enough for active bacteria de. growth in freshly distilled water. Distilled rived from Water has been used, in fact, to cultivate them water. through many successive generations. Of physical conditions temperature plays the most im- portant part. Roughly speaking, temperatures of 30° to Influence 80. C. (86° to 95° F.) are most favorable to active of tempera- cell multiplication, and also for the formation ture, etc. of spores. Below 18° C. (64.4° F.) growth is re- tarded. Some organisms refuse to grow at the lower tem- peratures, and others refuse to grow at the higher ; others, again, vegetate very well at temperatures below 18° C. (64.4° F.), so that a general statement is hardly permissible. The vegetative cells are killed in a few minutes by temper- atures above 60° C. (140° F.) (Sternberg et al.). The pres- ence or absence of light seems to make no difference, ex- cept that direct sunlight killsthe spores of anthrax in a few hours (Arloing). Pressure of 600 atmospheres continued for twenty-four hours had no effect upon anthrax bacilli, and yeast stood a pressure of 3800 to 400 atmospheres ; putrefaction did not cease under a pressure of 350 to 500 atmospheres (Certes). Electricity has no effect ex- cept very powerful constant currents, which check the growth of organisms (Cohn and Mendelssohn). Mechani- cal agitation has been repeatedly tried, but the results of the experiments do not agree. It would seem, however, that rest is conducive to growth, for the peculiar class of aquatic bacteria multiply with enormous rapidity in stagnant water (Cramer), but whether this is due to stag- nation alone or to other causes is not known. A great many chemical substances have been found to kill micro-organisms, but the most valuable one for disinfecting purposes is corrosive sublimate (Koch), when it can be applied. In the laboratory a 0.1 per cent. solution is employed to disinfect cultures when they are to be destroyed, and for similar purposes ; but a very much more dilute solution is sufficient, if allowed to act for an hour or so. Aqueous solutions of chlorine, bromine, iodine, carbolic acid, osmic acid, permangan- ate of potash, and bleaching powder, all act as disin- fectants, but the solutions have to be much more con- REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Schizomycetes, . Schizomycetes, centrated than solutions of corrosive sublimate. Fora complete discussion of disinfectants and germicides see under the headings Disinfectants and Germicides. Media Hmployed for Bacterial Cultures.—From the above consideration of the conditions of growth, it be- comes apparent that suitable media must contain soluble albumen and certain salts, and, moreover, abundance of water. Three substances have come into universal ac- ceptance as fulfilling all these conditions : Infusions of flesh, boiled potatoes, and blood-serum. most generally used, and is prepared as follows : A half of a kilogramme of lean beef is freed of all tendons, etc., and chopped up fine in a sausage-mill or ee otherwise. It is then put into a litre of pure tion of nu- Water and allowed to stand in the cold eigh- trient gela- teen to twenty-four hours. The'water, which tine and has by this time dissolved out most of the solu- fe ble albumen, salts, etc., from the meat, is now filtered through a cloth. One per cent. (ten grammes) of peptone and a haif per cent. (five grammes) of common salt are then added. Gelatine in the proportion of five to ten per cent., or even more, or agar in the proportion of 0.5 to one per cent., are also added for reasons which will become apparent presently. But this mixture is acid, so for the cultivation of bacteria and yeast fungi it is necessary to neutralize with carbonate of soda. Gelatine itself has an acid reaction, so the neutralization must take place after its addition and solution by heat; but agar is neutral, so that where it is used it is immaterial at what point the soda solution is added. In both cases the mixture is now boiled until all the coagulable albu- men is precipitated, and poured at once upon a hot paper- filter which has been just before washed with boiling water. If the filtrate is not absolutely clear, a small amount of egg-albumen is added, and it is again boiled and filtered. While it is still hot 5-10 c.c. of the filtrate are poured into test-tubes stopped with cotton wool. Now, it is evident that the cotton will prevent the subse- quent entrance of organisms from the air, but the cotton wool itself and the test-tubes all have organisms clinging to them, so that before the nutrient gelatine or agar is poured in they must be sterilized, ¢.e., freed from adherent germs. This sterilization is effected by plugging the tubes pretty tightly with cotton and heating them up in an air bath to 140°-150° C. (284° to 302° F.) for about an hour. But in the process of filtering and in filling the tubes organisms are likely to find their way in, so that after the tubes have been filled they must be again sterilized. Koch’s Lhis is accomplished by subjecting them to a steam ster- temperature of 100° C. ina Koch’s steam ster- ilizer. ilizer. The sterilizer is simply a metallic cylinder set upright upon a boiler, so that all the steam which escapes from the boiler: streams through the cyl- inder. It has been found that all objects placed in the cylinder are brought up to 100° C. (212° F.) ina few min- utes after the steam begins to be given off. The steril- ization in the steam apparatus has to be repeated upon three successive days for the following reason: ‘The first sterilization kills all the vegetative cells, but we have seen that spores resist the boiling temperature for sev- eral minutes. The spores which were not killed in the first sterilization will have germinated by the second or third. It would simplify the process to steam the tubes for a half or three-quarters of an hour at once, for this would kill vegetative cells and spores as well, and agar may be treated in this way. But if gelatine is boiled too long at a time it turns to paragelatine, so that the sterilization has to be effected as above described. The method of preparing potatoes is very simple. Pieces of potatoes, with the skin removed, are put into Potatoes Some convenient vessel and steamed in the for bacteri- sterilizer for an hour or more. For reasons alcultures. readily understood, the vessels containing the bits of potatoes must have an arrangement for excluding the micro-organisms of the air. Small glass dishes with perpendicular sides, and tops to fit over them, are useful for this purpose (Esmarch). The dishes should be of such a size that a thick round slice of potato will about fill one of them, and the flange of the top should come Beef-broth is — well down around the sides of the dish. Wide test-tubes plugged with cotton serve also equally as well. In this case the potatoes are cut in the shape of cylinders and fitted nicely into the tubes. The cylinders should have one side cut away obliquely, so as to afford a greater sur- face. Of course, the dishes and test-tubes may be first sterilized in the hot-air bath, but it is hardly necessary. Blood-serum is prepared by allowing a quantity of blood to stand until the serum separates from the clot. It is then drawn off with a pipette and dis- tributed into sterilized test-tubes as for agar and gelatine. It is desirable to catch the blood, in the first place, with all possible aseptic precautions, in a sterilized vessel. The carotid artery of a dog or other animal affords a convenient source. The instruments used in opening the artery, and the cannula which is in- serted, should be first heated, z.e., sterilized, in the Bunsen flame and then allowed to cool. The blood is allowed to flow into a wide-mouthed vessel, which has been sterilized by heat and has a cotton stopper; after the serum sepa- rates it is drawn off as already indicated. If the process has been successfully accomplished it is unnecessary to sterilize the serum. It can be at once coagulated by placing the test-tubes containing it in a slanting position in a special apparatus, and subjecting them to a tempera- ture of not above 70° C. (158° F.) for three hours. If desired, the serum may be first sterilized by Tyndall’s method, which consists in keeping the tubes at a tem- perature of 60° to 65° C. (140° to 149° F.) an hour or more at a time, for five or six successive days. The principle of this is readily understood from what has gone before. Other media, such as chicken-broth, veal-broth, and so forth, have been employed, but the three media above described are more employed than any other. They are sometimes varied, for special purposes, by the addition of sugar, glycerine, etc. The most useful of them all is nutrient gelatine, but its use is limited to comparatively low temperatures, for it Applica- becomes liquid at about 22° or 23° C. (71.6° to bility of the _73.4° F.). The other media may be used at all various me- temperatures. Gelatine is liquefied by many Bee organisms, and Sternberg has shown that this liquefaction is not necessarily dependent upon the growth of organisms, for cultures of liquefying organisms, in which the latter had all been killed by heat, were capable of liquefying a second tube of solid gelatine, even when introduced in small amounts. Only one or two organ- ismsas yet known liquefy agar. Where it is not specially mentioned in the following, it is understood that it is not liquefied. Most organisms have a very characteristic growth upon gelatine and potatoes ; their growth is less characteristic upon agar. The French school use bouillon without the addition of gelatine or agar, but the growth of organisms is not as characteristic in liquid media; and for purposes of isolat- ing various species of organisms, and for the study of pure cultures, the solid media possess very great advantages. METHODS OF OBTAINING PURE CULTURES.—Various methods of obtaining pure cultures have been suggested, and more or less successfully employed. Lister suggested a method which is essentially the same as that employed by Miquel and the French school generally. It consists in diluting a suspension of the micro-organisms to be isolated with sterilized water or other liquid, so that in a certain volume, é.g., one drop, it is estimated that only one organism is present. Several flasks of bouillon are inoculated with one drop each of the diluted suspension, so that only one organism is thus introduced and grows out to form a pure culture. But this and the other methods now employed by some of the French school are so far inferior to those which we owe to Robert Koch, that I shall restrict myself to a description of the latter. Solid media had been already employed by Klebs and others, but Koch’s adaptation was so original that it may __ almost be said that he was the first to use them. Solid och’s methods are very readily understood, media. ' °p and their advantages are manifest. It is plain that a number of different species may grow 331 Blood-se- rum. Other media. . Schizomycetes. Schizomycetes. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. for a longer or shorter time, side by side, on the surface of a potato or upon a layer of gelatine, without coming Aavanta- in contact, at least until the colonies grow so ges of the large that they touch; or, in the case of nutri- Paine. ent gelatine, until the latter becomes liquefied. If, on the other hand, liquid media are used, all the spe- cies which happen to be present are mixed together by the currents in the liquid, by their power of independent motion, etc. If, now, a trace of any of the isolated colo- nies on the potato or gelatine be inoculated into any proper medium, and the culture thus made protected from subsequent contamination, it is evident that it will be a pure culture. It is also equally evident that a pure culture cannot be obtained by inoculating directly from any liquid containing more than one species, for every trace of the liquid will almost certainly contain repre- sentatives of each of the species present. To illustrate the actual process, suppose it is desired to separate the various organisms in any substance which Process Contains them. A tube of nutrient gelatine, as for isolat- above described, is liquefied at a temperature ing bac- not exceeding 40° C. (104° F.), and a small quan- tgs tity of the substance under examination is intro- duced and thoroughly disseminated through the gelatine. The contents of the tube are then poured out upon a cold glass plate which has been previously sterilized in the hot-air bath. The plate is allowed to stand under a cover till the gelatine is solidified, and it is then transferred to a glass dish with a cover, and placed at a temperature of 18° to 22° C. (64.4 to 71.6° F.). In a few days there will bea number of dots apparent in and upon the gelatine, and a microscopic examination shows that these dots are lit- tle masses of micro-organisms. Each one of these masses, or colonies, is composed of micro-organisms of the same sort ; for while the gelatine was fluid the various organ- isms were distributed through it, and when the gelatine became solid each separate organism, or zodgloea, was fixed in the place where it happened to be, and had to remain there and grow without interfering with any neighboring organisms. If a trace of one of these colonies is intro- duced into a tube of solid gelatine, it grows and consti- tutes a pure culture. If agar is used the process is essentially the same. Agar does not become liquid at any temperature below the boiling-point of water, and becomes solid again at 40° C. (104° F.). So it becomes necessary to liquefy it and allow it to cool down nearly to the solidifying-point before in- troducing the substance under examination. In practice there are always a number of dilutions made from this first or ‘‘ original tube,” by inoculating a second from it, and a third from the second, and so on. The reason for this is, that usually there are so many organisms in the first tube that when they grow out they may come in contact with each other, and thus one colony may con- taminate another. But if several diluted plates are made, one or more of them will have the colonies well isolated, and they may be studied and used for inoculations. When the plates are examined there is always danger of contamination from the air, or contact with the fin- gers, etc., so that Esmarch’s modification of the Koch- plate method has great advantages. According to Es- march’s method, the original tube and dilutions are made just as in the other, but instead of pouring the gelatine or agar upon sterilized plates, a rubber cap is fitted over the tubes and they are held horizontally and twirled in ice-water till there is a film of the nutrient medium coy- ering the inside of the tube. Dr. Booker, in the Johns Hopkins Pathological Laboratory, instead of using ice- water, rolls the tubes ina groove melted ina block of ice. This avoids the use of rubber caps, which some- times permit the ice-water to run into the tubes. After the colonies have grown out, they may be examined, under the lower powers of the microscope, through the walls of the tube. They are thus not exposed, for the cotton remains in; but even when it is removed for pur- poses of transplanting, etc., the danger of contamination is reduced toaminimum. The Esmarch tube is, there- fore, a most valuable contribution to our technique. The inoculation of the gelatine and the transplanting - 332 from colonies are effected by means of a platinum wire melted into the end of along glass rod. Hach time be- fore it is used the wire is glowed in the Bunsen flame, and the glass handle is also passed a few times through the flame. Cultures may be made either with a straight platinum wire, by taking a trace of a colony, or culture, upon the end of it and simply thrust- ing it into a tube of gelatine or agar; or the surface of any of the media may be inoculated by means of a plati- num loop. The latter cultures might be called smear- cultures, and the former stick- or stab-cultures. Agar and gelatine for smear-cultures are allowed to solidify with the tubes in an oblique position, so as to afford a greater surface. Several methods have been recommended for the culti- vation of anaérobic organisms. Theair may be excluded from the colonies upon plates by covering the tion of an- gelatine or agar with a thin sheet of isin- aérobic mi- glass, applied directly to the surface. Another cro-organ- method is to place the plates under a bell-glass ce and displace the air with hydrogen or CO.. Test-tubes of peculiar construction have also been used.! These test-tubes have a narrow glass tube opening in the side, about 5 ctm. from the bottom, just above the gela- tine or agar. The tubing projects for about 3 ctm. at right angles to the test-tube, and it then bends downward and is plugged with cotton. The air in the test-tube is displaced by connecting the narrow tubing with a COs, or, preferably, with a H generator, and allowing the gas to stream through. As soon as the air has been displaced the upper end of the test-tube and the narrow tubing are melted off. A modification of these tubes consists in having the narrow tubing to project down into the bot- tom of the test-tube, so that the gas bubbles through the gelatine, or agar, which in both cases is kept liquid till after the gas has been allowed to stream through. Still another way is to make Esmarch tubes and fill them afterward with gelatine or agar, as the case may be. Flasks with narrow necks and a tube projecting from the side have also been used as follows (Hifner, Rosenbach) : The agar is boiled in one of these flasks till all the air is replaced by the gases from it, and the narrow neck and projecting tube are sealed. This. projecting tube has had some of the material containing the anaérobic organism previously introduced, and after the agar has cooled down to 40° C. this material, which must be fluid, is driv- en into the flask by gently heating the end of the tube. Anaérobic organisms only grow at the bottom of the tube in a stab-culture, but if the air is excluded by a layer of oil they grow nearer the upper part. They grow at the bottom of the vessel in liquid media. The methods are all simple and readily understood, but require great care in manipulation. Merrnops oF Examination.—The difficulty of dis- tinguishing between bacteria and cell-nuclei, and so forth, which Henle met with, was overcome in the most satis- factory way by Weigert’s brilliant discovery of the tenac- ity with which bacteria retain watery solutions of the | aniline dyes. Nearly all parts of a tissue are readily de- colorized, after staining with various aniline colors, by treatment with acids, etc. ; but to effect a decolorization of the bacteria, the decolorizing agent has to be allowed to act for a much longer time. This is a perfectly deci- sive, sharp reaction, and renders the detection of bacteria in most cases very simple. The limits of the present paper will not allow a full ac- Methods count of the various methods of staining, and I of staining can merely give a few general principles and one bacteria. or two special applications. Ehrlich distinguishes two classes of aniline dyes, acid and basic. The acid dyes need not necessarily have an acid reaction, but they include all the dyes which form salts with the bases, and whose coloring property is con- sequently due to an acid radical. The basic colors are generally not found as free bases in the market, but are sold as salts ; thus fuchsine is a chloride or acetate of ros- aniline. The basic dyes are almost exclusively used as stains for the bacteria. The cell-nuclei also show an affin- ity for this class of dyes, and in order to get rid of the Pure cult- ures. Cultiva- REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Schizomycetes, Schizomycetes, diffuse stain in other parts of the tissues the latter are decolorized in very dilute acetic acid or in alcohol. This treatment leaves the bacteria and nuclei stained, and the rest of the tissues unstained. If sections treated in this way are afterward slightly stained with some contrasting color, the bacteria and nuclei often show to better advan- tage. The most usual colors are methylene blue, gentian violet, fuchsine, and methyl violet, all in watery so- lutions. These solu- tions are conveniently prepared by having sat- urated alcoholic solu- tions and adding a few drops to water as re- quired. Saturated alco- holic solutions may be kept indefinitely. Bacteria in sections of tissues are stained by oe ee Section of the Kidney allowing the latter to re- Sete ee erate Ny main from twenty min- utes to several hours in a watery solution of any of the above dyes. They are then put for a very few seconds into very dilute acetic acid, about 1 drop acid to 20 c.c. water, and are after- ward thoroughly washed in water, dehydrated in alcohol, cleared up, preferably, in origanum oil, and mounted in balsam dissolved in xylol. Most bacteria stain very well in this way, but tubercle bacilli require special staining as follows: 11c.c. of a sat- Staining Urated alcoholic solution of fuchsine or gentian of tubercle violet, 100 c.c. of a saturated aqueous solution bacilli. of aniline oil, and 10 c.c. of alcohol, are mixed. The aqueous solution of aniline oil is prepared by thor- oughly shaking 6 or 7 c.c. of the oil in 100 c.c. of water, and after fifteen minutes filtering, Sections must be left in the staining fluid twenty-four to forty-eight hours, and are then decolorized in twenty to thirty per cent. nitric acid, or, better, in dilute hydrochloric acid and alcohol mixed as follows: 100 c.c. of alcohol, 20c¢.c. water, and 1 c.c. concentrated hydrochloric acid. Tissues are embedded and cut in the usual way. Cel- loidine and paraffine are used for embedding. A mixture of glycerine and gelatine, in such proportions as to be of a firm consistence at ordinary tempera- tures, is a convenient embedding medium for bacteriological purposes. | i — e) he rf hy iy hy ) kh cA membrane, and rolls itself up when freed from its adhesion to the corneal parenchyma, seems no longer to be doubted. On its inner surface Descemet’s membrane carries one 350 Fra, 3407.—The Loops of Blood-vessels found in the Periphery of the Cornea. A, Region of the bulbar con- junctiva ; B, region of the cornea; C, line of junction between cornea and sclera. 1, Arteries; 2, veins; 3, marginal loops; 4, lacuna-like enlargements where several loops join each other and the veins. (Waldeyer.) face and form special nervous corpuscles there (Cohn- heim), is, as yet, an unsettled question. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Selera, Sclera,. As has been already stated, the nerves lie in canals, which communicate with the lymphatic canals of von Recklinghausen and can be injected. These nerve-canals seem to have a layer of endothelial cells. At the corneo-scleral junction the corneal epithelium goes directly over into the conjunctival epithelium. Ee Ee Ts Re eee Eee ee Sea Wat elvan ones sano aa op aatny qoeE ESA eas GonGaasoaas A CANS Pi COEv Orage ce Hesoae ah eats os a GOVE SoS Ioana Ora wails bos Vo Wau abandon gt INS Sect ARO GK Cornea ee cierenO LEAIRSOP DEER NCCES On i Beeb oeceen Ss aspo ce daneeae x oy, onSaaaiaior eo [i e We 'SaQd0GGG (tA Be ‘ 7 real Fie. 3408.—Oblique Section through Human Cornea stained with Chlo- ride of Gold. (Waldeyer.) A, epithelium with intra-epithelial nerve- plexus ; B, substantia propria of the cornea; C, nerve branching off dichotomously ; D, axes-cylinders; 1 and 2, anastomosing axes-fibrille. Bowman’s layer and the anterior layers of the corneal parenchyma pass over into the conjunctival tissue, and the bulk of the parenchyma of the cornea becomes scleral tissue. The membrane of Descemet and the adjacent layers form a network of fibres which lies on the inner surface of the tendon of the ciliary muscle, and is called ligamentum pectinatum (pectineum). (See Fig. 3409.) In accordance with this arrangement, the anterior portion of the cornea has been called the conjunctival, the mid- Fic. 3409.—A Portion of Descemet’s Membrane and the Ligamentum Pectinatum. On Descemet’s membrane may be seen some endothelial cells, and between them a number of glassy warts. dle the scleral, and the posterior the choroidal, portion of the cornea. The fibres of the ligamentum pectinatum, when de- tached, appear as tough vitreous fibres to which a num- ber of endothelial cells adhere. These fibres form a network, the meshes of which (Fontana’s spaces) are in communication with a system of lymphatic spaces which lie between the inner fibres of the corneo-scleral junction and go to Schlemm’s canal. The fibres of the ligamentum pectinatum are lost in the tissue of the ciliary body and iris. The tissue of the sclera, like that of the cornea, consists of very fine connective-tissue fibrille, which are, how- ever, not quite so transparent, and differ from the corneal fibrille in their chemical character. It contains, more- over, some elastic fibres. The scleral fibrille, like those of the cornea, are bound together by a cementing sub- stance, and thus form fasciculi. The scleral fasciculi are not arranged in more or less parallel lamella, but are interwoven at different angles. In a general way, the fasciculi in the sclera run in a meridional (longitudinal) direction. An equatorial (circular) arrangement of the fasciculi, however, is found constantly around the optic- nerve entrance and near the corneo-scleral junction, be- hind the ligamentum pectinatum. Between the fasciculi of the sclera, and within the ce- menting substance, we find a network of lymphatic canals similar to those of the cornea. Their arrange- ment is, however, very irregular, and resembles more the arrangement found, for instance, in the tissue of larger tendons. This system of lymphatic canals is read- ily demonstrated by staining with nitrate of silver or chloride of gold, or by injection. We find then that the scleral system of canals has also lacune, like the corneal ones, and embedded in these lacunez are stellated cells, the analogue of the fixed corneal cells. They resemble the latter in shape, are protoplasmic bodies with a num- ber of offsets and a round or oval nucleus. Near the corneo-scleral junction, and around the optic-nerve en- trance, these cells are often found to contain a granular brownish pigment. This is especially the case in ne- groes’ eyes. A smal] number of lymphatic (wandering) cells are also found in the canals of the sclerotic. At the optic-nerve entrance (see article Optic Nerve and Retina) the sheaths of the optic nerve merge into the tissue of the sclerotic, the dura-mater sheath joining the outer layers, the pia mater mingling with the inner lay- ers of this membrane. The intervaginal space reaches into the sclera to a varying depth, sometimes splitting this membrane for a short distance into two portions. The fibres of the sheaths of the optic nerve make a part of the equatorial (circular) fibres of the sclera found around the optic-nerve entrance. The tendons of the six extra-ocular muscles are in- serted upon the sclera at very acute angles. Their fibres are seen to enter the scleral tissue, and may be traced for some distance, when they are gradually lost. According to Loewig, the fibres of the tendons of the recti muscles form longitudinal (meridional) fibres in the sclera, while the fibres of the oblique muscles form circular (equa- torial) fibres. As we stated above, the optic nerve is not admitted into the eyeball by one large round opening in the sclera, but in such a manner that its bundles enter the eyeball separated from each other by a sieve-like network of fas- ciculi of the sclera (lamina cribrosa). The outer and inner surfaces of the sclera are covered with a layer of flat endothelial cells, of a more or less rhomboid shape. These cells can be easily demonstrated by staining with nitrate of silver. On the inner surface of the sclera the endothelial lining is pierced by numer- ous fibres, which unite the choroid with the sclera and form the lamina fusca. This name has been given to the network of fibres, in- termingled with pigmented stellate cells, which remain adherent to the sclera when the choroid is torn from it. On the outer surface of the sclera a similar condition obtains, the endothelial layer being pierced by many fibres, which form the loose episcleral tissue, and join the conjunctiva anteriorly and posteriorly to Tenon’s cap- sule. Endothelial cells are also found adhering to these fibres. The whole thickness of the sclera is pierced in a num- ber of places by blood-vessels and nerves, which in this manner enter the eyeball and go to the uveal tract or come from it. These are the ciliary arteries and nerves, 351 Sclera. Sclera. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES, and the ven vorticose. Blood-vessels and nerves are surrounded by a lymphatic space with an endothelial membrane. ‘The posterior ciliary arteries and nerves fre- quently lie together in one such sheath. By these sheaths the suprachoroidal lymph-space directly communicates with Tenon’s space. During their passage through the sclera both the ante- rior and posterior ciliary arteries give off branches for this membrane. The same is done by the nerves. The anterior ciliary arteries enter the sclerotic with the tendons of the recti muscles. At the corneo-scleral junction we find always a larger number of blood-vessels of an arterial character. Aside from these there is a venous plexus (Leber) which sur- rounds the periphery of the cornea, lying near the inner surface of the corneo-scleral junction. There is, further- more, always a large canal to be found in this tissue just to the outer side of the insertion of the tendon of the ciliary muscle and the ligamentum pectinatum, which seems to be a lymphatic canal, and goes by the name of Schiemm’s canal. In longitudinal sections it appears as an elongated opening with an endothelial lining. Its in- ner wall is perforated, and by means of Fontana’s spaces and the lymph-fissures in the tendon of the ciliary mus- cle, Schlemm’s canal seems to communicate with the an- terior chamber. Leber contends that what by others is maintained to be a lymphatic canal, is the very venous plexus so well described by him. Iam of the opinion that there is a venous plexus, and, aside from it, also a lymphatic canal, which latter corresponds to what has been called Schlemm’s canal. The crystalline lens consists of the lens- W's capsule (anterior and posterior), the in- tra-capsular epithelium, and the lens-sub- stance (lens-fibres, lens-bands). The lens-capsule forms a hyaline sac, so to speak, in which the remainder of the constituents of the lens are inclosed. It is one continuous membrane. From the clinical distinction between an ante- rior and a posterior capsule, it might seem to follow that we have to deal with two different membranes, but this is not the case. There is, however, a distinct dif- ference between that part of the capsule which covers the anterior surface of the lens and the portion which covers the posterior surface, in so far as the former is considerably thicker than the latter. The reduction in thickness takes place near the equator of thelens. This differ- ence in thickness seems to be mainly due to the fact that a much larger number of the fibres of the zonule of Zinn (suspensory ligament) merge into the capsule in front of the equator of the lens than behind it. The lens-capsule is an elastic hyaline membrane. In a plane view it appears homogeneous. Its transverse section, with a very high magnifying power and after the use of certain reagents, shows a fine striation. Its elastic nature is proven by the fact that it rolls up when severed from the lens-substance. The inner surface of the anterior lens-capsule is lined by a single layer of epithelial ceils. In a plane view they appear more or less hexagonal. In transverse sections their height is about that of the thickness of the lens- capsule ; yet their size and shape vary in different eyes. They are held together by a small quantity of cement- substance. Their nucleus is round or oval. This epi- thelial layer does not reach beyond the equator of the lens, and near it we find that the cells become elongated, cylindrical, and gradually assume the form of lens-fibres. The view which is maintained by almost all investigators on this subject, that the continued formation of new lens- fibres takes place at the equator, has of late been declared absolutely incorrect by Robinski. The opinion advanced by him is that new cells are formed all over in the epi- AIS Fa TINIAN SS —— = “WWW FeO TTDI IDA AS: == SSR RASAN SASS SEES Fria. 3410.—Isolat- ed Lens - fibres stained with Ni- trate-of Silver. (Arnold. ) 352 thelial layer by karyokinesis, and that the process is therefore not confined to the equator. The posterior capsule has no epithelial lining. The lens-substance consists of the so-called lens-fibres (lens-bands, lens-tubes). Iso- Ue SS ELE RLU CAT! lated Jens-fibres appear as flat ay Y ! NIN bodies with a very fine longi- | | tudinal striation (see Fig. Ni “, 3410), and in rare cases also a transverse one. When they happen to lie on edge they appear much thinner. In transverse sections they are seen to be in reality hexagonal prisms (see Fig. 3411), which are smaller and thinner when Uy | taken from the nucleus of the Lea Odes Du ( if MW ni lens than when taken from its Fie. 3411.—Section through a periphery. While the younger Frozen Lens stained with Ni- and peripheral lens-fibres have trate of Silver, showing Hexa- gn oval nucleus somewhere in Pasecy of Lens-fibres. their protoplasmatic body, the older and central lens-fibres have none for the most part. The lens-fibres have also been called lens-tubes, since they evidently consist of a tough peripheral substance and a more fluid one within this. The latter is called liquor Morgagnt. This fact is es- pecially evident in the young lens- fibres near the periphery. As we come nearer to the centre of the lens, the Morgagnian fluid disap- pears gradually, and the fibres grow flatter and harder. The out- lines of the fibres in the nucleus of the lens are rough and indented, and their lines.of union with each other resemble bone-sutures. All the fibres are held together by a small quantity of cementing sub- stance. From the foregoing it will be seen that in the lens-substance we find layer upon layer of lens-fibres | arranged in a more or less con- centric manner. The _ peripheral fibres are the youngest ones, the central fibres are the oldest ones. The latter form the nucleus of the lens. The whole of the lens-tissue is epithelial in nature, and the old nuclear lens-fibres. correspond to the oldest epidermic cells which have undergone a horny metamor- phosis. In a meridional section through the poles of the lens, the nuclei of the lens-fibres are seen to be arranged in a convex line, with the convexity toward the capsular epithelium and near it. (See Fig. 3412.) According to J. Arnold, the pe- ripheral lens-fibres are from 0.010 to 0.012 mm. in breadth, : and from 0.0045 to 0.0055 mm. in thickness ; while the central ones are but 0.007 to 0.008 mm. in breadth, and from 0.0022 to 0.0021 mm. in thickness. Their length, according to Robinski, averages in the eye of the newly- born 5.5 mm., while in the eye of the adult it varies from 7.18 to 10.64 mm. Fig. 3413.—Equatorial Sec- The vitreous body, which fills ea Uinerpabeng ge 7 aha about the posterior two-thirds of Fluid. (Schwalbe. ) the eyeball, consists of a more solid mucoid part.and a thin fluid one, which runs off when the vitreous body is taken from the eyeball. The firmer portion amounts to 0.021 to 0.07 Section through Lens of the Embryo of the Calf. (Arnold.) Shows the ar- rangement of the nuclei of the lens-fibres. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Selera ° Sclera. parts in 100 parts of vitreous body, according to Loh- meyer. This substance seems to form a number of very thin meridional and equato- / rial septa in which the fluid portion of the vitreous body (vitrina ocularis) is held con- fined. (See Fig. 3413.) ~ It is very difficult to x j}demonstrate these 7 septa, yet their exist- * ence seems to be gen- erally admitted. Con- centric (equatorial) septa seem to be want- ing in the more homo- geneous central por- tion of the vitreous body, while they appear to be very numerous in its periphery. Prob- ably for this reason the peripheral portion of the vitreous body is denser and firmer than are its cen- tral portions. From the lymphatic canals of the optic nerve a central Fie, 3414,—Cells from the canal in the vitreous body may be wreate ody injected, which reaches from the optic papilla to the fossa patellaris. In this canal (canalis hyaloideus) during foetal life the hyaloid blood-vessels go to the crystalline lens, After birth these blood-vessels Fre. 3415.—Zonula Ciliaris (Suspensory Ligament of the Crystalline Lens). Plane View. The pigment of the ciliary processes remains lying on the pars non-plicata (a) of the zonule; the fibres of the pars plicata (b) go to the lens-capsule (c) and merge into it. (Arnold.) no longer exist, excepting in a few cases in which persist- ent hyaloid blood-vessels may be found as an anomaly. A number of authors have described a separate mem- Vou, VL—23 brane, as membrana hyaloidea, which was said to cover the whole of the vitreous body, and thus to lie between it and the inner surface of the retina. Others contend that no such separate hyaloid membrane exists. The latter seems to be the correct opinion. The vitreous body always contains a number of cellu- lar elements, but their mass in the normal condition is but small in comparison to the bulk of the vitreous body. There are usually more cells to be found in its peripheral parts than in the central ones. The nature of all of these cells is that of lymph (wandering) cells, which enter the vitreous body from the surrounding membranes. (See Fig. 3414.) With regard to their shape these cells (like all wander- ing cells) differ very greatly. There are simple round cells with one or more nuclei; there are round cells con- taining one or more vacuole, which sometimes crowd the nucleus aside so as to give the cell the appearance of a seal ring; there are, furthermore, cells with one or more offsets, some of which are very long. Fibres, which by some investigators have been found in the vitreous body, seem to be pathological in nature. The suspensory ligament of the crystalline lens (zonule of Zinn) springs from the vitreous body near the ora ser- rata of the retina. (See article Optic Nerve and Retina.) It lies at first close to the retinal (inmost) portion of the ciliary body, and has, therefore, here a pars non-plicata and a pars plicata just like the ciliary body. At the level of the ciliary processes the suspensory ligament is bent toward the axis of the eyeball, and is inserted into the lens close to itsequator. This ligament consists of tough glassy fibres which sometimes show a fine transverse stria- tion. They are held together in the manner of a mem- brane by a very small amount of a homogeneous cement- substance. From the ciliary processes these fibres are seen to go in the main to the anterior capsule of the lens, while a few go to the posterior capsule, and some return to the vitreous body. It was formerly thought that there was a triangular space bounded by the two portions of the suspensory ligament and the equator of the lens (cana- lis Petiti). Such a single large space does not actually exist, but the fibres crossing each other on their way in different directions leave a multitude of small spaces be- tween them. At their point of insertion upon the lens- capsule the fibres of the suspensory ligament are lost in the tissue of the capsule. The cells which are sometimes found lying upon and between the fibres are lymph-cells. Adolf Alt. SCLERA, DISEASES OF THE. Although the sclera becomes secondarily involved in various morbid processes originating in other parts of the eyeball, primary disease of this structure is comparatively rare. Scleritis, or in- flammation of the sclerotic, as a primary affection, is rec- ognized only as originating in a narrow zone of the sclera, bounded in front by the cornea and behind by the - insertion of the recti muscles. In this situation we meet with two varieties of scleritis—simple and complicated. SIMPLE SCLERITIS (episcleritis) commences as a local- ized subconjunctival hyperemia at a short distance from the corneal margin. As the episcleral tissue becomes in- filtrated, a smooth swelling appears, which is but slightly elevated above the surrounding surface, and is usually of a dingy yellowish-red color, sometimes resembling a pust- ular formation, though ulceration or loss of ‘substance never occurs. The conjunctival vessels over and around the swollen part are more or less engorged, but the con- junctiva in general remains normal. After a few days or weeks the nodule assumes a dull violet hue and be- comes flatter, in which form it may remain stationary for a long time, or may gradually disappear, leaving a more or less permanent dull gray or ash-colored spot. Occasionally two or more such nodules are present at the same time, or as one disappears others may develop. The slow progress and tendency to recurrence of these nodules frequently render the disease tedious and pro- tracted. One or both eyes may be affected, or as one re- covers the other may undergo the same process. The subjective symptoms are seldom severe ; they con- 303: Sclera. Scleroderma, REFERENCE HANDBOOK OF THE MEDICAL SCIENCES: sist in an unpleasant sensation of weight or pressure in the eye, undue sensitiveness to light or cold, and perhaps slight headache ; rarely there may be considerable photo- phobia and sharp pain. This disease belongs almost ex- clusively to adult life, and is most common in elderly people. The gouty, the rheumatic, and the scrofulous diatheses are all credited with lending a predisposition to this form of scleritis. Treatment.—Any special dyscrasia on the part of the patient must be taken into account and suitably dealt with ; and while exercise in the open air is to be enjoined, the eye must be protected from strong light and from sudden changes of temperature. The local use of sul- phate of atropine is allowable in the early stages, espe- cially if there be marked symptoms of irritation. In the absence of these, instillations of solution of eserine—gr. ij. ad %j. (eserine, 0.10 ; water, 25.00)—twice daily, are often very efficacious. Massage, with the employment of oxide of mercury ointment (amorphous yellow oxide of mercury, 1 part, and fat or vaseline, 25-50 parts), has been highly recommended. Dry or moist heat, applied to the eye in the usual way, several times daily, may be beneficial. In regard to internal medication the choice of remedies will depend on various circumstances. Mineral waters, iodide of potassium, salicylate of soda, proto-iodide of mercury, hypodermic injections of pilocarpine, and many other remedies have been used with more or less success, according to the special indications present in the individ- ual case. COMPLICATED SCLERITIS (sclero-keratitis, scrofulous scleratitis)—This is a much more serious affection, owing to the involvement of the cornea, iris, and ciliary region in the inflammatory process, and also to the ten- dency which exists to disastrous changes in any or all of these parts. Sclero- keratitis, com- \X\\ mencing on the sclerotic, begins \\\) With one or more dusky infiltra- tions of the sclerotic, as in sim- ple scleritis, but close to the corneal margin, the cornea be- ing involved from the first, or after the scleral affection has existed only a short time; the pericorneal tissues are more deeply and more generally in- volved than in simple scleritis, and in some cases the cornea becomes extensively opaque ; sooner or later the iris may participate in the inflammation, as is shown by visible changes in its appearance and by the presence of posterior synechia, or the entire ciliary region may be- come intensely congested and sensitive (irido-cyclitis). The special dangers to which the eye is subjected in any given case may be approximately estimated by the se- verity of the disease in the several parts affected—ex- tensive changes in the cornea threatening permanent opacity of this structure ; in the iris, more or less com- _ plete posterior synechia, and in the ciliary region, cil- lary staphyloma. ‘There may be one or more foci of in- flammation ; when there are several of these, the entire pericorneal zone may be involved, or the same thing may happen more slowly through repeated relapses, each time a different area of this zone being attacked. The low dusky swelling of the sclerotic, continuous with a patchy opacity, of the adjacent cornea, is the characteristic ob- jective sign of this disease, which, as a rule, is subacute in all its manifestations. Occasionally, however, the in- flammatory process is more active, and there are intense photophobia, considerable lachrymation, and severe pain. The disease may at any time subside, leaving a dull grayish, thickened appearance of the sclerotic, and a cor- responding irregular marginal opacity of the cornea. If several foci have been present, the cornea will have the appearance of being irregularly encroached upon by the sclerotic. With the subsidence of the inflammatory pro- cess the dull slaty-gray sclerotic may present a zone of thickened tissue around the cornea, which sometimes looks as if it were pushed forward, giving the anterior Za \ ih é WH Fia. 3416. 354 part of the eyeball an elongated appearance ; or, more frequently, the sclerotic immediately around the cornea yields in certain places, and an irregular, nodular-looking projection is formed behind the cornea. This nodule is sharply defined anteriorly, but becomes gradually flat- tened toward the level of the normal sclerotic posteriorly. After repeated attacks of inflammation the staphyloma- tous bulging may involve the entire circumcorneal zone of the sclerotic, giving rise to great enlargement and dis- tortion of the anterior part of the eyeball (Fig. 3416); at the same time the iris may become expanded from the periphery, and the anterior chamber is often considerably enlarged. The development of staphyloma from this cause does not often depend on increased intraocular tension, but on a gradual expansion of the softened sclerotic, and the most extensive changes in the form and appearance of the eyeball are not inconsistent with fairly good vision. The subjects of this disease are usually young adults, and it affects women far more frequently than men. ‘‘It is not known to be associated with any special dyscrasia, but it generally goes along with a feeble circulation and a liability to ‘catch cold ;’ in some cases there is a defi- nite family history of scrofula or phthisis”’ (Nettleship). Treatment.—During the irritative stages soothing rem- edies are indicated. Protection from cold air and strong light is always advisable, warm fomentations are gener- ally beneficial, and instillations of atropine are useful if there is much irritation, especially if the iris is at all involved. In the more acute forms of this disease the writer has seen great improvement follow the use of antipyrine in doses of fifteen grains several times daily. Mercury may be used in moderation if the patient is not too anemic. Iridectomy may be performed if there are extensive ad- hesions of the iris and a tendency to the development of staphyloma. If vision is destroyed and the eyeball is greatly enlarged, an operation for the removal of the staphyloma may be indicated. Staphyloma of the sclera (ectasia) occurs under the most varied conditions, but usually as the result of pro- longed increase of intraocular tension. As a congenital anomaly of rare occurrence there is sometimes a partial bulging of the sclerotic, associated with congenital coloboma of the choroid (scleral protu- berance of Von Ammon). There may also be a general uniform bulging of the sclerotic, associated with enlarge- ment of the cornea, existing from the earliest infancy, and known as congenital ‘‘ buphthalmus ;” it commonly affects both eyes. Nothing is known of the etiology of this rare affection. Extensive destruction of the cornea from suppurative keratitis is commonly followed by more or less complete corneal staphyloma, and this may extend to the sclera, giving rise to more or less general enlargement of the eye- ball. Irido-cyclitis and irido-choroiditis, followed by occlusion of the pupil, give rise to increased tension of the eyeball, which, in the course of time, if not relieved, causes scleral staphyloma, usually in the ciliary region. Protracted increased tension from neglected glaucoma (glaucoma consummatum), or from dislocation of the lens, is a common cause of scleral staphyloma. Under these circumstances the bulging is usually far back, be- hind or between the insertion of the recti muscles. In an ectasia following inflammatory or glaucomatous processes the protruding part is lined by a corresponding portion of the stretched and attenuated uveal tract. Bulg- ing of the sclerotic may occur at any part, during the course of suppurative panophthalmitis, prior to rupture of this tunic and the escape of the contained pus. Intraocular growths likewise cause bulging of the sclerotic, either by softening of the tunic in the vicinity of an intraocular growth, by the increased tension which such growths induce, or by simple expansion from ex- cessive development of the growth. For the diagnosis of these conditions, see article Eye, Tumors of the. Ectasia of the sclerotic at the posterior pole (sclero- ectasia posterior), as met with in axial myopia, is a condi- tion of frequent occurrence. (See Myopia.) Its presence is easily determined, by means of the ophthalmoscope, by REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. the existence of a crescent or irregular circle of choroidal atrophy, which nearly always commences at the temporal side of the optic papilla. F. Buller. SCLEREMA NEONATORUM. This rare affection isin no way connected with scleroderma, although the latter was at one time called sclerema of adults. It usually shows itself in the first days of extra-uterine life, having in all probability begun in foetal life. The first marked symptoms are commonly observed from the third to the sixth day after birth, when the lower extremities are seen to show considerable areas of shin- ing, tense, white skin, sometimes tinged with red, or of a dirty-brown or yellowish color.. The tissues are cedema- tous, pitting on pressure with the finger, while the skin is so much thickened that it cannot be pinched into folds between the thumb and fingers. Beginning in the calf, the disease soon extends to the thigh, spreads over the abdomen, up the trunk, involves the head and upper ex- tremities, and, in fine, after a brief period (three hours to - three days) invades the entire body. Of course we can know nothing of the subjective symptoms, but the rapid fall in body-temperature, the frigidity of the affected parts, and the general depression of functional activity point to a serious general condition. The infant’s bodily movements are imperfect and re- strained ; it lies numb and stiff, usually with closed eyes and wrapped in lethargic slumber ; it declines food, partly on account of mental hebetude and partly because of the difficulty of making the movements of the mouth neces- sary to nursing. The heart is weak, and the pulse is rapid and sometimes almost imperceptible. The respi- rations are irregular and shallow, with occasional rales. The patient occasionally utters a complaining whine. The urine and stools are diminished in quantity. The symptoms mentioned usually increase in severity with continually falling bodily temperature and increas- ing weakness, until death ends the scene at the end of from four to ten days. Sclerema neonatorum is almost invariably fatal, though recovery has been noted in a few cases where the disease was not extensive. The cause of the disease seems to lie in an extensive implication of the blood-vessels. Atelec- tasis of the lungs, congenital disease of the heart, or other constitutional anomalies have been brought for- ward as explanatory of the origin of the disease. Sur- rounding and pre-natal conditions of an unfavorable hy- gienic character—want, privation, etc.—appear to have some influence in the causation of the disease. Anatomical examination shows deep involvement of all strata of the cutaneous envelope. The widespread infil- tration of the subcutaneous tissues allows the easy separa- tion of these layers from the deeper layers of muscles and the fascia. On section a yellowish-white serous fluid, mostly composed of oil-globules, exudes. Of the inter- nal organs, the lungs and kidneys are usually hyper- zmic, while the brain and the serous membranes are usually cedematous. The brief duration of the affection, however, usually allows only the earlier stages of these changes to be observed. The treatment of sclerema neonatorum is of a roborant and restorative nature, and should be undertaken at the earliest possible moment. Rubbing with hot blankets, etc., and the internal administration of restoratives may relieve the patient, and, if begun in time, may work a cure. (The above article is based upon that of Schwimmer, “«Ziemssen’s Handbuch,” Vierzehnter Bd., Erste Halfte, 8. 451.) Arthur Van Harlingen. SCLERODERMA. An affection of the skin chiefly characterized by changes in the color and density of the integument, and in some cases accompanied by marked deformity. Two varieties are usually described, Scleroderma dif- Susa and Scleroderma localis. SCLERODERMA DirrusA.— This is the affection de- scribed first, under the name of sclérémie des adultes, by Alibert, in 1817. The affection occurs most commonly Sclera. Scleroderma, in women and in adult life. No previous ailment seems to exercise a predisposing influence, unless it be rheuma- tism. The immediate cause in many cases has been ex- posure to dampness and cold. The induration, which is so marked a symptom of the affection under consideration, is variously described in different cases, and writers seem to vie with one another in their attempts to express vividly the peculiar sensa- tions offered to the sight and touch. In some cases the skin is described as being of stony or board-like hardness, or feeling like that of a frozen corpse, without the sensation of cold. In other cases it is compared to brawn or leather. Adherence of the skin to subjacent tissues is not uncommon—‘“ hide bound,” or ‘‘perfectly immovable,” are the expressions used. In a case coming under the writer’s personal observation, the skin over the forearms was so bound down that the limbs seemed as if carved out of wood. The underlying mus- cles, particularly those of the limbs, are generally more or less wasted. One of the most distinctive characteristics of this vari- ety of scleroderma is symmetry and diffusion as distin- guished from localization. Commencing, as in most of the cases reported, on the back of the neck, the disease spreads equally on either side of the median line ; or, when it begins in the limbs, both are usually attacked at once. The surface covered is almost invariably large ; those cases reported in which the disease seems to tend toward localization, are usually to be regarded as, in all probabil- ity, belonging to the other variety of the disease. A marked characteristic of this variety of scleroderma is that no distinct boundary exists to the affected areas ; they seem to melt imperceptibly into the surrounding skin. The color of the affected skin varies much in different cases. In many cases pigmentation exists to various degrees, while in othef cases the skin either retains its normal tint, or becomes pale-yellowish or waxy in color. A curious fact is that the pigmentation seems much deeper in the immediate neighborhood of the sebaceous follicles. In a certain number of cases, it is said that spots or patches of pigmentation at various points pre- cede and presage the induration of the skin in these localities. This, however, is more likely to occur in the circumscribed and localized form of scleroderma. Neither fever nor local inflammatory reaction of any kind ushers in, accompanies, or follows the appearance of the disease in any typical case. Oidema is rarely, if ever, observed in diffuse scleroderma. Occasionally swell- ing of the hands or feet has been observed as a result of mechanical interference with the circulation. The rapidity with which the disease attacks and spreads over the skin varies in different cases. In some, large areas of skin become indurated in a very short time; in others, the onset is slow and insidious. In no case is there any marked elevation of the indu- rated skin above the level of the surrounding and unaf- fected parts, though tubercular elevations have occasion- ally been observed. Where the tightened skin plays over prominent bony parts, as the knuckles, a tendency to ulceration is often observed. Cutaneous sensibility in most cases remains unaltered. — The appendages to the skin, the glands and hair, are rarely affected. Scleroderma diffusa runs a very chronic course ; many cases may be under observation for years with little or no change apparent, and this under the persistent em- ployment of decided and varied treatment. The exist- ence of. scleroderma does not necessarily exclude that of other skin diseases; acne, comedo, and eczema have been observed simultaneously, and in the same localities. Scleroderma diffusa is not in itself a fatal.affection. In the few cases in which death has occurred while the patient has been under observation, it has usually oc- curred from some intercurrent disease, totally uncon- nected with the scleroderma. It is true that, in one case recorded, death was hastened by the extremely inflexible condition of the facial integument, which interfered 355 Scleroderma, Scurvy. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. greatly with deglutition, while in some others respiration was much impeded through immobility of the thoracic walls. . The pathological anatomy of scleroderma diffusa is simply that of a hyperplasia of the fibrous element of the papillary layer and corium, with decrease of subcutane- ous fat and increase in pigment deposit. SCLERODERMA Locatis.—The symptoms and course of this disease, or form of disease, are very different from those of scleroderma diffusa. The affection is sometimes preceded by nervous symptoms, neuralgic pains, rheumatism, etc. At other times there are no gen- eral prodromes. The advent of the local symptoms is usually insidious, so that they are not often observed until the disease has made considerable progress. The most prominent skin symptoms are the appearance of parchment-like patches, with sclerotic strie. In a typi- cal case described by Bésnier the patches were irreg- ular in shape, usually elongated in the direction of the axis of the body and members, isolated or confluent, sometimes symmetric, sometimes asymmetric. At first sight these patches can be distinguished from the sur- rounding skin only by their deeper color, their finely stri- ated surface, slightly depressed beneath the level of the surrounding skin, and particularly by a lilac border com- posed of fine blood-vessels. To the touch the affected patches seem slightly rough, dry, parchment-like, and superficially indurated, so that the skin can be pinched up only in thick folds. Sensa- tion is in no way altered. ) The striated patches are sometimes fine and diffuse, and hard to recognize, at other times they are united, forming large patches of convergent stripes. | The localized patches of scleroderma may be observed in any part of the body, but are more common on the trunk. The cases which have been observed by the writer have presented only the parchment patches (morphea) with lilac areola, and have been observed about the clavi- cles and on the face. In addition to the more characteristic patches above described, keloidal lesions and areas of pigmentation are observed at times. Occasionally also ecchymoses and phlyctenular lesions occur, and hyperesthetic points, but these are usually evanescent. In some cases deep-seated and superficial neuralgic pains precede and accompany the appearance of the lesions, occurring in attacks often nocturnal, In other cases no such symptoms are present. Accompanying the skin symptoms, rheumatic pains with articular symptoms, anchyloses, and even osseous degenerations have been reported. The hands and fin- gers, in particular, are said to be involved. The disease runs a very chronic course, and but few cases have been followed through their entire evolution. It will be seen from the above description that scleroderma, whether of the diffuse or localized form, presents itself in so many varieties as to make it difficult of definition. As to the nature of the localized form, all the evidence points to- ward a tropho-neurotic origin. - Arthur Van Harlingen. SCROFULODERMA. There are a number of skin dis- eases so Closely connected with the condition of the system _ called scrofulous as to be properly designated scrofulo- dermata. Of these, one of the commonest is that which begins in one or more of the superficial lymphatic glands, especially under the jaw, about the neck and clavicular region. The glands become enlarged and the process ex- tends to the skin overlying them, which becomes red and infiltrated. Finally a cold abscess forms, and is dis- charged through the skin, and an ulcer of slow progress, with undermined violaceous berder, results. Bésnier calls scrofulous nodes, especially when they occur superficially, ‘‘ scrofulous gummata,” on account of their resemblance to syphilitic gummata. The most superficial of these gummata begins as a small infiltra- tion or node in the skin, of a livid red color. Increasing in size, slowly at first, and later more rapidly, it some- times extends in one or more directions, involving the en- tire skin, and softening at one or more points to form 356 small ulcers, with burrowing sinuses extending from one to another. The discharge from these ulcers is usually sero-purulent or sanious, and occasionally bloody, and the skin may be undermined by numerous communicat- ing galleries. Occasionally the disease takes on a diffuse, infiltrating form, spreading in an irregular patch over the skin, involving its entire surface, and giving rise to serpiginous shallow ulcers. The scrofulous ulcer never shows any disposition to heal. It may look as if it were on the very verge of cica- trization, but it does not actually scar over, or, if it does, a week or two later the cicatrix may open in one place while forming in another. In addition to the localities above mentioned, this form of scrofuloderma may occur over the cap of the shoulder, in the groin, and elsewhere. It is generally accompanied by other signs of the scrofulous condition, by old scars, etc. This form of scrofuloderma is to be distinguished from lupus vulgaris and from syphilis by the concomitant gen- eral symptoms of scrofulosis and by the peculiar features of the lesions, which differ materially from those of lupus and syphilis. The characters of the primary lesions, the form of the ulcers and their course, and the amount of crusting differ materially. Where the diagnosis between scrofuloderma and syphilis is difficult, the history in some cases will aid. Another and rarer form of scrofuloderma is character- ized by the formation of papillary, wart-like, or fungous growths of a pale, bright, dusky, or violaceous red color. The surface of these growths soon ulcerates, with a thin discharge and some crusting. These lesions are apt to occur upon the backs of the hands, and may extend to such depth as to lead to bone-changes. The course of this form of scrofuloderma is exceedingly chronic. A fourth variety of scrofuloderma may be referred to, which shows itself in the form of small, hard, scattered, flat papules with a raised violaceous areola. The lesions may occur upon any part of the body, but are usually met with upon the forearms, legs, and face. At first they look like the pustular syphiloderm, but crust over after some weeks, leaving a depressed pit-like cavity, of a size to receive the head of a pin, in the lesion. Fi- nally the lesion disappears, leaving a punched-out scar like that of small-pox. This form of scrofuloderma is chronic to an extreme degree. New lesions form while the old ones are cicatrizing ; and while the affection does not give rise to any pain or other annoying sensation, it is very rebellious to treatment. The treatment of scrofuloderma is both general and local. Cod-liver oil, iodine—usually in the form of iodide of potassium, or of Blancard’s pills of iodide of iron—and iron alone, are most frequently serviceable. Milton has reported excellent results from the administration of calomel or gray powder, two or three times a week at bedtime for a fortnight, with a saline every morning, so as to produce a daily action of the bowels. Then the mercurial is suspended for from a fortnight to a month, the saline being continued. If the appetite fails, bitters and mineral acids are to be given. Locally a mild zinc ointment is applied. Milton lauds this treatment as cur- ing where all else fails. Locally the ulcers are to be treated, as a general thing, with stimulating ointments, preferably those containing mercury. Ointments and powders of iodoform are also useful. .Tincture of iron and chlorinated soda solution may also be used. Where the disease is extensive, scrap- ing with the curette or sharp spoon, to remove the mor- bid tissue, as in lupus, is the quickest method. [TUBERCULOSIS OF THE SKIN. — Our knowledge of tuberculosis of the skin is of recent date, and even now but little is known of this affection on account of its comparative rarity. Tuberculosis of the skin usually shows itself as a single roundish or oval ulcer, which soon becomes crusted over, giving rise to little pain. On removal of the crust a reddish-yellow granular surface, bleeding easily, is ob- served. The walls of the ulcer are only slightly infil- trated, soft, not undermined, though sometimes movable REFERENCE HANDBOOK OF THE MEDICAL SCIENCES, Scleroderma, Scurvy. over the subjacent tissues. The edges are not smooth, but irregular and eroded, with occasional pits filled with pus. It is extremely rare to find any miliary tubercles. The ulcer grows by gradual destruction of the edges in an irregular way, presenting occasionally a serpiginous appearance. The tuberculous ulcer is never large, rarely exceeding the area of ten to twenty square centimetres. It shows no tendency whatever to heal. The seat of the ulcer is almost always about some mucous orifice, as the mouth, anus, or vulva, or on the glans penis. The diag- nosis is to be made by exclusion. The treatment, in addition to that described above un- der scrofuloderma, consists in scraping and applying py- rogallic acid. The prognosis is usually unfavorable. Arthur Van Harlingen. SCULLCAP (Scutellaria, U. S. Ph.), Scutellaria lateri- flora Linn.; order, Labiate. This genus consists of scent- less bitter perennials, destitute of the aromatic properties found in most species of this large order, and further distinguished by a peculiar helmet-like development of the upper sepal, to which it owes its name. Calyx two- lipped, persistent ; closed-in fruit until maturity, when it splits and opens widely. Corolla labiate, ascending ; stamens four, also ascending, and under the upper lip of the corolla ; lower anthers one-celled. Leaves oppo- site, petiolate ; flowers axillary, usually solitary, some- times in apparent spikes or racemes. There are about ninety species, forming a very distinct and natural genus, distributed over nearly the whole north temperate zone. There are about a dozen in the United States. The above-named species is a branching herb, from one to two feet high, with small flowers arranged in one-sided racemes, whose floral leaves are reduced, excepting those near the base, to small bracts. It has opposite, ovate-ob- long or lanceolate, coarsely serrate, pointed leaves about two inches long. Stems squarish. The commercial Scullcap is the entire herb, or the leaves and branches, dried. It has but little odor, and a bitterish taste. Both this and other species of Scutel- laria have had from time to time some transient or pop- ular reputation in medicine for the cure of mad-dog bites, chorea, epilepsy, or other nervous diseases ; also as ton- ics, antiperiodics, etc. The present species, S. lateriflora, is considerably used by the Eclectic school of practition- ers, and in home medication. It is reputed to be anti- spasmodic, anticonvulsant, etc., and is given for restless- ness and wakefulness. Its composition has not been determined, and there is nothing in its obvious action to indicate that it has any particular value. Dose from five to ten grams (3 j. ad 3 iij.). ALLIED PLANTS, ETC.—See PEPPERMINT. Lycopus resembles it in properties. W. P. Bolles. SCURVY, or SCORBUTUS. Philologically consid- ered, the word ‘‘ scurvy” appears to be of North country or Scandinavian origin, being derived from the Swedish skérbjugg, or the Danish skojwerbug, signifying soft or re- laxed stomach, the relaxation of the abdomen being one of the characters of this malady. The German scharbock and English scurvy have the same sense. As the disease, scurvy, prevailed among the ancient Danes, it is prob- able that they have given us the word, which, together with numerous other technical terms applied to naviga- tion, has left an imprint on our language showing plainly the Viking influence. Symptomatic definitions of scurvy are almost too well known to require repetition. On running over a number of them, selected at random from standard works, three distinct points are fixed in the mind, namely: 1, Skin and muscle lesions ; 2, mouth and gum phenomena ; and, 8, physical, physiological, and psychical depression. Be- sides this, the definitions agree in attributing the alteration of the blood to a defective alimentation. Many writers speak of scurvy as a nosohemia of the same nature as purpura, from which it differs in greater intensity only. However strange the statement may seem, scurvy should properly be classed with the condition of multiple neu- ritis known as beriberi. The two diseases do not resem- ble each other in all essential points, yet we see in beri- beri the result of insufficient alimentation brought about by the abuse of a vegetable regimen, and the absence of meat, salt, and fat, and one that is best treated by butter, cocoanut oil, and fat meats ; while scurvy, which origi- nates from the abuse of an animal regimen and the ab- sence of fresh vegetable matter, is cured most readily by a diet of fresh succulent vegetables. Few diseases have been more observed and written about than scurvy, and few have so exercised the sagacity, and sometimes the imagination, of medical writers. The bibliography of the disease is enormous, and, so far from settling mooted points in the pathology of scurvy, it only adds to the confusion. To write the history of scurvy would almost be to write the history of medicine and to chronicle the sani- tary circumstances of most human events, since the dis- ease has occurred from time immemorial both on sea and on land. (See Army Diseases.) To pass in chronological review the various epidemics of scurvy of which a record is preserved would serve no good purpose. The disease was often described, but the first use which we find of the present name was in the sixteenth century, when a learned botanist, Enricus Cordus,! says of an antiscorbu- tic, the Chelidonium majus, ‘‘Saxones vero Scharbock’s- Kraut (eam nominant), quod forte morbo quod illi Schar- bock nominant medeatur.” From this period clinical pictures of scurvy, more or less exact, occur in various publications up to the time of the appearance of the mag- nificent works of Lind, of Krebel, and of Mahé. The word ‘‘ scurvy ” is no longer on the ‘‘ Statistical Reports of the British Navy,” and Sir Thomas Brassey says that the disease has been unknown for eighty years in the Royal Navy, or in the better class of merchant ships.?, With the opening of the Suez Canal, the recent improvements in steam machinery, and better methods of preserving food, it is certainly humiliating to find that scurvy should occur in the merchant marine, as it has occasion- ally done within the last decade. The English Govern- ment has made energetic efforts to diminish and stamp out scurvy from its commercial marine, and these efforts have been nobly upheld by The Lancet and the English medical press generally. Yet the high naval authority quoted above informs us that of late scurvy has been by no means rare in the British merchant service. A naval medical officer tells me that he knows of the occurrence of a number of cases of scurvy on board a British man- of-war on the South Pacific station, and that he has seen one case in the United States Navy. Dr. Guillemard re- ports the death of the boatswain, from scurvy, on board a well-found English yacht cruising in the Malay Archi- pelago in 1883.* Cases of scurvy have also lately come to the notice of the United States Marine Hospital Service. Four cases are reported from the Marine Hospital at San Francisco, in 1880, with one death, and another death from the same cause is reported in 1881. Both cases were complicated with pneumonia. Six cases were re- ceived into the Contract Hospital at Astoria, Ore., in 1881, and in 1885 the barkentine William Phillips, from Iloilo, Philippine Islands, arrived at Norfolk, Va., with scurvy on board. During the year ending June 30, 1887, the following cases of scurvy were treated in the United States Marine Hospitals: At Boston, 6; Chicago, 1; Port Townsend, 1; San Francisco, 4; Vineyard Haven, 2; and Wilmington, N. C.,1. Of this number 12 recovered and 3 improved. Only a few years since I had an op- portunity to study, in the Baltimore Infirmary, a number of cases from a vessel that had come around Cape Horn, In the spring of the year 1887, in the remote parish of Hornstrandir, Iceland, 62 out of 400 died from typhoid fever. After the fever had worn itself out, Hornstrandir was attacked by scurvy, with several fatal cases. While the existence of beriberi corresponds more or. less to the geography of insufficient alimentation, scurvy may be said to have no distinct geographical limits, since its symptoms are likely to appear on land or at sea, in the tropics or at the poles, under diametrically opposite me- teorological states, when the conditions necessary for its development are present. The polar regions have long 307 Scurvy. Scurvy. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. been regarded as the principal home of scurvy; but the geographical voyages of Kotzebue through Behring Strait (1815, 1818) ; that of Sir John Ross to the Arctic, accomplished without the loss of a man ; and that of the late circumpolar expeditions, among which scurvy did not appear, are an evidence of what sanitary and prevent- ive measures may do to ward off the effects of extreme polar cold. On the other hand, numerous facts attest the existence of scurvy in such warm places as India, Aden, Hindustan, Brazil, Egypt, Algeria, and Senegal. In thearid plains on the way to California, before the days of the Union Pacific Railway, emigrants were often attacked with scurvy, and entire caravans would perish ‘from this cause. In late years almost the same thing has occurred in Australia. I have also seen it on the Rio Grande River in Texas, among persons whose diet was mainly beef and black coffee. In fact, having to subsist for some time upon the same diet, I had personal experience of the premonitory symptoms. Although we were surrounded by thousands of cattle, milk was not to be had, and we were also wholly deprived of fresh veg- etables, on account of the extreme heat and dryness. The foregoing observations show that this disease is by no means extinct, and that it may again become active whenever the conditions are favorable to its development. Nor is it confined wholly to the higher order of animals. I have seen. the experiment of feeding two rabbits, one exclusively on meat, the other on vegetable diet. After a few weeks the animal fed on meat developed symptoms of scurvy, while the other was sleek and fat. Hogs, though growing fat on an exclusive animal regimen, be- come scorbutic. It has also been observed that mon- keys and gorillas on board ship become scorbutic at the same time that the sailors are affected. It would be sur- prising, then, if the African should escape scurvy, as he was formerly supposed to do, when placed under the same conditions as his white brother. The fact is that the negro victims on board the slavers lived principally on vegetable diet, such as manioc, while the crew lived on salt provisions, and in addition had to contend with the circumstances of a previous voyage. The blacks, when subjected to the same dietetic causes as the whites, contract scurvy with them, as is shown by the history of sieges when both races had to live on the same food. Scurvy, therefore, is impartial in the selection of its vic- tims ; nevertheless, it would seem to be a disease of civ- ilization rather than of primitive life, since it appears to spare degraded savages who subsist on roots and grubs, and Eskimos and Kamschatdales, whose diet is highly nitrogeneous.* Properly speaking, scurvy is not a dis- ease of famine. ‘The Terra del Fuegan and the African negro may starve from want of vegetable food, but they do not die from scurvy. On the other hand, according to Parkes, men fed on a uniform diet of fat have gained in weight but have become scorbutic. Regarding the etiology of scurvy two sets of opinions prevail. ‘The first admits but one cause in the production of the malady, viz., the prolonged deprivation of fresh vegetable food; the second admits a variety of causes— physical, moral, and dietetic—which may produce scurvy when combined, or when one or the other of them is asso- ciated with some adjuvant cause of a different nature. Generally speaking, scurvy is engendered by the per- sistent and prolonged action of causes susceptible of weakening the metabolism of the general nutrition. And eae there are many causes which may contribute to this. Among physical causes may be enumerated the rota- tion of the seasons, overcrowding, and excessive fatigue, or its opposite, enforced immobility. Other considera- tions being equal, humidity of the atmosphere favors the development of scurvy. Numerous reports by differ- ent authors show that dampness and atmospheric changes constitute the most invariable elements among the pre- disposing and exciting causes of scurvy. Epidemics of * It has been suggested that the marked absence of salt may account for this immunity. Having spent two seasons among the Eskimos of Behring Strait, [ have been impressed with the fact of their aversion to all salted articles of food. 308 scurvy have prevailed among soldiers living in cold, damp casemates, though provided with a suitable ration ; it has appeared on board ships and in fleets where fresh provisions abounded—for instance, in the squadron of Admiral Martin cruising in the English Channel; and the bad weather experienced in doubling the Cape of Good Hope or Cape Horn has, for a long time, been recog- nized as one of the causes of scurvy. Of course it would be imprudent to say that cold and damp, overcrowd- ing, or any one of the forementioned causes is an indis- pensable factor in the outbreak of scurvy. They may have acted like sparks in lighting up the effects of a train of previously existing unhygienic circumstances. Fatigue is mentioned by most writers as an adjuvant cause. The assertion finds its application in the instances of overworked and underfed prisoners, in the disastrous retreats of armies, during sieges, in shipwrecks and dis- asters at sea. Among recent examples is the outbreak of scurvy among the enfeebled men of the Spanish squad- ron returning from the bombardment of Callao. Immobility or inaction, whether forced or voluntary, takes a part in the genesis of scurvy. It has often been observed in prisons and asylums. The crews of ships doing blockade duty have been attacked with scurvy, which has disappeared as if by magic on making prepa- ration for an engagement or on going into battle. Ac- cording to Dr. Charles Smart, United States Army, the average annual rate of cases of scurvy reported to the War Office during the eighteen years before the Civil War was 23.3 per thousand of strength, or nearly twice as large as that which prevailed among our white troops during the years of the war.°® To these causes may be added those referable to de- fects in lodging, bedding, clothing, and antecedent. physi- cal state. We may mention the filthy bedding in such dark, ill-ventilated places as the forecastle of most mer- chant ships as perhaps concerned in the causation, and it is well known that the excesses in which men indulge when ashore furnish a strong predisposing cause, so that men leaving port on a long-distance sailing ship, after a debauch, are more likely to acquire a scorbutic taint than those who have kept sober. Next to the physical are the mental and moral causes. Psychological misery and moral depression in prisoners have long been looked upon as preponderating causes, and in years gone by nostalgia was thought to have caused scurvy on board French ships. A comparatively recent example, in which the alimentary origin cannot be admitted, is the outbreak of scurvy among French prisoners at Ingolstadt (1871), who, according to report, received excellent rations of fresh meat and potatoes. In this instance the malady was thought to be owing to the damp cold of the casemates, to inactivity, and to mental depression. Deported convicts and prisoners on board ships have also suffered from scurvy, though receiving the same ration as the crew. Notable instances of late years are the epidemics of scurvy on board the French transports which conveyed political convicts to Caledonia in 1873. On board the Var and the Orne the food of these unfortunates is said to have been irreproachable as to quantity and quality ; they received exactly the same ration as the crew and the free passengers, except that they had only half a ration of wine and no brandy ; the drinking water was excellent, and clothing and bed- ding were sufficient. But chagrin, want of employment, ennui, and painful preoccupation affected the prisoners, and they slept in a vitiated atmosphere that was damp and hot. Recent travellers also speak of the prevalence of scurvy among Siberian prisoners. Physical and moral causes may together engender scurvy, more particularly after prolonged and uniform usage of salt provisions that have undergone an isomeric modification that causes a loss of their reparative prop- erties. Salt in itself is, however, not a cause of scurvy. The experiment of drinking sea-water for a month has been followed by harmless results, and numerous in- stances are reported in which the prolonged use of salt provisions has not been followed by scurvy. On the other hand, we have examples of the outbreak of the mal- REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Scurvy. Scurvy. ~ady in cases in which salt food has not been employed. Yet it cannot be denied that the chief cause of scurvy is to be found in the absence or the insufficient quantity of certain materials or principles necessary to good alimen- tation, and notoriously in the prolonged deprivation of milk, and of fresh vegetable food. Epidemics of scurvy in English and Scotch prisons have often been attrib- uted to the privation, or to the suspension, of the ordi- nary ration of milk served to the prisoners. The uni- formity and monotony of the diet in most merchant ships are not conducive to the preservation of health. Sir Thomas Brassey says the allowance differs little, except in quantity, from the dietary in use during the last century; and this notwithstanding the great improvements in the preservation of meats and vegetables. The abuse of to- bacco is also claimed to be a pathogenic factor in scurvy. For convenience of description the ordinary phenom- ena of scurvy may be divided into three degrees or pe- riods. The first period, that of. evolution, is marked by general adynamia. The physiognomy is expressive ; the characteristic pale-yellow tint of the skin being dis- tinct from that of icterus, or of any other cachexia. Ex- treme lassitude, with an undefinable sensation of ma- laise in the voluntary muscular system, is accompanied by a sad and downcast air, disturbance of the appetite, dyspnoea, insomnia, hebetude, and other indications of diminished vitality. These are followed usually, though not always, by gingivo-buccal symptoms. At the margin of the gums, and in the intervals of the teeth, appears a change of color and consistency, owing to alteration of the capillaries ; the gums become livid, soft, and bleed- ing; and the breath has a characteristic earthy, fetid odor. Pains occur in different parts of. the body, more particularly in the lower limbs, and extravasation of blood in the outer skin and other tissues causes small purpuric spots that often assume a large size and induce a brawny hardness in the cellular tissue of the legs. In the second period these symptoms are greatly ag- gravated. The purpuric spots become true ecchymoses, varying in color from yellow-brown to blue-black; the sanguineous infiltration, affecting the muscles of the calf and thigh, causes a characteristic induration ; the loosened teeth sometimes fall out ; and the alteration may extend to the osseous system, causing detachment of the epiphyses, if the subject is young, and sometimes exos- tosis and periosteitis. In addition to these, there may be bleeding from the mucous membranes, painful dysp- noea, a relaxed and pendulous condition of the abdo- men, and fever. In the third or last period the aspect of the patient is that of a breathing cadaver. In addition to the fever and other symptoms already described, there follows a gen- eral prostration, with septic or putrid hemorrhages ; the legs assume a sphacelated appearance ; phlyctenz are followed by rapidly extending and spontaneous ulcera- tions of the skin ; fractures which have long been united again separate ; necrosis of the tibia and bones of the foot occurs, and marasmus supervenes. Death occurs from extensive suppuration, from the intensity of the hectic fever, or by hemorrhage, visceral lesion, or syncope. So little is known of the pathological lesions of scurvy that the subject may be dismissed in a few words. Al- though the disease is dependent upon some chemical alteration in the quality of the blood, it cannot be said that we know positively of any morphological modifica- tion of this fluid that is proper to scurvy. ‘The same may be said of the other morbid changes that have been noted. Beyond the sanguineous effusions into the splanchnic cavities ; softening, or more often hardening, of the muscles ; the occasional cartilaginous detachment of the ribs, and caries of the bones, scurvy has no ana- tomical characteristics that are not common to many other diseases. It is rather in the complications of scurvy that the more marked anatomical lesions are to be found. To study even the more immediate of these complications would require systematic examination of most of the or- gans of the body, since pleurisy, pneumonia, pericarditis, etc., are morbid processes occurring side by side with scurvy under the influence of accessory causes; and many great epidemics of disease, especially in armies, have been preceded, accompanied, or followed by scurvy. In fact, scurvy may color or modify many diseases or accidents, prolong convalescence, and increase mortality to a serious extent. The most common complications of scurvy are dysentery, diarrhoea, and malarial fever, which some regard as epiphenomena of the disease. Hemeral- opia and nyctalopia have a like origin with scurvy, and the pathological annals of navigation of the last two cen- turies are filled with the disastrous associations of the fore- mentioned diseases. If properly treated an uncomplicated case of scurvy leaves no trace. Many ex-soldiers are, however, borne | on the Invalid Pension List on account of the results of scurvy incurred in the late Civil War. In these cases the chief sequele are loss of teeth, scars from extensive ulcers, and occasional lesions of one or more of the tho- racic or abdominal organs. ° Simple, uncomplicated cases of scurvy often disappear, as if by magic, on removal of the cause ; but the repara- tive process is ordinarily slow, and severe cases require two months’ treatment. The patient may be considered out of danger if, after several days of treatment, he re- gains the use of his limbs and has no dysentery, chest complication, or bleeding at the nose. An improved state of the skin is also a favorable indication. The prog- nosis, however, depends on the intensity of the symp- toms; upon previous or concomitant diseases, such as fevers and lesions of the digestive organs ; upon pro- longed treatment for syphilis ; upon malarial poisoning ; upon the fact of a previous attack ; and upon atmospheric and climatic conditions. The diagnosis of scurvy is a matter of no difficulty. Perhaps some distinction should be made between it and purpura and Alpine pellagra, in order to avoid nosologi- cal confusion. The only morbid conditions with which scurvy is likely to be confounded are the different ane- mias and spangzemias, hematophilia, beriberi, and the cachectic condition brought about by dirt-eating. (See Appetite. ) No disease is more easily prevented, and none is more amenable to treatment than scurvy. The means of its prevention are now so well understood that an outbreak of scurvy among soldiers, sailors, prisoners, or the in- mates of an asylum, or among any other persons subjected to discipline or restraint, is, in most cases, presumptive evidence of neglect on the part of somebody. The law takes cognizance of this neglect, as is shown in Sections 4.569 and 4,570 of the Revised Statutes. The prophylaxis of scurvy is so apparent, after its causes are known, that to particularize the details would be to repeat unnecessarily. Regarding the prevention of scurvy, the most effica- cious hygienic precepts are now a matter of common knowledge. The principal ones that bear emphasizing are the enforcement of dryness and cleanliness, especially on the berth-deck or forecastle of a ship, and the use of so-called antiscorbutics. We have no rational explana- tion of the power of the latter as a preventive ; their use being in the large and true sense purely empirical. New Bedford whalers cruising in the Pacific Arctic provide themselves with a sufficient supply of live pigs, cocoa- nuts, pickled cabbages, onions, and potatoes. From the captain of a Russian fur-trading vessel I learned of an excellent antiscorbutic in the use of cranberries, espe- cially the little ones that grow in Alaska and the Aleutian Islands. Lime-juice, in great renown with the English, has won for them the sobriquet of ‘‘ lime-juicers” from Yankee sailors. It is, however, very unpopular among many sailors, because they think the use of lime-juice causes impotency ; and it is doubtful whether it be as effective as a liberal allowance of potatoes, onions, sauer- kraut, and condensed milk, or the occasional issue of beer, cheap light wine, or even wine of absinthe, the three lat- ter being regarded by Lind as antiscorbutics of the first order. The same authority also recommends eating a bit of raw onion every morning before exposure on deck. When practicable, cider may be added to the dietary, and 309 Scurvy. Sea-Sickness, REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. the daily use of lemonade at dinner is to be highly com- mended. The curative treatment of scurvy being almost entirely hygienic, but little is to be done in a therapeutic way. Admirable results may be obtained from a good dietary consisting chiefly of milk, vegetables, and fruit. (See Grape Cure.) A chlorinated or an antiseptic mouth- wash ; an alcoholic or a camphorated lotion for the pur- puric spots; the administration of brandy or quinine to overcome adynamia and cardiac insufficiency ; and rest in a horizontal or sitting position, in order to avoid pos- sible syncope, are the salient and essential therapeutic points to be observed in ordinary cases. The treatment of complications and sequel should be mainly directed against the asthenic condition, and so the economy should be fortified against a return of the disease, which may happen on the slightest provocation. For the future observer there still remains much to be done in clearing up points of disagreement and in filling up the gaps left in the pathological anatomy of scurvy. To this end the newer experimental methods of investi- gation—chemical, clinical, and histological—should be made to take the place of the old hypotheses and sterile reasonings of our forefathers. In spite of numerous efforts, much remains to be done in the way of investi- gations bearing upon the component elements of the blood, such as a rigorous enumeration of the red globules, the amount of hemoglobine in the corpuscles, and the chemical analyses of the globules themselves. In addi- tion, it is desirable to know the proportions of iron and potassium, as well as of the principal substances elimi- nated by the excretions, particularly the urine. A_bet- ter and more extended study of the state of the capillary system in the principal organs and tissues is a desideratum, and the same may be said of the study of the patholog- ical anatomy of the principal viscera of the abdominal cavity. On the side of the nerve-centres almost nothing has been pointed out up to the present in the patho- logical anatomy of scurvy, and we are equally ignorant of the anatomical changes that occur within the organs of sight. Irving C. Rosse. 