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New York 

State College of Agriculture 

At Cornell University 

Ithaca, N. Y. 



Library 



Cornell University Library 
R 125.R3 

V.1 

A Reference handbook of the medical scie 



3 1924 003 371 576 



Reference Handbook 



MEDICAL SCIENCES 



Being a Complete akd Convenient Work of Reference for Information 
UPON Topics belonging to the entire range of Scientific and Prac- 
tical Medicine, and Consisting of a Series op Concise 
Essays and Brief Paragraphs, arranged in 
THE Alphabetical Order of the 
Topics op which they treat 



rREPAUED BY 



WRITERS WHO ARE EXPERTS IN THEIR RESPECTIVE DEPARTMENTS 



ILLUSTRATED BY CHEOMOLITHO.GRAPHS AND FINE WOOD ENGRAVINGS 



Edited by ALBERT H. BUCK, M.D. 

Naw York City 



VOL. L 



WILLIAM WOOD cfe COMPANY 

NEW YORK 



COPTBIGHT, 1885, 

BT WILLIAM "WOOD & COMPAKX 



LIST OF CONTRIBUTORS TO VOLUME I. 



WILLIS J. ABBOT, LL.B Chicago, III. 

Counsellor and Attorney-at-Law. 

GORHAM BACON, M.D New York, N. Y. 

Aural Surgeon, New York Eye and Ear Infirmary. 

FRANK BAKER, M.D Washington, D.C. 

Professor of Anatomy, Medical Department of George- 
town University. 

ELIAS H. BARTLEY, M.D Brooklyn, N. Y. 

Lecturer on Chemistry, Long Island College Hospital ; 
Chemist to the Board of Health of Brooklyn. 

E. A. BIRGE, Ph.D Madison, Wis. 

Professor of Zoology, University of Wisconsin. 

ALBERT N. BLODGETT, M.D Boston, Mass. 

Professor of Pathology and Therapeutics, Boston Den- 
tal College. 

W. P. BOLLES, M.D , . . .Boston, Mass. 

Professor of Materia Medica and Botany, Emeritus, at 
the Massachusetts College of Pharmacy ; Visiting 
Surgeon to the Boston City Hospital. 

L. BREMER, M.D St. Louis, Mo. 

WILLIAM N. BULLARD, M.D Boston, Mass. 

Physician to the Nervous Department, Boston Dispen- 
sary ; Physician to Out-Patients, Carney Hospital. 

FRANK BULLER, M.D Montreal, Canada. 

Professor of Ophthalmology and Otology, McGill Uni- 
versity. 
CHARLES H. BURNETT, M.D.. Philadelphia, Pa. 
Professor of Otology, Philadelphia Polj^clinic and Col- 
lege for Graduates in Medicine ; Aurist to the Pres- 
byterian Hospital. 

ARTHUR T. CABOT, M.D Boston, Mass. 

Surgeon to Out-Patients, Massachusetts General Hos- 
pital. 
DONALD M. CAMMANN, M.D... New York, N. Y. 
Instructor in Diseases of the Chest, New York Poly- 
clinic ; Visiting Physician to the Orphans' Home and 
Asylum. 

RUSSELL H. CHITTENDEN, Ph.D New 

Haven, Conn. 
Professor of Physiological Chemistry, Yale College. 

W. J. CONKLIN, M.D Dayton, O. 

Professor of Diseases of Children, Starling Medical 
College. 
WILLIAM T. COUNCILMAN, M.D. .Baltimore, Md. 
Associate Professor of Pathological Anatomy, Johns 
Hopkins University. 

EDWARD CURTIS, M.D New York, N. Y. 

Professor of Materia Medica and Therapeutics, College 
of Physicians and Surgeons, New York. 

CHARLES L. DANA, M.D New York, N. Y. 

Professor of Diseases of the Mind and Nervous System, 
and of Medical Electricity, New York Post-Graduate 
Medical School and Hospital ; Physician to the North- 
western Dispensary, Nervous Department. 

N. P. DANDRIDGE, M.D Cincinnati, 0. 

Professor of Genito-Urinary and Venereal Diseases, 
Miami Medical College. 

D. BRYSON DELAVAN, M.D....New York, N. Y. 
Surgeon to Department of the Throat, Derailt Dispen- 
sary. 

BASKET DERBY, M.D Boston, Mass. 

Ophthalmic Surgeon, Massachusetts Charitable Eye and 
Ear Infirmary, Boston. 



HENRY FLEISCHNER, M.D New Haven, Ct, 

Lecturer on Dermatology, Yale College. 

WILLIAM H. FLINT, M.D New York, N. Y. 

Attending Physician, Presbyterian Hospital ; Assistant 
to the Chair of Principles and Practice of Medicine, 
Bellevue Hospital Medical College. 

EUGENE FOSTER, M.D Augusta, Ga. 

President of the Board of Health of Augusta. 

FRANK P. FOSTER, M.D New York, N. Y. 

Assistant Surgeon, Woman's Hospital in the State of 
New York. 

GEORGE B. FOWLER, M.D New York, N. Y. 

Professor of Physiological Chemistry, New York Poly- 
clinic ; Physician to the New York Infant Asylum. 

JAMES M. FRENCH, M.D Cincinnati, O. 

Assistant Demonstrator of Pathology and Instructor in 
Physical Diagnosis, Medical College of Ohio. 

WILLIAM W. GANNETT, M.D Boston, Mass. 

Assistant in Pathological Anatomy, Harvard Univer- 
sity. 
WILLIAM GARDNER, M.D. ...Montreal, Canada. 
Professor of Gynaecology, McGill University ; Gynse- 
cologist to the Montreal General Hospital. 

GEORGE W. GAY, M.D Boston, Mass. 

Surgeon to the Boston City Hospital. 

H. GRADLE, M.D.. Chicago, III. 

Professor of Physiology, Chicago Medical College. 

JOHN GREEN, M.D St. Louis, Mo. 

Lecturer on Ophthalmology, St. Louis Medical College. 
CHARLES E. HACKLE Y, M.D. . . .New York, N. Y. 

Attending Physician, New York Hospital. 
ALLAN McLANE HAMILTON, M.D. . . .New York, 
N. Y. 
Professor of Diseases of the Mind and Nervous System, 
New York Polyclinic. 

CHARLES HARRINGTON, M.D Boston, Mass. 

Instructor in Chemistry, Harvard Medical School. 

FREDERICK P. HENRY, M.D. .Philadelphia, Pa. 

Professor of Pathology and Microscopy, Philadelphia 

Polyclinic and College for Graduates in Medicine ; 

Physician to the Hospital of the Protestant Episcopal 

Church. 

WILLIAM B. HILLS, M.D Boston, Mass. 

Assistant Professor of Chemistry, Harvard University. 

CHARLES B. KELSEY, M.D New York, N. Y. 

WILLIAM. G. LE BOUTILLIER, M.D..New York, 
N. Y. 

HENRY LEFFMANN, M.D Philadelphia, Pa. 

Professor of Clinical Chemistry and Hygiene in the 
Philadelphia Polyclinic ; Assistant to the Chair of 
Chemistry, Jefferson Medical College. 
GEORGE W. LEONARD, M.D. . . .New York, N. Y. 
Late House Surgeon, New York Hospital. 

R. L. MACDONNELL, M.D Montreal, Canada. 

Demonstrator of Anatomy and Lecturer on Hygiene, 
McGill University. 

LEWIS L. Mc ARTHUR, M.D Chicago, III. 

WALTER MENDELSON, M.D. . . .New York, N. Y. 
Instructor in Clinical Microscopy in the Physiological 
and Pathological Laboratory of the Alumni Associa- 
tion of the College of Physicians and Surgeons ; At- 
tending Physician to the Roosevelt Hospital, Out- 
Patient Department. 



Ul 



LIST OF CONTRIBUTORS TO VOLUME I. 



T. WESLEY MILLS, M.D Montreai,, Canada. 

Lecturer on Physiology, McGill University. 
JAMES LAUNCELOT MINOR, M.D. . . .New Yobk, 
N. Y. 
Assistant Surgeon, New York Eye and Ear Infirmary ; 
Visiting Ophthalmic Surgeon, Randall's Island Hos- 
pitals. 
CHARLES SEDGWICK MINOT, M.D Boston, 

Instructor in Histology and Lecturer on Embryology, 
Harvard University. 
WILLIAM OLIVER MOORE, M.D. .New York, N.Y. 
Professor of Diseases of the Eye and Ear, New York 
Post-Graduate Medical School ; Assistant Surgeon, 
New York Eye and Bar Infirmary. 
WILLIAM H. MURRAY, M.D. . . .New Yokk, N. Y. 
Late House Surgeon, New York Hospital House of 
Relief ; Attending Physician, New York and North- 
ern Dispensaries. 

JOHN H. MUSSER, M.D Philahblphia, Pa. 

Chief of the Medical Dispensary of the Hospital of the 
University o^ Pennsylvania ; Pathologist to the Pres- 
byterian Hospital. 

WM. OLDRIGHT, M.D Tobonto, Canada. 

Lecturer on Sanitary Science, Toronto School of Med- 
icine ; Chairman, Provincial Board of Health. 

HENRY F. OSBORN, Sc.D Princeton, N. J. 

Professor of Comparative Anatomy, Princeton Uni- 
versity. 

ROSWELL PARK, M.D BtJi-i-ALO, N. Y. 

Professor of the Principles and Practice of Surgery, 
University of Buffalo, N. Y. 

T. MITCHELL PRUDDBN,M.D..New York, N. Y. 

Lecturer on Normal Histology, Yale College ; Director 

of the Physiological and Pathological Laboratory of 

the Alumni Association, College of Physicians and 

Surgeons, New York City. 

MARY PUTNAM JACOBL M.D..Nbw York, N. Y. 
Professor of Materia Medica and Therapeutics in the 
Women's Medical College, New York. 

LEOPOLD PUTZEL, M.D New York, N. Y. 

Visiting Physician to Randall's Island Hospital. 

JOSEPH RANSOHOFF, M.D Cincinnati, O. 

Professor of Descriptive Anatomy and Clinical Sur- 
gery, Medical College of Ohio ; Surgeon to the Good 
Samaritan Hospital, Cincinnati. 

J. C. REEVE, M.D Datton, O. 

Late Professor of Materia Medica and Therapeutics, 
Medical College of Ohio ; Chief of Staff of St. Eliza- 
beth's Hospital, Dayton. 

HUNTINGTON RICHARDS, M.D. .New York, N.Y. 
Assistant Aural Surgeon, New York Eye and Ear In- 
firmary. 

M. H. RICHARDSON, M.D Boston, Mass. 

Demonstrator of Anatomy, and Assistant in Surgery, 
Harvard University. 

HENRY A. RILEY New York, N. Y. 

Attorney and Counsellor-at-Law. 

GEORGE ROSS, M.D Montreai;, Canada. 

Professor of Clinical Medicine, McGill Univefsity ; Phy- 
sician to the Montreal General Hospital. 

IRVING C. ROSSB, M.D Washington, D.C. 

THOMAS E. SATTERTHWAITE, M.D. .New York, 
N. Y. 
Professor of Pathology and General Medicine, New 
York Post-Graduate Medical School ; Pathologist to 
the Presbyterian Hospital. 

WILLIAM T. SEDGWICK, Ph.D Boston, Mass. 

Assistant Professor of Biology, Massachusetts Institute 
of Technology. 
N. 8ENN, M.D Milwaukee, Wis. 



SAMUEL SEXTON, M.D New York, N.Y. 

Aural Surgeon, New York Eye and Ear Infirmary. 

FRANCIS J. SHEPHERD, M.D. .Montreal, Canada, 

Professor of Anatomy, McGill University. 

CHARLES SMART, M.D Washington, D.C. 

Surgeon, United States Army. 

M. ALLEN STARR, M.D New York, N. Y. 

Late House Physician, Bellevue Hospital ; Attending 
Physician, New York Dispensary. 
THOMAS L. STEDMAN, M.D. . . .New York, N. Y. 
Assistant Surgeon, New York Orthopedic Dispensary 
and Hospital. 
HENRY W. STEL WAGON, M.D. .Philadelphia, Pa. 
Physician to the Philadelphia Dispensary for Skin Dis- 
eases ; Chief of the Skin Dispensary of the Hospital 
and Instructor in Dermatology, University of Penn- 
sylvania. 
GEORGE M. STERNBERG, M.D. .Washington, D.C. 
Surgeon, United States Army. 

JAMES STEWART, M.D Montreal, Canada. 

Professor of Materia Medica and Therapeutics, McGill 
University. 

LEWIS A. STIMSON, M.D New York, N. Y. 

Professor of Physiology, University of the City of New 
York ; Visiting Surgeon, Bellevue and Presbyterian 
Hospitals. 

SAMUEL THEOBALD, M.D Baltimore, Md. 

Professor of Diseases of the Eye and Ear, Baltimore 
Polyclinic and Post-Graduate Medical School; Sur- 
geon to the Baltimore Eye, Ear, and Throat Charity 
Hospital. 

WILLIAM GILMAN THOMPSON, M.D. .New York, 
N. Y. 
Assistant Physician to the New York Hospital, Out- 
patient Department ; Physician to Roosevelt Hos- 
pital, Out-Patlent Department. 

WILLIAM H. THOMSON, M.D. . . .New York, N. Y. 
Professor of Materia Medica and Therapeutics and Dis- 
eases of the Nervous System, Medical Department of 
the University of the City of New York ; Visiting 
Physician to Bellevue and Roosevelt Hospitals. 

L. McLANE TIFFANY, M.D Baltimore, Md. 

Professor of Surgery, University of Maryland. 

ARTHUR VAN HARLINGEN, M.D. .Philadelphia, 
Pa. 
Professor of Diseases of the Skin in the Philadelphia 
Polyclinic and College for Graduates in Medicine ; 
Consulting Physician to the Dispensary for Skin Dis- 
eases. 
WILLIAM L. WARD WELL, M.D. .New York, N. Y. 
Surgeon to the Eastern Dispensary ; Assistant Sur- 
geon, New York Polyclinic. 

CHARLES WARE, M.D New York, N. Y. 

Assistant Gynsecologist, Out-Door Department of 
Roosevelt Hospital. 

J. COLLINS WARREN, M.D Boston, Mass. 

Assistant Professor of Surgery, Harvard University; 
Surgeon to the Massachusetts General Hospital. 

LEONARD WEBER, M.D New York, N. Y. 

EDMUND C. WENDT, M.D New York, N. Y. 

MOSES C. WHITE, M.D New Haven Conn 

Professor of Pathology, Medical Department of Yale 
College ; Medical Examiner for New Haven, Conn. 

GEORGE WILKINS, M.D Montreal, Canada 

Professor of Medical Jurisprudence, McGill University 
CHARLES F. WITHINGTON, M.D...B08TON Mass 
JOHN McG. WOODBURY, M.D. . .New York', N Y 
Assistant Demonstrator, Bellevue Medical College 

W. GILL WYLIE, M.D New York N Y 

Professor of Gynaecology, New York Polvclinio- 
Gynaecologist to Bellevue Hospital ; Surgeon to St 
Elizabeth's Hospital. 



IV 



PREFACE. 



The character and scope of the Handbook may be judged better from a brief inspection of the 
present volume than from any detailed description which I might be able to give. It is essentially a 
collection of articles — some brief, others of considerable length — treating of many of the more impor- 
tant topics in regard to which medical men are likely to desire information. In selecting these topics, 
and in determining how much space should be allotted to each, I have been guided by the following 
considerations : In the first place, the size of the entire work — eight volumes of about eight hundred 
pages each — precluded the possibility of treating exhaustively all the topics for which one might fairly 
consider it necessary to make provision. In the presence of this difficulty I was obliged to choose be- 
tween two courses : either to retain a reasonably full list of topics, and give to each its proper share of 
space ; or to curtail the list, and so gain enough space for a fairly satisfactory and thorough treatment 
of at least the more important subjects. The former plan, which to many would appear to be the more 
natural one of the two, and which is in fact the one generally pursued in works of a similar character, 
leads inevitably to the production of a book containing articles so brief and so lacking in fulness of in- 
foi-mation that the reader cannot fail to experience more or less disappointment in them. The latter 
plan, on the other hand, is open to the objection that the reader will now and then search in vain for 
information in regard to some topic in which he is interested. Between these two plans I have not 
hesitated to choose the latter. The objections which may be brought against it seem to me to be 
fewer and of less weight than those which are inseparable from the more strictly symmetrical plan of 
construction. The advantages, on the other hand, appear to me to more than compensate for the de- 
fects. Under this plan the editor feels himself at liberty to use his own judgment in regard to the 
selection of topics and in regard to the degree of importance which shall attach to each. In the next 
place, it has seemed to me desirable to bear in mind the varied tastes and professional wants of those 
who are likely to make use of the Handbook. While, therefore, I have given the lion's share of the 
space to matters of a practical nature — the diagnosis and treatment of disease — I have not forgotten to 
make ample provision for such departments as medical botany, cHmatology, embryology, physiological 
a,nd pathological chemistry, applied anatomy, medical jurisprudence, military and naval surgery. 

In harmony with these considerations I have not hesitated to leave out separate articles on some 
of the topics which appear as independent headings in other works of a similar character ; and, on the 
other hand, I have introduced articles on many topics which are not discussed in any of the treatises 
which ordindTrily find their way into the libraries of medical men. 

In working out the problem which was set before me as editor, I have derived not a little as- 
sistance from Quain's "Dictionary of Medicine," from Eulenburg's Real Encyclopddie, and from 
Jaccpud's Nouveau DicHonnaire de MMecine et de Chirurgie Pratiques. I have also received valuable 
aid from Drs. Charles Sedgwick Minot, James J. Putnam, and W. P. Bolles, of Boston ; Drs. William 
Osier and Arthur Van Harlingen, of Philadelphia ; Dr. John Green, of St. Louis ; Surgeons Charles A. 
Smart, B. A. Clements, and Alfred A Woodhull, of the United States Army ; and Drs. Frank P. Foster, 



PREFACE. 



Huntington Sichards, D. Bryson Delavan, Edward Curtis and Mr. Benjamin Vaughan Abbott, of New 
York, to all of whom I desire to express publicly my thanks. In the difficult task of correcting the 
proof-sheets, I have been aided by Drs. William H. Flint, Huntington Richards, and Thomas L. Sted- 
man, of this city. I also take pleasure in acknowledging the assistance afforded, in the department 
of Climatology, by Hon. H. B. Small, of Ottawa, Canada ; Professor J. C. Smock, of New Jersey, and 
many others whom I have not the space here to mention. 

It also gives me pleasure to acknowledge the generous manner in which the publishers have 
acceded to all my requests and suggestions in regard to the construction of the book ; some of these 
requests involving a considerable increase in the expense of publication. 

This volume, as will be noticed, is not self-indexing. Without a reasonably exact knowledge of 
the contents of the remaining seven volumes, it would not be possible to introduce such a running 
index, or at least one that would be sufficiently complete to be really useful. It seemed to me, therefore, 
that much valuable space might be saved by omitting altogether the independent cross-references {i.e., 
those which constitute separate headings), and introducing, instead, at the end of the work, a reason- 
ably fuU index. 

Finally, I desire to call attention to the running titles at the upper corners of the pages. These 
are intended to aid the reader in searching for a particular topic, and they are therefore placed where 
they can be most easily seen in turning over the pages rapidly. The upper title always indicates the 
first topic on the left-hand page, and the lower one the last topic on the right-hand page. 

A. H. B. 

New Yoke, August 31, 1885. 

vi 



A KEFEEENOE HANDBOOK 



MEDICAL SCIENCES 



Aachen. 
Aactaen. 



AACHEN (Fr. Aix-la-Chapelle), renowned for the num- 
ber, variety, and singular efficacy of Its springs since the 
days of Charlemagne, has maintained its ancient repute, 
and in our own times ranks as one of the most valuable 
of health resorts. It is a city of Bhenish Prussia, near 
the western border of the empire (Lat. 50° 47' N., Long. 
6° 12' E.). Its elevation above the level of the sea is 
about 565 feet. Its name is derived from the Teutonic 
Aa, Aach = water (Latin, Aqua). The great quanti- 
ties of thermal waters which well up from numberless 
springs in its immediate vicinity justify the appellation. 
The most noteworthy of the springs are the Kaiserquelle, 
having a temperature of 55° C. (131° F.), Quirinusquelle, 
50° 0. (123° F.), Rosenquelle, 47.5° 0. (117.5° F.), and 
the Corneliusquelle, 45.5° C. (114° F.). Their waters 
supply, in addition to the Elisenbrunnen, which has a 
temperature of 53° C. (127.5° F.), eight sumptuously 
arranged bathing establishments, of which those known 
as the " Kaiserbad" (rebuilt in 1864), the " Konigin von 
Ungarn," the "Neubad," and the " Quirinusbad " are 
the most prominent. The waters are all of them but 
slightly impregnated with carbonic acid gas ; their chief 
saline constituent is sodium chloride. They contain, 
besides, a small proportion of bromine and iodine. Sul- 
phur is an important component part. The Kaiserquelle 
contains it in greatest abundance ; but in all of the springs 
the amount and chemical condition of the sulphur pres- 
ent are subject to great and frequently varying change. 
The presence of sodium carbonate in the water points to 
the proximity of extinct Eifel volcanoes. The chemical 
composition of all the waters varies only within very 
narrow limits. According to the analysis of J. von 
Liebig, the Kaiserquelle, which may serve, for all prac- 
tical purposes, as a standard for the others also, contains 
in 10,000 parts of water : 

Sodium chloride S6 101 

Sodium bromide 0.036 

Sodium iodide 0.005 

Sodium sulphide O-OSS 

Sodium eulubate 2.836 

Potassium sulphate - lo27 

Sodium carbonate no 

Lithium carbonate 0.029 

Magnesium carbonate 0.506 

Calcium carbonate 1-579 

Strontium carbonate n noc 

Ferrous carbonate n?e5 

Silica hydrate 0.661 

Organic matter U. (b9 

Total 40.791 

Carbonic oxide (free and partially free) B.OOO 

Traces of fluorine, boron, and arsenic. There is probably an organic 

sulphide (allyl) present in minute quantity. 

The action of the Aachen thermal water on the econ- 
omy is analogous to that of any chloride water of the 
same temperature. By reason of its alkalinity it does 
not generally disturb the stomach. The sulphates fre- 
quently produce a slight aperient effect ; but where baths 
are taken simultaneously with the habitual drinking of 
the waters, this laxative action is annulled, and a slight 
constipation not infrequently ensues. The sodium 
sulphate is probably the great factor in producing 
therapeutic effects in torpid conditions of the abdominal 
VoL L-1 



viscera, "particularly on the mucous membranes of the 
intestinal tract. Its presence, although in minute quan- 
tity, is easily appreciated by the senses. The sulphate 
is either absorbed unchanged, or is decomposed into 
hydrogen sulphide, and taken into the blood-current as 
such : in either case it promotes metamorphosis of the 
blood-disks and albumen, and has a distinct solvent 
action on metallic deposits in the tissues. The researches 
of Guntz have shown that the internal use of Aachen 
waters promotes the secretion of urea, and it follows that 
protein decomposition is accelerated in proportionate 
ratio. This is further proven by the appearance or in- 
crease of xanthin in the urine of Aachen patients. In 
hydrargyrosis, the drinking of the water of the Kaiser- 
quelle produces elimination of mercury by the kidneys. 
■ For purposes of local treatment the waters are used as 
baths, which are taken in stone basins. There are no in- 
tegumentary irritants in the waters ; hence there are no 
immediate local effects. Neither is the temperature at 
which the bath is taken high enough to act by its caloric 
property ; but the sulphur, which in the bath water is 
suspended in the most minute particles, adheres to the 
skin, and finds lodgment in the pores, but it is still an 
open question whether it is possible for the sulphur to 
find its way into the absorbents in this way. The alka- 
line reaction of the bath imparts emollient properties to 
it ; it exerts also a solvent action on the sebum and other 
fatty skin elements, and promotes absorption in this way ; 
and this may explain why inunctions immediately fol- 
lowing the bath, are so remarkably prompt in their action. 
The temperature of the bath usually varies from 38° to 
36° C. (91.4° to 96.8° F.) ; it rarely fails to act as a seda- 
tive. A method of bathing peculiar to Aachen consists in 
the application of a douche in a manner differing from 
that pursued in any other place. A stream of warm water 
is poured from a hose upon the bather for ten or fifteen 
njinutes, from a height varying from five to ten metres 
(16 to 83 ft.). The streams used vary in diameter from 
three to nine millimetres, and the temperature of the 
water ranges from 35° to 37° C. (95° to 98° F.). For a 
period of from five to twenty minutes the douche is kept 
playing upon the back and limbs, and especially over 
the affected regions. At the same time, massage and 
shampooing are carried out by a skilled attendant. The 
mechanical and thermic effects of these procedures are 
made manifest by reddening of the skin and profuse 
diaphoresis. They are very agreeable to the patient, 
and do certainly act as a lymphatic stimulant. They 
promote absorption of chronic inflammatory products, 
and of syphilitic, rheumatic, and gouty new-formations ; 
and it is this tissue metamorphosis which is the object of 
an Aachen cure and which is hardly attainable, in the 
same degree, at any other bath on the Continent. 

Syphilis is not treated exclusively by the water cure : 
inunctions with mercurials and the internal administra- 
tion of mercury and potassium iodide are resorted to 
simultaneously ; and although such a complex treat- 
ment would seem to prove nothing as ^o the waters 
themselves, experience has shown that the specific treat- 
ment alone is not as efficacious as the combined specific 
and thermal treatment. The same statement will hold 



Aaclien. 
Abdomen. 



REFERENCE HANDBOOK OF THE MED ICAL SCIENCES. 



good with regard to gout, rheumatism, acne, eczema, 
furunculosis, metallic deposits and their systemic effects ; 
and, lastly, with regard to all diseases of the abdominal 
viscera characterized by engorgement, hypertrophy, and 
new growth. The singular effectiveness of the Aachen 
baths has led to the artificial preparation of the same, 
but neither the prepared Aachen bath water nor the 
Aachen soap produces the least effect, excepting in the 
imagination of the patient. The water of the ' ' Elisen- 
brunnen " is bottled for export. Aachen enjoys another 
advantage which is of some moment : it is situated in a 
mild latitude, where no great variation of temperat^ire is 
ever experienced ; it is rarely visited by epidemics ; in 
the main there is plenty of space around the houses ; in a 
word, it is admirably adapted for a place, of sojourn in 
the winter months, and the number of guests who fre- 
quent it during this season of the year is gradually be- 
coming greater, so that it can hardly be said that there 
is a limited season. (The preceding account is derived 
from Eulenberg's "Real Encyclopadie.") 

Hemry Fleisehner. 

ABDOMEN. — Medical and Surgical Appldbd An- 
atomy. — The term abdomen is applied to the cavity 
bounded above by the diaphragm, below by the iliac fossae 
and brim of the true pelvis, behind by the luinbar verte- 
brae, and at the sides and front by the abdominal mus- 
cles. The space thus included extends upward far 
under the chest-walls. Its summit is formed by the con- 
vexity of the diaphragm, which reaches upward to the 
level of the fifth right chondro-sternal articulation. A 
horizontal section of the body at this level will shave off 
just a thin slice of liver covered by the diaphragm. On 
the left side the arch of the diaphragm reaches but as 
high as the level of the junction of the sixth rib with the 
sternum. Posteriorly the vertebral column, covered by 
the crura of the diaphragm, projects into the abdominal 
cavity. The distance from the umbilicus to the lumbar 
vertebrae is scarcely more than two inches. The lateral 
portions of the posterior wall are formed by the psoas, 
which rests closely against the sides of the bodies of the 
lumbar vertebrae, as well as the quadratus lumborum, a 
thin plane of muscle lying between the posterior portion 
of the crest of the hip-bone below and the last rib above, 
and the apices of the transverse pi-ocesses of the lumbar 
vertebrae toward the middle line. The sides and front of 
the abdomen are formed by the three flat muscles, the ob- 
liquus externus, obliquus internus, and the transversalis, 
united at the linea semilunaris to enclose the fourth ab- 
dominal muscle, the rectus, which is the anterior bound- 
ary of the belly- wall. The space thus enclosed contains 
the stomach, the intestines, the liver, the spleen, the 
pancreas, the kidneys and their ducts, the vessels of the 
trunk, nerves and lymphatics. 

Superficial Anatomy of the Abdomen. — The belly 
is convex on its anterior surface, more especially so in 
the corpulent. Unusual prominence of the lower part 
of the belly is often seen in those whose chests are shal- 
low. Infants are normally pot-bellied, owing to the 
relatively large size of the solid viscera, as well as to the 
narrowness of the pelvis. In rickets, as in other condi- 
tions of malnutrition in children, the belly becomes very 
prominent, partly from a depression of the liver and 
spleen, partly by reason of the anterior curvature of the 
spine and the fact that the intestines in this disease are 
commonly distended with gas. In cretins the belly is 
pendulous from laxity of the skin, and after pregnancy, 
ascites, and ovarian dropsy the abdominal wall tends to 
remain permanently flaccid. Retraction of the anterior 
abdominal wall is seen in diseases accompanied by much 
emaciation. In tubercular meningitis it is a very marked 
symptom, helping to distinguish it from enteric fever, in 
which there is usually tympanitis. In peritonitis gas 
distends the cavity, and abdominal respiratory move- 
ment ceases. Various kinds of skin eruption appear 
upon the surfece of the abdomen. Herpes zoster is seen 
upon one or other side of the trunk, following the course 
of the intercostal nerves. The rash of typhoid fever is 
dotted over the front of the abdomen. Often, when ab- 



sent in front, it is to be found over the lumbar region, 
and the same may be said of the syphilitic secondary 
rash. Tinea versicolor sometimes descends from its fa- 
vorite position on the front of the chest, and spreads out 
upon the abdomen. In the vicinity of the navel, scabies 
is often met with, while eczema prefers the scrotal in- 
tegument. 

The pit of the stomach is that depression in the middle 
line just below the ensiform appendix. Here the skin 
is tender and sensitive. A blow upon the scrobiculus 
cordis, as the older writers called it, is dangerous. The 
solar plexus lies underneath the pit of the stomach. In a 
few cases fatal results have immediately followed an in- 
jury of this nature. The epigastrium is the seat of pain 
m stomach affections generally, and to it is referred the 
feeling we call hunger, and that condition impossible to 
define, nausea. The ingestion of irritant poisons is fol- 
lowed by burning pain at the pit of the stomach. Con- 
versely, counter-irritation in this region will relieve gas- 
tric pain and nausea. There are few remedial agents so 
efficacious as a mustard poultice to the pit of the stomach 
in severe gastralgia, whether of organic origin or not. 
What, then, is the connection between the stomach and 
the skin of the epigastric region ? The sympathetic 
nerves which supply the stomach are the branches of the 
coeliac plexus, which is derived from the fore part of the 
great solar or epigastric plexus. The semilunar ganglion 
is part of the solar plexus ; it receives the great splanch- 
nic nerve, the origin of which is from the lower thoracic 
ganglia. Each of these thoracic ganglia is connected to 
the nearest anterior root of the spinal nerves. Now it 
happens that the skin of the epigastrium is supplied by 
these very same nerves, viz., from the fourth to the 
seventh intercostal nerve. There is therefore a com- 
plete nervous circuit from the mucous membrane of the 
stomach to the skin of the epigastrium. 

In the .jnid-line in front is the depression of the linea 
alba, the abdominal furrow. At about its centre is the 
umbilicus, the remains of that opening in the abdominal 
wall through which there passed the structures connect- 
ing the embryo with the internal surface of the ovum. 
The linea terminates below in the symphysis pubis, and 
above in the tip of the sternum. In this median depres- 
sion, the linea alba, the incision is made in all cases 
where the surgeon has to open the abdominal wall, as in 
ovariotomy, Caesarean section, and other operations. The 
prominence formed by the rectus muscle lies on each 
side of the furrow. In thin, muscular subjects the 
transverse marks on the rectus are plainly perceptible. 
There are usually three of these cross-marks— one at the 
level of the navel, one just below the ensiform appendix, 
and a third between these two points. In the living 
body not more than two are commonly perceptible. 

The abdominal aorta lies a little to the left of the 
middle line, with the inferior vena cava on its right side. 
The bifurcation takes place opposite the middle of the 
body of the fourth lumbar vertebra, three-quarters of an 
inch below and to the left of the umbilicus. This point 
is nearly on a level with a line drawn from the highest 
point of the iliac crest to the other. A line drawn from 
it to the midpoint between the iliac spine and the sym- 
physis pubis indicates the direction of the common and 
external arteries. The upper third of this line represents 
the common, and the lower two-thirds the external iliac. 

The cffiliac axis arises from the aorta at a point four 
inches above the uinbilicus. Posteriorly it corresponds 
to the lower part of the body of the last dorsal vertebra 
opposite the first lumbar spine. Immediately below the 
coeliac axis is the pancreas, which crosses the arch of 
the aorta and the vertebral column at a point between 
three and four inches above the umbilicus. Below the 
pancreas is the superior mesenteric artery, two or three 
inches above the navel. One inch above the umbilicus 
the duodenum crosses the aorta. Immediately beneath 
the duodenum, about one inch above the navel, the 
inferior mesenteric artery is given off. At the outer 
border of the prominence formed by the rectus muscle is 
a shallow depression on each side, the upper ends of 
which are bent in toward the middle line. This is the 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 



Aachen. 
Abdomen. 



linea semilunaris, the point where the aponeuroses of the 
ahdominal fasciae unite just before they diverge to form 
the sheath of the rectus. Its direction corresponds with 
that of a slightly curved line drawn from the tip of the 
ninth costal cartilage to the spine of the pubes. In 
former days incisions for paracentesis were made in the 
linea semilunaris. In one reported case at least, the tro- 
car struck the epigastric artery, just as it crossed the line. 
The operator was the illustrious Cline. ' The prepara- 
tion is to-day in the Museum of St. Thomas' Hospital. 

The spine of the pubes is an important landmark. In 
the male subject it is to be felt from below by tucking 
up the scrotal tissues with the forefinger. The line of 
the adductor longus, which is made manifest by abduc- 
tion of the thigh, leads up to it. The spine having been 




Fio. 1. — Superficial Abdominftl Veins distended from Intra-tboracic 
Pressure. The superficial thoracic veins are also enlarged, though 
not represented by the engraver. 

found, the external ring may be felt immediately to its 
outer side. In the normal condition of parts the tip of 
the finger should feel a slight depression over the ring, 
and when the patient coughs anything like a distinct 
impulse should not be felt. When a patient has had a 
rupture for some time, the sharp edges of the ring dis- 
appear, and the finger slips easily through the opening 
into the abdominal cavity. The spine of the pubes is on 
a horizontal line with the upper edge of the great tro- 
flhanter. The internal ring corresponds to a point upon 
the surface midway between the anterior superior spinous 
process of the ileum and the symphysis pubis and half 
an inch above Poupart's ligament. Between the two 
rings the epigastric artery takes its course from its origin 
from the external iliac artery upward and inward to- 
ward the umbilicus. Passing over Poupart's ligament, 
and superficial to the deep abdominal (Scarpa's) fascia 



are the branches of the femoral artery and vein which 
ascend up the abdominal surface, the superficial epi- 
gastric and superficial circumflex iliac. These veins be- 
come enlarged when there is obstruction to the circula- 
tion in the abdomen. Figure 1 is a portrait of my patient, 
Jean Larance, aged fifty-nine, in whose case thoracic 
aneurism was diagnosed. The superficial abdominal 
veins are as thick as one's little finger, and are very 
tortuous. The superficial epigastric vein becomes lost 
in the enlarged venous plexus on the surface of the 
thorax ; the superficial circumflex iliac vein is directly 
continuous with the axillary veins. Billroth records a 
similar case of enormous enlargement of superficial ab- 
dominal veins. The autopsy showed the presence of a 
malignant bronchocele in the upper part of the chest, 
causing pressure upon the innominate vein on the left 
side. 

Regions of the Abdomen and their Contents. 

For purposes of description the abdomen has beeh 
divided into nine regions. The landmarks from which 
the boundary lines of these are 
to be drawn vary according to 
difl'erent authors. The most satis- 
factory directions are as follows : 
Draw a. horizontal line on a level 
with the lowest part of the tho- 
racic wall on each side, another 
horizontal line on a level with 
the highest part of the iliac crests. 
Bisect Poupart's ligament, and 
through each point of bisection 
draw a vertical line upward. 
The abdominal surface is thus 
divided into nine regions, named 
as in the diagram. 

The Right Htpochondkiac 
Region. — This region contains 
the greater part of the right lobe 
of the liver, whose convexity is 
in relation with the concavity of 
the diaphragm, the hepatic flex- 
ure of the colon, and part of the 
right kidney. "That surface of 
the liver which is now called upper, corresponds with 
the surface in contact above with the diaphragm, and in 
front with a portion of the anterior chest- wall. Morb- 
id adhesions between 
the liver and dia- 
phragm are of not un- 
common occurrence, 
notably in cirrhosis, 
where the junction of 
the two surfaces en- 
ables the branches of 
the portal vein to 
communicate with 
the veins of the dia- 
phragm. These vein? 
take the course of the 
phrenic arteries, on 
the left side often 
joining the left renal 
vein. Portal engorge- 
ment is in this way 
partly relieved. Fre- 
richs has been able to 
make out this com- 
munication in every 
case in which he has 




Fig. 3.— Outline of the Front 
of the Abdomen, showing 
the Division into Begions. 
1, Epigastric region ; 2, um- 
bilical ; 3, hypogastric ; 4, 
4, right and left hypochon- 
driac ; 5, 5, right and left 
lumbar ; 6, 6, right and left 
iliac. (Proiri Quain.) 




Pia. 3.— Area of Hepatic Dulness Viewed 
Anteriorly. A, B, right mammary line ; 
C, D, median line ; B, splenic dulness ; P, 
cardiac dulness. (After Murcbison.) 



injected the portal 

vein. 
Hepatic Dulness. — 

The upper margin of 
hepatic dulness on percussion is not exactly defined. 
The flat note elicited on percussion over, the liver be- 
comes gradually clear as we percuss upward, the reason 
being the fact that a margin of clear lung overlaps the 
convex upper surface of liver. The line at which abso- 



Abdomen. 
Abdomen. 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 



lute dulness ceases is spoken of as the upper margin of 
hepatic dulness. This line is not quite horizontal, but is 
somewhat arched. " Commencing posteriorly at about 
the tenth or eleventh dorsal vertebra, it ascends gradually 





Fig. 4. — Area of Hepatic 
Dulness viewed from 
tile Bight Side. A, B, 
right axillary Hne. 



Fig. 5, — ^Area of Hepatic Dulness 
viewed Posteriorly. A, B, right 
dorsal line ; G, splenic dulness ; D, 
left kidney; B, right kidney; F, 
descending colon; G, ascending 
colon. 



toward the axilla and nipple, and then again descends 
slightly toward the middle line in front" (Murchison). 
In the right mammary line, which is an imaginary straight 
line let fall vertically from the right nipple, the upper 
margin of hepatic 

dulness is situated in I 

the fifth intercostal 
space. In the median, 
line in front, it usual- 
ly corresponds to the 
base of the ensiform. 
cartilage, or rises 
slightly above it. To 
the left of the ster- 
num, the upper mar- 
gin of liver dulness is 
lost in that of the heart 
(see Epigastric Re- 
gion) ; " but a line 
drawn from the upper 
margin of hepatic dul- 
ness in the middle line 
to the apex of the 
heart, will usually cor- 
respond to the line of 
separation. In the 
right axillary line, a 
line falling perpen- 
dicularly from the 
centre of the axilla. 



ninth right costal cartilage, close to the outer edge of 
the rectus abdominis. 

The size of a liver is usually measured by the extent 
of dulness in the right mammary line, which in an or- 
dinary adult is about 4 inches, and by that in the axil- 
lary and dorsal lines, which measure respectively 4^ and 
4 inches. 

Paris in the Transverse Fissure of the IMer. — From be- 
fore backward there are found in the transverse fissure 
of the liver the bile-duct, the hepatic artery, and the 
portal vein. These structures lie between the layers of 




*?*«*» ffC*PB«W^ 



tttp* 



I- I \ 

the upper margin of j-,a, 6._Horizontal Section just above the Body of the First Lumbar Vertebra 
hepatic dulness corre- Dwight.) 

sponds to the seventh 

intercostal space, or more rarely to the seventh rib. In the 
right dorsal line, or a line falling perpendicularly from the 
angle of the scapula, when the arm is dependent, it cor- 
responds to the ninth intercostal space or the ninth rib " 
(Murchison). Percussion and palpation determine the 
lower margin of hepatic dulness. In the right mammary 
line it corresponds roughly to the lower margin of the 
thoracic wall. In the right axillary line it is opposite 
the tenth interspace, and in the right dorsal line, the 
twelfth rib. The gall-bladder projects opposite the 



Fig. 7. — The Liver of a Toung Subject, sketched from below and behind. 
(From " Quain's Anatomy.") B. Z., right lobe ; L. £., left lobe ; Z. S., 
lobe of Spigelius ; Z. C, caudate lobe ; L, Q., quadrate lobe ; p, portal 
fissure; M./., umbilical fissure; /. d. »., fissure of the ductus veno- 
sus ; ff. 6i., gall-bladd%r ; v. c. i., vena cava inferior ; /, g, impression 
on the under surface of the left lobe corresponding to the stomach ; c, 
position of the cardia ; t. o., projection of the posterior surface of thq 
left lobe against the lesser omentum (tuber omentale, His) ; i. c, im- 
pressio colica ; i,r,, impressio renalis; i. s, 7*., impressio supra-renalis ; 
P}^ P^i i?^, P^t lines of reflection of the peritoneum ; +, surface of the 
liver uncovered by peritoneum. 

the gastro-hepatic omentum at its right border, in front 
of the foramen of Winslow. The duct lies most to the 
right side, the artery toward the left. There are many 
lymphatics and nerves in the transverse fissure. These 

important structures 
are so closely related 
that alterations in size 
or shape of one affect 
the function of the 
others. The hepatic 
artery may be the seat 
of an aneurism, which 
may press upon the 
vein and cause portal 
obstruction and its 
attendant symptoms, 
or upon the bile-duct 
and cause obstructive 
jaundice. An hepatic 
aneurism has been 
known to burst into 
the gall-bladder (Fre- 
richs). The lymphatic 
glands in the trans- 
verse fissure may en- 
large and obstruct 
either duct or portal 
vein. Neighboring 
tumors of all sorts 
act in the same way. 
Concretions in the 
bile-ducts may ob- 
struct the portal vein, 
Into it, an occurrence 
the death of Ignatius 




(From 



or even ulcerate their way 

which is said to have caused . _. „ 

Loyola. The close relation of the hepatic flexure^ofthe 
colon to the duct explains the fact that an overloaded 
bowel may cause jaundice. The nerves of the liver are 
derived from the ccellac plexus of the sympathetic and 
the vagus, more especially the left, which sends some 
filaments between the layers of the gastro-hepatic omen- 
tum to join the hepatic plexus. The connection of the 
nerves of the liver with the solar plexus, and indirectly 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 



Abdomen. 
Abdomco. 



with the splanchnic nerves, serves to explain the pain in 
and about the right shoulder which is felt in some dis- 
orders of the liver, the skin of the parts about the 
scapula being supplied by the upper dorsal spinal nerves, 
which are in direct communication with the origin of 
the splanchnics. 

The hepatic artery conveys the main supply of blood 
for the nourishment of the organ. It may, however, be 
occluded without causing serious interference with, the 
functional activity of the liver. The collateral circula- 
tion, when there is complete or nearly complete obstruc- 
tion, may be kept up by (1) accessory hepatic arteries, 
which are sometimes met with coming from the gas- 
tric arteries, less frequently from neighboring arteries ; 
(3) the anastomoses of the pyloric artery, provided the 
obstruction be beyond the giving oflE of that branch ; 
(3) possibly the portal vein may in sucli a case nourish 
and keep up the secreting functions of the liver. The 
reverse is positively true. The hepatic artery can sup- 
ply the liver with sufiBcient blood to carry on its func- 
tions when the obstruction of the portal vein occurs. 

The hepatic veins which collect the blood from the 
lobules of the liver open into the inferior vena cava by 
an oblique entrance, which serves as a valve. In cases 
of abdominal tumor the effects vary as to the relation 
of the pressure to this junction of the hepatic vein. If 
the tumor compresses the inferior vena cava above the 




Fio. 8. — The Pancreas and Adjoining ViRcera, seen from before. (From 
Quain.) The stomacb, the greater part of the Rmall intestines, and 
the transverse colon have been removed. P., pancreas ; d., duo- 
denum ; d.j.^ its iunction with the jejunum ; above the duodenum 
and between it and the head of the pancreas are seen the bile-duct, 
portal vein, and hepatic artery ; aac. col.^ deac. coL, ascending and 
descending colon; apl., spleen; r. X:., Z. X;., right and left kidney; 
s. n, 8. ri, right and left suprarenal capsules ; pt.^ peritoneum, at 
the back of the abdominal cavity ; 7n., line of reflection of the mesen- 
tery ; the line of reflection of the transverse mesocolon is seen along 
the lower edge of the pancreas and crossing the duodenum. 

hepatic vein the result will be a damming up of the 
blood-current in the liver as well as in the general cir- 
culation. (Edema of the lower extremities and portal 
obstruction will both occur. If, on the other hand, the 
pressure be below the hepatic vein, then cedema of the 
feet will be the most prominent symptom. 

The Portal Vein. — There are no valves in the portal 
vein. Its-left branch is joined in the longitudinal Assure 
of the liver by the so-called round ligament, which is 
really the obliterated umbilical vein. This latter is 
sometimes open during adult life. Osier ("Montreal 
General Hospital Reports," vol. i.) reports a case of 
cirrhosis of the liver where the collateral circulation was 
carried on by means of an enlarged umbilical vein. At 
the navel this enlarged vessel became continuous with 
the deep epigastric vessels of the left side. The trib- 
utaries of the portal vein originate in the stomach, intes- 
tines, pancreas, and spleen. It is made up of the superior 
and inferior mesenteric and splenic veins, joined by the 
pyloric and gastric veins, and sometimes by the cystic 
vein from the gall-bladder. All these viscera, then, would 
suffer interference of function were there to be impeded 
circulation in the portal vein. This condition is com- 
monly met with. Its causes, from its anatomical rela- 
tions, are easily understood, and the symptoms pro- 
duced thereby are such as might be expected to be met 
with after consideration of the sources of its tributaries. 



1. Engorgement of the gastric and mesenteric veins 
gives rise to catarrh and hemorrhages from the mucous 
membrane of the stomach and bowels. 3. Ascites from 
the over-distention of the veins that return the blood 
from the peritoneum. 3. The spleen is enlarged from 
obstruction of the current in the splenic vein. 4. An 
attempt is made to carry on the current by enlargement 
of the abdominal veins. 5. Hemorrhoids from stagna 
tion in the hemorrhoidal plexus, the superior hemor- 
rhoidal vein being a tributary of the portal vein. 

The hepatic duct leaves the liver and passes down in 
front of the portal vein, between the two layers of the 
gastro-hepatic omentum, behind the first part of the 
duodenum. A stone in the duct may work its way 
into the stomach and be expelled by vomiting. Pistulse . 
into the duodenum are not uncommon, indeed a calculus 
may ulcerate into the duodenum and cause death by ob- 
struction of the small intestine. 

The Epigastmo Region. — In this region the re- 
mainder of the right and nearly all the left lobe of the 
liver are found. In the middle line of the trunk the 
heart rests upon the upper surface of the liter, separated 




Fig. 9. — The Portal Vein. (From Wilson.) The pancreas drawn down 
to show the splenic vein behind it. 1, Inferior mesenteric vein, 
passing behind 3, the pancreas, to terminate in 3, the splenic vein ; 
4, the spleen ; 5, gastric veins opening into the splenic vein ; 
6, superior mesenteric vein; 7, descending portion of the duo- 
denum ; S, its transverse portion crossed by the superior mesenteric 
vein and part of the trunk of the superior mesenteric artery ; 9, por- 
tal vein ; 10, hepatic artery ; 11, ductus communis choledochus ; 
13, division of the duct and vessels at the transverse fissure of the 
liver ; 13, cystic duct leading to the gall-bladder. 

from it by the pericardium, the diaphragm, and the peri 
toneum, this last extending three-quarters of its way 
back between liver and diaphragm before its reflection 
The left ventricle and right auricle of the heart are in 
close relationship with the liver, and there passes through 
it the inferior vena cava. This relation is illustrated by 
a remarkable case quoted by Treves. " A loose piece of 
liver, weighing one drachm, was found in the pul- 
monary artery. The patient had been crushed between 
two wagons ; the liver was ruptured and the diaphragm 
torn. A piece of the liver had been squeezed along the 
vena cava into the right auricle, whence it had passed 
into the right ventricle, and so into the pulmonary ar. 
tery. The heart was quite uninjured." A needle thrust 
through the abdominal wall at the tip of the xiphoid 
appendix, from before backward, would most probably 
pass through the diaphragm, the left lobe of the liver, 
the lobus Spigelii, the diaphragm again, the vena azygoa 



A-bdomen. 
Abdomen. 



BBFERBNCE HANDBOOK OF THE MEDICAL SCIENCES. 



jiajor, and strike the lower edge of the tenth dorsal ver- 
tebra. The lower margin of the liver in the epigastric 
region extends in contact with the abdomen in a line 
from the ninth right to the eighth left costal cartilage, 
and in the middle line its depth below the subcostal 
angle may be roughly estimated at 3^ or 4 inches, about 
a hand's breadth. On the right of the epigastric region 




tio. 10.— Horizontsl Section through the Upper Part of Abdomen. 
(From Treves, after Eiitdinger. ) a, Liver ; &, Btomach ; c, transverse 
colon ; tZ, spleen ; e, kidneys ; /, pancreas ; ff, inferior vena cava ; A, 
aorta, with thoracic duct behind it. 

is found the gall-bladder, opposite the ninth cartilage, 
close to the margin of the rectus muscle. Underneath 
the liver on the right, and under the diaphragm on the 
left of the space, the stomach is situated, occupying from 
time to time a varying position. Its two orifices are 
found in the epigastric region ; the cardiac, usually a 
fairly fixed point, is behind the seventh left costal car- 
tilage, one inch from the sternuln; while the pyloric 
end is continually shifting its position, being found two 
or three inches below the ensif omj appendix, and mov- 




ifie. 11.— View of the Abdominal Viscera from Behind, after removal of 
the Spinal Column and the whole of the Posterior Wall of the Abdo- 
men, the Peritoneum being left, (Prom Quain, after His.) jP,, pan- 
creas; /", its head; d., duodenum; 9t„ stomach; spi., spleen; R. X., 
right lobe of the liver ; L, S.j Spigelian lobe ; v. c. i., vena cava in- 
ferior; p, ?*., portal vein ; &., common bile-duct; i. r., impression for 
the right kidney on the posterior surface of the liver (the situation of 
the two kidneys is well sliown by the corresponding impressions in the 
cut) ; asc. CO?., aeac. eol., ascending and descending colon ; pt., back 
of the perit<meum ; m., line of reflection of the mesentery seen 
through ; VIII, IX, X, XI, the corresponding ribs; U., ilium. 

ing toward the right as it becomes distended. The first 
and second parts of the duodenum are deeply placed. 
A horizontal cut through the abdomen, one inch below 
the ensiform cartilage, shows the transverse portion of 
the duodenum, situated in a square, of which the four 
sides are formed, in front by the hepatic flexure of the 
colon ; to the right by the liver, behind by the kidney, 



and toward the middle line by the pancreas. (See Fig. 
11.) At the back of the epigastric region the abdominal 
aorta and vena cava inferior lie against the bodies of 
the twelfth dorsal and first, second, and third lumbar 
vertebrae. A needle passed in one inch below the ensi- 
form appendix and pushed horizontally backward to tho 
spine would, after passing through the integuments, 
wound (1) linea semilunaris, (2) the left lobe of the liver, 
(3) the stomach, (4) the anterior and posterior layers of 
the lesser bag of the peritoneum, (5) the coeliac axis, (6) 
the aorta, (7) the junction of the twelfth dorsal and first 
lumbar vertebrae. 

The pancreas extends horizontally across the epigastric 
region, being curved forward from side to side, over 
the arch of the vertebral column, like a towel thrown 
across one's arm. Its horizontal level is about three or 
four inches above the umbilicus. In a horizontal section 
of the frozen body, through the first lumbar vertebra, 
the saw splits the pancreas from end to end. 

The spleen, in its upper and inner part, and a small 
portion of the kidneys, are also included in the epigastric 
region. 

The Left HypocHOiTDRiAC Begion. — The upper and 
anterior portion of this region is occupied by the stomach, 

which is covered to- 
ward the right side 
by a small part of the 
left lobe of the liver. 
The spleen is packed 
away in the outer and 
back part of the re- 
gion. To the front 
of the spleen lies the 
stomach; to its left 
side the tail of the 
pancreas and the left 
kidney. The cardiac 
end of the stomach is 
situated opposite the 
seventh costal carti- 
lage of the left side, 
one inch from the 
sternum. When full, 
the stomach occupies 
the left hypochondri- 
ac and epigastric re- 
gions, a small portion 
projecting into the 
right hypochondriac 
region. It lies partly 
in apposition with 
the anterior wall of 
the abdomen, and 
partly underneath the 
liver and diaphragm, 
and above the trans- 
verse colon. The relations of the stomach vary with 
its distention. As it fills, the surface which was for- 
merly anterior becomes superior, and the great curve 
comes to the front. The pyloric end is pushed over 
nearly three inches to the right of the median line 
when the stomach is distended, but when it is quite 
empty the pylorus remains on the left of the linea alba. 
When a gastric ulcer is present, and threatening to per- 
forate. Nature often attempts to stop the leak by attaching 
the stomach to neighboring organs. Thus adhesions to 
the diaphragm, to the pericardium, the liver, the colon, 
are not uncommon. Sometimes the process goes too far, 
and fistulous communication between the stomach and 
these other cavities is the result. The close relation of 
the stomach with the viscera immediately behind it, the 
pancreas, the left kidney, and the spleen, renders difficult 
the accurate diagnosis of the diseases to which these 
parts are subject. It is not uncommon to find malignant 
disease of the pylorus attacking, at the same time, the 
spleen, liver, and kidneys. In connection with gastrot- 
omy and gastrostomy, the relation of the stomach to the 
abdominal wall is of importance. That part of the ab- 
dominal wall with which the stomach is in apposition 




Fio. 12.— View of the Abdominal Organs 
from in Front. (From Banney, after 
Luschka.) The numerals are placed upon 
the respective ribs, I., the stomach: II., 
duodenum; III., ileum; IV., colon; V., 
sigmoid flexure. 



REFERENCE HANDBOOK OP THE MEDICAL SCIENCES. 



Abdomen. 
Abdomen. 



corresponds to a triangle upon the surface of the body, 
of which the sides are formed on the right by the edge 
of the liver, on the left by the cartilage of the eighth and 
ninth ribs, and below by a horizontal line passing be- 
tween the tips of the tenth costal cartilages. Gastric 
fistulse usually occur in this space. The operation is 
generally performed by an incision in the triangle above- 
mentioned, along the course of the left linea semilunaris, 
from the sternal end of the intercostal space, between 
the eighth and ninth ribs, vertically downward, along 
the border of the rectus. The stomach, being reached in 
this way, is withdrawn far enough to prevent the escape 
of its contents into the abdominal cavity. In gastros- 
tomy the stomach-wall is stitched to the margin of the 
incision, and subsequently an opening is made into it. 

The spleen lies between the stomach and the ribs, 
beneath the diaphragm, and above the kidney and the 
colon, in contact with the diaphragm, from which it is 
Separated by peritoneum, and connected with the pan- 
creas by its vessels. The peritoneum encloses the spleen 
in, as it were, a bag, of which the front portion is de- 
rived from the anterior layer of the gastro-hepatic omen- 
tum, and the back portion is continuous with that part 
passing over the back of the kidney. On the surface the 
spleen is situated opposite the ninth, tenth, and eleventh 
ribs of the left side, and at its upper edge is separated 
from them by the diaphragm, and also by the margin of 
the lung. The highest and lowest points correspond to 




Fio. 13. — The Pancreas and Adjoining Viscera from Before. (Prom 
Quain.) The stomach, the greater part of the small intestines, and 
the transverse colon have been removed. P., pancreas ; d,, duodenum ; 
d.i., its jnnction with the jejunum ; above the duodenum, and between 
it and the head of the pancreas are seen the bile-duct, portal vein, and 
hepatic artery ; aac. col., dene, col.^ ascending and descending colon ; 
«pZ., spleen; f. A:., I. *., right and left kidneys; «. r., ". r., right and 
left suprarenal capsules ; pt.^ peritoneum at tlie back of the abdominal 
cavity ; m., line of reflection of the mesentery ; the line of reflection 
of the transverse mesocolon, as seen along the lower edge of the pan- 
creas, and crossing the duodenum. 

the level of the ninth dorsal and first lumbar spines. 
The longest diameter is directed forward and downward, 
following the direction of the tenth rib. The spleen 
rarely if ever can be depressed below the free border of 
the costal cartilages ; hence, unless enlarged, it cannot 
be felt by the hand. The percussion note of the spleen 
is by no means as flat as that obtained from the liver, 
especially in the case of children ; in fact the upper third 
of the organ, covered by lung, even in expiration, is not 
to be defined by percussion. The notches or depressions 
on the surface of an enlarged spleen serve to distinguish 
it from any other tumor in the left hypochondriac re- 
gion. As a rule, there is one large fissure to be made 
out by palpation, as well as one, sometimes two, smaller 
ones. 

The Right Ltjmbak Region. — The ascending colon 
is situated far back up against the posterior abdominal 
wall, in relation with the right kidney and the quad- 
ratus lumborum ; the front of the region is occupied by 
the ileum. The ascending colon is deeply placed, being 
external to the peritoneum, and bound down by it to the 
quadrattis lumborum, but in some instances the intestine 
is more free, there being a mesocolon, which is sometimes 
several inches long. The right kidney is also extra-peri- 
toneal ; it rests upon the eleventh and twelfth ribs, the 
crura of the diaphragm, psoas, and quadratus lum- 
borum, and is covered in front by a thick investment of 



adipose tissue and the peritoneum. The upper end of 
the kidney makes its impresm renalis upon the under 
surface of the right lobe of the liver ; the anterior sur- 
face is in relation with the ascending duodenum and 
the hepatic flexure of the colon. A study of the rela- 
tions of the kidney (see Fig. 14) will show that the or- 
gan could be operated upon from behind, or even re- 
moved, without necessarily wounding the peritoneum or 
injuring an organ. In hydronephrosis, and in cases 
where any large cyst exists in the substance of the kid- 
ney, puncture should be practised. The trocar should 
be inserted into any spot where the skin looks thin and 
soft, but in the absence of any such indication, no better 
place can be selected on the left side than an inch in 
front of the last intercostal space ; but if the tumor be 
of the right side, this is too high, as the liver would 
probably be traversed. " On the left side the spleen, 
under ordinary circumstances, runs no risk of being 
punctured by inserting the needle well in front of the 
eleventh intercostal space. Where the right kidney is 
to be tapped, the needle should be inserted half way be- 
tween the last rib and the crest of the ileum, between 
two and two and a half inches behind the anterior supe- 
rior spine of the ileum. This spot is on a level with the 
front of the bodies of the lumbar vertebrae, and a needle 
here passed horizontally inward will be altogether in 




FlQ. 14. — ^Horizontal Section through Second Lumbar Vertebra, showing 
the Relations of the Kidneys. (Prom Dwight.) 

front of the kidney. It may, however, with safety he 
conjectured that in any case of hydronephrosis of the 
right side requiring to be tapped, if the trocar be inserted 
at this place and directed somewhat forward, the peri- 
toneum and colon will be sufficiently in front to escape 
injury, the liver will be safely out of reach above and 
the kidney behind, while the dilated pelvis of the kidney 
will be tapped at its anterior and lower part " (Mr. Henry 
Morris).' 

The kidneys present many varieties both in shape and 
size. They have been found unequal, lobulated as in 
the lower animals, or even joined together across the 
middle line forming the horseshoe kidney, or abnormally 
placed, the single kidney, for example, having been 
found entirely on one side of the vertebral column, or 
even in the lumbar region or pelvis. 

The MoatiTig Kidney. — A glance at Fi^. 14 will show 
that the kidney might with no great difficulty be dis- 
placed either forward, carrying its peritoneal covering 
before it, so as to form a mesonephron, or upward or 
downward. This condition is more common in women 
than in men. Its presence may be inferred when a 
reniform tumor is met with in the abdomen, and when 
the percussion note over one or other lumbar region is 
clear. The right kidney is more frequently out of place 
than the left. 

The renal arteries are subject to many variations, the 



Abdomen. 
Abdomen. 



REFERENCE HANDBOOK OP THE MEDICAL SCIENCES. 



most important being tlie presence of two arteries on 
each side entering the kidney at its upper and lower ends. 
This abnormality should not be forgotten in the opera- 
tion of nephrectomy. The renal veins pass inward from 
the kidney in front of the arteries to join the vena cava 
nearly at right angles. The left renal vein receives the 
spermatic vein of its own side, an arrangement which 
has been thought to be the cause of varicocele, and 
which is accounted for by the history of the descent of 
the testicle. In foetal life the left kidney and the left 
testis lying the one directly above the other, send their 
emulgent veins to join one another before crossing the 
middle line. The descent of the testis converts the acute 
angle at which the left spermatic vein joins the renal 
into a right angle. 

The renal plexus and the least splanchnic nerve supply 
the kidney. The lumbar pain of kidney disease may be 
accounted for by the fact that the lesser splanchnic 
nerves originate from those sympathetic ganglia which 
are connected with the lower dorsal (eleventh and 
twelfth) spinal nerves, which supply the skin in the 
dorsal region. The renal plexus of the sympathetic is 
derived from the semilunar ganglion, but some of its 
fibres come from the aortic and the solar plexus. Why 
does irritation in the kidney, e.g., the presence of cal- 
culus, cause pain shooting into the testis ? The answer 
is found in the fact that the spermatic plexus is con- 
nected with the renal plexus. The deadly sickening sen- 
sation experienced when the testis receives a blow, or is 
squeezed, is due to the connection of the spermatic 
nerves with the solar plexus, by means of the aortic 
plexus as well as by the above-mentioned means of 
communication. In fact, the testis belongs to the ab- 
domen. This so-called "testicular" sensation is merely 
what would be experienced if any of the solid viscera 
were subjected to sudden severe pressure. 

The Umbilical Region. — The transverse colon crosses 
the upper part of the region inclining upward toward the 
spleen. The third part of tjie duodenum lies behind 
the colon in the middle line crossing the aorta beneath 
the superior mesenteric artery. The small intestines are 
disposed at the sides of the space, being suspended in the 
mesentery which lies close to the anterior wall of the ab- 
domen, with the great omentum in front of it. The ab- 
domen is very shallow in the umbilical region. In a tall, 
muscular man, the distance between the skin and the 
lumbar vertebrse in the vicinity of the navel is but about 
two inches or less. The bodies of the lumbar vertebrse 
project, and, as it were, push the small intestines to one 
or other side. In the retracted abdomen a penetrating 
wound may reach the backbone without necessarily in- 
juring the intestine, or, in fact, any structure except the 
abdominal wall, the omentum, and the peritoneum. 
Hennen records the "recovery of a soldier who had been 
shot through the abdomen by a ramrod, which passed in 
anteriorly and actually stuck in one of the transverse 
processes of the vertebrae, from which it was not disen- 
gaged without the application of some force." Green 
records a fatal case of impalement : a spike passed 
through the abdomen and deeply indented the third lum- 
bar vertebra, after having torn the common iliac vein ; 
none of the viscera were injured. A needle pushed 
horizontally into the abdomen at the umbilicus will 
most likely wound the great omentum, the transverse 
colon at its lowermost part, pierce the mesentery, possi- 
bly touch the superior mesenteric artery, the aorta, and 
penetrate the disk between the third and fourth lumbar 
vertebrse. 

In connection with the umbilical region, the great 
omentum and the mesentery may be considered in their, 
medical and surgical relations. The gastro-colic, or 
great omentum, is commonly described as consisting of 
the two layers of peritoneum continued from the an- 
terior and posterior walls of the stomach downward to 
the lower part of the abdomen, where they are reflected 
backward and pass upward, the two posterior layers to 
separate and to enclose the transverse colon. The omen- 
tum consists, therefore, of four layers of serous mem- 
brane, containing fat, which varies in amount according 



to the quantity of adipose tissue present generally in the 
individual. The great omentum is frequently the pro- 
truded viscus in herniae, more especially in those occur- 
ring at or near the umbilicus ; in some cases it en- 
velops the protruded intestine, and forms a sac for it. 
The mesentery encloses almost the whole extent of the 
small intestine, and attaches it to the back of the abdo- 
men, supporting its vessels and nerves. The duodenum 
is not contained in the mesentery ; its first part is en- 
veloped like the stomach, of which it is really the con- 
tinuation ; the second part is covered by peritoneum 
but in front, while the third part, that which crosses the 
abdominal aorta, lies between the layers of the trans- 
verse mesocolon, and then beneath the superior mesen- 
teric vessels. The mesentery, after surrounding the je- 
junum and the ileum, is attached to the spine at the left 
side of the body of the second lumbar vertebra, and ex- 
tends downward, from left to right, to the sacro-iliac 
joint ; between its two layers are found the trunk and 
branches of the superior mesenteric vessels, branches of 
the sympathetic nerves, lymphatic vessels and glands ; 
of the last the largest surround the superior mesenteric 




Fio. 15.— Horizontal Section through the Body at the Level ot the TJm- 
bilicup. (After Braune."! ff, Spine of fourth lumbar vertebra ; 6, disk 
between third and fourth vertebree ; c, umbilicus ; d, quadratus lum- 
borum ; e, psoas ; /, external oblique, with internal oblique and trans- 
versalis beyond ; fif, rectus ; A, descending colon ; i, transverse colon ; 
J, aorta ; k, inferior vena cava ; I, ureter. 

artery. Inflammatory conditions of the intestines give 
rise to glandular enlargements, which are, in fact, buboes, 
and act as buboes do. In some cases, absorption not 
bein^ completed, the glands shrink into hard nodules, 
and in typhoid fever those which receive the absorbents 
from the lower part of the ileum are enlarged and in 
rare cases suppurate. It must be remembered that en- 
larged mesenteric glands may produce anomalous ab- 
dominal symptoms by pressure upon vessels and nerves. 
The ileum, as compared to the jejunum, is narrower, 
its coats are thinner and paler, and its valvulae con- 
niventes are smaller. A given length of jejunum weighs 
more than the same length of ileum, consequently the 
ileum is more frequently intussuscepted. The jejunum 
and the ileum vary greatly in their liability to ulceration, 
the jejunum being rarely or never diseased ; hardly a 
single instance of primary ulceration of this bowel has 
been recorded, while the' ileum is remarkably liable to 
disease. Meckel's diverticulum is a protrusion of the 
intestinal waU, which is often met with opposite the 
umbilicus ; it is all that is left of the omphalo-mesen- 
teric duct which connected the yelk-sac with the foetal 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 



Abdomen. 
Abdomen. 



intestine ; the persistence of this structure is thought to 
be the origin of umbilical rupture. 

The Left Lumbab Region. — The relation of parts in 
this region does not materially differ, from that in the 
right lumbar region. By an opening in the left loin the 
descending colon may be reached, and that -without 
wounding the peritoneum, for the gut lies up against the 
outer edge of the quadratus lumborum, the peritoneum 
covering its anterior portion only. The extent of gut 
uncovered by serous membrane varies considerably, but 
on the left side the existence of a mesocolon is less likely 
than on the right. The operation generally known as 
lumbar colotomy is performed in this way : The colon 
is first to be mapped out. Find the centre of the iliac 
crest, take a point half an inch behind it, and from that 
point draw a vertical line upward to the margin of the 
ribs. After this line has been marked with ink, an in- 
cision about four inches long is made diagonally down- 
ward across its centre ; the mid-point of the incision 
should correspond to the centre of the line. The mus- 
cular walls of the abdomen are then divided in such a 
manner that the extent of division at the bottom of the 
cut should correspond with that at the surface, lest the 
surgeon should have 
to hunt for the gut 
at the bottom of a 
conical pit. The fat 
surrounding the pos- 
terior part of the 
colon will then be 
found, its thickness 
depending on the fat- 
ness of the patient. 
On its division the 
colon will be found. 
The intestine is then 
seized, stitched to 
the margins of the 
wound and, lastly, 
opened. The parts 
divided in the opera- 
tion are : 1, Areolar 
tissue ; 3, the latis- 
simus dorsi at the 
posterior part of the 
incision ; 3, the ex- 
ternal oblique mus- 
cle toward the ante- 
rior third ; 4, the in- 
ternal oblique , 5, the 
origin of the trans- 
versalis and the fas- 
cia lumborum ; 6, oc- 
casionally the quad- 
ratus lumborum ; 7, 
the layer of adipose 
tissue which covers 
the intestine ; 8, the 
colon. 

The Right Iliac 
Region. — The csecum rests upon the iliacus and the 
psoas, occupying the right iliac fossa. The peritoneum 
covers it in front and laterally ; posteriorly it is connected 
with the subjacent fascia by a quantity of loose connec- 
tive tissue, and is in relation with the nerves of the lum- 
bar plexus. The extent of the serous covering varies 
greatly. At times there is a mesocsBcum, but cases are 
reported where this mesocsecum was long enough to 
allow the csecum to enter an inguinal hernia. The struc- 
tural peculiarities and the anatomical relations of the 
caecum are specially favorable toward the occurrence of 
accumulations of the solid and liquid contents of the in- 
testine, which lead to the production of pressure symp- 
toms. A csecum full of hard matter has been known to 
cause ulceration of large blood-vessels, while pressure on 
nerves has given rise to retraction of the testis. Accu- 
mulations, too, are likely to set up inflammation of the 
wall of the intestine ending in perforation and the es- 
cape of fecal matters into the loose areolar tissue which 




Fig. 16. — Posterior View of the Trunk, Rhow- 
ing the Relative Positions of the Principal 
Thoracic and Abdominal Viscera. (From 
a drawing by B. J. Godlee.) The trachea 
and lungs are indicated by thin lines ; the 
aorta by thick lines ; the liver, pancreas, 
and spleen by broken lines ;. the cesopha- 
gnSfStomach, and descending colon by thick 
dotted lines, and the kidneys by thin dotted 
lines ; X X , seventh cervical and first lum- 
bar spines. 



lies between the posterior wall of the abdomen and the 
csecum. Pus formed in this region can work its way 
along the back part of the abdomen, either perforate or 
pass behind the diaphragm, enter the pleural cavity, or 
finding its way into a bronchial tube be the cause of 
f secal expectoration. The pus in perityphlitis may take 
a downward course, passing into the pelvis and perfora- 
ting the rectum, or out of the pelvis along the pyrif or- 
mis muscle presenting itself in or below the buttock, or 
above Poupart's ligament, or below it travelling along 
the psoas and iliacus muscles. 

The vermiform appendix proceeds from the left side 
of the lower and posterior part of the csecum, to which 
it is attached by a mesentery ; the latter being in some 
cases unusually long allows the appendix to hang into 
the pelvis. The attachment of this free end is a com- 
mon cause of strangulation by adhesion ; foreign bodies 
finding their way into this little diverticulum set up an 
inflammation which is often the starting-point of a 
general peritonitis. - 

It has been observed in fatal cases of perforation of 
the appendix vermiformis that, though the concretion 
is lodged in the middle or upper part of the appendix, 
yet the perforation is found at the end. This has re- 
cently been explained on anatomical grounds by Dr. 
Fenwick in his recent lectures " On Cases of Difficult 
Diagnosis," in the Laricei, December 6, 1884. " Now 
the appendix is supplied with blood by means of a small 
mesentery of its own, which sometimes terminates be- 
fore the extremity of the process, so that the end must 
derive its nutriment from the blood-vessels of the part 
nearer to the csecum, and, under such conditions, any 
acute inflammation or ulceration that obstructs the cir- 
culation must tend to rapid disorganization of the 
structures. That this is by no means an uncommon 
cause of the perforation is shown by the fact that in the 
majority of cases the perforation is found at the extrem- 
ity, and very rarely near to the csecum." 

The ileo-colic valve prevents regurgitation into the 
small intestine, the colon being usually the part of in- 
testine distended in tympanites. 

The Htpogastkic Region. — The bladder surrounded 
by small intestine occupies the lower and central part of 
this region. (See Pelvis.) It is commonly stated that 
this organ comes into the abdomen merely when dis- 
tended. In a vertical median section of a frozen body, 
that of a tall, thin man, I found the bladder occupying 
a considerable space in the abdomen above the sym- 
physis pubis ; a horizontal section at the top of the 
symphysis would have almost divided the organ into 
equal parts. 

The Left Iliac Region. — The sigmoid flexure is 
loosely connected by a mesocolon to the abdominal wall, 
so that its position is by no means constant. Occasion- 
ally it is found upon the right-side, the intestine having 
crossed the abdomen completely before making its down- 
ward bend. The colon is narrowest just at the sigmoid 
flexure, a part often the seat of cancerous stricture, and 
a part more liable to obstruction by twist or volvulus 
than any other of the whole tube. The ureter, the sper- 
matic and iliac vessels lie beneath the sigmoid flexure ; 
hence an overloaded condition of the lower part of the 
intestine has been thought to have been the cause of 
varicocele as well as of milk leg. Recently the iliac 
vessels have been compressed by means of a lever intro- 
duced per rectum, for the purpose of controlling hsemor- 
rhage in amputations of the hip (Davy). 

The Abdominal Walls. 

The lateral cutaneous branches of the lower inter- 
costal nerves, five or six in number, supply for the most 
part the skin of the abdomen. After penetrating the 
muscles they lie beneath the fat, and divide into anterior, 
lateral, and posterior branches. The largest of the cu- 
taneous branches is that given off by the twelfth dorsal 
nerve, which is found near the iliac crest. The first 
branch from the lumbar plexus, the ileo-hypogastric, by 
its iliac branch supplies the skin over the highest part 



9 



Abdomen. 
Abdomen. 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 



of the iliac crest, and, by its hypogastric branch the 
surface over the region of that njime. The inguinal 
branch of the ileo-inguinal nerve supplies the skin on the 
inner side of the groin, as well as that upon the scrotum 
and penis in the male, or labia in the female, communi- 
cating with the inferior pudendal nerve. Near the mid- 
dle line of the abdomen the anterior cutaneous branches 
of the dorsal nerves make their appearance through the 
deep structures. 

In the clinical study of spinal disease, the knowledge 
of the distribution of these nerves becomes of very gl'eat 
importance. One of the earliest symptoms of caries of 
the vertebral column is an ill-defined superficial pain ex- 
tending around the trunk, more severely felt upon one 
side than another, taking up its position most frequently 
upon the chest, the epigastric, or the umbilical region. 
Careful mapping out of the painful area might lead to 
detection of the exact point of disease in the spine. In 
spinal-cord affections the seat of the lesion may be dis- 
covered by a careful study of cutaneous reflexes. Irri- 
tate the skin in the epigastrium, a dimpling on the cor- 
responding side of the region is the common result. The 

mechanism o f 
the reflex act is 
in such a case 
perfect. Persist- 
ent absence of 
such action 
points to disease 
mthe dorsal part 
of tile cord, high 
up, for these epi- 
gastric cutane- 
ous nerves are 
derived from the 
fourth to the 
sixth or seventh 
dorsal nerves. 
Similarly, loss 
of skin reflex 
over the abdom- 
inal surface, be- 
tween the mar- 
gin of the ribs 
and Poupart's 
ligament, is evi- 
dence in favor 
of a lesion lower 
down in the 
cord, this area 
being supplied 
by the branches 
of the eighth to 
the twelfth dor- 
sal nerves. Gir- 
dle sensations, 
when felt in the 
line of distribu- 
tion of the abdominal cutaneous nerves, similarly in- 
dicate lesion in the lower half of the dorsal part of the 
cord corresponding externally to that space between the 
upper border of the fifth dorsal spine (seventh dorsal 
nerve) and the lower border of the tenth dorsal spine. 
" Girdle sensations may be felt at different levels, the 
umbilicus corresponding with the tenth dorsal nerve, 
and the ensiform area with the sixth or seventh dorsal 
nerve" (Bastlan). When the lumbar part of the cord is 
involved there are no girdle pains. 

The blood-supply of the skin of the abdomen is derived 
from the intercostal arteries which accompany the 
nerves, and from those branches of the femoral which 
pass from below upward — the superior external pudic, 
the superficial epigastric, and the superficial circumflex 
iliac. Superficial branches of the internal mammary 
and deep epigastric are found joining these. The super- 
ficial abdominal veins correspond in extent and direction 
with the arteries ; they appear to be valveless, inasmuch 
as the blood seems to run both ways in them. When 
enlarged by obstruction of the vena cava" the veins 




Fio. 17.— View of the Anterior DivisionB ct the 
Dorsal aha some of the othor Spinal Nerves 
from Before. (From Hursohfeld and L6veill6.) 
The pectoralfs major and minor muscles have 
heen removed; on the right 'side, the rectus 
abdominis and internal oblique muscles are 
shown. 



transmit the blood upward, while in the normal con- 
dition of parts, the direction of the current is down- 
ward. 

There are no lymphatic glands in the abdominal wall. 
The superficial vessels of the lower part of the trunk, to- 
gether with those of the gluteal region, perineum, and gen- 
ital organs empty themselves into the superficial inguinal 
glands, which are arranged in two sets, a superior set 
above Poupart's ligament, an inferior or vertical set be- 
low it. The former are ranged in a line parallel to the 
ligament, the latter surround the saphenous vein and re- 
ceive the lymphatic vessels of the lower limbs. The 
superficial lymphatics of the upper part of the ab- 
dominal wall, commencing about the level of the um- 
bilicus, ascend to the lowest glands of the axillary set, 
which lie upon the serratus magnus, near the long 
thoracic artery at the lower border of the pectoral 
muscle. The line of glands upon the subscapular ves- 
sels receive the lymphatics of the back of the abdomen. 

The Abdominal Fascia. — The superficial fascia of 
the abdomen consists of two layers : 1. A subcutaneous 
layer in no way distinct from that covering the body 
generally. This layer contains much fat, even in thin 
subjects. 3. A deep layer, which in many anatomical 
and surgical works is spoken of as the superficial fascia 
of the abdomen, but which is more commonly known as 
Scarpa's fascia. This fascia contains much elastic tissue, 
which in the lower 
animals is highly 
developed, form- 
ing the tunica ab- 
dominalis, a struc- 
ture which aids in 
the support of the 
viscera. Scarpa's 
fascia lies in direct 
apposition with 
the aponeurosis of 
the external ob- 
lique muscle of the 
abdomen, to which 
it is attached by 
very loose connec- 
tive tissue which 
would easily allow 
the passage of pus. 
About the umbili- 
cus the fascia is 
adherent to the 
other abdominal 
fasciae. In the 
middle line inf eri- 
orly it gives off 
that fibro - elastic 
band, theligamen- 
tum suspensori- 
um, and becomes 
continuous with 
the superficial fas- 
cia of the penis as well as with the dartos of the scro- 
tum. On the front of the groin Scarpa's fascia descends 
over Poui)art's ligament, and becomes attached below 
to thefascia lata of the thigh ; at the external abdomi- 
nal ring it becomes prolonged over th6 cord along 
with the subcutaneous layer, which, as it approaches 
the scrotum, loses its fat. The united layer finally 
forms the musculo-fibrous bag, the dartos of the scro- 
tum. _ The attachments and connections of this fascia 
explain the course taken by extravasated urine into the 
perineal tissues beneath the deep layer of the superficial 
fascia of the perineum. The membranous is the part of 
the urethra which usually gives way, the urine leaks 
between the layers of the triangular ligament, where the 
canal is weak and where it is least supported by neigh- 
boring structures. The extravasated urine afterward 
works its way through the anterior layer of the tri- 
angular ligament at the point where it is perforated by 
the urethra. The fluid is in this way now situated be- 
tween the deep layers of the superficial perineal fascia ; 




Fia. IS.— Superficial Plan of the Begion of the 
Groin. (After L6veill6.) o, &, The obliquus 
externus and its aponeurosis, which latter, at 
c, crosses the fibres of its fellow of the other 
side, and at d forms the pillars of the ring ; 
e, spermatic cord ; /, fir, suspensoi-y ligament 
of the penis ; A, crural aroh ; i, fascia lata ; 
J, fascia cribriformis ; m, superficial epigastrio 
artery. 



10 



EEFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 



Abdomen. 
Abdomen. 



it cannot pass into the ischio-rectal fossa, because the 
triangular ligament winds around the transversus perinei 
muscle, to become directly continuous with the deep 
layer of the superficial fascia ; nor can it run down the 
thighs, because these two layers of fascia are firmly ad- 
herent to the ramus of the ischium and pubes. The only 
path left for the urine is upward into the scrotum, for 
the dartos is continuous with the deep layer of the super- 
ficial perineal fascia. The scrotal and penile tissues 
are now Infiltrated. The leakage increases. Where 
next ? The dartos is continuous with both the abdominal 
fasciae, the urine passes readily under them, and mounts 
up on the surface of the belly. Why does not gravity 
exert its influence then, and allow the fluid to run into 
the thighs ? This move is prevented by the attachment 
of Scarpa's fascia to the fascia lata just below Poupart's 
ligament. 

The ABDOMiNAii Mttscles. — The tendinous intersec- 
tions of the rectus have been mentioned as being in some 
persons perceptible during life. The most constant of 
these inscriptions are one at the umbilicus, another on a 
level with the tip of the ensiform appendix, and a third 
immediately between the first 
two. The rectus is a polygas- 
tric muscle, each intersection 
receiving a separate nerve sup- 
ply and being, under certain 
circumstances, capable of in- 
iependent action. Phantom 
tumors are found In the rec- 
tus more frequently than in 
any other muscles, and are 
very difiicult to recognize. 
Abnormal conditions of the 
nerve supplying one segment 
of the muscle will develop a 
tumor which is "firm, nearly 
hard, constant in its charac- 
ters and place, often painful, 
and distinctly pulsating like 
an aneurism" (Paget). The 
sheath of the rectus is formed 
by the aponeurosis of the 
neighboring muscles. Pos- 
teriorly the sheath is deficient 
at its upper end, where the 
muscle is in contact with the 
cartilages of the ribs, and infe- 
riorly for a space correspond- 
ing with its lower fourth. 
These surfaces of the rectus 
which are devoid of covering 
are penetrated above by the 
internal mammary, and below 
by the deep epigastric arteries. 
The sheath keeps the muscle 
in its place, and by strength- 
ening the abdominal wall pre- 
vents the more frequent oc- 
currence of hernia. Possibly 
the deficiency of the sheath at 
the lower fourth of the muscle 
intensifies its expulsive action 
upon the uterus and the bladder. Pus at times forms in, 
and is limited by, the sheath of the rectus. In the re- 
duction of a knuckle of intestine in abdominal wounds 
through this muscle, the surgeon must be careful lest 
he push the gut into the rectus sheath, and so defeat the 
object of his manipulations. 

The External AbdominaZ Oblique takes the direction of 
the external Intercostals of the thorax ; it arises from 
the outer surface of the eight lower ribs by serrations, 
four or five of which interdigitate with the serratus 
raagnus, and three or four with the latissimus dorsi. 
The lowest digitation is connected with the cartilage of 
the twelfth rib. The posterior fibres, almost vertical, 
are inserted into the external margin of the crista ilii for 
about the anterior half of its length. The rest of the 
muscle inclines forward, and is attached to the whole 




Fio. 19.— Deep Muscles of the 
Forepart of the Trunk and 
Shoulder. (From Quain.) c, 
Symphysis pubis; /, anterior 
superior iliac spine ; 12, origin 
of the serratus magnus ; 13, 13, 
on the right side, the rectus 
abdominis; on the left side, 
13', 13', the divided ends of 
the same muscle, a portion 
being removed ; 14, pyramida- 
lis muscle exposed on the left, 
side ; 15, on the right side, the 
internal oblique muscle; 15', 
origin of its lower fibres from 
the deep surface of Poupart's 
ligament; 15", conjoined ten- 
don of the internal oblique 
and transversatis. 



length of Poupart's ligament below, and in the mid-line 
of the body joins with its fellow of the opposite side. 
The posterior border of the external oblique is free. 
At its lower end it occasionally forms, with the iliac 
origin of the latissimus dorsi and the ileum, a triangular 
space known as the triangle of Petit, through which 
lumbar hernia has been known to protrude. The apo- 
neurosis of the external oblique occupies the front of the 
abdomen anterior to a line drawn from the eighth rib to 
the forepart of the crest of the ileum ; it is narrower in 
the middle than at either upper or lower end, and joins 
the linea alba along the middle line of the body. The 
aponeurosis is thin above, and is continued from the 
surface of the rectus to form the covering of the pecto- 
ralis major and the ribs ; as it descends it increases in 
strength, and its fibres become gathered together in a 
firm band between the spine of the pubes and the iliac 
crest forming Poupart's ligament. The aponeurosis 
splits just above the spine to allow the passage of the 
spermatic cord. The external abdominal ring will be 
described in connection with the groin. 

The course of the fibres of the internal oblique is 
directly the reverse of those of the external oblique. 
Its aponeurosis lies directly on the transversalis muscle, 
and in the neighborhood of the symphysis pubis is not 
to be separated from it. Between the internal oblique 
and the transversalis will be fourtd the lower inter- 
costal, the ileo-hypogastric, and ileo-inguinal nerves, as 
well as the branches of the circumflex iliac artery. 

The Oremaiter, a suspensory muscle, consists of fibres 
continuous with those of the lower border of the in- 
ternal oblique. Externally it arises from Poupart's 
ligament below, and in part beneath the internal ob- 
lique. Internally it is attached to the front of the 
pubes, rejoining the tendon of the internal oblique. 
Between these points of attachment it forms loops 
which descend in front of the spermatic cord, and of 
which some few reach the level of the testicle. These 
looped bundles of fibres are united by areolar tissue, so 
as to give rise to a covering on the front of the cord, 
the cremasteric fascia. The cremaster Is subject to 
many variations. In some cases but a few fibres are 
seen descending from its outer attachment, in others the 
muscle not only lies upon the cord, but behind it and 
upon its sides. The action of the cremaster is to raise the 
testis. The muscle is supplied by the genital branch of 
the genito-crural nerve, whose cutaneous division sup- 
plies the skin on the upper part of the thigh. Irritation 
of the skin in this region ought to' be followed by slow 
retraction of the testis. This cremasteric reflex is best 
seen in the young. Its absence is a point in the evi- 
dence of the existence of disease or injury of the cord 
above the first and second lumbar nerves. The pres- 
ence of these reflexes (plantar, cremasteric, abdominal) 
is proof that the reflex path through the cord is not 
seriously interrupted, but we cannot simply infer from 
their absence that this path is impaired. The reflex ex- 
citability of the cord varies much In different indi- 
viduals, is always greatest in early life, and is often 
lessened in the old (Gowers). 

The fibres of the transversalis run directly backward 
and forward. Posteriorly its aponeurosis Is in connec- 
tion above with the lower border of the last rib, and 
with the lumbar fascia, the strong aponeurotic envelope 
of the quadratus lumborum and the erector spinse, 
which is attached to the spines of the transverse pro- 
cesses and sides of the bodies of the lumbar vertebrse, 
and below to the ileo-lumbar ligament. The transver- 
salis on its inner surface is lined by the transversalis 
fascia, which separates it from the peritoneum. 

The abdominal cavity is lined by the transversalis 
fascia, which is_ thick below, but as it approaches and 
covers the diaphragm it becomes thin. At the outer 
part of Poupart's ligament it is attached to the perios- 
teum of the crest of the ileum where it comes into con- 
tact with the iliac fascia, and passes below Poupart's 
ligament at its middle, forming the anterior part of the 
sheath of the femoral vessels and of the femoral canal. 
Pus beneath the transversalis fascia is limited ; the 



11 



Abdomen. 
Abdomen. 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 



outer edge of the psoas prevents its going backward ; 
the attachments below of the fascia to the bone and 
Poupart's ligament prevent its passing downward ; 
gravity prevents its ascent. Such abscesses most 
commonly point just above the iliac crest or Poupart's 
ligament. It must be remembered that the transver- 
salis fascia furnishes one of the coverings of the cord, 
so that pus may force its way along the inguinal canal 
and cause its distention. 

If the reader will look at Fig. 20 he will perceive 
that, in front of the quadratus lumborum, there is a 
strong taacm— the lumbar fascia — continuous externally 
with the origin of the transversalis, that there is a layer 
behind the muscle, between it and the erector spinsE, 
and that this last muscle itself derives a covering from 
the spine of the lumbar vertebrae. For purposes of de- 
scription the lumbar fascia has been divided into three 
layers. The first extends over the anterior surface of 
the quadratus lumborum, arising from the root of the 
transverse processes of the lumbar vertebrae, and is con- 
tinuous at the outer edge of the quadratus with the 
origin of the transversalis. The middle layer is the ten- 
don of- the transversalis, arising from the tips of the 
transverse processes in the lumbar region ; it lies be- 
tween the quadratus and the erector spinae, and gives 
origin to the posterior apo- 
neurosis of the internal 
oblique. The posterior 
layer is attached to the 
spines of the vertebrae, 
covers the posterior sur- 
face of the erector spinae, 
and becomes on its outer 
side continuous with the 
middle layer. That layer 
of the lumbar fascia which 
covers the anterior surface 
of the quadratus lumbo- 
rum gives origin to the 
tendinous margin of the 
diaphragm, and is called 
the ligameutum arcuatum 
externum. The posterior 
layer gives origin to the 
latissimus dorsi and serra- 
tus posticus inferior. 

LuMBAB Abscess. — Ab- 
scess in connection with 
disease of the vertebrae 
points either in the lum- 
bar region (lumbar ab- 
scess) or in the groin (psoas 




Fig. 21. —Sketch of the Human 
Embryo of the Tenth Week, 
showing the Coil of Intestine in 
the Umbilical Cord. (From 
Quain.) The amnion and vil- 
lous chorion have been opened, 
and the embryo drawn aside 
from them. The vitello-intes- 
tinal duct with the omphalo- 
mesenteric vessels are seen pro- 
jectmg into the rudimentary 
umbilical cord. 




Fia. '20. — Section throuRh the Intervertebral Disk, between the Third and 
Fourth Lumbar Vertebrffl. (Dwight.) 



The course of pus in lumbar abscess is deter- 
mined by the arrangement of the fasciae and muscles at 
the back of the abdomen. Its common course is out- 
ward, separating the erector spinae from the quadratus, 
or perforating the latter and reaching a point beyond the 
margin of the erector. Here, covered in by the lumbar 
aponeurosis, it may form a considerable swelling in the 
flanks, or, working its way into the origins of the abdo- 
minal muscles, slip between them and point upon the 
groin above Poupart's ligament ; the pus being guided 
along the course of the nerves. The twelfth dorsal 
nerve and the first lumbar artery, after crossing in front 
of the quadratus at its outer edge, perforate the posterior 
aponeurosis of the transversalis, and enable the pus to 
reach a point between the latissimus dorsi and the exter- 
nal oblique. The ilio-hypogastric nerve takes a similar 
course. , 

Psoas Abscess. — The anterior lamella of the fascia 
lumborum lies in front of the quadratus, and at its 
outer edge forms the origin of the transversalis abdom- 
inis. The psoas muscle lies to the innpr side of the 
quadratus ; its fascia is a distinctly enclosing sheath, 
which below is continuous with the iliac fascia, and 
both pass under Poupart's ligament. When abscess 
forms in the neighborhood of the spinal column, espe- 
cially in the lumbar region, it usually collects under 
this sheath, in many cases occupying it, splitting up and 



absorbing the psoas, and passing downward beneath 
Poupart's ligament, so as to point in the groin, usually 
to the outer side of the vessels. In other words, a psoas 
abscess follows the course of the anterior crural nerve, 
which lies in the structure of 
the psoas muscle. The psoas 
fascia is continuous with that 
covering the iliacus, the lat- 
ter passing over the muscle 
beneath Poupart's ligament, 
to form the posterior layer of 
the sheath of the femoral ves- 
sels. It should be noted that 
the common and external 
iliac vessels are above the 
iliac fascia, and rest upon its 
abdominal surface, while the 
anterior crural and other ab- 
dominal nerves are situated 
within the fascia. 

The Umbilical Ring.— 
The umbilical ring is the 
opening through which in 
embryonic life communica- 
tion was kept up between the uterus and the foetus. At 

that period there passed 
through it the omphalo- 
mesenteric duct, the om- 
phalo-mesenteric vessels, 
the tubular communica- 
tion of the bladder with 
the allantois, called the 
uraohus, the umbilical ar- 
teries and veins. The om- 
phalo-mesenteric duct was 
once wide, and at about 
the third month of utero- 
gestation contained a coil 
of the small intestine. 
Thus, as a matter of fact, 
umbilical hernia was at 
that period of life a nor- 
mal condition. The in- 
complete shrinking of the 
canal allows this form of 
rupture to take place, and 
accounts for the fact that 
it is in the vast majority 
of cases congenital. Ac- 
quired umbilical hernia 
occurs most commonly in 
very stout persons or in 
those women who have borne many children, owing 
to the stretching to which the linea alba has been 
subjected. In such cases protrusion of the omentum 
nearly always occurs, either through the ring itself or 
through the abdominal wall in the immediate neighbor- 
hood of it. A congenital umbilical hernia usually dis- 
appears as the child grows, but acquired ruptures of this 
kind are sometimes very large and frequently irreduci- 
ble. The coverings of an umbilical hernia consist merely 
of skin and expanded linea alba. The peritoneum of the 
hernial sac is very thin, and tends, especially in a case of 
long standing, to be firmly adherent to the hernial open- 
ing, so that in herniotomy it must of necessity be opened. 
In certain cases the omphalo-mesenteric duct is closed in 
but part of its extent. The intestinal end of the duct 
remains wide, forming the diverticulum of Meckel, but 
in rarer cases the extremity of the diverticulum is con- 
nected with the umbilicus. Cases are on record of the 
passage of faeces from the navel, as well as of bile and 
even gall-stones. 

Incomplete obliteration of the urachus accounts for 
those cases in which urine passes from the bladder 
through the umbilical ring. An exaggeration of this 
condition constitutes what is known as extroversion of 
the bladder. The abdominal wall from the navel to the 
pubes is deficient ; the posterior wall of the bladder 
with the opening of the ureters becomes visible, being 



12 



REFERENCE HANDBOOK OP THE MEDICAL SCIENCES. 



Abdomen^ 
Abdomen* 



pvessed outward by the weight of the superincumbent 
intestines. 

B. i. MacBonnell. 

1 Lectures on the Principles and Practice of Surgery, by Sir Astley 
Cooper. London, 1830. 

2 London Lancet, March l."!, 1884. 

8 See case reported by Mr. Monllin. Lancet, vol. i., 1884. 

ABDOMEN, Wounds and Contusions of. — Injuries 
to the abdomen will in this article be considered under 
the heads of : 1. Contusions of the abdominal parletes. 
2. Injuries to the viscera. 3. Superficial wounds of the 
parietes (without penetration into the peritoneal cavity). 
4. Wounds opening into the peritoneal cavity. 5. Wounds 
opening into the peritoneal cavity, with protrusion of 
viscera. 

1. Contusions of the abdominal parietes may be caused 
by blows, kicks, falls against protruding bodies, or .by 
heavy bodies falling upon or passing over the abdomen, 
or by spent balls or bullets. With regard to such con- 
tusions, even though apparently slight, we must be care- 
ful in treatment and guarded in prognosis. Leaving out 
of consideration for the present all danger of visceral 
complication, we cannot always measure the amount of 
injury to the deeper tissues of the abdominal walls and 
their peritoneal lining. We may have extensive extrava- 
sation of blood between the layers, or such laceration of 
the muscular or other tissues as to give rise to trouble- 
some sloughing or burrowing. We may have peritoni- 
tis, arising either from primary injury to the peritoneum 
itself, or by extension from superjacent tissues. If ex- 
travasation is great, and especially if it is at the same 
time circumscribed, we shall have fluctuation ; but we 
may have blood in broad, thin layers, which will not 
give this sensation. We should also observe whether 
there is any depression indicative of division of muscle. 
If we find either of the above conditions well marked, 
it may be necessary to resort to such operative procedure 
as shall bring them under the next class of injuries, 
where they will be further considered. 

In the treatment of injuries of the abdomen the fol- 
lowing general indications are presented : To procure 
absolute rest, both mechanical and physiological ; the 
arrest of haemorrhage ; the evacuation of pus and other 
morbid products ; the derivation of blood by counter- 
irritation ; to combat collapse and exhaustion. By at 
once securing absolute rest in the recumbent posture, we 
shall lessen the tendency to extravasation, promote the 
repair of the lacerated tissues and their restoration to 
vitality, and diminish subsequent inflammatory action. 
Freedom from pain and physiological rest may, if neces- 
sary, be induced by opium (gr. j. to ij. every three or 
four hours), or morphia may be given hypodermically. 
Minute doses of atropine are often added, to check 
vomiting ; to prevent collapse, ammonia and other stim- 
ulants may be administered. 