1 Botanologicon. Colon, 1534. ? The British Navy: Its Strength, Resources, and Administration, vol. v., p. 174. London, 1883. 3 Cruise of the Marchesa, vol. ii., p. 8353, London, 1886. 4 See writer's ‘‘ Cruise of the Corwin to Alaska and the Northwest Arc- tic Ocean.” Washington, 1881. 5 Medical and Surgical History cf the War of the Rebellion. SEAL, GOLDEN (Hydrastis, U. S. Ph., Yellow Puc- coon, Yellow Root, ete.). The rhizome and rootlets of Hydrastis canadensis Linn. ; order, Ranunculacew. This is a low perennial herb, with a tuberculated, crooked, yellow rhizome, marked along its upper surface with frequent scars (seals) of fallen stems, and bearing numer- ous wiry, wavy, or crooked, yellow roots. The aérial stem, situated at the extremity of the rhizome, and sur- rounded at the base by a few brown scales, is upright, from two to three decimetres long, and bearing two un- equal five- or seven-lobed leaves. The lower of these is the larger, and petiolate ; the upper is sessile; flower solitary, terminal, about as large as a buttercup ; it con- sists of three fugacious, greenish-white sepals, numerous stamens, and about a dozen pistils ; fruit a raspberry-like cluster of red berries. Hydrastis grows abundantly in the northern and western parts of the United States and inCanada. In New England, and the Middle and South- ern States it is more scarce. It was originally used by the Indians as a dye and medicine, and has been known to us about a hundred years. DEsCRIPTION.—It comes in pieces four or five centi- metres long, slightly branched, or simple, covered with rather numerous rootlets, yellowish-gray outside, bright yellow within ; the rhizome is slightly wrinkled longi- tudinally ; odor strong; taste very bitter. The principal active derivatives of Hydrastis are the alkaloid berberine, the same as that found in Barberry Bark and other plants, and hydrastine. This latter substance, discov- ered about 1852, crystallizes in brilliant, white, four- sided prisms, soluble in alcohol, chloroform, and ether, 360 but scarcely at all in water. No odor; taste, in solu- tion, bitter. A third alkaloid, vanthopuccine, appears to exist in the drug, but is less fully known than the others. The proportion of hydrastine in the dried root is about one anda half percent. An odorous principle and a resin have not yet been isolated. © Action AND Use.—It is difficult to find in Hydrastis anything more than the usual tonic qualities of the der- berine-yielding drugs; in small doses they all are thought to improve the appetite and promote assimilation ; in large ones they derange the stomach. It is given in in- termittent and other fevers, and for the various uses to which quinine is put—sweating, typhoid, diarrheea, etc. Locally used, Hydrastis is in considerable favor as an in-. gredient of urethral and vaginal injections, as well as for washes for other surgical cases—ulcers, heemorrhoids, vegetations, etc. * ADMINISTRATION.—Hydrastis is not often given in sub- stance ; the dose would be from three to ten grams. A Fluid Extract (Hztractum Hydrastis Fluidum) and Tinct- ure (Tinctura Hydrastis, 4) are officinal. An infusion may be also made. For a wash or injection hydrastine and berberine are both to be had ; doses from two to ten decigrams. ‘‘ Hydrastin” is an impure preparation ob- tained in the usual way for ‘‘resinoids;” it is a combi- nation of the three alkaloids and some resinous substance. Dose about three decigrams. ALLIED PLANTs.—See ACONITE. ALLIED DRuGs.—CopPTis, BARBERRY, COLUMBO, etc. W. P. Bolles. SEA-SICKNESS. The assemblage of morbid symp- toms denominated sea-sickness, or more properly sea-ill- ness, is too well known to require formal definition, since there are but few that have not had both subjective and objective experience of the malady. In spite of the distressing character of sea-sickness it fails to elicit much pity from others. It is also strange that the unpleasant phenomena of sea-sickness have been so little elucidated; such little advancement having been made in the study of the subject that ‘it is practi- cally a fresh one with an unlimited field of observation, and he that succeeds in working it will reap the re- ward of a public benefactor. The great medical writ-. ers of antiquity scarcely allude to sea-sickness, and the published observations of sea-going surgeons are most meagre. The majority of writers on the subject have been landsmen who knew but little of the sea, and sailors who knew less of medicine. In fact, the subject has been so little scrutinized by physicians, that it pre- sents the remarkable anomaly of the existence of an ail- ment almost without a medical bibliography, the two hundred or more references to this subject consisting chiefly of a few theses or inaugural dissertations and short journal articles. It is rather to general literature that one must turn to find illustrations of the subject. Plutarch appears to be the first author to describe its symptoms and treatment. The malady is also mentioned by Suetonius and Juvenal, and every school-boy knows of Cicero’s desperate resolve to fall into the hands of his executioner rather than endure longer the horror of sea- sickness. In Burton’s ‘‘ Anatomy of Melancholy” sea- sickness is mentioned as being very good at times; in Boswell’s ‘‘ Johnson” the great doctor recommends the salutary effects of a smart sea-sickness ; Goldsmith inter- ested himself to the extent of attempting to invent a ma- chine for its prevention ; in ‘‘ Tristram Shandy ” the cere- bral effects of the malady are felicitously described; and so citations might be extended indefinitely from the ‘‘ quite, quite down” of Shakespeare to Browning’s ‘‘swooning sickness on the dismal sea,” not to mention the com- ments of Rabelais and Montaigne. : Most of the attempted explanations of sea-sickness are pure figments of the mind, that of the greatest German savant being, in point of fact, but little above that of the humblest fisherman. It is, however, generally conceded that the symptoms are owing to the influence of the mo- tions of the ship, which admit of infinite variation, as anyone may observe while sitting on the quarter-deck, or REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Scurvy. Sea-Sickness, when lying in a bunk, during rough weather. In en- deavoring to balance or right itself, the ship rolls, pitches, seems to pause, and then darts with a side motion fore- and-aft, or, in more precise language, a variety of oscilla- tions take place around both the transverse and the longi- tudinal axes of the ship. These motions alone are the cause of sea-illness, and bad smells, heat, sight of the waves, fear, ‘‘ biliousness,”’ and other alleged causes are mere accessories. The same idea, aphoristically expressed more than two thousand years ago, does not admit of greater refinement, notwithstanding the advanced knowl- edge of the day. There are, however, certain unusual and disorderly movements that may cause phenomena similar to those of sea-illness, such as the trembling of the earth during a volcanic. eruption or an earthquake, experiences of the kind having been common during the late seismic dis- turbances at Charleston and Mentone. Riding backward in a railway train, going up and down in a lift or ina balloon, the act of swinging, riding a camel or a drome- dary, rapid gyratory movements of the body, the concus- sion experienced by workmen in riveting boiler-plates, or, in short, any series of unusual and disorderly shocks that disturb the cerebro-spinal or the ganglionic nervous system may bring on this peculiar functional disturb- ance. It is estimated that of those who go to sea about three per cent. are never sick, and three per cent. are never well. Others, after temporary illness, recover rapidly ; a few are prostrated for weeks, and, in rare instances, some delicate or susceptible persons may never recover. There is also much that is odd and enigmatical regarding indi- vidual susceptibility to sea-sickness. Although women are more subject than men, it sometimes happens that a delicate, hysterical girl will escape illness, while a strong man is prostrated. Champion pugilists during a voyage at sea have been overcome, while many of the weaker passengers were exempt. One of the greatest sufferers I have ever known was a celebrated member of the Lon- don Athletic Club. The liability to illness is much af- fected by the class of ship and by certain motions. Many ' persons will cross the Atlantic with impunity, and yet get ill on a Channel steamer. The sensibility of others is such that travel on a comparatively smooth river or lake causes unpleasant sensations. As a rule, navigation is easiest on a sailing-ship; the tendency to illness is in- ‘creased on board a paddle-wheel steamer, and it is great- est on board a screw steamer. If the force of the wind should cause a list in the steamer to one or the other side, the tendency to become ill is greater. I have often no- ticed, in a transatlantic steamer, that passengers who had recovered from an illness incurred during a fore-and-aft motion of the ship, with the wind astern or off the quar- ter, would invariably become ill again when the wind shifted so as to cause a beam-sea, which changed the di- rection of the ship’s oscillations. Owing to the greater amplitude of the oscillations experienced in going aloft, I have often seen boys become ill on board a training-ship, who kept well as long as they remained on deck. After staying ashore for some time, the inuring process of get- ting one’s sea-legs has often to be repeated, even in ‘‘ old sea-dogs.” Sonve years since, in a gale on the Pacific, just after quitting the Golden Gate, I was a fellow-sufferer with an old Nantucket whaling captain ; and though hav- ing personal claims to being something of a sea-rover, I lately became squeamish on board a steam yacht while witnessing a race. Nothing dampens enthusiasm like sea-sickness. Men full of military ardor start on an ex- pedition, and after a day or two at sea on board a trans- port suddenly come to the conclusion that there is really no cause for war. History tells how Bonaparte’s sea-sick- ness paralyzed and brought to naught his grand enter- prise of invading England. Many professional sailors suffer greatly from sea-sick- ness, and even Nelson was a martyr to this cause. I know of several naval officers who are great sufferers ; one, a fleet captain, tells me that he often, in his cabin, suffers agony on this account. With many persons the susceptibility is so great that the sensorial perversions —~ continue for days after going ashore, and in others any- thing suggestive of the sea causes unpleasant sensations. I have known such to be caused by a boatswain’s whis- tle. A naval officer of my acquaintance, who is sorely troubled by this form of illness, has all the premonitory } symptoms on the reception of his orders for sea duty, and I know an old lady in New Bedford who is unable to look at the heaving figure of a ship on the face of an old-fashioned clock without becoming ill. Another in- stance, in which the mere recollection of the occurrence caused renewal of the nausea, is that of the late Henry Ward Beecher, who relates that, many years after his first voyage across the Atlantic, he heard some sailors in a Brooklyn dock singing the same old ‘‘chanty” song that he had heard when ill at sea, and that the mere lis- tening to this song produced symptoms of sea-sickness. That something less than perverted sensation may arouse the unpleasant associations of sea-sickness is evi- denced by the effects upon a highly susceptible person on reading one of Clark Russell’s novels, say, ‘‘ Wreck of the Grosvenor” or ‘‘Sailor’s Sweetheart.” Carried almost beyond the realms of fancy, one sees a complete nautical picture in his mind’s eye; he hears the thud of the sea and the sounds of the running rigging; smells the tarred rope and bilge, and feels the close atmosphere and nauseating roll of the ship. The cerebral action which recalls such phenomena can hardly be said to exist in the lower order of animals— such as birds, dogs, sheep, horses, and elephants—who often suffer greatly from sea-sickness. It is easier to look for a mechanical or physical cause in the disturb- ance of the cerebro-spinal tluid from the effects of a cen- trifugal force, analogous to the change that takes place in such a liquid substance as milk when placed in the tubes of a whirling machine for testing. Similar effects of cerebro-spinal disturbance appear in a tumbler-pigeon, which seems lifeless after being whirled around for afew moments with the head under its wing; gulls, Mother Carey’s chickens, and other aquatic birds, when placed on a ship’s deck become nauseated from the rolling and pitching, that is to say, from the great oscillations of the ship around its axes; and many per- sons have observed the phenomena of sea-sickness in chil- dren who have ridden too long on a merry-go-round. The many explanations that are offered to account for the symptoms of sea-illness differ one from another, and are all more or less objectionable. One of the causes as- signed to account for the nausea is neither the motion in itself nor the appearance of motion, but the violation of the habitual conceptions of contrasted effects of motion, which may obtain not only in those having sight, but in the blind. The motions of the ship cause mental con- cepts totally at variance with the ordinary experience. Dr. William James, of Boston, states that deaf-mutes, as a class, are exempt from sea-sickness, and for that rea- son it is suggested that the malady does not occur in the ease of destruction either of the auditory nerves or of their labyrinthine terminations, and that the semicircular canals are the probable starting-point of the affection. An illustrative instance is mentioned in which a person much subject to sea-sickness was entirely cured after re- ceiving a blow on the head which crushed the mastoid process and caused deafness. That there is some connection between aural defects and certain symptoms simulating those of sea-illness ap- pears to be the fact. Such symptoms are at times ob- served when the Eustachian tube is obstructed, and still more commonly when there has been concussion of the labyrinth, or when the structures contained within this cavity have undergone pathological changes as the result of cerebro-spinal meningitis. . ; Whether the nausea be owing to irritation in certain states of defective aural mechanism ; to irritation of the nerves of the eye caused by the apparent instability of all surrounding objects; to agitation of the abdominal viscera ; to the continuity of the muscular contractions necessary for the maintenance of the equilibrium ; to the pumping motion of the liquids of the body, analogous to the rise and fall of the mercury in a barometer ; to reflex 361 Sea-Sickness,. Secretion. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. action disturbing the medulla, the spinal cord, the solar plexus, and the splanchnic nerves, or to concussive 1m- pact resulting in cerebral anemia and diminution of the brain mass, we are not in a position definitely to say. These are questions too subtile and problematical, but it is possible that there is more or less truth in each, and that the symptoms vary accordingly as the cerebral, the spinal, or the visceral contents are most acted on; so that in some, whose cerebro-spinal system is less resistant, the trouble experienced is headache, giddiness, and un- steadiness, rather than the vomiting and loss of appetite of others, whose organic nervous system is principally affected. No illness is less harmful and sooner forgotten than is this. Ordinarily it passes off in a few days, leaving the patient none the worse for his experience. In fact, it is highly beneficial in many ailments, as affections of the liver and digestive organs, melancholia, certain kinds of mental alienation, and obstinate intermittent fever, which I have known to be broken up by this curative means alone when all others had failed ; and were it not for the rare occurrence of death in persons suffering from some antecedent malady, and the alarming weakness and erethism produced in other delicate subjects, the matter of deciding whether there is any effective prophylactic or any infallible treatment that may ward off, alleviate, and abate the ravages and woes of this unpleasant ad- junct of sea-travel, would scarcely occupy the serious attention of the physician. As arule, sea-sickness is dangerous in organic disease of the stomach, brain, heart, or lungs, and to pregnant women. All such should avoid sea-voyages. Heemor- rhages and hernia may occasionally result from the straining caused by the frequent vomiting, and defective nutrition may bring about great wasting of the body. Obstinate constipation, marked diminution of the urine, and occasional spasmodic contraction of the urethra, are among what may be called the complications of sea-sick- ness. In addition to these, sugar is sometimes found in the urine, owing to irritation of the diabetic centre in the medulla; convulsions may occur in some cases, and in- stances of temporary insanity from this cause are re- ported. I have seen one such case in a Frenchman in crossing the English Channel from Dieppe. Dr. Rey- nolds states that he has seen three cases.! Pretended specifics for sea-sickness have not been want- ing from the earliest times, and most of them, from old women’s remedies down to the sort of liver-pad praised by Bacon, are as worthless as they are foolish. We do not know the contents of the box of which Shakespeare says, ‘‘If you are sick at sea, a dram of this will drive away distemper” (‘‘ Cymbeline,” act iii., scene 4.) Nor was it perhaps so effective as the rope’s-end formerly used on green midshipmen in the British navy ; or the bucket of cold water that is usually dashed over sea-sick men on board whaling-vessels ; or the treatment pursued in the case of boys on training-ships, who are supported by two other persons, if necessary, and made to walk the deck and swallow occasional spoonfuls of hot soup until they get well. Such heroic measures, of course, cannot be resorted to when dealing with delicate, susceptible people, invalids, and pregnant women, who make up the larger part of the passenger list of an ocean steamer ; so recourse is often had to such drugs as chloral, opium, chloroform, amyl nitrite, and numerous other sedatives, most of which are of little more value than the colored spectacles, supposed to prevent sea-sickness, which were sold in large quantities, a few years since, by an enter- prising individual in Cadiz to Spanish soldiers embark- ing for Cuba. Although like advising a sufferer from toothache to be philosophical, it is best, if one must go to sea, to exercise his courage and force of will. He must keep up and show his stoicism by remaining in the open air, and eat- ing at usual hours, regardless of the fact that the food is vomited. The vomiting, which, by the way, is not one and the same thing with sea-sickness, is often al- layed by lying down and by swallowing crushed ice or small quantities of iced champagne. According to Dr. 362 Coniat, of the Compagnie Générale Transatlantique, the rebellious vomiting is arrested with ‘‘ prompt and evi- dent success” after faradization of the epigastric region, combined with the external employment of a solution of atropia, the intensity of the current being graduated according to the susceptibility of the person and the ob- stinacy of the vomiting.’ The debilitated stomach is soon- est brought back to its normal state after drinking a little bitter beer, or eating an orange, a lemon, or other bland and delicate food ; but, as a rule, all spirits, liquids, and sweets should be avoided, as they disturb the stomach and irritate the gastric mucous membrane to the extent of causing a predisposition to illness. A teaspoonful of Worcestershire sauce is often excellent in the earlier stages ; and fat bacon, smoked herring, and curry will often stay down when other things are vomited. , Mechanical contrivances against sea-sickness, as tight belts, swinging beds, the Bessemer saloon, and the proj- ect of affording greater amplitude by connecting two or four vessels after the manner of a catamaran, have proved inoperative. A course of exercise in a swing, with a view to pre- paring for a voyage, has proved as futile as the habit of taking medicine previously to embarking. No malady, in fact, has afforded a more ample field for polyphar- macy, and none is more rebellious to treatment. In fact, there is no remedy for sea-sickness, and as long as men go to sea, so long will they be liable to suffer from this distressing malady. Irving C. Rosse. 1 Lancet, 1884, i., 1161. London. 2 Archiy. Méd. Navale, November, 1868. SEBACEOUS CYST, or ‘‘wen,” as it is popularly called, appears as a variously sized, firm or soft, round- ish tumor, seated in the skin or subcutaneous connective tissue. The skin covering the tumor is natural in color, or whitish from stretching. The tumors may occur singly or in great numbers, and may vary from the size of a pea to that of a walnut, or larger. They are usually firm, but sometimes doughy, and are generally freely movable and painless. Their usual seat is upon the scalp, face, back, and scrotum, though they may be met with anywhere, even on the soles, it is said. They may last for years un- changed, but sometimes break down and ulcerate. They may degenerate into epithelioma in old persons. Some sebaceous cysts are flat, with a minute hole in the centre, others tend to rise above the surface of the skin and be- come semiglobular. The latter are those commonly found upon the scalp, when they are devoid of hair. The contents of sebaceous cysts may be milky or cheesy in consistence, and are often decomposed and fetid. The tumors are, in fact, nothing more than enor- mously distended sebaceous ducts and glands, the walls of which have become hypertrophied until they form a tough sac. The treatment of sebaceous cyst is excision. The cyst- wall should be carefully dissected out, as otherwise the disease is apt to recur. Arthur Van Harlingen. SEBORRHGEA. A disease of the sebaceous glands of the skin, characterized by an increase in the quantity of sebum poured out ; and also, in most cases, by an altera- tion in quality of the secretion. There are two varieties — seborrhea oleosa and seborrhea sicca. Seborrhea oleosa appears in the form of an oily coating upon the skin, giving it an unctuous and greasy feel. Its most common seat is on the scalp and about the face, particularly the nose and forehead, where it appears as a greasy coating, containing more or less dust and dirt, and looking as though the skin had been smeared with a dirty ointment. In the scalp it collects on the hair, giv- ing it a dark, limp look, as if it had been freely oiled, or, when the scalp is bald, looking as if oil had been poured over it. Seborrhea sicca, or dry seborrhea, occurs in infants as vermx caseosa, or smegma of the new-born. Here it is almost physiological, and is usually soon removed. If it remains it becomes a diseased condition, and as such is often seen upon the scalp. Dry seborrhea shows REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Sea-Sickmness, Secretion. itself on both the hairy and non-hairy portions of the body as a more or less greasy mass of scales, of a dirty yellowish color, and somewhat adherent to the skin. On the scalp these masses are larger and oilier, tending to cling to the skin in thick plates, and leaving, when picked off, a smooth, grayish, moist or oily surface beneath. In old persons the scalp, and sometimes the region of the beard, is covered to a greater or less extent with a brown, adherent greasy coating, which is essentially seborrhceic in character. Seborrhcea of the scalp, like pityriasis, with which it is sometimes confounded (see Pityriasis simplex), is some- times followed in the young by premature baldness. If taken in time, however, baldness from this cause can be prevented, and it is desirable in all cases to remove the seborrheeic condition, even if it gives rise to little or no annoyance. Seborrhcea of the foreskin and glans penis is an abnor- mal flow of the normal secretion of this part, known as smegma preputit. If not attended to, it leads to balanitis, from the irritation of its rapidly decomposing sebaceous products, Seborrhcea is induced by a variety of causes, promi- nent among which is the chlorotic or anemic state. It is more apt to occur about puberty or in early adult age. It may occur in persons otherwise healthy. In such cases it is usually curable by local measures. The diagnosis of seborrhcea is usually not a matter of much difficulty, the evidently sebaceous character of the products of disease pointing out its nature with sufficient certainty. The treatment of seborrhea should usually be both constitutional and local. Fresh air and exercise, espe- cially in the case of young women, is to be insisted upon. Attention should also be paid to diet. The history should be looked into, and any functional irregularities corrected when possible. Success in treatment often depends upon ascertaining and meeting the exciting cause in the indi- vidual. Cod-liver oil, iron, and arsenic are the most generally useful remedies. Iron may be given in the form of the tincture of the chloride alone, or with phos- phoric acid. Arsenic is best given as Fowler’s solution, in the dose of four or five minims, thrice daily, in wine of iron. Cod-liver oil is particularly beneficial in cases in which oily seborrhcea is accompanied by acne, particu- larly acne indurata in strumous subjects. The local treatment of the disease is very important. In seborrheea of the scalp the scales and crusts must first be removed. If they are hard and caked, as is sometimes the case in old people, the scalp should be soaked in olive- or almond-oil overnight. Hot water and soap will then remove the softened crusts. An excellent means of removing the crusts and scales is by means of the spiritus saponis kalinus, an alcoholic solution of Hebra’s green soap. A tablespoonful of this may be applied to the scalp with a sponge and a consid- erable quantity of warm water added, so as to make a lather. After yigorously shampooing the scalp for a few minutes, the soapy matters are to be washed away with an abundance of clear warm water, and the scalp dried quickly with a soft towel, when it is ready for the appli- cation of the more strictly remedial agents, usually in the form of medicated oils. An excellent formula is the following : Bev ACIdLeArpolicin 20 e.2+ Gm. 38 (gr. xlv.) CU pe PLO OI sions sina hte Gm. 4(f3j.) CL ALMODIS odie « henn « we Gm. 2(f38s.) Aq. cologniensis ...... ad Gm. 64 (f 2 ij. On the bald scalp and other places where there is no hair an ointment of one part of sulphur to eight parts of cosmoline may be employed. The prognosis of seborrhea is generally favorable. . The oily variety is that which is most apt to be stubborn under treatment. Arthur Van Harlingen. SECRETION, PHYSIOLOGY OF. Secretion in gen- eral may be defined as the separation of certain prod- ucts from the blood, usually in a liquid form, which are poured out on the free epithelial surface of the secreting organ. When the secreting surface happens to have a somewhat complicated structure it is usually spoken of as a gland. Simple epithelial membranes, such as the pleura or peritoneum, may, and often do, form secretions from the blood, and though not ordinarily described as glands, there is, nevertheless, no fundamental distinction between the process of secretion in them and in the more complicated secreting organs, such as the salivary glands. That is, in both cases we have to deal with se- cretions, as defined above, and though the secondary differences between the two are many, they are, perhaps, not more numerous than those which exist among the glands, usually described as such, in the body. Indeed, the phenomena shown in the action of the different glands are often so diverse that some physiologists are inclined to doubt whether any general theory of secretion will ever be obtained ; but these differences, as well as the resemblances, will be better appreciated after the ac- tion of the various glands has been described. Defining a gland as a secretory organ, the simplest form of gland that we have to consider ry) consists of three es- sential parts, viz., (1) a simple base- ment-membrane, or membrana propria, supporting on one side a layer (2) of secreting cells, nucleated epithelial cells, and on the other side (3) a network of blood-capil- laries, as shown in the diagram (Fig. 3417). All the secreting organs of the body are constructed essentially on this plan; and the serous, mucous, and synovial membranes furnish examples of this simplest form of secreting apparatus. It is obvious, however, that if all secreting organs were constructed exactly in this way, as plain surfaces, the extent of the secreting surface would be greatly limited. The various compli- cations of structure that we meet with in the different glands seem to have for their primary purpose economy of space. A plain secreting membrane, such as that described, may have its surface increased, without occupying more space, in one of two ways. First, by protrusion in the form of folds. These folds or processes may be either Fie. 8417.—Typical Secreting Surface. a Basement-membrane ; 0, secreting cells; ¢ capillary network. ’ ] simple or compound, according to the extent of surface demanded, as shown in Fig. 3418. Examples of this oun Fie. 3418.—Increase of Secreting Surface by Protrusion. ; a, Basement- membrane ; b, epithelial cells; ¢c, network of blood-vessels. method of increasing the surface are found in the villi of the mucous membrane of the small intestines, and in other places, though this method seems to be one that is not generally used. Second, by a denting in of the sur- face to form a crypt or follicle. The cavity thus formed may be either tubular or saccular. Most of the glands of the body are formed on this plan, and may, therefore, be divided into two great classes—the tubular glands and the saccular, or, as they are more commonly called, the racemose glands (from racemus, a cluster of grapes). The invagination of the membrane may form only a simple tube or sac, making what is known as a simple tubular or racemose gland—as in the crypts of Lieberkiihn of the small intestine, the sweat-glands, and some mucous crypts. Diagrams of this form of gland are shown in Fig. 8419. The increase in the extent of surface in these cases is not very great, unless, as in the sweat-ducts, the simple tube is very much elongated and twisted into a compact knot. The invagination, however, instead of 363 Secretion. Secretion. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. being a simple tube or sac, may be variously compounded, forming what are called compound glands, of which again we have two kinds—compound tubular and com- pound racemose glands—diagrammatic representations of which are given in Figs, 3420 and 3421. In the compound racemose gland the separate little ao ppDLeLnp Fie. 3419.—Increase of Secreting Surface by In- vagination. A and CU, forms of simple tubular - glands; B, simple racemose gland. sacs are spoken of as alveoli or acini, and they open into canals or ducts which finally unite into one or more com- mon secretory ducts. The salivary glands and pancreas are good examples of this type of gland, the secreting surface being enormously increased without any great loss of space. The different alveoli are united into lob- ules, and these, bound together by connective tissue, form . the gland. The actual secreting cells are found in the alveoli, while the epithelial cells lining the ducts have, _ probably, simply a protective function. Exam- ples of the com- pound tubular glands are found in the kidneys and testes, and to a less marked extent in the gastric tubules of the stomach. In the kidney and testes, by this subdivision of the tubular gland, a really vast ex- tent of secreting surface is obtained within a very limited space. In such glands we can also distinguish a portion in which the epithelial cells have an active secretory func- tion, from that known as the duct of the gland, in which the epithelial cells seem to form sim- ply a protective covering. It was formerly customary to di- vide the secretions into two great classes, viz., excretions and secre- tions proper. Johannes Miiller, in his ‘‘ Physiology,” defined these two classes in this way: Excretions are substances which exist already formed in the blood, and are merely eliminated by the gland without be- ing changed in the process—the urea / of urine, for instancé ; while the se- cretions proper are substances which do not previously exist in the blood, but are first manufactured from it by the cells of the secreting gland— a good example of this type is found in the milk produced by the mam- mary gland. | _ It has as yet been found impossi- ble, however, to establish any such distinction as this. Even in the case of urea it has long been doubted whether the kidneys simply eliminate this substance from the blood after -J-Je-J- Fre. 3420.—Compound Racemose Gland. it has been formed in other tissues, '1% ,242!.— Compound - Tubul many contending that the cells of ate a the uriniferous tubules take part in the formation of the urea. Indeed, the question may still be regarded as an open one, needing further investigation before decisive statements can be made. The more usual conception of an excretion as a prod- 364 uct, formed in a gland, which is of no further use in the animal economy, and is simply eliminated from the body as waste matter, while sometimes a convenient ex- pression, is also inadmissible from a scientific standpoint. In the first place, we have secretions, such as the bile, which contain both waste products, of which no further use can be made, and also true secretory products of great functional importance in the body. In the second place, the method of formation of these so- called excretions—the urine, for instance—cannot be clearly separated from the processes of ordinary secretion. It will be better, then, to abandon any attempt to make a distinction between secretions and excretions, and to describe the processes in both cases under the general term of secretion, as is done in the best text-books of physiology at the present time. Another classification of secretions that has been suggested divides them into transudations and se- cretions proper. By transudations we mean those secre- tions which can be conceived as derived from the blood by the simple physical processes of filtration and diffusion. Examples of this are found in the secretions formed on serous membranes—the pericardial liquid, or that in the tunica vaginalis of the scrotum, for instance. These liq- uids contain no specific elements, such as we find in most secretions, but have a chemical composition similar to that of the blood from which they are derived. It would seem very probable, then, at’ first glance, that such secretions are formed as the products of filtration and diffusion. The plasma of the blood in the capillaries is under greater pressure than the lymph impregnating the tissues, so that we should expect a steady filtration of the plasma through the capillaries into the lymph of the tissues, and, in turn, « transudation of this lymph upon the free surface of membranes, such as the ordinary se- rous membranes. According to this view the epithelial cells of such a membrane. take no active part in the for- mation of the transudation or secretion, whichever we choose to call it. Since in all secretions, even those in which we have a specific element characterizing the se- cretion, and undoubtedly formed de novo by the meta- bolic activity of the gland-cells, we have also certain products, the water and salts, which may.be considered as derived directly from the blood by the physical pro- cesses mentioned, it will be necessary to distinguish in each secretion two kinds of substances—one manufact- ured by the cells of the gland from nutritive material furnished by the blood, or, more correctly speaking, the lymph ; and one derived from the lymph by filtration and diffusion—that is, transudation-substances—w hose formation is not dependent upon the life-processes of the gland-cells. Some such distinctign is actually made at present by physiologists, as we shall see when describing the secretion of the salivary glands. But the distinction is not usually drawn as sharply as indicated above, for the reason that many facts are known which seem to show that the formation of even the water and salts of secretions is in some way connected with the activity of the secreting cells. To illustrate the difficulties encountered in explaining transudations by referring them to the physical processes of filtration and diffusion, some recent experiments of Tigerstedt and Santesson! may be quoted. These ex- perimenters found that while filtration takes place read- ily through dead animal membranes, nevertheless, when living membranes were used, such, for instance, as the lung of a frog, and filtration was attempted under the same pressure, with serum or normal salt solution, no fil- trate at all was obtained. If the living lung-tissue that allowed no liquid to filter through it was killed by heat, or by any other means, filtration quickly commenced. Similar results were obtained with the frog’s intestines and abdominal wall; and if we were justified in applying these results to the other membranes of the body, it would be necessary to explain transudations by some- thing more than simple physical laws. The authors cite many facts to show that even the formation of lymph, which has always been regarded as caused by the filtra- REFERENCE HANDBOOK OF THE MEDICAL SCIENCES, tion of blood-plasma through the thin walls of the capil- laries, is apparently independent of the blood-pressure, in many cases at least ; for, if produced by filtration, the amount of lymph obtained ought to increase with in- crease of blood-pressure. They conclude from their ex- periments that the transudation of the blood-plasma to form the lymph is caused by the activity of the cells composing the capillary walls, and this conclusion, if correct, will apply @ fortdort to transudations of the lymph through the basement-membrane and epithelial covering of glandular walls. Investigations like this compel us to be cautious in explaining the simplest phe- nomenon of the animal body by physical laws obtained from the study of dead matter. It may be convenient to speak of transudations as opposed to secretions proper. The distinction has some basis in the fact that in transu- dations the chemical constituents are qualitatively the same as those of the blood or lymph from which the transudation is derived, while the secretions proper are characterized by the presence of certain constituents not normally contained in the blood, but manufactured in the glandular cells in consequence of their metabolic pro- cesses ; nevertheless it would be gratuitous, at present, to assume that in transudations the epithelial cells act simply as a filter or membrane through which certain things pass in consequence of a greater pressure on one side. It is certainly possible that the epithelial cells may take an active part in the production of the water and salts of a secretion, as well as in the formation of mucin or specific ferments. As long as the word transu- dation has the significance it possesses at present, a divis- ion of the secretions into transudations and secretions proper has, perhaps, as little right to acceptance as the old separation into excretions and secretions. The facts known and the theories maintained, with re- gard to secretion, can be best presented by a description of the physiology of the salivary glands and the pancreas, from the study of which most of our knowledge on this subject has been obtained. But before passing on to the physiology of these glands it will be well to review briefly the principal theories of secretion held by physi- ologists from the time of Haller, since the relative im- portance of the facts which we now possess can be more clearly emphasized by such a comparison. Though Hal- ler is credited with being one of the chief opponents of the old mechanical school of physiologists, the physiol- ~ ogy of secretion as given by him is almost entirely mechanical. He divided the secretions into four classes, and held that the substances composing these secretions all pre-existed in the blood, from which they were sepa- rated by various mechanical means. The alveoli of the glands were supposed to be formed of ‘‘ arteries and veins, divided and subdivided,” and the arteries were connected directly with the ducts of the glands by pores or canals of varying sizes. This belief in the connection between the arteries and ducts was a deduction from the heroic injections of those days, or what Haller calls “‘ the superlative art of great anatomists,” by which wax In- jections were forced from the arteries into the gland- ducts. The fact that the different secretions, although derived from the same source, the blood, possess marked and constant differences of composition was explained by supposing that the pores or canals connecting the ar- teries and ducts were of different sizes; none of them were large enough to allow the unchanged blood with its corpuscles to pass through, but some were smaller than others and allowed only the lightest and most volatile particles of the blood to pass, while the larger pores gave passage to the grosser particles. Additional factors In causing the differences in the different secretions were found in the angle, whether acute or a right angle, which the artery supplying the gland made with the main trunk, and also in the difference in velocity of the blood- stream in the secreting arteries, depending on the width of the artery, distance from the heart, etc. Similar me- chanical views were held well into the nineteenth cen- tury, until the masterly work of Johannes Miller, on the structure and physiology of secreting glands, laid a true foundation for modern views. Secretion. Secretion. Miiller proved that no pores of communication exist between the arteries and ducts of the gland ; he described the anatomy of the glands and the relations of the blood- vessels to them, and showed that the nature of the secre- tion was not dependent on the gross structure of the gland, nor on the way in which its vascular supply was obtained. ‘‘ The nature of the secretion depends solely on the peculiar vital properties of the organic substance which forms the secreting canals,” is his final conclusion, and he states his belief that ‘‘the variety of secretion is due to the same cause as the variety of the formation and vital properties of organs generally ; the only differ- ence being that, in nutrition, the part of the blood which has undergone the peculiar change is incorporated with the organ itself, while in secretion it is eliminated from it.”? The extensive researches of modern times have added very much to our knowledge of the histology and chemistry of secreting tissues; but, as Heidenhain re- marks, if we substitute the term ‘‘cells” for ‘‘ living substance,” or ‘‘ organic substance,” the words of Miller just quoted express the conclusion to which modern physiologists have come, and but little can be added to them. The most important advances made since Miiller’s work have .been connected with the cell-theory of Schwann, and the discovery of the laws of diffusion through membranes by Dutrochet. Schwann’s concep- tion of the cellular structure of the animal body was fol- lowed by careful histological investigations of the struct- ure of glands as well as of other organs. The glandular epithelium was described, though the physiology of se- cretion was not at first directly benefited by this discov- ery. The laws of diffusion of liquids through mem- branes seemed to promise great things for the physiology of secretion, and investigations upon this basis were eagerly taken up by some of the best physiologists. As a consequence of this, the physical theories of secretion again came to the front, and have since occupied an impor- tant position in the explanation of secretory phenomena. Ludwig, in his ‘‘ Physiology” (vol. ii., 1861), develops in detail the conceptions of filtration and diffusion in their application to the processes of secretion. According to him, the forces concerned in the production of secre- tions are filtration, diffusion, and also the action of stim- ulated nerves, though he was careful to say that other forces still might contribute to this result. Ludwig knew, of course, at the time of the publication of his ‘‘ Physiol- ogy,’ that the organic material found in the secretions of the salivary gland, etc., was not obtained directly from the blood, but was made in the gland itself ; but it is im- portant to notice that, by the aid of the simple physical phenomena of diffusion and filtration, he was able to build up a theory of secretion that to a large extent ac- counted for the specific differences found in the secre- tion of different glands. The discovery by Ludwig that some of the glands—the submaxillary gland, for example —give a secretion when the nerve-fibres going to them are stimulated, was an extremely important addition to our knowledge of secretion, and has played a large part in recent theories of the physiology of glands. The re- searches of the same distinguished physiologist proved that the secretion in this case is not owing to simple fil- tration from the blood, even if the water and salts alone of the secretion are considered ; for it was found that in some cases the pressure in the gland might rise to nearly double the mean pressure of the blood in the carotid artery. An equally important observation, also made by Ludwig, was that the temperature of the gland and of its secretion increases during the act of secretion, a fact which would seem to indicate that active chemical changes take place. At about this same period, also, Claude Bernard found that during stimulation of the nerve going to the submax- illary gland the blood-flow through the gland is greatly in- creased, suggesting again an increased nutritive activity of the gland in secretion. If Ludwig, at the time his ‘‘ Physiology ” was published, laid too much emphasis on the purely physical factors in secretion, it is neverthe- less mainly owing to the important discoveries made by 365 Secretion. Secretion. himself and his pupils that these physical forces have been found to be insufficient. The numerous researches of the last twenty years have shown that, in many of the glands we have true secretory nerves, comparable in their functions to the motor nerves of muscles. Just as stim- ulation of the nerve of a muscle causes the muscle to enter into functional activity, to contract, so the stimula- tion of the secretory nerve causes the gland to enter into functional activity, and form its proper secretion. Chem- ical examination of these secretions has shown that, in some glands at least, the most distinctive constituents of their secretion do not exist at allin the blood, but are formed within the gland. This dependence of secretion on nervous influences, and the undoubted chemical changes which take place in the gland during its period of activity, have forced us back again to the position held by Miiller, that the nat- ure of the secretion depends upon the properties of the living substance which forms the glands. This living substance we now know consists of glandular epithe- lium cell's, and it is to-day the most difficult problem in the study of secretion to understand the properties of these secreting cells. As Miller pointed out, it is only a particular case of the wider problem of nutrition shown by all living cells. ) Sores None. Ta 1 | None (or Hyphy- | Branchial* ...... IBILIRL Yee ache) Radix longa of cil- | Ophthalmicus | Motor oculi ...... Recti super. in- sis?) jary gang]. profundus, ter, and inf. and obliq.inf. of eye. 1B Te iS Mont big esis. Branchial * ...... Gasserian........ Trigeminus..... Ophthalmicus su- | Trochlear........ ‘Muscle of mouth. i perficialis sine obliq. sup. of eye, port. facialis, EVE Da TELVOIGE tata hdaee 5 - Branchial *—. 7.7. HaClaleysteyacs west JREOONDE hae he ae Part.facialofoph- | Abducens........ Rectus. externus. thal. sup. and ramus buccalis. Ve ENON Guay tee y ieer ieke AQIGibOry 45-042 0% ATIGHEOLY: sie ns cle PATICIUONY, 4.9 do cre: INOMO% eee ect INONG Aye once . | None, Viet vo First branchial...| Branchial* ...... Glosso-pharyn- | Glosso-pharyn- | Supra-temporal...| None ........ None. geal. geus. | Val Ucreee Onlclatec spam dry Omen kere oie aan eG Ae GL Mn SRamO MRE celle lt ee el aye Supra-temporal ../ None ............ None. ‘ iG i Second to fifth | Branchial*...... Vagus i. to iv....| Vagus, to iv ....| (Of vag. ii. to iv.. | None ........... | None, xX 9° branchial. lateral nerve? ?) ; a RGR kt ) | ° RET alec dep CIN OMG de yeni ne, UN ONG ea aati pyres ADOERINOF a nies. PA DOLLLVeE1OOtsias alt NODC). ..5 jocanie Hypoglossus ..... None. MITL. +3 19'} * Aborts. + Dohrn and Beard regard the facial nerve as double, and think that one myotome and one cleft are lost between the mouth and hyoid cleft. SEGMENTATION OF THE OVUM. There follows upon the impregnation of the ovum aremarkable process known as the segmentation, This term is used to desig- nate the series of divisions of the impregnated ovum into a number of cells, of which all the cells of the future ani- mal are the direct descendants. Common usage applies the term only up to the time of development, when the two primitive germ-layers are clearly differentiated and the first distinct organs are beginning to appear. The word was introduced before the masses into which the ovum di- vides were known to be cells. The cleavage of the ovum was described by Prevost and Dumas, and again by Rusconi in 1836.27 Since then it has been investigated very frequently. The cell doctrine dates from 1839. As stated in the article on Impregnation (vol. iv., p. 5), the nucleus of the impregnated ovum ts formed by the union of the male and female pronuclet. Van Beneden had af- firmed that there was no real union in the eggs of Ascaris, but Carnoy '? has shown that Van Beneden’s observations were incomplete, and Zacharias*® states that they were so very defective as to be fundamentally erroneous, and that in reality the eggs of Ascaris offer another proof of the actual union of the pronuclei. It seems to me safe to accept the generalization just made as to the origin of the first or segmentation nucleus. The position of this nucleus is determined, first, by the form of the egg; second, by the distribution of the for- mative (ectodermal) and nutritive (entodermal) yolk. In round eggs, with very little yolk—alecithal ova—such as those of Echinoderms, the nucleus lies nearly in the cen- tre. It is commonly stated to lie exactly in the centre, but I must question the accuracy of such statements. When there is an evident differentiation of nutritive and forma- tive yolk—telolecithal ova—the nucleus is always eccen- tric and its eccentricity increases with the amount of yolk, for it always tends to approach the so-called ‘‘ ani- mal” pole, where the protoplasmatic or formative yolk is accumulated. In oval eggs with little yolk the nucleus lies in the middle of the long axis, as in Nematod eggs, but whenever there is differentiation of an animal pole the nucleus tends to approach it. In brief, we may say that the segmentation nucleus takes the most central posi- tion possible with regard to the protoplasm of the ovum. The vitelline granules are not regarded as protoplasm, hence, when they accumulate they may increase the bulk Charles Sedgwick Minot, on one side of the nucleus without otherwise disturbing the radial distribution of the protoplasm around it. After the segmentation nucleus is formed there occurs a pause, which lasts, according to observations on several invertebrates, from half to three-quarters of an hour. During this period the yolk gradually expands again (having contracted during impregnation), and also ac- quires a radiating appearanee starting from the nucleus as acentre. The radiation is due to the arrangement of the protoplasmatic network, and the conforming distri- bution of the yolk granules. The physiological mechan- ism is unknown which causes this radiation and the other radiations of protoplasm which appear during cell di- visions. Morphologists often speak loosely of nuclear attraction as the cause, but it need hardly be pointed out that this notion is, physiologically speaking, vague and crude. The monocentric radiation soon disappears and is replaced by a dicentric radiation, which marks the end of the period of repose, and the commencement of the first division of the ovum. For figures see Hertwig’s memoirs. !*® 19 The external appearances of segmentation in the living ova vary, of course, especially according to the amount and distribution of the yolk material. The appearances in holoblastic ova with very little yolk are well exem- plified by Limax campestris. Mark’s description * is, nearly in his own words, as follows: In Limax, after im- pregnation, the region of the segmentation nucleus re- mains more clear, but all that can be distinguished is a more or less circular, ill-defined area, which is less opaque than the surrounding portions of the vitellus. After a few moments this area grows less distinct. It finally ap- pears elongated. Very soon this lengthening results in two light spots, which are inconspicuous at first, but which increase in size and distinctness, and presently become oval. If the outline of the egg be carefully watched, it is now seen to lengthen gradually in a direc- tion corresponding to the line which joins the spots. As the latter enlarge, the lengthening of the ovum increases, though not very conspicuously. Soon a slight flattening of the surface appears just under the polar globules ; the flattening changes to a depression (Fig. 3485), which grows deeper and becomes angular. A little later the furrow is seen to have extended around on the sides of the yolk as a shallow depression, reaching something 381 Sezmentation. Segmentation. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. more than half-way toward the vegetable or inferior pole, and in four or five minutes after its appearance the de- pression extends completely around the yolk. This an- nular constriction now deepens on all sides, but most : ae rapidly at the animal pole; as it deepens it becomes narrower, almost a fissure. By the further deepening of the constriction on all sides, there are formed two equal masses, connected by only a slender thread of protoplasm, situated nearer the vegetative than the animal pole, and which soon becomes more attenuated, and finally parts. The first ; cleavage is now accomplished. Fia. 3435. — Ovum of Limax Both segments undergo changes Campestris during the First Magnified 200 ai- Of form ; they approach and flat- Cleavage. : ameters. The envelopes are ten out against each other, and Sata in, (After E. L. after a certain time themselves divide. The division of al? ova, so far as at present known, is indirect (karyokinesis, mitosis), there being nuclear spin- dles, amphiasters, etc. The dicentric radiation just men- tioned marks the appearance of the first amphiaster. The plane of the first division determines those of the subsequent divisions, and also of all the axes of the em- bryo ;* it is itself determined by the position of the long axis of the first amphiaster or nuclear spindle, to which it isat right angles. It, therefore, is a matter of great in- terest to ascertain what factors determine the position of the first spindle, or, in other words, the axis of elonga- tion of the segmentation nucleus. So far as at present known, there are two factors: 1, Relation to the axis of the ovum ; 2, position of the path taken by male pronu- cleus to approach the female pronucleus. The axis of the ovum is fixed before impregnation ; it passes through the centre of the animal, and that of the vegetable pole. Usually the nuclear spindle which leads to the formation of the polar globule has its long axis coincident with that of the ovum, hence the point of exit of the polar glob- ule marks one end of the ovic axis. The first amphias- ter or spindle ts always at right angles to the ovie axis, This, however, leaves the meridian plane undetermined. Roux,*4 from a series of interesting experiments on frogs’ ova, concludes that the plane is fixed by the path of the spermatozoon. So far as I know, this idea was first suggested by Selenka, in 1878, in his paper on ‘‘The Development of Toxopneustes Variegatus ;” compare also Mark, JU. ¢., p. 500. In the frog’s egg the path of the male pronucleus is marked by a line of pigment, as was first described by Van Bambecke,”* and has been well figured by O. Hertwig.’?? The pigment renders it easy to ascertain the position of the male road, even after the first cleavage of the ovum. This Roux has done in sec- tioned ova, and from his experiments and observations reaches this result: The long axis of the first segmentation spindle lies in a plane, which passes through the axis of the ovum and the path of the male pronucleus. If Roux’s con- clusion is confirmed, it will become of fundamental im- portance. Yet there must be other factors which can at least replace the male pronucleus in this special réle, since the development of parthenogenetic ova, in which there is no male pronucleus at all, is equally determinate. It is probable that the distribution of the protoplasm is the real cause determining the position of the nucleus ; thus in oval eggs the spindle lies in the direction of the long axis ; it is quite probable that if the male pronucleus has the effect ascribed to it by Roux, it produces it in- directly by altering the distribution of the protoplasm within the ovum; that such alteration takes place is in- dicated by the occurrence of the male aster. After the spindle is formed it divides, and the daughter * In certain cases, notably in birds, as described below, the segmenta- tion is irregular ; and it is therefore not known yet whether the scheme of arrangement of the cleavage planes here given can be applied to all ova or not. We may say, however, that the scheme is the primitive one, from which any modifications arose phylogenetically, The best discus- sion of the subject is by Whitman.! 382 nuclei form the centres of two segmentation spheres or cells. Each of these cells again divides in the meridional plane at right angles to the first. The third cleavage is at right angles to both the first. If an egg is placed with its axis vertical, the planes of the first and second divisions both will be vertical, but that of the third will be horizontal. ; Segmentation occurs with many variations, according to the manifold modifications of ova, and these varieties we must now briefly consider. It has long been customary to describe the various modifications of segmentation as belonging to three types: 1, regular or equal; 2, unequal; 8, partial. It has become traditional to state that the first type is found in the Echinoderms, etc., and is characterized by the regular and uniform division of the cells (segments), so that there are first two, then four, eight, sixteen, thirty- two, sixty-four, and so forth, cells. But this statement is fundamentally erroneous. The frog’s ovum is taken as the example of the second type, and the bird’s ovum of the third. This classification is most unfortunate, for it leads attention off from the essential feature of the process of segmentation, as first pointed out by Minot in 1877. Minot” established the generalization that in all animals the yolk undergoes a total segmentation, during which the cells of the ectoderm divide faster and become smaller than the cells of the entoderm (Fig. 8436). There are, however, a small, and it seems diminishing, number of cases where the process of segmen- tation and the forma- tion of the germ-layers is imperfectly under- stood, and which can- not yet be shown to conform to this gener- alization. ‘‘ All the known variations in the process of segmentation depend merely upon: ee : : 1, The degree of differ- Fra. 8436.—Ovum of Amphioxus Lanceo- ence in size between the latus during Segmentation ; stage with two sets of cells: 2. the 88 celis. Magnified 280 diameters. (After time Gv heneihe ; alfaie Hatschek.) One pole is occupied by ence appears; 38, the large, the other by smaller, cells. mode of development, whether polar or by delamination,* either of which may or may not be accompanied by axial infolding. In Gas- teropods, Planarians, Calcispongize, Gephyrea, Annelida, fish, birds, and Arthropods the difference is great and ap- pears early. In Echinoderms, most Coelenterates, some sponges, in Nematods, Amphibians, etc., it is less marked and appears later” (Minot, J. ¢.). In most cases the entodermic cells are very decidedly larger and less numerous than those of the ectoderm. This distinction is obviously necessary on account of the mutual relations of the two primitive layers. The ecto- derm has to grow around the entoderm, which it can do only by acquiring a greater superficial extension—this the ectoderm accomplishes by dividing very quickly at first into small cells. After the entoderm is fully en- veloped it may then continue to grow until its superficies is much greater than that of the outer layer, within which, however, it still finds room by forming numerous folds; thus is gradually reached the condition in the higher adult animals, where the intestine sometimes has an enormous surface, but is nevertheless contained in body-walls covered by ectoderm presenting much less surface. It is, therefore, only during the early stages of segmentation that we find the entoderm expanding more slowly than the ectoderm. The degree of difference in size between the ectoderm and * There is notasingle satisfactory description of the process of delami- nation known to me, and one cannot avoid hesitating to accept it as an actual occurrence. It is certainly at most a very rare, and probably secondary, modification of segmentation. It does not occur among verte- brates. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Segmentation. Segmentation. entoderm cells depends upon the amount of yolk present. The yolk-granules are s¢twated, not quite exclusively but almost so, in those parts of the ovum out of which the entodermal cells are formed. Hence, when there is a great deal of yolk, the Anlage of the entoderm in the ovum becomes bulky, and the entoder- mal cells correspondingly big, as may be seen very plainly in amphibian ova. On the other hand, when the amount of yolk is very small, as in the eggs of echinoderms, the difference in size of the two kinds of cells is very slight at the start of segmentation ; but, as the cleavage process continues, the ecto- dermal cells, in consequence of their more rapid divisions, become marked- ly smaller than their entodermal fel- lows. Thesame may be said in regard to mammalian ova, the segmentation of which is described more fully be- low. Besides its effect upon the vol- (After Bobretzky.) Ume of the entoderm, the yolk matter Nuclei are seen scat- seems to actually retard the develop- tered through the ment of the inner germ-layer, by im- ee peding the division of cells. This ef- fect was pointed out many years ago, and is one of the familiar principles of embryology.* This is well exem- plified in the bird’s egg, in which the nuclei divide in the entoderm, but only gradually gather distinct cell-bodies about themselves, and in consequence the ventral side of the primitive entodermic cay- ity is bounded by a mass of protoplasm with scattered nu- clei and numerous yolk-gran-, ules; and as these last are transformed into protoplasm, the cells are completed as separate individualities. The proliferation of the nuclei without part passu separation of the cells occurs in similar manner in elasmobranchs, and comparable phenomena occur in many invertebrates, notably among the arthropods (Fig. 3437), with the so-called su- perficial segmentation. The terms holoblastic and meroblastic are applied to ova according to their manner of segmentation. The first is employed for those ova in which there is either very little or only a moderate amount of yolk, so that the whole of the ovum splits up into distinct masses (cells), which enter into the composition’ of the embryo. The second desig- nates ova with a very large amount of yolk, so that while the protoplasm from which the ectoderm arises divides rapidly into distinct cells, the entodermal portion merely de- velops nuclei at first, with the result that while one portion of the egg is ‘‘ segmenting,” another portion (the entoder- mal) remains unsegmented, so far as the external appearances are concerned. Eggs, then, with much yolk undergo the so-called partial segmenta- tion ; hence the adjective meroblastic. The result of segmentation is to produce two kinds of cells, ectodermal and entodermal ; the latter are the larger Fia. 3487.—Section of the Egg of a Moth. * It is not a little curious that two embryologists have recently discussed this principle as if it were quite a new discovery of their own. and contain most of the yolk-granules ; the entodermal cells may be represented for a certain period, partly or wholly, by a mass of yolk with scattered nuclei (Fig. 3437). The cells are arranged so as to form, each kind, a layer of epithelium. The two epithelia are joined at their edges ; the line of junction is the ectental line. (See Fetus.) Between the two layers, ectoderm and entoderm, is a space known as the segmentation cavity, and which varies in farm and size according to the species of ovum. Among radiates it approaches a spherical shape, and the two epithelia make a hollow sphere ; this arrangement is known as the Siastula form, and by some writers has been considered the primitive type of structure resulting from segmentation. In other cases the segmentation cavity is a mere slit between the entoderm distended with yolk and the ectoderm. (See the figures in the article on the Blastoderm.) Ultimately, the segmentation cavity is in- vaded by cells, which enter into the composition of the mesoderm (see Germ-layers, Gastrula, and Foetus, develop- ment of), and by which the cavity is ultimately filled up. The body cavity arises subsequently in the mesoderm. (See Ceelom.) The segmentation cavity is very much re- duced in amniote ova, and in birds is obliterated so early by the precocious thickening of the ectoderm that it scarcely can be said to appear. The best-known example of a meroblastic ovum is the hen’s egg. Its segmentation commences while it is pass- ing through the lower part of the oviduct, and shortly before the shell has begun to be formed. Viewed from above, a furrow is seen to make its appear- Fia. 3438.—Four Stages of the Segmentation-of the Hen’s Ovum. Only the germinal disk, seen from above, and part of the surrounding yellow yolk are represented. (After Coste.) ance, running across the germinal disk, though not for its whole breadth, and dividing it into two halves ; this furrow is developed in accompaniment with the division of the first segmentation nucleus. The primary furrow is succeeded by a second, nearly at right angles to itself. The surface thus becomes divided into four segments or quadrants (Fig. 3488, A), which are not at first separated 383 Segmentation. Seminal Incont’nece, REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. from the underlying substance. The number of radiating furrows, of which there are now four, increases to from seven to nine, when there occur a series of cross-furrows by which the central portion of each segment is cut off from the peripheral portion, giving rise to the appearance of a number of small central segments surrounded by more external elongated segments. Division of the segments now proceeds rapidly by means of furrows running in various directions. Not only are the small central segments di- vided into still smaller ones (Fig. 8438, D), but also their number is increased by the addition of more seg- ments cut off from the peripheral ones. Sections of the hard- ened blastoderm show that segmentation is not confined to the surface, but extends through the mass, there being also hori- zontal furrows, 7.¢., furrows parallel tothe surface of the ovum. According to Duval,!® whose ac- count of the segmenting hen’s ovum is, on the whole, the most satisfactory, when quite a small number of cells are separated off there is a small space between them and the yolk, as shown in his Figs. 2, 8, 4,5, and 6 of PI. L. ; this space he calls the segmentation cavity ; but this can hardly be, as the cells formed below it make part of the ectoderm (primitive blastoderm) ; the cells referred to are those marked 7m in Fig. 8 of the same plate; the space there lettered cg is the entodermal cavity. We can now speak of the primitive blastoderm (compare the article Blastoderm, vol. i., p. 528). The several-layered mass of cells represents the ectoderm ; it has only traces of the segmentation cavity. The yolk represents the entoderm. At this stage the ectoderm is not completely separated Fre. 3439.—Ovum of a Rabbit of Twenty- four Hours; the first cleavage has been completed. (After Coste.) Fie. 3440.—Ovum of Vespertilio Murina, with Four Cleavage Spheres, (After Van Beneden and Julin.) off, but still receives peripheral accretions from what may be called the segmenting zone around the blastoderm. For the further history see Blastoderm, and the first sec- tion of the article Foetus, where the differentiation of the cellular entoderm is described. The ovum of the placental mammalia is called holo- blastic, because it contains very little yolk and under- goes ‘‘ total” segmentation. Its segmentation was first clearly recognized by Bischoff, though it had been pre- viously seen and misinterpreted by Barry.? Very beau- tiful figures are given by Coste.!4 A number of more re- cent writers have dealt with the subject, among whom Hensen deserves especial mention. Reference may 384 —— also be made to Heape’s observations on the mole ;!* to Kupffer’s on rodents ; to Selenka’s on rodents and the opos- sum in his ‘‘ Embryologische Studien ;” to Van Beneden and Julin’s on bats,® and to Van Beneden’s on the rab- bit ;** but of these last the entire accuracy may be doubted. The ovum is discharged from the ovary sur- rounded by the so-called corona radiata, which is com- posed of cells of the discus proligerus. It passes quite rapidly through the first half or two-thirds of the ovi- duct, and during this period is impregnated and loses the corona radiata. In the lower half, or third, of the oviduct segmentation begins, and may be wholly or only partially completed when the ovum passes into the uterus. The ovum spends about seventy hours in the oviduct in the rabbit, and about eight days in the dog. The first cleavage plane passes through the axis of ex- trusion of the polar globules (Fig. 3439); the two seg- mentation spheres flatten out against one another. The second cleavage plane is probably also meridional, as is indicated by Selenka’s observations on the opossum ; and there are four equivalent cells as the result. Van Beneden asserts, however, that the cells are unlike, two being smaller than the others (Fig. 3440). These smaller cells he regards as the representatives of the ectoderm. The successive cleavages have never been followed ac- curately, but after a time there appear an outer layer of Fie. 8441.—Rabbit’s Ovum in an Advanced Stage of Segmentation. Z, zona pellucida; Hc., ectoderm of authors ; im., inner mass of cells, cells (Fig. 3441), He., forming an epithelium under the zona pellucida, Z, and an inner mass of cells, 7m., of darker appearance, which at first completely fill the space within the epithelium. During all these early stages the cells (segmentation spheres) are all naked, 7.e., Without any membrane; the nuclei, when not in karyokinetic stages, are large, clear, and vesicular; the yolk granules are small, highly refractile, and more or less nearly spherical; they show a marked tendency to lie in the egg, half-way between the nucleus and zona, or, when the cells are-large, around the nucleus, but a little distance from it. The outer layer of cells is not complete, but interrupted at one point, where the inner mass (Fig. 3441, im.) comes through to the surface. By the continued division of the cells of the subzonal layer, that membrane forms a larger vesicle, and there arises a space between the outer epithelium and the inner mass, as shown in Fig. 421, Vol. I. The cavity, I think, is probably the true segmentation cavity ; the outer layer is the entoderm, and not the ectoderm, as commonly de- scribed ; and the inner massis the true ectoderm. For the reasons of this interpretation see Blastoderm. LITERATURE, The literature upon Segmentation is very extensive. I cite a few of the principal articles, giving the majority of those which deal with the mammalia. There is no research published on mammalian segmenta- tion which meets the present requirements of embryology. 1 Agassiz, A., and Whitman, C. O.: On the Development of some Pelagic Fish-eggs. Preliminary notice. Proceedings of the American Academy, xx., 23-75, Pl. i., 1884. ‘ Seminal Inecont’nce. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES, Seementation. 2 Barry: Researches on Embryology, Series I., Philosophical Trans- actions, 1888, 301-341, Pls. v.-viii.; Series II., Philosophical Transactions, 1839, 807-880, Pls. v.-ix.; Series III., Philosophical Transactions, 1840, 529-612, Pls. xxix.-xxx. 3 Beneden, E. van: La Maturation de l’Ciuf, la Fécondation, et les premiéres Phases du Développement embryonnaire des Mammiféres, d’aprés des Recherches faites chez le Lapin, Journ. Zool., 1876, v., 10-56. e 4 Beneden, H. van: Recherches sur ’?Embryologie des Mammiféres, I.a_-Formation des Feuillets chez le Lapin. Arch. biol., 1880, i., 136-224, Pls. iv.-vi. 5 Beneden, E. van, and Julin, Charles: Observations sur la Matura- tion, la Fécondation et la Segmentation de ];Giuf chez les Cheiroptéres, Arch. Biol., i., 551-571, Pls. xxii.-xxiii. (Abstract in Bull. Acad. royale de Belgique, xlix.) 6 Bischoff, T. L. W. : Entwicklungsgeschichte des Hunde-Hies, 134, 15 Taf. Braunschweig, 1845. 7 Bischoff, T. L. W.: Entwicklungsgeschichte des Meerschweinchens, 4to, 56, 8 Taf. Giessen, 1852. 8 Bischoff, T. L. W.: Entwicklungsgeschichte des Rehes, 4to, 36, 8 Taf. Giessen, 1854. 9 Bischoff, T. IL. W.: Ueber die Bildung des Saugethier-Hies und seine Stellung in der Zellenlehre, Sitzb. k. bayr. Akad. Miinchen, 1863, i., 242-264, 1 Taf. 10 Bischoff, T. L. W.: Ueber die Ranzzeit des Fuchses, und die erste Entwicklung seines Eies, Sitzb. k. bayr. Akad. Munchen, 1863, ii., 44—- 55 11 Bischoff, T. L. W.: Neue Beobachtungen zur Entwicklungsge- schichte des Meerschweinchens, Abh. bayr. Akad., 1870, Ch. ii., x., 115-166, Taf. 7-10. 12 Bonnet, R.: Beitrége zur Embryologie der Wiederkiéuer, gewonnen am Schafei, Arch. f. Anat. u. Entwicklungsgeschichte, Anat. Abth., 1884, 170-230, Taf. 9-11. 13 Carnoy, J. B.: La Segmentation chez les Nématodes (La Cyto- diérése de ’Guf, etc., Seconde partie). ‘‘La Cellule,” iii., 1-108, Pls. v.-viii., 1886. 14 Coste, J. J. M. O. V.: Histoire générale et particuliére du Déve- loppement des Corps organis¢és. Paris, 4°, tome i., 1847; tome ii., 1859. Atlas, fol., 50 Pls. 15 Duval, M.: De ia Formation du Blastoderme dans l'Giuf d’Oiseau, Ann. Sci. Nat. Zool., 1884, xviii., 1-208, Pls. i,-v. 16 Heape, Walter: The Development of the Mole (T'alpa Europea), the Ovarian Ovum, and the Segmentation of the Ovum, Q. J. M.S8., xxvi,, 157-174, Pl. xi. Reprinted in Sedgwick’s Studies, ii., 201-218, PAS SOxT 17 Hensen, Victor von: Beobachtungen tiber die Befruchtung und Entwicklung des Kaninchens und des Meerschweinchens, Z. Anat. u. Entwicklungsgeschichte, 1876, i., 211-353. 18 Hertwig, O.: Beitrage zur Kenntniss der Bildung, Befruchtung und Theilung des thierischen Hies, Morph. Jahrb., 1875, i., Taf. 10-13. 19 Hertwig, O. : Beitrége zur Kenntniss der Bildung, Befruchtung und cheene des thierischen Hies, Morph. Jahrb., 1878, iv., 177-218, Taf. 20 Hatschek: Studien uber Entwickiung des Amphioxus, Arb. Zool. Inst. Univ. Wien, 1881, iv., 1-88, Taf. 1-9. 21 His, W.: Untersuchungen ber die erste anlage des Wirbelthier- leibes. Die erste Entwicklung des Hilmchensim Hi. Leipzig, 4°, 237, 12 Taf., 1868. 22 Mark, E, L.: Maturation, Fecundation, and Segmentation of Limax campestris, Binney: Bull. M. OC. Z., 1881, vi., 178-625, Pls. i.-v. 23 Minot, C. 8. : Recent Investigations of Embryologists, Proc. Boston Soc. Nat. Hist., 1877, xix., 165-171. 24 Roux, Wilhelm: Beitrige zur Entwicklungsmechanik des Embryo. No. 4. Die Richtungsbestimmung der Medianebene des Froschembryo durch die Kopulationsrichtung des Hikernes und des Spermakernes, Arch. f. mikr. Anat., 1887, xxix., 157-218, Taf. 10. 25 Schafer, E. A.: Description of a Mammalian Ovum in an Early Condition of Development, Proc. Roy. Soc., 1876, xxiv., 399-403, Pl. x. 26 Zacharias : Arch. Mikrosk. Anat., 1887, xxx. 27 Rusconi: Ann. Sci. Nat. Zool., tome v., p. 304. oe Bambecke: Bulletin Académie royale de Belgique, 1870, xxx., Dp: 65; 29 Hertwig, O.: Morph. Jb., iii., Pl. v., Figs, 4 and 5. Charles Sedgwick Minot. SELTERS is a village in the province of Hesse-Nas- sau, Prussia, near which is a spring which is the source of the well-known Selters or Seltzer-water. The follow- ing is the composition of this water. In one thousand parts of water there are: Calcinnibicarbona tere onthe rs ocak ch bee eioes 0.550 Magnesium: bicarbanateryg we). nis 4455 h 0s felde' viens (4 OF210 arrous: bicaroonatarn tite.) a teirelatwetc cat cee «cle 0,080 OGM sR PNAte emer Hs. ee aes Coase pat ce cisins a 6 ee 0.150 Sodiunitphorphates then tiehe se cees adds oes lobes 0.040 Podtmm.chicride te» ian? Ler S hahah Saree eee es 2.040 HR OURBETIIINY. CL OTIC Ou, <'cahoe:sleseiere’ =: alel otros tagttoms Mate averacshchow 0.001 Bilics’and alnminitim, ..<-..s0e.0.. pit Cea. 25 0.050 IOLA ae Bey eee Os Ped She Se seats eT ore Raney 4,092 Selters-water is exported in large quantities, very little use being made of it at the spring itself. It is recom- mended in the treatment of dyspepsia and catarrhal troubles of the respiratory organs. Its chief employ- ment, however, is as a beverage, 1 as? Vou. VI.—25 SELTZER SPRINGS. Location and Post-office, Men- docino County, Cal. Access.—By San Francisco & North Pacific Rail- road to Cloverdaie ; thence by stage. AwnaLysis (H. G. Hanks).—One pint contains (61° Fahr.) : Carbonvateiol SOUR ras. cee eek etter oie alt Hoa renee seers Carbonaterol MAPNesIa mle. 4 is ss ne se See ante oe 10.118 Oarbounte Ohlimess 3) 8. cee. oe ee eee eS 1.938 Carbonate ordronts Wises ete cee che tanned eet eee 0.567 Chloride GiasOduMiiastare reer. ceed on Waele oe eek 1.478 IIA Ree ye ce By ee carte ge SEES Ae cae SR ae tn rene I 0.075 SRO NCE Re th ig ey eu AR MOR LA ICAL dion 5 aaa rete Me Rae 0.729 PLOtales ths serde: tees. eku Ashes ote. MAST Eason ie ee Ue Gas. Cub. in Garbonic'acid) ay. cy. a6 asia ekee ae es. Hee ee ee 45 Goliad. SEMINAL INCONTINENCE. Derrinrrion.—By this is meant the involuntary loss of seminal fluid, whether one is asleep or awake, by ejaculations or passive flow. The term spermatorrhea has commonly been applied to this condition, but not with uniform significance. By some writers this word is made to signify only the passive flow of semen, according to its etymology (omépya, semen, and pew, I flow); and losses accompanying erections, spas- modic ejaculations, and orgasms, are styled pollutions. Some make a distinction between nocturnal and diurnal pollutions, or those in sleeping and waking hours, and so have three forms of the malady. Those who apply the term spermatorrheea to all forms of seminal inconti- nence, speak of true and false spermatorrheea, but here the distinction is not uniform. With some the irwe va- riety means emissions with erection and orgasm, while others restrict its use to cases in which the emissions con- tain spermatozoa. This last distinction is lacking in both precision and convenience, for the presence of sper- matozoa must be determined by microscopical examina- tion, and in the same case they may at one time be pre- sent, and at another time absent, according to frequency of emissions. In this article seminal incontinence will express all forms of involuntary seminal emission; the word spermatorrhea will be restricted to that form in which erection, spasmodic ejaculation, and orgasm are absent ; and other forms will be styled nocturnal and di- urnal pollutions, according as they occur in sleeping or in waking hours. NATURAL History.—It is to be premised that seminal incontinence may be physiological or pathological. Most men in vigorous health, who do not indulge in sexual intercourse, have occasional nocturnal emissions, and they may occur once in two weeks, once a week, or even oftener, without any impairment to health. It is only when they are followed by a sense of muscular exhaus- tion, pain in the head and back, mental hebetude, and de- pression of spirits, that they become morbid and require measures for theirarrest. In health the testicles, prostate gland, and seminal vesicles are in the constant exercise of their functions, from the period of puberty to the de- cay of old age, and their secretions are commonly re- dundant, that is to say, more than the absorbents can take up and carry off in the general circulation. This redun- dancy is relieved by a due amount of sexual intercourse, or by occasional involuntary emissions. Excessive stimu- lation and use of these organs result in seminal inconti- nence, and later in impotence. It is unnecessary to re- peat here what is described in other articles about the anatomy of the male sexual organs and their functions. Most cases of morbid seminal incontinence begin with nocturnal pollutions, which become more and more fre- quent unless the exciting causes be discontinued. In neglected cases the malady is aggravated, gradually the pollutions become more frequent, they begin to occur In waking hours from indulgence in libidinous thoughts, from the friction of the clothing, especially in horseback- riding, from toying with women, from perusal of inde- cent books or pictures, and frequently during defecation and urination. The erections and orgasm diminish, until the complaint runs into the third stage, when they cease, 385: Seminal Inconvnces REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Senega. and the flow is passive, sometimes intermittent and some- times constant. There are instances, however, in which the emissions are passive from the beginning, but these result from gonorrhcea and are exceptional. As the pollu- tions become more frequent, they contain fewer sperma- tozoa, which are immature, have little or no motion, and finally are absent. In consequence of catarrh of the pros- tate gland and seminal vesicles the spermatic fluid loses viscidity and becomes watery. In some cases digestion is much impaired and the bowels become constipated. In an advanced stage the moral depression is the most seri- ous feature ; for the unhappy subject is usually ashamed to seek relief, as he would in ordinary complaints, and is apt to fall into the hands of those rapacious quacks who hire the services of a venal press to promote their nefari- ous business of exciting groundless fears and delusive hopes, by which victims are attracted to their toils, to be plucked without mercy. An analysis of 175 cases by Professor 8S. W. Gross, M.D.,! shows the relative frequency of a large number of symptoms, as follows: Anxious and depressed condi- tion of mind, 72; constant dwelling on sexual matters, 72; hypochondria, 14; mental dejection after intercourse or emission, 60; impairment of memory, 55; incapacity for prolonged mental exertion, 68; headache, 69 ; vertigo, 30; broken sleep, 15; insomnia, 6; drowsiness, 11; iras- cibility, 2 ; asthenopia or musce volitantes, 31; noises in the ears, 26; muscular weakness of the limbs and fatigue, 118; trembling of the limbs, 10; temporary reflex para- plegia, 1; pain in the back, 95; oppressed breathing, 7; pain in the chest, 3; constipation, 61 ; dyspepsia, 40 ; pal- pitation of the heart, 26; subjective sensation of cold, 11 ; and of heat, 4; loss of flesh, 9 ; pallor of the face, 15 ; feebleness of erection, with premature ejaculation, 38 ; irritable weakness, 29; total failure of erection, 10; elongation of the prepuce, 29; relaxation of the scrotum, 19; irritable testis, 9; varicocele, 6; hemorrhoids, 5; coldness of genitalia, 8 ; sensation of heat in genitalia, 3 ; painful ejaculation on intercourse, 3; bloody ejaculation, 1; irritability of the bladder, 8. As the emissions become more frequent, the erection and the orgasm are less pronounced, and the ejaculation is premature. There is pain in the head and back, with muscular fatigue and indisposition for mental effort. Then follow vertigo, loss of memory, depression of spirits, aversion to company, especially that of females, asthenopia, trembling, palpitation, shortness of breath, indigestion, and constipation. Finally there result im- potence, hypochondria, insomnia, neuralgia, cold ex- tremities, and a peculiar expression of shame. This is the usual course in neglected or ill-managed cases. Morsip ANATOMY AND PatHoLocy.—In the early stage of seminal incontinence there is preternatural ir- ritability of the ejaculatory muscles and of the ducts of the seminal vesicles, together with excessive sensibility of this part of the urethra from undue excitation. As the case progresses the canal becomes inflamed and its walls are thickened, with narrowing of its calibre, par- ticularly in the prostatic portion and near the meatus. Of 1538 masturbators who became subjects of seminal incon- tinence, Professor 8. W. Gross found that 127 had one or more strictures, of rather moderate narrowing in most instances, and 22 other cases not traced to masturbation all had stricture, with a single exception. Hyperesthe- sia of the urethra existed in all but 11 cases. In an advanced stage the ducts of the seminal vesicles are en- larged and lose their sensibility. Inflammation of the epididymis, or of the seminal vesicles, may occur, and in the latter case is accompanied with painful purulent or bloody emissions. Errotoegy.—In a large number of instances a neurotic temperament may be regarded as a predisposing cause, and this view will be confirmed by the discovery of other neuroses in the same subject, or among his near rela- tives. It might be more correct to say that this tem- perament induces the habit of masturbation. Undoubt- edly ascarides, or a long and narrow prepuce, with a mass of imprisoned smegma and an irritable and herpetic glans penis, will lead to early masturbation. Habitual consti- 386 conditions. pation, piles; fissures, and pruritus ani have the same ef- fect in later years. Inquiry into the previous history will show that a considerable number have been subjects of nocturnal incontinence of urine in early childhood. In- dulgence in erotic thoughts, and perusal of lascivious books, also lead directly or indirectly to seminal inconti- nence. The concurrence of seminal emissions with tabes dorsalis is explained by the diminished inhibitory control of the spinal cord in the functions over which it presides. Its occasional concurrence in the early stage of pulmo- nary phthisis, in variola, typhus fever, and chronic al- coholism, is probably to be accounted for on the same ground, but the connection is less apparent. In the 175 cases analyzed by S. W. Gross, the exciting cause was found to be masturbation, 153 times ; gonor- rhea, 7 times; masturbation and gonorrheea, 11 times ; toying with women, 1; cause obscure, 3 times. It was attributed to inherited predisposition once only. In the same list 154 were unmarried, 18 married, and 3 were widowers. Twenty-two occurred under twenty years of age; 103 between twenty and thirty years of age ; 36 be- tween thirty and forty years of age; and 14 between forty and fifty-four years of age. All the married men indulged excessively in sexual intercourse. DraGnosis.— Whenever the emissions take place with erection and orgasm, there can be no question that they are seminal. In cases which have begun in this way the presumption is strong to the same effect. The detec- tion of spermatozoa requires a microscopic power of four hundred diameters, but they may be absent in chronic and aggravated cases of seminal incontinence. With a history of gonorrhcea rather than of masturbation, and with emissions without erection or orgasm from the beginning, diagnosis of gleet or prostatorrhcea would be presumptive, to be confirmed by absence of spermatozoa. Proenosis is favorable in cases which have not ad- vanced to protracted impotence, and are not attended with profound hypochondria. carted straight into the middle floor, where closed latches are provided for simply shooting it into the railway wagons. All the general city refuse, which is composed of (1) contents of ash- pits and bins, (2) excreta, and (3) street Sweepings, is taken to the top floor, where special pro- vision is made for each variety. The contents of ash-pits and bins are shot into revolving screens of new design. Each DBD] IN an if H Oo ! . ra ! FLU E@d 6 UI || DESTRUCTGR h \ A \ SN \\\ \\ \ 7 N S N fp \ A WA Wi a NS WS N WRC Fia@. 3465.