If there is reason to suspect slow extravasation, cold 
may be applied for a short time, but we must be careful 
not to lessen too much the vitality of the tissues ; and it 
must bo borne in mind that very hot applications are 
also of great service in the arrest of haemorrhage. By 
some it has been recommended to make gentle pressure 
by means of a bandage and a broad compress of cotton 
batting, or other light material ; this may be of service 
both in arresting haemorrhage and securing rest, but it 
must be moderate. 

A rather novel expedient has been resorted to by some 
practitioners, that of imprisoning blood in the arms and 
legs by means of elastic bands, so applied as to retard 
the return of venous blood from them to the trunk, the 
object being to lessen the amount of blood in haemor- 
rhage and in congestion or inflammatory action. The 
trial of this contrivance has not been suflBciently exten- 
sive to warrant any positive conclusion regarding it. 
Haemostatics may also be given, care being taken not 
to induce vomiting. As it is of importance to secure 
prompt haemostasis, one large dose of acetate of lead, say 
thirty to sixty grains, may be given, followed by ergot, 
gallic or sulphuric acid, or hamamelis, in repeated doses. 



After haemorrhage has ceased, collections of fluid blood 
may with advantage be removed by the aspirator. 

Should peritonitis supervene, we shall generally have 
increased and deep-seated pain, aggravated by continu- 
ous steady pressure, or by extension and flexion of the 
thighs ; anxious, pinched countenance ; tympanites ; 
dry, brown tongue ; high temperature ; quick, wiry 
pulse, and vomiting. Although it is always understood 
that some of the symptoms of a given disease will at 
times be absent, yet we are so accustomed to look for 
high temperature in peritonitis that it may be worth 
while to remark here that cases will occasionally occur, 
and proceed to a fatal termination, with sub-normal tem- 
perature ; it is in cases of traumatic peritonitis (with 
their severe shock) that this is most apt to occur. On 
the occurrence of peritonitis, the first of the indications 
stated above is instinctively acted upon, the abdomen 
being tense, the breathing thoracic, and the legs drawn 
up to avoid pressure. It is well that greater rest be 
secured at times by placing pillows or other supports 
under the patient's knees, relieving the muscles of the 
thighs and legs. Opium has often been characterized as 
the "sheet anchor" in the treatment of peritonitis; and 
the expression is so apt that we may be pardoned for re- 
peating it here. It should be administered freely in the 
forms before indicated ; to it are sometimes added at the 
outset small doses of calomel, say one grain ; besides, 
atropine, bismuth, and cerium are often given to control 
vomiting ; later on, turpentine may be of service, espe- 
cially if there is much tympanites, and we are sure that 
there is no wound of the stomach or intestines. In the 
early stage of traumatic peritonitis, if there has not been 
much haemorrhage, cardiac sedatives may be given. Gen- 
eral bleeding has not now many advocates ; but, if used 
at all, it would be in cases of the character just described, 
and in such cases, too, leeches may be applied to the 
abdomen. 

Counter-irritants and hot fomentations should be con- 
stantly applied. A good and very common mode of 
fomentation is to have two bags, which will cover the 
abdomen and hang slightly over the hips ; they should 
hold a layer of bran or hops about four inches thick, and 
should be heated alternately in a steamer the lid of 
which is not completely closed down. When pain is 
subdued, they may be replaced by poultices or a layer of 
cotton batting. Some of these applications should be 
kept on until pain has been entirely absent for some 
days, it being borne in mind that peritonitis, whether 
acute or sub-acute, is very treacherous. (For fuller re- 
marks on peritonitis and its treatment, the reader is re- 
ferred to the article on that subject.) 

To return to the consideration of the tissues of the 
abdominal walls : if there is subsequently any indication 
that suppuration is about to take place, light emollient 
poultices should be applied, and we should watch care- 
fully for the formation of pus and secure its evacuar 
tion. If we consider the nature and relations of the 
tissues of the abdominal parietes, we will see how 
careful we must be to prevent burrowing of matter 
or absorption of septic material. The various details 
of diagnosis, exploration and evacuation of pus, drain- 
age, and aseptic irrigation usual in the treatment of 
suppurating wounds in general must be here employed. 
(See article on Wounds.) Attention must also be 
paid to constitutional treatment : the patient must be 
sustained by tonics and good nourishment, and care 
must also be given to the eliminative organs and to 
the sanitary surroundings. (See Air, Ventilation, Bath- 
ing, etc.) 

In " Holmes's Surgery," Mr. George Pollock, Sur- 
geon to St. George's Hospital, discusses at length the 
popular belief in sudden deaths arising from blows 
on the abdomen, and especially on the epigastrium, 
without . organic lesion : death from such blows is 

fenerally attributed to the shock to the solar plexus, 
[r. Pollock expresses himself as being very sceptical 
as to whether such deaths do occur without some or- 
ganic injury, and is very certain that they are at least 
very rare occurrences. 



13 



Abdomen. 
Abdominal Tumors. 



REFERENCE HANDBOOK OE ,THE MEDICAL SCIENCES. 



2. Contusions and ruptures of abdominal viscera may 
result from the same causes as contusions of the ab- 
dominal parietes. Mr. Erichsen applies the name of 
" bufEer accidents" to a class of cases occurring in rail- 
way employes caught between approaching cars. Occar 
sionally such injuries are produced by causes other than 
external violence ; rupture of the gall-bladder from gall- 
stones is a common occurrence, and the writer has in 
his possession a liver with an extensive laceration from 
this cause. In this case death resulted from peritonitis ; 
large quantities of blood and small calculi were found 
scattered throughout the abdomen, two very large cal- 
culi being embedded in the liver. Other examples are 
rupture of the bladder from retention of urine ; and 
perforation of the stomach and intestines from ulcera- 
tion. There is also in the Museum of the Toronto 
School of Medicine the spleen of an elderly woman in 
which the cause of rupture is said to have been fright 
from the occurrence of a fire in close proximity to the 
woman's residence. 

Rupture of the gall-bladder or of the ductus commu- 
nis choledochus is almost invariably fatal. The symp- 
toms are great pain in the immediate neighborhood, 
anxiety, and rapid collapse. 

Rupture of either the liver or spleen alone is not neces- 
sarily attended with much pain. If the wound is slight it 
may heal without the occurrence of grave symptoms ■; if 
extensive we are very likely to have f aintness and collapse 
from loss of blood and from the injury to the peri- 
toneum ; and if the patient survive this stage we will 
subsequently have from the same causes violent peri- 
tonitis with the symptoms before described. Injuries to 
the spleen are also apt to be followed by secondary mis- 
chief. It will be understood that in the remarks made 
regarding the course of these injuries, they are spoken 
of without reference to any modifying influence from 
their being accompanied by corresponding wounds iu 
the abdominal parietes. 

Rupture of the stomach, if in a healthy condition, is 
of rare occurrence. The size of the wound will be 
modified by the amount of food in the stomach at the 
time of the accident. Vomiting of blood generally 
occurs, but not invariably. The injury causes deatid 
either from haemorrhage or from the escaping contents 
causing fatal peritonitis. Cases are on record in which 
post-mortem examination has revealed the fact that rupt- 
ure had taken place between the lines of attachment of 
the layers of the omentum, death having been delayed 
for some time and having finally resulted from the forma- 
tion of pus, which found its way by ulceration, in some 
cases into the peritoneal cavity, causing great distress 
and rapid collapse, and in others forming a gastric fistula 
discharging externally through the abdominal walls. 

Wounds of the intestines are the most common fatal 
lesions of abdominal viscera met with, and will form 
the subject of a separate article. 

In wounds of the kidneys the consequences and 
symptoms will vary with the position and extent of the 
wound. In all cases we may have profuse haemorrhage 
and troublesome vomiting. If the anterior portion be 
injured and the peritoneum ruptured, the passage of urine 
into the cavity of the latter will cause severe peritoneal 
symptoms ; if the posterior portion, we shall have ex- 
travasation of the urine into the cellular tissue, followed 
by extensive suppuration. Bloody urine will be a pretty 
constant symptom. 

Rupture of the bladder will, similarly to wounds of 
the kidneys, give rise to different results according as 
it occurs above or below the line of peritoneal reflection./ 

Emphysema sometimes occurs from flatus finding its 
way through a rent both in the inner surface of the ab- 
dominal wall and some portion of the alimentary canal. 

In addition to the general indications of treatment 
mentioned in the early portion of this article as ap- 
plicable to all injuries of the abdomen, there is one 
which is common to wounds of the viscera, namely, 
to check the passage of the secretions and contents 
of the viscera into the abdominal cavity, and to di- 
vert them out of the body by natural or artificial chan- 

14 



nels. Pull doses of opium, hsemostatics, and the othel 
remedial measures and precautions before referred to 
will assist us in the first-named direction. Opinion 
does not yet seem to warrant us in ordinary practice to 
open the abdominal cavity ior exploratory purposes, 
even with the hope of remedying conditions which we 
have every reason to believe will otherwise end in death. 
The following procedures are, however, commonly re- 
sorted to when occasion arises : free incisions into the 
cellular and muscular tissues in the region of the kid- 
neys and bladder, and into the abdominal walls to get 
rid of extravasated urine, pus, or other irritating ma 
terials. We must be careful in making these not to 
wound the epigastric artery or other blood-vessels of 
any size. Incision of the lower part of the abdominal 
cavity has been resorted to by several surgeons to allow 
of the escape , of urine in cases of rupture of the 
bladder. This has sometimes been effected by an in- 
cision below Poupart's ligament. By some, among 
whom may be mentioned Vincent and Slee, more ex- 
tended incisions have been fecommended, for the pur- 
pose of exposing the bladder, removing extravasated 
blood and urine, cleansing the pelvic and abdominal 
cavities, removing any foreign body which may be in 
them or in the bladder, and uniting by suture any 
rent that may be in the latter. In the last-named step 
the edge of the wound must be turned in, bringing the 
peritoneal surfaces in contact, and close sutures used, 
as in wounds of the intestines (g. «.). In wounds 
both of the kidneys and bladder a catheter, frequently 
changed or cleansed, must be kept constantly in the 
bladder for two weeks or more, and for some weeks 
longer frequent catheterization must be practised. 

3. In wounds of the abdominal parietes not entering 
the abdomen it will be evident, from considerations simi- 
lar to those already made, that it is of the utmost im- 
portance to arrest all haemorrhage before closing the 
wound. After carefully cleansing it and removing all 
foreign material, the mouths of bleeding vessels must 
be found, and closed by torsion or ligatioh. If neces- 
sary, hot water may be applied to the bleeding surface : 
all oozing must be stopped. If any muscles have been 
divided they must be reunited by suture ; this, not only 
for securing muscular action, but so that the weakened 
abdominal wall may not allow of hernial protrusion. 
In any case the wound must be brought together by 
sutures extending to the deepest portion of it ; the 
quilled suture answers well. A compress and bandage 
may then be applied ; carbolized cotton answers well for 
the compress. It may be necessary to flex the thighs by 
supporting them with, pillows, so as to relieve the wound 
of tension. Precautions as to rest, position, and other 
points mentioned when speaking of contusions, must 
not be overlooked. 

4. In wounds opening into the peritoneal cavity our 
first care, after hsBmorrhage has been arrested and the 
wound cleansed, should be to determine, as far as prac- 
ticable, and as far as circumstances seem to require, 
whether there has been any lesion to the viscera. The 
extent, position, and character of the wound, and. the 
thickness of the abdominal wall, may be such that wo 
are enabled readily to determine whether or not such 
lesion exists. The nature of the wound and of its pro- 
ducing cause may do us the same service, or we may 
have protrusion of the viscera, so that they may bo 
readily examined. The question may have been deter- 
mined in the afflrmfltive by the escape from the wound 
of feculent matter, of food— partly digested it may be— 
of bile or of urine, or there may be haemorrhage from 
within the cavity ; and it is well that the patient should 
be so turned for a time that the wound may be in a de- 
pendent position, so as to allow of the escape of any of 
the above-named fluids. The duty of the surgeon is 
clear under each of the conditions above alluded to, and 
will be described presently. 

But supposing that they do not exist, and that there is 
reason to suspect that there may be injury to the viscera 
or to some blood-vessel in the abdominal cavity. What 
is then the proper course ? In the days when men ap- 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 



Abdomen. 
Abdominal Xamors. 



plauded the saying, "Abdominal surgery is abominable 
surgery," the maxim of giving the poor unfortunate " the 
benefit of the doubt " was thought to be best carried out 
by leaving the doubt unsolved. But as the statistics of 
each succeeding year show a great increase in the per- 
centage of recoveries from operations on the abdomen, 
and a great increase in the number and extent of such 
operations, the opinion is now becoming prevalent that 
there is less risk in doing what is necessary for a proper 
exploration and cleansing of the abdominal cavity than 
there is in closing that cavity, while we are not certain 
but that we are leaving a ruptured viscus or blood-vessel 
to discharge its contents into it, and produce results de- 
scribed when speaking of rupture of viscera. If there is 
grave reason to suspect the existence of such a condition, 
and we cannot otherwise come to a determination, it 
will be desirable to administer an anaesthetic, enlarge the 
wound or make another in some suitable position, and 
examine carefully the viscera in the track of the wound 
and its neighborhood. In undertaking such an explora- 
tion, the air of the room should be made warm and 
moist. The pouring out of hot water in pans will be of 
assistance in rapidly providing the heat and moisture. 
The desirability of this mode of procedure must be very 
apparent when we consider the serious consequences 
which may result from overlooking such an injury ; and 
the progress, experience, and results in abdominal sur- 
gery in recent years justify such a proceeding. 

If there be any discharge of blood or feculent matter, 
we must not abandon our search until we have found 
the seat of rupture in the alimentary canal, when it must 
be treated in the manner to be described in the article on 
Wounds of the Intestines. The course to be pursued, 
if there be discharge of the urine, has already been re- 
ferred to. If there be any haemorrhage, we must search 
for its source and ligate with antiseptic ligature any 
bleeding vessel. The cavity of the abdomen must be 
cleansed by irrigation and the use of sponges, absolutely 
clean, freed from sand or other extraneous material, and 
rendered antiseptic. The irrigation will be with water 
raised to such a temperature that it will be of blood-heat 
when discharged into the abdominal cavity ; this will 
be best efiEected by the nozzle of a syringe passed into the 
most dependent portions of the cavity, the fluid welling 
up and escaping from the wound. It is by some pro- 
posed to add a little table-salt and white of egg to the 
water, by others to add a disinfectant ; if the latter, then 
the solution should be very weak, as any portion left is 
liable to be absorbed. The writer has seen alarming 
symptoms from a small quantity of solution of carbolic 
acid retained in the meshes of cellular tissue in a wound. 
All blood and other extraneous material having been re- 
moved, the wound must be closed. The only additional 
point to be noted here is, that the sutures should pass 
through the abdominal wall, piercing the peritoneum, 
say a quarter of an inch from the inner lips of the 
wound, and these lips being everted so that peritoneum 
shall be apposed to peritoneum ; otherwise, instead of a 
smooth peritoneal surface presenting inward, there will 
be the roughened edge of other and wounded tissues : 
the rule is the opposite of that to be observed for union 
in a mucous or integumentary surface. The same pre- 
cautions are now to be observed as in the previous 
classes of injuries of the abdomen. 

5. The viscera most commonly extruded from abdom- 
inal wounds are intestine and omentum ; sometimes stom- 
ach, liver, or spleen. The extruded viscera must be care- 
fully examined, any wounds in them treated as already 
described, foreign substance adhering to them carefully 
washed away, bleeding arrested, the viscera returned, and 
the cavity cleansed and closed as before. If, however, 
any portions of the viscera are so bruised, lacerated, 
or strangulated that they will become gangrenous, they 
must not be returned. If the intestine is in such a 
condition, an artificial anus may be formed. (See Wounds 
of Intestine.) In the case of a stomach in a similar 
condition, if anything at all is done, the formation 
of a gastric fistula may be attempted by sewing the 
margins of the wound in the stomach to those of 



the external wound, peritoneum being apposed to peri- 
toneum. The case of Alexis St. Martin is too well 
known to be here more than alluded to. In all cases 
where the stomach is known to have been injured we 
should, while giving it rest, keep up the patient's strength 
by nutrient enemata. 

Cases are on record where portions of liver and spleen, 
and even the whole spleen, have been removed, and re- 
covery has taken place. 

Portions of injured omentum are frequently removed 
without ill result, and if there is any doubt about the 
vitality of any such portion, it should certainly be ex- 
cised, the omentum being firmly ligated on the proximal 
side of the injured portion, either by a single ligature or 
by a double one passed through the substance of it, the 
halves being ligated separately. Some surgeons use 
whip-cord, and leave the stump in the wound ; but the 
preferable way is to use stout carbolized catgut, and re- 
turn the stump into the abdomen. 

In returning the viscera the part last protruded must 
be returned first, and so on, little by little, until the 
whole mass suddenly slips in. It is sometimes necessary 
to enlarge the opening slightly or divide constricting 
bands. This must be done carefully, as in operations 
for hernia. If the intestines or stomach be much dis- 
tended with flatus an aspirating needle may be used. 
Viscera should not be exposed longer than is absolutely 
necessary ; and, if any delay occur, they should be cov- 
ered by cloths dipped out of warm water. The same is 
true of exposure of the abdominal cavity itself. 

While there are such differences of opinion as to the 
necessity for carbolic spray in abdominal surgery as are 
exhibited in the views of Mr. Lawson Tait and Professor 
Lister, for example, it is needless to say that no delay 
should he incurred in waiting to arrange for it ; but the 
abdominal wound should be closed with all possible de- 
spatch, having first been thoroughly cleansed. 

Rupture of the diaphragm is attended with sharp pain, 
and usually with difficulty of breathing. It is generally 
followed, after a time, by extrusion of some of the ab- 
dominal viscera into the thoracic cavity. The signs will 
vary with the seat of the laceration and the nature of 
the organs extruded. The impulse of the heart may be 
heard more to one or other side, according as it is pushed 
out of place by these extruded viscera. In the lower part 
of the thoracic cavity there will be absence of respiratory 
murmur and abnormal dulness or resonance, according 
as spleen or liver in the one case, or stomach or intestine 
in the other, has been extruded. Death may result from 
haemorrhage, peritonitis, pericarditis, or pleuritis, or 
from strangulation of the viscus involved. Nothing can 
be done beyond following out the indications referred to 
in the first part of this article. 

Further consideration of injuries to the abdomen and 
abdominal viscera from explosive missiles will be found in 
the articles on Gunshot Wounds, Wounds of Intestines, 
and Peritonitis. Wm. Oldright. 

ABDOMINAL TUMORS. Interpreting the above title 
in its broadest sense, the writer designates by it all 
abnormal abdominal enlargements, whether general or 
local., . Referring the reader to the articles on diseases 
of the abdominal organs for the morbid anatomy, prog- 
nosis, and treatment of abdominal tumors, the writer 
proposes to briefiy tabulate the distinctive etiological 
and clinical features upon which their practical differen- 
tial diagnosis may be based. Selecting, in most cases, 
a prominent tumor of a given organ, he will endeavor to 
collate those morbid conditions most likely to be mistaken 
for it, and to contrast their distinguishing physical signs 
and salient rational symptoms with those of the tumor 
in question. He will then subjoin a brief description of 
other tumors, affecting the given organ, which present 
only remote resemblances to the typical enlargement 
chosen, and of those possessing no special analogy to 
other tumors. In other cases, the various tumors of 
organs will be described without reference to any typical 
enlargement, and, usually, in the order of their frequency 
and importance. 



15 



Abdominal Xumo™: REFERENCE HANDBOOK OP THE MEDICAL SCIENCES. 



In examining abdominal tumors we may employ 
posture. Inspection, palpatioii, auscultation, percussion, 
mensuration, rectal injections of fluid or gas, aspiration, 
and, rarely, exploratory incisions. 

The position best adapted to the relaxation of the ab- 
dominal walls is that of recumbency, the head being 
somewhat elevated above the hard, plane surface upon 
which the trunk reclines, while the thighs are flexed and 
everted. Complete muscular relaxation may be obtained 
by anaesthesia. The lateral, prone, stooping, or erect 
positions may sometimes aid in bringing abdominal 
tumors into prominence. 

Inspection reveals changes in the size, form, and move- 
ments of the abdomen. Changes in form may afford 
important information relating to the local or general 
character of a tumor. Abdominal enlargements naturally 
limit the abdominal respiratory movement, or, if painful 
and tender, cause its complete arrest. Inspection occa- 
sionally shows the gastric and intestinal vermicular 
movements. 

_ By palpation evidence is obtained regarding the posi- 
tion, consistency, depth, size, outline, mobility or fixa- 
tion, smoothness or nodosity, and tenderness or insensi- 
tiveness of tumors. Impulses from aneurisms, the hy- 
datid^ fremitus, and fluctuation are also perceived by 
the aid of palpation. Palpation should be gently prac- 
tised in order that no spasm of the abdominal muscles 
be excited. The ball of the fingers should be horizon- 
tally and evenly applied, as pressure with the vertically 
directed finger-tips may cause pain and muscular con- 
traction. Deep palpation may be best performed by 
superimposing the fingers of the disengaged hand upon 
those In direct contact with the abdominal wall. The 
patient having been then instructed to make a series of 
eflicient expiratory efforts, the fingers are further de- 
pressed at the occurrence of each expiration. By this 
gradual process the fingers may finally even be brought 
into close contact with the aorta "and the vertebral column. 
An enlarged liver or spleen may sometimes be grasped 
between the fingers and thumb, the latter resting upon 
the organ while the former are inserted beneath it. The 
kidneys may be seized in a similar manner, the fingers 
and thumb of one hand being applied posteriorly and 
anteriorly, respectively, to the lumbar region. Vaginal 
palpation yields information regarding abdominal en- 
largements originating in the pelvis, and Simon's intra- 
rectal method, combined with external manipulation, 
enables the examiner to explore almost the entire ab- 
dominal cavity. Auscultation discloses aneurismal mur- 
murs, friction sounds, the hydatid fremitus, and various 
intra-uterine sounds. By means of percussion the con- 
tours of tumors are mapped out and the differentia] 
diagnosis between solid, fluid, and gaseous enlargements 
established. Mensuration shows the exact amount of 
enlargement or diminution undergone by tumors within 
definite periods. Fluid or air may he injected into the 
large intestine in order that the position of the latter, 
relatively to renal or ovarian tumors, may be better ap- 
preciated. Aspiration and analysis of the fluid contained 
In abdominal tumors, is an auxiliary diagnostic measure 
of great importance. Bkploraiory incisions are occa- 
sionally made for the purpose of ascertaining the charac- 
ter of tumors and of deciding as to the advisability of 
their removal. The discovery of one abdominal tumor 
should never deter the diagnostician from instituting a 
thorough search for other enlargements, similar or dis 
similar in nature and affecting the same or other organs, 
The following order will be adopted in the writer's de 
scriptlon of abdominal tumors : 1. Tumors of the Liver, 

3. Tumors of the Stomach. 3. Tumors of the Kidney 

4. Tumors of the Spleen. 5. Tumors of the Pancreas, 
6. Tumors of the Intestine. 7. Tumors of the Omentum 
8. Tumors of the Bladder. 9. Tumors of the Uterus. 10, 
Tumors of the Ovary. 11. Miscellaneous Tumors. 

1. Tumors of the Livbk. 

Cancer and othbr Malignant Tumors. — Cancer of 
the liver, which is usually secondary to that of the stomach, 

16 



intestine, uterus, ovary, or mamma, and Is of the medullary 
variety, attacks males and females with equal frequency, 
occurs, generally, between the ages of forty and sixty, 
in those possessing an hereditary tendency, and presents 
the following signs and symptoms : On inspection. In 
advanced cases, the right hypochondrium is ordinarily 
seen to be unduly prominent, and the respiratory move- 
ments of the right side diminished. These signs are 
absent in cases unattended by heijatic enlargement. On 
palpation, the liver is found unsymmetrically enlarged, 
extending below the free border of the ribs, and oc- 
casionally even reaching beyond the umbilicus. Hard 
nodules, tender and sometimes umbilicated, are often 
felt upon its surface, but maj' be absent In central or 
colloid carcinoma. "The nodules may be soft or fluctu- 
ating. "Bj percussion the area of hepatic dulness is found 
to be increased, in advanced cases nearly or quite reach- 
ing the iliac crest, occupying the epigastrium, and even 
invading the left hypochondrium. On auscultation, a 
friction sound, due to perihepatitis, may be perceived. 
In rare cases no signs are discernible. Bymptoms. — Pain, 
dull and constant, or lancinating and paroxysmal. Is 
either localized in the organ or radiates Into the right 
shoulder, the back, the abdomen, or the lower extremities ; 
sometimes only weight and tension are complained of, 
and, rarely, no abnormal sensations are present. Hepatic 
enlargement is usually rapidly progressive. Ascites oc- 
curs in fifty per cent, of all cases ; hepatogenous icterus 
is present with almost the same frequency. Gastritis 
and enteritis may result from portal congestion, or from 
primary gastric or Intestinal cancer ; hsematemesis and 
melaena owe their origin to the same sources. Hy- 
draemia, subcutaneous ecchymoses, haemorrhage from 
mucous surfaces and haemorrhoids are occasional symp- 
toms. The temperature is normal or subnormal, except 
In the presence of inflammatory complications. Dysp- 
noea, painful respiration, and cardiac palpitation result 
from encroachment upon the intrathoracic space, and 
from implication of the peritoneum and pleura. The 
inguinal and cervical glands are sometimes enlarged. 
(Ederaa of the lower extremities is a late symptom. 
Emaciation is ordinarily extreme, the cachexia evident, 
and asthenia progressive. None of the above svmptoms 
are constant: Other malignant hepatic tumors, as lym- 
phadenoma and sarcoma, present such close resemblances 
to cancer that their differentiation is rarely possible. 
Diagnosis.—Cancer of the liver may be mistaken for 
hepatic abscess or hydatids; for amyloid, syphilitic, 
cirrhotic, and fatty liver ; for hypertrophy, hyperplasia 
congestion, or malposition of the organ ; for obstruction 
of Its ducts ; for enlargements of the gall-bladder, right 
kidney, colon, omentum, stomach, spleen, ovary, or pan- 
creas ; for faecal impaction or abdominal aneurism. 

Abscess ov the Liver is dLstinguished from cancer 
by its smaller average size, its smooth surface, its more 
rapid development, and its fluctuation ; by the absence 
of ascites, of primary cancer elsewhere, of cachexia and 
generally, of jaundice ; by the discovery of pus on as- 
piration, and by the history of residence in a warm 
climate, of injury to the right hypochondrium, of ante- 
cedent pylephlebitis, pyasmla, or ulcerations in the 
stomach, intestine, or gall-bladder. The discharge of 
pus m considerable quantity from the stomach, bowels, 
bronchial tubes, or renal pelvis, or Into the peritoneum 
pleura, or pericardium, simultaneously with the rapid 
subsidence of the tumor, is a symptom of great diagnostic 

Hydatid tumors ai-e globular, smooth, and, when 
large, fluctuating. They often present the hydatid fremi- 
tus, Ihecolorless, saline, non-albuminous, neutral or al- 
kaline, and occasionally saccharine, liquid withdrawn the 
specific gravity of which varies from 1.007 to 1.015 con- 
tains echinococcl booklets. Hydatids grow more slowly 
than cancer, and are unattended by pain, tenderness (un- 
less inflamed), by nodular Induration, cachexia, hsema- 
temesis, melaena, or ascites. Jaundice is rare and fever 
usually absent. Hydatids may remain latent. The above 
remarks relative to the rupture of hepatic abscesses ap- 
ply with equal force to that of hydatid cysts 



REFEEENCE HANDBOOK OF THE MEDICAL SCIENCES. 



Abdominal Tninor» 
Abdominal Tumors. 



The amyloid liver increases slowly in size. It is 
smooth, indurated, and uniformly enlarged ; its edge is 
sharply defined and its form preserved ; it is painless. 
Icterus, fever, and the cancerous cachexia are 'wanting. 
Ascites occurs in one-quarter of the cases, according 
to Bartholow, and cedema of the lower extremities is 
apt to precede the hydroperitoneum. The spleen is en- 
larged ; diarrhoea and waxy disease of the kidneys are 
present. Phthisis, syphilis, protracted suppuration, es- 
pecially that of bone, or chronic malarial poisoning have 
pre-existed. 

The syphilitic livek, with amoiATA, presents in- 
durated nodules simulating cancerous ones, hut not um- 
bilicated. The organ is smaller than in cancer, and even 
smaller than the normal liver. There is a history of 
specific disease ; the spleen and lymphatic glands are en- 
larged ; the liver is not tender ; icterus and ascites are 
generally lacking. The progress is slow. 

HypBKTEOPHic ciKKHOsis OF THE LIVER causcs Uni- 
form enlargement. The surface of the organ is smooth, 
or but slightly granular ; there is no tenderness or not- 
able pain ; jaundice is usually a prominent feature ; 
ascites is ordinarily slight or absent, but may be 
marked; the spleen is invariably enlarged. The dura- 
tion of the disease is greater than that of carcinoma, 
and there is a history of alcoholic excesses. 

Fatty Litbk. — The enlargement is uniform and less 
marked than in cancer or in amyloid degeneration ; the 
surface is smooth, yielding, and insensitive, the border 
blunted, the shape of the organ preserved ; ascites and 
pain are not present ; icterus is rather rare ; the spleen 
is of normal size. The history is that of intemperance 
in food or drink, of indolence, of phthisis, or of a seden- 
tary life. 

Congestion of the Liver. — (a) Acute Congeatum or 
Active EJypermnia. — In this case the organ undergoes 
uniform, moderate, rapid, and temporary enlargement ; 
it is smooth and resisting ; it is generally somewhat 
painful and sensitive ; its normal contour is retained ; 
jaundice is usually, ascites and fever almost always, ab- 
sent. Among the causes of active hyperremia are trau- 
matism, malarial and other blood poisons ; according to 
Frerichs, injury to the semilunar ganglia ; high tempera- 
ture, over-indulgence in alcohol and stimulating foods, 
and suppressed menstruation, (b) Ohronie Congestion or 
Passive Mypermnia. — The etiology of this condition fur- 
nishes the key to its diagnosis, and embraces all causes 
of obstruction to the hepatic circulation. Chief among 
the latter are dilatation of the right ventricle, with tri- 
cuspid insufficiency, due to valvular disease of the left 
heart, or to an obstructed pulmonary circulation ; the 
latter may be referable to emphysema, chronic pleurisy, 
or extensive fibroid induration of 'the lung. Feeble 
cardiac action and pressure exerted upon the inferior 
vena cava by mediastinal tumors are other causes. The 
liver is uniformly enlarged, in the first stage, some- 
times to a considerable extent ; its surface is smooth and 
sensitive on pressure, its outline regular, its consistency 
firm. Icterus is rare ; ascites, gastritis, enteritis, hsema- 
temesis and haemorrhoids frequent ; the liver pulsates ; 
the spleen is enlarged ; in the later stages, the liver is 
reduced in size, having undergone the changes known 
as ' ' red or cyanotic atrophy." If the chronic congestion 
be due to malarial poisoninff, the physical signs are es- 
sentially as stated above. The spleen is notably enlarged, 
there is a history of antecedent malarial disease, and 
pigment may be detected in the blood. Cerebral dis- 
turbances, diarrhoea, albuminuria, and melsena, symp- 
toms incident to melanaemia, are sometimes observed. 

Hypertrophy and Hyperplasia of the Liver. — (a) 
Leukcemic. — The enlargement of the organ is marked and 
symmetrical, the surface smooth and insensitive ; the 
spleen is hypertrophied and the blood presents the pa- 
thognomonic characters of leucocythsemia ; the lym- 
phatic glands are enlarged; in pseudo-leucocythsemia 
the liver presents the same physical signs, but the blood 
does not contain an excess of white corpuscles, (b) 
Simple Hypertrophy.— The liver is simply abnormally 
large, sometimes attaining twice its normal size in all its 
Vol. L-2 



dimensions ; it is smooth and insensitive. No symptoms 
attend this form of enlargement, which, according to 
Klebs, occurs at times in drunkards. According to the 
same authority, hypertrophy, unattended by hyperplasia 
and presenting essentially the same physical features, 
complicates diabetes mellitus. 

Malpositions op the Liver. — These may be either 
congenital or acquired and are ordinarily due to trans- 
position of the organ, to depression from tight lacing 
and interthoracic diseases, or to upward displacement, 
occasioned by ascites, excessive tympanites, or abdominal 
tumors. Relaxation of the hepatic ligaments from preg- 
nancy and chronic peritonitis may, according tO Meissner, 
constitute a predisposing cause. Malpositions will be 
diagnosticated from genuine hepatic tumors by the fact 
that the liver preserves its normal size, consistency, and 
usually its natural sensibility, and by a consideration of 
the causes operative in each case. A sense of abdomi- 
nal weight and discomfort is generally complained of. 
Sometimes the notch separating the right and left lobes 
can be recognized. 

Enlarged Liver prom Obstruction op the Bile- 
DUCTS.^This is either a temporary or a permanent con- 
dition, resulting from a variety of causes, chief among 
which may be mentioned gastro-duodenitis with tume- 
faction of the mucous lining of the ducts, impacted cal- 
culi, cicatrices following ulceration of the ducts, parar 
sites and tumors growing in the biliary passages, enlarged 
lymphatic glands, tumors of the stomach, duodenum, 
omentum, liver, kidney, or pancreas, impacted faeces, 
contracting peritoneal tiands, perihepatitis, abdominal 
aneurlsims, uterine and ovarian tumors. The liver is 
enlarged in all its dimensions, being smooth, tender on 
pressure, and painful ; the gall-bladder is sometimes 
distended and sensitive to the touch ; jaundice remains 
long after the disappearance of the obstruction, in cases 
of temporary occlusion, and is a persistent symptom in 
permanent closure of the ducts. The enlargement dis- 
appears with the removal of the obstacle to the exit of 
the bile or may give place to atrophy of the livery if the 
occlusion be permanent. 

Enlargement op the Gall-bladder. — This may 
be due to distention from the accumulation of bile, of 
serous fluid, as in hydrops eystidis fellcB, of inflammatory 
products or of gall-stones, and to cancer. In the first 
two cases there is a history of antecedent biliary colic, 
the rounded or pyriform shape of the gall-bladder is 
evident, jaxindice and hepatic enlargement are present, 
except when the cystic duct is alone occluded, the evac- 
uation of the bile may sometimes be effected spontane- 
ously or by careful pressure, and tenderness is localized 
over the pear-shaped tumor, which is of rapid growth, 
movable, soft, and fluctuating. Ascites and splenic en- 
largement are absent. The examination of fluid with- 
drawn by aspiration will establish the diagnosis and 
reveal the character of the bladder's contents. If cystic 
distention be due to calculi, there is generally a history 
of the passage of gall-stones, and the tumor, although 
nodular and indurated, is neither painful nor sensitive. 
It does not increase in size and is not attended by ascites, 
jaundice, or cachexia. If carcinoma be the cause of the 
enlargement it can hardly be distinguished from hepatic 
cancer, unless plainly limited to the gall-bladder. The 
diagnostic problem is further complicated by the usual 
simultaneous involvement of the liver. 

For the diagnostic features of enlargements in organs 
other than the liver, most liable to be mistaken for 
hepatic tumors, mz. , cancer of the intestine and omentum, 
enlargements of the stomach, pancreas, kidneys, spleen, 
and ovaries, faecal accumulations, and abdominal aneu- 
risms, the reader is referred to the remarks contained in 
this article and in that on abdominal aneurisms regard- 
ing the subjects just enumerated. 

3. Tumors of the Stomach. 

Cancer op the stomach, which is almost always 
primary, is the most frequent of all primary carcinomata. 
It is, generally, of the scirrhous variety and usually in- 

17 



ibdomlCa! Tumor*: REFERENCE HANDBOOK OP THE MEDICAL SCIENCES. 



volves the pyloric extremity, lesser curvature, and pos- 
terior surface. It, however, attacks the cardiac orifice 
in about ten per cent, of all cases, and occasionally de- 
velops in the greater curvature. It is sometimes of the 
colloid or cylindrical epithelial variety. It rarely occurs 
before the fortieth year, is most frequent between the 
ages of fifty and sixty, attacks males, by preference, and 
shows a marked tendency to hereditary transmission. 
Signs. — A tumor is discoverable, by palpation and per- 
cussion, in seventy-five per cent, of all cases, according 
to Da Costa, and in eighty per cent., according to Brin- 
ton. The tumor is usually hard, nodular, and immova- 
ble, varying in size from that of a small hen's egg to that 
of a man's clenched hand, is ordinarily sensitive to press- 
ure and located somewhat to the right of the median 
line, between the umbilicus and the free border of the 
ribs. It may, however, often be detected in the right 
hypochondrium, sometimes in the left hypochondrium, 
occasionally even lower than the umbilicus, and, rarely, 
as low as the anterior-superior iliac spine or the hypogas- 
trium. It is not depressed by forced contraction of the 
diaphragm. If the pyloric extremity be the seat of the 
disease those symptoms and signs of gastrectasia, else- 
where detailed, are present. Byrwptoms. — Pain at the site 
of the neoplasm is rarely absent ; it may be lancinating, 
with paroxysmal exacerbations, or dull and gnawing; 
when present it is hardly ever intermitting ; it often 
radiates into abdominal regions other than those occupied 
by the tumor, or into the back, and sometimes possesses 
excruciating intensity ; it is not materially affected by 
the ingestion of food. Vomiting occurred, according to 
Brinton, in eighty-seven per cent, of his recorded cases ; 
when the fundus or greater curvature is involved it may 
be wanting ; in cancer of the cardiac orifice emesis is 
very constant, taking place immediately after the intro- 
duction of food, while, in pyloric carcinoma it occurs 
only after a longer or shorter interval ; vomiting does 
not relieve the pain ; the egesta often contain blood, 
usually in small quantity, presenting the appearance of 
cofEee-grounds ; genuine hssmatemesis, such as attends 
ulcer, is rarely observed. Anorexia and indigestion, 
emaciation, obstinate constipation, alternating with diar- 
rhoea, flatulence, enlargement of lymph-glands and de- 
velopment of secondary cancerous growths, moderate 
fever, progressive asthenia, and cachexia complete the 
clinical history, the end of which is death, usually within 
a year, although some cases may be protracted to one 
and a half or two years. Differential Diagnosis. — Those 
enlargements of the stomach most liable to be con- 
founded with cancer are due to chronic interstitial gas- 
tritis, to acute circumscribed parenchymatous gastritis, 
to gastrectasia, and to other malignant "growths. Gastric 
ulcer and chronic diflluse gastritis must also be differ- 
entiated from cancer. 

Gastkic ttlcbr may be distinguished from carcinoma 
by the following facts : It is independent of heredity ; 
attacks, preferably, young women ; presents no tumor ; is 
not attended by fever, but by pain, which is more violent, 
more intensified by food, more relieved by emesis, and 
more frequently intermittent than that of cancer. Vomit- 
ing occurs more constantly in ulcer, at a shorter Interval 
after food, and relieves the pain more certainly than in 
carcinoma ; hsematemesis is more frequent and abundant 
in ulcer, which may have a longer course than cancer 
and end in recovery. Anorexia is less constant in ulcer, 
and enlargement of lymph-glands is not observed. Ema- 
ciation and cachexia are not marked ; tenderness is lo- 
calized. 

Chkonic gastritis is differentiated from cancer by 
the following points : Pain and soreness are diffused and 
constant, but slight, and are aggravated by food ; emaci- 
tion is not marked, and cachexia is absent ; vomiting is 
less frequent, and heematemesis very rare ; there is no 
gastric tumor, and no enlargement of the lymphatic 
glands ; there is slight pyrexia, with furred tongue and 
constant thirst ; the course is protracted, sometimes for 
many years, and may end in recovery. 

Chronic Intbrstitial Gastritis and Hypertrophic 
Stenosis oy the Pylorus. — A discrimination between 



these comparatively rare diseases and cancer wntiicuU is 
not alwavs possible; the etiology, however, presents 
some points of difference. In the former, or jWroid in- 
duration, there is no history of hereditary malignant dis- 
ease, but sometimes one of excessive indulgence m alco- , 
holies ; the patients are usually younger than in cancer, 
their average age being, according to Dr. Brinton, only . 
thirty-four ; the course of the disease is longer than in 
cancer ; pain and tenderness are less marked, while 
hsematemesis is rare, and the cancerous cachexia absent ; 
the introduction of only small quantities of food causes 
a sensation of distention, and emesis frequently soon fol- 
lows ; there are no evidences of secondary tumors, and 
no glandular enlargements ; emaciation, from inanition, 
progresses rapidly ; a movable, smooth, slightly sensi- 
tive, indurated tumor, presenting the form of the con- 
tracted stomach, occupies the normal site of that organ, 
and yields a less decidedly tympanitic note than the 
healthy stomach. In hypertrophic stenosis of the pylorus 
a small, smooth, indurated, movable, and more or less 
sensitive tumor can be felt in the position corresponding 
to that of the pylorus, while the remainder of the organ 
gives the signs of dilatation presently to be described. 
In this case, obstinate constipation and profuse vomit- 
ing, long after eating, of partly decomposed aliment, 
only containing blood in very exceptional cases, but 
often sarcinm ventriculi, are cardinal symptoms. 

AcnTB Circumscribed Parenchymatous Inflamma- 
tion OP THE Stomach ; Abscess. — This disease, which is 
one of great rarity, may be either idiopathic, in which 
case it occurs preferably in middle-aged men addicted 
to excesses in drink, or secondary to pyaemia, acute infec- 
tious diseases, or hemorrhagic infarction. The abscesses 
may be single or multiple, acute or chronic ; diffuse 
purulent infiltration of the gastric parieties also occurs, 
but presents so little resemblance to cancer as to render 
its present consideration unnecessary. The differential 
symptoms and signs between abscess and carcinoma are 
as follows : In the metastatic or secondary variety there 
is the history of antecedent pysemia, but the subsequent 
clinical features are identical with those of idiopathic 
abscess ; in abscess, the access of gastric disease is an- 
nounced by a chill, which may be repeated at irregular 
intervals ; this is not true in cancer ; the temperature is 
often greatly elevated, reaching 104° or 106° F., while 
in cancer it is slightly raised, or not at all ; the egesta 
in emesis from abscess do not contain blood as in cases 
of cancer, but pus in large quantity, in the event of 
rupture into the stomach ; pain and tenderness are often 
more severe than in cancer, especially if the peritoneum 
be involved ; the course of idiopathic abscess is generally 
acute, extending, according to Dr. A. Flint, on the 
average only from Iwo to ten days ; the duration of car- 
cinoma is usually many months ; the abscess may fluc- 
tuate, which is rare in cancer, the latter ordinarily being 
of the scirrhous variety ; sudden subsidence of the tumor, 
attended by the vomiting of considerable pus, is a strong 
though not decisive point for abscess ; the latter is not 
attended by the cancerous cachexia, by hepatic disease, 
or by enlarged lymph-glands. 

Dilatation op the Stomach. — This is a source of 
abdominal enlargement which often results from can- 
cer, but is not very likely to be mistaken for it if de- 
pendent upon other causes. According to Kussmaul's 
classification, it is either hypertrophic, as is the case 
when the pyloric obstruction leading to the gastrectasia 
is compensated, or atrophic, when paresis of the mus- 
cular walls or uncompensated obstruction exists. Its 
leading physical sign is an unsymmetrical prominence of 
the left side of the abdomen, occupying, chiefly, the 
hypochondriac and umbilical regions ; the epigastrium 
is often depressed or flattened ; undulatory movements, 
usually proceeding from left to right, may sometimes 
be seen, and these exaggerated peristaltic phenomena, 
which are more distinctly revealed by palpation, occur 
most frequently after meals. If the stomach be empty, 
the peculiar gastric tympanitic resonance is elicited over 
an enlarged area, or if the organ contain solids and 
fluids, there is flatness below and tympanitic resonancd 



18 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 



Abdominal Tumors, 
Abdominal Tumors. 



above the level of the fluid, while a splashing sound is 
obtained by succussion ; metallic tinkling, proceeding 
from the stomach, may be heard if fluid be swallowed 
by the patient at the moment of auscultation ; the exact 
contours and dimensions of the dilated stomach may be 
ascertained by Frerich's method of evolving gas within 
the organ, which consists in the successive introduction 
of one half drachm of bicarbonate of soda, dissolved in 
lukewarm water, and of fifteen or twenty grains of tar- 
taric acid, likewise in solution. The leading symptom of 
obstrucUm gastrealasia is profuse vomiting, at intervals 
varying from some hours to several days, of partially di- 
gested aliment, in process of fermentation and putre- 
faction, containing torulm cerevisieB and sarcinm mntriculi 
in considerable qiiantities ; there is a sense of oppression 
at the epigastrium, which is only partly relieved by eme- 
sis, as the stomach js hardly ever completely evacuated ; 
pyrosis is present, thirst and constipation persistent, 
and dyspnoea, from pressure on the diaphragm, occa- 
sional ; the appetite is generally excellent, but emacia- 
tion is rapidly progressive ; there is no localized in- 
durated enlargement; pain on pressure is slight or 
absent, unless in cases of acute dilatation ; the com- 
plexion is often clear ; heematemesis is very rare, and 
no glandular tumors are perceptible. In atonic dilatation 
there may be no emesis, but merely epigastric oppression 
and eructations, sour or tasteless, together with the 
physical evidences of gastric enlargement and of the 
continual pressure, within the organ, of a varying 
amount of fluid and gas ; constipation is constant ; 
emaciation and asthenia are less marked than in the 
former variety. The diagnosis may be facilitated by a' 
consideration of the etiology, which embraces, for ob- 
structive gastrectasia, earcm/yma mntriculi, ulcers result- 
ing in cicatricial contraction of the pyloric extremity of 
the duodenum, fibroid induration of the pylorus, tu- 
mors of organs adjacent to the stomach, as of the 
pancreas, liver, omentum, and gall-bladder ; adhesions 
from old peritonitis, tractions, exerted by hernias and 
polypi, on the pyloric extremity. Spastic pyloric con- 
traction and the pressure of a wandering kidney are 
rare causes of obstructive gastrectasia. The chief 
causes of atonic dilatation are, according to Kussmaul, 
paralysis of the gastric motor nerves, weakness of the 
gastric muscles from impaired nutrition in fevers and 
chronic diseases, diminished irritability of the peristaltic 
nerves or nerve-centres, and reflex inhibition of gastric 
peristalsis. Habitual over-distention and chronic gastritis 
are also efficient predisposing causes of atonic gastrec- 
tasia. Those tumors of neighboring organs most fre- 
quently mistaken for cancer and other tumors of the 
stomach are enlargements of the left lobe of the liver 
and of the pancreas, aneurisms, fKcal accumulations, 
besides tumors of the spleen, right kidney, peritoneum, 
and intestine. These are described under their respec- 
tive titles. 

3. TUMOKS OF THE KiDNEY. 

These may be classified as solid and cystic tumors. 
The former variety embraces carcinomata and other 
malignant neoplasms, syphilomata, tubercles, and large 
calculi. To this class may be appended movable kidney. 
The chief tumors of a cystic character are pyonephrosis 
and abscess, hydronephrosis, hydatids, and true cystic 
degeneration. All of these conditions produce, when 
sufficiently developed, a lumbar tumor corresponding 
to the site of the diseased organ, which may be dis- 
covered by palpation. The extent of enlargement may 
be ascertained by percussion, for which the prone 
position is most favorable. The cystic tumors will 
often fluctuate, and the fluid character of their contents 
is demonstrated by the hypodermic needle. An en- 
larged right kidney may be mistaken for hepatic tumors, 
for impacted faecal matter in the hepatic flexure of the 
colon, for ovarian, pyloric, or ometital tumors, and for 
perinephritic and psoas abscesses. An enlarged left kid- 
ney may be confounded with faecal impaction in the 
splenic flexure, tumors of the left ovarjr, and splenic en- 
largements. A renal tumor may be distinguished from 



enlargements of the liver by its immobility during deep 
inspiration, by its position inside of the colon on the 
right and behind it on the left side, and by its relation 
to the ribs, between which and the enlargement the 
palpating fingers may, generally, be inserted during 
forced expiration. Psecal masses are in the course of 
the colon, retain an indentation imprinted by the finger, 
and are removed by cathartic remedies. Ovarian tu- 
mors first appear in the iliac regions and grow upward, 
are in front of the colon and present other characteristic 
features elsewhere detailed. Pyloric and omental tu- 
mors, as well as perinephritic and psoas abscesses and 
splenic tumors, present certain distinctive features, for 
which the reader is referred to the remarks devoted to 
these subjects. 

Solid Rbistal TuMOKS. — Cancer. — Symptoms and Signs : 
The renal enlargement is either smooth or nodular, in- 
durated or soft, and is sometimes even fluctuating ; it is 
behind the colon, or to its inner side ; it is generally sen- 
sitive, immobile on deep inspiration, fixed by adhesions, 
of rapid growth, and often of great size, extending from 
the lumbar into adjacent regions. Primary cancer is 
ordinarily unilateral, and does not produce metastases ; 
children under ten years are most often affected, and 
next in order of frequency persons above fifty years ; 
the disease is usually non-hereditary and primary, espe- 
cially in children, but. may be secondary, arising either 
by continuity or by metastasis from other abdominal 
and pelvic carcinomata ; albuminuria, alone or with 
hsematuria, is frequent ; renal haemorrhage is sometimes 
profuse ; there is intense pain, which occasionally radi- 
ates down the ureter or into the lower extremities ; the 
constitutional symptoms of cancer are more or less 
plainly manifest. Sarcomata of flie kidney are rare, and 
present essentially the same clinical features as cancers, 
except that they rarely occasion haematuria. Benal 
gummata do not often attain a sufficient size to be per- 
ceived by palpation, are not painful, are coincident with 
other local manifestations of a general syphilitic dyscra- 
sia, and yield to constitutional treatment. 

Benal Tuberculosis. — A renal tumor due to tubercles, 
when of sufficient size to be accessible to palpation, 
is ordinarily sensitive, and may be either hard or soft ; 
it is generally nodular, occupies the usual position of the 
kidney relatively to the colon, and is secondary to tuber- 
culosis of the lungs, vertebrae, testicle, prostate, bladder, 
or vasa def erentia ; it may, however, in rare instances be 
primary ; it attacks males, in the majority of cases, and 
is more frequently developed, according to Stewart, in 
the right kidney. "The prominent rational symptoms are 
haematuria, pyuria, cheesy and granular detritus in the 
urine, pain in the kidney, hectic fever, asthenia, emacia- 
tion, and possibly bacilli tuberculosis in the urine. 

Benal Calculi. — One renal calculus, or several cal- 
culi, retained in the pelvis may, rarely, attain dimensions 
even surpassing those of the healthjr kidney, thus sub- 
stituting for the latter a hard insensitive tumor, either 
smooth or nodular, the differential diagnosis of which is 
best established by the exclusion of carcinoma, syphilo- 
ma, and tubercle, which affections present the signs 
and symptoms already described. The previous history 
may furnish valuable evidence of antecedent or existing 
pyelitis or renal colic. 

Movable Kidney. — This form of renal ectopia, some- 
times designated by the terms wandering and floating 
kidney, usually presents itself in hysterical, middle-aged 
multiparse, and on the right side. The physical signs 
are those of a mobile tumor, possessing the form, out- 
line, and peculiar sensibility of the normal kidney, gen- 
erally located in the hypochondriac or the umbilical 
region, either behind or to the outer side of the colon. 
At the normal site of the organ a hollow is observed, and 
tympanitic resonance is obtained, tut the former disap- 
pears, and the latter is replaced by the natural dulness 
if the kidney be forced to assume or spontaneously regain 
its usual position. Bartholow states that the kidney de- 
scends on deep inspiration, ascending again with the 
ensuing expiratory act. The leading symptom, by no 
means constantly present, is pain, either of a dragging 



19 



Abdominal Tumors. 
Abdominal Tumors. 



BEFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 



character and located in the hypocliondrium or radiating 
into the testicle and thighs, and especially severe in walk- 
ing. Sometimes the pain is very acute, and accompanied 
with vomiting, headache, rigors, nervous shock, and 
hsematuria ; in this case the tumor is often swollen and 
peculiarly tender. The kidney may compress the vena 
portBB, the vena cava, or the howel, thus occasioning 
ascites, cedema of the lower extremities, and obstipation. 
Gystia Senal Tumors. — These are pyonephrosis or 
renal abscess, hydronephrosis, hydatids, and renal cysts, 
each of which presents a fluctuating nephritic enlarge- 
ment. The differential diagnosis of these affections 
may ordinarily be established by a careful consideration 
of the constitutional symptoms, and by analysis of the 
urine or of the fluid withdrawn from the tumor. 

Pyonephrosis an^ renal abscess, of sufficient size to 
produce perceptible tumors, are generally accompanied 
by local sensitiveness and by the usual constitutional 
symptoms of suppuration. The enlargement is com- 
monly smooth and globular, rarely nodular, and may 
attain the size of a child's head. In pyonephrosis the 
urine voided from the bladder is normal, if complete 
obstruction of the affected ureter exist, otherwise it con- 
tains pus, blood, and epithelial cells ; the sudden appear- 
ance of the latter, accompanied by renal colic and coin- 
cident with rapid subsidence of the tumor, is strongly in 
favor of pyonephrosis, although, the same phenomena 
may attend renal abscess. The pre-existence of pyelitis 
or of renal colic, due to calculi, and the demonstration 
of some condition capable of obstructing the ureter, 
point to pyonephrosis. An antecedent surgical injury 
of the lumbar region, followed by the development of a 
fluctuating renal tumor, the urine long remaining nor- 
mal, would indicate the existence of renal abscess. As- 
piration and microscopical examination of the fluid 
withdrawn from the tumor demonstrate the presence of 
pus in either case. 

Sydi'onephrosis.— This condition is generally unilateral, 
is caused by the accumulation, within the pelvis, of the 
renal secretion, and is uncomplicated by inflammation. 
Its causes may furnish a clue to the diagnosis. They 
are congenital or acquired obstructions of the ureter, 
either partial or complete. The existence of congenital 
obstructions can rarely be ascertained. Among the 
causes of acquired obstruction are impacted calculi, the 
pressure of pelvic tumors, especially those of uterine 
origin, stricture of the urethra, cystic diseases, as cancer 
and hypertrophy, which obstruct the oriflces of the 
ureters, and cicatricial contractions of the latter. The 
tumor is fluctuating ; sometimes of large size, insensitive, 
usually smooth, but occasionally nodular and lobulated ; 
constitutional symptoms and local pain are absent. The 
urine, which is ordinarily normal, may be suddenly 
augmented in quantity by the removal of the obstruction, 
the lumbar enlargement simultaneously disappearing. 
The fluid obtained by aspiration is free from blood and 
pus, and commonly contains urinary constituents, al- 
though these may, in very rare instances, be wanting. 

Hydatids of the Kidney. — A tumor, varying in size from 
that of an orange to that of an adult's head, is found, 
according to Roberts, in only one-third of these rare 
cases. The tumor is generally smooth, painless, fluctu- 
ating, elastic, and, at first, insensitive ; it may, rarely, 
present the hydatid thrill. When adhesions are formed 
the tumor excites pain from inflammation and ulceration, 
and it may rupture into the pelvis, stomach, or intestine, 
the characteristic fluid being then evacuated through 
these channels. The disease is unilateral, and especially 
attacks men. There are no constitutional symptoms, 
unless suppuration of the sac or secondary adhesive in- 
flammation occur. The urine is normal, unless rupture 
into the renal pelvis, takes place, when the echinococci 
booklets are detected, the tumor meantime subsiding. 
The passage of the booklets to the bladder may excite 
venal colic, and their arrival in the viscus often produces 
vesical tenesmus. Fluid withdrawn by aspiration pre- 
sents the characteristic appearances noticed in the de- 
scription of analogous hepatic tumors. 

Benal cysts closely resemble hydronephrosis in signs 



and symptoms, but no cause for obstruction of the uretel 
is demonstrable. The cysts do not, generally, occasion 
constitutional symptoms, except in the advanced stages, 
when they may lead to uraemia. The cysts are painless, 
smooth, insensitive, and fluctuating ; the urine is com- 
monly slightly albuminous' or bloody, and of low specific 
gravity ; its quantity is often abnormally large. The 
fluid obtained by aspiration differs from that withdrawn 
in hydronephrosis in frequently containing pus and 
blood, but may possess a distinctly urinous character. 

4. TUMOKS OF THE SPLBBN. 

These are either temporary or permanent. The former 
class embraces rapidly-developed and temporary splenic 
enlargements, due to physiological congestion, inflam- 
mation, and acute febrile processes. 'The latter class 
includes enlargements from chronic malarial poisoning, 
leucocythsemia, pseudo-leucocythsemia, obstruction to 
the portal circulation incident to hepatic, pulmonary, or 
cardiac diseases, waxy degeneration, cancer, syphilo- 
mata, tubercles, hydatids, and splenic ectopia. The 
splenic enlargement common to all the above-mentioned 
conditions occasions a feeling of weight in the left hypo- 
chondrium, and is revealed by inspection, which often 
shows a more or less marked prominence over the normal 
site of the organ, and in the neighboring abdominal and 
thoracic regions. Palpation reveals the form of the 
spleen, which it retains even when greatly enlarged, its 
consistency, its notched anterior border, its descent dur- 
ing deep inspiration, its mobility on change of posture, 
unless this be prevented by adhesions, the rounded char- 
acter of the tumor's lower border, and the possible upward 
displacement of the heart. Percussion accurately defines 
the exact limits of the organ, which may sometimes 
reach the iliac fossse. The various splenic tumors must 
be distinguished from each other rather by their con- 
comitant conditions than by their individual physical 
characters. 

(a) Tempokaet Enlaegbments. — Physiological con- 
gestion, leading to temporary enlargement, occurs habit- 
ually after eating, and at the menstrual epoch, but is 
accompanied by no pain, tenderness, or other abnormal 
symptoms. Inflammatory splenic enlargements may be 
either local or general. They are due to traumatism, the 
history of which can easily be obtained, to extension of 
inflammation from neighboring organs, to hemon-hagic 
infarctions, or to embolism in pysemic endocarditis. In 
the last two cases abscesses, fluctuating and yielding pus 
on aspiration, may be formed, and will excite the ordi- 
nary constitutional symptoms of suppuration ; the tu- 
mors are usually painful and sensitive ; the existence 
of perisplenitis is shown by the discovery of a f rjction- 
sound, occasioned by the respiratory movements of the 
diaphragm and by the occurrence of lancinating pains. 
The abscess may rupture into the stomach, bowel, or 
peritoneum. In the flrst and second cases pus will be 
rejected by vomiting or in the evacuations ; in the last 
instance peritonitis rapidly supervenes. If the abscess 
be small, the above signs and symptoms may be absent, 
and the diagnosis be impracticable. Perinephritic ab- 
scesses majr offer insuperable obstacles to a correct dif- 
ferential diagnosis. 

The splenic enlargements dependent upon acute febrile 
diseases occur, most frequently, in connection with 
malarial, typhoid, and puerperal fevers and in pyaemia, 
but are often observed in the eruptive fevers, in diph- 
theria, cerebro-spinal fever, pneumonia, erysipelas, and 
acute miliary tuberculosis. The presence of symptoms 
characteristic of these diseases, with the usually rapid 
subsidence of the tumor, after defervescence, will de- 
monstrate the acute nature of the enlargement. 

(b) Pbrmanbnt Enlargements. — The chronic splenic 
enlargement, familiarly known as ague-cake, will be 
distinguished by thfi history of past or present acute 
malarial attacks, and by the existence of the malaria? 
cachexia ; pigment-particles may be discovered in the 
blood. In levAMcythoemia and pseudo-leucocythamia, the 
lymphatic glands are hypertrophied, as well as the 



20 



REFEEEKCE HANDBOOK OF THE MEDICAL SCIENCES, ibdominai Tumo".* 



spleen, aad in the former disease the white corpuscles 
wUl be present in abnormally large proportions in the 
blood. Anasarca, fever, and haemorrhage from mucous 
surfaces are quite constant advanced symptoms of both 
conditions. Splenic tumors, dependent upon portal 
obstruction, will be accompanied by the symptoms 
characteristic of the mca'bid conditions producing the 
obstruction ; these are mainljr mitral and tricuspid 
valvular lesions, fibroid phthisis, chronic pleurisy with 
retraction, pulmonary emphysema, obstruction of the 
inferior vena cava by thoracic tumors, cirrhosis of the 
liver, pylethrombosis, pylephlebitis, and such hepatic 
tumors as exert pressure directly on the portal vein. 
Other symptoms of portal obstruction will facilitate the 
diagnosis, especially gastro-enteritis, hemorrhoids, as- 
cites, and, in the case of portal congestion from intra- 
thoracic disease, the symptoms of chronic renal con- 
gestion. The a/myloid spleen is developed in connection 
with waxy degeneration of the liver, intestines, and 
kidney, which will present a familiar train of symptoms, 
and which are etiologieally dependent upon chronic 
suppurative processes or syphilis. Cancer of the spleen 
is rare and always secondary ; its existence will be in- 
ferred if a tender and painful splenic tumor be de- 
veloped consecutively to carcinoma of abdominal, pel- 
vic, or thoracic viscera. Ghimmata in tie spleen im- 
part no distinctive characters to the splenic tumor, but 
the presence of syphilomata in other organs or tissues 
and the history of constitutional infection will facilitate 
the diagnosis. Tubercles are developed in the spleen 
during general tuberculosis, but offer no pathognomonic 
signs ; their existence may be assumed in the absence 
of other causes for splenic enlargement and in the pres- 
ence of symptoms of acute tuberculosis. Hydatids of 
the spleen are generally coincident with their existence 
in the peritoneum or liver ; they may present the 
hydatid thrill and fluctuation ; the discovery of 
booklets in the fluid withdrawn from the tumor estab- 
lishes the diagnosis. Splenic ectopia is due to increased 
size and weight of the organ incident to various mor- 
bid conditions. The tumor presents the characteristic 
splenic contour and smoothness, but is usually tender 
and accompanied by other symptoms produced by 
pressure on adjacent organs. The abdoniinal tumors, 
most frequently confounded with splenic enlargements, 
are those of the left lobe of the liver, of the stomach, 
particularly cancer ; of the kidney, the omentum, the 
pancreas, the ovary, and tumors due to f secal impaction 
in the splenic flexure of the colon. For the diagnosis 
of these enlargements the reader will please see the re- 
marks under their respective titles. 

5. TUMOBS OF THE PaNCBEAS. 

These tumors frequently oppose insurmountable dif- 
ficulties to the diagnostician' on account of their depth, 
their rarity, and the ambiguity of their symptoms. Those 
pancreatic diseases producing perceptible tumors are 
cancer, cystic degeneration, and acute or chronic inflam- 
mation. All of these morbid conditions produce im- 
movable epigastric tumors, unaffected by deep inspira- 
tion, and occasional symptoms of all are glycosuria and 
fatty diarrhoea due to interference with the pancreatic 
digestive functions. All the tumors may occasion grave 
disturbances by compressing neighboring organs. 

Cancer of tJie pancreas is commonly secondary to gas- 
tric, omental, retroperitoneal, or hepatic carcinoma. It 
is generally of the scirrhous variety, attacks men over 
forty years of age, by preference, is usually developed, 
if primary, in the head of the organ, and may involve 
any adjacent viscus. The tumor, present, according to 
Bartholow, in one-third of the cases, is transverse and 
sensitive. The neighboring lymph-glands may be en- 
larged and cachexia apparent ; pain, often radiating into 
the back, is present and is aggravsrted by the erect post- 
ure ; it is frequently paroxysmal and is intensified by 
deglutition, coughing, or the assumption of the abdomi- 
nal decubitus, and is relieved when the body is bent 
forward. Emesis, jaundice, constipation, gastrectasia, 



ascites, cedema of the lower extremities, and pancreatic 
cysts may result from pressure on the stomach, ductus 
communis, duodenum, portal vein, vena cava, and pan- 
creatic duct. 

A pancreatic cyst produces a spherical, insensitive, uni- 
form or lobulated epigastric tumor, unattended by pain 
or symptoms, other than glycosuria and fatty diarrhoea, 
and commonly referable to obstruction of Wirsung's 
duct by pancreatic calculi, by the pressure of neighbor- 
ing neoplasms, or by interstitial inflammation. It may, 
according to Bristowe, attain the size of an orange. 

Chronic interstitial infkt/mmation of the pancreas gives 
rise to an indurated, painless, and insensitive enlarge- 
ment in the epigastrium, possibly accompanied by the 
symptoms already described as common to all pancreatic 
tumors. Acute pancreatitis, which may result from the 
abuse of mercury or may occur as a complication of 
puerperal and essential fevers, presents a soft, painful, 
tender, fluctuating tumor, often attended by emesis and 
pyrexia. Pancreatic tumors are to be distinguished from 
cancer of the pylorus, abdominal aneurism, omental tu- 
mors, and biliary calculi. Pyloric carcinoma usually 
presents more marked gastric symptoms, with hsemate- 
mesis and melssna ; the pylorus is, however, often in- 
volved simultaneously with the pancreas. The charac- 
teristics of abdominal aneurisms are stated in the article 
on that subject. Omental tumors are more superficial 
and, if tuberculous or cancerous, excite chronic peri- 
tonitis. The diagnostic features of biliary calculi wiU 
be found in the article devoted to that affection. 

6. TlTMORS OF THE INTESTINE. 

The intestinal tumors possessing the greatest clinical 
interest are due either to cancer, faecal impaction, or to 
various forms of obstruction. Intestinal sarcomata, 
myomata, fibromata, adenomata, lipomata, angiomata, 
papillomata, and cysts also occur, but the first of these 
can hardly be differentiated from cancer, and the others 
are ordinarily of such small size as to escape detection. 

The diagnosis of intestinal ca/ncer must be mainly based 
upon its situation and its symptoms. It is, generally, 
inherited and primary, is developed after the fortieth 
year, most frequently attacks the rectum, sigmoid fiex- 
ure, andcsecum, but is, sometimes, found in the duo- 
denum and, rarely, in the jejunum or ileum. Pain, 
intestinal obstruction, the presence of a sensitive tumor, 
constipation followed by diarrhoea, and cachexia are 
common to all intestinal carcinomata, wherever situated, 
although these symptoms are not constant. If the rectum 
be the seat of the new-growth it will be easily discovered 
and microscopically examined ; the pain may radiate 
into the thighs and testes, the fasces will be ribbon-shaped 
early in the disease, and later will be mingled with blood, 
pus, and putrid particles of the cancer. Should the first 
portion of the duodenum be involved there may be 
emesis, the ^ecta sometimes presenting the appearance 
of coffee-grounds, or icterus from occlusion of the com- 
mon bile-duct. IHagnom. — Intestinal cancer must be dif- 
ferentiated from aneurisms, fsecal tumors, carcinomata, 
and other tumors of neighboring abdominal organs, from 
floating kidney, enteritis, and intestinal ulceration, and 
from all other causes of intestinal obstructioij. Enteritis 
and ulceration can be excluded by the absence of tumor, 
constipation, and cachexia in those diseases. The diag- 
nosis of the other morbid conditions simulating cancer 
is presented in connection with their general description. 

P.ffi:cAL TxtMOBS. — These are situated in the colon, and 
most frequently at the sigmoid, splenic, or hepatic 
fiexures, and in the csecum. The tumor will be found 
in the course of the bowel, its long diameter correspond- 
ing to that of the intestine ; it may be nodular, but is 
not sensitive, and can be indented by the finger ; owing 
to its inelasticity the fsecal mass retains the digital inden- 
tation. The tumor can often be displaced in the axis of 
the intestine ; diarrhoea may be present from irritation, 
although constipation is the rule. The absence of ca- 
chexia, constitutional symptoms, and pain facilitate the 
exclusion of cancer and of other intestinal obstructions. 



2] 



/Ibdominal Tumors. 
Abdominal Tumors. 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 



Free purgation usually completely removes the tumor, 
which often spontaneously changes its position. 

Intestinal Obstkuction. — The classification of in- 
testinal obstructions here adopted is derived from the 
lectures of Dr. H. B. Sands. It embraces : 1. Errors of 
position, as intussusception and volvulus. 2. Compres- 
sion from bands, diverticula, accidental rings, internal 
hernias, benign or malignant tumors. 3. Obturation from 
foreign bodies, polypi, gall-stones, enteroliths, or fsecal 
masses. 4. Strictures of the bowel, either fibrous or 
malignant. The symptoms of invagin-ation are some- 
what different from those of other obstructions. They 
ordinarily supervene rapidly, the patients being, usually, 
children who have suffered for some days from diar- 
rhoea. The symptoms are, chiefly, severe localized 
pain ; the development of a tender, rather soft abdomi- 
nal tumor, which yields a dull note on percussion, may 
cliange its form or position, and is most frequently 
found in the right iliac fossa ; emesis, sometimes ster- 
coraceous and diarrhoeal, or sanguinolent evacuations 
which may contain gangrenous shreds or masses. The 
leading symptoms of the other varieties of obstruction are 
obstipation ; vomiting, which appears early, is bilious at 
first and may remain so if the obstruction be high up in 
the small intestine, but which comes late and becomes 
stercoraceous if the small bowel be occluded low down, 
or the colon at an}' part of its course ; the formation of 
a sensitive, painful tumor, dull on percussion, if the ob- 
struction be not too high in the small intestine ; increas- 
ing tympanites above the tumor, singultus, lowered 
temperature, and finally collapse. The diagnosis re- 
lates both to the nature and the situation of the ob- 
struction. The existence of invagination may be in- 
ferred if obstruction suddenly occur in a child pre- 
viously affected with diarrhoea, and be accompanied by 
bloody stools ; a rectal examination may confirm the 
diagnosis. Volvulus is sometimes induced by violent 
muscular exertions, as in jumping or lifting. If the 
liistory points to pre-existing peritonitis, or to other ab- 
dominal tumors, obstruction from compression is probable. 
Should there be a history of biliary colic, obstruction 
by a gall-stone or by fsecal masses developed around a 
calculus is assumed. The pre-existence of ulcers points 
to strictures of the bowel. The situation may be deter- 
mined by exact localization of the original tumor, but 
this often fails. In obstruction of the duodenum or 
jejunum the urine is scanty, the abdomen undistended, 
and the ejecta bilious in character ; if the caecum be 
the seat of the occlusion the large intestine will be 
empty, but the latter will be distended throughout if 
the rectum be obstructed ; if a rectal tube can be made 
to penetrate a foot or more, the rectum and sigmoid are 
free ; if the colon can be distended throughout by in- 
jected air or water, it is, of course, unobstructed. 
Simon's method of manual intrarectal examination may 
furnish important information. Differential Diagnosis. 
— The chief conditions with which obstruction may be 
confounded are peritonitis, acute gastritis, hepatic and 
renal colic, enteritis, external hernia, simple enteralgia, 
and gastralgia. Peritonitis is characterized by great 
tenderness, high temperature, and incompressible pulse, 
a peculiar decubitus, and facies. Acute gastntis is 
marked by elevation of temperature, and by great ten- 
derness and heat of the epigastrium ; there is no ob- 
stinate constipation, but often diarrhoea ; the ejecta 
are not stercoraceous. In liepatie colic there is no tym- 
panites, fascal vomiting, or obstipation ; the pain begins 
suddenly, radiates from the right hypochondrium to the 
right shoulder, or into the back, and ceases abruptly ; 
there may be jaundice and colorless stools ; bile is found 
in the urine and the calculus is perhaps detected in the 
evacuations. In renal colic there is no fever, tympanites, 
faecal emesis, or constipation ; the pain, which begins 
and ceases abruptly, radiates into the penis and thighs ; 
the urine is often bloody, and may contain uric acid 
crystals or the offending calculus ; the testicle is re- 
tracted. Enteritis is accompanied by diffused abdominal 
pain and tenderness, by diarrhoea and an elevated tem- 
perature, but not by emesis or tympanites. Inguinal 



and femoral hernias are excluded by a thorough physical 
examination. Enteralgia and gastralgia are devoid of 
the leading symptoms of obstruction, while the pain of 
these neuralgic affections is paroxysmal and may be 
relieved by pressure. 

7. TCMOKS OF THE OmBNTUM. 

The omental tumors most deserving of attention are 
cancer, tubercle, and hydatids. Fibromata, hsematomata, 
myxomata, dermoid and simple cysts are also developed 
from the omentum, but are so rare as not to claim con- 
sideration in this place. 

Omental cancer, a rare disease, as compared with 
tubercle, is usually secondary to cancerous degeneration 
of other abdominal organs or of the sexual apparatus, 
but may be primary, particularly if of the colloid variety. 
Its siyns are those of tumors, either nodular or diffuse, 
which sometimes attain large dimensions, are bilateral, 
superficial, tender, movable, unless bound down by 
peritoneal adhesions, and often accompanied by par- 
oxysmal pain and peritoneal friction-sounds. 

Omental tubercles, although occasionally primary, gen- 
erally merely constitute one local manifestation of general 
tuberculosis, the point of departure for which may have 
been the lungs or the genito-urinary organs. The tuber- 
culous nodules are too minute to be certainly disclosed 
by physical exploration. Cancer, tubercle, and hydatids 
excite chronic peritonitis, which is often insidious in 
development, and latent as regards symptoms; cancer 
and tubercle present, in addition, their familiar trains of 
constitutional symptoms, and, generally, evidences of the 
primary disease. In tuberculosis there is more frequently 
pleuritis, diarrhcea, fever, emesis, and tympanites than in 
cancer, and the average age of the patients is less. The 
fluid withdrawn from the peritoneal cavity in cancer is 
said, by Foulis and Thornton, to contain characteristic 
groups of large, budding cells. 

Hydatids of the omentum may present the characteristic 
fremitus, and yield fluid containing echinococci booklets ; 
they excite less constitutional disturbance than cancer 
or tubercle, but may exceed either in size. Ascites is 
often mistaken for chronic peritonitis, secondary to omen- 
tal tumors ; it is, however, not accompanied by fever, 
pain, or abdominal tenderness. Ascites is, moreover, 
caused by cirrhosis of the liver, or by obstruction to th( 
hepatic circulation from intrathoracic diseases, whicl' 
also occasion splenic enlargement, gastro-enteritis, and 
distention of the superficial abdominal veins. 

8. TUMOKS or THE Bladdbk. 

New-growths in the bladder are cancerous, tuberculous, 
villous, or fibrous in nature, but do not occasion suf- 
ficient enlargements to justify their inclusion among 
abdominal tumors. Vesical cancer is generally secondary 
to other pelvic carcinomata, and causes cystitis, enlarge- 
ment of lumbar glands, and sudden, abundant hemor- 
rhages. Cystic tubercles are secondary to tuberculous 
deposits in other genito-urinary organs, or occur in gen- 
eral tuberculosis. Villous tomors produce long-continued 
parenchymatous hemorrhages. Mbroids occasion cystitis 
and dysuria. 

A distended bladder occupies, first, the hypogastrium, 
and gradually invades the adjoining regions. The tumor 
is oval, central, flat on percussion, smooth, painless, and 
insensitive, until an extreme degree of distention is 
reached, and sometimes fluctuating. Catheterism estab- 
lishes the differential diagnosis between vesical distention 
and ascites or uterine tumors. Distention should always 
be sought for in delirious or comatose patients, and will 
often be found in cases of incontinence following atony. 
In these cases the history of frequent urination some- 
times causes the physician to overlook the necessity for 
physical exploration. 

9. UTBBrNE Tumors. 

The principal causes of uterine enlargements are preg- 
nancy, hydatidiform mole, retained dead foetus, retained 



22 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 



Abdominal Tumors, 
A bdomliial Tumors. 



menstrual or serous fluid, fibromata, flbro-cystomata, car- 
cinomata, sarcomata, and physometra. If the uterine 
abdominal tumor be of small size it will occupy the 
hypogastrium, unless adhesions from antecedent peri- 
uterine inflammation or other abdominal enlargements 
exert such traction or pressure upon it as to displace it 
into one of the inguinal regions. 

If normal pregnancy exist it will be revealed, after the 
fourth month, by the foetal heart-sounds, the uterine 
soufile, ballottement, and the foetal movements, together 
with the familiar mammary and cervical changes ■, the 
tumor is firm, non-fluctuating, and inelastic. If s, dead 
faius be retained in utero, the history will be that of 
normal pregnancy up to a certain time, after which no 
evidence of foetal vitality or of progressive uterine en- 
largement can be obtained. Having undergone either 
maceration or mummification, the foetus may be expelled 
before the expiration of the normal period of utero- 
gestation, or, having been transformed into a lithopcedion, 
may be indefinitely retained. The hydaiidiform mole, 
when of large size, is distinguished by the occurrence 
of uterine contractions, resulting in the expulsion of a 
muco-sanguinolent fluid containing the cysts peculiar to 
this disease, possibly by the presence of slight fluctua- 
tion, by unusually rapid enlargement of the uterus, by 
the failure of ballottement, and by the absence of foetal 
heart-sounds. If the tumor be due to retained menstrual 
fluid, the signs of pregnancy will be absent, the dis- 
charge at each menstrual epoch will be insignificant or 
absent, intense pain will recur at each period, and 
physical examination will disclose obstruction of the 
genital canal. The history will, also, often point to 
some antecedent inflammatory disease of such a nature 
as to have occasioned occlusion of the genital passage. 

The accumulation of a serous disaha/rge from the en- 
dometrium, in old women, will present the above signs 
and symptoms without periodicity or severe pain. 

The connection of uterine neoplasmata, which have not 
involved neighboring viscera, with that organ is shown 
by the displacement of the tumor when the uterus is 
moved either by the palpating finger or the uterine 
sound, by the elongation of the uterine cavity, ascer- 
tained with the probe, and by the results of abdominal pal- 
pation, vaginal exploration, Simon's intra-rectal method, 
or by a combination of these methods of examination. 
The symptoms of pregnancy are absent. Uterine fl^oids 
attack the body or fundus of the organ, by preference, 
and cause irregular, unsymmetrical enlargement ; their 
consistency is firm ; they are usually developed between 
the thirtieth and forty-fifth year. Negresses are especially 
predisposed. The chief symptoms are metrorrhagia or 
menorrhagia, pain from pressure on the pelvic nerves, 
uterine tenesmus, dysmenorrhoea, leucorrhoea, and hy- 
drorrhoea. I%rocystomata of the uterus may present 
obscure fluctuation and yield fluid on aspiration, which 
does not possess the characters of ovarian fluid ; their 
growth is more rapid than that of fibromata, and their 
size usually greater. Uterine earoin/ymata attack aged 
multiparse possessed of an hereditary predisposition ; 
they generally afEect the cervix, but may invade the 
body and fundus, when they become accessible to ex- 
amination through the abdominal walls ; they are hard 
and nodular until ulceration occurs, after which an ir- 
regular and bleeding ulcer remains ; the microscope 
decides the character of the neoplasm. Menorrhagia, 
metrorrhagia, fetid discharge, and cachexia are the chief 
rational symptoms. Sarcomata always develop in the 
uterine body, are generally soft and friable, though 
sometimes hard ; the cervix is dilated, and the uterine 
cavity enlarged ; there are present menorrhagia, metror- 
rhagia, uterine tenesmus, and an offensive discharge ; 
the microscope establishes the diagnosis. Physometra or 
l)jmpanites Uteri. — This rare condition, dependent on 
the presence of air or gas in the uterine cavity, is shown 
by the existence of tympanitic resonance over the entire 
organ. Tympanites uteri occurs during labor, as the 
result of the entrance of air through the ruptured mem- 
branes, and is either due to the air alone or to the gases 
which are the product of putrefactive processes excited 



by the presence of air, heat, and moisture in utero. The 
pains grow feeble or cease in physometra, there is an 
offensive discharge from the uterus, and septic symptoms 
ensue. Ovarian tumors, spurious pregnancy, ascites, 
cysts of the broad ligaments, and salpingitis may be 
mistaken for uterine tumors. 

10. OVAKIAN TtTMOKS. 

These enlargements occur with greater frequency than 
all other abdominal tumors. They appear first in the 
iliac fossae, and gradually extend to the adjoining regions. 
On inspection they present, early in the disease, an ir- 
regular, unilateral, more or less globular projection. In 
the later stages this prominence may occupy all the ab- 
dominal regions, being especially marked in the middle 
line. The tumors may, according to their structure, be 
hard and unyielding, or soft and fluctuating. They are 
movable, unless adhesions have formed between them 
and neighboring viscera, and may be either sensitive or 
insensitive, painful or the reverse. Flatness on percus- 
sion exists over the tumor, and does not change place 
with alterations in the patient's position. Tympanitic 
intestinal resonance is found above the tumor and, often, 
on either side of it. The uterus is generally movable, 
of normal size, and displaced backward or laterally. It 
is often found behind the ovary, as is the large intestine. 
"An aortic impulse may be imparted to the enlarged 
ovary. 

Ovarian neopltismata are, according to the classification 
of Thomas, either solid or cystic. 'The leading members 
of the former group are cancers and fibroids, those of 
the latter are cysto-fibromas, cysto-carcinomas, dermoid 
cysts, ovarian cysts, and cystomata. Acute ovaritis also 
leads to enlargement of the organ. 

Solid Tumobs. — Cancer. — A cancerous ovarian tu- 
mor is primary or secondary, painful, usually sensi- 
tive, and of either firm or soft consistency. It develops 
rapidly in aged women, and is accompanied by marked 
asthenia, cachexia, ascites, oedema of the feet, and sec- 
ondary glandular tumors. Fibromata of the ovary are 
rare, and usually of small size. They are firm, unyield- 
ing, insensitive, painless, movable, and of slow growth. 
Acute ovaritis produces enlargement of the exquisitely 
tender organ, vaginal sensitiveness near the site of the 
ovary, with vesical tenesmusi febrile movement, and 
sympathetic emesis. 

Cystic Tumors. — Cysto-flbromata are of large size, 
fluctuate, and yield, on aspiration, a serous, sero-san- 
guinolent, purulent, or colloid material. Oysto-carcino- 
mata are characterized by. their very rapid development, 
their involvement of neighboring organs and consequent 
immobility, their frequently nodular character, their 
tenderness, their painful nature, and their constitutional 
symptoms ; they are rarer than cysto-flbromata. Der- 
moid cysts are commonly spherical and indurated, single, 
although occasionally multiple, painless and movable ; 
they vary in size from that of a hen's egg to that of an 
adult head ; they may suppurate, and may rupture into 
the peritoneal cavity. Ovarian cysts present the physical 
characters described in the introductory remarks on ova- 
rian enlargements, the most striking being fluctuation. 
The chemical analysis and microscopical examination of 
the fluid withdrawn are of great diagnostic value ; the 
fluid is not generally spontaneously coagulable ; it is 
usually viscid, sometimes serous, has an average specific 
gravity of 1.018 or 1.030, and contains albumen and 
paralbumen ; it may contain cholesterine, cylindrical 
epithelial cells, Drysdale's ovarian corpuscles, the inflam- 
matory cells of Grliige, and blood-corpuscles. The age 
at which ovarian cysts commonly develop is from twenty 
to forty years. The leading symptoms are dysuria and 
dysmenorrhoea, pelvic pain, constipation, and ascites. 
For some time the general health remains tolerable, but 
hectic fever, emesis, diarrhoea, oedema, and asthenia 
finally develop. 

Differential Diagnosis. — The abdominal enlargements 
most likely to be mistaken for ovarian tumors are those 
of the uterus, bladder, omentum, intestine, broad liga- 



23 



Abdominal Tumors. 
Abortion. 



REFEEENCE HANDBOOK OF THE MEDICAL SCIENCES. 



Dients, and Fallopian tubes. Tumors of the kidneys, 
stomach, liver, and spleen, must also be differentiated, 
besides ascites, tympanites, chronic peritonitis,- pelvic 
abscess, cellulitis and hsematocele, aortic aneurisms, en- 
largements of the retro-peritoneal glands, osteomata, and 
enchondromata of the pelvic walls. 

Enehondromata and osteomata of the ipelmc hones are 
hard, immovable, non-fluctuating, and contain no fluid ; 
the other morbid conditions mentioned are described, 
at the proper place in this article, or in those treating of 
the subjects in question. 

11. Miscellaneous Ttjmobs. 

ExTKA-UTBEiNE Pbbgnancy. — The diagnosis of this 
condition is based, according to Lusk, upon the existence 
of the signs of pregnancy, the exclusion of an ovum in 
the uterine cavity, and the presence of a tumor outside 
the womb. The signs of pregnancy need not be repeated. 
The absence of an ovum from the uterus is shown by 
the cautious use of the uterine sound or by the introduc- 
tion of the finger, after cervical dilatation. The tumor 
may sometimes be felt before the fourth month by vagi- 
nal touch, and, occasionally, after that time, by abdomi- 
nal palpation. The heart-sounds may then be heard. 
Dr. Lusk suggests that friction of the abdomen, over the 
tumor, may aid in the diagnosis, as the uterus will alone 
contract under this stimulation. 

Tubal Dbopst ob Hydbosalpinx. — This condition, 
due to the occlusion of the Fallopian tube, usually 
from preceding peritonitis or cellulitis and the accumu- 
lation of a serous fluid in the tube, leads to the develop- 
ment of a tumor, generally small, but sometimes attain- 
ing the dimensions of a child's head. The enlargement 
is in so close proximity to the ovary that it can be diag- 
nosticated from ovarian cyst only by analysis of the fluid 
withdrawn. 

Cysts of the Beoad Ligaments. — These cysts yield 
a superficial fluctuation and closely simulate ovarian 
cysts, uterine fibro-cysts, and hydrosalpinx. They are 
unilocular and, hence, not irregular or nodular. Their 
differential diagnosis rests on an examination of their 
fluid contents, which are clear and albuminous. These 
cysts are generally cured by tapping ; they grow slowly 
and do not interfere with the general health. 

Pelvic H^simatocble. — The tumor designated by this 
name is usually first developed behind the uterus and 
vagina, in the cul-de-sac of Douglas, and may extend 
thence only to the pelvic brim or even as high as the 
umbilicus. It is at first smooth and fluctuating, later 
it is nodular and hard ; the vagina and rectum are more 
or less obstructed and the uterus is displaced by the 
tumor ; the enlargement is rapid and is accompanied by 
shock, metrorrhagia, uterine tenesmus, tympanites, and 
pelvic pain. 

Pelvic Cellulitis. —In the beginning of this affec- 
tion the only physical sign is great tenderness on one 
side of the uterus. After effusion has occurred a tumor 
will be found, and should suppuration ensue, fluctuation 
will be detected and the uterus will be partially fixed. 
Metrorrhagia, dysuria, and fever are the chief early 
rational symptoms. If suppuration take place hectic 
fever is developed. 

Abscesses. — The principal abdominal abscesses are 
preperitoneal, iliac, lumbar, peritoneal, and parietal. Ab- 
scess in the preperitoneal space, or the space of Ricius, 
between the umbilicus and the apex of the bladder, leads 
to the formation of a tender, painful, deep-seated tu- 
mor of the hypogastrium, which occasionally fluctuates, 
yields pus on aspiration, and excites constitutional symp- 
toms of the hectic type. These abscesses may be trau- 
matic, secondary to bladder or pelvic diseases, or, rare- 
ly, idiopathic. IUm Abscess.— khacess in the iliac fossa 
may be traumatic, but is generally secondary to peri- 
typhlitis, pelvic cellulitis or peritonitis, psoitis, caries or 
necrosis of the pelvic bones, or to pelvic abscess of what- 
ever origin ; lumbar abscesses may also point in this 
region, and idiopathic abscesses occasionally develop 
here. Should the abscess be the result of perityphlitis, 

24 



palpation reveals the deep-seated character of the tumor, 
and percussion yields an obscure tympanitic resonance. 
Well-marked tympanites is indicative of rupture of the 
intestine and the escape of gas into the cellular tissue. 
In perityphlitic abscess there will be pain in the thigh, 
inability to flex the latter, emesis, diarrhoea, and perhaps 
cedema of the lower extremities, with the characteristic 
constitutional symptoms of suppuration ; the aspirator 
will often obtain pus, which is stercoraceous in odor and 
actually contains f secal matter if perforation of the cae- 
cum have given rise to the abscess. Abscesses not due 
to csecal disease yield no symptoms relative to the diges- 
tive tract and excite comparatively little pain or fever. 
Small .size of the iliac tumor and marked inability on the 
patient's part to flex the thigh, indicate that the abscess 
is beneath the iliac fascia, and, therefore, probably not 
perityphlitic in nature. If the abscess be secondary to 
pelvic suppuration, the characteristic symptoms of the 
latter will precede the appearance of the abdominal tu- 
mor ; if the iliac abscess rupture into the intestine, pus 
is evacuated with the alvine dejecta ; if rupture into the 
peritoneum take place shock and peritonitis rapidly su- 
pervene. Lumbar Abscess. — This is secondary to verte- 
bral caries, to suppurative pyelitis, pyelonephritis, renal 
tubercles, cysts, parasites, and calculi, to typhlitis and 
perityphlitis by extension from the iliac fossa, to pelvic 
cellulitis, and to pyaemia, typhus, typhoid, variola, cold, 
and traumatism. If it result from lumbar vertebral 
caries the pus, being prevented from infiltrating the con- 
nective tissue of the lumbar region by the tense sheath 
of the psoas muscle, follows the course of the latter, 
commonly making its appearance in the thigh, below 
Poupart's ligament, or even at the knee or ankle. In 
rare instances the psoas abscess may point in the lumbar, 
the iliac, or in the other abdominal regions. Psoas 
abscess is especially characterized by pain, tenderness, 
weakness and stiffness in the spine, pain on flexion of 
the thigh, and inability to assume or to maintain the 
erect posture. Lumbar abscesses, other than those due 
to vertebral disease, generally present a painful, sensi- 
tive, lumbar prominence, yielding or fluctuating, and 
unaffected by the respiratory movements. The rational 
symptoms of suppuration are present and aspiration 
yields pus, which, if the abscess emanate from renal dis- 
ease with perforation of the kidney, will be mingled 
with urinary constituents. These abscesses may point 
in various directions and occasion the most diverse 
symptoms by rupturing into the pleura, peritoneum, 
pelvis, intestine, renal pelvis, etc. They most frequently- 
open, however, in the lumbar region. Peritoneal aS- 
sossses are preceded bylocal or general pe'ritonitis, present 
obscure fluctuation, and excite hectic fever. They are 
not affected by the respiratory movements, and yield 
pus on aspiration. Abscess of the abdominal wall is 
usually traumatic and occasions a superficial, rapidly 
growing tumor, at first hard, hot, red, painful, and ten- 
der, then soft or fluctuating. It is generally connected 
with the rectus muscle and is located near the umbilicus ; 
coughing and movement cause considerable pain ; aspira- 
tion, after fluctuation, reveals pus, which may contain 
degenerated and disintegrated muscular fibres ; hectic 
fever is present. These abscesses may be mistaken for 
peritoneal abscesses which must be excluded by the 
absence of sufficient causes or symptoms of intra-abdomi- 
nal suppuration. The differential diagnosis may, some- 
times, be made by causing the patient to forcibly perform 
the expiratory act, when, the recti having become tense, 
a superficial tumor will be made more prominent buf a 
deeper one obscured. 

Ascites.— This common symptom of various diseases 
produces general abdominal enlargement, which is es- 
pecially noticeable, on inspection, at the most depend 
ent parts of the abdomen. The abdominal respiratory 
movements are limited or suspended, and the superficial 
abdominal veins often greatly distended. Fluctuation 
is obtained hy palpation, and percussion yields flatness at 
the lowest portion of the abdomen, irrespective of the 
patient's position, unless peritoneal adhesions be present 
with tympanitic resonance in the highest regions Oii 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 



Abdominal Tumors. 
Abortion. 



aspiration a yellowish, serous, albuminous, flbrinogen- 
ous, spontaneously coagulable fluid, possessing a specific 
gravity ranging between 1.006 and 1.018, is withdrawn. 
This fluid may contain chyle. The chief causes of 
ascites are obstructions to the portal or hepatic circula- 
tion from hepatic or intrathoracic disease, and hydrse- 
mia incident to various cachexise. Ascites may be mis- 
taken for tympanites, ovarian, renal, hepatic, and splenic 
cysts, for pregnancy, chronic peritonitis, distended blad- 
der, gastrectasia, and cysts of the Fallopian tube. All 
of these diseases are elsewhere described. 

Tympanites causes a general abdominal enlargement, 
over every part of which tympanitic resonance is found. 
The causes of tympanites are the excessive accumula- 
tion of gas in the intestine, or the introduction of air 
from without. It is incident to indigestion, hysteria, 
enteritis, and peritonitis. 

TtTMOHS FKOM CONTRACTIOlir OF ABDOMINAL MuSCLBS. 

— These tumors are most frequently occasioned by con- 
traction of the rectus abdominis, which causes a prom- 
inence yielding a dull percussion-note. This enlarge- 
ment, if combined with tympanites, constitutes the 
so-called "phantom tumor," observed, generally, in 
women, and often mistaken for a serious intra-abdomi- 
nal swelling. Its true nature may be established by the 
employment of ansesthetics. 

Tabes Mesenteric a. — This disease produces abdomi- 
nal enlargements, which are sensitive and nodular, at 
first, but which fluctuate at a later stage of the affection. 
The disease occurs chiefly in so-called scrofulous chil- 
dren, who are greatly emaciated, and who suffer from 
indigestion, diarrhoea, and fever. The cause of the 
tumors is tuberculous degeneration of the mesenteric 
glands. The existence of tuberculosis of other organs 
affords aid in the establishment of a diagnosis. 

TuMOKS OP THE Retropebitonbal Glands are gener- 
ally cancerous. They may be located in the lumbar or iliac 
regions. Sometimes they are discovered in the median 
line, posteriorly, between the last rib and the iliac crest, 
and occasionally anteriorly, near the linea alba. They 
may involve the diaphragm or the pelvic lymphatic 
glands, by extension, and may occasion cedema of the 
lower extremities by compressing the vena cava. The 
characteristic cancerous cachexia is sooner or later de- 
veloped. William H. Flint. 

ABERYSTWITH. A much-frequented seaside resort 
on the coast of Wales. The town of Aberystwith lies on 
the shore of Cardigan Bay ; its populatipn, in 1871, was 
6,898; it possesses a fine beach; has excellent hotel ac- 
commodations ; a,nd, situated as it is in the midst of some 
of the most attractive scenery of Wales, the excursions 
into the surrounding country are very enjoyable. Con- 
cerning the climate of Aberystwith, the writer is unable 
to present accurate data for the place itself, but the sub- 
joined table, copied from Hann's Handbuch der Klvma- 
tologie, may- serve to give some idea of its temperature 
during the colder months of the year. Llandudno lying 
some 75 miles north of Aberystwith, and Barnstaple lying 
about 1215 miles to the south, both of which places have 
a similar exposure to that of Aberystwith, it is fair to 
assume that the temperature of the latter place differs but 
little from that of either of the above-mentioned towns, 
whose average temperature is given by Dr. Hann. It 
would therefore appear that the winter temperature of 
Aberystwith must be very little colder that that of Vent- 
nor in the Isle of Wight, the figures for which latter 
resort are also quoted from Hann's table for purposes of 
comparison. 



Name of Place. 


N. Lat. 


Nov. 


Deo. 


Jan. 


Feb. 


Mar. 


Llandudno 

Barnstaple 

Ventnor 


63° 21' 
51° 5' 
60° 35' 


44.96° 
45.60° 
46.S2° 


42.44° 
42.63° 
43.16° 


41.72° 
43.26° 
41.72° 


42.44° 
43.34° 
42.63° 


43.70° 
44.1)6° 
44.24° 


Aberystwith .... 


52° 85' 





a.B.. 



ABORTION. While most Continental writers apply the 
term abortion to all cases in which the product of con- 
ception-is expelled from the uterus at any time preceding 
the period at which the foetus becomes viable, that is to 
say, before the seventh calendar month of gestation in the 
human subject, many American and English writers 
make a distinction between abortion and miscarriage, 
restricting );he former term to the expulsion of the ovum 
prior to the fifth month, and applying the latter to such 
expulsion between the fourth and the seventh months. 
This distinction, although more or less arbitrary, has 
some practical justification, inasmuch as abortion, thus 
defined, differs notably in several particulars from the 
process of parturition at term — a difference that becomes 
trifling in the case of miscarriage. It is well for the prac- 
titioner to use the word miscarriage when talking to 
patients, for women seem to have an aversion to the 
term abortion. Certain qualifying words are occasion- 
ally added, such as " ovular," " embiyonal," and "foetal," 
but they are of little real significance. 

Causes. — These attach either to mechanical injuries to 
the ovum or its uterine attachment, to morbid conditions 
of the ovum, or to diseases of the maternal organism. 
Under the first head fciust be included not only direct 
traumatism, but also haemorrhages between the foetal 
and the maternal layers of the placenta, whether due 
to violence, such as falls, blows, and the like, or to a 
diseased state in either the mother or the ovum ; the 
latter, of course, falling also under one of the remain- 
ing heads. Strictly speaking, indeed, the immediate 
cause of almost every abortion is some abnormal state 
of the ovum resulting in the death of the embryo, but 
this in turn may be due to some defect in the maternal 
organism, or, for that matter, to disease in the father, as 
exemplified by the frequency with which abortion takes . 
place as the result of syphilitic contamination of one or 
the other of the parents. Habitual abortion, it is well 
known, raises the presumption of syphilis. As regards 
pathological conditions of the ovum, it is generally to 
disease of the placenta, or a crippling of its respiratory 
and nutritive functions by effused blood, that the death 
of the embryo is to be traced, although cases are not 
wanting in which the circulation in the umbilical ves- 
sels has been so interfered with as to produce the same 
result. 

In so far as the mother's system is at fault, much 
stress was laid by the older writers on the "habit of 
abortion." It was taught that when several successive 
pregnancies in the same subject had ended in abortion, 
no matter what the cause, a habit was thereby estab- 
lished by virtue of which there was a tendency for sub- 
sequent pregnancies to end in the same way, and at 
about the same period, even if the original causes were 
no longer operative. There may be some truth in this 
doctrine, but it certainly has not now the hold upon 
medical opinion that it had formerly. The exanthe- 
matous fevers, it is well known, and particularly small- 
pox, are prone to give rise to abortion, either by infect- 
ing the embryo, or by the tendency to hEemorrhages, 
uterine among the others, to which they ^ve rise. 
Apart from these acute diseases, it is possible that 
various depraved conditions of health on the part of 
the mother may occasion abortion, but on this score our 
jjrecise knowledge is meagre. There are certain medici- 
nal substances that, when taken into the mother's sys- 
tem, may induce uterine contraction, and thus bring 
about the premature expulsion of the ovum, such as 
spurred grain (generally ergot of rye) and cotton-root 
Excessive purgation also may lead to the same result 
Surgical operations done on pregnant women have been 
supposed to involve grave risk of abortion, but evi- 
dence has been accumulating of late years to show that 
this danger has been overrated. A striking example is 
seen in the frequency with which even so serious an 
operation as ovariotomy is performed during pregnancy 
without interrupting the process of gestation. 

Various morbid conditions of the uterus and its sur- 
roundings, however, are justly credited with producing 
a tendency to abortion, but, with regard to one of them. 



25 



Abortion. 
Abortion. 



REFERENCE HANDBOOK OE THE MEDICAL SCIENCES. 



it seems to me that more has heen assumed than the facts 
warrant. I refer to laceration of the cervix, whereby a 
lack of retentive power is said to he set up. It. cannot 
be denied that lacerations are often accompanied by con- 
ditions unfavorable to the due continuance of gestation, or 
that they tend to keep up such conditions, even if not 
directly chargeable with their production, but this is 
quite a different matter from admitting a loss of me- 
chanical retentive power in the cervix as a cause of 
abortion, for it should be borne in mind that the ovum 
maintains its position in the uterus by the implantation 
of its chorionic villi in the uterine mucous membrane, and 
not in any sense by resting on a support beneath, as on 
a shelf. 

Abortion induced for therapeutical purposes will be 
found treated of under the head of Labor, Premature, 
Induction of. 

frequency. — Although abortion does not figure prom- 
inently in the statistical lists of public institutions, 
since it is only under unusual circumstances that women 
betake themselves to a hospital during the process, the 
general experience of family practitioners shows that its 
occurrence is common. Add to the cases they are called 
upon to treat those which are brought to their knowledge 
long after they have taken place, while questioning pa- 
tients as to their past history, and allowing for those 
that are concealed, as well as for those as to which there 
is an honest feeling of doubt (since it is unquestionable 
that many abortions occur during the very early weeks 
of gestation, before the existence of that condition is 
suspected, and are mistaken for a mere unusually copious 
and painful menstruation), and we find ourselves obliged 
to admit that abortion is by no means of uncommon 
occurrence. As to the period of gestation at which it 
oftenest takes place, the experience of most writers is to 
the effect that it is on the completion of two and a half 
or three months of gestation, leaving out of account the 
very early abortions before alluded to, since they are in- 
volved in so much uncertainty that it is impracticable to 
estimate their frequency with any approach to precision. 

Symptoms and Diagriosia. — Sometimes the ovum is cast 
off rapidly, with scarcely a symptom beyond a sharp 
onset of abdominal pain, and a few gushes of blood. 
In such cases, either the diagnosis is established very 
promptly, or else it is never made with certainty ; but it 
never rests on symptoms. These cases, however, are 
exceptional. Usually a considerable period is occupied 
by certain symptoms pointing to a disturbance going on 
within the pelvis, notably, uterine haemorrhage and pains 
like those of labor. When these two phenomena are 
found to coexist in a marked degree in a woman supposed 
to be pregnant, the inference that an abortion is impend- 
ing presents itself at once, and most commonly it will be 
justified by the event. But such is not always the case. 
Uterine haemorrhage, or at least haemorrhage from the 
cervix, is not very uncommon in pregnant women who 
go to full term, depending generally on antecedent 
uterine disease. Let one of these haemorrhages coincide 
with an attack of colic, or of lumbago even, and the 
symptoms that ordinarily usher in an abortion may be 
very closely counterfeited. It may even happen that 
what, in a certain sense, may be called a product of 
conception, may be expelled from the uterus, and yet no 
abortion takes place. Reference is here had to the de- 
cidua that is commonly cast off from the uterus in cases 
of extra-uterine pregnancy, a condition that is most 
frequentljr accompanied, too, by haemorrhage. 

Still, with every allowance for these exceptional occur- 
rences, the fact remains that paroxysmal uterine pain, 
accompanied by a flow of blood from the vagina, almost 
invariably, when met with in a pregnant woman, presages 
the premature expulsion of the ovum. This suspicion 
once aroused in the practitioner's mind, the first thing 
to be settled is the question of the existence of pregnancy. 
The diagnosis of pregnancy will be found treated of 
elsewhere in this work, and, therefore, it will not now 
be dwelt upon. Nor, for practical purposes, is it neces- 
sary to give much more consideration to the diagnosis of 
threatened abortion. The practical rule should be, in 



all cases in which the two symptoms, uterine pain and 
uterine haemorrhage, are marked in a pregnant woman, 
to treat her as if an abortion were impending. There 
are, indeed, certain cases of uterine disease that may 
simulate abortion very closely — notably cases of sub- 
mucous uterine tumors so situated and so attached as to 
cause expulsive pains by the impediment they may offer 
to the escape of the flow of blood to which their presence 
gives rise. In such instances, however, we shall usually 
be able to get the history of past occurrences of the sort 
— a history to be contrasted with the sharp picture of 
suspended menstruation followed by a profuse and pain- 
ful flow in a woman previously free from such troubles. 
A more difficult problem is presented in cases where an 
abortion is really in process, but has been arrested in its 
course. Perhaps the simplest form of this condition is 
the so-called "cervical pregnancy" of certain German 
writers, in which the ovum is detached from its connec- 
tion with the uterine wall, and is forced down into the 
cervical canal, where it is retained in consequence of a 
failure of the os externum to dilate, or simply by reason 
of a suspension of the uterine contractions. These cases 
commonly offer no special diagnostic difficulty, and, the 
retention being but transitory, any doubt is speedily 
cleared up. A more common irregularity is the rupture 
of the foetal membranes and the escape of the foetus, 
either unperceived or unacknowledged, before medical 
aid is summoned, the placenta still being retained. 
Under such circumstances, it happens not infrequently 
that the patient resumes her ordinary course of life, 
seeking treatment, if at all, only on account of a uterine 
discharge, which may not even be bloody. In such in- 
stances the uterus will be found enlarged and especially 
elongated, freely movable, free from tenderness, and 
with nothing to account for its enlargement and its 
peculiar shape save the supposition of an incomplete 
abortion, and usually the question can speedily be settled 
by giving ergot — a practice quite safe under such cir- 
cumstances. It is scarcely necessary to add that, in all 
cases of suspected abortion, everything expelled from 
the vagina should be saved for examination. In the 
absence of the embryo, the recognition of chorionic villi 
will be decisive. These will often be found on the inner 
side of the bag-like structure expelled, the membranes 
having been turned inside out in the process of expul- 
sion. In very early abortions the ovum is usually cast 
off entire. 

Prognom and Sequelm. — If we disregard the foetus, 
which is necessarily sacrificed, the prognosis for the 
mother is always a matter of some doubt, but generally, 
provided the case is well managed, favorable. The im- 
mediate danger is from haemorrhage, which ceases on the 
complete evacuation of the uterus ; next, and much 
more to be feared, is the risk of septic fever from the 
absorption of decomposing portions of the ovum retained 
in the uterus ; these perils passed, inflammatory com- 
plications, subinvolution, and the like are still to be 
feared. But very few women die from the direct effects 
of haemorrhage occasioned by abortion, but many are ex- 
sanguinated to a degree that materially deteriorates their 
health ; more often they succumb to septic absorption. 
The acute inflammatory sequelae may be either perito- 
nitis, cellulitis, oophoritis, or any one of the various forms 
of metritis. Aside from the part played by mild septic 
contamination, these affections are largely dependent on 
the cause of the abortion, being uncommon in cases not 
occasioned by instrumental interference. On the whole, 
it may be said that the great majority of women escape 
a fatal result. At the same time, abortion is one of the 
most fertile causes of chronic pelvic disease ; usually, 
however, these consequences may be avoided by careful 
treatment. 

Treatment.— Tlxis resolves itself into the prevention of 
abortion, the management of the process, and the after- 
treatment. If we admit the "habit" of abortion, we 
must usually look for its solution in some degeneration 
of the placenta, whereby it becomes unfitted to carry on 
the processes of respiration and nutrition for the embryo. 
This occurrence may be due to syphihs ; in that case 



26 



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Abortion- 
Abortion. 



mercurial treatment affords the main chance of success ; 
the corrosive chloride of mercury in doses of from one- 
thirty-second to one-twenty-fourth of a grain, three times 
a day, will commonly be found to afford all the advan- 
tage that is to be gained in this direction. In the absence 
of syphilitic infection, some obstetricians believe that an 
error of hsematosis is often at the bottom of repeated 
abortions, and on this theory the administration of 
chlorate of potassium has been recommended. I am not 
aware, either that the theory is well founded or that the 
remedy is of any value ; still, with proper precaution, 
there can be no objection to its use — that precaution 
being to guard against the injurious effects of the drug 
upon the kidneys ; and, therefore, to avoid large doses, 
and to abstain from them particularly in cases where 
the pregnancy is somewhat advanced, since the latter 
months of gestation are apt to be fraught with more or 
less interference with the renal function. As for the 
use of so-called uterine sedatives, it is not to be thought 
of until the process of abortion is actually threatened. 
Of course, such patients as are now referred to should be 
instructed to refrain from all the excesses and irregular- 
ities that have been mentioned as among the exciting 
causes of abortion. 

Suppose, however, that symptoms are present show- 
ing that an abortion is imminent. In many instances 
the process may be prevented, and the expectation of 
success should not be abandoned until there is physical 
evidence that the expulsion of the ovum is going on. 
No amount of haemorrhage and no amount of pain, 
within ordinary bounds, should be talien in themselves 
as rendering attempts at prevention absolutely hopeless. 
Perfect rest is to be enjoined, but the low diet and cool- 
ing drinks of bygone times are not to be depended upon in 
the slightest ; the moderate use of opium and the appli- 
cation of heat to the spinal column, at the junction of 
the dorsal with the lumbar portions, are the most trust- 
worthy measures. Theoretically, we may admit that 
ergot may sometimes be useful, by checking a haemor- 
rhage that might detach the placenta, but, practically, 
there is such Sanger of its inducing uterine contraction 
that it must be regarded as at best but a doubtful remedy. 
The use of viburnum prunifolium has of late j^ears been 
recommended as a uterine sedative, and there is respect- 
able testimony in its behalf. It should be given in doses 
of half a teaspoonf ul of the fluid extract every three hours. 
To mitigate its disgusting taste, it may be combined with 
an equal amount of tincture of cinnamon. 

When it has once beecrne evident that abortion must 
take place, the safe conduct of the case calls for close 
supervision ; but, even then, discretion is usually more 
to be advised than activity. Ordinarily, manual in- 
terference is quite unnecessary, beyond what may be 
needed to keep the physician informed of the progress 
made, and to check haemorrhage. The utmost pains 
should be taken to maintain the integrity of the ovum 
as long as possible, for when it is expelled entire there 
is commonly an end to all anxiety. Herein, in great 
measure, lies the safety of accidental abortions as com- 
pared with those induced by criminal practices, in which 
the foetal envelopes are almost always punctured, with 
the result of allowing the embryo to be cast off early 
in the process of abortion, while the secundines remain 
behind, a shapeless mass, upon which the uterus has to 
act at a great mechanical disadvantage. So long as rup- 
ture of the membranes can be prevented, our interfe- 
rence should be limited to controlling pain and haemor- 
rhage ; a vaginal tampon, properly introduced, may 
always be relied upon to fulfil the latter indication. It 
should be inserted leisurely and methodically, with the 
aid of a Sims speculum, and generally it should be re- 
moved at the end of twelve hours, when a fresh one may 
be applied, if necessary, after treating the vagina with 
an antiseptic douche. To allay excessive pain, there is 
nothing equal to opium, but it should not be pushed to 
narcotism or to such an extent as to abolish uterine 
action ; ergot may properly be given if the haemorrhage 
is excessive and accompanied by inertia, but the more 
its use is avoided, the better will be the results on the 



whole. It is better to rely on .the tampon, and that of 
itself stimulates uterine contraetion. 

If, unfortunately, the sac dPthe ovum has been emp- 
tied of its contents, and the secundines are retained, the 
question of their removal will come up. There are extrem 
ists who are given to energetic interference in all such 
cases. On the other hand, the timorous trust too long to 
nature. In such a case, as in most others, the middle 
course is followed by the judicious. The best practice 
seems to be not to resort to forcible removal of the rem- 
nants of the ovum unless there are particular reasons for 
doing so. These reasons are for the most part : 1, Signs of 
septic changes; 3, the undue continuance of haemorrhage. 
Under either of these circumstances there should be no 
hesitation ; but the operation should be done without 
instruments, if possible. In some cases, however, a wire 
curette is necessary. The patient should be anaesthe- 
tized, and, as she lies across the bed, on her back, with 
the hips brought well to the edge of the bed, the opera- 
tor should pass one or more of his fingers as far as may 
be necessary into the uterine cavity and tease away the 
retained portions of the ovum. The work will be de- 
cidedly facilitated if the uterus is gently but firmly 
depressed by an assistant, who should make pressure on 
it through the abdominal wall. As a preliminary step, 
dilatation of the cervix may be necessary, but, as a rule, 
this should not be accomplished with tents, whether of 
sponge or of any other material that expands on im- 
bibing moisture. If the fingers will not answer, gradu- 
ated metallic or hard-rubber dilators should be em- 
ployed, and, when they are used, the operator should 
himself make the counter-pressure on the fundus. After 
the operation is finished, the uterus should be washed 
out with an antiseptic solution, preferably a straw- 
colored mixture of tincture of iodine and water, injected 
through a double cannula. 

The after-treatment in cases of abortion hinges 
chiefly upon enforcing rest for a length of time equal 
to that usually adopted after labor at term. The special 
indications do not differ from those met with after or- 
dinary parturition, except that the breasts are not apt to 
give trouble. 

Aktificial Abohtion. — In this article only criminal 
abortion will be considered, the induction of abortion 
for legitimate purposes being treated of elsewhere in this 
work. 

The physician has to look at the matter of criminal 
abortion from three points of view : his duty to the preg- 
nant woman, his own protection, and the aid he may be 
able to afford in judicial investigations. 

As to his duty to the woman — and, supposing her to 
ask his assistance in procuring an abortion, this includes 
his duty to any accomplices she may have — there can be 
no question but that he is under the most stringent moral 
obligation, not only to refuse his co-operation, but also to 
throw all possible obstacles in the way of the crime con- 
templated, for it is a crime under all circumstances, ex- 
cept when called for to save the woman's life. It neces- 
sarily involves the destruction of the embryo, and, poten- 
tially, the murder of a citizen. This should be explained 
to the woman, for in the majority of instances she has no 
idea of the enormity of the act, and in many cases it will 
dissuade her from further pursuit of her plan ; at all 
events, he must refuse point-blank to render any aid, and 
he should not even give a placebo to gain time, for by so 
doing he may render himself criminaUy liable, courts 
having ruled that any attempt at producing abortion, 
no matter how inadequate, implies guilt ; failure, and 
even proof of the non-existence of pregnancy, being no 
presumption of innocence, provided only the intent is 
proved. It is easy to see that, such being the law, a 
physician may put himself in the power of a designing 
woman if he is unwary enough to prescribe anything for 
her, however powerless it may be to produce abortion. 

But, suppose abortion has already taken place, and 
medical services are required for the woman. There 
need be no hesitation to render them, but the utmost care 
should be taken that no circumstance calculated to incul- 
pate the physician should remain unexplained. It is 



27 



Abortion. 
Abortion. 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 



impracticable to enumerate all such circumstances ; suf- 
fice it to say, that no man of tact will commit an indis- 
cretion in this regard. iTthe woman dies, the physician 
is hound to express his opinion as to the cause of death, 
in the form of a certificate ; but, in the opinion of the 
writer, he is not called upon to act as an informer further 
than that ; if the case comes to trial, he should testify 
without reserve. 

In case of a legal investigation, the following questions 
may arise : 1. Has an abortion taken place ? 3. Was it 
artificial ? 3. If artificial, was it justifiable, criminal, or 
accidental ? 

An absolute aflfirmative answer to the first question 
can rest only upon proof that an ovum, or some part of 
an ovum, has been expelled from the woman's genital 
canal, or has been found therein after her death. When 
an embryo is found, the case is simple ; otherwise, the 
opinion must rest on the finding of placental or chorionic 
tissue, for neither the membranes (apart from the villi 
of the chorion) nor the liquor amnii can be positively 
identified as products of conception. The appearance of 
the uterus is not proof, for the enlargement of the organ 
due to pregnancy, as well as the characters of its inner 
surface usually found after recent delivery, may be 
counterfeited by morbid conditions, and, to some extent, 
even by ordinary menstruation. It must not he forgotten, 
however, that death may have been due to an attempt at 
abortion, aHhough there was no pregnancy; hence in- 
juries to the maternal structures should be looked for 
carefully, quite irrespective of the evidences of abortion. 
But it is not solely in explanation of the cause of death 
that this question may come up ; a woman may pretend 
to have suffered an abortion when in fact such is not the 
case. The same rules of evidence hold good here ; how- 
ever, the whole or a portion of an ovum must be proved 
to have proceeded from her genital tract. 

As to the second and third questions, it cannot always 
be ascertained with certainty whether the abortion was 
due to artificial interference, for, even when the fact of 
such interference is obvious, the abortion may have pro- 
ceeded from other causes nevertheless. But here the law 
solves the difficulty, proof of intent being held sutflcient 
for conviction, although the means employed may have 
been manifestly inadequate ; it is not even necessary that 
pregnancy should have existed, or, if it did exist, that the 
attempt at abortion should have proved successful. 
Praotically, then, the question is : Were means employed 
with the intention of producing abortion ? These means 
include the administration of any one of a long list of 
drugs, mostly drastic purgatives and so-called emmen- 
agogues, among which ergot and oil of tansy are those 
most commonly employed in this country. These drugs 
seldom accomplish the purpose for which they were 
given, and, when they do, it is commonly impracti- 
cable to prove the fact of their having been used by evi- 
dence discovered on medical examination ; it is chiefly, 
therefore, with reference to the question of mechanical 
interference that such examination is of value. Most 
professed abortionists seek to accomplish their purpose 
by puncture of the festal envelopes, and the traces of 
their work are generally at the same time the evidences 
of their unskilfulness, in the shape of injuries to either 
the mother or the f cetus ; the discovery of such injuries 
raises the presumption of criminality, to be dispelled or 
weakened only by evidence that the injuries might have 
been inflicted unwittingly, as in the unskilful use of in- 
struments for legitimate purposes. Here, to disprove a 
criminal intent, it must be shown that a legally qualified 
practitioner did use instruments for the investigation or 
treatment of a uterine disease, real or supposed ; under 
such circumstances he may be innocent, and the woman 
guilty, for she may have feigned uterine disease or con- 
cealed the existence of indications of pregnancy ; on all 
these points circumstantial evidence will have to be relied 
on mainly. It may be added that those authors are un- 
just who hold that mechanical injury to the uterus indi- 
cates the intervention of a third person, for nothing is 
more certain than that women sometimes produce abor- 
tion upon themselves by the use of instruments, or that 



they occasionally inflict mortal injury upon themselves 
in this way. Another statement by authors may well be 
questioned, namely, that the woman is necessarily acces- 
sory to the act. It is quite conceivable that a guilty 
paramour should deceive his victim into submitting to 
surgical manipulation, wholly apart from any intention 
of hers to procure an abortion. The fact of an in- 
tentional abortion having been proved, the act should 
not be held to have been justifiable unless it appears 
clearly to have been undertaken with the manifest pur- 
pose of saving the woman's life ; the best proofs of such 
a motive lie in the mother's physical condition and in 
the fact of a consultation having deliberately decided 
upon the operation, the physicians concerned being per- 
sons of known skill and probity. Frank P. Foster. 

ABORTION, Chimin AL. — Abortion is defined as the 
expulsion of the foetus at a period of utero-gestation so 
early that it has not acquired the power of sustaining life. 
Abortion may be divided into three classes, viz. : — 

I. Natukal Abobtion.^ — (a) Miscarriage, i.e., the ex- 
pulsion of the ovum or non-viable foetus. (J) Premature 
labor, i.e., the expulsion of the child after it is viable. 

II. Aetificial Abobtion, i.e., the inducing of prem- 
ature labor for the purpose of saving the life of the mother 
and, if possible, of the child. 

III. Obiminal Aboktion, OB Foeticide. 

Of Abtificial Aboktiois:. — In cases where it seems 
necessary to the physician to have recourse to artificial 
abortion in order to save the life of the mother, it is 
advisable, when practicable, to consult previously with 
another medical man as to the necessity of the operation. 
If, owing to the death of the child in a case of artificial 
abortion, the physician should be indicted for abortion or 
manslaughter, as has often happened, it would be neces- 
sary for him to show, first, a necessity for the operation, 
the life of the mother being at stake and the operation 
less to be feared than a natural delivery ; and, second, that 
his action was ionAfide. Therefore the physician, before 
assuming the responsibility of causing an artificial abor- 
tion, should take steps to make such evidence readily 
available in case of an emergency. While the laws do 
not formally recognize the right of the physician to 
induce premature labor, yet the judges have always held 
that medical practitioners are morally justified In inducing 
premature labor, provided the object be to save the life 
of the mother, of the child, or of both. By statute, in 
most States, it is jDrovided that the prosecution need not 
prove that such a necessity did not exist, thus throwing 
the burden of proof upon the defendant. It is, therefore, 
highly important that the physician should be prepared 
for this exigency before assuming the responsibility. A 
learned writer upon the subject says :' " We strongly urge 
upon medical men (1) not to induce premature labor or 
abortion without the most mature consideration ; (3) not 
to undertake it until after consultation with a second 
practitioner ; (3) in any case to have the full consent, in 
writing if possible, of the parent or guardian." 

Of Cbiminal Abobtion ob FtETioniB. — In earlier 
days the question as to the extent to which the criminality 
of foeticide was affected by the degree to which gestation 
had proceeded was one of considerable importance. By 
the common law a distinction was made between the de- 
struction of an unborn "quick" child, and that of one 
not yet arrived at the period of quickening. 'The stage 
of pregnancy at which the child should be considered 
"quick" was vigorously debated by different writers 
and schools without arriving at any general agreement. 
Among the Stoics it was considered that the soul was 
not united to the body before the act of respiration, and 
while the ideas of the Stoics were popular the destruction 
of a child en ventre de sa mire was not regarded as a 
criminal act. Periods ranging from three days to ninety 
have been assigned by different writers as the time at 
which quickening occurs. In England the common law 
considered life not to commence before the infant is able 
to stir in its mother's womb, and, until recently, the 
English law punished with death the procuring of abor- 
tion after quickening, while the same crime anterior to 



28 



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Abortion. 
Abortion. 



quickening was regarded merely as a felony. Through- 
out all the European nations, save England,' and in some 
of the States of the American Union, the same pernicious 
distinction is to-day incorporated in the statutes. How- 
ever, the tendency of modern legislation is to do away 
with this distinction. In England, this has already been 
done by a statute which makes an attempt to abort 
criminal, even though the woman be shown not to have 
been pregnant at the time. In the United States, legis- 
lators, realizing that the civil rights of the unborn child 
are protected, that it can have a guardian appointed, 
and can receive property by bequest or deed, have been 
inclined to enact laws for the preservation of its personal 
rights to life. In Massachusetts, the Supreme Court hav- 
ing held that at common law it was no offence to produce 
abortion, unless there was viability, the Legislature 
immediately cured the supposed deficiency by statute. 
The Massachusetts statute presents the law as it is sub- 
stantially in all the States in which the viability of the 
child is not regarded as essential to the criminality of the 
offence. The statute reads as follows : 

" [10] Whoever with intent to procure miscarriage of 
a woman unlawfully administers to her, or causes to be 
taken by her, any poison, drug, medicine, or other 
noxious thing, or unlawfully uses any instrument or 
other means whatever, with the like intent, or with like 
intent aids or assists therein, shall, if the woman dies in 
consequence thereof, be imprisoned in the State prison 
not exceeding twenty nor less than five years, and, if 
the woman does not die in consequence thereof, shall be 
punished by imprisonment in the State prison or jail, 
not exceeding seven years nor less than one year, and by 
fine not exceeding two thousand dollars. 

"[11] Whoever knowingly advertises, prints, pub- 
lishes, distributes, or circulates, or knowingly causes to 
be printed, advertised, published, distributed, or cir- 
culated, any pamphlet, printed paper, book, newspaper 
notice, advertisement, or reference containing words 
or language, giving or conveying any notice, hint, or 
reference to any person, or to the name of any per- 
son, real or fictitious, from whom, or to any place, 
house, shop, or office where any poison, drug, mixture, 
medicine, or noxious thing, or any instrument or means 
whatever, or any advice, direction, information, or knowl- 
edge may be obtained for the purpose of causing or pro- 
curing the miscarriage of a woman pregnant with child, 
shall be punished by imprisonment in the State prison or 
jail not exceeding three years, or by fine not exceeding 
one thousand dollars." 

This is the law as prescribed in the majority of the 
States of the Union, but in some, notably New York, 
the old common law distinction between the killing or 
attempting to kill an unborn quick child and one not 
quick is still retained ; but the courts have not agreed as 
to the exact stage of pregnancy at which the child 
should be considered quick. Great latitude is permitted 
the judge in presenting to the jury the law on the sub- 
ject. In this connection a celebrated legal writer ^ says r 
" The weight of medical authority is that quickening is 
a mere circumstance in the physiological history of the 
foetus, which indicates neither the commencement of a 
new stage of existence nor an advance from one stage to 
another ; that it is uncertain in its periods, sometimes 
coming at three months, sometimes at five, sometimes 
not at all ; and that it is dependent so entirely upon 
foreign influences as even to make it a very incorrect 
index, and one on which no practitioner can depend, of 
the progress of pregnancy." 

Of Medical Testimony in Casbs of Suspected 
Abortion. — It is as a medical expert giving testimony 
before the courts that the reputable practitioner will 
most frequently be brought into contact with cases of 
f tBticide. The questions as to whether an abortion has 
actually been procured, as to the means of inducing it, 
whether a child found dead was brought to its death by 
violence, and if so whether the injuries were inflicted 
before or after birth ; all these questions and others of 
equal importance must mainly depend for their solution 
upon the testimony of the medical expert. To differen- 



tiate between the crimes of infanticide and abortion the 
services of the medical expert are essential. If a child 
die after birth, in consequence of injuries received before 
birth, it is infanticide ; but the fact of a'ctual birth must 
be proved. The fact that the child died in consequence 
of want of viability resulting from premature delivery is 
no defence to an action for infanticide if this delivery 
was caused by the defendant's misconduct in bringing 
about a miscarriage for the purpose of destroying the 
child : the test, then, of viability is of the greatest im- 
portance to the courts in cases of this nature. To illus- 
trate : In the case of a man indicted for infanticide the 
evidence showed the child's throat to have been cut, the 
wound dividing the right jugular vein, and further that 
the lungs floated in water, showing that they must have 
been inflated hy the act of inspiration ; it was shown, 
however, by the testimony of medical experts that this test 
merely established the fact that the child had breathed, 
not that it had been born alive. Numerous instances 
were cited of children having sustained similar lacera- 
tions in the act of delivery. In presenting the case to 
the jury. Baron Parkes charged them that if thejr had 
any doubts as to whether the child was born alive, it 
would be hardly necessary to go into the evidence in be- 
half of the prisoner. The jury, without further debate, 
returned a verdict of acquittal. 

Of the Examination by Medical Experts in Cases 
OF Suspected Abortion.^ — The physician who is re- 
quired to testify in cases of suspected abortion should 
endeavor to ascertain whether the abortion has actually 
been committed, by what means, and at what period. To 
attain tliis end, it is well to follow a methodical plan in 
making the examination. In elaborating this plan it will 
be well to divide the examination into three classes : 
1, The examination of the female during life or after 
death ; 3, the examination of substances expelled from 
the womb ; 3, the examination of instruments or of drugs 
in the possession of the accused. 

l.,C^ t^e Exa/mination of the Woman During Life. — 
In making this examination it should be remembered that 
the duration of the signs of delivery varies greatly in dif- 
ferent subjects. They may disappear very rapidly, cases 
being on record where all signs had vanished in twenty -four 
hours ; or they may be very persistent, having been known 
to continue for a month. Much depends on the state of 
health of the mother, and the period of gestation reached. 
If abortion has occurred at an early period of gestation, 
the indications are of a very evanescent character, and 
may, in some cases, be entirely absent. Some of the signs 
may be simulated by menstruation. 

Signs of Abortion in the Living. — A relaxed condition of 
the vulva and passages, patulousness of the os uteri, the 
presence of a lochial secretion in the earlier stages, and a 
white mucous secretion at a later period, together with an 
acid odor characteristic of puerperal women. The breasts 
are distended, have a hard knotty feeling, and yield a flow 
of milk on pressure. The loss of blood produces a general 
anaemic appearance, and the eyes are noticeably sunken. 
A peculiar excitement of the pulse, with dryness of the 
Skin, is invariably present. The os uteri is generally per- 
ceptibly lacerated. The examining physician should note 
any signs of violence to the uterus or vagina, also any 
excessive inflammation of the genital organs. All marks 
on the body of the woman which may indicate general 
violence inflicted for the purpose of inducing abortion 
should be most carefully recorded. 

If abortion occurs at an early period of utero-gestation, 
the indications thereof may be very slight, or even alto- 
gether absent. After the third month the insertion of the 
placenta may be detected by a rough place on the inner 
uterine wall. In making a post-mortem examination, care 
is necessary in removing and laying open the uterus, as, if 
a wound appear, it may be suggested that it was made 
during the autopsy. Punctures, lacerations, and incisions 
in the uterus and contiguous organs must be especially 
looked for ; all signs of Irritant poisoning in the stomaxih 
and intestines, or any inflammation of the bladder or kid- 
neys resulting from the administration of abortive drugs, 
should be carefully noted. Note, further, any general 



29 



Abortion. 
Absinthism. 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 



marks of violence, especially on the abdomen, also the 
general appearance of the viscera, i.e., vrhether they show 
loss of Mood during life such as commonly results from 
abortion. 

2. Examination of Substances Expelled from tlie Wirnib. 
—If a foetus be found, a careful examination must be 
made to determine its age, whether it was born alive, and, 
if so, what killed it. It should be carefully examined for 
punctures or wounds, and should any such be found, try 
to form an opinion whether the injuries were inflicted 
during life or after death. 

3. Examination of Instruments or Drugs in the Posses- 
sion of the Accused. — In making this examination, note 
whether the injuries found upon the body of the woman 
could have been inflicted by the instruments found in the 
possession of the accused, and whether such instruments 
show indications of having been recently used. If drugs 
are found, state whether the symptoms manifested by the 
woman were identical with those caused by the use of the 
drug in question. 

The results of such examinations as the foregoing are 
of the utmost importance to the courts of law in the ad- 
ministration of justice. The case of the people against 
the suspected abortionist must in every case rest upon 
the testimony of the medical expert. The crime is a 
secret one ; often the law of the State prevents the ad- 
mission of the woman's testimony. In the graver cases 
the death of the victim precludes the possibility of her 
lending assistance to the course of justice. For these 
reasons many nations have seen fit to commission regular 
boards of physicians as medical experts, who examine 
into such cases, and whose testimony alone is received by 
the courts as that of medical experts. Such is the case 
in Germany and some other European States. In the 
United States any physician may testify as an expert, 
and almost every physician during the course of his prac- 
tice finds himself called upon for such testimony. Such 
being the case, it would be well if a formal plan of ex- 
amination be laid down to aid the medical expert in pre- 
paring his testimony. Such a plan has been formulated 
by Mr. Tidy for the use of the physician called on for 
testimony in cases of abortion. It is as follows : 

Medico-legal Examination in Cases op Ajsobtion. 
— 1. Examination of the Woman if Living. — {a) Tempera- 
ment. (A) As to the woman's predisposition to abort and 
the period at which abortion had commonly occurred, 
(c) General state of health. (Note existence of leucorrhoea, 
excessive menstruation, syphilis, asthma, malignant dis- 
ease, uterine diseases, etc.) {d) Whether woman be well 
or ill formed. (Note pelvic malformations, effect of tight 
lacing, etc.) (e) Any signs of recent delivery or expulsion 
of uterine contents. (/) Whether any cause can be as- 
signed to account for the abortion, e.g. , violent coughing, 
blood-letting, violent exercise, undue excitement, septic 
poisoning, violence, administering of medicine, etc. (g) 
All injuries of the genital organs. (Consider whether 
they could have been self-inflicted.) 

3. Examination of Body of Woman if Bead. — In mak- 
ing this examination the physician should note : (1) the ne- 
cessity for care not to mistake the effects of menstruation 
for those of abortion ; (3) to avoid injuring the parts by 
the knife or otherwise during the autopsy ;' and (3) to con- 
sider the possibility of the injuries having been self-in- 
flicted. 

(a) Note the existence of any marks of violence on the 
abdomen or other parts. (6) The condition of the genital 
organs, noting all inflammations, rents, tears, perfora- 
tions, etc. (If the uterus be injured it should be pre- 
served.) Note also: (1) The condition of the passages 
(relaxed or otherwise). (3) The condition of the os uteri. 

(3) Vaginal secretions, and, if present, their character. 

(4) The general appearance of the breasts, presence of 
milk, etc. («) Whether there be any signs of irritant poi- 
soning in the stomach, or of inflammation of the bladder, 
kidneys, rectum, etc. (The contents of the stomach, if 
necessary, to be preserved.) (d) Whether the viscera gen- 
erally indicate loss of blood during life. 

3. Examination, of the Product of Conception.— (a) Na- 
ture of the supposed product of conception. (J) Consider 

30 



whether it i^ merely an evidence of a diseased condition 
of the membranes, or of the placenta, e.g. , structural de- 
generation, (c) If a foetus be found, determine: (1) 
whether it was born alive ; (2) its probable age, and (3) 
the cause of death, (d) Determine, if there be wounds or 
other injuries, whether they were inflicted during life or 
after death. 

4. Examination of all Brugs, Instruments, eta. — De- 
termine whether said drugs or instruments could be used 
to produce abortion, and if evidence of such use exists on 
the person of the woman or the foetus expelled. 

Willis J. Abbot. 

* Tidy's Legal Medicine, vol. ii., page 160. 

3 Wharton on Criminal Law. 

3 This subject is ably discussed in Tidy's " Legal Medicine,"' vol. ii. 
The ensuing discussion of the subject is largely drawn from Mr. Tidy's 
work. 

ABSCESS. [Latin, abscessus, from verb abseedo, I de- 
part ; abseedo and abscessus, used by Celsus in the sense of 
the gathering of the corrupted fluids (of the body) into 
an abscess. Greek, iirrfo-rij^ua. French, dbcis. German, 
Eiterbeule; though the Germans more commonly use tht 
word Abscess.'] By the term abscess is meant a collection 
of pus within the body ; this may occur in one of the pre- 
formed spaces, or in a new-formed cavity in solid parts. 
Certain adjective prefixes are used to denote duration, 
situation, and character of abscesses ; thus, as regards 
duration, they may be acute or chronic ; as regards situa- 
tion, retropharyngeal, perinephritic, perityphlitic, ischio- 
rectal, psoas, etc. ; as regards character, the various terms 
used will be mentioned later. A collection of pus in the 
pleural cavity has received the special name of empyema, 
but in the other serous cavities one speaks simply of a 
purulent pericarditis, peritonitis, ependymitis, or arthritis ; 
a single exception to this is the so-called pelvic abscess, by 
which is meant a collection of pus in the pelvis, due to a 
circumscribed peritonitis, the remainder of the peritoneal 
cavity being shut off by adhesions. Although pus forms 
the greater part of the contents of an abscess, there may be 
other constituents present, as blood, shreds of tissue of the 
part in which the abscess has arisen, foreign bodies, para- 
sites, cheesy material. One speaks of abscesses as primary 
and as secondary, or metastatic ; but, inasmuch as the 
latter are due to emboli, the term embolic abscess has now 
wholly superseded the older term metastatic abscess. 

An abscess represents the results of a purulent inflam- 
mation ; occurring in a preformed cavity its walls are, 
primarily at least, those of the cavity ; if in a solid organ, 
there is in its earliest stage an infiltration of the tissues 
with round-cells, later a liquefaction of the pre-existing 
tissues, thus giving rise to the formation of a cavity con- 
taining pus. At this stage the wall has a smooth lining, 
consisting of a vascularized connective-tissue layer, to 
which the name of pyogenic membrane has long been ap- 
plied, the supposition being that it was this hning which 
secreted the pus. That all the pus comes from this source 
can readili?^ be shown to be erroneous from the fact thai 
in the earlier stages, abundant pus is present before tliis 
membrane has formed. Often there is not this tendency to 
remain circumscribed ; on the contrary there is an exten- 
sion of the pus, the so-called "burrowing," in the direc- 
tion where the least resistance is offered, soft parts, like 
muscles, readily yielding, whereas fibrous tissues, lilie 
fasciae, afford a stronger barrier. In the lymph-sheaths of 
tendons tlie progress of the pus is very rapid. Abscesses 
situated near the exterior of the body tend to approach 
nearer the surface, and are then said to "point ; " the skin 
over the abscess becoming thinned, may finally rupture 
spontaneously, and thus permit a discharge of the con- 
tents. Abscesses in organs having a serous covering often 
extend peripherally, perforate the capsule, and dischai-ge 
the pus into tlie- serous cavity, setting up a purulent in- 
flammation of the same. If, however, at the point of 
rupture two serous surfaces lie In contact, an adhesive 
inflammation between the two may occur previous to 
perforation, and thus prevent the escape of the pus into 
the cavity in which the organ lies. It is in this way 
tliat abscesses of the liver occasionally discharge into the 
bronchi, adhesions occurring between the capsule of the 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 



Abortion. 
Absliitblsm. 



liver and under surface of the diaphragm, also between 
the upper surface of the diaphragm and the lung, with 
perforation of the liver, diaphragm, and lung. Some- 
times a sudden and atiundant expectoration of pus is 
the first recognizable indication of an abscess of the 
liver. Instead of pus being discharged, it may be re- 
absorbed, either by the individual pus-cells wandering 
back into blood- or lymph-vessels, or by a fatty degenera- 
tion of the cells and then absorption. Occasionsdly the 
pus undergoes inspissatioh, i.e., cheesy degeneration, 
leaving a crumbling, grayish, mortar-like material ; this 
mass, in turn, may later undergo liquefaction, i.e., 
saponification, or lime-salts may be deposited in it, form- 
ing calcareous masses or plates. Where such changes take 
place the material occupying the site of the abscess is 
always surrounded by a dense connective-tissue capsule, 
separating it from the surrounding parts. A section 
through a typical abscess shows three distinct portions : 
in the centre the pus ; then the pyogenic membrane ; out- 
side of this a zone of the parenchyma, the vessels of which 
are injected, the tissues oedematous. 

Abscesses may be either acute or chronic ; the former 
sometimes called "hot," from the increased warmth of 
the part ; the latter "cold," from the absence of any in- 
crease in the temperature. 

With regard to the causation of abscess it may be said, 
that since abscesses are the result of a suppurative in- 
flammation, one must look for their causes in the causes 
of suppuration. There must of necessity be an irritant, 
and the next question that arises is as to the nature of the 
irritant — ^is it inorganic or organic ? or may it be both ? 
It has long been known that turpentine and croton oils, 
also mercury, when applied externally or injected into 
the tissues, are capable of setting up suppuration ; but 
it was not proved that they do so in virtue of irritant 
properties possessed by themselves, and not from any or- 
ganisms present, until the experiments of Orthmann and 
Councilman showed that under antiseptic conditions, sup- 
puration followed the injection of such irritants. But, 
inasmuch as the above causes are of theoretical rather 
than of practical interest, accounting as they do for 
scarcely a fraction of abscesses as ordinarily seen, it is 
obvious that there must be another irritant or series of 
irritants capable of like results. That these agents are 
certain lower organisms has been rendered probable by 
the work of Lister. SlUroth, Pasteur, W. Cheyne, Ogston, 
and above all by Rosenbanh, who in a recent monograph 
has described several forma of micrococci found con- 
stantly by him in the pus of acute abscesses, and which, 
isolated, cultivated and inoculated in animals, were cap- 
able of setting up a suppuration. In the pus from cold 
abscesses, Rosenbaeh was unable to find any micro-organ- 
isms, or more strictly speaking, the culture-tubes re- 
mained sterile after pus from such abscesses had been 
sown in them. Although there is much in favor of the 
idea that suppuration is dependent upon the presence of 
micro-organisms, yet it cannot, at the present time, be 
stated as absolutely proven. 

Secondary abscesses are those which are developed at a 
distance from the primary seat. They are termed em- 
bolic, and are usually multiple and small, hence often 
called miliary abscesses. They are invariably septic, and 
in most cases the emboli are derived from thrombi under- 
going putrid softening. If one wishes to find the source 
of embolic abscesses, one follows back the circulatory 
current and searches for a thrombosed vessel. Thus, if 
such abscesses are present in the lungs, one is likely to 
find the source eitlier in the sinuses of the brain, the 
venous plexuses surrounding the pelvic organs, or in the 
peripheral veins. Embolic abscesses in the brain, heart, 
spleen, or kidneys, almost invariably have their origin in 
an ulcerative endocarditis ; those in the liver are derived 
from the radicals of the portal vein. Embolic abscesses 
probably always contain micro-organisms, and in virtue 
of these their tendency, when once started, is to extend 
peripherally, causing a progressive destruction of the 
tissues in which they lie ; the process ceasing only, as a 
rule, with the death of the individual. In the lung, such 
abscesses are situated, for the most part, beneath the 



pleura, and by extension they often perforate the latter, 
discharging their contents into the pleural cavity, and so 
setting up a rapidly fatal pleurisy. 

A form of abscess seen in hot climates and occasionally 
in other regions, occurring in the liver, has received the 
name of tropical abscess. In such cases diarrhoea or 
dysentery is always an earlier condition, the abscess in the 
liver representing a secondary result, due to the transfer 
of septic material from the intestinal mucous membrane 
to the liver, through the portal vein. 

Many of the chronic or cold abscesses are associated 
with carious arthritis and ostitis, usually tubercular. Fre- 
quently in these cases the pus, which is slowly formed, 
obeys in its further extension the laws of gravity rather 
than that of extending in the direction of least resistance, 
as observed in acute abscesses. Thus pus from abscesses 
associated with caries of the upper cervical vertebrae often 
appears in the pharynx ; from those situated in the lower 
cervical and upper dorsal regions the pus commonly 
makes its way downward until the diaphragm is reached, 
then follows along its surface, appearing externally near 
the xiphoid. In case the caries affects the lower dorsal or 
lumbar vertebrae, the pus makes its way downward along 
the psoas, and gives rise to a fluctuating swelling above or 
below Poupart's ligament. It should, however, be stated 
that not all cases of caries of the vertebrae are associated 
with pus formation. Another form of chronic cold abscess, 
the pathology of which is exceedingly obscure, is the so- 
called lymph-abscess. Its usual seat is in the connective 
tissue of the back — rarely in the muscles. The cavity is, in 
most cases, a flattened one, and may extend laterally for a 
considerable distance. The walls are flaccid ; the contents 
a thin pus resembling lymph. The growth of these ab- 
scesses is very slow. The term scrofulous abscess is applied 
to cases in which a suppuration takes place in hyperplastic 
lymph-glands. A consideration of the diffuse abscess 
comes properly under the heading of phlegmon or phleg- 
monous inflammation, what the surgeons formerly called 
a cellulitis. In connection with the infective disease 
known as actinomycosis abscesses form, the pus in which 
presents very peculiar appearances, due to the presence of 
very numerous, small, sulphur-yellow fungi, which have 
been proved to stand to the disease in the relation of cause 
and effect. 

The treatment of abscesses, in general, consists of free 
incisions ; washing out of the cavity with an antiseptic 
solution ; free drainage ; Lister or iodoform dressing. If 
within the liver, simple tapping is all that can be done. 

W. W. Gannett. 



ABSINTHISM. — A term applied to the train of morbid 
symptoms following the abuse of the liquor called Ab- 
sinthe. ' 

In its general features Absinthism is almost identical 
with the alcoholism brought on by the immoderate use of 
any other alcoholic beverage (vide article Alcohohsm, 
under the heading Insanity) ; and some observers have 
even doubted whether any special and peculiar symptoms 
could be attributed to any of the non-alcoholic ingredients 
contained in the liquor. Nevertheless, according to most 
authorities, the evil effects of intemperance not only ap- 
pear earlier in those addicted to the habitual and exces- 
sive use of absinthe than they do in the case of abusers of 
other alcoholic drinks, but these effects are in themselves 
of a severer nature, and there is, besides, a more marked 
disturbance of the nervous system in its various parts. 
Vertigo, severe headaches, a condition of stupor and of 
apathetic listlessness, terrifying hallucinations, and epilep- 
tiform convulsions are particularly noticeable among the 
symptoms oelonging to the absinthe tippler, and this liquor 
is especially prone to bring on an early condition of men- 
tal decay, and seems to be facile princeps in its power to 
enslave its victim. That the active principles of absinthe 
(Artemisia absinthium and its congeners) are the agents in 
causing the special toxic effects of the liquor, has been 
pretty well established bj Marce in his experiments on 
dogs and rabbits. 

Huntington Bicliardg. 



31 



Absorption. 
Absorption. 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 



ABSORPTION. Definition.— The non-traumatic en- 
trance of a substance through the tissues of a free surface, 
integument or mucous membrane, into l3anph- or blood- 
channels. Re-absorption of effused lymph (resorption) 
-will be considered under the head of the lymphatic system. 
Mere imbibition, as of water, by the epithelial cells is not 
to be regarded as absorption, nor is the term here used so 
as to include in its application the entrance of heat or 
other forms of motion. 

The elementary processes involved are : (1) Diffusion in 
the form of osmosis, or dififusion through a porous septum. 

(3) Filtration, or permeation of a porous septum under 
pressure. (3) The cataphoric working of electric currents. 

(4) The complex or vital activities of epithelial cells, 
similar to those exhibited in secreting glands, but in in- 
verse direction, i.e., from the free surface inward, instead 
of from the blood or l3;mph outward. (5) The migratory 
activity of leucocytes involved in the theory of intestinal 
absorption of Zawarykin, or the less extreme view advo- 
cated by Schafer and others. 

Absorption varies with the locality and the substances 
soliciting absorption. The skin will be treated of first, 
then the alimentary canal. 

Absorption, by the Skih, 01" Water and Watery 
SoLTJTiONS. — Investigations upon this subject have been 
made chieliy by three methods. The first consists in weigh- 
ing the body before and after prolonged immersion in a 
warm bath. This method is vitiated by the presence of 
various factors afifecting weight. The skin and lungs con- 
tinue to excrete, and their activity is affected by the bath 
itself ; a considerable amount of water is soaked up by the 
epidermis without proceeding to real absorption ; some re- 
mains adhering to the body, especially in hairy regions ; a 
considerable quantity of epidermis scales are rubbed off 
in wiping dryj Moreover, the water is during the bath in 
contact not only with the ordinary skin, but also with 
such mucous or semi-mucous places as the prepuce, glans, 
and regio analis, which are known to absorb water. The 
results attained by this method are discordant, and serve 
only to show that the absorption is not sufficiently great 
to render negligible the sources of error enumerated above. 
Fleischer's carefully conducted experiments (1877) illus- 
trate the second method. The arm was immersed in a 
plethysmograph cylinder, and variations in the quantity 
of water were indicated in a small tube leading from the 
cylinder divided into .01 c.c, and susceptible of still finer 
readings. With suitable vessels, water was also applied 
to other and larger portions of the body. These local 
baths were prolonged to between twc( and three hours. 
The conclusion reached by Fleischer was that there was 
no aqueous absorption by diffusion through the intact 
human epidermis. The third method consists in applying 
to a part of the integument a solution of some substance 
capable of either producing a pl^siological effect, or of 
being detected in the secretions. The value of the earlier 
experiments of this form is much impaired by lack of 
care to exclude absorption by mucous surfaces. This 
fault, however, only affects positive results. The more 
recent investigations f oUow mostly the metljod of Sereys 
(1863) and Rohrig (1872 and 1876). The arm or leg is 
passed through a hole in the partition between two apart- 
ments, and the fitting made air-tight. The arm or leg is 
then sprayed with the solution In one apartment, and the 
urine passed and examined in the other. Rohrig found 
iodine in the urine after spraying the human arm with an 
aqueous solution of potassium iodide, aqd potassium 
f errocyanide in the unne after spraying with a solution 
of that substance. But v. Wittich (1881), employing the 
same method with solutions of iodide of potassium of 
varying strengths, obtained uniformly negative results. 
80 also did v. Ziemssen (1883) with solutions of potassium 
iodide, salicylic acid, sodium sulphindigotate, and pilo- 
carpin ; and there are numerous negative results obtained 
by older observers, in which solutions of digitalis, bella- 
donna, strychnine, hydrocyanic acid, etc. , were employed. 
These experiments are on the human skin. With rabbits 
Rohrig states that he obtained absorption from sprays of 
curare, morphine, digitalin, and iodine ; and v. Wittich, 
though unable to obtain any toxic effects with a strychnine 



spray, did find iodine in the urine after a potassium iodide 
spray. 

In the foregoing experiments diffusion alone is called 
into play. Expenments have been made on filtration 
through the recently removed skin. V. Wittich (1881) 
was able to carry the pressure up to 67 ctm. of mercury, 
without obtaining aqueous filtration in either direction 
with human skin ; and the earlier results of Krause were 
also negative. From such experiments, however, exact 
conclusions cannot well be drawn respecting the effect of 
pressure in forcing water throuj^h the living skin. 

Through its cataphoric working a current of electricity 
appears to be able to introduce aqueous solutions in small 
quantities across the ordinary human integument into the 
vascular channels. H. Munk (1873) used electrodes of clay, 
wet with an aqueous solution of the substance under trial, 
and of 10 to 15 mm. diameter. A Grove's battery, with 
ten to eighteen cells, was used. The direction of the cur- 
rent was frequently reversed. Experiments were made on 
rabbits, and on Munk himself. With the rabbits the hair 
was clipped close, but without injury to the epidermis. 
A rabbit, after ten or fifteen minutes of current between 
strychnine electrodes, showed heightened reflex excita- 
ibility ; after twenty to twenty-five, spontaneous tetanic 
spasms. One which had received the current from 
18 Groves for forty-five minutes, went into almost un- 
interrupted spasms, resulting in death half an hour later. 
In general, the intensity of the toxic effects varied with 
the strength and continuance of the current. To control, 
the strychnine electrodes (disconnected) were held on the 
skin for hours without the least sign of absorption. When 
Munk passed the current between quinine electrodes 
placed on his arm for fifteen minutes, quinine was found 
in his urine for the next twelve hours. With potassium 
iodide electrodes and a current lasting fifteen minutes, 
iodine was foimd in the urine thirty minutes later, increas- 
ing for five or six hours. To control, larger pieces of clay, 
wet with a strong solution of potassium iodide, were bound 
upon the arm for a day. No sign of iodine appeared in the 
urine. The outcome of all experiments and observations 
respecting the absorption of water and aqueous solutions 
of non-volatile substances by the ordinary human skin, 
may be stated as follows : 

"rhe application of these fluids to the skin does not re- 
sult in any sensible absorption. 

The skin does not probably admit of the introduction 
of these fluids under pressure (filtration), unless possibly 
when that pressure is very high. 

By the cataphoric action of electric currents, these 
fluids can be made to permeate the skin in small quan- 
tities. 

The place of resistance to diffusion seems to be the 
outer harder layers of the epidermis, and when these are 
removed, as by blistering, absorption readily takes place. 

These statements cannot be applied indiscriminately to 
animals other than man, nor do they apply to such semi- 
mucous places as the prepuce, glans or regio analis. Al- 
cohol and alcoholic solutions seem to traverse the skin 
as little as water. The experiments of v. Ziemssen (1888) 
on alcoholic solutions of iodine, salicylic acid, carbolic 
acid, and pilocarpin gave entirely negative results. 
_ The existing evidence seems to be in favor of the be- 
lief that oils can be rubbed in, and can carry with them 
finely divided substances with which they have been 
rubbed up. But there seems to be considerable varia- 
tion in results obtained by different experimenters. 
Lassar ' finds that in rabbits the skin absorbs oils readily 
and in large quantities, and that ■without any pressure or 
rubbing in, the oil being simply painted over tlie bared 
skin or simply poured over the unsheared rabbit. Due 
precautions seem to have been taken to prevent the ani- 
mal from licking up the oil. Rapfeseed oil, olive oil, cod- 
liver oil, and petroleum were tried with positive results. 
Lassar extends his conclusions to the human skin without 
direct experiments of his own, but calling in the observa- 
tions of Unna and others, in which, however, the unin- 
jured state of the skin does not seem to be adequately 
vouched for. 

Fleischer in reply " calls attention to his previously ob- 



32 



REFERENCE HANDBOOK OP THE MEDICAL SCIENCES. 



Absorption. 
Absorption. 



tained results,' in which salves of veratrin, morphine, 
and potassium iodide were rubbed into the intact human 
skin without result, and states that he has repeated the 
trial with potassium iodide under most favorable con- 
ditions, with entirely negative result. There is not, how- 
ever, any doubt about the absorption of mercury 
ointments. Scattered and not wholly unimpeachable 
testimony claims the introduction of morphine and other 
substances in the form of ointments. There is, on the 
other hand, considerable evidence that the oleates dis- 
solved in oleic acid or in fats are easily absorbed by the 
human skin. (See Marshall, Lancet, May 35, 1873 ; Shoe- 
maker, "Trans. Penn. State Medical Society ; " Squibb's 
Ephemeris, November, 1883.) 

The absorption of volatile substances, such as turpen- 
tine and camphor, has been shown by the researches of 
Lehman (1861) and of R5hrig (1876). The solutions of 
alkaloids and inorganic salts in chloroform and ether are 
capable of absorption, as shown by Parisot (1863) and con- 
firmed by Rohrig and others. The same was proved true 
of solutions of pilocarpin, apomorphine, salicylic acid, 
and other substances in chloroform, ether, or turpentine 
forcibly sprayed on the skin. 

Gases permeate the skin with ease, as has been proved 
in the case of carbonic oxide, carbonic dioxide, chlorine, 
illuminating gas, and chloroform vapor. They are also 
absorbed when dissolved in water. 

Absorption in the Intestine. — The intestine, espe- 
cially the small intestine, is the principal region of absorp- 
tion in the alimentary canal. We should be led to expect 
this from anatomical facts, viz., from the extent of sur- 
face insured by the small size and great length, by the 
folds or valvules conniventes, and by the villi, with their 
plexuses of blood-vessels and lacteal radicles : and this is. 
proved by direct observation and experiment. This ex- 
tent of siuface is of obvious advantage, whatever may be 
the relation between the shares taken in absorption by the 
purely physical process of diffusion and filtration on the 
one hand, and thfi vital activities of the intestinal epithe- 
lium on the other. From the fact that the plexus of 
blood-vessels in the villus lies outside of the lymphatic 
radicle, we should expect that the more diffusible sub- 
stances, such as minerals, sugars, and peptones, would be 
in lar^e measure conveyed away by the portal system, 
while It would not be easy to see how the fats would gain 
entrance to those blood-vessels, or be carried off except by 
the lymphatic system ; these considerations, too, would 
be entirely independent of the forces involved in the 
passage through the epithelium of the villus. We should 
not be led, however, to a too exclusive distribution of the 
various substances between the lacteals and blood-vessels. 
We should expect that the blood-capillary network, 
though it might catch most, would not probably fail to 
let pass a small quantity of the more diffusible products 
of digestion ; we should not be surprised to find small 
quantities of minerals, sugars, or peptones in the chyle. 
If the products of digestion of amyloids and proteids 
contained less completely transformed and diffusible sub- 
stances, along with the sugars and peptones, we should 
find it natui-al that these should enter largely the lacteals. 
If, on the other hand, the fats should be largely converted 
into soaps in digestion, and, as soaps, should pass from 
the epithelium into the body of the villus, they might be 
expected to find their way in not inconsiderable quantities 
into the blood-capillaries. We find the results of direct 
experiment coinciding very fairly with these anticipations, 
which rest on general considerations and anatomical facts. 

The investigations regarding the absorption of salts are 
very scanty, and almost wanting in recent times. The 
observations of Lehman* made upon potassium iodide and 
ammonium sulphocyanate, showed absorption both by 
lacteals and blood-vessels, and, contrary to what would 
have been expected, as early in the former as in the latter. 

The paths of principal absorption for sugar were inves- 
tigated by V. Mering (^Areh. f. Anat. u. Physiol., 1877, 
S. 379), who found that the amount of sugar in the chyle 
was uninfluenced by the ingestion of amylaceous food, 
while that in the portal blood was increased. Hoppe- 
Seyler {PJiysiologiaehe (Jhemie, S. 353) records repeated 
Vol. I.— 3 



observations of the fact that while fatty meals cause a 
rapid flow of chyle in the lacteals, abundant feeding with 
amyloids and proteids alone have no such effect, the flow 
remaining quite slow. 

With regard to the paths taken by the proteids the ob- 
servations of Hoppe-Seyler just quoted are in point. 
Schmidt-Muhlheim {Archw f. Anai. u. Physiol. , . 1877) 
finds that when the chyle is prevented from entering the 
blood, the proteids continue to be absorbed, and that the 
effects of proteid feeding in increasing the amount of urea 
are not diminished. 

That fats are absorbed by lacteals in large quantities is 
shown by the peculiar whitish appearance which they 
present after a fatty meal. No corresponding appear- 
ance of fat is exhibited in the portal system, but the ques- 
tion with regard to soaps, which we know to be formed 
to a greater or less extent from the fats, is a more difficult 
one and still unsettled. Lebedefl' {Arch. f. Anat. u. 
Physiologie, 1883 ; " Studien iiber Fettresorption " ) found 
fatty acids in the liver ; and, in contradiction to Munk 
and others, none in the chyle, after feeding with fatty 
acids, and holds it likely that they were conveyed to the 
liver in the portal blood. 

The mechanism of intestinal absorption doubtless in- 
volves, to a certain extent, diffusion or osmosis. The 
conditions seem favorable for it ; a thin and apparently 
permeable membrane separates the blood from the very 
different intestinal contents. There is no reason known 
which should prevent a considerable degree of absorption 
by diffusion of the more diffusible substances ; eve& fil- 
tration may play a part, though probably a small one ; 
the pressure developed by peristaltic action must ordi- 
narily, however, be small. The pumping action of the villi 
deserves more attention ; the muscular fibres of the villi 
may squeeze out the contents into the lacteals about, and 
then, there being no return of this fluid, a suction will be 
developed by the return of the villus to its expanded state 
in virtue of the elasticity of its tissues, tending to draw in 
the intestinal contents. But whatever role is assigned to 
diffusion and filtration in intestinal absorption, their action 
can hardly be deemed sufficient to account for all that 
takes place, especially in the case of fats ; the factor sug- 
gested by what we have learned elsewhere is furnished 
by the epithelial cells. The whole drift of investigations 
on the physiology of secretion has been to assign the 
highest importance to the vital activities of the epithelial 
cell. It is the secreting cell which selects certain sub- 
tances from the blood upon one side and passes them out 
on the other, more or less changed in the process. It is 
probable that it is the epithelial cell of the villus which 
takes up what it will from the intestinal contents to pass 
it out into the body of the villus, possibly, too, somewhat 
changed, as from peptone to albumen, or from fatty acid 
to neutral fat. The epithelial cell of the villus will differ, 
then, from the secreting epithelial cell only in the direc- 
tion of its action and the nature of the substances which 
it transports, and, it may be, transforms ; the pumping 
action of the villus would then, independently of any 
filtration, be of service in removing the pressure against 
which the epithelial cell would have to work. The re- 
sults obtained accord with this view. Tappelner ( Wien. 
Sitzungsberichte, Bd. 77, 1878) found that sodium §lyco- 
cholate and sodium taurocholate were not absorbed in the 
duodenum or upper jejunum, but that the absorption of 
sodium glycocholate began in the lower jejunum, and the 
taurocholate in the ileum. This can hardly be explained 
under any theory of absorption built merely upon diffu- 
sion and filtration, but falls easily in with the assumption 
of an epithelial action. The greater number of observa- 
tions have had reference to the absorption of fats ; most 
observers are agreed that the epithelial cells are filled 
with fat cells during fat absorption, and that the begin- 
ning of the paths to the lacteals lies in the cells, not be- 
tween them. Von Thanhoffer* describes and states that 
he saw in motion cilia-like processes on the surface of the 
intestinal epithelium in the frog ; the activity of these 
processes seemed to be increased by bile and nervous irri- 
tation ; the ingestion of fatty particles by the cell is, ac- 
cording to Von Thanhoffer, effected or furthered by the 



33 



Absorption. 
Acclimation. 



EBFERENCE HANDBOOK OP THE MEDICAL SCIENCES. 



activity of these processes. Similar moving processes 
and active amcsboid movements on the luminal surface 
of the cells were seen by Wiedersheim in the intestine of 
Spekrpes fuacus and in young sharks. « Wiemer ob- 
served the same processes in specimens from the frog, 
hardened in osmic acid.' Spina,' from microscopical ob- 
servations on living tissues, in maggots, frogs, and sala- 
manders, satisfied himself of the active part played in 
absorption by the epithelial cells of the intestine, and, in 
the frog, of the skin. The method of transference from 
the inner end of the epithelial cell to the lymphatic radicle 
is unsettled. Schafer has held for some, time the view 
first printed (" Qualn's Anat.," 8th ed.) in 1876, that the 
fat-particles are received from the epithelial cells by the 
lymph-corpuscles of the reticular tissue of the villus, and 
carried by them into the lacteal radicle. By others the 
reticular tissue has been made to play a part, and others 
still have held that the fat was thrown out by the epithe- 
lial cells into the interstices of the villus. 

Two obsei'vers, Watney and Zawaryldn, in contradic- 
tion to the belief of almost all other investigators, have 
held that the fat passes between the cells, not through 
them. Watney' holds that the fat-particles are taken 
up by a reticulum of lymphoid tissue embracing the epi- 
thelial cells, extending up between them. He takes the 
view, however, that this is no mere diffusion or filtration 
process, but is active protoplasmic work, vv hile TVatney 
merely would transfer the absorptive process from the 
epithelial to the lymphoid protoplasm, Zawarykin '» calls 
into j)lay the amoeboid movements of lymph-corpuscles, 
which he sees reason to think crawl up between the epi- 
theUal cells, fill themselves with fat, and crawl back into 
the body of the villus. These are both interesting and 
curious theories, but of little apparent viability. 

All recent views reject the explanations of intestinal 
absorption by mere filtration and diffusion, and have re- 
course to the vital activities of living cells. If this takes 
place in fat absorption it is made probable that something 
of the same kind occurs in the intestinal absorption of 
other less easily followed substances, and this presump- 
tion is favored by the observations of Tappeiner and of 
Spina referred to above. 

The transformation of products of digestion in the pas- 
sage through the intestinal walls is the subject of active 
investigation at present, but the results are as yet too un- 
certain to warrant presentation here. 

AbSOBPTION Df OTIEBB SCATTERED LOCALITIES. — With 

regard to other various mucous or semi-mucous surfaces, 
there has been little careful experimental work. That 
the conjunctiva absorbs is a matter of daily experience. 
Respecting the bladder. Sir Henry Thompson" states 
that "the mucous membrane of the bladder appears to 
have no absorbing power," and injects, in reply to a critic, 
four drachms of liq. opii sed. into the bladder of a patient 
with chronic cystitis, on four separate occasions, without 
sensible effect. Subsequently, in the same patient, twenty 
minims by the mouth produced marked contraction of the 
pupil. In the lungs the evidence seems to show that the 
gaseous absorption is a purely physical process. Pine 
solid particles entering the alveoli are taken up by round 
cells, which may be either metamorphosed epithelial cells 
or wandering cells of the vascular system, and transported 
by them inward along lymphatic channels to be deposited 
in the thicker connective tissue septa of the lungs, the 
bronchial lymphatic glands, or even more remote points ; 
the condition thus produced being known as pneumono- 
koniosis. » # » « * 

1 Lassar ; TTeber den Zusammenhang, etc, Virchow's Archiv. Bd. 77. 
S. 157. 1879. 

" Fleischer : Zur Frage der Hautresorption. Virchow's Archiv, Bd. 
79. S. 588. 1880. 

8 Fleischer : Untersuchungen ueber daa ReBorptionsvermOgen d. 
MeiHchl. Hant. Habllitationschritt. Brlangen, 1877. 

< Lehman ; Notiz iiber die EeBorption elniger Salzo aus dem Barme 
l'fltiger'8 Archiv, Bd. 33, S. 188, 1884. 

sVoii Thanhofler: Beitrage zur Fettreaorption und hiRtoIogisctaen 
Stniotur der Dilnndarmzotten. Pflilger'n Archiv, Bd. viii., 1874. 

' Wiedersheim ; Ueber die meohanitche Aufnahme der Nahi-ungamittel 
in der Darmsohleimhant. Foalachr. d. 5B, Vera. d. Natnrf. u. Aerzte zu 
Freiburg, 1 Bd., 1883. 

' Wiemer : TJober den Mechanismua der Fettreaorption. Pflilgor'a Ar- 
chiv. Bd. 33, 1884. 



Fig, 22. — Echino- 
rhynchus Uomi- 
nia, X 10 timea, 
(Lambl.) 



f* Spina : TTntersuchungen fiber die Mechanik d. Darm- und Hautre- 
aorption. Wien. Sitzungsb., Juli, 1881. 

' Watney : On the Minute Anatomy of the Alimentary Canal. Phil. 
Trans. London, 1876. 

10 Zawarykin: TJeber die Fettreaorption im Diiiindarm. Pfliiger'a 
Archiv, Bd. xxxi. 1883. 

1' Thompson: Siseaaes of the TTrinary Organs, Filth Ed., p. 301. 
1879. 

ACANTHOCEPHALA (thorny-headed worms) form an 
order of helminths including only one genus, the echi- 
norhynchus, of which there are several 
varieties, which infest swine, monkeys, 
birds, etc., but only two cases have been 
reported of their occurrence in man. In 
one there is some dispute as to the vari- 
ety ; the worm was found in the small 
intestine of a boy, and by Lambl, the re- 
porter, was called eehinorhynchus liomi- 
nw. The second case was reported by 
"Welch as occurring in an English soldier 
returned from India. Cobbold expresses 
his belief that this worm was a penta- 
stoma. 

The eehinorhynchus is characterized 
by a retractile head armed with several 
rows of hooks, bjr means of which it re- 
tains its position in the intestines orborea 
its way through ; its body is elongated, 
cylindrical, and pointed behind. 

E. gigas is found in the hog ; the ma 
ture female may be two feet long by one 
third of an inch broad ; the male is about 
three inches long. The embryos infest 
the larvsB of the cockchafer, as their 
.temporary host, before entering the swine. 

Ohas. E. BacUey. 

ACARI, or mites, belong to the class of Arachnidae. 
Two varieties chiefly infest man. The acarus scaMd, 
sarcoptes hominis, or itch-mite, is nearly circular in 
shape ; the f e- 
maleisfrom one- 
fourth to haU a 
millimetre in its 
long diameter ; 
the male is 
rather smaller ; 
the body is whit- 
ish ; young ones 
have six legs till 
they ■ change 
their skin, sub- 
sequently they 
have eight legs, 
two on each side 
of the head, and 
two on each side 
behind. Of the 
front feet the 
two next the 
head have suck- 
ers, the others 
have projecting 
bristles. There 
is an intestinal 
canal opening' 
posteriorly, but 
no respiratory 
organs have 
been recognized. 
The female bur- 
rows under the skin, sometimes to the length of an inch ; 
this burrow is called the cuniculus ; as she progresses she 
lays eggs, perhaps ten or fifteen in a furrow ; in a week 
or two these hatch into young acari, ready to begin work. 
By boring into the skin they cause itching, which induces 
scratching, and this probably develops the nodules, vesi- 
cles, and pustules, which are found on patients with itcli 
or scabies, of which disease they are the sole cause. Fe- 
male acari are stated to live three or four months. 




Fig. 2.3.— Acams Scabiei. Female. Front feet with 
Buckera ; hind feet with briatleB : posteriorly sex- 
ual openings. Magnified, (Gustav Behrend.) 



34 



REFEEENCE HANDBOOK OF THE MEDICAL SCIENCES. 



Absorption. 
Acclimation, 




The disease may be transferred from one person to an- 
other by the passage of a pregnant female or of young 
acari, which sub- 
sequently breed. 
This transfer is 
more apt to occur 
in bed, when pa- 
tients can scratch 
readily and tear 
the insects out of 
their burrows. 
The diagnosis is 
rendered certain 
by opening a cu- 
mculus with a 
needle and find- 
ing the acarus 
and eggs. 

Treatment con- 
sists in killing the 
insects and eggs 
by frictions with 
green soap and 
sulphur, petrole- 
um, balsam of 
Peru, etc. Hebra 
thought that the 
insects in cloth- 
ing, etc., soon 

died, and that it Fio.a4.-Aoarus Soabiei, Male. Front feet and 
was hardly neces- two hind feet with suckers, other hind feet 
sary to bake these have bristles. Magnified. (GrUHtav Behrend.) 

articles for the purpose of disinfecting. 
Aca/rus folliculwv/m, (entozoon fol., steatozoon fol., 
demodex fol.) is a minute whitish 
parasite, from one-tenth to three- 
tenths of a millimetre long by one- 
^^ fortieth of a millimetre broad, which 

^^W^^g" is found in the orifices of the sebace- 
|Wj^f^ ous glands of the nose and in the 
^^^pSP^ hair-follicles. It occurs in many 
^^^m^ people, especially in those with greasy 

^^whM^ skins, and may often be obtained by 

scraping the skin with a spatula. 
Under the microscope it is found to 
consist of a cephalo-thorax about one- 
fourth the whole length, the other 
three-fourths constituting the abdo- 
men. The head has two palpi with a 
proboscis between them ; on each side 
of the thorax are four feet with claws. 
Fio.25.— Acarus Poiiion- A species is described with but three 
lorum. Tail is fore- feet on each side ; these, however, are 
shortened. Magnified, „ . , .__ _ ' ' . ' 

probably young ones, as in acarus 

scabiei. There may be from two to a dozen in one folli- 
cle ; they are not known to have any injurious effect. 

Charles E. Hockley. 

ACAROIDES, GUM : Botany Bat Gtjm ; Rksina 
LuTEA. — By these names are designated two or three 
closely connected aromatic resins, obtained in Australia 
from several species of the small and peculiar genus 
Xanthorrhcea {Xcmtorrhcea Liierssen). The genus, by 
some botanists considered to belong to the Liliacem, but 
placed by Bentham and Hooker among the Juneaceoe, 
consists of less than a dozen species of sometimes low, of- 
tener shrubby, or even arborescent plants, with the general 
appearance of screw pines. Stems leafy, frequently con- 
taining an abundance of yellow or reddish resinous juice ; 
leaves long, linear, rigid, brittle, with dilated, imbricated, 
persistent bases. Inflorescence a long terminal close 
spike of small flowers. Perianth persistent, its segments 
distinct, the outer glumaceous, the inner petaloid or trans- 
parent. Ovary three-celled, ovules few ; capsule coriace- 
ous dehiscent The resinous sap exudes spontaneously, 
and hardens upon the stem in tears or masses. Two 
principal varieties of the "gum" are distinguished; the 
red, in deep-red lumps or fragments resembling lumpy 
specimens of dragon's blood, having a weak odor of ben- 



zoin, and a spicy cinnamon-like taste ; the yellow, in 
orange-yellow pieces or tears, having a strong benzoin 
odor. 

The balsam, for such it really is, contains, besides some 
bassorin and uninteresting ingredients, a large proportion 
of cinnamic acid and some benzoic acid. Decomposed 
with melted potash parbenzoic and protocatechuic acids, 
pyrocatechin and resorcin are formed. In nitric acid the 
balsam dissolves readily, and yields abundance of picric 
acid, together with oxalic and nitrobenzoic acids. 

The xanthorrTuea resins have long been used in Aus- 
tralia as a remedy for gastric troubles, intestinal catarrhs, 
diarrhoeas, etc., and are occasionally prescribed in this 
country for similar conditions ; but their principal uses 
are in the arts as a source of picric acid, and in the manu- 
facture of lacs and varnishes. 

Dose, from one-half to one gramme (gr. viij. ad xvj.). 
It may be given In alcoholic solution. 

Allied Plants. — The Juncacece (rush family) is a 
smallish order, of which juncus is the principal genus ; 
they differ from Liliacem chiefly in their habit and mem- 
branous perianth ; they have no important medicinal 
qualities. The XantkorrJwsas resemble some I/iliaeem in 
habit (Aloe, Yucca, etc). 

Allied Dbugs. — Benzoin, balsam of Tolu, balsam of 
Peru, etc. W. P. Bolles. 

ACCLIMATION. When any animal, brute or human, 
is removed from the environment to wliich he and his 
ancestors have long been accustomed, a considerable dis- 
turbance of the whole economy is liable to ensue. The 
process of evolution has developed certain organs and 
certain functions in accordance with the requirements of 
those circumstances under which his race has found itself, 
and when he is suddenly transplanted into new conditions 
some of his faculties become without occupation, while 
others hitherto uncalled upon, and therefore undeveloped, 
are suddenly subjected to a demand to which they are 
quite unable to respond. The process of accommodation 
of 'the individual to new conditions of climate is known 
as acclimation or acclimatization. These conditions in- 
clude temperature, moisture, morbific germs, elevation, 
sunshine, food, and other less tangible factors. Such 
elements as are connected with the social rather than the 
natural environment, as, for instance, education, the stand- 
ard of public morality, and the avocation or means of 
livelihood, while in any radical change that they may 
undergo, profoundly alfecting the individual, are yet to 
be held distinct from the conditions to which accUmation 
properly refers. 

No other animal is so facile in his accommodation to 
changes of climate as man. The lower animals and plants 
often do not recover from the effects of transplantation 
for several generations. The Societe d'Acclimatation of 
Paris has for years being carrying on an extensive zoo. 
logical experiment, in its gardens, on the domestication of 
foreign animals and plants which it is believed can be 
made useful to European countries. The record of their 
failures and successes is embodied in the numerous vol- 
umes of their reports. Man's comparative immunity from 
the disastrous effects of changing climate is due in part 
to his ability, by an intelligent prevision of the dangers 
which are to beset him, of guarding against them. The 
records of arctic explorers present abundant evidence of 
the ability of the denizens of temperate climes to endure 
winters in which the thermometer averages from 40° to 
50° P. below zero. On the other hand, Europeans have 
lived in health and cheerfulness on the banks of the 
Senegal when the thermometer in their tents stood at 
from 130° to 130° F. Men endure extremes of barometric 
pressure ranging from that of several atmospheres, as 
found in caissons, to the tenuity of the air experienced at 
great elevations. In the Himalayas men have lived at 
the height of 15,000 feet, and Humboldt even went to the 
elevation of 19,386 feet, where he remained for a time 
without ill effects ; but where no animal but a dog would 
follow him, and this creature quite lost the power of 
barking. 

The differences in the facility of acclimation at various 



35 



Acclimation. 
Accommodation. 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 



points in the same latitude are shown by an article reprinted 
in the Popular Science Monthly for July, 1884. Between 
30° and 35° N. latitude, Europeans acclimate much less 
readily than in the same latitudes south. Algiers, for 
instance, is vastly more difficult for the European to live 
in than Cape Colony, yet both places are about latitude 
35°. The Argentine Confederation and New South Wales 
are more healthy than the East and West Indies, which 
are of the same latitude. The mortality of the French 
and English troops has been found to be about eleven 
times as great at foreign stations in the northern as at 
those in the southern hemisphere. The chief cause of the 
difference is in the prevalence of miasmatic fevers so 
deadly to Europeans. Those fevers in the northern hemi- 
sphere occur even in high latitudes, while south of the 
equator they do not extend beyond the tropic. The island 
of Tahiti, for instance, about latitude 18° 8., is quite ex- 
empt from these fevers. The records of the French and 
English soldiers on foreign service show, in South America, 
a sickness from malarial fevers of 1.6 in 1,000 men per 
annum ; while in similar latitudes in the northern hemi- 
sphere, the number of such cases annually is 224 per 
thousand. 

To persons removing from one point to another within 
the temperate zone, one principal obstacle to acclimation 
is change (especially diminution) in barometric pressure. 
Many persons on going to an elevation of not more than 
6,000 feet experience a sense of constriction in the chest 
as well as across the liver and stomach. The pulse is quick- 
ened, as is also the respiration. The individual sometimes 
feels that he cannot take a long breath, and is often testing 
himself to see if he can do so, but the act does not relieve the 
air-hunger. Slight exertion causes fatigue and the sleep is 
disturbed and fitful. If there was any pre-existing heart 
trouble, the condition may soon become perilous. Any- 
thing like a congestion of the internal organs adds to the 
danger of ascending to high altitudes. If the unpleasant 
symptoms continue after a day or two of perfect rest, it 
is advisable to make no further attempt to secure accli- 
mation. 

The acclimation of Europeans in tropical countries 
may be simply meteorological, as in Tahiti and other 
kindly climates of Polynesia, where no diseases lie in 
wait for their prej^, and where the new-comer, but for 
the changed condition of the temperature and a certain 
physical and mental lassitude accompanying It, lives 
much' as he does at home. By reason of the insalubrious 
character of most places in the tropics, however, acclima- 
tion becomes more or less a pathological process. Yet 
even in such countries acclimation may take place with- 
out the intervention of any morbid process whatever. On 
the other hand, foreigners sometimes pass through an 
attack of a seemingly specific fever, which, when it does 
occur, seems to facilitate acclimation, though it is by no 
means essential to the accomplishment of that process. 
This fever of acclimation is thus described by M. Ruf?; 
de Lavison ("filtude sur la population de la Martinique, 
1850-63 ") : " When neither yellow nor intermittent fever 
nor dysentery is in the air, a fever often shows itself, 
characterized by headache, heat, coloring of the skin, 
tliirst, great restlessness ; in fact, the complexus of symp- 
toms belonging to yellow fever. If the latter disease 
were epidemic, this would be likely to be diagnosticated 
as yellow fever. But all the symptoms yield at once to 
treatment, and convalescence is established by the third 
or fourth day. It is a common belief of the people of 
Martinique that those jDcrsons who do not pay this tribute 
to the climate, will be sicker in any subsequent attack of 
disease than those who have had the acclimating fever ; 
but it certainly is not indispensable to successful acclima- 
iion, and affords no immunity against yellow fever." 

The diseases to which a European is especially subject 
on removing to the tropics are yellow fever, dysentery, 
hepatitis, anaemia, and malaria. The first of these, yel- 
low fever, constitutes the greatest immediate danger for 
the unacclimated stranger. The Creole population, as is 
known, are largely exempt from susceptibility to this dis- 
ease, though even they, after having resided for a time in 
the temperate zone, have to go through an acclimation 



on their return before they are safe from the disease. 
Their acclimation is more quickly accomplished, however, 
than that of the European. Immunity against this fever 
is gained by a previous attack, and also by having passed 
through an epidemic of it, even without having con- 
tracted the disease. The time necessary to secure abso- 
lute safety against yellow fever is variable. The other 
tropical diseases which impede acclimation, dysentery, 
hepatitis, etc. , afford no security against yellow fever. 

Dysentery, which is, perhaps, next to yellow fever, the 
most fatal obstacle to the acclimation of Europeans in the 
tropics is rarely, except in great epidemics, fatal at the 
first attack ; but with successive years it is apt to recur, 
either as dysentery or as chronic diarrhoea. The British 
Admiralty, on the theory that the mortality of the co- 
lonial troops from this cause is in direct ratio of the period 
of their stay in the tropics, removes and replaces such 
garrisons at short intervals, while the French Govern- 
ment sends annually to her colonies transports to carry 
away those soldiers who have become enfeebled by re- 
lapses and recurrences of. dysentery. A certain number 
of cases never can become acclimated to this disease, and 
find relief only by a return to temperate climes. 

Another obstacle sometimes fatal to acclimation, but 
of rarer occurrence, is hepatitis. This may be either 
primary, due to heat or malarial infection, in the latter 
case the enlargement of the liver being analogous to the 
accompanying splenitis ; or the hepatitis may be second- 
ary to dysentery, in which case abscess of the liver may 
result with usually a fatal ending. These hepatic ab- 
scesses are said to be more common in Europeans than in 
Creoles after a dysentery. Other liver diseases, cancers, 
hydatids, and icterus, due to affections of the gall-bladder 
and ducts, are said by Dr. Saint- Vel, in his work, "Hy- 
giene des Europeens dans les Climats Tropicaux," etc., to 
ibe rarer in the torrid than in the temperate zone, in spite 
of the common belief to the contrary, i 

A degree of ansemia may be considered physiological 
in hot countries. But it not unfrequently becomes ex- 
cessive, interfering with the nutrition of the body and 
combining with a certain amount of malarial poisoning, 
and perhaps also of hepatitis, to impart the doughy, pale, 
and sallowish tint not uncommon in those who have liv«d 
long in the tropics. This ansemia, sometimes amounting 
quite to a cachexia, is most extreme in the immediate 
neighbor-hood of the equator, growing less with every de- 
gree of latitude, and is by no means confined to the white 
race, though it is only as it occurs to Europeans seeking 
acclimation that it deserves mention in this connection. 

Intermittent ajid remittent fevers and other manifesta- 
tions of malarial cachexia are the obstacles which most 
commonly stand permanently in the way of acclimation. 
Recent observations have shown that malaria exists, at 
least in the northern hemisphere, nearly as far up as the 
arctic circle, and the deadljr nature of the Tuscan Ma- 
remma (lat. 43°) has even given a name to the disease. 
Still, the most virulent types of the disease are of tropical 
origin. An individual may resist these influences for a 
time, to fall a victim without any apparent change either 
in his own carefulness or in the nature of the surrounding 
miasmatic influences. Malaria is not confined, like yel- 
low fever, to the coast regions, but is distributed widely. 
High altitudes are not exempt from it, and it was found 
by Curran even on the chain of the Himalayas. Still, it 
is more common in lower levels where vegetation once 
covered with moisture is left by a subsidence of the water 
exposed to the atmosphere. There are kome regions, as, 
for instance, parts of Senegal, Madagascar, and French 
Guiana, where the malarial influence is so strong that, 
while individuals have overcome it, it may be said that, 
as a race, Europeans hitherto have failed to become ac- 
climated. : 

In passing from the tropics to the temperate zone, the 
obstacles in the way of acclimation are much less than 
to those who emigrate in the other direction. The tran- 
sition of seasons from the heat of smnmer to the cold of 
winter has a tonic effect, and is favorable to those suffer- 
ing from ansemia, hepatitis, and malaria. Certain inflam- 
matory chest affections, however, are liable to be caused 



36 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 



Acclimation. 
Accommodation. 



in Creoles by a northern winter, as weU as some cutaneous 
diseases, dependent perhaps on the change in the amount 
of perspiration. It is often claimed that persons remov- 
ing to the temperate zone are in special danger from 
phthisis. Dr. Saint- Vel (loc. cit.) says that the reverse of . 
this is true. Some negroes die of tuberculosis in the hos- 
pitals, but there are usually circumstances of special expos- 
ure in these cases, while those negroes who are well cared 
for and live at service are remarkably free from phthisis. 
Confusion has perhaps been made of the negro with 
the monkey in this respect ; but the tuberculosis so com- 
mon in the latter animal is due to his confinement and to 
other conditions not obtaining in the case of the negro. 
The experience of all the Northern States of our country 
shows that the negro acclimates well in the temperate 
zone, but observations are wanting as to his power of 
adapting himself to really cold climates. 

The Creoles residing in France are particularly long- 
lived. Their acclimation is said to be more readily accom- 
plished than that of whites returning after a long residence 
in the tropics ; but, as a whole, the effects of removal from 
lower to higher latitudes is more beneficial than that of 
moving in the contrary direction. Arctic animals do less 
well in temperate regions than those from the tropics. 

Hygiene of Acclimation. — Hygiene can do some- 
thing to overcome the obstacles in the way of acclimation. 
It is especially important in combating dysentery, anaemia, 
and malaria. Contrary to what has been sometimes 
taught, a robust frame is an assistance to acclimation. 
The immigrant to the tropics should, if possible, reach his 
destination in the cool season, that the transition may be 
as moderate as possible from his native clime. For the 
same reason the tropical emigrant should reach the tem- 
perate zone in the summer. In going to the tropics one 
should not deprive himself wholly of a meat diet, though 
of course less meat and very little fat are required. The 
food should be sufficient in all its constituents to keep up 
the strength. Alcoholic excess is to be especially avoided. 
The light wines are much preferable to spirits. A slight 
diarrhoea is to be checked at once, as otherwise it may 
run on to the severe chronic intestinal fluxes. The dwell- 
ing should be situated high, with the sleeping-room on 
the second floor. Alluvial bottoms are to be avoided as 
places of abode, and the domicile should not be placed in 
the track of breezes blowing over marshy districts. Ex- 
posure to the night air is unwise, especially when there is 
a fog hanging about. Food should be taken before going 
out m the morning, and a dally dose of quinia should be 
made use of. 

Direct exposure to the equatorial sun during the middle 
of the day should be avoided. Only the natives can 
withstand its fierceness. On the other hand, draughts, es- 
pecially of night wind, should be as carefully avoided as 
in temperate climes. While the clothing should of course 
be light, it should be of cotton rather than linen, and 
merino undergarments should be worn, and changed fre- 
quently in order to keep the large amount of transuded 
moisture absorbed. Nostalgia, which retards acclima- 
tion, should be avoided as far as possible. If society is 
wanting, work must be relied upon to take up the mind. 
It is said that the workers acclimatize more readily than 
the idlers in hot countries. Of the various forms of exer- 
cise, which is always so important from a hygienic point 
of view, riding and driving are especially desirable in 
warm countries. Cool and cold baths daily are of use. 
The advantages of hydrotherapy are often combined 
with those of high elevation in the sanatoria which are 
located in the mountainous districts (where such exist) in 
many warm countries, and whither the half-acclimated 
European repairs from time to time with much benefit to 
paludic, dysenteric, and hepatic affections. Finally, if 
dysentery obstinately recurs, in the high altitude, or if 
the system does not throw off miasmatic impressions, it 
is better, after a reasonable time, to abandon the attempt 
at acclimation and return to a temperate climate. The 
ocean voyage will be likely to cause some relief, and 
after a reconstitution of the bodiljr powers in the home 
country, a second attempt at acclimation may be .more 
successful. Cha/rles F. WUMngton. 



ACCOMMODATION AND REFRACTION. 

Physiology. 

Refraction. — 1. The term refraction refers in physics 
to the deviation of a ray of light from its straight path on 
passing from one transparent medium into another of 
different nature. In physiological optics, however, this 
term is used with a special significance, denoting the re- 
lation of the focal length of the eye to the position of the 
retina. The eye has a normal, or emmetropic (from 
^nfieTpos, according to measure, and fii^, eye), refraction, 
if images of distant objects are sharply defined on the 
retina ; the refraction is myopic, or near-sighted. If dis- 
tant objects form images in front of the retina ; while 
hypermetropla is that refractive state in which images of 
distant objects can only be sharply defined behind the 
actual place of the retina. Any refractive state other 
than emmetropia is referred to in general as ametropia 
(from &/ierpo9, disproportionate, and fif, eye). 

The eye of all vertebrates is an optic instrument, the 
principle of which is illustrated by the photographer's 
camera obscura. By means of a convex lens, the rays oi 
light coming from the different points of external objects 
are so reunited as to form inverted, but geornetrically 
correct, images of those objects on a screen. The screen is 
the retina, while the convex lens is constituted by all the 
transparent media of the eyeball. 

A correct knowledge of the optic properties of the eye 
is not possible without some familiarity with the laws of 
physical dioptrics. Hence we must begin with a reswni 
of the laws of the refraction of light. In order to keep 
this article within the allotted space, we will not attempt 
to follow out the mathematical deduction of all the various 
formulae of which we nlust make use. For the complete 
mathematical proof of all the statements the reader must 
consult some of the works mentioned in the bibliography, 
especially those of Helmholtz and Donders. 

The paths of the rays of light entering the eye, and the 
Influence of the different media upon them, can be de- 
duced from the following optic principles : 

3. Law of Refraction. — From every point of a luminous 
or illuminated object there proceed rays of light in all 



A 




FiQ. 36. 

directions. Every ray pursues a straight course as long 
as it passes through a uniform medium. When a ray 
passes from one transparent medium into another of dif- 
ferent optic properties, it is refracted or deflected from its 
straight path, except when its original direction is vertical 
to the surface of the second medium. The extent of de- 
flection depends on a specific property of each medium, 
viz., its refractive power. The relation of the refractive 
power of any one medium to that of another is termed 
the refractive index, and is usually designated by the 
letter n. Air is taken as the standard of comparison, 
and its index of refraction is called 1. Compared with 
air the refractive index of water is 1.334 ; of crown-glass, 
1.533 ; of flint-glass, 1.664. A medium having the greater 
refractive index is said — in a somewhat loose manner — to 
have a greater optic density than another rarer medium. 

The extent to which a ray of light is deflected from its. 
straight path, by refraction, depends on the angle at which 
it strikes the surface, as well as on the refractive indices 
of the media. 

Let A, in Fig. 36, .be air, with the refractive index = n. 



37 



Accommodation. 
Accommo datlo u . 



REFERENCE HANDBOOK OP THE MEDICAL SCIENCES. 



and B be glass, with the index = n', the two being sepa- 
rated by the surface ss'. A ray of light, having the direc- 
tion a « in the air, will be bent in the direction cd on 
entering the glass. If we erect the normal bee vertical 
to the surface at the point c, the angle a obis the angle 
of incidence of the ray ae; the angle ecdis the angle of 
refraction. The latter is here smaller than the former, 
for, in the denser medium, the refracted ray is bent 
toward the perpendicular. The relation of one angle to 
the other depends on the relation of the refractive indices 
of the two media, so that the sine of either angle is to the 
sine of the other inversely as the index of the correspond- 
ing medium is to that of the other, or 

sine a eb _ n' ,.4^ 

sine ecd n _ 
Since the sine of an angle zero is likewise zero in value, 
it follows that when the incident ray is itself perpendicular 
to the refracting surface, it continues to be perpendicular 
after its entrance into the second medium, i.e., it is not 
deflected at all from its course. 

The path which a ray describes in passing through one 
or more refracting surfaces is the same, whether that ray 
travels forward or backward from any given point in its 
course. 

3. If the denser medium is in the form of a plate 
bounded by parallel surfaces and surrounded by the same 

rarer medium on 
both sides, a ray, af- 
ter passing through 
the plate, follows a 
direction parallel to 
its original course, 
but is displaced lat- 
erally. 

For in Fig. 27, 
where A represents 
the air, and B the 
plate of glass, the 
ray a c on entering 
the glass is bent toward the perpendicular (ic to an extent 
exactly counterbalanced by its deflection from the perpen- 
dicular ef on leaving the glass. Hence the ray e b after 
passing through the glass is parallel to the prolonged 
direction of the original ray a c. 

4. Befmetion by a Single Befracting Surface.— 'When 
the denser medium is bounded by a convex spherical sur- 
face, all rays (except one) coming from any point in the 
rarer medium are deflected in such a manner as to be less 
divergent after their refraction than they were before. 
The one ray not deflected is the one striking the surface 
vertically, hence coinciding in the radius or axis of that 
point of the surface. It is hence termed the amal ray. 









■b 








.-' 






















^ 


■'^ 




^ 


^s>-^ 


e 


a,-^ 


A 


B 


A 



Fig. S 




Fig. 28. 



In Fig. 38, let as be a point in the air from which rays 
proceed toward the convex surface b c separating the air 
from the glass. Let o be the centre of curvature of the 
refracting surface b e. Let the ray a c be vertical to the 
surface, i.e., coinciding with the direction of the radius 
oc; it will hence not be deflected from its course. The 
ray ab is, however, refracted. If o J is the radius of the 
surface, and is hence vertical to the point b, the angle of 
refraction /S o can be found by the formula 
sine fb : sine ab d = n : n' 

It is evident from Fig. 28, that if the point a be not too 
near t» the refracting surface, the refracted ray J/will verge 
toward the undeflected axial ray, and will meet it in some 
pomt which we will designate /. It can be shown by a 
mathematical analysis, that not only this one ray, but that 
all rays proceedmg from the point a toward the convex 
surface b c are so refracted as to meet, the axial ray at the 

38 



point/, provided we limit our analysis to those rays only 
which are not very oblique to the axis, and do not strike 
the surface far from the axis. With this provision, the 
point/ is the collecting point of all rays coming from a/ 
the point/ is therefore the image of the point as. If we 
trace, however, the course of the rays which are very 
oblique to the axial ray, or which strike the surface far 
from its axis, we will find that they meet the axial ray at 
various points different from /. Such a want of exact 
reunion of all the rays, when too large an extent of the 
refracting surface is exposed, constitutes the fault of optic 
instruments known as spherical aberration. The refrac- 
tion of such very oblique rays is represented, in a some- 
what exaggerated manner, in Fig. 29. 




Fio. 29. 

5. Focal Length. — When the luminous point is situated 
in the rarer medium at a distance infinitely great com- 
pared with the dimensions of the refracting surface, the 
different rays emanating from that point strike the refract- 
ing surface with so little divergence as to be practically 
parallel to each other. These parallel rays are rendered 
convergent by their refraction. The point where these 
refracted rays meet is called the principal posterior focus, 
and its distance from the refracting surface is the- posterior 
focal length. This distance, designated usually as F", 
depends on the relative indices of refraction of the first 
and second medium and on the radius of curvature of the 
refracting surface. If we call this radius r, the formula 
for the posterior focal length is 



F" =- 



n (3) 

The plane drawn through the posterior focus vertical tt 
the axis of the refracting surface is called the posieriot 
focal plane. 

As the luminous point moves nearer to the refracting 
surface, so as to make the incident rays more and more 
divergent, their focal reunion recedes further from the 
surface, until a certain point in front of the convex sur- 
face is reached, the rays proceeding from which are so 
divergent that they can no longer be rendered convergent 
by their refraction, but only parallel. Their point of 
focal reunion may then be considered as infinitely fai 
behind the surface. The point in front of the surface 
from which these rays proceed is the principal anterior 
focus, and its distance from the surface, which we will 
call F', is the anterior focal length. A vertical plane laid 
through it is the anterior focal plane. F' can be found by 
the formula 



F' = 



(2a) 



A comparison of formulae (3) and (2a) shows that the ante- 
rior and posterior focal lengths are noi alike under the 
circumstances, but that 

F' : F" = n : rC (2b) 

Remembering that the path of rays is the same, whether 
these rays travel forward or backward, the anterior focus 
can also be defined as the point in which rays unite, which 
proceed parallel to each other in the denser medium to- 
ward the refracting surface. 

6. The distance of the focal reunion from the refract- 
ing surface can be calculated for any set of rays, coming 
from any point, if we know the distance of that point 
from the surface, and also the anterior and posterior focal 
lengths of the refracting surface. If/' be the known di» 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 



Accommodation. 
Accommodation. 



tance of the luminous point, the distance of the corre- 
sponding focal reunion /" will be 

/ ~ fi pi (3) 

Conversely the distance of a luminous point, /", can he 
found, if we know the distance of its corresponding focal 
reunion or image/', according to the formula 

A very convenient formula for finding the place of the 
focal reunion of rays coming from a point at a known 
distance can be obtained by the transformation of (3) and 
(3a). If we designate the distance from the luminous 
point to the anterior focus, viz. : f'—F' as I' (counting I' 
negative if /' is nearer to the surface than F'), and the 
distance from the posterior focus to the point of focal re- 
union of the rays in question, viz. : /"— F" as I", then 

V I" = F' F" (3b) 

In all these instances the relation of luminous point and 
corresponding image can be reversed without change of 
position ; in other words, if the point x is the image of 
the point a, then for rays proceeding in the reverse direc- 
tion, a is also the image of the point x. Any two points 
having such a relation of luminous point and correspond- 
ing image, are called conjugate points. 

7. Virtuallmage. — When the rays, coming from a point 
nearer than the anterior focus, strike the refracting sur- 




Fio. 30. 

face, their divergence is too great to be entirely over- 
come by the refraction. They cannot therefore be united 
to form an actual image ; but if their direction, after the 
refraction, be prolonged backward, their prolongations 
meet to form a virtual image. The focal reunion of such 
rays is therefore negative. 