—Beehive Destructor: Plan through Line S 7 of Fig. 3466. screen (making fourteen revolutions per minute) has a double action, and, although in one piece, is practically a screen within ascreen. By the first action upon the inner mesh, sloping from west to east, all the rougher rubbish which will not pass through a one and one-third inch opening is separated and delivered on a travelling carrier at the east end of the screen; and by the second action upon the outer mesh, sloping in the opposite direction, the material which has passed through the inner mesh travels back over the one-half inch outer mesh. The material—chiefly cinder—which passes over this one-half inch mesh is delivered at the opposite end of the screen from the rubbish, and is thereafter passed down a shoot to 412 \\ WE . [N SS - REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. the front of the boilers, where it is used as fuel and serves to raise steam for the works. The fine ash and smaller manurial particles fall through both meshes of the screen, and thence down a shoot into the mixing machines, which stand upon an elevated platform on the floor immedi- ately below. Into these mixers there passes at the same time a mechanically regulated quantity of excreta. The carts and vans in which this material is collected also ascend to the top floor, where the contents are passed through gratings into closed cast-iron tanks, which rest on the second floor, and from which, by a simple mechanical arrangement, the desired supply is allowed to escape into the mixers along with the fine ash, which absorbs and deodorizes it. In order to fix the ammonia and further deodorize the compound, provision is made for adding sul- phuric acid, or other disinfectant or deodorant, to the excreta in the tanks.” The other material which is shot into the mixer is the more concen- trated detritus from the paved streets of the city (the sweepings and scrapings of the macadamized streets being sent off to a heather swamp which is being reclaimed). It is also taken to. the top floor, passed, if wet, through drainage tanks, and then added, in certain proportion, to the com- pound already de- scribed sin yt be WRN mixing machines, whose _ revolving blades thoroughly mix the whole into a deodorized com- pound, which is delivered into the railway wagons di- “rect, and the farm- ers are supplied with a prepared ma- nure in good con- dition for spreading on the land. The rough rubbish, it has been observed, is delivered by the inner screen on a travelling carrier. This is an endless web of iron plates on pitched chains, which is made to travel thirty feet “per minute. Wom- en are stationed in front of it to pick off anything which can be sold or util- ized. One picks off, first of all, what is manurial, such as dirty straw, pulsy ; matter, vegetable refuse, etc., and this garbage she drops down a shoot by her side to the wag- on direct, where it gets mixed with the compound as it comes from the mixer. The other materials picked off for use are old iron, old boots, meat tins, rags, paper, etc. The remain- der is shot from the carrier into a specially constructed cremating furnace, where it is reduced to cinders, which are, of course, innocuous, and, like common furnace ashes, go to make roads or fill up ground. [In some places they are ground up for mortar and sold.] The various articles of garbage above referred to are mostly sold to persons who can make use of them. Old iron goes for precipi- tating copper; ammonia is extracted from old boots; solder is taken from meat tins, and so on.” There are four sets of rails running inside the building, with a trav- | H S t S Me DESTRUCTOR } P i H QB WN WY ~ WSS ENN \\ WN \ REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. erser for shifting wagons from one ps to the other; all traversing and haul- ing are done by steam-power. A large exhaust-fan carries off foul air and sends it through the furnace-tires, Lavatories, baths, and eating-rooms are provided for the work-people. One great feature of this establish- ment is that nothing capable of de- composition is left on the premises for twenty-four hours. Of refuse crematories, or destructors (as they are mostly called to distin- guish them from ¢ncineraria), there are already many varieties. In the most successful it is claimed that little or no fuel is used, except to start the fires, but that, on the other hand, the heat from the burning ref- use is used in destroying night-soil, furnishing motor power, ventilating sewers, etc. One that has been long and extensively used is the Bee-hive Destructor of Mr. J. E. Stafford, A.M.1.C.E., of Burnley, Lancashire, England; for which there are agents in America, There may be used either a single cell-destructor, or one of many cells, the latter being the most effec- tive, the heated gases from one cell being carried over to the next—con- tributing heat and giving up to de- struction the noxious vapors. A de- structor with six cells is shown in Fig. 8465, the plan being taken just below the grates, on the line S 7 of Fig. 3466. Fig. 3466 shows a vertical section through two opposite cells on the line 7 P of Fig. 3465, Fig. 3467 is a vertical section through the zig- zag line Y Z of Fig. 3465, and shows the flues leading from the upper sur- face of one fire to the lower surface of the next, and from the last fire to the chimney. ~ Fires being lighted on the grate-bars K, carts are driven to the shoot J (Fig. 3466), down which the garbage is dumped ; sliding down the refuse chamber B, where it becomes some- what dried, it reaches the combustion- chamber A. When the fires are first started, or when from any other cause there is a poor draught through the flues C, C (Figs. 3465 and 3467), the dampers D, D, D (Figs. 3467 and 3465) may be shut, and #, #H, H opened (Fig. 8465), and the smoke will pass through the flues 5, 0, 5, directly to the main flue G, and so to the chim- ney. When the fires are good and the flues (, C clear, the position of the dampers is reversed, and the va- pors pass through the flues (0, C and through the successive fires on their way to the main flue G. As in all crematories, the parts exposed to fire are lined with fire-brick. The Engle Cremator ‘‘ has been re- cently invented at Des Moines, I[a.; it contains two fireplaces, one at each end, and is so arranged that the gases of either can be passed through the other fire by a shifting of dampers. The bottom of the furnace is made of heavy iron plates, so set that they form a chamber beneath, through which the fire may pass on its way to the flue. Just above these plates VA\ NUNS Or on) sib< Hb GAGSSZ Bis YinT EX RS n ined TeleFerbod poke N NY 3 = St e ae Ab N AAS Bs. WA; AH (id Aly a SA Gf Uf. Wir as Uf a WWE @ZZzMWO = | { 4 s a Ky uinken Door T nate SSL NG Tot’ VA Ze Nae rb ai) Lis aT BG Z Ne NEN ee A ml: G Sie Yn. es 7 ia is an ee Z | 7 Wf Si\ a ZY Se % @ = KS hi c D\ oo LMA SS LG ® A Gy ad Yj: ASQ SSS Y ASS Pie SAN YY WIA MES Ww Lf \ \ eS SW WS VBS WS ge P anes C= * & : B \\\ ‘ WIZZ. NAC ION Ge, ONLY UN TEN DON aD) tigi ; Z oe Section through Line A F of Fig. 8465. Fia. 3466.—Bee-hive Destructor: Sewage. Sewage. there is a grating upon which the material lodges after it is dumped or thrown in at the top. The fires are so arranged that one will pass over the top of the material to be consumed, driving the gas forward and down- ward through the other fire, there inflaming all of the gases from the material, and using the heat to main- tain the fires of the furnace, and at the same time rendering the escaping material [gas] from the flues inodor- ous and nearly transparent.”’ At Montreal, Q., garbage and night- soil are cremated in a furnace (Fig. 3468) of very simple construction, and the result is said to be very satisfac- tory. The furnace was planned by the City Contractor, Mr. William Mann. The grate isa little over six- teen feet long and nine wide, extend- ing by a gentle upward incline from the fireplace at one end, where the fire is started, to the flue at the other end. The combustion-chamber is quadrilateral, a little over sixteen feet long, nine broad, and ten high. On each side of it are nine doors; three at its upper portion open out upon a stage on to which carts are driven, the refuse being put into the furnace through these doors ; the next lower doors open just above the line of the grate, and are used for stirring the fire; the three lowest are at the bot- tom of the furnace, and are used for removing the ashes. Under the grate is a receptacle for water (not shown in the sectional cut, Fig. 3468). This may be varied in, different furnaces, the object being to prevent over-heat- ing and destruction of the grate. This latter consists of iron bars, their ends being laid on the brick, the in- ter-spaces between them being two inches. The flue is about twenty-two inches long and eighteen wide—in- side measurement. The chimney is ninety feet high. Among other fur- naces may be mentioned the Rider Furnace, of Pittsburg, Pa., which has been but a very short time in opera- tion, and of which, therefore, nothing very satisfactory can be said. While there is no doubt as to the success of garbage-cremation, the va- rious forms of furnace may be said to be still on trial, as the reader may have inferred from the above descrip- tions. It seems as though the best results would be obtained by cremat- ing on a large scale, and maintain- ing a constant high temperature ; by so arranging the furnaces that surface- heat may be utilized in drying mate- rial on its way to the fire; and by consuming the heated gases on their way to the chimney. Individual householders can mate- rially aid in the disposal of garbage. Vegetable matters, if carefully kept from grease and animal contamina- tion, may be given toa horse or cow, if one is kept. In some cities and towns garbage is, to a great extent, burned by the householders. It may be prepared for burning in a recepta- cle fashioned something like a steam- er used for cooking. 413 Sewage. Sewage. 8. OF DRY-EARTH AND DRY-ASH METHODS nothing need be added to what was said in the section treating of imme- diate disposal. 4, Liguip SrwaGE.—The modes of ultimate disposal are: (a) Emptying into tanks or cesspools ; (0) discharg- ing into some body of water ; (c) irrigation ; (d) filtration ; (e) precipitation and deodorization. (a) Cesspools are excavations in the earth into which sewage is allowed to flow. They are sometimes water- WK SSS SS ‘J ‘ T= Wee SF Lig cme ose t HTS ES UK ECZEMA ZZ SHEEN f SS AN REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. dation takes place far less readily than in fresh water (see Sewerage). (c) rrigation.—This consists in discharging the sewage upon or into the soil in such a way that it shall be acted on by growing vegetation. The soil acts as a filter, straining out particles ; then, by the separating action of the earth-particles, a large surface of the fluid is ex- posed to the action of the air, and the organic is reduced to inorganic matter. The experiments of Mintz, Pas- ey A A N= BD6C.KE.l6C6pCU KKK SK < \ Z yi M ] YY Y Li MMMM IR G CHIMNEY [7 /R Ele oy tH NEAL Ze SEZ Fic. 3467.—Bee-hive Destructor: Section through the Zig-zag Line Y Z of Fig. 3465. tight, and sometimes the sewage is allowed to percolate through the bottom. Their walls and roofs may be of wood, brick, masonry, or cement. Sometimes the walls are allowed to be pervious as well as the bottom. They are generally provided with an overflow, unless the soaking away of the sewage is fully insured. Old wells are oc- casionally turned into receptacles for sewage. In those rare cases where cesspools are allowable, they should be ventilated by a tall outlet, and shorter inlet, shaft. (0) Discharge into some body of water.—This is the mode which has been generally adopted and continued in each individual case, until it has caused a nuisance such that means have been taken to prevent it. So gen- eral had the nuisance become in England, owing to the density of population, that in 1876 the Rivers Pollution Prevention Act was passed, providing that no rivers or streams should be polluted through the admission of crude sewage. For years, both before and since that time, the question of sewage-disposal has engaged the attention of numerous parliamentary committees and commissions, and of many of the foremost scientific men. Some places, as, for example, cities situated on rivers like the Lower Missis- = S ike | 4 sippi and St. | | 1 IZ Lawrence, tage INA Daoars, far are so favor- fer Carty, NZ ably situated INZ that they are RAS: teur, and others, go to prove that this process is aided by micro-organisms in the soil. Vegetation also assists by utilizing the inorganic substances. Hence, it will be apparent that there must be alterna- tions of sewage and air in the soil, and that the soil must be in such a condition as to allow the sewage to run through and out of it, and that the vegetation must not be overdosed. ‘There are great differences, moreover, in the capacity of various kinds of plants for utilizing sew- age: In England osiers, Hungarian grass, Italian rye- grass, cabbages, mangolds, and other coarse-grained and succulent vegetables are especially recommended. But the market must also be considered. During a recent visit to Pullman the writer was informed by the cour- teous farm-superintendent, Mr. E. T. Martin, that he grew Italian rye-grass, but could not get cat- tle-feeders to take it away, although he of- fered finally to give it to them. The stalks the Pnlrance of Refuse : . Tz SR S ry 7 L e@. relieved from this yy. LAE rs fr" stirring FU ee = difficulty; butin very Lab =! heal pars: aes many places on this [| grate _acsseeeee ZR continent it has be- peecesenesee SVv come a very urgent u— paeas Ash, Doors. SV and serious one, ow- € SCL ing to the pollution et - LZEZEZZZZZLZTEZZ DZD OB WWMXx‘wW ww A celle of the atmosphere “\WIZIiyy AURNINIEZINN NSAI IN SIN ZY SB WNT Ses NENG WETS Se Sl ZONE ENB TNE WI SI and of the sources of NP cI NW Zoi NEV @ Say, yl 47 = Ne SME WAG yp LY! water-supplies ; and it has given rise to commissions of inquiry, the reports of some of which form valuable contributions to the literature of the sub- ject. Among them may be mentioned the reports of Dr. Charles F, Folsom, Mr, J. P. Kirkwood, C.E.,; and others, in the Annual Report for 1876 of the Massachusetts State Board of Health, and the later report (1884) of Mr, Sam- uel Gray, City Engineer of Providence, R. I. In discharging into the ocean much difficulty has arisen from the action of tides, coupled with the fact that oxi- 414 Fic, 3468.—Cut showing principle of Montreal Garbage Destructor. grew very thick, rank, and watery. The principal crops at Pullman are cabbages, celery, and onions; turnips do well, but the market is unreliable. Potatoes fail utterly. Other vegetables can be raised, but those mentioned are found to suit best. It is a common mistake to suppose that rain is not needed on sewage-farms ; it is necessary for the destruction of insect-pests. The Pullman farm has yielded a fair profit on the investment, apart alto- gether from sanitary advantages, except in those years Q REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Sewage. Sewage. when frost or other unfortunate accidents have had a de structive influence. Sandy loams, and loams with a substratum of gravel or chalk, are well adapted for irrigation. In the case of stiffer soils, subsoil drainage is necessary. Experi- ence has Shown that it is not well to use pipes of a smal- ler diameter than four inches for this purpose. ; They should be laid ata depth of from four to six feet, but the distance between the lines of drain varies very much in practice; in some places we read of their being forty inches apart, in others as much as eighteen feet. These subsoil pipes should, of course, be porous and open-jointed. Solid substances are screened out before the sewage is applied to the land. In some places the sewage is con- ducted or pumped to the highest part of the farm, and thence distributed by sluices and ‘‘ carriers” in the sev- eral methods presently to be described ; in others it is carried in underground pipes and pumped from hydrants placed at intervals—one hydrant to every two and one- Fie. 3469.—Tile-carrier, with separate Side-pieces. form of broad irrigation is what is termed the ‘ con- tour” or ‘‘catch- water” method, which consists of a series of shallow channels, or carriers, terraced one above the other, with gently sloping land between; the water flows into and overflows the highest carrier, then down the slope into the next, and soon. The carriers fol- low as far as possible the contour of the ground, and the distance is regulated by the slope and nature of the soil— an average of two hundred feet is recommended. The ‘‘carriers” may be formed in the earth itself, which is generally firm enough, or they may be edged ‘with turf, or tiles may be used, as shown in Fig. 3469. The capping of these tiles may be used as a footpath—a great advantage. It may be noticed, too, that the side R is higher than L, which allows the sewage to overflow. In carriers valves are sometimes placed, similar to the flap-valve in the Palmer trap (see Sewerage), but regulated as to the amount of opening byahandle. These must, of course, be contained in a closed-pipe carrier. The side- pieces (L, R, Fig. 3469) are made separate from the bot- tom tile B, and additional side-pieces may be let in, thus making the carrier deeper, if required as a conducting main. ‘These main carriers or sluices are sometimes con- structed in the earth and edged as above described, or they may be of tile or cement. Fig. 3470 represents a farm on the ‘ flat-bed” system. ie il Fia. 8470.—A Sewage-Farm, Irrigated on the Flat-bed System. third acres is the apportionment at Pullman. It is ap- plied to the land in various ways: it may be poured out upon it in a stream, the direction of which may be changed by hose, boxes, or half-pipes, which latter may be turned with the foot ; to this the term ‘‘ broad irriga- tion” is applied. Grass land often receives a ‘‘ surface treatment” of this kind, a section thus treated being oe, Fia. 3471.—Section of Land Irrigated on the Flat-bed * System, the sew- age in this case being confined by a strip of turf on the lower edge of each bed, and supplied by a carrier at the upper edge. fenced off for a few days before cattle are allowed on it. A rain following the application of the sewage improves the land very much for pasture purposes. A modified *T am aware that the term “ flat-bed” system has received a different application at the hands of some: but it is used as given in the text by Mr. Wm. Eassie, O.E., F.L.S., F.G.S., as also are the terms ‘‘ pane and gutter” and ‘“ sewage-cropping,” respectively applied to the next two modes. See Our Homes, Cassell & Co., London, 1883. (From Dr. Foisom’s Report.) The surface must be graded so as to have a slight incli- nation—say one foot in fifty, to one in one hundred and fifty, according to the nature of the soil, the crop, and the amount of irrigation required. The sewage 1s con- ducted along the main sluice A, E, and can be stopped at any desired point by the main dam F;; it is led into the laterals by the gates G, G, G, and it may be stopped at Frq. 3472.—* Pane-and-gutter”’ or ‘‘ Ridge-and-furrow” System of Sew- age [rrigation. any required distance by the lesser dams D, D. The sewage is thus made to flow over a portion of the land for a few hours at a time, at intervals of as many days as may be found necessary. A method is in operation (and is being gradually extended) at Pullman by which a more uniform result is obtained. The beds are arranged in sets of six, three on each side of a broad, low, turf 415 Sewage. Sewage. wall, which runs lengthwise down the slope; the re- maining sides of each bed are also surrounded by a little turf wall, and in this rink-like form the sewage can be more evenly spread ; a hydrant stands at the head of the broad dividing wall, and, by means of a sluice-box, sup- plies sewage to the beds on either side ; at the lower end of each of the first and second beds, close by this median H) if) ra ff Ue. y /} My Hf My Wy) Wy] f Yi if ik Hf / , I, fi | WAT i} YL i / Fic. 3473.—‘‘ Sewage-cropping,” by allowing the sewage (C) to flow in the gutter (D) and percolate into the beds on either side. i I) if Hf} ‘ YY yh WIN Fa Hy Wi Hy, f wall, is a small sluice-gate, so that the sewage can be let into the lower beds only, or into any of them at will. In Fig. 3471 is shown a section of a series of beds on a somewhat similar principle. The ‘‘ pane and gutter ” or “‘ ridge and furrow” method is represented in Fig. 3472. The land should be deeply cultivated and well pul- verized, and arranged in ridges and furrows so as to form long beds, as shown in Fig. 8472. These should be from forty to ninety feet wide, according as the land is light and loamy, or of a less porous nature. The slope should be from one in twenty to one in forty, according to the nat- | ure of the soil. The sewage is then conducted in a carrier or shallow trench along the ridge, and allowed to overflow uA and soak Pay oF, through oon Be the slop- HE. C4 ; : vg er ing bed; Bee o if grad- Siooper ing and distanc- ing be carefully done, there will be little over- flow left to be carried off in the gutters by the time they are reached. In some places porous or perforated and open- jointed tiles are placed on the ridges instead of the carriers. Another mode of ap- plying the sewage is to allow it to flow into gutters or channels in the earth, and soak through the sides of these channels into beds on either side, from BA, Oa EGR Fic. 3474.—A Diagram showing the mode of disposing of the Sewage of the Double Cottage A, by Subsoil Irrigation. which it is taken up by the roots of vegetation. It will be evident that the sides of these channels will require to be scraped or loosened more frequently than in the other methods, so as to allow more ready percolation. Fig. 3473 gives an example of this method of irrigation, to which the term ‘‘sewage-cropping” is applied by Mr. Eassie. In this case the distance A B from centre to cen- tre of the beds is about two feet, but they are often much wider ; the depth of sewage-space in the gutter, C to D, is 416 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. about nine inches ; the length of the distance to be trav- ersed in the gutter by an outflow of sewage will, as be- fore, depend upon the character of the land, and may be about one hundred feet in light soils, and more in less porous soils. Subsow Irrigation.—There are at times circumstances, such as close proximity to dwellings, which render it undesirable to have sewage exposed on the surface, and in these cases it may be applied about a foot below the surface. This must not be confounded with subsoil drainage referred to above. Unless the subsoil is very porous, we still have to employ subsoil effluent drains below the subsoil irrigation-drains. This is shown in connection with the disposal of the sewage of two cot- tages in Fig. 3474. It is not prudent to have the sewage discharge into the soil near the dwellings, and the black lines nearest the tanks D D represent water-tight glazed tiles which conduct the sewage into porous tiles with open joints, represented by the branch lines CC CC; the effluent drains are represented by the light lines B B, converging into O, the main effluent. Subirrigation- drains have to be raised, as they are liable to become clogged. It is well to do this every season, or bends only may be raised, as they are most liable to clog. In taking up the drains another advantage may be gained, as their lines may then be laid in fresh portions of the soil. In places where the flow is small, as in private houses, tank is employed, the sewage be- ing discharged periodically. The tank may be made to discharge by some automatic ar- rangement, as seen in Field’s Flush-tank (Fig. 3475). This is a cylin- drical iron tank, A. In the case of its receiving sewage from a discon- nected pipe (see Sew- erage) it should have a trapped in- let, B, which also serves aS a mova- ble cover. Cis a ventilating opening; D is the siphon; /’, termed the ‘* discharging trough,” consists of asmall chamber, which may be turned around so that it may connect properly with the pipes G, through which the sewage discharges. It has a movable cover for getting at the mouth of the siphon. This trough forms a temporary check to the flow, so that the siphon can be brought into action. An- other advantage of this periodic discharge is the period of rest which is given to the soil, the necessity for which has been alluded to. In irrigation on the large scale this intermittent action must be regulated by the attendants according to the crop. Sometimes it is desirable to allow three or four days to elapse between ‘the successive irrigations. It is always desirable to have a fallow or idle field on to which sewage may be turned, when the crops would be injured by it, or when they are being taken off. In irrigating on the large scale the distance traversed is generally sufficient to break up fecal matter, and the action of pumps has a similar effect, so that all may be turned on to the land. ‘There are many other matters in sewers, however, which must be screened out. Where their value as manure is not a consideration, the excreta are sometimes intercepted, and treated by some of the methods recommended for night-soil. In household ir- rigation—by gravity—they are generally intercepted. The solids are sometimes precipitated by some of the methods presently to be described, and the supernatant fluid alone is used in irrigation. This is not to be rec- ommended from an economic point of view. I have before stated that in the dry and pneumatic methods the disposal of the slop-water has to be pro- vided for. This may be done.by means of irrigation. Si i eg) a Ps Me ~ Fie, 3475.—Field’s Automatic Flush-tank. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Town sewage can be far more profitably treated if the separate system of sewerage (see Sewerage) has been adopted, thereby rendering the sewage less in quantity and more concentrated. The amount of land required for irrigation will, of course, vary with the nature of the soil and character of the sewage, but one acre to one hundred people is given as a fair proportion. It was at one time considered doubtful whether sewage could be disposed of by irrigation in winter in very cold climates. This difficulty has been solved by the expe- rience of Dantzig, of the City of Pullman, before al- luded to, and of the State Asylum for the Insane at Au- gusta, Me., where the sewage flows out in winter. Its warmth keeps it from freezing, and it flows over the ground ; if this is covered with snow it works its way underneath. It is found that the soil purifies it even without the action of growing plants. (d) Filtration. —Intermittent downward filtration resem- bles very much the mode of irrigation with subsoil drain- age. The drains are placed at a greater depth if the nature of the soil and outfall permit, and larger quanti- ties of sewage are poured upon the land, and with greater frequency ; as less regard is had to the paying result in cropping, a less quantity of land is required. The land is divided into several filter-beds—four at Merthyr Tydvil —the sewage being successively poured for a certain UaivMm 1G Sewage, Sewage. ‘“‘ The phosphate sewage process patented by Mr. David Forbes and Dr. Astley P. Price. Phosphate of alumina and lime.” ‘‘ Bird’s process. Sulphuric acid and clay.” ‘“‘Stothert’s process. Lime, sulphate of alumina, sul- phate of zinc, and charcoal.” ‘2, Processes which employ lime as the chief precipi- tating agent : ‘‘ Hille’s process. Lime, tar, salts of magnesium, etc.” “‘ Marsden and Collins’ process. Lime, carbon (a waste product of prussiate of potash manufacture), house ashes, soda, and perchloride of iron.” ‘‘ Holden’s process. Sulphate of iron, lime, coal-dust, and clay.” A ‘*Fulda’s process. Lime and sulphate of soda.” ‘‘ Blythe’s process. Superphosphate of lime, with mag- nesia and lime.” ‘“Whitthread’s process. Dicalcic and monocalcic phos- phate and milk of lime.” ‘“Campbell’s process. Soluble phosphate of lime.” ‘“Hanson’s process. Lime, black ash, and red hematite treated with sulphuric acid.” ‘‘Goodall’s process. Lime, animal carbon, ashes, and sesqui-persulphate of iron.” ; ‘The Lime process. Milk of lime.” ‘“General Scott’s process. Milk of lime; the sludge being burnt, forming Portland cement.” cCARBOY SULPHURIC . Fie. 347%6.—Process of the Widnes Alkali Co., for Deodorizing the Contents of Sewers, by forming and mixing with them (as made) Permanganate of Soda. A is an iron tank about six feet by six feet by four feet, with cold-water supply-pipe and overflow-pipe. Manganate of soda is introduced into this tank, the cold-water inlet-tap opened, and the solution flows out of the overflow-pipe into the mixing vessel C, a small, lead-lined cistern | about two feet by two feet by two feet. Here it meets with sulphuric acid from the lead-lined cistern B (about four feet by four feet by two feet in dimensions), the flow of which acid is regulated in such quantity as to turn to a bright pink color the manganate of soda solution from tank A. The manganate of soda solution is thus turned intoa permanganate of soda solution in the tank C, and runs through the overflow-pipe at the top of C into the drain or sewer where it is required, ~ regulates the rate of overflow to the required quantity. number of hours upon each ; in this way time for aéra- tion isgiven. At Merthyr Tydvil irrigation upon another tract has been added. Upward filtration has been tried, as at Ealing, but has not proved satisfactory. Of carbon-filtration the same may be said, the carbon being at present too expensive. (e) Precipitation and Deodorization.—After the agitation against sewage-pollution began, a vast number of pro- cesses were proposed, ranging from simple subsidence in tanks to the use of chemicals, appalling in their number and variety. It most cases these chemicals are mixed with the sewage in settling tanks, the clarified liquid be- ing decanted off and the precipitated sludge being dried, or put on land at once. Some of the processes contem- plate the addition of the chemicals in the sewers. the most recent of these is the permanganate of soda pro- cess of the Widnes Alkali Co., of Widnes, Lancashire, which may be understood by the accompanying cut (Fig. 3476), and description. The following well-arranged, brief list of some of the more important chemical methods that have been tried I extract from Gray’s Report, before alluded to : ‘1. Processes that employ salts of alumina as the chief precipitating agent : ‘“The Coventry process. salts of iron, and lime.” ‘The Native Guano, or A, B, C, process. Alum, blood, clay, and animal charcoal.’’ [In addition to these the original specification stated that magnesia, magnesia lime- stone, manganate of potash, chloride of sodium, and burnt clay might be added, and that vegetable might be substi- tuted for animal charcoal. | Vou. VI.—27 Crude sulphate of alumina, Among | The process is a continuous one, the manganate being fed slowly into A, while the inlet water-pipe ‘¢3. Processes in which salts of iron are used as pre-. cipitants : ‘* Chloride of iron and lime.” ‘* Sulphate of iron and lime.” ‘‘4. Miscellaneous processes.” These processes are very numerous, but have led to no practical results. In England, from 1856 to 1876, there were four hundred and seventeen patents issued, all more or less connected with sewage and manures. Of the many methods that have been tried for the chemical treatment of sewage, there are but three that stand prominent at the present time. These processes are those of ‘‘ The Rivers’ Purification Association, Limi- ted [which controls and employs principally that which is], better known as the Coventry process. ‘“The Native Guano Company, Limited—better known as the A, B, C, process ; and ‘« The lime process.” The precipitated ‘‘sludge” itself becomes a nuisance during the drying process ; in order to get rid of the wa- ter (which generally amounts to about ninety per cent.), heated floors, blasts of air, and other artificial methods are resorted to. But one which seems more likely to prove satisfactory is the filter-press of Messrs. 8. H. Joln- son & Co., of Stratford, England (Fig. 3477). ‘‘Tt consists of a number of narrow cells held in a suit- able frame, the interior faces being provided with appro- priate drainage surfaces communicating with an outlet, and covered by a filtering medium, generally cloth or paper. The interiors of the cells so built up are 1n com- munication directly with each other, or with a common channel for the introduction of the matter operated upon, 417 Sewage. Sewage. 7 } hs t | | 5) TT NNN ine REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Fia. 3477%.—Johnson’s Filter-presses for drying Sludge, and as nothing introduced into the cells can find an exit without passing through the cloth the solid matter fills up their interior, the liquid leaving by the drainage sur- faces.” The sludge is forced into them by the action of compressed air. The sludge-cakes are removed upon opening the press; they contain about fifty per cent. of solids and fifty per cent. of water, eight hundred parts per thousand of water having been forced out, leaving still one hundred of water and one hundred of solids. The cost of the treatment of sewage by precipitation varies in English towns from seventeen cents to sixty cents per head of population per annum. But, as labor, chemicals, and apparatus are more costly in this country, we might have to double these amounts in order to obtain practical results here. III. A CoMPARISON OF THE ABOVE METHODS, AND THEIR ADAPTABILITY TO CITIES, VILLAGES, ETC.—We will now compare the merits of the various methods de- scribed, and their relative adaptability to the needs and circumstances of cities, villages, and isolated houses. The Privy-pit and Privy-vault Systems.—It is hardly necessary in a work of this kind to describe at length the evils of the privy-pit : the poisoning of wells, the pollu- tion of soil and air, the effects of the exposure of the nude person over a large pit full of cold and mephitic gases, the conveyance of germs of disease into the air and . water, the general deterioration of health from taking into the body such air and water even when specific germs are not present—all these evils the medical reader should be able to comprehend and amplify for himself. I may, however, state a few facts illustrative of the extent of pollution from this cause. .I was asked to examine, a few days ago, a site on which is to be erected an addition to one of our largest public schools. On one edge of the site a row of privies had existed ; on the contiguous edge, about fifty feet distant, is an old well; the cellar excava- tion, about forty-three by twenty-eight feet, had been dug to the required depth of about seven feet. The structure of the soil is sand overlying a stratum of blue clay, with pockets of sand dipping into the latter. It was found that 418 ‘this entire area was a mass of stinking filth. How far be- yond and around this filth extends I cannot say. The school has been supplied for some time with city water from Lake Ontario. A method of treating such a sewage- polluted site would be to remove all the soil down to the clay, to scrape the latter and flood it with a solution of bi- chloride of mercury, 1 in 500, and to lay a good concrete floor, the space between the clay and the concrete being previously filled with a mixture of clean clay loam and chloride of lime, or quick-lime; as an additional precaution air-spaces of porous tile, or brick arches, might be formed under the concrete floor, connecting with a hollow wall air-space outside the foundation at two sides of the build- ing, one of these latter being connected with a furnace flue, the other communicating with the outside air. A con- temporary issue of a newspaper in one of our country towns relates the following incident: ‘‘ A short time since in making an excavation for a building, the work- men struck a vein of polluted earth, the stench from which was almost unbearable. Being curious to see and know the cause, I had the men follow the vein and found that it had its origin in a pit, and its outlet in a well, the distance to which was about one hundred and forty feet. In its passage the liquid matter from the pit had defiled the earth for several feet in all directions.” Similar soil pollution exists around and amid dwellings in city, town, and country, everywhere, and we are occasionally aroused by unmaskings of what is continually, but secretly, going on around us. =): = = SS Fie, 8482,—Doulton’s Opercular Pipe. points in the construction of sewers. CONSTRUCTION OF SEWERS. —The materials of which sew- ers are constructed. Tiles answer well up to a diameter of eighteen inches or two feet. They should be of salt-glazed, vitrified earth- enware ; lead-glazed pipes chip, and allow soakage and leakage. Their strength may be tested by placing heavy weights upon them, or dropping weights on to them in a trench ; they may be placed under a weighted lever, ar- ranged like the arm which carries the weight of a safety- 422 Fig. 3483.—Jenning’s Access Pipe. of the passing contents. Their strength may be tested by a weighted lever, as above described in the case of tiles. Their porosity is a very important point, and may be tested by weighing them when kiln-dried, and again after soaking in water. Great care should be exercised in seeing that they are built with good (water-proof) ce- _ REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Sewerage. Sewerage. ment, that the joints between the bricks are smooth and even, and that the sewer is not covered in too soon, be- fore the joints have had time to set and harden. ; Concrete and artificial stone have been used, but not very extensively, nor with much success. Wood. The too common prac- tice of using wooden box-draing must be condemned, unless as a temporary makeshift. Sometimes a form of: barrel-drain, bound with metallic hoops, is used. This pro- test against box-drains might seem Fie, aN Ae ne Aa to be superfluous; but it is not pepe ke more than five years since it was found that, in a city afflicted with an epidemic of ty- phoid fever, one of the main sewers was a box-drain, with no bottom (except the earth), the sides being held together by pieces of scantling laid on the earth. With this were connected the drains of cesspools and houses, some of the latter of wood and untrapped. The shape of sewers is a very important consideration, and must vary according as the flow is expected to be equable or variable ; if equable, the circular form (Fig. 3484) is to be preferred, because it gives the greatest capacity with the least expense of wall. Hence it is almost ex- clusively used in the separate system of sewerage. If the flow is variable, the ovate shape gives the advantage of the deep narrow stream ; and when the quantity of sewage is small, de- posit is less apt to take place. Hence the use of this shape in the combined system. In old times sewers had to be cleaned out by scav- engers, with the same regularity as chim- neys were swept. The bottoms were broad, flat, and uneven ; the slow, sluggish streams =! allowed deposits to be formed, which Fra. 3486.—Box- quickly increased by their own impeding drain laid flat, action. The same plan is commonly fol- xocumilatne, lowed with box-drains (Fig. 3486). In ‘cases ‘ where they are employed (and it should only be temporarily), they should be set angle down, so -as to give the fluid its greatest possible depth and force, and prevent deposit. Joints have been incidentally de- scribed above as regards their modes of formation, when a description was given of sewer-pipes. They should be true fitting, so as to prevent gaps out of z which the cement or clay may fall or = be forced. Care should also be taken pye. 3487. — Box- to prevent the apposed ends from los- drain placed angle ing their concentricity when laid: if aR Se ae ie the joints be fitted with puddling-clay Wa or other soft material, this will give way under the down- ward pressure of the small end of the pipe, until this lat- ter rests directly on the receiving collar of the next pipe, leaving no space be- tween them on the under wall, but a large gap on the upper (Fig. 38488). This will be especially the case if no spaces have been cut to receive the tN BAN shoulders. To prevent it the joints pavine rotates 3 should be stuffed with oakum, and then the spigot end has with puddling-clay or cement, or, if the displaced the ce- pines be of iron, with Peete *“ lead, and should be | "thoroughly calked. El/= This method of aww S naking joints wil a also prevent the fill. & ing of cement or &= lead from running into the inside and forming a nucleus for deposit. It will also help to pre- vent the intrusion of rootlets of trees, which are apt to in- Fria. 3485.—Ovate- shaped Sewer. Fre. 3489.—Improper Junction, sinuate themselves and cause accumulation and choking. Some persons try to kill rootlets by mixing bichloride of mercury in the filling. This is a poor expedient at best. Juncttons of sewers, whether they are in a vertical or horizontal plane, should not be at right an- gles (Fig. 3489), as the Sz interruption ~~ of the stream and the eddies thus formed will cause deposit which, when once commenced, will rapidly increase. The tribu- tary stream should be made to enter in a course some- what parallel to that in the main sewer (Fig. 3490). For junctions, Y-pipes (Figs. 3490 and 3493) and V-pipes (Fig. 3492) are manufactured. Theuse . of the T-pipe (Fig. 3491) should Fie, 3491.—T-pipe, for Use be for inspection holes and ven- in Pouuabenon for In- tilating openings. The V-pipe is ase ter ak ste Yt used where the main drain is made of two branches uniting, and flows in a direction between the lines of the branches; two branches should never run into a third drain with their mouths opposite to each other ; one should enter a little lower than the other. Where a small sewer-pipeshas to be received into the socket of a larger one, an ‘‘increasing- pipe” (Fig. 3494) is used to pre- vent a bad joint, which would be made if the gap were filled with cement and pieces of brick or stone. Fig, 8495 shows the reverse, or ‘‘ diminishing-pipe.”’ The direction of a sewer should be as straight as possible, so as to retain the velocity. If it requires to be changed, grad- ual curves should be made. It sometimes happens that an impediment or junction may require a slight deflec- tion. An ‘‘offset” (Fig. 3496), or ‘* bends,” ‘‘ quarter-bends,” or “‘ el- bows” (Fig. 3497), may then be of service. The foundation or bed of a sew- er should be firm and solid, so as not to permit of any breaking or disjointing. If pipes are used, small excavations should be made to receive the shoul- ders, so that these shall not have to bear the whole weight of pipe, contents, and superincumbent earth, with no support to the rest of the pipe, which . is then liable to break or crack. Provision 7 should be made for SSS carrying away sub- iat. soil water, which is a Fie. 8494,—Increas- Jighle to make for the F!@ 495.—Diminish- ee ERS new earth formed in ree digging the bed of the drain. If the drain lie ¢n a po- rous stratum and over an impenetrable one, the chances of the water running along its course will be especially great. Some tiles are made with a subsoil space, porous or perforated, so as to carry off this water. Fig. 3498 repre- sents a sewer made of artificial stone in iene this way, in which | [-— the sewer, A, and pre 3497.—Bend, Fia. 3496.—An Offset. Subsoil space, J, or Elbow, are allin one piece ; C, CO, C, are small orifices through which the subsoil water makes its way into the subsoil space. Invert blocks with subsoil space are also made separately for the bottoms of brick sewers, which are then built upon them. 423 Fiac. 3492.—V-pipe, for Junc- tion where the Main Drain runs in a Direction different from that of either Branch. Fie. 3493.—Y-pipe. Sewerage. Sewerage, REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Want of attention to the foundation of sewers, espe- cially where tiles are used, is one of the most common causes of deposit and of sewage pollution of the soil ; ; then decompositon occurs, and foul gases are evolved. The writer has seen rows of houses rendered unten- antable from the occurrence of diphtheria and other zy- motic diseases from this cause. In one _ instance, where a sewer had been laid in sand, it had to be taken up in less than a year; the sewer had assumed a zigzag outline, and the tiles were choked with sand and sew- age. The velocity of the stream in sewers is dependent, not only upon the slope or fall, but also upon the shape, size, smoothness, and even- ness of surface and the volume and equableness of flow. The ordinary velocity required will also depend upon the nature of the mat- ters to be carried and the facilities for flushing. Some of these interdependent points have already been consid- ered. ; The size of the sewer requires careful consideration on the part of the engineer. If the sewers are too small there will be flooding of the connections with the lower portion of the insufficient sewer or system of sewers ; if too large there is needless expense, and, what is of greater importance, there may be deposit from sluggish flow, and there will be a larger space for sewage exhalations to form in. I know of an institution with about five hundred in- mates, situated about one hundred yards from the edge of one of our great lakes, which has two five-foot brick sewers to carry off its sewage! They were built in the good old times, and by convict labor. Fortunately, they had a short and rapid fall. The invert of one of them subsequently made a good foundation for a one-foot tile sewer which was recommended to be put in. It has been found by experience that it is not well to have sewers fora mixed population smaller than nine inches, as they are very liable to obstruction. In Mem- phis, I am informed by Colonel Merriwether, City Engi- neer, that it isa common thing to find them obstructed by the carpenter’s rule with its six-inch joints. Mr. Baldwin Latham, in his work on “Sanitary En- gineering,” gives formule and tables for computing the velocity in sewers of various slope, size, and volume. He also states the results of a number of experiments for determining the carrying power of sewer-streams. From these it would appear that, for efficient house-drains, a velocity of three feet per second is necessary ; and that this would require, in a nine-inch drain, a fall of 1 in 206 ; in a six-inch, 1 in 137; and in a four-inch, 1 in 92; and it is presupposed that the drains would run half full. The quantities of sewage discharged under these circum- stances will be 39.76, 17.66, and 7.85 cubic feet, respec- tively. When running full they are capable of discharging double these amounts, but the velocity and scouring force will not receive any further increase. The point to be borne in mind is, that if the sewers cannot obtain sufficient fluid to half fill them, the slope must be greater. In the case of street-sewers it will be evident, on consideration, that it is in the upper ends that the least volume of sewage will be found, and hence the most natural position for flush- ing apparatus—the head of the sewer—is that where it is most needed ; the size, too, may here be less, and this will add to the facility for flushing. For flushing, various devices are in use. One very extensively employed is Field’s automatic flush-tank, represented and described in the article on Sewage, Dis- posal of (see Fig. 3475). Somewhat similar is Van Vran- Fie. 3498.—Sewer-pipe of Artificial Stone, with Subsoil Space. 424 ken’s flush-tank (Fig. 3499). The lower end of the longer or descending limb of the siphon is constantly immersed in water contained in a small tilting-tank, hung in a chamber below the bottom of the main tank. The drain is connected with this chamber. When the water rises in the main tank as high as the arch of the siphon and trickles over into the tilting-tank, the centre of gravity in the latter is changed, and it tilts over to the position shown by the dotted lines; the level of the water in it is suddenly lowered about an inch, and this starts the siphon action by which the main-tank is rapidly emptied. With both these tanks the intention is to allow them to fill slowly by a small trickle of water; by experience this can be so adjusted as to fill them once or twice in the twenty-four hours. In some places suspended mat- ter in the water interferes with this intention. The tanks hold from one to two hundred gallons each. It is found that only about two per cent. of the total water-supply is required for flushing. In valve-tanks (such as Pierson’s tank) the valve is dis- placed from the outlet by a float attachment. In col- lapsing-tanks the sides collapse by the sudden filling and sinking of a floating vessel. Large tilting-tanks and flushing-gates are also em- ployed. They may be operated by automatic mech- anism. Flushing-gates are sometimes placed in the courses of sewers at long distances from their heads, the sewage itself being the flushing medium. It should be borne in mind that such an arrangement is liable to cause deposit above the gate, and that the scouring action is exerted below, and not to any appreciable extent above, the point where it is situated. Hence this method is not to be recommended. In some sewers, where only a very slight fall can be obtained, flushing all along the line of the sewer has to be resorted to. In Chicago, for example, a “‘ pill” (to be ex- plained presently) is placed just above the man-hole open- ing, and the contents of a flushing-cart are poured down the latter into the sewer. . Cleansing of sewers by other methods has sometimes to be resorted to, notwithstanding the fact that the aim of sanitary engineers is to so construct them that they shall be self-cleansing. To facilitate the task of keeping TH ULL = sewers clean, man-holes, inspection openings, lamp-holes, and cleansing openings are constructed. Fig. 3500, copied from Dr. Ford’s article in Buck’s ‘‘ Hygiene,” shows a form of man-hole with ventilating grating and dirt-box adopted by Mr. Denton. It is pro- vided with steps for descending to the sewer-pipe with which it is connected. Another form of man-hole and ventilator (Fig. 3501) will be described when we come to speak of the ventila- REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Sewerage, Sewerage. tion of sewers. The object of these man-holes is for workmen to descend, inspect the sewers, and cleanse them. This is done by means of various kinds of scrap- ers, rakes, hoes, drills, screws, balls, brushes, hooks, etc., which may be mounted on jointed rods such as those used by chimney-sweeps. Even with the sewers of the separ- ate system, specially designed to avoid deposit, and flushed daily, it is found necessary, in Memphis and elsewhere, to use periodically the ‘‘ pill” and brush. The ‘‘ pill” isa hollow water-tight globe of thin metal, made three inches smaller in diameter than the sewer. The end of a rope is attached to a staple on one side of the pill, which is lowered down a man-hole or inspection-opening into the sewer and allowed to float (still held by the rope) down to the next opening. The pill may be held, or drawn back a little, at any point, and the volume of fluid, being obliged to pass through the three-inch crescent beneath it, will scour away any movable deposit. As soon as the pill reaches the next opening, a brush may be attached to the other end of the rope at the opening above, and drawn through the portion of sewer which has just been traversed by the pill. Observation- or inspection-openings have been suffi- EEA: Fie. 3500.—Man-hole Connected with Pipe-sewer. ciently explained in the above description. They are, of course, smaller than man-holes. — Lamp-holes are still smaller; they are generally con- structed at no great distance from the man-holes, and are for the purpose of literally throwing light upon the inter- vening portion of sewer. The absence of light will in- dicate complete obstruction. Sometimes cleansing- and flushing-openings are made to enter the sewer af obtuse angles with the portions be- low them. In this way a flushing-hose or cleansing-tool may be introduced through a comparatively small and inexpensive opening. — In some of the older sewers of the combined system, pits have been left in the invert at the bottom of the man-holes, for the purpose of collecting, and ‘periodically removing, deposit. This is not to be recommended, as it favors deposit, which, if neglected, forms a nucleus, and which by its decomposition gives off offensive and inju- rious gases rising into the street. Similar pits are also made, in the course of the small sewers of the separate system, below stables and other points where obstructions have, in the experience of the officers, been found to re- sult from the habits of careless people. The writer has atmosphere. seen plans of these, with their contents graphically de- picted, and labelled as ‘‘ Sardines,” etc. (the ‘‘ Sardines” were empty boxes, of course). Care must be taken to have these pits frequently inspected and cleansed. In some of the large Paris sewers trucks were made to run, with the wheels on platforms, on each side of, and above, the sewage-channel, while a sort of gate the shape of the sewer-channel dips into it; this is carried along by the sewage and shoves deposit in front of it, while it also carries along the truck to which it is attached. When the deposit in front obstructs the action of the gate, the dirt is scooped up into the truck. Ventilation of Sewers.—I have endeavored to point out the methods in the construction of sewers by which we are to avoid the retention of decomposable material, and to so cleanse the sewers that foul gases will be re- duced toa minimum. But it has at the same time been made manifest that we are still liable to their formation. Among the gases more commonly evolved from sewers may be mentioned sulphuretted hydrogen, carbonic acid, carburetted hydrogen, nitrogen, and ammonia. Many cases of asphyxiation in sewers and cess-pits are on rec- ord; no less than eight deaths from this cause occurred in the sewers of Chicago in one year. The rise and fall of sewage, with the alternate wetting and drying of the walls of the sewers, cause a continual evolution of vapor. It is no conclusive proof of the ab- sence of sewer-gases that they cannot be perceived by the sense of smell. Some injurious gases reveal them- selves unpleasantly to the nose, while others do not. These last are so insidious in their nature as to be doubly dangerous. As examples, the baneful results which en- sue from living in houses under which water lodges and becomes stagnant may be referred to. There are few medical practitioners who have not witnessed these re- sults. The miasmatic poison of ague is inodorous, or has no necessarily unpleasant odor. In like manner sew- ers have sometimes very little unpleasant smell. Some- times there is a smell somewhat similar to that produced by those burning fluids into the composition of which fusel-oil enters. We must be very careful, therefore, how we accept negative evidence as to the presence of noxious gases. In the experience of most practitioners, living in sewered districts, instances are common of the occurrence of zymotic diseases, clearly traceable to the presence of sewer-gases, where there has been little or no unpleasant smell. I am not aware of any ap- preciable odor from the contagia of scarlatina and measles, and yet they act through the medium of the One or two specific instances, in proof of what has now been stated, may be mentioned when we come to speak of some particular defects in sewerage. It is evident, then, that every care must be used to estab- lish a thorough ventilation of sewers, and to secure it in such a way that the gaseous contents shall not, in making their exit, come in contact with human beings. ‘Too often, and by too many avenues, they find their way into dwelling-rooms. How this should be avoided has been pointed out in the article on Habitations. It falls within the scope of the present article to point out the means commonly employed for the ventilation of sewers, the pneumatic forces which are at work in them, and the means which, in the opinion of the writer, should be adopted; to change the air in them as frequently as possible. It will be found that most of the agencies at work in sewers are variable and alternating in their action, some- times drawing air into the sewer, and sometimes ex- pelling gas through the same opening. ‘The principal of these agencies are, besides the natural diffusion of gases, the following: Difference of temperature between sewer and external air, causing an-interchange in accordance with the laws which regulate the movements of unequal weights of air. Upward draught in houses, acting as a ventilating shaft, in the wake of which the sewer-air will follow if allowed ; sometimes a full flow of water down into the sewer will cause a current of air to accompany it. ) The expansion force created by the sudden accession 425 Sewerage. Sewerage. of heat in the drain, viz., by pouring down hot arenas of boiling water. This’ expansion is equal to 1 volume in 491 for each degree of Fahrenheit. As air expands the pressure is increased, If the temperature of the air in the drain be raised from 50° to 150°, the result will be COVER ct MN ri Anan AO SA Ma TAN TAT Cy ‘| WM Ws Fig, 8501.—Rawlinson’s Manhole Charcoal tans and Tumbling- bay. pressure equal to that of 6;% feet head of water. And this rise of temperature is not at all an improbable one. The flow of water into the drain causes an expulsive force. When water is poured into a drain it must, of course, displace its own bulk of air (less the small amount gained by compression), for two bod- ies cannot occupy the same space at the same time. Out of which end of the drain (suppos- ing that it has no ventilator) this air shall pass will be determined by circumstances ; it passes most readily where it meets with least resist- ance, always giving preference to an upward direction, owing to the greater gravity of the water, Storm-water suddenly filling the sew- ers acts powerfully in this way. This ebb and tlow operate like a double-acting piston or syringe. Partial choking of the drain gives rise to confined air constantly increasing, ex- panding, and being displaced. Tides have a similar action. Wind blowing up the mouth of a sewer will drive gases before it ; wind blowing across its mouth will often produce a down current. From the rising of sewer-gases to the upper ends of sewers the higher, ae at one time more healthy, portions of towns and cities have sometimes compared badly with the lower por- tions which have been improved part passu. Until lately the principal dependence for the ventilation of sewers has been on the ventilating “ gratings in the road-bed, both as inlets and outlets. Sanitary engineers, having experienced the necessity of deodorizing the air exhaled from the sewers, have in- vented and patented ventilators containing charcoal. One of these, Mr. Rawlinson’s, is shown in Fig. 8501, which i is copied from Dr. Ford’s paper in Buck’s ‘“ Hy- giene.” An inspection of the diagram shows the course taken by the sewer-gas. The man-hole has a tight cover 426 uy a me so 0 | trough S, by means of the handle h. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. to keep the charcoal dry. Below the ventilating cham ber is a space for collecting the dirt which falls in, and’ which may be removed by unscrewing the plate at the bottom of the space. The flap-valve and bay are for the purpose of directing the gas up the ventilator, and the tumbling-bay is for the purpose of getting rid automati- cally of any deposit which may be caused behind the flap- valve. Mr. Baldwin Latham gives a figure and description of a spiral charcoal ventilator (Fig. 3502), invented and thus described by him: ‘‘The larger sizes combine in themselves man-hole cover, lamp-hole, and ventilator, while the smaller sizes fulfil the two last offices. Each of the large ventilators consists of four parts : ‘‘ist. The frame a, for receiving the cover, and on the bottom of which hangs the dirt-box and charcoal venti- lator. “©2d. The cover C, the centre part of which is solid, so as to form an efficient cover for the charcoal and protect it from rain, or the water used in street watering; g is the open grating in the cover by which air escapes or is drawn into the sewers. The openings of this grating are arranged concentrically, and are formed with the aper- ture wider below than at the street level, so that mud is not likely to adhere, or, if it does, is soon removed and falls directly into the dirt-box immediately below the grating. The cover in the illustration is shown filled in with wooden blocks (placed endways of the grain), for deadening the sound and giving an efficient foothold for horses. The covers, however, may be filled with any other suitable material, such as stone, concrete, or asphalt. ‘*3d. The dirt-box d hangs in a groove, 2, made in the lower part of the frame a. The dirt-box is circular on plan, and the groove @ is intended to be filled with fine sand. The weight of the dirt-box and ventilator press- ing into the sand forms a gas-tight joint ; , /', are han- | dles attached to the dirt-box for raising or lowering it ; S represents an open spiral trough which forms part of the dirt-box, and which is used for conveying away the overflow-water from the dirt-box to the sewer ; 0 is a slot in the side of the dirt-box, communicating with the upper portion of the spiral trough, through which the water enters the trough. “4th. The spiral trays ¢, for containing the charcoal, which are screwed into the ventilator over the spiral TUT CEA Hee ll a === a | u a Ui ¢ | Ee a — —— Qh IMGE S Mi Fig. 8502.—Latham’s Charcoal Ventilator. _ Each tray consists of a central shaft P, which is square, and out of every face project arms of T-iron. These arms are attached at the extremities by a strip of iron coiled spirally, and the bottom of the trays is filled in with network. “To recapitulate the advantages of this ventilator: 1. That, should the charcoal concrete in the tray, or if its pores are stopped with dust, no impediment is offered to REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Sewerage, Sewerage, ventilation, as there exists a free communication between the sewer and the external atmosphere. 2. That the char- coal is completely protected from rain or water entering the ventilator or leaking through the joints of the cover, consequently it will retain its efficiency for a long period. 3. That the passage provided for the overflow-water from the dirt-box is not dependent upon traps, or any other uncertain device needing assistance to maintain it in perfect working order. 4. The escaping vapors are all brought in contact with the charcoal, it being impos- sible for any to escape by the sides of the tray or in any other way.” These charcoal ventilators are now mostly discarded as impeding the passage of air, and the contention of engineers often is that they are generally inlets; but the frequent stench, and the steaming exhalations from them in heavy winter days—exhalations through which our boys delight to run—do not support this contention, but rather go to show that the surface of the road-bed, amid the traffic of street passengers, is not asafe place in which to discharge these gases.* As regards charcoal trays, even were the charcoal con- stantly dry, sewer-gas at times makes its exit too rapidly for the charcoal to exert any action upon it; so that, however useful an adjunct charcoal may be, it cannot be considered a preventive to the injurious effects of sewer- gas, and we cannot rely upon it as a germicide. At one time it was a common practice to have the openings from the gutters untrapped; but as these open- ings were noticed to be very offensive, and were nearer to the foot-walks, they have been provided with traps. (See below.) Laying aside the propriety of having such a point of escape for sewer-gases, it will be evident on considera- tion that the size of the street-gratings is insufficient, even when they are open ; in our northern climate many of them are at times closed for weeks together, and they are often partially clogged with mud. But even when open, their interstices, if combined, would yield about forty-nine square inches, and if allowance be made for friction in the little openings, their carrying capacity would be about equal to that of a five- or six-inch pipe, and this to ventilate a length of six hundred feet (the distance given by Mr. Latham) of average street sewer. Hence, it seems evident to me that the principle which is now being advised and adopted by leading sanitarians and architects, for the safety of the individual house- holder in regard to his house-drain, ought to be advised and adopted by sanitarians and engineers for the safety of the whole community in regard to the street sewers. A four- or five-inch pipe should be carried from every house-drain to the roof of the house which the drain is intended to serve, and should discharge the sewer-gas at a sufficient distance from all chimneys, windows, doors, or other openings into the house. Between this pipe and the sewer no trap should intervene. And this is the plan now generally adopted in Memphis and some other places, sewered on the separate system, there being no trap, save in exceptional instances, between the sewer and the soil-pipe extended above the roof. In the state of plumbing practice still in existence in many places, it would, in my opinion, be better to have a trap between the pipe and the house, provided that, in addition to the extension upward from the soil-pipe there is another four-inch pipe, forming a counter-opening and allowing a current of air to circulate freely through the house- drain and its connections and vents ; but wherever good plumbing and rigid inspection are insisted upon, this mul- tiplicity of pipes and traps could, and should, be done away with. There would then be a direct passage from the sewer to a point above the roof, carefully removed * On the day after the above was written the writer was called to visit a patient living near the head of a street in one of the finest districts of the city. Persons residing in the neighborhood have made loud com- plaints regarding the stench arising from several man-holes in this street and a street which crosses the head of it. At times, when a south wind is blowing, windows are kept shut and children cannot be allowed out to play in the immediate locality. Complaints have been made to the Med- ical Health Office regarding the matter. Numerous other instances of this kind might be reported did space permit. from chimneys, doors, windows, and all other openings into the house. Colonel Waring is a strong advocate for the abolition of traps on house-drains, contending that they impede ventilation and are themselves sources of danger. It must be borne in mind that by the plan advocated the air allowed to escape through the soil-pipe (or outside vent-pipe) is not the same concentrated foul gas that often arises through street-gratings, for the number of openings, each of them almost of the same capacity as a (subdivided) manhole-grating, is so great that the gas is very much diluted ; in a closely built street, with houses on each side of from twenty-five to fifty feet front, there will be one such opening for every twelve to twenty-five feet—instead of every six hundred feet, the limit for street-gratings given by Mr. Latham. Of course, this system, when adopted, should be made general. In places already sewered it could be introduced by the corpora- tion authorities putting in ventilating pipes at such dis- tances as would give some relief, and passing a law re- quiring that every new house-drain, and every drain that shall need to be reopened, be ventilated in this way, and that within a reasonable time the same shall be the case with all house-drains. It has been objected that, inasmuch as house-drains do not usually enter the sewer at the highest point of the latter, there is a space in the crown of the street sewer that cannot be ventilated through the house-drain when the water in the sewer is higher than the mouth of the drain. To this I would answer that the air being con- fined to the crown of the sewer, its temporary stagnation during the time of flood-water will do no harm to any- body ; if the pressure becomes very great the gases will be dislodged and will be carried off at a point higher up the line of sewer, where the drains are not water-locked ; it is only at times that the house-drains will be so full as not to allow of counter-currents and through-drafts ; and there is nothing to prevent the house-drains from entering sewers close to the crown, if so designed. It has also been objected that air will not enter the sew- ers down the long stand-pipes; so long as the gas, when it does move, moves off overhead, we need not so very much mind its remaining in the sewer for a short time. But, asa matter of fact, a careful consideration of pneu- matic laws and of the forces acting in sewers will show that the objection does not hold. The columns of gas or air on opposite sides of the street, if they are of the same temperature and density, will counterbalance each other ; but let the sun shine on one side, and immediately an ascensional action begins; or let a cold wind blow on the other, and a dense column begins to descend. Be- sides, the rising and falling of the liquid in the sewer will cause the gas to be expelled, or the air to be drawn in. Again, the air will blow up the sewers from their mouths ; and, for this reason, flaps should never be placed on the mouths—free vents being made all along the course of the sewer—although the contrary practice is recommended by some engineers. Various contrivances for propelling air into sewers and extracting gases from them, such as fans, pumps, steam- jets, and furnace chimneys, have been employed. They are costly, and, alone, are insufficient and unsatisfactory. When plenty of free vents and good traps exist they are unnecessary, and when these do not exist they are dan- gerous, inasmuch as such propulsion will force traps, and such extraction will empty them by suction where free vents do not exist. The true plan seems to be to make plenty of breathing- holes, plenty of channels through which currents will continually pass, and which will discharge gases at a safe distance overhead. In many of our larger cities sewer ventilation is quite insufficient and faulty, and much apathy—or rather a want of appreciation of correct principles—is found in regard thereto. It has therefore been thought a subject which should receive here a full consideration. YARD- AND GULLY-TRAPS.—In discussing the means to be adopted inside of houses to secure the exclusion of sewer-gases from dwelling-rooms, various forms of traps 427 Sewerage. Sewerage. have been described, and the methods and principles by which their efficiency is to be maintained have been dealt Fie. 3504.—Trap with Hand- hole on the Upper Side of the Seal. F1a. 3503.--Trap with ‘‘ Hand-hole” in Centre; not suitable for drain with floating filth. with. (See Habitations: General Principles of Plumb- ing. in dealing with the means of excluding sewer-gases from _ __. __ frequented places out of doors, it only re- | YAA, Ynains, therefore, to describe some forms of traps applicable to these places. Fig. 3508 shows a form of glazed-tile trap very suitable for a drain conveying rain or other water free from floating filth. Pipes may be brought from the hand-hole in the centre up above the ground-level, with Hand-hole for the purpose of observing and remov- below the Seal. ing deposit. Filth in such a trap might remain floating for a long time in the hand-hole above the current, and hence it is not suitable for a house-drain. Figs. 3504 and 3505 show traps more suitable for con- veying floating filth. If the hand-holes are to be used merely for removing obstructions (should they occur), their sockets should be plugged and cemented ; by means of pipes the openings may be brought up within a foot or two of the surface. But these hand- holes may also be used for purposes of ven- tilation, and for protecting the seals of the & traps from accidents explained in connection with house-traps, due care being exercised as regards securing a sufficient supply of water. Fig. 3506 represents a ‘“bell-trap ;” to the left it is seen with the seal perfect, and in the centre the seal is broken, the ‘‘ bell” (to the right) having been lifted out. This ental | ’ 4 4 UJ ? $ My is Y, —<——— ma ; ap i y qa SS SG ELT he Sette “ace pte: Was SAC ONGCRE TEM te: SS Sed Se ee > st A Ewes FR LE Y “2 Fie. 3507.—Intercepting Grease-chamber, with Disconnecting Gully- trap. constitutes a great objection to the bell-trap ; the grating becomes clogged, or the space below becomes filled with 428 LOOR LINE. Hat REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. dirt, and the bell is taken out, and by careless persons not replaced. If it is so fastened down that it cannot be removed, the dirt in the box around the mouth of the descending pipe collects and decomposes. It is better to use the forms of traps already described, protecting them with a grating. Masonry or wooden traps may be constructed on the ‘mid - feather” principle, with partitions extending vertically across the drain and dipping down from the crown into the trap-cham- ber, between the points of entrance and discharge. Traps and drains are liable to become choked with congealed fat; to prevent this, grease-traps are sometimesemployed. A form of grease-trap is shown in Fig.. 3507, copied from a paper in ‘Our Homes,” by Mr. William Eassie, an English engi- neer. To the left may be seen the grease-chamber, closed by a cover, which may be removed in order to skim off the floating fat. This chamber should be ventilated by k a pipe or pipes, carried to a safe position away from openings into the house. In the centre is seen a gully -trap for taking surface- water from the yard, and also for discon- necting the sink-waste outside the house. This ‘‘ disconnection ” is, of course, unsuit- ed to the climate of the northern portions of our continent, but in England it is com- mon to disconnect the house-drainage just outside the house. Fig. 3508, from the same work, shows Dean’s yard- or gully-trap, which contains a box, 8, for catching any dirt that may drop through the grating G. To the box is attached a rod, R, by which it may be lifted out when it is neces- sary to empty it. H is the discharge-pipe. Fig. 3509 represents a street-gully, from which sewer- gas is excluded by Bt ise wh esate ed As Fria. 3508.—Dean’s Yard- or Gully-trap. Re me meee e eS . means of’a trap in- 0 3 bee vented and patent- ed by the late Mr. ; Thomas Gueérin, } C. E., of Ottawa. rl i ert a The water from | the gutter runs} through Ointothe |" pe====== Spee! het hogs guily-chamber' Oy. fo.) [Swe lvire ihe as it rises it lifts . ~~. the floating V, which rises in the trap-chamber A, and permits the fluid to escape. As the fluid evaporates, or if it leaks away, the plug falls back into its seat. The plug being conical in its lower por- tion, R (Fig. 3510, which is an enlarged view of the trap only), any backward pressure of gas drives it more firmly into its seat. It is made of wood tipped with brass, and is furnished with a small hook for lifting it out. The Fia. 3509.—A Street Gully, protected by Gué- rin’s Gully-trap. - REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. trap-chamber is of iron, and fitted with a tight movable cover, X. A trap of this kind will obviate the dangerous, and sometimes disgusting, va- por which we frequently notice § from unsealed gullies. salt Dry Traps.—The principle of “YJ dry traps is illustrated in Fig, 3011. Fig. 3512 represents the | same style of trap, with a coup- lingclamp attachment. In these traps the flap is hung without bolt or pin, by being hooked on to two little projecting pieces above the circular opening which it is intended to close. The trap thus formed is inserted into the socket end of any pipe and kept in place by the spigot end of the next pipe above. Its place in asystem of sew- erage may be tersely described by a certificate given by the writer in 1878, and which he hardly expected would be deemed sufficiently meritorious for publication. Per- haps the pa- AM tentee valued i iy 24 it as bearing a stamp of du- SS SCbious honesty on the face of 1G. ‘The best method of preventing reflux of sew- er-gas is, in my opinion, a good water-trap, with sufficient seal, suffi- cient vent and ventilation, and frequent change of its fluid contents. Where these conditions cannot be ob- tained, then resort must be had to a dry trap, and the very best of these I have ever seen is Palmer’s trap.” Iam glad to be able to refer now to what escaped me at that time, viz., its power of preventing reflux of back water from sewers into cellars in low-lying districts. One great reason for the preference of water-traps over dry traps is the tendency of the latter to become foul and clogged with deposit, and the liability of their mechanism to become ineffective by reason of rust, dirt, and the in- terference of solid bodies. WEEPING DRAINS, for draining the subsoil of houses, should not be laid inside the foundation, if it can possibly be avoided. The subsoil of houses, or blocks of houses, can generally be drained by porous tiles laid outside, so as to surround the foundation-walls at a sufficient depth below the level of the cellar floors. When the builder or owner of any particular house cannot accomplish this, he should be careful to provide the trap interposed below the weeping drains with some slight automatic water- supply, so that its contents shall be frequently changed. Sickness arising from want of attention to this particular is common ; the supply of subsoil water ceases, the traps become dry, and sewer-gas passes up into the house. Two examples may be cited. Becoming convinced that there was something wrong with the drainage of a house in which § Fig. 3511.—Palmer's Trap. Sewerage. Sewerage. careful individuals a hopper-closet, washed while in use by an automatic swirl of water from a valve set below the frost line, may be used; but when numbers of per- sons of various classes have to use closets, they cannot be relied upon for care and cleanliness. Latrines should therefore be used to supersede the privy-pit in the densely populated districts in which the water-carriage system is established, unlessit is resolved to use the dry system un- der corporation management. In many places the change from the old system to the new is being gradually made. No new pits are allowed to be dug ; and when any exist- ing one becomes a cause of complaint, it is ordered to be cleaned and disinfected, and filled with fresh earth. These latrines can be controlled by some servant of the corporation, or other person, who shall, from time to time, change their contents and supply them with water. Of the various forms of latrines, the following may be mentioned : So-called tron stinks are manufactured in various cities on this continent, and are being largely introduced. One of them, Mott’s Latrine, is shown in Fig. 8518. The hopper, or receptacle, and: its corresponding section of drain, are made in one piece, and the several portions of the drain are then © connected. The con- tents are run off peri- odically by raising a plug at one end of the drain, and the drain and latrines are refilled. When these are situat- ed out-doors, slight ar- tificial heat must be used in winter. These latrines are very mod- erate in price. The Liverpool trough- closet ‘‘may be described as consisting of a series of clos- ets communicating with a long trough (W), situated be- neath and behind the seat, which receives the excreta from each closet in the series. The lower end of the trough communicates with a drain (D, Fig. 3514), leading to the sewer by an opening which is closed by a plug (P). Behind the back wall of the closet there is a small space to which no one has access but the scavenger, and from which alone the plug can be raised by means of a handle. The scavenger visits the closet daily, empties the trough, washes it out with a hose (A) connected with a hydrant, Fie. 8512.—Palmer’s Trap, with Coupling Attach- ment. I was attending several members of a family showing symptoms of low fever, I requested a thorough examination to be made. There was no smell of sewer-gas, but on raising the board cover of a trap in the furnace-cellar over which the weeping drains emptied, a blast of air shot upward. Five members of this fam- ily were prostrated by typhoid fever, The other instance was in a house where diphtheria persisted in remaining, and recurring ; the weeping drains were found to connect with the sewer (a very foul one), without any traps. OuT-DooR CLOSETS AND LATRINES. — That out-door closets and latrines, in connection with the water-carriage system, can be used even in the northern part of this con- tinent, is now established by experience. In the case of Fig. 3513.—Mott’s Latrine, or School Sink. and again charges it with water. As much water is let in as will cover the excreta received during twenty-four hours, and so prevent any smell. The closets are kept clean by the users.” 7'represents a trapped overflow from the closet-trough to the drain, to prevent any accident from leakage of the hose-pipe. 429 Sewerage. Sewerage. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. The Bristol Hject.—This consists of a strongly con- structed dip-trap, interposed between the privy-trunk, as It thus admits the receptacle is termed, and the drain. of the ready extraction of foreign matters which may be thrown in; it is not easily broken; and, as it is flushed and kept clean by the servants of the corpora- tion, it is found to answer much better than ordinary water-closets among the poorer classes of large towns. Other forms of latrines, on the same principle, are thus spoken of in Wilson’s ‘‘ Handbook of Hygiene:” ‘For barracks, prisons, etc., water-latrines of a much simpler construction than either of the above answer ex- ceedingly well. An open metal trough, roofed in, and with the necessary partitions , i. : ME jE and doors, receives fi Pee the excreta, while its = eA f; anterior upper margin 4 A WA Mie Pp, constitutes the seat. ON Ot ie In order that the ex- 2 a creta may be constant- mee ly covered, the trough - should be kept one- third full of water. It should also be well flushed at least twice daily, and the contents allowed to run off into a drain con- nected with a sewer. A plug, or flap-door, at the lower end of the trough, will be required to prevent the water from draining off at intervals. ‘“There is a further advantage, common to all closets of the trough system, which may here be pointed out. In the event of an epidemic of cholera or enteric fever raging in the crowded courts where these closets are in use, it will be an easy matter to throw disinfectants into the troughs and thus destroy the infectious power of the alvine discharges.” In some latrines water does not stand in the receptacle, but is admitted daily to sweep out the contents with a sudden flush. Those in which feces are received into the water, the whole being suddenly let off and flushed, are to be preferred. If a moderate artificial heat were introduced with the use of such latrines a double gain would be secured. The exposure to severe cold is sometimes very injurious. Not to enter deeply into the subject, let us take the case of a school-child just recovered from scarlet fever, the peel- ing of the skin having been accomplished ; exposure of the skin to severe cold may produce fatal disease of the kidneys. If, however, these conveniences cannot be heated, we must place the water appliances deeply, as is done now with our water-pipes, hydrant-services, and drains, always remembering that the open troughs are more exposed to atmospheric changes of temperature. In this regard great care needs to be exercised. URINALS become offensive through want of proper pro- vision for preventing the incrustation of them with de- posits from the urine, and of proper means of frequently cleansing or removing surfaces which collect the drop- pings. A tray of ashes or sawdust in front of and be- neath the urinal will meet this latter requirement, the contents of the tray being frequently changed. The urinal should have in front a narrow projecting lip. For the first mentioned cause of offensiveness it seems neces- sary to have a flow of water washing the urinal while in use. For this purpose various automatic contrivances have been arranged, such as the opening of a valve-tap, ay person stands upon a platform in front of the urinal. INTERCEPTING SEWERS may be divided into those which intercept or receive the whole of the contents of other sewers, and those which intercept only a portion Fia. 3514, Liverpool Trough-closet. 430 of the contents, allowing the rest to flow on. There is nothing peculiar in the construction of the former. They may be used under various circumstances. For example, a city may be so situated that the sewage of the upper district would flow by gravity to the intended outfall, while that of the lower districts would not; in such case the sewage of the upper district would be collected and carried off to the outfall by an intercepting sewer, the sewage of the lower district being pumped either to the intercepting sewer on the higher level, or directly to the outfall. Or the configuration of the place may be such that the natural drainage of the streets has a very long fall, while there may be a water-course lying at a comparatively short distance to one side; in this case a great saving in the size of the sewers may be effected by intercepting and beginning anew below the inter- cepting sewer. Or the city may be built on knolls, so that an intercepting sewer becomes a necessity, unless Shone’s system (see below) is employed. Sometimes it is desirable to collect only the more con- centrated portion of the sewage, and allow the less im- pure to flow on, either because the former has to be utilized or pumped, or in order to save expense in the size of the intercepting sewer. How this object may be accomplished is shown in Fig. 8515. The intercepting sewer is seen below the divided invert, C, #, of the sewer, the concentrated sewage of which is to be intercept- ed. The ordinary fair-weather flow, and the first impure flush of a rainfall, will drop through the opening B, Fic. 38515.—Intercepting Sewer, with Overflow. while a heavy flow or flood of water will shoot over, as represented by the dotted line A in the diagram. Another example of intercepting sewer is shown in Fig. 3516. The description is taken from an ‘‘ Account of the Trunk-sewer of Buffalo,” by Col. George L. War- ing, Jr.: ‘‘The connection of the trunk-sewer with the city sewers is shown in Fig. [3516], representing the Por- ter Avenue interception. The dry-weather flow of the sewer is delivered at an-angle of forty-five degrees with the course of the trunk sewer, through a cast-iron pipe two feet in diameter. The bottom of this pipe is one foot above the bottom of the sewer, and its top is one foot be- low the middle of the sewer. “For dry weather and light rains this would suffice. In order to secure the introduction of as much as pos- sible of the discharge of the city sewers during heavy storms, it was arranged that its flow should be somewhat stilled in a well over the mouth of the inlet-pipe, to allow the escape of the rarge volume of air sometimes involved in the rapid current of steep sewers during storms. This is so done as to bring the full head of the intercepted sewer to bear on the inlet. ‘‘So much of the flow as cannot gain access to the REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. trunk-sewer through the lower inlet, passes on over the vertical well and runs into it through a three-foot open- ing in its crown. Should the sewer be so full that the entire flow of the intercepted sewer cannot gain admis- sion, the surplus passes on to the canal.” Tidal variations cause much difficulty in connection with outfall sewers ; by the ebb and flow of the sewage- laden tide a serious and wide-spread nuisance is often created. And in this connection it should be borne in mind that sewage oxi- dizes more slowly in N Fic. 3516.—Intercepting Sewer, Porter Avenue, Buffalo, with Overflow. sea-water than in fresh water. If the sewer discharges continuously on the shore at or near high-water mark, the nuisance is intensified ; if it discharges below low-water mark, the rising tide causes a backing up of the sewage and deposit of its solid portions, with all the evils inci- dent to such a condition. It will also, by rising in the sewer, force backward the gases therein contained. To prevent this, flap-valves are often placed on the mouths of such sewers. It is more desirable to make ample vents for discharging the sewer-gases, as before described when speaking of the ventilation of sewers. Fig. 3517, copied from ‘‘ Suggestions as to Plans for Main Sewerage,” by Robert Rawlinson, C.B., C.E., of the Local Government Board of Great Britain, is a ‘‘ sug- gestion” for an outfall adapted to tidal variations. Its High .water? of Spring ‘lides. such lenses are still manufactured, but the special advantage once claimed for them, over the sevy- eral forms of lenses with spherical surfaces, is altogether illusory ; their existence in commerce made it possible, however, to furnish a cylindrical surface, on demand, at a time when plano-cylindrical lenses were not yet obtain- able. Cylindrical lenses proper, as used for the correc- tion of astigmatism, were first employed by G. Airy, As- tronomer Royal (1827),?° who was himself the subject of compound myopicastigmatism. Airy discussed the relative advantages, in compound astigmatism, of a bi-cylindrical lens of unequal radii of curvature, and a spherico-cylin- drical lens ; he gave the preference to the latter combi- nation, for reasons which are still generally accepted as * Bartisch (1583) protests strongly against the widely spread abuse of spectacles which prevailed at his time.?° + ‘*Maurolicus, in his treatise de lumine et umbra (1554), considers the crystalline as the principal instrument of vision, and as transmitting to the optic nerve the images of objects; and he explains why some persons are long-sighted and others short-sighted, according to the less or greater convexity of the surfaces of the crystalline, showing that in the former case the rays have not been converged to a focus when they reach the retina, while in the latter they have been converged before they reach it. He explains, also, how the convergency may be hastened in the long-sighted eye by the use of a convex glass, and delayed in the short-sighted by a concave one. These observations of Maurolicus were not known to Kepler, when it was proposed to him, as a question by his patron, Dietrichstein, in what manner spectacles assisted sight? The first answer he gave, as he tells us in his ad vitellionem+paralipomena (1604), was, that convex glasses were of use by making objects appear larger. But his patron observed, that if objects were by them rendered more distinct, because larger, no person would be benefited by concave glasses, since these diminished objects. . . . He now gave a clear account of the effect of lenses, whether within or without the eye, in making the rays of a pencil of light converge or diverge ; and explained, that convex glasses assist the sight of presbyopic persons, by so altering the direction of rays diverging from a near object, that they fall upon the eye as if they had proceeded from a more remote one, that concave glasses benefit the myopic, by producing a contrary effect upon rays which diverge from a distant object, making them fall npon the eye as if they proceeded from a near one.” 21 ¢ Aside from the misinterpretation of special optical formule, caprice has played a conspicuous part in determining many eccentricities of practice; the business of selling spectacles appears always to have been deeply tainted with quackery. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. valid. The common use of cylindrical spectacle lenses dates from the special study of astigmatism by Donders.*" Quite recently Mr. Borsch, an ingenious practical opti- cian of Philadelphia, has undertaken the manufacture of C —— ‘ \ \ | ! / Fie. 3563. spectacle lenses with a convex or concave surface of un- equal radius of curvature in its several meridians, thus combining in one surface the effect usually obtained by the combination of a cylindrical with a spherical sur- face.*° The curved surface of such a convex lens repre- a b ‘sents a small area cut out from a large surface of revolu- tion corresponding to the rounded rim of a wheel ; the concave surfaces produced by this method are such as may be worked upon a grinding tool having the form of such a wheel. * Prismatic glasses, first suggested to Donders by his colleague, Krecke, as a possible means of re-establishing binocular vision when it has been lost through the deviation of the visual axes in strabismus, —_——_— —— i i -b Sparta Springs, Spectacles, Fie. 3564. —C external muscular apparatus of the eye. The decentra- tion of ordinary convex or concave lenses, in order to give to the combination of the two spectacle glasses some measure of prismatic effect, was also discussed by Don- ders.*!_ Decentrated convex lenses had already been used in the dissecting spectacles of Briicke,** and in the re- fracting stereoscope of Brewster.