Thus, in Fig. 30, if F' be the principal anterior focus of 
the refracting surface s s', and/' the luminous point, the 
rays proceedmg from/' will have a divergence after their 
refraction, as if they came from the point /", which is 
therefore the image of/'. Since /" is on the same side 
of the surface as /', its distance is counted negative. It 
can be determined by formula (3a) or (Bb). 

8. Formation of Images. — Since an object is made up of 
an infinitely great number of points, and since of every 
such point in front of the refracting surface an image is 
formed somewhere behind the surface, therefore an image 
must also be formed of the entire object. Prom every 
point of the object there proceeds one ray, which is not 
bent from its course by refraction, viz. : the ray which 
strikes the surface perpendicularly, and hence coincides 
in direction with the radius of the point of the surface. 
Such rays are termed rays of direction Since all other 




Fio. 31. 



rays proceeding from any one point of the object meet 
the ray of direction at the corresponding distance of focal 
reunion, the Image of every point of the object is situated 
somewhere in the path of the ray of direction coming 



from that point. Since every ray of direction coincides 
with one of the radii of the refracting surface, the rays of 
direction must, therefore, like the radii, intersect at the 
centre of curvature of the surface. Since the focal length 
of a refracting surface is always greater than its radius, 
according to formulae (3) to (3a), therefore the actual 
images of objects farther off than the anterior focus are 
formed somewhere beyond the point of intersection of 
the rays of direction, and are hence inverted. This is 
illustrated by Fig. 31. 

The point where the rays of direction cross, viz. : the 
centre of curvature of the surface, is also called the optic 
centre. 

9. When the object lies in a plane vertical to the axis 
of the refracting surface, all points of the object near the 
axis are sensibly at the same distance from the refracting 
surface, as measured by the length of the rays of direc- 
tion. Their images are therefore likewise situated at 




Fio. 32. 



equal distances behind the surface, and hence lie in a 
plane vertical to the axis. But this is true only as long 
as the angle included between the ray of direction com- 
ing from that point of the object, and the axis of the re- 
fracting surface is so small as to permit the substitution 
of its chord for its arc without practical error. In the 
case of objects of dimensions exceeding this limit, the 
images lie in a curved line, with the concavity toward 
the refracting surface, as shown in Fig. 33. 

Such extensive images are blurred, on account of spher- 
ical aberration. (See Section 4.) 

10. Circles of Diffusion. — An image is sharply defined 
only in the plane of focal reunion of the rays. In any plane 
anterior to this the rays are not yet united ; in any plane 




Fig. 33. 



posterior to this the rays diverge again. Hence a screen 
placed in front or in the rear of the focal reunion receives 
a blurred image, since every point of the object is repre- 
sonted^not by a single point — but by a circle of diffu- 
sion. The size of the circles of diffusion increases with 
the distance of the screen from the point of focal reunion 
in either direction, and with the extent of the refracting 
surface through which rays pass. This is evident from 
Fig. 33. 

11. Size of Images. — The size of the image is to the size 
of the object as the distance of the image from the optic 
centre is to the distance of the object from the same point. 




B"- 



If we designate, in Fig. 34, the distance of the object A B 
from 0, the optic centre, as g', and the distance of the image 



39 



Accommodation . 
Accommodation. 



REFERENCE HANDBOOK OP THE MEDICAL SCIENCES. 



a b from o a.s g", we can express the relation of size by 
the formula ■ , ,,^ 

ab:AB = g'':g' (4) 

the truth of which is evident from the similarity of the 
two triangles A B o and a bo. For certain calculations 
the relation of size can be more conveniently stated as 
ab:AB:=f"-F": F' (4a) 

in which formula F" is the principal posterior focal 
length, and/" the distance of the image from the sur- 
face. The derivation of this formula is shown in Fig. 35. 




Fig. 35. 



For if we draw in this figure the ray A d from the 
point A parallel to the axis, it is refracted as if it were a 
ray coming from some point in the axis at an infinite dis- 
tance, that is to say, it is deflected to F" the posterior 
focus, and proceeds beyond F" until it meets the other 
rays coming from A in the point of focal reunion a. 
Thereby are formed the two similar triangles d c F" and 
a b F"- Hence, 

' ab:dc=f"F": e F" 
Since the line A d has been drawn parallel to B e, the side 
d c is equal in size to the object A B. If we substitute 
the term F" for the line c F", and the term/"— J?"' for the 
iinB f"F' according to our premises we get the equation 
ab:AB=f"-F" : F" 

12. Virtual Images.— When the object is nearer to the 
refracting surface than the principal anterior focus, there 
is no real image, but only a virtual image is formed on 
the same side of the surface as the object is itself. In this 
case/" is hence negative, otherwise the same formulse 
apply as above. Since the rays of direction do not cross, 
this virtual image is erect, and since it is always farther 
from the optic centre than the object, it is larger than the 
object. The amplification of the image diminishes as the ob- 
ject approaches the refracting surface, for when the object 
has just passed through the anterior focus the image 
is at an infinitely great distance, and is therefore in- 
finitely enlarged, while when the object touches the re- 
fracting surface, object and image coincide in position and 
size. The formation of virtual images is shown in Fig. 36. 







Fig. 36. 



18. All the facts above stated with reference to images 
formed in the denser medium of objects situated in front 
of the refracting surface, are equally true conversely of 
images formed in the rarer medium of objects situated 
behind the refracting surface. 

14. Bef Taction by Gonoane Bwrfaces. — When the refract- 
ing surface is concave on the side of the rarer medium, 
rays coming from any one point are not reunited in an 
actual focus. But if the direction which they assume 
after their refraction be prolonged backward, the pro- 
longed rays will meet in a point representing the focus. 
This focal length is therefore always negative, that is to 
say, the focus is alwws on the same side of the surface 
as the object itself. The position of the principal foci or 



any conjugate point of focal reunion can be found by 
the same formula as in the case of a convex surface, but 
these values are always negative, because the radius of cur- 
vature of the concave surface is negative in direction. 
The images formed by a concave refracting surface are 
hence always on the same side as the object, that is to 
■say, they are not real, but virtual, and can only be 
smaller than the object, as is shown in Fig. 37. 




Fib. 37. 



15. Refraction hy Successive Surfaces. — When light passes 
through a number of surfaces of different media, the 
above developed formulae apply to the refraction through 
each surface. Thus the focus of the first surface forms 
the luminous point for the second refraction, Its distance 
being counted positive when it is in front of the second 
surface, and negative when it happens to be behind that 
surface. Similarly the image formed by the second sur- 
face is the object for the third surface, and so on. But 
such calculations become very cumbersome if we try to 
follow a,ctually the course of the rays through their suc- 
cessive refractions. The matter is simplified by treating 
the series of surfaces as one system having certain fixed 
points, the position of which determines the path of all 
rays. These are called the cardinal points. Their posi- 
tion remains constant in any given system, and can be 
calculated, if the refractive indices of the media, the radii 
of curvature of all the surfaces, and the distances of all 
the surfaces from each other are known, provided the 
centres of curvature of all the surfaces lie in a straight 
line, the axis of the system. If the latter condition is 
fulfilled, the system is said to be centred. The cardinal 
points are the two foci, the two principal points, the two 
nodal points. 

16. The Foci. — The foci, anterior or first, and posterior 
or second, are the two points — one on either side of the 
system — at such distances that rays coming from the 
focus are rendered parallel to each other by their last 
refraction. Conversely parallel rays, entering the system 
from either side, are united in a point in the focus on the 
other side, as has been shown to occur in the case of a 
single refracting surface. The distance of either one of 
the foci of a compound system from the surface next to 
it may be computed in the following manner : Let n be 
the refractive index of the first medium, rii of the second, 
»a of the third, and so on. Let /S, be the first refracting 
surface, and ri its radius of curvature ; Si the second 
surface, and r^ its radius, and so on. The value of r is 
positive if the surface is convex on the side of the lumi- 
nous point ; negative if it is concave. Let di be the 
distance from the first surface to the second, d^ from the 
second to the third, and so on. Determine the foci of 
each surface by itself, without reference to the other 
surfaces. According to formulae (3) and (3a), we get for 
the first surface. 



F,' = 



nri 



Wi — ra 
and for the second surface 



andi?'i"=: 



rii ri 
fii — n 



F,' = 



Wi ?'a 



-andi'V' = 



n, ra 



— «! Wa — Wi 

The posterior focus for the first and second surfaces taken 
together will now be found by considering F^'' as the 

luminous point for 8, ; and, on applying the formula (3), 

jpii j>i 

viz., /' = , _ m" "^^ g^' t^6 equation 
Wf 4- 1" - J'»" id' - F," ) 



(5) 



40 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 



Accommodation. 
Accommodation. 



■w hich states the distance of the posterior focus of the 
system of surfaces Si and St from S2. The distance of 
ttie anterior focus of Si and S, together, from S,, is simi- 
larly found by the application of formula (3a), viz.,/' = 

-^ and following the light in the reverse direction, 



hence 



Fu+^y 



_ Fi'{di-F,') 

By treating the surfaces ^1 and 8, as one system, we can 
then proceed to determine the foci for (9 d + 2) and 8>, 
and so on. 

The foci of an optic system having been determined, 
the focal length is now measured by the distance of each 
focus from its corresponding principal point. If we call 
the anterior or first principal point H', and the posterior 
or second principal point H ", then F'H' is the anterior 
focal length, and H"F" is the posterior focal length. 

17. The Principal Points. — The principal pomts are 
the two points where the axis of the system is cut by the 
two .principal planes. The significance of the principal 
planes can be best explained on comparing the refraction 
by a single surface with the course of rays through a 
compound system. In the case of the single surface a b. 




Pig. 38, the ray F' a, coming from the anterior focus, is, 
by its refraction, made parallel to the axial ray F' F". 
Incident and refracted rays intersect here in the plane of 
the refracting surface. The same is true of the ray F" b 
coining from the posterior focus, and its continuation, 
b c, after refraction. In Fig. 89, however, where there 
are two refracting surfaces, a b and a' b', the ray, F' a, 
coming from the anterior focus, is twice bent from its 
course, viz., at each surface, so as to finally assume the 
direction a' d, parallel to the axial ray. In this .case the 
incident ray, F' a, and the refracted ray, a' d, do not 




intersect, being separated by the space between a and a' ; 
but if we prolong them through this space, their pro- 
longations intersect at the point h'. A plane, K H', laid 
through this point, vertical to the axis, is the first prin- 
cipal plane. Similarly, if we prolong the ray F" V, which 
proceeds from the posterior focus to the surface as' V, it 
will cut the backward prolongation of the refracted ray 
S c at the point li", which point determines the position of 
the second principal plane. It is evident, from Fig. 39, 
that the ray which before entering the system is directed 
toward the point h' in the first principal plane, has a 
direction after its last refraction as if it came from a point 
in the second principal plane at the same distance from 
the axis as the point K. Likewise the ray which proceeds 
in the opposite direction from F° toward the point h" has 
a direction, after its last refraction, as if it came from a 
point in the first principal plane at the same distance from 
the axis as the point h". This mutual relation of the 



two principal planes is the same for all rays, not merely 
those coming from F' or F'; and it is true also for any 
distance at which the points K and h," may be from the 
axis within the limitations of Section 4. In other words, 
any ray which is directed toward a given point in the 
principal plane, on the side from which It comes, ap- 
parently emerges from the other principal plane at the 
same distance from the axis. We can thus determine by 
construction the direction of any ray after its refraction 
through a compound system, and thereby find the place 
of the image formed by such rays, if we know the position 
of the foci and the two principal planes. In Fig, 40, let 





a./ 


u 


. 


nC 


\ 


1 




--^ /« 




rf" 




T ^-^ 


^ 


'•*> 






1 


^"^^^ 


~-~" — It 




^i^ 




W 


k 







Fig. 40. 

a a' be the first, and x x' be the last refracting surface 
of a compound system ; let H' be the first, and H' be 
the second principal point, F' the anteiior, and F' the 
posterior focus. Draw the axis F' F". Prom the point 
B there proceeds the ray B a, parallel to the axis, and 
verging toward the point m' in the first principal plane. 
Hence, after its last refraction, that ray has a direction as 
if it came from the point to" in the second principal plane, 
going through the posterior focus F". Another ray con- 
venient to follow is the one coming from B and passing 
through F'. This verges toward the point n' in the first 
principal plane. Hence, by its refraction, it is turned in 
the direction n" b, as if coming from m" and proceeding 
parallel to the axis. Where the two refracted rays meet, 
at the point b, is the image of the luminous point B. 

Since the course of rays is determined by their relation 
to these imaginary principal planes, the focal lengths of 
a system must be measured by the distance of each focus 
from its corresponding principal point, and not by the 
distance of the foci from the refracting surfaces. Indeed, 
for all subsequent purposes, we can practically ignore the 
position of the refracting surfaces of any system, after we 
have once determined the position of the foci and of the 
principal planes. For now all the problems relative to 
the position of object and image can be solved by the 
same formulae as in the case of a single refracting surface, 
by measuring the focal lengths from the principal planes. 

18. The position of the two principal points is deter- 
mined by the position of the two planes in which the 
images of a certain other plane are of equal size and 
direction. In every refracting system there exist only 
two such planes, and these are the principal planes ; and 
there exists, moreover, only one plane of which two 
images of equal size and direction are possible. Hence, 
in order to find the principal points, we must determine 
where a line must be in order to form two images of the 





1 


.•/ Uh. \,- 










1*---^ 


T' 




S' H< 


LH" S" 





Fio. 41. 

same size and direction, and then learn the place of these 
two images. 

This proposition can be demonstrated by means of Pig. 
41, in which we have a refracting system bounded by the 
surfaces s' 8' and s" 8". F' is the first and F" the second 
focus. Draw the ray F' c, which is deflected toward s" 
by the surface «' ^S", and is made parallel to the axis by 
the surface «" 8". By the intersection of the prolonged 
incident and refracted rays the point h' determines the 



41 



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REFERENCE HANDBOOK OP THE MEDICAL SCIENCES. 



positioQ of the first principal plane. Similarly a reverse 
ray going from F" to e is bent twice, so as to follow ulti- 
mately the direction s' b parallel to the axis. The pro- 
longations of the ray before entering and after leaving the 
system give us the point h", and thereby the position of 
the second principal plane. If we draw a line d d' verti- 
cal to the axis from the point d, where the rays coming 
from each side intersect after their first refraction, the 
virtual image of d d' produced by the surface »' 8' coin- 
cides with the first principal plane A' !£, while the image 
formed by the surface s" -S" coincides with the second 
principal plane h" S", as is evident from the refraction 
of the rays according to the construction ; and these two 
images are aUke in size. The distance of d' from each 
surface is determined by the equation (4a). 

a b (image) : A B {object) =f' — F" : F" 
or more conveniently on account of the erect position of 
the virtual image, 

ab : AB = F" —f" : F" 
Each surface is here considered independently of the 
other. Hence it can be deduced that the distances of d' 
from each surface must be to each other as the focal 
lengths of the surfaces, in order to have the images formed 
by the two surfaces of equal size. This is shown in Fig. 




Via. 4S. 

4Si, where P' ,S" is the focal length of the surface s" 8" in 
the medium between the two surfaces and P' 8' ot the 
surface s' 8'. 

A consideration of the two triangles P 8" i' and P" 8' «' 
and their segmentation by the lino d d' proves that 

d' 8' . d' 8" - P" 8' : P 8" (6) 

Hence, in order to find the principal planes of a system, 
determine the position of a point in the axis, the distances 
of which from the two refracting surfaces are to each 
other as the focal lengths of these surfaces in the medium 
between them. Then calculate the place of the images 
of this point formed by each surface independently of the 
other, according to formula (3). 

When the optic system consists of more than two re- 
fracting surfaces, determine the principal points for two 
adjoining surfaces, and then divide the distance between 
the one principal point next to the third surface and the 
third surface into two parts, which are to each other as the 
corresponding focal lengths in the intervening medium. 
The images of the dividing point formed independently 
by the third surface, and by the system of the other two 
surfaces are then the principal points of the system of 
three surfaces. 

19. The Nodal Points. — The nodal points of a compound 
system replace the optic centre of a single refracting sur- 
face. For while all rays of direction pass undeflected 
through the optic centre of a single surface, a second sur- 
face will deflect all rays with the exception only of the 
axial ray. Hence a single optic centre cannot exist in a 
compound system. But there exist two points in the 
axis, viz. , the nodal points, of such properties that a ray 
directed toward the first before entering the system pur- 
sues a course after its final refraction as if it had passed 
through the second nodal point parallel to its original 
direction. 

That a pair of points of such properties must exist in 
any compound system is evident from Fig. 43, where F' 
is the first and F" the second focus, and m' E! n' the first 
and m" R" n" the second principal plane. A ray B m', 
coming from the luminous points B, forms with the re- 
fracted ray m" b any angle of less than 180° as seen from 



below, while the ray B n' forms with its refracted pro- 
longation n' b an angle greater than 180° as seen from be- 
low. Somewhere between m! and n' there must be a 




Fia. 43. 

level where the incident ray includes with its continua- 
tion beyond the second principal plane an angle of 180° 
exactly, in other words, where the two are parallel. Let 
this be at the level V. If we prolong the incident ray 5?, 
the points where this prolonged ray and the refracted ray 
I" b cut the axis, viz., K' and K" answer the require- 
ments of the nodal points. The position of the nodal 
points relative to the principal points is made evident in 
Fig. 44. 

In this figure we will draw the line B F' on F' vertical 
to the axis. From the point B there proceeds a ray of 
direction B K' to the first nodal point K'. According to 
our premises the ray K' b must be parallel to B K and 
in the direction E" b lies the image of B, at an infinite 
distance from the optic system. Since the point B lies in 
the anterior focal plane, every ray proceeding from it is 
rendered parallel by its refraction to the ray of direc- 
tion coming from B. Hence the ray B K parallel to the 
axis is continued after passing through the second princi- 



IC V 




pal plane, as h" F" parallel to K' b, and hence also to 5^. 
From the similarity of the triangle B F' IC and A" E" F" 
it is evident that the distance 

F' K' = E" F" (7) 

and by reversing the figure and constructing the course 
of rays coming from the posterior focal plane, we can 
similarly learn that the distance 

F' K" = S F' (7a) 

and that hence 

E E" = K'K" (7b) 

which latter corollary is also apparent from Pig. 43. 
The position of the nodal points can hence be at once 
learned by formulse (7) and (7a), after knowing the posi- 
tion of the principal points and of the foci. And thus we 
have all data necessary to follow the course of rays 
through any compound optic system. 

20. Lenses. — It will be best to refer briefly to the optic 
properties of glass lenses before we proceed to the eye 
itself. According to the curvature of their surfaces and 
the distance between them, lenses either reunite into one 
point all the rays coming from one point, or disperse 
them. The former, or collecting lenses, have a positive 
focal length. They form inverted actual images of dis- 
tant objects, and erect, virtual, and enlarged images of 
objects nearer than their focus. The latter, or diverging 
lenses, have a negative focal length, and can form only 
erect, virtual images, smaller than their object. When 
both surfaces of a lens are convex, or one is convex and 
the other plane, the lens belongs to the former variety ; 
when one surface is concave and the other plane, or when 
both are concave, we have a diverging lens with negative 
focus. When one surface is convex and the other con- 
cave, the positive or negative value of the resulting focal 
length depends not only on the curvature of the two sur- 
faces, but also on the distance between them. 



42 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 



Accommodation. 
Accommodation. 



The refractive index of the glass used for spectacles is 
so near 1.5 that we can calculate on that basis without 
important error, at least for spectacles. Taking this in- 
dex we find that in a plano-concave, or plano-convex lens, 
the focal length is twice the length of the radius of the 
curved surface, measuring from the curved surface, ac- 
cording to formula (2) or (3a). The first and second focal 
lengths are of course equal to each other, when the lens 
is surrounded by the same medium on both sides, accord- 
ing to (3b). The distance of the foci from the plane sur- 
face is, however, not the same as from the curved surface, 
for the focal lengths are measured from the principal 
points, one of which coincides with the curved surface, 
while the other is between the two surfaces. But for 
most of our purposes we can ignore the thickness of the 
glass lenses, as long as this is slight compared with the 
other dimensions, and practically measure the focal 
length from the surface, or, indifferently, from the cen-- 
tre of the lens. If, hence, we express the focal length of a 
plano-convex lens as 

F' z= F" = 2 r 
we get for a bi-convex lens the formula 



F = 



r + rj 



If the radii of curvature of the two surfaces are alike, we 
find the focal length equal to the radius, provided the in- 
dex of refraction is practically 1.5. This applies simi- 
larly to biconcave lenses, F being, however, negative. 
In lenses with one convex and one concave surface, the 
measurement of the focal length is not quite so simple, 
because the thickness of such a lens cannot be ignored 
without error, and the principal points can in such a 
combination be outside of the substance of the lens. 

The so-called strength of lenses is measured differently, 
according to the unit which we adopt. Formerly a lens 
of the focal length of one inch — either negative or posi- 
tive — was taken as the standard and called 1. Any lens 
of longer focal distance could only be named in fractions, 
i, being one-half of that strength ; that is to say, having 
a focal distance of two inches, and -i^ having twelve inches 
focal length, while a stronger lens, greater than 1, had a 
corresponding shorter focal distance. Since the adoption 
of the metric system in ophthalmology, the opposite way 
of enumeration has been employed. A lens of the focal 
length of one metre is now taken as unit, and called one 
dioptric, or 1 D. Any lens of longer focal length is ex- 
pressed in a decimal fraction, thus, 0.35 D, means a lens 
of 4 metres focal length. The stronger lenses, on the 
other hand, are measured by several dioptrics ; thus, 
10 D, being a lens of -iV metre, or 10 centimetres focal 
length. Since both systems of measurement are yet in 
use, it is best to become familiar with both. As regards 
the convenience in calculation, for which purpose the 
dioptric system was introduced, there is i-eally not much 
difference between them. In order to convert the num- 
ber of a lens from one system into another, it is to be 
remembered that the metre is equal to 39.37 English 
inches, or 36.94 French inches. On account of inaccura- 
cies in grinding glasses, the whole number, 40 (English), 
and 36 (French), are close enough for practical purposes. 
Hence, to get the dioptric equivalent of an English num- 
ber, divide that number into 40, and to translate a certain 
number of dioptrics into the French inch system, divide 
the number into 86. 

31. In order to examine the refraction in the eye we 
must determine the refractive indices of the different 
media, the curvature of the surfaces, and the distances 
between the separate surfaces. 

23. Bef r active Indiees of fhs Media of the Eye. — The re- 
fractive indices have been measured by various observers 
in dead eyes by means of different physical methods. On 
account of less perfect methods former results must be 
taken with some caution. Even the more recent deter- 
minations made with Abbe's refractometer have yielded 
not inconsiderable discrepancies amongst different ob- 
servers, which may perhaps be attributed to individual 
variations. The following table of refractive indices is 



copied from Zehender and Matthieson.' 
complete of all recent determinations. 



It is the most 





1.3770 
1.3772 

1.3721 

1.8754 


1^ 

1- 


S 
f 


Lens. 




1.3348 
1.3342 

1.3340 
1.S848 




Subject. 


h 


1.4087 
1.4067 
1.4044 
1.4044 
1.4056 
1.4062 
1.4076 

1.4018 
1.4078 

1.4059 


!5 


h 


Male, 50 years, I.... 

Female. 45 years.!!; 

Female, 26 years, . . 
Male, I..... ..... .. 


L.8338 


1.3600 

1.3821 

1.3780 


1.3953 
1.8853 

1.3867 
1.3902 

1.3980 

1.3811 


1.4181 

1.4il2 
1.4094 
1.4164 
1.4077 
1.4091 
1.4096 
1.4101 
1.4107 


1S45S 
1.3658 

1.8508 
1.8672 

1.3547 




Unknown,! 

Female, 45 years, !.. 

ChUd of two days, i! 
II. 




Average 


.3^ 


1.3734 1.SS86 


1.4106 


1.888J 



The indices of cornea, aqueous humor, and vitreous 
body are so nearly alike that an average index of the three 
can be used as a basis for calculation without appreciable 
error. Helmholtz assumes 1.3365 as the most nearly cor- 
rect average in his latest publication. While the index of 
the capsule of the lens is considerably above this figure, 
this membrane is so thin and its surfaces so nearly paral- 
lel to each other that its influence on the rays can be 
neglected without error. The index of the lens itself in- 
creases from the external layer to the nucleus, so that the 
lens really consists of a large number of layers of in- 
creasing optic density. By reason of this stratified ar- 
rangement the total refractive power of the lens is greater 
than it would be were the entire lens of the refractive 
index of its nucleus. For each layer, as we proceed to- 
ward the nucleus, increases not only in refractive index 
but also in convexity. This is evident when we compare 
the following two lenses, the thickness of which must 
not be more than a small fraction of the focal length. Let 
one of these lenses. A, be homogeneous and have the re- 
fractive index n", the index of the surrounding medium 
being n, while the other lens, B, has only a core or nucleus 
more convex than the surface of the lens of the index »", 
the superficial layer having an index n' , intermediate be- 
tween n and n . If n' is now very nearly equal to n, 
we have practically a lens of the same index as that of 
the lens A, but of shorter radius of curvature, and hence of 
shorter focal length. If n', however, is very nearly equal 
to n", the lens B will be practically of the same strength 
as the lens A, but never less. Hence, no matter in what 
ratio the index increases as we proceed toward the nu- 
cleus, the lens gains thereby in strength. The special ad- 
vantages of tliis stratification over a homogeneous lens is 
the more regular refraction of rays very oblique to the 
axis, as has been shown mathematically by Hermann.' 
Thereby the images of objects situated laterally from the 
axis of the eye are not distorted as they would be when 
projected by a glass lens. The actual refraction of the 
excised human lens was found by Helmholtz in two 
measurements to be equal to that of a homogeneous lens 
of the same curvature, but with a refractive index = 1.4519 
and 1.4414. But in his latest estimate (1874) he adopts 
1.4371 as the more nearly correct average total refractive 
index of the lens in its normal attachment during life. 

33. Curvature of the Ocular Surfaces. — The curvature 
of the surfaces cannot be measured vrith accuracy in the 
dead eye, on account of the altered tension of the eyeball. 
In the living eye the curvature can be calculated from a 
measurement of the size of images reflected from the sur- 
faces. The cornea, for instance, acts as a polished con- 
vex mirror, producing diminutive images, apparently 
behind its surface. The size of such an image is to half 
the radius of curvature of the mirror as the size of the 
object is to the distance of the object from the cornea. 
The size of the image is most conveniently measured by 
means of Helmholtz's ophthalmometer. This consists of 
a telescope, in front of which there is a thick plate of 
glass with parallel surfaces, which has been cut in two, 



43 



Accommodation. 
Accommodation. 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 



so that the line, separating its two halves, exactly bisects 
the field of the telescope. The two plates can be turned 
on an axis vertical to the line of separation. As long as 
the two plates are practically one, that is to say, lie m 
one and the same plane, objects are seen through them m 
their natural shape ; but when the two plates are turned 
in opposite directions, the objects appear split into two 
halves, which are displaced laterally in opposite direc- 
tions, in proportion to the rotation of the plates. The ex- 
planation of this displacement has been given in Section 3. 
For actual use the ophthalmometer is directed toward the 
observed eye, at a distance of several metres, and the 
images of two lights, one placed on either side of the tele- 
scope, or, rather, the ideal line uniting the two lights, 
are observed as reflected from the cornea. The two 
lights are, of course, placed in the prolongation of the 
line separating the two glass plates of the instrument. 
These plates are then turned by a screw until the image 
is doubled ; that is to say, until the two halves are dis- 
placed laterally through the open space occupied by the 
image. From the observed degree of rotation, and the 
thickness of the plates, the extent of displacement, and 
hence the size of the image, can be calculated, and there- 
by the radius of curvature of the cornea be determined. 

The radius of curvature, measured by reflection from 
the middle portion of the cornea, has been found to vary 
in different ej'-es from 7 to 8.2 mm., an average 
near 7.8 mm. being the most common. No deflnite 
relation has been found between this radius and any ex- 
isting ametropia. On observing the reflection from the 
marginal portion of the cornea, it can be seen, even with 
the unaided eye, that the images are larger than in the 
centre ; that is to say, that the convexity of the cornea 
diminishes from the centre toward the periphery. The 
cornea is therefore not a segment of a sphere, but of an 
ellipse, the major and minor axis of which are to each 
other in the ratio of about 9 to 10 or 11. The posterior 
surface of the cornea is found in the dead eye to be nearly 
concentric with the anterior surface. This fact, in con- 
nection with the rather slight difference in the indices of 
cornea and aqueous hrnnor, allows us to consider the 
cornea, aqueous humor, and vitreous body as one opti- 
cally homogeneous medium, bounded hy a single surface. 

The radius of curvature of the anterior surface of the 
lens has been found to vary between 9 and 12, and, ex- 
ceptionally, even 14 mm. ; and that of the posterior sur- 
face between 5.5 and 6.5 mm. The images reflected 
from these surfaces are so faint, on account of the small 
difference in the refractive indices of aqueous humor and 
lens, that the ophthalmometer can be used to advantage 
only with sunlight. The apparent size of these images 
requires a correction, for the cornea and aqueous humor 
act as a magnifying lens, interposed both in the path of 
the rays from the object to the reflecting surface, and, 
again, between the latter and the ophthalmometer. In 
the case of the images reflected from the posterior sur- 
face of the lens, the substance of the lens must also be 
taken into account as part of the magnifying system. It 
is necessary hence to know the distance from the cornea 
to the anterior surface, and from the latter to the pos- 
terior surface of the lens, in order to calculate the radii 
of curvature. The posterior surface of the lens acts as a 
concave mirror, giving an inverted and very small image; 

24. Distances between the Befracting Surfaces. — The dis- 
tance of the anterior surface of the lens from the cornea 
has been determined according to various methods by 
Helmholtz and his pupils. By means of a focussing 
microscope with graduated screw, or by means of the 
ophthalmometer with the aid of movable lights, it was 
learned how far the rim of the iris appears behind the 
cornea, and the true position of the pupil was then calcu- 
lated from the known refractive power of cornea and 
aqueous humor. Values between 3.2 and 4 mm. have 
been found in different eyes. Helmholtz adopted 3.6 mm. 
as a sufficiently accurate average to use in his diagram- 
matic eye. The distance of the posterior surface of the 
lens from the cornea can be measured only by compli- 
cated methods, based on the observation of the parallax 
between the reflection from the cornea and that from the 



posterior surface of the lens, and by taking into account the 
influence of cornea, aqueous humor, and lens-substance on 
the rays. It has been found to approximate very closely 
to 7.2 mm., which gives 3.6 mm. as the average thickness 
of the lens (while the eye is not accommodating). The 
lens taken out of the eye increases in thickness on account 
of elastic retraction, as will be explained in the article on 
accommodation. 

25. Diagrammatic Eye. — "We learn thus that there are 
noticeable differences in the optic constants of normal 
eyes, so that two eyes, both emmetropic, are not neces- 
sarily identical in construction. But within the latitude 
of emmetropic eyes the deviations of the different figures 
from the average counterbalance each other, so that the 
object, the formation of sharp images of distant objects in 
the plane of the retina, is equally attained in all. From 
numerous measurements made by himself and others, 
Helmholtz has constructed the following diagrammatic 
eye, corresponding to the average figures of human em- 
metropic eyes : 

Hi11imeti<es. 

Refractive index of cornea, aqueous, and vitreous humor 1.3365 

Befractive index of the lens as a whole 1.4371 

Badius of curvature of the cornea 7.829 

Radius of curvature of the anterior surface of the lens 10. 

Radius of curvature of the posterior surface of the lens 6. 

Distance from the anterior surface of the cornea to the lens 3.6 

Thiclvness of the lens 3.6 

From these data are computed : 

Anterior focal length of the cornea, aqueous and vitreous humor, S3.S66 
Posterior focal length of thecornea, aqueousand vitreous humor, Sl.OiJo 

Focal length of the lens (in place) 60.671 

Distance of first principal point of the lens from its anterior sur- 
face 2.12 

Distance of second principal point of the lens from its posterior 

surface 1.274 

Distance of the first principal point B' of the entire eye behind 

the cornea 1.760 

Distance of the second principal point S^^ of the entire eye be- 
hind the cornea 2.1 ir 

Distance of the first nodal point K' of the entire eye behind the 

cornea 6.96** 

Distance of the second nodal point K" of the entire eye behind 

the cornea 7.33^ 

Anterior focal length of the entire eye 15.50.'*' 

Posterior focal length of the entire eye 20.71b 

This latter figure plus the distance of H" from the cor- 
nea gives us 22. 834 mm. as the optic axis from the anterio/ 
surface of the cornea to the sensitive plane of the retiua, 
and adding to this number the thickness of the sclerotk 
coat, viz. , 1 . 3 mm. , we obtain about 24. 1 mm. as the length 




Via. 46. 

of the eyeball. Anatomical rheasurement has fihoWn tht 
eyeball to vary between 32.5 and 27 mm. in length, 
24 to 24.6 mm. being the most common limits. Unfor- 
tunately these anatomical measurements refer mostly to 
eyes the refractive state of which was not determined 
during life. The diagrammatic eye of Helmholtz and the 
position of its cardinal points is illustrated by Fig. 45, 
amplified twice. 

26. In the calculation of the size of retinal images and 
of the influence of glasses on sight, in fact, in almost all 
the problems not relating to the changes during accom- 



Ad. 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 



Accommodation. 
Accommoctation. 



modation, we can arrive at results sufficiently accurate by 
taking as a basis the simplified diagrammatic eye of Don- 
ders, in which the lens is omitted. It consists of a single 
refracting surface, representing the cornea with a radms 
of curvature of 5 mm. The single internal medium, opti- 
cally identical with the cornea, has a refractive index of 
1.333 (J). Thereby we deal with but one principal 
point, viz., in the plane of the cornea, and hut one nodal 
point, the centre of curvature of the cornea. The first 
focal length is 15 mm., the second 20 mm., which latter 
figure represents likewise the length of this eye. 

The human eye has some advantages not possessed by 
artificial optic instruments, but also various faults which 
a skilful optician can avoid. 

27. Visual Meld. — There exists no instrument which has 
as extensive a field as the eye, since Images are depicted 
on the retina of objects situated as far as 55 to 65 degrees 
from the line of direct sight, and on the temporal side even 
as far as 90 to 100 degrees. The fact that images formed 
near the periphery of the retina are not seen distinctly, is 
due principally to the relative dulness of sensibility of 
the peripheral portion of the retina. The images them- 
selves are quite sharp, as we can learn by examining the 
periphery of the retina in the eye of another person with 
the ophthalmoscope. When the refraction is emmetropic 
in the centre of the retina, it is very nearly so also in the ex- 
treme periphery. This is due to the elliptical curvature of 
the rear of the eyeball and of the retina (compare Section 
9). Moreover, the elliptical curvature of the cornea, and 
still more the stratified structure of the lens prevent the 
distortion of images, which ordinary spherical, homoge- 
neous lenses would produce in the case of objects situated 
far laterally from' the axis of the system. 

28. Splierical Aberration. — Spherical lenses do not col- 
lect in the common focus those rays which are very 
oblique to the axis or strike the refracting surface far 
from its centre. This spherical aberration is shown in 
Fig. 29. In the eye it is almost wholly obviated by the 
elliptical shape of the cornea and the stratification of the 
lens. The iris, moreover, serves the purpose of a dia- 
phragm, so that the extreme marginal rays cannot ordi- 
narily pass through the pupil. 

29. Chromatic Ah&rration. — The chromatic aberration 
of lenses gives rise to colored rings around images other- 
wise well defined. It is due to the fact that the index of 
refraction is not the same for waves of light of different 
length. Hence there is necessarily a slight separation of 
the different colors when mixed or so-called white light 
is refracted by a lens. The eye is not free from this de- 
fect ; it possesses it to about the same extent as if it con- 
sisted of water. If either end of a sharply defined 
spectrum be observed through an achromatic telescope, 
the other end appears diffuse until the adjustment of the 
telescope (or of the eye) is altered. The difference in ad- 
justment corresponds to about 1.5 to 2 dioptrics ; that is 
to say, an eye forming a sharp image of an object emit- 
ting violet light, requires an additional convex lens of 
some 75 to 50 centimetres focal length, in order to bring the 
less refrangible red rays into a focus upon the retina. Or- 
dinarily we are not conscious of this defect, because the 
eye is adjusted for the middle and brightest portion of 
the spectrum, viz., yellow and green to blue, while the 
red and violet rays form circles of diffusion around the 
Image, which blend, and thereby diminish in distinctness 
of color, being, moreover, much less bright than the 
sharply defined image which they surround. But we 
can see these colored circles of diffusion quite distinctly 
on looking at some bright object, while covering one-half 
of the pupillary aperture with an opaque screen, for by 
thus cutting off half of the pencil of light, we prevent the 
blending of the color-rings, and the object shows then a 
blue edge on one side and a yellow margin on the other. 
The chromatic aberration is also quite noticeable on ob- 
serving a luminous point through a violet glass, which 
absorbs the middle part of the spectrum, whereupon we 
see either a red point surrounded by a blue halo, or a red 
margin around a blue point of light, according to the re- 
fractive state of the eye. 

30. Imperfect Centring . — The optic system of the eye 



is not perfectly centred. The centre of the cornea coin- 
cides, indeed, with the vertex of its ellipse ; but the majoi 
axis of this ellipse forms an angle with the visual line, or 
line of direct sight ; that is to say, the line of the ray of 
direction passing from an observed point through the 
nodal points to the centre of the retina. The visual line 
deviates toward the nagal side of the corneal axis (pro- 
ceeding outward) to an extent of 4 to 8 degrees. This 
relatively oblique direction of the corneal axis, when ex- 
treme, may give some eyes a false appearance of diver- 
gent squint. Still no noticeable deficiency of sight can be 
attributed to this want of centring. 

31. Astigmatism. — ^More serious defects are those due 
to irregularities in the curvature of the refracting surfaces. 
We have so far considered only the refraction of rays 
which lie in one plane, with the tacit assumption that our 
refracting surfaces are the surfaces of true bodies of ro- 
tation, that is to say, that the radii of curvature are equal 
in all meridians. For, in this case, any of the figures 
illustrating the course of rays in the plane of the paper, 
may be supposed rotating on their axis in order to illus- 
trate the course of rays in all planes. But this assumption 
is scarcely ever correct in the case of the human eye. On 
measuring with the ophthalmometer the corneal radius 
of curvature in the horizontal, and then in the vertical 
meridian, the two radii are found to differ from each 
other to a trifling extent even in the most normal eyes. 
More commonly, but not always, the radius is smallest in 
the vertical direction. The two meridians presenting the 
greatest discrepancies are not necessarily horizontal and 
vertical ; they may have any inclination. A difference 
of 0.1 mm. between the radii of two meridians at right 
angles to each other, separates the focus of one meridian 
from that of the other to the extent of about 0.3 mm. 
Differences of 0.01 to 0.05 mm. in the radii are the most 
common. The cornea is hence the segment of an ellip- 
soid with three unequal axes. As a result, the focal 
length is not the same in any two meridians of unequal 
curvature, and hence the points of an object cannot be 
represented by points in the images formed in such an 




B 



eye. If in Fig. 46, A, we represent the ellipsoid cornea 
with the horizontal meridian A h having a greater radius 
of curvature than the vertical meridian » «, the focus in the 
former meridian /A must be further off than/«, the focus 
of the vertical meridian. If we place a screen successively 
in the positions numbered 1, 2, 3, 4, and 5, the image of a 
distant point would appear as shown in an exaggerated 
manner in Fig. 46, B, 1, 3, 3, 4, and 5. The refraction 
by such an ellipsoid cornea can be imitated by means of 
an ordinary spherical lens, to which is added a cylindrical 
lens, the segment of a cylinder, thereby introducing a 
difference in the refractive strength in the two meridians, 
of which one is parallel with, and the other at right angles 
to, the axis of the cylinder. This defect of the eye is known 
as the regular astigmatism (from a, privative, and <rTiyti.a, 
a point). There are very few, if any, eyes entirely free 
from it. When the inequality in the refraction of two 
meridians exceeds the strength of about one-half to one 
dioptric, it may necessitate correction by means of cylin- 
drical glasses (see under Astigmatism). As the result of 
regular astigmatism, lines of different inclination are not 
seen equally distinctly. If, for instance, the eye be ac- 
curately emmetropic in the horizontal meridian, while 
the greater curvature of the vertical radius brings the 



45 



Accommodation. 
Accommodation. 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 



focus behind the retina in the latter meridian, then only 
horizontal lines at infinite distance will be sharply defined 
on the retina, while the more a line approaches the ver- 
tical direction, the more diffuse will be its retinal image. 
The interference with sharp sight increases, of course, 
with the degree of astigmatism. A discrepancy between 
two meridians amounting to less than half a dioptric does 
not Interfere with sight to any practical extent. 

Irregular Astigmatism gives rise to such slight imper- 
fections of retinal images as the radiation of "rays" 
around stars and other small luminous points. It is due 
to optic inequalities in the different sectors of the lens, 
whereby some of the rays are deflected from the path 
which they would pursue in a perfect eye. This ir- 
regular astigmatism does not exist after the lens has been 
removed. 

32. MuseoB Volitantes. — Few, if any, eyes do not at 
times see flying specks, so-called muscse volitantes. They 
appear in the form of transparent rows of beads or groups 
of granules, or simply shadowy streaks floating about 
when the eye Is moved. They are due to the presence 
of similarly shaped objects floating in the vitreous body, 
cells and groups of cells, and shreds of membranes, 
transparent, but of an index of refraction slightly dif- 
ferent from that of the medium surrounding them. 
Their rims hence cast shadows similar to those of a glass 
ball between a light and a screen. These shadows are 
most marked when the rays of light are parallel in the 
vitreous body, when the source of light is in the anterior 
focus of the eye. We can observe them well by using 
as source of light a pinhole in an opaque screen held close 
to the 6ye and toward the sky, or on looking into a 
microscope. When the attention has once been called 
to them they may continue to annoy nervous persons, 
mentally rather than optically. These shadows, even if 
inconvenient, are not Indicative of any disease. 

33. Ametropia. — The last and most important imperfec- 
tion of the eye is the not uncommon want of harmony 
between the focal length and the anatomical length of the 
eyeball, the refractive defect known as ametropia. We 
have seen that the radii of curvature, the distance from 
cornea to lens, the length of the eyeball, and perhaps even 
the refractive indices, may vary within certain limits in 
different eyes. It is only in the more fortunate instances 
that the ideal result, viz. : the coincidence of tlie posterior 
focal plane with the position of the retina, Is obtained, 
while in many eyes, otherwise healthy, the images of dis- 
tant objects are formed, either in front of the retina, con- 
stituting inyopla, or behind the retina, the condition of 
hypermetropia. In either of these two cases the retinal 
images of distant objects are blurred in proportion to the 
distance of the retina from the focal plane, and in propor- 
tion to the size of the pupil. The lower degrees of ame- 
tropia may be due to an unproportional curvature of the 
corneal and lenticular surfaces, while the length of the 
eyeball Is normal ; but when the anomalies of refraction 
reach any high degree, the eyeball is found, not merely 
relatively, but absolutely too long in myopia, too short in 
hypermetropia. 

While emmetropia is the most fortunate refractive con- 
dition, it is not necessarily the most common. Statistics 
show that in the upper classes of schools, and especially 
high schools, in European countries, from one-third to 
one-half, and sometimes even two-thirds of the eyes are 
near-sighted, and some five to ten per cent, are far-sighted. 
In this country the figures are a little more favorable, as 
regards the frequency of emmetropia. Puller details of 
these statistics vdll be given under the heading Myopia. 

34. Befraetion during the Qrowih of the Eye. — In the 
infantile eye all the dimensions are, of course, smaller 
than in the adult organ. The shorter axis of the eyeball 
is, liowever, proportionate to the shorter radii of curva- 
ture of cornea and lens, so that emmetropia can exist. 
Indeed, during childhood there are more emmetropic eyes 
than in adult life. The eyes of babes, however, are most 
frequently far-sighted, as shown by ophthalmoscopic ex- 
amination. Jaeger formerly asserted the contrary, hav- 
mg found 78 eyes myopic out of 100, and but 5 accurately 
emmetropic in new-born babes. He seems to have been 

46 



misled however, by the accommodated condition of the 
infantile eye, for later observers, who paralyzed the ac- 
commodation by means of atropia, have arrived at differ- 
ent results. Thus Eli^ found but 11 eyes myopic, 17 
emmetropic, and 72 hypermetropic in 100 eyes of infants. 
Bjerrum * noted 61 hypermetropes, 23 emmetropes, and 3 
myopes on examining 87 babes. Horstmann' found in 
50 new-born infants 88 far-sighted eyes, 10 emmetropic, 
and but 2 short-sighted eyes. In 50 children, of the age 
of one to two years, 84 eyes were far-sighted, 10 normal, 
and 6 short-sighted ; while in 50 children, four to five 
years old, hypermetropia had diminished, involving 74 
eyes ; myopia had Increased to 13 eyes ; 13 eyes being 
emmetropic. These figures show that the refraction in- 
creases ordinarily as the child advances in years. During 
the years of school attendance this growth leads, in many 
instances, to a myopic refraction. Indeed, as we pass 
from the lower to the higher classes in schools, we find 
myopia increasing steadily in frequency and in degree. 
The refraction remains stationary from the time of pu- 
berty, in healthy eyes. The increase of myopia so often 
noted from this time on until about the thirtieth year must 
be considered a morbid change. 

35. Beyond the sixtieth year of age the refraction di- 
minishes again, so that emmetropia turns into slight hy- 
permetropia, on account of senile changes In the lens. 

36. Accommodation. — According to the laws of refrac- 
tion, the emmetropic eye can form sharp retinal Images of 
those objects only which are situated at an infinite dis- 
tance from the eye, or at least at a distance very large 
when compared with the dimensions of the refracting 
surfaces. Practically this amounts to any distance beyond 
five metres. But every-day experience teaches us that we 
can also see distinctly objects quite close to the eye ; but 
we can never see equally distinctly, and at one and the 
same time, two objects, one far and the other near. On 
looking at a. distant sign through a veil held in front of 
the eye, we can get alternately sharp images of the distant 
letters or of the threads of the adjacent veil, but we can- 
not see them both distinctly at one and the same time. 
This power of successive adjustment of the eye for dis- 
tant and adjacent objects is termed the faculty of accom- 
modation. 

The exertion of the accommodation Increases for the 
time being the refractive strength of the eye. It is evi- 
dent that an eye accommodated for an object four inches 
distant must be equal in refractive strength to the emme- 
tropic eye plus the strength of a convex lens of four 
Inches focal length. For were the eye deprived of its 
power of accommodation it would be necessary to add to 
it the strength of this lens in order to get sharp retinal 
images of objects four inches off. The accommodative 
effort of an eye can therefore be represented by the 
strength of a convex lens of a focal length equal to the 
distance from the eye to the object accommodated for. 

37. Oliangea in the Eye during Accommodation. — The 
optic changes upon which accommodation depends occur 
solely in the crystalline lens. Neither the corneal curva- 
ture nor the position of the retina is altered. Removal 
of the lens deprives the eye completely of its power of 
accommodation. Any eye, except one extremely myopic, 
becomes highly hypermetropic upon removal of the lens, 
requiring then a strong convex glass in order to see dis- 
tinctly at a distance. On account of the impossibility to 
accommodate, the strength of this glass must be increased 
for near objects, and with a given glass accurate sight is 
possible on^ at one given distance. If the individual can 
read at different distances, it is done by ignoring the 
circles of diffusion, especially when they are small, on 
account of a narrow pupil. The most rigid test, whether 
in this or any other case an eye is adjusted for a certain 
distance, is known as Scheiner's experiment. 

88. Scheiner's. Experiment. — If some luminous point — 
for instance, a pin-hole in a screen in front of a light— be 
viewed through two pin-holes in another screen which 
are closer together than the diameter of the pupil, the 
only effect of the latter screen held close to the eye will be 
to diminish the number of rays, and thereby reduce the 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 



Accommodation. 
Accommodatiou. 




Fie. 47. 



brightness of the retinal image, if the latter be sharply de- 
fined on account of proper adjustment of the eye for the 
light. But if the eye is not adjusted for that distance, 
and circles of diffusion are formed on the retina, the 
screen with two perforators will cut off the rays forming 
the middle por- 
tion of the dinuse 
image, leaving 
instead two sepa- 
rate images of the 
luminous point, 
to which the eye 
is much more 
sensitive than to 
the circles of dif- 
fusion. Hence 
any want of adjustment causes the luminous point to ap- 
pear double, as is evident from Fig. 47. 

39. Ghanges in the Shape of the Lens. — During accom- 
modation the lens becomes more convex, especially its 
anterior surface, which also moves forward on account of 
the thickening of the lens. If we place a light slightly to 
one side of an observed eye and watch the images reflected 
from the various surfaces, they will appear as seen in 
Fig. 48, A, while the observed eye looks at a distant ob- 
ject. When the eye observed is then adjusted for some 
near object, the images change, as seen in B; Pig. 48. 
The corneal image, as, remains the same in both cases. The 
reflection from the anterior surface of the lens, b, dimin- 
ishes in size, indicating increased curvature of the surface, 
, and moves later- 

I _±_ 

c a.^ ^'^ 
c 



I 



Fig. 48. 



ally toward the 
corneal image, a 
motion referable 
to the advance- 
ment of the ante- 
rior surface of the 
lens. The small, 
sharply defined, 
and inverted im- 
age produced by 
the concave pos- 
terior surface of the lens shrinks likewise slightly in size, 
showing that the radius of curvature of that surface dimin- 
ishes as well, though but little. No indication of any 
motion of the posterior surface can be observed. These 
changes in the curvature of the lens have been more accu- 
rately measured with the ophthalmometer, which shows 
that the radius of curvature can be reduced during a strong 
accommodative effort to about 6 mm. for the anterior sur- 
face, and about 5.5 mm. for the posterior surface of the 
lens, while the thickness of the lens may increase from 
3.6>to 4 mm. Thereby the focal length of the lens in the 
diagrammatic eye would be reduced from 50.671 mm. 
during rest to 39 mm. during a strong accommodative 
effort. Calculating on this basis the refractive strength of 
the diagrammatic eye, we shall now find the principal 
posterior focus 1.644 mm. in front of the retina, while the 
retina itself is in the plane of focal reunion for rays com- 
ing from an object 146.6 mm. (not quite 6 inches) distant 
from the first principal point, which latter is 1.566 mm. 
behind the cornea in such an accommodated eye. Mathe- 
matical analysis thus confirms that the increased curva- 
ture and the advancement of the front surface of the lens 
sufBce to account for the accommodative changes. 

During accommodation the pupil diminishes in size. 
The utility of this contraction of the fa'is is evident on re- 
membering that according to Section 4, the spherical aber- 
ration would increase with the divergence of the rays, and 
hence with the proximity of the object. On account of 
the advancement of the front surface of the lens the iris 
is also moved forward, which can be seen on looking in 
profile view at an eye during accommodation. 

40. Mechanism of Accommodation,. — The accommodative 
changes of the lens are brought about by the action of the 
ciliary muscle. The lens itself is not a muscular or- 
gan, it is devoid of contractility. It is, however, an 
elastic body kept stretched by its attachment to the an- 
nular ligament, as an elastic hoop would be flattened by 



the traction of two cords attached at two opposite points. 
Relieved of this traction the lens increases in convexity 
and becomes more nearly globular, so that the lens re 
moved from the eye is more convex and thicker than while 
in place. During the accommodation effort the ciliary 
muscle contracts. . Its meridional fibres pull the choroid 
forward. This has been shown by Hensen and Voelkers, 
by the movements of a needle put through the sclera and 
choroid on sending an electric current through the ciliary 
muscle in the ej'es of animals and in a human eye just 
extirpated on account of disease. The circular, rmg- 
shaped muscular fibres of the ciliary body on contracting 
cause the ciliary processes to project further toward the 
centre of the pupil, which movement of the processes is 
favored by the above-described traction on the choroid 
and consequent relaxation of its anterior insertion. In 
eyes in which a sufilciently extensive segment of the iris 
has been removed by the operation of iridectomy, and 
through the translucent intact iris of albinos this ad- 
vancement of the ciliary processes toward the centre of 
the pupil has been directly observed. Since the ligament 
of the lens is attached to the ciliary processes the crowd- 
ing of this ring-shaped structure into a narrower space 
necessarily re- 
laxes the circular 
band stretched 
across the aper- 
ture within this 
ciliary ring. 
Thus the lens is 
permitted to re- 
tract by yielding 
to the tension of 
its own elastic 
substance ; for 
the arrangernent 
of the fibres of 
the lens-sub- 
stance is such 
that they are re- 
laxed by the ap- 
proach of the 
lens toward the 
globular shape, 
while the flatten- 
ing of the same 
by traction of its 
ligament puts 
them on the 
stretch. The 
changes in an 
eye during ex- 
treme accommo- 
dation are shown 
in Fig. 49, in 
which the upper 
half represents 
the front half of 
the eye at re'st, 

and the lower half the contraction of the ciliary muscle 
and its effect upon the shape of the lens. 

41. Bange of AccommMation. — The most distant points 
of which the "eye at rest can form a sharp image on its re- 
tina has been termed by Donders the far-point (punctum 
remotum = R) of the eye. In the emmetropic eye the 
far-point is— according to our definition of emmetropia— 
at an infinite distance. The myopic eye, however, can- 
not see distinctly beyond a certain short finite distance, 
depending on the degree of shortsightedness, while in 
hypermetropia the eye cannot bring into focal reunion on 
the retina any but convergent rays, and the far-point is 
therefore negative, that is to say, situated at some finite 
distance behind the eye. The fact that many hyperme- 
tropes can see distinctly at a distance with the unaided 
eye, is due to their using a part of their accommodation 
continuously in order to increase the actual refraction of 
the eye. The near-point (punctum proximum ~ P) on 
the other hand, is the nearest point of which the accom- 
modated eye can get a well-defined image. The range of 




FlQ. 49. 



47 



Accommodation. 
Accommodation. 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 



accommodation is the total accommodative power which 
an individual eye possesses. We can represent it by the 
strength of the lens equivalent to the refractive difiference 
between the eye at rest adjusted for the far-point and the 
eye accommodated for the near-point. Thus, an emme- 
tropic eye, which can see distinctly an object as close as 
five inches, has a range of accommodation representable 
by a lens of five Inches focal length or of the strength of 
about 8 D. For deprived of its accommodative power 
this eye would require such a lens to be held in front of 
it in order to get a sharp image of this near object on its 
retina. Practically, it will do to hold the lens Very close 
to the cornea ; for theoretical accuracy, however, the lens 
in question, of an infinite thinness, must be assumed 
situated in the first principal plane of the eye. The sig- 
nificance of the range of accommodation is made plainer 
by the use of Donders' formula, 

J__ 1 1 
A - P ~ a' 

in which we represent by A the range of accommodation, 
by P the near-point, and by M the far-point. This for- 
mula is applicable to ametropia eyes as well as to emme- 
tropia, for anomalies of the refraction do not necessarily 
alter the range of accommodation. Thus a myope whose 
far-point is at twelve in- 
ches' distance, and who ^'^^ 
can accommodate for ob- 
jects four inches from 
the eye has an accommo- 
dative range = \ — -,^=: 
i. Another instance will 
illustrate both the con- 
dition in hypermetropia 
and the use of the diop- 
tric system. Suppose a 
certam hypermetropic 
eye, the axis of which is 
so short that it requires 
a correcting glass of 4 
D in order to obtain 
sharp retinal images of 
distant objects. In this 
eye the far-point is neg- 
ative, that is to say, it is 
situated twenty-five cen- 
timetres behind the an- 
terior principal point. 
If this eye possesses an 
accommodative range 
equal to eight dioptrics, 
four of them are re- 
quired to see distinctly 
at a distance and only 4 
D are left, enabling the person to get distinct images of 
objects twenty-five centimetres distant by the extreme em- 
ployment of his accommodation. Donders' formula re- 
versed expresses this on using centimetres as follows : 
1 1 




13.5 D. 



which is in numerals 



^li + 



P 35 "*■ 12i - 25' 

or employing dioptric notation, which is the reciprocal of 
the focal length, 

P= _42) + 8Z> = 4i>; 
in other words, the distance of the near-point from the 
eye IS equal to the focal length of a glass of 4 D strength 
= 25 centimetres. ° 

J^?^J^^'^^^^ "f ^3" ^ *^«« Accommodation.— From 
childhood on, the rigidity of the crystalline lens increases 
ana the extent of its elastic retraction diminishes. Hence 
the range of accommodation diminishes as the years ad- 
vance because the lens cannot retract as much in the later 
period of life as during youth, though the contracting 
ciliary muscle relaxes the annular ligament. The rano-? 
ot accommodation sinks thus from beyond ten dioptrics, 

48 



during childhood, to zero toward the age of sixty years. 
Donders has constructed a diagram (Fig. 50), based on 
numerous observations, which illustrates this decline in a 
graphic manner. The heavy line represents the refraction 
of the eye at rest. As before stated, the emmetropic 
eye becomes slightly hypermetropic in advanced age, 
presumably from an actual flattening of the lens or a 
diminution of its refractive index. The range of accom- 
modation extends from the heavier line of passive re- 
fraction to the thin line indicating the extreme active 
adjustment of the eye. The figures at the bottom give 
the age in years ; those at the side the (active or passive) 
adjustment in French inches (or expressed in dioptrics on 
the right side). Occasionally deviations are found from 
this standard of decline. Thus, among others, the 
writer has seen a gentleman, seventy years of age, who 
could read the finest type up to eight inches' distance. 
He had a slight myopia and myopic astigmatism, less 
than 1 D, so that this accommodative range was still a 
trifle over 4 D, a very unusual amount for his age. Ex- 
ceptions of the opposite liind, a falling short of the 
accommodative range normal to the age of the patient, 
are always due to disease of the eye or general impair- 
ment of the health. 
43. Innervation of the Accommodative Apparatus. — The 

ciliary muscle derives its 
nerve supply from the 
third cranial nerve or 
motor oculi, which sends 
the motor root to the 
ciliary ganglion, whence 
issue the ciliary nerves 
which penetrate the 
sclera. It is a common 
clinical observation to 
find paralyses of other 
branches of this nerve 
accompanied by paraly- 
sis of the mechanism of 
accommodation. Expe- 
riments by Trautvetter* 
have shown that tlie 
fibres of accommodation 
run in the trunk of the 
motor oculi in pigeons, 
while in other animals 
the results were nega- 
tive. In dogs, Hensen 
and Volkers have traced 
the fibres up to the floor 
of the third ventricle of 
the brain, as shown by 
the result on stimulating 
those parts. 

Although the ciliary muscle consists of unstriated fibres 
in mammals, its movements are both as rapid and as 
much under the control of the will as those of any striated 
muscle. In birds, indeed, having evidently a very ener- 
getic accommodative mechanism, the ciliary muscle is 
striated. "While the ciliary movements are voluntary in 
a certain sense, we are ordinarily not conscious of any 
accommodative effort. The movements of the ciliary 
muscle are guided by the retinal impressions which we 
get ot the objects viewed, and may hence be classed 
among the complicated cerebral reflex movements. The 
accuracy of these movements is wonderful, inasmuch 
as the most rapid changes of adjustment of the eyes for 
different distances never give rise to any blurring of the 
images for which the eye accommodates. The regulating 
mechanism does not miscalculate the distance of the 
objects. The accommodating movements are always 
accompanied by an exactly corresponding convergence 
of the two eyes, so that in normal instances the object 
accommodated for is also the one toward which both 
eyes are directed, so as to place its image in the centre of 
the retina of each eye. The association of the movements 
of accommodation and convergence is so intimate that 
we cannot voluntarily perform either movement to any 
appreciable extent without the other. But by optic means 



+ 1.5 



l.BD. 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 



Accommodation. 
A cconaniodatlon. 



■which simulate the effect of one or the other movement, 
-we can temporarily rupture the association. Thus, with 
a given degree of convergence for a certain fixed object, 
we can either force ourselves to a greater accommodative 
effort by looking through concave glasses, or relax the 
accommodation by means of convex spectacles. Simi- 
larly, we can vary the degree of convergence associated 
with a certain accommodative effort by jSacing prisms of 
variable strength and inclination in front of one or both 
eyes. The ability to separate these two movements 
ordinarily associated is increasQd by practice. It is evi- 
dent that the correlation of the two movements, as well 
as the disturbance of this association by optic means, 
subserve the same purpose, viz., distinct vision without 
double images. 

44. Movements and Nerves of the Iris. — On account of 
the association with the accommodation, the movements 
of the iris can be best discussed in this connection. The 
iris serves the purpose of an optic diaphragm, the aperture 
of which can vary in size according to necessity, the 
physiological limits being from two to six millimetres diam- 
eter. By reflex action the pupil contracts with increasing 
illumination, therebjr diminishing both the fatiguing 
brightness of the retmal image and the width of any cir- 
cles of diffusion due to optic imperfections. When the 
light is relatively feeble, a large pupil, on the other hand, 
permits a relatively greater brightness of the retinal 
images,, while the enlarged circles of diffusion do not 
blur the sight so much, on account of their feebler inten- 
sity. The pupil contracts also with each accommodative 
effort, thereby diminishing the spherical aberration, which 
the proximity of the object and the increased convexity 
of the lens would produce. Independently of external 
light, the pupil is very narrow during sleep and during 
artificial narcosis. The mechanism of this latter contrac- 
tion is not yet known. When the narcosis is interrupted 
by any sensory stimulation, or by asphyxia, the pupil in- 
dicates this change by dilatation. 

The nerves of the iris are the ciliary nerves, coming 
from the ciliary ganglion, which, in man, has three roots 
— the short root from the motor oculi, the long root from 
the naso-cUiary branch of the fifth nerve, and the sympa- 
thetic fibres reaching the ganglion along with its arteries. 
The motor oculi controls the sphincter muscle of the iris. 
Its experimental irritation contracts the pupil ; its section 
or accidental paralysis, allows it to remain dilated. The 
reflex pupillary contraction produced by light starts with 
the excitation of the optic nerve. When the optic nerves 
are rendered inactive by disease, the normal play of the 
pupils ceases, and they remain in a state of moderate dila- 
tation. Excitation of one optic nerve, however, controls 
the pupUs of both eyes, at least in those animals which, 
like man, have a visual field common to both eyes. Hence, 
in cases of unilateral blindness the two pupils are usually 
alike in size. The centre concerned in this reflex action 
is the anterior half of the tubercula quadrigemina 
(Budge). Various instances of disease of higher parts of 
the brain have been observed with integrity of these parts, 
and hence sensitiveness of the pupils to light, although 
conscious sight did not exist. According to i3rown-S6- 
quard the muscular tissue of the iris itself is somewhat 
sensitive to light, a tonic contraction being induced in it 
by strong Ught, even after extirpation of the eyeball. 

The sympathetic nerve fibres control the dilator muscle 
of the iris. The existence of these radiating muscular 
fibres, which seemed pretty well established by the re- 
searches of Henle, Iwanoff, and Merkle, after much con- 
troversy with Gruenhagen, has latdy been questioned 
again by Eversbusch (meeting of the Heidelberg Ophthal- 
mological Society, September, 1884). He maintains that 
the radiating fibres in the posterior layer of the iris, which 
have been interpreted as smooth muscular fibres, are 
really nerve fibres, as shown by various staining methods. 
If these statements are corroborated, it will be impossible 
to account satisfactorily for the action of the sympathetic 
nerve on the iris. The view that these nerves change the 
size of the pupil, through their action upon the muscular 
walls of the blood-vessels of the iris, is not well supported 
by the facts. 

Vol. I.— 4 



Their course toward the eyeball is partly along the walls 
of the arteries, partly along anastomoses which join the 
fifth cranial nerve. Section or paralysis of the sympa- 
thetic nerve of the neck is followed by contraction of the 
pupil, while its irritation dilates that aperture. These 
fibres can be traced through the rami communicantes of 
the last two cervical and the first two dorsal nerves into 
the spinal cord (Budge and Waller). The reflex centre 
of these fibres is partly in the corresponding region of the 
spinal cord, and partly in the medulla oblongata. Reflex 
dilatation of the pupil through this nerve-channel can be 
readily induced by any sensory impression through most 
any sensory nerve,' at least when the pupil is not con- 
tracted by strong light, especially during sleep and in- 
complete narcosis. The pupil, indeed, is very sensitive to 
irritations of sensory nerves. It is not known that this 
reflex dilatation is of any utility. 

It has recently been asserted by Tuwim ' that the su- 
perior cervical sympathetic ganglion maintains a shght 
tonus of the dilator nerves of the iris, independently of, 
and even after, its separation from the central nervous 
systein. Although his experiments seem conclusive, the 
question should be further investigated, since this would 
be the first instance known of tonic activity of nerves 
maintained by a sympathetic gangUon. 

The fifth cranial nerve is the sensory nerve of the iris, 
endowing it with very great sensibility. Irritation of this 
nerve contracts the pupil very energetically in some ani- 
mals, for instance the rabbit. Section of the nerve has 
the same effect, temporarily, the fibres being evidently 
kept in a state of transitory irritation by the injury, as 
occurs as well in certain other nerves. This influence of 
the fifth nerve upon thf pupil does not exist in carnivo- 
rous animals. The observations in disease of that nerve 
in man are too conflicting to be decisive. The study of 
eye diseases attended with irritation renders it very likely 
that in man the fifth nerve is the vaso-dilator nerve of the 
iris, and that its reflex excitation congests the iris and 
contracts the pupil mechanically by the engorgement of 
the vessels. This is also the most plausible explanation 
of the intense pupillary contraction obtained on punctur- 
ing the anterior chamber, which result does' not occur on 
operating on the dead eye. 

BiBLiOGKAPHY. — The optic properties of the eye were 
not understood until Kepler, in 1602, evolved the theory 
of optical instmments in general. The importance of the 
various parts of the eye in refraction was further eluci- 
dated by the Jesuit Scheiner in 1619. Minor additions 
were successively brought out by the labor of different 
authors, but it was only after Gauss had published his 
mathematical investigation of the cardinal points (" Diop- 
trische IJntersuchungen," Gottingen, 1841) that the com- 
plete theory of the refraction in the eye could be deduced. 
This was done successfully by Listing, in the article 
"Dioptrik des Auges" in Wagner's " Handworterbuch 
der Physiologic " (1853), who, by a critical selection of the 
older measurements of the refractive indices of the eye by 
Chossat and by Brewster, of the anatomical measurements 
of dimensions and curvature by Krause, Kohlrausch, and 
others, determined the position of the ocular cardinal 
points with considerable accuracy. The most marvellously 
accurate methods, however, for measurements of the living 
eye were first introduced by Helmholtz, who, in his 
" Handbuch der physiologischen Optik" (1867), has pro- 
duced a masterly treatise of rare originality, which every 
student of the subject must consult in the original. Since 
the publication of his large work, the first part of which 
on refraction appeared in 1856, Helmholtz has pursued 
these studies vnth the aid of numerous students, most of 
whose articles have appeared in the running numbers of 
the ArcMv fur OphthMmologie. In an article by Reich 
{Arch. f. Oplith., 1874, vol. xx., 1), Helmholtz corrects 
some of his former measurements and figures, and accepts 
as more nearly representing the values of the cardinal 
points in the average eye the figures which we have re- 
produced in the text of this article. Extensive measure- 
ments, especially of the curvature of the cornea, have also 
been made by Donders ("Anomalies of Accommodation 
and Refraction," 1864) and by Mauthner (" Vorlesungen 

49 



Accommodation. 
Accommodation. 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 



fiber d. optlschen Fehler des Auges," 1872), and more re- 
cently by Reuss {Areh.f. OpMhalmologie, xvii., 1, p. 37). 
The entire theory of the formation of images in the eye, 
including physiological optics in general, is most exhaus- 
tively treated in Aubert's " Grundzuge der phys. Optik," 
in vol. ii. of Graefe and Saemisch's "Handbuch der ge- 
sammten AugenheUkunde " (1876), while important recent 
additions are to be found in Nagel's " Anomalien der Re- 
fraction," in vol. vi. of the same work. Very complete is 
also the treatise of Fick in vol. iii. of Hermann's " Hand- 
buch der Physiologic." All of these works must be con- 
sulted for the complete literature of the subject. In the 
English language the most extensive but older treatise is 
the work by Donders on " Anomalies of Accommodation 
and Refraction " (1864), which book marked quite an era 
in our knowledge of the physics of the different refractive 
conditions of the eye. In connection with this latter sub- 
ject the work of Jaeger (" Einstellungen d. dioptrischen 
Apparats," 1861) must also be mentioned. 

■The mechanism of accommodation has been extensively 
discussed by former authors, by whom, however, no facts 
were brought forth beyond those taught by every-day 
observation. By some the accommodative changes were 
refeiTed to the variations in the size of the pupil, while 
others even denied the existence of any accommodation. 
The most complete mathematical discussion was furnished 
by Th. Young in the "Philosophical Transactions" of 
1801, in which it was shown by experiments and by deduc- 
tions that the accommodation cannot depend on any 
changes except those in the form of the lens. The experi- 
mental proof that such changes do occur was furnished 
simultaneously and independently of each other by Cramer 
(in various publications in the Dutch language, between 
1851 and 1855) and by Helmholtz {MoTiaUbenchte d. Ber- 
liner Academie, February, 1853). The mode of action of 
the ciliary muscle was first explained by Helmholtz theo- 
retically, and has since been confirmed experimentally by 
Hensen and Volkers, who have likewise studied the in- 
nervation of the accommodative apparatus ("Experi- 
mentaluntersuchung fiber den Mechanismus der Accom- 
modation," 1868, and Arohivf. Ophthalrmlogie, 1873, vol. 
xix.). Important measurements of the changes in the 
curvature of the lens during accommodation, and a mathe- 
matical inquiry into their efliciency were published by 
Knapp (Archw f. Ophth., 1860, vols. vi. and vii.). Our 
knowledge of the range of accommodation in health and 
disease is due mainly to the researches of Donders 
("Anomalies of Accommodation and Refraction"). 

On the innervation of the iris there exists an extensive 
literature, scattered throu^out numerous physiological 
and ophthalmic serials. The older literature is exhaus- 
tively compiled in Budge's " Bewegungen der Iris," 1855. 
The present writer presented likewise a full review of the 
physiology of the iris in the Chicago Journal of Mrwus 
and Mental Diseases (April and July, 1874), in which the 
complete literature up to that date can be found. What- 
ever has been done since 1874 is explicitly referred to in 
tlietext. s. GradXe. 

' Nagel : Anomal. d. Kefraotion, in &riiefe and Saemisch's Handb. d 
ges. Augenheilkunde, p. 461. 

" Ueber schiefcn Durchgang von Strahlenbiindeln durch Linsen, 
Gratulationschrift an C. Llidwig. 3874. 

> Archives of Ophthalmology, toI. ix, p. 29. 

< Proceedings of the International Congress at Copenhagen, 1884 
Ophthalmic Section. ' 

» Report of the Heidelberg Ophth. Society iu Deutsche med. Wochen- 
achrift, October 9, 1884. 

• Archiv f. Ophthalmologie, 1866, xli., p. 9B. 

' Archiv f. d. gesammte Physiologie, Bd. xxlv., p. 115. 

ACCOMMODATION AND REFRACTION. Patholo- 
GT.— The normal refractive condition of the eye {emmetro- 
pia, E) is best described as a correct relation between the 
curvatures of the refractive surfaces and the length of 
the antero-posterior diameter (axis) of the eyeball. In 
emmetropia, parallel rays, such as are received from any 
distant object, are accurately focussed upon the retina by 
virtue of the refractive power of the eye, without aid 
from the accommodation. If this normal relation is dis- 
turbed, whether through abnormal curvature of the cor- 
nea or the anterior or posterior surface of the crystalline 

50 



lens, or through a variation from the normal length of the 
axis of the eyeball, a refractive anomaly (ametropia) is 
the result. 

In the two principal tjrpes of ametropia the axis of the 
eyeball is actually, in most cases, either too short or too 
long. In the former case the refractive power of the eye 
is insufficient to focus parallel rays accurately upon the 
retina, and some exercise of the accommodation is neces- 
sary for distinct vision at a distance. For the focussing 
of divergent rays, such as are received from any near 
object, the accommodative adjustment is necessarily in 
excess of that which the emmetropic eye employs for dis- 
tinct vision at the same distance, and this excess is always 
equal to the degree of accommodation required for vision 
at a distance. From the fact that the focus for parallel 
rays is behind or beyond the retina, this refractive anom- 
aly has received the name hypermetropia, H (from 
iirepfierpos, overmeasure, and ^^, eye). The hyperme- 
trope, if his accommodation is sufficient to overcome the 
refractive deficiency, may see distinctly at all distances, 
but only through active accommodative effort, and gen- 
erally with more or less sense of fatigue, when the eyes 
are used continuously. Moreover, as the range of the 
accommodation has always a nearly definite limit, which 
is closely related to the age of the subject, the nearest 
point of distinct vision (near-point, p) is always somewhat 
further from the eye than in emmetropia. Hypermetro- 
pia is ordinarily an inherited condition, and may be prop- 
erly considered as a form of incomplete development of 
the eyeball. (See Hypermetropia.) 

In the case of an abnormally long axis of the eyeball, 
parallel rays are focussed in front of the retina, and only 
divergent rays are focussed accurately upon it. Such an 
eye is, therefore, fitted only for near vision, and for this 
reason is called near-sighted or short-sighted. Short- 
sightedness was known to the classical writers, who men- 
tion it under the fanciful name myopia, thus precluding 
the adoption of the really descriptive name Irachymetro- 
pia (from Ppaxi, short, /ifrpoy, measure, and &\ji, eye), as 
suggested by Donders to express the opposite condition to 
hypermetropia. The myope sees all distant objects indis- 
tinctly, and he sees objects at some definite shorter dis- 
tance (far-point, r) clearly, without exercise of the ac- 
commodation. For objects which lie nearer to the eye 
than its far-point, the myope accommodates, but always 
less than does the emmetrope for the same distance. 
When the myope makes use of his entire accommodation 
he is able to see clearly at a somewhat shorter distance 
(near-point, p) than can the emmetrope under the same 
condition of full accommodation. Myopia is generally an 
acquired condition, and is then the result of pathological 
distention of the eyeball. (See Myopia.) 

The emmetropic eye has its far-point at an infinite dis- 
tance, and its near-point at some sliort distance, which is 
determined by its range of accommodation. At the age 
of twenty years this is equal to about ten metric units 
(dioptrics'), and the near-point is about one-tenth of a 
metre (10 ctm. =4 in.) from the eye. In myopia 
the grade of the refractive anomaly, expressed in diop- 
trics, determines the position of the far-point, and from 
this the near-point may be found by adding the number 
of dioptrics which expresses the range of the accommoda- 
tion. With a myopia of five dioptrics (5 D), and a range 
of accommodation of ten dioptrics (10 D), the far-point 
is one-fifth of a metre (20 ctm. = 8 in.) from the eye, 
and the near-point is about one-fifteenth (tt^tis = -h) 
of a metre (6.6 ctm. =2.6 in.) from the eye. In hy- 
permetropia the grade of the refractive anomaly is sim- 
ilarly expressed in dioptrics, but with the minus (— ) sign, 
and the place of the near-point is determined by the alge- 
braic sum of this minus quantity and the plus (-I-) quan- 
tity which represents the range of the accommodation. 
With a hypermetropia of five dioptrics (— 5 D), and a 
range of accommodation equal to ten dioptrics (10 D), the 
place of the near-point is determined by the algebraic ad- 
dition of those two quantities (10 D — 5 D = 5 D), and 
is one-fifth of a metre (30 ctm. =8 in.) from the' eye. 
In a higher grade of hypermetropia, say of ten dioptrics 
(10 D), with a range of accommodation equal to ten diop- 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 



Accommodation. 
Accommodation. 



tries (10 D), this addition (10 D — 10 D = = ^-) places the 
near-point at an infinite distance, which means that the 
full exercise of the accommodation is only sufficient for 
distinct vision at a distance, and that the eye has no ac- 
commodation to spare for vision at shorter distances. In 
a still higher grade of hypermetropia, say of fifteen diop- 
trics ( — 15 D), with the same value of ten dioptrics (10 D) 
for the range of accommodation, we find 10 D — 15 D = 
— 5 D, or, in other words, a virtual hypermetropia of five 
dioptrics ( — 5 D), notwithstanding the full exercise of the 
accommodation. In the highest grades of hypermetropia 
there is no distinct vision at any distance. 

It is only in emmetropia that the entire range of the 
accommodation is available for distinct vision at all dis- 
tances from infinity to the normal near-point. In ame- 
tropia the range of accommodation remains unchanged, 
but the limits within which it acts are displaced, so that it 
is rendered less effective in adjusting the eye for distinct 
vision at different distances. This region of aecomm<oda- 
twn may vary greatly in extent according to the kind and 
degree of the ametropia. In myopia it is limited for dis- 
tance by the far-point (r) and for the near by the near- 
point (p), and the higher the grade of the myopia the 
nearer are these two points to each- other. In hyperme- 
tropia a part of the accommodation is expended in the 
adjustment of the eye for vision at a distance, and the 
region of accommodation is correspondingly curtailed 
through the recession of the near-point from the eye. 
Moreover, in hypermetropia the accommodation is over- 
taxed, and, even within its actual limits, its exercise is 
attended with some degree of strain and consequent 
fatigue. Lastly, as the range of accommodation dimin- 
ishes with increasing age, the near-point recedes more 
rapidly than in emmetropia, until it passes the limit of 
distance at which reading is possible, and premature old 
sight (presbyopia) is developed. 

The positions of the far-point (r) and of the near-point 
{p), respectively, are measured, in metres and centimetres, 
from the anterior nodal point of the eye, which is situ- 
ated in the crystalline lens near its posterior surface. 
Representing these distances by R and P, respectively, the 
range of accommodation, expressed in dioptrics, by A, 
and the degree of myopia or of hypermetropia, expressed 
also in dioptrics, by M or H, respectively, we have : 

1 



In emmetropia, R 



.= «>. 



m myopwi, 



P = 



R - 



A' 

M' 



M + . 
P = 



A-H 

As, however, the actual limit of vision for distance is 
infinity, this must represent the position of the far-point 
(»•) in hypermetropia, and the expression of the real con- 
dition becomes : 

In hypermeii'opia, R = oo, 

From a comparison of these formulae it will be seen that, 
with the same range of accommodation, the region of ac- 
commodation is most extensive in emmetropia. In my- 
opia this region is greatly contracted through the approach 
of the far-point (r), with but slight and generally unim- 
portant compensation in the approach of the near-point 
(p) to the eye. In hypermetropia the region of accommo- 
dation is seriously curtailed through the recession of the 
near-point (p) from the eye, while the far-point (r) re- 
mains, as in emmetropia, at infinity. 
By the correction of the ametropia, by means of the 



proper concave or convex glass, the far-point (r) is ad- 
justed to infinity, and the near-point (p) is then determined 
solely by the range of accommodation (A). The formula 
then becomes indentical with that of emmetropia : 

1 1 



In myopia 



R = 



R = 



M 


— 


M 
1 







M 


— 


M 


+ 


A 




1 




= 


1 


H 


— 


H 









1 







H 



= — = CD, 
1 

^A' 



J. 
A' 



H + A 



We have thus far considered only the case of ametropia 
as if in a single eye, and have ignored all complications 
growing out of the fact that vision is actually the result 
of the concurrent action of the two eyes. In brief, it 
may be stated that we see with each eye the object or 
part of the object to which the eye is directed, and 
that in order to see the same object with the two eyes, 
the two eyes must be accurately directed each to the 
same point, and this point must be a point for whose 
distance each eye is accommodated. There is, in fact, 
a very intimate connection between the two adjustments 
of accommodation and conmergence, which may lead to 
important complications both in myopia and m hyper- 
metropia. In myopia, we have seen that there is com- 
paratively little occasion for the exercise of the accom- 
modation, but the need for convergence remains un- 
changed, or may even be somewhat mcreased by reason 
of the shorter distance at which the strongly myopic eye 
sees small objects. This normal, or excessive, conver- 
gence may in turn evoke excessive accommodation, and so 
necessitate the holding of the book still nearer to the eyes, 
thus again necessitating still stronger convergence. The 
needless accommodation which is thus excited may cause 
the myopic eye to appear more strongly myopic than it 
really is, and may lead to injurious tension of accommoda- 
tion, and through this to a progressive increase in the 
grade of the myopia. On the other hand, the eyes may 
fall into the habit of relaxing the accommodation to the 
degree requisite for distinct vision at or near the far-point, 
and this relaxation of the accommodation may be attended 
by a corresponding relaxation of the convergence, which 
may lead to weakness or insufficiency of the recti interni 
muscles (muscular asthenopia) , and ultimately to divergent 
strabismus. In hypermetropia, as we have seen, the eyes 
accommodate even in distant vision, and must accommo- 
date more strongly than in emmetropia in order to see 
near objects distinctly. Accordingly in hypermetropia 
one of two complications may arise ; either the conver- 
gence may be habitually adjusted to the distance of the 
object, in which case the correlated degree of accommoda- 
tion may be insufficient for distinct vision or for continu- 
ous work, and so the eyes may suffer from accommodative 
insufficiency or fatigue (accommodative asthenopia) ; or, on 
the other hand, the accommodation may be maintained to 
the degree requisite for distinct vision, and this excessive 
accommodative effort may evoke a tendency to excessive 
convergence, which may ultimately develop into conver- 
gent strabismus. (See Strabismus.) 

The effect of the disturbed correlation between the ac- 
commodation and the convergence in ametropia may be 
concisely formulated, as follows : 

In myopia there is a tendency to abnormal tension of 
the accommodation, and through this to a progressive in- 
crease in the grade of the myopia, or else to muscular 
asthenopia and insufficiency of the recti interni muscles, 
and ultimately to divergent strabismus. 

In hypermetropia the tendency is to fatigue or insuffi- 
ciency of the accommodation (accommodative asthenopia), 
or else to abnormal tension of the recti interni muscles, 
and ultimately to convergent strabismus. 

Astigmatism is a refractive anomaly in which the re- 
fractive power of the eye is unequal in different merid- 
ians (see Astigmatism). This inequality is greatest in 
two meridians which lie at right angles to each other, and 



51 



A ccommodatlon. 
A ccommodatlon. 



EEFERBNCB HANDBOOK OP THE MEDICAL SCIENCES. 



which are called the principal meridians. The astigmatic 
eye may be emmetropic in one of its principal mendians, 
in which case it is either myopic or hypermetropic in the 
other ; or it may be either myopic or hypermetropic in 
both meridians ; or, lastly, it may be myopic in one of its 
principal meridians and hypermetropic in the other. If 
the astigmatic eye is hypermetropic in its horizontal merid- 
ian, the accommodative disturbances are generally those 
which belong to hypermetropia, namely, accommodative 
asthenopia, or a tendency to convergent strabismus ; if, on 
the other hand, the eye is myopic in its horizontal merid- 
ian, the complications are ordinarily those which belong 
to myopia, namely, accommodative tension, or muscular 
asthenopia, or insufficiency. Moreover, as in astigmatism 
the acuteness of vision is more or less impaired, the incli- 
nation is always to hold the book quite near to the eyes, 
and thus the tendency to accommodative tension or to 
muscular insufficiency, on the one hand, or to muscular 
tension, or to accommodative insufficiency, on the other 
hand, is materially aggravated. 

Irregular astigmatism (see Astigmatism) necess'arily 
impairs the acuteness of vision at all distances, and may 
prove a source of disability or of danger through the 
forcing of the accommodation and convergence in the 
effort to read continuously at a very short distance. 

The correction of astigmatism, together with anjr ac- 
companying ametropia, by means of appropriate cylindri- 
cal or spherico-cylindrical glasses, both improves the 
acuteness of vision and removes the disabilities incident 
to the displacement of the region of accommodation. 
Even in irregular astigmatism a part of the refractive 
defect may often be corrected by means of cylindrical 
glasses, with corresponding improvement in the acute- 
ness of vision. 

Unequal refraction in the two eyes — anisometropia (from 
o privative, To-os, equal, /i^rpov, measure, and &\li, eye) — 
may give rise to certain complications growing out of the 
close connection between accommodation and convergence. 
Moreover, as the accommodation is always equal in the 
two eyes, the same degree of inequality must exist in ac- 
commodation as in a state of rest, so that the two eyes 
are never accurately accommodated for the same distance 
at the same time. In order to see any object clearly, one 
of the eyes must accommodate accurately for its dis- 
tance, while the other eye is necessarily accommodated for 
some other distance. Hence, one of the retinal images Is 
distinct, while the other is imperfectly defined. This 
difference in definition is, however, not of much impor- 
tance, for, practically, the attention is attracted to the 
clearer image, and the confused details of the other im- 
age are disregarded. Both images are, however, utilized 
in binocular vision, as is shown by the persistence of the 
faculty of estimating differences of distance and of ap- 
preciating the form of solid objects (stereoscopic vision). 
On theoretical grounds a certain improvement in the 
acuteness of vision might be expected from the accurate 
correction of both eyes by means of glasses of different 
foci, and this is undoubtedly true in the case of lesser 
differences in refraction, but in cases of greater difference, 
equalizing glasses may not be readily accepted. A per- 
son with one emmetropic eye of normal acuteness will 
not ordinarily accept . glasses for the sole purpose of 
remedying a visual defect of which he is perhaps un- 
conscious and which causes him no inconvenience, and, 
similarly, most persons with ametropia of a different 
grade in the two eyes will rest satisfied with glasses of 
equal foci, which leave the existing refractive difference 
unchanged. Hence the general rule not to give glasses 
for an uncomplicated refravUive error of one eye, and, 
except in the case of a trifliing difference (one dioptric or 
less), to give glasses of equal foci, selected with reference 
to the eye which is habitually in use, in cases of uncom- 
plicated refractive error of a different grade in the two 
eyes. 

The complications which may make it necessary to pre- 
scribe glasses of different foci in anisometropia; occur 
chiefly in cases of myopia of one eye, or of myopia of a 
different grade in the two eyes. In myopia of one eye, 
with emmetropia or moderate hypermetropia of the 

52 



other, the myopic eye is ordinarily used in reading and 
the emmetropic or hypermetropic eye in distant vision. 
Such a person may suffer from muscular asthenopia or 
insufficiency of the recti interni, as a consequence of the 
habitual relaxation of the accommodation in reading, or 
from injurious tension of the accommodation, with a ten- 
dency to progressive increase of the grade of myopia, . 
incident to the habit of converging accurately for the 
reading distance. In such cases it is .generally best to 
correct the myopic eye by means of a suitable concave 
glass, and to prescribe for the other eye either a plane 
glass or a convex glass suited to the grade of its hyperme- 
tropia. In myopia of a different grade in the two eyes it 
is the rule to correct the less myopic eye for distance, and 
to give the same glass, or one of shorter focus, to the more 
myopic eye, as may be found most satisfactory upon 
trial. If the difference in the refraction of the two eyes 
is large (two dioptrics or more), a partial correction of 
the more myopic eye may be preferred in the beginning, 
and the full correction may be demanded after the lapse 
of a few weeks or months.' 

Apliakia (from o, privative, and ^oxh = lens, a lentil) 
is the condition in which the crjsstalline lens is either 
wholly wanting or is so displaced that it no longer lies in 
the axis of the eyeball. Of the total refraction of the eye 
(about 50 dioptrics) about five-eighths (31.5 dioptrics) is 
due to the cornea, and about three-eighths (18.5 dioptrics) 
is due to the crystalline lens. The aphakial eye has there- 
fore sustained a loss of refractive power equal to 18.5 
dioptrics, besides the loss of its entire accommodation, 
which in youth amounts to about ten dioptrics more. 
In correcting aphakia by means of a convex glass, the 
position of the glass (about half an inch in front of the 
cornea) is considerably more advantageous than that of 
the crystalline lens which it replaces, and consequently a 
glass of about eleven dioptrics is sufficient, in most cases, 
to make good the refractive deficiency. The retinal image 
is also enlarged by about one third, in consequence of the 
change in the position of the nodal point. A certain de- 
gree of accommodation, with additional enlargement of 
the retinal image, may be obtained by holding the glass 
farther from the eye, but the distance at which the glass 
can be easily held is limited to the length of the nose, and 
is too small to admit of the necessary adjustment for read- 
ing. Hence two glasses are generally required, a weaker 
glass, of ten or eleven dioptrics, for distant vision, and a 
stronger glass, of fourteen or fifteen dioptrics, for reading. 
If the aphakial eye is of hypermetropic construction, pro- 
portionally stronger glasses, and if of myopic construction, 
proportionally weaker glasses, are required. In the case 
of aphakia of one eye, with normal visual acuteness of the 
other eye, it is hardly practicable to equalize the refrac- 
tion, even for distance, by means of glasses of different 
foci ; but the aphakial eye, though uncori'ected, takes 
some part in binocular vision, and is of use not only by 
enlarging the general field of vision, but also by assisting 
in the estimation of distances. A considerable grade of 
astigmatism is frequently present in aphakia, which may 
be due either to original asymmetry of the cornea or to an 
acquired distortion of the cornea incident to the healing of 
the incision in the operation for the extraction of cataract. 
Low grades of astigmatism are often overcome by looking 
obliquely through the strong convex glasses worn to cor- 
rect the aphakial condition ; higher grades may require 
correction by a spherico-cylindrical lens. (See Astigma- 
tism.) 

DisoRDEBS OP ACCOMMODATION may occur as a result 
either of an abnormal condition of the special organ of ac- 
commodation, the crystalline lens, or of disordered in- 
nervation. 

The absence of the crystalline lens involves not only a 
notable reduction in the refractive power of the eye, but 
also the total loss of accommodation. 

Cases of ectopia lentis (from ^leroros, out of place), and 
of incomplete luxation of the crystalline lens from injury 
to the eye have been observed, in which the lens has re- 
mained nearly, or quite, transparent. In such cases the 
refractive power of the eye is generally considerably in- 
creased, owing probably to an increase in the convexity of 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 



Accommodation, 
Accommodation. 



the lens, but the faculty of voluntaiy accommodation is 
wholly wanting. 

The progressive hardening of the crystalline lens, which 
has already begun in youth, and which goes on, probably, 
throughout the entire duration of life, becomes, after mid- 
dle life, an insurmountable obstacle to such changes in 
the form of the lens as are essential to perfect accommo- 
dation for the usual reading distance (see Presbyopia). 
Only in myopia is there an apparent exception to this 
statement, owing to the fact that the far-point (?•) often 
lies so near to the ej;e as to bring it within the ordinary 
reading distance of thirty centimetres (twelve inches). In 
such cases the myope never becomes presbyopic in the 
sense of being unable to read without the aid of convex 
glasses; but whereas in youth he reads easily with the 
concave glasses which perfectly correct his myopia, he is 
compelled, with advancing age, either to lay aside his 
glasses in reading, or to exchange them for weaker con- 
cave glasses than those through which he sees well at a 
distance. In hypermetropia, on the other hand, the loss 
of accommodation shows itself by an early recession of 
the near-point {p), so that help is sought from convex 
glasses, perhaps long before the usual age of from forty 
to forty-flve years. Still the hypermetrope, wearing con- 
vex glasses which correct his hypermetropia, is able both 
to see at a distance and to read, and it is only at the age 
of about forty-flve years that he finds himself compelled 
to exchange these glasses for stronger reading glasses. 
Under no circumstances can a presbyope see clearly at a 
distance and read easily with the same glasses. Either he 
is an emmetrope, in which case he requires convex glasses 
for reading, but none for distant vision ; or he is a myope, 
and so requires concave glasses for the distance, and 
weaker concave glasses, or no glasses at all, for reading ; 
or he is a hypermetrope, and so sees distinctly at a dis- 
tance with convex glasses, but requires stronger convex 
glasses for reading. 

Paralysis or paresis of accommodation from defective 
innervation may be the result of an affection implicating 
the terminal branches of the ciliary nerves, or any part of 
the nervous tract between these and the central origin of 
the motor-oculi nerve in the ganglia and cortex of the 
brain. With rare exceptions it is accompanied by dilata- 
tion and loss of mobility of the pupil (mydriasis), and in 
many cases also by paralysis or paresis of one or more of 
the ocular muscles supplied by the motor-ocuU nerve, 
namely, the levator palpebrae superioris, the rectus supe- 
rior, the rectus inferior, the rectus internus, and the 
obliquus inferior. 

A typical example of paralysis of accommodation de- 
pendent on impairment of the function of the terminal 
branches of the ciliary nerves, is that which follows the 
instillation of a mydriatic solution into the conjunctival 
sack. Within fifteen minutes after the instillation of a 
drop of a solution of atropia sulphate of a strength of one 
per cent. (1 : 100), the pupil begins to dilate, and within 
half an hour the dilatation reaches its maximum, and the 
pupil no longer contracts under the stimulus of strong 
light. Shortly after the establishment of full mydriasis, 
or about half an hour after the instillation, the near-point 
(p) begins to recede rapidly from the eye, and the paralysis 
of accommodation is complete at the end of an hour and a 
half. The dilatation of the pupil and the paralysis of ac- 
commodation continue without sensible change for about 
two days, after which both begin to pass away, the former 
very gradually, the latter more rapidly for two or three 
days and afterward more slowly, until at the end of ten or 
twelve days the effect of the diTig disappears altogether. 
The effect of very weak solutions of atropia, say of a 
strength of one-hundredth of one per cent. (1 : 10,000) is 
to dilate the pupil in the course of an hour and a half or 
two hours, but without rendering it immovable under the 
influence of bright light, and without greatly affecting the 
accommodation. Under the action of atropia the near- 
point (p) recedes from the eye until it comes to coincide 
with the far-point (r). Hence the visual disturbance varies 
very conspicuously according to the refractive condition 
of the eye. In emmetropia distant vision remains clear, 
but accommodation for the near is rendered impossible ; 



in hypermetropia vision becomes indistinct for the dis- 
tance, and still more so for the near ; while in myopia of 
a rather high grade there may be no trouble in reading, 
and the loss of accommodation, within the narrow limit 
of distance between the far-point and the near-point, may 
give rise to little inconvenience or may even pass un- 
noticed. To the hypermetrope or myope wearing glasses 
which correct his refractive defect the visual disturbance 
is the same as in emmetropia. Several other plants, be- 
longing mostly to the natural family solanacem, or to a 
closely allied order, yield alkaloids whose action is nearly 
identical with that of atropia, and quite recently a valuable 
mydriatic property has been discovered in cocaine, the 
active principle of erythroxylon coca. 

Concussion of the eyeball is sometimes followed by 
weakening or loss of the accommodation, conjoined with 
dilatation of the pupil. This condition may soon pass 
away, or it may be permanent. It is evidently the result 
of injury to the ciliary nerves, in the ciliary region of the 
eye. 

Diphtheria is often followed by paresis of accommo- 
dation, with some enlargement of the pupils. It occurs, 
as a rule, after recovery from the throat affection, and 
has ordinarily a duration of several weeks, or perhaps of 
two or three months. It is frequently associated with 
paresis of the palatine muscles, giving rise to charac- 
teristic alteration of the speech. The external muscles of 
the eye are seldom affected, but cases of true convergent 
strabismus have been observed as a result of excessive 
efforts to accommodate in the weakened condition of the 
accommodative apparatus. The symptoms of paresis of 
accommodation following diphtheria are essentially the 
same as in asthenopia resulting from the overloading of 
the accommodation in hypermetropia, and the use of con- 
vex glasses is often indicated as an aid in reading during 
the continuance of the disability ; the instillation of a drop 
of a weak solution of pilocarpine, two or three times a 
day, is also of positive utility ia many cases. 

Syphilis is recognized as an occasional cause of paralysis 
of accommodation with mydriasis. It occurs ordinarily 
as one of the later manifestations of the disease, and is 
not generally amenable to treatment. 

Pressure upon the ciliary nerves, from intraorbital 
haemorrhage, inflammatory exudation, tumor, etc., may 
give rise to loss of accommodation and dilatation of the 
pupil, without affecting the function of any of the exter- 
nal muscles of the eyebaU. 

In lesions affiecjting the conductivity of the motor-oculi 
nerve, the accommodative disturbance and dilatation of 
the pupil are accompanied by paralysis of the levator 
muscle of the upper lid, of the recti muscles (excepting 
the abducens), and of the inferior oblique muscle. 

Mydriasis, with loss of accommodation, may occur as a 
symptom of intracranial disturbance, affecting the central 
origins of the motor-oculi nerve. Such disturbance may 
be the result of a pathological process (syphilis, embolism, 
etc.), in which case it is apt to be associated with paraly 
sis of one or more of the external muscles of the eyeball. 

Exposure to sudden changes of temperature, sitting in 
a cold draught, etc., are sometimes followed by paralysis 
of one or more of the motor nerves of the eye or of the 
eyelid. These cases, which, in the absence of positive 
knowledge, are generally designated as rheumatic, end 
frequently in perfect recovery after a few days or weeks ; 
in other instances they prove rebellious to all treatment. 

The constitutional effect of an overdose of any one of 
the common mydriatic drugs (belladonna, datura, hyos- 
cyamus, duboisia), administered by the stomach or hy- 
podermically, is marked by conspicuous dilatation of 
the pupils, with loss of accommodation. If the patient 
survives the toxic influence, these symptoms disappear 
after a short time. 

True spasm of accommodation, as distinguished from 
the condition of accommodative tension already noticed 
in connection with ametropia, is of quite rare occurrence, 
and is a result of irritation of the ciliary nerves or the 
oculo-motor nerve-centres,' or of a paralytic affection of 
the cervical sympathetic. It is associated with contraction 
of the pupil (myosis), and is the exact opposite of accom- 



53 



Aocoinmodatlon. 
Acetabulum. 



REFERENCE HAKDBOOK OF THE MEDICAL SCIENCES. 



modative paralysis with mydriasis. Certain drugs {myo- 
tics), Instilled into tlie conjunctival sack, have the property 
of evoking accommodative spasm with myosis, which may 
be studied hy observing the action of a single drop of a 
solution of eserine sulphate (the active alkaloid of Calabar 
bean) of the strength of one-half of one per cent. (1 : 200). 
Contraction of the pupil and spasm of accommodation 
begin nearly simultaneously within about ten minutes, 
and both reach a maximum in from thirty to forty min- 
utes. After about two hours, the far-point (r), which at 
the height of the action of the drug is not over twenty 
centimetres (eight inches) from the eye, is found to have 
receded to its normal position (oo in the emmetropic eye), 
but the near-point, in voluntary accommodation, is con- 
siderably nearer to the eye than normal after the lapse of 
six hours, thus showing a positive increase in the range of 
accommodation. The contraction of the pupil begins to 
diminish after about two hours, at first slowly, then more 
rapidly for about four hours more, and afterward slowly 
until, at the end of two days, the pupil has nearly or quite 
regained its normal diameter. With a weaker solution of 
eserine the spasm of accommodation is much less than 
with the half per cent, solution, and is painless ; with the 
stronger solution the action is accompanied by a sensation 
of spasmodic twitching, and with some pain. Pilocarpine, 
the active alkaloid of jaborandi, is much milder in its 
action than eserine, but is nevertheless an efficient myotic, 
and exerts also a very positive effect in stimulating the 
accommodation. 

Contraction of the pupil is frequently observed in cen- 
tral nervous affections, and notably in tabes dorsalis. 
Myosis, with spasm of the accommodation, follows also 
the administration of large doses of eserine, opium, and, 
probably, some other drugs, internally. The internal or 
hypodermic use of pilocarpine does not produce contrac- 
tion of the pupil or spasm of accommodation. 

John Cfreen. 

' Dioptric (or dioptry), a word proposed by Monoyer to designate the 
unit of the metric system ; it is the generally received expression for 
a lens of one metre focal length, which is almost exactly equivalent to 
the glass numbered 40 ( V40) ^ ^^^ °^^ French system. 

3 In a case of myopia of 4.5 dioptrics in the right eye, with hyperme- 
tropia of 5.5 dioptrics in the left eye, which came under the care of the 
writer about ten years ago, the right eye was first corrected by a concave 
glass of 4.5 dioptrics, and a; plane glass was given for the left eye. 
The patient, a young man of eighteen years, was well satisfied with those 
glasses for a few weeks, and then demanded a correction for the left 
eye. At the end of ten weeks he was wearing correcting glasses for both 
eyes with comfort, and still wears the same glasses with entire satisfao- 
tion. 

8 Irritation of the fifth cranial nerve (ophthalmic division) is followed 
by contraction of the pupil, and the same phenomenon may attend iiTi- 
tation of the terminal branches of this nerve in the cornea. Myosis from 
this cause may also be attended with spasm of accommodation. 

ACETABULUM, Fbactukbs of, may be divided into 
compound and subcutaneous, or, as regards their causa- 
tion, into direct and indirect. The hip-joint is so deeply 
situated and so efficiently protected by the surrounding 
bony projections and soft tfssues against direct violence 
that fractures produced in this manner almost invariably be- 
long to the compound variety, and, in the great majority of 
cases, they are the result of gunshot injuries. Gunshot 
wounds of the hip- joint, with or without fracture of the 
acetabulum, have always been considered by surgeons as 
formidable and dangerous lesions. Pirogoff made the 
statement that during the Crimean War all injuries of 
this kind proved fatal. During the war of the Rebellion 
nearly all eases of gunshot injuries of the hip-joint treated 
on the conservative plan resulted in death. Of 63 cases 
of similar injury where resection was performed, only 5 
recovered. In his classical treatise on this subject, B. 
von Langenbeck collected 119 cases which occurred dur- 
ing the Franco-Prussian war, with 29 recoveries ; 88 were 
treated on the expectant plan, with 25 recoveries ; 31 were 
submitted to excision, with 4 recoveries. 

The acetabulum may be fractured without injury of the 
head or neck of the femur, as the bullet may impinge 
upon the floor of the acetabulum, from within the pelvis, 
with sufficient force to break the bone, producing a fissure 
or stellate fracture of its base, or it may, in its course, 
carry away the rim of the cotyloid cavity. An exceed- 

54 



ingly interesting case, illustrating the latter assertion, is 
reported by Dr. J. F. Miner, of Buffalo (Buffalo Med. 
and Surg. Journal, vol. v., p. 383). Lieutenant-Colonel 
James Strong, of the Thirty-eighth New York Volunteers, 
was wounded. May 5, 1862, at the battle of Williamsburg, 
Va. The ball entered a little below the anterior superior 
spinous process of the ilium, and made its exit near the 
outer margin of the sacrum. The ball passed deeply, and 
fractured, in its course, the rim of the acetabulum, which 
was removed, an inch and a half in length, and of a 
diameter sufficient to show that the whole upper rim had 
been carried away. This fragment of bone was removed 
from the wound at the dressing made in the hospital to 
which he was carried, after having lain on the field for 
some hours. The wound was very large, and a thorough 
examination could be made by the easy passage of the 
finger. The patient passed through a serious and pro- 
longed illness from the suppuration and hectic fever which 
followed, but finally recovered, with five inches shorten- 
ing of the limb, inward rotation of the foot, and bony 
anchylosis between the dislocated thigh-bone and the 
ilium. The points of entrance and exit of the projectile 
furnish valuable information in regard to the probable 
injury of the acetabulum in gunshot fractures of the hip- 
joint. In the case just reported, the ball entered just 
below the anterior superior spinous process of the ilium, 
and passed out near the margin of the sacrum, leaving 
intact the head of the femur, but opening the hip-joint by 
carrying away the superior and posterior margin of the 
rim, thus permitting the subsequent dorsal dislocation of 
the head of the femur by muscular force. B. von Lan- 
genbeck states that, in case the ball enters directly below 
and toward the outer side of the spine of the pubes, and 
takes its exit in the region behind the greater trochanter 
of the same side, as a nile it penetrates the hip- joint ; 
and, at the same time, it fractures in its course the upper 
rim of the acetabulum. Escape of synovial fluid, swell- 
ing in the region of the hip- joint from extravasation of 
blood or the products of inflammation, preternatural mo- 
tion in the joint, crepitation, and dislocation of the head 
of the femur spontaneously, or on manipulation, are other 
important diagnostic symptoms. The most important 
information regarding the exact nature of the injury is, 
however, obtained by enlarging the track of the bullet and 
rendering the hip-joint accessible to touch and sight. This 
procedure, done under antiseptic precautions, alfords not 
only an opportunity to ascertain the true nature and grav- 
ity of the injury, but it is imperatively called for as the 
first and most important step in the treatment. All for- 
eign bodies and detached pieces of bone should be re- 
moved, all haemorrhage carefully arrested, and'the whole 
injured surface and surrounding parts thoroughly disin- 
fected ; effective drainage should be established, and every 
possible source of infection guarded against by dressing the 
wound antiseptically. All these measures are essential, 
as the success of the operation and the life of the patient 
depend on procuring and maintaining an aseptic condition 
of the wound. The leading principle in the treatment 
should be, from the very beginning, to convert the com- 
pound into a simple fracture, and thus protect the patient 
against the disastrous consequences of traumatic infection, 
exhausting suppuration, pyaemia, and septicaemia. 

Subcutaneous or simple fractures are again divided into 
those which involve the floor and those which involve tho 
rim of the acetabulum. This division rests on clinical ex- 
perience as well as on the results of experimental research. 
Fractures of the base or floor of the acetabulum, notwith- 
standing their rare occurrence, yet present a great diver- 
sity in the direction and extent of the line of fracture. 
Courant observed a fracture which traversed the ilio-pec- 
tineal tubercle, the entire acetabulum, and the ischium. 
Earle and Travers describe two cases where two lines of 
fracture passed through the acetabulum ; Neill and San- 
som saw cases with three lines of fracture which extended 
beyond the rim. In Dr. Neill's specimen the lines of 
fracture followed those Of the embryonal division of the 
bone ; the union which followed was complete, and there 
was very little callus on the articular surface, a circum- 
stance undoubtedly due to the slight displacement of the 



EEFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 



A ccommodatlon. 
Acetabulum. 



fragments. More serious to the life of the patient and 
the future utility of the limb are those cases where a mul- 
tiple fracture at the base exists with such wide separation 
between the fragments as to allow the head of the fe- 
mur to be driven into the pelvis by the fracturing force, 
thereby producing an intrapelvic dislocation of the thigh. 
A number of such cases have been reported. Astley 
Cooper alludes to three cases. In two of these the thigh 
was rotated inward, in the third, case the leg and thigh 
were supinated. Mr. Moore's case demonstrates the pos- 
sibility and manner of repair in these cases (" Medico- 
Chir. Transactions," vol. xxxiv., p. 107). A man suffered 
a severe injury of the hip, which was diagnosticated and 
treated for fracture of the femoral neck. The thigh was 
not inverted or everted, only slightly flexed and adducted. 
The man recovered, and several years afterward died 
from other causes, when an autopsy revealed that the in- 
jury had been a fracture of the pubes, ilium, and acetabu- 
lum, which allowed the head of the femur to pass 
through into the pelvis, the trochanter resting against 
the acetabulum. Similar cases have been reported by 
Kendrick and Morel-Lavellee. In all cases of fracture at 
the base of the acetabulum, without displacement of the 
head of the femur, the diagnosis usually remains doubt- 
ful. Main reliance must be placed on the manner in 
which the injury was inflicted, the intensity of the force 
applied, and the location of the pain. Accurate measure- 
ment will always furnish important negative evidence. 
In case of intrapelvic dislocation of the head of the 
femur through the fractured base of the acetabulum, the 
. shortening of the limb, and the approximation of the tro- 
chanter major toward the pelvis will be proportionate 
to the degree of penetration of the head and neck into 
the pelvis ; rotation of the limb will not be practicable ; 
flexion and extension' will be found to be either impaired 
or rendered impossible ; and at the same time the head of 
the femur may be felt within the pelvis on making a digi- 
tal examination through the rectum. In the adoption of 
therapeutic measures it is necessary to ascertain the de- 
gree of impairment of the functional capacity of the ace- 
tabulum. If the head of the femur is retained firmly in 
its normal position the fracture will unite promptly and 
firmly without any special retentive measures. Rest in 
bed with the thigh slightly flexed and resting upon pil- 
lows ■wall be sufficient to fulfil the local indications. If 
the pelvic ring is more extensively fractured, a plaster-of- 
Paris splint including the pelvis, both thighs, and the en- 
tire leg on the affected side, or Verity's suspension splint, 
will prove most efficient in securing immobility of the frag- 
ments, and will aflEord the greatest amount of comfort to 
the patient. When the base of the acetabulum has been 
perforated by the head of the femur it is of paramount 
importance to replace the dislocated bone and retain it in 
situ by a plaster-of -Paris dressing, or by applying exten- 
sion by weight and pul- 
ley, as advised by Hueter, 
until the opening is closed 
by callus or connective 
tissue which will definite- 
ly prevent redislocation. 
Fracture ov the Rim 
of the acetabtiltjm. — 
A number of well-authen- 
ticated cases of this acci- 
dent have been reported, 
so that no further doubt 
can exist that some por- 
tions of the rim can be 
fractured without further 
injury to the acetabulum. 
Some years ago the writer 
collected from various 
sources twenty-seven cases of this kind of fracture, the 
cases being supported by. an accurate clinical history, and 
in some cases verified by a post-mortem examination. 
Dr. H. O. Walker, of Detroit, has in his possession a 
typical specimen of this kind, an illustration of which 
is here inserted (Detroit Lancet, July, 1879). In the 
text-books on Surgery this subject is usually referred 




Fio. 61. 



to under the head of complicated dislocations of the head 
of the femur. As this fracture usually involves the upper 
and posterior portion of the rim, the resistance to the 
head of the femur in that direction is lost, and as a result 
— either with the concurrent aid of some extraneous force, 
or even without such aid, simply by the force of muscu- 
lar contraction — a dorsal dislocation of the thigh takes 
place, with adduction, flexion, and rotation of the thigh 
inward. The difficulty experienced in retaining the head of 
the femur in the acetabulum under these circumstances, as 
well as the obscurity of the diagnosis, imparts to this sub- 
ject an unusual amount of interest. The older works on 
surgery mention direct and gi'eat violence as the only cause 
of fracture of the acetabulum ; indeed, until more recently, 
it has been considered impossible for a fracture of the rim 
to take place without more extensive injury to the ilium. 
When the fracturing force is applied over the centre of 
the trochanter major, in the direction of the neck of the 
femur, the head of the bone is driven directly against the 
socket, and a stellate or perforating fracture of the base 
of the acetabulum is the result, according to the amount 
of violence applied ; but if the force is applied in such a 
manner that it first rotates the femur outward or inward, 
then one margin of the acetabulum acts as a fulcrum to 
the neck, and the head is forced against the opposite side, 
and a linear fracture through the acetabulum, or a fracture 
of the rim, takes place. In such cases, the traction of the 
capsular ligament assists the head of the femur in produc- 
ing the fracture of the rim, but independent of other 
causes such traction is insufficient to produce the injury. 
When the force is applied to the posterior part of the pel- 
vis, the pelvis becomes the movable point, and the foot, if 
the leg is extended, or more frequently the knee, becomes 
the fixed point, and furnishes the necessary amount of re- 
sistance. These assertions have been verified by the 
writer by numerous experiments on the cadaver. At the 
moment the injury is received, it is essential for the thigh 
to be abducted, as adduction would favor a dislocation by 
the head of the femur gliding over the inclined plane of 
the internal surface of the acetabulum. The pelvis may be 
the fixed point, and the force may be transmitted through 
the femur by a blow or fall upon the knee. In most in- 
stances where this accident occurred, the thigh was more 
or less flexed at the time of injury ; hence, in the majority 
of cases, the upper and posterior segment of the rim was 
fractured, and the head of the femur dislocated into the 
upper sciatic notch or upon the dorsum ilii. Of the 
twenty-seven cases of fracture of the rim of the acetabu- 
lum, the extremes of the ages were eighteen and seventy- 
eight years, so that most of these cases occurred during 
the time of life when the individual is most exposed to grave 
injuries. It is also well to remember that, in young per- 
sons, dislocation and diastasis occur in preference to fract- 
ure, while in the aged, the altered position of the neck of 
the femur, as well as the increased fragility of its tissue, 
is a potent predisposing cause of fracture of the femoral 
neck. 

The symptoms presented by a case of fracture of the 
rim of the acetabulum are those of dislocation and fracture 
combined ; the symptoms of the former resemble ordinary 
dislocation, while those of the latter are directly referable 
to the broken bone itself. A certain de^ee of displacement 
of the head of the femur was present m all cases where a 
diagnosis was made during life. Benjamin Travers be- 
lieved that in some cases of fracture of the rim of the 
acetabulum the displacement takes place gradually some 
time after the injury has been received, but it is more 
probable that these vrere cases such as have been described 
by Hueter as inflammatory dilatation of the acetabulum, 
the interstitial absoi-ption of the margin of the cavity per- 
mitting the head of the femur to glide upward and back- 
ward. In twenty-four cases the direction of the disloca- 
tion is mentioned, and in fifteen of these the head of the 
femur was dislocated upward and backward, in four into 
the great sciatic notch, in two directly backward, in two 
downward, and in one case forward. It will be seen, 
then, that in a large majoritjr of cases that portion of the 
rim is fractured which is m the direction of the usual 
form of dislocation, so that the same injury which pro- 



65 



Acetabulum. 
Acetic Acid. 



REFEBENCE HANDBOOK OF THE MEDICAL SCIENCES. 



duces a dislocation may also cause a fracture, provided the 
force applied be sufficiently great, and the hmb happen 
to be abducted at the time the injury is sustamed. 

The amount of shortening corresponds to the distance 
the head of the femur recedes from the socket. In Ag- 
new's case no shortening could be detected on careful 
measurement. In all of the other cases where mention is 
made of this symptom, it was present, but varied in degree 
from a quarter of an inch to four inches. If the head of 
tlie femur has left the socket the position of the limb is 
the same as in simple dislocation, the direction being de- 
termined by the form of dislocation. Flexion to a greater 
or less extent was present in all cases where reference is 
made to this subject. Inversion of the foot and rotation 
of the femur inward were present in fourteen cases, while 
the opposite condition existed in three cases, and in ten 
cases no mention is made of this symptom. When the 
dislocation was complete, the limb remained immovable 
in its abnormal position until reduction was effected. The 
characteristic symptoms of the injury are those which are 
referable to the fracture itself, and these are crepitus, easy 
reduction, and difficult retention. Crepitus is always an 
important symptom in ascertaining the existence of a 
fracture. If it is distinctly felt there can be no further 
doubt that a bone has been broken. The presence of this 
symptom is of special diagnostic value in connection witli 
this subject, as the symptoms of dislocation are usually so 
prominent as to engage the whole attention of the surgeon. 
In the cases reported, this symptom is alluded to eighteen 
times, and in the following terms ; distinct, eleven times ; 
faint, once ; marked, twice ; indistinct, once ; slight, 
once ; and in two cases it was absent. Bigelow lays great 
stress on this symptom as being essential to the diagnosis 
of fracture ; his words, as quoted from the work pre- 
viously mentioned, are : "To afford satisfactory evidence, 
cases of this sort should have been identified by autopsy, 
or at least by crepitus." I believe that the crepitus is not 
the same as in ordinary fractures, for in these it is the re- 
sult of two rough bony fragments rubbing against each 
other, while in the cases under consideration it is a rough- 
ness we obtain by rubbing an articular surface against a 
broken surface of bone, hence not quite as loud and dis- 
tinct. The detached margin of the acetabulum, unless 
comminuted, remains attached to the capsular ligament, 
and is pushed in front of or to one side of the head of 
the femur at the time dislocation occurs, and is dragged 
after it when reduction takes place. In most of these 
cases it is clearly stated that crepitus was felt just 
before the head of the femur slipped into the socket, or 
at the moment reluxation took place, and in both in- 
stances it must have been produced by the head passing 
over the rough broken edge of the acetabulum. The 
ease with which reduction has been effected has attracted 
the attention of almost every observer. This is due to a 
more extensive laceration- of the capsular ligament than in 
simple dislocation, and also to the removal of the obstacle 
offered by the intact margin of the acetabulum. By the 
fracture of the rim, a more direct and even route has been 
prepared for the head of the femur to return to its socket. 

Reluxation lias always constituted the most perplexing 
feature of these cases. Its occurrence has usually led to 
a more thorough examination and correct diagnosis. It 
is well known that in ordinary dislocations of the hip- 
joint, when the bone has once been reduced, it remains in 
its place regardless of the after-treatment, differing greatly 
in this respect from the same lesion of the shoulder-joint 
on account of the greater depth of the socket, and the 
action of more numerous and powerful muscles for main- 
taining retention. Hueter believed that the cases of ha- 
bitual dislocation of the hip- joint reported by Karpinski 
may have been the result of injury to the rim of the ace- 
tabulum. Reluxation takes place from the inability of the 
defective margin to resist muscular contraction. The dif- 
liculty in retaining the bone is increased by the depth of 
the fracture and its approach to the junction of the supe- 
rior and posterior portions of the rim. In this connection 
it is important to determine what po,j:tion of the rim is 
most frequently the seat of the fracture. In 20 of the cases 
special mention is made of this fact, as follows: supe- 



rior portion of rim, 3 ; superior and posterior, 7 ; poste- 
rior, 5 ; posterior inferior, 4 ; inferior, 1 ; anterior, 1. 
When the inferior or anterior portion of the rim is fract- 
ured, there is no tendency to reluxation provided the limb 
is kept in the extended position and slightly inverted. 

Diagnom. — A most thorough and critical examination 
while the patient is profoundly under the influence of 
an anaesthetic, is always necessary to establish a positive 
diagnosis. If spontaneous reluxation does not follow 
immediately after reduction has been accomplished, and 
there are sufficient symptoms present to warrant a sus. 
picion of the presence of the injury, it would be advisa- 
ble to test the functional integrity of the acetabulum by 
flexion, adduction, and rotation of the thigh ; if any 
part of the rim has become defective by fracture, re- 
luxation will be sure to take place. This mancEuvre, 
associated with the presence of crepitus, may be re- 
garded as the crucial test. 

The differential diagnosis must consider fractures of 
the neck of the femur with displacement, and simple 
dislocation. To distinguish this fracture from fracture 
of the neck of the femur, it is necessary to compare their 
most prominent symptoms : 



VBACTURE OF THE BIM OF THE 
ACETABUlitTM. 



FRACTURE OF THE NECK OF THE 
FEMUK WITHOUT IMPACTION. 



PoBition of Limb, 
Thigh and leg flexed, adducted, and I Thigh and leg straight and rotated 
rotated inward. I outward. 

Jfobility of Limb. 
Mobility of limb is diminiahed. | Mobility of limb ia increased. 

Arc of notation. 
The trochanter major rotates in its 1 The arc of rotation of the trochan- 
normal arc. | ter major la diminished, 

Crepitun. 
Crepitation is not rough, and is felt I Crepitation is rough, and is felt 
aa the head pasHes over the broken when the limb haa been drawn 
edge of the acetabulam. | down to its normal length. 

Jlead of Ike Femur. 
The head of the femur is felt to be I The head of the femur \» normal in 
displaced. , | its position. 

ReUntion. 



The deformity reappears if by any 
movement of the limb the head of 
the femur ia made to leave the 

socket. 



The deformity reappears as soon as 
extension ceases. 



History, 



Is moat frequent in middle life and 
is the result of great violence. 



If intra-capsular in variety, it oo> 
curs in the aged and is the result 
of slight violence. 

Crepitus, and a tendency to reluxation, are the symp- 
toms on which we place the most reliance to differenti- 
ate this fracture from simple dislocation. Acupuncture, 
as advised by Middeldorpf , may be of great service to 
determine the existence of fracture of the rim. After 
reduction has been accomplished, a long stout needle, 
previously well disinfected, is passed through the tissues 
to the supposed seat of fracture. By lateral movements 
of its point the defect in the margin, as well as the 
roughness of its surface, is ascertained. An effort should 
now be made to fix the detached fragment with the point 
of the needle, and by rubbing it over the broken margin 
a rough crepitus is elicited. 

Prognom. — The prognosis must have reference to the 
preservation of life and the restoration of the utility of 
the limb. AIJ of the old authors regarded fracture of 
the pelvic bones a grave lesion, almost necessarily lead- 
ing to a fatal termination. I believe that all uncompli- 
cated fractures of these bones tend to recovery, and that 
death is attributable in most instances to a lesion of some 
important pelvic or abdominal viscera. In twenty-three 
cases where the result is noted in this regard, thirteen re- 
covered and ten died. The prognosis is less favorable if 
the floor of the acetabulum is also implicated in the fract- 
ure. Of four cases of this sort only one recovered. In 
nine cases out of the thirteen that recovered, the limb 
remained in place after reduction, and the recovery was 
complete. In four cases redislocation took place, the 
limb assuming the same malposition as after simple un- 
reduced dorsal dislocation of the femur. 



56 



REFERENCE HANDBOOK OP THE MEDICAL SCIENCES. 



Acetabulum, 
Acetic Acid. 



Treatment.— The indications to be fulfilled in the treat- 
ment of this class of injuries are : 1, To reduce the disloca- 
tion ; 8, to retain the head of the femur in the socket 
until union has taken place between the fragments. The 
dislocation maj be reduced by manipulation or by exten- 
sion ; in both instances flexion constitutes an important 
step in the operation. Bigelow says : " These displace- 
ments, especially the displacement backward, demand 
the usual attempts at reduction by flexion. Although 
the bone inclines to slip from the socket it can be re- 
tained there, in cases of a sort heretofore considered 
difficult of treatment, by angular extension, with an 
angular splint attached to the ceiling, or some other 
point above the patient ; or if any manoeuvre has reduced 
the bone, the limb should be retained, if possible, in the 
attitude which, completed the manoeuvre." In 17 of the 
cases reported, the maqner of reduction is specified as 
follows : By extension, 11 (in most of these cases exten- 
sion and flexion were combined) ; by manipulation, 2 ; 
by manipulation and extension, 1 ; by manipulation over 
Sutton's fulcrum, 1 ; by extension with pulley, 3. In 
all but one of the cases the displacement was corrected 
without diflSculty. As inmost instances a diagnosis can- 
not be made before reduction has been accomplished, 
surgeons will resort to their favorite methods of reduc- 
tion. Should the nature of the lesion be determined be- 
forehand, traction in the direction of the broken edge of 
the rim, and rotation of the limb inward, will readily re- 
store the normal relation of the parts. As we possess no 
direct measures of keeping the fractured surfaces in ap- 
position, all our efforts must be directed toward prevent- 
ing reluxation bjr appropriate position and fixation of 
the limb and pelvis. The depth and extent of the fract- 
ured margin, as well as the location of the fracture will 
determine the difficulty in retaining the head of the 
femur in its normal position. If sufficient depth of the 
upper portion of the rim is left to serve as support to 
the head of the bone, all that is necessary is to dress the 
thigh in the abducted position, so as to press the head 
of the femur against the floor of the acetabulum. As 
the contusions of the soft parts about the hip and pelvis 
are severe, a plaster-of -Paris splint cannot be applied as 
a primary dressing. The healthy limb and pelvis should 
always be included in the retentive dressing. Bonnet's 
wire-breeches, Dzondi-Hagedorn's apparatus, or Hamil- 
ton's splint, as advised by him in the treatment of fract- 
ures of the femur in children, will be found sufficient 
to maintain retention. After the swelling in the soft 
parts has subsided, nothing more perfect could be devised 
than a plaster-of-Paris dressing, including both limbs 
and the pelvis. 

When nearly the entire depth of the upper or posterior 
portion of the rim has been detached, muscular contrac- 
tion must be counteracted by permanent extension with 
the weight and pulley, and immobility of the joint should 
be secured by appropriate splints. In cases of this sort, 
angular extension with an angular splint, as advised by 
Bigelow, will answer an admirable purpose. The un- 
brokeii part of the rim should be made the support of 
the head whenever practicable. Thus, for example, 
when the posterior part of the rim is fractured the thigh 
should be dressed in the position of hyperextension ; a 
broad, firm, pelvic band, with a compress above the tro- 
chanter, being employed to aid in keeping the bone in 
place, in approximatmg the fractured surfaces, and in 
preventing muscular spasms. 

The treatment should be continued for a sufficient 
length of time to secure a firm union of the detached 
fragment with the broken rim, which, as in other fract- 
ures, generally requires from four to six weeks. The 
patient must be directed to exercise great care in the use 
of the limb for a considerable length of time after all 
dressings have been removed, so as to obviate any un- 
due pressure against the recently repaired rim of the 
acetabulum. 

Literature. 

N. Senn : A Contribution to a. Knowledge of Fracture of the Rim of tlie 

Acetabulum, etc, Milwaukee, 1880. 
Emmert: Lehrbuch der spec. Chir., vol. lii., p. 750. Stuttgart, 1862. 



Detroit Lancet, July, 1879 : H. 0. Walker's case. 

Buffalo Medical and Surgical Journal, vol. /.. p. 883: Colonel Strong'! 
caKe. 

Hamilton : A Practical Treatise on Fractures and Dislocations. Phila- 
delphia, 1871. 

Bigelow: The Mechanism of Dislocation and Fracture of the Hip, Phila- 
delphia, 1869. 

Travers : Further Observations in Surgery, p. 27. 1860. 

Hueter : Klinik der Gelenkkrankheiten, part ii., p, 316. Leipzig, 1876. 

Stimson; A Treatise on Fractures. Philadelphia, 1883. 

Hueter :' Grundriss der Chir., part ii, Leipzig, 1882, 

Albert: Lehrbuch der Chir,, vol. iv. Wein. 1883. 

Agnew : The Principles and Practice of Surgery, vol. i. Philadelphia, 

iV. Senn. 

ACETIC ACID. Acetic acid, HCHsOa, the well- 
known acid of vinegar, is a body fluid at ordinary tem- 
peratures, and miscible in all proportions w^ith water. 
Mixtures of the acid and water in different proportions 
constitute the different grades of the acid in commerce. 
Strong acetic acid is caustic, largely through its property 
of dissolving the formed material of the connective tissues 
to a pultaceous translucent substance. Being caustic, it 
is of course irritant, and swallowed in concentrated con- 
dition operates as a corrosive poison, the effects and symp- 
toms being substantially the same as in poisoning by the 
strong mineral acids. Two cases of death have been re- 
corded. The treatment is similar to that to be employed 
in case of poisoning by a mineral acid. In non-corrosive 
strength of solution (five or six per cent., the equivalent 
of vinegar), acetic acid produces the usual local effects 
of the sour acids — exciting the flow of saliva and tending 
to oppose sour fermentation of the food, and is also dis- 
tinctly astringent. Inhaled, the fumes are reviving in 
faintness and may relieve headache. 

Acetic acid has many uses in pharmacy ; in medicine 
the strong acid may be employed as a caustic, as to warts 
or cancers, and the weak acid used to make refreshing 
acid draughts in fever, or cooling lotions in inflammatory 
skin affections. Acetic acid is officinal in the IF, S, 
Pharmacopoeia in the following forms : 

Acidum AceiiBum Glaeiale, Glacial Acetic Acid. — This is 
defined to be "nearly or quite absolute acetic acid," It 
is "at or below 15° C. {59° P.) a crystalline solid; at 
higher temperatures a colorless liquid. When liquefied 
and as near as possible to 15° C. (59° F.) it has the 
specific gravity 1.056 to 1.058 " (U. S. Ph.), According to 
Squibb {Sphemeris), the specific gravities thus stated are 
from 0.0001 to 0.0002 too high. This grade of the acid is 
for pharmaceutical uses. 

Acidum Acetieum, Acetic Acid. — The grade of acid 
thus simply named is a "liquid composed of thirty-six 
per cent, of absolute acetic acid and sixty-four per cent, 
of water." It is "a clear, colorless liquid, of a distinctly 
vinegar-like odor, a purely acid taste, and a strongly acid 
reaction. Specific gravity, 1.048 at 15° C, (59° P.) Mis- 
cible in all proportions with water and alcohol, and 
wholly volatilized by heat" (U. S. Ph.). This grade of 
acid is somewhat stronger than the best samples of the 
commercial so-called " No. 8 " acid, these " No. 8" acids 
rarely being of higher specific gravity than 1.030 and 
often sinking to 1,025 or less (Squibb). This is the acid 
that results from the purification of the crude acid — crude 
pyroligneous acid, so called — obtained by the destructive 
distillation of wood. 

Acetic acid of the present quality is sharply irritant and 
even mildly caustic. Dangerous symptoms have resulted 
from swallowing it, undiluted, in quantity of two or 
three ounces. The acid may be used as a mild caustic, 
but its principal uses under its own form are pharmaceu- 
tical. 

Acidum Acetieum Diluium, Diluted Acetic Acid. — 
This preparation is compounded of seventeen parts of 
acetic acid of the foregoing grade and eighty-three parts 
of water. It " contains six per cent, of absolute acetic 
acid, and has the specific gravity 1,0088 " (U. S. Ph.). 
Tills diluted acid is of the stren^h of the best qualities 
of vinegar, and is better than vinegar for all the pur- 
poses of the same,, medicinal or dietetic. Squibb says, 
"If one part of alcohol be added to about two hundred 
and fifty-six parts of this diluted acetic acid — that is. 



57 



Acetic Acid. 
Acidity. 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 



about lialf a fluidounce to the gallon, and the mixture be 
set aside for a few weeks— the longer the better, enough 
acetic ether is generated to give it the full, clean aroma 
of fine vinegar, and then for table use it is very far su- 
perior to any vinegar made in the ordinary way by fer- 
menting cider." . 
Diluted acetic acid is the most convenient grade of the 
acid for medicinal use, and has also, in the U. S. Pharma- 
copoeia, superseded vinegar for pharmaceutical purposes. 
For an acid draught a five per cent, addition to water is 
appropriate, and for a lotion a twenty-five per cent, ad- 
dition. The popular notion that the habitual use of vine- 
gar tends to deterioration of nutrition and health is cer- 
tainly not true of a moderate indulgence, if indeed it be 
true at all. Edwa/rd Curtis. 

ACETIC ETHER. Under the title u^lher Aeeticus, 
Acetic Ether, the IJ. S. Pharmacopoeia makes oflicinal a 
preparation consisting of the ethereal salt, ethylic acetate, 
with a little contaminating alcohol and water. Acetic 
ether is described as " a transparent and colorless liquid, 
of a strong, fragrant, ethereal, and somewhat acetous 
odor, a refreshing taste, and neutral reaction. Soluble, 
in all proportions, in alcohol, ether, and chloroform, and 
in about seventeen parts of water. Specific gravity, 0. 889 
to 0.897. It boils at about 76° C. (168.8° P.). It is in- 
flammable, burning with a bluish yellow flame and ace- 
tous odor" (U. S. Ph.). It should be kept in well-stopped 
bottles, and away from lights or fire. Dr. Squibb notes, 
concerning the foregoing description, that while the odor 
is "refreshing," the tote is rather "pungent and biting 
almost to acridity ; " and that the solubility in water is 
nearer one part in 11.86 than one in 17 ; and that few of 
the commercial samples of acetic ether will reach the 
oflicinal range of specific gravity. 

The effects of acetic ether upon the animal economy 
are similar, in a general way, to those of common ether, 
the most important point of difference being that acetic 
ether is the slower in operation. For this reason this 
ether is not available as a surgical anaesthetic ; but, on the 
. other hand, by reason of its agreeable odor, it makes an 
excellent and grateful cardiac stimulant, antispasmodic 
and carminative, taken internally, or, used externally, it 
may serve to mask disagreeable odors. It may be given 
internally, in quantities ranging from fifteen to thirty 
drops, well diluted with water or with some medicinal 
preparation, to which the ether is added as an adjuvant 
or corrigent. Acetic ether enters into the composition of 
the officinal preparations, perfumed spirit (cologne water), 
and tincture of acetate of iron. Edma/rd Curtis. 

ACETONEMIA. This term is used by many writers 
to express a diseased condition of the blood, due to the 
supposed presence in it of acetone, or of some of its de- 
rivatives. This state of the blood, according to their 
views, accounts for the nervous symptoms peculiar, more 
especially, to diabetic coma. It is believed to be the 
cause, also, of somewhat similar symptoms occasionally 
present in certain anaemic conditions of the blood, such as 
pernicious anaemia, and that associated with some of the 
more rapidly wasting forms of cancer, as cancer of the 
stomach. 

Fetters first observed the acetone-like smell of the urine 
in a case of diabetic coma. He drew attention to the sub- 
ject in 1857, and supposed it to be due to the presence of 
acetone in the blood. Since then Kussmaul has paid 
more attention to the subject, and has endeavored to ac- 
count for the sudden death in these cases by the rapid 
accumulation of this substance in the blood. He con- 
siders it a species of intoxication produced by the ace- 
tone. Numerous experiments on animals have been made 
by him, which seem to confirm his view of the subject. 
Dogs, to which he administered acetone hypodermically, 
as well as by inhalation, presented some of the nervous 
symptoms in connection with respiration, circulation, dhd 
locomotion that seemed to support his views. Frerichs 
decidedly objects to this theory of the causation of the 
comatose symptoms of these cases of diabetes. He thinks 
the term acetoneemia should be expunged from pathol- 

58 



ogy (Zeitschr. f. kliniseh. Med., vi., 28). His experiments 
do not bear out Kussmaul's conclusions. He adminis- 
tered acetone in doses varying from ten or twelve to 
twenty grains, to both man and animals, without pro- 
ducing any nervous symptoms at all similar to those 
observed in diabetic patients. He considers it quite a mis- 
take to attribute the nervous symptoms of diabetic intoxi- 
cation to the presence of either acetone or its derivatives. 

Kussmaul has stiU numerous supporters of his views. 
In the cases described, the breath has been observed to 
possess a fruity odor, resembling apples ; or, as described 
by some, an odor similar to chloroform. The mucous 
membrane of the mouth and throat has a dry and glazed 
appearance, and is generally very red. The urine also 
possesses a similar odor. (See Acetonuria.) 

Von Jaksch asserts that acetone occurs, to a slight ex- 
tent, as a normal product in the blood as well as in the 
urine {Zeitschr. f. klin. Med., v., 347). 

It is doubtful it free acetone can be obtained from 
the blood ; nevertheless, in many cases of diabetic coma, a 
substance with which acetone is combined can be obtained 
from it, and free acetone derived from this. There is yet 
some doubt as to what this body is. Some investigators 
are inclined to consider it to be ethyl-diacetate, while more 
recent authorities believe aceto-acetic acid to be the sub- 
stance. There seems to be very good ground for thinking 
this to exist in the blood, as we know it to be one of the 
products of alcoholic fermentation of glucose. 

Oeorge WilMns. 

ACETONE. Acetone, CsHsO, the ketone of acetic 
acid, called also pyroacetic spirit and pyroacetic ether, is a 
colorless, limpid, and inflammable liquid of pungent qual- 
ity, miscible in all proportions with water, alcohol, and 
ether. Its effects upon the animal system are, doubtless, 
of the general nature of those of the volatile alcohols and 
ethers, but the substance has never been systematically 
employed as a medicine. Edward Curtis. 

.ACETONURIA. According to Von Jaksch, acetone 
enters into the composition of every normal urine, to 
the extent of about one centigramme per day. When 
the quantity exceeds this amount, the pathological condi- 
tion of acetonuria is present. In continued fevers, with 
high temperature, the quantity secreted has been found 
as high as five decigrammes. In these cases, it is only 
after the fever has lasted a considerable time that acetone 
has been found in the urine. 

There are four principal diseased conditions in which it 
exists. These are, first, in fever of any kind, especially 
if the fever rises hi^h and the febrile condition lasts a long 
time ; second, in diabetes ; third, in cancer ; fourth, in 
acetoneemia. 

Observers are not yet quite agreed as to what the sub- 
stance is that is found in the blood as well as in the urine 
in these cases ; for, while some believe it to be acetone, 
others are of the opinion that it is a body such as aceto- 
acetic acid or ethyl-diacetate, from which acetone can be 
obtained. Acetone gives to the urine a peculiar odor, de- 
scribed by some as resembling chloroform, by others as of 
a more fruity character, such as that of apples, or, again, 
like that of hot vinegar. 

Frerichs and others have experimented with acetone, 
both on man and the lower animals, administering it in 
doses as large as twenty grains, and have so far found it 
harmless, although traces of it have been obtained from 
the urine in these cases. Diabetic urine containing ace- 
tone gives a deej) red or reddish-brown color in the pres- 
ence of perchloride of iron' (Gerhardt's test), and a rose- 
tint in the presence of sulphuric acid. For the former 
test, take a few cubic centimetres of the urine supposed to 
contain acetone ; add to it one or two drops of liq. ferri 
perchlorid.; this gives a grayish- white precipitate; the 
addition of a few drops more o5 the solution of iron in 
excess causes the precipitate to disappear if acetone is 
present, and gives a beautiful reddish-brown, which is not 
produced in normal urine. 

The sulphuric-acid test is performed by adding a few 
drops of the acid to the urine containing acetone when a 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 



Acetic Acid. 
Acidity. 



beautiful rose color is produced ; on subsequently adding 
a few drops of perchloride of iron, this rose tint is con- 
verted into a yellowish orange, which is characteristic. 

The peculiar reaction with perchloride of iron has been 
obtained from the urine of other diseases than diabetes. 
Various observers have obtained it in typhus, pneumonia, 
diphtheria, perityphlitis, pleurisy, and acute rheumatism. 

The diabetic cases in which but a small amount of 
acetone is present in thp urine are usually very slight. 
In many of these cases, Gerhardt's reaction (the bur- 
gundy red with perchloride of iron) cannot be obtained. 
On the other hand, the cases in which it is present are 
usually very severe, and frequently die with comatose 
symptoms. 

Treating distilled urine with a solution of iodine in 
iodide of potassium and caustic soda causes the yellow 
precipitate of ■ iodoform, if acetone is present. This is 
known as Lieben's test. Penzoldt recommends a test 
known as his ivMgo test. It depends upon the fact that 
acetone, in the presence of an alkali, changes orthonitro- 
benzaldehyde into indigo. Caustic alkali is to be added 
to the suspected urine, so as to render it distinctly alka- 
line. A watery solution of orthonitrobenzaldehyde is to 
be prepared and the alkaline urine to be added to this. 
If acetone is present, a yellow color is produced, which 
changes Immediately to green, and in about ten minutes 
assumes an indigo color. 

Other tests are Legal's and Le Nobel's. The former is 
the addition of cyanide of potassium and a few drops of 
a concentrated solution of caustic soda or potash to the 
suspected urine ; this produces a dark-red color, which 
changes to yellow after a few minutes ; if acetic acid is 
now added, the solution changes to carmine-red if only a 
small quantity of acetone is present, to a purple-red color 
if a large quantity is present ; after two or three hours 
this changes again to a brownish-green. Le Nobel's test 
depends upon the fact that substances containing acetone 
become of a violet-red upon the addition of cyanide of 
sodium with ammonia or its bicarbonate. 

Oeorge Wilhins. 

' This color is frequently referred to by foreign writers as '* burgundy 
red," from its resemblance to that of the wine of that name. 

ACIDITY, literally the quality of being sour, is a term 
used in medicine to denote either (1) a quality of the 
normally acid fluids of the body ; (2) a change in their 
character or amount ; or (3) the alteration of a normally 
alkaline to that of an acid secretion. It may, then, be 
either physiological or pathological. 

Physiological AcroiTY. — We have several well- 
marked instances of the former, e.g., in the gastric juice, 
the urine, the cutaneous excretions, and in the secretions 
of the muciparous crypts of the mouth and vagina. 

The gcbstne cusidity, in health, is due, so far as is at pres- 
ent known, to the secretion of lactic acid (Query : from 
the small but constant quantity of glycogen in the 
blood ?) by the gastric follicles ; which, reacting upon 
the sodic chloride (NaCl) also jjresent, produces free hy- 
drochloric (HCl) acid. The acidity of this secretion va- 
ries between 0.01. to 0.32 per cent., the average being 
0.17 per cent. 

The normal acidity of the urine is due indirectly to the 
uric acid excreted. Reacting upon the mildly alkaline 
sodic phosphate of the blood it abstracts part of the so- 
dium, leaving the acid sodium phosphate, viz. : 

"Uric Acid + 

HaCiHjNiOj -f 



""'^htp?!^™ = sodic Hydric Urate 

" HNaCsHaNiOs 



NaaHPO, 

Acid Sodic Phosphate. 

NaHaPOi 

This gives urine its acid reaction ; the degree varying 
within quite a wide range. Variations in health bear an 
intimate relation to the digestive process and the foods 
taken. Generally speaking, an hour after meals the acid- 
ity is least, due to the organic potassium and sodium 
salts taken in the food having been converted in the 
blood into the alkaline bicarbonates. Gradually increas- 
ing in acidity, it reaches a maximum after two and a 



half to four hours ; this gain being caused by the oxida- 
tion products (uric acid, etc.) of the proteids and nitro- 
genous tissues, occasionally, too, by such organic acids 
as oxalic and hippuric, the latter formed from benzoic 
acid, and often present in fruits (cranberries). 

The normal acidity of the cutaneous excretions is owing 
to the presence of some of the fatty acids of the acetic 
series, chiefly capric and caproic acids. TThe acids of the 
buccal and vaginal mucous crypts are unknown. 

PATHOLoeicAL AciDiTT. — Pathological changes in the 
acidities of the various body fluids may be of degree or of 
kind. 

The blood during life is always alkaline, no investi- 
gators having ever found it otherwise. (See Art. Alka- 
linity.) Its degree of alkalinity may vary. To speak of 
" acidity of the blood," then, is an erroneous expression, 
but one not infrequently applied to a greatly diminished 
alkalinity. The oxidation products of the foods and tis- 
sues form the principal source of the acids in the system ; 
though some, it is true, are supplied, often intentionally, 
with the foods. Their representatives are lactic, uric, 
and oxalic acids. Since the liquor sanguinis is always 
alkaline, they cannot exist in it in the free state. They 
must, therefore, remain where they were formed (either 
in the cells or between them), external to the capillaries, 
until they can have received either sufBcient alkaline 
bases to neutralize them or oxygen to destroy them, or 
both. Thus we have, after muscular exercise, free lactic 
acid in the muscle- juices ; but, after rest for some time, 
it disappears. It has be^ repeatedly shown that about 
890 grms. (28 oz.) of carbonic acid through the lungs, 
and acid matter equal to 2 grms. (31 grs.) of oxalic acid 
through the kidneys, are daily excreted. When under- 
going oxidation in the system, complex organic sub- 
stances are not changed to their lowest oxidation pro- 
ducts at one step, but by gradual transitions, each time 
to simpler substances, thus affording a gradual liberation 
of vital energy. 

So glycogen changes into lactic, then oxalic, and finally 
carbonic acids. The various acid products are easily, in 
health, converted by the ozone of the blood into COs — 
HjO — NHa — and urea, all readily excreted. Inefficient 
oxidation would increase the intermediate products, 
which are chiefly acids. 

The degree of alkalinity of the blood, therefore, de- 
pends upon (1) the amount of acids formed ; (3) the 
amount of oxidizable matter furnished ; and (3) the rate 
of elimination. 

(1.) The amount of acids formed will be increased by 
interference with the assimilation of oxygen, because 
complete oxidation cannot well occur ; and the inter- 
mediate acid products will result. This interference may 
be of a mechanical or a pathological character. We may 
class tumors of the thorax or abdomen and ascites with 
the former ; leucocythsemia, ansemia, chlorosis (diseased 
oxygen carriers), or heart and lung diseases with the lat- 
ter class of causes. 

(2.) Excess of oxidizable matter with normal oxygen 
supply will cause increased acid products. Here the 
oxygen is not diminished, but the matter to be oxidized, 
being in excess, finds insufficient oxygen for complete 
combustion. Such an increase occurs in that class of 
so-called " gouty" patients who, leading a very seden- 
tary life, consume large quantities of rich animal and 
vegetable food ; or again, in the acute febrile processes, 
where the body tissues, having, seemingly, lost theii 
power of resistance, fall a prey to the insatiable oxygen. 

(3.) Interference with elimination will, naturally, cause 
an accumulation in the system of acid products that 
may diminish the alkalinity of the blood to an extent 
sufficient to cause death. Diseased conditions of the 
emunctories, particularly the kidneys and skin, are fre- 
quent causes, but inattention to hygienic conditions and 
lack of exercise, without diseased conditions, may do 
the same. In severe cases of interference with elimina- 
tion, uric acid has been found in the nasal, pharyngeal, 
gastric, vaginal, cutaneous secretions (Boucheron), and 
in the menstrual blood ; also in the saliva in all forms of 



59 



Acldltr. 
Acids. 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 



Under any of those conditions in wliicli the alkalinity 
of the blood has been reduced to a minimum, even the 
alkaline secretions, by a sort of vicarious action, elimi- 
nate some of the acid products ; and this continuing tor 
some time, will induce a catarrhal inflammation. Ihus 
a bronchial, intestinal, or genito-urinary catarrh, is not 
infrequently caused. , , , j 

"Acidity of the stomach," a term rather loosely usea 
to denote heartburn, pyrosis, acid dyspepsia, etc., raay be 
dependent upon several causes. The normal acidity ot 
the stomach, ranging between 0.10 per cent, to 0.33 per 
cent., and averaging 0.17 per cent., may be increased 
or diminished. The majority of cases of "acidity of 
stomach" belong to the former, where a greater amount 
of acid is secreted than is needed for the purposes of 
digestion. In a fewer number of cases a diminished flow 
occurs (0.01 per cent.). Here the foods not protected by 
the antifermentative action of the gastric juice undergo 
one of the various acid fermentations (e.g., lactic, butyric, 
or acetic), thus giving rise to the same phenomena as in 
excessive flow. Reichmann has recently furnished an in- 
teresting explanation of the subjective symptoms developed 
in acidity. His conclusion, based upon carefully con- 
ducted experiments with such cases, as compared with 
similar experiments upon the healthy adult, is, that the 
peculiar burning pain, vrith sensations of oppression, 
weight, etc., is always the result of regurgitated normally 
(or abnormally) acid gastric fluids into the lower extremity 
of the oesophagus. Here the normal secretion is alkaline. 
It has been shown that irritation of the gastric mucous 
membrane from any cause induces, by a reflex action 
transmitted through the vagus to its branch (the nervus 
dilator cardise recently demonstrated by Openchowski), 
an active dilatation of the cardiac orifice, thus permitting 
a partial regurgitation of the acid fluids. By an ingenious 
method he found the reaction always acid here, when the 
patients complained of the above symptoms, while in other 
cases it was alkaline. Now, th e irritant which produces this 
dilatation permitting regurgitation is most frequently that 
arising from too acid secretions acting on the membrana 
mucosa ; but it should be borne distinctly in mind, for 
purposes of diagnosis, that any other irritant might occa- 
sion the same phenomena without an increased acidity. 
Such we see exampled frequently in those who drink irri- 
tating liquors, and eat hot sauces with their highly spiced 
foods ; or characteristically in the "sour stomach" of the 
beer drinker, where the gastric acidity has been demon- 
strated as reduced to a minimum (0.01 per cent.). Nor is 
the gastric juice abnormally acid when from the irritation 
of small gastric ulcers all the signs of so-called acidity arise. 

In the conditions described as existing in so-called 
"acidity of the blood," the amount of acid matter ex- 
creted by the kidneys is greatly increased, particularly 
the uric acid. When a slightly larger quantity of uric 
acid is excreted than can be neutralized by the replaceable 
sodium in the sodic phosphate, the excess remains free 
and uncombined in the urine, which, the condition en- 
during, will often induce a catarrhal inflammation of 
the mucous membranes with which it comes in contact. 
Should the uric acid be in still greater quantity, it, being 
very insoluble (1 to 15,000), may be precipitated in any 
part of the urinary tract, or after emission in the cooled 
urine. Thus originate the uric acid calculi of the kidney 
and- bladder. 

The normal cutaneous excretions contain some of the 
volatile fatty acids (chiefly capric), which, under certain 
conditions or idiosyncrasies not well understood,, are 
greatly increased. To this condition the term bromidrosis 
has been applied. When the skin endeavors to eliminate 
the excess of acids from the blood, not infrequently an 
urticaria, herpes, or eczema arises, subsiding as soon as the 
normal alkalinity of the blood is reached. For quantita- 
tive estimation of acid excreta in urine — an index to the 
proportion of acids in the system — see Art. Urine. 

Thekapy.— The existing conditions being known, the 
indications are evident. If the diflSculty lies in faulty 
oxidation, then means should be directed to its improve- 
inent. Such are increased exercise, ferruginous tonics, 
simple foods in moderate quantity, and especially an in- 



crease of the alkalinity of the blood, because it is a phys- 
iological fact that ' ' oxidation occurs easiest in alkaline 
media." (See Art. Alkalinity.) The idea, then, is not 
simply to neutralize, but to destroy the acid products. 
This can be accomplished by the use of either the alkaline 
salts of potassium, sodium, or lithium {e.g. , their carbon- 
ates), or, better, by the employment of, the neutral salts 
of those bases with the (easily oxidizable) organic acids, 
such as acetic, citric, or tartaric acid. These are pref- 
erable, because entering the circulation without neu- 
tralizing the gastric acids and impairing digestion, they 
are soon converted into the bicarbonates by oxidation, 
when they will neutralize any acids present in the econ- 
omy. All the vegetable acids entering the circulation, 
combined with the alkaline bases, are completely de- 
stroyed, appearing in the excreta as carbonates ; but if 
taken in the free state (in quantity) they are excreted 
wholly or in part unchanged. Liebig's explanation is • 
that the alkalinity of the blood is so greatly reduced by 
their absorption that oxidation cannot well take place, 
and they are excreted as salts. Thus the existence of gallic 
acid in alkaline media with oxygen is impossible. Where 
an immediate effect is desired, two or three large doses, 
1 to 3 grms. (grs. 15 to 45), of the bicarbonates (prefer- 
ably sodium), given in considerable water at short inter- 
vals, will accomplish the desired result. Thus an urticaria 
caused by acid excretions through the skin may often- 
times be relieved. If the "acidity" be through faulty 
elimination, the good sense of the physician will dictate 
appropriate remedies. The urate of lithium, being far 
more soluble than either the potassium or sodium salts, 
the carbonate of this base would form a more scientific 
remedy in cases of the so-called " uric acid diathesis." 

Lewis L. McArthur. 

ACIDS. PHYSioiiOQiCAL. — Normal Butyric Acid, CsHi, 
CO. OH, occurs principally as a glycerine ether in but- 
ter, but also in Sweat. It is formed abundantly by the 
butyric fermentation of lactic acid, 

SCsHeOs = CiHsOa + 2C0a + SHj, 

and at the same time also acetic and caproic acids are 
formed. It may be conveniently isolated by allowing 
grape-sugar or cane-sugar to ferment with rotten cheese 
and some calcium carbonate. After standing for a con- 
siderable time, calcium butyrate is formed, which sepa- 
rates out on boiling, and the acid may then be set free by 
hydrochloric acid. Normal butyric acid, CHs, CH^, 
CHa, CO. OH, is an oily fluid, boiling at 162.3° C. (324° F.) 
(Linnemann), solidifying at —19° C. (— 2.3° P.), and mix- 
ing in all proportions with water. The glyceride tri- 
butyrin, C3Hs(CiH,02)3, occurs in cows' butter, but can 
also be made synthetically. It is a colorless neutral oil 
of specific gravity, 1.056 at 8° C. (46.4° F.). 

Isovalerianic {Isopropj/laeetic) Acid, CiH,, CO. OH, oc- 
curs as a glyceride in the blubber oil of certain dolphins 
{delpMnus globiceps and phoemncC). It is also formed 
by the decomposition of albuminous bodies (casein), 
but is most easily prepared by the oxidation of fusel 
oil (amyl alcohol) by chromic and sulphuric acids. 

Isovalerianic Acid, (CHs),, CH, CH,, CO. OH, is an 
oily, colorless fluid, smelling like rotten cheese. It boils 
at 176.8° C. (349.4° P.) (Kopp) ; specific gravity, 0.931 at 
20° C. (68° F.), and soluble in water. 

Triismalerin, CsHt(C6H90a)s, found in dolphin blub- 
ber, is a colorless oil, neutral, and insoluble in water. 

Oaproic Acid, CtHu, CO. OH, occurs as a glyceride in 
cows' butter ; also formed, as a rule, with butyric acid in 
fermentation. It is an oily, colorless liquid, solidifying 
at-18°C. (-0.4° F.), boiling at 205° C. (401° F.) ; specific 
gravity, 0.938 at 30° C. (68° F.). Insoluble in water, with 
a faint, unpleasant smell. The pure glyceride has not been 
isolated. 

Oaprylic and Owpric Acids. — Normal caprylic acid, 
C,H,5, CO. OH, and normal capric acid, CjHu, CO. 
OH, occur in very small quantities as a glyceride in 
cows' butter. The first crystallizes in leaflets, melting 
at -1-16.5° C. (62° F.), boiling at 236° to SS?" C. (457° to 



60 



REFERENCE HANDBOOK OP THE MEDICAL SCIENCES. 



Aclditr. 
Acids. 



458° P.), and of very difficult solubility, even in boiling 
water. Capric acid occurs in fine needles, melting at 
30° C. (86° P.), boiling at 368° to 270° C. (514° to 518° P.) : 
very insoluble in boiling water. The pure glycerides of 
these acids are not known. 

Laurie and Myj-ktie Aeids. — Laurie acid, CuHjs, CO. 
OH, and myristic acid, CisHai, CO. OH, are both found 
as cetylic ethers in spermaceti (Heintz). The first crys- 
tallizes in needles, melting at 43.6° C. (110.5° P.) ; the lat- 
ter in leaflets, melting at 53.8° C. (139° P.). 

Palmitic Acid, CisHsi, CO. OH, is found in all fats, 
generally as a glyceride, in combination with stearic and 
oleic acids, sometimes as cetylic ether (spermaceti) and 
myricylic ether (beeswax). When pure, palmitic acid 
crystallizes in scales, which melt at 63° C. (143.6° P.). 
The glyceride, Ifripalmitin, C3Hii(Ci6H3iO!i)s, is crystal- 
• line, melts at 61.5° C. (143° P.) ; is almost insoluble in 
spirit of wine, but slightly so in absolute alcohol (boiling) ; 
very easily in ether. 

Cetylic Mh&r, CieHsa, CxeHaiOs, constitutes the prin- 
cipal part of spermaceti. It crystallizes in leaflets, and 
melts at 53.5° C. (138.5° P.) (Heintz). 

Myricylic Ether, CsoHg,, CieHjiOa, forms the principal 
part of beeswax ; is insoluble in alcohol ; crystallizes in 
feathery aggregations, and melts at 73° C. (161.6° P.) 
(Brodie). 

Bteamc Acid, CitHjs, CO. OH. — Pound as a glyceride, 
especially in the solid fats, and may be obtained in large 
quantities from mutton- or beef-suet. Pure stearic acid 
crystallizes in leaflet, melting at 69.3° C. (156.5° P.) 
(Heintz) ; soluble with difficulty in cold ^irit of wine, 
but easily in benzol, carbon disulphide, and ether. 

The glyceride THstearin, C8H6(Ci8Hsi>Oa)a is found in 
all fats. It crystallizes in scales, glistening like mother-of- 
pearl. According to Heintz, it has two melting-points — 
first at 56° C. (133.8° P.), becoming again solid at a higher 
temperature, and melting again at 71.6° C (161° P.). It is 
easily soluble in boiling absolute alcohol and ether. 

Arachie Acid, dsHsj, CO. OH. — This acid is found in 
cows' butter as a glyceride. It crystallizes in small glis- 
tening leaflets, which melt at 75° C. (167° P.). 

THarcuihin,, C3H6(CaoH8jOa)a, is granular ; very slightly 
soluble in ether. 

Medullic Acid; Oi^liii, CO. OH. — According to Eylerts, 
the glyceride of this acid is found in the spinal cord of the 
ox. It melts at 73.5° C. (162.5° P.). 

Hyamrm Acid, CjiHio, CO. OH. — The glyceride of hysena' 
acid was found by Carius in the secretion of the anal 
glands of the hyaena, from which it is obtained by saponi- 
fication and fractional distillation. The pure acid crys- 
tallizes in small clumps of feathery needles, melting at 
77° to 78° C. (170° to 173° P.) ; soluble in cold absolute al- 
cohol with difficulty, more easily in hot absolute alcohol, 
and very easily in ether. The pure glyceride is probably 
contained in hysena fat, but has not been isolated. 

Gerotic Acid, CaeHss, CO. OH, is found free in beeswax. 
As cerylic ether it forms the principal part of Chinese 
wax. The free acid forms granular crystals, which melt 
at 78° C. (173° P.) ; it dissolves with difficulty in alcohol. 
The cerotic acid cerylic ether, C27H66(Ca7H6a02) is crys- 
talline, wax-like, and melts at 83° C. (179.6° P.). 

Phyaetoleic Acid, Cis, Ha«, CO. OH, was found by Hof- 
stadter in the oil from physeter macrocephalus. It melts 
*t 30° C. (86° P.) ; oxidizes in the air. 

Oleic Acid. CnHaa, CO. OH, is found as a glyceride in 
almost all fats, solid and fluid, especially the latter. 
When pure, it crystallizes in colorless needles, which melt 
at 14° C. (57.2° P.); specific gravity, 0.898 at 14° C. 
(57.2° P.). When perfectly pure, it is soon oxidized in 
the air. With ioduretted hydrogen and phosphorus, when 
heated to 300° to 210° C. (393° to 410° P.) it passes into 
stearic acid. 

Triolein, CaH6(C,6H8s03)a, is a colorless neutral fluid, 
which is very little soluble in spirit of wine, but very 
easily soluble in ether. At body temperature it dissolves 
solid fats. 

Another acid ("Doglingsdure") has been found in the 
blubber of iaUena rosVrata, as a glyceride. 

T. Wesley Mills. 



ACIDS. Therapeutics.— The acids in general are 
substances, either solid, liquid, or gaseous, possessed of 
a sour taste, corrosive action, and the property of turn- 
ing blue litmus paper red, and of combining with bases 
or their oxides to form salts. Two of the acids of the 
Pharmacopoeia, however, carbolic and oleic, are, when 
pure, of a neutral reaction and will not redden litmus 
paper. The following-named substances are the ones 
which possess the characteristics of the acids in the most 
marked degree, and which are commonly understood 
when mention is made of this group. Though the Phar- 
macopoeia contains many other drugs which are, chemi- 
cally speaking, acids, nevertheless, as regards their thera- 
peutic action, they belong rather to some other family, 
and will be more properly considered in connection with 
the other members of their respective groups. (See 
articles Antiseptics, Astringents, Disinfectants, Sedatives, 
etc.) The pharmacopoeial " acids," commonly so called, 
and which will be here considered, are acetic, chromic, 
citric, hydrochloric (or muriatic), lactic, nitric, nitro-hy- 
drochloric (or nitro-muriatic), phosphoric, sulphuric, and 
tartaric. To these may also be added arsenious and car- 
bolic acids, which may, with propriety, be treated of here 
as regards their toxicology and external uses, and oxalic 
acid, which is of interest in this connection only as a 
poison. 

Toxicology. — Before speaking of the therapeutic uses of 
the acids, a portion of the space allotted to this article 
may perhaps be profitably devoted to a very brief con- 
sideration of the symptoms and treatment of poisoning 
by these substances. The mineral — arsenious, carbolic, 
oxalic, and tartaric — acids are those from which poison- 
ing, either by accident or design, most frequently occurs. 
When the mineral acids have been swallowed in concen- 
trated form, the symptoms are those produced by a cor- 
rosive poison — intense burning pain in the mouth and 
throat, wherever the acid has come in contact with the 
mucous membrane, severe thirst, weak pulse, and 
dyspnoea. If hydrochloric or sulphuric acid have been 
taken the lips will show black stains, while the corrosive 
action of nitric acid colors the parts yellow. In cases of 
poisoning by these acids, alkalies should be at once ad- 
ministered in large draughts of milk or water. Any 
alkali that is nearest at hand may be used — chalk, tooth- 
powder, whitewash scraped from the ceiling, soap, or 
washing- or cooking-soda. The patient should then be 
made to swallow olive oil, melted butter, or lard. The 
attempt to use the stomach-pump in these cases should 
never be made, as serious injury may thereby be done to 
the softened tissues. (Por the symptoms and treatment 
of arsenical poisoning, see under the head of Arsenic). 
Poisoning by carbolic acid is evidenced by extreme de- 
pression, weakness of the heart, and dyspnoea. The 
breath is redolent of the drug, leaving little doubt as to 
the nature of the case. It is not very often that carbolic 
acid is swallowed in sufficiently concentrated form to 
produce severe local escharotic effects. When this hap- 
pens the eschars are white in color. The treatment em- 
braces the use of the stomach-pump or emetics, washing 
out the stomach, the administration of oily or mucilagi- 
nous drinks, and, later, stimulants to combat the depres- 
sion. Poisoning by oxalic acid is not infrequent, owing to 
the resemblance of this substance to Epsom salts. Oxalic 
acid also exists in the leaves of the common rhubarb or 
pie-plant, and several cases of poisoning from eating these 
leases have been recorded. This substance is an acro- 
narcotic poison, and when taken in toxic dose causes 
burning in the throat, intense gastric pain, vomiting, and 
collapse. Lime and magnesia are the proper antidotes, 
and should be given at once in large quantities, after 
which the stomach may be emptied by emetics or the 
pump. Potash or soda must not be given, as these alka- 
lies form poisonous compounds with oxalic acid. After 
the immediate danger of death is averted by these means 
there remains a gastro-enteritis which is to be treated by 
the ordinary remedies. Instances of fatal poisoning by 
tartaric acid are extremely rare. The symptoms are those 
of an irritant, and consist in burning of the throat and 
stomach, with the signs of gastric inflammation. Any 



61 



Acids. 
Acne. 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 



alkali that is nearest at hand should be given, and the re- 
sulting gastritis is to be treated on general principles. 

The therapeutic uses of the acids are varied and im- 
portant, but their consideration here must necessarily 
be brief. For a detailed account of the individual prop- 
erties of the acids the reader is referred to the special ar- 
ticles under their respective titles. 

External Uses. — The stronger acids are markedly es- 
charotic in their action, this property depending upon 
their strong affinity for the water and the bases in the 
tissues, and upon their power of coagulating and dis- 
solving albumen. They are employed for the purpose of 
destroying new growths, removing sloughs, stimulating 
indolent and unhealthy granulating surfaces, cauterizing 
poisoned wounds, and, in diluted form, as astringents 
and haemostatics. The caustic action of the acids is 
difficult of exact limitation, and hence they should not 
as a rule be used where only a superficial destruction of 
tissue is desired. They may be applied by means of a 
glass rod or a clean splinter of wood, and the surrounding 
integument should be protected by previously smearing 
it with oil or some other fatty substance. After the 
cauterizing action has proceeded far enough it may be 
in a measure limited, and the resulting pain relieved, by 
washing the part with an alkaline solution or soap-suds. 
The acids are used for the destruction of condylomata, 
small haamorrhoidal tumors, naevi, chancres, and chan- 
croids, to provoke healthy action in sloughing and phage- 
dfenic ulcers, and in uterine applications. Nitric acid, 
on account of its comparatively superficial action is the 
one usually selected for these purposes, though in many 
cases chromic acid is to be preferred. The latter pene- 
trates deeply, and its application is not so painful as 
that of the former. Sulphuric acid is seldom employed 
as an escharotic, as it penetrates deeply and is with diffi- 
culty limited in its action ; sometimes, however, it is 
selected because of these very qualities. It has been 
highly recommended, when diluted with two or three 
parts of water, as an application to carious or necrosed 
bone. Glacial acetic acid is one of the best applications 
for the removal of warts or corns. Carbolic acid (un- 
diluted) is an excellent mild escharotic ; it is employed 
for the removal of small condylomata, in the treatment 
of herpes, and as a uterine application. Somewhat 
diluted it finds employment in various ways as a local 
anaesthetic. Sponging the body with water acidulated 
with sulphuric or acetic acid is of service in excessive 
sweating, and it is also grateful as a refrigerant measure 
in feverish conditions. Dilute acetic acid or vinegar 
may be used to control epistaxis and other slight capil- 
lary haemorrhages. Nitro-hydrochloric acid is employed 
externally in baths or on compresses applied over the 
liver in the jaundice due to cirrhosis or other chronic 
hepatic disorders. Hydrochloric acid was at one time, 
on the authority of Bretonneau, largely employed locally 
with a view to dissolving away the false membrane in 
diphtheria, but it has now, and justly, fallen into disuse. 
Lactic acid has also been recommended for the same 
purpose, but it is seldom so employed at the present 
day. 

InUmal Uses. — The acids are to be ranked among the 
antipyretics, since their power of reducing the body 
temperature in febrile conditions, though not very great, 
is yet not to be gainsaid ; in healthy individuals, how- 
ever, their effect upon the temperature is nil. Dilute 
hydrochloric is the best to use for this purpose, though, 
when an astringent effect is also desired, aromatic sul- 
phuric acid may be substituted. The vegetable acids 
are frequently employed in the preparation of cooling 
drinks for fever patients. Citric acid or lemon-juice is 
the more palatable, but when for any reason this cannot 
^e obtained, a very refreshing drink may be made by 
adding a little vinegar to sweetened water. Tartaric 
acid may also be used for the same purpose, but is in- 
ferior to citric. Perhaps the most frequent use of the 
mineral acids is in the treatment of dyspepsia, either to 
correct excessive acidity of the stomach or to supple- 
ment a defective secretion. Hydrochloric acid is the one 
usually selected, and is to be given before meals when 

62 



the fault lies in too great acidity of the gastric secretions. 
When the opposite condition prevails, the acid is to be 
given after meals, and for this purpose lactic acid is 
preferred by many to hydrochloric ; indeed, it is prob- 
able that when the latter is exhibited it is converted into 
lactic acid in the stomach. The acids just mentioned are 
also frequently employed when there is an excess of uric 
acid in the urine. In alkaline conditions of the urine the 
mineral acids, as well as citric or tartaric acid, are often of 
service. In hepatic disorders nitro-hydrochloric acid 
should be selected, and its internal administration, as 
mentioned above, may be supplemented by external ap- 
plications. Carbonic acid water is of value in slight 
nausea and in the acute indigestion following excesses in 
eating or drinking. The mineral acids possess some 
value in the treatment of scurvy, but are far inferior to 
citric acid, especially as it exists in lemon-juice. The 
acids are also largely employed to control haemorrhages 
of the uterus, lungs, or intestinal tract, especially of the 
first and last-named ; in haemoptysis they are of less effi- 
cacy. Sulphuric and phosphoric acids are the ones given 
for this object, but sulphuric is to be preferred. Aro- 
matic sulphuric acid is used to restrain excessive sweat- 
ing. Atropine and other drugs find more favor in the 
treatment of the night-sweats of phthisis ; but in certain 
conditions, especially in corpulent individuals, in which 
profuse perspirations occur at night or foUow upon very 
slight exertion, aromatic sulphuric acid given in ten or 
fifteen drop doses before 'retiring is very efficient. Care 
should be observed, however, not to continue its exhibi- 
tion for too long a time, owing to the danger of disturb- 
ing the digestive functions. Sulphuric acid is useful as 
a temporary measure for the relief of lead colic, but it 
does not eliminate the poison from the tissues, and should 
never be relied upon to the exclusion of other more 
efficient remedies in the treatment of this condition. 
Workmen in lead factories make use of sulphuric acid 
lemonade as a prophylactic against poisoning, and the 
same drink is vaunted as a preventive of cholera. Sul- 
phuric acid when added to Epsom salts markedly in- 
creases their purgative action. The acids, finally, are very 
often given, with or without iron, as a tonic. For this 
purpose either nitric, hydrochloric, or phosphoric acid is 
to be selected. For a certain class of nervous ansemie 
women who present an indescribable train of symptoms, 
various indefinite pains, nervous startings, palpitation of 
the heart, headache, etc. , no tonic answers Ibetter than 
the following : Sulphate of iron, 13 grammes (3iij.); 
nitric acid, 13 grammes ( 3 iij.) ; water, 90 grammes 
(|iij.) ; fifteen drops to be taken in water three times 
a day after meals. It should never be forgotten that 
the action of acids is very injurious to the teeth, and 
they should therefore always be taken through a glass 
tube. The mouth should immediately afterward be rinsed 
out with a solution of bicarbonate of soda or other weak 
alkaline solution, as a further precaution. 

Tlwmas L. Stedman. 

ACNE. Acne is an inflammatory, usually chronic, 
disease of the sebaceous glands, characterized by the 
formation of papules, tubercles, or pustules, or a com- 
bination of these lesions, occurring for the most part 
about the face. It may occur alone or in connection 
with other affections of the sebaceous glands, as comedo 
and seborrhoea. The lesions are of various sizes, from a 
pin's head to a large split-pea, and are commonly seen in 
both the papular and pustular, or the tubercular and 
pustular forms combined. There is not often any sensa- 
tion of burning or itching, but occasionally a feeling of 
soreness when the lesions are touched. Their color may 
vary from bright red to dusky or violaceous, with usu- 
ally a pustular centre. The number of lesions varies 
greatly in different cases. There may be only one or two 
present, or they may be verjr numerous. The inflam- 
mation may be superficial or it may be deep, even occa- 
sionally leading to the formation of abscesses. The indi- 
vidual lesions may come and go within a few days or 
they may be of slow evolution, but the disease itself is 
apt, in all cases, to run a chronic course, the process 



REFERENCE HANDBOOK OP THE MEDICAL SCEENCES. 



Acids. 
Acne. 



frequently lasting for j-ears. If there has been much 
suppuration, more or less unsightly scars may remain. 

The chief seat of acne is upon the face, neck, shoul- 
ders, and chest, although it may occur upon any part of 
the body, except the palms and soles. The severity of 
the disease varies very greatly. In some instances it 
may be represented by one or two lesions only, while in 
others the face, neck, shoulders, chest, and even the 
whole trunk may be covered with unsightly papules, 
pustules, suppurating tubercles, and abscesses. 

Acne is one of the commonest diseases of the skin. 
In this country the statistics of the American Derma- 
tological Association show its occurrence, in the practice 
of specialists, to be in the proportion of seven per cent, 
in all diseases of the skin, and its comparative frequency 
among the people is probably much greater. Acne oc- 
curs in the young of both sexes, appearing about the age 
of puberty. It does not occur in children, and only 
rarely makes its appearance for the first time in mature 
years. 

Acne may occur in several different forms, described 
as "acne punctata," "acne papulosa," "acne pus- 
tulosa," but all these are stages of the same process, 
and all may usually be found represented in the same 
individual simultaneously. As one kind of lesion rather 
than another usually predominates, it will be convenient 
to consider the aflcection more closely under several 
heads. 

Papular acne is the earliest stage of the disease, and 
is chiefly characterized by the occurrence of papular 
lesions, of pin-head to small-pea size, flat, or more or less 
pointed, lightish in color, situated about the sebaceous 
follicles, and often showing a minute black point, which 
indicates the mouth of the sebaceous duct. This variety 
of acne is often accompanied by comedo. (See Comedo.) 
There are usually a few pustular lesions scattered 
among the papules. The latter are not acutely inflam- 
matory, and papular acne is the least developed form of 
the disease. 

Pustular acne is the typical form of the disease, though 
even when fully developed pustules form the chief feat- 
ure of the eruption many lesions of a papular and inter- 
mediate character are found. The pustules are pin-head 
to large-pea size, rounded or acuminate, seated on a 
more or less infiltrated base of superficial or deep inflam- 
matory product. Suppuration may be slight or abun- 
dant Occasionally several lesions run together, or the 
suppurative process extends more widely and deeply, 
and abscesses form. Such lesions are apt to occur about 
the lower part of the face, neck, and chest, but chiefly on 
the shoulders and back, forming the most serious and 
annoying phase of the disease. The smaller pustular 
lesions may heal up without a scar, while the larger 
ones leave a pitted cicatrix like that of small-pox. When 
abscesses f oi-m, very deforming cicatrices, with pockets 
or bridles of tissue, and with large comedones about or 
in them, may result. The disfigurement thus produced 
is increased by the occasional supervention of keloid in 
the cicatrix, but the lumpy scars thus produced usually 
assume the ordinary cicatricial condition after some 
months, the keloidal condition spontaneously disap- 
pearing. 

"Artificial acne" is sometimes observed as the result 
of the external employment of tar, chrysarobin, and other 
agents. The acieform eruptions produced by the in- 

festion of various medicinal substances, will be found 
escribed under the head of "Dermatitis medicamentosa." 
Tho causes giving rise to acne are numerous and varied 
in their nature. In its commoner forms it appears to be 
dependent, to some extent, upon the character of the skin. 
Persons with thick oily skins are most apt to suffer from 
the diffuse form of acne with numerous papular and pus- 
tular lesions mingled with comedones, while the sparse 
eruption of flat and papular lesions is often found in pnlo, 
anaemic individuals, with dry, rather harsh skins. The 
most frequent cause of acne is puberty. The affection 
shows itself for the first time, in the vast majority of 
cases, at this' period, and is apt to continue, unless re- 
medial measures are adopted, until the system has assumed 



the equilibrium of adult life, or in women until a later 
period. 

Other causes which may, either alone or combined, 
give rise to the occurrence of acne, are scrofula and ca- 
chexia or general debility, anaemia, and chlorosis. 

Habitual derangement of the alimentary canal is of 
great importance in the causation of acne, and dyspepsia, 
with, or more rarely without, constipation will be found 
present in the majority of cases. Very often a fresh 
attack of acne, with a new crop of lesions, follows closely 
upon each attack of dyspepsia or constipation. 

Disorders of menstruation are often the direct cause of 
acne, and in many women suffering from this skin affec- 
tion, a fresh outbreak may be expected before, during, or 
just after each menstrual period. At other times the 
cause of the disease remains obscure, the patient enjoying 
otherwise good health. 

The anatomical seat of the inflammation in acne ia 
about the sebaceous glands and hair-follicles, with their 
common opening. In the milder forms of papular acne 
(acne punctata) we have a comedo about which the sur- 
rounding papUlee and corium show enlarged blood-vessels, 
serous effusion, and exudative cells in the widened net- 
work. When the process goes on to form pustular acne, 
there is purulent exudation in the gland-ducts. When 
larger tubercles and pustules are found, extensive inflam- 
mation of the glandular structure and surrounding tis- 
sues with purulent collections in the gland-duct, and hair- 
follicle, and loosening of the hair-sheath, with destruction 
of the epithelium, is observed. When the inflammation 
is more intense, the sebaceous gland may be entirely lost 
in the suppuration, while the hair-follicle may escape. In 
large acne abscesses, gland, hair-f oUicle, and all are swal- 
lowed up in suppuration. 

The diagnosis of well-developed acne presents no diffi- 
culty. When only a few lesions are present, however, 
and especially when these are illy developed, it is by no 
means easy, at times, to decide whether we have to deal 
with this affection or with others of a widely different 
nature. The age of the patient, the seat of the lesions, 
their chronic character, and their inflammatory nature, 
must be taken into account. Tar acne may be recog- 
nized by the smell of that drug, and acne due to chryso- 
phanic acid by the purplish discoloration of the skin 
where it has been applied. In both forms of acne the 
presence of the drug in the follicles causes a marked ap- 
pearance of black points. Acne may be distinguished 
from the similar eruptions due to iodine and bromine 
(see Dermatitis medicamentosa) by the fact that the le- 
sions in these drug eruptions are apt to be larger, and 
that they come out in considerable numbers simultane- 
ously. In addition the lesions are of a brighter and 
more inflammatory nature in the drug eruptions, and 
when fully developed are apt to cluster together, coa- 
lesce, and form inflammatory areas covered with charac- 
teristic crusts. The lesions of true acno raroly occur in 
groups or coalesce, -rd never show the cheesy sebaceous 
secretion of the acnef orm dermatitis from the ingestion 
of drugs. Acne often closely resembles the papular and 
pustular syphilodermata, and the two affections are not 
infrequently mistaken for one another. The history of 
the case, the presence or absence of characteristic lesions 
on other parts of the body not ordinarily attacked by 
acne, the uniform or scattered distribution of the lesions, 
those of syphilis tending to group, are all elements of 
the diagnosis which must be taken into consideration. 
When the syphilitic lesions occur on the forehead, or 
only to the extent of one or two about the nose, without 
any history, it is sometimes difficult to make the diag- 
nosis, and great caution must be exercised in coming to 
a decision at the first examination. Acne in a severe 
and pustular form looks not unlike small-pox, but the 
absence of fever or other concomitant symptoms, and 
the chronicity of the acne eruptions, should prevent this 
mistake from being perpetrated even by one quite unac- 
quainted with skin diseases. 

The treatment of acne should be both constitutional 
and local. In order to use the constitutional treatment 
with effect, we must first ascertain by careful cross- 



63 



Acne. 

Acne Rosacea. 



KEFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 



examination of the patient exactly what is the weak 
point. If constipation exists, this must be remedied. If 
dyspepsia is present, a careful regimen, with remedies ap- 
propriate to the peculiar form of digestive disturbance 
operative in the case under consideration, must be em- 
ployed. When uterine difficulties present themselves as 
probable causes of the acne, these must be attended to, 
and, m short, to deal successfully with acne, the physi- 
cian must he a master of his art. Of course, only the 
outline of treatment can be given in an article like this, 
and the treatment must be varied to suit the case. 

When anaemia seems to be the efficient cause, without 
concomitant digestive difficulty, iron and arsenic alone 
or combined are called for. The tincture of the chloride 
in five to ten minim doses, always prescribed in water, so 
that the patient is not left to measure out the drops, is 
one of the best forms of iron to use alone. The arsenic 
is preferably given in the form of Fowler's solution in 
water or in wine of iron ; the dose at first should not be 
more than two to four minims, which may be gradually 
increased to eight minims if the case require it : beyond 
this it is rarely advisable to go. Constipation is a very 
common accompaniment of acne, and should always be 
removed. Saline or vegetable laxatives, with an occa- 
sional dose of blue pill, is useful in some cases. The 
majority of patients will get along best under the admi- 
rable mixture devised by Startin, and known as " Mistura 
ferri acida." It is composed as follows: 8. Magnesii 
sulphat., § j. (31 grm.) ; ferri sulphatis, gr. iv. (.26grm.) ; 
sodii chloridi, 3 ss. (1.95 grm.); acid, sulphuric, dil., 
f 31]. (7.75 grm.) ; infus. quassise, ad f |iv. (130 grm.). 
M. Sig. : A tablespoonf ul in a tumbler of water before 
breakfast. Although a very disagreeable mixture to most 
persons on first taking, it usually agrees well with them, 
and becomes less revolting after use for a short time. In 
the dyspepsia with constipation of acne it is an incom- 
parable remedy. Its use should be governed by the effect 
on the bowels. If it is too purgative the amount can be 
diminished, or if not sufficient laxative effect be produced 
the proportion of magnesium sulphate can be increased, 
or the dose repeated before supper, or it may even be 
given thrice daily. The natural mineral waters are some- 
times useful in acne, especially the Hathorn water of 
Saratoga and the Hunyadi Janos as sold in the bottled 
form. 

Where there is much irritability and hyperaemia ac- 
companying the acne, good results are often gained by 
the prolonged administration of alkalies. Taylor recom- 
mends the following formula : 3 • Potassii acetatis, § j. 
(31.10 gi"m.) ; sodii et potassii tart, |ij. (62.20 grm.); 
syr. zingiberis, f § ij. (60 grm.) ; aquae, q. s. ad f J viij. 
(240grm.). M. Sig.: A tablespoonful in a wine-glass 
of water after meals. 

When there is a scrofulous taint, and especially in 
those cases in which there is a tendency to the formation 
of abscesses, cod-liver oil is indicated. Occasionally, 
when this disagrees, extract of malt may be substituted. 
The bitter tonics and mineral acids are likewise of value 
in many cases. 

Hygiene is of the utmost value in the management of 
acne, and the beneficial effect of change of air, particu- 
larly to mountainous regions, is often more marked than 
that of drugs. The sea-shore, it may here be remarked, 
usually disagrees with acne patients. Exercise in the 
open air, cold bathing, moderate gymnastics, all are of 
use. Occasionally a sea voyage benefits a patient whom 
medicines have failed to relieve. 

The local treatment of acne is of great importance, 
especially with regard to the choice of remedies. Appli- 
cations innumerable are recommended in the books and 
in periodicals, but only a few are generally useful. Some 
cases of acne show acutely inflammatory symptoms, and 
must be treated by means of soothing applications, of 
which the bland ointments and lotions used in acute 
eczema are examples. (See the treatment of acute eczema.) 
But by far the greater number of acne cases demand 
stimulant treatment, often of a vigorous sort. When the 
skin is coarse and sluggish, with numerous comedones 
and a general greasy look, and without much acute in- 



flammation, frictions with alkaline soaps, as sapo viridis 
or the solution of the latter in one-half its weight of alcohol, 
known as " spiritus saponis alkalinus," are of use. These 
should be briskly rubbed in and then washed off the 
skin again, and followed by applications of cold water or 
of powdered starch. Occasionally a solution of potassa, 
fifteen grains to the ounce of water, may be applied with 
advantage, followed by a stimulant ointment, as the fol- 
lowing: ]j. Ung. hydrarg. praecip. alb., 3 j. (3.90 grm.) ; 
ung. aquae rosae, 3 iij- (11.65 grm.). M. Sulphur and its 
preparations are among the most valuable remedies in 
our possession for the treatment of acne in most of its 
forms. The following is a generally useful formula: 
]J . Sulphuris precipitat. , 3 j. (3.90 grm.) ; ung. aquae rosae, 
vaselini, aa3iv. (15.50 grm.). M. Camphor may some- 
times be added in the proportion of a scruple (1.30 grm.) 
to the above formula. Sometimes lotions are more suit- 
able, especially where there is a tendency to rosacea (see 
Acne Rosacea). The following is a convenient prepara- 
tion : B. Sulphuris precipitat. , 3 j. (3. 90 grm.) ; pulv. cam- 
phorae, gr. v. (.32 grm.); pulv. tragacanthae, gr. x. (.65 
grm.) ; aquae calcis, aquae rosae, sa f | i. (30 grm.). M. 

When the lesions are sluggish, and especially in in- 
durated acne of the back, V lemingckxs's solution is a 
valuable local application. ? . Calcis vivae, | ss. (15.50 
grm.) ; sulphuris sublimat., | j. (31.10 grm.) ; aquae, f | x. 
(311 grm.). Boil down to six ounces and filter. This is 
a very stimulating application, almost caustic in fact, and 
should always be diluted with several parts of water be- 
fore using, at least until the effect upon the skin has been 
ascertained. 

Indurated and pustular acne may sometimes be bene- 
fited by the application to each lesion of a drop of solu 
tion of the acid nitrate of mercury on the end of a sharp- 
ened match, followed by bathing with hot water. The 
lesions may also be punctured with a sharp instru^nent 
when there is a tendency to the formation of abscesses. 
(See Fig. 53.) The severer plans of treatment, as rubbing 
with sand, scraping with the sharp spoon, are not par- 
ticularly beneficial, and are usually objected to by pa- 
tients. In some cases the use of sulphur soaps, applied 
in lather and allowed to dry on, is of advantage. 

Whatever plan of treatment be adopted^ it is essential 
that it should be thoroughly carried out, and the patient 
should be frequently examined to ascertain if the direc- 
tions have been complied with. In any case the prog- 
nosis should be guarded. The more extensively devel- 
oped cases are very often more amenable to treatment 
than those where half a dozen lesions alone represent the 
disease, and where the patient enjoys apparently good 
health. The question is, in the long run, one of time 
only, as a spontaneous cure sooner or later invariably 
occurs. If neglected, however, unsightly and disfigur- 
ing scars, sometimes keloidal, supervene in severe cases, 
and unremitting efforts should, therefore, be used lo ob- 
tain, if possible, a speedy cure. 

Arthur Van Harlingen. 

ACNE ROSACEA. Acne Rosacea is a chronic, hyper- 
aemic, or inflammatory disease of the face, more par- 
ticularly the nose, characterized by redness, dilatation 
and enlargement of the blood-vessels, hypertrophy, and 
more or less acne. Hyperaemia is the first symptom, 
and this shows itself in a diffuse flush on the nose and 
neighboring parts, and in some cases over the cheeks, 
chin, and even the ears. This may at first occur only 
intermittently, but after a longer or shorter period the 
redness becomes settled, more marked, and permanent, 
A condition at first only brought on by exposure to cold 
or a close atmosphere, or following the use of alcoholic 
stimulants or a full meal, finally becomes habitual. 
Small tortuous blood-vessels can be seen ramifying 
over the tip of the nose and the prominence of the 
cheek-bones, the nose is cold to the touch and often 
shows slight seborrhoaa. This condition may remain 
stationary for months, or even years, and may then 
disappear, or it may go on to the gradual formation 
of pin-head to split-pea-sized hard papules, either iso 
lated or grouped into indurated masses. This second 



64 



EEFERENCE HANDBOOK OP THE MEDICAL SCIENCES. 



Acne. 

Acne Rosacea. 



form shows best the combination of conditions which 
has given the affection -its name, acne rosacea. A 
third and much rarer variety affects the nose alone, 
and consists in an inflammatory connective-tissue hy- 
pertrophy, with enlargement of the sebaceous folli- 
cles and hypertrophy of the papillary layer of the 
corium. The organ becomes grotesquely enlarged and 
misshapen, the surface rugous and covered with irregu- 
lar, sometimes overlapping growths, showing, enlarged 
and tortuous blood-vessels, thickly strewn with acne 
pustules and with the blackened points of comedonef 
and of a deep vinous red color. At other times the sur- 
face remains smooth and shining, while a uniform thick- 
ening of the skin causes great increase in the size of the 
aose. 

The causes of acne rosacea are various. The first two 
varieties may occur in men as well as in womeL, but fhe 
third is found in men alone. In women the disease is 
apt to be connected with disturbance of the generative 
apparatus. Dyspepsia, anaemia, and chlorosis are also 
among the causes. Habitual indulgence in alcoholic 
and malt liquors is among the commonest causes, al- 
though the disease is in no sense an indication of alco- 
holic indulgence, as it is very common among dyspeptic 
water-drinkers. Persons whose business or profession 
leads to much exposure to inclement weather, as hack- 
drivers, sailors, etc., 
are apt to become the 
subjects of acne rosa- 
cea. The immediate 
cause of the lesion is 
paresis of the most 
minute capillaries of 
the skin at their cxt 
tremities, leading to 
chrotoic enlargement 
and sluggish circula- 
tion. 

The pathology of 
acne rosacea is in part 
explained by what has 
been said regarding 
its etiology. In the 
first variety or stage 
there is simply a 
blood stasis in the 
skin. This condition 
may last for years 
Without change. 
Sooner or later, how- 
ever, permanent dila- 
tation and hypertro- 
phy of the capillaries 
takes place, together with an involvement of the seba- 
ceous glands in the form of acne. Still later more or less 
hypertrophy of all the tissues of the affected part takes 
place, and a connective-tissue new-growth is the result, 
with the marked distortion above described. Piffard has 
described a case, microscopically examined by him, 
where the horny layer was scanty, but the rete mucosum 
thick with well-formed cells. The papillae were enlarged 
in lerigth and breadth, and contained round and fusiform 
cells. Some of the sebaceous, glands were unaltered, 
others were undergoing degenerative changes. The 
corium was greatly thickened, and presented the appear- 
iLCv 3f a formed tissue. 

The only diseases with which acne rosacea is liable to 
be confounded are syphilis, lupus vulgaris, lupus ery- 
thematosus, and acne. From the tubercular syphilo- 
derm acne rosacea is to be distinguished by its chronicity. 
The syphiloderm is indeed chronic, but it lasts months 
where acne rosacea lasts years. In syphilis the-lesions 
do not especially involve the glands, in acne rosacea the 
glands form the centre of the pustular lesions. Crusts 
are apt to be present in syphilis, and some of these on 
removal show ulcers beneath. Ulcers never form in 
acne rosacea. The color of the syphilitic eruption is apt 
to be a dull, coppery red ; in acne rosacea the color is 
either a bright red or violaceous, according to the stage 

Vol. L— 5 




Fio. 52.— Acne Bosaceii. (After Dnhring.) 



of the disease and its form. The characteristic enlarge- 
ment of the bloodvessels seen in acne is wanting in 
syphilis. Syphilis occurs on one side of the nose more 
than on the other in many cases, whereas acne is symmet- 
rical. In doubtful cases the history may be of some aid, 
but is not always to be depended upon. 

The characteristic roundish, reddish, or yellowish 
papules or tubercles of lupus vulgaris, pin-head or larger 
in size, and usually involving only a portion of the nose, 
as the tip or one ala, usually serve to distinguish this af- 
fection and to prevent its being mistaken for acne rosacea. 
Moreover, ulceration, followed by crusts and disfiguring 
cicatrices, is present in lupus vulgaris, but is absent in 
acne rosacea. 

Sometimes lupus erythematosus, when it occurs upon 
the end of the nose, may be mistaken for acne rosacea, 
but the presence of sebaceous crusts, with the wide-open 
mouths of the oil-follicles, are> characteristic of this form 
of lupus, and are quite absent in acne rosacea. 

Prom acne the affection under oonsideration may be 
distinguished by the presence of enlarged blood-vessels 
and by the hypersemia. As the line dividing acne and 
acne rosacea is in some cases an arbitrary one, and as 
the former may merge into the latter, of course many 
cases are practically undistinguishable. 

The treatment of acne rosacea varies with the stage of 
the disease and with the cause in the given 
case. Constitutional and local remedies are 
both to be employed. The cause of the disease 
is in each case to be diligently sought out and, 
when possible, removed. Especially is this the 
case when disorders of the generative apparatus 
in women are involved. The stomach and 
bowels are to be kept in good order. Iron, 
arsenic, and bitter tonics are to be used as occa- 
sion requires. Change of air to the mountains, 
or to the sea-shore, may in some cases be re- 
quired. 

Locally, the acne lesions when present are to 
be gotten rid of by the remedies above described 
under acne. The sulphur preparations are the 
best, both for this purpose and for the removal 
of the rosaceous condition, and the sulphur and 
tragacanth wash, described above, may be ap- 
plied frequently with the greatest benefit. G. 
H. Pox recommends the following : B . Pulv. 
chrySarobin, 3 ss. (1.95 grm.) ; collodii, fjj. 
(33 grm.). This is to be painted over the af- 
fected part daily, the effect being watched with 
the view of avoiding possible untoward results 
from over-action of the chrysarobin. In the 
later stage, when well-defined blood-vessels can 
be seen coursing under the skin in numbers, 
the treatment must be different. _ _ fio. 53.— 

The dilated capillaries may be incised with a Aone-puno- 
flne, sharp knife, in the hope that adhesive in- tor- 
flammation may result, with the effect of closing the caU- 
bre of the vessels. Cold water compresses or pledgets of 
dry lint may be applied to control any bleeding, and a 
small number of vessels may thus be operated upon 
thoroughly until the ground has been entirely gone over. 
A lance-headed punctor (Pig. 53) may be used for the same 
purpose, small punctures being made in the line of the di- 
lated vessels at short intervals. Hardaway recommends 
electrolysis, using a No. 13 cambric needle inserted into 
any convenient handle, and connected with the negative 
pole of a galvanic battery ; a sponge electrode is then 
connected with the positive pole. The needle is inserted 
sufficiently deep to enter the dilated vessel ; as soon as 
this has been accomplished the patient completes the 
circuit by taking the sponge electrode into his hand. 
When the electrolytic action has been properly devel- 
oped, the patient releases the sponge electrode, after 
which the operator withdraws the needle. Six or eight 
elements will generally suffice. If the vessel to be op- 
erated upon is a long one, several punctures must be 
made at suitable intervals of space. The needle may be 
inserted perpendicularly or in a line with the course of 
the vessel. One discouraging fact must be taken into 

65 



Acne Rosacea. 
Aconite. 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 



consideration in the endeavor to heal acne rosacea by 
means of destruction of the calibre of the enlarged blood- 
vessels, that is, that a collateral circulation is apt to be 
established which will bring the same condition of the 
skin back again, and which must be expected and met 
by a renewed operation. In these rare and severe cases 
of acne rosacea, when knobby and gross hypertrophic 
deformity of the nose exists (Fig. 53), decortication with 
the knife is the only effectual remedy, although in less 
advanced cases scraping with the sharp spoon may im- 
prove the condition of the skin to a considerable degree. 
The prognosis in the early stages of acne rosacea is 
favorable, and there are few affections of the face in 
which more striking and rapid results can be attained, 
up to a certain point, than in these cases of acne rosacea 
where there is a red, flushed condition of the face, with 
numerous acne papules and pustules, and with little or 
no distinct capillary dilatation. When, however, the 
disease has become thoroughly established, only thorough 
and long-continued treatment will avail. When the 
capillary enlargement is already marked, treatment be- 
yond a certain point is only palliative ; it may prevent 
further progress— a result of no small value, and pa- 
tients should be encouraged to persevere. 

Arthur Van Harlingen. 

ACONITE \A.amUum, U. S. (the root) ; Aconitum 
napellus L. (DelpMnum aconitum Baillon) ; order Ea- 
nunculacm, Monkshood] is a tall, handsome herb, with 
large, irregular, purplish blue flowers, compound leaves, 
and a fleshy, conical, biennial — but by stolons, perennial — 
root. It is a variable and widely distributed species, 
growing abundantly in the mountainous districts of 
Central Europe, Asia; and the western part of America ; 
extending up the mountain sides to a very high eleva- 
tion, as well as deep into the valleys. It is cultivated 
for medicinal use in parts of continental Europe and 
England, and as an ornamental flower in the United 
States, where it occasionally escapes from gardens, and 
takes an uncertain possession of waste places. 

The aconites were known to the ancients, both in 
Europe and Asia, as poisons, and are said to be still 
used by some of the hill tribes of India to envenom 
their arrows. They were 
employed as medicines in 
Germany in the twelfth, 
and on the island of Great 
Britain in the thirteenth 
centuries ; but afterward 
fell into disuse until 1763, 
when Stoerck, of Vienna, 
again introduced them to 
the medical profession, 
since which time they have 
been constantly but not ex- 
tensiveljr used. 

The simple, stiff, upright 
stem of aconite rises from 
fifty to one hundred centi- 
metres (twenty to forty 
inches) from the ground, 
bearing numerous alternate 
leaves, and a long, close, 
terminal, spike-like raceme. 
The leaves {folia aconiti, 
Br. Ph. ; feuiUea Waconit 
napel, Codex Med.) are from 
five to twenty centimetres 
in diameter (two to eight 
inches), are rather stiff and 
thick, smooth, shining, and 
. , mi, I., , . , dark green above, and paler 

below. The blade is palmately three-parted ; the lateral 
segments are again divided nearly to the base. The 
narrowly wedge-shaped divisions are further three- or 
two-lobed, and these lobes are again incised, or cleft 
with linear or pointed tips. The leaves become less 
compound toward the upper part of the stem, and are 
finally reduced to three- or several-cleft bracts. They 

66 




Fio. 54.— Dclphlnum Aconitnm 
(Bnillon). 