** Stenopzic spectacles —from orevds, narrow, and émq, a peep-hole—were also introduced by Donders,** chiefly for the purpose of ad- mitting to the eye such rays only as correspond to a se- lected limited area of the cornea or crystalline. Like the so-called panoptic spectacles of Serre d’Uzés,* they are essentially the same thing as the very old but long disused strabismus goggles (Schielbrillen — lonchettes). The snow-goggles of the Esquimaux, which cover the entire front of the eyeball, with the exception of a nar- row horizontal slit, are also properly to be regarded as stenopexic spectacles, although designed merely as pro- tectives against the injurious effects of strong sunlight reflected from the snow. The several forms which have been or may be given to spectacle lenses are shown, for concave and convex lenses respectively, in Figures 3564 and 3565. Of the convex lenses (of positive focus), a and g (Fig. 3564) are menisci, and may be designated as convex-concave and concave-convex, according as the convex or concave surface is turned toward the eye; 6 and jf, which have one surface plane, may similarly be designated as con- vex-plane and plane-convex ; ¢ and é are double-convex lenses, with surfaces of unequal radii of curvature ; and d is double-convex, with surfaces of equal radii. In concave lenses (of negative focus), we recognize the corresponding forms: Fig. 8565, -a, concave-convex, -e =f -J Fie. 3565. were made the subject of special study by Donders,* and have since held a place among the recognized means of dealing with conditions referable to disorders of the + * The entire surface of revolution, as shown in section, takes one of the three forms, Fig. 3563, @, 0, c, the last of which is an open ring ; the interior surface of such a ring gives a surface (c’)convex in one principal meridian and concave in the other, and applicable, therefore, to the correction of mixed astigmatism.?9 and -yg, convex-concave; -), concave-plane, and -f, plane-concave ; —c and -e, double-concave, with surfaces of unequal radii of curvature, and -d, double-concave, with surfaces of equal radii. Of these forms, the two shown in Fig. 3564, g (positive meniscus, with the con- cave surface turned toward the eye), and in Fig. 3565, -a (negative concave-convex), are especially designated as periscopic (from mept and cxoréw) glasses ; they offer a. 503 Spectacles, Spectacles, REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. slight advantage when the eyes are so turned as to look obliquely through the right or left half of both glasses. These several forms of lenses, other than the plano- sponding to the axis is that of greatest, and that at right angles to the axis is that of the least (positive or nega- tive), focal length. Cylindrical lenses are someiimes ig g h Fie. 8566. spherical, may all be resolved into combinations of two lenses, each with a spherical and a plane surface, placed with their plane surfaces in contact (Fig. 3566; a, 0, c, d). Inasmuch as a smaller effective area than that bounded by the usual setting is quite sufficient for most of the uses for which spectacles are worn, it is possible greatly made to order with two cylindrical surfaces of unequal radii of curvature and with crossed axes, but the same optical effect can always be produced with greater ease, and at less cost, by a combination of a single cylindrical (convex or concave) surface with a spherical (convex or concave) surface, * Laas Fie@. 3567. to reduce the weight of the glasses, when required to be of very short focus, by the adoption of forms like those shown in Fig. 3566, e, f, g and A. Cylindrical lenses are found in trade of two forms, Fie, 8569. namely, plano-convex and plano-concave (Fig. 3567, a - and b); the dotted line represents the axis of the cylin- drical surfaces, which is parallel to the axis of the cylin- der of which the lens-surface is a segment. Any re- quired spherical surface, convex or concave, is ground to order by the optician, upon the plane sur- face of any convex or Fia. 3568. Prismatic glasses, with plane surfaces, are of the form shown in Fig. 3568; any desired curvature, whether spherical or cylindrical, may be given to either surface, or to both surfaces, of the prism. s when a ray of white light is transmitted the bar. This condition =e through any transparent body, the sur- is ‘fulfilled in two>posi. wait oh a ee eee faces of which are not parallel. The general form tions of the lens, at right which this transparent body takes is that of an angles to each other, in L equilateral prism of glass, the sides forming an which positions the di- ron, : : ; . angle of sixty degrees. Hollow prisms with sides rectionof one or the other *""*** a a ne Low Hoop at the same angle are also used, being filled with I@. . principal meridian coin- cides with the direction of the bar. The middle point of any spherical or spherico-cylindrical lens is readily found by noting the point at which the crossing of two sash- bars coincides in the image and in the object. John Green. 1 Chaucer: The Wif of Bathes Tale. Canterbury Tales, v., 6785. 2cheler: Dictionnaire d’Etymologie Frangaise, Nouvelle Edition, Bruxelles, 1873. 3 Encyclopedia Britannica, ninth edition, article Beryl. 4 Guy de Chauliac: Chirurgia Magna. Venetiis, 1546. 5 Skeat: Etymological Dictionary of the English Language, Oxford, 1882. 6 Klein: HEulenburg’s Real-Encyclopiidie der gesammten Heilkunde, article Brillen. T Encyclopedia Britannica, ninth edition, article Microscope, ®8 Paulus Aegineta: Lib. iii., sect. xxii. ® Pliny: Naturalis Historia, lib. xi., cap. liv. 10 Thid., lib. xxxvii., cap. xvi. 11 Seneca: Naturales Questiones, lib. i., cap. vi. 12 Pliny : Naturalis Historia, lib. xxxvii., cap. x. 13 Thid., lib. xxxvi., cap. 1xvii. \4 Thid., lib. xxxiii., cap. xlv. 15 Alhazen: Opticee Thesaurus (Latin version). Basilise, 1572. 16 Klein: Eulenburg’s Real-Encyclopidie, article Brillen. 17 Ceesemacker: Annales d’Oculistique, xvii., 1846. 18 Klein: EKulenburg’s Real-Encyclopadie, article Brillen. 19 Salvino degli Armati—inscription on his tombstone in the Church of Sta. Maria Maggiore at Florence, 20 Bartisch: "OPOadmovdoAreia. Dresden, 1583. 22 Mackenzie: A Practical Treatise on the Diseases of the Hye, p. 914. Fourth edition, London, 1554, 22 De Sauvages: Nosologia Methodica, cl. vi. ord.i., iii, 3 and 4. Edo. Ultima. Amstelodami, 1768. 23 Rosas: Handbuch der theoretischen und practischen Augenheil- kunde, Bd. i., § 648. Wien, 1850. 24 Wollaston : Nicholson’s Journal of Natural Philosophy, vol. vii., pp. 143, 192, 242, 291; vol. viii., p. 88. London, 1804. Cited from Mac- kenzie, op. cit., p. 917, note. 25 Rosas: Op. cit., Bd. i., § 657. 26 Airy: Transactions of the Cambridge Philosophical Society, vol. Lig p. 267. Cambridge, 1827. Cited from Mackenzie, op. cit., p. 928, note. 27 Donders: Astigmatisme en cylindrische glazen. Utrecht, 1862. On the Anomalies of Accommodation and Refraction of the Eye, chap. viii. The New Sydenham Society, London, 1864. 28 G. C. Harlan: Transactions of the American Ophthalmological So- ciety, Twenty-first Annual Meeting, p. 96. 1885. 29 J, Green: American Journal of Ophthalmology, March, 1886. 30 Donders: On the Anomalies of Accommodation and Refraction of the Eye, chap. iv., pp. 152-135. 31 Ibid., chap. iv., pp. 166-168. 82 Bracke: Archiv fir Ophthalmologie, v., ii., S. 180. 1859. 83 Brewster: Edinburgh Philosophical Transactions, xv., 1844. 34 Donders: Op. cit., chap. iv., pp. 128-182. 516 transparent liquids. Sir Isaac Newton first made the observation that when aray of white light is transmitted through a prism the ray is not only bent out of its course, but is spread into an array of colors, the order of which is nearly invari- able, no matter what the source of light or the material of which the prism is composed. Since the facility of differentiating colors varies in different persons, the ex- act tints of the spectrum so formed are not easy to ex- press, but they are generally assumed to be seven in number, and arranged as follows: violet, indigo, blue, green, yellow, orange, red. If the ray of light be, as in Newton’s original experiment, admitted through an open- ing of appreciable dimensions, the colors will be somewhat confused and will appear unbroken, but when the open- ing is very narrow a more distinct effect is produced, and, as will be seen below, the spectrum is crossed by numerous dark lines. It is a law of the propagation of light that when a ray passes from one transparent sub- stance to another of different density it undergoes a de- flection, known technically as refraction. The direction and extent of this refraction depend on the nature of the materials and on the difference of the densities. When the ray passes from a rarer to a denser substance, for in- stance, from air to water, or from water to glass, the ray is bent (refracted) so as to be more nearly parallel toa line perpendicular to the surface of contact, while if the ray passes in the reverse direction, that is, from a denser to ararer body, as from glass to water, the refraction is away from the perpendicular. It is upon this principle that the image-forming and magnifying properties of all lenses depend. The accepted theories in regard to light refer it to very rapid vibration, and the difference between the various colors is supposed to be due to difference in the rate of vibration. White light is supposed to contain all the rates of vibration, and when such a ray undergoes re- fraction the different vibrations are refracted to different degrees, and hence are separated. If we view a ray through a plate of glass or other transparent body with parallel sides, the refraction produced in one direction on REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Spectacles, Spectroscopy. entering the glass is corrected by the refraction in the opposite direction on emerging, so that, with the excep- tion of a slight displacement of the line of light, no strik- ing optical change is manifest. If, however, the equi- lateral prism is used, the refraction on emergence is in the same direction as on entering, and the optical action is exaggerated. The separation of the different vibrations that compose aray of white light is called déspersion, and is not coextensive with refraction, that is, bodies of equal refractive power do not necessarily separate the colors to the same extent. This law is a very important one in practical optics, for all lenses are forms with more or less prismatic outlines, and hence produce a disper- sive effect. If it were only possible to prevent produc- tion of color by neutralizing the refraction, it would be impossible to construct any convenient optical apparatus free from colored images, but by combining different va- rieties of glass in such forms as to have equal and oppo- site dispersive powers with difference of refraction, large lenses entirely free from color defects (achromatic) may be constructed. In the spectroscope the object is to secure as complete and extended a dispersion as possible ; that is, to separate the colors thoroughly. For these purposes prisms of dense glass, or hollow prisms filled with carbon disul- phide, CSz, are used. The simplest method of examining the spectrum is to allow aray of light to enter a dark room or dark box through a small opening and fall upon a prism. Upon the side of the room opposite the opening will be seen a more or less confused spectrum, in which all the colors will be found diverted from the path which the original ray would pursue if it did not enter the prism, the violet being most diverted and the red the least. Such a method of observation, however, is unsuitable for scientific pur- poses. The most serious defect in it is that if the ray has an appreciable thickness the vibrations on one part inter- fere and overlap those of the other, so that the series of colors obtained is really a combination of a number of spectra not coincident with each other. To obtain a pure spectrum the ray must be reduced to an exceedingly tine line of light, in which there will be but few sets of vibrations. This is accomplished by using a very narrow slit, and shutting off all light from the prism except that which passes through this slit. The observation is also much facilitated by viewing the spectrum through a telescope of low magnifying power. About the beginning of this century Dr. Wollaston, an English chemist, discovered, by using such aslit, that the spectrum of sunlight is not continuous, but is interrupted by numerous fine, dark lines. He did not develop this observation, and it was not until 1814 that Fraunhofer, a German optician, rediscovered these lines and mapped the positions of a considerable number of them. Some of the most prominent he distinguished by letters of the alphabet. They have in consequence generally been known as the Fraunhofer lines. They are all at right angles to the direction of the spectrum, and their distance from each other depends on the dispersive power of the prism. Since each particular line is always seen in the same color, and is more easy to define than the limits of the color itself, these lines are preferred for purposes of comparison. Various improvements and advances in the construc- tion of apparatus for observing spectra have been made from time to time, until the spectroscope in its usual form consists essentially as follows: A straight tube terminates at one end by anarrow, upright, adjustable slit, and at the other a convex lens, the focal length of which is the dis- tance between it and the slit, so that the rays of light as they pass through the latter are rendered parallel by the lens. In the course of these rays is placed a dense glass prism, or series of prisms, greater dispersion being at- tained by acombination of prisms. A-movable telescope of low magnifying power, arranged so that it can be brought in the course of the rays emerging from the prism, enables one to view conveniently the spectrum formed. Such an arrangement constitutes a refraction spectroscope. In the cut there is shown a third tube, illuminated by a candle. This contains a graduated scale, an image of which is projected in the field of view above the spec- trum, for the purpose of measurement, as given below. Another form of the instrument depends on a some- what different principle, and as it is now in frequent use and possesses advantages over the older form it will be necessary to describe it. When the surface of a polished flat plate is ruled with a considerable number of fine lines in very close prox- imity, on viewing the plate obliquely, series of spectra are seen which are due to interferences in the different light waves as they are reflected from the angular sur- faces produced by theruling. This effect is called diffrac- tion, and a plate so arranged is called a diffraction grating. The superiority of such an instrument rests principally on the fact that in all parts of the spectra the colors are proportionately distributed. In the ordinary spectrum, as seen by the prism, the dispersion is proportionately greater toward the violet end, and consequently this por- Zn ci Fie. 3605. tion is abnormally spread out and the distances between the dark lines are exaggerated. Spectra, by whatever method observed, may be divided into three groups: 1. Continuous spectra: Those in which a more or less continuous sheet of color is seen, usually beginning with violet and ending with red. Such spectra are produced by the light which is emitted from solid objects in a highly heated state. 2. Interrupted, or bright-line spectra : Those in which the colors are seen in the form of narrow lines or bands, separated by proportionately wide, dark spaces. Such spectra are derived from light emitted by gaseous bodies in a highly heated condition. 3. Absorption spectra: Those in which a nearly contin- uous series of colors is present, but interrupted by dark lines or bands. Such spectra are produced by various conditions, principally, however, by the transmission of white light, or light which would give a continuous spectrum, through substances which have the power of absorbing or annihilating special vibrations. In the ap- plications of the spectroscope to medicine and organic chemistry these absorption spectra are the most impor- tant. It is obvious from the above considerations that we have in the spectroscope, whether of the refraction or diffraction form, a“very valuable means of studying structure. In the first place, we can determine with great exactness the character of the source of light, 7.e., whether it is composed of gaseous matter intensely heated or of solid particles. Further, taking a source of known 517 Spectroscopy. Spectroscopy. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. character, we can, by interposing various substances in the path of the light, determine the effect which those substances produce upon the different forms of light vibrations present in the ray, and as particular effects are often peculiar to particular bodies, we have here a means of identification. Thirdly, using a source of heat practically non-luminous, such as the flame of the Bun- sen burner, we can detect different substances by the color they impart to this flame, and when several such substances are present the eye alone is unable to separate and distinguish the colors, but by the spectroscope each tint is distinctly indicated. As stated above, it is the absorption spectra that are most important in reference to the medical applications of the spectroscope. Except in the comparatively rare cases of the study of the character of light emitted by luminous organic bodies, living or dead, and in the detec- tion of certain metals present in minute amount in the tissues and secretions, é.g., lithium, the direct study of normal spectra is not much resorted to in biological work. The arrangement of the spectroscope for observation of absorption spectra is simple. An oil- or gas-flame is ad- justed so as to throw a beam of light through the slit of the instrument, by which a continuous spectrum not broken at any point by dark lines is obtained. Sunlight does not answer so well for the purpose, because, owing to certain interfering conditions occurring at the surface of the sun, and also during the passage of the sunlight through our atmosphere, there are numerous absorption bands (Fraunhofer’s lines) always present in its spectrum. The material to be examined is placed in a cell with flat sides.in the path of the light before it enters the slit. It is scarcely necessary to observe that to secure a satisfac- tory result the body must be sufficiently transparent to permit some light to pass through, otherwise no compar- ison as to the effect on different parts of the spectrum can be made. Such a condition is easily obtained by using solutions of the substance in the usual colorless sol- vents—water, alcohol, ether, glycerine, etc., and diluting until a satisfactory result is obtained. The character of the absorption spectra sometimes differs, according to the solvent used and the presence of free acid or alkali. Working spectroscopes are generally arranged so that two spectra can be compared, one being a. standard ob- tained under known conditions, the other being that of the body to be tested. To understand the functions of the spectroscope it is necessary to bear in mind that the colors seen are practi- cally images of the slit through which the light passes, and that when the ray contains all the colors, that is, every vibration from violet to red, the prism, in setting out the vibrations according to dispersive-power, gives, of course, a continuous series of images, that is to say, a continuous spectrum. When, however, in the ray of light that enters the slit any vibrations are missing, as in sunlight, or when by some interposed condition cer- tain colors are struck out of the ray, the images which would otherwise be formed by those rays are missing, and hence the spectrum appears interrupted. When the interposed substance strikes out many rays, eg., deep- colored glasses, the great bulk of the spectrum is miss- ing. The red glasses, for instance, used in photographic dark-rooms strike out all rays but the red. The spectro- scope as ordinarily constructed is, unfortunately, subject to serious defects, which can be avoided only by instru- ments of very expensive form. It has been found that all the forms of glass possess marked absorption powers for certain rays of light. If, instead of employing glass lenses and prisms, we use those made of quartz, and em- ploy as a source of light the electric arc, or burning mag- nesium wire, a spectrum is obtained which is very much extended at the violet end. This portion of the spec- trum exists to a greater or less extent in white light from any source, but 1s absorbed to such an extent by glass that it is not seen in the ordinary spectroscope. There are also color waves beyond the red, which are only de- monstrable by special apparatus. In the usual applica- tions of the spectroscope we cannot, therefore, utilize the so-called ultra-red and ultra-violet rays. 518 A very important advance has been made recently in practical spectroscopy in the application of photography. A sensitive plate is capable of responding to and record- ing conditions which the eye is unable to recognize, and we have, therefore, not only a method of extending our knowledge of spectra, but we may obtain permanent records of absolute accuracy, and independent of any general or special defects in vision. This method is yet incompletely developed, but it promises well. The pho- tographic plate is especially capable of receiving impres- sions from the violet and ultra-violet portions of the spectrum, which are especially those which the eye ap- preciates with the greatest difficulty, while the yellow and red rays are practically inactive. . Many substances are known which have the power to retard the rate of vibration of light rays, so that they change the color of the light falling on them. Now, the ultra-violet rays, which are inappreciable to the human eye, are caused by extremely rapid vibrations ; any sub- stance which will reduce this rate will bring the rays within the range of vision. This property is known as fluorescence. It does not come within the scope of this article to more than refer to it, but it may be men- tioned that one of the most recent advances in the prep- aration of photographic plates is to incorporate into the sensitive material some fluorescent body by which the rays of light are modified and effects produced with colors that would otherwise be inactive. It is not un- likely that we have in this method a line for still further ‘extension of the application of photography to the spec- troscope. The only way of acquiring familiarity with spectro- scopic appearances is by actual use of the instrument. No drawing, colored or otherwise, can convey perfectly the appearances, Nevertheless, a method of indicating the character and position of the lines is useful, and sev- eral plans have been adopted. The use of colored plates is, of course, the most vivid, but too costly for most pur- poses. The usual methods are either by recording the position of any line, or the centre of a band, by its posi- tion on an arbitrary and fixed scale, or by angular posi- tion. A form of spectroscope made by Browning, of London, has this latter arrangement. The view telescope moves in a graduated arc, and cross lines in the field en- able it to be brought to exact position with any line. By such method or by the scale the lines may be mapped in their relative positions as seen in that particular in- strument. Another method is to indicate the positions of lines by their calculated wave-lengths ; that is, the length of one complete movement constituting the ray which pro- duces a line at the given point. Such a method has the advantage of being an absolute indication, and not de- pendent on any particular instrument. Wave-lengths are determined by mathematical calculation by means of the phenomena observed in diffraction, and the calculation may be easily applied to ordinary cases by plotting off on a chart certain lines of which the wave-lengths are known, and interpolating those of which it is desired to deter- mine the wave-length. ‘These lengths are very minute, and are usually expressed in millionths of a millimetre. DESCRIPTION OF SPECIAL SPECTRA. DBright-line Spec- tra.—Each of the known elements gives a special and distinct spectrum when heated sufficiently to become a luminous gas. It has been pointed out at the beginning of the article that solid substances give continuous spec- tra, and hence there is no appreciable difference between the spectroscopic appearances of the different elements as long as they remain solid bodies. When the temperature rises sufficiently to convert them into gases, and render them at the same time luminous, the characteristic bright- line spectra are obtained. This temperature can be at- tained with most elements only by the use of the electric spark. A few bodies, among which are potassium, so- dium, lithium, barium, calcium, strontium, and boron, yield at the temperature of the non-luminous gas-flame— Bunsen-burner flame—a limited number of rays which are early observed by the spectroscope as bright lines. Thus sodium imparts to flame a deep yellow color which REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Spectroscopy. Spectroscopy. consists of two tints, and is seen in the spectroscope as a narrow double line. Potassium gives red and violet lines. By increasing the temperature some of these spec- tra are modified. When the electric spark is employed the spectra obtained are usually more complex, the bright lines being numerous. The detection of the different elements by this means is not so widely applicable as might at first be supposed, for the method is extremely delicate, and it is difficult to distinguish between the mi- nute traces which often have no significance and the pres- ence of an appreciable amount. Nevertheless, the method has been of great usefulness in special cases in showing the occurrence of some elements in unexpected relations, and the wide distribution of others in minute quantities. Several elements have been discovered by the spectro- scope, occurring in such minute quantities that ordinary chemical analysis would have failed to indicate them. There are a few rare metals which give a limited bright- line spectrum before reaching the temperature at which they became gaseous. | Absorption Spectra.—These are of several kinds. The absorption may affect a considerable part of one or both ends of the spectrum, by which a whole block of color may be cut out, or it may take place in broad bands or in fine lines. The spectrum of the sun and of many of the fixed stars is an example of this latter class. The lines of absorption are numerous, but they are narrow and repre- sent but a small portion of the entire field, which appears to the unassisted eye to be a uniform sheet of color. Band absorption, that is, the cutting out of a considera- ble number of rays at some point on an otherwise con- tinuous spectrum, is brought about very easily by means of many organic bodies. Extended absorption, by which a considerable portion of the spectrum is absorbed, is seen in many substances possessing deep color, and the absorption may include all but a single color. Various colored glasses may be used. To test the effect of a graduated increase of color, wedge- shaped glasses may be employed. Hollow wedge-shaped cells are often used for the examination of colored liquids. The method of observing absorption spectra has been given above. It has been also already pointed out that no description, nor even drawing, can give an adequate idea of the actual appearances of spectra, but for the purpose of completing the article and indicating some of the practical applications of the methods a few absorp- tion spectra will be described. Line-absorption Spectra.—Some of the rarer elements possess the peculiar property, when in solution, of ab- sorbing special rays of light. Among the best known of these is the metal didymium, which occurs only in some moderately rare minerals. Its compounds have a delicate but distinct rose-red tint, but even when so far diluted as to make the tint not perceptible, they give several ab- sorption-bands about the middle of the spectrum, The vapors of bromine and of nitrogen dioxide, NO, which to the eye have much the same color, give each a pecul- jar series of numerous fine absorption-lines in the central part of the spectrum. The absorption-lines that normally occur in the spectra of the sun and stars are an impor- tant clue to the chemical composition and physical con- dition of those bodies, but a consideration of this topic does not belong here. Band-absorption.—One of the most familiar and strik- ing instances of this form of absorption is seen in chloro- phyll, which is the general term under which the green coloring matter of plants is designated. < about 75V diameters. (After H. H. Brown.) the salamander, and gives a plate of diagrams which is instructive as a facile means of comparison. The spermatoblasts arise from the nuclei of the second daughter-cells (spermatocytes), and not as Brown’? and many others have, I think, erroneously believed, each out of a whole cell. Biondi® seems to me right in his state- ment that the bodies of the cells break down, or at any rate lose their boundaries, thus creating a granular pro- toplasmatic column in which the nuclei lie. The mother- cell participates in these changes, hence its nucleus comes to lie at the base of the column. This nucleus has mean- while altered its character, and become large, clear, and nucleolated. Now, these columns are the same as the large Sertoli’s, or supporting cells above described. By no means all writers agree with this account of the ori- gin of Sertoli’s cells, but all other explanations that I 523 Spermatozoa. Sphygmograph. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. have found appear to me vague and confused, and the history of the changes here advocated is clear, and ac- counts for the well-established grouping of the spermato- blasts in the substance of Sertoli’s column ; this essential phase is explained satisfactorily by no other theory. The nuclei congregate at the inner end of the column, and there change their character and become recogniz- able spermatoblasts (Figs. 3612 and 3616). Development of the Spermatoblasts into Spermatozoa.— The nuclei change into spermatozoa as follows: The chromatine is at first une- qually distributed through- out the nucleus; it then in great part accumulates at the end of the nucleus toward the outer wall of the tubule; particles of the chromatine are said to remain in other regions of the nucleus, and finally to gather together to form the small accessory cor- puscle mentioned below. The main mass of the chro- matine is concerned in the formation of the head of the spermatozoon ; it is at first quite round (Fig. 3612, a and b), but soon begins to alter its shape, gradually assuming the form of the spermatozoon head (Fig. 3612, c, d, e, f). The tail appears very early as a delicate filament, lying entirely within the nucleus (Fig. 3612, a), but shortly after is found to project be- yond the nuclear membrane b, and lengthens rapidly, é, Quica. A, B, C, different stages. t, g. The nuclear membrane Se is very distinct ; it elongates into an oval bag, 0, ¢, one end of which lies close against the chromatine, while the other surrounds part of the tail and is wide; the length- ening continues, é, f, g, with accompanying changes of form, best indicated by the figures; the part of the tail within the nuclear membrane becomes the middle piece (Fig. 3613), but the spiral thread is not developed until later. The accessory body may be readily seen in the rat; unlike the chromatine of the head it can be stained by chloride of gold, hence if it is formed of chromatine at all, the chromatine must have undergone alteration. Finally, the nuclear membrane ruptures (Fig. 3614), a portion of the membrane remains upon the head, and the caudal bag sometimes endures longer (Fig. 3612, g), but at last also disappears, except that in certain cases a trace of it remains visible as a fine cross- line at the end of the middle piece. » First and _ others think that the axis of the tail is formed from the chromatine, and that the sheath of the axis arises from the achromatic sub- stance of the nucleus (caryoplasma). After the rupture of the nuclear mem- brane, the young spermatozoa still develop a little further. The sperma- tozoa are ultimately liberated, and, falling into the lumen of the tubule, pass off. From their mode of development, it is evident that the spermatozoa necessarily lie in bundles, each bundle be- ing held together by a Sertoli’s column (Fig. 3615) ; at first they lie at the inner end of the column, at a consid- erable distance from the basal nucleus (Fig. 3615), but as the nuclei (spermatoblasts) lengthen, the heads push their Fra. 3613.—Developing Spermato- zoa of a Marsupial, Metachirus Fie. 3614.—Human Spermatoblasts, to Il- lustrate the Rupture of the Membrane, (After Wiedersperg. ) 524 way toward the base of the column (Fig. 3616). Now, as the development of the daughter-cells (spermatocytes) is continually progressing between Sertoli’s columns, we obtain in sections the long-known remark- able appearances shown in Fig. 3616, of bundles of spermatozoa alternating with columns of pro- liferating cells. : 4. Hisrorican. — The seminal animalcules were, it is stated, first discovered by Ludwig Hamm, then a student at Leyden, in Aug- ust, 1677. Loewenhoeck claimed the merit of having made the dis- covery in November of the same year, and in 1678 Hartsoeker pub- lished an account of them, pro- fessing to have seen them as early as 1674. They were long consid- ered to be probably parasites, and it was not until Prevost and Du- mas’s researches that it was defi- nitely ascertained that the “‘ ani- malcules” were the essential fertilizing element. Thus Richard Owen, in his article on ‘‘ Entozoa” (1836), in ‘‘ Todd’s Cyclopedia,” includes the spermatozoa under that head, although he writes— ‘it is still undetermined whether they are to be regarded as analo- gous to the moving filaments of the pollen of plants or as indepen- dent organisms ” (vol. ii., p. 412). But just after he adds: ‘‘ Although no distinct organs of generation have been detected, there is reason to suspect that the spermatozoa are oviparous; they are also stated to propagate by spontaneous fission, the separa- tion taking place between the disk of the body and the caudal ap- pendage; each of which de- velop the part required to form a perfect whole.” Meanwhile the investi- gations of Spallanzani, Wagner, Czermak, and many others, grad- ually increased the knowledge of the ¢, forms of the spermatozoa. Dujardin’® was the gp first to con- Fre. 8615.—Sertoli’s Col- umn, with a Basal Nucle- ated Nucleus and a Clus- ter of Developing Sperma- toblasts. (After H. H. Brown.) sider the sperma - tozoa as generat - ed from the inner “* layer of the seminif- erous tubules, and, therefore, not as parasites. The dis- covery of the sper- matoblasts, or im- mature spermatozoa, by von Siebold (Miiller’s Archiv, 1836 and 1843), soon confirmed by Kélliker and Reichert, Fia. 8616.—Part of a Cross-section of a Sem- iniferous Tubule of a Rat. >< about 750 di- ameters. (After H. H. Brown.) REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. marks an important step. Now followed a series of pub- lications by which one detail after another was added to our knowledge. During the past twenty years there has been rapid progress, which may be said to have begun with Schweigger-Seidel’s important memoir,* and to have made us acquainted with the minute structure of the spermatozoa, and their development. Another line of investigation was opened by O. Hertwig (1875), in follow- ing up the history of the spermatozoon within the ovum after impregnation. For further historical data see Waldeyer’s address *? (1887). LITERATURE. The literature is enormous. The following references include most of those which have been consulted for the preparation of this article: 1 Ballowitz: Anat. Anzeiger, i., 363. 2 Beauregard, C. R.: Société de Biologie, Paris, viiie Série, t, iv. 3 Benda: Arch. mikrosk. Anat., xxx., 49. 4 Beneden et Julin: Bulletin de l’Acad. des Sci. Belge (3), vii., 312. § Biondi: Arch. f. mikrosk. Anat., xxv., 594. 6 Blomfield, J. E.: Quarterly Journal of Microscopic Science, xx., 79. 7 Blomfield : Quarterly Journal of Microscopic Science, xxi., 415. 8 Blomfield: Review of Recent Researches on Spermatogenesis, Quar- terly Journal of Microscopic Science, xxiii., 320. 9 Brock, J.: Zool. Jahrb., ii., 615. 10 Brown, H. H.: On Spermatogenesis in the Rat, Quarterly Journal of Microscopic Science, xxv., 343. 11 Von Brunn, A.: Arch. mikrosk. Anat., xii., 528, and xxiii., 108. 12 Von Brunn, Max: Arch. mikrosk. Anat., xxiii., 413. 13 Carnoy: La Cellule, i., 191-440. 14 Czermak: Uebersicht-Arbeiten Schles. Ges. Vaterland. Cultur, 1848. 15 Dujardin: Annales des Sciences Naturelles, viii., 291. 16 Ebner: In Rollett’s Untersuchungen, 1871. 17 Kimer : Verh. phys.-med. Ges., Wurzburg, N. F., Bd. vi., 1874. 18 Flemming, W.: Arch. mikrosk. Anat., xviii., 233. 79 Flemming (Karyokinesis of Spermatocytes in Salamandra): Arch. mikrosk. Anat., xxix., 889. 2° Furst: Arch. mikrosk, Anat., xxx., 336. 21 Geddes and Thompson: Procecdings Royal Society, Edinturgh, 1885-86. 22 Gibbes: Quarterly Journal of Microscopic Science, xix., 487. 23 Helman: Inaug. Diss., Dorpat, 1879. 24 Hermann: Robin’s Journ., 1882, 373. 25 Jensen, O. S.: Die Struktur der Samenfdden, Bergen, 1879, 1 Taf. 26 Jensen, O. S.: Archives de Biologie, iv., 1883, pp. 1-94 and 669- TAT. 27 Jensen: Anat. Anzeiger, i., 251. 28 Jensen: Arch. mikrosk. Anat., xxx., 3 29 K6lliker: Zeitschr. wiss. Zool., vii., 201. 30 Krause: Biol. Centralblatt, i., 25. 31 Krause: Internat. Monatschr. Anat. Histol., ii. 32 Ta Vallette St. George: Der Hoden (Cap. xxiv.), in Stricker’s Hand- buch der Gewebelehre. 33 Leydig: Untersuchungen zur Anat. und Histologie der Thiere, Bonn, 1883. 34 Merkel: In Unters. Anat. Inst., Rostock, 1874. 35 Merkel: Miller’s Archiy, 1571. ‘38 Miescher: Verh. Naturforsch. Ges., Basel, vi., 138. 37 Mihalkowics: Ber. K. Ges. Sachs. Ges., Wiss., Juli 26, 1878, p. 217. 38 Neumann, H.: Arch. mikrosk. Anat., xi,, 292. 39 Nussbaum, Moritz: Arch. mikrosk. Anat., xviii., 1. 40 Platner, G,: Arch. mikrosk. Anat., xxv., 564 (Spermatogenesis in Pulmonata). 41 Platner, G.: Arch. f. mikrosk. Anat., xxvi., 343. 42 Renson, G.: Arch. Biol., iii., 291. 43 Retzius, Gustav (Best Description of Human Spermatozoa) : Biolo- gische Untersuchungen, i., 77-88, Taf. x. 44 Romiti: In his Notizie Anatomiche, No, ix., p. 23; Abstract in Biol. Centralbl., 1855, 505. 45 Schweigger-Seidel: Ueber die Samenkor- fs per und ihre Entwickelung, Arch. mikrosk, Anat,, i., 309-835, Taf. xix. 46 Semper: Das Urogenital-System der Pla- giostomen, etc., Arbeiten Zool.-zoot. Inst., Wurzburg, ii., 195. 47 Sertoli: Arch. Sci. Mediche, ii., 107. 48 Sertoli, E.: Arch. Ital. Biol., vii., 369. ¢ 49 Spengel: Arbeiten Zool.-zoot. Inst., Wurz- burg, iii., 114. 50 Swaen et Masquelin: iv., 749. } 51 Wagner and Leuckart: Article Semen in Todd’s Cyclopedia, vol, iv., Part I.. p. 472 (an invaluable summary). } _ 52 Waldeyer (Summary of Recent Investigations): Anat. Anzeiger, U., 345. 58 Weissmann: Zeitschr. wiss. Zool., xxxiii., 55. 54 Wiedersperg: Arch. mikrosk. Anat., xxv., 113. 55 Zacharias: Arch. mikrosk. Anat., xxx., 111. Charles Sedgwick Minot. ba) ON} UTIL SPHYGMOGRAPH AND CARDIOGRAPH. _ Instru- ments for ubtaining graphic representations of the pulse- movements of the arterial wall, or of the movements imparted to the chest-wall by the impulse of the heart. They cause a lever or style, which follows and magnifies the movements, to write upon a surface passing at a con- stant speed, and thus trace a record of the rhythmical movements in a series of curves. In order to fulfil the fundamental requirements, such instruments should ac- curately follow the pulse-movements, without modifying Spermatozoa. Sphygmograph, them by their own inertia; they should magnify the movements sufficiently to permit convenient study of their record ; and the rate at which the recording surface moves should be reasonably constant, so that the time occupied by the various phases of the movement can be calculated. A great number of instruments have been devised, which meet these conditions more or less successfully. The first-named requirement offers the only problem dif- ficult of solution. The first useful sphygmograph, the curves of which have been shown to represent the actual movements of a pulsating artery, was introduced by Marey, the great master of the graphic method, in 1860, Before him the most important apparatus designed for the same end was the sphygmograph of Vierordt (1855), who failed to register the real movements of the pulse only from his anxiety to produce curves like those of the kymographion—an instrument which indicates the varia- tions of mean blood-pressure with great exactness, but does not follow the quick and delicate variations of the pulse. The sphygmograph of Marey (originally con- structed for the radial artery alone) was at once em- ployed not only by physiologists, but by clinicians, and added sphygmography to the methods of clinical investi- gation. It has since been variously modified and im- proved, and the principle of its construction—‘‘ sphygmo- graphe a pression élastique’’—is the basis of most of the instruments now in common use. Moreover, it has been critically tested by other competent observers, and -has been found to answer the requirements of an instrument of precision, in spite of certain limitations.! ELASTIC SPRING SPHYGMOGRAPHS.—WMarey’s sphygmo- graph. A rather strong elastic steel spring, a, Fig. 3617, is fixed by one end, 0, to a frame of brass to be applied to the forearm, while its other (free) end is provided with a thin ivory button, c, intended to press upon the radial artery at the wrist. The pulse-movements communica- ted to this button are transmitted to the lever by means of an upright toothed rod, d, which presses against a small similarly toothed wheel, e, turning on an axis to which the light wooden lever, f, is fastened. Every movement of the upright turns the wheel and elevates or depresses the lever. he axis of the lever revolves in a bearing in the end of the frame which rests 7 upon the wrist. The other end of the brass frame, to which the spring is fastened, sup- \ DO ciated pes L a clockwork, Fie. 3617.— Scheme of Marey’s S phygmo- graph, with Mach and Bé- hier’s modification. Breguet’s manufacture. 1g natural size. g, that drives a light brass sled, /, in the direction toward the wrist, as indicated by the arrow. This sled carries the recording surface of smoked paper or glass upon which the end of the lever—a fine-pointed style, 7— scratches its record. The described connection between the spring and the lever, by means of the toothed rod and cog-wheel, is a modification by Mach? (1863) and by Béhier? (1868), and is now used in all the instruments made by Breguet. The rod is movable on an axis in a brass plate on the free end of the spring, so that it can be laid flat upon the lat- ter while the sphygmograph is being adjusted to the arm, and lifted up against the toothed wheel of the lever when the instrument is set in action. The spring itself keeps it closely applied to the cogs of the wheel. : The pressure of the spring upon the artery 1s modified by means of the screw s, which presses the spring down- ward with greater or less force. While by this means the pressure can be varied, it cannot be measured. To obviate this defect Burdon-Sanderson (1867) introduced a modi- 525 Sphygmograph. Sphygmograph. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. fication, by which the instrument is at the same time more securely fixed to the wrist. Removing the wings by which Marey binds the frame upon the forearm, he i RATT Cc ie ina JUST I i} aaa Fia. 3618.—JZ, Marey’s Sphygmograph, Applied; ZZ shows the manner in which the upright toothed rod of Béhier is joined to the end of the spring, (Rollett, in Hermann’s Hdb. d. Physiologie, Bd. iv.) adjusts to the end of the instrument (between the letters a and 6 in Fig. 3618) ‘‘a rectangular block of brass, by the under surface of which [covered with ebonite] it rests on the tendon of the flexor longus pollicis, and on the __ space between that tendon and the spine of the ra- fig dius ; the block being kept closely applied to the sur- |i face by means of a strong elastic band which encircles the wrist.” 4 By means of a screw the distance between the ebonite surface and the frame is varied at will and the pressure modified ; the amount of the pressure is measured by the deflexion of the spring (the distance between the spring and the lever) as determined by experimental test. Ma- homed® (1872) substituted for the screw s, which in Marey’s sphygmograph varies the pressure of the spring, an excentric wheel m (Fig. 3619), graduated in accord- ance with the degree of pressure, so that the latter may be read off at once. Fie. 3619.—Mahomed’s Sphygmograph, Applied. Marey’s instrument is fixed to the forearm by means of japanned wings hinged to the frame, which are provided with hooks, and a silken cord passed under the arm from hook to hook. This mode of adjustment is defective. Mahomed’s sphygmograph is more securely attached, by Fia, 3620.—Scheme of Landois’s Angiograph. (Rollett.) means of two straps, one at each end of the frame, toa supporting pad placed under the arm, as seen in Fig. 3619. INSTRUMENTS IN WHICH THE PRESSURE IS EXERTED BY WerIGHTSs.—Instead of the elastic spring pressure, 526 : (Bramwell. ) methods have been devised for applying the pressure by weights, which afford the advantage of numerical accu- racy. Such are the modification of Marey’s sphygmo- graph by Baker ° (1867), the angiograph of Landois* (1872), the sphygmograph of Sommerbrodt ® (1876), and the sphygmo- graphe passif of Brondel® (1878). Baker and Brondel replace the steel spring of Marey’s instrument by sliding weights ; ‘ the most important contrivance for car- rying out the principle of pressure by direct weight, however, was invented by Landois. Landois’s Angtograph.—On the proxi- mal end of a plate, g, g, (Fig. 8620), that serves as the base of the instrument, is balanced on an axis the solid rod d, z, which takes the place of the spring in Marey’s sphygmograph; to its longer arm, near d, are attached, below, a stem carrying the button c, which explores the artery, and above, a stem carrying a dish or scale, @, for holding the weights, and .a toothed rod which, as in Béhier’s modification, moves the toothed wheel /, attached to the spindle of the writ- ing lever. This lever bears upon its extremity a light | needle, k, hung from the joint Zin such manner that it falls by its own weight upon the smoked plate ¢; this plate—the recording surface—is moved by clock-work at right angles to the plane of the lever (and to the forearm). Fig. 3621.—Marey’s Tambour with Registering Lever. (Gscheidlen.) One-half natural size. This arrangement secures vertical movement of the nee- dle instead of the curved movement of the style of Marey’s sphygmograph, as well as the least possible friction in the tracing apparatus, but at the same time involves a clumsiness which detracts from the convenience of the instrument. The lever itself, as well as the rod d z, with all its attachments, being bal- anced by counterpoises, é and z, the pressure upon the artery is exerted only by the weights placed in the scale. ; Sommerbrodt made use of a like accurate method of pressure by weights in his some- what complicated modification of Marey’s sphygmograph. TRANSMISSION #SPHYGMOGRAPHS, io POLYGRAPHS, PANTOGRAPHS, —A new j } principle in the construction of pulse- « / writers wasintroduced by Marey (1868), ‘ following the methods of Upham and Buisson, in his instruments ‘‘@ trans- mission.” With the help of a suitable mechanism the pulsatory movements are conveyed to a Marey’s tambour or tympanum, which is put in communi- cation, by a flexible tube, with asecond tympanum. The second tympanum carries the writing lever. The tympanum is a shallow capsule of metal covered by a caoutchouc membrane, the centre of which bears a Fia. 8622,—Marey’s Registering Tambour ; new construction. (Gscheid- len.) Natural size. very light round metal (aluminium) plate. In the second (or registering) tambour this plate is provided with a REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Sphygmograph. Sphygmograph. wooden bridge or knife-edge upon which the writing lever rests. Figs. 8621 and 3622 show the details of con- struction of this apparatus, now well known in the physi- ological laboratory. The expanding movement of the artery compresses the air in the first (or receiving) tam- bour and forces a part of the contained air into the sec- ond tympanum, whose membrane is thereby raised and lifts up the lever placed upon it. The lever magnifies the movements. The recording surface may be so large and so constructed ul NN zi Uh sh SSS —— Fia. 3623.—Receiving Tympanum of Brondgeest’s Pansphygmograph, (Gscheidlen.) One-half natural size. that a number of levers can register upon it at the same time, one exactly under the other, and the pulse-move- ments from two or more sources can be inscribed upon it synchronously ; such instruments have been called poly- graphs, Sphygmographs of this construction differ mainly in the mode of application of the receiving tambour to the pulsating surface ; many of them can be applied to any pulsating artery, as well as to the chest-wall over the impulse of the heart, and are known collectively as a 3623), whose elastic membrane, C, is provided with a button, D, is held over the vessel by means of a metal bow in which its short metal tube, B, is fastened by a screw, F, in such manner that the button bears upon the artery with the necessary degree of pressure. The tube B is connected by a caoutchouc tube with the reg- istering tambour. Two systems of tambours, or three, hele Fic. 38625.—Marey’s Sphygmographe @ transmission. (Ozanam.) can be employed to register movements upon a revolving cylinder simultaneously. Meurisse and Mathieu (1875) made use of a more com- plicated receiving apparatus, adding spring-pressure ; they also placed the recording apparatus, for greater clinical convenience, in a portable box which contains the clock-work that propels a strip of paper on which the tracing is inscribed. This sphygmograph has been modified by Grunmach (1876) and by v. Knoll (1879). Fig. 8624 shows its modern form. The exploring but- ton -D is detached from the cap- sule ; it is carried on the end of a curved steel spring, B C, ris- ing from a_horse-shoe plate, which serves as the base; the degree of pressure of the spring is regulated by the screw E. The capsule is held over the button by two vertical rods fixed upon the base-plate, so that the stem of the button touches the centre of the membrane of the tam- bour. The latter is set higher or lower by a ratchet mechanism. The use of the spring-pressure in connection with the transmission-apparatus seems to have been suggested by Burdon-Sanderson’s Fig. 8624.—Grunmach’s Modification of Meurisse and Mathieu’s Poly- graph. (Gscheidlen.) One-fcurth natural size. j pantographs. Many cardiographs (see below) are con- structed on this principle, which was, indeed, first used for demonstrating the movements of the heart by Up- ham, Buisson, and Marey. Brondgeest (1878), in his pansphygmograph, devised a mechanism for applying the tambour to all pulsating surfaces; the capsule A (Fig. cardiograph (see below). In Marey’s sphyymographe & transmission (1878) (Fig. 3625), spring-pressure is also used, the mode of application being the same as in his elastic-spring sphygmograph ; the same frame, without the clock-work, carries a steel spring and a Béhier-Mach grooved stem, which rests against one end of an angular lever; the other end of this lever touches the centre-plate of the re- ceiving tambour, which is set upright facing the wrist. Dilatation of the artery raises the spring, presses the lever against the membrane of the tambour, and, by com- pression of the air within, raises the membrane of the recording tambour and lifts the writing lever. i ‘Keyt,'° of Cincinnati, starting with a ‘‘ sphygmometer of his own invention, similar to the old sphygmometer of Hérisson and the sphygmoscope of Naumann, evolved the ‘compound sphygmograph,” which Fig. 3627 shows in its most complete form—a transmission sphygmograph, in which water is used as the medium, instead of air. His sphygmometer was a graduated glass tube, cight or 527 Sphygmograph. Sphygmograph. ten inches long, with an exploring ‘‘ base” of brass (Fig. 3626), ‘‘ semicircular in form, with an oblong free edge below, and a shallow neck into which is inserted, air- tight, the glass tube.” The free edge of the base, one and three-eighths by three-eighths inch, is closed by a rubber membrane. This base is used in the perfected instrument for receiving the pulse movements. When the base is pressed upon the artery, the water in the tube follows the movements of the arterial wall. He then closed the top of the tube (filled with water) by a rubber membrane, and placing on this a pin and lever, was ready to register the enlarged movements on a passing plate. In the complete instrument (Fig. 3627) there are supplied two exploring bases, each with its tube and lever, one of which regis- ters exactly below the other. The communicating tubes are made of stiff rubber, or of glass with rub- ber joints, so that the bases can be freely moved. The upper end of Fic. 3626.--Base of Keyt’s the tube is now a metal cylinder Sphygmometerand closed by a rubber membrane. sa rete (After Bach base can also be put in com- munication with a manometer tube indicating the degree of pressure applied. The register- ing plate is driven by a clock-work, and receives, besides the tracings of the lever, the simultaneous markings of a chronograph. The instrument thus becomes one of the best polygraphs, and lends itself especially to the study of the synchronism or succession of events in the circulation. Keyt asserts that in his manner of employing water as the medium for the transmission of movements, the in- ertia of the water does not become obnoxious, and its power of transmission is greater than that of air. His tracings seem to bear out this claim. But when Ozanam, in his sphygmograph,'! resorts to the much heavier medium mercury, the resulting curves are scarcely more than the rec- ords of rhythmical oscillations of the mercury. — fl Fia. 3627.—Keyt’s Compound Sphygmograph, and clinical convenience have been consulted in two in- struments, which have been used more extensively by physicians, perhaps, and which have bred more amateur sphygmographers than any others, in America as well as in England and Germany—those of Pond (Vermont, 1877) and of Dudgeon (England, 1878-80). 528 Facility of application ° (Keyt.) | REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Pond’s sphygmograph, in its present form, when in use, is held in the fingers by the hollow cylindrical body a, (Fig. 8628) and the necessary pressure is thus exerted on the artery more readily, and quite as steadily, as by use of the arm-rest furnished with the instrument in its earlier phases. The foot of this body is an oval metal capsule, 6, closed by a pure- rubber cap; the base is thus made of a slightly stretched elastic membrane, which is made more or less tense ac- cording to the pressure used. Upon this membrane rests a small metal plate bearing an upright rod, which moves loosely within the body and terminates in the button ec. From the upper part of the body spring two metal arms, one of which supports the clock-work d, and a stage, e, for the card-board or mica slide on which the trace is written (the slide moves, in the figure, at right angles B to the plane of the paper, and toward the specta- a tor). The other metal arm bears the system of levers and ie bi Oe Wir Lb Fic. 3628.—Scheme of Pond’s Sphygmograph. B,Side ; dl view of the base; C, shape of rubber membrane clos- in g- needle, ing the bottom of the base, One-half natural size. When the instrument is pressed upon the artery the rod concealed in the cy- lindrical body rises and touches the screw 7, which can be set to conform to the pressure, 7.¢., to the height to which the rod is lifted; any further upward movement now imparted to the rod by the pulse raises the screw and turns the lower lever about the pivotal point g, so that its upper end moves outward toward the letter A. This end, by a loop, embraces the short arm of the second lever, and, pushing it to the right (in the figure), moves its long arm to the left. From the end of this lever is sus- Wg pended, by the loose joint 7, the needle n, whose f point rests upon the slide and traces the pulse- curve. The short arm of the upper lever ends in a counterpoise, which by its weight secures the return of the lever when the " upward pressure is withdrawn. In this instrument, the pressure made over the artery is that of the more or less tense rubber membrane at the base. The defects of this instrument are obvious. The weight of the levers and their counterpoise is so great, as com- pared with that of the rod, which lies loosely upon the membrane of the base, that the inherent vibrations of the appa- ratus make themselves felt in the curve. , The excursions of the needle are limited = to the distance of the upper lever (at rest) from the stage on which the slide travels, which is not much over half an inch ; the tracing cannot be higher than this ; if the lever strikes at either ex- tremity of its course, the curve is viti- ated. This imperfection could be easily removed; the former defect pertains to the plan of the instrument, and is more difficult to rem- edy. Better workmanship and some modifications in detail have been introduced in the construction of this instru- ment by Edwards (Buffalo, 1880), but without apparent improvement in the results, as Hopkins’ curves testify.” REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Sphygmograph, Sphygmograph. Dudgeon’s sphygmograph combines in an ingenious manner the steel spring of Marey with the registering mechanism of Pond. A rather short steel spring, A, Fig. 3629, whose pressure is regulated by a Mahomed’s eccentric, N, indicating ounces, is provided at its free end with a movable exploring button, B, and transmits its movements to the writing-needle L, by asystem of levers on the plan of Pond, as seen in the illustrations (Figs. 3629 and 8630). The whole instru- ment is given a more compact form, and is fastened to the wrist by a sin- gle strap, the tightening of which can be usefully controlled by the fingers of the experimenter. This mode of application has some advan- tages. The use of the steel spring is a decided improvement upon the rubber membrane of Pond’s sphyg- mograph ; the system of levers is, however, as in Pond’s, subject to vi- brations of its own which are apt to mar the curve. CARDIO- GRAPHS.—The principle of transmission was first car- ad A ried out in the older form of Marey’s cardi- ograph (1865) (Fig. 3631). The receiving mechanism of this instrument was, however, defective and has been re- _ placed by a later device in 1875. The transmission instru- ments intended for the heart are now constructed with a receiving tambour, whose earliest and simplest form was embodied in Brondgeest’s pansphygmograph (1878), al- ready described. Burdon-Sanderson, in the same year, added the elastic curved spring, and supported the exploring tambour on an adjustable tripod which was fastened over the heart by straps passing round the chest. The receiving apparatus of Meurisse and Ma- thieu (1875), and its modifications by Grunmach and v, B Fic. 3629.—Scheme of Dudgeon’s Sphygmograph, (Dudgeon.) Natural size. (Dudgeon.) Natural size. Fie. 8630.—Dudgeon’s Sphygmograph. Knoll (1876, 1879), which also presses the exploring button upon the pulsating surface by means of a curved spring, has been described before. Marey (1875) im- proved his instrument by inclosing the receiving tam- bour, furnished with a central button, in a cylindrical capsule, in which a spiral spring exerts the necessary pressure (Fig. 3633). In all these transmission instru- ments the registering apparatus is constructed on similar principles. Keyt’s compound sphygmograph, transmitting move- ments through water, as before described, is as well Vou. VI.—34 adapted for recording the apex beat as the arterial pulsa- tions. Marey’s sphygmograph in its ordinary forms has also been extensively used for the exploration of the heart’s impulse, and with excellent results, e.g., by Landois. It f t) sli i iM | 4} ll i | Fig. 3631.—Marey’s Cardiograph, original form. (Ozanam.) has also been specially adapted to use as a cardiograph by Galabin '? (1872). He suspends a Marey’s sphygmo- graph, of the Mahomed pattern (so modified that the magnifying power of the lever can be varied at will from ten to about a hundred), from two transverse rods held Fia. 36382.—Burdon-Sanderson’s Cardiograph, Receiving Apparatus, (Gscheidlen.) Natural size. up by four vertical rods inserted into two bars of wood covered with leather, which rest upon the chest. The attachment of the transverse rods to the vertical supports permits their being raised or lowered at either end, so that the instrument can be levelled, and the bars can be Fic. 3633.—Marey’s Cardiograph, Receiving Apparatus of later form, 18%5. (Gscheidlen.) Natural size. separated to a width of nearly five inches, and adapted to a chest of any size or shape. The whole is fixed upon the chest by straps passed round the body. 529 Sphygmograph. Sphygmograph. Pond’s and Dudgeon’s sphygmographs have but a limited use as cardiographs, and give curves which are imperfect in some details. For specimens of tracings obtained by various cardi- ographs, see article Pulse, Arterial, section Cardiogram. HypROsPHYGMOGRAPHS, — The pulsating movement constituted by the increase and decrease of volume of an entire extremity, caused by the arterial diastole and sys- tole, can be recorded by instruments combining the re- ceiving apparatus of a plethysmograph with the register- ing mechanism of a transmission sphygmograph. Such are the hydrosphygmographs of Frangois-Franck '4 (1876) and of Mosso!® (1879). The latter, especially, affords curves very similar to those of the ordinary sphyg- mograph. The receiving apparatus of Mosso’s instru- ment consists of a large glass cylinder filled with water, into which the forearm can be inserted, air-tight, through an opening closed by a rubber sleeve. The cylinder is suspended from above by a chain; it communicates by its smaller end with a reservoir of water which regulates the hydrostatic pressure ; by another opening on top it is connected, by means of a flexible tube, with a Marey’s tambour and lever. The curves thus obtained record the pulsatory changes in volume of the forearm. It is not to be expected that they agree perfectly with those ob- tained with the sphygmograph ; the latter registers the changes taking place in the short piece of artery touched by the exploring button—practically one cross-section of the arterial system; the hydrosphygmograph registers the increments of volume of all sections of the arterial system of the forearm and hand at once, and since these increments do not take place at exactly the same time, a certain amount of fusing of details in the curve must re- sult; that this fusion is, under ordinary circumstances, small, is explained by the high rate of transmission of the pulse-wave. The instrument lends itself especially to investigations requiring continuous registration for hours, uniform ex- ternal pressure upon the blood-vessels uninfluenced by their own changes of calibre, and immutable local con- ditions during changes in position and action of the body ; and it permits the synchronous registration of curves of the heart’s impulse, the carotids, the respiration, etc., by other instruments. It has yielded valuable results in the hands of its author. THE RECORDING SURFACE.—Some of the transmission instruments register upon a revolving drum, such as is used in the graphic instruments of the physiological laboratory (see Fig. 8631). Other sphygmographs are con- structed for registering upon strips of smooth paper or glazed card-board, or upon slides of glass, smoked. Pond, I think, was the first to recommend slides of mica, useful by virtue of their lightness, and because, being very thin, they can be used as negatives for direct photographic reproduction.* Mica slides must be selected with care ; those which are warped must be rejected, especially for Marey’s instruments ; in Pond’s and Dudgeon’s they are excellent substitutes for card-board. Paper and card- board answer well in the instruments which write with a loosely suspended needle ; but the tracings cannot be multiplied as readily as when taken on transparent slides. Thin plate-glass is the best material for use in Marey’s and in Keyt’s sphygmographs, because of its smooth and level surface. Glass and mica are best smoked ina large gas flame, which yields a very even coat of soot of any desired density. Paper must be smoked over a flame emitting less heat and more smoke, as an open petroleum flame, and this requires greater skill to obtain an even coating. In either case the coating of smoke should be as thin as is compatible with the purpose. The curves are fixed by dipping the slides, of whatever material, into a thin, quickly drying varnish. Perhaps the most useful varnish is a concentrated solution of the best white shel-lac in alcohol. in use by photographers. * Most of the tracings illustrating this article, and the article Pulse, were taken on mica; some on glass, 530 Some prefer the varnishes . REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. The method of writing with ink upon a glazed paper surface, by means of a pen or marker at the end of the lever, aS in the older Marey instruments, has been aban- doned, mainly because the friction involved in this method is far too great to give delicate traces, In the foregoing account of instruments, no attempt at completeness has been made. Many other instruments have been invented ; some have been confined to the physiological laboratory, or employed only by the in- ventors; others have been quickly abandoned. The sphygmographs in present use in medical practice, hos- ° pital or private, are chiefly the spring sphygmograph of Marey and its modifications by Burdon-Sanderson and by Mahomed, Grunmach’s modification of the transmission sphygmograph of Meurisse and. Mathieu, Pond’s, and Dudgeon’s. TAKING THE TRACING.—To give in this place detailed directions for the application of each instrument were fruitless. The use of the sphygmograph is not easily learned, and skill in its application can be acquired only in conjunction with knowledge of the tracing and the pulse. The serious study of sphygmography is best be- gun with a Marey, Mahomed, or Burdon-Sanderson ; al- though these are difficult to operate, they sooner teach the much more difficult art of recognizing whether or no the trace taken is a correct and adequate representa- tion of the pulse explored. In order to write a correct sphygmogram it is neces- sary (1) to explore the artery at the best possible point ; (2) to exert just the requisite pressure upon it, neither too much nor too little ; and (8) to let the lever write with the least possible friction. 1. The radial artery is best reached just before it crosses the end of the radius. Beginners often err, es- pecially when using spring sphygmographs, in applying the exploring button higher up. At the point indicated the artery is most superficial, and rests upon a firm sup- port ; above this point it lies upon the pronator quadra- tus muscle and is embedded in abundant adipose tissue. In all sphygmographs the exploring mechanism and the means of fixing the instrument are constructed with spe- cial regard to this artery, but they do not all adjust them- selves equally well even to this locality. In Marey’s instrument, notably, the correct adjustment of the press- ure upon thevartery is sometimes impossible with the mechanical means provided ; the best tracings are often obtained by hoiding the lower end of the instrument in the fingers. With Dudgeon’s sphygmograph the exact spot and the proper pressure are more easily found, most easily with Pond’s, and with the movable bases of transmission sphygmographs. Care must be taken to place the button or explorer exactly over the artery ; if the — button les to one side of it, the curve is stunted in its details ; if it slips off and lies alongside the artery, there often results a so-called negative curve. The arm should be slightly tlexed at the elbow, the hand supinated and fully, but not forcibly, extended at the wrist. A rest for the hand, as the wedge-shaped cushion of Mahomed, is often useful in connection with the spring sphygmographs, but not indispensable. The rest provided for the original Pond’s was a useless encum- brance, and has been abandoned. 2. Next to the most available locality, the degree of pressure is of greatest importance. The exploring but- ton or base should come into such (mediate) contact with the arterial walls that it must follow their movements closely. If too far removed (too lightly applied), it re- ceives the impulse of the artery too feebly or too late, and fails to record them in proper extent or time ; if pressed too forcibly upon the artery, the expansion of the latter is diminished and delayed ; in either case the curve is too small and otherwise deformed. Figs. 3634 to 3636 afford examples; also Fig. 3637, e and f. With insufficient pressure, the curve is small and inex- pressive, and the secondary waves are ill developed (Figs. 3634, a ; 3636, a.) As the pressure is increased the second- ary events become more pronounced and characteristic, and the curve grows higher. With a pressure exactly REFERENCE HANDBOOK OF THE MEDICAL SCIENCES, Sphygmograph,. Sphygmograph.,. suited to the pulse, the details of the curve are most per- fect, and the secondary waves, especially the dicrotic, most distinctly delineated (Figs. 3634, ) ; 3635, b,; 3636, 6). Still increasing the pressure, we see the curve di- minish in amplitude, the up-stroke being shortened (ex- pressing a celerity greater than the actual) ; but the apex is still sharp, and the predicrotic wave well expressed, while the dicrotic elevation becomes smaller (Fig. 3635, c, vA ze ee a aed Cc Fie. 3684.—Radial Pulse of Healthy Man, aged fifty. Dudgeon’s. a, Pressure, 1 0z.; b,8 02.3 ¢, 4 0z,; d, 5 oz., the instrument meanwhile remaining i7 situ. : d). With still increasing pressure the curve becomes much smaller, the upstroke short, the first secondary wave is much enlarged, and the dicrotic wave disappears (Fig. 3634, c, d). The resulting trace is that of a very hard, even anacrotic curve-(Figs. 3634, d ; 3636, c), such as only highly atheromatous arteries could truly give. Still stronger pressure finally suppresses the pulse alto- gether. The evident importance of this point, and the desire, by means of the pressure found necessary, upon trial, to MARIA AR NINISINIIAY : oe Fic. 8635.—Healthy Boy, aged six. -Dudgeon’s. 3 OZ: 4)-€, 4.07.5, dy 5 02, a, Pressure, 2 0z.: , evoke the most perfect curve, to estimate the blood-press- ure within the living artery, has led sphygmographers to devise means not only for varying, but for expressing the pressure of the instrument in numbers. This object has been accomplished only in those pulse-writers which exert their pressure by weights instead of springs, as in Landois’s angiograph—an instrument of great scientific accuracy—and in Keyt’s sphygmograph.by means of the manometric tube. But even in this case the weights in- dicate only the pressure upon the skin, not that upon the a ce A ee Fre. 3636.—Woman, aged forty-eight. Dudgeon’s. a, Pressure, 1}¢ 0z.; b, 214 02.3 ¢, 3 OZ. artery, which must be less than the former, by the vari- able amounts of elastic resistance of the intervening skin, fascia, and neighboring tendons. This source of error, and the impossibility of estimating the force exerted in fastening the sphygmograph upon the wrist, has made all attempts at measuring the pressure with other instru- ments illusory. The devices to this end of Burdon-San- derson and of Mahomed furnish numbers of only ap- proximate value, useful when the pressure is varied while the instrument remains 77 sétw, but not comparable with observations at different times or on different arte- ries—not at all comparable with the numbers expressing the pressure in other instruments. Sphygmographs in which the pressure is controlled by the hand alone, as in Pond’s, are most easily adjusted, and the pressure can be more evenly applied in this way than would seem possible. Even if the degree of pressure could be accurately known, it would still give no correct information as to the blood-pressure ; the form of the pulse-curve assists in judging of the comparative degree of tension of the artery ; but accuracy in determining the compressibility of the pulse must be sought by aid of other instruments, such as Waldenburg’s Pulsuhr or Basch’s sphygmoma- nometer. 3. When the lever of the instrument meets with too much friction the curve is altered in the same direction as when excessive pressure is used ; it loses in delicacy, the minor events are obliterated, and the apex is apt to be blunted or flattened. Hence it is essential that the recording surface be very smooth, and smoked only just enough to make the trace distinct. For the same rea- son, the method of writing with an inked style upon a glazed paper has been almost discarded. Moreover, the lever should not bear too firmly upon the surface. In judging of the adequacy of a curve, two points are of special importance: the apex should be sharp, and there should be no evidence of vibrations due to inertia of the instrument itself. A curve witha rounded, blunt, or truncated apex is to.be suspected until all source of error is eliminated. This defect is common in the trac- ings by the spring sphygmographs, and is owing either to excessive pressure (too hard a spring, as in many of Marey’s instruments) or to undue friction in the writing apparatus. Vibrations by inertia, exaggerated excur- sions of the needle, are apt to deform the curves by Pond’s and Dudgeon’s instruments. Not only may evi- dent and avoidable monstrosities of curves * result in this manner, but there is a genera] tendency to exaggera- tions of certain events in the curve.+ The fall of the lever is apt to be too rapid and too sudden, deepening the depressions preceding the secondary waves, and hence also increasing the size of the latter. (Compare Fig. 3637, b, c). These sphygmographs produce dicrotism too easily, with lower fever-temperatures, than the spring sphygmographs do, and generally their curves have the look of low tension. On the other hand, the frequently exaggerated predicrotic wave sometimes gives the appear- ance of higher tension than is found with other instru- ments.{ This error in interpretation is in a measure guarded against by comparing the relative height and position of the predicrotic with the dicrotic wave. It is evident, therefore, that the instruments described differ greatly in the two practically important respects of (1) facility of application and (2) accuracy of results. Unfortunately, those which excel in the one are most apt to fail in the other. In ease of handling, Pond’s and Dudgeon’s sphygmographs take the first rank, and the transmission instruments with movable bases, especially Keyt’s, are likewise easy of adjustment. Among the spring sphygmographs, Mahomed’s and Burdon-Sander- son’s are more readily applied than Marey’s own. For * Broadbent (British Medical Journal, March 26, 1887, i., p. €57) gives a curve to illustrate the vagaries of Dud geon’s sphygmograph, but which shows, rather, the inexperience of the operator who would seriously pre- sent it as the curve expressing the movements ofthe artery. Bad curves can be taken with a Marey as well, erring mostly in an opposite direc- tion, as the student can best learn from the excellent article ** Ueber fehlerhaftes Pulszeichnen,” by Wolff, in the Prager Vierteljahrsschrift f. prakt. Heilk., 1871. : + A glance at the curves taken with an Edwards sphygmograph (modi- fication of Pond’s), and published by Dr. H. R. Hopkins (Medical Press of Western New York, November, 1885, pp. 7. 9, 10, 12), will illustrate this point ; some of these curves reproduce only the vibrations of the in- strument itself, e.g., Fig. 5 (M. S.), 4(B.), and 6 (KE. H.). i t In Guy’s Hospital Reports, 1881, p. 337, Mahomed reproduces a trac- ing by Pond’s to show ‘ very high tension,” which by no means shows it. He was evidently led into error by comparing Pond’s curves with those of his own sphygmograph, without due allowance for inherent dif- ferences in the action of the two instruments. 531 Sphygmograph. Spinal Abscess, REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. his angiograph Landois himself does not claim clinical convenience. In accuracy of results, however, the sphygmographs named rank in nearly inverse, order. Jurves obtained with different instruments in different cases cannot be directly compared, no matter how per- fect of their kind they may be. Those written with Marey’s spring sphygmograph are universally accepted as reproducing most exactly the movements of the arte- rial wall, and to them all others must be referred. ‘The use of Pond’s and Dudgeon’s sphygmographs, so thor- oughly convenient for every-day practice, can be recom- mended only to those who are familiar with the working of the spring sphygmographs ; their convenience is off- set by the danger of misinterpretation from neglecting to allow for the inherent defects of the instruments. For illustrations of the tracings afforded by a number of sphygmographs and cardiographs the reader is re- AS redhat pelea BY illo avanraWuberoi ao heh wrhhahahchathh, e ! Fia. 3637.—Man, aged fifty-three to fifty-four. Moderate Hypertrophy of the Heart. Subject to infrequent attacks of angina pectoris. a, May, 1886, Pond’s; 6, June, 1886, Pond’s; c, August, 1886, Pond’s; d, October, 1886, Marey’s ; e and 7, March, 1887, Dudgeon’s. Pressure, 214 oz. and 44g oz., respectively. (The latter pressure is too great.) ferred to the article Pulse, Arterial, and to the series of Fig. 3637, which reproduces the pulse-curves in the case of one individual, in fair general health, taken at different times under varying conditions, by Pond’s, Marey’s, and Dudgeon’s sphygmographs. G. Baumgarten. 1 Landois: Lehre vom Arterienpuls, Berlin, 1872, p. 49, where the reader will find a résumé of Mach’s experimental criticism, with refer- ences. 2 Mach: Sitzungsberichte d. k. k. Akademie der Wissensch. zu Wien, 1863. 3 Béhier: Bulletin de Acad. de Médecine, Paris, 1868. 4 Burdon-Sanderson : Handbook of the Sphygmograph, p.'%. London, 1867. Handbook of the Physiological Laboratory, pp. 229, 230. Philad., 1873. 5 Mahomed: Med. Times and Gazette, 1872. -§ Baker: Brit. Med. Journal, 1867, p. 604. 7 Landois: loc. cit.,1 p. 70. § Sommerbrodt: Ein neuer Sphygmograph. Breslau, 1876. ® Figured in Ozanam ; La Circulation et le Pouls, p. 41%. Paris, 1886. 10 Keyt : Sphygmography and Cardiography. New York and London, 1887. 11 Ozanam : loc. cit.,® p. 432 et seq. 12 Hopkins : Medical Press of Western New York, November, 1885, p. 5. 13 Galabin ; Medico-Chirurgical Transactions, vol. lviii., p.:359. Fig- ured and described, also, in Bramwell: Diseases of the Heart, p. 7538. New York, 1884. ; ‘4 Frangois-Franck : Travaux du Laboratoire de M. Marey. Paris, 1876. 195 Mosso: Die Diagnostik des Pulses. Leipzig, 1879. SPINAL ABSCESS. Usually in the course of caries of the spine, or Pott’s disease, suppuration takes place. To the collections of pus which result may be givea the generic term ‘‘ spinal abscess.” Surgeons, however, have been long in the habit of naming these collections after . the regions in or near which they first make their appear- ance on the surface. Hence the terms cervical or post- pharyngeal (retro-pharyngeal), dorsal, lumbar, iliac, psoas abscess, etc., depending on the locality diseased or in- vaded. FORMATION OF SPINAL ABSCESS.-—As in caries or ulcer- ation of bone elsewhere, granulations rapidly spring up 532 in the affected vertebra, raising the periosteum, which in turn becomes much thickened and vascular, and is itself often penetrated by the same granulations. Thus not only is pus formed, but at the same time the soft parts outside the periosteum become gradually inflamed, infil- trated, and thickened, and ultimately constitute the chief boundary wall of the purulent collection. Where the caries originates in the centre of one of the vertebral bod- ies these changes progress very slowly, and adjoining vertebree may become invaded before pus appears exter- nal to the bone. Indeed, the abscess may never become visible (caries sicca), remaining within the limits of the bone. To this variety the term ‘‘ vertebral abscess” has been given. The tendency, however, is to the formation of large collections, which usually take a downward course, limited only by the resistance of the soft parts. The pus resulting is at first usually curdy, but later be- comes more homogeneous, though seldom laudable. Bone-dust and fragments of necrosed bone are also occa- sionally present. The occurrence of spinal abscess is always a serious complication of Pott’s disease, and is probably the most common cause of death. It has been noticed also that the more circuitous the route taken by the pus, the more serious are the consequences likely to be. The variety of spinal abscess will depend on the region affected with caries, on the resistance offered to the pus as it leaves the diseased bone, a on the route subse- quently taken to reach the surface of the body. While caries of the vertebre is by far the most fre- quent cause of spinal abscess, it is well to mention that collections of pus due to other causes are occasionally found in the immediate vicinity of the spinal column, and may receive the same name. Thus we occasionally find abscesses in the cervical region due to tubercular and syphilitic ulcerations about the pharynx, while a more acute form is now and then met with as a compli- cation of acute pharyngitis and quinsy. So psoas ab- scess may occur quite independently of disease of the vertebre. CERVICAL ABSCESS, termed also post-pharyngeal and retro-pharyngeal abscess.—This usually results from dis- ease of one or more of the cervical vertebra, and is often the first indication of caries. It is, however, not in- variably due to this cause. The writer has seen retro-pha- ryngeal abscess, evidently following tonsillitis or pharyn- gitis, in children, where there were restrained movement of the neck, retraction of the head, and other signs of ca- ries. The abscesses were evacuated behind the sterno- mastoid muscle, when all symptoms suddenly disap- peared and complete. recovery followed. Usually when the disease is confined to the anterior or lateral surface of the bodies of the vertebra, a soft, fluctuating, and somewhat cedematous swelling is to be seen and felt bulging forward on the posterior wall of the pharynx. This may increase to such an extent as to interfere with deglutition, and even to cause troublesome and alarming dyspnea, Purulent collections from cervical disease, however, more frequently proceed in a lateral or postero- lateral direction, between the longus colli and scaleni muscles, first appearing in the posterior triangle of the neck, behind the sterno-cleido-mastoid muscle. In very exceptional cases cervical abscess points posteriorly near the ligamentum nuche, and still more rarely the pus gravitates downward into the posterior mediastinum, whence it may enter the pleura or pericardium. Cer- vical abscess has likewise been known to penetrate the cesophagus and trachea, and in one case reported, first appeared in the axilla. The diagnosis of abscess from cervical disease is sel- dom difficult, if due attention be paid to the signs and symptoms of bone disease invariably present, namely, stiffness of the neck, with limited movement of the head, deformity, and increased pain on pressure over the cer- vical spine. The dangers of cervical abscess are chiefly dyspncea and suffocation, the latter from sudden bursting of the collection, especially during sleep, and the entry of pus into the air-passages. Gautier collected 97 cases, of which REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 41 proved fatal, but this is an exceptionally large mortal- ity, and it is probable that not more than from fifteen to twenty per cent. terminate in death. The treatment of all the forms of spinal abscess will be described further on in this article. DorsaL ApBscEss.—By this is meant usually a collec- tion of pus, the result of caries of the dorsal vertebre, which has passed backward between, or external to, the transverse processes, and opened on the back. The col- lection in this case may be part only of a large psoas abscess, some of the pus gravitating backward in con- sequence of long confinement of the patient in the recum- bent position. Dorsal abscess usually first appears on one side of the spine, its inner margin being often not more than an inch or two from the vertebral column. The pus occasionally passes outward along the intercos- tal muscles, and points in the lateral region of the thorax or abdomen, or near the middle line in front. Dorsal abscess is frequently mistaken for fatty tumor, chiefly on account of its smooth outline and the absence of inflammatory symptoms. Besides, this is a favorite situation for lipoma. The aspirating needle should be resorted to in all cases of doubt. From abscess, the re- sult of a necrosed rib, and from a pointing empyema the diagnosis should be made with ease by due attention to the symptoms. It is remarkable, considering the proximity of the pleural cavity, how seldom abscess, the result of caries of the thoracic vertebree, encroaches on that cavity. Cases are reported, however, in which this cavity has become the receptacle for a dorsal abscess, and fatal pleurisy has resulted from this cause. Agnew! refers to a case in which, through inflammatory adhesion, the two layers of the pleura, with the lung, united to the sac of the ab- scess, and through ulceration the purulent accumulation opened into one of the bronchial tubes and was discharged by the mouth. Psoas ABscEss.—This is the commonest variety of ab- scess, resulting from vertebral disease. It may follow dis- ease in any part of the dorsal or lumbar portions of the spine, but is most frequently met with in cases where the lower dorsal or upper lumbar regions are affected. The pus, guided by the thickened periosteum and soft parts, reaches the diaphragm, where it arches over the lumbar muscles, and forcing a passage beneath the internal arcu- ate ligament, enters the substance of the psoas magnus muscle, along which it passes to its insertion beneath Poupart’s ligament, and presents in Scarpa’s space. Thus the entire psoas sheath may become converted into a bag of pus, the muscle being removed by a process of absorp- tion. Bifurcation of the abscess sac has been known to take place high up, the pus descending in both psoas muscles forming adouble psoas abscess ; or two abscesses may form independently at the source of the disease. The latter variety, however, is very rare. The pus may leave the psoas sheath at any part in the course of the abscess, proceeding sometimes in odd di- rections, Thus it may pass forward and find its way along any of the planes of areolar tissue in the abdominal wall, travelling between the transversalis muscle and fascia, or, perforating the fascia, may get between the latter and the peritoneum. Again, taking a more super- ficial course it may point in front, perhaps in the position of the external abdominal ring, closely simulating in- guinal hernia. Or a portion of the abscess may pass along the sacrum by the side of the rectum and present in the perineum, like an ischio-rectal abscess. Or, finally, leaving the pelvis by the great sacro-sciatic notch, either above or below the pyriformis muscle, it may appear in the gluteal region (gluteal abscess), and thence pass down the thigh in the course of the sciatic nerve. The small intestine, colon, rectum, and bladder have all been pene- trated by the pus from psoas abscess. Broca? reports a rare form of psoas abscess where the pus entered the hip-joint, penetrating the anterior part of the capsule. In its passage through the iliac fossa it is not uncommon for a psoas abscess to be arrested in its progress and form a prominent swelling. It is then termed “iliac ab- scess,” Sphygmograph, Spinal Abscess, Below Poupart’s ligament a psoas abscess generally takes an independent course, either spreading over the front of the thigh, or, guided by the sartorius muscle and the fascia, passes down the inner aspect and back of the limb, until, as in a case reported by Erichsen,’ it may reach even to the heel. Diagnosis.—This is usually an easy task, providing always that a rigid investigation has been made regard- ing the condition of the spine. It is true, psoas abscess may make its appearance before any noticeable change has taken place in the contour of the spine, but there will be present, almost invariably, a feeling of stiffness of the back, and a persistent pain in one locality. As before intimated, it is possible to have suppuration within the sheath of the psoas muscle as the result of sprain or in- flammation of the muscle itself (psoitis), quite indeper- dently of disease of the vertebrae. Here there will be an absence of all the ordinary signs of Pott’s disease, and thorough evacuation of the abscess should be followed by speedy cure. The simple form is found most fre- quently in adults. Among the conditions met with in the vicinity of Pou- part’s ligament, with which psoas abscess might be con- founded, are the following : Large buboes or glandular ab- scesses, Suppuration from hip-joint disease (in those cases where the bursa of the conjoined tendon of the psoas and iliacus muscles communicates directly with the hip- joint), hernia, serous cysts, fatty tumors, pus from an empyema which has found its way into the psoas sheath, aneurism, and phantom tumors in hysterical females. While the abscess is still in the iliac fossa there may be some difficulty in diagnosing it from peri-cecal abscess (on the right side only), perinephritic abscess, fluctuating renal tumors, and iliac abscess, the result of disease of the sacro-iliac joint or of the pelvic bones. There is, be- sides, the possibility of an abdominal or iliac aneurism, communicating with the sheath of the psoas muscle and forming a diffuse, non-pulsating extravasation. The pain from erosion of the vertebre in such a case may easily be mistaken for the pain of Pott’s disease. It would be impossible within the limits of this article to give the diagnostic differences between psoas abscess and all the conditions above enumerated. It is simply necessary to state that in the latter, almost without ex- ception, there will be an absence of stiffness and pain in the dorsal and lumbar spine ; whereas in none but ab- scess accompanying Pott’s disease will there be any ex- curvation. LuMBAR AxsscEss.—This usually results from disease of the lumbar spine, although it is possible to have this variety of spinal abscess from disease in the dorsal re- gion. Here the pus, whether it comes from a psoas ab- scess, or directly from caries of the lumbar vertebre, passes to the outer edge of the quadratus lumborum muscle, and projects posteriorly in the space between the last rib and the crest of the ilium. Like all cold ab- scesses in the back, this may readily be mistaken for fatty tumor, but attention to the points referred to in connec- tion with dorsal abscess should obviate the possibility of such a mistake. GENERAL OBSERVATIONS. —Spinal abscess seldom makes its appearance for many months after the disease in the vertebree has begun. In fact, many years have been known to elapse before suppuration was noticed. Such cases are probably examples of what Paget‘ terms ‘‘residual abscess,” meaning an old abscess cavity, in which from some cause, as ill-health or injury, a fresh in- flammation, and suppuration, have been suddenly lighted up. On the other hand, abscess may be the first indica- tion of.the presence of caries. As might be imagined, the more acute the disease in the bone, and the greater the constitutional disturbance, the more rapidly does ab-. scess form and make its appearance on the surface. Again, we meet with cases where great excurvation has occurred without any evidence of suppuration. ProGnosis oF SprnaL ABscess.—The larger the ab- scess, and the more extensive the ground traversed by the pus, the more serious will be the prognosis. The most favorable cases are those in which the abscess opens close 533 Spinal Abscess. Spinal Cord. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. to the seat of disease. The greatest of the primary dan- gers in connection with suppuration are exhaustion and septicemia. Secondary dangers are inflammation of serous membranes, due to the invasion of cavities by the pus ; hemorrhage from ulceration into a large artery or vein ; suffocation (in cervical abscess only), and amyloid disease of the liver and kidneys. Many of the deaths from Pott’s disease occur soon after the abscess is opened. Thus Michel records a series of 28 cases where, in ten instances, death followed the evacuation of the abscess within twenty days. The presence or absence of hered- itary predisposition to struma, the social conditions and hygienic surroundings of the patient, and the quality of surgical skill employed in the case, will be found to in- fluence the prognosis in a marked degree. TREATMENT OF SPINAL ABSCESS.—Up to a very recent date there was a general consensus of opinion among sur- geons that spinal abscess should not be opened hastily. This advice should still be followed in cases where sup- puration appears to be arrested, and absorption or casea- tion is likely to supervene. As arule, however, where the collection is large, and evidently increasing, early in- terference is in order. Since Lister began to teach sur- geons how to take care of these abscesses the old dread of interfering with them has ceased to exist. Cervical Abscess.— Here, perhaps, more than in any other form, should the practice of early opening prevail, lest, bursting unexpectedly, the pus might be drawn into the larynx and produce suffocation. Opening through the Mouth.—Should the abscess point in the pharynx more markedly than elsewhere, one often has no alternative but to evacuate it through the mouth, by means of a trocar or of a guarded bistoury. The patient should be placed in the sitting position, with the head thrown well forward. An anesthetic is not usually re- quired, excepting perhaps in the case of a very rebellious child. The mouth should be held open by means of some simple gag, which can be withdrawn simultaneously with the bistoury, so as not to interfere with the action of the palatal and pharyngeal muscles in their endeavor to pro- ject the pus forward. The forefinger of the left hand may be used to depress the tongue and push it backward, thus forcing the epiglottis to close. The incision should be made as nearly as possible in the middle line, and di- rectly upward. When the abscess is pointing, the sharp- ened finger-nail of the surgeon may be employed to open it, instead of the bistoury. Some antiseptic mouth-wash, containing carbolic acid, iodine, or Condy’s fluid, should be used freely as a gargle, as well as for injecting the abscess-cavity. Opening in the Neck.—When the collection tends to point laterally it will usually first be detected behind the sterno-mastoid muscle, on a level with the angle of the jaw. Here, when practicable, cervical abscess should al- ways be opened, chiefly because of the comparative ease with which it may be kept aseptic. Professor Chiene, of Edinburgh, was one of the first surgeons to advocate this method of treating post-pharyngeal abscess. He recommends a free incision through skin, superficial fas- cia, and platysma muscle, carried along the posterior bor- der of the sterno-mastoid. Then asmall opening is made through the deep fascia, into whieh a director is pushed onward until pus is reached. The deeper parts of the incision are opened up by means of dressing-forceps, after Hilton’s method. A drainage-tube is then introduced, and throughout the strictest antiseptic precautions are taken. There can be no objection to the use of the aspi- rator here, as in any variety of spinal abscess, providing the purulent collection can be accurately located in the neck. When the abscess is undoubtedly due to caries, the head and neck should meanwhile be well supported, either by means of sand-bags or by a leather collar. The writer employed plaster-of-Paris in a memorable case® of caries of the upper cervical vertebre, with post-pharyn- geal abscess, in which the weight of the plaster caused partial dislocation of one of the diseased vertebrae and alarming asphyxia, with almost complete paralysis of sensation and motion. The patient died of exhaustion in about four weeks. 534 In all varieties of spinal abscess the bag of pus acts as a sort of splint to the crumbling vertebree ; hence, before removing the purulent collection by operation, means should be taken to provide a substitute of some kind for the support about to be withdrawn. Sayre’s plaster dressing (with the jury-mast in cases of cervical and upper dorsal disease) will be found one of the most con- venient methods for carrying out this indication. Dorsal and Lumbar Abscess.—These need not be inter- fered with until they show signs of rapid enlargement. The aspirator should first be brought into requisition. The needle should not be thrust into the summit of the abscess, but introduced at a considerable distance from the border, so as to traverse an inch or two of healthy tissue before entering the abscess-cavity.' In this way leakage and the admission of air are effectually pre- vented. These fibres terminate in the net-work of the anterior horns of the cord at various levels, some of them reaching its very lowest part. Any lesion in the cells of the cortex, or in the course of the fibres which cuts them off from those cells, results in the degeneration downward of the cerebro-spinal element to its termination in the motor cells of the spinal cord. The first form of spinal paral- ysis is due to a lesion at the spinal part of this cerebro- spinal element of the motor tract. Ifthe cord is divided by a transverse lesion at any point, the function of this element of the motor tract is thereby suspended. Asare- sult, voluntary motion is arrested in the parts below the lesion. If the lesion involves but one-half of the cord, it is the limbs on the side of the lesion which are paralyzed. If it involves the entire cord, both sides are paralyzed. The extent of the paralysis. depends upon the level of the lesion ; the higher the lesion the more extensive the paralysis. The degree of the paralysis will depend on the character. of the lesion, slight compression of the cord at one point by a tumor, or a pachymeningitis, or a projecting vertebra being followed by some stiffness of movement and rigidity of the muscles, with weakness, rather than by absolute loss of power in the parts below the level of the pressure. The cerebro-spinal element of the motor tract also transmits the inhibitory impulses which continually keep the spinal reflex and automatic mechanisms in check. A lesion of this tract, therefore, produces not only weakness and paralysis, but also in- crease of the deep reflexes, and impairment of control over the bladder and rectum. The muscular action of the limbs being no longer controlled by the brain, is gov- erned wholly by the centres in the spinal cord. These act in response to sensory impulses, or spontaneously, without check, and hence the preponderating strength of flexor over extensor muscles tends to produce a position of adduction and flexion of the limbs which are para- lyzed, and a heightened muscular tone, with tendency to rigidity. The nutrition of the paralyzed muscles may suffer somewhat from disuse, and from the attendant vaso-motor paresis, but no rapid atrophy is noted when the cerebro-spinal element of the motor tract is alone in- volved. And it is also to be noted that the paralysis Spinal Cord. Spinal Cord. affects the entire limb or limbs, and not any special group of muscles. In these cases the electric contractility re- mains normal in the paralyzed limbs. A typical example of this form of spinal paralysis is seen in compression of the spinal cord, below the lesion, and in lateral sclerosis or spastic paraplegia (q.0.). The second form of spinal paralysis is due to a lesion in the spinal part of the second element of the motor tract, viz., the spino-muscular element. This consists of the cells of the anterior gray horns of the cord, and the anterior nerve-roots which pass out through the anterior columns of the cord. Destruction of the cells suspends both voluntary and refiex motor impulses to the muscles. The cells not only control the motion, but also the nu- trition, of the nerves to which they give origin, and of the muscles to which these nerves go. Therefore destruc- tion of the cells produces atrophy of the muscles with which they are connected. If the destruction is grad- ual, the atrophy is gradual, as in progressive muscular atrophy. If the destruction is rapid, the atrophy is rapid, as in infantile paralysis. The degree of the atrophy depends upon the degree of destruction of the group of cells which govern the particular muscle af- fected. If the group is wholly destroyed, the muscle be- comes totally atrophied. In addition to paralysis with atrophy there is in the second form of spinal paralysis a change in the electric reaction of the paralyzed muscles. They lose their contractility to the faradic current, and alter their contractility to the galvanic current, respond- ing in asluggish manner, and to the positive more readily than to the negative pole. This is called the Reaction of Degeneration (¢.2.). The extent of the paralysis depends upon the extent of gray matter affected, and a reference to the table of the localization of functions already given will enable one to determine the effect of a lesion at any particular seg- ment, or through a group of segments, of the spinal cord. A typical example of the second form of spinal paralysis is found in infantile paralysis or poliomyelitis anterior. The muscles in this disease are paralyzed, atrophied, ex- hibit the reaction of degeneration, and lose their reflex excitability. An entire limb is rarely affected, certain groups of muscles being usually paralyzed together, e.., the deltoid, biceps, brachialis anticus, and supinator longus (upper arm group) ; or the extensors of the wrist and hand muscles (lower arm group); or the glutei and thigh muscles, with the tibialis anticus (thigh group) ; or the posterior tibial and peroneal groups of the leg (leg group). The muscles affected are not those which are supplied by a single peripheral nerve—a fact which en- ables a diagnosis between a lesion in the spinal cord and a lesion in a peripheral nerve to be easily made—but those which act together to produce a definite physio- logical act. The contrast between these two forms of spinal paral- ysis can be seen at a glance in the following table: First TyPE OF SPINAL PARALY- SECOND TYPE OF SPINAL PARAL- SIS. Lesion in pyramidal tracts. Paralysis usually on both sides equally, in legs, or in legs and arms, never in arms alone. All muscles are about equally af- fected. No muscles are entirely normal. Muscular tone is heightened. Tendency to rigidity appears. Reflex excitability is increased. Atrophy is absent, or is slight; and merely due to disuse, hence is gradual in progress. It affects the entire limb. Electric contractility is unchanged. Vascular tone is diminished; cy- anosis and cedema may occur. Paralyzed limb is cold, and sweat may be increased. Trophic disturbances in the skin are not infrequent. The control over the bladder and rectum may be diminished or lost, Example: Spastic paraplegia. YSIS. Lesion in anterior gray horns. ‘ Paralysis may be limited to any single limb, and rarely affects both limbs equally. Certain groups of muscles only are affected. Others escape wholly. Muscular tone is diminished. Muscles are relaxed. Reflex excitability is lost. Atrophy is always present in the paralyzed muscles. It advances rapidly, and may become ex- treme, Electric contractility is changed. Reaction of degeneration is pres- ent within two weeks of the onset. Vascular tone is diminished, but cedema does not occur. Paralyzed limb is cool, but sweat is not increased. Trophic disturbances in the skin do not occur. The control over the bladder and rectum is not impaired. Example: Infantile paralysis. 541 Spinal Cord. Spinal Cord. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. The third type of spinal paralysis is a combination of the first and second types. When a transverse lesion of the spinal cord entirely destroys a single segment, it pro- duces paralysis of the first type in the parts below the level of the lesion by cutting off the tracts to those parts, and paralysis of the second type at the level of the lesion by destroying the gray motor cells at that level. The general effect of such a lesion depends entirely upon the level at which it occurs ; the higher the lesion, the greater the extent of the first type of paralysis. The distribu- tion of the second type will depend on the level of the segment involved. The greater the extent of the lesion at the level affected, the greater the extent of the second type of paralysis. An example of this is also found in amyotrophic lateral sclerosis. When a longitudinal le- sion of great extent occurs—such as the general destruc- tion of the cord in general myelitis—the second type of paralysis is the form which is found, but all the muscles are affected, not merely a few groups. The bladder and rectum are also affected, and bed-sores are frequent. In any case of spinal paralysis, if the electric condition of the muscles paralyzed be ascertained by the aid of a faradic battery, and the diagnostic points here brought together be applied, reference to the table of the locali- zation of functions will enable the exact level of the le- sion to be determined. SPINAL AN#STHESIA.—The course of the sensory tract in the spinal cord is still somewhat imperfectly under- stood. It is known that all sensory impulses reach the spinal cord through the posterior nerve-roots, which partly enter the apex of the posterior horn, and partly enter the column of Burdach, and pass upward as al- ready described. The sensations of muscular sense as- cend on the same side as that on which they enter. . Those of touch, temperature, and pain cross. over as soon as they enter to the opposite side and ascend init. The various views regarding the tracts transmitting these sen- sations have been already stated. In transverse lesions of the spinal cord the area of an- vesthesia present in the skin depends upon the level of the lesion. Ansesthesia of the feet, legs, and thighs, except- ing their inner surfaces, indicates a lesion in the sacral and lower lumbar enlargement. Anesthesia of the en- tire surface of the legs, thighs, and buttocks, including the genitals, indicates a lesion involving the entire lum- bar enlargement. Aneesthesia around the body, attended by the so-called ‘‘ girdle sensation,” as if a band were drawn around the trunk, indicates a lesion in the dorsal region of the cord, and its level is indicated by observing the exact nerve above which sensation is normal. An- esthesia of the trunk, and of the inner surface of the arms and one-half the hands, indicates a lesion of the lower portion of the cervical enlargement, not higher than the seventh cervical segment. Anesthesia of the trunk and entire hand, forearm, and arm—the neck, upper chest, and outer surface of the shoulder only escaping— indicates a lesion as high as the fifth cervical segment. Transverse lesions higher than this cause sudden death from paralysis of the phrenic nerves. Limited areas of anesthesia in the skin, at any part of the body, are to be ascribed rather to lesions in the peripheral nerves or nerve-roots (as in tumors of the cord) than to any local lesions in the cord itself; for posterior poliomyelitis as a distinct lesion is unknown. The areas of the skin which are connected with the various segments have been described already in the table. When a transverse lesion involves but one-half of the spinal cord, the anes- thesia is found upon the side opposite to the lesion, below the level of the lesion, and extends around the trunk in a band at the level of the lesion, the width of the anes- thetic band depending upon the longitudinal extent of the lesion. On the side of the lesion below the level of the anesthetic band the skin is hypersensitive to touch. Such unilateral lesions produce a loss of muscular sense on the hyperesthetic and paralyzed side, not upon the side of the aneesthesia—a fact which proves that the sen- sations of muscular sense do not decussate within the cord. Hyperesthesia sometimes occurs from spinal lesions, 542 but is quite rare. It indicates an irritation of the sen- sory tracts in the cord by hypersemia, or by pressure, rather than destruction of those tracts. Gowers sug- gests that this hypereesthesia may be due to an increased irritability of the part of the cerebral cortex to which the injured tracts pass, as well as to an intensification of the impression passing in them. Pain is arare symptom in spinal-cord disease, excepting in locomotor ataxia. And here it is to be ascribed to irritation of the posterior nerve-roots within the cord, similar in character to their irritation without the cord, as occurs in meningitis and in diseases of the vertebral column. Numbness is a fre- quently mentioned symptom of spinal-cord disease, and has some value in local diagnosis, as the area of the skin in which the numbness is felt depends upon the level of the cord affected. Hence, when the numbness is limited to certain parts, especially to the extremities, a reference to the table will indicate the segment of the cord which is diseased. Thus in locomotor ataxia the beginning of numbness or pain in the little fingers indicates that the disease has advanced up the spinal cord and has reached the first dorsal and lowest cervical segments. SprnaAL ATAXxIA.—This symptom always indicates an affection of the posterior nerve-roots in their passage through the column of Burdach. Inco-ordination is due to an interference with the reception of sensations of muscular sense which are sent in from the skin, joints, and muscles, These sensations may be intercepted as they pass through the nerves, for ataxia is a symptom of toxic multiple neuritis; they may be intercepted as they pass through the column of Burdach, as is the case in locomotor ataxia; they may be intercepted in the brain by lesions in the lemniscus (see Pons) or in the cerebellum (see Cerebellum). It is probable that a por- tion of the muscular sensations are sent to the gray mat- ter of the cord, producing reflex action of balancing, and unconscious co-ordination, and that the remainder are sent upward to the brain. For the inco-ordination in cerebral disease, when the latter only are disturbed, is less severe and intense than in spinal-cord disease, where all are implicated. Ataxia from neuritis is usually ac- companied by tenderness in the nerves and muscles. Ataxia from cerebellar disease is only present in the act of walking, and is attended by vertigo. Ataxia from spinal disease is not attended by these two symptoms, but is usually accompanied by severe lightning pains and by loss of deep reflexes, together with other charac- teristic symptoms of locomotor ataxia (¢.2.). It must be stated here that in lesions of the spinal cord, as in those of the nerves, the motor symptoms are usually more pronounced than the sensory symptoms ; and even when the spinal cord is greatly compressed, or disintegrated, sensory impulses may continue to pass after motor impulses are entirely arrested. DISTURBANCES OF THE SPINAL REFLEX AND AUTO- MATIC AcTION.—Whatever view may be held regarding the nature of spinal reflex action, it is well established that certain structures are necessary to its production. It is necessary that a sensory nerve from the surface of the body be capable of transmitting impulses to the spinal cord. Itis known that the fibres transmitting the cen- tripetal impulses from the skin enter the apex of the pos- terior horn, while those transmitting impulses from the tendons enter the median surface of the posterior gray matter after traversing the lateral part of the column of Burdach called the root zone. Itis also necessary that the net-work of nerve-fibres through which impulses pass from the posterior gray matter to the cells of the anterior horn be intact. It is also necessary that the groups of cells in the anterior horn, and the motor nerves from them to the muscles, be in a normal state, or capable of exercis- ing theirfunctions. These structures, together, make up a reflex arc, and a lesion in any part of this are will ar- rest the reflex activity. Thus neuritis, outside the cord or due to meningitis, may interfere with the conduction of impulses to and from the cord; posterior sclerosis may arrest centripetal impulses as they reach the root zone ; general myelitis may destroy the net-work of fibres within the gray matter; and anterior poliomyelitis may REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Spinal Cord. Spinal Cord. destroy the motor cells in the anterior horn, Al these diseases, therefore, may cause a loss of tendon reflex. There are reflex activities governed by almost every seg- ment of the cord, as may be seen in the table ; and the particular reflex which is suspended in disease will de- pend wholly on the location of the lesion. Hence the loss of any one or more reflexes gives important informa- tion as to the seat of the lesion. And this can be ascer- tained after examination of the patient by a reference to the table. It has been already stated that an inhibitory influence is exerted by the brain upon spinal activity, and that this influence is conducted to the spinal motor cells through the motor tracts in the lateral column. Any- thing which impairs the conduction of impulses through this tract will result in removing restraint from the spinal reflexes and allowing them fullsway. Hence an increase in deep spinal reflexes indicates a suspension of function in the lateral pyramidal tracts. A transverse myelitis, therefore, will cause an increase of the reflexes below the level of the lesion, and a loss of the spinal reflex governed at the level of the lesion. This has been already men- tioned in connection with spinal paralysis. The skin reflexes are, however, not increased by lesions in the py- ramidal tract. The automatic activity of the cord includes the mech- anisms of micturition and defecation. These mechan- isms are complex reflexes, several sensory impulses combining to produce a compound motor effect, a part of which is inhibitory and a part of which is active. Thus in micturition, the sensations of pressure on the sensitive neck of the bladder, and of distention of the en- tire organ, produce an inhibition of the motor impulses which normally hold the sphincter tight, and set in ac- tivity the motor impulses which contract the detrusor urine, thus emptying the bladder. The same is true, mutatis mutandis, of the other automatic acts. The struct- ures necessary for any one of these acts are similar to those underlying the simple spinal reflex, and the same lesions arresting it may arrest these acts. But the result of such arrest is more serious, for, in the case of the bladder or rectum, retention or passive incontinence of urine or feeces may follow. And if the inhibitory impulses from the brain to these centres are cut off, the voluntary control over these mechanisms is impaired, and the acts cannot be initiated voluntarily, and active incontinence may result. The location of the rectal mechanism is in the lower sacral region. That of the bladder and sexual mechanisms is in the mid-lumbar region. Hence, when these parts are the seat of a lesion, or are cut off from the brain by a lesion at a higher level in the motor tract, in- continence, either active or passive, or retention, may result. A part of the automatic mechanism of respiration is governed by the cervical and dorsal regions of the cord, and is interfered with in disease in those regions. Lesions of the upper cervical region paralyze the diaphragm and thus cause death. DISTURBANCE OF VASO-MOTOR AND TROPHIC FUNC- TIONS of the cord may occur from various forms of lesion. Anterior poliomyelitis produces atrophy of the muscles paralyzed, and a sufficient affection of the vaso-motor system to cause objective, as well as sub- jective, coldness in the limb ; and when the lesion hes deep in the anterior horn, an arrest of development of the bones of the limb affected. General myelitis is usu- ally associated with a tendency to bed-sores upon the parts exposed to pressure, which cannot be avoided by the most scrupulous cleanliness, and to cystitis, and these are ascribed to a disturbance of trophic impulses to the skin and bladder. Posterior sclerosis is some- times associated with trophic changes, such as perfo- rating ulcers, joint affections (Charcot’s arthropathies), and eruptions on the skin. In a few cases of leprosy serious lesions of the posterior gray horns have been ob- served. In general myelitis there is a partial vaso-motor paralysis, indicated by cyanosis, sluggish circulation, cdema, and coldness, with abnormal sweating in the paralyzed parts. But any definite statement regarding the exact localization of vaso-motor or trophic functions in the spinal cord cannot be made as yet. And recently many vaso-motor and trophic symptoms, formerly sup- posed to be due to spinal lesions, have been found to be produced by disease in the peripheral nerves. It is, however, established that trophic lesions are most frequently observed when the gray matter of the spinal cord in the vicinity of the central canal, including the ve- sicular column of Clarke, is the part diseased ; or when all sensation is cut off from the paralyzed limbs by a transverse le- sion. The regulation of uri- nary excretion is presided over by a centre in the medulla, and the nerve- tract thence to the liver and kidneys is traced through the cervical re- gion of the spinal cord to the first dorsal segment, where it enters the sym- pathetic chain of ganglia. A lesion in the lateral column of the cervical cord, by involving this tract, may cause a vaso- motor paralysis of either the liver or the kidneys. In the former case diabe- tes mellitus is produced ; in the latter, diabetes in- L4 sipidus results. It is therefore necessary, in le- sions of the spinal cord, to examine the amount and constituents of the urine. In any case of spinal disease where it is desir- able to localize accurately the lesion, it is suggested that a written summary of the symptoms be com- pared with the table of localization of the func- tions of the cord, when it will become evident, by contrasting the nor- mal with the abnormal conditions, what part of the cord is affected. As Bramwell justly ob- serves, ‘‘the essence of the clinical examination of the spinal cord consists in the systematic and separate examination of each spinal seg- ment, by observing the motor, sensory, reflex, vaso-motor, and trophic conditions of its body area.”” Such an exami- nation will lead to accurate diagnosis of local lesions. But one point remains to be mentioned, that is, the re- lation of the various segments of the cord to the bodies and spines of the various vertebre. As the cord extends only to the level of the second lumbar vertebra, its various segments do not lie opposite to the vertebrae from which they are named. The accompanying diagram of Gowers displays the mutual relation between the segments and their nerves, and the bodies of the vertebra, and no further description is needed. — he, SSE ia USS talons eS ad Fia. 3645. AUTHORITIES. Gowers: Diseases of the Spinal Cord. Luderitz: Ueber das Ruckenmark Segment, Arch. f. Anat. u.. Phys., 1881, 543 Spinal Cord. Spinal Cord. Spitzka: Jour. Ment. and Nerv. Dis., 1880. Ferrier: Brain, vol. iv., p. 223. Beevor: Med. Chirurg. Transactions, vol. 1xxvili. Ross: Brain, April, 1884. Starr: Localization of the Functions of the Spinal Cord, Amer. Jour. Neurol. and Psych., August and November, 1884. M. Allen Starr. 1 For a full account of the grouping of these cells, see Localization of the Functions of the Spinal Cord, by M. A. Starr, American Journal of Neurology and Psychiatry, vol. iii., p. 443 et seq. Ross: Diseases of the Nervous System, vol. i., p. 829. 2 Gaskell: Journal of Physiology, 1886, 3 See Brain and Pons, Diagnosis of Local Lesions in the. Tract, vols. i. and v. 4 Schultze, F.: Ueber Secondare Degeneration im Rickenmarke, Arch, f. Psych., xiv., from which article the figures are taken. 5 For the anatomy of this motor tract, see Diagnosis of Local Lesions in the Brain, vol. i. The Motor SPINAL CORD DISEASES. GENERAL SyMPTOMA- TOLOGY AND DrAGNnosis.—The spinal cord is a conductor of outgoing impulses, which are: 1, motor, to muscles ; 2, secretory, to glands ; 3, vaso-motor, to blood-vessels ; 4, trophic, to skin, muscles, bones. It conducts ingoing impulses, causing: 1, general sen- sations—cutaneous, articular, muscular, and visceral ; 2, special sensations—tactile, thermic, and muscular; 3, exciting reflex actions, simple and complex, and arous- ing automatic centres. The cord contains arrangements of cells forming reflex and automatic centres. These are the vesical centre, the anal, sexual, uterine, subordinate sweat and vaso-motor centres, cilio-spinal centres, and centres which regulate in a measure the functions of the abdominal viscera and the development of heat. The symptoms produced by disease of the spinal cord are due to interference with these various functions, and a thorough knowledge of the anatomy and physiology of this organ is the best means of guiding one to their interpretation. Those which may be called the dominant, and, in a measure, characteristic symptoms of spinal cord disease are the following, it being remembered that we have not only the individual symptoms to study, but their distribution and clinical history, in order to learn that they are peculiar to an organ or a disease. I. Of the motor class we have, in diseases of the spinal cord peculiar paralyses and spasms. These are either bilateral and paraplegic, as is usually the case in adults, or monoplegic and unequally distributed, as is often the case in children. Spinal paralyses are very rarely indeed hemiplegic, and they, of course, never involve the face. They are accompanied with wasting and sensory disor- ders, and involvement of the organic spinal centres. By these signs we can thus readily distinguish spinal from cerebral paralyses in almost all cases. Paralysis that oc- curs from involvement of the nerves is usually more cir- cumscribed, and if widespread, as in multiple neuritis, is painful, with the sphincters, vesical and rectal, only very exceptionally involved. Spasm is rare in the paralysis from neuritis, but frequent in that from spinal and cere- bral disease. In general, a paralysis with atrophy and without pain, or one with spasm and pains, means an involvement of the cord; a paralysis with pain and wasting means in- volvement of the nerves; a paralysis with spasm, but without wasting or much sensory disturbance, means in- volvement of the brain. Excessive motor action (hyperkinesis) without paraly- sis is a somewhat rare condition in spinal cord disease. Spinal convulsions, however, occur in tetanus and as the result of some poisons ; while in the spasmodic disorders known as writers’ cramp and chorea, the cord is in part involved. The peculiar electrical reactions in different forms of paralysis are of great help in determining the seat of the disease (see special articles). II. The pains due to spinal cord disease are somewhat characteristic. They are usually darting in character, and radiate through a number of branches of outgoing nerves ; or they are cinctural, causing a feeling as if the trunk were squeezed in a vise. Band-like feelings 544 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. also occur about the head and lower limbs. Pain and tenderness along the spine occur in spinal irritation, in meningitis, and acute myelitis, but are rare in chronic diseases of the cord. The tissue of the spinal cord is probably somewhat sensitive to painful irritations in the posterior and antero-lateral parts, but practically most spinal pains come from irritation of the posterior roots, or root zones. Ansesthesia rarely follows organic cere- bral disease, and it is then unilateral ; therefore, when present in any other form of distribution, it is usually a symptom of involvement of the medulla, cord, or nerves. If the lesion is in the cord, the anesthetic region is most likely to be diffuse and bilateral, and to be limited at a certain level of the limb or trunk. Delayed sensation and allocheiria, or transferred sensation, are usually evi- dence of cord disease. Parasthesige, and in particular burning sensations, are, as arule, due to neuritis, while a peculiar sense of heaviness, often complained of, is of spinal origin. Ataxia due to disturbance of muscular and articular sensibility used to be thought a sign of dis- ease of the spinal cord, and such is usually the case. But ataxia may occur in neuritis. It will be seen that the extent and location of sensory symptoms determine the question of spinal or peripheral origin more than the character. III. In certain spinal affections involving the central gray, such as syringomyelia and progressive muscular atrophy, there are decided disturbances of the vaso-motor system and of the sweat-glands. The involvement is usually widespread and includes a whole limb, or nearly all of the bodily surface. idema, hyperidrosis, vaso- motor spasm, and paralysis, occur in a more localized and limited manner, from disease of nerves. IV. It is quite impossible in many cases to say posi- tively what neuro-trophic changes are due to spinal, and what to peripheral, neural influence. However, the rule is that the profounder trophic dis- turbances, such as decubitus, symmetrical gangrene, os- seous and articular lesions (arthropathies), scleroderma, and the severe forms of muscular atrophy, are of spinal origin. The more superficial lesions of the skin, such as herpes, glossy skin, etc., and minor degrees of mus- cular atrophy, are more likely to be peripheral. Mus- cular atrophies result from degenerative myositis, from neuritis, and from myelitis. For the special characters of the different forms the reader is referred to the arti- cles on these subjects. V. Among the common symptoms of cord disease are disturbances of the superficial, the deep, and the organic reflexes. The presence or absence of the superficial skin reflexes gives us very little practical information, as they are not abolished or exaggerated without other symptoms. In some cases a study of them may furnish a guide to the height of the cord lesion. The deep, or tendon, reflexes are always present in healthy persons (the exceptions are not one per cent.). When exggerated, they indicate a great degree of cere- bro-spinal irritability (hysteria, neurasthenia), or some cerebro-spinal lesion. Organic disease of the peripheral nerve may usually be excluded. A loss of tendon reflexes, on the other hand, may be due either to peripheral nerve or spinal cord disease, but not to cerebral disease unless there is also paralysis. If the loss is not due simply to motor paralysis, the trouble may, in the majority of cases, be referred to the cord. Disturbance of organic reflexes and centres of visceral control is a common, early, and almost pathognomonic sign of disease of the spinal cord. Some vesical weakness, or sexual weakness, may be for years the only sign of ap- proaching degenerative changes. It is only in certain rare cases that the bladder and rectum become involved through inflammation of the nerves (multiple neuritis). In profound cerebral and mental disturbance, control over the organic centres may also be lost. In diseases affecting the central gray of the cervico- dorsal segments of the cord, pupillary disturbances, retrac- tion or bulging of the eyeball, and facial flushing, pallor, or sweating may occur. The spinal cord contains thermogenetic centres in its REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. central gray, and an increase or lowering of bodily tem- perature from disease of these parts is sometimes ob- served. A lowering of temperature is especially notice- able in poliomyelitis anterior. GENERAL PatHoLocy.—The spinal cord is subject to nearly all the diseases which affect other tissues of the body. Owing, however, to its peculiarly guarded posi- tion, the nature of its tissue, and its vascular supply, it is much less often affected with fatal disease than most or- gans, and is practically exempt from all but a few types of pathological processes. (Among 2,456 deaths from nervous disease, not more than 50 can be attributed to the spinal cord, leaving out the acute meningitis of chil- dren.—‘‘ Rept. New York City Health Board.”) These are acute and chronic inflammations and degenerations. But though organic disease is rare, the cord, being a highly organized tissue, is often subject to functional or nutritional disorders, and to secondary degeneration from brain disorder. Blood-vessels.—The arteries of the cord are numerous, but are of small calibre, smaller considerably than the veins, and carry blood at a low pressure. Embolism and thrombosis are very rare, so far as is known, owing to the tortuous course of the arteries, and the capaciousness of the veins. Endarteritis and athe- roma are not rare as compared with other organs, but are much less frequent than in the brain. ‘The arterial branches, after penetrating the cord, anastomose with each other but slightly ; hence the plugging of a single branch tends to produce softening, asin the brain. But softening may, perhaps, be produced in another way. The small blood-vessels of the cord are richly supplied with vaso-motor nerves, which have a powerful influ- ence over the calibre of the arteries. The result is that by reflex influence, or direct irritation, these arteries may be so tightly closed as to produce complete anzmia, with consequent softening, or they may be so completely par- alyzed as to produce minute hemorrhages and incipient inflammatory conditions. Such, at least, seemsto be the mechanism of many cases of acute white softening, of transverse myelitis, and of acute poliomyelitis. The anterior horns of the cord, which are particularly liable to this latter affection, are supplied each by a branch of the anterior median artery, and occlusion of ‘this would cause suppression of nearly all motor func- tion in one segment of the cord (Ziegler). According to Stenon’s experiments, a stoppage of ar- terial supply to the spinal cord affects first the gray mat- ter, then the white, and lastly the nerves and muscles. It is evident, from both anatomical and physiological con- siderations, that the gray matter is most richly and sensi- tively supplied with blood. The veins are also numerous, are larger in calibre than the arteries, and communicate with the very rich plexus lying outside the dura mater, which also receives return- ing blood from the vertebre, bones, and tissues posterior to these. The spinal cord veins cannot be injected from these large spinal plexus, and passive congestion of the cordes, from obstruction to the general circulation, rarely occurs to such an extent as to cause symptoms. The circulation of the cord and its functions as a cen- tre are, so to speak, ‘‘segmental.”” The blood flows in, horizontally, through Jateral branches of the intercostal, lumbar, or sacral arteries, and flows out through veins at about the same level. Hence it is that acute disorders, which depend so much upon the vascular disturbance, are focal or transverse. — Fibre Systems.—The conducting portions of the cord necessarily embrace long stretches of nerve-fibres, and these must exist in their whole continuity, if at all. If disease attacks one point, cutting off a strand, it extends slowly till it involves a large part of the fibres. Hence chronic diseases of the cord, involving the white matter, always eventually extend up or down the cord. Regions of Least Resistance to Disease.—For some rea- son, Which is not at present well understood, the upper part of the dorsal cord is particularly liable to be affected in subacute or acute diffuse inflammation. The poste- rior columns in their lower part are most susceptible to Vou. VI.—85 chronic degenerations. Spinal Cord, Spinal Cord. The cervical and lumbar en- largements are especially often attacked by the ischemic softening known as acute anterior poliomyelitis. Of the gray matter, the anterior cornual cells are especially sus- ceptible to slow degenerative atrophy. Hemorrhages, tu- mors, syphilitic and tubercular growths, rarely attack the substance of the cord, but take their start in the meninges. Infections.—The cord enjoys considerable immunity against infections, that of cerebro-spinal meningitis be- ing the only one frequently attacking it. The virus of tetanus, rabies, and of leprosy also especially involve the cord. Syphilis rarely affects it with peculiar growths, but often predisposes it to chronic degenerative and inflam- matory disorder. Tuberculosis of the cord is also very rare, and tumors of all kinds, occurring primarily, may be considered pathological curiosities. Meningeal Disease.—The spinal meninges are subject somewhat frequently to chronic or subacute inflamma- tion ; but primary acute spinal meningitis is not very often seen, except as part of the infective cerebro-spinal disorder. Trauma.—Traumatism causes heemorrhages, inflam- mation, and softening, and may start up degenerative processes. The list of general pathological disturbances of the spinal cord is as follows: I, Malformations. — Myelocele, meningo-myelocele (spina bifida), meningocele, heteratopia, micromyelia, macromyelia, and duplication of cord. II. Vascular Disorders.—Congestion and ansemia, en- darteritis, hemorrhage, aneurism, embolism and throm- bosis, oedema. IIL. Syringomyelia. IV. Inflammatory Disorders.—Acute, subacute, and chronic myelitis, ischemic and hemorrhagic softening, acute and chronic meningitis, abscess of cord. V. Degenerative Processes of Cells.—Simple atrophy, fatty degeneration. Degenerative Processes of Fibres and Neuroglia.—(1) Gelatinous degeneration. (2) Gray degeneration, or sclerosis, primary and secondary. VI. Tuberculosis.—(1) Miliary, without or with men- ingo-myelitis. (2) Solitary tubercle. VII. Syphilis.—(1) Gummatous. (2) Meningo-myelitis. VIII. Zumors.—Chiefly sarcomata, gliomata, and gum- mata. IX. Diseases of the Meninges.—External meningitis, internal meningitis of dura, internal meningitis of pia, hemorrhages, malformations, tumors. I. Under the head of malformations, or agenetic dis- orders, should be mentioned a bioplasmic tendency which leads, under slight causes, or simply in the course of de- velopment, to degenerative changes of the proper tissue of the cord. An illustration of this is the cord in heredi- tary ataxia, which is often micro-myelic or deformed, as well'as degenerated. Syringomyelia is also usually associated with, or caused by, some congenital malformation. Of other malformations meningo-myelocele is the one oftenest observed. II. Hyperzemia of the cord, so great as to cause symp- toms, occurs occasionally as the result of sexual excesses, over-exertion, the stoppage of fluxes, and possibly in the caisson disease. An hyperemia, affecting especially the meninges, seems sometimes to remain after attacks of meningitis. Spinal hyperemia, however, of a chronic character, is a doubtful pathological entity, and though the spinal circulation is believed to be sluggish, its course is not easily interfered with. III. Spinal anzemia is a more real thing. Profuse he- morrhages, and mechanical obstructions, such as thora- cic and abdominal aneurisms, may cause an anemic paraplegia. Reflex paralysis from intestinal or other visceral injuries is probably due to a spinal ischemia. Injuries such as gunshot wounds have produced reflex paralyses of presumably similar origin. In general ane- mia, when very pronounced, the spinal cord shows some evidence of depression or irritation, but hardly more than do other organs. 545 Spinal Cord. Spinal Cord. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. After exhausting fevers and depressing traumatisms a paraplegic condition sometimes occurs ; it is attributed to spinal anzemia, but probably the condition is more often due to nutritive disturbance. Chronic spinal ane- mia can hardly be placed as yet in the category of distinct spinal affections. Embolism of the spinal cord has been known to occur, but only very rarely. Thrombosis is still more infre- quent. Miliary aneurisms, such as develop in the cere- bral vessels, are sometimes found in the cord, but they do not, as in the brain, lead to spontaneous apoplexy. IV. Inflammation is a peculiarly damaging process to the spinal cord ; its nervous tissue, once destroyed, has no power of regeneration. Acute inflammation is usually accompanied at first with such exudation and congestion that function is completely and widely suspended. Later, when absorption takes place, the focus of disease becomes more circumscribed and the symptoms lessen. Hence, in acute and subacute myelitis, not ending fatally, the paral- ysis is usually retrogressive. This is especially the case in myelitis of the gray matter. Chronic inflammation has a tendency, on the other hand, to extend, either by a progress in the inflammation or by setting up secondary degenerations. Hence chronic myelitis causes usually a progressive paralysis. Acute myelitis, after improving, may develop into a chronic form, when we have first retrogressive, then progressive, paralysis. The character- istic changes in acute myelitis and meningitis will be de- scribed under the special headings. Inflammation of the spinal cord has this peculiarity, that it is usually necrotic and rarely leads to suppuration or abscess. The initial stage of acute myelitis is often an ischemic or hemor- rhagic softening. In chronic myelitis the process affects the interstitial connective tissue primarily. As this in- creases in nutritive activity and anatomical extent, the nerve-fibres and cells atrophy. V. In degenerative processes, however, the nerve-tis- sue suffers first, and then the interstitial proliferates. There is thus an inverse ratio in the activities of the two (Gowers). Primary degenerative processes attack, first, the long-fibre systems of the cord and the anterior cornua, throughout more or less of their extent. The primary degenerative process travels both up and down the strand, while secondary degencrations only travel in the direction in which the impulses are carried (Striimpell). Forel shows that in certain pathological conditions which cut the fibre off near its trophic cell, the degeneration ex- tends up to this cell as well as along the peripheral part. After a degeneration is established in one strand, there is a tendency for it to extend to neighboring parts, through proliferation of the connective tissue. The term sclerosis has been used to indicate the condition in chronic mye- litis, and also in primary and secondary degeneration. It is used as an equivalent also to gray degeneration. @elat- inous degeneration is a term applied to the earlier stages of the latter process. VI. For details regarding the rarer conditions of tuber- culosis and tumors of the cord, the reader is referred to the special articles. Syphilis appears powerfully to pre- dispose the cord to chronic myelitis and degenerative dis- orders. The peculiar products of syphilitic development, such as gummata and diffuse gummatous inflammation, are rare. When present they attack, first, the meninges. GENERAL ETioLocy.—The remarks made upon this head must bear chiefly upon the more common cord af- fections, viz., inflammations and degenerations. Acute inflammation of the anterior cornual gray matter (anterior poliomyelitis) is mainly confined to children, while acute transverse myelitis belongs to adults. Males suffer more from both forms. Exposure, over-exertion, injuries, and infective fevers furnish the prominent exciting causes. It is not unlikely that a specific infection is the active agent in the acute poliomyelitis or acute ischemic soft- ening of children. In chronic myelitis there is some- times, though rarely, a hereditary tendency. Early and middle life, the male sex, syphilis, sexual excess, chronic alcoholism, occupations calling for exposure and over- exertion, are among the chief predisposing causes. The causes which lead to chronic myelitis are much 546 the same as those that lead to the typical degeneration disease, locomotor ataxia. In ataxia, however, the in- fluence of a hereditary taint and of syphilis is more marked. Syphilis and lead-poisoning seem to favor the develop- ment of chronic degenerations of the anterior horns (pro- gressive muscular atrophy). Alcohol has less influence, pathologically, on the cord than on the peripheral nerves and brain, and it is a minor factor in causing its degen- erations. Malariararely affects the cord, and then chiefly to produce vascular disturbances of the gray matter. Like alcohol, arsenic causes paralysis, if at all, by produc- ing inflammations of the nerves. Chronic poisoning by ergot may lead to a sclerosis of the posterior columns. In lathyrismus the lateral columns are especially at- tacked. In certain forms of podagra both lateral and posterior columns degenerate (Tuczec). Hence certain poisons seem to pick out definite physiological tracts. Chronic disorders of the brain, particularly general pa- ralysis, lead often to degenerative changes in the cord ; and the brain undoubtedly holds a certain amount of trophic influence over the cord. Traumatism is an important element in spinal pathol- ogy. Severe shocks and blows to the trunk may lead to heemorrhage (usually meningeal), or excite a chronic my- elitis, or lead to the development of degenerative pro- cesses. Still more often do traumatism and mental shock, combined, lead to nutritive or functional disor- ders. It is usually the case, however, in these instances, that the patient has some neuropathic predisposition. It is doubtful if purely mental shock can cause a spinal dis- order, though it may lead to a neurasthenic or hysterical condition in which spinal symptoms predominate. In conclusion, among the remaining causes of spinal cord disease are sudden disturbances of the circulation, such as hemorrhoidal discharges, suppressed menses, in- fectious fevers, irritation and disease of peripheral or- gans, GENERAL THERAPEUTICS.—In the functional diseases of the spinal cord, such as spinal irritation, spinal ex- haustion, and the various disturbances associated with hysteria or the morbid diatheses, treatment must always be more of a general than of a special character. In the scleroses and degenerations specific attempts to affect the nutrition of the cord are attempted. Drugs, diet, rest, counter-irritants, electricity, and mechanical appliances are here used. The posterior spinal nerves supply directly the skin of the back with sensation. They contain excito-reflex fibres, and by acting on them through the counter-irritants the circulation in the cord is profoundly affected. The veins carrying blood from the cord join with those supplying the postérior spinal region, and unite with the intercostal, lumbar, etc., veins. By drawing blood from the tissues of the back, therefore, we presumably draw some away from the cord. Hence cupping the back is a favorite therapeutical measure. Slight changes in the spinal circulation are produced by posture, and this is of some importance. Faradic currents act on the cord by counter-irritation ; galvanic currents, in addition, reach, and to some extent affect, the cord. It may be considered certain that strychnia causes a hyperemia of the cord in large doses ; probably phos- phorus does the same. Ergot can very probably cause some spinal aneemia, the bromides have a direct sedative power, and iodide of potassium has some resolvent prop- erties here as in other organs. There is ground for be- lieving that mercury has some antiphlogistic powers in acute spinal inflammatory disorders. It would not be worth while to discuss other drugs or remedies here. It will be seen that the spinal cord can be affected by the therapeutist, 1, through the posterior spinal and other excito-reflex nerves; 2, through the efferent blood-ves- sels; 38, through drugs that directly affect the circula- tion, the tissue irritability, and the nutrition. The history of lathyrism, ergot-poisoning, and podagra leads one to hope that we may yet find that certain drugs especially affect certain parts of the cord. 7 Charles Loomis Dana, REFERENCE HANDBOOK OF SPINAL CORD DISEASES: ACUTE ANTERIOR POLIOMYELITIS. Synonyms: Acute inflammation of the gray anterior horns; acute atrophic spinal paralysis ; infantile spinal paralysis ; acute spinal paralysis of adults. DEFINITION.—The disease is characterized by a rapidly setting-in paralysis of various parts of the body, most commonly the lower extremities, preceded, especially in children, by a fever of short duration, sometimes by con- vulsions, coma, or other nervous symptoms. ‘The paraly- sis, attended by flaccidity of the muscles, reaches its great- est intensity very quickly, and at the end of a few days begins to decrease. The permanently paralyzed muscles undergo rapid atrophy. In children, when the disease is extensive, there is arrest of development of the bones, and various deformities are produced. The pathological basis appears to be an acute myelitis, affecting chiefly the anterior cornua. The clinical appearances of the disease in children were pointed out by Heine in 1840, though its anatomical char- acter was not recognized until a much later period. Since the report of cases by Meyer in 1868, it has been known that the disease occurs also in adults. Errotocy.—The disease occurs chiefly in childhood. According to some observers three-fourths of all cases occur between the ages of six months and two years. It is possible that the liability to disease in early life is due to the yet incompletely developed condition of the spinal cord, especially its motor portions. It oceurs chiefly dur- ing the summer months. According to Sinkler, 77 of 149 cases appeared in July and August. Sex, heredity, and previous condition of health, seem to exert no influence. External injury, dentition, and exposure are often as- signed as exciting causes, but their influence is, at least, doubtful. — The paralysis often appears after an attack of measles, scarlatina, or the like, so that in these cases—possibly this is true of other instances—the disease appears to be produced by a poison circulating in the blood. Symproms.—The disease presents a somewhat different appearance in children and in adults, so that it is well to describe each separately. (a) Acute Anterior Poliomyelitis of Childhood.—The pa- ralysis sometimes sets in suddenly, without any prior man- ifestations of disease ; but, more commonly, it is preceded by high fever of a few hours’ or days’ duration, which may be complicated by various nervous symptoms, as somnolency, or even complete coma. In a large number of cases the disease is ushered in by convulsive seizures. _ These are like eclamptic attacks, and are of short duration. They may occur in large number, or there may be but a single seizure. The fever in these cases is, possibly, due to the acute inflammatory changes in the cord, but it is singular that such severe cerebral symptoms should usher in what appears to be a purely spinal disease. The paralysis sets in very rapidly and soon reaches its greatest intensity. When the children are removed from bed, after subsidence of the fever, it is observed that the paralyzed parts hang lifeless, a condition which may at first be attributed to mere weakness. In older children, in whom such observations can more easily be made, the paralysis is usually observed to have come on overnight, or to have reached its height in a few hours, very rarely in several days, while every part affected is paralyzed at the same time. The distribution of the paralysis is variable. Frequent- ly a single limb, or only a group of muscles, is affected, but more commonly several members are attacked. The paralysis occurs most frequently in a paraplegic form, in the lower extremities, but it may attack the four extrem- ities, and even the trunk, at the same time, or the upper extremities alone. More rarely it occurs in hemiplegic form, affecting a leg and arm of the same side, or even a leg on one side and an arm on the other. The para- lyzed muscles are quite flaccid, so that the limbs can eas- ily be moved in a passive manner; the reflexes, both superficial and deep, are abolished. The paralysis reaches its height very quickly, and from that time the changes are only toward improvement, which takes place, to a greater or less extent, in all cases. Spinal Cord. THE MEDICAL SCIENCES. Spinal Cord. The improvement is usually manifest within one or two weeks, and, for a time, progresses rapidly. In rare cases there is complete recovery (temporary spinal paralysis). But in the great majority of cases a greater or less degree of paralysis remains permanently. Of the paralyzed ex- tremities some may entirely recover, while in others, especially the lower, groups of muscles remain perma- nently paralyzed. The improvement is most rapid during the first six or eight weeks, and then continues very slowly for six or eight months, and, with proper treat- ment, possibly without it in some instances, the muscles may gain in strength for a year or two. The profoundly paralyzed muscles soon undergo atro- phy. This is usually observed within a week or two. When their power is restored the muscles regain their volume, but in those permanently paralyzed the atrophy may be so complete that no muscular tissue can be felt beneath the skin. The atrophy is sometimes concealed by the accumulation of adipose tissue. Along with the muscular atrophy are observed changes in the electrical reactions. These are very important, both as diagnostic and prognostic indications. When the paralysis is profound, the faradic irritability of the nerves and muscles is diminished in from three to five days, and entirely abolished in a week. When, on the other hand, at the end of the second week the faradic contractility of the muscles, though diminished, is not abolished, the muscles will not remain paralyzed perma- nently. The changes in the galvanic reactions are those characteristic of the reaction of degeneration—first, in- creased gaivanic irritability, then anodal closure contrac- tion stronger than cathodal closure—the reverse of the normal formula; finally, the galvanic reactions become weaker and may be abolished. In muscles not so pro- foundly paralyzed there is usually only a quantitative change in the electrical reactions, a diminution of the fa- radic and galvanic irritability, but no qualitative change, no reversal of the normal formula of contractions. The bones and joints are often greatly altered. The bones may be arrested in their development, be much shorter and narrower than the corresponding ones on the other side, and also be more yielding or friable. In this way the whole limb remains smaller than its fellow. This is especially true of the lower extremity, which may be from two to six inches shorter than the sound one ; but the arm is also frequently reduced in size, and even the bones of the pelvis are sometimes arrested in their development. The changes in the bone need not correspond to those in the muscles. There may be con- siderable atrophy of muscles and but little change in the bones, or vice versa. The joints may become deformed and abnormally mov- able, due partly to atrophy of the cartilages and the epiph- yses of the bones, partly to a weakness of the ligaments of the joints. The skin is usually cold and cyanotic, and sometimes becomes dry, liable to indolent sores, etc. The most characteristic features of the long-standing disease are the various deformities which occur. Vari- ous factors play a part in their production. One is the weight of the limb, as when the child lies on its back the paralyzed foot naturally falls into a state of exten- sion, and talipes equinus results. A more important fac- tor is the state of the muscles. The deformity is greater when not all of the muscles of a joint are paralyzed. The limb is then drawn and maintained in its new position by the unantagonized sound muscles, which may subsequent- ly become shortened to adapt themselves to their changed relations. Some other factors may come into play, as re- traction of the connective tissue related to the atrophied muscles. In fact, the explanation of the production of deformities is still largely a controversial point. The most common deformities are the different kinds of club-foot, especially equino-varus. Among others are various contractures of the knees and hips, lateral and antero-posterior curvature of the spine, and contractures of the hands, wrists, and arms. Apart from those mentioned there are, as a rule, no nervous symptoms. In the very beginning there may be some pain and hyperesthesia, and weakness of the blad- 547 Spinal Cord. Spinal Cord. der. But these soon disappear, and then there are no sensory symptoms, and the functions of the bladder and rectum are normal. The mind isclear, the general health unaffected, and the patient may live to old age. (b) Acute Anterior Poliomyelitis of Adults.—The dis- ease is ushered in by fever and nervous symptoms, as in children, though convulsions have not been observed. The paralysis sets in rapidly, the paralyzed muscles are flaccid, the permanently paralyzed muscles undergo rapid atrophy, and there are changes in the electrical reactions, just as we found them in children. Less frequently than in children is a single limb affected. Often the four ex- tremities, at least the lower, are paralyzed, though the upper may be alone affected. Improvement soon begins, and, as in children, rare cases of recovery occur. As a rule, more or less paralysis remains permanently. The deformities, which appear at a later period, are not so great as in children, for the bones have attained their full size, and the joints are firmer. Morzsip ANATOMY.—The great majority of post-mor- tem examinations have been made in cases where the disease had existed many years. In these extensive changes have been found in both the white and gray matter of the cord, as well as in the nerves and muscles. But most of these are to be considered secondary changes. In the few cases where an examination could be made at a comparatively early period (after the disease had ex- isted four weeks or longer), evidences of myelitis were found, affecting chiefly the anterior cornua, and, to the largest extent, the cervical and lumbar enlargements. The large ganglion cells were always affected, and their destruction appeared to correspond to the extent of per- manent paralysis. It is now generally believed that the paralysis, as well as the trophic changes in the muscles, bones, etc., is due to the destruction of these cells— which have both motor and trophic functions—or to the severance of their relations with the peripheral nerves. The acuity of the inflammatory process accounts for the rapid onset of the paralysis, and the considerable resolu- tion of the pathological process which takes place ex- plains the improvement which is always observed. The naked eye appearances in recent cases are some- times negative ; sometimes there is indistinctness of out- line on section, and discoloration and diminution of size of the anterior cornua. In several instances distinct foci of red softening were found. The seat and extent of the pathological changes are more accurately seen in the mi- croscopical appearances. Foci of disease may be found in various parts of the cord, especially the anterior gray matter, while those of greatest intensity are usually in the cervical or lumbar regions. They may reach for some distance up and down the cord, occupying, at the same time, but a part of the anterior cornua. These are, usually, foci of red softening, in which the blood-vessels are much dilated, and granular cells appear in more or less abundance, and where the nervous elements, large ganglion cells and nerve-fibres, have mostly disappeared. The areas of disease may be distinctly circumscribed, and the neighboring tissues be entirely normal, or a slight and more diffuse inflammation may be observed to ex- tend beyond this in various directions. Occasionally there is found slight sclerosis of the an- tero-lateral columns, and diminution of their size, while the anterior roots, those corresponding to the diseased areas, are usually more or less atrophied. In old cases, where the disease has been extensive, changes are readily seen by the naked eye. The anterior cornua, and often the antero-lateral columns, are much shrunken, and the anterior roots greatly atrophied. On microscopical examination quite circumscribed lesions are usually found in the anterior cornua of the cervical or lumbar enlargements, which are composed mainly of fine wavy connective tissue, with corpora amylacea and pigment granules, and in which the nervous elements have mostly disappeared. If ganglion cells are present they are usually in various stages of degeneration. At the same time the ganglion cells are often reduced in num- ber in other parts of the cord, which may present other slight pathological changes. 548 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. In the antero-lateral columns, either in the immediate neighborhood of the greatest changes in the anterior cor- nua or involving a greater part of those tracts, are evi- dences of sclerosis, increase of the neuroglia, and atrophy of nerve-fibres. ‘ The muscles present pathological changes correspond- ing to the intensity of the disease. Sometimes a few normal muscular fibres are found among others which are to a greater or less degree degenerated. In other in- stances the muscular fibre has altogether disappeared and been replaced by connective or adipose tissue. More or less degeneration and atrophy are also found in the peripheral nerves, tendons, bones, and joints. Draenosis.—Usually a diagnosis is easily made, on ac- count of the striking and characteristic features of the disease. These are flaccidity of the paralyzed muscles, altered electrical reactions, rapidly developing atrophy, and loss of the reflexes, together with absence of sensory or other nervous symptoms. In young children pseudo-paralysis from disease of bone or other surgical affection might be mistaken for in- fantile paralysis, but a careful examination, or the lapse of a short period of time, would clear up the diagnosis, Cerebral infantile paralysis can be distinguished by the absence of pathological atrophy, the normal electrical re- actions, presence of the reflexes, the frequent involve- ment of the intellect, and the hemiplegic form of the paralysis. The differentiation of hematomyelitis, or hemorrhage into the substance of the cord, will often be impossible. The same is true of some cases of neuritis, though ten- derness over the nerve and presence of anesthesia or other sensory symptoms will usually point to the true disease. In transverse myelitis there are usually indications of disease of the posterior as well as the anterior part of the cord. Compression myelitis from Pott’s disease presents, usu- ally, the appearance of spastic paralysis, exaggerated ten- don reflexes, etc. Proenosis.—It is possible that some of the fatal cases of convulsions in children were in the initial stage of this disease ; otherwise it is not attended by serious danger to life. The prospect is less favorable as regards the pa- ralysis, more or less remaining permanently in most cases. The electrical current is of great value in informing us at an early period as to the probability of permanent paralysis. The information to be gained from it has al- ready been mentioned. The greatest amount of improve- ment will take place in the first two months. It may be much furthered by proper treatment, and may even con- tinue after a year or more has elapsed. _ TREATMENT.—The early symptoms—fever, etc.—re- quire chiefly rest in bed. Ergot and belladonna have been recommended, on the theory that they limit the in- flammation through their influence on the circulation. Applications of ice to the spine, and revulsive applica- tions, have been made for the same purpose. The ad- ministration of iodide of potash to promote the absorption of inflammatory products seems appropriate treatment. Electrical applications are often made at an early period. The object of making them, at this time, is to directly influence the spinal cord.. For this purpose a large elec- trode should be selected and applied over the spine, while the other is applied to a distant part, for in this manner the largest quantity of the current may be expected to reach the cord. The positive pole is usually applied to the spine, and as near as possible to the seat of the dis- ease—for instance, to the cervical spine if the upper, to the lower dorsal and lumbar spine if the lower, extrem- ity is paralyzed. Ata later period the current should be applied to the paralyzed nerves and muscles. It must now be looked upon as one of the most valuable agents in treatment. The faradic current is appropriate if it can produce mus- cular contractions ; otherwise the galvanic current should be selected. Duchenne, who was an enthusiast on the subject, believed he could create entire muscles out of a few fibres by means of faradization. At the same time REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Spinal Cord. Spinal Cord. massage of the muscles, and other gymnastic exercises, should be instituted. Arsenic and strychnine have been extolled for their power over the paralyzed muscles. Cod-liver oil, tonics, open air, and all else that can invigorate the system are indicated. During this time efforts must also be made to counter- act the tendency to deformity. In this effort the meas- ures already mentioned—electricity, gymnastic exercise, especially the frequent stretching of the retracted mus- cles—accomplish much. Avoiding positions in which the weight of the limb may cause deformity, sometimes easy walking, holding the joints in proper positions, but not too firmly fixed, may all assist in preventing deformi- ties When the latter are well marked, suitable appa- ratus, sometimes tenotomy, etc., are called for. Philip Zenner. SPINAL CORD DISEASES: ACUTE ASCENDING PARALYSIS. Synonym, Landry’s Paralysis. DEFINITION.—A rapidly progressing paralysis, usually beginning at the lower extremities, extending to the up- per extremities, the muscles of the trunk, and finally to those supplied by the cranial nerves, death often re- sulting from paralysis of respiration. The paralyzed muscles are flaccid, but there is no special atrophy, and no alteration in the electrical reactions. There are slight, if any, symptoms on the part of sensibility, blad- der, or rectum, no bed-sores, and usually little fever. There are no anatomical changes to account for the symp- toms. In 1859 Landry gave an accurate description of this disease, noting, at the same time, the absence of appre- ciable anatomical changes, and since that time many similar cases have been reported. In 1875 Westphal, in connection with a report of four cases, gave a critical re- view of the subject. He excluded a number of reported cases in which some anatomical changes were found post mortem, and made an absence of the latter an essential feature of the disease. His views have been very largely accepted. The absence of anatomical changes in the nervous system has been pronounced by most competent patholo- gists, such as Vulpian, Cornil and Ranvier, Bernhardt, -Westphal, and Kahler and Pick, so that the accuracy of their observations cannot be questioned. But, especially since Westphal’s report, a number of cases have been recorded, whose histories are almost or altogether in full accord with those of acute ascending paralysis, in which lesions in the nervous system were found. We must leave it to the future to decide whether the latter do not belong to the same class of diseases, or whether the nega- tive results in earlier cases merely indicate that the path- ological changes had not yet progressed far enough, or were not sufficiently intense to be recognized by our pres- ent methods of examination. EtroLtogy.—The disease occurs chiefly in men, and in adult life. It does not seem to occur specially in those predisposed to nervous diseases. Exposure to cold, sup- pressed menses, etc., have been assigned as causes. It sometimes occurs in syphilitic subjects, and some have believed, especially on account of the apparent results of treatment, that the disease is sometimes of syphilitic ori- gin, but post-mortem examinations find nothing to up- hold this view. It has occurred in the course of, or dur- ing convalescence from, acute diseases, as typhoid fever and diphtheria. Westphal believes that some toxic agent causes the disease. In a case of Baumgarten’s, where the disease complicated splenic fever, bacilli anthracis were found in the blood and in the cord. SymptToms.—The disease is sometimes ushered in by shooting pains in the back and legs, sometimes by slight fever, or there may be a general sense of debility and dis- comfort for some days preceding the paralysis. Numb- ness and tingling in fingers and toes are not infre- quently felt, and this is often the only sensory symptom. The paralysis begins generally in the lower extremities. From a degree of weakness which the patient first com- plains of, it increases rapidly to complete paralysis. Either at the same time, or shortly afterward, the arms become affected, the paralysis rapidly increasing in in- tensity. Then the muscles of the abdomen are affected, making defecation, etc., difficult ; next, the muscles of the chest, causing respiratory difficulties. Lastly, the cranial nerves are involved, chiefly the hypoglossal and pneu- mogastric, causing difficult deglutition, indistinct speech, and difficult breathing, the latter oftenin paroxysms, but occasionally the seventh and other motor cranial nerves are also paralyzed. The paralysis does not always follow this course. It occasionally begins in the upper extremities, occasionally in the cranial nerves. In the latter case there is usually a very rapidly fatal issue. The further characteristics of this disease are negative symptoms. The muscles are quite flaccid, but they do not undergo atrophy, at least to any considerable extent, and the electrical reactions remain normal. In a num- ber of instances the patellar tendon reflex was abol- ished. There are no bed-sores, and no, or at least very slight, disturbance of the. bladder and rectum. Sensory symptoms are slight, or altogether absent. Anesthesia of the soles of the feet, or other parts, has been observed. Usually the general health is but little disturbed, and the mind is unaffected. The duration of the disease is from a very few days to several weeks, the average being from ten to twelve days. A fatal issue is usually brought on by paralysis of respiration. But the disease does not always terminate fatally. Of ten cases mentioned by Landry, eight recovered. But there is often room for doubt whether cases that recover really belong to this disease. In favorable cases the dis- ease is usually arrested before it reaches the cranial nerves, though cases of recovery are reported even after the latter have been affected. The progress toward im- provement is usually in an inverse order to that of attack, the part affected last being the first to improve. The patient usually remains weak for a long time after the more pronounced paralysis has disappeared. The prog- ress of convalescence is liable to interruptions from re- lapses, which may even take a serious course. Morgpip ANATOMy.—It has already been stated that, so far as the central nervous system is concerned, the re- sults, in cases generally accepted as those of this disease, were negative. Enlarged spleen, lymphatic glands, etc., as in cases of infectious diseases, were found in a number of instances. This gives some basis to Westphal’s view, that the disease is due to a kind of intoxication. Eisenlohr reported a case (Virchow’s Archiv, Ixiii., page 73), with almost typical history, of acute ascending paralysis, in which there were slight evidences of myeli- tis and small capillary hemorrhages in the medulla ob- longata. Ina case of Kiimmell (Zeitsch. f. klin. Med., ii., page 272), coming on during the convalescence from typhoid, and with a typical history of ascending paraly- sis, small hemorrhages in the medulla oblongata were found. Schulz and Schultze reported a case (Archiv f. Psychiatrie, xii., page 457) with the usual symptoms of ascending paralysis, only that the course was a slow one, its whole duration being nearly two months, in which the electrical responses of most of the paralyzed muscles were those of the reaction of degeneration. But the electrical test was not made until about the sixth week of the disease, and, as pointed out by the authors, it is not improbable, if tested in the first or second week, as in other cases, the electrical reactions might have been nor- mal. The post-mortem revealed a fresh myelitis, chiefly of the motor tracts of the cord, of the anterior gray matter, and of part of the medulla oblongata. Lastly, Hoffman (Archiv f. Psychiatrie, xv., page 140) reported a typical case of ascending paralysis, only that there was double facial paralysis, with some diminution of the elec- trical irritability of the right facial nerve and muscles, though the electrical reactions were elsewhere quite nor- mal. On post-mortem examination a moderately intense meningitis, and slight myclitis, chiefly of the antero- lateral columns in the cervical and dorsal regions, were found. In none of these cases did the extent of morbid 549 Spinal Cord. Spinal Cord, changes appear to correspond to the intensity of the symptoms manifested during life, but they, nevertheless, indicate that those symptoms were dependent on a pal- pable lesion. Draanosis.—The rapidly progressive course, the pres- ence of mostly motor symptoms and normal electrical reactions, will usually distinguish these cases. Acute multiple neuritis can usually be distinguished by the sensory symptoms, pain, tenderness, anesthesia, etc., and by the atrophy of muscles and altered electrical reactions. Some cases of subacute anterior poliomyeli- tis run a very rapid course, so that they closely simulate this disease. But there is greater likelihood of muscular atrophy and altered electrical reactions, bulbar symptoms usually appear at a much later period, and the disease runs a less rapid course. Acute central myelitis, also, often causes an ascending ‘paralysis, and runs a rapid course. But in this disease the sensory symptoms, anesthesia, etc., are prominent ; there are paralyses of the bladder and rectum, acute de- cubitus, fever, etc. ProGnosis.—The disease must always be looked upon as a serious one, It is true, cases, apparently of this affection, recover, but in most of these the disease is ar- rested at an early period. The more rapid the progress of the disease, and the earlier bulbar symptoms appear, the more unfavorable the prognosis. TREATMENT.—Cold to the spine, cupping, and blisters have been tried at an early period. ILodide of potash should be administered, especially where there is a syphilitic history. In the latter case inunctions of mer- cury should also be tried. In Schulz’s case hot baths seemed to do much harm, while the constant current to the spine was followed by considerable improvement. In cases running a favorable course, the use of electric- ity, hydrotherapy, tonics, change of air, etc., are indi- cated. Philip Zenner. SPINAL CORD DISEASES: ACUTE SPINAL MEN- INGITIS. Synonyms: Acute inflammation of the spinal pia mater and arachnoid ; lepto-meningitis spinalis acuta ; perinmyelitis and arachnitis. This disease, which is the most frequent and impor- tant of the affections of the spinal meninges, is an acute inflammation of the spinal pia mater, with implication to a greater or less extent of the arachnoid, the sub-pia connective tissue, the connective tissue between the pia mater and arachnoid, and the internal surface of the dura mater. As a sporadic affection it is rare, but it is often found associated with lepto-meningitis of the brain, con- stituting the affection known as epidemic cerebro-spinal fever. PATHOLOGICAL ANATOMY.—This affection may be di- vided pathologically into three stages: First, the stage of hyperemia, or commencing exudation; second, the stage of purulent or fibrinous exudation ; and third, the stage in which chronic changes are established. In the first stage, which is seldom observed post mor- tem, the pia mater appears thickened, opaque, rosy, or dark red in color, and dotted with hemorrhagic extrava- sations; the tissues around are swollen from infiltra- tion of serum ; the spinal fluid is increased in quantity, and turbid. The sub-pia connective tissue, the arach- noid, the connective tissue between the pia mater and arachnoid, and the internal surface of the dura mater are also congested, the hyperemia frequently extending to the cord and nerve-roots arising from the affected re- gion. In the second stage the spinal fluid becomes more and more turbid, and assumes a sero-purulent appearance, containing numerous flakes of fibrin. The pia mater, and the connective tissue underneath the pia, and between that membrane and the arachnoid, become more and more opaque and softened, and are converted into a gelat- inous mass by a more or less infiltrated, dense, whitish, fibrinous, or purulent exudation, composed of leucocytes and fibrin. This exudation is more or less resisting, and may appear in lamelle. Small miliary nodules are found, in some cases, distributed along the course of the 550 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. vessels of the pia mater, constituting tubercular spinal meningitis. The arachnoid is opaque, and sometimes adherent to the dura mater. The dura mater is hyper- eemic, reddened, and opaque, and fibrinous flakes and plates are found adherent to its internal surface. Peri- pachymeningitic hemorrhages occasionally occur. The nerve-roots are always involved ; they are enveloped in thick masses of exudation, and are swollen and soft- ened. The cord itself is pale, edematous, or congested, and finally softened in spots or diffusely. Microscopical examination shows in the soft membranes of the cord all the signs of an exudative inflammation—abundant cell- infiltration, especially along the vessels; fulness of the capillaries; swelling and spreading of the bundles of connective tissue, and infiltration of cells in the nerve- roots. The nerve-fibres are swollen, granular, and be- ginning to break down; the axis-cylinders are swollen and granular, and the bundles of root-fibres entering the cord are similarly affected. In the cord the neuroglia is infiltrated with small celis and nuclei, or actual paren- chymatous myelitis is found; the axis-cylinders are enormously swollen and breaking down ; the medullary sheaths are cloudy and undergoing granular decay ; in the gray substance swelling and cedema of the ganglion-cells occur; the central canal is closely packed with round exudation-cells. The distribution of the exudation in the membranes varies greatly, both as regards its consistency and thick- ness and the longitudinal extent it occupies. Asa rule, it is circular, covering the whole periphery of the cord, being thicker, however, at the posterior surface of that organ, and it extends the whole length of the spinal canal. The greater thickness of the exudate on the pos- terior surface has been attributed by some to the fact that the patients lie more on the back. This explanation would not hold good in one of my cases, here reported, where the same thing was observed in a patient who almost constantly lay on his side or face. Others have thought this difference in the thickness to be due to the richer supply of nerves in the posterior region. When the meningitis is limited in longitudinal extent to the length of one or two vertebree, the inflammation is, as arule, due to disease of the bone. It is very sel- dom that the exudation extends upward from the spinal canal to the membranes of the brain, though this has occasionally been seen, as in one of Ollivier’s cases and in the second case reported by me. The third stage, or that in which chronic changes are established, is, of course, only seen in those cases in which acute inflammation gives place to a chronic one. The most common of these changes are opacity and thick- ening of the spinal membranes, with the formation of adhesions ; accumulation of fluid in the arachnoid space (hydrorrhachis); and sclerosis or atrophy, either diffused through the cord or affecting isolated portions or sys- tems. When absorption has taken place, there is, of course, no third stage. Errotocy.—The causes of acute spinal meningitis are still very obscure. It occurs more frequently in the young and aged than in those in middle life, but is not altogether limited to these extremes, a number of cases having been observed in adults. Men seem to be more often affected by the disease than women; but this depends, probably, rather on the fact that they are more exposed to traumatism by the nature of their occupations, and that they are more given to excesses and dissipation, than it does upon any special susceptibility inherent in the sex. Of the known predisposing causes, the most important are a scrofulous or tuberculous constitution ; insufficient. food ; damp dwellings; sexual, alcoholic, and other ex- cesses, and syphilis. Omitting the epidemic and infectious influences which. affect the occurrence of cerebro-spinal meningitis, with which we are not here concerned, and not considering those cases of extension of the affection from the cerebral meninges to the spinal membranes, as in the tubercular and other forms, the following are credited with having been the exciting causes of this affection in some in- stances : Injuries to the spinal column from blows, falls, REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Spinal Cord. Spinal Cord. or railroad accidents, causing either fracture, disloca- tion, or concussion of the spine; gunshot wounds of the spine, or punctured wounds of the membranes, as in the operation for spina bifida ; violent bodily efforts, as in lifting a heavy weight; sacral eschars perforating the dura mater ; a sudden fall into cold water; a cold- air current striking the back when the person is sweat- ing ; exposure to wet and cold, as from sleeping on damp ground, or standing long in water while working; the suppression of the menstrual and hemorrhoidal fluxes ; suppressed perspiration of the feet ; communication of a peripheric neuritis to the spinal meninges, observed in a case of tetanus ; dentition; the puerperal state; the opening of an abscess from neighboring parts into the spinal canal; and the extension of inflammation from parts around into the vertebral canal. The following constitutional diseases are known to have been occasion- ally complicated with acute spinal meningitis: Acute rheumatism ; pneumonia; scarlet fever, and the other exanthemata ; and pyemia. Of these causes the following are rather doubtful : Den- tition; the disappearance of acute exanthemata; the suppression of the menstrual and hemorrhoidal fluxes ; suppressed perspiration of the feet. SYMPTOMS AND CLINICAL History.—In the study of the clinical history of this disease it will be best to di- vide it into two stages: First, that of congestion and be- ginning exudation, the irritative stage ; and second, that of complete exudation, or compression. First Stage. —Acute spinal meningitis is only in excep- tional cases preceded by the usual symptoms denoting inflammatory action, such as chilly sensations, restless- ness, headache, etc. Its onset is generally sudden, a sharp rigor being the first indication of the disease in most cases. This is followed by an irregular fever, and a quick, hard, full pulse. Pain in the back, either con- fined to a limited region or extending along the whole spine, makes its appearance. This pain, at first dull, soon becomes acute, boring or shooting in character, and is greatly increased by movements of the trunk and limbs ; but, as a rule, it is not affected by pressure on the spinal processes of the vertebrae. The pain soon extends around the body, in the form of a girdle, and down the limbs; the alternate passage of a hot and cold sponge along the Spine increases it ; it is greatest at the site of the princi- pal lesions. In a very short time contraction of the back and limbs is observed, and when the cervical region is involved the head is drawn backward and arched in a condition of more or less complete opisthotonos. Hy- peresthesia and various pareesthesiz of the skin are well marked. The muscles of the trunk and extremities are also hypersensitive, and the patient remains motion- less in bed, with the limbs rigid, not from paralysis, but from fear of the acute pain which accompanies the slightest motion ; the muscles are in a state of tension or spasm, which is increased by motion, but not by reflex irritation ; there are also spontaneous muscular twitch- ings, giving rise to severe pain. Dyspncea, amounting in some cascs to asphyxia, is sometimes seen, owing to implication of the respiratory muscles. The pupils are irregular ; sometimes they are normal, at other times they may be contracted or dilated, or one of them only may depart from the normal. Violent headaches, verti- go, vomiting, irritation or paralysis of the oculo-motor nerves, together with delirium and coma, are due to inva- sion of the cerebral meninges. The reflexes, skin and tendinous, are, as a rule, exaggerated in this stage, and there is also exaggerated electrical reaction. Functional derangements of the bladder and rectum appear early in the disease; there is at first costiveness, with retention of urine from spasms of the sphincters of the anus and bladder, then afterward dribbling of urine from overdis- tention, and later on paralysis of the sphincters. The urine is at first dark, scanty, and cloudy from the urates, but later on it becomes abundant, light, and clear; in some cases an excess has been observed, due probably to direct nervous stimulation of the secretory centres in the cord ; in rare cases mellituria has occurred. The abdo- men is sunken and tense, and free from meteorisms and swelling ; diarrhcea is rare. Eruptions on the skin have occasionally been observed, but not so frequently as in the epidemic form of the disease. The duration of this stage is variable, lasting from two or three days to a week or more, the disease being oc- casionally, though very rarely, arrested at this period. At times deceitful signs of temporary improvement will show themselves, but are soon followed by symptoms denoting invasion of the cord or of the meninges of the brain. Death occasionally closes the scene at this period ; but this is rare, unless the affection is a sequel to some exhausting disease, or unless the membranes of the brain and medulla are severely affected. Asa rule, the symp- toms of irritation belonging to the first stage gradually give way to symptoms of paralysis of motion and sensa- tion, denoting compression of the cord and nerve-roots. Second Stage.