Fio. B5.— Entire Flower of 
Aconitum Kapellua. 



have no marked odor, but upon being chewed, produce, 
like the root, a persistent stinging sensation in the mouth. 
They contain a small and uncertain amount of aeonitine, 
and considerable aconitic acid; the latter of no therapeutic 
importance. The flowers are of striking appearance ; 
the corolla is nearly wanting, and its place is taken by a 
large, colored calyx, of which the upper sepal is de 
veloped into a deep cup-shaped helmet, that sits upon 
the rest of the flower like a bonnet. 
The pistils are three, containing 
numerous small ovules. 

The mature root gives the speci- 
fic name to the plant (napellus, a 
little turnip). It is a simple, coni- 
cal, tapering tuber, ending in a 
long, slender, cylindrical tap-root, 
and bearing numerous rootlets 
upon its sides. (See Fig. 57.) 
From its scaly crown arises the 
flowering stem, and at the base of 
this stem a short stolon extends 
horizontally under the ground, and 
bears, on its extremity, a young 
tuber, more or less developed according to the season, 
and destined to produce the plant of the succeeding year. 
There may also remain upon the other side of the crown 
a similar but dead connection between the present root 
and the remains of that of the preceding year. 

Fresh aconite root is brown externally, white within, 
and has a biting, benumbing "taste," which has caused 
it to be occasionally stupidly mistaken for horseradish. 

The dried root, which constitutes the 
usual drug {pMnitum, U. S. Ph. ; aconiti 
radix, Br. Ph. ; tubera aconiti. Ph. G. ; raeine 
d'aconit napel, Codex Med., etc.), is from 
one to two centimetres in diameter at the 
base, and from five to seven inches in length 
(two-fifths to four-fifths inch by two to 
three inches) ; much shrivelled- and wrin- 
kled longitudinally, especially below; often 
curved and twisted, or broken. The exter- 
nal color is dark brown ; internally it is 
grayish, showing, in a transverse section, a 
distinct, five- to eight-pointed stellate cam- 
bium ring, in each angle ' of which is a 
well-developed flbrd-vascular bundle. Frequently the 
roots are attached in pairs ; when not, the scar where 

they were broken 
apart can be seen. 
The taste is similar to 
that of the fresh root, 
but the stinging sen- 
sation may be a little 
slower in coming. 

Aconite root, even 
when coming solely 
from aconitum napel- 
lus, is very variable 
in quality and often 
poor. The age of the 
root has much to do 
with this ; when gath- 
ered just before blos- 
soming it is large and 
juicy, and of the best 
quality ; after this it 
rapidly deteriorates, 
and the autumn-flow- 
ering root is worth- 
less. The young root, 
in the autumn or 
spring, however, is of 
good size and next in 
value to the first 
named. Light, hol- 
low, rotten-stemmed 
„ . j.~ pieces should be dis- 

Grown in different countries, or under varying 
circumstances, it is subject to considerable variation in 




Fio. B6.— Seed- 
veEsel of Aco- 
nitum Napel- 

lUB. 




Pig. B7.— Hoot of Delphinum Aoonitnm 
(Baillon). 

carded 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 



Acne Rosacea. 
Aconite. 



quality. Commercial aconite is also frequently mixed 
with the tubers of several other similar but less active 
species. On the whole, it is one of the most unreliable 
medicines in the market. 

Aconite owes its medical value and poisonous qualities 
to the alkaloid oeonitiTie, which it contains, associated 
with one or two others, and in combination, probably, 
with aeonitic acid. It was discovered in 1833 by Geiger 
and Hesse in the leaves of aconitum na/pelltis, and after- 
ward, in the root, by Bley. It exists also in several 
other species in smaller quantity. Although easily sep- 
arated as an amorphous powder of varying quality, it 
has proved to be an exceedingly difficult base to prepare 
in a state of chemical purity. Groves first obtained it in 
crystals. Duquesnel, and finally Wright and Luff, have 
distinguished themselves in more recent studies upon it. 
Crystallized aconite is now offered as an article of com- 
merce by several chemists, especially by Duquesnel of 
Paris, whose product is considerably used in the United 
States. It is in regular rhombic tables, or short four- 
sided prisms, or often in small crystalline masses, anhy- 
drous, nearly insoluble in water, but soluble in alcohol, 
ether, etc. ; usually not quite white, often pale brownish 
yellow, of a bitter taste, which is followed by an intense 
prickling of the mouth and fauces (it must only be 
tasted with great care in a dilute solution). The nitrate 
is similar to the above, but more soluble. 

According to the conclusions of Messrs. Wright and 
Luff {Phai'maceutical Jour, and Trans., 1875 et seq.), 
aconite contains also another similar and equally poison- 
ous crystalline alkaloid, but in very minute quantity, 
namely, paeudaconitine, the alkaloid of aconitum ferox 
(see below). Both these bases exist also in an uncrystal- 
lizable condition. Besides these, two inferior bases, 
aeonine and pseiidaconine, are always found in the course 
of the examination, but as they are easily produced as 
decomposition products of aconitine and pseudaconitine 
respectively, their separate existence in the plant, al- 
though probable, is not -proved. The ordinary commer- 
cial, amorphous "aconitine" is an uncertain mixture of 
all the above. " English aconitine " is said, by German 
chemists, to be pseudaconitine. Resin, fats, starch, gum, 
sugar, etc., are ordinary vegetable products found in 
aconite, but of no medical interest.' Too much value 
must not be placed upon the various estimates of the yield 
of aconite root. Fliickiger (" Pharmakonosie des Pflan- 
■ zenreiches") gives it as 0.04 per cent., the older authori- 
ties as much higher. 

Aconitine, as would be expected, considering its active 
qualities, has been repeatedly and assiduously studied in its 
physiological aspects, but, excepting as far as its most evi- 
dent action goes, much remains yet to be made sure. This 
is, in part, undoubtedly ascribable to the uncertainty of the 
composition of many of the preparations heretofore used, 
but it is in part also due to the peculiar difficulties pre- 
sented by the drug itself. Its physiological properties 
appear to be the following ; 

First. — To disturb and reduce sensation. A mild feeling 
of prickling or tingling of the extremities and tongue is 
often noticed after one or two moderate medicinal doses, 
and is a recognized warning that the limit of its thera- 
peutic use has been reached. In large doses this symp- 
tom is one of the first to appear, and becomes very 
intense, accompanied by diminution of sensation, due to 
anaesthesia of the surface and, perhaps also, of the deeper 
parts. 

Second.^— To paralyze the motor nerves. This is not as 
prominent an effect of aconitine as the preceding ; and, 
after moderate doses, may be even unnoticeable, excepting 
as a slight clumsiness oi the limbs ; but in large ones is 
evident enough. Both the sensory and motor effects 
appear to begin, and have their intensest manifestation, 
at the surface, and to proceed gradually upward along 
• the nerve-trunks. Whether a portion of them are also 
due to direct action upon the sensory or motor centres, 
in the brain itself, is still a matter of doubt, but not 
unlikely. 

Thvrd^—Uhe depressing action of aconite upon the heart 
is one of its most prominent and dangerous qualities, as 



well as the one for which it is most often given. Slowness 
and feebleness of the pulse, and consequent reduction of 
the arterial pressure, are constant results of its administra- 
tion ; but liow these results are brought about, whether 
by direct action upon the heart itself, or upon its nerve- 
centres, or all together, is not known. Much of the 
weakness attending aconite poisoning — the cold sweats, 
blindness, syncope, fall of temperature, etc. , which occur 
— is undoubtedly due to the enfeebled circulation. 

Fourth. — The respiration is retarded and enfeebled, 
probably from both peripheral and centric paralysis. 
Convulsions are not common ; the mind is usually clear. 

Medicinal Uses. — One rational application of the above 
effects of aconite is to reduce the frequency and force of 
the heart's action, when uncomfortably or dangerously 
excessive. Conditions indicating its use are often present 
in acute febrile affections, especially at the onset : pneu- 
monia, pleurisy, bronchitis, scarlet fever, and other ex- 
anthemata, as well as the febrile excitement attending 
the passage of the catheter, menstrual disturbances, 
coryzas, etc., are examples. Marked and grateful relief 
often follows, very quickly, the use of aconite in these 
cases ; and, if the condition is a transient one, it effects 
an apparent cure. In the later stages of dangerous fevers, 
or when the fever is of an adynamic type, it should never 
be used. It sometimes relieves the palpitation of exoph- 
thalmic goitre. 

Another application, which may be logically deduced 
from its action upon the nerves, is it» use in certain pain- 
ful affections, especially certain neuralgias, in which it 
occasionally gives marked relief — often, unfortunately, 
not any. The greater the probability the pain is trivial 
or peripheral in origin, the greater the amount of benefit 
which may be expected. It sometimes diminishes the 
vomiting of pregnancy, and may be useful in other cases 
where diminution of nervous irritability is desired. 

Empirically, it has been used in many chronic diseases 
and opprobria mediea without establishing itself in the 
treatment of any. Locally applied to painful parts, as a 
liniment or an "oleate," it is often more beneficial than 
when taken internally. 

Administration. — Aconite is not often given in sub- 
stance, but its dose, as authorized by the Pharmacopoeia 
Germanica, may be taken as a standard for computing 
those of its preparations. The maximum single dose, 
according to that authority, is one decigramme (0.1 grm. 
= gr. jss.), or not more than five times as much in a single 
day. The officinal preparations are all made by first ex- 
hausting the root with alcohol, slightly acidulated by 
the addition of tartaric acid, and then evaporating or 
otherwise reducing to the standard of strength. They 
are : 1. Abstract of aconite (a^stractum aconifi), in which 
the alcoholic liquid is evaporated nearly to dryness, and 
then standardized by the addition of enough sugar of milk 
to make the product weigh one-half the amount of aconite 
used. Full dose, therefore, five centigrammes (0.05 grm. 
= gr. f). 3. Extract of aconite {exir actum aconiii), made 
by evaporating to a pilular consistence, and preserved 
from drying completely by the addition of a little gly- 
cerine. This product varies in strength from \ to f, 
according to the season in which the root was gathered, 
and other conditions. Dose uncertain. 8. Fluid extract 
of aconite (extractum aconiti fluidum), strength |. Dose, 
the same as that of the root. A good, but inconveniently 
strong preparation. 4. Tincture of aconite (tinetura aco- 
niti), strength f ; the most generally used form. Full 
dose, two and a haU decigrammes (0.25 gr. = Ht iv. 
gtt. viij.). 

Aconitine is not officinal. The old amorphous prepara- 
tion should never be used. Pure crystallized aconitine, 
or its nitrate, appears to be more uniform, and may be 
given in doses of three or four ten-thousandths of a 
gramme (0.0003 to 0.0004 grm. = gr. li-^ to gr. tW- 

Oleate of aconitine, a two per cent, solution of the 
above, is useful for painting painful surfaces, but should 
be used very cautiously. 

Liniment may be made by mixing the tincture or fluid 
extract with other liniments. 

Fleming's tincture is an old preparation, which, on 



67 



Aconite. 
Acromion Process. 



EEFERENCE HAKDBOOK OP THE MEDICAL SCIENCES. 



account of its strength (|), should be known; but it is 
better not to call for it, as it has no advantages over the 
United States tincture or fluid extract. 

The above-mentioned are full adult doses, and should 
not be repeated more than three or four times a day 
without close watching. In febrile cases it is much 
better to divide each dose into twenty, and give, say a 
quarter of a drop of the tincture, every fifteen minutes 
until some effect is produced, than to give the larger 

Botanical RBLATioisrs.— The genus aconite contains 
eighteen species, natives of hills and mountains of the 
northern hemisphere, like our species, showy, handsome, 
large-flowered, perennial herbs. 

Aconitumferox, Wallitch ; Indian aconite, or bish, re- 
sembles the A. napellus, but has a larger, fuller, and 
longer root. It contains chiefly pseudaconitine, with a 
little aconitine. Qualities, similar to ^. wajjeZ^M*/ said to 
be more active. Supposed to be the source of some of 
the "English aconitine." 

Aconiium variegatum, L., has short, roundish, egg- 
shaped tubers ; Europe. 

Acomtum Stoerckeanum, Rehb., has its tubers in 
threes, or even more together. Both the above species 
occur occasionally in lots of commercial aconite. 

Aconiium , Japanese aconite, yields Jap- 

aconitine ; very poisonous ; similar to aconitine. 

Aeordtum lycootonum, L., has yellow flowers and 
branched, not tuberous, root ; poisonous. 

Aconiium lieterophyllum, Atis, a yellow-flowered spe- 
cies, native of the Himalayas, yields a bitter, not poison- 
ous alkaloid, atisine; used in India as a tonic and anti- 
periodic ! 

The natural order Banunculacem, of which aconite is, 
medically, the most important member, contains between 
five and six hundred species, distributed over nearly all 
parts of the globe, but especially abundant in the north- 
ern temperate zone. It furnishes our gardens with 
scores of beautiful flowers — clematids, anemones, butter- 
cups, the Christmas rose (hellebore), columbines, lark- 
spurs, monkshoods, peonies, etc. — the medicinal plants 
being among the number. They are, as a rule, herbs 
(occasionally soft- wooded shrubs or vines) with large, 
handsome flowers, alternate, more or less divided leaves, 
and a clear juice. They have a bitter, often peppery, 
biting taste, which benumbs the tongue, and frequently 
leaves it anaesthetic for several hours. Their principal 
active constituents are anemonin, helleborin, delphinine, 
aconitine, and berberine ; all but the last are intense 
poisons, having a strong family likeness. 

Although it contains some perfectly innocent plants, 
the general character of the order is poisonous. The 
following enumeration of its most important genera 
will give an idea of its qualities : 

Clematis, poisonous vines, having a benumbing, bit- 
ing taste, irritant and vesicant, have been used both 
internally and externally ; now obsolete ; contain a pun- 
gent stearoptine allied to anemonin. 

Adonis, a European wild flower, contains "adonin," 
an active heart-poison resembling digitalin. 

Thalictruin: several species said to resemble aconite 
in poisonous properties ; active principle, thalictrin. 

ArtsmMies (see Pulsatilla) contain a poisonous sub- 
stance, which finally separates into anemonin and ane- 
monic acid. 

Ranunculus : numerous species of ranunculus appear 
to have properties similar to Pulsatilla, and to contain 
also anemonin ; not now used. 

Hydrastis (see Seal, Golden) : not poisonous ; contains 
hydrastine, berberine, etc. 

Helleborus (see Hellebore, Black), an active heart- 
poison, resembling digitalis ; also drastic, like many 
other ranunculaceae ; contains helleborein and helle- 
borin. 

Coptis : not poisonous ; contains berberine and "cop- 
tine." (See Goldthread.) 

Delphinium (see Stavesacre) : very poisonous, and 
somewhat like aconite ; contains delphinine, etc. 

Aconitum, various aconitines. 



Cimieifuga (see Snake-root, Black) : active principle 
and qualities not definitely known. 

Xanthorrhiza, not poisonous, contains berberine ; 
obsolete. 

PcBonia : not active ; properties obscure ; obsolete. 

Allied Drugs. — Besides those given above in the 
section upon allied plants, the following may be men- 
tioned: Veratrum, mride, as a cardiac depressant, acts very 
much like aconite (and is often employed for similar 
conditions), as also do the now comparatively little used 
tartar emetic and tobacco. As a peripheral ansesthetic, 
the local anaesthesia produced by cold gives much the 
same subjective results. It is too earhr yet to say 
whether cocaine will take its place. Carbolic acid, 
locally applied, benumbs the nerve extremities. There 
is no other drug known which, taken internally, haf 
exactly the effect of aconite. W. P. JBolles. 

1 For a detailed resume of the chemical history of aconite, see Hiis< 
man^s paanzenstoffe, 2cl ed., i., 6S4. 

ACONITE. Toxicology.— The first symptoms of aco 
nite poisoning are manifested in from five to twenty 
minutes after a toxic dose has been taken, and are those 
of an acro-narcotic poison. There is burning in the throat 
and stomach, and soon a tingling sensation is felt in the 
extremities, and extends over the whole body ; at the same 
time there is numbness, proceeding even to anaesthesia of 
the integument. There is a very brief period of cardiac 
stimulation, but the pulsations are speedily reduced in 
frequency and force, then becoming irregular and flut- 
tering, and finally cease. The respirations are infrequent 
and shallow, gasping, and then are arrested altogether. 
The skin is livid, cold, and bathed in a clammy perspira- 
tion. The eyes are staring, and the whole countenance 
is expressive of great anxiety. The pupils are, as a rule, 
dilated, though they may be contracted or normal, and 
vision is often disturbed. There is extreme muscular 
weakness. Nausea and vomiting are not infrequently 
noted, and retention of urine is a common symptom. 
The temperature, both internal and external, is lowered, 
sometimes as much as 3° F. (1.1° C). Convulsions 
sometimes occur, but consciousness is usually preserved 
to the end, except during the convulsive seizures. 
Death often occurs in syncope, after some slight exer- 
tion. The characteristic sign of aconite poisoning is the 
peculiar numbness and tingling of the integument and . 
buccal mucous membrane. In cases of recovery, the. 
effects of the drug have usually almost entirely passed 
off at the expiration of from three to six hours, and by 
the following day the patient is in his ordinary health, 
except that he feels weak and languid. 

Poisoning by aconite is not a very rare accident, since 
at the present day the drug is so extensively used in the 
febrile conditions of childhood that it has come to be 
regarded almost as a domestic remedy, and a bottle of 
the tincture majr be found in nearly every house. Many 
cases of poisoning have occurred also from eating the 
root by mistake for horseradish, which it greatly re- 
sembles. Children sometimes chew the leaves of the 
plant, and are poisoned in this way. Great care should 
be observed in the employment of aconitine, since toxic 
symptoms have followed its external application to an 
extensive surface. It should never be given internally, 
as very alarming symptoms have followed the ingestion 
of TiV grain (0.0013 grm.) Recovery has been recorded 
after the swallowing of an ounce (30 grms.) of Fleming's 
tincture. 

Treatment. — After the stomach has been emptied by 
emetics or the pump, prompt measures must be taken 
to sustain the action of the heart. The patient should 
be kept in a recumbent position with the head low, and 
should on no account be permitted to sit up or stand. 
Stimulants, ammonia and alcohol, should bie given by 
the mouth and hypodermically, and external warmth 
applied to the body. Strychnine, digitalis, or atropine, 
are to be given for their cardiac effects. There is no 
chemical antidote to aconite, though astringents and ani 
mal charcoal are said to be useful. 

Thomas L. Stedman. 



68 



REFERENCE HANDBOOK OE THE MEDICAL SCIENCES. 



Aconite. 
Acromion Process. 



ACQUI, Lat. 44-40' N., altitude, 139 metres (423 
feet), a Piedmontese watering-place of considerable 
repute, situated in the beautiful valley of the Bormida, 
within easy reach of Alessandria by a branch railroad, 
or of Nizza by stage. The bathing establishment is 
situated on an elevated plateau, which is planted with 
mulberry trees, and is distant about a mile from the 
town, in a southerly direction. The medicinal hot 
springs at this point do not possess either the thermal 
force or chemical value of the "Bollente," a spring 
which is located within the precincts of Acqui itself, 
but which has fallen into complete disuse. No satisfac- 
tory analysis has been made of the waters of these 
springs, but they are said by Baedeker to be not unlike 
those of Aachen. The chief chemical constituents are 
sulphur, in inconstant but not inconsiderable propor- 
tions ; sodium chloride, and earthy sulphates. There 
are also traces of iodine and carbon dioxide. The cold 
springs of Puzzolente or Ravanesco, which are situated 
at some distance from the others, have essentially the 
same chemical composition. The temperature of the 
waters varies from 17.9° to 43° C. (64.5° to 109.4° F.). 
Although mention is made of certain sulphur springs 
whose waters are used as a beverage, and although the 
"Grande Vasca" and "Hemicycle" are employed for 
bathing purposes (both the douche and the ordinary bath), 
yet the customary mode of employing these medicinal 
waters is in the form of mud baths. The sediment which 
collects in the basins of these springs, and which consists 
partly of soil and partly of sulphur, various salts of slight 
solubility, and a little organic material, is removed in the 
month of April to large reservoirs, and thoroughly 
mixed with the thermal water. The resulting m$,ss is 
a greyish, soft, unctuous mud. The temperatures of the 
mud in the different reservoirs are, respectively, 31° C. 
(88° F.), 43.5° C. (110° P.), and 51° C. (124° F.). The 
bather does not enter the reservoir, but is laid upon a 
mattress, and the affected part of the body is then plas- 
tered with a layer of the warm mud to a depth of five or 
six centimetres (about two inches), and enveloped in 
thick cloths. According to the thickness, extent, and 
temperature of this mud plaster, the immediate effects 
are an acceleration of the pulse, increased heat of skin, 
profuse perspiration, redness of the skin, and even, at 
times, an eruption of one kind or another. These mud- 
baths are particularly efficacious in the various forms of 
rheumatism. Sciatica of the worst type is often not 
only benefited, but in many very rebellious cases a com- 
plete cure is obtained After the mud has been removed, 
the patient is put into an ordinary warm bath, of mod- 
erate temperature, and allowed to remain there for from 
fifteen to forty-five minutes. 

The bathing establishments of Acqui are the most ex- 
tensive to be found in Italy (Bulenburg). 

Henry Vleiacliner. 

ACROMION PROCESS, iKjrmiES Am) Diseases of. 
Very little appears to have been written on diseases and 
injuries of the acromion process, except in relation to 
simple fractures of the part. A few cases only of caries 
and necrosis have been reported ; not more than one 
case being reported by the same writer. In no instance 
is there anything more than a brief report of the case ; 
nothing being said in general as to the symptoms and 
treatment of these diseases. Nothing appears to have 
been written concerning new-growths of this process. 

Injurieb. 

The principal injury, in fact the only one of impor- 
tance, to which the acromion process is subject, is fract- 
ure. This may be simple or compound. 

Simple Fkacturb. — Fracture of the acromion process 
is a very uncommon accident. It is, however, the most 
frequent of fractures of the scapula. Out of 1,901 cases 
of fracture (Middlesex Hospital) 18 only were of the 
scapula, and 8 of these were of the acromion process. 
Out of 1,578 cases of fracture (Pennsylvania Hospital) 
14 were of the scapula, and of these 4 were of the acro- 



mion process. Out of 41 cases of fracture of the scapula 
collected by Dr. Agnew, 13 were of the acromion pro- 
cess. 

Causes. — As the acromion process is the highest point 
of the shoulder all blows from above impinge upon it, 
and all violence occurring in consequence of falls on the 
shoulder, as well as violence transmitted through the 
arm, is expended at this point. Hence fractures of this 
process are caused by blows from above, by a fall on the 
shoulder, elbow, or hand, and by muscular contraction, 
as in a case reported in the London Medical Gazette for 
1846. In this instance the fracture was caused by the 
sudden contraction of the deltoid muscle in raising the 
arm quickly. 

Situation of Fracture. — The acromion process is gener- 
ally broken at or internal to the acromio-clavicular ar- 
ticulation, near the junction of the epiphysis and dia- 
physis. The general direction of the fracture, according 
to Malgaigne, is transverse and vertical. Nelaton says, 
however, that it is generally oblique. If the fracture is 
at or internal to the acromio-clavicular articulation, 
there will generally be displacement of the outer end of 
the clavicle. In some cases merely the tip of the pro- 
cess is fractured off. In four cases seen by Dr. Hamil- 
ton the point of fracture was as follows : in two cases 
the bone was broken external to the acromio-clavicular 
articulation ; in the third case the fracture extended into 
the articulation and was accompanied by dislocation of 
the outer end of the clavicle upward ; in the fourth the 
fracture was in the same place, but there was no dis- 
placement of the acromion or the clavicle. 

Diagnosis. — The signs of this fracture vary with the 
situation. In nearly all cases there will be crepitus, the 
false point of motion may be made out, and frequently 
the loss of continuity may be appreciated by passing the 
finger along the process. . There will be distinct flatten- 
ing of the shoulder with loss of power in the arm, as in 
fracture of the clavicle ; the fragment being drawn 
downward with the arm. If there be no displacement 
the diagnosis will depend on crepitus and local tender- 
ness ; there will be partial loss of power in the deltoid 
muscle, which would become manifest after the patient 
attempts to raise his arm to the head. Erichsen says 
that when the clavicle is involved the flattening is more 
noticeable from behind. 

Treatment. — Two forms of treatment have been recom- 
mended. The ordinary form is similar to that employed 
in fracture of the clavicle. The shoulder is raised by 
supporting the elbow in a sling, and a pad is placed in 
the axilla. A body-bandage binding the arm to the side 
will insure complete immobility. The other form, de- 
scribed by Dr. Hamilton, requires the patient to be kept 
in bed : the arm is then carried out at nearly a right an- 
gle with the body and retained in that position ; by this 
method the fibres of the deltoid muscle are completely 
relaxed and the fragment allowed to remain in its natu- 
ral position. 

Prognosis. — Bony union is comparatively rare as a re- 
sult of this injury ; generally the union is ligamentous, 
with formation of a false joint ; this is particularly the 
case with fractures of the tip of the process. When the 
fracture is external to the clavicle it generally unites 
with a slight downward displacement. When the acro- 
mio-clavicular articulation is involved, it is doubtful if 
complete reduction can be accomplished if there be dis- 
location of the clavicle. When the fracture is internal 
to the clavicular articulation, if much displacement ex- 
ists, perfect readjustment will be difficult. 

Separation of the epiphysis of the acromion process is 
no doubt the real injury in a great manv cases of sup- 
posed fracture. As the centres of ossification for this 
process do not appear until the fifteenth or sixteenth 
year, and as ossification is not complete until the twenty- 
second to the twenty-fifth year, it seems very probable 
that in some cases of supposed fracture resulting in liga- 
mentous union the separate parts had never completely 
united. Several pathological specimens confirm this opin- 
ion. (Holmes states that there is some unexplained con- 
nection between this imperfect ossification and chronic 



Acromion Process, 
Active Principles. 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 



rheumatic arthritis of the shoulder-joint.) The causes, 
symptoms, and treatment of this condition are the same 
as in fracture of the acromion process. 

CoMPOimD FBACTTIBBS of the acromion process are of 
very rare occurrence, very few cases having been re- 
ported. 

In one instance (Dr. H. N. Fisher, New Tm-k Medical 
Press, 1860), where the injury was inflicted by a moving 
crank striking the shoulder, a wound large enough to 
admit the finger was made, on exploring which it was 
found that the whole of the acromion process was fract- 
ured off, the deltoid muscle being torn from its attach- 
ment. The fragment of bone was removed, and the 
wound treated as an ordinary severe lacerated wound, 
a counter-opening being made posteriorly to allow of 
drainage. There was considerable sloughing, followed 
by healthy granulation. The patient was progressing 
favorably when the case was reported. No cases of com- 
minuted fracture of the acromion are reported. 

Diseases. 

The reported cases of disease of the acromion process 
are so few that it is evident that such disease is very rare 
indeed. 

A case of caries was reported by Mr. Ferguson, in the 
London Lancet for 1843, the first manifestation being 
pain in the shoulder, followed by the formation of an 
abscess, which discharged itself and resulted in the for- 
mation of two sinuses, through which the probe passed 
to bare bone ; there were also the usual signs of caries. 
Eventually both sinuses were laid open, and the entire 
acromion process was found to be carious and was re- 
moved, a large gap being left between the spine of the 
scapula and the outer end of the clavicle. The patient 
made a good recovery, with fair use of the arm, the 
outer end of clavicle and spine of the scapula being iti 
close approximation. 

Two cases of necrosis have been reported, one by Du- 
play and one by; Friton. In the first case (Bull, et Mini, 
de la 8oc. de Olm-urg. de Paris) there was death of the en- 
tire acromion process, and also of a small portion of the 
outer end of the clavicle. The disease was first mani- 
fested by pain, swelling, abscess, and the formation of a 
fistulous tract ; after an interval of some months resection 
was performed and the necrosed portion was removed. 
The patient recovered, with good use of the shoulder. 

Diseases of the acromio-clavicular articulation are dis- 
cussed under the head of Disease of Joints. 

Willia/m H. Murray. 

ACTINOMYCOSIS. This is an infectious disease, 
characterized by the appearance of new formations which 
are esjjecially prone to undergo degeneration, and give 
rise to inflammation and suppuration in the surrounding 
tissues. The disease is most common in cattle and hogs ; 
in man it is rare, not more than twenty or thirty cases of 
its appearance having been recorded. It is only in the 
past few years that actinomycosis has been recognized as 
a true specific disease. Bollinger described, in 1877, un- 
der this name, a disease of cattle chiefly marked by great 
swelling of the lower jaw. The swelling is due to the 
formation of large tumor-like masses, which seem always 
to originate in the alveolar process of the jaw, and by 
gradual growth to involve the neighboring tissues. The 
tongue is frequently attacked, and here numbers of nodu- 
lar growths from the size of a walnut to that of a pea are 
found. Sometimes these nodules are single, at other times 
numbers of them are bound together by dense masses of 
connective tissue. Various names had before been given 
to designatb this condition ; it was called medullary sar- 
coma of the jaw, osteo-sarcoma, and was generally known 
simply under the name jaw sarcoma, and was thou£rht to 
iDe a peculiar form of sarcoma only occurring here It 
IS due to the labors of Dr. W. T. Belfleld, of Chicago, 
that we know the disease termed "swelled head " which 
IS not uncommon in the cattle in the United States, to be 
Identical with the disease Bollinger has named actinomy- 
cosis. •' 



70 



Bollinger described as peculiar to this disease certain 
yellowish seed-like bodies which were always found in 
the pus of abscesses and in the middle of the tumors. 
These were visible to the naked eye, and when rubbed 
between the fingers had a greasy feel. Microscropically, 
they were found to consist of threads similar to the ordi 
nary mycelium, which terminated in bulbous ends (Fig. 
58). Sometimes but one of these bulbs is connected with 
a thread, at other times there may be several. The forms 
which they assume are various ; in many cases a filament 
is connected with a mass of bulbs which branch in every 
manner {a. Fig. 58). Apparently the highest type of de- 
velopment is seen in the mulberry-like body in Fig. 59, 
where all the filaments and bulbs seem to radiate from a 
common centre. 

The nodules are found on microscopic examination to 
be composed of a great number of small masses not 
larger than miliary tubercles, which they greatly resem- 
ble. They are composed of small cells similar to the 
granulation tissue in the centre, and cells more spindle- 
shaped at the periphery. Each of these small masses is 
surrounded by a capsular investment of firm fibrous tis- 
sue. In the centre of each the fungous mass is seated; 
somewhat as the giant cell usually occupies the centre 
of the miliary tubercle. By the constant growth and 
agglomeration of smaller and larger tumors, masses as 
large as a man's fist and even larger than this are formed. 




Fio. 68.— Various Forma of Aotlnomyoea. (After Ponfiok.) o, Pecnliiir 
formation of bulbs; 6, beaded form: c, branohlog of bulbs from 
bypha. 

Degenerative processes usually begin early, and destruc- 
tion of the nodule by necrosis and suppuration takes 
place. Still the formation of new tumors keeps pace 
with the processes of decay ; a termination of the disease 
in this way seems never to be brought about. Both in 
animals and man the disease usually begins in the alve- 
olar processes of the jaw, and from here spreads along 
the base of the skull and the vertebral column. In man, 
the soft parts of the neck, the lungs, and chest- walls are 
often attacked. In consequence of the necrosis and at- 
tending suppuration abscess cavities and fistulee are 
formed, in which the fungus is always seen. In the pus 
the recognition of the fungus is as easy macroscopically 
as microscopically. Here it appears in radiate masses like 
that shown in Fig. 59 ; these are about the size of a mil- 
let-seed and of a bright yellow color. The pus from 
these abscesses and fistulee is always devoid of a fetid 
odor. The bones attacked are roughened, and an abun- 
dant formation of osteophytes takes place, leading to for- 
mations as bizarre as are seen after the maceration of an 
osteo-sarcoma. The disease spreads by gradual infection 
of adjoining parts. Metastasis seldom occurs, owing to 
the large size of the fungus and the diflSculty of its entry 
into blood-vessels. Ponfick, however, mentions one 
very interesting case in which the tumor projected into 
the lumen of the internal jugular vein. In this case there 
was a metastatic growth about the size of an orange in 
the right auricle, and numerous metastases in the lungs. 



REFERENCE HANDBOOK OP THE MEDICAL SCIENCES. 



Acromion Procesa. 
Active Principles. 



The peculiar fungus associated with the disease has 
been named actinomyces, or ray fungus, from its pecu- 
liar manner of growth (as seen in Fig. 59). It occupies 
a place by itself and forms a distinct species, no other 
allied forms being known in botany. By some it has 
been placed among the bacteria, but more probably it 
comes nearer to the hyphamycetes, and the bulbous en- 
largements may be regarded as analogous to the conidia. 

It may be regardea as the cause of the disease. Not 
onljr will inoculations with pieces of tissue or pus con- 
taining the fungus produce the disease, but it has been 
cultivated in suitable media outside of the body, and 
inoculations made with the product of a pure cultivation 
have been equally successful. Infection seems to take 
place, in most cases, from the buccal cavity. Israel, 
Johne, and Ponflck have found the fungus growing in 
the crypts of the tonsils and in concretions of the 
lachrymal duct, under normal conditions. It has aJso 




Fig. 59.— Perfect Form of Fungus. (After Ponflck.) A long filament 
termluating in bulbs is given ofC at one eide. 

been found in carious teeth. From these places it could 
easily be taken into the tissues by means of injuries of 
the mucous membrane or by the extraction of teeth. 
According to Israel, the fungus can be aspirated into 
the lungs, and infection may take place in this way. 
Among animals, the carnivora seem to enjoy an im- 
munity. Outside of the body the fungus has never 
been found ; most probably here it exists on various 
plants and green food. 

The honor of having recognized the disease in man 
belongs to Ponflck. Israel published, shortly after 
Bollinger's publication, the account of two cases in 
man, but he regarded it as a peculiar form of septi- 
caemia, and not as identical with the disease described 
by Bollinger. Up to the present, no case of its occur 
rence In man has been recorded in the United States, but 
judging from the frequency with which it occurs here in 
cattle it is probable that it has also, without being recog- 
nized, affected man. Clinically, it can always be de- 
tected by the presence of the yellow, seed-like bodies in 
the pus. W. T. Goundiman. 

ACTIVE PRINCIPLES. A name given to a ^reat 
variety of substances, chiefly alkaloids and glucosides, 
existing in drugs, and to the presence of which the drugs 
owe their peculiar physiological and therapeutical action. 
Many of the active principles have been isolated and are 
employed medicinally — either in their basic form or in 
combination with acids as salts. They possess advan- 
tages over the crude drug for therapeutic purposes by 
reason of the smallness of the dose in which they can be 
exhibited, oftering themselves especially for hypodermic 
use. But they do not always correspond in their eft'ccts 
to the plants or other drugs from which they are derived, 
A single plant, as, for example, opium, may contain a 
large number of active principles which produce effects 
upon the animal organism, varying_ among themselves 
both in degree and in kind. ■ Hence in certain cases it is 
more desirable to exhibit some preparation of the crude 
drug rather than any single one of its isolated active 
principles. Or again, the active principle may be so ac- 
tive a poison that its administration is inconvenient or 



dangerous by reason of the extremely minute dose re- 
quired. 

AliEAIiOIDS. 

The substances thus designated are natural organic 
bases, containing carbon, hydrogen, oxygen, and nitro- 
gen, which possess an alkaline reaction and a bitter taste 
and which unite with acids to form salts. They are 
generally of crystalline form, though some, like nicotine, 
which contain only carbon, hydrogen, and nitrogen, 
exist as oily liquids. They are supposed to be substitu- 
tion compounds of ammonia, but their chemical consti- 
tution is very complex and but little understood. They 
are for the most part derived from plants, though some 
are formed in the animal organism, and attempts have 
recently been made, with partial success, to produce 
them'synthetically. They are, as a rule, the active prin- 
ciples of the plants in which they reside. Several may 
exist in the same plant, opium, for example, containing 
at least eighteen or twenty distinct alkaloids, which differ 
not only m chemical composition but also, more or less, 
in their effects upon the animal organism. The pure 
alkaloids are sparingly soluble in water, but soluble 
usually in alcohol, chloroform, and ether ; their salts, 
however, dissolve with much more readiness in water. 
Most of the alkaloids used in medicine are active neu- 
rotic poisons, being either excitants or paralyzers of the 
nervous centres. The mode of action of the alkaloids is 
difficult of explanation. Rossbach believes that they 
render the cells incapable of taking up oxygen, and thus 
disturb their function ; and possessing no affinity for 
the superflcial tissues, as most of the other chemical 
poisons do, they are carried by the blood in a free state 
until they reach the nervous centres, upon which their 
force is expended. The names of the alkaloids termi- 
nate in English in -ine ; in Latin the termination was f or- 
rnerly -ia, as morphia, atropia, but at the last revision 
of the U.S. Pharmacopoeia in 1880 this was changed to 
■ina, as morphina, atropina, etc. 

There is another class of substances derived from 
plants, many of which are similar in their action to the 
alkaloids, called glucosides or neutral principles. They 
are substances which, on boiling with a dilute acid, take 
up the elements of water and are split into sugar and 
some other compound, varying in each case with the 
glucoside used. They are distinguished in the Pharma- 
copoeia of 1880 by the termination -in in English, and 
■inum, in Latin. There are some other substances used 
in medicine which are commonly called by names having 
a terminology similar to that of the alkaloids, but which 
are very different both in their chemical composition and 
in their therapeutical action from this group of drugs. 
Thus podophylline is not an alkaloid, but is the resin of 
podophyllum, and what is usually called ergotine (of 
Bonjean) is the aqueous extract of ergot. There is also 
an alkaloid called ergotine, which, however, is not used 
in medicine. The employment of these incorrect terms 
should be avoided in prescribing. 

The following is by no means a complete list of the 
alkaloids and glucosides, but includes only the more 
important members of these groups. Only the briefest 
mention is made of their physical characters and medic- 
inal uses. For a full account of the physiological ac- 
tions and therapeutical applications of these active prin- 
ciples, the reader is referred to the special articles 
treating of them or of the plants from which they are 
derived. The principal alkaloids are : Aconitine, apo- 
morphine, atropine, caffeine, cinchonine, cocaine, co- 
deine, daturine, hyoscyamine, morphine, physostigmine, 
pilocarpine, quinine, strychnine, and veratrine. The 
only glucosides that require any notice are digitalin, 
picrotoxin, salicin, and santonin. 

Aconitine, CsoH^tNOt, non-officinal, derived from 
the root of cbconitum napelhis and other varieties of 
aconitum. It exists in the form of a white amorphous 
powder, or of colorless rhombic crystals. It is used ex- 
ternally for the relief of neuralgia, especially of the fifth 
nerve. 

Atropine, CnHsjNOa, officinal, prepared from atropa 



71 



Active Principles. 
Arnpuucture. 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 



belladonna. It exists in the form of "colorless or 
white acicular crystals, permanent in the air, odor- 
less, having a bitter and acrid taste, and an alkaline 
reaction." It is usually exhibited in the form of the 
officinal sulphate. Atropine is employed to dilate the 
pupil for the purposes of ophthalmoscopic examination, 
and in the treatment of keratitis, conjunctivitis, and 
other affections of the eye. It is used externally to re- 
lieve superficial pain, and internally in neuralgia. It is 
one of the most effectual means which we possess to pre- 
vent the night-sweats in phthisis. It finds further em- 
ployment in chorea, epilepsy, mania, and in nocturnal 
incontinence of urine. Daiurina, an alkaloid of datura 
stramonium, and Hyoseyamina, derived from liyoseya- 
mus niger, possess almost identical properties with atro- 
pine, and are ocoasiohally employed for the same pur- 
poses. The sulphate of hyoscyamine is ofiicinal. 

Caffeine, CBH10N4OS-I-H2O, officinal, exists in tea, cof- 
fee, guarana, and other plants. Occurs in the form of 
"colorless, soft, and flexible crystals, generally quite 
long, and of a silky lustre ; permanent in the air, odor- 
less, having a bitter taste and neutral reaction." It is 
employed as a cardiac stimulant and diuretic, being of 
especial value in many cases of cardiac dropsy. It also 
frequently relieves headache. 

Cocaine, OnHjiNOi, non-officinal, derived from the 
leaves of erythroxylon coca. Occurs in the form of 
large colorless prismatic crystals. The hydrochlorate 
exerts a local anaesthetic and astringent effect, especially 
on the mucous surfaces. It is also a mydriatic. It is 
employed as a local anaesthetic in operations upon the 
eye, and also to reduce inflammation and relieve pain in 
conjunctivitis, toothache, earache, coryza, and gonor- 
rhoea. It is likewise of value in superficial neuralgias, 
pruritus vulvae, and many other affections in which an 
astringent and benumbing effect is desired. 

Alkaloids of Cinchona. — There are several of these al- 
kaloids used in medicine, but we need consider but two 
here. 1. Quinine, CjoHjiNaOj, officinal, derived from 
all varieties of cinchona, but existing in greatest propor- 
tion in cinoTwna flava. It occurs as "a white, flaky, 
amorphous, or minutely crystalline powder, permanent 
in the air, odorless, having a very bitter taste, and an 
alkaline reaction." The sulphate, bisulphate, hydrobro- 
mate, hydrochlorate, and valerianate are the officinal salts. 
Quinine has a very wide therapeutic application. It is 
employed in the treatment of malaria, septicaemia, neu- 
ralgia, and as a tonic, antipyretic, and microbicide. 2. 
CincTwnine, C2oH24NaO, officinal, exists in all varieties 
of cinchona, but in greatest proportion in the pale bark. 
Occurs in the form of " white, somewhat lustrous prisms 
or needles, permanent in the air, odorless, at first nearly 
tasteless, but developing a bitter after-taste, and having 
an alkaline reaction." Cinch'onine possesses properties 
similar to quinine, but is weaker. It is employed as a 
substitute for quinine, chiefly on account of its cheap- 
ness. The sulphate is the officinal salt. The other offi- 
cinal alkaloids of quinine are sulphate of cinchonidine, 
prepared chiefly from cinchona rubra, and sulphate of 
quinidine, derived principally from cinchona pitayensis. 

Alkaloids of Opium. — This drug contains a very large 
number of alkaloids, of which, however, only three 
deserve special mention : 1. Morphine, CuHioNOa-f-HsO, 
officinal, occurs as " colorless or white, shining, prismatic 
crystals, or a crystalline powder, permanent in the air, 
odorless, having a bitter taste, and an alkaline reaction." 
The officinal salts are the sulphate, hydrochlorate, and 
acetate. Morphine is anodyne, antispasmodic, and hyp- 
notic, and is employed in the relief of cough, asthma, 
diarrhoea, convulsions, to control vomiting, to relieve 
pain, and for a variety of other conditions. 8. Codeine, 
CisHsiNOa-t-HjO, officinal. " "White, or yellowish- white, 
more or less translucent rhombic prisms, somewhat efflo- 
rescent in warm air, odorless, having a slightly bitter 
taste, and an alkaline reaction." It is employed as a 
hypnotic, and to relieve cough, and is similar to, but 
weaker in its effects than morphine. It has been 
specially recommended in the treatment of diabetes. 
3. Apemorphine, C„Hi,NOj, The hydrochlorate is offl- 

73 



cinal. This is not a natural alkaloid existing in opium, 
but is prepared artificially from morphine by heating 
with concentrated hydrochloric acid. The salt occurs 
in "minute, colorless, or grayish- white, shining crystals, 
turning greenish on exposure to light and air ; odorless^ 
having a bitter taste, and a neutral or faintly acid re- 
action." It is employed hypodermically to produce 
emesis. Vomiting occurs promptly with little or no 
nausea. It is also highly recommended by some as an 
expectorant. In very small dose (0.0005 grm. = -^311 
grain), it is said to control vomiting. Narceina, nar- 
ootina, papaverina, and thebaina, are other alkaloids 
derived from opium, which have been used to some 
extent in medicine ; none of them is officinal. Thebaine 
is somewhat analogous in its effects to strychnine. 

Physoatigmine, CibHjiNsOj, an amorphous, colorless 
powder, derived from physoatigma venenosum or Cala- 
bar bean. The salicylate (officinal) and sulphate are the 
salts used in medicine. The officinal salt occurs as 
"colorless, shining, acicular, or short, columnar crystals, 
gradually turning reddish when long exposed to air and 
light ; odorless, having a bitter taste, and a neutral re- 
action." It has been recommended in tetanus, but finds 
its principal employment in ophthalmology. It produces 
contraction of the pupil, thus opposing atropine. It is 
employed in the treatment of paralysis of accommodation, 
and in glaucoma to diminish intra-articular pressure, and 
to produce rupture of posterior and anterior synechiae. 

Pilocarpine, ChHibNiOs, derived from the pHocai-piis 
pennatif alius, or jaborandi. The hydrochlorate is offi- 
cinal. This occurs in " minute white crystals, deliques- 
cent, odorless, having a faintly bitter taste, and a neutral 
reaction." Like the preceding alkaloid, pilocarpine causes 
contraction of the pupils. It increases very markedly 
most of the secretions of the body, especially those of 
the salivary and sweat glands. It is employed chiefly 
as a diaphoretic, in the treatment of uraemia, puerperal 
eclampsia, cardiac dropsy, and to promote the absorption 
of pleuritic exudations. Very small doses have been 
used to check the night-sweats of phthisis. 

Strychnine, CnHaaNiOj, officinal, derived from strych- 
nia nux vomica or strychnos ignatia, occnia as "color- 
less, octahedral, or prismatic crystals, or a white 
crystalline powder, permanent in the air, odorless, but 
having an intensely bitter taste, which is still perceptible 
in highly diluted (1 in 700,000) solution, and of an alka- 
line reaction." The sulphate is the officinal salt. Strych- 
nine is a tetanizing poison. It is employed in spinal 
and peripheral paralysis (when there is absence of 
rigidity), in the treatment of functional amaurosis, in 
constipation, prolapsus ani, in atony of the genital organ, 
and as a stomachic tonic. 

Veratrine, CsTHtsNOu, officinal, prepared from the 
seeds of asagrma officinalis or mratrum aabadUla. " A 
white or grayish-white, amorphous, rarely crystalline 
powder, permanent in the air, odorless, of a distinctive 
acrid taste, leaving a sensation of tingling and numbness 
on the tongue, producing constriction of the fauces, and 
highly irritant to the nostrils." Veratrine is not employed 
internally. It is used externally in the treatment of 
neuralgia of the flfth pair, of sciatica, and for the relief 
of rheum^itic nerve-pains. The ointment and the oleate 
are officinal preparations. 

GlucoSides. 

Digitalin, CiHsOa, non-offlcinal, prepared from the 
leaves of digitalis purpurea. It occurs as small, white 
scales, or a yellowish-white powder. It is employed for 
the same purposes as digitalis, but possesses no advan- 
tages over the officinal preparations of this drug, and its 
use is not to be recommended. 

Pierotoxin, CbHuO,, officinal, prepared from the 
seeds of anamirta panieulata or cocculus indicus, occurs 
in " colorless, shining, prismatic crystals ; permanent in 
the air, odorless, having a very bitter taste, and a neu- 
tral reaction." It is highly excitant of the medulla ob- 
longata, accelerating and finally arresting respiration. 
It has been employed successfully to arrest the night 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 



Active PrlnclpIeB, 
Acupuncture. 




sweats of phthisis, and has also been recommended in 
certain varieties of headache and in epilepsy. 

Salicin, CisHibOt, officinal, prepared from the bark 
of salix helix and other varieties of willow, occurs 
in "colorless, or white, silky, shining crystals, perma- 
nent in the air, odorless, having a very bitter taste, and 
a neutral reaction." It is employed as an antipyretic 
and as a stomachic tonic, but its principal use is in the 
treatment of rheumatism. 

.Santonin, dsHisOs, officinal, prepared from the 
unexpanded flower-heads of a/rtemimif mariiima (san- 
tonica), occurs in "colorless, shining, flattened, pris- 
matic crystals ; not altered by exposure to air, but turn- 
ing yellow on exposure to light ; odorless, and nearly 
tasteless when first placed in the mouth, but afterward 
bitter, and having a neutral reaction." 

Santonin is employed as an anthelmintic. It causes 
the death and expulsion of round- and thread-worms, 
but has little effect on tape-worm. It is Said also to be 
of value in amaurosis. 

Thomas L. Stedman. 

ACUPRESSURE. A procedure devised by Sir J. Y. 
Simpson, of Edinburgh, in 1859, for arresting haemor- 
rhage from a vessel by 
means of pressure made 
by a needle transfixed 
through the neighbor- 
ing tissues. The flow 
of blood through an ar- 
tery may be arrested in 
any one of three ways. 
The vessel may be sim- 
ply compressed between 
the needle and some firm 
tissue, as a bone or the 
integument, as repre- 
sented in Figs. 60 and 

61. "When the artery lies imbedded in a soft tissue, as in 
a divided muscle, its occlusion may be accomplished by 

torsion. This is done by 
introducing the needle on 
one side of the vessel, and, 
when it has passed through 
a portion of the tissue, twist- 
ing it around the artery and 
fixing its point in the tissue 
in a direction opposite to 
that in which it was first 
entered ; or the artery need 
not be included in the bight 
of the needle, but the latter may be turned before reach- 
ing the vessel, the latter then being compressed by the 
elastic force of the twisted tissues acting upon the needle. 
A third method, 
applicable also in 
cases in which 
the vessel lies in 
a yielding tissue, 
consists in pres- 
sure between the 
needle and a slip- 
knot. The needle is passed beneath the artery, and a loop 
of fine wire is slipped over its point, the ends of the loop 
passing over the artery, and being fastened by two or 
three turns over the shaft of the needle (see Fig. 63). In 
the case of small vessels, the needles may be withdrawn 
at the expiration of twenty-four hours ; but when large 
arterial trunks are occluded, the pressure should be 
maintained for forty-eight hours at least. 

The advantages claimed for this method are : the ease 
and rapidity with which the needles may be applied, no 
delay being caused in the operation ; the absence of dan- 
ger from suppuration of the ends of the divided vessels, 
and non-interference with rapid closure of the wound, no 
inflammation being excited by the presence of the n6edles 
in the tissues for so short a period of time. These advan- 
tages, however, are less manifest at the present time, since 
the introduction and general employment of antiseptic 




Fig. 61. 




Fio. 63. 



ligatures, and it is not likely that the procedure will 
ever again enjoy the popularity which it at one time 



Thomas L. Stedman. 

ACUPUNCTURE. An operation which consists in 
the introduction of needles into the body, either as a 
means of giving exit to the fluid in (Edematous tissues or 
for the relief of pain in neuralgia and muscular rheuma- 
tism. It is a method in great vogue in China, and is 
used by the physicians of that country not only to 
assuage pain, but to promote reparative action in ulcers 
and in the treatment of various other affections. It is 
said to have been introduced into Europe from China, 
by the missionaries in the seventeenth century. The 
instrument employed is a round polished needle, having 
a cylindrical handle of sufficient size to permit of its 
being readily manipulated by the fingers. It is intro- 
duced into the tissues by a quick rotatory movement, 
and is then left m situ for a number of minutes, or even 
for an hour. Sometimes the insertion of a single needle is 
sufficient to relieve the pain, but ordinarily half-a-dozen 
or more are employed. This little procedure may be 
practised almost painlessly, and is sometimes wonder- 
fully effective in controlling neuralgic and rheumatic 
muscular pains. It often fails, indeed, and it seems im- 
possible to determine beforehand in what cases it will 
prove serviceable, but certainly no case of lumbago or 
sciatica should be abandoned until acupuncture, as well 
as the more ordinary remedies, has been tried. In ana- 
sarca, when the scrotum and lower extremities are dis- 
tended with fluid, the patient may experience comfort 
from a few punctures with a three-cornered surgical 
needle. The operation should be practised with caution, 
however, as it is apt to excite an erysipelatous inflamma- 
tion of the integument. In the treatment of paralysis 
insulated needles are sometimes used as a means of in- 
troducing the electric current into the deeper tissues. 
This procedure has received the name of eleeiro-puneiure. 

There is another form of acupuncture, called Baiin- 
soheidtismibs, whicli at one time enjoyed a great popular 
reputation, and which even now is hot very infre- 
quently employed. It was devised by a German named 
Baunscheidt, who is said to have conceived the idea from 
observing that the irritation caused by the bites of in- 
sects afforded him considerable relief from the pain of 
an articular affection from which he was suffering. The 
instrument employed consists of a cylinder enclosing a 
button into which are inserted from twenty to thirty 
short needles. The open end of the cylinder is placed 
on the integument, and then by means of a handle the 
button with needles attached is drawn up into the cylin- 
der compressing a spiral spring ; when the handle is 
released the force of the spring impels the needles sud- 
denly and sharply into the skin. The operation may 
rest here, or an irritating fluid, such as mustard-water or 
cajeput oil, may be applied to the punctures. This is 
employed for the relief of neuralgia and muscular pains, 
and often proves of very great service. 

There is still another form of acupuncture, if such it 
can be called, though it is more nearly related to hypo- 
dermic medication. It consists in the hypodermic injec- 
tion of pure water, and has received the name of aqua- 
puncture. Many superflcial pains, even though quite 
severe, may be relieved by this simple procedure. That 
the relief thus obtained is not merely the effect of im- 
agination, is evidenced by the fact that neuralgias of 
distant parts are not benefited by aqueous injections, but 
in order to be effectual the operation must be practised 
at a point as near as possible to the seat of pain. Aqua- 
puncture is employed in various forms of neuralgia, in 
lumbago, and in painful functional affections of the ab- 
dominal viscera. Bartholow states that he has obtained 
excellent results from the injection of water into the 
substance of paralyzed and atrophied muscles. From 
two to four grammes (one-half to one drachm) of fiuid 
may be used for each injection, and the operation may 
be repeated if no relief is experienced at the expiration 
of two or three minutes. Thomas L. Stedman. 



73 



Adams Go. Springs. 
Addison's Disease. 



EBFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 



ADAMS COUNTY SPRINGS, Ohio. The springs are 
situated in a picturesque region of Southern Ohio, sev- 
enty-five miles east of Cincinnati, and thirty miles west 
of Portsmouth. The name of the nearest station, on the 
Cincinnati & Eastern Railroad, is Mineral Springs 

Analysis.— A qualitative analysis by Prof. E. S. Wayne 
states there are fifteen grains of solid matter to the pint, 
composed of chloride of magnesium, sulphate of lime, 
carbonate of lime, chloride of sodium, chloride of cal- 
cium, and oxide of iron. The water is a chalybeate, and 
has a temperature of 56° P. (Walton.) O. B. F. 

ADAMS SPRINGS. Location and Post Office, Glen- 
brook, Lake County, Cal. 

Access. —By railroad from San Francisco to Calistoga, 
seventy-three miles, thence by stage to Glenbrook, twen- 
ty-three miles, over an excellent road, where teams from 
the hotel meet the stage to convey guests to the springs, 
three miles distant. 

Analysis. One pint contains : 

Soma. OraltiB. 

Carbonate of lime i^'^«q 

Carbonate of magnesia 12.378 

Carbonate of soda "^'n^? 

Carbonate of iron 064 

Chloride of sodium B14 

Silica 908 

Organic matter 351 

Nitric acid traces. 

Salts of potash " 

Total 24.9S7 

Carbonic acid gas, 38 cubic inches. 

Thbbapbutic Pbopbrties. — This is a valuable alkaline 
water, diuretic and purgative, and has proved very use- 
ful in kidney and liver diseases, dyspepsia, and aggra- 
vated cases of constipation. 

These springs are located in the pine mountains of 
Lake County. The geological formation of the sur- 
rounding country is soft granite, in which are embedded 
veins of slate, iron, and gravel. The spring issues from 
a deposit of blue clay and gravel. The climate is salu- 
brious, with a mean temperature of 85° P. in summer and 
15° to 20° above zero in winter. The average annual rain- 
fall is twenty-five to thirty-five inches. Accommodation 
is supplied by the Adams Springs Hotel and cottages, hav- 
ing a capacity for forty people. Pure and soft drinking- 
water is brought to the hotel by pipes from a distance of 
one mile. The neighborhood is covered with pine for- 
ests. Game, such as grouse, quail, hare, and deer, fur- 
nish amusement for the sportsman. Clear Lake, eight 
miles distant, stocked with various kinds of fish, and 
the creeks full of trout, give occupation to the lovers of 
the piscatorial art. 

HiSTOBY. — The springs are said to have been discovered 
accidentally eighteen years ago, by a man named Adams, 
travelling in search of health. He was suffering at the 
time from " liver disease," and, having been cured by the 
water, he spread the fame of these springs. 

George B. Fowler. 

ADDISON'S DISEASE (Bbonzed Skin Disease ; Me- 
lasma Supba-rbnale). Of the above terms the first is 
to be preferred, for while the peculiar discoloration of the 
skin is not an invariable characteristic of the affection, 
the credit of Addison to the discovery of the disease 
called by his name has never been called in question. 

DBppiTiON.— A disease characterized by progressive 
asthenia, digestive disorders, pain and tenderness chiefly 
seated in the epigastrium, hypochondria, and lumbar re- 
gions, and an abnormal pigmentation of the skin and 
mucous membranes. 

Historical Notice.— The first case of Addison's dis- 
ease on record is to be found in Lobstein's treatise, " De 
nervi sympathici humani fabrica et morbis," Paris, 1823 
from the English translation of which, by the late Pro- 
fessor Joseph Pancoast, I take the following extract : 
" I have myself observed the nerves forming the supra- 
renal plexus, much thicker in disease, where the capsule 
renales, which were more than twice as large as usual, 

74 



had degenerated into tuberculous substance." The pa 
tient was an unmarried woman, twenty-five years of age, 
who died in " convulsive spasms analogous to the epilep- 
tic. . . . Nothing unusual was discovered in the 
body of this woman but the aforesaid change in the supra- 
renal glands, and the enlargement of the nerves." 

Notwithstanding the fact that there is no record of any 
darkening of the complexion, the above was undoubt- 
edly a typical case of Addison's disease, in which, more- 
over, death by convulsions is not uncommon. "The ob- 
servation regarding the thickening of the nerves in this, 
the first recorded instance of the disease, is of remarka- 
ble interest. The second case was recorded in the 
"Halle Hospital Reports" by Dr. Schotte, in October, 
1823, and is published in volume vii. of the Deutsches 
Archivf. Klin. Med. by Risel, in the course of his article 
" Zur Pathologic des Morbus Addisonii." The third 
case came under the observation of Dr. Richard Bright 
at Guy's Hospital, in July, 1829. It is contained in Dr. 
Bright's classical "Reports of Medical Cases," and also 
figures as Case V. in Addison's original memoir. The 
lesions of the <;apsules were characteristic ; there was no 
other affection of any consequence, and for the first time 
in the history of this disease it was noted that the " com- 
plexion was very dark." A few other cases were re- 
ported before the year 1855, when Addison published his 
work " On the Constitutional and Local Effects of Dis- 
ease of the Supra-renal Capsules," but it was reserved 
for his sagacity to detect the relation between the well- 
marked constitutional symptoms of the aflEection, the pe- 
culiar pigmentation of the skin, and the structural 
changes in the suprarenal capsules. 

It IS no disparagement to the memory of Addison to 
say that the general acknowledgment of his discovery 
has been retarded by his including in his treatise cases 
which, at the present day, would be rejected from the 
category of Addison's disease. Of his eleven cases there 
are but four uncomplicated with other affections, two 
complicated, while of the remaining five, one was a case 
of softening of the brain with advanced kidney disease 
and tubercular deposit in various organs, among others 
in one suprarenal capsule, and the other four were cases 
of widespread carcinomatous deposit, the suprarenal 
capsules being more or less involved in each. Addison 
was evidently under the impression that the symptoms 
of the disease were due to the suppression of the un- 
known function of the suprarenal capsules, and that, 
therefore, any destructive lesion of these bodies was 
capable of causing them, but it is now established that 
they are invariably associated with one particular lesion, 
to be described under the head of the Anatomical Charac- 
ters of the affection. 

Anatomical Chaeactbbs. — The lesion of typical cases 
of Addison's disease is a primary, chronic, interstitial in- 
flammation of the suprarenal capsules, beginning in the 
medullary substance in the form of gray granulations 
precisely resembling those of tubercle, which enlarge, 
coalesce, and undergo caseous degeneration. The in- 
flammation extends to the cortical substance, and finally 
obliterates all traces of the primary structure of the or- 

fans. The fibrous investment alone resists destruction. 
t becomes much thickened through an inflammatory hy- 
perplasia, and contracts adhesions with neighboring or- 
gans, such as the kidney, liver, diaphragm, pancreas, 
etc. Under the microscope the process is seen to consist 
of a small-celled infiltration of the connective tissue 
septa of the organ, which partly develops into fibrous 
tissue, while the remainder undergoes caseous degenera- 
tion. The latter change occurs in the form of nodular 
masses varying from the size of a pea to that of a 
pigeon's egg, which are at first dry, then undergo puri- 
f orm softening, and, later, through the absorption of 
their fluid portions, become converted first into putty- 
like, and finally into calcareous masses. These last 
changes are accompanied with much shrinking of the 
previously greatly enlarged organ. The puriform fluid 
of the stage of softening has precisely the naked-eye ap- 
pearance of pus, but under the microscope is seen to con- 
sist of granular detritus and oil-globules. "The gross ap 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 



Adams Co. Springs. 
Addison's Disease. 



pearances correspond with the stage of the disease. 
There is nocase on record in which the morbid deposit 
could be said to be at its earliest stage in any portion of 
the capsule. In those cases in which the anatomical al- 
terations are least advanced, the suprarenal capsules are 
enlarged, indurated, and nodular, the enlargement some- 
times equalling that of the subjacent kidney, as in a case 
of my own, recorded in the tenth volume of the " Trans- 
actions of the Pathological Society of Philadelphia." On 
section of such an enlarged capsule it is seen to be com- 
posed of a grayish, semi-translucent substance, in which 
are imbedded irregular roundish masses of a yellowish 
color and friable consistence. At a later stage, the yellow 
nodules soften and the organ is honeycombed with cavi- 
ties containing the puriform fluid above mentioned. The 
last stage is that of absorption of the fluid contents of the 
altered organ and the deposit of cretaceous matter, with 
coincident shrivelling to a size perhaps below the normal. 
As to the exact nature of the morbid process, authorities 
are united in considering it an inflammation which they 
variously qualify as strumous, tubercular, or caseous. 
These terms are one and all appropriate, conveying, as 
they do, to the minds of all pathologists the Idea of an 
abundant infiltration of cells of low vitality, which partly 
become organized into fibrous tissue and partly undergo 
caseous and puriform degeneration. The affection is 
generally bilateral, although Rlsel (Deutsches Arch, fur 
klin. Med., vol. vii., 1870) has reported two cases, in 
each of which the left capsule only was involved. 

Of equal interest with the morbid changes in the supra- 
renal capsules are certain alterations in the neighboring 
nerves and ganglia, of which mention has been made in 
a number of cases. The significance of these lesions of 
the nervous system is impaired by the fact that they are 
not invariably found. Eulenberg and Guttmann {Jour- 
nal of Menial Science, January, 1879) have collected 
twenty cases in which well-marked lesions of the supra- 
renal plexus and the ganglia and nerves of the solar 
plexus were found, opposed to which are twelve cases 
in which careful examination demonstrated no change 
whatever. The positive observations include fatty de- 
generation of the semilunar ganglion and solar plexus, 
first observed by Queckett in' one of Addison's cases ; 
swelling and redness of the nerves of the lesser splanch- 
nic and ganglia of the solar plexus, atrophy, pigmenta- 
tion of ganglionic cells, increase- of connective tissue In 
the ganglia and in the neurilemma of the nerve-fibres ; 
and, finally, suppuration and caseation of the semilunar 
ganglia. 

Notwithstanding the above-mentioned negative exami- 
nations, It is the opinion of the writer that the abdominal 
sympathetic Is functionally impaired in every case of 
Addison's disease. This question will be more fully dis- 
cussed under the head of the Pathogeny of the disease. 

Enlargement of the mesenteric and retro-peritoneal 
glands is frequently observed. In one of my own cases 
it is recorded that the " mesenteric glands were greatly, 
and the lumbar glands enormously, enlarged" ("Path. 
Soc. Trans., Phila.," vol. x.). 

More or less gastro-intestinal hypersemla and catarrh, 
with enlargement of the solitary and agminated follicles, 
are present in every case. A mammlllated condition of 
the gastric mucous membrane was observed by Dr. 
Hodgkin in one of Addison's cases. Ecchymoses and 
hsemorrhagic erosions of the gastric mucous membrane 
are sometimes present. Enlargement of the spleen is oc- 
casionally observed ; also an abnormally dark color of 
spleen, liver, kidneys, and -pancreas, and brownish hue 
of the peritoneum. These lesions are due to long-con- 
tinued hypersemia of the abdominal organs. This hy- 
persemia is sometimes evident at the necropsy, as in the 
case of my own last referred to, in the report of which it 
is noted: "The blood was fluid, and on removing the 
liver It poured out of the inferior vena cava in large 
amount. There was none of the dryness and translu- 
cency of tissue so constantly met with in severe cases of 
anaemia." 

Many of the symptoms of Addison's disease are attrib- 
uted by vn:iters to a high grade of general anaemia, with- 



out any evidence in favor of such an opinion. In several 
of Greenhow's cases the blood was examined microscop- 
ically with "virtually negative results." In another 
case, under the care of Dr. Bristowe, Greenhow exam- 
ined the blood, and found it "rich in red globules." 
Wilks states positively that anaemia Is not present. 
These statements require some modification. In many 
cases of Addison's disease, especially those complicated 
with pulmonary tuberculosis, there is a high degree of 
anaemia, although not to be compared with that found in 
cases of progressive pernicious anaemia, and In almost all 
cases I am confident that a careful enumeration of the 
red globules would demonstrate their deficiency. Long- 
continued intestinal hypersemia invariably leads to anae- 
mia, as is commonly seen in the cachexia of heart dis- 
ease, the cacMxie ea/rdiaqim of Andral. An Increase in 
the number of the white cells has been observed in sev-. 
eral cases, but as no figures are given, it is impossible to' 
say how near the condition approached that of leucocy- 
thaemla. Free pigment is said to have been found in the 
blood in one case, by Van den Corput. Dr. W. E. 
Hughes, of Philadelphia, kindly sent me the following 
notes of his examination of the blood of a case of Addi- 
son's disease ; the patient left the city, and the diagno- 
sis, which was based upon the presence of all the charac- 
teristic symptoms of the disease, was never confirmed by 
a necropsy : 

_ " Addison's disease, two years' duration. Pigmenta- 
tion of skin and mucous membrane of mouth ; no ema- 
ciation ; moderate anaemia ; great weakness. Red cor- 
puscles, 5,180,000 ; white corpuscles, 9,000 per cubic milli- 
metre. Red are a little below normal in size and a trifle 
pale, well shaped ; some few are deeply pigmented, the 
pigment granular. Floating free in the blood-plasma are 
irregular granules of black pigment, from one to four 
times the size bf red corpuscles. They are not at all 
numerous, not more than two in field at one time ; some- 
times not more than two on the slide." 

The abnormal surface pigmentation has its seat in the 
skin and mucous membrane of the buccal cavity, includ- 
ing that of the tongue ; It has been said also to attack the 
vagina, but this Is not established. The pigment is de- 
posited in the youngest layers of the rete Malpighii, in 
contact with the papillae. It appears both as a diffuse 
coloration of the cells and also in the form of distinct 
granules in the cells, or free ; in the latter case It is 
supposed to be left after the dissolution of the cells. 
It rarely appears in the corium, though sometimes 
branched, pigmented connective-tissue cells are found. 
The parts of the external surface most deeply pigmented 
are those which, under normal circumstances, are the 
seat of oft-recurring hypersemia, either from atmospheric 
influences or friction, such as the cheeks, neck, and 
backs of the hands. There is also a special tendency 
to the deposit of pigment in those parts where It is 
found normally in greater amount, such as the nipples, 
genital organs, and axillae. In well-marked cases, it 
pervades the entire cutaneous surface, being deeper in 
the parts just mentioned. The discoloration, at first of a 
grayish hue, deepens into a more or less deep brown, 
in which there is, in some cases, a yellowish or greenish 
hue. The color depends to some extent upon the nor- 
mal complexion of the patient. It Is most striking, on 
account of its incongruity, when the patient is naturally 
fair, with light hair and blue eyes. It has been noted in 
numerous cases that the heart was abnormally small, and 
in several that it had undergone fatty degeneration. 

The urine is normal in the majority of cases. The 
most careful study of the urine in any single case was 
made by Dr. Thudichum, for sixty-five consecutive days, 
in a patient of Dr. Burdon-Sanderson. Without com- 
plicating fever or diarrhoea, there was a great diminu- 
tion in the daily amount of urine, it being reduced more 
than one-half ; the specific gravity was l.OSO, and up- 
ward, and the reaction acid. The observations were 
chiefly directed toward the determination of the per- 
centage of uric acid as well as uromelanln, omicholln, 
and uropittin, three products of decomposition of the 
urinary pigment of which the first is the most Important. 



75 



Addtsoa's Disease. 
Adenoma. 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 



It has almost the same chemical composition as the 
melanin of the choroid, and of melanotic tumors, and, 
like the pigment in the skin in Addison's disease, is iron- 
free. Thudichum found that these pigments were greatly 
reduced in amount, the uromelanin never rising above 
one-twelfth of the normal, and he appears to be of the opin- 
ion that the diminution in the amount of these pigments 
may be in relation to the excess of pigment in the skin. 

Symptoms.— The sum of the symptoms of Addison's 
disease may be divided into four parts : a progressive 
asthenia, disorders of digestion, an abnormal pigmenta- 
tion of the skin and oral mucous membrane, and pain 
seated chiefly in the lumbar and abdominal regions. Of 
these, the asthenia is the first to appear. In all histories 
of this disease the patient has been compelled to aban- 
don his usual occupation by muscular weakness, and 
where there is no complication with other wasting dis- 
ease, this prostration is unattended, at least in the early 
stage, with any marked diminution in the volume of the 
muscular and adipose tissues. Symptoms referable to 
disordered digestion soon become prominent, such as 
anorexia, nausea and vomiting, constipation alternating 
with diarrhoea, and epigastric tenderness. Cardialgia 
is often complained of, and the ingestion of food is 
sometimes followed by painful meteorism. The pulse 
is remarkably weak and small, and usually slightly accel- 
erated. Dyspnoea is produced by the slightest exertion 
such as sittmg up in bed. Cephalalgia, vertigo, and men- 
tal hebetude are often observed at an early stage, also pain 
and tenderness in both hypochondria, and in the back, 
loins, and epigastrium. This tenderness on pressure 
was a prominent feature in two cases that were under 
my care at the Episcopal Hospital, Philadelphia. In the 
report of the first I noted that "at times there was great 
tenderness about the umbilical region, and on one occa- 
sion, after palpating the abdomen, the patient uttered 
lohd cries for ten or fifteen minutes, and seemed in great 
agony" ("Trans. Path. Soc, Phila. ," vol. v.). In the 
second of my cases, "the pain was latterly most severely 
felt in the left lumbar region, in which situation there was 
also a great degree of tenderness on pressure " (" Trans. 
Path. Soc, Phila.," vol. x.). In the first of these cases 
nothing was found at the necropsy to account for this 
remarkable tenderness ; in the second it might have been 
due to the great tumefaction of the lumbar glands. As 
the disease progresses, restlessness, iactitation; delirium, 
sometimes maniacal, delusions of sight and hearing, at- 
tacks of epileptiform convulsions, and uncontrollable 
vomiting make their appearance ; also attacks of pro- 
longed prostration and loss of consciousness ; some- 
times a condition of collapse that has been compared by 
"Wilks to that of cholera. Contrary to the usual frequency 
of the pulse in collapse, a remarkable diminution in the 
number of the heart-beats has been observed in several 
cases (Risel mentions seven), and this without any dis- 
ease of the brain or important cardiac disease. In a case 
reported by Cholmeley {Medical I%mss and Gazette, 1869, 
vol. ii., p. 319) in which death was preceded by profound 
collapse, dyspnoea, and convulsions, the pulse fell to 
thirty-six per minute. The date of the appearance of 
the pathognomonic discoloration of the skin is very varia-. 
ble. It may either precede or follow the constitu- 
tional symptoms, or the disease may terminate fatally 
without its manifestation. Greenhow has collected a 
number of cases illustrating the erratic appearance of 
this, the only pathognomonic feature of Addison's dis- 
ease. In many cases the symptoms have pursued an 
irregularly remittent course. The digestive disorders may 
temporarily cease, the appetite improve, the muscular 
power increase, and the skin become decidedly paler. 
This is invariably followed by a fresh exacerbation, 
after which the status of the patient is on a lower plane 
than during the previous remission. The words of Dr. 
Weir Mitchell, as applied to the course of locomotor 
ataxia, are here appropriate: "I have," says he, "else- 
where compared the progress of Duchenne's disease to 
that of a man who has an inevitable staircase to descend. 
He may linger or go back, but the descent is still to be 
taken, and the best he can hope for is to go down slowly 

76 



and with long pauses and rare retrogressions " (" Pro- 
ceedings Phila. County Med. Soc," vol. ii.). 

Pathogeny. — The symptoms of Addison's disease being 
invariably associated with a destructive lesion of the supra- 
renal capsules, vi[ere at first naturally attributed to sup- 
pression of the function of these bodies. Brown-Sequard 
first endeavored to ascertain the effect of removing the 
capsules from animals. The animals speedily died with, 
according to his statement, the accumulation of pigment 
in different parts of the body. On the other hand, a num- 
ber of other experimenters, such as Harley, G-ratiolet, 
Philippeau, and Martin Magron, have removed the supra- 
renal capsules without the supervention of death or 
melanoderma. Again, well-marked cases of Addison's 
disease have been observed, as above stated, in which but 
one capsule was involved in the morbid process. Finally, 
instances are on record of congenital absence of the supra- 
renal bodies ' without the cutaneous pigmentation or other 
symptoms of Addison's disease. The attention of pathol- 
ogists was next directed to the ganglia and nerves of the 
abdominal sympathetic, and experiments instituted upon 
animals to determine the effect of their removal or sec- 
tion. Pincus invariably found, after extirpation of the 
solar plexus, alterations in the mucous membrane of the 
stomach and upper part of the small intestine, consisting 
of hyperemia, blood extravasation, and ulceration. These 
were absent in control experiments, in which the same 
operation was performed minus the removal of the solar 
plexus. "When the deeper plexus encircling the aorta 
was removed, the alterations in the mucous membrane of 
the stomach were absent, but the whole of the small and 
large intestine, including the rectum, was affected. En- 
largement of the liver and spleen was also observed by 
Budge after section of the abdominal sympathetic. With 
the results of these experiments corresponds the invariable 
intestinal catarrh of Addison's disease, with enlargement 
of the solitary and agminated glands, and sometimes ul- 
ceration and ecchymosis. The theory of the pathogeny 
of Addison's disease at present accepted by many authori- 
ties, notably by Risel, and the one to which I adhere, is 
that of a paralytic dilatation of the abdominal blood- 
vessels, and it is not necessary that there should be a de- 
structive lesion, such as fatty degeneration or atrophy, of 
the solar plexus and semilunar ganglion, in order to pro- 
duce vaso-motor paralysis in the area of their distribu- 
tion. Irritation of a sensory nerve produces vaso-motor 
paralysis in tlie irritated region, and the well-known ex- 
periments of Goltz " (Klopf versuch) have shown that irri- 
tation of the intestines produces complete vaso-motor 
paralysis of their blood-vessels, causing thereby so great 
an accumulation of blood that the animal shows symp- 
toms of syncope, the same as if it had been bled copi- 
ously.^ The irritation of the numerous nerves of the 
suprarenal capsule produced by inflammation with new 
formation of tissue and subsequent softening, such as 
exists in Addison's disease, is transmitted to the semi- 
lunar ganglion and solar plexus from the beginning of 
the deposit in the medullary substance of the suprarenal 
capsule, and later by direct extension of the inflammatory 
process to these nerve-centres. By this means a vaso- 
motor paralysis of the intestinal vessels is produced, as in 
the experiments of Goltz, except that, unlike in the latter 
case, it is constant. This constant hypersemia of the in- 
testinal vessels leads to enlargement of the solitary glands 
and Peyer's patches so constantly found in Addison's dis- 
ease, and, when more intense, to catarrh and ulceration of 
the stomach and intestinal mucous membrane. It ac- 
counts for the dark color of the liver, spleen, kidneys, 
and pancreas so often observed, as well as for the brown- 
ish hue of the peritoneum noted in a few instances. In- 
directly it explains the anaemic and dry condition of other 
parts of the body, and fully accounts for the great mus- 
cular weakness, syncope, gastro-intestinal disturbance, 
dyspnoea on slight exertion, and small radial pulse. 
These symptoms have been, and still are, attributed to a 
high grade of general anaemia, such as exists in progres- 
sive pernicious ansemia ; and this is due to the fact that 
many of the symptoms in these two affections are iden- 
tical. Repeated examinations of the blood have, however, 



REFERENCE HANBBOOK OF THE MEDICAL SCIENCES. 



Addison's Disease. 
Adenoma. 



demonstrated that the reduction in the number of the red 
corpuscles in Addison's disease is trivial compared with 
that found in cases of progressive pernicious anaernia. 
The symptoms resembling those of pernicious aneemia, 
such as dyspnoea on slight exertion, syncope on assuming 
the upright posture, rapid, small, and feeble pulse, are 
due to an insutflcient supply of blood, albeit of fair 
quality, to the supra-diaphragmatic portion of the trunk. 
The permanent changes in the muscular tissue of the 
heart are to be attributed to the same cause, oligaemia. 

Etiologt. — The affection is much more common in 
the male sex and among the laboring classes. In one 
hundred and eighty-three undoubted cases tabulated by 
Greenhow, one hundred and nineteen Tvere males and 
sixty-four females, and more than nine-tenths of the 
whole number were engaged in laborious physical work. 
Several cases have been associated with psoas or lumbar 
abscess, caused by injuries of the spine. In others, 
devoid of such spinal complication, the origin of the 
disease has been attributed by the patient to over-ex- 
ertion of the spinal muscles. Such was the fact in one 
of my own cases, the patient's first symptoms having 
been weakness and pain in the back immediately follow- 
ing the occupation of weeding her garden. As regards 
age, the majority of cases occur between the ages of 
twenty and fifty, that is to say, during the most active 
period of adult life. 

BiAGNOSis. — When the disease is primary, the con- 
stitutional symptoms well-marked, and the discoloration 
of skin present, the diagnosis presents no difficulty to one 
who has studied a single case of the disease. On the 
other hand, when the constitutional symptoms are well 
pronounced in a primary case, and the bronzing of skin 
not yet developed, the diagnosis is only to be made by 
the absolute exclusion of other wasting diseases, espe- 
cially cancer of abdominal organs and progressive per- 
nicious anaemia. When the disease is secondary to psoas 
or lumbar abscess, the diagnosis is often very difficult, 
and especially so when there is the further complication 
of amyloid kidney disease which 'is so apt to be associated 
with extensive suppuration. Several years ago there 
came under my care at the Episcopal Hospital, a case of 
lumbar abscess with several open sinuses leading to 
carious vertebrae. The general surface of the body was 
of a dark, dingy hue, and the orifice of each sinus was 
surrounded by a broad, deeply pigmented ring. The 
case had previously been at the tJniversity Hospital, 
where secondary disease of the suprarenal capsules had 
been suspected. The autopsy showed these bodies to be 
perfectly normal. A dingy discoloration of the skin is 
not uncommon in amyloid disease of the kidney, as first 
pointed out by Grainger Stewart. 

The discoloration of skin, although not the most essen- 
tial characteristic of the disease, is justly regarded as its 
most important diagnostic feature. It is to be dis- 
tinguished from melasma gravidarum, pityriasis versi- 
color, lichen, and pigmentary syphilides, and this is 
readily done by anyone faimlliar with these affections. 
The melanoderma of phthisical patients presents more 
serious difficulty. Although the latter is often confined 
to the face and does not invade the mucous membrane 
of the buccal cavity, the difficulty is a real one and is 
augmented by the fact that pulmonary tuberculosis is 
the most frequent complication of Addison's disease. 
The seat of the melasma suprarenale upon the face and 
neck, the dorsum of the hands, areola of the nipple and 
about the umbilicus, in the axilla, groin, and genitals is 
characteristic. Its outline is never circumscribed as in 
other pigmentary affections, but gradually fades into the 
surrounding dingy integument. Upon the darker 
patches also are frequently seen black specks resembling 
moles or freckles. Another discoloration of the skin 
liable to be confounded by the inexperienced with that 
of Addison's disease, is sometimes seen in badly nour- 
ished paupers, of dirty habits, whose skin is the abode 
of vermin. 'The pigmentation shows itself in the form 
of patches separated by healthy skin ; the epidermis is 
often roughened, and the discoloration more marked 
upon the trunk than on the face and hands. The skin 



is also often marked with the nails on account of the in- 
tense itching. Under the microscope, the particles of 
pigment in this affection are found in all the layers of 
the epidermis, instead of being limited, as in Addison's 
disease, to the deeper layers of the rete Malpighii. The 
pigmentation of chronic malaria} poisoning is dis- 
tinguished from that of Addison's disease, not only by 
its distribution, but by the history of the case and the 
frequent presence of splenic enlargement. Chronic 
icterus is distinguished by the presence of pigment in the 
ocular conjunctiva and in the urine. The pulse also is 
rapid in Addison's disease, whereas in icterus it is habit- 
ually slow. 

Prognosis. — The prognosis is invariably fatal as to 
the ultimate result, but the occasional remittent charac- 
ter of the affection is to be borne in mind in making pre- 
dictions as to the duration of the disease. A case seen 
during the period of exacerbation may lead to the progno- 
sis of a speedily fatal result, but the worst symptoms may 
disappear and be followed by a prolonged period of re- 
mission. Sudden death without preceding exaiJerbation is 
sometimes observed, the fatal result being apparently due 
to syncope. 

'TkeaTmbnt. — The cessation of work is the first thing 
to be insisted upon in the way of treatment, and during 
the exacerbations, strict confinement to bed. An im- 
mediate mitigation of the symptoms has often followed 
the admission to the, hospital of a patient who, up to that 
time, had been endeavoring to resist the gradually in- 
creasing weakness. A moderate amount of stimulants is 
generally well borne ; but cod-liver oil, which might 
seeni appropriate on account of the strumous character 
of the affection, is, as a rule, not tolerated. Remedies to 
allay irritability of the stomach are frequently indicated, 
such as ice,. lime- water, carbonic acid water with brandy, 
bismuth, creasote, hydrocyanic acid, and small doses of 
opiulh. Massage and faradization of the cutaneous sui;- 
face are well worthy of a trial, in order to derive from 
the abdominal vessels. Cathartics are to be avoided, as 
profound depression has often followed their employ- 
ment in this disease. When constipation is troublesome, 
enemata are to be made use of. The diet should be sim- 
ple, but nourishing, consisting of soups, milk, eggs, meat 
jelly, and the like. Peptonized foods and koumyss are 
also indicated. Frederick P. Henry, 

1 Martini: Comptes. Kpndus de TAcad. des Sci., 18B6, tome xliii., p. 
1053. John Kent Spender; Brit. Med. Jour., September 11, 1868. 

^ Vague und Herz., Virchow'B Archiv, vol. xxvi. 

3 " II en resulte une dilatation des vaisseaux abdominaux qui constituent 
en quelqne sorte un bassin de reserve ou de derivation pouvant loger la 
moitie de la masse totale du sang " (Demontroud, Th^se de Paris, lb78). 

ADELHEIDSQUELLE. This spring is situated in Up- 
per Bavaria, at an elevation of 774 metres (3,540 ft.), near 
the foot of the " Benedictenwand," and about four miles 
from the station Tolz. The water is mostly bottled for 
export. It is used internally, and has acquired renown 
for its beneficial effects in cases of scrofula (in children), 
in glandular swellings, struma, chronic metritis, and 
-oophoritis, and in tumors of the female sexual organs. 
Von Nussbaum speaks of the water in very high terms ; 
it having produced markedly beneficial effects in some of 
the worst cases of scrofulous bone disease which had 
come under his care. Among one thousand parts of this 
water, by weight, the solid constituents represent a total 
of 6.01 parts, and'among these the most important are : 

Sodium chloride 4.956 

Sodium iodide 0.0286 

Sodium bromide 0478 

Sodium carbonate 0.0S09 

(Carbon dioxide, 409.3 o.c.) 

Temperature, 11.2 " C. (62 ° F.). (Bulenburg.) 

H. F. 

ADENOMA. The adenoma is a glandular tumor, con- 
forming, in its histological structure, with the general 
type of gland-tissue, and originating in glandular epi- 
thelium. We cannot describe any particular cells or 
arrangement of cells as peculiar to this tumor any more 
than we can regard any special cells as peculiar to physi- 
ological glandular structure. The adenomata differ 



77 



Adenoma. 
Adenoma, 



REFERENCE HANDBOOK OP THE MEDICAL SCIENCES. 



among each other ia structure as much as the structure 
of the liver differs from that of the lachrymal gland. 
Generally speaking, the epithelial cells of the tumor are 
arranged in alveoli, with a central lumen, the alveoli 
being separated from each other by connective tissue, 
in which the nutrient vessels and lymphatics are con- 
tained. The epithelial cells may be cylindrical or cu- 
boidal their shape depending somewhat on the character 
of the cells of the gland in which the tumor has origi- 
nated. Their arrangement in alveoli, with a central 
lumen, may be regarded as that which gives the adenoma 

"We cannot regard every new formation of glandular 
tissue, every glandular hyperplasia as an adenoma, 
and sometimes it is difficult or impossible to say 
whether we have to do with a simple hyperplasia 
or a tumor. Nature does not create with special ref- 
erence to the classification of her products, and we 
come here into the difficulty which is constantly met 
when we attempt to bring such products under an arti- 
ficial classification. A gland which is increased in size 
in consequence of excessive growth or a chronic in- 
flammatory condition, cannot be called an adenoma, 
but belongs simply to the hyperplasias. In the same 
way we must consider 
those formations in 
mucous membranes 
which frequently de- 
velop in consequence 
of chronic inflamma- 
tions, and take the 
form of tumors. 
These are local new 
formations of tissue, 
which project above 
the surfaces in the 
form of polypi or pap- 
illary masses. This 
growth commences 
in the connective tis- 
sue, and the epithe- 
lium also takes part, 
in that, by the increase 
of the surface, the 
covering epithelium 
must also increase. 
If there are glands 
present, their ducts 
are usually stopped 
up, and cysts are 
formed with papilla- 



"i 



I 



"0 



e' 



I 









i 









V* 



- "^ -«««• 



I ■» 

f- 

^ • , » 









ry projections within 

them On the other ^"'' 63-— Adenoma of the Kicjney. a, Normal structure of the kiiiney ; 6, adenoma ; c, 

1 /q' +V, a i^a sheath of connective tissue investing the tumor and separating it from the kidney ; d, 

nana, mere are aae- colloid masses in the acini of the tumor, (x ■JO.) 

nomata which arise in 

the mucous membranes and which have the form of 
polypi, and may greatly resemble the simple polypi in 
structure. Clinically, of course, the two processes can 
be distinguished, since the simple polypi are usually 
multiple, and disappear spontaneously when the cause' 
which led to their formation (i.e., chronic inflamma- 
tion) is removed. The separation of the adenomata 
from many other tumors is often difficult. If the devel- 
opment of glandular vesicles with formation of cavities 
must be regarded as the essential moment to justify us 
in naming a tumor an adenoma, this development cannot 
take place without the formation of new connective tissue 
with vessels. Since the pathological features of a tumor 
only consist in the variation of the arrangement of its 
tissue from that of the normal tissue, we find in the 
adenoma that at one time the formation of the epithelial 
elements becomes most prominent, at another that of the 
connective tissue and vessels. Mixed forms are here com- 
mon. When the development of connective tissue is ex- 
cessive, far beyond what we find in a normal gland, it 
must receive some recognition in naming the tumor, for 
it is as truly new-formed as the epithelial part ; in such 
cases we speak of an adeno fibroma. When this neatly 
formed connective tissue is especially abundant in cells. 



and represents an embryonic tissue, we speak of an 
adeno- sarcoma. 

Though the adenoma may have the most typical gland- 
ular structure, it is always, when considered as an en- 
tirety, an atypical formation. As a rule it represents 
a circumscribed formation and macroscopically differs 
in consistence and color from its surroundings. These 
growths usually form nodular tumors, which arise with 
in glands or in mucous membranes which contain glands. 
In some cases only a small portion of the gland is taken 
up by the tumor, in others the whole is inyolved in its 
growth. The adenoma usually differs in its histological 
structure more or less from the structure of the tissue 
in which it originated. This is well seen in the figure 
here given, which represents an adenoma of the kidney. 
Nothing could be more typical of glandular structure 
than the tumor, yet instead of the typical kidney struct- 
ure with its various tubules and special structures, as the 
glomeruli, we have here simply the structure of a tubular 
gland, the tubules being of different sizes and lined with 
a simple cuboidal epithelium. The tumor from which 
the specimen was taken was of the size of a walnut, 
located in the left kidney, and entirely surrounded by 
normal kidney structure, from which it was separated 

by a distinct capsule 
of connective tissue. 
In other adenomata of 
the kidney we may 
find, in place of the 
cuboidal, long cylin- 
drical cells. In one 
lihat I examined, 
which came from the 
collection of Rokitan- 
sky, the cells were 
cylindrical in shape, 
and differed greatly 
in size, some being 
three times as large as 
the others. We never 
find, however, in an 
adenoma of the kid- 
ney, the typical kid- 
ney structure with its 
glomeruli and tu- 
bules. This departure 
from the type of the 
mother tissue is also 
seen in other places. 
In adenoma of the 
large intestine, where 
this form of tumor is 
frequently met with, 
in place of the simple 
crypts of Lieberkuhn, 
we have branched and twisted tubules, with an epithe- 
lium identical with the ordinary cylindrical epithelium 
of the intestinal tract. Fig. 64 shows a secondary nodule 
in the liver from an adenoma of the rectum. The 
general type of the glands of Lieberkuhn is well shown, 
though in one place the buds given off and the union of 
the two tubules show the tendency to a departure from 
the type. We sometimes find in the liver small circum- 
scribed nodules about as large as a miliary tubercle, 
which differ markedly from the liver-tissue. The cells 
composing them are larger than the liver-cells, are 
paler, finely granular, and wanting in the ordinary bile 
pigment in cases where from cirrhosis or other cause the 
liver-cells are strongly pigmented. This latter fact would 
show that the cells did not serve the same physiological 
purpose as the liver-cells. The lines separating the cells 
of the nodule are more sharply marked than in the nor- 
mal tissue. The typical arrangement of the liver-struct- 
ure, the framework of cells branching out from the 
hepatic vein, with capillaries between them, is wanting 
here. On the contrary, the cells are in some places ar- 
ranged in masses, in others they seem to be irregularly 
arranged around a lumen, as in the ordinary tubular 
gland. This would seem to represent a return of the 



\^ 



» -v. 



■ t 



i 



78 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 



Adenoma, 
Adeiiomat 



complicatea liver structure of the higher vertebrates to 
the simple tubular form of gland which is found in 
some reptiles. Other large adenomata have been de- 
scribed in which a distinctly tubular arrangement was 
found. Whether such larger tumors represent a further 
stage of development of these small microscopic nodules 
is not known. The latter seem to have escaped the at- 




FiG. 64. — MetaBtaBis in the Liver from an Adenoma of the Rectum, a, a. Acini of tnmor ; 
i, blood-veasel. { x 280.) 

tention of writers on this subject, and should be con- 
sidered as true adenomata. 

There is one adenoma which, from the frequency of 
its appearance, and its importance as concerning the 
life of the patient, merits a special description. This is 
the adenoma of the ovary. We owe to the works of Wal- 
deyer and Klebs the recognition of this form of 
tumor in this organ. It generally appears under 
the form of multilocular cysts, which contain a 
thick viscid fluid of about the consistency of 
starch paste. The contents may be colorless, or 
have every shade of color up to a dark brown, 
this color depending, of course, on haemorrhages 
which have taken place within the cysts. The 
larger of these cysts are lined with a single layer 
of cuboidal or cylindrical epithelium. In other 
places, where soft medullary masses are found, 
and where, macroscopically, no cysts are to be 
seen, we find a different structure. Here, under 
the microscope, we find small cysts lined by a 
membrane in which are indentations similar to 
simple tubular glands ; these pouches are lined 
with cylindrical epithelium. There are long 
papillary projections of the lining membrane 
into the cysts, and Wilson Fox supposes that the 
numerous cysts are formed by the union of these 
papillse, either with each other or with the cyst- 
wall. Klebs, on the other hand, supposes they 
are formed from dilatation of the small pouch- 
like glands of the lining membrane. Pfliiger 
has pointed out the glandular structure of the 
ovary, and Spiegelberg and Langhans have 
shown in it, even after jbirth, residues of its em- 
bryonic glandular structure, and there is little 
doubt that the adenoma develops from this tis- 
sue. Other adenomata are found here which are com- 
posed of cysts lined with distinctly ciliated epithelium. 
Although frequently in these tumors nothing of the 
ovary can be found, there is little doubt that they do not 
develop in this organ, but at a little distance from it, in 
the parovarium. There are other cysts in the ovary 
which are formed from simple dilatation of the Graafian 
follicles ; but these, as we have shown, should be ex- 
cluded from the tumors. (See Art. Tumors.) 



All of the forms of adenoma of which we have spoken 
differ more or less in histological structure from the 
parent tissue ; but there are others which conform in 
every detail with the tissue in which they arise. The 
thyroid body is very frequently the seat of adenoma 
formations ; these appear under the form of distinctly 
circumscribed nodules, separated from the rest of the 
gland by a sheath of connective tissue. The 
colloid formation common to the gland is 
always seen in these adenomata. There is an 
hypertrophy of the gland caused by a diffuse 
hyperplasia of all parts of it, which must be 
separated from the tumors. This appears to 
depend upon the existence of a distinct miasm, 
which is found only over a limited geographi- 
cal area. It can be distinguished from the 
adenoma by its affecting all parts of the gland, 
and by its spontaneous recovery when the pa- 
tient removes from the miasmatic region, or 
under the use of suitable medication. Here 
we have a case in which, from a microscopic 
examination alone, we cannot say whether we 
have to do with a hyperplasia, a tumor, or 
normal glandular tissue. 

Many tumors of the mamma combined with 
the formation of cysts have been described 
under the name of adenoma. In such cases 
the tumor is generally a fibroma or sarcoma, 
which has grown into the acini and ducts of 
the gland in the shape of papillary projec- 
tions. These, of course, will be covered with 
lining epithelium, and there must be some 
growth of the epithelium in consequence ; but 
this is only secondary, and the tumor should 
be considered as a connective-tissue formation. 
From some descriptions of circumscribed tumors, in or 
adjoining the gland, which are almost entirely epithelial 
in character, we must believe that they are adenomas. 
Regarding these circumscribed adenomata, Billroth says 
(" Krankheiten der Brustdrusen," p. 76) that he has 
never seen a tumor which, after exact histological anal- 




FlG. 65. — Miliary Adenoma of the Liver. At a the cella are arranged around a 
lumen; b, &, blood-vessels, (x 380.) 

ysis, allowed only the interpretation of a pure circum- 
scribed adenoma to be given it. Cornil and Ranvier 
take almost similar grounds. There are a few cases on 
record in which the glands at an early age, the time of 
puberty or a little later, grew suddenly to enormous 
dimensions. In one case observed by Billroth, in a 
virgin of fifteen years, the breasts grew to mammoth 
proportions in two and one-half months ; the left meas- 
ured 23 inches in circumference, and in its largest part 



79 



Adenoma. 
Aerotherapeutlcs. 



EEFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 



was lOi inches In diameter. Tliere is little known about 
the histological structure in these cases. The one case 
investigated by Billroth was complicated by the forma- 
tion of numerous fibroid tumors in the gland. There 
was, however, between the tumors an abundant forma- 
tion of glandular tissue which was similar to that of the 
normal mamma. Such cases are set down as diffuse 
adenoma of the breast. 

The rapidity of growth of an adenoma differs in the 
various parts of the body in which it has its seat, and the 
same holds true for its malignity. There are few which 
can be strictly considered as benign tumors ; there are 
several cases reported in the literature, of fatal metas- 
tases from the adenoma of the thyroid. In the sweat, 
sebaceous, and lachrymal glands they grow slowly and 
usually remain local ; in the lachrymal gland they may 
reach a large size, and by the displacement of the eye 
produce great disfigurement. Some, as the adenoma of 
the ovary, never produce metastasis, though they may 
endanger life by their immense size. There are few 
tumors which are more malignant than the adenomata of 
the digestive tract. They have all the properties of ma- 




FlQ. 66. — Adenamn Destniens of the Stomach, a. Mucosa j 6, sub- 
mucoBa ; c, muscular coat ; d, peritoneum ; e, £, e, the acini of the 
tumor. (FromZiegler.) (x40.) 

lignant tumors ; they infect surrounding parts and cause 
metastases. In the intestine the different coats are suc- 
cessively attacked, and perforation often results. Zieg- 
ler, in recognition of these destructive properties, has 
given the name of adenoma destruens to these forma- 
tions. The figure here given shows such an adenoma 
of the stomach. As might be expected from the simi- 
larity of their respective histological structures, transition 
forms between the carcinoma and adenoma are frequently 
seen. The typical glandular structure of the adenoma has 
only to become atypical and we have the carcinoma. In- 
deed, the relation between the two has always seemed to 
me to be similar to that between the fibroma and sarcoma, 
the former representing the typical connective-tissue 
tumor, and the latter the atypical. Just as we can have 
every transition stage between the fibroma and the sar- 
coma, so we can have the same condition of things 
between the adenoma and carcinoma ; and just as we 
speak of the fibro-sarcoma in such cases, so we can 
designate these glandular tumors by the term adeno- 
carcmoma. Such tumors are frequently seen in the 
uterus and digestive tract. One part of the tumor will 



represent the typical arrangement of the adenoma, tn.; 
alveoli of epithelial cells with a central lumen, and 
the other part the carcinoma with the solid irregular 
masses of epithelium growing into the tissue in all direc- 
tions. All sorts of degenerations are common in the 
adenoma, and hsemorrhages are frequently met with. 
In one point they differ most markedly from the hyper- 
plasias, and that is in their never being able, no matter 
how typical of gland structure their tissue may be, to 
exercise the physiological function of a gland. 

We' know very little with regard to their aetiology ; 
perhaps they will bear out Virchow's theory as to irritar 
tion less well than any other tumor except the teratoma. 
For some, as the adenoma of the axilla, where a tissue is 
found corresponding to that of the mamma, or the sub- 
sternal tumors in which a tissue similar to that of the 
thyroid body is found, it is probable that the germinal 
theory of Oohnheim gives us the true explanation ; in 
the one case the axillary tumor depending on a formative 
defect in the embryonic development of the mamma, and 
in the other on portions of the embryonic structure of the 
thyroid gland being left behind in the ascent of the gland. 
The writer once saw an adenoma as large as a hen's egg 
seated alongside the lumbar vertebrae, outside of the 
peritoneum. The tumor was composed of acini, lined 
with long cylindrical cells ; there were metastases in the 
livef which showed the same structure. Here it was evi- 
dent that the tumor was due to an error of formation at 
a very early stage of embryonic life. It would hardly 
seem possible that such a tumor could develop from the 
connective tissue ; there could be no irritative influence 
at work here. 

We sometimes find adjoining the various organs, some- 
times at a distance from them, small formations which 
resemble the larger organ in every respect. These are 
known as supernumerary glands, and are most commonly 
found in the neighborhood of the spleen, suprarenal cap- 
sules, etc. At other times parts belonging to one organ 
may be enclosed in another, as portions of the pancreas 
in the mucous membrane of the stomach. Such super- 
numerary glands have been accused of being the parents 
of adenomata ; but there is no proof of this, though such 
a nodule of pancreatic tissue enclosed in the mucous 
membrane of the stomach could easily be mistaken for an 
adenoma. 

William T. Councilman. 

ADIPOCERE. [Adeps, fat, and cera, wax French, 
adipocere, gras des cada/eres. German, Feitwachs, Adi- 
pocire.] As the name suggests, adipocere is a material 
resembling in its gross appearances fat and wax It is a 
semi-translucent, white, or slightly yellowish substance 
of about the consistency of cheese at ordinary tempera- 
tures ; has a greasy feel, and yields slightly when pressed 
between the fingers. If a piece be rolled between the 
fingers for a few minutes it becomes much softer. 
When rubbed with water it forms a lather. Its com- 
position is that of a soap, being made up of oleic and 
margaric acids in combination with an alkali. Examined 
under the microscope it shows, occasionally, very nu- 
merous scales having a crystalline form ; more commonly 
nothing but fat-globules are to be seen. If it be melted 
and again allowed to cool, it is found, often, to have 
crystallized in round masses made up of needle-shaped 
crystals, radially arranged ; hence like stearin. 

Most of the specimens of adipocere with which one is 
familiar come from the macerating-troughs of anatomical 
departments and from museum jars which have long con- 
tained specimens immersed in dUute alcohol. It thus 
represents the results of a metamorphosis of dead animal 
tissues placed under peculiar circumstances. 

The only special point of interest in connection with 
adipocere lies in the fact that it is occasionally found in 
dead bodies which have been buried a considerable time. 
In fact, nearly all the structures of the body, except the 
bones, have been found converted into this material. 
For centuries its presence had been noted in disinterred 
corpses, but no opportunity was afforded for studying it 
on a large scale until 1786, when, upon the removal of 



80 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 



Adenoma. 
Aerotberapentlcs. 



the BodifS from one of the cemeteries in Paris, a con- 
sideraole proportion of those buried in the common 
grave (veve found by Poucroy to have been converted, to 
a greater or less degree, into this peculiar, fatty, wax-like 
material, wd to it he gave the name by which it has since 
beenkno.A'n. 

The conditions favoring its formation in buried corpses 
are still unknown. Doubtless moisture is always neces- 
sary ; but why, of six or eight bodies buried in close 
proximity, and hence presumably under like conditions 
of soil aad moisture, one should undergo almost com- 
plete change into adipocere, while the others undergo 
ordinary putrefaction, as has been observed, is at present 
inexplicable. 

At one time it was thought that adipocere might be of 
medico-legal importance in helping to determine the 
length of time a corpse had been buried. Poucroy be- 
lieved that thirty years was required for its formation. 
Later, this was reduced to one year ; and Caspar men- 
tions finding adipocere in the body of a new-born child, 
which had lain for three raontl^ in a house cesspool. 
It is therefore impossible to establish an idea, from the 
presence of adipocere in a corpse, as to the length of time 
it has been buried. 

Artificially, adipocere can readily be produced, either 
by soaking muscle in dilute nitric acid for two or three 
days, and then washing it thoroughly in warm water, or 
by allowing the muscle to soak for months in a trough 
supplied with running water. 

Adipocere is probably closely allied to cholesterine. 

W. W. Gannett. 

ADIRONDACKS. The Adirondack mountain region 
has recently come into notice as a health resort for per- 
sons suffering from pulmonary phthisis. To summer 
tourists, especially to those of them who are fond of hunt- 
ing, fishing, and camp life, this region has long been well 
known, and it is highly esteemed for the beauty and wild- 
ness of its scenery. The Adirondack Mountains lie in 
the northern portion of the State of New York, west of 
Lake Champlain ; many of the mountain peaks attain an 
altitude of over four thousand feet, and the highest of 
them (Mount Marcy) is five thousand three hundred and 
thirty -seven feet in height. " The mountains rise from 
an elevated plateau, which extends over this portion of 
the country for one hundred and fifty miles in latitude 
and one hundred in longitude, and is itself nearly two 
thousand feet above the level of the sea" (Appletons' 
" Handbook of Summer Resorts," second edition). Over 
two thousand square miles of this elevated tract of coun- 
try is covered with primitive forest growth, the trees be- 
ing chiefly of the evergreen variety. For his information 
concerning the climato-therapeutical characteristics of the 
Adirondack country the writer is indebted to a valuable 
communication from the pen of Dr. Alfred L. Loomis, of 
New York City, entitled, " The Adirondack Region as a 
Therapeutical Agent in the Treatment of Pulmonary 
Phthisis," and constituting a paper read by its author be- 
fore the New York State Medical Society in 1879. In 
this paper Dr. Loomis describes the climate of the Adi- 
rondacks as steadily cold in winter, cool in summer, and 
having a preponderance of cloudy weather at all seasons. 
The soil is dry. The annual rainfall is about fifty-five 
inches. Quotmg from Dr. E. L. Trudeau, of Saranac 
Lake, he specifies certain climatic, peculiarities of the re- 
gion in question as follows: "There is no marked pre- 
ponderance of clear days at any season ; on the contrary, 
the sky; especially in winter, is constantly overcast. Tms 
cool, cloudy weather is a marked feature of this cli- 
mate. . . . The soil Is very light and sandy, with 
here and there rocks, but little or no clay. . . . Pine, 
balsam, spruce, and hemlock trees abound, and the air 
is heavily laden with the resinous odors which they ex- 
hale." 

Dr. Loomis gives the condensed medical histories of 
twenty cases of pulmonary phthis'is, who, up to the time 
of presenting his paper, had found an alleviation or cure 
of their disetise by a more or less prolonged sojourn in the 
Adirondack country. Of these twenty no less than six- 

VoL. I.— 6 



teen were cases of "catarrhal phthisis," while two were 
sufferers from " fibrous phthisis," and two were of the 
"tubercular" variety. Out of the whole number of 
twenty patients ten recovered, six were improved in 
health, two received no benefit, and two died. The ten 
cases cured were without exception cases of "catarrlial 
phthisis." Of these Dr. Loomis says : "In all the cases 
of catarrhal phthisis which have reached recovery, either 
the pulmonary changes were not extensive or they, were 
of recent origin, and improvement commenced soon after 
reaching the Adirondacks." Of the six improved cases 
four were cases of " catarrhal," and two were cases of 
"fibrous" phthisis. The two patients who died wer3 
both affected with "catarrhal phthisis." Dr. Loomis 
says of these, "Although when they came into this re- 
gion their lungs were extensively diseased, they were 
much benefited during their stay, and it seems to me that 
impatience and imprudence had very much to do with 
the fatal result." The two unimpi-oved cases were both 
"tubercular." Dr. Loomis concludes his paper by rec- 
ommending the Adirondack region as suited to cases of 
" catarrhal phthisis," while he considers the Colorado cli- 
mate better for patients presenting the lesions and symp- 
toms of " fibrous phthisis." "Tubercular " cases he con- 
siders unlikely to derive much benefit from climate cure. 
Anything like full and accurate meteorological data for 
the Adirondack country the writer of this contribution to 
the Handbook has been hitherto unable to procure. He 
hopes to be able to present data of this kind for individual 
health-resorts lying within, or on the borders of, the Adi- 
rondacks, in the accounts of such places which will ap- 
pear in their alphabetical order in later pages and later 
volumes of the book. For description of the Home for 
Consumptives, established by Dr. E. L. Trudeau at Sara- 
nac Lake, see article on Saranac Lake. 

Huntington Bicha/rds. 

AEROTHERAPEUTICS. Aerotherapeutics, or pneu- 
mato-therapeutics, treats of the use of atmospheric air as 
a curative means by artificial changes of its density, as 
opposed to climatology. This air of increased or dimin- 
ished density may be applied to the whole or part of the 
body ; the former by means of a pneumatic chamber, the 
latter by special apparatus, according as it is desired to 
affect the air-passages, limbs, or other part. 

The pneumatic chamber is an apartment usually made 
of iron, so built that it may be closed air-tight, and capa- 
ble of standing great pressure external or internal, and 
large enough for the comfort of the patient. By forcing 
air in or sucking it out by means of an air-pump, after 
the patient is in the chamber, the air is increased or 
diminished in density, the amount of change of pressure 
being shown by a manometer. There may also be ar- 
rangements for regulating' the temperature and dryness 
of the air in the chamber. In using the compressed air- 
chamber the pressiu:e of the air and the duration of the 
exposure are gradually increased, possibly to two atmo- 
spheres. The time of each bath may be from one and a-half 
to two hours ; the patient going in at the ordinary press- 
ure, this is gradually increased and as gradually dimin- 
ished. If the pressure be changed too suddenly, the fol- 
lowing symptoms maybe induced : redness of face, hard, 
frequent pulse, dyspnoea, cough, haemorrhages from ear, 
mouth, nose, or bronchi, spmal troubles, etc. These 
symptoms are due to the mechanical effect ; but there is 
also increased supply of oxygen. When in an air-cham- 
ber, as a diving-bell, the pressure is increased, there comes 
a feeling of fulness in the ears from difference in density 
of the air in the ears (i.e., in the drum cavities) and out- 
side of them ; unless this difference of density be equalized 
by passing air througii the Eustachian tubes by swall&w- 
ing, the feeling in the ears becomes very painful, and there 
may be rupture of the drum-membranes with htemorrhage. 
This motion of swallowing must be repeated occasionally^ 
till the maximum density is reached, and again as it is 
being reduced in density. But the most important effects 
are on respiration, and these are the usual cause of emploj'- 
ment of the remedy. Compressed air increases the vital 
capacity of the lungs, reduces the frequency of inspira- 

81 



Aerotlierapeutlcs. 
^stliesiometer. 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 



tion ; consumption of oxygen is increased, and excretion 
of carbonic acid diminished ; change of tissue is pro- 
jnoted ; the strength, weight, and appetite are increased ; 
there is no special change in the bodily temperature. 
Under the continued use of compressed air this improve- 
ment in symptoms may become permanent. The parts 
most directly exposed to this compressed air are the sur- 
face of the body and the lungs ■; hence the blood would 
be driven from the surface and the lungs dilated. After 
the change of pressure has continued some time, this dif- 
ference ceases. As the pressure is reduced, the first effect 
is again on the surface and lungs ; the skin and external 
mucous membranes are filled with blood ; the lungs are 
retracted, until the state of equilibrium is reached. Ac- 
cording to this, we might hope from treatment in the 
compressed air-chamber to drive blood from the periph- 
ery, to arrest secretion from the bronchial mucous mem- 
branes, by enriching the blood and tissues with oxygen 
to improve nutrition, to cause absorption of exudations, 
and to increase excretion of urea, and by expanding the 
lungs to increase their vital capacity. The action of the 
compressed air-chamber in lung diseases may be to some 
extent replaced by portable apparatus for respiration. 

The diseases in which 
benefit may be hoped for 
by using increased air- 
pressure are chronic bron- 
chial catarrh, with in- 
creased secretion; chronic 
vesicular pulmonary em- 
physema, especially if 
due to bronchitis or asth- 
ma ; pulmonary phthisis. 
In this latter disease, as 
well as in pleuritic exu- 
dations and whooping 
cough, it is said the 
symptoms are relieved 
and actual improvement 
brought about. Advan- 
tage has also been claimed 
for its use in ansBmia and 
obesity. It is said to be 
contra-indicated in or- 
ganic diseases of the 
heart. 

The compressed air- 
chamber may be so ar- 
ranged (by letting a tube 
through one of the walls) 
that while the patient is 
in it he may expire into 
the free air ; this has the 
same effect as if, being in 
the free air, he expired 
into rarefied air. The 
air-chamber may also be 
used for treating patients 
by rarefied air; but 
mountainous regions fur- 
nish about the same rare- 
fled air, with various advantages over the pneumatic 
chamber. In the latter there is diminished supply of oxy- 
gen ; at first the breathing is superficial and frequent, but 
after a time the inspirations become deeper ; expiration is 
facilitated ; the surface colors up ; there may be dizziness 
and mental hebetude. "Waldenburg found increased ful- 
ness of the radial artery, increased rapidity of circulation 
and relief to the heart's work. 

Health resorts, which are frequented on account of 
their elevation, are usually from '550 to 1,900 metres 
(alJout 1,800 to 6,300 feet) above the level of the sea, 
and this diminution of atmospheric pressure would 
represent about one-flfteenth to one-flfth of an atmo- 
sphere. The effect of these is stated in the article on Cli- 
matology. 

Portable pneumatic apparatuses are arranged for per- 
mitting inspiration of, or expiration into, compressed or 
rarefied air ; of these the only methods used are inspira- 

82 




Pig. 67.— Waldenburg's Apparatus lor 
Compressing Air. Natural height 
is one metre. 




tion of compressed air, or inspiration into rarefied air. 
Pneumatic treatment of diseases of the lungs and heart 
by these portable apparatuses is of recent introduction ; 
they offer the air under a positive or negative pressure 
(compressed or rarefied) of yiir to jV of an atmosphere 
+ or — . 

There are many different patterns, of which perhaps 
the most practical are Waldenburg's and Biedert's ; the 
former is made like a gasometer, the latter much like a 
round accordeon, with one end fast to a stand having 
guide rods at the side, with an axle in the middle on 
which the instrument may be rotated so as to bring the 
end which is fast ■ uppermost ; in this position the pa- 
tient may breathe 
into rarefied air, 
the. rarefaction be- 
ing increased by ad- 
dition of weights to 
the lower, free end; 
when the attached 
end is down, more 
■weight on top in- 
creases the density 
of the air in the 
reservoir, so the pa- 
tient may inspire 
condensed air. An- 
other instrument, 
Frankel's, is made 
on the harmonicon 
principle, the pa- 
tient condensing or 
rarefying the air 
by compressing or 
opening the instru- 
ment. All of these 
instruments have 
tubes connecting 
with them, and have mouthpieces and masks at the 
other encs for the patients to breathe through, and some 
of them have means for warming or medicating the air 
entering the reservoir. 

Inspiration of compressed air fills the lungs to an un- 
usual degree, expands the chest, and even causes a feel- 
ing of distention and fulness ; it multiplies inspiratory 
inovements, increases the exchange of gases and the 
capacity of the lungs, relieves dyspnoea and promotes 
expectoration. 

Expiring into rarefied air has effects somewhat sim- 
ilar to those of 
breathing con- 
densed air; 
more air is 
drawn out of 
the lungs by 
this process 
than can be 
forced out by 
the muscles. 
It is asserted, 
that, with a 
vital capacity 
of 3,000 to 4,- 
000 c.c, by ex- 
piring into air 
rarefied by 
one-sixtieth to 
one-fortieth of 
an atmos- 
phere, 500 to 
1,000 c.c. more 
may be drawn 
out ; this 



Fig. 68. — Biedert^a Apparatus. 




— The Same, reversed. 



would leave so much more air to be breathed in ; and 
ventilation in the lungs would be increased to this extent, 
the respiration would become more active than from in- 
spiring compressed air, and the respiratory muscles would 
be strengthened, 
Prof. Bazile Feris, considering dyspnoea in emphysema 



EBFERENCB HANDBOOK OF THE MEDICAL SCIENCES. 



Aerotlierapentlcs. 
.Slstbesloineter. 



to be due to lack of elasticity of the alveolar walls, has de- 
vised an '■■ elastic respirator " to facilitate expiration. "It 
resembles a double hernia truss ; from a pad between the 
shoulders the two limbs of the truss pass around under 
the arms to the terminal pads in front." The effect of 
pressure at the upper anterior part of the chest is to in- 
crease expiration, inspiration then following easily. In 
thirteen cases the immediate relief is said to have been 
marked. In the very aged, with rigid ribs, or when the 
emphysema is accompanied by bronchitis, the relief is 
less marked. 

Inspiration of rarefied air would be merely for gym- 
nastic purposes, to increase the strength of the respiratory 
muscles ; the same would be true of expiring into com- 
pressed air. Inspiration of compressed air increases the 
pressure of blood in the aortic circulation, and reduces it 
in the pulmonary. As a consequence, we have its diuretic 
effect and its aid in removing pleuritic exudations. 
The deep inspirations, with the consequent movements 
of the diaphragm and stomach, improve digestion and 
the general condition of the patient. In cases of lung 
disease, it is sometimes advised to have the patient lie on 
the healthy side, or to apply adhesive plaster to the 
healthy side, or, in disease of the apices, to compress the 
lower part of the thorax by a bandage, so as to throw 
more work on the affected part. Another method is to 
place the hand of the sound side on the hip, the other 
hand on the head while breathing. Climbing mountains 
is good gymnastics for those patients able to indulge in 
such exercise. Inspiration of compressed air is indi- 
cated where the breathing is weak, where the lungs do 
not expand well and contain too much blood, to hasten 
absorption of fluid exudations, in disease leading to 
phthisis, chronic bronchial catarrhs, etc. In most of 
these diseases it is well to begin with air but slightly 
increased in density, and to increase the density up to 
one-sixtieth or one-twentieth of an atmosphere additional. 
Medicinal vapors of creasote, turpentine, tar, muriate of 
ammonia, etc., may be added to the air. The inhalations 
at one sitting may amount to one hundred, and may be 
given twice daily. In dyspnoea from asthma, pneumonia, 
pressure of pleuritic or ascitic fluid, poisoning by gases, 
etc., compressed air has afforded great relief (just as 
oxygen has), but, in pulmonary emphysema, expiration 
into rarefied air has a better effect ; it should be used in 
the sa,me manner. Especial benefit has been claimed 
from its use in cases of pleuritic effusions< and in de- 
formities of the thorax from compression of a lung after 
pleurisy. In addition to the above cases, in which the 
pneumatic apparatus may be said to have served as a 
curative remedy, it is sometimes resorted to for temporary 
relief in contraction of the larynx or trachea from croup, 
syphilis, goitre, etc. 

Contra-mdications to the use of such apparatus are 
tendency to haemorrhages from the lungs, stomach, and 
kidneys, haemorrhoids, or profuse menstruation, and ex- 
istence of atheromatous arteries, in which latter condi- 
tion cerebral haemorrhage may be induced. 

Other therapeutic applications of compressed and 
rarefied air are made by means of various apparatus pre- 
pared to be applied over different parts of the body ; a 
metal casing may be made for part of or the entire thorax 
(especially of children), fitted close at its edges by means 
of india-rubber and adhesive plasters, so that air may be 
pumped out of it ; the pressure of ordinary air entering 
the lungs would then expand them more thoroughly. 
In chronic inflammations and exudations about the joints 
» metal casing may be applied over the limbs, and alter- 
nations of pressure applied in the same way. The old 
ippliance thus constructed, called Junod's boot, was 
^{reatly vaunted in its day. 

_ In the Bull. gen. de Thh-wp., September, 1883, Dr. Mau- 
rice Dupont has an article on "Douches of Compressed 
Air." He employs air under a pressure of three atmos- 
pheres, conveying it by an elastic tube with a nozzle hav- 
ing an opening of eight to ten millimetres. The jet of 
compressed air is played on the patient as water might be ; 
what he terms the "flagellation" drives the blood from 
the surface, making it cold ; this is soon followed by 



reaction, without friction being required, as when water 
'*is used. After the douche the patient feels warm. This 
mode of treatment is recommended for phthisis, chlorosis, 
anaemia, and obesity ; and for certain local troubles of 
joints, contractures, etc. 

Compression of air in the lungs, by closing the mouth 
and nose while making forced efforts at expiration (Val- 
salva's method) may be tried when a pneumatic apparatus 
is not at hand ; the effect is something like breathing 
into compressed air. The reverse, viz., trying to inspire 
while mouth and nose are closed, would be like breathing 
rarefied air, and has been advised in diseases of the right 
heart. Deep, slow inspirations increase the flow of blood 
to and expand the lungs, and increase the aeration and 
muscular tone of the thorax ; hence they are useful in 
phthisis. Expirations may be made more effective by 
pressure on the thorax walls by the hands ; this forces 
out some of the residual air, and with it mucus which 
may have clogged the smaller bronchi. This forced ex- 
piration may be repeated twenty oi thirty times at one 
sitting. 

CJuwles E. Hockley. 

^STHESIOMETER. The word sesthesiometer is de- 
rived from the Greek alaedm/iat, I perceive, aiaitiaLs, per- 
ception, sensation, and lierpov, a measure ; thus meaning 
literally a measure of sensation, and is used to denote 
an instrument, which measures that form of sensation 
known as tactile sensibility (Tastsinn in German). 

Tactile sensibility comprises all those forms of sensa- 
tion which are conveyed to the central organs by the 
so-called tactile fibres or nerves of touch, and is to be 
distinguished from the common sensibility, which com- 
prises the sensations conveyed by the sensitive nerves 
proper. Through these latter nerves we are enabled to 
feel the general or common sensations, which include pain, 
itching, titillation, sensual pleasure, and the sensation 
resulting from electrical stimulation. On the other 
hand, through the tactile fibres we obtain the sensations 
of tactile impression, which are composed of the sensa- 
tions of locality or position {Raumsinn, Ortsinn, in Ger- 
man), of pressure and of temperature. Not only is it 
probable that these different classes of afferent nerves 
possess different terminations and end organs, but they 
have, in all probability, each special afferent fibres of 
their own, which take different courses in the spinal 
cord. 

JEsthesiometers, properly so-called, are instruments 
for testing the sense of locality. The first one used, one 
which under slight modifications still retains its place, is 
that of E. H. Weber, who in 1839, appears to have pub- 
lished his first account of his investigations in regard to the 
sense of locality. The instrument had probably, however, 
been for some time in use at that date, for in 1846 he re- 
fers to its use twenty years ago. It consisted simply of a 
pair of compasses with cylindrical arms, the points of 
which were so ground down that their ends had a 
diameter of one-third line, so that they should pro- 
duce simply a sensation of touch and should avoid 
any sensation of pain. To use this instrument it was 
only necessary to place the two points upon the skin of 
the person to be examined, taking care at the same time 
that he should not see whether both points or only one 
touched his skin, and by examination find out at what 
distance from each other it was necessary that the points 
should be in order that they should be distinctly felt as 
separate. For in any portion of the skin two distinct 
points if placed near enough together will be felt as only 
one. 

Weber found that, the sense of locality, that is, the 
distance at which the points could be distinguished as 
two, varied much in healthy individuals in different 
parts of the body, and varied also somewhat, especially 
on the limbs, according to the direction in which the 
points were placed, whether longitudinally, obliquely, or 
transversely. His figures and those of Valentin for the 
normal distance between two points, which can be dis- 
tinguished as such in the various parts of the body, are 
as follows ; 



83 



JC8tliesIoineter> 
iEstbeKiometer. 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 



Table op Vabiations of the Sense of Looaliti in Diffeeent 

POKTIONS OF THE SEIN (WEBEE AND VALENTIN). 

[The snbioined table gives the mean minimum distanoee (in Paris 
lines) for different parts o( the body between the points of the ffisthe- 
siometer at which two impressions can be distinguished when the points 
are applied simultaneously. The first column gives the results of the 
experii*nts of Weber, the second of those of Valentin, while the third 
column (also from Valentin) gives the relative obtuseness of each por- 
tion of the body, the most delicate part, the tip of the tongue, being 
taken as the unit of measurement.] 



Part of Sdbfaoe. 



Tip of tongue '. 

Palmar surface, third phalanx of forefinger 

l^almar surface, third phalanx of middle finger 

Palmar surface, third phalanx of ring-finger 

Palmar surface, third phalanx of thumb 

Palmar surface, third phalanx of little finger 

Ked surface of under lip 

Bed surface of upper lip 

Palmar surface, second phalapges of fingers . , , 

Palmar surface, first phalanges of fingers 

] }orsum of tongue (one inch from tip, Weber) 

!Dorsiil surface, third phalanges of fingers 

Portion of lips not red 

Tip of nose 

Edge of tongue, one inch from tip 

Palmar surface of the metacarpus (capitula ossium). . 

L-iteral surface of dorsum of tongue 

End of great toe (plantar side of last ioint, Weber).. 

Metacarpal joint of thumb 

External surface of eyelids 

Palm of hand 

Dorsal surface of second phalanx of thumb 

Dorsal surface of second phalanx of forefinger 

Dorsal surface of second phalanx of middle finger. , . , 

Dorsal surface of second phalanx of little finger 

Dorsal surface of second phalanx of ring finger 

Centre of h )rd palate 

Mucous membrane of lips near gums . . ., 

Skin of cheek over buccinator 

Skin of cheek over anterior part of malar bone 

Dorsal surface, first phalanges fingers 

Prepuce 

Dorsal surface of heads of metacarpal bones 

Cheek, over posterior part of malar bone 

Plantar surface of first metatarsal 

Lower part of forehead 

Back of hand 

Lower part of hairy scalp in occipital region 

Surface of throat beneath lower jaw 

Back of heel , 

Pubes 

Crown of head 

Patella and surrounding parts 

Areola around nipple 

Dorsum of foot, near toes 

Axilla 

Skin of forearm (upper and lower extremities of fore- 
arm. Weber) 

Back of neck (over spinal column, Weber) 

.Upper and lower extremities of lower leg 

Penis 

Acromion and upper part of arm 

Sacral region 

Srernum 

Gluteal region 

Middle of arm 

Middle of thigh 

Spine near middle of cervical vertebree 

Spine near fifth dorsal vertebra 

Lower part of thorax, and over lumbar vertebrje. . . . 
Middle of dorsal vertebrce 



0.60 
1.00 
1.00 
l.CO 

1.00 

1.00 

2.00 
2.00 
2.00 

4'.60 
3.0U 
4.00 
3.0(1 



3.00 

B.OO 
4.00 
5.0U 
B.OO 
B.OO 
5.00 
5.00 
6.00 
6.00 
6.00 
9.00 
B.OO 
7.00 
7.00 

8!6o 
10.00 

7.00 
10.00 
14.00 
12,00 
IB.OO 
10.00 



15.00 
16.00 



18.00 



18.00 1.5. 
24.00 l.S. 
18.00 1.3. 



18.00 

18.00 

18.00 

00 

18.00 

.00 

00 

30.00 

24.00 

24.00 

30.00 



.i a 



1.000 

1.248 

1.462 

1.497 

1.501 

1.B18 

3.106 

3.147 

3.226 

8.416 

3.967 

4.400 

4.572 

4.6'58 

6.130 

6.434 

6.17B 

6.729 

6.901 

7.986 

7.936 

8.060 

8.0H0 

8.075 

8.163 

8.221 

8.369 

8.540 

9.402 

9. .666 

10.180 

10.659 

10.869 

10.944 

12.164 

12.422 

14.42:1 

17.168 

17.168 

18.634 

19.048 

19.840 

21.1S5 

24.982 

25.932 

26.915 



27.520 
27.520 
28,.S81 
28.675 
28.708 
30.969 
875;32.867 
62634.420 
O&S 35.368 
6.S3'36.507 
,.542!38.389 
000'39.337 
912 41.226 
208,60.120 



Weber's aesthesiometer is still in constant use, and 
servos its purpose well, but certain other forms or modi- 
fications have been introduced. In 1858 Sieveking pub- 
lished the account of his sesthesiometer in the British and 
Foreign Medico-Ohirurgical Review. The principle is the ' 
same as that of Weber's, but the form is somewhat al- 
tered. Instead of using the common compasses Sieve- 
king has made his instrument in the form of the beam- 
compass used by mechanics ; that is to say, of a solid 
graduated bar of metal, which terminates at one end in 
a point running at right angles to the bar, while on the 
bar shdes another point of horn or ivory, which can be 

84 



fixed at any desired distance from the first, by means of 
a screw on top. A modification of Sieveking's aesthesi- 
ometer has been made by Brown^Sequard, who has appar- 
ently made both the bar itself and the points lighter, and 
has done away with the screw at the top of the movable 
point. In his instrument the points are of steel, and 
there is a roughened prominence on the side of the sec- 
ond point to enable it to be readily moved by the finger 
or thumb (see Fig. 70). Nearly all the sesthesiometers 



Fio. 70. — Brown-Seqnard'B .^stbesiometer (reduced in size). 

at present used are modifications of these two forms. 
Hammond's convenient little instrument is a modifica- 
tion of Weber's, consisting essentially in allowing the 
index-bar to swing on a rivet fastened to one arm of the 
compass, the bar, while in use, being held by a catch on 
the other arm, in which it slides freely, When not in 
use, it can be lifted from the catch and swings into ap- 
proximation with the arm to which it is fastened, so that 
the whole instrument, when closed, occupies but little 
space and can readily be carried in the pocket. Carroll's 
instrument is simply a compass, each arm of which ends 
in two points, one blunt and one sharp, either of which 
can be used as desired ; while Vance's is an arrangement 
of compass with flattened arms, which shuts up in a case 
like a penknife. 

The delicacy of the sensation of space in various parts 
of the skin may be tested by the sesthesiometer in two 
ways. In the first place, as mentioned above, by deter- 
mining how far apart the points must be placed in order 
to be felt distinctly as two separate points in any part of 
the skin; and, secondly, by fixing the points of the 
sesthesiometer at a certain distance apart and moving the 
instrument from one portion of the body to another. 
Thus it is found that the distance of the two points ap- 
pears to increase when the sesthesiometer is drawn from 
the cheek horizontally over the mouth, one point resting 
on each lip, to the median line, and that if continued 
across that tine to the other cheek, the distance appears 
proportionately to diminish. This method of testing 
with the sesthesiometer is, however, of no practical use, 
as we have no means of measuring the strength of our 
sensations. 

From the numerous experiments made in regard to the 
normal tactile sensibility the following results have been 
deduced : 1. The points of the sesthesiometer always 
seem to be farther apart when one point is placed on one 
side of a natural opening and one on the other. Thus, 
when one point is placed on the upper lip and one on the 
lower, they appear farther separated than if both points 
are placed in a corresponding position on either lip. 
This in part accounts for the increase apparent when the 
sesthesiometer is moved from the cheek to the median 
line in Weber's experiment. 3. Other things being equal 
the points of the sesthesiometer seem farther apart when 
they rest upon different tissues. Thus, for example, when 
one point is placed upon the mucous membrane of the 
lip and one point upon the skin, they seem farther apart 
than when both points are upon either the skin or the 
mucous membrane. 3. As a rule the points seem farther 
apart when they are on different sides of the median line 
than they do in corresponding positions when both are 
on the same side. This law does not, however, always 
hold good. 4. The direction in which the points are 
placed in relation to each other is of considerable impor- 
tance in certain parts of the body, especially on the limbs. 
When placed transversely they appear to be at a greater 
distance from each other than when placed longitudinally. 
On the body proper there seems to be but little difference, 
while it is more marked on the face, and more so still on 
the limbs, especially the lower arms and legs. The causa 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 



.SIsthesIoineter. 
^stlieslometer. 



of this is as yet unknown, but it may be that the skin 
over different muscles responds more readily to two 
stimulations than the skin over the same muscle when 
touched at two equally distant points. (According to 
Vierordt the relative delicacy of the sense of locality at 
any point on the skin of a special portion of the body, as 
compared to that of the other points of the same portion, 
is a function of its mobility, and increases proportion- 
ately to its distance from the axis on which that part 
moves, since it depends on the relative greatness of the 
excursions which it effects about its axis through the 
movements of the part concerned.) 

In applying the aesthesiometer certain precautions should 
always be observed. In the first place, the operator 
should take especial care that both points are applied as 
nearly as possible simultaneously, as the element of time 
enters distinctly into our tactile impressions, and the 
greater the time which elapses between any two impres- 
sions of a similar kind, the more readily are such im- 
pressions recognized as distinct. For this reason, also, 
the points, when once applied, should not be moved, for 
if they be moved, a new sensation, or a series of sensations, 
will he produced, which will enable us to interpret the im- 
pressions mi^re easily. It is a curious fact that, if two points 
be placed so near together that they are felt as only one, 
and a third point be drawn across the skin between the two, 
the sensation of a moving object c^n be felt, although its 
position cannot be localized. The impression produced by 
the points, moreover, becomes clearer the longer they re- 
main in contact with the skin. Hence, in making compara- 
tive observations, the points should be held on each place 
for the same amount of time. In addition to the simultane- 
ousness of the touch, the pressure at the two points should 
be as nearly equal as possible. As far as possible, all 
pressure should be avoided, and when this cannot be, it 
should he as slight as possible. As we shall hereafter see, 
the ratio of the sense of pressure in different parts of the 
body varies considerably from that of locality, and the 
two different sensations should be carefully distinguished. 
For practical purposes, however, the amount of pressure 
exercised in ordinary cases when due care is taken is not 
sufficient to in any way affect the result. It is otherwise, 
however, when a different amount of pressure is exerted on 
the two points. The force of the stimulus produced at one 
point is liable so to act that the stimulus produced at the 
other is perceived but indistinctly or not at all. A third 
and obvious precaution to be observed in using the 
eesthesiometer, when testing corresponding portions of the 
body, is that the points should in each case be placed in 
the same direction, that is, longitudinally, obliquely, or 
transversely, as may be, and that they should be on ex- 
actly corresponding parts and at an equal distance from 
the median line. This is of especial importance in patho- 
logical cases, where the aesthesiometer is used for the pur- 
pose of diagnosis. 

In an examination for physiological purposes we must 
also take into consideration the mental condition of the 
subject. Whenever the attention is strongly fixed upon 
any point in the body, sensations produced there by ex- 
ternal objects are more readily and more quickly perceived 
than when the mind is occupied by other thoughts. 
Hence, when the attention is fixed upon the action oi the 
aesthesiometer, the points wiU be perceived more j:eadily 
and more distinctly than would otherwise be the case. 
The readiness with which the points are perceived and 
their position determined varies also greatly with prac- 
tice. Cold diminishes the tactile sensibility, as does also 
extreme heat. Hyperiemia, as well as anaemia, probably 
likewise diminishes it. 

BAB2ESTHESI0METEK. 

The term baraesthesiometer, from $ipos, weight, and 
jesthesiometer, has been applied to instruments which are 
used to determine the delicacy of the cutaneous sense of 
pressure. 

The first attempts to measure the cutaneous sense of 
pressure were made by B. H. Weber, who for this pur- 
pose used weights laid directly upon the parts to be 




Fia. 71 . — Eulen burghs 
Barsesthe siometer. 
Front view. 



tested, the muscular sense being excluded by firmly sup- 
porting the part to be examined upon some solid body. 
Various weights, as nearly as possible of the same size 
and same temperature, were applied in succession to the 
part, and the smallest difference which could be thus de- 
tected was carefully determined for 
each part. Weber himself made use 
for this purpose of coins (thalers) 
which he laid upon the forehead, the 
head being supported, and thus ob- 
tained some important results. Ac- 
cording to his researches, the sense 
of pressure varies much less in the 
different parts of the body than the 
sense of locality, and does not vary 
in the same proportion in the differ- 
ent parts. In the place of coins 
Kammler and Aubert made use of 
small disks of cork or elder-pith, on 
which weights could be placed, while 
Dohrn estimated the sanse of pressure 
by means of a blunt point attached to 
tiie arm of a pair of scales. In 1863 
Goltz published ithe account of his 
apparatus, by means of which he 
sought to d.etermine the smallest 
rhytlvmical pressure which can be 
perceived on any given part. For 
this purpose he made use of an India- 
rubber tube, both ends of which were closed and which 
was rendered tense by being filled with water. The pul- 
sations produced by the experimenter at one end of the 
tube were transmitted to the other end, which was laid 
upon the part to be tested. Goltz's results corresponded 
with those of Weber for the sense of locality, except that 
the tip of the tongue was found to be 
proportionately much less sensitive to 
pressure. 

To determine the deUcacy of the 
sense of va/riation of pressure, Bulen- 
burg used the baraesthesiometer which 
bears his name (Fig. 71). It consists 
simply of a hard-rubber plate, on to 
which is screwed a spiral spring 
through whose greater or less tension 
a stronger or weaker pressure can be 
exerted on the plate. This spring is 
placed inside a case, and can be more 
or less compressed at will by means of 
a. guiding-rod. Through a toothed 
wheel, which is placed in connection 
with this rod, an index is set in mo- 
tion, which marks on a dial-plate the 
amount of tension of the spring, thus 
showing the strength of the pressure 
exerted. Each figure on the dial cor- 
responds to a pressure of one gramme. 
Eulenburg found that the sensibUity 
to variations of pressure was most delicate on the face, 
especially the forehead, then on the lips, the back of the 
tongue, cheeks and temples. Here it is ^, often -shr. 
On the upper extremities it is ^V to-iV, and does not var> 
much in the different parts. In the lower extremities the 
anterior portions of the lower leg and thigh seem to pos- 
sess the greatest insensibility ; next follow the back of the 
foot and dorsal surface of the toes, while on the plantar 
surface of the toes, the sole of the foot, and the posterior 
portions of the lower leg and thigh the sensibility is much 
weaker. LSwitt and Biedermann found that by the fin- 
ger-tips the differences between weights which bear to 
each other the proportion of 39 to 30, could be appreciated, 
provided the weights were not too light nor too heavy. 

Thebm^esthesiombtek. 

For measuring the sensibility to differences of tem- 
perature, Weber used two long glass phials filled with 
oil, into each of which he introduced a thermometer, 
passing it through the stopper. By means of this ap 




Fig. 72. — Back view 
of the same instru- 
ment. 



85 



^stbeslometer. 
Age. 



REFEBENCE HANDBOOK OF THE MEDICAL SCIEKCES. 



paratus he found that the skin of the face was the most 
sensitive, especially that of the eyelids and cheeks. The 
lips, on the contrary, which are more sensitive to sensa- 
tions of place, are less so to those of temperature. 
Moreover, the sense of temperature, as tested in this way, 
instead of heing greatest in the middle of the lips, is 
greater on the lateral portions of the upper lip, greatest 
on the cheeks, and less as we approach the median line. 
In 1866, Eulenburg described his thermsesthesiometer. 
The instrument consisted simply of a "frame" and two 
thermometers thereto attached. For "frame" he made 
use of Sieveking's aesthesiometer, to the bar of which he 
fastened two exactly similar thermometers which corre- 
sponded accurately to each other. Their lower ends were 
drawn into broad glass bulbs, and flattened at the bot- 
tom so as to rest readily upon the skin. These ther- 
mometers worked like the points of the sesthesiometer, 
one of them being fixed at the end of the bar, while the 
other could be moved along it as desired, and be fastened 
at any distance by means of a screw. Thus the distance 
between the thermometers was determinable at will, and 
could be estimated by a scale marked on the bar. In 
using this apparatus, one thermometer was heated or 
cooled as desired, while the other was left at the tem- 
perature of the room. In the following year, 1867, 
Nothnagel published a series of very careful investiga- 
tions into the cutaneous sensibility of the temperature, 
in making which he used a special instrument. Noth- 
nagel's therm£esthesiometer consists of two exactly simi- 
lar cylindrical vessels, two and a half inches high and 
one and a half inch in diameter. Their walls are made 
of wood and are double, some poorly conducting sub- 
stance, as ashes, being placed between the two parts. 
The bottom is formed of copper, a good heat-conductor. 
On the top of the vessel is a tightly closing wooden 
cover which moves on a hinge, and which has an open- 
ing on one side. Corresponding to this opening there 
rises perpendicularly from the edge of the vessel a piece 
of wood to which are fastened two rings. Through 
these rings and through the opening in the cover a 
thermometer is thrust into each vessel, which is partially 
filled with water, whose temperature may readily be 
rendered different in the two vessels by plunging into it 
some good conductor, which has been previously heated 
or cooled. The vessels should be placed rapidly one 
after the other on the part to be examined, and the time 
of contact lasts until the subject has formed a judgment 
in regard to the temperature. Care must be taken that 
the whole surface of the bottom of both vessels should 
rest against the skin, since, as is well known, the strength 
of the impression and the delicacy of the sensibility to 
temperature grows with the increase in the number of 
nerve-fibres affected. By this means Nothnagel deter- 
mined that the greatest capacity for distinguishing differ- 
ences of temperature exists when the temperature is 
between 27° and 33° C. ; up to 39° C. it is but slightly 
diminished, but from thence to 49° C. it diminishes 
rapidly, and at the latter point pain occurs. From 37° 
to 14° C. the capacity diminishes in much the same ratio 
as from 33° to 39° C, but between 14° and 7° C. it falls 
off rapidly. He found that in different parts of the 
body the following differences in temperature could be 
distinguished : 

Centigrade. 

Sternum 0.6° 

Chest, upper and outer portion 0.4" 

Epigastrium 0.5° 

Abdomen, upper lateral portion 0.4° 

Middle part of back 1.2° 

Lateral portions of back 0.9° 

Palm of the hand 0.5° 0.4° 

Back of hand 0.3° 

Fore-arm— extensors 0.2° 

Fore-arm— flexors [ 0.2° 

Upper-arm — extensors and flexors 0.2° 

Dorsal surface of foot 0.5°-0.4° 

Lower leg — extensors 0.7° 

Lower leg— flexors (calf) .'.'.'.'.'.'.'.'.'".*,'..'." 0.6° 

Thigh extensors and flexors 5° 

Cheeks 0.4°-0 2° 

Temples .......'.."..'.".'!.'.'.'!'..'.' 0.4°-0!3° 

The sensibility to variations of temperature seems dull- 
er as we approach the median line, The hand and fingers 



are generally alike, the lower arm more sensitive than 
the hand, and the upper arm more so than the lower 
arm. By extremes of heat or cold a thermansesthesia is 
produced. Anremia increases sensibility to temperature, 
hyperaemia is said to diminish it. 

The only other thermsesthesiometer which deserves 
mention is Kronecker's, which resembles Eulenburg's, 
in which the latter's thermometers are replaced by metal 
tubes, each divided nearly to the end by a partition, as 
in a double-irrigating catheter. Through these water of 
a fixed temperature can be caused to flow. 

Bibliography. 

E. H. Weber : De piiTsu, resorptione, auditu et tactu. Lipsife, 1834 ; and 
in Wagner's Handworterbuch d. Physiologie, iii., 2te Abth. 

Valentin : Lehrbuch d. Physiologie ; Brit, and For. Med.-Chirurg. Be- 
view, January, 1858. 

Goltz : Centralb. fiir d. med. Wissensch., 1863, No. IS. 

Leyden : Virchow's Archiv, 1864, vol. xxxi. 

Eulenburg : Berl. klin. Woohensch., 1866, No. 46; and 1869, No. 44. 

Nothnagel; Deutsch. Arohiv. f. klin. Med., 1867, vol. ii. 

Also the works of Landois, Foster, and Flint, and especially Funke's and 
Bering's articles in Hermann's Handbuch der Physiologie. 

William H. Bullard. 

AGARIC, PURGING. White agaric (agaric blanc, 
officinal Codex Med.), the decorticated hymenium of 
PolypoTUS officinalis Fries (Boletus Laricis Linn.) ; order, 
Basidiomycetea, Hymenomycetea ; a large fungus grow- 
ing upon the stems of the European larch and one or two 
other conifers. It forms large hoof -shaped masses upon 
the sides of the trunks, and penetrates with its mycelium 
deep into the wood. When young they are soft and 
juicy, but, when fully grown, hard, and of a consistence 
between spongy and corky. The masses are collected in 
Europe, Asia Minor, etc., and usually prepared by dry- 
ing and peeling. Agaric is in yellowish-white, friable, 
light, and spongy irregular balls and lumps, from the 
size of an orange to that of a cocoanut, and larger. It 
has evidently been peeled, and the surface is finely 
rough and dusty with minute separated particles. The 
texture is rather firm, but soft ; it can easily be reduced 
to a coarsish powder by friction or by rubbing on a 
sieve, but is difficult to pulverize finely ; its microscopic 
structure — a tissue made up of interlacing, thread-like 
cells — explains its peculiar consistence. 

Agaric has a heavy fungous odor, and a slowly de- 
veloping, bitter, nauseous taste, which is at first sweetish. 
Its powder is very irritating to the eyes and nose, and 
produces violent sneezing. As it is also, light and dusty, 
persons employed in beating it in mortars are obliged to 
resort to devices to prevent its rising. 

It contains nearly one-third of its weight of resinous 
matters, extractible by strong alcohol, which can be 
separated further into three or four simple resins by 
taking advantage of their different degrees of solubility 
in diluted alcohol, chloroform, etc. (Massing). 

Agaric is principally a purgative, owing this quality 
to one or more of the resins just mentioned. It is also 
said to be tonic, and to reduce the sweating of phthisis. 
But although it has undoubtedly purgative powers, it 
has fallen greatly into disuse, and is only now and then 
called for, even in Europe, in the United States scarcely 
ever, as a medicine ; jt is still in repute in parts of Asia. 
Can be given in powder. Dose, as a tonic and anti- 
diaphoretic, fifteen to sixty centigrammes (0.15 to 0.6 
Gm., gr. ij. to x.) ; the last, perhaps, might act upon the 
bowels. The resin has also been used. 

Allied Plants. — Polyporus igniarius Fries (see 
Spunk) is an. allied, although very different-appearing 
product, used entirely on account of its texture. Com- 
position unimportant. A number of other polypori have 
been found to be bitter and laxative ; some poisonous. 

Agarioua campestris Linn, yields an interesting and 
very poisonous alkaloid, muscarine (see Jaborandi). For 
a list of fungi used in medicine, see Ergot. 

Allied Dbugs. — Cathartics : say jalap, scammony, 
podophyllum, etc. Its relation to tonics, " anti-rheumat- 
ics," antisudoriflcs, etc., are too indefinite for compari- 
son. There are better medicines in each of these groups 
than agaric, W. P. Bolles. 



86 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 



-^stbeslometer. 
Age. 



AGE. The age of a human being does not, as usualty 
reckoned, correspond to the length of time it has existed, 
because the ordinary calculation starts from the date of 
birth, and excludes the preceding period of uterine exist- 
ence. If we are to be strictly accurate, the age of any 
animal ought to be reckoned from the time of impregna- 
tion, especially if we are to compare different species, 
one with another, in regard to the changes which corre- 
spond to successive ages. The act of impregnation 
creates a new individual, which alters as time elapses, and 
the liberation from the womb is only one of the altera- 
tions, one event, occurring in the life-history of the indi- 
vidual ; it is therefore artificial to arbitrarily select the 
date of delivery as the zero point from which to start 
the reckoning of the age, the more so as we know that the 
period of gestation varies very considerably in length, and 
that consequently the age of the child at birth is not by 
any means uniform. In the case of man it is the niost 
convenient plan to adopt popular custom, because the 
ages as reckoned from birth are generally known with 
exactitude, but the age of the foetus at birth is almost 
never known for a given individual. Indeed, we have at 
present no means of determining satisfactorily the age of 
a human embryo or foetus, because we have no sufficient 
available data for ascertaining when impregnation takes 
place. As is shown in the articles Foetus and Impregna- 
tion, there is always a possible error of several days in 
any estimate of the age of a foetus, even when the history 
of the case is fully and accurately known, and there are 
decided reasons for thinking that there may be sometimes 
an error of a month or whole menstrual period. Obvi- 
ously it is not practicable to calculate the age of man from 
an event the time of which we cannot know correctly, 
and it is the only practicable course for us to follow cus- 
tom, and assume the commencement of life's journey to 
be some way along the route, namely, at birth ; at least, 
whenever we have occasion to measure age. 

From impregnation to death, at the natural term of life, 
the organism undergoes a definite series of changes, which 
are termed the phenomena of senescence ; in plain words, 
the organism grows old. The most important, if, indeed, 
not all the changes, may be grouped under three heads : 
First, the increase in the number of cells ; second, the 
weight of the cells ; and third, the difEerentiation of the 
tissues. The first and second are the essential factors of 
growth, and under Growth they are more fully discussed. 
Unfortunately, we have no knowledge as to the number 
of cells in the body at different ages, nor is it possible to 
make even a valid estimate. It appears entirely practi- 
cable for some patient investigator to make an approxi- 
mate determination of the number of cells in the body ; a 
trustworthy result would be extremely valuable. But 
though we cannot speak of actual numbers, we are able 
to say that the rate of multiplication of cells diminishes 
gradually with one or two possible interruptions in man. 
The demonstration of this law is given in the article on 
Growth. As regards the size of the cells, we know that 
at first the size is reduced ; during the segmentation of 
the ovum, the amount of material remains nearly con- 
stant, while the segments (cells) multiply ; hence, they 
necessarily become smaller. During foetal life they re- 
main small, even after their differentiation into distinct 
tissues, but it is still uncertain how much of the growth 
of children is due to the mere increase in size of the his- 
tological elements and how much to the increase in their 
number. The difference between the foetal and adult 
cells is readily seen ; unfortunately, it is impossible to give 
a table of comparative measurements, for the micrometric 
data, even of the best authorities, are, with very rare ex- 
ceptions, utterly worthless, from their extreme inaccuracy. 
The structure of the tissues varies according to the age ; 
for each age there is a characteristic phase of development 
of the histological elements, both in structure and arrange- 
ment ; hence, the general anatomy and, therefore, also 
the functions alter in correspondence with the age. Thus, 
in a philosophical view of the career of any organism, we 
are compelled to regard it as a function of the time elapsed 
since the procreation of the individual. It is important to 
insist upon this conception, because the student of human 



anatomy derives his notions almost exclusively from the 
study of the adult, and consequently fails to seize the idea 
that much of what he conceives to be essential and typical 
is only temporary. 

There is another general consideration to be urged 
upon the attention of the reader : the older the organism 
the longer it requires to change. An infant alters more 
rapidly than a child, an adult more rapidly than an old 
person. This fact has a more profound significance than 
at first appears, because it not only suggests the only 
theory of the origin and nature of natural death having 
any serious value, but also is the clue to the distribution 
of variations in age. For the theory of death, see the 
concluding portion of the article on Growth. The law 
of variations to which we refer demands brief elucidation. 
Varieties occur in all degrees ; with living organisms 
there is in each case a certain variety which occurs most 
frequently, and on either side of this most frequent type 
(geometrical mean) occur other varieties which are found 
to be less frequent the more they depart from the central 
type. On the doctrine of chances the distribution should 
be alike above and below the mean, provided always 
there is no predominating factor or factors of variation 
to disturb the symmetry. In the development of living 
organisms there is such a disturbance through the effects 
of age; a concrete example shows the phenomenon 
plainly. The following table, after Heinricius,' gives the 
ages and number of persons observed in 3,500 recorded 
cases of first menstruation in Finland. Below the table 
is given the graphic representation of the same data. 

Tablb of 3,500 Cabeb op First Mxnstbitatioh (observed by 
Hbinbioius in Finland). 

Ages (years).. 11 12 1.3 14 15 IB 17 18 19 20 21 22 2.3 25 26 
No. ol Cases. . 9 33 135 440 766 846 660 347 198 102 41 12 7 4 1 



aw 






































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Age.. 11 12 13 14 16 16 17 18 19 ! 
Fio. 73. 



21 22 83 24 26 26 years. 



The curve shows that the year in which the first men- 
struation occurs most frequently is the sixteenth, and the 
further we follow the curve from the maximum, either 
forward or back, the lower it sinks. Moreover, from the 
maximum to the minimum is (probably) only seven years 
on the young side, but ten years on the old side. Here, 
then, we see that an equal range of variation covers a 
much shorter period of childhood than of later life. 
When a larger series of statistics are compiled, the dif- 
ference in the pre-maximal and the post-maximal periods 
is found to be considerably greater. This phenomenon 
occurs not only with menstruation, but with many, and 
probably all, or nearly all, phases of the development of 
the body ; the tirne at which a given change takes place 
varies in different individuals, and, as far as at present 
known, always according to the law just indicated. In 
the article on Growth another set of facts are brought for- 
ward, demonstrating the same principle, which we may 
now formulate as follows : Tli^ time required to accomplish 



87 



Age. 
Aiken. 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 



a change of a given extent increases with the age of the 
organism. 

It is evident that this generalization needs to be tested 
with great thoroughness, especially to ascertain whether 
it is rigidly applicable in details, or only in regard to the 
whole course of development broadly considered. As no 
researches have heretofore been made to settle the alter- 
native stated, it is very desirable that they should be 
undertaken. It may be discovered that diseases and 
recovery from diseases vary in rapidity in accordance 
with age, the rate of change decreasing with the age. 
This can be decided only by extensive statistics in regard 
to organic diseases. A large number of observations of 
the progress of fatal new formations, of cancer, for ex- 
ample, would be of high value. It is not to be anticipated 
that the diseases of a parasitic or zymotic character would 
exhibit, necessarily, any such correlation with age, be- 
cause their course is dependent primarily on other causes 
than the condition of the.organism in which they appear. 
If the rate of disease does vary with age, the desirability 
of knowing the fact is too obvious to require further 
emphasis ; we can, therefore, only express the hope that 
some one having a proper opportunity will soon make an 
adequate investigation. 

It is a common custom to divide the period of life into 
a succession of ages, but all such divisions are more or 
less arbitrary, and though extremely convenient are quite 
without scientific significance. The ages commonly 
adopted are : 1, Infancy, from birth to the appearance 
of the temporary teeth ; 3, childliood, from the cutting of 
the first permanent teeth to puberty ; 3, youth, from 
puberty to the attainment of the full stature, that is, 
eighteen or nineteen for girls, twenty-one to twenty-two 
for boys ; 4, maturity, covers the interval from youth to 
the climacteric, after which follows 5, the period of de- 
cline or old age. Another very common distinction is 
made between the period of development, say up to 
twenty-five or thirty years, and the period of decline, but, 
as is explained under Growth, there is a steady decline 
going on during the first period also. It would, per- 
haps, be more scientific to designate the earlier phase as 
the period of histogenesis, during which the tissues are 
being evolved, and the latter as the period of histolysis, 
in which the tissues are breaking down — degenerating. 
But, after all, though a great deal has been written and 
said, very seriously too, vipon the division of life into 
ages, the discussions have never, and can never, lead to 
much result beyond fixing upon a set of arbitrary terms, 
which will always be convenient, provided they are left 
sufficiently vague. 

The other matters which might be put under Age are 
to be found elsewhere, such as the determination of the 
age of a skeleton, the age at which the teeth are cut, etc. 
For the characteristics of infancy and childhood, ana- 
tomical and physiological, see the articles on these topics. 
For the changes in old age, see Senility. 

Oharles Sedgwick Minot. 

1 Centralblatt fiir Gynakologie, 1883, vii., 72 to 78. 

AGORAPHOBIA {hyoph, a market-place, i^xiySo!, fear). 
[Ger., Platzsehwindel, Platzangst, Platzfurcht ; Fr., peur 
des espaces, peur du vide; It., agorafobia ; Dan., agora- 
iphoU; Rus., Mestoboyazin.'\ Etymologically speaking 
these names signify "fear of spaces," and are used to 
describe a peculiar emotional neurosis characterized by 
morbid fear of being alone in an open space, or under 
analogous circumstances. The name agoraphobia not 
having satisfied every one, its philological accuracy has 
been questioned, and such terms as isohphobia, eisophobia 
or autophobia, and kerurphobia have been proposed. How- 
ever appropriate these designations may be, the term 
agoraphobia is adopted in the current medical literature 
of all nations ; it is clear, concise, and elegant ; it has 
moreover, a certain element of fitness and admissibility' 
since ochlophobia is a prominent svmptom of the com- 
plaint, and one of the latest contributions to the subiect 
IS a paper in Greek that is to be found in the " Acts of 
the Congress of Greek Physicians, held in Athens in 

88 



1883." A better notion of the word may be given by 
detailing some of the salient phenomena that are found 
in a typical case of agoraphobia. Among the prominent 
somatic troubles are a sudden weakness and a tremor of 
the muscles, which render standing difficult. The tremor 
extends sometimes to the trunk, thence to the arm and 
to the lower jaw ; sometimes there is a wavy sensatioa 
going from the heart to the back of the neck. Chilly 
sensations in the back, stomach, breast, and limbs are fol- 
lowed by heat, redness of the face, profuse sweating, and 
violent palpitation. At the same time there is oppressioa 
and contraction of the pectoral muscles ; the speech is 
abrupt and anxious, and sometimes is momentarily im- 
possible ; intermittent pains of a sharp, rapid, and fatigu- 
ing character, following the trunk of the nerves, run 
along the legs, ascend the body, and extending to the 
arms, seem to lose themselves in the hollows of the 
hands ; there is formication, with numbness in different 
parts of the body ; f estination is observed in some cases ; 
in others sudden loss of motor power comes like a stroke 
of palsy, and the patient falls powerless with his face 
downward, in a state of waking nightmare. 

But these physical troubles are only the outward and 
visible signs of the moral trouble that is the true primi- 
tive phenomenon and the cause of all the others. That 
which is pathognomonic and constitutes agoraphobia, is 
terror, up to its extreme degree, and consequent motor 
impotence. The single primitive phenomenon, as the 
name indicates, is fear. Imagine looking down a deep 
mountain gorge, hanging over the brink of a burning cra- 
ter, crossing Niagara on a tight-rope, or falling from such 
a precipitous height as the Washington monument, and 
the sensation is not more fearful, more astonishing than 
that felt by a patient in an attack of agoraphobia. Ago- 
raphobic terror causes a patient to feel dumbfounded, 
thunderstruck, exhausted, and at the same time isolated 
from the entire world ; space seems to extend to infinity 
under his feet ; he feels persuaded that he will never ac- 
complish a given journey ; walk a certain distance with- 
out fainting ; hold out for a certain time without food, 
or support existence for a certain period without fresh 
air. He experiences fear and want of self-confidence 
when in a crowd, at theatre, church, or in a boat, omni- 
bus, or railway car. A case is related of an agrophobe 
who could not ride on a railway train without a brandy 
fiask in the left hand and a bible in the right, presuming 
that one counterbalanced the effects of the other. Fear 
to rneet acquaintances; fear of spiders, mice, and snakes; 
fear of apoplexy and of death come over the patient like 
the fear that seizes a timid child in the dark ; sensations 
like those of a swimmer deceived by false chances, or 
those of a victim to tantalizing hopes, cause the patient 
to be on the point of screaming or weeping, and he is, 
figuratively speaking, frozen with terror, motionless 
with fear, so great is the anguish that takes place during 
this psychical collapse. 

Agoraphobic symptoms are not new, Pascal having suf- 
fered from them, and Flemming says Brtick described 
them in 1832, and again in 1869, under the title of 
" Schwindel- Angst." It seems, however, that their sys- 
tematic observance and study are of recent introduction 
into science (1871). For convenience of study two forms 
of agoraphobia are spoken of, namely, primary and sec- 
ondary. The primitive form may occur suddenly in ap- 
parent good health and normal mental conditions, without 
other morbid symptoms than the usual somatic and 
psychical ones ; the secondary form occurs as an acces- 
sory phenomenon complicating a previous pathological 
condition : it is slow and progressive, and may coexist 
vnth other neuropathic conditions. Primitive agorapho- 
bia may come on suddenly without assignable cause amid 
varying circumstances, in a boat, during a lecture, or' 
while skating, at the sight of an extended horizon, or 
while looking at the summit of a high monument, as is 
the case with two of the writer's patients, who cannot 
look up to the dome of the Capitol or the summit of the 
Washington monument without being seized with agora- 
phobic symptoms. In one of the late St. Petersburg 
cases the patient could not look out on the sea without 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 



Age. 
Aiken. 



agoraphobic symptoms. There was also the " torment- 
ing fear of heights," the rooms on a second story being 
unbearable, and the patient in crossing a high bridge, al- 
ways did so in diagonal lines to avoid the sight of the 
space between him and the water below. Secondary 
agoraphobia comes on slowly, generally in patients whose 
neurotic antecedents are bad. Numerous prodromatic 
symptoms, more or less painful and persistent, are experi- 
enced, and at a certain time, while out alone in a public 
place or highway, or under analogous circumstances, 
there is added intense emotion and momentary suspension 
of motor power, which complete the attack. These symp- 
toms often disappear spontaneously, when the sufferer, in 
crossing a space, can fix his eye on some limited object, 
such as a carriage, a street lamp, a tree, or an open um- 
brella held over his head ; and often the companionship 
of a small child, or even the support of a cane will act as 
a preventive. Among the latest reported cases is that of a 
Russian officer, who escaped the agoraphobia brought on 
at the sight of carriages and pedestrians, by always taking 
an orderhr along and keeping on the least frequented 
streets. He did not have these symptoms outside of St. 
Petersburg, in a suburban village, nor did they come on 
when riding horseback through a crowded street at the 
head of his regiment. 

But little is known of the cause or of the precise nature 
of agoraphobia, and the numerous theories relative thereto 
are to be mentioned only as objects of medico-historic cu- 
riosity. Over-work, prolonged watching, early and ex- 
cessive sexual indulgences, venereal disease, alcohol and 
tobacco, excessive use of coffee, gastric disturbances, 
taenia, rapid decline of corpulency or a rapid change to 
corpulency, the gouty and the rheumatic diatheses, bad 
atavistic antecedents, and habitual indulgence in ground- 
less fears, may give rise to its development. In fact, one 
may become agoraphobic from moral weakness. The 
atrophy of will that allows imagination full career and 
gives rise to the superstitious fears, moral miseries, and 
morbid impressions that assail certain persons, may cause 
violent commotion of the organism with psychical sensa- 
tions of terror. By these facts, therefore, it is satisfac- 
torily established that in agoraphobia there is a kind of 
moral softening, a nervous adynamia, a psychic insuf- 
ficiency that may dominate the faculties of the individual 
and sterilize his acts. Whether the condition arise from 
organic insufflciencies, such as non-activity of the eye or 
of the ear, brain trouble resulting from anaemia, fatty 
heart, haemorrhoids, lesion of the cervix uteri, abscess of 
the liver, or from a morbid state of the ganglio-nervous ap- 
paratus, we are not prepared to say in the present state of 
our knowledge of the subject. But a consensus of med- 
ical opinion warrants the statement that the pathological 
change in agoraphobiai is a cerebral one, giving rise to a 
cerebro-spinal neurosis that should not be confounded 
with epilepsy, hypochondria, or the different forms of 
vertigo. Agoraphobia is said never to occur in hypo- 
chondriacs. A patient with hypochondria is constantly 
under the influence of the disease ; it is not so with agora- 
phobia. It differs also from vertigo caused by looking 
down from a height. The seeming impossibility to give 
a purely physical explanation of the disease arises from 
the fact that it is a purely mental trouble, and it is a curi- 
ous fact that none of the recorded cases have occurred in 
ignorant persons. Nor do any of the cases appear to have 
been accompanied by illu.sive transformation. Suicidal 
impulses are, however, reported to have occurred in sev- 
eral cases. The majority of them occurred in adult men 
of education and intelligence, who, in nearly every in- 
stance, kept the symptoms concealed from every one as 
long as possible for fear of being thought insane. 

The administration of drugs in agoraphobia is of less 
consequence than the removal of the cause, which is to 
be done mainly by moral treatment. The primitive 
form often disappears spontaneously, but the healing of 
the secondary form presents all possible and impossible 
difficulties, surprises, and uncertainties that the neurolo- 
gist is accustomed to meet. Among the therapeutic 
agents recommended are antispasmodics, the bromides, 
ergot, tonics, and iron ; cutaneous revulsives, cups, 



hydrotherapeutics, electricity to the cervical and to the 
sympathetic nerves, and electric baths. A case has 
been bettered after an operation for the removal of 
haemorrhoids ; in another the agoraphobic symptoms 
disappeared after aspiration of the liver and draining off 
a quantity of pus from an abscess. Two cases caused 
by taenia have been cured after removing the cause. 
Another case improved after a residence in the country, 
a course of hydrotherapeutics, and the avoidance of to- 
bacco. In addition to combating the functional and 
the physical alterations with proper medication, there 
must be a radical and complete change in the habits and 
surroundings, which should be as much opposed as pos- 
sible to the conditions in which the disease has originated ; 
and, above all, the physician should order and enforce 
a course of moral gymnastics that shall train the patient's 
imagination, and tame his terror by progressive and reg- 

^1^^«*<^P«- Irnng 0. Basse. 

AGRIMONY {Agremoine, Codex Med. ; Agrimonia 
Eupatmia Linn. ; order, Mosacece) has been employed in 
Europe from the time of the ancient Greeks and Romans, 
by whom it was prized as a vulnerary. It is, however, 
now almost obsolete, excepting in domestic or country 
practice. Both herb and root have been used. 

It is a perennial plant, with slender, upright, leafy stem, 
from thirty to sixty centimetres high (one to two feet), 
bearing a wand-like spike of smallish yellow flowers ; 
leaves imparl- and interruptedly-pinnate, with adnate 
leafy stipules ; leaflets lanceolate, sharply serrate ; 
flowers perfect, polypetalous, stamens from five (seldom) 
to fifteen or more ; pistils, two or three, the ovaries 
buried in the receptacle, which becomes dry and woody 
in fruit, and is surmounted by a crown of rigid incurved 
spines. 

It is extensively distributed throughout the northern 
hemisphere, growing along roadside hedges and the bor- 
ders of cultivated fields in Europe, Asia, and America. 
The leaves, and especially the flowers, are rather agree- 
ably fragrant ; all parts, the root particularly, bitter and 
astringent. An essential oil has been obtained from the 
plant by distillation. It is a mild, stimulating astrin- 
gent, which has proved of some use as a vulnerary, as a 
gargle, a mild haemostatic, and an astringent in chronic 
diarrhoeas. More doubtful is its utility in jaundice and 
other indications of hepatic obstruction, or as so-called 
alterative. Dose, 4 to 8 grm. ( 3 j. to 3 ij.), in infusion. 

Botanical Connbctions. — Agrimony resembles the 
true roses in most details of botanical structure, but dif- 
fers from them in habit and general appearance, which 
are more like those of spirma ulma/ria. It is also bo- 
tanically connected with brayera anthelmintica (Kouso) 
Kunth., from which it also differs greatly in habit and 
the purpose for which the latter is used. 

Allied Deugs. — Astringency, bitterness, and aroma, 
with varying preponderancy of each, form one of the 
most common medicinal combinations of the vegetable 
kingdom. Alchemilla, sanguisorba, strawberry, poten- 
tillas, geums, blackberries, and spiraeas in the same bo- 
tanical family are instances, and numerous others might 
easilv be mentioned. For remarks on Bosacem, see Roses. 

W. P. Bolles. 



AGUE-CAKE. A chronic enlargement of the spleen 
following repeated attacks of intermittent fever, or ac- 
companying chronic malarial cachexia. (See Malarial 
Fevers.) To be treated with full doses of quinine and 
the local application of cold. M W. 8 

AIKEN. [For detailed explanation of the accompany- 
ing chart, and suggestions as to the best method of using 
it, see Climate.] The village of Aiken lies not far from 
the western border of the State of Georgia, between the 
Savannah and Edisto rivers, but at a considerable dis- 
tance from either, and standing upon the elevated table- 
land or plateau forming the common watershed of both. 



89 



Aiken. 
Alnlium. 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 



From the Atlantic Ocean, Aiken is distant a little more than 
a hundred miles in a "bee line." The elevation of the 
town above sea level is five hundred and sixty-five feet. 
The soil is very sandy, consisting, indeed, of very little 
else than such absolutely pure and unmixed sand as is 
usually to be found only upon the very borders of the sea. 
Grass grows but scantily, and the vegetation of the sur- 
rounding country is that characterizing a region possess- 
ing a dry porous soil, and, in consequence, a dry atmos- 
phere. The yellow pine of the South finds here its 
congenial habitat, and in every direction the country 
about Aiken is covered with a dense, forest growth of 
these lofty evergreen trees, shading the ground from the 
rays of the sun, and filling the atmosphere with the de- 
licious balsamic odor exhaled from their leaves and trunks. 
Several varieties of oak are also to be found in the woods 
about Aiken, and not a few flowering vines and shrubs ; 
but the pine is the characteristic growth of the country, 
and it is to the soothing and purifying effect exerted upon 
the mucous membrane of the respiratory passages by the 
exhalations from this tree that the climate of Aiken owes 
much of its well-deserved reputation as a health resort 
for persons suffering from all forms of disease affecting 
the respiratory tract. The other chief factors in produc- 
ing the healthfulness of this now celebrated resort are the 
mildness and general equability of its winter climate ; the 
preponderance of bright sunny days, which enable the in- 
valid to pass much of his time in the open air ; the pro- 
tection against the wind afforded by the dense growth of 
forest trees ; and last, but by no means least, the remark- 
able dryness of the air, already alluded to, and depending 
upon the peculiar character of the soil and the distance 
from any large body of water. With the exception of 
certain stations lying in close proximity to, or west of the 
Rocky Mountains, no drier air is to be found in the whole 
United States, and, so far as present observations extend, 
none so dry as that which exists at Aiken. As might well 
be expected from what has been stated above, there are no 
marshes about Aiken, and Doctor W. H. Geddings, a well- 
known writer on climate and health resorts, and a prac- 
tising physician resident in the town, makes the following 
statement in a letter received from him a short time ago : 
" Malaria is remarkable for its absence. During a practice 
of fifteen years I have never known a case to originate 
here." From the dryness and warmth of its climate it 
may well be inferred that cases of gout and of rheuma- 
tism would also be benefited by a sojourn at Aiken. In 
support of the greatly beneficial effect produced by a resi- 
dence at Aiken upon cases of pulmonary phthisis, the fol- 
lowing statistics from the pen of Dr. Geddings are sub- 
joined Out of a total number of 113 cases of this disease 
treated at Aiken during a period of three years there 
were : Arrested, 17 cases, ci- 15.3 per cent. ; improved 
50, or 44.6 per cent. ; unchanged 10, or 8.8 per cent. ; the 
number of patients who grew worse was 29, or 25.3 per 
cent. ; the number of those who died was 7, or 6.3 per 
cent. 

These statistics, which certainly speak well for the cli- 
mate of Aiken, were originally published in an article 
contributed by Dr. Geddmgs to the New York Medical 
Record (January 14, 1883). 

It is almost superfluous to call attention to the fact 
that inasmuch as cases of so grave a disease as pulmo- 
nary phthisis derive so much benefit, patients suffering 
from the less serious and less severe affections of the res- 
piratory system, such as laryngitis and naso-pharyngeal 
catarrh, may be expected to derive, and, as experience 
has proved, actually do derive an equal and even greater 
degree of such benefit from a resort to this favored spot 
during the colder, damper, and more changeable months 
of the year. 

To illustrate the comparatively small amount of varia- 
bility in temperature possessed by the climate of Aiken 
the following figures are quoted from •' Appletons' Hand- 
book of Winter Resorts. " The figures show the mean va- 
riation of temperature in twenty -four hours for the seven 
colder months of the year. The length of the period of ob- 
servation, whether for one year or for several years, is not 
stated by the writer in 'Appletons' Handbook," but the 

90 



figures were " compiled from reports on file at the Signal 
Office, Washington." 



Month. 


Sept. 


Oct. Nov. 


Dec. Jan. 


Feb. March. 


Daily variation 


10.03° 


ir.OS" 18.26° 


18.06°|l2.45° 


19.14° 17.64° 



A table shovdng this same factor of dally mean variation 
of temperature during the year 1873, but which, unlike 
the former table, is based upon the tri-daily observations 
at the hours of 7 a.m., 2 p.m., and 9 p.m., instead of upon 
observations recorded from the maximum and minimum 
thermometers, is also given by Dr. Geddings on page 23 
of the little pamphlet entitled, "Aiken, S. C, as a win- 
ter Resort." For further illustration of this same point 
these figures of Dr. Geddings are likewise herewith ap- 
pended. 

Obsebvations of 1873. 



Month. 


Jan. 


Feb. 


March. 


April. 


Sept. 


Oct. 


Nov. 


Deo. 


Mean diurnal 
range 


12.96° 


10.98° 


13.45° 


15.66° 


10.46° 


14.19° 


12.45° 


13.00° 



The following figures, showing the mean temperature at 
Aiken for each of the twelve months, for each of the four 
seasons, and for the year, are quoted from "Smithsonian 
Contributions to Knowledge," No. 377. The observa- 
tions upon which these figures are based were taken at 7 
A.M., 2 P.M., and 9 p.m., (by Messrs. H. W. Ravenel, J. 
H. Cornish, and Newton), and extended over a period of 
seventeen years, from January, 1853, to December, 1869. 



January 

February... 

March 

April 

May 


... 44.15° 
.. 47.83° 
... 6.3.22° 
... 61.49° 
... 69.25° 
... 76.08° 


July 

August 

September... 

October 

November. . . 
December. . . 


.. 78.f0° 
.. 77.19° 
.. 72.83° 
.. 61.80° 
.. 51.84° 
.. 45.48° 


Spring. 

Summer. . . 
Autumn.. . . 
Winter 


... 61.32° 
... 77.86° 
... 61.96° 
... 46.82° 
«1 «1» 


June 





The mean relative humidity for the year at Aiken, ac- 
cording to a footnote appended to his observations con- 
cerning the climate of that place, which are given by Dr. 
Geddings on pages 19 to 30 of " Aiken, S. C, as a Winter 
Resort, is fifty-eight per cent. The chart next following 
gives meteorological data of various sorts for the six months 
of the year during which Aiken is commonly resorted to 
by invalids, and for its careful filling out the writer is 
much indebted to Dr. Geddings, through whose kindness 
the proper figures were obtained. 

The water-supply at Aiken is chiefly derived from 
wells, which have to be sunk to a depth of about one 
hundred feet. In its character this water is pure and 
palatable, and it is said to be quite free, not only from all 
admixture of animal or vegetable matter, but also from 
any mineral ingredient except iron, a certain proportion 
of which is to be found in the water derived from some of 
the natural springs. The sandy roads leading in various 
directions through the pine woods afford ample facilities 
for driving and riding. 

HoTBLB, Etc. — Aiken is justly celebrated among the 
health resorts of the Southern States for the excellence of 
its hotels. The largest and best known of these is the 
Highland Park Hotel, which not only provides for its 
guests an abundant and well-supplied table, but also pos- 
sesses many other conveniences, and stands upon a reservar 
tion of ground extending over no less than two hundred 
and fifty acres of forest-land. The Park Avenue Hotel is 
under the same management and proprietorship as the 
Highland Park Hotel. Besides these two, the contributor 
of the article on Aiken, in "Appletons' Handbook of 
Winter Resorts," makes favorable mention of the Aiken 
Hotel, and of the Clarendon, and further states that " a 
group of neat cottages " exist, which are let to families, 
and that " there are many boarding-houses in the town, 
charging from ten dollars to twenty dollars a week." In 
repljr to an inquiry concerning the educational facilities 
existing at Aiken, Dr. Geddings informs the writer, in a 
letter bearing date of January 30, 1885, that " there is no 
first-class school for advanced pupils, but, on the other 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 



Aiken. 
Alnhum. 



hand, there are abundant opportunities for the best pri- 
vate instruction in English, classics, and music." In con- 
clusion, it may be added that, situated as it is upon the 



line of the South Carolina Railroad, Aiken is extremely 
easy of access to travellers from all parts of the United 

States. 



OUrmte of Aiken, S. G.— Latitude 33° 33", Longitude 81' Z4!'— Period of Observations, 1873 to 1884^JSl6vation of 
Place above the Sea Level, 565 feet— Name of Observer, W. H. Gbddings, M.D., Aiken, 8. O. 



January. . 
February. 
March.... 

April 

November 
December 

Winter'.'."! 



temperature of months 
at hours of 



7 A.M. 

Denrees 
&.21 
48.24 
49.03 
57.12 
48.68 
41.81 



2 p.m. 

Degrees. 
53.35 
56.99 
63.82 
70,80 
60.87 
54.25 



9 P.M. 
Degrees 
«.74 
49.75 
56.38 
62.72 
53.03 
46.81 



(Feb., March, and April. ) 
(Nov., Dec, and Jan.) 



II 



1^ 



48.01 
49.93 
58.40 
68.34 
53.88 
47.42 

56.55 
49.77 



Mean temperature 
for peiioa of ota- 
serration. 



Highest. 

Degrees. 
EB.OO 
58.27 
61.87 
66.13 
59.80 
54.83 

58.74 
53.06 



Lowest. 

Degrees. 
41.38 
45.85 
.51.48 
60.63 
50.33 
37.13 

53.44 
47.06 



Degrees. 

7S;54 
78.41 
84.00 
76.72 
70.45 



D 






Degrees. 
20.80 
26.27 
30;64 
41.57 • 
27.63 
20.81 



Absolute maximum 
temperature for 
period. 



Highest, 
Degrees. 

82 
84 
89 

81 
75 



Lowest. 
Degrees 



66 
74 



71 
61 



Absolute minimum 
temperature for 
period. 



Highest. 
Degrees. 

34 
39 

48 



Lowest. 
Demrees. 

18 
23 
40 
22 
03 






H 



feg -I 

J P w 



January. . , . 
February... 

March 

April 

November. . 
December . . 

Spring 

Winter 



Degrees. 
70 
64 
61 
49 
59 
72 

71 

78 



it 

si 



Per cent. 
65.03 
54.13 
49.00 
53 90 
63.67 
61.59 

52.34 
63.43 



19X 

w 

20)4 

64M 

59X 



Inches. 
3.64 
3.26 
4.86 
4.71 
3.43 
3.28 

12.83 
10.35 



.9 



From 
S.W. and W. 

S.W. 

S.W. 

S.W. 

S.W. 
S.W. and W. 

S.W. and W. 

S.W. 



.a ^ 
■g 



I S3 



Miles. 
3.60 
8.70 
3.28 

No obs. 
2.46 



3.49 
3.09 



NOTK— .Aiken being a voluntary station of the United States Signal 
Service, the hours of the tri-daily observations of temperature differ from 
those observed at the regular stations. The term " fair," in column L, is 
not employed in the purely technical sense adopted in the charts from reg- 
ular stations. Attention is called to the fact that in this chart Pabiuary is 
reckoned among the Spring months, and November among the Winter 
months. 

Huntington Richards. 

AINHUM, A disease, supposed to be a form of sclero- 
derma, occurring in one or more of the extremities, and 
resulting frequently in gangrene or spontaneous amputa- 
tion of the distal end of the affected member. It was first 
clearly described by J. F. da Silva Lima, a physician of 
Brazil, in 1867 ("Estudo sobre o ainhum," Gaz. Med. 
de Bahia, No. 1, 1867), although isolated cases had been 
previously reported by others. In the cases seen and 
studied by him, the disease was confined to the negro 
race, and the morbid process involved only the little toe 
of adults. It began as a slight depression on the plantar 
aspect of the metatarso-phalangeal articulation of the fifth 
toe, gradually increasing in extent until a distinct sulcus 
was visible, entirely surrounding the digit. The constric- 
tion growing deeper, the distal end was, in time, sepa- 
rated from the foot, retaining its connection only by a 
slender pedicle. The separated toe was sometimes un- 
changed in appearance and structure,.but more frequently 
the phalanges became atrophied, and in time disappeared, 
leaving only an oval-shaped fleshy knob, united to the 
foot by a fibrous pedicle. Finally, the pedicle itself was 



destrayed, and amputation of the toe was completed. 
The limitation of the disease to the fifth toe of adult ne- 
groes, as maintained by Silva Lima and other writers on 
the subject, in Brazil, is too narrow, for later observers 
have seen an identical process taking place in others than 
adult negroes, and involving different members. It may 
occur in any race, and at any age, and may be located in 
any one or several of the fingers or toes, or even in the 
legs. It may also take place in intra-uterine life, being 
probably the most frequent cause of congenital amputa- 
tions. The progress of the disease is usually very slow, 
and it seems at times to become arrested before any very 
serious changes have been produced in the distal portion 
of the affected extremity. The morbid process may even 
cease before the constriction embraces the entire circum- 
ference of the limb, so that the sulcus forms an imperfect 
ring of greater or less extent. 

In a case of ainhum examined by Guyot, the morbid 
process was found to be located in the deeper layers of the 
dermis, and to consist in an aggregation of fibrous bands, 
running in a direction at right angles to the axis of the 
limb. The band was thickest at the centre, becoming 

fradually thinned at each side until it was lost in the 
brous tissue of the integument. These fibres contract 
slowly, like cicatricial tissue, gradually constricting the 
Umb, as "would an elastic ligature, and by compressing 
the vessels and nerves, inducing degenerative changes, 
and, finally, death of the parts beyond. The affection 
arises independently of traumatism or other external 
causes, and is supposed to be due to a disturbance of the 
trophic nervous centres. If the disease is seen to be ad- 
vancing, and to threaten the function or the life of the 
limb, an endeavor should be made to arrest its progress 
by practising one or more incisions through the constrict- 
ing band in a line parallel to the axis of the limb. If this 
procedure do not suffice, the fibrous band should be dis- 
sected out. An incision is to be made on either side, 
parallel to the sulcus, and the intervening portion of in- 
tegument is then removed, care being taken to leave none 
of the transverse fibres. The gap remaining after the 
exsection of the sclerosed strip of skin is bridged over 
by direct approximation and suture of the edges of the 
wound. Only one-half of the circumference should be 
removed at one time, the remaining portion being excised 
at a subsequent operation. 

For a more extended description of this disease the 
reader may consult: Fox and Farquhar, " On Certain 
Endemic and other Skin Diseases of India," London, 
1876; L. P. Despretis, "fitude sur Tainhum," Mont 



91 



Alnhnm. 
Air. 



REFERENCE HANDBOOK OP THE MEDICAL SCIENCES. 



pellier, 1873 ; P. Reclus, " Amputations congenitales et 
Ainlium " Paris, 1884 ; L' Union MMieale, October 18, 23, 
and 35, 1883 ; and other French, Spanish, and Portuguese 
periodicals of recent years. TTumas L. Stedman. 

AIR. The atmosphere, according to the chemist, con- 
sists of a mixture of two gases, oxygen and nitrogen. 
The former is active in its properties, combining with 
many susceptible elements, and especially with the carbon 
and hydrogen of devitalized organic matter, constituting, 
according to the rapidity of the process, either oxidation 
or combustion, and with the same elements in the living 
tissues of animals constituting one of the essentials for 
the continuance of life. The latter is passive, negative, 
and merely diluent. 

, Oxygen forms 20.96 per cent, by volume of the gaseous 
mixture ; and this proportion is preserved in all parts of 
the atmospheric ocean. Specimens taken from the sea 
level, and from the mountain-tops give practically the 
same percentages, a result due to the constant motion 
produced by cosmical forces, and especially to the power 
of diffusion or penetration into inter-molecular areas 
which gaseous molecules are known to possess. _ Ref- 
erence is here made only to the general constitution of 
the. air. Samples taken from enclosed localities where 
deteriorating agencies prevail, as in an unventilated and 
occupied school-room, church, theatre, etc., will, of ne- 
cessity, show a diminished percentage of oxygen. 

A certain small percentage of the oxygen of the air 
exists in the form of ozone, a peculiar modification of 
oxygen which, although much studied since first dis- 
covered by Schonbein in 1840, has yet to have its chemical 
and natural history fully written. Its nature is uncer- 
tain, but it is generally regarded as OjO. The quantity 
present in the air cannot be determined, and even its 
existence is at times indicated with doubt by the iodized 
starch papers which have been largely used for its detec- 
tion, as they are affedted by other matters, as nitrous acid 
and peroxide of hydrogen, occasionally present in the 
atmosphere. Iodized litmus papers have been shown by 
Dr. Fox to be of value as a qualitative test, and as indi- 
cating comparative quantities when known volumes of 
the air are aspirated over them. It is certain, however, 
that ozono has stronger affinities than ordinary oxygen, 
and that oxidation goes on more rapidly in its presence 
than in its absence. It undoubtedly destroys the volatile 
substances which are evolved during the putrefactive 
process. Where foul organic odors are present, ozone is 
absent. Hence, when the presence of ozone is indicated 
by the test-papers, the air is regarded as free from organic 
contaminations susceptible of oxidation. But there are 
grounds f oi supposing that the specific contagia are not 
destroyed by it. (See Malaria.) 

In the atmosphere, however, the chemist recognizes 
the existence of small and varying quantities of matters 
accidentally present, such as carbonic acid, ammonia, 
watery vapor, and organic matter. 

The ca/rbonic acid is produced by the oxidation of 
carbon in dead and living tissues, and its percentage 
varies with the local causes which determine its produc- 
tion. Thus it is greater in the alleys and streets of a city 
than in the open country ; and, as this gas is soluble in 
water, its proportion varies with the hygrometric and 
other conditions, being greater in a damp atmosphere, 
before rain has fallen, than in the air of the same locality 
after the watery vapor has been precipitated. The wind 
and the diiBEusive power of gases tend to equalize the 
percentage; but, as production is constant in certain 
localities, the air of these must always show a larger 
proportion of this gas than that of others remote from 
such sources. It is generally stated that 4 volumes of 
carbonic acid are found in 10,000 volumes of atmospheric 
air ; and this, according to the writer's experience, may 
be accepted as the average. In 1881, in connection with 
a report on the ventilation of the public schools of 
"Washington, D. C, he found in the air of the streets of 
the city, a little over or a little (inder 4 volumes in 10,000 ; 
but on one occasion 4.9 volumes were obtained, and on 
another 2.2 volumes. Two years before this he got 



similar results from the air of the Capitol grounds, 
while engaged in an investigation having reference to 
the ventilation of the House of Representatives ; and, in 
the spring of 1874, in a series of examinations into the 
ventilation of soldiers' quarters, at Fort Bridger, Wyo- 
ming Territory, he found a steady and gradual decrease, 
day by day, as the season advanced, from 4.5 to 2.6 
volumes per 10,000. 

Some points have been determined concerning these 
tides in the carbonic acid volumes, especially by the ob- 
servations of De Saussure ; but, practically, no one can as 
yet predicate, from the experiment of one day, the prob- 
abilities as to the result of that of the next. Carbonic 
acid in the air of dwellings has, as will be shown here- 
after, an important bearing on the subject of ventilation. 

Ammonia emanates and is diffused from putrefactive 
processes in progress on the surface of the earth. It is 
also produced from the nitrogen of the atmosphere by 
electric agency, as during thunder-storms. Its quantity 
is variable, but 0.1 mm. in a cubic metre of air is a not 
unusual amount. This corresponds to a grain in about 
33,000 cubic feet. In a series of analyses of the free ex- 
ternal air, preliminary to an investigation of its abnormal 
conditions, the writer frequently obtained this quantity. 
Rain washes the ammonia from the air to the surface of 
the earth, and in the rainfall it may always be detected 
and measured. Its quantity is increased during thunder- 
storms. It varies from less than 0. 2 to more than 0. 5 mm. 
per litre (one grain in from 84 to 86 U.S. gallons). In 
dealing with cubic feet of air the ammonia is necessarily 
a very minute quantity, but when the annual rainfall 
over a tract of country is made the basis of calculation, 
the subject becomes one of importance in agricultural 
chemistry. 

The ammonia of the air is condensed on exposed sur- 
faces, and R. A. Smith has suggested that the quantity 
of ammonia deposited on a given surface in a given time 
may be taken as an exponent of the sanitary condition of 
the atmosphere. A glass or other surface which has been 
exposed for some time in an unventilated bedroom, when 
washed with pure water, will show in the washings the 
presence of a readily determinable quantity of ammonia ; 
but the attempt to demonstrate the relative purity of 
atmospheres by the quantity deposited on equal and sim- 
ilar surfaces in equal periods of exposure meets with 
failure unless the temperature, the hygrometric condi- 
tion, and the air movement are the same in both instances. 
This concurrence of similar conditions is difficult, if not 
impossible, to obtain in practice. The writer failed by 
this method to show the presence of sewer air in an at- 
mosphere in which it was known to be present. 

Watery vapor is constant in its presence in the atmos- 
phere, but in such varying quantities that it is viewed by 
many as an accidental constituent. Its importance, how- 
ever, not only in the preservation of the purity of the 
atmosphere, but as a preservative of the vitality of all 
the organisms submerged in it, is so great that it must 
be regarded physiologically as an essential. The capac- 
ity of air for holding aqueous vapor is limited and 
varies with the temperature. When air of a given tem- 
perature is so permeated with aqueous vapor that no 
more can be taken up, it is said to be saturated for that 
temperature. Thus air at 0° C. (32° F.^ will take up and 
hold 4.875 grammes of aqueous vapor in one cubic metre 
(equivalent to 2.13 grains in a cubic foot). But It this 
same air is attenuated by increasing its temperature to 
21.1° C. (70° F.) its capacity for holding the vapor of 
water will be increased and a cubic metre will not be 
saturated until it contains 18. 334 grammes (or 8.01 grains 
in the cubic foot). Precipitation of vapor occurs when 
the air is cooled to a temperature below that which is 
needful to enable it to retain the vapor which it contains. 
If a cubic metre of air at 21.1° C. holds only 4,875 
grammes of aqueous vapor, precipitation will not take 
place until the air has been cooled to 0° C. 

The degree of temperature at which moisture begins 
to be deposited from air is called the dew-point. Wlien 
air is saturated, its temperature and the dew-point coin- 
cide. The quantity of vapor which air is capable of re 



92 



REFERENCE HANDBOOK OP THE MEDICAL SCIENCES. 



Alnliam. 
Atr. 



taining has been accurately determined for all ordinary 
temperatures. It is, therefore, only needful to ascertain 
the dew-point to learn, not only how much vapor the air 
contains, but, which is of more importance, how much 
more it is capable of taking up. As this latter quantity 
varies with the temperature and the difference between 
that temperature and the dew-point, medical climatolo- 
gists have endeavored to effect a uniformity in their 
records by expressing the results of such observations in 
terms of relative humidity, saturation being represented 
by 100. The dew-point may be obtained, after Regnault's 
method, by evaporating ether in a test-tube containing a 
sensitive thermometer, and noting the temperature when 
the surface of the tube becomes dimmed by deposited 
vapor from the air. But it is usually calculated from 
the difference between the dry and wet bulbs, and the 
relative humidity is obtained therefrom by the use of 
Glaishers' tables. 

The air constituents which have been mentioned must 
be regarded, from the scientific and sanitary point of 
view, as individually essential to the constitution of the 
atmosphere. The oxygen is vital to animals, its quan- 
tity being preserved by the evolution from vegetation 
and the equilibrium established between these two king- 
doms of nature. The carbonic acid is vital to vegetation, 
being the source of much of the carbon solidified in its 
tissues ; its quantity is preserved by the evolution from 
animals and by the retrogressive metamorphosis of the 
organic carbon of devitalized tissues. The ammonia is 
needful to the building up of organic structures by veg- 
etable life, which afterward figure in the life-history of 
the animal kingdom, and which, when ultimately over- 
taken by death, are returned to the ammoniacal condi- 
tion by the agency of microscopic organisms. The ni- 
trogen is primarily a diluent presenting the oxygen to 
the animal kingdom, and the carbonic acid to vegetation, 
in the strength best suited for their respective needs. 
Speedy death occurs to the animal organism exposed to 
an atmosphere of undiluted oxygen from exaggeration 
of the vital actions. Presumably a similar effect would 
be produced on the vegetation of to-day by a carbonic 
acid atmosphere, for, if we look back through the geo- 
logic eras to the time when a carbonic acid atmosphere 
enveloped the earth, we find the genera then living 
wholly different from those which are now their succes- 
sors under different conditions. But there is ground for 
supposing that the inorganic nitrogen of the air is a 
store from which the organic kingdoms may draw sup- 
plies. Nitrogen is transformed into ammonia and nitrous 
acid by electrical agency, and thus becomes susceptible 
of assimilation by the vegetable kingdom. The name 
asoie, originally applied to this gas by the chemists, be- 
cause animal life could not be sustained in it, is a mis- 
nomer. Without nitrogen there is no life. Some of the 
products of vital action, as the fats and starches, contain 
no nitrogen, but the active tissues of vitality which elab- 
orated these carbonaceous products are nitrogenous. 
Watery vapor prevents desiccation. Without a certain 
relative humidity life, vegetable or animal, would be an 
impossibility. As the fish dies when taken from the water, 
though in a medium which is richer in oxygen than is its 
natural habitat, so would all air-breathing organisms 
perish were the humidity of the atmosphere removed. 
But this water, by its absorption into and deposition 
from the atmosphere, under altered conditions as to 
temperature, exercises another and most important func- 
tion. Among what may be considered, in accordance 
with our present knowledge of vital actions, as the 
purely accidental substances found in the atmosphere, 
particulate matter in fine division, in other words, the 
dust of the earth, occupies a prominent place. As the 
earth is composed of organic and inorganic, living and 
dead matters, its dust is of similarly varied composition. 
Among the various species of the genus dust are some 
which, as will be shown hereafter, are exceedingly dele- 
terious to animal life ; but the greater number in the 
quantity usually present in the air are individually and 
collectively harmless. Nevertheless, without the aque- 
ous vapor, there is no provision of nature by which life 



may be preserved from suffocation by this otherwise 
harmless dust. With the reduction of the atmospheric 
temperature to a point below the dew-point, water is lib- 
erated and precipitated to the surface of the earth, carry- 
ing with it all particulate matters which would otherwise 
accumulate without end. The clearness of the atmos- 
phere after a rain-storm, which has been preceded by a 
period of dry weather, is a matter of common observ- 
ance, and can be readily understood. The impurities 
are washed to the surface. Rain-water is the sewage of 
the atmosphere. 

The matters occasionally or accidentally present in the 
atmosphere are gaseous or solid. Of the former, carbonic 
acid in excess of the average quantity must be regarded 
quantitatively as the most important. Its sources are or- 
ganic decomposition as occurring in the soil, animal res- 
piration, and the combustion of fuel. Hence it is found 
in excess or as an impurity at or near the surface of the 
ground in the narrow streets of closely built cities, and 
within the walls of occupied buildings. Carbonic acid 
is probably harmless per se, unless in very unusual quan- 
tities, but as its sources, in most instances, evolve also 
matters which are harmful, its presence is of much im- 
portance. Coming from the interstices of the ground or 
from the sewers, carbonic acid may be accompanied by 
specific miasms. In the former instance it may be sug- 
gested that the specific miasms, being particulate, are re- 
moved by the filtration which the air undergoes. It is 
well known to every experimenter that a plug of cotton- 
wool will protect a sterilized culture-fiuid from impreg- 
nation by the germs of putrefaction — that is, that the 
wool will act emciently as a filter when the air-current is 
only such as is caused by variations in temperature and 
barometric pressure. Professor Pumpelly has shown 
that asbestos, sand, and other dry filters are efficient 
against putrefactive agencies even when the air is drawn 
rapidly through them. Moreover, the writer knows, by 
experiments performed for the National Board of Health, 
and as yet unpublished, that the nitrogenous matters of 
sewer, garbage, and marsh airs are particulate and sus- 
ceptible of removal by filtration. But it remains to be 
proved that such nitrogenous particulate substances are 
removed by a filtration through the organic matrix, the 
soil, in which they are multiplying. Besides, in this ques- 
tion, evaporation from the surface is involved as well as 
filtration through the substance. The passage of air 
through and from the soil promotes evaporation from the 
surface, which carries with it the miasmatic exhalation. 
Hence may be inferred the inadvisability of furnishing 
cellar air, or air introduced by tunnels into a building for 
purposes of ventilation. In fact cellars, in default of an 
impermeable lining, should have a free circulation of air 
separate from the ventilation system of the superimposed 
building. 