—The pains in the back and limbs still persist, but have lost their acuteness ; the patient feels dull and heavy ; cutaneous and muscular hypereesthesia are replaced by aneesthesia and muscular paralysis, with contracture and atrophy ; the reflexes and electrical reac- tion become diminished, and sometimes altogether lost ; the sphincters of the anus and bladder become paralyzed, and there is incontinence of urine and feces ; more or less paresis, or paralysis, of the extremities exists, the exten- sor muscles being generally more affected than the flex- ors; bed-sores and cystitis supervene as dangerous com- plications. Paralysis of the muscles of deglutition and of the tongue, usually a fatal complication, denotes inva- sion of the medulla oblongata. Rapidity and irregularity of the pulse and respiration, occasionally observed at this stage, are due to compression of the vagus. The tem- perature at times rises to 106° or 108° F., denoting exten- sion of the disease to the cerebral meninges; delirium and coma ensue, and speedily lead to a fatal termina- tion, but more often death is brought on by exhaustion and marasmus, The location of the disease at different levels of the cord naturally causes variations in the symptomatology ; as we have said before, it is more common to see the meningitis extending along the whole spinal canal, but at times, in traumatic cases especially, it is more local- ized. When the lumbar and sacral regions are alone affected, the pain is felt in the sacrum and loins; the stiffness is limited to the lower part of the spine ; the pain radiates to the hypogastrium, perineum, and lower extremities, and the spasms and paralysis are limited to those parts ; the urinary troubles are very severe. When the dorsal region is also involved, the pain and stiffness extend higher up in the back, as far up as the shoulders; there are disturbances of respiration, etc., added to the symptoms manifest in the lower extrem- ities. When the cervical region is also implicated, there are, in addition, stiffness and pain in the back and neck ; ex- centric pain, extending to the upper extremities ; difficulty in breathing and swallowing ; derangement of the heart’s action, pupillary symptoms, etc. When the inflammation extends to the medulla ob- longata and base of the brain, in addition to the spinal symptoms those of a cerebral nature are observed, such as violent headache, vomiting, vertigo, delirium, trismus, oculo-motor paralysis, disturbances of speech and respi- ration, and coma. Some of the symptoms above enumerated are due to the inflammation of the meninges, but the physiological explanation of by far the greater number of these is to be found in the implication of the nerve-roots or periph- ery of the cord itself, almost invariable accompaniments of spinal meningitis. For instance, the pain in the back, according to Hallopeau, is not due to irritation of the posterior nerve-roots, but is caused by irritation of the meningeal nerves ; the spinal meninges have been demon- strated, he says, not to be sensitive in their normal con- dition, but become extremely so when in a state of in- flammation, and he bases his argument on the fact that the pain is almost always absent in myelitis. That irri- tation of the nerves of the pia and dura mater 1s account- 551 Spinal Cord. Spinal Cord. able for a certain amount of this pain admits of no doubt, but the very character of the pains—their excentric nat- ure, occurring in portions of the body which derive their nerve-supply from the affected regions of the cord—prove beyond contradiction that irritation of the posterior nerve- roots acts as an important factor in their production. The same explanation must be given for the hyperes- thesia and paresthesia found in different portions of the body. The stiffness of the back and extremities, the muscu- lar tension, the contractures and spasms, are due chiefly to direct irritation of the motor apparatus—that is, in part to inflammatory irritation of the anterior roots, in part to irritation of the motor paths in the lateral columns of the cord by secondary points of myelitis. That these motor disturbances are in some cases caused in a reflex manner, by the abnormal irritation of the posterior roots, must be also admitted, as well as the fact that this muscular tension is half voluntary in character, or is increased by a voluntary act which has for its object the prevention of movement when all movements are so painful. The motor and sensory paralyses, neuralgia, and anees- thesia of the extremities which occur in the later stages of this disease are due to affection of the anterior and pos- terior nerve-roots, but it is not impossible that myelitic points in the white columns of the cord contribute, in some cases, to the production of this paralysis. The retention of urine occurring early in the disease is explained by the direct or reflex spasms of the sphinc- ter of the bladder. The later paralysis of this viscus is due to the same causes that produce the paraplegia. The disturbances of the digestive apparatus and the cos- tiveness which accompany this affection are referred by Koehler to spasm of the intestinal muscles and consequent interference with peristaltic action, and to the spasmodic tension of the abdominal muscles. But to this must be added the sluggishness and weakness which are so char- acteristic of intestinal movements in spinal diseases. The disturbances of respiration which occur, from sim- ple accelerated and difficult breathing up to extreme dyspnoea and asphyxia, are due to implication of the cervical roots, causing tension and spasms or paralysis of the respiratory muscles, or to implication of the white matter of the cervical cord, in which are situated the respiratory paths, or to an extension of the disease to the respiratory centre in the medulla oblongata. The pupillary changes may be due either to irritation of special fibres in the cervical cord or to disturbances of the oculo-motor nerves by extension of the disease to the brain. The symptoms denoting invasion of the brain have been referred to. CouRskE, DURATION, AND TERMINATION.—In the most acute forms of the disease death may occur in a few hours, but more generally it occurs in three or four days, from asphyxia. In less violent cases the duration of the disease is two or three weeks, recovery ensuing at the end of that time in exceptional cases. In other cases the violence of the symptoms is abated, but the patient remains an invalid for a number of weeks or months, improvement in the paralyzed muscles being very slow ; and at times contractures and paralysis of certain groups of muscles remain permanent. In other cases, again, the acute symptoms subside and the disease assumes a chronic form, which is usually associated with myelitis, the patient dying, later on, of cystitis and bed-sores. The following two cases give a clear clinical illustra- tion of spinal meningitis ; hence their insertion here. Case of Acute Meningitis ending in Recovery.—John G—,, aged thirty-five, born in England ; a machinist by occupation ; has been a hard whiskey-drinker for years ; smokes and chews to excess ; has never contracted syph- ilis ; gives no history of hereditary predisposition. About June 16, 1888, he went on a spree, and slept all night on the ground in one of our public squares, where he was picked up by the police next morning. The day pre- vious had been a very rainy one, and the ground, on which he must have lain for hours, was quite wet. When aroused he felt stiff in the legs, but was able to accom- 552 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. . pany the officers to the jail, and on that same day he was discharged by the police-court and. was admitted into Charity Hospital, in the ward for nervous diseases, com- plaining of great pain of a shooting character in the lum- bar and dorsal regions of the spine. The pain extended all around his body at the level of the nipples, and shot down the legs ; these felt numb and stiff, but he was still able to stand; his pulse was hard, full, and fast, about 104 per minute; his respiration somewhat accelerated, and his temperature 1014° F. I saw him on the next day, and made the following notes of his case: Patient is well nourished ; general appearance good ; complains of sharp, shooting pains along the spine, from the neck down, ex- tending around the body and around the arms and down the legs; this pain is not increased by pressure on the spinous processes, but the slightest movement of the body or extremities brings on an exacerbation ; the back is stiff and arched, and the legs flexed on the thighs, and the thighs on the pelvis; he is unable to extend the extrem- ities, not that any paralysis exists, but from the fact that the attempts at motion give rise to severe paroxysms of _ pain ; the muscles in the trunk and extremities are tense and contracted, and the patient complains at times of in- voluntary twitching, giving rise to exquisite pain ; his bowels are constipated, and he has passed no urine since admission. With asoft catheter over a pint of highly colored urine was drawn from his bladder. The pulse is 112, full and hard, and the temperature has reached 102° F. The patient’s mind is clear, and, aside from some frontal headache, he complains of no disorder about the head. CaClC, the contraction is slow, and faradic contractil- ‘ity is abolished. In slightly affected muscles there is simple diminished reaction to both currents. The muscles do not undergo contracture ; the integu- ment of the affected parts presents well-marked bluish or ~ reddish marbling. The subcutaneous adipose tissue may 580 be increased. The temperature of the affected limbs is considerably diminished. These symptoms are less marked in the upper than in the lower limbs. In four cases, sensation was undisturbed. In one of Eichhorst’s cases there was hypereesthesia of the dorsum of the foot ; in another case there was diminished sensi- bility in the legs. In one of Charcot’s cases there was anesthesia to touch and temperature, which became less marked in the upper part of the limb. There were also retardation and per- sistence of sensation, and the muscular sense was also slightly affected. This patient suffered from pains in the lower limbs. . Pains have also been observed in other cases, but do not seem to be an essential feature of the symptomatology.. Cramps in the calves were noticed in almost every case. The other bodily functions were normal. The disease generally begins in childhood or youth. Among 19 cases, 14 began before the age of twenty-two years. In one of Eichhorst’s patients the disease was perhaps congenital; in another it began at the age of thirty-six years ; in two of Wetherbee’s patients, at thirty- nine years. Pathological Anatomy.—A. number of cases have been reported in which the most careful and competent exam- ination failed to reveal the slightest evidences of change | in the nerves or spinal cord. In a number of other cases slight lesions have been found in the spinal cord, but these were entirely disproportionate to the muscular dis- ease, and were probably either secondary or mere coinci- dences. ; ‘‘Granular disintegration”’ of various parts of the spi- nal cord has been observed a number of times by various English writers, but there is very little doubt that this le- sion is an artefact, produced during the hardening of the tissues in alcohol. Changes in the muscles, on the other hand, are found in all cases, but while the histological appearances ure quite distinct from those described in spinal progressive muscular atrophy, those found in the various myopathies differ greatly from one another. : I will first give the results of my own examinations. In a case of pseudo-hypertrophic paralysis, I observed the following: A large amount of adipose and fibrous tissue was situated between the muscular fibres. A few capillaries were found distended with blood, their walls thickened, and presenting nuclear proliferation. The vas- cular changes constituted a minor part of the morbid pro- cess, The muscular fibres were very markedly changed. They were very unequal in size, and few of them main- tained the same dimensions throughout their entire length. A few fibres had a peculiar convoluted appearance, and a number branched dichotomously. In many the trans- verse strive were indistinguishable, in others they were less distinct than the longitudinal stria. Even in those fibres in which the transverse striz were distinct, they did not seem to be as far removed from one another as in the normal condition. Some had a homogeneous swollen ap- pearance (vitreous degeneration), and the sarcolemma had a jagged outline as if it were distended by its con- tents. In many places the muscle nuclei within the sar- colemma were increased in number, rounded, and only about a third the length of the normal nuclei. There was very great increase in the number of nuclei upon and around the sarcolemma. In a case of Erb’s juvenile atrophy the appearances were very similar to those just described, but not identi- cal. The blood-vessels did not seem to be changed, but there were broad bands of fibrous tissue, containing nu- merous nuclei, and here and there a few clumps of adi- pose cells, running between the muscular fibres. The latter were very scanty and presented a striking contrast in size. The majority were very large, but a consider- able proportion were much narrowed. Almost all had a vitreous appearance, but the strie were distinct. In not a few there was transverse fissuring, and rarely longi- tudinal fissuring. No dichotomous fibres were seen, but there were a few convoluted ones. The nuclei within the sarcolemma were slightly increased. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. In Schultze’s case, which also resembled Erb’s juve- nile form, the increase of connective and adipose tissue between the muscular fibres was comparatively slight. - Most of the latter were unchanged in size, but some were hypertrophied. There was increase of sarcolemma and muscle nuclei; the striz were preserved ; some of the hypertrophic fibres branched dichotomously. Schultze also observed a peculiar vacuolization of certain fibres. In some the vacuole included almost the whole width of the fibre, leaving only a small rim of muscle-tissue at the circumference. In others there were several vacu- oles in one fibre, with a delicate meshwork of muscle- tissue between them. In a case of atrophy with implication of the facial muscles (infantile progressive muscular atrophy), West- phal examined a piece of the left deltoid. He found simply hypertrophy of fibres (0.185-0.203 mm. wide, the normal width being 0.010-0.062 mm.), which otherwise looked normal ; there was also some increase in the num- ber of sarcolemma nuclei. Gowers believes that the apparent hypertrophy is the result of ‘‘a vital contraction excited by the process of excision.” This seems to be disproved by Schultze’s case, in which the hypertrophy was observed on post- mortem examination, and not after excision in the living subject. Hardly anything is known concerning the pathologi- cal anatomy of the peroneal type described in the section on Clinical history. Charcot and Marie suggest that it is the result of peripheral neuritis, and in three cases in- terstitial neuritis was really found on autopsy. It must be admitted, however, that our knowledge of this affec- tion is too imperfect to warrant us, for the present, in drawing any conclusions with regard to its pathology and pathological anatomy. Pathology.—Extreme views are entertained with re- gard to the pathology of the affections under considera- tion. Some pathologists look upon them as being purely myopathic, others are inclined to regard them as purely central in origin. The majority of writers, however, look upon some of them as myopathic, others as myelo- pathic. With regard to the pathology of bulbar paralysis, there can be very little doubt. It was long supposed, in accordance with the teachings of Duchenne, that this disease differs essentially from the progressive muscular atrophy usually regarded as spinal in origin, in the fact that the paralysis and atrophy of the muscles do not go hand in hand, the former being usually far advanced before the latter is appreciable. This statement is not in accordance with the facts, and the apparent discrep- ancy arises from the frequent difficulty of detecting atrophy in the affected parts. In more than one case I have remarked the failure of good observers to de- tect atrophy of the orbicularis oris in progressive bulbar paralysis, although this becomes evident at once as soon as the lips are grasped between the fingers, and the thickness of the muscular tissue is compared with that in healthy individuals. In the tongue the atrophy is usually evident from a very early period in the disease. In all other respects this disease runs the same course as myelopathic progres- sive muscular atrophy, and the frequent combination of lateral sclerosis with one or both of the above-mentioned diseases points to the intimate relations between these three affections. Indeed, it seems very probable that they all are the result of one underlying cause, which, for some unknown reason, attacks only the motor sys- tem (one case of amyotrophic lateral sclerosis has been reported, in which not alone were the pyramid tracts in- volved in their entire course through the brain, but also the ganglion-cells of the motor cortical zone), and that, as the localization of the lesion takes plaee in one or the other locality, we shall find the symptoms of bulbar paral- ysis, progressive muscular atrophy, or amyotrophic later- al sclerosis. The histological appearances of the paralyzed muscles also furnish a strong argument for the nervous origin of bulbar paralysis. Although our knowledge of the mor- Spinal Cord, Spinal Cord, bid anatomy of the muscles in the various muscular atrophies is still imperfect, nevertheless I think I am warranted in saying that the morbid appearances in those forms which are undoubtedly myopathic, are very dif- ferent from those observed in paralyses of undoubted spinal origin, for example, acute anterior poliomyelitis ; and also from those found in bulbar paralysis and the so-called spinal progressive muscular atrophy. The con- stant occurrence of the degeneration reaction is another important point in favor of the nervous origin of the dis- ease. As we have seen in thie section on clinical history, this is exceedingly rare in the various forms of myo- pathy, and has been observed hitherto only in lesions of cae pele! nerves or the anterior horns of the spinal cord. The theory of the other school proves too much. If the spinal lesions, as is claimed, are secondary to the dis- ease of the muscular system, there is no apparent reason why advanced stages of the latter should not always give rise to lesions of the cord. That this is not true is proven by numerous cases in which the central nervous system was found intact., This very fact seems to me to prove that the myopathic theory is insufficient for all cases, The frequent combination of bulbar paralysis with pro- gressive muscular atrophy points to the similarity of the two affections. Moreover, the clinical history is practi- cally the same if we take into consideration the vital im- portance of the parts affected. In addition to the fact that the anterior horns of the spinal cord have been found diseased in pure cases of progressive muscular atrophy, we have the further fact that the symptoms of the disease are also observed in other affections of the spinal cord which extend to the anterior horns (deutero- pathic). We are therefore forced to the conclusion that bulbar paralysis and progressive muscular atrophy are due to primary lesions of the motor cells in the medulla oblon- gata and anterior horns of the spinal cord, respectively. The lesion in question is apparently of the nature of a simple atrophic degeneration, but some pathologists. re- gard it as inflammatory initsnature. We possess insuffi- cient data to decide this question, although I think the weight of evidence is in favor of the former view. On the other hand, there are undoubted cases of pri- mary myopathic disease, such as pseudo-hypertrophic paralysis and its allied affections, and it seems as if these latter diseases were more frequent than was formerly supposed. Many cases which were regarded as central in origin are now placed in the category of myopathic affections. But what the nature of the muscular lesion is 1 am unable to state. The theory of its inflamma- tory character does not seem to be in accordance with the pathological appearances. Nor is there, in my opin- ion, any satisfactory foundation for the theory that the changes in the muscular fibres are the result of com- pression, due to primary increase of the interstitial con- nective and adipose tissue. We may merely beg the question by saying that the disease is the result of a trophic disturbance in the muscular substance itself, re- sulting from a congenital or acquired anomaly of nutri- tion in the muscular system, and which probably gives rise secondarily to the changes which are observed in the interstitial tissue. We are also entirely in the dark with regard to the differences in the localization of the affection. It must be left to future investigations to de- cide whether these variations are the result of vital dif- ferences in etiology, or whether they are different forms of one disease. The prevailing opinion, at the present time, is very decidedly toward this latter theory. The nature of the lesion in the ‘‘ peroneal type” of muscular atrophy must be left for future investigations. We may say, however, that the strong hereditary, ele- ment and the clinical history seem to indicate a periphe- ral, rather than a central, origin. Diagnosis,—We will first consider the differential diag- nosis of spinal progressive muscularatrophy from atrophy of myopathic origin. The occurrence of fibrillary contractions is an impor- 581 Spinal Cord. Spinal Cord. tant sign. This symptom is quite constant in myelo- pathic atrophies, and until very recently it was supposed never to occur in the myopathic affections. We now know, however, that it is observed in rare cases of the latter. In myopathies, however, the symptom is not a prominent one, and does not appear to be of long dura- tion. The electrical reactions of the paralyzed muscles fur- nish another differential sign. As a rule, complete or partial (usually the latter) degeneration reaction is ob- served in myelopathic atrophy, even at an early stage of the disease. As we have pointed out in the remarks on symptomatology, this symptom may be elicited with dif- ficulty when the healthy fibres in a muscle predominate over the atrophic ones ; and if the latter are very scanty in proportion to the others, even the most careful exam- ination may not disclose any change. In myopathic atrophies, on the other hand, simple diminution of excit- ability to both currents is the almost invariable rule, al- though recent observations have shown that partial de- generation reaction is present in some cases. As a general thing, the diagnosis can be made from the manner in which the disease spreads from one part of the body to the other. Myelopathic progressive muscu- lar atrophy begins almost invariably in the small muscles of the hand or in the shoulders, and then spreads to the muscles of the arms and trunk. In the myopathies, the small muscles of the hand are hardly ever attacked, even after the disease has lasted a Jong time and made great advances in other parts of the body. Furthermore, spinal progressive muscular atrophy usually attacks one muscle after another in such a way that we can follow its course, while the myopathic forms attack whole groups of mus- cles at apparently the same time. For example, the for- mer disease will attack one interosseous muscle after another, then successive muscles of the thenar and hy- pothenar eminences, next the muscles of the arms, etc. But in the myopathic forms, for example in pseudo- hypertrophic paralysis, the patient will be found suffer- ing, at the beginning of the disease, from weakness of al- most all the muscles of the lower limbs and back, though some are affected more severely than others. Heredity as an etiological factor is found almost ex- clusively in the myopathies, so that the occurrence of muscular wasting in more than one member of the same family is a strong argument in favor of its myopathic origin. The latter diagnosis is favored in an equal meas- ure by the occurrence of the disease in childhood or _ youth. Finally, the microscopical examination of excised por- tions of the affected muscles may throw some light on the diagnosis. In wasting of central origin, the muscle usually presents, at least for a long time, the evidences of simple degenerative atrophy ; in myopathies hyper- trophy of fibres is found in almost all cases, the trans- verse and longitudinal striation is usually quite well pre- served, and interstitial changes are found at an early period. In conclusion, it may be said that, while a careful examination of all the facts will generally enable us to decide between the muscular or central origin of the dis- ease, in some the doubts can only be dissipated by post- mortem examination. A few words with regard to the differentiation of spinal progressive muscular atrophy from other diseases of the nervous system. At the onset of the malady the diagnosis of lead palsy is sometimes excluded with difficulty. The latter may begin apparently in the interossei and, in exceptional cases, the muscles of the thenar and hypothenar emi- nences undergo early atrophy. As a rule, however, the supinator longus escapes on the extensor side of the fore- arm, and the flexors remain normal, or approximately so. But if we remember that the wasting of lead palsy may also extend to the muscles of the arm and shoulder—in- deed, sometimes tothe lower limbs—and that DeR is pres- ent, it is evident that mistakes may arise. A case is at pres- ent under the writer’s observation in which the interossei, thenar, and hypothenar eminences were first attacked, 582 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. and for some time it was regarded as probably a case of progressive muscular atrophy. The patient has no blue line on the gums, no mode in which lead could have entered the system can be discovered, and chemical ex- amination of the urine for lead was attended with nega- tive results. The diagnosis of lead palsy was made on account of the previous occurrence of abdominal colic (without any ascertainable cause), the paralysis of the extensors without implication of the flexors, the com- plete DeR at an early period, and the comparative rapid- ity of improvement under treatment. In this case, as in a number of other undoubted cases of lead palsy, the supinator longus is also paretic, though not to such a marked degree as the extensors, Deuteropathic progressive muscular atrophy, 7.e., that form of disease in which the atrophy results’ from the extension of a lesion in other parts of the spinal cord to the anterior gray columns, is distinguished from the pro- topathic variety by the presence of the symptoms of the primary disease (pains, ansesthesia, occurrence of paraly- sis before the development of atrophy, interference with the functions of the bladder and rectum, etc.). After the diagnosis of myopathy has been made, the special variety is recognized by the localization of the wasting and hypertrophy of the muscles, and the course of the disease as described in the section on clinical his- tory. A large number of cases, however, constitute transitions between the different types there mentioned, and cannot be definitely relegated to any special class. Prognosis.—Complete restoration of parts which have undergone wasting or hypertrophy never seems to occur. In all cases, the chance that the disease will not shorten life is so much greater, the later the period at which the disease begins. When this takes place in adult life, the patient may live to an advanced age, unless carried off by an intercurrent disease. It must always be remem- bered, however, that diseases of the respiratory organs are a special source of danger in myopathies, on account of the frequent implication of the respiratory and abdom- inal muscles. In pseudo-hypertrophic paralysis the lease of life is usually shorter than in the other varieties, but even here the disease may come to an apparent standstill for years. More rapid progress is often made after the patient is permanently confined to bed. Treatment. — Pseudo-hypertrophic paralysis does not seem to be influenced by treatment. Massage and elec- tricity have been recommended. Benedikt claims to have cured five cases by galvanization of the sympathetic, but his statements should be received with a great deal of caution. Uhde and Gowers have derived benefit from cutting the tendo Achillis when walking is prevented by contracture of the calf muscles. Duchenne reports two cases in which the disease was arrested by prolonged fara- dization of the muscles. . Better results seem to have been obtained by faradiza- tion and galvanization of the muscles in the other forms of myopathy, notably in Erb’s juvenile form. Leopold Putzel. SPINAL CORD DISEASES: SPINAL HEMIPLEGIA. Synonym: Brown-Séquard’s Spinal Paralysis.—Spinal hemiplegia is the name, not of a disease, but of a group of symptoms, produced by unilateral lesions of the cord. Such lesions are in part of traumatic origin, such as gunshot wounds, or wounds with sharp instruments, resulting in partial destruction or section of one-half of the cord, the injury being limited to that side; in part the result of disease, as compression of one-half of the cord by a tumor, or blood-clot, circumscribed sclerosis, etc. Similar manifestations have been produced by ex- perimental hemi-section of the cord in animals, especially at the hands of Brown-Séquard. It was the latter who first drew a clear picture of spinal hemiplegia, based partly upon his experiments, partly upon the analysis of reported clinical cases. Both the clinical picture and the physi- ological conclusions drawn from it, though often looked upon with distrust, are now pretty generally accepted. Yet, future modifications of the physiological views are REFERENCE HANDBOOK OF Spinal Cord. THE MEDICAL SCIENCES. Spinal Cord. not improbable. This is more likely to be true of the paths of the sensory fibres, the study of which has al- ways met with great difficulties, than of the motor fibres, whose course seems to be pretty definitely determined. Modifications are the more probable, because the lesions of the cord upon which physiological views are based— experiments on animals are not now referred to, because their results are not always directly applicable to man— have rarely the precision necessary for exact conclusions, and observations in different cases have been, to some extent, at variance with one another. The most prominent symptom is motor paralysis of only the lower, or of both lower and upper extremities, according to the location of the lesion. It is on the side of the lesion, though there is also, at times, slight pare- sis of the other side. There is often a temporary vaso- motor paralysis on the side of the lesion, indicated by a rise of temperature of the paralyzed limb. There is at the same time sensory paralysis—anesthesia—of the oppo- site side of the body, while there is heightened sensibility —hyperesthesia—on the side of the lesion. But this is only true of certain kinds of sensibility—that to touch, pain, temperature, etc.—while the muscular sense is abol- ished on the side of the lesion. The physiological deductions from these clinical data are as follows: The motor fibres run in the cord on the same side as are the muscles supplied by them. They cross to the other side in the medulla oblongata. The slight paresis sometimes found on the other side is per- haps due to a small number of the motor fibres decus- sating with those of the opposite side in their passage through the cord, or, perhaps, each cerebral hemisphere is, to a certain extent, related to both sides of the body. The sensory fibres pertaining to muscular sense also run through the cord on the same side, while all the other sensory fibres, very soon after their entrance into the posterior roots, decussate with those of the other side and run to the brain in the opposite side of the cord. Brown- Séquard believes that there are different nerve-fibres for the different kinds of sensibility—touch, temperature, pain, ete.—and that they lie in different parts of the cord ; for there may be loss of one kind of sensibility and not of others, or one may be affected to a greater extent than the others. If this be true, those of pain and tempera- ture are most nearly related, for they are usually affected to about the same degree. The symptoms thus far given are those of severance or destruction of the nerve-strands in the cord. But there may be further symptoms dependent on injury of nerve- cells in the cord, or of the nerve-roots, or due to second- ary degenerations. Destruction of the large ganglion- cells causes muscular atrophy. This atrophy is found in the muscles innervated from the level of the lesion. Destruction of the anterior nerve-roots also causes muscu- lar atrophy ; destruction of the posterior roots, aneesthe- sia. The latter is always on the side of the lesion. Therefore, on the side of motor paralysis the hyperes- thesia is limited above by an anesthetic border. Second- ary degeneration of the lateral columns below the seat of lesion causes muscular rigidity, exaggerated tendon re- flexes, etc., in the parts affected by motor paralysis. * In some instances temporary paralysis of the bladder and rectum was observed. Rarer occurrences were acute decubitus on the side of sensory, and inflammation of the knee-joint on the side of motor, paralysis. — After disap- pearance of paralysis of the lower extremity ataxia has been observed, probably due to injury of the posterior column. Philip Zenner. SPINAL CORD DISEASES: SPINAL IRRITATION. INTRODUCTION AND DEFINITION.—A]though the complex of symptoms described by older authors under the name of Spinal Irritation has no pathological anatomy beyond the very probable one assigned to it by Hammond, of anemia of the posterior columns of the spinal cord, the affection is, nevertheless, of sufficient importance, and is frequently enough met with, to deserve to be retained in the more recent nosology of nervous diseases. It is an affection characterized by acute pain in the spinal region, always increased by pressure over the spinous processes, and is associated with various disturbances of sensibility along the course of the spinal nerves, arising from the affected region, and with certain visceral functional de- rangements ; the motor nerves are also affected, but in a lesser degree. Spinal irritation is most frequently found in women between the ages of fifteen and thirty-five years. These subjects frequently present symptoms of hysteria, but the affection is often enough observed independently of the latter malady, and is occasionally seen in men, so that its distinct identity cannot be seriously doubted by anyone with moderate experience. ErroLocy.—Among the predisposing causes of spinal irritation, sex comes first in order. As already men- tioned, women are peculiarly liable to this affection, and those who show greater tendency to hysteria are more frequently attacked, but at times even the most phleg- matic become victims to it, and men arenotexempt. This disease is most frequently seen between the ages of fif- teen and thirty-five years, and therefore young adult life would seem to predispose to it ; but it occasionally occurs at a later period, and even in old age, and it has been ob- served, though rarely, in childhood. The hysterical temperament, even in those who have never had any dis- tinct hysterical attacks, must be considered as an efficient predisposing cause. Also, heredity plays an important role, the disease being very often met with in members of a neurotic family. In a number of cases the disease cannot be traced to any special cause. Anything that weakens or excites the nervous system may act as an ex- citing cause ; such are strong emotions, violent passions, grief, fright, care, love, anxiety, mental over-exertion, etc. ; also violent bodily exercises, excessive watching or working at night, forced marches, strains, falls, or blows on the back, insufficient physical exercise, abuses in venery, onanism, excess in the use of alcohol or tobacco, frequent ungratified sexual desires, bad food, and ex- hausting diseases, such as typhoid, malarial, and scarlet fevers, dysentery, diphtheria, ete. Formerly affections of peripheral organs were credited with bringing on the disease in a number of cases, but this is no longer thought of. Symproms.—The development of the disease is usually | gradual, the first symptom being a slight feeling of dis- comfort, scarcely amounting to pain, somewhere over the spine, more generally in the dorsal region and be- tween the scapule. This is at first felt only after un- usual fatigue or exertion, but very soon becomes constant and amounts to severe pain. This pain varies consider- ably in intensity at different times and in different pa- tients, and it is described as a sharp, burning, boring, or lancinating pain ; it is always increased by pressure on the spinous processes of the vertebrae; occasionally the skin in the region of the pain is very hyperesthetic, and contact with the clothing even is insupportable ; at other times the pain in the back is so slight as to escape the patient’s attention, who complains only of the excentric symptoms to be presently mentioned, and the pain is ex- cited only by pressure over the spine. The location of the pain varies much in different patients, and in the same patient at different times ; its most usual seat is the dorsal region, between the shoulder-blades, and the next most common locations are in the back of the neck, and, less frequently, in the loins; occasionally it is felt over the whole spine. Hammond, and others after him, de- scribe a deep-seated pain over the other vertebre, which is increased by pressure or movements of the spine. Besides this pain, and more noticeable to the patient, are a number of excentric symptoms, more or less referable to disturbances of sensibility and of the func- tions of the vegetative organs, but also affecting, though to a lesser extent, the motor apparatus. The symptoms vary according as the pain in the back affects different portions of the spine. When the cervical spine is com- plained of we have neuralgic pains, and various pares- thesia, such as tingling, formication, and a feeling of heat or cold in the neck, chest, and upper extremities ; at times vertigo, headache, noises in the ear, disturbances 583 Spinal Cord. Spinal Cord. of vision, fulness and a sense of constriction across the forehead, and tenderness of the scalp, especially in the occipital region. In some cases distinct disturbances of the functions of the mind, sleeplessness, etc., also nausea, vomiting, hiccough, palpitation, and pain in the stomach, fibrillary twitchings or stiffness, clonic or tonic contrac- tions, or more or less violent choreic movements of the muscles of the arms and neck, and occasionally loss of power in the upper extremities. These symptoms are, of course, only in part present in each case, and vary con- siderably in intensity in different cases, When the dorsal portion of the spine is complained of we have, besides pain and tenderness in that region, intercostal neuralgia, infra-emammary pain, gastralgia, nausea and vomiting, dyspepsia, gastric flatulence and acidity, heartburn, palpitations, and attacks of syncope, and some slight disturbances in the sensibility or motility of the lower extremities. — When the lumbar portion is affected the symptoms are tenderness in the lumbar spine, neuralgic pains, with for- mication and other paresthesiz round the abdomen and down the lower extremities, cold feet, at times spasm of the neck of the bladder giving rise to retention or incon- tinence of urine, costiveness, and pain in the rectum, uterus, and ovaries ; also at times weakness of the lower extremities, or contractures, spasms, or clonic movements in the same. When the whole spine is affected we have more or less a combination of the above, the symptoms being the most prominent in those regions which are supplied by the nerves arising from the cord at the point of the great- est spinal tenderness. The symptoms of spinal irritation are, as a rule, alle- viated by rest in a horizontal position. CouRSsE AND Duration.—The course of the disease can be inferred, from what has been already said, to be very fluctuating, improvement and relapses alternating in quick succession without any apparent cause, the chief symptoms sometimes rapidly changing and affect- ing different regions of the spine and body. Its course is in some Cases very acute, the disease developing rapid- ly and terminating in the same manner. In most cases, however, it runs a chronic course, developing slowly, and is equally as siow in improving, lasting months, or even years, under the most efficient management. Some patients suffer more or less all their lives from some form or other of the affection. As a rule, however, a cure may be promised as a result of proper medical and hy- gienic treatment. The question, ‘‘Can the disease lead to some more dangerous spinal affection ?” may with safety, I be- lieve, be answered in the negative, if we take into ac- count the views of the more recent authors, who certainly have had better opportunities to study the disease, and who have not confounded it, as older authorities occa- sionally did, with organic affections. As to the true nature of the affection, nothing is posi- tively known; numerous hypotheses have been advanced to explain it, but none is absolutely proven. Some au- thorities claim that it is due to hyperemia of the cord, while others, with Hammond, and I believe with some reason, assert that it is due to anemia of that organ. CasE I.—C. B , white, female, aged thirty-one ; has been married two years, has one child living, does not belong to a neurotic family, gives no history of hysteria or any other nervous disease. She is a housemaid, but is much above her class in education, and is quite refined in manners, and evidently has seen better days. About a year before her application to me for treatment, the initial symptoms of her affection began to show them- selves. After a period of prolonged grief she began to be troubled with an uneasy, painful feeling in the spine, about the upper dorsal region, after every severe exertion ; this feeling soon became continuous, and was increased whenever she was accidentally touched on her back at that part of the spine; she was always easy at night, or when lying down. With the increase in sever- ity of the pain she was also troubled with attacks of breathlessness and palpitation, and had a constant sharp 584 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. stitch in the infra-emammary region on the left side. Her appetite soon began to fail, and she was greatly troubled with nausea and occasional vomiting ; her head, she said, was not quite right, and she was troubled with some dizzi- ness; she felt weak in the legs, and had feelings as of ants crawling between the skin and flesh of the lower limbs. She remained pretty much in that condition, one day feeling badly and the other better, for about six months, when she was forced to relinquish work and went to consult a physician, who treated her several weeks for dyspepsia, but with no relief. She became almost bed- ridden at that time, and, after changing several medical advisers, sent for me in December, 1884. I found the patient in nearly the condition described, though very much weaker and considerably emaciated ; she remained . altogether indoors, getting up from bed two or three times during the day, and only for a few minutes ata time. She felt well only while in the supine posture ; her only nourishment consisted of two or three cupfuls of milk and weak beef-tea. I had no difficulty in im- mediately recognizing in her affection spinal irritation. I prescribed first a little whiskey and milk-punch at fre- quent intervals, day and night; this she retained with comfort. I then ordered a more generous diet, and gave internally one-sixtieth grain of strychnine three times a day, progressively increasing the dose, and the compound syrup of hypophosphites ; I also began electrical applica- tions, using the galvanic battery, and applied ascending and descending currents to the spine for from five to ten minutes every day. Ina month’s time the patient was so much benefited that she was able to come to my office, and in a few weeks more I discharged her cured. I meet this patient at frequent intervals, and she has had no return of her affection. Case II.—In the summer of 1883 I was called in con- sultation by Dr. Bemiss, to see one of his patients in Ward 18 of the Charity Hospital. A. R , aged nine- teen, white, male, born in New Orleans, had had ma- larial fever of an intermittent type for some weeks. When examined he had been free from fever for some days, but he complained of exquisite pain on pressure over the lower dorsal vertebre, with great weakness, pain, and numbness in the lower extremities ; he felt compara- tively at ease when lying down, but could scarcely stand on his legs; he had no gastric trouble, but had some difficulty in voiding his urine and was costive. The case was pronounced one of spinal irritation, and the patient, being put on progressively increasing doses of sulphate of strychnine, with a generous diet and free stimulation, made a rapid recovery. In searching over the patient’s history no tendency to neurotic affections could be detected, and the malarial fever was evidently the sole cause of the spinal irritation in his case. Case III.—M. B , white, female, aged twenty-six, who has had one child, is highly nervous, but has never had any hysterical attack ; gives a history of spinal irrita- tion affecting the upper dorsal region four years ago, . lasting several months, and being followed by complete recovery. She was admitted to Charity Hospital medi- cal service in the early part of 1886, where she remained several months ; she was then transferred to the gyneco- logical ward, and was operated on for lacerated cervix uteri with success, but with no improvement in her gen- eral condition. In October, 1886, she was transferred to my service, presenting the following symptoms: Great tenderness over the lumbar spine, great pain and tender- ness in the lower part of the abdomen and the lower ex- tremities, inability to stand from weakness of the legs, retention of urine of several months’ duration from spasm of the sphincter of the bladder, amenorrhcea of four months’ standing, and costiveness. The muscles of the paralyzed parts were stiffened but well nourished, and responded normally to irritation. Treatment for spinal irritation. The patient was discharged, cured, two months after admission. DraGenosis.—Spinal irritation, when fully developed, with all its regular complex of symptoms, is not difficult to recognize. In forming a diagnosis the principal points REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Spinal Cord. Spinal Cord. to be relied on are: The presence of pain in the back, developed or increased by pressure over the whole or part of the spine; excentric symptoms, affecting chiefly sensibility, but to a slighter extent the motility also, of parts of the body receiving their nerve-supply from the affected portion of the cord, and various visceral disturb- ances already mentioned; the changeable character of the symptoms and the fluctuations in the course of the disease ; and finally, the want of proportion between the severity of the subjective and the mildness of the objec- jective symptoms. The diseases with which it is more likely to be con- founded are: The earlier stage of myelitis and spinal meningitis; spinal hyperemia, hysteria, and_ spinal neurasthenia. In myelitis we have absence of hyperesthesia and ten- derness, except on deep pressure over the spine; severe paralysis of sensation and motion in the extremities, and complete visceral paralysis; painful contractures and spasms, the absence of the nervous condition found in spinal irritation, and generally a fatal termination. Meningitis spinalis is more difficult of differentiation ; stiffness and painful contraction of the muscles of the back, pain in the spine, increased by motion, but not affected by pressure, with absence of tenderness in the part, the presence of fever, late paralysis, etc., will, as a rule, however, be sufficient to enable us to establish the diagnosis of meningitis. Hyperemia of the cord is still more difficult to dis- tinguish from spinal irritation ; indeed, some authors claim, as stated above, that the symptoms of the latter disease are due to a congested condition of the spinal marrow. The general absence of tenderness or pain in the spinal region, and the fact that the symptoms are aggravated by the recumbent position on the back, are characteristics of importance in spinal hyperemia, and will generally suffice to distinguish it from irritation. ‘Hammond proposes as a test between these affections the relief given in hyperemia and organic spinal diseases by the administration of ergot, while spinal irritation is made worse by the drug; and, on the other hand, the marked improvement in the symptoms of the latter affec- tion caused by the use of strychnine, and the aggravation of spinal hyperzemia and the other diseases by the exhibi- tion of this drug. The characteristic globus, general spasms, and other symptoms of hysteria will suffice to establish a diagnosis between this affection and spinal irritation, though it must be remembered that the two are frequently found associated. Neurasthenia spinalis, though resembling the disease under consideration, will be recognized by the fact that it is usually found in the male sex, by the absence of ex- treme spinal tenderness, and by the general preponder- ance of motor symptoms over those referring to sensi- bility. The two diseases have, however, an undeniable general resemblance. Angular curvature of the spine from vertebral caries is not likely to be confounded with spinal irritation, and its characteristic symptoms need not be referred to here. Proaenosis.—The prognosis is in general favorable, the majority of cases being cured, and a large number of the others benefited by judicious treatment. In a minority of cases improvement is, however, very slow, and at times imperceptible, and in others relapses are very frequent. Death has never been known to be caused by this affec- tion, but some of the patients are doomed to a tedious illness, lasting perhaps for years. i TREATMENT.—The main treatment in spinal irritation should be directed to the removal of the cause of the af- fection, and to the improvement of the tone of the gen- eral nervous system and of the spinal cord in particular. It will suffice for us to refer our readers to the causes already mentioned to see how best they may be re- moved. To obtain the second object, hygienic and me- dicinal means are to be employed, such as a generous diet with plenty of wine and other stimulants, passive and active exercise for short intervals in the open air, the keeping of the recumbent posture for the greater part of the time, etc. The judicious use of certain drugs presently to be mentioned, and of electricity, is also nec- essary. Cupping and blood-letting are scarcely ever indicated ; - counter-irritation to the spine by means of blisters, tar- tar-emetic ointment, or iodine, is of great use; hot ap- plications to the back, or the use of the ascending gal- vanic currents with the two poles on the spine, one above and the other below the tender part, are recom- mended by Hammond as of great service in diminishing the tenderness. Of the drugs themselves strychnine, in progressively increasing doses, is very useful; the phosphide of zinc in one-tenth grain doses three times a day, phosphorus, and phosphoric acid, are also of service. Opium, the bro- mides, and chloral are sometimes indicated, and general faradization with central galvanization is also recom- mended. Mountain- and forest-air is to be advised. Cold-water baths have proved beneficial in some cases. AUTHORITIES CONSULTED. Ross: Diseases of the Nervous System, ‘vol. ii. Rosenthal: Diseases of the Nervous System. Haase, K. E.: Krankheiten des Nervensystems (being vol. iv., part i., of Virchow’s Handbuch der speciellen Pathologie und Therapie). Charcot: Le¢ons sur les Maladies du Systeme nerveux. Grasset, J.: Maladies du Systéme nerveux, 8d edition. Erb: Article in Ziemssen’s Cyclopedia of Medicine, vol. xiii. Bramwell, Byrom: Diseases of the Spinal Cord. Radcliffe, C. B., in Reynolds’s System of Medicine, vol. i. Ollivier: Maladies de la Moélle épinicre. ; P. H. Archinard. SPINAL CORD DISEASES: TABES_ SPINALIS. This term is applied rather vaguely to all forms of spi- nal disease attended by slow wasting of the substance of the cord, but of the posterior column especially. I think it is better than ‘‘ locomotor ataxia,” which is the term in popular use, or ‘‘tabes dorsalis,” which just now it is the fashion to apply to cases of locomotor ataxia when there are only a few or no motor disorders. ‘‘Locomotor ataxia” is simply a clinical appellation, and its symptoms are not necessarily due to posterior column disturbances, but to lemniscal lesions, alcoholic neuritis, or other conditions. There is still a condition which is denominated ‘‘ ataxic paraplegia,” which is, af- ter all, a hybrid disease. ‘Tabes spinalis may be said to be an affection confined for the most part to the posterior column of the spinal cord, and attended by abolition or impairment of centripetal transmission and the irritation of the posterior nerve-roots, with varying sensory derange- ments, abased or increased tendinous reflex activity, mo- tor inco-ordination, optic-nerve atrophy, and frequently various evidences of derangements of the sympathetic nervous system. Although Todd directed attention to a variety of symp- toms which are now recognized as those of the disorder, it is to Romberg! that the credit belongs of first accurately describing the disease under the name of tabes dorsalis, and who, presented an autopsy made by Froriep in which degeneration of the posterior parts of the cord was found. In 1868-78, Duchenne de Boulogne revived in- terest in the subject by an elaborate and advanced con- sideration of the subject, and about the same time Trous- seau, Charcot, Pierret, and other writers in France, and Westphal in Germany, added much to the literature, espe- cially of the morbid anatomy. In Charcot’s early work he established the existence of trophic changes, both os- seous and dermal, and very little has been since added to his description of the arthropathies. In England Russel Reynolds was among the first to consider locomotor ataxia, objecting. to the prefix ‘‘ pro- gressive,” which had been applied by Duchenne, and latter- ly Buzzard and Gowers have written well and extensively. In 1870-75 American writers, including Hammond, Cly- mer, Seguin, and myself, described the affection and pre- sented cases. The disease is one of a chronic and progressive nature, and while there are rare exceptions to this rule—espe- cially those of traumatic causation—the greater number run a prolonged course marked by three stages: 1, The 585 Spinal Cord. Spinal Cord. prodromal, or pre-ataxic of some authors ; 2, the developed, or ataxic ; 8, the degenerative, or stage of decline. ‘There are irregular varieties, one of which is known as the /e- reditary, or family, in which the subjects are young echil- dren, and there is a family history ; and Obersteiner and others have considered an ascending form which event- ually has a cerebral extension, and is expressed by symp- toms of mental disorder. There is also a form described by Fournier as sclérose cérébro-spinale postérieure, which is so irregular as to lead me to divide all cases of the dis- ease into the syphilitic and non-syphilitic, the former, as it will be seen later on, being largely in the majority. ErroLtoay.—It was the generally entertained belief, un- til within a few years, that locomotor ataxia was due in nearly all instances to sexual excesses, an impression which probably grew out of the fact that most of these patients were syphilitic, and many syphilitic patients were amorous free lances. The real nature of the syphi- litic causation was lost sight of until ten or twelve years ago, when Erb ‘and others brought forward most aston- ishing statistics. The conclusions of the first author are very extreme, and he holds that ninety per cent. of all patients have a history of specific disease. In Germany and elsewhere he has many supporters, but there are a few men of temperate diagnostic zeal who reduce the proportion of syphilitic cases. Seguin has been unable to find more than twenty per cent.* My own experience leads me to the conclusion that there are two classes of cases which possess some common characteristics, but which are very dissimilar in some ways. In one of these syphilis plays an active part, in the other there is no veritable specific history ascertaina- ble. If we group these cases together a very high percent- age of syphilitic cases is to be found, but the ratio of the hybrid cases,t in which syphilis is undisputed, is great to those of regular type and conventional progress. Of this class it is probable that fully ninety per cent. are syphilitic. Of what may be called the fixed-type class, there is not more than twenty per cent., or even less, where a reliable history of syphilis is to be found. Locomoror ATAXIA OF IRREGU- | LOCOMOTOR ATAXIA OF REGULAR LAR TYPE (SYPHILITIC). TYPE (RARELY SYPHILITIC), Of rapid progress; prodromal Of slow progress ; first stage of- stage short: ocular symptoms early | ten long—ten or twelve years; Ar- and diversified ; tendon reflex usu- | gyle- Robertson symptom; pains ally returns and is exaggerated, or | and absent reflexes almost only early is exaggerated from injury; mental | ocular symptom ; slow white atro- symptoms marked ; optic neuritis; | phy; ataxia of slow origin and bi- choked disk; ataxia irregular; pos- | lateral; plantar anzesthesia usually sible extension to ‘‘ general pare- | well distributed; mental defects sis;” aneesthesia often irregular, rare; arthropathies common. Arthropathies uncommon. The Rarely helped by iodide of potas- young subjects with local cranial | sium. paralysis complicated with ataxic | symptoms are usually syphilitic. Buzzard calls attention to the error one may fall into by impulsively choosing syphilis as a cause, when the pains and early symptoms may have preceded the syphilis for some years. I have borne this in mind in the examina- tion of every case, and can support his views most em- phatically.. So far as sexual excesses go, I believe that any method of cohabitation which implies repeated spinal shock and exhaustion, must invite the approach of dis- ease, and it is probable that forced and frequent connec- tion, especially when the pleasures of Bacchus and Venus are enjoyed simultaneously, may sometimes originate a spinal exhaustion which will soon terminate in sclerosis ; but thisisrare. The exceedingly fanciful ideas in regard to these causes entertained by the Germans are sometimes very laughable and improbable, and one writer in Ziems- sen gravely alludes to the perils of coition in the erect posture, while another finds that twelve of his cases were addicted to the habit of cottus reservatus, a method which in this country, I believe, is common only in the Oneida community. Sudden exposure to damp and cold, for which the per- * Buzzard, while admitting that his notes are imperfect, found that 25 of 53 cases had a syphilitic history. Of Fournier and Erb's 127 cases, 59.8 per cent. were syphilitic. The average percentage of five American au- thors was 41.4. + Many of them cases of ataxic paraplegia. 586 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. son is unprepared, is quite likely to cause the disease. As instances I may mention patients who fell overboard or who stood in wet places while shooting. One patient left his warm bed and descended into his yard to chase burglars, without taking the precaution of putting on shoes or slippers. ‘Traumatic cases of the malady are by no means unusual, though the exact manner in which injury gives rise to the disease is a matter of doubt. In making this assertion I leave out of question the cases of actual local vertebral violence, and the production of spinal bone lesions, and possibly meningitis confined chiefly to the posterior part of the cord. Railway con- cussion has resulted in a manifestation of symptoms in- dicative of locomotor ataxia. It is not of these cases I speak, however, for the morbid expressions are usually diverse. The traumatic scleroses are those, strange to say, where the rapid appearance of symptoms of pos- terior column disturbance has followed fracture of one of the long bones. I have seen several such cases. Hereditary cases are of a distinct type, and I am con- vinced are not purely localizable posterior sclerosis. I feel sure that the real cause of such congenital disease is often a syringo- or hydro-myelia, the cavity occupying the posterior half of the cord. Tabes is rarely found in women, and I can recall but a dozen personal cases of several hundred I have seen during the past twenty years, and four of these were syphilitic subjects. But two of these patients were class- ical cases, and the symptoms were due to lesions limited to the posterior root-zones of the spinal cord. Of Eulen- berg’s 149 cases, 128 were males and 21 females. The experience of other authors is my own. As to age we find that, except in rare instances, the disease seldom at- tacks individuals under twenty. Leyden fixes the limit as between the twenty-fifth to forty-fifth years. Of Eulenberg’s cases, to which allusion has just been made, the ages of invasion were : Male. Female. Belowijl0:: Prat eee oe eee 1 LO to 205th, as eae Sec eae 2 0) BO 40! SOF Oe, Oh Pe ee, Bax TaD 12 30 to 40 Le Pie oe Lee eee 39 v's 40 TOO, Poa es Pee eer oe 47 1 50 TOGO ae ee. we Cee 5 0 Over 00;7/amaa Fee ea eee eee 0 0 Symproms.—The prodromal symptoms of tabes are vague and irregular, but, like the early indications of so many serious nervous diseases, are mostly sensory. For a long time the early advances of the malady may be dis- regarded by the patient or his friends, and the pain as- cribed to several causes. Many ataxics are regarded in the beginning as hypochondriacs, even by competent medical men, and sometimes a careful examination will fail to reveal anything positive ; for while the two earliest positive indications—the Argyle-Robertson pupil and the absent tendon reflex—are to be determined in the majority of cases at a time when nothing else is manifested, there are many exceptional cases where the ocular symptom is not present, and where it is possible to evoke a patellar ten- dinous reflex by proper excitation. In the ordinary cases the patient complains at a very early period of fatigue and uneasiness in the lower extremities, and some per- sons have likened the sense of tingling and fatigue to that which follows a long walk. The muscles at the back of the thighs and legs are tired and sore, and the ankles and knees are ‘‘ weak” and ache. Slight exer- tion produces discomfort, and after a while actual pain of a shifting character and some plantar formication. Mental feebleness is also manifested, sometimes the pa- tient being depressed or peevish, and hypochondriacal. He is annoyed, morbidly conscious of the attitude of his friends, and fearful of some impending disaster. Appe- tite and flesh are often reduced, and the bowels become sluggish. Some of my patients have complained of headaches, and these have been dull, lasting for several hours, and with subsidence there has been a free action of the kidneys, with the elimination of a large quantity of clear urine. The vision is more or less impaired, and REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. transient attacks of diplopia are annoying. undergoes a change in its susceptibility to light stimu- lation, which has been described by Argyle-Robertson. This consists in preservation of the ability of the eye to accommodate with, of course, normal contraction or dila- tation, but a failure of pupillary response to light stimu- lation ; and it has been found that, owing to the abolition of the skin pupillary reflex, no dilatation of the pupil follows the pinching of the neck, which is the case in the normal individual. This symptom is by no mfeans con- stant, but is a very common and suggestive indication. -In many cases we find even the pre-ataxic stage of the malady marked by disappearance of the patellar tendon reflex. The absence of the knee-jerk, which was first de- scribed by Westphal, may be determined best by mak- ing the patient sit upon a high table or desk, so that his thighs are well supported and his legs hang loosely at right angles. Then a smart blow may be struck with a ruler or small percussion hammer just below the patella, or to one side over the fibular head. No movement of extension may follow, though a light tap over the vastus » externus may evoke a well-marked contraction. The loss of the reflex may be unequal, that is, it may be pres- ent on one side and absent on the other. The other re- flexes of the lower extremities are apt to be lost or dimin- ished. Mitchell and a host of other observers have shown that the tendon reflex varies under different conditions. According to the latter, the action of the will in some other direction is apt to increase or conserve an appar- ently dormant reflex. This I have not been.able to verify. This bluntness of the reflex is quite apt to be found in other places, and the reflex functions of the bladder are deranged, with a resulting difficulty in voiding urine. Brissaud has devised a remarkably ingenious appara- tus, by which the force of the knee-jerk may be exactly measured. In some cases, even at a very early stage, the tendinous reflex will be increased. THE EsTABLISHED DIskASE.—After a variable siege of premonitory symptoms we come to the pre-ataxic stage, which is often of long duration, and is characterized by the advent of pain, the loss of the tendinous reflex, the occurrence of pupillary changes. The pains of the ataxic are peculiar and almost unique. They are paroxysmal, fugitive, and intense—and, like those of the uncompli- _ cated neuralgie, are greatly aggravated by change of barometric pressure. ‘I have kept the records of one pa- tient for several years, and in his case every easterly or southwesterly wind was preceded by an exacerbation of leg pain, which was as certain as the barometer. The pains more often have their seat in the thighs—usually the inner surface—but the tract of the great sciatic may be the chosen spot. With great suddenness a twinge of the most intense description. will affect a spot not much larger than a quarter. Light at first, it increases in gravity, and, after a few minutes or a few hours, sub- sides and attacks some other spot. The quality of the pain has been likened to the tearing of flesh, the intro- duction of red-hot needles, and to various methods of torture—and the names terebrating, needle, boring, stab- bing, have been applied, and fulgurating, lightning, with regard to their suddenness and violence. Sometimes the ankles or soles of the feet may be the seat of the painful spots, and I have often found the popliteal space to be the locality. In some cases the pains dart up and down the course of anerve. There is a second variety, which is dull and in some respects resembles.rheumatism ; with this there is pain on movement, and considerable inter- paroxysmal soreness. The pains of posterior spinal scle- rosis are by no means regular in their expression, for the patient may have them on one side or on both, and with varying degrees of severity. Subjective coldness of the limbs is common, and with the pain there is often cramp- ing of the toes, and clonic contractures of the lower ex- tremities, which is semi-involuntary. The patient does not seem to be free from suffering at any time that may be counted upon. The suffering is perhaps more ex- treme at night and more constant. In some cases the ataxic pains choose sites which are peculiar—the light- ning pain attacking parts about the anus or running up The pupil | | spfuol cords “NY \ Spinal Cord.» ON ie. {YA ald Ni | , the rectum, and with this there is a sense-of ‘perinéaY weight and some tenesmus. Testicular pains are rare, but are sometimes found, nevertheless, and. clinicians have called attention to a horrible form of misery which consists in vaginal and vulvar pains, which are Dae in sclerosis in women—which is rare. After a variable siege of pain lasting from a few months to even twenty years, we find other sensory manifestations, such as anesthesia, hyperesthesia, and paresthesia, delayed conduction of sensation, and a loss of the muscular sense. As the disease is more often in the lumbar part of the cord than elsewhere, we naturally find most of the trouble below the waist. The anesthesia may be uneven at first, and afterward general, or, if there ' be ascending degeneration, the fingers, hands, and arms are involved. A rare locality in cases in which the tabes invades the upper part of the cord is the episternal. In a few cases I have found a circumscribed area of an- sesthetic skin in this situation. The common form is that known as ‘‘ plantar,’ and much of the patient’s unsteadi- ness is due to his inability to preserve his sense of con- tact. When his eyes are closed he readily falls, or when he washes his face he is apt to pitch forward. At night it is impossible to walk about the room without support of some kind. This aneesthesia of the soles may be un- equal, so that perverted impressions are received. lp Spinal Cord. Spinal Cord. of being run over. He comes down upon his heels, and these will be found worn. He spreads his feet, and the gait is swaying, the soles being ‘‘ brought down with a slap,” which gives his propulsion an appearance never to be mistaken. When he attempts to turn there is much tottering, and when he is embarrassed he is sometimes almost helpless. If the disease advances beyond this, defective co-ordination is seen when he attempts to perform acts requiring delicacy of adjustment—such as buttoning his clothing, winding his watch, writing, or using small instruments of any kind. He is unable to localize small spots. The ocular symptoms of tabes are numerous. I have already alluded to the pupillary derangements, and, en passant, to the atrophy. There may be paralysis of the third nerve, usually single, but occasionally double. (See Charcot’s case.) In fact, any of the muscles of the ball may be paralyzed, or all of them, giving rise to oph- thalmoplegia externa. A slow atrophy beginning in the early stage of the dis- ease is a frequent symptom, and with it we find color- blindness and limitation of the field of vision. In one case of my own, a woman, there is very slight ataxia, absent reflex, light pains, a gradual loss of vision, and in- tense headache. In fact, this headache is very common with the neuritis of tabes. The sexual organs undergo changes which consist usually of a tendency to priapism, nocturnal emission, and other evidences of irritability in the beginning, and a complete loss of power later on. The action of the blad- der is impaired and the urine is passed slowly, and often falls with but little force from the end of the penis. It often contains a large quantity of the earthy phosphates or epithelial débr7s, and decomposes rapidly. When the ataxic stage has existed for some time, the sympathetic nervous system seems to participate in the production of symptoms, and a variety of trophic changes occur which have elsewhere been described. (See Arthro- pathies.) Articular destruction, with luxation resulting from absorption of the heads of the long bones, especially of the lower extremities, is common. The alveolar pro- cesses undergo a change, so that the teeth become loose and drop out even when they are sound. Various skin disorders, among them herpes and pem- phigus, are found in old cases, and there may be der- mal roughening or thickening. The nails, too, become affected, as Charcot has pointed out, and even exfolia- tion occurs. One evidence of a sympathetic complica- tion in tabes is the acceleration of the pulse, which is per- manent. A grave trophic degeneration is that known as pe7rfo- rating ulcer, and is peculiar to tabes. Luckily itis a rare feature. An indolent ulcer forms usually upon the sole of the foot, which may lead to ‘the necessity of amputation. The last stages of tabes are Fia, 3654.—Perforating Ulcer of the Foot in Tabes. (Gowers.) * those attended by complete helplessness. The motor dif- ficulties increase, the patient becomes thin and feeble, and the possible existence of repeated gastric crises, with vom- iting and diarrhcea, leads to great exhaustion. Tubercu- losis is not a rare result of such malnutrition. In some cases the arthropathies cripple the patient to such an ex- tent that he passes the last years of his life in bed. Morzsip ANATOMy.— When the spinal cord is removed and examined, it is possible to find some external pinkish- 588 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. gray discoloration at its posterior part. When a trans- verse section is made, this same opalescent appearance is detected. It is uneven both as to extent and situation, but more uniformly present in the lumbar region than elsewhere, though plaques of sclerosis are often found at higher levels or in the trunks of nerves. The finger passed over the posterior surface of the cord often re- veals an induration. When a transverse section is made, discoloration may be detected by the naked eye betwcen the two posterior cornua, which is somewhat translucent. The microscope reveals characteristic appearances in the lumbar, dorsal, and cervical portions of the cord, and the extent of the sclerosis depends largely upon the duration of the disease. We may find that the entire tract included by the commissure in front, the external roots laterally, and the posterior boundary of the cord, is the seat of a dense hardening, or we may appreciate various degrees of transformation. The most constant appearance, when the morbid process can be recognized at all, is adjacent to the posterior cornua, and next the col- umn of Goll or postero- median columns. In as- cending degeneration we find in the cervical and dor- sal regions a density of ten- sion in these columns, even when there is a more com- plete increase of neuroglia below ; while the postero- external columns are longer exempt from involvement. Fie. 8655.—Diagrammatic Repre- sentation of Common Areas of Sclerosis. A, Sclerosis of postero- median columns (Goil’s column), most distinct in cervical region. B, Sclerosis of entire posterior col- umns, OC, Sclerosis of parts of pos- tero-median and postero-external The gravity of alteration is usually at first seen quite posteriorly, and even af- ter extension the fibres of connective tissue radiat- ing from the periphery are columns, leaving central parts ex- aes thicker than elsewhere. In some cases we find a tract of healthy tissue surrounded by a territory of scle- rosis. In this form of sclerosis, as in others, the nerve- elements are more or less destroyed and their places are filled by thickened trabecule containing nuclei. The vessels found have thickened walls, and the outer coats are especially the seat of degeneration. Broken-down elements, amylaceous corpuscles, and the like are seen. Numerous associated changes are often present—such as atrophy of the spinal nerves, meningeal thickening, and extensions of the morbid process into the lateral columns, and even the gray matter, are found. It is rare for any disappearance of the large nerve-cells of the anterior horns to take place, unless there is an associated atrophic condition. Sclerosis of the cranial nerves, or of the pons and posterior cerebral ganglia, are found in a small num- ber of cases. DraGnosis.—Tabes spinalis is apt to be confounded with disease of the pons, alcoholic neuritis, cerebellar disease, cerebro-spinal sclerosis, and certain hysterical affections. In the early stages the pains are apt to be mistaken for those of rheumatism or neuralgia, but the peculiar nature of the symptoms—the non-involvement of the articulations and the association of the lost knee- jerk—are guides which should not be disregarded, and the same may be said of the Argyle-Robertson symptom. In some cases of disease of the pons there is inco-ordination, but the other associated symptoms—especially the pupil- lary contraction and absence of lightning pains—are sug- gestive. Alcoholic neuritis occasionally gives rise to REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Spinal Cord, Spinal Cord, _— ——+- inco-ordination and ataxia. The pains in the lower ex- | suggest themselves ; but the physician is urged to care- tremities are, however, nearly always present, and there is tenderness of the plantar surfaces, glossy skin, and or- dinarily atrophy. In many cases there is noticeable mental weakness. In cerebellar disease there is reeling and vertigo, and the walk is rather that of a drunken man. There is nystagmus, double neuritis, headache, and vomiting, none of which symptoms are ordinarily found in tabes. The tremor of cerebro-spinal sclerosis is not found in tabes ; the mental dulness of the former is char- acteristic, and the speech disturbance is unknown in the spinal affection. The pains of tabes are never found in any of the forms of coarse disease I have mentioned. Proanosis.—Tabes spinalis is a progressive and fatal affection, and I do not know of a well-authenticated cure. In making this statement I exclude the syphilitic cases, but these even are only rarely cured by any treatment. The duration of the disease is exceedingly variable, and may extend from a few months to twenty years or more. The traumatic and some syphilitic cases are rapid in their development and unfavorable progress. The course of the disease is marked by periods of temporary im- provement, and is retarded by proper therapeutical meas- ures. I have effected an apparent improvement, in some cases, which has lasted several years, but the symptoms returned and the disease advanced. Optic-nerve atrophy is an exceedingly bad feature, and the development of the second or ataxic stage is an almost positive sign of a hopeless prognosis. Of the reported cures, doubtless these include examples of ataxia due to alcoholic neu- ritis, hysteria, or plantar anzesthesia of limited dura- tion. TREATMENT.—In specific cases our main reliance must rest upon heroic doses of the iodide of potassium—even several hundred grains daily may be given if the patient can bear such a quantity. The use of alkaline waters as a vehicle will enable him to take a much larger dose with- out gastric derangement than if water or other men- struums are used. Nitrate of silver and the tribasic phosphate sometimes improve tlie patient’s condition, but arsenic is one of the best agents, and Gowers speaks highly of its efficacy in his hands. There is nothing, I am con- vinced, so important, not only in tabes, but all other forms of sclerosis, as rest. When. this is possible we may greatly relieve, if not permanently improve, the patient, and a lady who consulted me after the development of the second stage, and who took to her bed and remained there for six months, has had very little trouble for sev- eral years, her gait being almost unaffected, and her pains entirely absent. I have known of very decided relief afforded in other cases by enforced rest. The gastric crises and occasional diarrhoea are best helped by mor- phine, and at such times rest is more important than at any other. Cod-liver oil and the hypophosphites are especially serviceable in the third stage. The pains of the first stage are very difficult to relieve, except by morphine, which, strange to say, is usually well borne, and I have never seen the formation of the habit but twice. Sometimes the cases are helped by the salicy- late of soda, antipyrin,. or acetanilide (antifebrin), the latter by the mouth or subcutaneously. Various au- thors recommend the local application of chloroform, the tincture of aconite, or bisulphide of carbon by means of pledgets of cotton in wide-mouthed bottles. _Cod-liver oil and the fats are necessary, and the discontinuance of tobacco, alcohol, except in an easily assimilable form, sexual intercourse, and exposure to extremes, is impera- tive. A warm winter climate should be selected—one of low elevation and withal dry is better than any other ; and if it is possible to go to some sulphur bath, such as Sharon or Richfield, or the springs of Virginia in this country, or Aix-la-Chapelle, or those in the south of France, the patient will doubtless obtain much benefit. I would advise Southern California or Thomasville, Ga., or, in fact, any inland warm place. The Florida sea- coast is not recommended, but such pine districts as that in the neighborhood of Seville, Fla., are suggested. I will say nothing about a variety of agents for the relief of special symptoms, vesical or trophic, for remedies will fully attend to the many little disturbances that may without care attain a dangerous magnitude. It will be found that the patient’s comfort can be greatly increased by the use,of leaden insoles which are heaviest in front. Allan McLane Hamilton. 1 A Manual of the Nervous Diseases of Man, New Sydenham Transla- tions, vol. ii., p. 395. i853. SPINAL CORD DISEASES: TOXIC SPINAL PA- RALYSIS. Paralysis may be caused by various toxic agents, among the more Important of which are lead, alcohol, arsenic, phosphorus, mercury, carbonic oxide, -carbon sulphide, tobacco, camphor, ergot, and copaiba. The paralysis may occur in hemiplegic or paraplegic form, or may attack only groups of muscles, but in most instances its exact character has not been definitely deter- mined. The toxic paralysis most carefully studied is that due to lead-poisoning. It is most commonly found in the form of wristdrop—paralysis of the extensors of the fin- gers and wrists—but lead may cause far more exten- sive paralysis. Post-mortem examinations in such cases have revealed extensive degeneration of both muscles and nerves, and in a number of instances disease of the anterior cornua of the cord. The view now most com- monly accepted is that the disease is primarily an an- terior poliomyelitis—inflammation of the gray matter of the cord—and that the pathological changes in the mus- cles and nerves are secondary effects. Lead-paralysis would then be a spinal paralysis. But many still believe that it is mainly a peripheral paralysis, primarily in the nerves and muscles. Their opinion is based upon the extensive disease in the latter, and the ofttimes negative results of examination of the cord. The question cannot be considered as definitely answered. One of the most common, if not most common, forms of toxic paralysis is that due to alcohol. Most post- mortem examinations of such cases in recent years have revealed the presence of multiple neuritis, with, in some instances, inflammatory changes in the cord at the same time. Alcohol-paralysis seems, then, in greater part to be a peripheral paralysis, due to neuritis. _ Arsenical paralysis, especially in its clinical aspects, has been carefully studied in recent years. It sometimes has the appearance of peripheral paralysis, sometimes occurs in paraplegic form, and occasionally simulates locomotor ataxia, with ataxic gait, absence of patellar tendon reflexes, etc. It is not improbable: that most of these paralyses are also due to neuritis, The same patho- logical basis may exist in the other forms of toxic paral- ysis, which have been less carefully studied. We may therefore be permitted to discontinue the discussion of the subject in this article, which is to treat only of spinal paralysis, particularly as it requires much further eluci- dation before anything can be stated definitely. But it is not improbable that toxic agents produce paralysis some- times through the central nervous system, brain, or spinal cord, sometimes through the nerves ; and the question is yet to be answered to what extent neuritis, especially multiple neuritis, so much spoken of recently, is due to conditions of the central nervous system. Philip Zenner. SPINAL CORD DISEASES: TUMORS OF THE CORD AND ITS MEMBRANES. Tumors within the vertebral canal, whether they spring from the cord itself or the meninges, produce symptoms mainly through ir- ritation or destruction of nervous tissues. As they can rarely, if ever, be differentiated during life, it is conven- ient to treat of tumors of the cord and of the membranes at the same time. The larger number of intraspinal tumors grow from the membranes, from the dura mater more frequently than from the pia mater ; a smaller number originate in the cord, either in its substance or in the peri-ependy- mal tissue around the central canal. Some intraspinal growths spring from the bone or intervertebral sub- stances, others from the tissues outside the vertebre, 589 Spinal Cord. Spinal Cord. entering the canal through the intervertebral foramina. Circumscribed inflammatory exudations, from caries of the vertebre, and hematoma, as they may produce sim- ilar manifestations, are sometimes included among in- traspinal tumors. The most common forms of tumors springing from the membranes are fibroma, sarcoma, and gumma; from the cord itself, glioma and tubercle. Among the tumors less frequently found in the cord or its membranes may be mentioned psammoma, lipoma, myxoma; tumors of a mixed type, myxo-sarcoma, glio-sarcoma; and parasitic growths, echinococcus, more rarely cysticercus. Neuro- mata, especially false neuromata, are found on the spinal roots, sometimes in large numbers. Enchondromata, sarcomata, and cancerous tumors sometimes spring from the bones or intervertebral tissues and compress the cord. Primary carcinoma is scarcely, or not at all, found in the cord or its membranes, but secondary deposits, espe- cially after primary disease of the breast, are not very rare. Tumors are most frequently single, but neuromata on the spinal roots are often multiple, and tubercles in the cord, though usually solitary, may occur in larger num- ber, while secondary carcinomatous deposits are, perhaps, usually multiple. The shape of intraspinal tumors is usually round, oval, or elongated. Their size is necessarily very limited, varying from that of a hemp-seed to the diameter ot an inch or more. Tumors in the dura mater are usually larger than those in the pia mater. In the cord they rarely exceed one-half inch in transverse diameter, but sometimes have quite a considerable vertical extent, in some instances of glioma and myxo-glioma reaching the whole length of the cord. Tumors may be found anteriorly, posteriorly, or lat- erally in the membranes, and therefore encroaching upon the cord, sometimes in one direction, sometimes in an- other. They may also be found in any part of the verti- cal extent of the cord or membranes, though tubercles are said to occur most frequently in the lumbar enlarge- ment, and gliomata in the cervical region of the cord. The tumors are usually distinctly circumscribed ; some- times—this is especially true of gliomata—they blend with the cord-substance. The secondary changes in the nervous structure, pro- duced by the compression or destructive action of the tumor, are of the greatest importance in the production of symptoms. Tumors growing from the membranes usually produce decided inflammatory or atrophic changes in the spinal roots and cord. The spinal roots are usu- ally swollen and red, or ina state of inflammatory soft- ening ; in other instances they are degenerated and atro- phied. Compression of the cord causes it to be flattened or narrowed at the point of pressure; sometimes pro- duces an entire solution of continuity at that point, the extremities of the upper and lower segments being connected together by membranous tissue. The patho- logical changes in the cord-substance are sometimes only atrophy of the nervous elements, but usually there is a secondary myelitis, termed compression-myelitis. The cord is in a condition of white or red softening, with small extravasations of blood in the softened area, the microscope revealing granular cells and fragments of nervous elements. The inflammatory process is likely to extend some distance below the seat of compression, especially in the gray matter; and occasionally it ex- tends a short distance above the point of compression. Degeneration of the white columns of the cord above and below the lesion, according to the Wallerian law of secondary degenerations, is usually found. A localized chronic meningitis in the neighborhood of the tumor, often resulting in an increase of fluid within the verte- bral canal, is frequently present. Tumors in the substance of the cord compress and push apart the component parts. They may merely pro- duce atrophy of the neighboring tissues, but generally cause more or less inflammation. Often they produce transverse myelitis, with all its symptoms. Secondary degeneration takes place just as after other considerable 590 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. lesions of the cord. The tumor may also produce a lo- calized meningitis and morbid changes in the spinal roots. Various secondary changes also take place within the tumors themselves, such as softening and formation of cavities. Some cases of syringomyelia—cavities in the centre of the cord—a very interesting pathological con- dition, though of little practical importance, as it usually produces no symptoms, are merely secondary cavities in the middle of atumor. Hemorrhages sometimes occur within the tumor or in the surrounding tissues. This is most likely to take place in those rich in blood-vessels— angio-gliomata and angio-sarcomata. The secondary changes in the spinal roots and cord just described, and the symptoms induced by them, are produced to a variable degree by different tumors. These effects depend upon various factors, of which the most important are location, size, consistency, rapidity of growth, and tendency to destroy neighboring tissues. The last two qualities are especially important. Rapidly growing tumors produce great irritation, and have a spe- cial tendency to produce inflammatory changes. On the other hand, psammoma, a hard but slow-growing tumor, is slow to produce symptoms. Those tumors which have a tendency to destroy surrounding tissues—tubercles, to some extent gummata, but especially carcinomata—pro- duce very intense symptoms. Consistency is also im- portant. ‘Tumors softer than the cord may produce few symptoms. This has been found with cysticerci, for ex- ample. Gliomata, also of soft consistency, do not produce symptoms in proportion to their size and rapid growth. This seems to have been true of those which extended al- most the entire length of the cord. As to location, those outside the dura mater usually compress the cord less than those within it. The same is true of tumors in the more spacious parts of the vertebral canal—the middle and lower parts of the lumbar region. It is to be remembered, as regards symptomatology, that some of the secondary effects of tumors, as localized acute myelitis, hemorrhage into or about the tumor, are sudden in onset, and that, therefore, the clinical history, which is mainly that of gradual progression of symp- toms, may present acute exacerbations, often followed by temporary improvement. ErroLogy.—Some tumors, as gumma and tubercle, are due to diathetic conditions. In case of the latter, tu- bercles are almost always found in the lungs or the brain, often in the spinal meninges. Carcinoma is almost al- ways secondary. Parasitic tumors—echinococci and cys- ticerci—have their usual cause. Beyond this the causes of intraspinal tumors are very obscure. Injuries—blows to the spine, etc.—seem often to be the etiological factor. Exposure, nervous shocks, etc., have been assigned as causes, though their influence in that direction is doubt- ful. Symproms.—Usually the first symptom, and the most prominent one throughout the course of the disease, is pain. This is often intense, and of a shooting, boring, or tearing character. In the beginning it is commonly limited to one side, and radiates along the course of the nerves given off at the level of the tumor. It may be thus localized on one side for a long time before it affects the other side or extends to other parts of the body. Such pain is due to irritation of the spinal roots, and is chiefly produced by tumors of the membranes. On the other hand, in intramedullary tumors, when the sub- stance of the cord is directly irritated, the earliest pains may be in lower parts of the body, and not at the level of the tumors. There is often pain in the back over the seat of the tumor, also tenderness to pressure. The pain may be in- creased by movement of the spine, especially if made in such a manner as to compress the tumor. Such move- ment may produce not only local, but also excentric pain. The latter symptom is probably found in proportion as the meninges, and especially the bone, are involved in the morbid process, In addition to the pain there is often hyperesthesia or pareesthesie—numbness, tingling, formication, etc.—in REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. the painful area, and frequently a sense of constriction, or girdle sensation, near the level of the tumor. Along with the symptoms of sensory irritation just described there are often signs of motor irritation—mus- cular spasms. They are more marked with tumors of the membranes than with those of the cord. There is often rigidity of the muscles of the back opposite the lesion, sometimes spasms of the abdominal muscles; and not in- frequently spasms, even contractures, of the limbs. The latter are sometimes due to irritation of the spinal roots. In other instances they are late manifestations, and due to secondary changes in the cord. Paralysis is a common symptom, but it usually ap- pears after irritation symptoms have been present for some time. Motor and sensory paralyses may appear at the same time, or one may appear before the other, the motor more frequently preceding, although this depends upon whether the anterior or posterior portion of the cord is first affected by the tumor. The paralysis is usually gradual in its development, beginning with paresis of one member, which increases to paralysis, extends to the other side, and finally involves every part below the seat of lesion. If the tumor is in the cervical region the paralysis usually begins in the arm, though some- times it appears first in the lower extremity ; but usually the four extremities and the trunk finally become para- lyzed. When the paralysis gradually increases from pa- resis to complete paralysis it is not liable to any improve- ment. But the paralysis does not always progress in this manner. Sometimes there is a sudden and considerable increase of the symptoms, due to an acute myelitis about the tumor, or to hemorrhage. If the lesion be in the cervical region, sudden paralysis of the four extremities may occur. In such instances there is often subsequent amelioration of the symptoms. The anesthesia, like the motor paralysis, is usually partial at first, and gradually becomes complete. It generally corresponds in distribu- tion to the motor paralysis. But in some cases of uni- lateral lesion we have the picture presented by spinal hemiplegia, viz., motor paralysis with hypereesthesia on one side, and anzesthesia on the other. In that case there is usually anesthesia at the level of the tumor on the side of motor paralysis, due to injury of the posterior spinal roots. a A S F 5 ~=- af Sacral the others at the cervical enlargement, while the second | come from the lat- 7 Peas is the largest of the sacral nerves. eral column of the | The ganglia upon the posterior roots are usually found in the intervertebral foramina, except in the case of the sacral and coccygeal nerves. The point of emergence of the trunks of these is a considerable distance below the origins of the nerves, and the ganglia are. withdrawn within the spinal canal by the downward growth of the column, and lie between the dura mater and the wall. The size of the ganglia is in proportion to that of the nerve upon which it is found. The characters which have been given for the spinal nerves are not entirely invariable. There may be certain fibres which do not leave the spinal canal. These may pass directly from one pair of roots to the other with out- ward convexity (ansa centripetalis, Hilbert), in which case they appear to be related to the fibres of recurrent sen- sibility, or they may pass from one root with an outward concavity (ansa centrifugalis) to the root next above or below, without connection with the cord. The meaning of this is not very clear; but it should be remembered that fibres may be displaced from their origin in the course of development in such a way as to deceive one as to their actual course. For instance, there is no doubt that fibres run down along the main trunk of the facial VoL. VI.—38 cord (crossed pyra- midal tract), and we have no absolute anatomical demon- stration of their ori- gin. yy} ~ It should be remembered, as a Yf matter of practical importance, Y that the nerve-roots usually in- cline downward somewhat from 1G. 8659-—Diagram showing their point of emergence to reach Fa Renee tae aie the the intervertebral foramina, Ow- Origin of the Spinal Nerves, ing to the lengthening of the canal already adverted to. The first and second cervical are exceptions, the former ascending slightly, and the latter being horizontal. Those below increase in their obliquity from above downward. Thus, while the lower cervical nerves leave the canal the space of an entire ver- tebra below their emergence from the cord, the dorsal nerves have an interspinal passage of from two to three vertebrae ; and for the lumbar and sacral and coccygeal nerves it is still greater, for the cord ends at the first lum- bar vertebra. Because of this fact it would be quite 593 Spinal Nerves. Spinal Nerves. possible to have a lesion affecting a nerve in the spinal canal considerably above its point of emergence, and symptoms might be caused which would be improperly referred to a lower situation if this fact was not taken into account. . The following table, from Tillaux, shows the relation between the spines of the vertebree and the origins of the nerves. Nerve. Relation to Vertebral Spines. Cervical I. At level of foramen magnum. II. A little below the occipital bone. III, A little below the middle of the space between the occipital bone and the spinous process of the axis. IV. At the spinous process of the axis or above. VY. Third vertebral spine or above. VI. Below 3d, but above 4th. VIL. From spine of 4th and above, to spine of 5th. VIII. From spine of 5th to above spine of 6th. Dorsal I: Above spine of 6th to the 7th. II. Seventh cervical to 1st dorsal. III. From 1st dorsal to middle of interval between it and 2d dor- sal. IV. From just above to a little below 2d dorsal. V. From just above to a little below 8d dorsal. VI. From just above to a little below 4th dorsal, VII. Fifth dorsal to above. VIII. From 5th dorsal to a little above 6th. IX. From 6th dorsal to a little above 7th. X. From 7th dorsal to a little above 8th. XI. From 8th dorsal to a little above 9th. XII. From 9th dorsal to a little above 11th. The five lumbar nerves arise successively from the spine of the 11th dorsal vertebra to the spine of the 12th. The five sacral nerves and the: coccygeal arise succes- sively from the spine of the 12th dorsal vertebra to that of the 1st lumbar. It follows from this table that any lesion which para- lyzes the neck and limbs must be above the 5th cervical vertebra. The phrenic nerve cannot be affected unless the nerves from which it arises (8d and 4th cervical) are involved. The centre for them is above the axis. A luxation of that vertebra is not, therefore, necessarily immediately fatal. A dislocation of the atlas is at once followed by death. A lesion at the 12th dorsal vertebra paralyzes the sacral plexus at the 11th dorsal, the lumbar, and sacral. If at the 5th dorsal, the abdominal walls are also paralyzed ; and at the 3d dorsal the paralysis will reach the 3d in- tercostal space. If at the 6th or 7th cervical, all the in- tercostal spaces are paralyzed. ‘These relations are also illustrated in Fig. 3659. After leaving the intervertebral foramen the mixed trunk soon divides into branches which have special relations to the different portions of the body-wall. set. ) Muscular. ) “minor eee 3D CERVI- | 6 | Rect. cap. later- CAL nerve. | 8 alis, : o Communicans noni. -Anterior DEEP | PHRENIC. branch of | BRANCHES. | 4TH CER- ( Sterno-mastoid. VIOAL Levator anguli nerve. scap. rapezius. Scalenus med. ( Muscular. External T set, Communicating. Spinal Nerves. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. altel ad os plying that muscle, its influence is so much predominant that the other nerves (branches from the intercostals) are not able to do the work. Its most exposed situation in the neck is where it lies in front of the scalenus anticus muscle. It may here be wounded by a stab. It also may be compressed by an aneurism when it passes into the thoracic cavity between the subclavian artery and vein, behind the sterno-clavicular articulation, or by peri- cardiac effusion as it passes down between the pericar- dial and pleural cavities. The cutaneous supply of the neck is derived from the cervical plexus, the areas being approximately shown in the annexed diagram, Fig. 3665. The brachial plexus supplies the arm and shoulder. Muscles which morphologically belong to the arm, like the latissimus dorsi, although far removed in their ori- gin, are supplied by it. It is subject to very great varia- tion, but it nevertheless may be reduced to a general plan, which may be said to be typical. A great many Fia. 3665.—The Nerve-supply of the Posterior Portion of Head and Neck. (Modified from Flower.) 1, Region supplied by the great occipital nerve; 2, region supplied by the auriculo-temporal nerve; 3, region supplied by the small occipital nerve; 4, region supplied by the great \ auricular nerve ; 5, region supplied by the third cervical nerve. So of the variations depend upon the fact that the different ot cords which compose it may unite sooner or later than Fie. 3664.—Connection of the Hypoglossal with the Cervical Nerves. usual. Fig. 3666 shows a type to which all variations (Hall.) XII, Hypoglossal nerves; I, II, III, anterior branch of cervi- : : 4 if cal nerves ; D, D', rami communicantes noni; a, branch of first cervi- oe a be reduced. It will be seen that the Ist dorsal and cal nerve, which sends a twig, ¢, centrally upward, and gives off twigs 8th cervical are the first to unite. Then the dth and 6th sential ho net Leon ; fie a descending | cervical combine, while the 7th remains free. There are aanen ee ie aansendions nent oe eon leg for etree aera | tus formed three stems, which Schwalbe calls primary g, the bundle from first and second cervical, uniting with f! from third trunks. From each of these there is given off an an- cervical ; 42, branch to thyro-hyoid; ge, branch to genio-hyoid. terior and a posterior branch. The three posterior y mae ? , branches unite to form a single cord, the anterior branch The most important nerve, clinically, is the phrenic, as | of the 1st and 2d trunks form another, while that of the when it is injured paralysis of the diaphragm imme- | 3d trunk remains ununited. There are thus formed diately ensues, for though it is not the only netve sup- | three cords which have a definite relation to the axillary = artery, lying posteriorly, externally, and internally from Ge V it. Krom these cords the main nerves are given off : from ee! the external the musculo-cutaneous, and one branch of F he ae the median ; from the internal the other branch of the CVI ae / ye _M ‘ana / ae ‘ median, the ulnar, and the internal cutaneous ; from the posterior the radial (musculo-spiral) and the circumflex. ¢.ViL Muse. C ul; Meoian Raolz acl Umar Fic. 3666.—Diagram of a Typical Brachial Plexus. (Schwalbe.) I, II, III, Principal trunks; @!, a?, a3, anterior branches ; .p!, 92, %, posterior branches ; 1, 2, 3, cords. C.V daa 597 Spinal Nerves. Spleen, REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. The following table! shows the other details of distri- | magnus muscle, its branches appearing laterally from it bution of the plexus : The Brachial Plexus. ( Posterior thoracic (external respiratory nerve of Bell). Supraspinatus. Suprascapular........ Infraspinatus. Shoulder-joint. Subclavius. S ii ; IMMISCIIaAT CO) eemienieete enone Mee | | Levator anguli scap- Branches above the clavicle. { | Rhomboidei muscles. ule. {| Communicating (to phrenic nerve). ; (Internal anterior thoracic. Interna] cutaneous. Lesser internal cuta- From inner cord..... 4 neous (Wrisberg’s nerve). Inner head of median nerve. | Ulnar nerve. | ssa anterior : thoracic. Branches below the Plavies | From outer cord ..... External cutaneous. Outer head of median | nerve. ist subscapular nerve. 2d subscapular nerve. 3d subscapular nerve. Radial nerve. Circumflex nerve. (From posterior cord. Rauber endeavors to simplify the plexus still more by considering the division as arising still further back. His scheme is shown in Fig. 3667. He divides each root at once into an anterior and posterior branch. The latter forms the posterior cord. The 8th cervical and 1st. dor- sal form the inner cord, then the 5th, 6th, and 7th unite to form the outer. There is thus a division of regions which control the entire arm. The muscles of the dorsal region, extensors and supi- nators, are generally controlled by the radial, those of the palmar surface by the musculo-cutaneous above and the median below, the hand being divided between the me- dian and the ulnar. The radial side of the arm is sup- plied by nerves which have a higher origin in the cord than the ulnar side. The thumb side of the hand is therefore to be considered as that which was originally directed forward. An inspection of Fig. 3668 will show that a similar law governs the cutaneous nerves of the arm. One of the mooted points in anatomy is the so-called antero-posterior symmetry of the limbs. Most anatomists hold that the radial side of the arm corresponds with the tibial side of the leg ; but others, among whom may be mentioned Wyman and Coues, suppose that the fibula and the radius are homologous. Wilder advances a the- ory that the limbs are reversed repetitions of each other, corresponding as an image in the mirror corresponds to the object producing the reflection. It will be seen that the distribution of nerves throws some light on this sub- ject. The lumbar plexus is buried in the fibres of the psoas Fig. 8667.—Diagram showing the Plan of the Brachial Plexus, according to Rauber. 598 mE or passing out below. The following table! shows its general distribution : ( Ilio-hypogastric nerve. F | [lio-inguinal nerve. Bien oro baat’ ist LUMBAR Communicating to 2d lumbar. VE. uy | nerve. | rete, : 7, é enito-crural nerve. . om © % |; External cutaneous nerve. eg OBE B lop LUMBAR | | Communicating to 3d lumbar. 4 5 nerve. fe 5 | } a pak a peter crural nerve. 5 art of obturator nerve. . cs | &| Part of accessory obturator pe AA ae = |38D LUMBAR! a nerve. . = nerve. | a Communicating to 4th lumbar. = e Hi. Aj Boe a puterioy crural nerve. TH LUMBAR art of obturator nerve. Gi iven off by the 4TH nerve. Lene accessory obturator LUMBAR NERVE. Lumbo-sacral cord. J It controls the psoas and iliacus, and the great extensor and adductor groups of the thigh. It sends no muscular branches below the knee. B. A, SPORTS SS iA Wen 3 LA Fria. 3668.—Cutaneous Distribution of the Nerves of the Arm. ‘A, Pal- mar aspect; B, dorsal aspect; sc, suprascapular nerves; ax, circum- flex nerve ; c.m, lesser internal cutaneous ; c. med, internal cutaneous 5 c.l, musculo-cutaneous ; 7, radial; m, median ; 2, ulnar, The sacral plexus, on the contrary, controls the great gluteal flexor and rotator groups of muscles, the thigh, and all the muscles below the knee. The cutaneous distribution (Fig. 3669) is such that the lumbar plexus (higher roots) gen- erally innervates the anterior surface and tibial edge, while the sacral plexus supplies the pos- terior surface and the fibular edge. Thus the conclusion arrived at from comparative anatomy and embryology, that the tibial and radial bor- REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. ders of the two limbs are properly comparable, is here confirmed. Fic. 3669.—Cutaneous Distribution of Nerves of Lower Extremities, A, Anterior view; B, posterior view; d./, d.s, dorsal branches of lum- bar and sacral nerves; v.s, inferior gluteal; 7.h, ilio-hypogastric; g, ilio-inguinal ; 7.7, genito-crural; c.l, external cutaneous; c.cr, middle cutaneous; 0, obturator; c.p, lower sciatic; sa, saphenous; p.e, ex- ternal popliteal ; y.m, post-tibial; sw, saphenous; y.s, musculo-cutane- ous; p.p, anterior tibial; m, internal plantar; /, external, The general distribution of the sacral plexus is shown in the following table :! Distribution of the Branches of the Sacral Plexus. Gluteus medius muscle. Gluteus minimus muscle. Gluteus medius muscle. Inferior branch. Gluteus minimus muscle. Tensor vaginee femoris. Superior branch, } SUPERIOR GLUTRAL. [ 5 bid again : urator internus, "branches. | Gemellus superior, * | Gemellus inferior. | Quadratus femoris. ARTICULAR coer Pe branches. i To hip-joint. Spinal Nerves. Spleen. f Inferior gluteal branch. i Gluteus maximus muscle. Infers , if eee Ss Ubelbaae njerior puden- } Integument of upper and inner part of SMALL dat branch. i the thigh, us : SCIATIC. | Integument of scrotum or labium. Inteyument over j gluteus maximus muscle. Ascending. { Cutaneous branch. ; { integument of inner and Descending. outer sides of posterior ( aspect of the thigh, Articular (to hip-joint). 6 f pe auees er tia REAT emimembranosus. SCTATIC. Muscular........ 4 Semitendinosus. | Biceps flexor cruris. § EXTERNAL POPLITEAL. Wlerminalyy.c. .: 3. ( INTERNAL POPLITEAL. { Cutaneous or ( Integument of anal region, | superficial , scrotum, penis, and labia. IRA OO Mason hadee 4 perineal. sphincter ani muscle. IMinsculattiee sists Muscles of the perineum. PupDIC 4 Inferior heemorrhoidal. NERVE. | Dorsal nerve of \2éegument of the dorsum and sides of Zs penis nis. Li * gee ( Brancli to corpora cavernosa. Frank Baker. 1 Darling and Ranney: The Essentials of Anatomy. SPLEEN, DISEASES OF THE. Inrropuction.—It is now generally admitted that the only ascertained function of the spleen relates to the production of the white and to the destruction of the red blood-corpuscles. Physiologists adduce, in support of this view, the facts that the blood of the splenic vein contains a larger num- ber of white corpuscles than that of the corresponding artery, particularly in cases of splenic leucocythemia, and that the opposite numerical relations obtain with regard to the red corpuscles. Writers upon physiology also advance the theory that the spleen’acts asa vascular diverticulum for the portal venous system, and conjecture, from the invariable presence of uric acid, leucin, and xanthin in the spleen, that this organ is the seat of va- rious undetermined metabolic processes.!' Since our knowledge of the physiology of the spleen is so meagre, it naturally follows that the relations of splenic diseases to morbid systemic conditions still constitute a terra in- cognita presenting a large and inviting field for original physiological, clinical and pathological research. Most of the diseases of the spleen are, thus, acknow]l- edgedly interesting rather as concomitants of other mor- bid conditions than because they exert any known direct influence upon the economy at large. On this account they are generally cursorily considered in systematic treatises upon clinical medicine, being regarded by many authors as of decidedly secondary importance. It is, however, desirable to emphasize the fact that splenic dis- eases often serve as trustworthy indices of other morbid states, and furnish valuable corroborative evidence of their existence at a stage when prophylactic measures may yet be successfully employed, or roborant treatment ad- vantageously inaugurated. The writer’s opinion, that the spleen should be careful- ly interrogated in every clinical examination, influences him to preface this article by a few hints in regard to the. methods of investigating the physical condition of this organ. It is important that the diagnostician have definite ideas relative to the normal shape and position of the spleen, inasmuch as diseased conditions susceptible of diagnosis almost always betray themselves by alterations in one or the other of these physical features. The means of physical examination at the physician’s command are inspection, auscultation, palpation, aspiration and percussion. The four former modes of investigation afford no assistance in the examination of the normal organ, while percussion gives only approximately correct information, as isevidenced by the discrepancies between the statements of different well-qualified observers. This diversity of opinion may be accounted for by the fact that the spleen varies very notably, in weight and size, in different healthy individuals, under varying conditions, 599 & Spleen. Spleen. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. and at different ages. Gray states that the weight of the spleen at birth is, in proportion to that of the entire or- gan, as one to three hundred and fifty, and in adult life as one to from three hundred and twenty to four hun- dred, while the proportion in old age is as one to seven hundred. The same author gives the average weight of the spleen, in adult life, as seven ounces, and the length as five, the breadth as from three to four, and the thick- ness as from one to one and a half inches, respec- tively.? 4 One great source of difficulty in accurately outlining the spleen is the occasional superimposition of neighbor- ing organs, viz., of the stomach in gastric tympanites or in the progress of normal digestion, of the colon in dis- tention of that viscus, and of the lung in emphysema or in other pulmonary diseases. Percussion shows, however, that the average normal adult spleen extends from the upper border of the ninth rib to the lower margin of the eleventh rib, where the splenic flatness imperceptibly merges into that of the kidney, and from about one and a half inch to the left of the spinal column, posteriorly, to the middle axillary line, anteriorly.* In practising percussion of the spleen, the examiner should place his patient upon the right side, or in the semi-prone position, the body being in- clined toward the right, in order that the stomach be prevented, so far as possible, by the force of gravity, from becoming interposed between the spleen and the abdominal wall. It is also useful to employ percussion during alternate full inspiration and complete expiration, in order to discover to what extent the lung overlaps the spleen in these opposite phases of the respiratory cycle, and to ascertain the extent of displacement of the organ occasioned by the ascent and the descent of the dia- phragm. It is only in diseased conditions of the spleen that in- spection, auscultation, palpation, and aspiration furnish positive information, If the organ be sufficiently en- larged, inspection may show an unusual prominence of the abdominal parietes in the hypochondriac region, or even in the epigastric, the umbilical, the lumbar, the iliac and the hypogastric regions. Pulsation of the spleen, perceptible to the touch, has been noted in cases of free aortic regurgitation. Auscultation may reveal friction sounds due to peri-splenitis, or, possibly, the hy- datid thrill, while the palpating fingers encounter a smooth, ovoid tumor, usually hard, smooth, and rounded above, and presenting a notch or depression in its an- terior border. In cases of only moderate enlargement palpation may be usefully employed in the following manner: The patient, being on his right side, is in- structed to flex his thighs and legs, thus relaxing the ab- dominal walls, and to alternately inhale and exhale as fully as possible. The examiner meantime places the thumb of his left hand in the left lumbar, and the corre- sponding fingers in the hypogastric region, and making deep pressure endeavors to grasp the spleen. Percus- sion, under these circumstances, shows flatness involving the normal splenic site and the other abdominal regions occupied by the tumor. If the patient assume the genu- pectoral position an enlarged spleen will often fall for- ward, and it may be made to rise on expiration and to descend during inspiration, if adhesions do not prevent it from so doing. Aspiration may be employed as a means of differential diagnosis in cases of fluctuating splenic tumors, as in hydatids and in abscess. The chief abdominal tumors liable to be mistaken for an enlarged spleen are renal growths involving the left kidney, feecal accumulations in the splenic flexure of the colon, gastric neoplasms, abscesses in the abdominal walls, or tumors of the pancreas, of the left lobe of the liver, of the omentum and of the ovary. Tumors of the left kidney may be distinguished from splenic enlargements by the facts that they are more fixed ; that, with the exception of movable kidney, they do not follow the respiratory movements of the dia- phragm, and that they are not displaced from their orig- inal position by changes in the patient’s position. The renal tumor will also usually occupy a position posterior 600 to the site of splenic enlargements, and may cause char- acteristic urinary symptoms. Fecal masses in the splenic flexure of the colon may | closely simulate splenic tumors, but they are usually of elongated form, their long axis corresponding to the course of the intestine, in which direction they may be spontaneously or artificially displaced. They may, more- over, be indented with the finger, and may then retain the digital impression, owing to their inelastic character. In many cases fecal tumors may be removed by the judi- cious and persistent use of purgatives and of laxative enemata. Malignant gastric growths generally do not occupy the position assumed by splenic tumors, are usually of small- er dimensions, do not readily change their place during respiration or on palpation, and are attended with a famil- iar train of diagnostic symptoms. Chronic abscess of the abdominal walls may be distin- guished by its superficial character, its traumatic ori- gin, and by the absence of sufficient causes for splenic enlargements. For the differential diagnosis between tumors of the spleen and pancreatic, hepatic, omental and ovarian enlargemenis, of which the first are less frequent than splenic tumors, and the others, from their position and history, are not likely to be confounded with these, the reader is referred to the writer’s article on Abdominal Tumors, in this HANDBOOK. AcuUTE SPLENIC Tumor. Definttion.—Sudden enlarge- ment of the spleen occurring in various febrile and infec- tious diseases, and due either to combined congestion and hypertrophy, or, in cases of short duration, to congestion alone. The physiological enlargements of the organ, incident to digestion and to menstruation, are not gen- erally included in the category of splenic tumors, al- though, strictly speaking, they might be classified under this heading. Etiology.—This form of splenic tumor occurs with great constancy in some of the infectious diseases, as in typhoid and in typhus fever, relapsing, intermittent and remittent fevers. It is also generally observed in the course of septicemia, pyzmia, acute yellow atrophy of the liver, acute miliary tuberculosis, erysipelas, puerpe- ral fever, dysentery, splenic fever, scurvy, glanders, ulcerative endocarditis, variola, scarlatina, cerebro-spinal fever, diphtheria and acute follicular tonsillitis. It is sometimes scen in pneumonitis, acute pharyngitis, pri- mary and secondary syphilis, and in acute coryza, gastro- enteritis and rheumatism. Acute splenic tumor may, moreover, be due to sudden occlusion of the portal vein in pyle-thrombosis or pyle-phlebitis, and to traumatism. Congenital acute splenic tumor sometimes occurs in chil- dren whose mothers have suffered from malarial fever during their pregnancy. Pathogeny.—The splenic enlargement is generally ex- plained by the assumption that the micro-organisms which constitute the materies morbt in many of these diseases accumulate in the spleen, owing to the filter- like arrangement of its vessels, occasioning congestion and inflammation both mechanically and by the irritat- ing quality of the excrementitious products resulting from their retrograde metabolism. The discovery of numer- ous micro-organisms in the spleen pulp, after splenic fever and pyzemia, lends probability to this view of the pathogeny of acute splenic tumefactions, which is, how- ever, not yet universally accepted. Pathological Anatomy.—In those forms of acute splenic tumor which are of very short duration, the only morbid anatomical change is a more or less intense hyperemia, Should, however, the pathological process, to which the splenic tumor is secondary, be at all protracted, the spleen, besides increasing in size, even to two or three times its normal volume, becomes soft, and sometimes almost diffluent. Its color is reddish-brown, or reddish- blue, and is sometimes mottled gray and red. Peri- splenitis may exist. On section the pulp becomes ele- vated above the cut surface of the capsule. The Malpighian bodies, which are generally not seen, may be plainly discerned in some cases, and are occasionally notably enlarged, particularly in scarlatina.® The trabe- REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Spleen, Spleen, cule are ordinarily obscured by the swollen pulp. The microscope shows the essential lesion to be either an hyperzemia, in cases of short duration, or an hyperplas- tic splenitis chiefly affecting the corpuscles of the splenic parenchyma, ‘The interstices of the pulp often contain an abnormally large number of red and white blood-cor- puscles, and some cells of varying size, pigmented, or fatty and granular. These inflammatory changes gener- ally undergo rapid resolution after the cessation of the primary disease. In cases of typhoid and relapsing fevers this retrogressive change is, however, often long delayed, and in malarial disease particularly, when the patient suffers from repeated attacks, or the lesions may persist indefinitely, constituting one variety of chronic splenic tumor. Clinical History.—An acute splenic tumor, of moder- ate or even of considerable size, may not reveal its pres- ence by any subjective phenomena, or these may be masked by the symptoms of the primary disease. Often, however, the enlargement causes a vague sense of weight and discomfort in the left hypochondrium, with tender- ness on pressure, and occasionally even pain, which, although ordinarily dull and constant, may, rarely, be sharp and shooting, radiating even into the left arm and leg. In the latter case, the existence of peri-splenitis may be rationally inferred. Rupture of the spleen has been known to occur in typhoid and intermittent fever and in other infectious diseases, but it is extremely rare and is hardly to be anticipated, except as the result of traumatism. If rupture occur, it will almost necessar- ily prove fatal from hemorrhage, shock, or peritonitis. It is desirable that statistics be gathered bearing upon the frequency with which, in infectious diseases, acute splenic tumor is developed in anticipation of the char- acteristic constitutional symptoms. It is to be hoped that the physician of the not distant future may be en- abled, having early discovered the approach of infectious diseases by splenic enlargement, to sometimes adopt effi- cient abortive measures of treatment. Mosler describes a murmur heard over the spleen during the febrile paroxysm of intermittent fever, and holds the opinion that the murmur is due to contraction of the splenic ar- tery in the cold stage of the fever.° Diagnosis.—In a case of splenic tumor, found coinci- dentally with an acute febrile disease, the only question requiring attention from the differential diagnostician relates to the exclusion of chronic splenic tumor. The previous history, particularly if it embrace records of thorough physical examinations, may here be of great service. Failing this, the disappearance or persistence of the tumor, after defervescence, will furnish the re- quired information. Prognosis.—This relates, first, to immediate danger from the splenic tumor, and, second, to the liability to the development of chronic splenic tumor as a sequela of the acute. Life is only imperilled, in acute splenic tumor, by the rare occurrence of rupture ; while a chronic tumor is not developed, even in malarial fevers, provided that proper and persistent antiperiodic treatment be adopted. Treatment.—Therapeutic measures especially directed to the splenic tumor are rarely required. The primary disease takes precedence of this, its local manifestation, and treatment adapted to the cure of this malady will effect all the improvement in the condition of the spleen that can be expected from internal medication. Should the pain be excessive or lancinating, local revulsive ap- plications, as dry cups and iodine, or hot fomentations, together with anodynes internally administered, will gen- erally fulfil the indications for treatment. CHRONIC SPLENIC Tumor. Stiology. — The chief causes of chronic splenic tumor are malarial fever or the malarial cachexia, leucocythemia, and pseudo-leucocy- themia. This form of tumor is also often found in those who have long resided in malarial districts, even although they have never suffered from any form of malarial disease. Of less importance, as etiological agents, are all the causes of mechanical obstruction to the portal system, of which the splenic vein is an impor- tant radicle. In this category belong hepatic cirrhosis, pyle-phlebitis, abdominal neoplasms pressing on the por- tal vein, thoracic tumors obstructing the inferior vena cava, mitral and tricuspid valvular lesions, interstitial pheunionitis or fibroid phthisis, chronic pleuritis with retraction or with great effusion, and pulmonary emphy- sema. Many of these conditions are, however, often found without a coexistent splenic tumor, and even when the spleen is abnormally small from fibroid contraction or from simple atrophy. Syphilis is said to occasionally produce this lesion independently of its own characteris- tic form of splenic tumor, and, in rare instances, no cause for the enlargement can be ascertained. Morbid Anatomy.—The size of the spleen is augmented sometimes to an enormous extent. The organ has been known to weigh fifteen or sixteen times as much as in the normal state.7 Its shape remains unchanged ; its consistency is greatly increased, and its color is, as a rule, dark red or brownish-black, but it may be normal or mottled. The capsule is thickened and may be adherent to surrounding viscera, as the result of antecedent peri- splenitis. On section the cut surface is seen to be smooth and indurated. The glomeruli and trabecule may be either almost invisible or very distinct. The microscope shows the lesion to consist in chronic hypertrophic sple- nitis, involving especially the trabecule, but often both these and the splenic cells. Pigmentation of the cells in the pulp, of the Malpighian corpuscles, or of the trabe- cule is not uncommon. For the pathological anatomy of leucocythemia and of pseudo-leucocythemia, the reader is referred to the articles in this HANDBOOK treat- ing of these subjects. Clinical History.—The subjective symptoms are essen- tially the same as those of acute splenic tumor, viz., slight pain, tension, or fulness, and a dragging sensation in the left hypochondrium, sometimes notably increased by the assumption of the lateral decubitus. In some cases there may be splenic ectopia. We may have certainsymptoms due to the pressure of the tumor upon adjacent viscera, such as cardiac arhythmia, gastric disturbances, obstruc- tion of the colon, and chronic ulcer of the leg from in- terference with the blood-current in the ascending venous channels. Gerhardt described a pulsating splenic tumor presenting a double murmur in a case of aortic insuffi- ciency.® All the above symptoms are insignificant when compared with those due to the diseases causing the splenic hypertrophy. Diagnosis.—For the chief differential points between chronic splenic tumor and other abdominal tumors, the reader is referred to the introductory remarks on the differential diagnosis, and for a fuller exposition of the symptoms and signs characteristic of other splenic tumors likely to be mistaken for this form of tumefaction he may consult the remarks made in this article regarding the other causes of splenic enlargement. Acute splenic tumor is easily distinguished by its brief duration, waxy spleen by the pre-existence of suppurative diseases, syphi- litic degeneration by the history of a constitutional taint, and hydatids by fluctuation, thrill, and aspiration. If the chronic splenic tumor be due to malaria, the peculiar cachexia of chronic paludism may be present and pig- ment particles be found in the blood ; if to leucocythe- mia, the blood will present an excess of white corpus- cles; if to Hodgkin’s disease, the lymph-glands will probably be enlarged. Prognosis.—The exact share borne in the lethal issue of any disease of which chronic splenic tumor is a subordi- nate clinical feature, by the pathological condition of this organ can, with our present knowledge, only be conject- ured. If vital organs are affected by pressure, the in- fluence of the tumor can but be prejudicial to the general strength. We can only repeat that the prognosis, as to life, will depend on the primary disease, and not on the secondary splenic condition. If new connective tissue has been formed in the spleen or in its capsule, a com- plete resolution is, of course, not to be expected. ' Treatment.—In chronic splenic tumor from malaria, quinine and arsenic are useful, and removal from a ma- larial district is to be strongly recommended. In any 601 Spleen. Spleen. form of chronic splenic tumor, electricity and ergot may be tentatively employed, the latter perhaps best, hypo- dermatically over the region of the spleen. Da Costa reports a case of splenic leucocythemia_ successfully treated with ergotin thus administered.? Ice-bags con- tinuously employed for long periods may render con- siderable service, probably in the same way as ergot and electricity, ¢.e., by stimulation of the intrinsic splenic muscular fibres. Counter-irritation, by means of tincture of iodine carefully employed, has been productive of good results. Occasional depletion of the portal system by mild cathartics is to be recommended whenever the chronic splenic tumor is due to portal obstruction. If aneemia and asthenia are present, ferruginous tonics and roborant measures are, naturally, indicated. Extirpa- tion of the spleen may be considered, as a last resort, when the tumor is so large as to produce injurious press- ure on important organs, or is progressively increasing in size. Crédé believes that the operation is justifiable. '° Collier found that out of twenty-nine operations tabu- lated by him sixteen were performed for the removal of leucocythemic spleens and were all fatal, while eight of the remaining thirteen patients made good recoveries. 1! PERI-SPLENITIS. Definition.—Acute or chronic, local- ized or diffuse inflammation of the capsule and of the peritoneal investment of the spleen. Httology.—Peri-splenitis is caused by great over-disten- tion of the capsule, as in cases of malarial fever and of other infectious diseases, by extension to the capsule of interstitial splenitis, by involvement of the capsule in in- flammations of neighboring tissues, as in perinepbhritis, in gastric ulcer or cancer, and in general or localized peritonitis. Chronic peri-splenitis often occurs with chronic splenic tumor. It may be a sequel of acute capsulitis, or be coincident with chronic peritonitis. Some writers maintain that peri-splenitis may be caused by chronic alcoholism and by syphilis. Pathological Anatomy.—In acute peri-splenitis fibrin and pus are formed upon the peritoneal coating of the capsule. In chronic peri-splenitis the capsule is more or less thickened from the development of new connec- tive tissue. It may be adherent, through the medium of this new tissue, to adjacent organs. Its color is lighter than normal, and the new tissue, particularly in localized peri-splenitis, is dense and of cartilaginous firmness. It may have undergone calcification. The new connective tissue sometimes assumes the form of nodules or of pap- illary outgrowths. In peri-splenitis of apparently syphi- litic origin the connective tissue may form small, opaque, whitish plates or disks. Clinical History.—In some cases of malarial and other fevers a friction-sound is heard over the enlarged spleen during the respiratory movements. This is the first, and in mild cases the only, symptom of peri-splenitis. Severer cases will be attended by the lancinating pain which is characteristic of local peritoneal inflammation, which is aggravated by movements of the diaphragm, or by changes in position, and which may radiate into the left arm or thigh. Beyond this there will be no symptoms or signs until after the development of adhe- sions between the spleen and neighboring organs, when the spleen may remain immobile during respiration and present certain irregularities and prominences to the pal- pating fingers. Adhesions may be assumed to exist if there is no enlargement of the spleen during acute in- fectious diseases, or if splenic dulness persists after the occurrence of intestinal perforation. Diagnosis.—Peri-splenitis is to be distinguished from perihepatitis over the left lobe of the liver, and from the first stage of pleuritis, particularly of diaphragmatic pleuritis. The differentiation is often very difficult, and is largely based upon the clinical history of these dis- eases. Thus the effusion of pleurisy, and the larger area over which hepatic friction-sounds are audible will somewhat assist the diagnostician. Prognosis.—This is invariably favorable in simple cases, since peri-splenitis leaves no after-effect, unless it be pain from traction of an enlarged spleen upon newly formed peritoneal] adhesions. 602 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Treatment.—This will embrace measures for the relief of the pain in the earliest stage of the inflammation, such as the application of hot fomentations, of revulsives, and of counter-irritants. For severe pain anodynes may be administered by mouth or hypodermatically.. The pain. due to traction of the spleen upon peritoneal bands and adhesions may be mitigated by the use of a belt or girdle for the support of the enlarged organ. INFARCTION. Stiology.—Splenic infarction is due to embolism of the splenic arterioles. These vessels belong to the class of arteries known as end-arteries, 7.¢., they do not terminate in anastomosing capillaries, but in in- tercellular vascular spaces. The most favorable condi- tions for the occurrence of hemorrhagic infarction are afforded by this vascular arrangement and by the ab- sence of valves in the splenic vein, which allows the free regurgitation of venous blood. The emboli causing ob- struction of these arteries usually come from the left. heart or the aorta, but in pysemic cases they may pro- ceed from the lungs, or, possibly, from even more remote parts of the body. They consist, either of vegetations from the endocardium, of atheromatous particles, of fibrin detached from thrombi, or of colonies of micro- organisms surrounded by fibrin. Splenic infarctions may be classified as simple and mycotic, in accordance with the character of the emboli which cause them. Pathological Anatomy.—Simple splenic infarctions are wedge-shaped, corresponding to the conical area sup- plied by the obstructed arteries, and generally near the surface. The apex of the wedge is directed toward the hilum, while the base often projects above the surface. There may be but one infarction, or there may be many infarctions. The size of the infarction varies ordinarily from that of a pea to that of an egg, but it may be much larger, owing to the coalescence of adjacent areas of in- farction. If such a coalescence be established, the char- acteristic wedge-shaped or conical form may be no longer preserved. On section the infarction is found to be either hemorrhagic, white, or mixed. In recent cases it is usually firm, whitish in the centre, and red at the periphery. Localized peri-splenitis may be found over the base of the infarction. In cases of longer standing the color is yellowish-white, from pigment absorption and from fatty degeneration of the cells. In some cases an infarction may soften and be absorbed, leaving a cicatrix. Again, it may successively undergo fatty, cheesy, and calcareous degeneration. Rarely it suppu- rates. The microscope shows that the hemorrhagic in- farction is made up of red blood-corpuscles and of com- pressed splenic tissues, while in the white infarction the cells are in a condition of coagulation necrosis. Mycotic infarctions are surrounded very early by zones of in- flammation, due to the irritation of the micrococci, and the pathological changes soon pass into those of splenic abscess (quod vide). Clinical History.—Simple splenic infarctions give rise to no symptoms, unless from accidental causes they oc- casion acute splenitis and perisplenitis, diseases de- scribed in this article under those headings. They are therefore devoid of importance, inaccessible to diagnosis, and claim no treatment, often being found at autopsies of persons in whom their existence was not suspected. The clinical history and the treatment of mycotic in- farctions merges into that of metastatic splenic abscess, to be presently described. Apsscess. LHttology.—There are two chief varieties of splenic abscess, namely, those due to traumatism, to extension of inflammation: from neighboring viscera, or to simple embolism, which are quite rare, and those caused by septic embolism, which are frequent. The former class of abscesses is caused by wounds or contu- sions of the spleen, by the extension of inflammation from the stomach in cases of gastric ulcer or cancer, by the presense of neoplasms, or, very infrequently, by sup- puration of a simple infarction. An abscess of this kind may complicate typhoid, relapsing, or intermittent fever, and sometimes may be developed without known cause. The second variety of abscess is the result of mycotic. endocarditis or of pyzmia. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Pathological Anatomy.—Abscesses of the former variety, which, in contradistinction from those due to septic em- bolism, may be designated as simple abscesses, are gen- erally, although not necessarily, larger than the latter. They may lead to the destruction of the entire parenchy- ma of the organ, the capsule becoming distended with pus and disintegrated splenic tissue. On section the trabecule may be seen traversing the diffluent mass, or they, too, may have been broken down. The capsule is indurated, thickened, often adherent to other organs or tissues, and occasionally destroyed by the advance of the abscess toward the surface of the spleen. Smaller sim- ple abscesses may become encapsulated, and, eventually, be reabsorbed, leaving a cicatrix, or they may undergo caseous and calcareous degeneration. Splenic abscesses in any of the above stages, latent as regards symptoms and signs during life, may be discovered at autopsies held upon the victims of various diseases. Large ab- scesses may rupture and discharge their contents either into the peritoneal cavity, the colon, the pleural cavity, upon the cutaneous surface, into the renal pelvis, or into the retro-peritoneal tissues. Septic abscesses are ordinarily of small size, because the diseases to which they owe their origin are so often rapidly fatal. Their form may be that of a splenic in- farction, from which they often develop, namely, wedge- shaped, the base being directed toward the surface, or it may be very irregular, when the area involved in the in- farction has undergone complete necrosis. On section one finds a central mass, which the microscope shows to be made up of leucocytes, granular amorphous detritus, and micrococci, surrounded by coagulated fibrin and bordered by a dark congested zone of otherwise normal tissue. Clinical History.—The symptomatology of splenic ab- scess is not well made out, on account of the great rarity of the disease. The symptoms of abscesses other than mycotic, as described by those authors who have ob- served them, are merely those of suppuration in any tis- sue, and collectively known as hectic fever, together with pain and tenderness in the left hypochondrium, de- pendent upon peri-splenitis and upon peritoneal adhesions. The pain is said to have radiated, in some cases, into the left shoulder. Rupture of the abscess into the perito- neum causes fatal peritonitis ; rupture into the pleura and the bronchi, pleuritis, bronchitis and pneumonitis. In a case of supposed splenic abscess, treated by the writer, pus was abundantly discharged by the bronchial tubes and recovery took place. Rupture into the stomach or into the intestine would be followed by the vomiting or by the dejection of pus and blood, and rupture into the kid- ney by pyuria and hematuria. The physical signs, if the abscess be of considerable size, are those of splenic enlargement with possible fluctuation ; but in small ab- scesses, terminating by caseation and calcification, these signs would probably be absent. The symptoms and signs of mycotic abscess are usually negative, or are completely masked by those of the coex- isting endocarditis or pyemia. They rarely occasion tenderness, pain, or perceptible splenic enlargement, ex- cept in chronic pyemia, when they may, by the coales- cence of several small foci of suppuration, become large and fluctuating. Should the capsule and the peritoneum covering the spleen become involved, there may be con- siderable lancinating pain and marked tenderness. Diagnosis.—Simple splenic abscess, large enough to present physical signs, might be mistaken for perine- phritis, for pyelo-nephrosis, for sacculated empyema occupying the most dependent part of the left pleural cavity and for hydatids of the spleen. The exclusion of all these diseases but the last one might prove almost im- possible, except by exploratory incisions. Some assist- ance in making a diagnosis might be derived from the fact that a splenic abscess which had not caused adhe- sions of the spleen would descend on inspiration, which a perinephritic, nephritic, or pleural abscess would not do. Hydatids of the spleen would furnish a character- istic fluid on aspiration. Carcinoma of the cardiac ex- tremity of the stomach and pancreatic tumors may also Spleen. Spleen. be mistaken for splenic abscess. The existence of my- cotic splenic abscess can generally only be suspected when local signs are developed in pyemic cases, but the large abscesses of chronic blood-poisoning are more easily diagnosticated. Prognosis.—Mycotic abscess is not, in itself, fatal, but the pyeemia of which it is a subordinate feature offers a grave prognosis. Simple abscesses are usually fatal, either by rupture or by gradual exhaustion. The prog- nosis is, however, by no means hopeless, since rupture onto the surface, or in almost any direction save that of the peritoneum, may be followed by recovery. Treatment.—In suspected cases of beginning simple abscess, active prophylactic treatment must at once be adopted. This treatment will embrace saline laxatives, local abstractions of blood and ice-bags kept constantly applied. Bartholow recommends warm fomentations, turpentine stupes and hot poultices, besides the free ad- ministration of quinine.!” Fluctuating abscesses, simple or pyemic, should be evacuated with strict antiseptic precautions. The smaller mycotic abscesses are not amenable to treatment. Waxy SPLEEN. Litology.—Amyloid disease of the spleen occurs under the same circumstances which occa- sion waxy changes in other organs, namely, during pro- tracted suppurative diseases, particularly in those aftect- ing bone or pulmonary tissue, and in syphilis. Malarial disease is sometimes included in this category of causes, and, in rare cases, no cause can be discovered. This dis- ease of the spleen is rarely encountered except in cases presenting waxy changes in the liver, the kidney, and the intestine. Pathological Anatomy.—There are two varieties of amy- loid spleen. The former is known as the ‘‘ sago spleen,” and the latter as diffuse waxy disease of the spleen. In the former variety the organ is sometimes enlarged, and is sometimes not so. In the latter, the spleen is en- larged, tenacious, and indurated, its capsule being tense and glistening and its edges blunt or rounded. On sec- tion the ‘‘sago spleen” presents grayish, round, or oval translucent bodies scattered through splenic tissue, which may either be otherwise healthy, or may, also, be invoived in the same pathological change. The above-mentioned granules correspond to the Malpighian bodies, and vary in size from about one twenty-fifth to about one-eighth of aninch. In the diffuse variety of amyloid spleen the degenerative change is generally held to have invaded all the splenic tissues, but chiefly the pulp and the trabecu- le. On section the cut surface is waxy and more or less translucent, varying in color from a grayish-red to a dark grayish-brown. It is probable that the waxy change oc- curs first in the walls of the arteries, in both varieties, and subsequently involves the other structures. The tests for the waxy material are as follows: If Lugol’s solution, z.e., the compound solution of iodine, be applied to the cut splenic surface, those tissues which have un- dergone the amyloid change will assume a mahogany color, the normal tissues merely taking on a yellowish tint. A still more delicate test-fluid is a solution of methyl violet, which imparts a red color to amyloid ma- terial, the normal splenic tissues becoming distinctly blue. Clinical History.—No symptoms can be directly re- ferred to waxy changes in the spleen, unless the organ has become so much enlarged as to cause a feeling of ful- ness, of weight, or of traction. The other symptoms ob- served, in any case, will almost invariably be due to the amyloid disease in other organs, as diarrhoea in intestinal disease, and characteristic urinary symptoms in amyloid kidney. There is usually profound anemia, with all its symptoms, and hemorrhages from mucous surfaces may occur. On physical examination the spleen is found enlarged and hardened, but it is smooth, retains its shape, is not adherent to any other organ, and is movable. Diagnosis.—This must ordinarily be based upon the concomitant symptoms of waxy change in other organs, t.e., in the liver, the kidneys, and the intestine, together with the physical signs and the early history of suppura- tion or of syphilis. Chronic splenic tumor might be er- 603 Spleen. Splints. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES, — roneously considered as waxy spleen, but the history of antecedent malaria, and the microscopical examination of the blood, would exclude both ‘‘ ague-cake” and leuco- cythemia; while the absence of general glandular en- largements would disprove the existence of pseudo-leuco- cythemia. ; chee Prognosis.—This is bad, not from the amyloid disease of the spleen, but from the existence of the same change in other and vital organs. Treatment.—The treatment is almost wholly prophy- lactic, embracing removal of all possible foci of suppu- ration and the eradication of the syphilitic cachexia. It is possible that the waxy disease, if not far advanced, may disappear, but it is uncertain whether there be ther- apeutic means of hastening the resolution. SpLentc NEopLasMs. 1. SypuHriiis.—Splenic syphilis may be congenital or acquired, circumscribed or diffuse. The acquired form is not very common, while congeni- tal splenic lesions are found in perhaps one-fourth or one-third of all cases of hereditary syphilis.'* Pathological Anatomy.—In the early stages of syphilis the spleen may be-enlarged by congestion, and, perhaps, by moderate hyperplasia, thus constituting one variety of acute splenic tumor, as in other infectious febrile dis- eases. We have already stated that lardaceous splenic disease, as well as diffuse interstitial hyperplasia, is some- times caused by syphilis. As these lesions have been described under their respective titles, it now only re- mains to mention the other pathological change wrought in the splenic tissues by the syphilitic virus, viz., the so- called gummata. These gummata are generally small, some of them being no larger than a grain of millet-seed, others as large as a small bean or lentil. They are, or- dinarily, not numerous, and may be either distinctly cir- cumscribed or somewhat diffused. They are usually situated near the surface of the spleen. Syphilomata are, at first, reddish-white, assuming, when less recent, a yellowish tint, and becoming dry, tough, and almost cheesy.!4 Clinical History.—This is negative. The diagnosis can hardly be made with any degree of certainty. The ex- istence of gummata may be, at most, suspected, if splenic tumefaction, with peri-splenitis, develops during the de- monstrated growth of syphilomata in other organs, waxy disease having been excluded. Treatment.—Acute splenic tumor, due to syphilis, may be reduced by the speedy adoption of specific treatment. Splenic gummata are often readily amenable to treat- ment with large doses of potassium iodide or to the mixed treatment, while diffuse syphilomata are uninfluenced by any therapeutic measures. 2. TUBERCLE.—Acute splenic tumor, without tuber- culous deposits, occurs during the progress of acute tu- berculosis. Splenic tubercles, proper, are apparently either always secondary to tuberculous growths in other organs, or appear, simultaneously with widely dissemi- nated tuberculous growths, during the course of acute miliary tuberculosis. In the former case the tubercles are often not very numerous and are visible to the naked eye, varying in size from that of a millet-seed to that of a pea, the largest ones being doubtless composed of sev- eral smaller aggregated tubercles. These growths are sometimes called solitary tubercles. They are, at first, grayish and translucent, assuming later a yellowish or cheesy appearance. Their histological features are the same as in tubercles of other organs, and they generally contain numerous bacilli. They are found in the trabe- cul, the capsule, the Malpighian bodies,;in the pulp and in the walls of the small arteries! (vdde article Tu- bercle, in this HANDBOOK). The splenic tubercles developed in acute miliary tuber- culosis are often invisible to the naked eye,:and are dis- tinguished with difficulty even by the microscope, since their structure, at an early stage, closely resembles that of the splenic pulp. Tubercles of the spleen are alike devoid of interest for the clinician, the diagnostician, and the therapeutist. é 3. MALIGNANT TuMoRS, CARCINOMA AND SARCOMA. —These new-growths are hardly ever primary, but usu- 604 ally develop secondarify to other malignant tumors, either by metastasis or by direct extension from a pri- mary neoplasm in the stomach, the liver, the pancreas, and the mesenteric or retro-peritoneal glands. Jeannel states that only seven primary splenic cancers have been reported.'® Splenic carcinomata are ordinarily of the medullary variety and are often pigmented. These ma- lignant tumors grow with great rapidity, and, if super- ficially located, may be discovered by palpation. As a rule, they escape detection. Their presence may be in- ferred if enlargement of the spleen be coincident with the development of malignant growths in other, and par- ticularly in abdominal, organs. These tumors are of little clinical significance, and affect the prognosis unfavor- ably only in that they give evidence of a more or less wide distribution of the carcinomatous or sarcomatous disease. 4, Ecutnococcus.—This is one of the rarest of splenic tumors. It develops, usually, simultaneously with hyda- tids in other abdominal organs, particularly with hepatic echinococcus. The disease attacks both sexes with ap- proximately equal frequency, and is chiefly found in middle-aged persons. The etiology is the same as that of hydatid disease, wherever located, the cause of the disorder being the entrance of the scolices of the tenia echinococcus into, and their establishment in the spleen. It has been asserted that echinococci of the spleen are generally secondary to other hydatid tumors of the ab- dominal organs, but this question is not definitely set- tled. Morbid. Anatomy.—As a rule, there is but one mother- cyst, within which numerous daughter-cysts develop, but there may be a large number of mother-cysts. The hydatids are ordinarily developed from the capsule of the spleen or from its serous investment, but they may originate in the spleen pulp, which, in either case, is de- stroyed by the pressure of the tumor. The cyst usually increases slowly in size, if uninfluenced by treatment, and, after months or years, finally ruptures into the perito- neum, into some hollow abdominal viscus, as the alimen- tary canal, into some thoracic cavity, as the pleura or the pericardium, or onto the cutaneous surface. In more favorable cases the cyst may remain stationary in size, occasioning no noteworthy splenic lesion. Suppuration of the cyst may occur, or the cyst may undergo calca- reous degeneration, remaining encapsulated and innoc- uous. - Clinical History.—Small, and sometimes even large hydatid cysts may give rise to no symptoms or physical signs. When, however, a certain size is attained, the patient may complain of weight, tension, and pain, either constant or intermittent, over the region of the spleen, which organ, on physical examination, may be found enlarged in various directions and displacing abdominal and thoracic viscera. Emesis may thus be occasioned by pressure upon the stomach, and obstipation by ob- struction of the large intestine. If peri-splenitis coexists, a friction, sound may be perceived. The hydatid thrill is occasionally present, as well as fluctuation. If the cyst ruptures, the symptoms will vary with the organ into which the discharge occurs, and need not be here enumerated, since they are almost identical with those occasioned by the rupture into these various viscera of a splenic abscess, and are described under that caption. Suppuration of the cysts will occasion the familiar symp- toms of hectic fever. Diagnosis.—The establishment of a differential diag- nosis involves the exclusion of abscess and of solid splenic tumors. Aspiration will distinguish between these and hydatids, if the characteristic saline fluid, containing hooklets, be obtained. Fluctuation will, when present, exclude solid tumors, and the hydatid thrill is pathogno- monic. Small or encapsulated hydatids will elude diag- nosis, and it may be impossible to distinguish between simple splenic abscess and suppuration of an hydatid cyst. Prognosis.—This is very bad, but not hopeless. Rupt- ure does not necessarily occur, but when it does happen REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. is almost always fatal. The growth of the cyst may be spontaneously arrested, and calcification sometimes ren- ders the tumors harmless, while judicious treatment may materially assist nature in effecting a cure. Treatment.—The treatment to which the majority of writers lend the weight of their authority consists in the partial evacuation of the cyst, or cysts, by which pro- ceeding the death of the parasites is brought about, and absorption, atrophy, and calcareous degeneration of the remaining contents of the cyst are favored. The evacua- tion of the fluid should be accomplished by means of a very small trocar, and it is advisable to excite localized adhesions between the cyst and the abdominal wall by means of caustics before aspiration is attempted. The operation and the whole after-treatment should be con- ducted in accordance with the most approved antiseptic principles. Should suppuration of the sac occur spon- taneously, or as a result of aspiration and the ingress of air, a free opening must be made and efficient drainage afforded. 5. MiscELLANEOvUS TumMors.—Other and rarer splenic tumors than those above described are fibromata, angio- mata, dermoid, and other cysts, besides calcified cysts containing the pentastomum denticulatum. All these new-growths are generally of so small size as to be quite devoid of clinical interest. RUPTURE OF THE SPLEEN. /ttology.—Rupture of the spleen may be either spontaneous or traumatic, but tri- fling injuries may so often provoke apparently spontane- ous lacerations that a sharp dividing line cannot be drawn between these two varieties. The so-called spontaneous ruptures generally occur in cases of acute splenic tumor complicating typhus, typhoid, and intermittent fevers, or other infectious diseases, as well as in abscess, aneurism, varices, or hydatidsof thespleen. Traumatic rupture re- sults from violence direct, or rarely indirect, exerted, in almost all cases, upon an enlarged and softened organ. Falls, kicks, and blows, fracture of the ribs, and pene- trating wounds are the most common traumatic causes, while acts of emesis, convulsions, and the contortions of parturition have been noted as rarer causative events. Pathological Anatomy.—Spontaneous rupture usually occurs at a single point, while traumatic rupture may cause lacerations in several different places. Autopsies, -in cases of rupture, reveal the diseased condition of the organ which predisposed to rupture, and the presence of blood and débris of the splenic tissues in that organ or cavity into which these materials have been discharged. If the patient’s life has been sufficiently prolonged, there will be found evidences of the secondary disease due to the rupture, as of peritonitis, pleuritis, or pericarditis. In distinctly traumatic cases there may be contusions or other visible surface evidences of violence, or these may be wanting. Clinical History.—The symptoms are those of rupture of any vital abdominal organ, and they particularly resem- ble those following perforation of the bowel, with or with- out hemorrhage into the peritoneal cavity. The leading symptoms are a feeling as if some vital organ had sud- denly given way, and violent pain over the spleen, soon followed by acute anemia and rapidly increasing asthenia. Death, either immediately or after a few hours, is the almost inevitable result. Recovery may, however, take place, if the rupture is slight and does not occur into a serous cavity. The treatment, which is usually unavail- ing, embraces absolute quietude, applications of ice to the abdomen, and generous doses of morphine, hypoder- matically administered. EcroPrA AND MALFORMATIONS.—Cases of splenic ec- topia, or floating spleen, are comparatively rare. They may result from failure of the suspensory ligament and of the gastro-splenic omentum to retain the organ in place. Such failure may be due to congenital relaxation of the ligaments, to their abnormal length, to traction upon them of an enlarged spleen, or to traction upon the spleen exerted by the contraction of newly formed peri- toneal bands. Atrophy of an criginally normal or of an hypertrophied spleen may be caused by torsion or compression of the splenic vessels incident to the organ’s | Spleen. Splints, displacement. Ectopia is to be differentiated from simple enlargement by the aid of physical exploration, and the spleen, having been restored to its normal position by careful manipulations, is to be retained there, if possible, by proper bandages or by abdominal supporters. The spleen may be displaced, either upward or down- ward, by abdominal or thoracic diseases of such a char- acter as to forcibly press upon the organ. Among such diseases are to be mentioned tumors, ascites, tympanites, emphysema, pleuritic effusions, pneumothorax and spinal curvatures. Lifting great weights and paroxysms of coughing may act as exciting causes of these displace- ments, which, in turn, cause various pressure symptoms, among which are vesical and rectal tenesmus, paresis of the lower extremities, emesis, and constipation. The spleen may sometimes escape into a hernial sac, either abdominal or thoracic, and it may, rarely, be found on the right side, in cases of visceral transposition. Two spleens, either of the same size or of different sizes, have been found in the same subject, and small accessory spleens, of various shapes, are often seen. The spleen may, in very rare cases, be congenitally absent in persons whose other organs are all present, and acepha- lous monsters have sometimes rudimentary spleens, or no spleens whatever. William H. Flint. 1M. Foster: Text-book of Physiology, pp. 59,60. Philadelphia, 1885. Kirke’s Handbook of Physiology, vol. ii., pp. 8,4. New York, 1885. 2 Gray: Anatomy, Descriptive and Surgical, p. 822. Philadelphia, 1883. 3A, Flint, Sr.: Manual of Auscultation and Percussion, pp. 37-89, 1885. Figs. from Weil’s Handbuch d. topo. Percussion, Atkinson, I. E.: Diseases of the Spleen, Pepper’s System of Medicine, vol. iii., p. 951. 1885. 4 Loomis: Lessons in Physical Diagnosis, p. 151. New York, 1874. 5 Delafield and Prudden: Handbook of Pathological Anatomy, p 362. 1885. 68 Hichhorst: Handbook of Practical Medicine, English translation, vol. iv., p. 42. William Wood, 1886. 7 Hertz: Ziemssen’s Encyclopedia, American edition, vol. ii., p. 629. 8 Hichhorst: Op. cit., p. 44; 9Da Costa: American Journal of the Medical Sciences, January, 1875, p. 11%. 10 Crédé: Centralblatt f. d. Med. Wissensch., June 23, 1883, p. 445. 11 Collier ; Lancet, February 11, 1882, p. 219. 12 Bartholow: A Treat. on the Prac. of Med., p. 191. New York, 1880. 13 Atkinson: Op. cit., p. 971. 14 Mosler: Ziemssen, vol. viii., Am. ed., p. 485. 15 Delafield and Prudden: Handbk. of Path. Anat. and Histol., p. 365. 1885, 16 Jeannel: Jaccoud’s Nouv. Dict. de Méd. et de Ch., vol. xxx., p. 503. SPLINTS. The study of splints and methods of splint- ing is a very interesting one, both to the practical surgeon and to the medical historian. Ingenuity—and too often misapplied ingenuity—has been expended lavishly in devising splints of the most curious and complicated character, intended to fulfil a number of different indications; splints elaborately carved and often based on false anatomical principles ; splints capable of adapting themselves—in a measure— to adults or to children ; splints that have been expected to supplement and improve upon the surgeon’s faulty work in reduction of fracture, and which have, accord- ingly, failed of their purpose. The shops are filled with almost innumerable varieties of splints, devised for the cure of every conceivable fract- ure. Especially numerous are those for fractures of the femur and of the lower end of the radius. If it is true— which I do not allege—that no obstetrician considers him- self eminent in his specialty until he has devised some modification of the obstetric forceps which shall bear his name, it is much more true that almost every surgeon who has written a book—and many who have not—in- vents some special splint. It is undeniable that some of the splints stand for < principle, and deserve permanent recognition, The vast majority, however, are relegated by the succeeding gen- erations into oblivion with their authors. This fact is strikingly impressed upon the reader of the surgical works of the last century and the early decades of the present. Here, as in regard to other therapeutic agencies, the pendulum of medical opinion has swung at times from extreme to extreme. John Bell declared the appliances for treating fracture in his day to be ‘‘instruments of torture more terrible 605 Splints.. Splints. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. than those used by the Inquisition for that purpose,” and substituted therefor much simpler means. Such com- plicated engines, intended to war against deformity, are not without their types at the present time. Looking at the other extreme of opinion, we find that at times certain reputable, but misguided, sur- geons have actually advocated the treatment of Fie. 3670.—MacIntyre’s Wooden Splint for Fractures of the Leg. many or all fractures of limbs with no splint save a roller bandage! And others have even done away with this, preferring absolutely nothing. Such absurdities as these are probably the natural revulsion following the contem- plation of limbs permanently deformed from splints im- properly devised and unskilfully applied. Those surgeons who are pre-eminently successful with Fia. 3671.—Suspension of the Leg from a Wire Cage. their fracture cases are not necessarily the ones who have the largest armamentarium of ready-made splints, of myriad shapes and sizes, wherefrom to select for the treatment of any given case. In fact the reverse is often true, and the greatest surgeon possesses few or no stock- splints; but, from splint materials nearest at hand, or readily obtained, makes at short notice for each case . a separate and differing splint ; one that shall vary ' with the infinite variety of 6 ie individual requirements, Py Fie. 3672.—Volkmann’s Sliding Leg-rest. and which is therefore apt to be better than the ready- made article. ; To effect this, a certain degree of deftness and ingenuity is necessary ; but this is true of all branches of surgery. 606 And the man who is lacking in this essential will do wisely to choose for his field another department of med- icine. : In this article will be discussed mainly the materials used in splinting and the modes of application. Only in- cidentally are appliances peculiar to some special bone- lesion named, and these are more appropriately studied in conjunction with the phenomena, subjective and ob- jective, which call for their application. Accordingly, the reader is referred for such information to the ap- propriate headings, as Fractures, Pott’s Disease, etc. ) Splints are usually divided, for convenience of clas- sification, into two broad groups: the rigid and the plastic. The latter are those composed of substances capable of being made to assume a soft and pliant condition, and subsequently of hardening and maintain- ing the shape into which they have been modelled. The plastic splints have been in turn subdivided into movable and immovable, which classification seems to the writer an utterly useless one, inasmuch as each and all members of the ‘‘immovable” plastic group can at will be so fash- ioned as to become easily capable of removal. Not as to substance, but as to method of splinting, the division ¢tmmovable splints becomes of some practical Fia. 3673.—Adaptation of the Double-inclined Plane to the Upper Ex- tremity. value. The discussion is not yet ended, in the profes- sion, as to the relative value, in acute injuries, of the class of immovable dressings of which that made of gypsum stands as a type. ‘They have certain advantages ; their objectionable features are also now well recognized. In the hands of competent and‘experienced men they are almost invaluable at times. In other hands they are oc- casionally either inefficient as a means of maintaining rigidity, or actually dangerous to life or limb. Besides a modicum of experience in the technique of their application, it is essential to the well-being of the patient that the surgeon should recognize certain fixed limitations to their employment. An immovable splint should never be ap- plied to a limb immediately upon the receipt of the injury, or within a few hours thereafter. Considerable inflam- J, mation and swelling inevitably follow the fract- ure, and continue for several days; and as the splint under consideration encircles the limb, it may cause agonizing pain by opposing an un- yielding barrier to this swelling. With the ordinary removable splints a patient so troubled could easily free himself. Not so in this case ; and if the surgeon be a country practitioner, and hardly able to call again soon, the outcome is occasionally most deplorable. From obstructed circula- tion gangrene of the point of greatest pressure, or even of the entire extremity, may supervene. This result is, for- _ tunately, rare, but as a danger it must be borne in mind. Should the patient with fracture be seen first at a period when the inflammation and consequent swelling are at their height, it would probably be wise to wait and not attempt reduction then, unless the fragments be in a decidedly bad relation to each other. But certainly, if splinting be attempted, here is another counter-indica- tion to the use of the immovable method. Upon the subsidence of the congestion the limb will quickly re- sume its normal size, and a splint closely fitting the limb vesterday may to-morrow be so loose as to aid little in immobilization. The surgeon will consequently have either to cut out a longitudinal strip of the splint, and then by bandage or straps narrow it transversely, or what is probably better and simpler, to remove it and make a new one; either expedient being more annoying and tedious to the attendant than the application of some sim- ple, temporary, removable splint. It cannot be gainsaid that it isa most desirable thing to have a fractured member freely exposed to the sur- geon's eye ; and that this is impossible by Pini re 190. visible to the naked eye, the smallest (rice) the ten- thousandth of an inch in diameter. The granules are hard, highly refracting, of rounded, oblong, or peculiar outline, uniform or characteristic in each plant. If large, they almost always show a series of concentric lines or shades around a spot.called the hilum, which may be he woe; f POSES nsverse Section of Wheat, with closely packed starch- granules, cuticular layers, wall of ovary, etc. >< 190. central, or more or less excentric. When dry, the hilum in many varieties season-splits and presents a variable stellate, branching, or single fissure, which, holding air when the starch is immersed under the microscope, looks black. Under polarized light in the microscope a dark cross, formed by two intersecting lines meeting at the eas Fic. 3699.—Portion of Transverse Section of Barley ; pai, husk (? spe- lye); gl, gluten-cells; 2, pericarp; 7, seed-coat. > 190. hilum, gives starch a very characteristic appearance. Cold water has little effect upon starch, further than to make its ruge a little-less prominent, unless the granules have been triturated with sand to cut them to pieces, when a little is dissolved by it ; but when heated in water to, say, 140° or 150°, the granules swell, lose their charac- teristic outline, and become less refracting to light; if the heat is carried still further the action upon polarized light is lost, and before the boiling point is reached they burst and form an opalescent granular mass (starch paste) in which some shreds of sac and tissue can usually be seen. Starch of all plants has essen- tially the same chemical compo- sition and. reac- tion (C.sHi.05 or Cs6H620n1, accord- ing to Nageli). It is white, odorless, or nearly so, taste- less, becoming finally sweetish in the mouth from partial change ; insoluble in alcohol and ether: boiled with about ten parts of water it gives a moderately stiff, bluish, translucent jelly or mucilage. Treated with a minute quantity of iodine, it is turned to an intensely blue color, which can be discharged by heat, returning again upon cooling. Starch is not a homogeneous substance, but consists of at least two constituent parts, one more soluble than the other, called granulose ; the other, which comprises the skeleton of the granule, is more like cellulose itself. Treated with diluted acids, heat, diastase, or one of a number of other vegetable or animal ferments, starch is converted into dextrine, a substance in extensive use as a mucilage or size; and finally into. grape-sugar or glucose, which is now made from it in great quantities, as a substitute for sugar in cheap confec- tionery, etc. PREPARATION, — Figs. 3693 and 3694, as well as Figs. 3697 to 3700, will show how closely the starch is entangled with cellular structure, and other pro- ducts of vegetable growth. ‘The problem is to separate it and get it as completely clean as the succeeding figures (Figs. 3701 et seq.) show it. This is generally accomplished by grinding and wash- ing; for arrow-root, for instance, the pulpy rhizomes are cleaned with care and ground, then the pulp is washed over sieves ; when the starch flows through with the wa- ter, it is allowed to settle, and then washed again and again until the soluble matters and the tissue are com- pletely washed away. Sago pith is treated in essentially the same way. Potatoes are ground to a pulp and al- lowed to stand until the mucilaginous matters are disin- tegrated by decomposition, then washed as above. From wheat the starch is washed out of the glutinous dough, made by mixing a coarsely ground meal with a lit- tle water; this may be kneaded under a stream over a sieve, or it may be put in large bags and Fig. 3700.—Transverse Section of Oats, show- ing composite granules. < 190. Fre. 3701.—Wheat Starch. _rinsed and pressed until the starch (*¥ is all washed out from the gluten. ~~ (Xe The processes, of which this is the Ne Wearing ian li cn Sigrent merest outline, have considerable variety in detail and in the machinery and conveniences used, ‘ah VARIETIES.—The only certain means of determining from what source a given specimen of starch has been derived is to examine it microscopically, when the size, shape, markings, and other visible peculiarities of the granules will generally suffice to make it certain. The 619 Starch. State Medicine. following characteristics of the commoner kinds are magnified uniformly three hundred and fifty diameters. 1. Wheat Starch (Amylum, U. 8. Ph., etc.), ‘In ir- Fie. 3703.—Potato Starch. regular, angular masses, which are easily reduced to powder; white, inodorous, and tasteless; insoluble in ether, alcohol, or cold water; under the microscope ap- pearing as granules, mostly very minute, more or less lenticular in form, and indis- tinetly, concentrically striated. Triturated with cold water, it gives neither an acid nor an alkaline reac- tion with test-paper. When boiled with water it yieldsa white es 3% jelly, having a bluish wy’ tinge which, when Fie. 3704.—Arrow-root, cool, acquires a deep blue color on the ad- dition of test solution of iodine” (U. S. Ph.). The only part of this description characteristic of wheat starch alone is that which is italicized. The gran- ules average about 0.050 millimetre in di- ameter. 2. Maize, or Corn Starch, is smaller than the preceding, about 0.030 mm. in diameter, of polyhedral form, with central hilum. 3. Rice Starch resem- bles maize starch, but is very much smaller. 4, Potato Starch con- sists of two classes of granules mingled together—fine spherical ones, from 0.01 to 0.03 mm. in diameter, and large ovoid ones with very excentric hilums and very distinct ruge, recalling oyster or clam shells, from 0.14 to 0.18 mm. long. 5. Arrow-root is finer than potato starch, which it somewhat resembles ; the granules are more spherical, with blunter, thicker ends, very distinct excentric fissures, and less distinct ruge. Canna starch, a variety of ar- row-root, has enormous granules, nearly twice as large as those of po- tato. Neither of these varieties has the small forms of that from potato. 6. Sago has medium-sized (0.04 to 0.07 mm.), oblong, rather irregular, often faceted, sometimes shoe-shaped ’ Fie. 3705.—Sago, Fra. 3706.—Tapioca. 620 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES, granules, with excentric hilum and pretty distinct ruge. The sago of commerce is often half-cooked, with many of the granules destroyed. | %. Tapioca: spherical, medium-sized granules, with large facets ; commercial tapio- ca is also partly cooked. Besides the above are the starches of numerous familiar grains and roots, which are not separated for sale or use, but which are of interest in detecting adulterations, mixtures, etc., or in identifying the powders of drugs. ‘The three accompany- ing cuts will serve as illustra- tions of this large class. Medical and Surgical Uses of Siarch.—This substance can in no sense be called a medicine, as it is absolutely without physiological action. It is the type of crude carbonaceous or non-nitrogenous food, and its conversion into sugar in the mouth and _ intes- tine is one of the elementary facts of digestive physi- ology. Asa toilet powder the finer varieties—rice and corn starches—are in universal use, ° and one or other of ¢ these is the foun- ©. dation of most of *& the proprietary powders. Boiled starch, and especially the flours of starchy substances, are fre- quently used as poultices, but they are not so convenient and suitable as the mucilaginous flours of linseed and slippery elm. Starch mucilage is occasionally used for immovable bandages, but it is less adhesive and less suita- ble for this purpose than flour- paste, glue, dex- trin, silicate of potash, or plaster-of-Paris. One part dissolved glue, as prepared for cabinet- makers’ use, and two or three of starch mucilage, a little thinner than the laundress uses it, mixed and applied hot, make a most excellent combination for such bandages—light, very stiff, and agreeable ih color. There are two officinal preparations of starch: the Glycerite (Glyceritum Amyli, U. 8. Ph., ten parts of starch dissolved in ninety of hot glycerine), is a perma- nent translucent jelly, useful in moistening pill masses, for emulsions, and similar purposes. Jodized Starch (Amylum Iodatum, U. 8. Ph.) is rather a preparation of iodine. It is made by triturating five parts of iodine with ninety-five of starch, with the aid of a little water. It is a blue-black powder, and a suitable preparation to ad- minister for free iodine if it is desired to give that drug internally. Starch is related, pharmaceutically, to the mucilages, chemically to sugar. W. P. Bolles. STATE MEDICINE. John Simon, C.B., F.R.S., for many years chief officer of the Local Government Board of England and Wales, says in a report made in 1874: ‘“‘In my recent Annual Report the vast amount of in- jury which is suffered day by day in this country through diseases well known to be preventable, was referred to, in regard to the duty it imposes on all who have under- taken to serve in the new sanitary organization of the country, and ‘I submitted that the Local Government Board, viewed as a Central Board of Health, and the more than fifteen hundred district authorities which, Fie. 3708.—Turmeric Starch. Fic. 3709.—Vetch, or Lentil Starch. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. \ Starch. State | Medicine. each with its medical officer of health, locally adminis- ter the health laws, may be regarded as having had their respective functions assigned to them in special and sys- tematic relation to that state of things.” ! Professor Loewenthal, of Lausanne, gives as his third division of instruction in hygiene: ‘‘ L’enseignement particulier pratique, destiné aux médecins qui aspirent aux postes d’application de lhygiéne, tels que ceux des médecins attachés aux services sanitaires publics (municipaux ou de |’Ktat) ;” and a recent American writer on the functions of Government says, that ‘‘it is the bus- iness of Goverament to do for the mass of individuals those things which cannot be done, or cannot be so well done, by individual action.” In these three quotations we have well set forth, from the theoretical, educational, and practical stand-points, the comprehensive character of the work which, in those countries where the functions of Government have been most progressively developed, is included under Public Hygiene, or, what is better designated, State Medicine. In articles found elsewhere in the HANDBOOK, as Sani- tary Inspection, Sewerage, Quarantine, Food Adultera- tions, have been discussed some of the principal subjects included properly within the scope of State Medicine ; quarantine, as generally understood, being a function of General Governments ; sewerage and sanitary inspection that of Municipal or Local Governments ; while the de- tection of food adulterations is usually in part performed by General Governments and in part by municipal au- thority. It is evident that, whatever theory might indicate as to the duties peculiar to a General Government, on the one hand, and to municipal authorities on the other, the form of government—whether it be an autocracy, such as Rus- sia, or a democracy, aS Switzerland or the United States —will be a primary factor in determining the extent to which the term State Medicine will have any distinctive meaning or importance. Our personal conception of what should properly be included under the term has grown out of a practical experience of some years, and is derived wholly from the stand-point of results obtained, and quite apartfrom any preconceived theories. Whatever system is found to save to the State the largest number of useful lives (in esse or in posse, €.g., workers or the children of our communities), and which further nurtures and matn- tains them tn the best possible condition of physical, intellec- tual, and moral health ts the best system. From this definition it will at once appear that in our ~ opinion the function of Government is to make such enactments as will give ample powers to central authori- ties to maintain efficient quarantine systems, both inter- nal and external; to endow such institutions as will supply the necessary education in practical hygiene to medical health officers, sanitary engineers, etc., and to establish laboratories wherein those scientific investiga- tions which appertain to the discovery of the causes of disease, and to the measures to be taken for their limita- tion and prevention may be carried on. At the instance of the central authority must further be enacted such legislation as shall clothe municipal or district authorities with ample powers for the isolation of those suffering from contagious diseases, and for the institution of such works—sewerage systems, public water-supplies, regula- tions for the construction of buildings, etc.—as shall con- duce to the maintenance of the public health in the high- est possible degree. Finally; it comes very naturally within the scope of State Medicine to encourage the teaching in all schools of those principles which regulate the life of the individual, as regards either personal con- duct or the regulation of the home, in those matters which bear most directly upon the preservation of health, and in some instances upon its improvement. Having, in general terms, outlined the scope and province of State Medicine, we may state, what at once is apparent, that climate, aggregations of people, occupa- tions, etc., will determine to what extent the functions of the State shall be exercised in order to conserve the high- est interests of the people. From what has been witnessed in the past, it is plain that legislation, at first sight often seemingly opposed to some individual interest, may be expected to fall, in many respects, short of what the needs of the general community demand ; but clear conceptions of what is required, and persistent efforts to make the public realize wherein their highest interests consist, are necessary before legislation is likely to supply the facili- ties for real progress in State Medicine. ~~ It would be of interest were we to givea history of the advances of State Medicine, and the degree in which the principles already laid down have been carried into prac- tical effect in different countries ; but the still crude con- dition of State Medicine in many countries would detract very much from any practical value appertaining to such a statement, even did space permit. Our purpose will, we judge, be equally well served if we indicate the scope of State Medicine in those countries where it has reached its highest state of development. It is everywhere read- ily conceded that in State Medicine, in so far as regards its practical application to the ordinary conditions of so- ciety, England has, up to the present, been in advance of all other countries; and further, that the scope of the work of the Local Government (Central) Board is wider, and the relations existing between the Central Board and Municipal Sanitary Authorities are closer and better de- fined, than in any other English-speaking community. Since the cholera years 1848-53, there have been framed various Public Health Acts, in which have been devel- oped to a considerable degree the principles already enun- ciated. These Acts are consolidated in the English Pub- lic Health Act of 1875. The whole of England and Wales is divided into urban and rural sanitary districts, governed respectively by urban and rural sanitary au- thorities. An Urban district is either a borough under the supervision of the mayor, aldermen, and burgesses, acting under direction of the Council, or an Improvement district under Improvement Commissioners, or a Local Government district under its Local Board of Health. A Rural Sanitary District is an area not included in any of the foregoing, and the guardians of the union (Poor Law Guardians) form the rural authority of such a district. Over the Local Sanitary Authorities there is the Local Government Board, which has supreme control in many respects in matters relating to the public health. London City does not fall within the operations of the General Act. Local Sanitary Authorities are elected by the people for terms of three years, and have all neces- sary powers to levy rates for necessary sanitary improve- ments, and in those cases where continued neglect to pro- tect the public is evident, the,Central Board can require public works to be undertaken by the municipality. Similar central powers to some extent exist in France ; but in few countries does this general control by the cen- tral authorities extend to matters other than enforcement of measures for the control of outbreaks of contagious diseases. As regards the present position of State Medicine in the United States, it may be said that to the American Public Health Association, a non-official body, though © including most prominent Federal and State sanitary officials, is due in large measure such progress as has been made during the past fifteen years; and that, asa result of its persevering efforts during an epidemic of yellow fever of unwonted extent and severity, was estab- lished, in 1878, the National Board of Health, a body appointed, and supplied with grants, by the Federal Government. Since 1882, the money grants which had enabled the Board to institute investigations of great in- terest and importance regarding the causation of disease, etc., have, through political prejudice, been in great part withheld, and but little practical work has been done by it; but there is réason to suppose that this anomalous state of affairs will soon be remedied. In the meantime, to the Marine Hospital Service has been committed the protection of the country against foreign outbreaks of dis- ease, in so far as the Federal Government is concerned. A limited amount of experimental work in the field of bacteriology is still carried on under the auspices of the National Board of Health ; but work such as that done by the Governments of England, France, and Germany 621 State Medicine. Sterility. ‘is conspicuously limited in amount. The field of conta- gious animal diseases is in a much more advanced state, controlled as it is by the Bureau of Animal Industries, under the Department of Agriculture. In keeping with State autonomy the State legislatures have done, in some instances, a considerable amount of sanitary work. With a few exceptions all the States of the Union have State Boards of Health, varying greatly in their powers and status. In some instances these organizations are crude, with limited funds and equally limited powers. Indeed, the control which State Boards have over Municipal Health Boards is of the most limited character, being little more than advisory. The Local Boards, which by some State enactments (é.g., those of New York State) are com- pulsory, have in a few instances statutory laws compre- hensive and uniform in character under which action may be taken. Their work is done almost wholly under mu- nicipal by-laws, which are naturally of the most varied character, as regards both the extent and the thoroughness of their execution. In some instances (as in New Jer- sey) State Boards have control of animal diseases ; while in others (as in Illinois) they are Boards for the Regulation of the Practice of Medicine ; and in others, again (as in New York), for the registration of births, marriages, and deaths. In Massachusetts practical laboratory investiga- tions have, to some extent, been carried on from time to time by the State Board. The first State to make such investigations systematically is the State of Michigan, where a hygienic laboratory is being erected at Ann Ar- bor, at a cost of $30,000, with an additional $5,000 for its equipment. The staff will consist of a professor of hy- giene, and an assistant professor. There will be a course of lectures by the Professor of Mechanical Engineering on ‘‘ Heating and Ventilation,” by the Professor of Civil Engineering on ‘‘ Sewerage Systems,” and by the Profes- sor of Law on ‘‘ Public Health Laws.” Special labora- tories for the various branches of the work will be estab- lished. The main object of the laboratory, as stated in the memorial asking for its establishment, is to conduct original investigations into the causation of disease. This new department, added to the very efficient work of the State Board in other matters, will place Michigan in the van of progress as regards State Medicine. In Canada, State Medicine is in a position which com- pares favorably with that in the United States. With two exceptions all the provinces have some form of State organization, while the Federal Government, by the Act of Confederation, has charge of quarantine, vital statistics, and food adulterations. In many respects the provincial statutes are modelled after English Public Health Acts. For instance, in the Province of Ontario, the most advanced in State Medicine, there is a Central or Provincial Board, whose duties and powers are defined by statute, and to it are given powers for investigating matters bearing upon the public health, and very com- plete facilities for acting promptly and effectively in threatened or actual outbreaks of contagious disease, whether occurring as a danger from without or from within. The Provincial Board has ample power, in accordance with statutory by-laws, to compel action to be taken by Local Boards, whose organization is com- pulsory, when contagious disease occurs in their muni- cipality. It also requires the submission to it of all schemes for the establishment of public systems of sew- erage and water-supply. So far very little experimental sanitary work has been done in Ontario, there being no special facilities enabling the Board to undertake such work. A special staff of medical health officers and sanitary police, under the direct control of the Provin- cial Board, has, in time of need, been organized to limit and suppress epidemics of disease likely to get beyond the control of individual municipalities. In other Prov- inces larger districts are assigned to medical officers, who act during epidemics, while elsewhere, as in many States, municipal councils have powers as health officers assigned to them. That part of State Medicine which deals with practical instruction in this science has, in Europe, been prosecuted 622 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. in varying degrees in different countries. Tosuch work as that carried on by Parkes, Klein, Creighton, Sander- son, Baxter, Smith, and others in England; to the investi- gations of Pasteur, Chauveau, Duclaux, Chamberland, and others in France, and to the bacteriological investi- gations of Koch, and the chemical studies of Pettenkofer in Germany, are we to attribute the present position of practical knowledge of hygiene. In some countries the instruction in public hygiene is of a limited character, being confined to a course of hygiene in some medical school. In others there are institutes of hygiene on the most extended scale, as, for instance, at Munich, Leipzig, and Copenhagen. In Hungary the province of instruc- tion in State Medicine is of an extended character. M. Trefort, the Hungarian Minister of Education, expresses the view that hygiene should be taught in all secondary or high schools, and that it can only be properly done by medically trained hygienists. He has, therefore, created in the medical faculties a special course of instruction for physicians aspiring to the position of professors of hy- giene for secondary schools. At Pavia and Turin, in Italy, and at Charcow and Moscow, in Russia, are impor- tant hygienic laboratories ; and Stockholm has an excel- lent institute of hygiene, established at a cost of 20,000 francs. The reader will perceive, from the illustrations here given, that these State organizations were originally started with the object of limiting outbreaks of conta- gious disease. They employed first, of course, the crude methods then in use, but have gradually improved upon themasa result of much scientific and experimental work. State Medicine was a creation of necessity in times of public danger, but its future development will be in pro- portion to the scientific character of its work, and to the appreciation on the part of the public of the economic and beneficent results of such work. Peter H. Bryce. STAVESACRE (Staphisagria, U. 8. Ph.; Staphisaigre, Codex Med.). The seed of Delphinium Staphisagria Linn. ; Order Ranunculacee. This is a showy annual or biennial herb, arising from a stout, tapering root, by an upright, branching, hairy stem, about a metre high. Leaves alternate, on hairy petioles, and themselves pu- bescent or hairy beneath ; the lower long-stemmed, of from seven to nine spreading, lanceolate lobes ; the upper more and more simple ; those of the inflorescence small, sessile, and simply lanceolate. Flowers irregular, large, in open racemes or panicles, about two centimetres across ; calyx of five petaloid sepals, the three upper erect, the middle one spurred at the base, the two lateral ones broad, rounded, and spreading. Petals four, the two upper narrow, erect, sending spurs into that of the upper sepal; the two lower rounder. Stamens numerous ; carpels three, ten-, or twelve-ovuled. Sepals and petals pink or purple, the former tipped with green. Seeds pyramidal, four-sided, slightly curved, about half a cen- timetre long; brownish-gray externally, white and oily within, odorless, but bitter and acrid. This plant is a native of the South European countries, Asia Minor, etc., and is also cultivated. The seeds are imported from the south of France and Italy. They were known to the ancients, and for twenty centuries have been used for about the same purpose as at present —killing pediculi and similar vermin. ComPposITIOoN.—The seeds contain about twenty-five per cent. of a non-drying jfived oil, and about one per cent. of alkaloids, of which the following have been isolated and named: Delphinine, in fine, large crystals; Staphis- agriné, amorphous ; Delphinoidine, also amorphous ; and Delphisine, in crystalline tufts. Of these, the first is the most important and active, the second least so, while the third and fourth resemble the first, but are weaker. ACTION AND UsE.—Stavesacre is an active and poison- ous drug, irritant to the skin and mucous membranes, causing itching, stinging, burning, sneezing, etc., as well as diarrhoea ‘and vomiting. Of the alkaloids, Delphinine best represents it; rubbed into the skin it causes local inflammation, on the tongue burning and numbness, in REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. State Medicine. Sterility. the stomach nausea and distress, and, when absorbed, car- | of the tubes as to prevent the morsus déaboli from coming diac and respiratory slowing, diminished spinal irritabil- ity, and sometimes mental disturbance. The others re- semble delphinine, but are less intense. Delphinine reminds one of both aconitine (to which it is botanically related) and veratrine. Staphisagrine is somewhat pecu- liar ; it is not very active, but appears to resemble curare in its action upon striped muscle. Neither the crude drug nor its alkaloids are given inter- nally, so its exact action has but little practical bearing. It has from a remote time been employed, either by itself or in ointments or other vehicles, solely for the purpose of killing pediculi, and related animal parasites, on man and animals. At the present time it is mostly consumed in veterinary practice, kerosene or petroleum, petrola- tum, sulphur, and unguentum hydrargyri taking its place in human medicine. An ointment can be made with twenty per cent. or so of the powdered seeds, or with from one-half to one per cent. of the alkaloid. ALLIED PLANtTs.—The beautiful genus contains the Larkspurs, many varieties, and is closely related to the equally beautiful Aconites. For the order, see ACONITE. ALLIED SuBSTANCES.—Sabadilla is another time-hon- ored parasiticide of very similar properties to the above, and is used in the same way. Kerosene and petrolatum are put to the same uses. W. P. Bolles, STERILITY IN THE FEMALE. Synonyms: Barren- ness, infertility ; Lat., sterilitas matrimonii; Fr., stéri- lité; Ger., Unfruchtbarkeit. Sterility in the female implies an inability to bring forth a living child. It involves two points for consid- eration : First, her inability to conceive at all; and sec- ond, her inability to complete successfully the period of gestation. Many women never conceive at all. Many other women conceive, but are unable to complete the period of gestation. Women who never conceive are said to be absolutely sterile. Women who have borne one or two children and do not conceive thereafter are said to be relatively sterile. ErTroLoGy.—Several organs are involved in the process of genesis in the female. The essential element of this process is the ovum, which is supplied by the ovary. The ovum is conveyed from the ovary through the Fal- lopian tube to the uterus, where it meets the spermato- zoa, and genesis follows. The semen reaches the uterus through the vagina. Consequently, the question of ster- ility involves the investigation of the condition of, 1st, _the ovaries ; 2d, the oviducts; 3d, the uterus; and, 4th, the vagina. In addition, upon the general condition of the patient alone non-conception often depends. Under this head may be classed the extreme gouty vice, the syphilitic taint, anemia, great obesity, chronic alcohol- ism, and spasmodic dysmenorrhea. The Ovaries.—1. The investigation of the ovaries in sterility includes inquiry into the possibility of the ab- sence or of the imperfect development of these organs, conditions rarely met with excepting when the other sex- ual organs are anomalous. 2. Inflammation, chronic or acute, of the ovaries may result in such adhesions of the organs that the ovum is totally prevented from entering the oviducts. It may lead to arrest of function, so that the ovum can no longer be matured. The ovary may become so embedded in in- flammatory deposit that extrusion of the ovum from its capsule is no longer possible. 3. Structural degenerations of the ovary may exist, é.g., cystic, carcinomatous, and sarcomatous, and are generally attended with sterility. 4. Displacement of the ovary, often attended with chronic inflammation, may place it beyond the reach of the fimbriated extremity of the Fallopian tube so com- pletely that the ovum cannot be transmitted to the uterus. The Fallopian Tubes.—1. Absence or defective devel- opment of the oviducts is usually associated with other abnormalities of the sexual system, and causes hopeless sterility. 2. Inflammation of the oviducts is a cause of sterility. It may affect the serous coat, resulting in such fixation in contact with the ovary, or in constricting bands that occlude the calibre of the tube. It may attack the mu- cous lining of the canal, and result in the production of secretions which are destructive to the spermatozoa or the ova, or it may result in permanent occlusion of the opening of the tube, whence may follow collections of blood, pus, or serum. In either case the ovum is pre- ae from descending to the uterus, and sterility fol- OWS. 8. Degeneration of the tubal structures produces a hopeless occlusion of the canal, and thus causes sterility. The Uterus.—Defective development of the uterus as: sumes various forms, such as its total absence, its under. size, or its abnormal lateral growth into either a uni- cornus or a bicornus uterus. Conoidal cervix, with the commonly attendant stenosis of the os, may be classed as one of the variations of defective development. The last: mentioned condition constitutes one of the most frequent: ly removable causes of sterility. Degenerations : 1. Myomata often cause infecundity, but they are not always a barrier to conception. The co- existence of this degeneration and of pregnancy consti- tutes one of the most serious conditions encountered by the obstetrician. . 2. Sarcomata seem always to prevent pregnancy. 3. Carcinomata, if extensive enough, cause sterility. In their early stage conception is often possible, and is now and then encountered. Abnormalities of involution: An excessive involution (hyperinvolution) or a deficient involution (subinvolu- tion) often constitutes a barrier to conception. The writer recently saw a healthy patient, aged twenty-seven, who bore a child at twenty-one years of age, and had not menstruated since that event. The uterus measured but one and one-fourth inch in depth. The organ may be still further decreased in size, even to a quarter of an inch. Subinvolution of the uterus is often accompanied with an inflammatory state, completely preventing the occur- rence of pregnancy. Inflammation of the uterus or the circumjacent tissues is a very common cause of sterility. The morbid pro- cess, according to its seat, may be endocervicitis, endo- metritis, metritis including cervicitis, parametritis, or perimetritis. Often two or more of these conditions co- exist, and render the cure very tedious. Endometritis may be accompanied by abnormal secretions destructive to the spermatozoa, there may be a dilated uterine cav- ity, the lining membrane of the uterus may be made so unhealthy that it becomes impossible for a fertilized ovum to secure a lodgement thereon, or the inflammation may cause more or less occlusion of the uterine orifices. Displacements: Malpositions of the uterus include prolapse, flexions (retroflexion, anteflexion, and latero- flexion), and versions (anteversion and retroversion). Anteversion and antetlexion exist most frequently in nullipare. Retroversion and retroflexion exist most fre- quently in those who have borne children. Lateroversion and lateroflexion are present when an inflammation has existed in either broad ligament, resulting in shortening of the ligament, or when some foreign growth or an in- flammatory deposit exists on the side of the pelvis opposite to the displacement, crowding the uterus away from its normal condition. The Vagina.—This organ may be so injured or may be- come the seat of discharges so fatal to the semen that it becomes a source of sterility. Malformations: The vagina may be absent congeni- tally. Its occlusion is very rare. A severe vaginitis has been the cause of an almost total occlusion by the agglu- tination of the vaginal walls. The hymen is sometimes so hypertrophied that it becomes a barrier to copulation. Unnatural shortness of the vagina renders it incapable of retaining the semen a suitable length of time. E Inflammation: Vaginitis nearly always produces dis- charges fatal to the semen. It is occasionally productive of that condition of spasm called vaginismus, but this may also be caused by other conditions. 623 Sterility. Sternutatories. Injuries: Extensive perineal lacerations often become causes of sterility. Fistule may also prevent conception. Degererations: Elephantiasis labiorum prevents col- tus, and thus becomes a barrier to insemination. Exten- sive urethral caruncle often interferes with successful intercourse. General State of the Patient’s Health.—An indefinable something in the patient’s general condition is oftentimes the apparent cause of a sterility. The proof of this state- ment consists in the fact that women, sterile when in poor health, often conceive when their general condition has been improved by remedies, by change of climate, or by travel. Some women are sterile because of the pres- ence of discharges from the genital tract which have their origin in a systemic taint. The lithemic state, for ex- ample, may give rise to such discharges, which cease when an anti-lithic course of treatment has been followed, and conception thereafter may follow. Many cases of sterility of this form have been wholly removed by a course of treatment at suitable mineral springs. Under this head may be also mentioned that variety of sterility which is dependent upon some obscure incompat- ibility of the parties, illustrations of which every physi- cian of experience has encountered. A woman, sterile in many years of married life, who has been, for this reason, abandoned by her husband, eventually secures a divorce, is married to a second husband, and bears a number of children. The old illustrations of Augustus and Livia, and of Napoleon and Josephine, are quoted by writers on sterility. Diaenosis.—It is not always that only one of the fore- going obstacles to conception is present. Very often two or more of them coexist. When the causes of sterility are manifold in the same patient, it is obvious that the skill of the gynecologist will often be taxed in recognizing and removing them. A complete diagnosis can be arrived at only by an exhaustive examination. It is always a safe plan for the physician to endeavor to find all the possible causes of sterility in each patient. It must be confessed that only too often does it occur that, after every discoverable removable obstacle to con- ception has been corrected, sterility will still exist. ProGnosis.—In no condition is the prognosis more un- certain. In a general way, it may be stated that imper- fect development or marked malformations constitute an absolute bar to conception. In the same manner, it may be stated that removable obstacles to conception, as inflammations, flexions, ver- sions, stenosis, some vaginal occlusion, or fistule, may be treated with a fair prospect of fruitful results. The apparently complete removal of these obstacles, however, only too often fails to render the woman fruitful. TREATMENT.—A successful treatment of sterility in the female is secured by removal of all the obstacles to con- ception. Such treatment does not include that of steril- ity in the male, although many gynecologists investigate the male first, since about one case in ten of infecundity in marriages has its origin in the male. With this branch of ie subject, however, the present article has nothing to do. After the physician has discovered as many obstacles to conception as he can find, he must set about removing them. Insufficient treatment nearly always results in failure. In no department of gynecology is more per- sistence in treatment demanded. Urethral caruncles, vulvar vegetations, and other sensi- tive excrescences must be removed or destroyed. Vaginal stenosis or contraction must be stretched and the canal must be kept patulous. Cervical stenosis must be overcome by sea-tangle or tupelo tents, or by stretching with dilators, Division of the cervix by the hysterotome has been much practised successfully in the past, but is at present falling into dis- use, forcible dilatation being preferred. Uterine deviations must be corrected. Versions can often be rectified by suitable pessaries. It has been sug- gested that anteversion may be corrected by allowing the bladder to become distended with urine, thus pushing the fundus uteri backward and throwing the cervix suf- 624 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. ficiently forward to place the os in a direct line with the seminal ejaculation, thus facilitating the entrance of semen into the cervical canal. Similarly, retroversion, it is alleged, may be temporarily corrected by allowing the rectum to become distended with feces, whereby the fundus uteri may be crowded forward. Flexions demand the use of the intrauterine stem-pes- sary. Hyperinvolution may be treated with the galvanic in- tra-uterine stem-pessary. Similarly, attempts may be made to stimulate the growth of an imperfectly developed uterus. Inflammations must be treated secundum artem. Vari- ous antiphlogistic methods of treatment are in vogue. Cauterizing applications, hot-water douches, glycerine tampons, the dry treatment of Englemann, etc., each has its adherents. Morbid growths on the endometrium must be removed or destroyed. Quite exceptionally, the method of introducing semen into the uterus by means of a syringe and a tube has been used, it is alleged, successfully. In the treatment of all cases of sterility the physician must never ignore the general condition of the patient. Systemic vices must be eradicated as far as possible. Many cases of sterility can be cured by general treat- ment. Repeated abortions indicate the possibility of the syphilitic taint. The existence of this vice in a marked degree is an almost certain obstacle to the chances of ges- tation being completed, and it must, therefore, receive continuous and persistent treatment for a period of at least two years. J. H. Htheridge. STERILITY IN THE MALE, This term, in its accepted sense, implies inability to impregnate the female, from other causes than that of impotence or loss of the power of copulation (see Impotence). ‘‘ Sterility not only does not include impotence, but is met with in subjects who are vigorous in intercourse, and who may ejaculate a fluid which, in the absence of minute examination, pre- sents all the properties of normal semen. Sterility in- cludes, first, azodspermism, or the condition in which either no semen whatever, or unproductive semen, is se- creted ; secondly, aspermatism, in which spermatic fluid is not ejaculated ; and, thirdly, misemission, or the fail- ure to deposit fertile semen in the upper portion of the vagina. In the first variety intercourse and ejaculation are natural, but the essential anatomical elements are ab- sent or dead, either because they are not formed, or are imprisoned behind an obstacle seated in the epididymes or vasa deferentia, or because they are unable to live in the medium in which they are suspended. In the second variety the ability to copulate is unimpaired, but the power to ejaculate is prevented by an impediment situ- ated between the seminal vesicles and the urinary meatus In the third variety coition and emission are perfect, but fruitful semen fails to reach its proper destination in con- sequence of congenital deficiencies of the urethra, or of fistulous openings in that canal, resulting from inflamma- tion, or of abnormal positions of the meatus” (S. W. Gross, ‘‘ On Impotence, Sterility, and Allied Disorders of the Male Sexual Organs.” Philadelphia, H. C. Lea’s Son & Co., 1883). 1. Azodspermism may be due: a. To congenital bilat- eral absence of the testes, or congenital bilateral deficiency of the epididymes or vasa deferentia. Such absence of the testes likewise results in impotence and may here be dismissed. Such deficiency of the excretory apparatus of the testes need not result in impotence, but prevents all escape of spermatozoa. 6. To non-descent of the testes into the scrotum. In- dividuals thus affected are potent; they are usually ster- ile, but may, in exceptional cases, be fruitful (S. W. Gross). c. To affections of the testes. Bilateral atrophy, from whatever cause, always diminishes, and sometimes pre- vents, the formation of spermatozoa. Simple parenchym- atous orchitis results in absolute azoédspermism. Par- tial destruction, by malignant or other new-growths, does REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Sterility. Sternutatories, not necessarily result thus. After syphilitic orchitis sper- matozoa may return under proper treatment. d. To bilateral obliteration of the epididymis and vas deferens, thus preventing the escape of spermatozoa from the testes. This is by far the most frequent cause of azodspermism, and in the great majority of cases is due to gonorrhceal epididymitis. It may also be due to tu- bercular, malignant, or syphilitic disease of these organs. It is held by some good authorities that epididymitis of one side may abolish the function of the opposite gland. e. To nervous exhaustion or neurasthenia, attended with abnormal seminal and prostatic discharges, and with various degrees of impotence, all of which is usually brought about by onanism, venereal excesses, or ungrati- fied desire. As a resuit of impaired nutrition induced by perverted innervation, the secretory activity of the testes is interfered with, and either the evolution of the spermatozoa is arrested, or their number and activity are diminished (8S. W. Gross). The diagnosis of azodspermism must be made by re- peated examinations of the ejaculated fluid, if such there be, under the microscope. The treatment is in many cases evidently nz. In ad- vancing atrophy of the testicles, galvanism gives some promise of good. In syphilitic orchitis or epididymitis, prompt and persistent treatment may avert the calamity or restore fertility. In bilateral epididymitis from other causes, early and vigorous antiphlogistic treatment ‘will often prevent occlusion. . But even if this exist, it may sometimes be overcome by iodide of potassium, bichlo- ride of mercury, and the local use of mercurial ointment or oleate of mercury. 2. Aspermatism, or the failure to ejaculate semen dur- ing copulation, may be due to the following causes : a. Organic lesions preventing the discharge of seminal fluid into the urethra,or preventing its ejaculation through the meatus. Congenital occlusion, absence or deviations of the ejaculatory ducts, have occasionally been met with. Stricture of these ducts and deviation of their orifices, due to inflammation or injury, are more frequent. This may follow gonorrhea, blows on the perineum, or the operation of lithotomy. Semen having been delivered in the urethra may fail | _to be discharged properly, owing to some obstruction anterior to the prostate gland. If this obstacle is in the posterior portion of the canal, the fluid will pass back- ward into the bladder ; if near its orifice, the semen will flow out after erection has ceased. Stricture of the ure- thra is the most common of these obstacles. grain ; and extract of belladonna, 4 grain. Great attention should be also paid to general hygiene, all patients being con- strained to keep early hours, to lead lives so far as possi- ble free from excitement, and, above all, to exercise mod- erately in the open air. The clothing should be warm, and the functions of the skin should be maintained by cool sponge-baths. In obstinate cases, washing the stomach is a measure of inestimable value. By this method the stomach is at once relieved of accumulated mucus, undi- gested aliment, acids and gas. The use of hot or cold water and of cathartics is thus, in a large measure, obvi- ated, and the bowels may be relieved by enemata. The writer’s method of employing lavage is given in the sec- tion on Gastrectasia. Lavage is, at first, best performed every morning, an hour before breakfast. After a short time the washing may be done every second morning, and then, at lengthening intervals, until convalescence is established. In cases requiring the use of the tube, the other therapeutic measures are, in general, identical with those already described as applicable to less severe cases of chronic gastritis. In the most refractory and chronic cases it may be necessary to temporarily resort to rectal ali- mentation, in the manner recommended under the cap- tion Acute Gastritis. The efficacy of the above treatment, systematically followed, is generally quickly manifest in the relief of symptoms, in the augmentation of weight and in the increase of mental and of bodily energy. SUPPURATIVE GASTRITIS. Definition. — Primary or secondary suppurative inflammation of the stomach, usu- ally affecting the submucous tissues, but sometimes in- volving other coats of the organ. Etiology.—The causes of primary suppurative gastritis, which is very rare, are not well known. — The disease af- fects men more often than women, and middle-aged persons rather than the young or the aged. It has been referred to traumatism, gastric ulcer, the abuse of alco- hol and to dietetic indiscretions. Silcock reports a case following gastrostomy. In many cases no adequate cause has been ascertained. Secondary, or metastatic, suppurative gastritis, which is more frequent than the primary form, occurs as a complication of acute infec- tious diseases, especially of puerperal septicemia and py- zemia, Morbid Anatomy.—The suppuration may be either cir- cumscribed or diffuse. The former variety is known as abscess of the stomach, which may be single or multiple. It is less rare than diffuse suppurative gastritis. In gas- tric abscess the pus first collects in the submucous tis- sues, whence it sometimes makes its way between the muscular layers and into the subserous tissue, or may even perforate the mucous and serous layers, pus being then evacuated into the stomach or into the peritoneal cavity. The abscess is sometimes, however, confined to its original seat in the submucous tissues. If the serous coat is involved, general peritonitis may follow. Ex- ceptionally the abscess cavity may close after the escape of its contents, and cicatrization, occurring, may lead to gastric stenosis. In diffuse suppurative gastritis the pus is also first formed in the tunica submucosa, whence it may invade the intermuscular connective tissue, the sub- serous structures, the mucous membrane, and the se- rous coat. In rare instances the inflammatory process is, however, confined to the submucosa. The suppuration commonly involves only a part of the gastric parietes, but it may be coextensive with them, and may even in- vade the duodenum and the cesophagus. Diffuse and circumscribed purulent gastritis sometimes coexist. The parts of the stomach affected are swollen, and the mu- cous membrane over the seats of purulent collection is cedematous and spongy, or perforated and ulcerating. The ulcers may be single or multiple. There may be evidences of pre-existing chronic gastritis or of fibroid gastritis. The serous coat frequently becomes inflamed, and general peritonitis may be the result. Thrombi some- times form in the veins of the stomach, and parts of the thrombi, becoming detached, produce metastatic abscesses of the liver and of the lungs. The microscopical ex- 638 ~marked at the pylorus. amination of the purulent matter often shows numerous streptococci and other bacteria. Clinical History.—Primary suppurative gastritis may be acute or chronic. In either case the symptoms are the same, except in their duration. The initial symptom is generally a chill, which may or may not be repeated at irregular intervals. Fever follows, with a rapid compres- sible pulse and a high temperature, scanty urine, torment- ing thirst, headache and anorexia. There is generally much nausea and vomiting, as well as great epigastric pain and tenderness, with meteorism, although these feat- ures are not invariably present. The vomited matter sometimes contains pus, but ordinarily only mucus, gas- tric juice, or bile. Sometimes a tumor, corresponding to an abscess, may be felt in the wall of the stomach. If the abscess ruptures into the stomach, large quantities of pus may be vomited. If perforation occurs into the peritoneal cavity, symptoms of shock appear and are fol- lowed by those of acute peritonitis, if the patient survives a sufficient length of time. Jaundice is sometimes pres- ent, and there may be either diarrhoea or constipation. Asthenia appears early in the disease and deepens into collapse, death being commonly preceded by delirium and coma. Secondary suppurative gastritis presents essen- tially the same symptoms, but they are generally com- pletely masked by those of the primary complaint (v7de article Septiceemia and Pyemia, in this HANDBOOK). Callow’s case, recited by Leube, presented no symp- toms up to the day of its fatal termination, when rupture of the gastric abscess took place, emesis occurred, and speedy collapse followed. Diagnosis.—The diagnosis can rarely be made during life, although the disease may be strongly suspected when, coincidently with the existence of the above symp- toms, a soft gastric tumor is felt, which suddenly disap- pears simultaneously with the vomiting of a large quan- tity of pus. Circumscribed suppurative peritonitis might, however, present almost identical symptoms. Prognosis.—This, although very grave, is not absolutely desperate, as some apparently authentic cases of recov- ery have been reported. Death usually ensues in about a week, but life may, in cases eventually fatal, be pro- longed three weeks or longer. : Treatment. — The treatment is purely symptomatic. Pain and emesis are to be relieved by the hypodermic use of morphine, rest of the stomach secured by rectal alimentation, and the strength sustained by fearless stimulation. Some authors recommend the persistent application of ice to the epigastrium, and the administra- tion of small ice-pellets by mouth. In secondary sup- purative gastritis the primary disease naturally claims appropriate treatment, CHRONIC INTERSTITIAL GASTRITIS AND HYPERTROPH- 1c Pytoric Stenosis. Definition.—Thickening of the stomach, either general or limited to the pyloric region, due chiefly to the development of new connective tissue, with which hyperplasia of the muscular coat is usually associated. Hiiology.—Cases of this disease are so rare that few opportunities have been afforded for the discovery of its causes. It affects middle-aged men most frequently, but has been observed in young men, in women, and, very rarely, in children. Chronic interstitial gastritis is of- ten associated with simple chronic gastritis, but there is no proof that it is produced by the latter disease. The abuse of alcohol is regarded as an exciting cause by the majority of authors, but the circumstances under which alcohol leads to this form of gastric inflammation, rather than to chronic gastritis, are not definitely known. Welch observed a case in which there were syphilitic gummata of the liver, and Snellen reported a case in which the disease followed an injury to the epigastrium. Many cases of hypertrophic pyloric stenosis are believed to owe their origin to the cicatrization of a gastric ulcer. Others are without evident cause. Morbid Anatomy.—The pathological changes may af- fect the whole stomach equally, or they may be most When the whole stomach is in- volved, the organ is generally heavier and smaller than REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. . normal. ‘The capacity of the stomach may be reduced to a few ounces, and its size to that of a small pear, which fruit it somewhat resembles in shape. The gastric wall has, in some recorded cases, been more than an inch thick. The dimensions of the stomach may, however, be either normal or abnormally large. Upon section the stomach sometimes does not collapse as in health, owing to the thickness and firmness of its walls, the con- sistency of which often resembles that of cartilage. The minute examination of the tunics of the stomach shows all the coats of the organ to be structurally altered by that growth of new connective tissue which is character- istic of the disease. The submucous tissues are usually most involved, and the submucosa thus stands out upon cross-section as a broad, firm, whitish layer. The mu- cous membrane sometimes escapes alteration, but gen- erally the microscope shows the gastric tubules to be compressed, or even obliterated, by hyperplasia of the intertubular connective tissue. In this case, the cellular elements present the same microscopical changes found in simple chronic gastritis (guod vide). The muscular layer is often greatly thickened, particularly in its trans- verse fibres, by hyperplasia of the muscular fibres and of the interfibrillary connective tissue. The subserous and serous coats are similarly thickened, the latter being opaque and of a milky-white color. The entire peri- toneum may, rarely, present a similar thickening, or only the visceral layer may be affected. Welch states that adhesions frequently exist between the stomach and sur- rounding organs. When the above-described interstitial changes involve only the pyloric region, hypertrophic stenosis of the pylorus is said to exist. The result of these localized pathological processes is, as the above name implies, a more or less complete occlusion of the pyloric orifice. Owing to the obstacle opposed to the es- cape of the gastric contents, the latter accumulate, and, overdistending the stomach, produce gastrectasia, to which is added hypertrophy of the muscular coat. Clinical History.—The symptoms of chronic interstitial gastritis are variable and ambiguous. In some cases there have been no symptoms, or these have been of so trivial a character that they have been referred to functional dyspepsia. Ina case reported by Nothnagel the disease presented the characteristic features of pernicious ane- “mia. If the disease involves the entire stomach, one somewhat characteristic symptom, at a late stage of the malady, may be inability on the part of the patient to take more than a very limited amount of food or drink without a disagreeable sensation of distention referred to the epigastrium. At this advanced period of the dis- ease the hardened and contracted stomach may be recog- nized by abdominal palpation, presenting the peculiar form and outline of the normal organ. In such a case the exact capacity of the stomach may be ascertained by first removing all the gastric contents with the soft tube, and then introducing water from a graduated receptacle until a sensation of discomfort is perceived. Before the development of the symptoms mentioned there may be those of a protracted chronic gastritis—vomiting, emacia- tion, and asthenia being particularly prominent clinical features, while pain is almost or quite absent. Some- times there is, however, violent gastralgia. In that form of chronic interstitial gastritis known as hypertrophic stenosis of the pylorus, the clinical history corresponds to that of obstructive gastric dilatation, to which the reader is referred. The symptoms of dilatation are sometimes preceded by those of chronic gastritis. The hypertrophic pylorus can occasionally be made out by abdominal palpation, and is apt to be mistaken for a car- cinomatous tumor. Differential Diagnosis. —Diffuse chronic interstitial gas- tritis is to be distinguished from simple chronic gastritis. The distinction can only be made with an approach to certainty when, in the later stages of the disease, a con- tracted and hardened tumor, presenting the contours of the stomach, can be mapped out. Hypertrophic stenosis of the pylorus may be mistaken for atonic dilatation of the stomach and for cancer. The differential points between hypertrophic stenosis of the Stomach, Stomach, pylorus and atonic dilatation are stated in the section on Gastrectasia. Cancer can, generally, be excluded by at- tention to the following points: Patients with carcinoma have almost always passed middle life, while stenosis of the pylorus may affect the young. In cancer there is often a family history pointing to that disease. In hy- pertrophic stenosis this is not true. In cancer the dura- tion of the disease is short, usually under two years; in hypertrophic stenosis it may be long. In cancer there is commonly much pain ; in stenosis there is generally lit- tle or none. In cancer haematemesis is common, but it is rare in simple stenosis. In cancer there is a peculiar cachexia, which is absent in hypertrophic stenosis. In cancer there may be secondary hepatic carcinomata, while metastasis does not, of course, occur in stenosis. In cancer the tumor is tender on pressure, while in hy- pertrophic stenosis it is not so. The prognosis of chronic interstitial gastritis, of either form, is serious, the patients ordinarily succumbing to inanition and asthenia, The treatment of chronic interstitial gastritis, when diffuse, embraces the exclusion of all irritating ingesta, the use of bland, and, if necessary, of predigested foods, given in small quantities and at frequent intervals, and the employment of rectal alimentation. In cases of hy- pertrophic stenosis of the pylorus the treatment is the same as that recommended in the following section.on Gastrectasia. : DILATATION OF THE STOMACH (GASTRECTASIA). De- jinition.—That condition of the stomach in which the organ is both abnormally capacious and inadequate to the performance of its functions, 7.¢., the digestion and absorption of some foods and the propulsion of other ali- mentary materials into the intestine. Two forms of gas- trectasia are recognized, namely, hypertrophic dilatation, in which the gastrectasia is preceded or accompanied by muscular hypertrophy, and atonic dilatation, in which no compensating hypertrophy occurs. Htiology.—The classification of the causes producing gastrectasia, suggested by Professor William H. Welch (Pepper’s ‘‘ System of Medicine,” vol. ii., p. 591, edition 1885), is so clear and comprehensive that the writer in- troduces it in this place. The three causative conditions recognized in Professor Welch’s classification are: L., Stenosis of the pylorus and of the duodenum; II., ab- normalities in the contents of the stomach ; and III., im- pairment of the muscular force of the stomach. These general causative conditions may be again subdivided into the following tabulated classes. It will be noticed that causes belonging to Class I. occasion dilatation with hypertrophy, while those of Classes II. and III. lead to atonic dilatation. I. Stenosis of the Pylorus or of the Duodenum. 1, Cancerous; 2, cicatricial; 8, hypertrophic (of pylorus) ; 4, from external pressure; 5, congenital (of pylorus) (?) ; 6, from torsion of duodenum. II. Abnormalities in the Contents of the Stomach. 1. Ingesta: (a) Excessive; (0) imperfectly masticated ; (c) indigestible. 2. Stagnation and fermentation in conse- quence of chemical insufficiency of the stomach, as in chronic catarrhal gastritis and functional dyspepsia. Ill. Impairment of the Muscular Force of the Stom- ach. 1. Organic changes in muscular coat: (a) Partial destruction by ulcers and cancers; ()) inflammation, as in chronic catarrhal gastritis and peritonitis ; (c) degen- erations (fatty, colloid, amyloid); (d) cedema (?); (e) cirrhosis of stomach. 2. Mechanical restraint: (a) By adhesions ; (0) by weight of hernie. 3. Impaired nutri- tion and general muscular weakness, adynamic dilata- tion from typhoid fever, tuberculosis, aneemia, ete. 4. Paresis from neuropathic causes (?). Obstruction at the pylorus, or near that orifice, in the duodenum, is the most important cause of gastrectasia, which is, generally, of the hypertrophic variety, ¢.¢., ac- companied by hypertrophy of the gastric muscles. Hy- pertrophy of these muscles may, however, sometimes quite compensate the obstructive lesion, in which case gastrectasia does not ensue. In almost all cases of hy- pertrophic gastrectasia the order of events is as follows : 639 ‘ Stomach. Stomach, First, obstruction, then compensatory hypertrophy with- out dilatation, and, finally, hypertrophic dilatation in which the dilatation eventually preponderates. I. Stenosis of the Pylorus or of the Duodenum. Py- loric stenosis is more frequently due to cancer than to any other morbid condition, and the next most fre- quent cause is contraction of cicatrices resulting from pyloric gastric ulcers. Duodenal stenosis, leading to dil- atation of the stomach, may also be brought about by cicatrices and tumors of that part of the intestine or by external pressure. Under the caption Chronic Interstitial Gastritis it has been stated that this disease, when limited to the region of the pylorus, may cause obstruction of that orifice, and stenosis may, very rarely, be caused by sarcomata, myomata, fibromata and other benign tumors. The most common causes of stenosis from external press- ure are tumors, such as hepatic carcinomata, and con- tracting cicatricial bands resulting from circumscribed peritoneal inflammation. The question of the existence of congenital pyloric stenosis is still swb gudice, Landerer reported ten cases of supposed congenital stenosis of the pylorus, but his conclusions regarding their congenital character have not been generally accepted. Torsion of the pylorus or of the duodenum, or traction upon these parts by complete inguinal hernias, particularly by those containing the transverse colon or the omentum, may lead to stenosis of the intestine, and to secondary gastrectasia. II. Abnormalities in the Contents of the Stomach. These abnormalities relate either to the character of the gastric contents or to unnatural fermentations in the food. Ingesta may be abnormal in quantity, in quality, or in their preparation. Vegetable foods, if relied upon to the exclusion of animal diet, may induce dilatation because of the large volume of aliment required, and liquids, as ice-water or beer, may act in the same way, when ingested in considerable quantities. Foods which are difficult of digestion, either because not easily penc- trated by the gastric juice or because readily fermentable, may cause atonic dilatation ; and the same is true of raw and of imperfectly cooked aliments, and of those not thoroughly masticated and insalivated. It is possible that the long continued abuse of drugs which diminish the secretions of the stomach, or which inhibit its peristole, may also contribute to the development of atonic gas- trectasia. Atonic dilatation is, moreover, often brought about by repeated attacks of indigestion and of gastritis, which favor the retention and decomposition of the con- tents of the stomach. In these cases both the secretion and the peristaltic movements are inhibited, and abnor- mal fermentation is the inevitable result. Fermentation leads to the evolution of gases which distend the stomach, and of acids—chiefly acetic, butyric, lactic and hydro- sulphuric acids—which by their irritating character ag- gravate the pre-existing inflammation. Ill. Impairment of the Muscular Force of the Stom- ach. Diminution in the muscular power of the stom- ach may be due to the various organic lesions of the gastric parietes enumerated in the above table. The weakening effect of chronic gastritis and of peritonitis has been already alluded to. Ulceration, whether simple or carcinomatous, and of varying depth, may diminish the stomach’s contractile power, as well as amyloid, col- loid and fatty degeneration of the gastric muscles, and the changes incident to chronic interstitial gastritis. Among the remaining tabulated causes of atonic dil- atation should be emphasized the general weakness and atony of all the bodily tissues, resulting from anemia, acute febrile diseases and chronic wasting affections. Fenwick refers to a case, reported by Willis, in which primary paralysis of the stomach followed an injury to the splanchnic nerve. It is often quite impossible to as- sign a single definite cause for the occurrence of dilata- tion in an individual case, as several etiological agents are almost certain to co-operate in its production. This is particularly true of gastritis, muscular insufficiency, and fermentation, which most frequently go hand in hand, and which are, to a large extent, interdependent. Diabetic patients suffer from gastrectasia on account of the polyphagia characteristic of their primary disease, and 640 - REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. a sedentary life, combined with a generous diet, has the same result. Hypertrophic dilatation of the stomach is most frequent after middle life, because cancer, the chief cause of this variety of gastrectasia, develops at that age. Atonic dilatation is most common in middle life, but may occur at any age. When occurring in childhood it par- ticularly affects rachitic children. Morbid Anatomy.—While the post-mortem recognition of largely dilated stomachs presents hardly any difficulty, that of slightly and of moderately dilated stomachs may be impossible, because of the wide limits within which the size of the normal organ varies. If a reliable history can be obtained, the clinical test of gastrectasia, viz., in- ability of the stomach to empty itself, may be utilized in making a post-mortem diagnosis. Even when the stom- ach reaches below the umbilicus, it is not necessarily di- lated. Perfectly normal stomachs, which are of a looped shape, or which occupy a vertical position such as exists in fetal life, may extend considerably below the navel. A. Flint, Sr., states that tight-lacing may depress the stomach to a notable extent. The size of a dilated stom- ach may, on the one hand, be so small that the clinical test of insufficiency is necessary to render the diagnosis at all certain, or, on the other hand, may be such that the stomach contains gallons of liquid, occupies nearly the whole abdomen, and reaches nearly or quite to the iliac bone. Cases have been reported in which the dilated organ descended even into the true pelvis, or into the sac of a complete inguinal hernia. Stomachs which are the seat of hypertrophic dilatation from obstruction are gen- erally of larger dimensions than those affected by atonic dilatation. The fundus becomes first dilated, and al-- though the entire organ may subsequently be involved, the fundus remains more largely dilated than the cardiac and the pyloric extremities. The increased weight of the dilated stomach generally causes it to be displaced down- ward, the pylorus occupying a lower plane than normal and dragging the duodenum downward from its natural position. The stomach thus sometimes comes to assume a more vertical position than that of health. If, how- ever, the pylorus be fixed, as in cancer, the long axis of the organ is more nearly transverse than normal, owing to the predominant dilatation of the fundus. In the early stages of gastrectasia from obstruction, the walls of the stomach are generally notably thickened, especially at the pylorus, by hyperplasia of the muscular coat. Ata later period of the disease the gastric parietes may be found normal in thickness, or even decidedly thinned In non-obstructive gastrectasia the muscular coat ma be hypertrophied, but it is commonly atrophied. In both varieties of gastrectasia fatty degeneration of the mus- cular fibres, and a pathological condition described by Maier as colloid degeneration of these fibres, is not very rare. ‘The mucous and other coats of the stomach ordi- narily present in dilatation the changes already described as characteristic of chronic gastritis. In addition to the morbid anatomical changes peculiar to dilatation, those of the primary disease, which has occasioned gastrectasia, will be observed. These primary pathological conditions are enumerated in the preceding etiological table. If the gastrectasia be caused by duodenal obstruction, this part of the bowel will be likewise dilated. The cesophagus is often dilated in pronounced cases of gastrectasia. The liver, spleen, intestine, diaphragm and heart are some- times displaced by the enlarged stomach. The spleen, liver and pancreas are frequently atrophied. Many writers refer these atrophic changes to the pressure of the stomach, but they are, more probably, merely subor- dinate features of the general emaciation resulting from gastrectasia. The pressure of indigestible foreign bodies, such as coins or bits of wood, is said by Leube, when long continued, to have occasionally produced circumscribed or sacculated dilatation of the stomach. Clinical History.—The symptoms presented by patients suffering from gastrectasia are referable partly to the original causative conditions of the disease, and, partly, to the dilatation proper. The symptoms due to the causes which eventually produce gastrectasia, may exist for a long time before the supervention of those denoting dila- REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Stomach, Stomach, tation, and, if properly interpreted, may thus afford an indication for the adoption of preventive treatment. The symptoms, which are to a certain extent premon- itory, as well as concomitant, are usually those of car- cinoma or of ulcer in cases of hypertrophic gastrectasia, and of chronic gastritis in the early stages of atonic dila- tation. These symptoms need not be enumerated in this place, as they are given in this article under their respec- tive headings. Ationg the symptoms properly referred to dilatation, but which do not occur in hypertrophic gastrectasia so long as compensation is complete, the most prominent is copious vomiting at irregular intervals. This symptom is almost constant in dilatation from ob- struction of the pylorus or of the duodenum, and is also frequent in the earlier stages of atonic gastrectasia. When, in either class of cases, the gastric nerves and mus- cles have partly sacrificed their functional powers, owing to compression, atrophy, or degeneration, emesis becomes less frequent and may entirely cease. The most charac- teristic features of this vomiting are its copiousness and its tendency to a more or less periodical recurrence. The volume of vomited matter often far transcends the normal capacity of the stomach, sometimes amounting to several quarts. The length of time intervening between successive acts of emesis varies with the irritability of the stomach and with the amount ingested. Two, or even more days, however, generally intervene between the paroxysms of vomiting, but the interval may be of only a few hours’ duration. The emesis commonly oc- curs several hours after meals, and is frequently explosive, being unaccompanied by notable straining. The vomit- ing does not completely empty the stomach, which is often found still largely distended after the emesis has ceased. The vomited matters consist largely of undi- gested food, which fact may be ascertained by macro- scopical inspection. In some instances portions of aliment taken days before their rejection may be recog- nized. Their odor is that of putrefaction. Their re- action is acid, from the presence of lactic, acetic, and butyric acids, or, rarely, from that of gastric juice. Their color varies with their composition. When the diet has been a mixed one, the color is generally yellow- ish, or brownish-red. Sometimes it is almost black or gray, with interspersed clumps of a blackish color. The upper layers of the vomited matters are often white and frothy. Strings and shreds, apparently of muco-pus, are dependent from this layer, reaching for some distance below the surface. At the bottom of the vessel are seen irregular masses of solid material. Microscopically examined, the vomited matter is found to contain food particles, either undigested or but partly digested, bacilli and other bacteria, sarcine ventricull, torule cerevisiz, and other fungi or their spores, crys- tals of fatty acids, flat epithelium from the stomach and cesophagus, mucus, pus, and occasionally blood-corpus- cles. Sometimes hematin is detected by chemical tests, when no blood-corpuscles can be recognized, and _ bile may be present in sufficient quantity to furnish its char- acteristic chemical reactions. Blood is more frequently found in cases of gastrectasia from cancer than in simple atonic dilatation, while bile is more often present in atonic gastrectasia, Various gases are held in solution in the vomited matters. Chief among these gases are oxygen and nitrogen, in about the same proportions as in the atmosphere ; sulphuretted hydrogen, hydrogen and car- bonic dioxide. In a case observed at Frerich’s clinic, olefiant gas and some undetermined gaseous hydrocar- bons were present. In this case the gases burned with a yellow flame. In other, comparatively rare, instances, the gas burns with a whitish flame. The gases in ques- tion mostly result from the abnormal fermentations in the stomach, but the nitrogen and oxygen may be swal- lowed with the food. Acetic, butyric, lactic and hydro- chloric acids are at times present. These, with the ex- ception of the last, result from fermentative processes. The clinical test of gastrectasia consists in the habitual discovery, among matters rejected from the stomach by vomiting, or withdrawn by the stomach-tube, of food taken on the preceding day, or even earlier, Subacute or Vou. VI.—41 chronic gastritis may cause the retention of food for an equal length of time; but, if this test be habitually suc- cessful, the existence of gastrectasia may be confidently assumed. The error is sometimes committed of consid- ering stomachs of unusually large size, as shown by phys- ical examination, to be dilated. The weight of authority is, however, in favor of regarding only those stomachs as dilated which, independently of their capacity, are inadequate to the performance of their digestive and pro- pulsive functions, Physical Signs.—Inspection of the abdomen sometimes reveals unusual prominence of the epigastric, of the left hypochondriac, and sometimes of other abdominal re- gions. If the abdominal walls are thin and relaxed, the outlines of the dilated stomach may be distinguished and the peristaltic gastric movements studied. This peristole may occur spontaneously, or may require to be excited by percussion and pressure. The movements begin at the cardiac extremity of the organ and slowly pass to- ward the pylorus. Rarely they alternately progress in either direction. These peristaltic movements are com- monly indicative of hypertrophic dilatation, but that they are not characteristic of gastrectasia alone is shown by their occasional occurrence in healthy stomachs, Kuss- maul refers such visible movements, occurring indepen- dently of gastrectasia, to a neurosis of the stomach, Similar vermiform movements in the intestine may simu- late those of the stomach. If, while the abdominal pro- tuberance is under observation, about thirty grains of sodium bicarbonate and fifteen grains of tartaric acid, in separate solutions, be drunk in quick succession, as rec- ommended by Frerichs, sufficient carbonic dioxide may be generated to more fully distend the stomach, and thus to render its outline more clearly apparent. In widely dilated stomachs a much larger quantity of these re- agents may be necessary to efficiently distend the stom- ach. This method of distending the organ is not uni- formly successful, inasmuch as the gas may sometimes escape into the intestine, through a relaxed pylorus, al- most as rapidly as it is generated. The method has, be- sides, the disadvantage of occasionally distending the stomach to such an extent as to cause severe pain. In such an emergency the prompt introduction of the stom- ach-tube is indicated, and quickly affords relief. Some authors advocate the employment of distention with gas, when the stomach is empty, to demonstrate the extent of the dilatation, but the method is open to so many objec- tions that its usefulness is problematical. Even a healthy stomach may be distended to a misleading extent through the rapid generation of gas by the method in question, and in an organ the walls of which are relaxed by dis- ease, the results would be still less reliable. “Were the supposed gastrectasia due to malignant disease, the fri- ability of the gastric walls might be such that rupture would occur from overdistention with the gas. Palpation may sometimes enable the examiner to out- line the borders of a dilated stomach, to obtain fluctuation and to perceive the peristaltic gastric movements. If the stomach be not overdistended with liquid, palpation may also elicit a splashing sound in the organ, which is, how- ever, generally more readily produced by gentle succus- sion of the entire abdomen. If succussion be resorted to, the patient is requested to lie upon his back and to relax his abdominal muscles. The physician then grasps the iliac bone and the lumbar region with either hand, the thumbs being directed forward, and imparts a quick, lat- . eral, vibratory motion to the body, simultaneously apply- ing his ear to the epigastrium. ‘This succussion sound is only diagnostic of gastrectasia when obtained six or eight hours after a meal, or from three to four hours after the ingestion of liquids, as it is often heard, under other cir- cumstances, in perfectly healthy stomachs. Some persons can produce it at will, by rapid movements of the dia- phragm, by holding the breath and quickly contracting the abdominal muscles, or by simply changing their posi- tion. The gastric succussion sound may be almost per- fectly simulated by a like splashing sound in the trans- verse colon, An accessory diagnostic measure, suggested by Leube, consists in feeling, through the abdominal 641 Stomach, Stomach. wall, the end of a hard stomach-tube introduced into the stomach. If the tube be felt far below the umbilicus, di- latation is, according to Leube, probably present. This method is, however, not to be recommended, since the hard tube may inflict injury upon the gastric wall, and, even when introduced, cannot always be recognized with certainty. Oser objects to Leube’s method because the sound may slip along the greater curvature, and, bending ~ upward, may even reach the pylorus, so that its point will be felt far above the most dependent part of the stomach. Palpation may show upward displacement of the heart, and cardiac arhythmia if the stomach is greatly distended ‘with gas. Auscultation, besides aiding in the detection of the gastric succussion sound, may reveal the presence, in the stomach, of fine crackling or hissing sounds, produced by the bursting of minute bubbles of gas upon the surface of the liquid contents of the stomach. This gas, as al- ready explained, owes its origin to abnormal fermenta- tions. Percussion often affords great assistance in mapping out a dilated stomach, but, in other cases, the information it conveys is negative or misleading, from the fact that in- testinal tympanites may displace the greater curvature upward or may overlap the stomach to a variable extent. Over a stomach which is considerably dilated, and con- tains liquid and gas, there is, when the patient is erect, a tympanitic percussion note above the level of the liquid. The line of flatness is changed, when the patient assumes the dorsal or the lateral decubitus, to that part of the vis- cus which is the most dependent, while the tympanitic resonance is heard over the highest point of the stomach. The most rational method of ascertaining the existence and the extent of dilatation is, in the writer’s opinion, that referred by Welch to Penzoldt. This method con- sists in withdrawing all fluids from the stomach by the tube, whereupon the pre-existing flatness disappears. If, now, a moderate quantity of liquid, from a pint to a quart, be introduced through the tube, flatness will reappear. If the flatness extends below the umbilicus, dilatation ex- ists, and the extent of the gastrectasia may be approxi- mately ascertained by noting the lowest level reached by the liquid. General Symptoms.—The bowels of patients suffering from gastrectasia are generally obstinately constipated, because a comparatively small amount of aliment gains access to the intestine within a given time, and the fecal matter is soon deprived of its fluid constituents by the intestinal absorbents. The bile and the intestinal juice are also reduced to a minimum, and intestinal peristole is consequently retarded. Sometimes diarrhcea alter- nates with constipation, and is best explained by the as- sumption that occasional relaxation of the pylorus al- lows the entrance of a large volume of undigested and fermenting matter into the bowel. The tongue may be either coated or clean. A‘coating speaks for the existence of gastritis. The urine is usually acid, scanty, high colored, and of high specific gravity, either from retention of liquids in the stomach or as a result of coincident gas- tritis. The urinary sediment is often abundant, and con- tains, chiefly, amorphous urates and oxalate of lime. In gastrectasia uncomplicated by gastritis, the specific grav- ity may be low and the reaction neutral or alkaline. In this case, amorphous phosphates and crystalline phosphates of lime and magnesia may be precipitated. Quantitative analysis has revealed a relatively small quantity of urea and a large amount of phosphates in many of the writer’s cases. The pulse is apt to be slow and feeble, the sur- face cool and dry, or clammy, and the temperature nor- mal. Owing to the lowered vitality, the temperature may be subnormal during the early morning hours, In- tercurrent attacks of subacute or of acute gastritis may reverse these conditions, and the pulse may sometimes become irregular, fluttering, frequent, and intermittent from disturbed cardiac action due to the pressure upon the thoracic viscera of a stomach distended with gas. Gastric tympanites may also induce temporary dyspneea. Patients are more or less emaciated, in proportion to the extent of their gastrectasia and to the nature of its cause. 642 | REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. They are ordinarily anemic, nervous, hypochondriacal, sleepless, and sometimes apathetic. They suffer from headache and nausea, perhaps referable to auto-infection with toxic ptomaines, and sometimes persisting for a number of days. ‘The appetite is generally diminished, and often lost. If, however, there be no gastritis, the ap- petite may be good and even ravenous, because of the small amount of nourishment assimilated. There is often constant and tormenting thirst, only aggravated by the ingestion of liquids, because they augment the gastric dilatation and still further retard absorption. There is, ordinarily, a sensation of gastric oppression and disten- tion, at least until the dilatation has progressed so far as to paralyze the gastric sensory nerves. This oppression is temporarily relieved by emesis. During the earlier stages of dilatation there is often acute gastralgia, prob- ably due to advancing distention, and generally occurring after meals. This pain may be entirely relieved by the prompt and efficient use of the stomach-tube. Pyrosis and the eructation of badly smelling and tasting gases and liquids are frequent symptoms. ‘True epileptic convulsions and tetanic spasms may occur in the latest stages of gastrectasia, as was first stated by Kussmaul. This author holds that they are due to abnormal dryness of the tissues from continuous abstraction of fluids, and are, hence, analogous to the convulsions in the asphyxia of cholera. Kussmaul supports this view by the fact that the spasms generally occur after emesis, or lavage of the stomach. It is, however, possible that the con- vulsions are due to cerebral and spinal anemia, to toxseemia from the absorption of ptomaines, or to imper- fect elimination of urea. The tetanic spasms involve by preference the abdominal muscles, the flexors of the. hands and forearms, and the calves of the legs, but sometimes affect the muscles of the neck and face. The pupils are sometimes contracted, and nystagmus has been observed. Consciousness is commonly retained, but oc- casionally it is lost. Coma may follow the spasms or be developed independently of them. The convulsions may be momentary, or they may continue for hours or days. They are followed by great asthenia and by tenderness over the affected muscles. The spasms are not, in them- selves, fatal. Diagnosis.— Chronic gastritis may be mistaken for slight grades of gastrectasia, but may be differentiated by the application of the clinical test for dilatation already alluded to, @.e., by ascertaining, with the syphon, wheth- er the stomach habitually contains remnants of food. in the morning, when the patient rises. If food be thus found, dilatation exists. Ascites may be mistaken for gastrectasia, but not if moderate caution be observed. In hydroperitoneum, flatness exists in the lowest abdominal regions when the patient is erect ; the reverse obtains in gastrectasia. In simple hydroperitoneum there is no succussion sound. In hydroperitoneum the withdrawal of fluid from the stomach, by means of the tube, does not affect the size of the abdomen nor the area of dul- ness. Hydatids of the liver, ovarian tumors, distention of the urinary bladder, and pregnancy are said to have been mistaken for gastrectasia, but such errors need never oc- cur, even to tyros in physical diagnosis. Prognosis.—The best prognosis is afforded by cases of atonic dilatation without pyloric or duodenal obstruction. In these cases, if the dilatation be moderate in degree, a cure may be reasonably expected from proper treatment persistently pursued. In cases of marked atonic gastrec- tasia a complete cure is only rarely effected, and it must be admitted that the treatment is usually only palliative. Still, even in these cases, marked relief is often obtained, the patients gaining in weight and strength sufficiently to pursue their ordinary avocations for an indefinite pe- riod. clotstssn boo ee cise tees ee eaters 1.321 TOGIMOics erace choco s eiieinays cles cateansl os icks het t weticteLslerepiia ote trace GiB alt. SUMACH (Rhus Glabra, U. 8. Ph.). ‘The fruit of Rhus glabra Linn. ; Order, Anacardiacee” (Terebintha- cee). The smooth sumach is a very common, and, when in full fruit, a very striking, American shrub. It has, like all its genus, large pinnate leaves and small, poly- gamous, greenish, regular, pentamerous flowers in pani- cles ; ovary single, one-ovuled ; styles or stigmas three. This species has smooth, somewhat glaucous leaves, white beneath, of from eleven to thirty-one leaflets, and close, upright, terminal, conical panicles of flowers and fruit. Berries, when ripe, of a most brilliant crimson color; they are ‘‘sub-globular, about one-eighth of an inch (3 millimetres) in diameter, drupaceous, crimson, densely hairy, containing a roundish-oblong, smooth putamen. It is inodorous, and its taste acidulous.” The pleasant acid taste of sumach berries is all in the crim- son pubescence with which they are covered, and is due to malic acid and acid malate of lime; the internal parts of the seed contain, like the rest of the plant, tannic acid. A fluid extract (Hzatractum Rhois Glabre Fluidum, U. 8. Ph., strength 7;) is officinal. Hither this diluted, or a decoction, may be used as a pleasantly sour, astringent gargle. ALLIED PLANTS.—See Ivy, Poison. ALLIED Drues.—Tamarinds, Barberries, Rose Hips, etc. W. P. Bolles. SUMBUL, U.S. Ph. (Sumbul Radix, Br. Ph., Musk- root). The root of Herula Sumbul Hook, f.; Order, Um- bellifere. This large perennial herb, belonging to the asafcetida-, galbanum-, and ammoniacum-yielding group of the family, has a large, rather short, cylindrical root, attaining a diameter of four or five inches, and a length of say a foot, when it divides into several stout branches, and a tall, erect, rather simple stem, six or eight feet in height. The leaves are large, tripinnate, with broad, sheathing petioles. Flowers small, greenish, polygam- ous, in compound naked umbels. All parts of the plant, but especially the root, exude a resinous, fragrant, milky juice (Bently and Trimen, 131). The sumbul plant is a recent addition to medical botany, having been discoy- ered by Fedschenko in Central Asia, in 1869. The root itself as a perfume, and afterward as a medicine, ap- peared in Europe about 1840. Sumbul root comes in transverse slices, one or two or more inches in diameter, and from one-half to an inch in thickness; the surface of these dried disks is a dirty brown, or gray marbled with dirty white ; the edges have a dark, loose, papery bark. Resin drops can be seen on it by aid of alens. The tissue is hard, but spongy ; odor decidedly like that of musk, but weaker. ComposiTion.—The most important constituent is the resin, of which there is nine per cent. (Flickiger) ; it has REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. a musky smell, more developed in contact with water, and a bitter, aromatic taste. The root contains also a small quantity of dull-bluish colored oil. Action AND UsE.—Sumbul has not any important medicinal value; like asafcetida, and its namesake, musk, it is gently stimulant and slightly anti-spasmodic, and may be given for the same nervous conditions as they ; but its principal employment is in the preparation of some perfumes, where it takes the place of musk. A tincture (Tinctura Sumbul, strength +!5) is officinal. ALLIED PLANTs.—See ANISE. ALLIED DruGs.—AsAFa@TIpA, Musk, VALERIAN. W. P. Bolles. SUMMIT MINERAL SPRING. Location and Post- office, Harrison, Cumberland County, Me. Access.—By the Grand Trunk Railway to Norway Station ; thence by conveyance nine miles to the spring. ANALYsIs (46° F., F. L. Bartlett).—One pint contains : Grains. Carbonate of soda and potassa...................... 0.175 Carbonatelof magnesia) Sir). o2 H0..cckin anak cee eee 0.031 Carbonate otslime preety en ee). eee ore 0.123 Ohiloride ob sodium. srs wo renee chvacin hetiansteee oo cis 0.021 Oxdeotiron:and alumina. 2... een eae cee. traces RSLLI CAI rae Sra ga cletae Settee lhe Sen sma aen, cote nas ate 0.122 Organiciand volatile: matters ..j.e0 a-ei ene eee 0.029 TOCA Ran crete wep sae ee crretccemes cs So So oa 0.501 THERAPEUTIC PROPERTIES.—This is almost an abso- lutely pure water, and on that account alone it should be valuable as a solvent and general tonic. The State of Maine abounds in these pure springs, some of which have established reputations as therapeutic agents—for example, the Poland and the Underwood Spring. Gb ar. SUMMIT SODA SPRINGS, Location, Alpine County, Cal. Accrss.—By Central Pacific Railroad to Soda Springs Station ; thence by stage twelve miles to the springs. ANALYSIS.—One gallon contains : Grains ibicarpanate: Of limen stuns per eniae site tala ciel « se ioe te 43,20 Carbonate of marnesiay clo. sseiecs cs ste scares ke cece 4,20 Carponave: orsodares ween wares ae weeks nice Ac. cealecs 9.50 GQioridetol sodium psa ceo tke oak scree atatd anes 26.22 Oxiictotelronsryrs see sae oie ie 3 oie aoe tbiefs.s 625 eteas 1.75 SHEE: Gudlniaey ab PAS Se OIC aan Be a See On cre F 2.06 JRAUC NGOS UTTER, meen BASS OEE 24 eR ce A Baer as, rey a a aie Me TEN [POGAR RA Rees hee ae on he ow aotatele's Wao ails cia trace a MOTE ate GS ROR Oe einec, ha Heiner S Pa cmusee 88.68 Cub, in Oarbonieiacideae maine rts: cece cock hues nice oe eee 186.35 THERAPEUTIC PROPERTIES.—The presence of so large ‘a proportion of carbonic-acid gas in this water, together with the oxide of iron, furnishes the latter in a very de- . ‘sirable form—that of the carbonate. There is no doubt but that this water will eventually prove very popular as. a tonic and alterative agent. These springs are situated in the Sierra Nevada Moun- tains of Eastern California, at an altitude of about seven thousand feet. Game abounds in the surrounding coun- try. From the latest accounts no hotel had yet been erected at the springs. Ger Bas SUNDEW (Drosera, Codex Med.), Drosera rotundifolia Linn.; Order Droseracee. This little plant, and others of its genus, have been used now and then for generations in medicine, generally for phthisis, and as often have fallen into neglect. They “appear to contain, besides ordinary vegetable products, a peculiar acid, irritating to the skin. In common with other insectivorous plants, the glandular hairs of the leaves secrete a substance capable of dissolving albumin- ous substances. They have probably no medicinal value, ALLIED PLANTs.—The most interesting plant in the order is the famous Venus Fly Trap, Dionea Muscipula, of North Carolina, whose leaves close like the jaws of a steel trap upon unfortunate insects alighting on them. W. P. Bolles. Sulphuric Acid. Superfoetation. SUPERFCTATION. By this term we mean the im- pregnation of a female already pregnant. Superfcetation proper must be clearly distinguished from superimpreg- nation (superfecundation). Most writers admit the pos- sibility of the latter: 7.e., that two ova belonging to the same period of ovulation can be fecundated during sex- ual intercourse practised by the same or different persons near the same period of time. This seems to be proved by that class of cases in which the same woman has given birth to twins bearing evident traces of being the offspring of fathers of different races. Dr. Mosely tells of a negress who brought forth two children, one a negro and the other a mulatto. She said that a white man on the estate had had intercourse with her directly after her black husband had quitted her. Rev. Dr. Walsh narrates the case of a creole woman who had three children at a birth, of three different colors—white, brown, and black—with all the features of the respective classes. Fodéré, on the authority of Buffon, records the case of a woman who gave birth to twins, one being white and the other black. She confessed that immedi- ately after her husband had left her she was forcibly raped by a negro. Dr. Nowlin reports the case of a negress who gave birth to twins, one a pure African, with all the typical features of that race, and the other a very bright mulatto, exhibiting evident characteristics of the Caucasian race. The mother was a pure black, with all the typical features of the African, as was also her hus- band. Upon inquiry, he ascertained from the mother that she had permitted intercourse with a white man the day succeeding the same act with her husband. Such cases seem to have been very common in slave-holding countries, and Beck gives nearly half a page to such references. Scanzoni, who rejects even the idea of superfecunda- tion, explains such cases on the ground that children sometimes resemble the father and sometimes the mother, both in features and complexion. In twin pregnancies one child may resemble the father and the other the mother ; and it seems quite possible that all that is nec- essary for the production of a black child and a white one is cohabitation between a black man and a white - woman, or, what is vastly more common, a white man and a black woman—one child resembling the father and the other the mother. Few, however, agree with Scan- zoni in this view, and the possibility of superfecundation is pretty generally admitted, being based chiefly on what we know from comparative physiology. On the other hand, the possibility of superfcetation has been vigorously opposed by many writers, and the evi- dence in its favor leaves much room for doubt. The idea implied is, that a woman who is already pregnant may, at a stage of pregnancy more or less advanced, again conceive, and carry at the same time the fruit of two conceptions between which there must be a consider- able interval. It is admitted by all that superfcetation may take place in extra-uterine pregnancy, and in cases of double uterus or bilocular uterus. An example of this is reported by Montgomery, in which, while the product of an extra- uterine pregnancy remained encysted within the abdo- men, the woman bore three children. Dr. Steigervahl records a similar case, and Dr. Cliét, of Lyons, reports a very interesting one in which a woman died suddenly, and at the post-mortem examination there was found an extra-uterine foetus of five months in the abdomen and a foetus of three months in the uterus. A careful analysis of the so-called cases of superfceta- tion shows conclusively that the phenomena in most of them can be explained by twin pregnancies. But, onthe other hand, there are numerous examples advanced in support of this idea which cannot be explained by this hypothesis. One of the arguments is based on the cases in which two living children have been born at different and widely separated periods. The following are the inter- vals in some of these cases: Four and a half months, Marianne Bigaud; five and a half months, Benoite Franquet ; five months, a woman of Arles ; seventeen 687 Superfcetation. Suspension Splint, weeks, a case of Dimerbroeck ; six weeks, a case of Lebas; four weeks, a case of Dr. Moebus; fifty-two | days, a case of Thielmann; forty-two days, cited by Fordyce Barker; one month, Giuseppe Generali (vide Ganahl, ‘‘ Superfcetation,” Paris, 1867). Supposing that two children be born at an interval of four months, and both be capable of being reared, we must acknowledge that superfcetation is probable, or admit that a five- months’ child is capable of being reared, which is in the highest degree improbable. Another argument is advanced by Dr. Bonnar, who gives a number of cases in which children born in wed- lock succeeded each other with very unusual rapidity. The question of superfcetation is here looked upon from a different point, in reference-more particularly to the period after parturition at which the female procreative organs are again capable of exercising their functions. He gives three cases in which there intervened between the two deliveries 182, 174, and 127 days respectively ; and all the children were sufficiently developed to be reared and, without exception, to reach maturity. In the latter case, subtracting from the interval (127 days) which occurred between the two deliveries 14 days, which Dr. Bonnar assumes to be the earliest possible period at which a fresh impregnation can occur after delivery, we reduce the gestation to 113 days—that is, to less than four months. As both these children survived, the second child could not possibly have been the result of a fresh impregnation after the birth of the first; nor could the first child have been a twin prematurely delivered, for, if so, it must have reached only a little more than the fifth month, at which time its survival would have been impossible. In regard to the objections based on the supposition that the decidua so completely fills up the uterine cavity that the passage of the spermatozoa is impossible, we may say that the decidua reflexa does not come into apposition with the decidua vera until about the eighth week of pregnancy, and, therefore, until that time there is a fre space between the two membranes. Lastly, respecting the cessation of ovulation during pregnancy, this no doubt is the rule, but there are, how- ever, a sufficient number of well-authenticated cases of menstruation during pregnancy to prove that ovulation is not always absolutely in abeyance. Therefore, the most reasonable conclusion seems to be that, although the vast majority of cases of so-called su- perfcetation can be explained by twin pregnancies, there is a small number of cases which cannot be explained upon this hypothesis, and this makes the existence of su- perfcetation seem probable. Dilion Brown. SUSPENSION SPLINT, HODGEN’S. The value of extension in the treatment of fractures of the femur is universally conceded. The effort to obtain continuous extension with immobility has resulted in a multiplicity of methods of treatment, some of which are compli- cated and troublesome, others cruel and inefficient. The most simple and effective continuous extension is found, I think, in oblique suspension, as first advocated by Na- than R. Smith, when he introduced his anterior splint. Suspension, with the amount of traction determined by the obliquity of the suspending cord, is more easily ap- plied and efficiently maintained in that modification of Smith’s anterior splint devised and so successfully used by the late Dr. John T. Hodgen, of St. Louis, than by any other method. This splint, in the hands of an ex- pert, secures nearly perfect immobilization, and extension so equable and effective as to give practically perfect re- sults. The freedom of motion allowed to the patient does not interfere with immobilization of the fractured bone. The illustration shows the splint in use, with leg sus- pended, as for the treatment of fractures of the thigh. The simplicity of the structure of the splint is evident, and the manner of the suspension of the leg is made plain. The leg is resting on muslin strips which pass under it. These are secured by pins at each end, after overlapping the arms D E and D’ E’ of the splint. Each strip supports its proportion of the weight of the leg. These strips extend from the heel to the gluteal fold. 688 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. The adhesive strip H, softened by warmth or by turpen- tine, is applied to the leg, and secured in position by a roller which extends as high as the knee. This strip secures the leg in the splint, since it is fastened by the cord and block N to the foot of the splint at F. The splint itself is composed of a single piece of No. 2 wire, bent as shown in Fig. 3746. The sliding hooks D, D' and E, E’ are used for attaching the suspending cords to the splint. The use of the arch O is to maintain the proper width of the splint at its upper end, viz., 20 or 25 ctm. (eight or ten inches), This arch is loose, and is easily slipped over the ends of the wire which forms the splint before the latter is applied to the leg. The width of the splint at the foot is about 10 ctm. (four inches), and is determined by the bend in the wire which forms the body of the splint. The wire hooks E, E’ and D, D’ present at one end a free loop for the attachment of the supporting cord, while the other end is coiled somewhat snugly about the lateral bars of the splint (at D and E). The lateral bars, to which the muslin strips are attached, extend upward on each side of the leg, so that the two ends of the wire reach, the one to a point above the pubes, and the other, on the outside, nearly to the crest of the ilium. The bend in the splint at the knee permits slight flexion of the leg. The distance from the foot of the splint to the bend of the knee is 56 ctm. (twenty-two inches), and from the angle to the upper free ends 50 ctm. (twenty inches). The suspending apparatus is composed of, first, the pulley A, which is fixed in a framework over the bed, or, prefer- ably, in the ceiling; secondly, the sliding block B, and the cord B, A, C; thirdly, of the two cords D, C, E and D’, C, E’, of equal length, and with a loop at each end for attachment to the wire hooks at D, D’ and E, EH’. These cords are passed through a loop in the cord at its end C. The suspension of the leg and splint is readily accomplished by sliding downward the block B on the cord B, A, C. The splint, as stated above, is a modification of Nathan R. Smith’s anterior splint, the lateral arms being sub- stituted for the anterior wires, to which the leg in his splint was secured by a roller bandage. Here the leg is sustained by the muslin strips, any one of which can be readily and quickly changed so as to give increased or diminished support to any part of the leg, thus maintain- ing the proper outline of the bone during the rapid atrophy of the soft parts which ensues upon theen forced rest of the limb. The extension is maintained through the adhesive strip H, which, extending from one tuberosity of the tibia to the other, across the board N at the sole of the foot, is fastened by a cord to the cross-bar at F, and thus securely holds the leg in the splint. Through this me- dium the extending force is transferred from the splint to the leg. The board at the sole of the foot should be as wide as the adhesive strip, and about 7 or 8 ctm. (three and one-half inches) long. It then protects the malleoli from the lateral pressure of the adhesive strips through which the extending force is applied. The splint as shown in Fig. 3745 is cheap, and readily made by any blacksmith. The splint as represented in Fig. 3746 is more expensive, but can be adjusted to a leg of any size. The lateral bars B and C are hollow square tubes, furnished with thumb-screws at their extremities, B, C. These tubes are of sufficient size to admit the terminal ends of the lateral bars, and by pushing in or pulling out the extremities of the lateral arms the length of the splint may be varied. Its width can also be changed by sliding the lateral arms into the hollow tube A, A, which is furnished with thumb-screws at A, A. The splint is fitted by sliding B, A and C, B to the proper point, and securing them by setting the thumb-screws at B and C. The hooks D, E, for suspending the splint, slide on the lateral bars B, C. The splint is used in the same man- ner as the one before described. The foot-piece P is to prevent passive extension of the foot. Its use is optional with the surgeon. Its chief utility is found in cases of compound fracture of the leg. The foot-piece here REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. shown is a thin board fastened to the heavy cross-wire, which is curved so that one end fits around the lateral arm of the splint, and the other is so bent as to maintain the foot-piece at its proper angle. Dr. J. Freund, of Champion, Mich., has devised a foot-piece which answers a good purpose. It is held in position by two transverse slips of wood fastened by thumb-screws, and _ has the in- clination of the foot-piece maintained by a third thumb-screw which is fixed in A one of the transverse slips. The application of the Hodgen sus- pension splint is simple and, in skilful hands, painless. Suppose the leg, with its fractured fe- mur, is resting upon the bed. A roller bandage is applied to the foot and ankle, to pre- vent swelling, excoriation, or. tenderness, from the pressure of the bandage or of the adhesive strips on the malleoli. Then | rosy _! de SSS EEUZ”™ iis ae = (WGCH, 0.0... eA SS Fra. 8745. the adhesive strip H, with its foot-piece and cord, is placed in position, an assistant grasps the foot with one hand, and, with the other hand under the knee, lifts the leg from the bed, while at the same time he makes steady extension of the femur. The surgeon then continues the application of the roller as high as the knee-joint, and thus secures more perfect adherence of the plaster to the leg. The leg is again allowed to rest upon the bed, but the assistant maintains moderate traction on the foot, so as not to relax extension of the fractured bone while an the splint is put in posi- tion.