Carbonic acid from the consumption of fuel and gas, 
while injurious by diminishing the proportion of oxygen 
in the air furnished for respiration, may be accompanied 
by other and more deleterious gases, such as carbonic 
oxide and sulphurous acid. One cubic foot of gas, ac- 
cording to Parkes, destroys in its combustion the entire 
oxygen of eight cubic feet of air. Carbonic acid as the 
result of animal respiration is accompanied by organic 
exhalations which are well known to be deleterious, pro- 
ducing headache and febrile action when the exposure is of 
short continuance, and predisposing to pulmonary affec- 
tions, phthisis, and typhous conditions when the exposure 
is habitual. Specific miasms or contagia, if present, are 
generally concentrated in proportion to the percentage of 
expired carbonic acid in the air. Hence the examination 
of the air of an occupied building usually resolves itself 
into a determination of the amount of carbonic acid 
present in it ; not because this gas is of much importance 
in itself as compared with the organic matters which are 
eliminated with it from the human system, but because 
both being the result of the same vital processes, pul- 
monary and cutaneous exhalation, the amount of the one 
may be taken as an expression of the quantity of the 
other. These organic matters are susceptible of separa- 
tion into particulate and gaseous ; the vital qualities of 



93 



Air. 
Air. 



EEFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 



the former may be examined microscopically by cultures 
and by inoculation, and the elementary analysis of both 
may be effected with the utmost accuracy ; but the col- 
lection of the organic matter for such quantitative ex- 
periments involves a tedious filtration, during which the 
character of the air to be examined may become ma- 
terially changed, and when collected the experimental 
proces'ses to which it must be subjected requires so much 
care, time, and experience in this special line of sanitary 
work that in practice the organic matter is seldom deter- 
mined. The carbonic acid, on the other hand, is quickly 
collected, readily and accurately estimated by any one 
who possesses experimental tact, and an experience of 
general volumetric analysis. It has therefore become the 
exponent of ths respiratory impurity of air ; the increase 
In its amount over that present in the external air being a 
measure of the respiratory use to which the air has been 
applied and of its fitness or unfitness for further use. In 
estimating the carbonic acid an alkaline solution of baryta 
or lime of known strength is used for its absorption, and 
the loss of alkalinity, as subsequently determined by 
some other acid, gives the figures from which the ab- 
sorbed carbonic acid may be calculated. 

The practical details are as follows : A solution of pure 
oxalic acid is made of such strength (3.864 grammes per 
litre) that one gramme will neutralize as much caustic 
baryta as may combine with one milligramme of carbonic 
acid. A baryta solution of equivalent strength, one 
gramme of the one neutralizing one gramme of the 
other, is then made and immediately transferred to bottles 
of from 50 to 60 c.c. capacity (two-ounce vials), each of 
which is corked securely and weighed, and the total 
weight of the bottle and its contents is marked upon the 
label. The air to be examined is collected in a clean and 
perfectly dry clear glass bottle or narrow-mouthed jar, 
the capacity of which is accurately known. Ten-litre 
bottles are large enough to give accurate results. A rub- 
ber tube and small bellows are conveniently used in fill- 
ing the jar with the air to be examined, but care must be 
taken that the air entering by the valve of the bellows is 
not contaminated by any direct respiratory streams from 
individuals present. As soon as the charge of air has 
been effected, one of the prepared baryta vials is care- 
fully uncorked and its contents poured into the jar, 
which is then closed by an accurately ground stopper, or 
preferably by a tightly fitting rubber cork. The baryta 
solution is then shaken in the jar, and made to flow all 
over its interior to promote its contact with the contained 
air ; but to insure thorough absorption of the carbonic 
acid the jar is usually permitted to stand until the follow- 
ing day before determining the loss of alkalinity. Mean- 
while the volume of the air operated on is ascertained 
from observations made at the time the air was collected. 
The height of the barometer and of the dry and wet bulb 
thermometers must be known, and the quantity of baryta 
solution introduced into the jar. The last is obtained by 
weighing the now empty vial in which it was stored and 
deducting this weight from the gross weight marked on 
the label. The quantity in grammes of the baryta solu- 
tion employed must be deducted as cubic centimetres 
from the known capacity of the jar. But in order that 
experimental results may be susceptible of comparison 
it is necessary to express the air-volume in the space 
which it would occupy when dry at zero Centigrade and 
under a pressure of 760 millimetres of mercury. In- 
creased pressure diminishes the volume of air, increased 
temperature expands it, and the pressure of the watery 
vapor present must also be taken into account. The 
temperature observations furnish the dew-point, and 
through it from the observations of Regnault the press- 
ure or tension of the aqueous vapor may be obtained. 
If p represents this pressure, t the temperature in Centi- 
grade degrees, * the barometric height in millimetres, 
and Fthe capacity of the jar, minus the number of cubic 
centimetres of baryta solution introduced, the corrected 
volume will be equal to 



V(b-p) 273 
(273 + t) m 



Next day the liquid contents of the jar are transferred to 
a small beaked flask or alkalimeter, and the weight of 
the flask and its contents is noted, that, by again weigh- 
ing, the loss of weight may indicate the quantity used in 
the subsequent experiment. Ten grammes of the oxalic 
solution are weighed into a smpjl beaker and colored 
with a few drops of tincture of litmus. Into this the 
deteriorated baryta solution (after the carbonate present 
has settled) is dropped from the alkalimeter rapidly, until 
a haziness is developed, and after this more slowly until 
the last drop changes the color to a dark purple. The 
oxalic acid has been neutralized, and the weight lost by 
the alkalimeter gives the quantity of the baryta solution 
used in effecting the neutralization. Let it be supposed, 
for example, that 50 grammes of the solution were in- 
troduced into the jar, and that 25 grammes of it are now 
required to neutralize 10 grammes of the standard acid, 
the total of 50 grammes will suffice to neutralize only 
20 grammes of the oxalic solution, while before absorb- 
ing the carbonic acid of the bottled air it was capable 
of neutralizing 50 grammes. There has therefore been 
removed by this carbonic acid as much baryta as would 
neutralize 80 grammes of the oxalic test, or, in other words, 
30 milligrammes of carbonic acid were contained in the 
air which was the subject of the experiment. 

The weight of the carbonic acid in milligrammes when 
multiplied by the factor .50685 gives expression to its 
volume in cubic centimetres. It must be remembered, 
however, that this volume of carbonic acid is not all 
carbonic impurity, but includes that which is naturally 
present in the air. When the result of a cotempo- 
raneous experiment on the external air has been de- 
ducted, the remainder indicates the carbonic acid due to 
imperfect ventilation. 

An easily applied method of ascertaining whether a 
given air contains more than a certain number of volumes 
of carbonic acid per ten thousand is based on the turbid- 
ity caused in lime-water by the precipitated carbonate. If 
a half -ounce of this liquid is shaken up in an eight-ounce 
vial filled with the air to be examined, the appearance of 
turbidity indicates the presence of eight or more volumes 
of carbonic acid in ten thousand volumes of the air, and 
that the arrangements for ventilation in the apartments 
which furnished the air are not as satisfactory as could 
be wished. Bottles of various sizes are used by the opera- 
tor in conducting this, the Tvousehold method of sanitary 
air analysis, and from the capacity of the bottle in which 
a just visible turbidity is produced the volumes of car- 
bonic acid per ten thousand become known. 

In another method, the minimetric, air is Introduced 
in small quantitjr into a vial containing lime or baryta 
solution, which is well shaken, with gradual additions of 
the air, until the liquid shows a certain loss of transpar- 
ency, when the carbonic acid is calculated from the 
quantity of air needful to the production of this result. 

These, although pretty experiments, and described in 
full by most sanitary writers, have not come into gen- 
eral use, because they are not required. As they yield 
results which are only approximative, they cannot take 
the place of the accurate determination needful in a 
scientific inquiry, while, as rough and ready methods, 
their results convey no more Information of practical 
value than may be gathered unpretentiously by the sen.se 
of smell. A well-ventilated room should not have more 
than one or two volumes per ten thousand in excess of 
the external air, equalling a total of five or six volumes. 
When the carbonic acid amounts to seven volumes, a 
want of freshness is recognized on entering. When nine, 
ten, or more volumes are present, the organic odor be- 
comes manifest. 

Although the carbonic acid, as has been stated, is 
generally accepted as a measure of the respiratory im- 
purity. It is not an accurate one, for it is more readily 
diffused and carried off by ventilating currents than the 
organic exhalations which accompany it from the human 
system. Whence it comes that the continued occu- 
pancy of an apartment may give rise to organic odors in 
its atmosphere, although carbonic acid may not be 
present in large quantity. The writer has frequently 



94 



EEFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 



Air. 
Air. 



detected the organic odor in barrack-rooms some time 
after the men had quitted them, when the carbonic acid, 
on account of open doors and windows, was but little in 
excess of that found in the open air. The exhalation ap- 
pears to adhere to walls and other surfaces, and textures, 
and to require time for its dissipation. 

But, while the carbonic acid is not an accurate measure 
of the organic contamination in the air of occupied build- 
ings, its estimation affords the best means of testing the 
effieieTicy of the wntilation. Sanitary inspectors do not 
recognize this fact. Sanitary chemists have not brought 
it prominently into notice. When questions of ventila- 
tion are to be settled, Cassela's air-meter is used, and 
the air movement is calculated from its indications and 
the areas of inflow and exit. The inspector shows that 
go much air has entered or that so much has escaped, to 
be replaced of necessity by a corresponding volume of 
fresh air through the inflow ducts. But this is not 
enough. It must be shown that the air introduced has 
offected the purpose for which it was introduced. This 
may be done by a calculation based on the amount of car- 
bonic impurity found by experiment. It is needful to 
know the average, rate at which carbonic acid is elim- 
inated from the person. This evolution varies according 
to conditions of rest or activity. Professor Parkes states 
the yield at from twelve to sixteen cubic feet in twenty- 
four hours, or from .5 to .66 of a cubic foot per hour. 
Huxley gives three hundred and sixty feet as the volume 
f air expired daily, and, as the air of expiration is 
known to contain four per cent, of carbonic acid, this is 
equivalent to an hourly production of .6 of a cubic foot. 
Other experimenters have arrived at similar results. This 
is a convenient number for calculation, as it corresponds 
with .01 of a cubic foot per minute. The capacity of 
the room must also be ascertained, and in exact calcula- 
tions deduction should be made for the body bulk of the 
occupants and for the furniture. The time during which 
the deterioration has been going on is another factor en- 
tering into the calculation. 

The carbonic evolution, .01 cubic foot per minute per 
person, multiplied by the number of minutes, gives the 
amount of the carbonic impurity generated. When this 
is divided by the carbonic impurity found by experiment 
in ten thousand volumes of the air, the quotient multi- 
plied by ten thousand will express, in cubic feet, the vol- 
ume of the air with which the respiratory products have 
been diluted. But, as the air-volume in the room has con- 
tributed to the dilution, its capacity has to be deducted 
from the total to obtain the amount of the inflow. 

Thus, if the data consist of 50 persons, 50 minutes, 
7,000 cubic feet, and a carbonic impurity experimentally 
found of 10 volumes : 



01 X 50 X 50 = 35 cubic feet of carbonic acid expired. 
,000 cubic feet of air requir 
18,000'onbio feet of inflow. 



-- X 10,000 = 25,000 cubic feet of air required for the dilution. 



25,000 - 7,000 

— ^— — = 360 cubic feet of inflow per minute, 
5U 

-— - = 5.1 cubic feet of inflow per minute per person. 
51) 

The inflow being known, other questions which need 
only be suggested, may be answered. An experiment has 
been made on the air of a room which contained only fifty 
persons, although seated for one hundred ; what would 
have been the result had all the seats been occupied ? 
The occupation of the room at the time of the experiment 
had continued but sixty minutes ; what would have been 
the result had the occupation lasted six hours ? 

In practice it is often found that the inflow, as deter- 
mined by the anemometer, is much greater than that ob- 
tained from the chemical results. That the air enters 
is certain, and that it fails to be utilized in diluting the 
expired air, is equally so. A want of diffusion must be 
inferred in explanation. In one of the schools of Wash- 
ington, D. C. , 800 cubic feet per minute entered the room, 
while but 324 cubic feet contributed to the ventilation. 
The cause in this instance was manifest. The tempera- 
ture of the incoming air was so great that it rose immedi- 
ately to the ceiling, whence it was drawn oflE by the 



lowered windows and foul air-flues. Somewhat similar 
conditions prevail in the Hall of Representatives in our 
National Capitol. Although the floor is largely and gen- 
erally perforated for the inflow of fau-driven air, certain 
of the ducts leading to these perforations carry a large pro- 
portion of the incoming air, while others bring but little. 
Over some of the gratings there is a vigorous current, 
over others the inflow is small. The impetus in the one 
case carries the air upward until it reaches the area influ- 
enced by the aspiration of the louvres on the roof, whence 
it is carried through the perforations in the ceiling with- 
out having been distributed in the body of the hall. 
While the spaces in front of the Speaker's desk, and in 
the centre of the hall are well ventilated by this upward 
current, the air of the sides and galleries is more or less 
stagnant. The volume of air which enters is .suflicient 
to effect a satisfactory ventilation, but it is not dis- 
tributed. The galleries are close and stuffy, while cer- 
tain of the occupants below may feel chilly in the upris- 
ing current. 

The gaseous products of fuel and gas consumption 
contain traces of ca/rbonic oxide, if the oxidation is not 
complete. This gas is highly poisonous, entering the 
blood and rendering the red corpuscles incapable of per- 
forming their function, even though pure air be after- 
ward supplied. Death is the result of asphyxia. In 
rooms heated by stoves the headache, languor, and op- 
pression occasionally produced are due to the escape of 
this with other gaseous products through the open stove- 
doors and leaky joints. Some experiments of St. Claire 
Deville and Troost indicated that the carbonic oxide 
might even pass through the pores of cast iron when the 
metal became strongly heated. The French Academy, 
therefore, caused an investigation to be made of this sub- 
ject, and the conclusion was reached that carbonic oxide 
does pass through the metal when its temperature reaches 
a dark-red heat. Since these experiments air heated by 
furnaces or cast-iron stoves has been regarded as in- 
jurious. But doubt has been thrown upon the results of 
the French chemists by several later experimenters, and 
particularly by Professor Reinsen, of Baltimore, Md., 
who has shown some possible sources of error, and who, 
having guarded against these, has concluded that, while 
carbonic oxide may be present in the air of furnace- 
heated rooms, it must exist in quantities so minute that 
it is questionable- if it can act injuriously on the health of 
those who breathe it. 

Carburetted hydrogen and sulphurous acid are liber- 
ated during combustion, but in such small quantities that 
they need not be considered as influencing the health. 

The gases evolved during the putrefaction of organic 
matter, as in impure soils, manure piles, cesspools, vaults, 
.drains, and sewers, consist of carbonic acid, nitrogen, sul- 
phuretted hydrogen, ammonium sulphide, carburetted 
hydrogen, and organic vapors. The action of the sul- 
phur gases on the animal system has been demonstrated 
experimentally by Barker on dogs and other small ani- 
mals. Sulphuretted hydrogen produces vomiting and diar- 
rhcea, prostration and coma, which last, like the effects 
of carbonic oxide, persist after removal from the con- 
taminated atmosphere. The exhaustion and coma con- 
tinue, and death results if the impression fixed on the 
blood is sufficiently powerful. But, while this undoubt- 
edly occurred in the subjects of Dr. Barker's experi- 
ments, it is well known that men may breathe with im- 
punity for a time a sulphuretted atmosphere many times 
stronger than those employed by him. Sulphide of am- 
monium, according to this experimenter, caused vomit- 
ing and febrile action, quickly followed by the develop- 
ment of a typhoid condition. In fact, he considered the 
sulphuretted hydrogen similar in its action to the poison 
of typhus, and sulphide of ammonium to that of typhoid 
fever. 

Chronic poisoning by sulphuretted hydrogen mani- 
fests itself, according to some observations, by gi-adual 
prostration, emaciation, anri anaemia, with headache, foul 
tongue, anorexia, and the occasional eruption of boils, 
but it is not certain that these symptoms are due to this 
gas and not to organic miasms which may accompany it. 



93 



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Air. 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 



The action of the more complex organic vapors given 
off during decomposition has not been determined. 1 he 
dogs subjected by Dr. Barker to the cesspool air were all 
more or less affected, the symptoms being those of intes- 
tinal derangement with prostration, heat of surface, dis- 
taste for food, and those general signs which mark the 
milder forms of continued fever common to " the dirty 
and ill-ventilated homes of the lower classes of the com- 
munity." But the sulphur compounds already men- 
tioned contributed to these results. 

Even the constitution of these organic vapors is not 
known with certainty. Dr. Odling distilled half a gal- 
lon of the liquid contents of a cesspool until all alkaline 
matters had come over He treated the fetid ammoni- 
acal distillate with hydrochloric acid, and afterward pre- 
cipitated with platinum. The platino-chlorides of the 
organic alkalies were found to crystallize in well-deflned, 
flattened, orange-colored tablets, evidently not the platino- 
chloride of ammonium. Incineration of this platinum 
salt yielded 41. 30 per cent, of the metal, while the platino- 
chlorides of ammonium, methylamine and ethylamine 
gave respectively, 44.36, 41.64, and 39.40 per cent, of 
platinum. The salt formed from the carbo-ammoniaml 
vapors was analogous in composition to that formed with 
methylamine. But inasmuch as the crystals were more 
like those of the ethyl salt, and as a mixture of the ethyl- 
amine and ammonium salts would correspond in per-, 
centage composition to that obtained from the distillate, 
he supposed .that the sewage emanations were ammoni- 
acal and ethylic. 

A series of experiments made by the writer has shown 
that the volatile matters evolved during the fermentative 
changes in organic substances are of two different char- 
acters, the one vaporous and ethylic, but not containing 
nitrogen if separated from the ammonia with which it is 
volatilized and condensed, and the other volatile, car- 
bonaceous, and solid, concreting on distillation into 
white, soft, and greasy particles. The former has a dull, 
mawkish, not positively unpleasant, odor, the latter a 
strong and intensely disagreeable smell. 

The solid matters disseminated in the air consist, first, 
of minute particles of inorganic matter, such as soot, 
amorphous silicates, irregular fragments of hard mineral 
dust, and crystals of salts, many of which have not been 
identified ; secondly, of the detritus of decaying vegeta- 
tion, starch-cells, epidermal hairs, filaments from the 
pappus of the compositae, pollen grains, etc. ; thirdly, of 
fragments of animal tissues, epidermal and epithelial 
scales, woolly fibres, plumelets of feathers, butterfly 
scales, and other debris of insect life, etc. ; and fourthly, 
of micrococci, bacilli, the spores of fungi, and rarely the 
germs of infusorial life. It is probable that among the 
micrococci and spores are included the essence of many 
of the specific diseases which affect the vitality of the 
higher organisms. (See Bacteria.) 

The microscope has separated the organic matter of 
the air into the living and the dead, the animal and the 
vegetable, and biological experiment has determined the 
life history and function of many of these living forms. 
On the other hand, chemistry has done but little to per- 
fect the oi-ganic analysis of air. "With known methods 
of analysis the results obtained by the expenditure of 
much time and care are of small value. If an air-speci- 
men contains an unusual amount of the organic ele- 
ments, it may be correctly considered as impure, but the 
nature of the impurity is not defined. The. carbon esti- 
mated may have been a harmless particle of soot, or in 
part it may have been essential to the spread of a deadly 
disease. Nevertheless, analyses are made as a matter of 
official routine by sat''tary officers in England and France. 
The organic substani, ?s are absorbed by aspirating large 
volumes of the air thi ugh a small volume of distilled 
water, and the liquid menstruum is then investigated by 
the processes of water analysis. Professor Remsen, of 
the Johns Hopkins University, Baltimore, Md., endeav- 
ored to improve on this process by filtering the air 
through powdered and moistened pumice before pass- 
ing it in fine bubbles through the distilled water. He 
thus snowed that, so far as could be determined by 



chemical means, all nitrogenous matter was retained by 
the filter. But, as germs or microscopic organisms might 
have passed through without thus showing their pres- 
ence in the absorbing liquid owing to the necessarily 
minute trace of nitrogen in them, the writer planned and 
carried out for the National Board of Health a series of 
experiments which determined, first, that the nitrogenous 
matter of air, excluding ammonia from consideration, is 
particulate ; second, that it consists in large part of 
micro-organisms ; and third, that filtration through Aus- 
trian glass-wool effects their removal from the passing 
air. The experiments were conducted in a sterilized ap- 
paratus. The air was drawn through a short glass tube 
one centimetre in diameter, lightly packed for two or 
three inches of its length with the glass wool. From 
this it was passed in fine division through pure distilled 
water. After this it was mixed with pure steam gener- 
ated from a dilute solution of alkaline permanganate of 
potash, the mixture immediately entering the tube of a 
Liebig's condenser, where the steam was deposited, car- 
rying down with it, after nature's process of air purifica- 
tion by the rainfall, any micro-organisms which might 
have escaped removal by filtration or absorption. The 
ditficulties in the way of sterilizing th^ various parts of 
this apparatus were such that the first experiments, which 
gave speedy developments in culture-liquids tainted by 
the filter, the absorbing liquid, and the condensate, were 
regarded only as the practical expression of these difficul- 
ties. The experiments were repeated with precautions 
suggested as necessary by the previous experience, and- 
ultimately success attended them. The culture-liquids, 
tainted with portions of the filter, became turbid in from 
two to nine days. Those impregnated with a portion of 
the water in the absorbing flask generally remained un- 
changed at the close of the experiments, three months 
and ten days after the date of the first one completed. 
Those tainted with the condensate became hazy usually 
a few days later than the liquids containing the filter 
taint ; but in two instances there were no developments, 
and in two others the haziness did not occur until three 
and five weeks, respectively, had passed. In comparing 
the results of cultivation "in the case of the filters with the 
stability of the culture-liquids in presence of the water 
from the absorbing flasks, it is evident that germs were 
removed by the glass-wool ; but that this removal was 
not thorough is manifested by the fecundity of the con- 
densate. Germs escaped the filter and passed through 
the distilled water in the air-bubbles, to be subsequently 
deposited with the vapor in the tube of the condenser. 
Ammonia, in like manner, in part escaped absorption, 
and was condensed. Nevertheless, the efficiency of the 
filtration must, in general terms be admitted, since, in cer- 
tain instances, the condensate failed to induce change 
in the culture-liquid. 

The mass of the matters collected respectively on the 
filter, in the absorber, and in the condenser were sub- 
mitted to chemical examination, the result showing the 
absence of organic nitrogen on the distal side of the glass- 
wool. 

One of the processes of water analysis to which these 
matters were subjected involved the distillation of the 
ammonia which was present in the liquid, and its estima- 
tion by the calorimetric method with Nessler's solution. 
Ammonia gives, with this test solution, a faint straw- 
yellow color, which deepens, in proportion to the amount 
of ammonia present, to a dark sherry-brown, or to a dark 
haziness or distinct precipitate. But it not unfrequently 
happened that in testing for ammonia in the distillate 
from the pure water in which the glass-wool containing 
the organic matter of the air was suspended, as well as in 
that from the absorbing liquid which contained most of 
the ammonia, and in that from the condensate which con- 
tained but a trace, a citron-green color was produced 
which marked the ammonia reaction and rendered its es- 
timation impossible. Dr. Kidder, of the Navy, observed 
this interference with the ammonia coloration, and at- 
tributed it to the presence of substances evolved in the 
putrefaction of organic matter. He concluded from the 
few experiments he made that the amines are not neces' 



96 



REFERENCE HANDBOOK OP THE MEDICAL SCIENCES. 



Air. 
Air. 



sarily concerned in its production, as he found that buty- 
ric acid gave a somewhat similar interference to that met 
with in the experiments on air-washings. But the hazi- 
ness with which the presence of butyric acid masks the 
true ammonia color is not the citron-green coloration 
which so frequently occurs in the analysis of foul airs. 
This is due to the presence of an ethyl compound which 
is given off from the carbohydrates while undergoing 
change. It may be obtained free from the ammonia 
which ordinarily accompanies it and obscures its reac- 
tion by submitting the liquid containing both to the pro- 
cess of nitrification. It may also be obtained f fom am- 
monia and free glucose, and from starch, cane-sugar, tan' 
nin, salicin, etc., after treatment with heat and acids. 
(See Water Analysis.) 

In some of the experiments referred to, the air volume, 
100 litres, was passed through the interior of a glass 
globe which contained liquid sewage and silt, garbage, 
or other foul and decomposing materials, and then 
through the glass-wool filter, absorber, and condenser to 
remove the matters with which it had become contami- 
nated. Culture experiments showed the satisfactory re- 
moval by the filter of all germs and nitrogenous matters, 
ammonia excepted and. chemical tests determined ap- 
proximately the quantity of organic matter thus removed. 
In some inst&nces a second air-volume of 100 litres was 
drawn over the organic matter in the globe, and the 
results obtained from the filter through which it was after- 
ward passed did not differ from those of the first experi- 
ment on the same organic matter. From these experi- 
ments the conclusion appears admissible that the volume 
of air which is contaminated by a certain decomposing 
organic mass is the volume which comes in contact with 
it. If no air is drawn through the foul globe, only that 
which is contained in it is rendered impure. This air has 
its oxygen in time replaced by the foul-smelling gases of 
decomposition. Evaporation takes place from the con- 
tained liquid until the stagnant and enclosed air becomes 
saturated. The ascensional force of the evaporation car- 
ries from the smeared and half -dried sides of the globe, 
and from the unsubmerged solids within it, some of the 
innumerable micro-organisms with which they are per- 
vaded, and the air becomes charged with organic particles 
to an extent proportioned to its temperature and hygro- 
metric condition. If a volume of air is drawn through 
the globe it will be contaminated by organic matters car- 
ried away by its own movement and by the increased ac- 
tivity of evaporation produced by it. If a second volume 
is drawn through, it will be contaminated in like manner, 
and to the same extent if the volume, rapidity of passage, 
temperature, and hygrometric condition are the same in 
both instances ; and so for a third, a fourth, or more vol- 
umes, until the decomposing mass has become changed 
by their agency. This is recognized practically in sani- 
tary work. The dead are buried that their decomposi- 
tion may not contaminate the atmosphere. For the same 
reason garbage is collected and removed. A receptacle 
for foul-smelling and fermenting matters is less of a nui- 
sance and less dangerous to health when fitted with an 
air-tight cover than when freely exposed to the air, for in 
the latter case every volume of air which comes in con- 
tact with it is a volume of air polluted. Sanitary of- 
ficials in growing cities protest against the continued ex- 
istence of small surface streams which of necessity pass 
into the condition of open sewers, tainting every volume 
of air which comes in contact with their foulness. These 
are bricked over and the air is preserved from the impure 
contact. But in the construction of regular systems of 
sewerage provision is made for this contact under the 
name of ventilation. The sewers are tapped at regular 
intervals along the streets for the exit of the contaminated 
air. From the present point of view this ventilation of 
the sewers is of questionable benefit. The volume of air 
rendered impure, and possibly dangerous, is proportioned 
to the thoroughness of the ventilation. Sulphuretted 

tases may be diluted, and the outflowing air be free from 
isagreeable odors, but the very air movement which ef- 
fects this may raise invisible clouds of fermentative and 
morbific agencies from the foul interior. Experiments 
Vol. L-7 



on this point would be of value. Those mentioned above 
seem to indicate that the communication with the outer 
air should only be such as is needful to relieve tension 
and prevent the forcing of seals, and that these air-holes 
should be guarded by some filtering material. But since 
the volume of air which becomes contaminated is that 
which comes in contact with the fermenting material, it 
may be reduced as well by diminishing the extent of the 
impure surface as by cutting off the ventilation. Hence 
sewers of small size, as in what is known as the separate 
system, are to be preferred, on sanitary grounds, to the 
large ramifying caverns of the combined system ; while 
the Liernur system must be regarded from this point of 
view as the perfect method of sewage removal. The foul 
airs which arise from sewer apertures are matters of 
every-day observation. If well diluted with air they may 
not affect the sense of smell, but they rise, nevertheless, 
from the grated covers on our streets, and may be seen, 
by the vapor precipitated from them, as an uprising col- 
umn in weather which clouds the air of respiration thrown 
out from the lungs. With open streets and lively breezes it 
is probable that these exhalations are dissipated, or rather 
diluted, to harmlessness, but in enclosed spaces and stag- 
nant atmospheres the sewer-air, which is so carefully ex- 
cluded from living-rooms by intelligent plumbing, may 
enter as fresh air through open windows and apertures 
specially devised for its admission. 

The influence of these particulate organic matters of 
the air on the health of those exposed to them will be dis- 
cussed under the caption Miasms. 

Before leaving the consideration of air in its sanitary 
aspects, it is needful only to refer to the influence of cer- 
tain climatic factors, which operate in a great measure 
through its medium. These are heat, moisture, and move- 
ment. The influence of varying barometric pressures 
usually finds an expression in the temperature. Heat is 
of importance in the generation and evolution of miasms ; 
but aside from this the degree of temperature of the at- 
mosphere ,s of importance to the animal economy, ac- 
cording as it does or does not necessitate an unusual 
activity of the vital energies, for the preservation of the 
animal heat. Moisture acts chiefly by interfering with 
the natural cooling process effected by evaporation from 
the skin. But the principal factor in the determination 
of climatic influences is the wind. The absolute tem- 
perature as recorded by the thermometer gives but im- 
perfect information regarding climate, unless supple- 
mented by a cotemporaneous report of the air movement, 
and unless the medical climatologist is able to appreciate 
and express in definite terms the change made by this 
movement in the value of the temperature. Zero Centi- 
grade, with no wind blowing, is one set of climatic con- 
ditions ; the same degree of absolute temperature, with 
a steady breeze of ten miles an hour, forms a wholly 
different climate. What is manifestly required is a ther- 
mometer which will enable us to say now cold it is to the 
feel, or, in other words, with what rapidity the animal 
heat is carried away under a given set of atmospheric 
conditions. 

The amount of labor which has been expended in the 
routine work of keeping meteorological records in the 
past has been enormous. These have been compared 
with fragmentary records of sickness and mortality, and 
the concurrence of cold with certain diseases of the res- 
piratory organs, and of heat with disorders of the diges- 
tive system, has been repeatedly presented, while lines 
have been drawn showing the fluctuations in the annual 
course of many diseases which are influenced directly or 
indirectly by temperature. Nothing more is to be ex- 
pected from such work. If there were on the record as 
many and as continual observations on the temperature of 
the soil in miasmatic regions as there are of the air, our 
knowledge of the fermentative processes which are con- 
nected with the exhalation of disease-poisons, or with the 
manifestation of disease-causes, would be more advanced. 
There is a field for work in this direction, which sanitary 
observers might cultivate, since the Signal Service Bureau 
has relieved them from the labor of taking the meteoro- 
logical notes. Charles Bmart. 

97 



Air-Passages. 
Air-Passages. 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 



AIR-PASSAGES, Foreign Bodies in. 

Nose.— The presence of foreign bodies in the nose ' 
is of common occurrence. The list ' of them comprises 
extraneous substances introduced either through accident 
or design by infants or insane adults ; sequestra of dis- 
eased bone ; and parasites. The history is usually as 
follows : A child of about two, old enough to creep, but 
not sufflciently intelligent to know better, thrusts some 
small, rounded object, such as a bean or a shoe-button, 
which it has found upon the floor, into its nostril. If 
the child be not cauglit in the act the body may escape 
immediate detection. Soon symptoms of chronic inflam- 
mation are established. Tliese are confined to the nostril 
in which the body is, and continue until it is removed, 
the irritation often being severe and the discharge ex- 
ceedingly fetid. The mucous membrane adjacent to the 
foreign body is in a condition of superficial erosion. The 
body, if too firmly impacted to be dislodged by simply 
blowing the nose, remains fixed, usually in the inferior 
meatus, until removed by the surgeon. Removal should 
be attempted by means of a hooked probe or fine forceps. 
The sensitiveness of the nasal cavity should be borne in 
mind, and if, after two or three gentle and carefully 
directed efforts success be not attained, an ansesthetic 
(chloroform to a healthy child under six) should be given, 
and the removal of the body carefully acconiplished. 
Copious hsemorrhage, lasting two or three minutes, often 
follows, but is generally of little moment. The nostril 
should be washed several times a day with a weak disin- 
fectant, preferably a solution of potass, permanganate. 
In four or five days the membrane will often have healed 
so completely that no trace of trouble can be seen ; the 
discharge ceases entirely, and cure is complete. The possi- 
bility of the presence of a foreign body in all cases of fetid 
discharge confined to one nostril should always be remem- 
bered, and the nostril having been cleansed with a warm 
douche, examination should be made with probe and specu- 
lum. In simple cases a gentle stream of salt warm water 
carried through the free nostril and out of the other, or a 
sternutatory, will sometimes succeed. If the object be 
lodged far backward care should be taken in removing it not 
to allow it to fall into the larynx. Rhinoliths ' are merely 
calculi formed by an accumulation of the earthy salts of 
the nasal secretions around some foreign body or inspis- 
sated mucus. Their presence has given rise to such irrita- 
tion that they have been mistaken for cancer. Careful ex- 
amination and the history of the case will easily establish 
the diagnosis. If they are too large to be readily removed 
they should first be crushed by a lithotrite of proper size. 
Sequestra of bone, particularly in tertiary syphilis, some- 
times remain in the nasal cavity after their separation, 
thus acting as foreign bodies. They must be thoroughly 
removed preliminary to further local treatment. 

Parasites. — In tropical countries, seldom elsewhere, 
various kinds of flies, of the order muscidm, may enter 
the nasal cavity, preferably of a patient suffering from 
catarrh, and there deposit their eggs." These are quickly 
hatched, causing in succession irritability, tickling, and 
sneezing ; later, formication, bloody discharges, and epis- 
taxis, with oedema of the face, eyelids, and palate ; ex- 
cruciating pain, generally frontal, insomnia, and if the 
condition be unrelieved, convulsions, coma, and death. 
Sometimes the larvae are sneezed out. or may be seen on 
examination of the parts. This will, of course, establish 
the diagnosis. Destruction caused by the larvee may ex- 
tend to the mucous membrane, the cartilages, and even 
the bones of the head ; the ethmoid, sphenoid, and palate 
bones having been found carious. Where the maggots have 
entered the frontal sinus, or the antrum of Highmore, injec- 
tions of tobacco or alum, or insufilations of calomel for- 
merly used, will be of little use. Chloroform or ether,' pre- 
ferably the former, either inhaled or driven into the nasal 
recesses in the form of spray, is the sovereign remedy as 
under it the larvae are not killed, to remain in situ and 
tlius cause further trouble, but escape with all haste to the 
outer air. Meanwhile, opium should be given to allay 
pain, and the patient's strength carefully sustained. 
Leeches, ascarides, earwigs, and centipedes • have been 

98 



found in the nose, causing insomnia, frontal pain, sanious 
discharge from the nose, Tachrymation, vomiting, and, iq 
some cases, great cerebral excitement. Sternutatories 
are generally suificient for their expulsion. It may be 
necessary, however, to trephine the mastoid. 

Tonsils. — Three general varieties of foreign bodies 
may be found in the tonsil : 1, Foreign bodies proper, or 
substances which have become lodged in the tonsil during 
deglutition; 3, tonsillary concretions or calculi; 3, par- 
asites. The last two conditions are not common; the 
first will te described under Foreign Bodies in the Phar- 
ynx. 

Tonsillary calculi are formed in the lacunae of a 
chronically inflamed tonsil by a perverted condition of 
the natural secretions, and their retention in the lacuna 
by closure of its outlet. They vary in size, seldom at- 
taining a greatet diameter than three-fourths of an inch, 
and consist of phosphate and carbonate of lime, some 
iron, soda, and potassa, with varying proportions of mu- 
cus and water. Hence, they are not necessarily of gouty 
origin. The symptoms, generalljr not prominent, may be 
slight pricking of the throat with, occasionally, dyspha- 
gia. The presence of the calculus is sometimes directly 
irritating, and may give rise to quinsy, ulceration of the 
cavity, and abscess. 

Diagnosis, by ocular examination or the use of the 
probe, is usually easy, as is the removal of the calculus 
by means of a forceps. Sometimes, however, the mass is 
so completely covered that it is only seen upon removal 
of the tonsil. In most cases the latter operation will 
afford the most certain cure. Very rarely hydatids and 
trichocephali have been found in the tonsil. 

Phakynx. — The frequency with which foreign bodies 
are arrested in the pharynx, and their variety, are very 
great. Certain individuals seem especially liable to this 
accident, either from carelessness in eating, insensibility 
of the parts, or from some unusual irre^ilarity in the 
pharyngeal walls. Foreign bodies of large size generally 
lodge in the lower part of the cavity, where the cricoid 
and arytenoid cartilages project backward, or between 
the base of the tongue and the epiglottis. Small and 
sharp-pointed bodies may become fixed at any part of the 
pharynx, particularly in the tonsils, on account of their 
exposed portion and the irregularity of their surface. 
They may also be entangled in the pillars of the velum, 
or in the lateral folds of the cavity. A large body may 
be found stretching across the whole width of the phar- 
ynx. 

Symptoms.— JuOC&X pain, dysphagia, occasionally in- 
flammation with ulceration or abscess of the pharynx, 
but generally localized inflammation and irritation. If 
an abscess be formed, the body may escape through a 
fistulous opening in the neck, or it may perforate some 
important blood-vessel, or even penetrate the interverte- 
bral substance and cause caries of the vertebral bodies. 

Inflammation of the pharynx may give rise to dyspncea, 
while a large foreign body may cause suffocation by ob- 
structing the entrance to the larynx. 

The diagnosis can generally be established by the his- 
tory of the case, and by inspection of the pharynx. Ner- 
vous patients often insist upon the presence of a foreign 
body in the throat, despite all assurance to the contrary, 
particularly if the pharynx be sensitive, or , as often happens 
when a hard substance may have caused a slight laceration 
of the mucous membrane while being swallowed. 

Treatment. — The patient's tongue should be well de- 
pressed, and the upper parts of the pharynx carefully ex- 
amined in a strong light. If the foreign body does not 
then appear, search should be made for it in the region of 
the base of the tongue, the glosso-epiglottic sinuses, and 
the upper portion of the larynx, with the tip of the finger, 
or, better still, by the aid of the laryngoscope. If present, 
it will generally be found without much difficulty, and 
should be removed by the finger or by a suitable forceps or 
probang. If dyspnoea be urgent, immediate surgical in- 
terference, of a nature suited to the special features of the 
case, either tracheotomy, thyrotomy, or, if possible, some 
form of sub-hyoidean pharyngotomy, may be required. 
The sensations of the patignt are often unreliable, and 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 



Air-Passages, 
Air-Passages. 



the sense of irritation caused by the presence of the body 
may continue for a long while after its removal. This is 
relieved by swallowing small lumps of ice, and later, if 
necessary, by the application of astringents and galvan- 
ism. 

Labtnx. — By reason of the danger to life which at- 
tends the lodgment of a foreign body in the larynx, this 
condition becomes one of the most important in surgery. 
The variety of objects found is infinite, and may be thus 
divided : Alimentary matters, introduced during mastica- 
tion, in the act of laughing or talking, in deglutition, 
or in inspiration during vomiting ; metallic bodies, such as 
coins, buttons, puff-darts,' etc.; teeth, artificial or natural, 
necrosed bone' from neighboring regions, as from the nose 
in tertiary syphilis, and fragments of the laryngeal car- 
tilages themselves, as thrown off in the late stages of 
syphilis, tuberculosis, and cancer of the larynx. Foreign 
bodies in the trachea may pass upward and become im- 
pacted in the larynx ; and, rarely, they may gain access 
to the larynx directly from without, by forcible penetra- 
tion of its walls, as in the case of bullets.' Again, the 
epiglottis may become incarcerated in the larynx,'" or oc- 
clusion take place from the so-called swallowing of the 
tongue." The symptoms vary with the size and position 
of the object. Thus a large body fixed in the rima glot- 
tidis may, unless dislodged, cause almost instant death. 
Again, small bodies lodged in out-of-the-way corners may 
remain indefinitely, causing nothing more than cough and 
discomfort. Dyspnoea may occur days after the reception 
of a foreign body, from inflammation and tumefaction of 
the soft parts of the larynx, and danger from the presence 
of a foreign body may suddenly become imminent from 
alteration in the position of the body. Great peril Some- 
times arises from violent spasm of the glottis, due to irri- 
tation caused by the foreign body. Mental anxiety and 
localized pain are prominent symptoms in cases in which 
the accident does not immediately threaten life, while ac- 
tive inflammation is speedily set up. A cautious prognosis 
must be given, even after removal of the body, as long as 
there are any symptoms of local inflammation. The dickg- 
rwsis is established by the history of the case, verified or 
otherwise by laryngoscopic examination. The greatest 
difficulties arise with children too young to express them- 
selves, in whom pain in the throat, and symptoms resem- 
bling croup, will often be the only indications obtainable. 
Here the laryngoscope will be indispensable. 

Treatment. — The offending body should, of course, be 
at once removed ; if possible, through the natural pas- 
sages and by means of the laryngeal forceps, aided by the 
laryngoscope, in case the symptoms are not urgent. If 
asphyxia threaten, tracheotomy should be done at once, 
and the foreign body afterward extracted as described 
above. Bodies at first immovable may sometimes be 
loosened by reducing the local inflammation. In rare 
cases, where the object has become firmly impacted, thy- 
rotomy Inay become necessary. A case is recorded m 
which a needle, transfixed in the larynx, was pushed 
through the anterior laryngeal wall, and thus removed." 

Tkachba and Bkonchi. — Any body which can pass 
through the rima glottidis may, of course, find its way 
into the trachea under the same circumstances described 
under the head of Foreign Bodies in the Larynx. Sharp 
objects lodged in the oesophagus, and even diseased 
bronchial glands, may work their way through the walls 
of the trachea, and into its cavity. Parts of instruments 
used in intra-laryngeal operations, and of tracheal canu- 
lae," laryngeal brushes, and even bits of solid nitrate of 
silver, occasionally, through accident or carelessness, drop 
into it. If too large to enter either main bronchus, the 
body will probably remain at the bifurcation. Otherwise 
it will pass into one bronchus or the other, preferably the 
right, on account of its anatomical position, in the propor- 
tion of five to three, and thence travel indefinitely into 
one of the more remote bronchial divisions. 

The symptoms will depend upon the nature of the 
body and its exact situation in the lung. Small objects 
have remained encapsulated with mucus for years with- 
out causing discomfort or serious results. Smooth, 
rounded bodies irritate less than irregular ones. Inflam- 



mation of the lungs from a foreign body may occur, the 
presence of the body being unknown. Large objects and 
fluids may cause death by instant suffocation, or death 
may result in the course of a few minutes, the symptoms 
presented being urgent dyspnoea, frantic efforts at relief 
on the part of the patient by thrusting the finger down 
the throat, rushing to the window for fresh air, and mak- 
ing great inspiratory efforts, while cyanosis quickly fol- 
lows, and if aid be not speedily afforded, death, with all 
the signs of asphyxia. Severe dyspnoea, followed by re- 
lief without extrusion of the foreign body, indicates that 
the body has probably dropped from the larynx into the 
trachea. Dyspnoea is, of course, more urgent when the 
trachea is occluded than when the foreign body only stops 
one bronchus. The body may change its position, pass- 
ing from one bronchus to that of the opposite side. A 
body, small when swallowed, may become more danger- 
ous through increase in size, either by swelling from im- 
bibition of water, or by forming the nucleus of a concre- 
tion. Physical signs from the preseuce of a foreign body 
in the lung may be altogether wanting, but are generally 
more or less distinct, the symptoms being whistling or 
flapping sounds at the point of lodgment, pain, and de- 
creased fremitus, with absence of respiratory murmur in 
the lung beyond. Diagnosis is often very difficult. At 
or about the bifurcation the body may be seen with the 
laryngoscope. The lodgment of a foreign body in the 
lung may result in pneumonia, tuberculosis, abscess, 
or gangrene. Or, it may become encapsulated and do no 
apparent harm. Rarely a body, generally an ear of bar- 
ley or other grain, havmg formed an abscess of the lung, 
has been discharged through the wall of the thorax, with 
complete recovery." 

Diagnosis. — The fact that some foreign body has been 
inhaled should be established if possible, and the site of 
the body determined. In children and incompetents, and 
in cases where the dyspnoea is urgent this may not be 
easy. The laryngoscope is useful m excluding the pres- 
ence of the body from the larynx, even if it be not visible 
in the trachea. The prognosis is serious, depending upon 
the nature of the body, the amount of dyspnoea, and the 
organic lesions which may result. The period of greatest 
danger is at the first, and although this diminishes in 
varying degree as time passes, it is never entirely absent. 
Even after expulsion death may occur from the organic 
disease set up. The expulsion of one object does not, 
especially with children, preclude the possibility of others 
remaining in the lung. 

Treatment. — Since the publication of Professor Gross's 
admirable article the necessity for operation in cases of for- 
eign body in the trachea has been an accepted law. Re- 
cently Weist has ably shown that the conclusions arrived 
at by Gross and Durham are, to some extent, misleading. 
His conclusions are based upon 937 cases of foreign body 
in the air-passages ; of these, 599 were not subjected to 
bronchotomy ; 460 recovered, or 76.79 per cent. ; 139 
died, or 23.30 per cent. Bronchotomy was performed in 
338 cases, with 345 recoveries, or 73.48 percent. ; 93 died, 
or 37.43 per cent. ; a difference in favor of non-interfer- 
ence of 4.31 per cent. Comparing the statistics with 
those of Gross and Durham, the former shows, in cases 
without operation, 11.03 per cent, more recoveries than 
those of Gross, and 19.39 per cent, more than those of 
Durham, and 7.34 per cent, more than the aggregate of 
the cases of both Gross and Durham. In cases operated 
on, Weist shows 12.31 per cent, less recoveries than Gross, 
1.40 less than Durham, and 4.29 less than the cases of 
both combined. Of the whole number of cases studied, 
1,674, there was one death in 3.5 cases without operation, 
and one death in 4 with operation. Bronchotomy, there- 
fore, has not shown such good results over non-interfer- 
ence as to justify unvarying recourse to it, so that the 
policy of awaiting spontaneous expulsion is often justi- 
fied. Since certain classes of foreign body, such as water- 
melon seed, corn, coffee bean, etc., are much more easily 
expelled from the air-passages than others, the nature of 
the substance, aside from other indications, must influence 
the decision as to the propriety of immediate interference. 

The conditions demanding speedy operation are : 1. Ur- 



99 



Air-Passages. 
Ajaccto. 



REFERENCE HANDBOOK OE THE MEDICAL SCIENCES. 



gent and dangerous symptoms, as progressive dyspnoea, 
or frequently occurring attacks of dyspnoea, or laryngeal 
spasm, when laryngoscopic examination fails to find 
the object or shows that its speedy removal by the natural 
passages is impossible. 2. Where a sharp and irregular 
body is impacted, as shown by the laryngoscope, in such 
a way that immediate extraction is impossible, and where 
acute inflammation, and especially osdema, are rapidly 
occurring, as evinced by increasing dyspnoea. 3. In the 
case of a foreign body of any nature, loose in the trachea, 
movements of which excite laryngeal spasm or cough of 
dangerous violence. 4. In case of a foreign body im- 
pacted in either of the primary bronchi, as ascertained by 
the rational and physical signs, particularly by ausculta- 
tion. Here low tracheotomy and immediate direct at- 
tempts at extraction are often successful. Direct exami- 
nation of the site, and demonstration of the foreign body 
in or at the mouth of a bronchus, by means of the fin- 
ger introduced quickly into the trachea, are possible, and 
this knowledge renders the subsequent instrumental re- 
moval of the body more easy. 5. Sharp-pointed, hard, 
and. irregular bodies within the air-passages will, as a 
rule, demand bronchotomy, provided they are not so lo- 
cated that they may be reached and removed by the nat- 
ural passages at an early momerft. The plan of treat- 
ment by inversion of the patient has of late years fallen 
into disrepute, and should seldom be practised, unless 
tracheotomy can be done at once it required. In em- 
ploying it, it should be remembered that the supine 
position will favor exit of the body, particularly if the 
glottis be in the condition of deep inspiration. In all 
cases the diagnostic importance of a thorough laryngo- 
scopic examination cannot be too strongly insisted upon, 
nor the great utility of the laryngoscope be overesti- 
mated. 

Bibliography. 
GroBs: Foreign Bodies In the Air-pafwages. Philadelphia, 1854. 
Bourdillat : Gazette de Paris, 1868. Nos. 7 to 16. 
Kuhn : Gi&nthers Lehre v. den Blut. Operat. v. Abtheil. 
Durham : Holmen's System of Surgery, vol, ii. 
Sanders: Foreign Bodies in the Air-passages, with Bibliography, 

Deutsch. Archiv. filr klin. Med,, 1875. Bd. xvi., Hefte 3. 
Johnson : Lancet, October 13, 1878. 
Leaming: Growths and Foreign Bodies in Air-passages, Diagnosis 

and Surgical Treatment, New York Med. Becord, 1879., xv., 808. 
Wagner : Ziemssen's Cyclopsediii, 
Holmes's System of Surgery. 

Morell Mackenzie : Diseases of Throat and Nose. London, 1880. 
I^lsherg: Archives of Laryngology, vol. iii., p. 275. 
Weist: Transactions American Surgical Association, vol. i. 188.3. 
Voltolini: The Operative Removal of Foreign Bodies and New 

Growths from the Air-pasaages. TraDsactions Eighth International 

Med. Congress. 
LcSerts ; Transactions Eighth International Med. Congress. 

D. Bryson Ddavan. 

"TUlanx: Soo. do Chirurg., January 26, 1876; also, Bron : Gazette 
Med. de Lyon, 1867, No. 36. 

I MoreU Mackenzie : Diseases of Throat and Nose.. London, 1880. 
= Sohmiegelow : Trans. Eighth Inter, Med. Cong., 1884. 

4 Buchanan : Phila. Med. Times, October 30, 1875. 

= John Ellis Blake : Boston Med. and Surg. Journal, April 10, 1862. 
To Dr. Blake belongs the credit of having first discovered and reported 
this method of expelling larvie from remote sinuses. 

» Packard : Phila. Med. and Surg. Reporter, August 3, 1878. 

' Bruce : London Lancet, February 18, 1863. 

* Lincoln : Archives Laryngology, vol. iii., p. 276. 

• Daly : Gunshot Wounds of the Larynx. Trans. American Laryn- 
gologlcal Association, vol. vi., p. 47. 

'» Cohen : Phil. Med. and Surg. Reporter, March 16, 1878. 

II Ingals: Trans. Araer. Laryngolog, Assn., vol. il., p 135 
'2 Field : N. Y. Med. Record, March 10, 1877. 

'2 Cohen : Diseases of the Throat. New York, 1879. 

" Howell White: N. Y. Med. Record, September 10, 1881. 

AIX-LES-BAINS (a station on the railroad which runs 
from Lyons to Turin) is a small town in the Arrondisse- 
ment of Chamb^ry, in Savoy. It is charmingly situated 
on the brow of a hill, in close proximity to lofty lime- 
stone mountains (the Beauges), a spur of the Savoy Alps 
and not far from the eastern shore of the Lake of Bour- 
get Its elevation above the sea-level is about 900 feet 
and above the lake about 100 feet. Climate mild • air 
and ordinary drinking-water both pure. Hence critins 
and those affected with goitre are rarely seen here 
There are two thermal sources which, in chemical com- 
position and in the temperature of the water, differ only 

100 



very slightly from each other. These are the Source de 
Soufre and the Source d'Alun. According to Boniean 
the temperature of the sulphur spring is 45° C. (113 F.)' 
and it contains in 1,000 parts : ' ' 

Sodium sulphate 0,0960 

Magnesium sulphate o!o352 

Calcium sulphate oioififl 

Aluminium sulphate ; *[ 0.0548 

Sodium chloride 0.0079 

Magnesinm chloride 0.0172 

Calcium fluoride. ( ' * 

Calcium and aluminium phosphate, J U.0024 

Potassium iodide Traces. 

Calcium carbonate 0.1485 

Magnesium carbonate 0.0958 

Ferrum carbonate 0.0088 

Silicon hydrate 0.11050 

Organic matter Traces. 

Total of fixed elements 0.4176 

The unstable elements in 1,000 cubic centimetres of 
the water are represented as follows : 

Hydrogen sulphide 27.24 c.c. 

Carbon dioxide 13.07 c'c! 

Nitrogen 25.46 cio! 

The alum spring has a temperature of 46.5° C. (115.8° 
F.), and its chemical composition is but little different 
from that of the sulphur spring. 

However, it is not so much to the chemical composi- 
tion of its waters that the hot springs of Aix owe their 
great celebrity, as it is to the systematic manner in which 
these waters are used. Durand-Pardel speaks of the es- 
tablishment of baths in Aix as pursuing a genuine sys- 
tem of thermal hydrotherapeutics. In this respect it may 
be compared with Aachen and Luchon. 

The principal form of bath employed is the douche, 
which is administered in a variety of ways, and usually 
in connection with massage and frictions. After the ap- 
plication of the douche, the patient takes a warm bath 
in the so-called " Bouillon," in which the water is kept in 
constant motion. 

The energetic and exciting methods employed at these 
baths render them especially efiBcacious in cases of rheu- 
matic or gouty exudations, m scrofulous swellings of the 
periosteum, or of the parts surrounding the joints, etc. 
They have also proved useful in cases of muscular atrophy, 
caries, contractures, etc.; in chronic affections of the 
skin, and in syphilis ; in affections of the larynx and 
pharynx ; in chronic bronchial catarrh ; and, finally, in 
quite recent times, in uterine affections. (Eulenburg.) 

Henry Fleisehmr. 

ALAP, a Hungarian village with railway connections, 
is divided into upper and lower Alap, each of which con. 
tains a remarkable spring of pure and very strong bitter- 
water ; in fact that of lower Alap is one of the strongest 
natural bitter-waters known. The waters of lower Alap 
are also used for bathing. In 1,000 parts, by weight, 
there are : 

Upper Alap, Lower Alap. 

Magnesium sulphate 3.13a parts. 4.094 parts. 

Sodium sulphate 5.711 " 18.149 '* 

Calcium sulphate ". 1.828 " o!260 '* 

Sodium chloride 4.186 " 14!486 " 

Totalsolids 16.549 parts. 37.6S5parts. 

S. F. 

ALBANY ARTESIAN WELL. Location, Ferry Street, 
Albany, N. Y. . j • 

Analysis. — One pint contains : 

„ Grains. 

Carbonate of soda 6.00 

Carbonate of magnesia !'.!!'.*.".!'.'..!*.*.!...!*...*!" 2.00 

Carbonate of lime ..!.!'.!!.....!!!!!!!!!!! 4.00 

Carbonate of iron .'...'.".*.'.,...".''".''.".'!! 1.00 

Chloride of sodium ......i !'.".!!!!.'.'!. 63.00 

IBM 
Carbonic acid gas, 28 cubic inches. 

The well is 500 feet deep, and has a temperature of 
about 53° F. This is a saline-chalybeate water, very 
similar to the Congress, High Rock, etc., of Saratoga, and, 
undoubtedly, has the same general source as those springs. 

G. B. F. 



REFEEENCE HANDBOOK OF THE MEDICAL SCIENCES. 



Air-Passages. 
Ajacclo. 



ALBINISM. The condition which has been termed 
albinism consists in a congenital absence of the normal 
pigment. There are two varieties, the universal and the 
partial. The first of these is that which is best known. 
The skin is perfectly pigmentless and white, excepting 
where the blood-vessels coursing beneath it give it a rose 
tint. The general condition of the skin is normal, other- 
wise than as regards the absence of pigment. The hair is 
white or flaxen in color (in one case reported it was red), 
of a fine texture, and peculiarly silky sheen. The eye 
partakes of the anomaly ; the iris is colorless, so that its 
blood-vessels give it a red hue, excepting in some cases, 
when viewed obliquely, the interference of light-rays give 
it a blue color. As a result of the want of pigment in the 
iris, albinos suSer from photophobia and nystagmus, and 
are seen constantly blinking the eyelids and rolling the 
eyes involimtarily from side to side. They see best in 
the twilight. 

Albinos are usually of weak constitution, and are apt to 
be intellectually deficient. Exceptions are known, how- 
ever, to both of these conditions, and one of the best 
papers extant on albinism, so it is said, was written by a 
German albino named Sachs. 

The only etiological element known or suspected in the 
production of albinism is heredity, and even this is want- 
ing in the greater number of cases. It seems probable 
that the sisters in any given family are likely to be at- 
tacked rather than the brothers, if more than one indi- 
vidual is affected. 

Partial albinism is ordinarily met with in the colored 
race, the so-called " piebald negroes," and its existence in 
the white races has been denied. Lesser, however, has 
recently described a case, and it is believed that instances 
of congenital partial loss of pigment are not excessively 
uncommon among the lighter colored races, but that cases 
have escaped attention. Partial albinism over limited 
areas has been shown in one case at least by Lesser to fol- 
low the course of the cutaneous nerve-distribution, as is 
the case with the pigmented skin in the so-called " nerve 
nsevus. " One peculiarity of the pigmentless patches in this 
form of albinism is that the decolorized skin fades gradually 
into the surrounding integument, whereas in vitiligo the 
skin immediately surrounding the white patches is more 
deeply pigmented, giving a sharply defined boundary line. 
The hair growing over the pigmentless patches in partial 
albinism is white, although it is a curious fact that in the 
similar decolorization of the hair, apparently due to 
the same causes, called sometimes poliosis (see Calvities) 
the skin underneath may be of normal color. 

Arthur Van Harlingen. 

ALBUMINOID DEGENERATION, the term used by 
the English to denote what is ordinarily called amyloid 
degeneration, it being supposed that the amyloid material 
represented a modified form of albumen, an acid albu- 
men. This has been shown to be wrong. See Amyloid 
Degeneration. W. W. Gannett. 

AJACCIO. The town of Ajaccio is situated at the 
head of a beautiful bay, bearing the same name, which 
indents the western coast of the island of Corsica. At 
its mouth (the broadest part) the width of this bay is 
about ten miles from cape to cape, and it extends inland 
in a northeasterly direction for about the same distance, 
having in its general outlines the shape of a letter U or of a 
blunt-pointed V. At a distance of some twentjr miles 
from the shores of the bay stand the lofty mountains (six 
thousand to nine thousand feet high) constituting the 
backbone of the island, while the outlying spurs of these 
mountains come down to the sea in such a manner as 
to afford to the town of Ajaccio an all but complete 
protection from northwesterly, northerly, and easterly 
winds, leaving it exposed to the warmer winds blowing 
from the south and from the southwest. From this ac- 
count of its situation it would naturally be inferred that 
the climate of Ajaccio should be a warm one, and, as 
will presently appear from the statistics of temperature 
about to be quoted, this inference is entirely correct. In 
this feature of exposure to the south and shelter on the 



north, the town gi-eatly resembles many of the celebrated 
winter resorts of the Italian Riviera, while its somewhat 
lower latitude should iilsure Its being even warmer than 
these. Accordingly, it is no surprise to learn that the 
mean winter temperature of Ajaccio is more than 3.7° F. 
(1.5° C.) higher than that of the Riviera. The writer of . 
the article on Ajaccio in "Eulenburg's Real Encyclo- 
padie," from whose contribution the preceding statement 
is taken, mentions further that there is less variation in the 
mean temperature from month to month of the winter 
season at Ajaccio than is to be found at places lying along 
the Riviera. The relative humidity of Ajaccio is given by 
the same writer as varying between seventy and seventy- 
eight per cent. The average total number of rainy days oc- 
curring during the months of October, November, Decem- 
ber, January, February, March, and April, he states to be 
from forty to forty-flve. The annual rainfall, according 
to Doctor Hermann Weber in "Ziemssen's Handbuch. 
der AUgemeinen Therapie," is 24. 8 inches (630 mm.). Dr. 
Lombard states {Traite de Glimatologie Medicate, t. iv., 
p. 620) that the average number of perfectly cloudless 
days at Ajaccio is 136 ; of partly cloudy days, 89 ; and of 
days on which the sky is completely obscured by clouds, 
51. He further remarks that the greatest proportion 
of cloudy days occurs during the spring months, only 43 
cloudless days being observed at that season, on the 
average, against 49 cloudy ones. The mean temperature 
at Ajaccio for the year, for each of the four seasons, and 
for eight out of the twelve months of the year is shown 
in the following table : 





















% 


1 


fB 


^ 






1 


O 


i 

Izi 


1 


1 


4 


^ 


1 


ai 


i 


a 


m 


1 


B 




fiS.IS 


SSR5 


mm 


SO.Sfi 


54.14 


m.i» 


59.36 












Z 


















76.'!H 


fi6.6H 


52.16 


60,26 


Ba.fio 


H 


78.08 


66.92 






50.86 






58.28 










63.68 



E., Eulenburg'B Real Encyclopadie ; Z., Ziemssen's Handbuch der AU- 
gemeinea Therapie (Weber) ; H., Hann's Handbuch der Eiimatologie, 

The dally variation of temperature is never great, not 
more than 9° or 10.8° F., even in November and Decem- 
ber ; the evenings are extremely mild, not colder than 
50° F., even in February (" Eulenburg's Handbuch"). 

On the authority of the Drs. Versini, father and son, 
the climate of Ajaccio is said by Dr. James Henry Ben- 
net to be a healthy one, and no epidemic disease prevails 
there, save only malarial fever of a mild type, which 
visits the town only during the latter part of summer and 
in the early autumn, its attacks occurring chiefly when 
the wind blows across from the east shore of the bay, 
where the Gravone and Prunelli rivers empty into the 
sea. On the other hand, the writer in "Eulenburg's 
Handbuch " remarks that the health of the resident popu- 
lation at Ajaccio is not especially good, which circum- 
stance he is disposed to attribute to the imperfect hygienic 
conditions prevailing in the town itself. The soil at 
Ajaccio is granite, and the surface-water drains rapidly 
away. The air is free from dust at all seasons. "The 
vegetation of Ajaccio and the neighborhood indicates a 
climate at least as warm as that of Cannes and Nice, per- 
haps even a shade warmer ; the olive, the orange, the 
prickly pear thrive with great luxuriance. . . . The 
lemon-tree grows also, and bears fruit out of doors, but 
only, as at Nice, in very sheltered and very protected 
spots. . . . The botanical productions of Corsica assim- 
ilate, as might be presumed, to those of the countries that 
surround it. The north by its vegetation approximates to 
the Riviera, the east to the Italian coast, the west to Prov- 
ence and Spain, while the south, and I may say the en- 
tire island, shows decided African affinities" (Dr. J. H. 
Bennet in " "Winter and Spring on the Shores of the Medi- 

So far as its climate is concerned, the town of Ajaccio 
presents, in the estimation of the writer in "Eulenburg's 
Encyclopaedia," greater advantages than any point in 
Italy as a place of resort for persons suffering from any 
form of ptilmonary or cardiac disease, or from scrofula, 

101 



A]acclo. 
Alcohol. 



EEFERENCE HANDBOOK OP THE MEDICAL SCIENCES. 



as well as for invalids merely seeking a quiet and suit- 
able place of rest. He specifies the three months of 
February, March, and April as those which it is most 
desirable for the invalid to select for his sojourn at 
Ajaccio. The Cours Grandval is generally chosen by 
.foreigners for residence, lying as it does in the north- 
western portion of the town, which is the section most 
protected and best sheltered from the winds. Although 
it is now no less than twenty-three years since Dr. Ben- 
net first pointed out, in 1862, "that the exception- 
ally sheltered situation of Ajaccio, on the western coast, 
renders It a suitable residence for invalids requiring a 
moister climate than that of the Genoese Riviera," and 
that it appeared to him " thoroughly eligible as a winter 
residence," it is somewhat disappointing to learn from the 
fifth edition of his own book (1875), and from the abovfe- 
cited work of Eulenburg, that, despite certain improve- 
ments in this direction, the character of the hotel accom- 
modation and the facilities for social life existing in the 
town still leave something to be desired before the place 
can become as popular a resort for invalids as it is justly 
entitled to be. Up to 1880 good accommodations were 
only to be found at certain of the hotels and in villas 
(Eulenburg). "Biermann," says Dr. Weber in "Ziems- 
sen's Handbuch," "speaks favorably of the climate ; H. 
Bennet and Rohden, who also know the place from per- 
sonal experience, have high hopes of its future, when the 
accommodations and the means of communication with 
the continent shall have been still further improved. My 
own experience in four cases of pulmonary phthisis af- 
fecting the apex of one lung, and in two cases of chronic 
emphysematous catarrh is favorable ; in one case of 
chronic pneumonia of the right lower lobe, and in two of 
asthma, unfavorable." Dr. Pietra Santa (quoted by 
Lombard) describes the climate of Ajaccio as both tonic 
and soothing in its effect, and as being well suited to 
cases of scrofula, to chlorotic and anaemic persons, and 
especially to those suffering from certain forms of pul- 
monary phthisis ("surtout aux phthlsiques chez qui 
predomine le lymphatisme et la forme torpide ; il exerce 
egalement une influence prophylactique pour ceux qui 
sont predisposes a la tuberculose "). 

"One of the objects of my visit," say ^ Dr. Bennet, 
speaking of his exploratory trip to Corsica in the year 
1862, "was to find a perfectly cool summer station for 
the EngUsh consumptive invalids who wish to pass the 
summer abroad. I found stations such as Arezza and 
the baths of Guagno, near Ajaccio, which would do very 
well for healthy persons anxious to escape from the ex- 
treme heat of Southern Europe during the summer months, 
but these localities are not sufficiently high and cool to be 
chosen as summer retreats by invalids. ... On 
crossing the granite chain on the way from Corte to Ajac- 
cio we came to a spot between Vivario and Bocognano, 
called Foci, the most elevated that is passed, which would 
no doubt do admirably for such a summer sanitarium. 
We were quite four thousand feet high. . . . The 
air was cool and pleasant, the sky clear, the mountains 
very beautiful ; but there was only a small, dirty roadside 
inn." Malarial fever does not prevail in Corsica, even in 
the' summer and early autumn seasons, according to Dr. 
Bennet, at any place having an altitude above sea level of 
five hundred feet. 

It is disappointing, after considering the evident desira- 
bility of the establishment of such a mountain summer 
resort and its entire feasibility, to judge from the above 
quoted remarks of Dr. Bennet, to read, as we do in Dr. 
Hermann Weber's contribution to Ziemssen's work (1880) 
that " the mountains of the island have not yet been made 
use of for the establishment of satisfactory places of sum- 
mer resort." " In the great primeval forests (of Corsica) 
are to be found wild boars and small game in abundance. 
In the higher mountains the native race of wild sheep 
called mouflons, are met with. Their presence in the 
mountains is a strong attraction to enthusiastic sportsmen. 
In the alluvial plains on the eastern coast game abounds 
and m the autumn and winter all kinds of water-fowl are 
met with in profusion. In the eariy autumn season how- 
ever, these districts are so very unhealthy that the pursuit 

102 



of the game would probably be followed by severe fever" 
(Bennet, op. cit.). 

Thanks to the good work done in Corsica by the French 
Government, excellent roads now intersect all parts of the 
island in every direction, and the entire suppression of the 
' ' vendetta " has rendered every portion of the island a per- 
fectly safe residence for foreigners. 

For the latest information concerning hotels, etc., and 
concerning the various lines of steamers which bind Cor- 
sica to the continent of Europe, the reader is referred to the 
tourists' guide-books of Murray and Baedecker. A great 
deal of useful and entertaining information respecting the 
scenery, history, climate, etc., of Corsica may be found 
in the pages of the delightfully written work of Dr. Ben- 
net, from which such frequent quotations have been made 
in the penning of this article. (See also Gregorovius's 
"Wanderings in Corsica, its History and its Heroes;" 
"Notes on the Island of Corsica," by Miss T. Campbell; 
and several other similar works, all of which are recom- 
mended to his readers by Dr. Bennet.) 

Huntington Sicha/rds. 

ALBURG SPRINGS. Location and Post-office, Alburg 
Springs, Grand Isle County, Vt. 

Access. — By Central Vermont Railroad to Alburg 
Springs Station. 

Analysis (C. T. Jackson). — One pint contains : 

Grams, 

Chloride of sodium 1.095 

Chloride of magneBium 0.627 

Chloride of calcium and carbonate of lime 0.601 

Sulphide of potassium and sulphate of potassa 1 ,2S7 

Sulphate of soda 0.887 

Insoluble matters 0.100 

Organic acid of the soil (crenic acid) and loss 0.250 

Total 4.797 

Sulphuretted hydrogen, a large proportion. 

These springs are situated in the extreme northwestern 
part of Vermont, on Missisquoi Bay, an arm of Lake 
Champlain. The scenery round about is beautiful, em- 
bracing lake and mountain views. The climate is salu- 
brious. (Walton.) G. B. F. 

ALCOHOL. The term alcohol (Syn. : ethyl hydrate, 
spiritus vini), once used to signify ethyl hydrate, is now 
generally applied, as a generic term, to a series of organic 
compounds, having in common certain chemical charac- 
teristics, the representative of which class is ordinary 
alcohol. It is produced by (1) the fermentation of all 
saccharine bodies, (2) by synthesis in the laboratory. In 
composition it is a hydrate, i.e., the combination of a 
basylous radical with HO, and possesses the chemical 
properties of other hydrates, in forming salts with acids, 
etc. 

Pbepakation. — Alcohol is produced by a particular 
ferment (torula; cerevisise) acting upon saccharine sub- 
stances ; causing them to split up into alcohol and carbon 
dioxide, viz. : 



Glucose 
CeHisOs 



Alcohol 
2C,H5HO 



Carbon dioxide. 
2COs. 



Cane-sugar and milk-sugar undergo a conversion first 
into glucose and then into alcohol. Minute quantities of 
acetic and succinic acids, also traces of aldehyde, fusel oil 
(amyl alcohol), and glycerine are produced at the same 
time. It is an interesting and important fact that the 
fermentation gradually ceases as the alcohol produced 
nears eighteen per cent, strength, and when the latter is 
reached, further action ceases. In the grape-juice, when 
this strength is reached, if there still be unf ermented sugar, 
a " sweet " wine results ; if none, a " dry " wine. This is 
due to the action, on the ferment, of the alcohol itself ; 
the strength named above being just able to precipitate 
it. Pure wines, therefore, in moderate quantity will not 
precipitate the pepsine of the gastric juice, because not 
strong enough to do so immediately on taking, and in the 
stomach they are quickly diluted. In a diluted condition, 
under the influence of another ferment, alcohol is changed 



EEFERENCE HANDBOOK OP THE MEDICAL SCIENCES. 



Ajaccio. 
Alcohol. 



to acetic acid, by a process t)f oxidation ; thus, e.g., white 
wine vinegar is produced. 



Alcohol 
CHsHO + 



O, =r 



Acetic acid + Water. 

CsH^Os + HsO. 



When any of the fermented liquors are distilled, alco- 
hol mixed with water passes over into the receiver. Re- 
peated distillations free it from the greater proportion of 
higher alcohols and water. Its degree of concentration 
can then he determined by taking its specific gravity and 
comparing the result with a fixed table in which the 
strength for each specific gravity is worked out. The last 
amounts of water can only be gotten rid of with the great- 
est difficulty ; as, for example, by distillation over quick- 
lime out of contact with air (from which it rapidly ab- 
stracts moisture). 

Phtsical Phopertibs. — Absolutely pure alcohol is a 
colorless, limpid, pleasantly-smelling liquid having a 
sharp, burning taste ; boiling at 78.5° C. (173.3° P.), and, 
at 20° C, having a specific gravity of 0.7895. Its affinity 
for water is intense, even abstracting it from the air when 
the bottle is not securely corked. If it be mixed directly 
with water, heat will be produced, the volume of the 
mixture being less than the sum of the volumes of the 
components, thus showing that combination has resulted. 
It is a solvent of great power, advantage of which is taken 
both in the arts and in medicine, e.g., in the solutions of 
the fixed active principles of drugs called tinctures, or 
the solutions of the volatile active principles called spirits. 
It dissolves the alkaloids, essential oils, many resins, some 
fats, and COa freely. 

Chemical Pkopbrtibs. — Alcohol occurs in commerce 
and pharmacy in varjfing degrees of concentration. When 
absolute alcohol is required, it should be freshly prepared, 
that of the shops being often only ninety-eight per cent, 
strong. Alcohol (U.S. Ph.) has a specific gravity of 0.83, 
and contains ninety-four per cent, by volume. Alcohol 
dilutum (U.S. Ph.) contains fifty-three per cent, by volume, 
and is the ordinary proof spirit. Its distinguishing chem- 
ical properties are : (1) its affinity for water ; (2) its coag- 
ulating power on albuminoids, and (8) its antif ermentative 
power when stronger than eighteen per cent. Advantage 
is taken of the first, in the mounting of microscopical 
sections, to abstract all the water before immersing them in 
the oils and balsams ; of the second, in the hardening of the 
tissues for studj' and section ; of the last, in the preserva- 
tion in bulk of anatomical specimens, and those medicinal 
agents which undergo change in other media. Pure 
alcohol, properly diluted, will be understood to have 
been given, when we speak of its 

Physiological Action. — Locally: Prolonged contact 
with the integument produces a sensation of heat which, 
if continued, results in inflammation. It hardens the 
same by coagulation of its albuminoid constituents and 
abstraction of water, the rapidity, to a certain extent, 
depending upon its concentration. Hence, it is useful in 
a relaxed condition of the skin, in sweating, and in ulcers ; 
it acts here as an astringent, preventing the escape of 
leucocytes, and promoting the healing process. 

Stomach and IntesiiTml Tract. — The action of this agent 
upon the stomach and intestinal tract has been one of the 
bones of contention between the advocates of teetotalism 
and those who, knowing its virtues, can utilize them. 
To incorporate the arguments of both sides would be 
foreign to the scope of this article which is to give the 
present status of scientific opinion. Small quantities of 
alcohol, properly diluted, taken into the stomach, produce 
an agreeable sensation of warmth which soon diffuses it- 
self over the entire body. It is quickly absorbed. A tur- 
gescence of the capillary plexus of the mucous membrane 
occurs, which is speedily followed by a free secretion 
from the gastric follicles, due, in all probability, to (o) the 
increased supply of blood, and (fl) the stimulation of their 
glandular orifices. Here, just as in any other organ of 
the body, long-continued or excessive stimulation will 
give rise to a pathological secretion, and a gastric catarrh 
will result. Larger quantities of alcohol interfere with the 
digestive processes, partly by rendering the albuminoids 
less soluble, partly by producing a secondary constriction 



of the stomach capillaries, and thus a diminished secretion. 
Experimentally applied to the mucous membrane of the 
dog's stomach (through gastric fistulas) , increased secre- 
tion and peristalsis of that viscus are observed. This is 
probably true in man. Even a few drops of the stronger 
alcohol, applied to the base of the tongue, has been seen 
to cause an almost immediate flow of gastric juice. 

Poisoning by concentrated alcohol excites a burning 
sensation in the mouth, oesophagus, and stomach, soon 
followed by a gastro-enteritis, with its attendant symptoms 
of epigastric pain, fever, vomiting, and purging (some- 
times of blood). Post-mortem appearances of the tissues 
in contact with which the concentrated alcohol has lain, 
are such as are naturally to be expected from its chemical 
properties, i.e., abstraction of the watery constituents of the 
epithelial lining, cell-shrinkage, coagulation of the blood 
in the vessels of the mucosa, and hsemorrhagic softening. 

The circulatory system, like the other portions of the 
organism, is affected by alcohol, but not in so marked a 
degree. In small quantities, its first effect is to stimulate 
the heart, causing a slight increase in frequency and a 
marked increase m force, accompanying which is a dila- 
tation of the cutaneous capillaries, and probably also those 
of the brain. The intravascular pressure is increased. 
These phenomena are plainly visible in the flushed face, 
glistening eye, and animated expression of the person in 
the early stage of alcoholic influence. In poisonous doses, 
a lessening of the heart's power by one-twentieth and 
the blood-pressure by one-sixth occurs. Nothnagel ex- 
plains this as a reflex result, due partly to the severe irrita- 
tion of the vagus, partly to a direct affection of the heart- 
plexus and pheumogastric centre in the brain. He cites, 
in proof, the experiment of cutting the vagus in animals 
under the influence of alcohol, when the blood-pressure 
and heart's action again increase. The circulatory sys- 
tem is the last to succumb to the toxic effects of alcohol, 
for when all volition has ceased, and the voluntary muscles 
are paralyzed, the weakened heart continues beating, until, 
if the intoxication be severe, death results from paral- 
ysis of respiration. The long-continued use of alcoholic 
drinks, particularly in the more concentrated forms, in- 
duces a fatty infiltration of the heart-muscle and an 
atheromatous condition of the arterial walls. 

Brain and Nerwus System. — The primary effect of al- 
cohol (in small quantities) on the nervous system is a 
stimulation of the functional activity of the brain. This 
is a result chiefiy of the direct stimulation of alcohol upon 
the nervous tissue, though the increased force of the 
heart-beat, its increased frequency, and the greater activ- 
ity of the entire bodily functions undoubtedly assist its 
local action. A sense of well-being pervades the body, a 
greater activity of intellection, increased volubility, and a 
general exhilaration result, which, enduring for a time, are 
followed by no depression. Such quantities have little 
effect on the spinal cord. If the quantity be increased, we 
have an exaggeration of the foregoing conditions. Mental 
activity is at its highest, ideas flow rapidly, and thought 
finds ready expression. Later, the cerebellum and cord 
begin to show interference with their function, by the 
muscular incoordination, beginning usually in the tongue 
and lower lip. If in this condition the quantity of alco- 
hol be again increased, a general incoordination ensues. 
The tongue refuses to give correct expression, ideas are 
confused, mental hallucinations, and even a temporary in- 
sanity may result. This state is followed by depression, 
sleep, coma, and even death. The investigations of 
Schulinus reveal the fact that alcohol induces a distinct 
change in the contents of the nerve-cells, discoverable by 
the microscope, the exact nature of which, whether it be 
a change in the lecithin, fats, or albuminoids, is not posi- 
tively known. Such a change probably occurs in the 
lastruamed stage. Long-continued use of alcoholic drinks 
to intoxication causes an increase in the connective tissue, 
the neuroglia, and an atrophy of the nerve-cells. Pure 
alcoholic drinks, i.e., those which have been carefully freed 
from the higher alcohols, or aldehydes, produce far less 
textural, as well as psychical, disturbances, than those 
containing such impurities. The peculiar condition 
known as delirium Premens most frequently occurs. in 



103 



/Llcobol. 
Alder, Black. 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 



those addicted to liquors rich in fusel oil (amylic alco- 
hol). An interesting fact in this connection, to which 
attention was first called by Richardson, is this, that the 
administration of fusel oil induces a condition almost 
identical with that of delirium tremens. The tempera- 
ment of the subject under such conditions will modify the 
psychical manifestations ; those of a genial temper become 
merry, noisy, and hilarious, while those of an opposite 
disposition become morose, taciturn, or quarrelsome. 
The action, upon the peripheral nervous system, of alco- 
hol is slight, except in toxic doses, when the nerves of 
sensation are benumbed. (See Alcoholism, under the 
head of Insanity.) 

The sympatTietic system— fiaough. the increased blood- 
pressure, in the first stage ; the capillary dilatation, and 
the marked fall of pressure, in the later stages of alcoholic 
intoxication — shows its susceptibility to this agent. Its 
action upon the sympathetic in healthy and in inflamma- 
tory areas appears to differ, for Binz has shown that there 
is a contraction in the latter condition of the arterioles and 
a lessening of the migration of leucocytes. 

Temperature.— Small doses of alcohol frequently re- 
peated will cause a slight primary rise in temperature. 
It is now generally admitted that alcohol in liberal quan- 
tities lowers the bodily temperature. All carefully con- 
ducted experiments prove this. That large quantities 
will do so is a matter of almost daily clinical demon- 
stration, either in the healthy or in the feverish organ- 
ism, but practical use of this agent as an antipyretic has 
been limited, owing to the comparatively large amounts 
and the long-continued administration which are neces- 
sary. In toxic quantities it is not infrequent for the tem- 
perature to drop below the normal from two to four 
degrees Fahrenheit. On what this fall depends there is 
much dispute. The causes are multiple rather than single. 

1. Since alcohol causes a superficial capillary dilatation, 
the volume of blood in the integument is increased, and 
since we have a radiation of heat from the body surface 
there will be a greater loss of heat than is normal. 

3. The functional activity of the sweat-glands is thus 
increased; hence freer perspiration, increased evaporation 
on the surface, and cooling. 

3. The value of alcohol in the economy is as a heat- 
producer ; but arguments based upon the theory that if 
it be burned up in the system, the body temperature 
should rise accordingly, are no more logical than to use 
the same reasoning for any of the other carbohydrates. 
Their combustion goes to the maintenance of the normal 
body temperature as the heat is lost by radiation. This 
is equally true with alcohol. But by the combustion of 
alcohol the fats — in part at least — escape oxidation, and 
are stored up in the tissues. The oxygen which, in the 
absence of alcohol, would have combined with them, com- 
bines readily with the more easily oxidizable alcohol, pro- 
ducing heat. 

Carbonic oxide + Water. 

CDs + mo. 

Now, Frankland has shown that a given weight of al- 
cohol, in. burning, produces but seven-ninths as much 
heat as the same weight of oil (cod-liver). A logical con- 
clusion then is that the temperature of the body, when 
supported chiefly by alcoholic combustion, will fall. 

4. Alcohol in appreciable quantity diminishes cell activ- 
ity. Since the body -heat depends in part on their activity, 
anything diminishing the latter will lower the body tem- 
perature. According to a well-known law of physics, the 
separation of complex chemical bodies into ones of simpler 
composition results in the production of heat. Such 
changes, in all probability, take place within the cell. If 
alcohol, therefore, will diminish cell activity, it will lower 
the body temperature. The fact that a diminished quan- 
tity of COa is excreted does not militate against the idea 
that the alcohol has been burned up, because there is far 
less C in alcohol, in proportion to the other constituents, 
than in the fats. Moreover, experimenters have found an 
increase of the fats and sugar in the blood after imbibi- 
tion of alcohol, which fact would strengthen the theory 
that the alcohol is burned. 



Rude experience, as well as actual experiment, conclu. 
sively teaches us tjjat alcohol diminishes the power of 
resisting exposure to cold ; the explanation being plain 
enough when the action of this substance on the body-tem- 
perature is understood. 

On the secretions alcohol has considerable effect. To its 
action on the salivary and gastric secretions we have al- 
ready referred. The liver being the first to receive the 
blood freshly charged with alcohol, in a more concentrated 
condition than after dilution by the general circulation, is 
the first to feel its stimulating effect, and the first to un- 
dergo pathological changes. The liver-cells are stimulated, 
and as a result we have an increased flow of bile. The 
cells enlarge and become infiltrated with fat-globules. The 
stronger drinks, particularly if taken undiluted and if the 
practice be persisted in for any considerable period, cause 
an irritation of the connective-tissue cells in the liver sur- 
rounding the portal radicles. A proliferation of the same 
occurs, and, as a final effect, contraction of this newly 
formed tissue — as is the case with all newly formed con- 
nective tissues — ensues, producing the so-called cirrhotic 
or hob-nailed liver. With the primary new formation 
there is naturally an increase in the size of the organ, while 
the secondary contraction causes an atrophy of the liver- 
cells, (o) by direct pressure, and (i8) by diminishing their 
normal blood-supply. In those countries where the more 
dilute alcoholic drinks (wines and beers) are the national 
beverage, the cases of cirrhosis are unusual ; while, on 
the other hand, the contrary is true where the more con- 
centrated drinks (brandy, wMskey, gin, or rum) are 
largely consumed. Finally, the portal radicles become 
so narrowed by the contraction of the connective tissue in 
which they lie, that the portal circulation is interfered 
with, thus producing a mechanical congestion of the 
intestinal, peritoneal, and gastric capillaries, with ascites 
and watery stools. 

The remarkable investigations of Dujardin-Beaumetz 
upon the action of the various alcohols on the lower ani- 
mals, have developed, among other things, this very in- 
teresting fact, that after the continued use for thirty months 
of all varieties of pure and crude alcohols, neither intersti- 
tial hepatitis, thickening of stomach- wall, nor ascites was 
induced. The animals chosen for experimentation were 
pigs, because of the similarity between their digestive ap- 
paratus and food and those of man. Congestion of the 
liver and of the mucous membrane of the stomach and 
duodenum was induced to a slight degree when ethylic 
alcohol was used, but it was intense when the higher 
alcohols were used. When the dose of pure diluted 
ethyl-alcohol did not exceed one gramme (grs. 15) per 
kilo. (3 lbs.) of body-weight, no pathological changes 
whatever were induced I 

Kidneys. — The alcohol being in a much less concen- 
trated condition on reaching the kidneys than is the case 
with the liver, the effects, both physiological and path- 
ological, are less marked. The watery portion of the 
urine is increased ; the solid, at least so far as urea is 
concerned, is diminished. The increased amount of 
water excreted is a natural result of the increased blood- 
pressure ; the diminution of urea is due to the lessening 
of oxidation of the nitrogenous tissues. In these organs, 
also, the irritating results manifest themselves more 
slowly than in the liver, but in an exactly similar man- 
ner. Eventually the cirrhotic kidney is produced. 

Excretion. — Experimenters all agree in this, that not 
more than sixteen per cent, of the alcohol taken can he 
found in the excreta. The greater portion disappears in 
the system. As to its mode of destruction nothing is 
positively known. None of the intermediate products 
of its oxidation — aldehyde and acetic acid — have been 
found either in the blood or in the excreta. If it is de- 
stroyed by oxidation, as we have reason to believe, COj 
and HjO — both normal constituents of the blood — would 
be the final products, and could not be identified as de- 
rived from alcohol. Through the lungs a small percent- 
age escapes. The heavy odor of the breath after drinking 
is chiefly due, however, to ethers and higher alcohols 
which exist naturally in the fermented, and are always 
added to the artificial liquors. Pure dilute alcohol does 



104 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 



Alcohol. 
Alder, Black. 



not taint the breath. As to excretion through the kidneys, 
Binz has shown that under the most favorable conditions 
not more than tliree per cent, of the alcohol ingested 
is excreted by them, thus exploding the theory once en- 
tertained that alcohol was entirely excreted unchanged in 
the urine. A small amount of alcohol is excreted through 
the skin. 

Administkation. — The physiological action of all pure 
liquors does not differ materially from that of alcohol of 
a similar concentration. Slight differences due to compo- 
sition will be spoken of in connection with the several 
liquors. 

The physical constitution of the patient, together with 
the state of health and the result to be acquired, must 
form the guide to the proper selection and dose. The 
carefully conducted experiments of Dujardin-Beaumetz, 
Richardson, and others, agree that one gramme (15 grs.) 
of absolute alcohol to every kilo (3 lbs.) of body-weight 
is about the daily limit that can be assimilated by the 
healthy adult without disturbance of digestion or other 
injurious consequences. It is true, however, that patients 
exhausted by the continued fevers can absorb amounts 
far exceeding the normal limits without injury, in fact, 
with benefit. 

A daily indulgence of two grammes per kilo induces 
Intoxication, and if continued for a few days, will cause 
loss of appetite, diarrhoea, vomiting of glairy mucus, etc. 
Finally, a dose of eight grammes per kilo will cause 
death within from twenty-four to thirty -six hours. In 
this connection it will be instructive to present the re- 
sults obtained by Dujardin-Beaumetz as to the average 
poisonous dose of the various alcohols per kilo of body- 
weight, sufficient to cause death in from twenty-four to 
thirty-six hours : Ethyl alcohol, 89 grm. concentrated ; 
propylic alcohol, 3.90 grm. concentrated, 3.75 grm. di- 
lute ; butylic alcohol, 2.00 grm. concentrated, 1.85 grm. 
dilute ; amylic alcohol, 1.70 grm. concentrated, 1.50 
grm. dilute. 

From this it majr be concluded that the higher, the de- 
gree of concentration of the alcohol the more poisonous 
will it be. The two last are more poisonous when dilute, 
because more soluble and better adapted for assimilation. 
Hence, the importance of administering only pure unso- 
phisticated liquors should be particularly borne in mind. 

It may be generally stated that the stronger wines are 
indicated in the weakened conditions occasioned by long- 
continued fevers, chronic suppurative processes, ai>d 
anaemia from frequent haemorrhages, and for convales- 
cents generally. The red wines, by reason of the tannic 
acid which they contain, are serviceable where we desire 
also an astringent effect ; hence their use in diarrhoeas, 
locally to ulcers, as gargles, or not infrequently as an in- 
jection in gonorrhoea. The sparkling wines, from the 
COa which they hold in solution, often are efficient in re- 
lieving such irritable conditions of the stomach as occur 
in seasickness, vomiting of pregnancy, or in true cholera. 
Brandies, whiskeys, etc. (of good quality), are indicated, 
undiluted, in cases of sudden weakening of the heart's 
action. Given after a full meal they certainly aid its 
digestion. This group of alcoholic drinks, when not 
abused, take the place, with the poor, of the costly con- 
diments of the rich, improving the appetite and aiding di- 
gestion. Diluted they can be used where wines are indi- 
cated, but not as efficiently. Externally they are fre- 
quently employed as alcohol is, to check sweating, as 
a counter-irritant for bruises, etc. 

The beers, ales, and porters are valuable because of the 
nutritive material which they contain. They are readily 
assimilated, and are pleasant to the taste, and the bitter 
principles contained in them, together with the alcohol, 
cause an increased flow of gastric juice. They are, there- 
fore, prescribed, together with food, as a dietary measure. 
The diastase which exists in the beer is present in suffi- 
cient quantity to aid in the conversion of the starchy 
foods. Their effect upon the brain is not so pleasant as 
that of wine, due (according to Rossbach) to the oil of 
hops, which resembles, in physiological action, oil of 
turpentine. They are desirable for those who cannot 
stand the cerebral effects of wines. 



Since one gramme of absolute alcohol per kilo (2 lbs.) 
of body -weight is the average limit per diem that cannot 
safely be exceeded, a list of the strengths of the more com- 
mon alcoholic drinks seems here appropriate. From it 
may be calculated the maximal dose, which it is not desir- 
able to exceed. The following table shows the average 
strengths of the ordinary liquors, as given by several 
authorities, with the extremes of variation : 

Per cent. 

Brandies, gin. and whiskeys 48to56 

Sherries and port 20 to 33 

Clarets and hoclc Stoll 

Sweet Spanish and Italian ._ 13 to 17 

Ales and porter .' 6 to 10 - 

Beers 4 to 6 

Stout 4 

Kumyss 1 to SJ 

The pure natural wines, of course, vary in strength, 
from year to year, according as the season has produced 
a very sweet or a sour grape. Sherries and port are fre- 
quently fortified by the addition of brandy, which explains 
their being stronger than the usual eighteen or twenty per 
cent, strength. Lewis L. McArthur. 

ALDEHYDE. The aldehydes form a genus of chemical 
compounds ; but acetic aldehyde being the commonest 
member thereof, the word aldehyde, when used singly, is 
always understood to mean that substance. Acetic alde- 
hyde, CjHjO, is, from the point of view of chemical com- 
position, the first outcome of the oxidation of common 
— ethylic — alcohol. It very closely resembles alcohol in 
physical and physiological properties, being a thin, color- 
less fluid of pungent smell and taste ; inflammable, miscible 
in all proportions with water, alcohol, and ether ; antiseptic, 
irritant, and narcotic. It is not used in medicine. 

Edward Curtis. 

ALDER, BLACK (Ffrinos, U. S. ; Ilex vertidllata Gray ; 
PHtws verticillatus Linn. ; order, Aquifoliacic^, a medium- 
sized shrub, with gra3rish bark, alternate, short, petioled, 
pointed, and serrated leaves, and small clusters of axillary, 
minute, whitish flowers ; fruit a glossy scarlet, six-celled, 
six-seeded, persistent berry, in small close clusters along 
the branches. This plant is common in most parts of the 
United States, growing along roadsides and moist by- 
ways and in swamps, and forms, in the autumn, a striking 
and characteristic portion of our country landscape. 

The bark is smooth, grayish or whitish ash-colored, and 
when dried for medicinal use is in "thin, slender frag- 
ments, about one millimetre thick {^g inch), fragile, the 
outer surface brownish ash-colored, with whitish patches, 
and blackish dots and lines, the corky layer easily separat- 
ing from the green tissue ; inner surface pale-greenish or 
yellowish ; fracture short, tangentially striate ; nearly in- 
odorous, bitter, slightly astringent" (tj. S. Ph.). 

No important or definite proximate principles have been 
found In this drug, which resembles the other hollies in 
its general properties. Like most bitter barks and woods, 
black alder has been considered to be tonic and anti- 
periodic, also, perhaps, slightly astiingent ; this latter 
quality has recommended it as a local applicatfon to in- 
dolent and foul ulcers, and, like most other medicines 
without definite active properties, it has been used as an 
alterative in the treatment of various chronic skin and 
other diseases. The utility of black alder for any purpose 
excepting a mild astringent tonic is very doubtful, and 
where it may be serviceable there are better drugs to select 
from. It is at present, in regular practice, almost obsolete, 
but in some demand for domestic use. 

Dose, internally, from 2 to 4 grm. ( 3 ss. ad 3 j.). There 
is no officinal preparation, but it may be given in the 
regular ten percent, decoction; dose, 25 to 50 c.c. (f 3 vj. ad 
f 3 xij,), two or three times a day. 

Botanical Rblations.— PKjios is, by Bentham and 
Hooker and Gray, included in the extended genus Ilex, 
which comprises about one hundred and forty five species, 
mostly of tropical America, a few in Europe and Asia, 
and is the principal genus of the order. 

Ilex aquifoUum Linn., the common holly of Europe, 
grows there both wild and cultivated, and is occasionally 



105 



Alder, Black. 
Algiers. 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 



cultivated in the United States as an ornamental or hedge- 
plant. It has similar tonic properties to those of black 
haw ; is also diaphoretic, and has been occasionally used 
as a popular remedy in digestive derangements, diarrhoea, 
etc. The berries are emetic and cathartic. A bird-lime 
was formerly prepared from the bark. The leaves, which 
are bitter, contain ilicic acid, ilexanthin (a yellow coloring 
matter), and the bitter principle ilicin, none of which are 
obtained in complete purity. The latter has been used as 
an antiperiodio, in doses similar to those of quinine, but 
has fallen into disrepute. 

Ilex opaca, American hoUy, a good-sized tree, has 
• qualities similar to the above. 

lUx vomitaria Linn., and other species act as bitter 
cathartics or emetics. 

Ilexparaguaiensis Lambert, contains caffeine (see Mate). 

Allibd Drugs. — The number of bitter drugs which in 
moderate doses may act as mild tonics, and in large ones 
certainly derange the digestion, is very large ; of these, 
too, a considerable proportion have been proposed as sub- 
stitutes for quinine ; none of them have held their place 
as antiperiodlcs ; most of them, it must be confessed, 
have a little value as tonics ; but while there is an abun- 
dance of typical bitters, like the gentians and quassias, it 
is hardly worth while to use them. If a laxative astrin- 
gent or stimulant is needed in addition to the bitter, it can 
easily be added to the pure bitters. For list of bitter 
tonics see Gentian. W. P. Bolles. 

ALEPPO EVIL. (Synonyms : Delhi boil, oriental 
sore, impetigo annua, mycosis cutis chronica, lupus en- 
demicus ; Fr., JBouton d'Alep, bouton du Nil, houlon du 
Caire, bouton de Biskra, bouton de Bagdad, bouton du 
Scinde, bouton de Bombay ; Ger., Beule mn Alep, Delhi- 
Beule, Jemen-Beule, Biskara-Beule ; It., gavoceiolo d'- 
Aleppo; Arabic, liabab el seneh , one-year ulcer ; Turkish, 
dous el kourmati, date disease ; Persian, salek.) Defini- 
tion : A non-contagious, indolent, and very intractable 
sore, commencing as a papule, terminating as an en- 
crusted ulcer, and producing a permanent cicatrix like 
that of a burn ; found chiefly on the skin of the face, 
neck, and dorsal aspect of the forearm, hand, and foot, 
and affecting both natives and foreign residents in many 
parts of Asia and Africa. The lesion is either single or 
multiple, usually multiple. Among the natives of places 
where it is endemic, it generally occurs during childhood, 
and it has even been seen in children at the breast ; it 
may occur in persons of any age. In Aleppo, where the 
disease was first observed (by Richard Pococke, in 1745), 
it is said that not one of the native inhabitants escapes. 
It maybe reproduced by inoculation ; it attacks dogs, and 
perhaps horses, as well as men. 

Etiology. — Nothing at all definite is known as to the 
cause or causes of this, as yet, imperfectly understood 
disease. Drinking-water (as in the case of the water of 
the Koweik River at Aleppo), parasites, bites or stings of 
insects, the influence of climate and of particular seasons, 
general insanitary conditions, lupus, and syphilis, have all 
in turn been held to blame for its causation. 

Geographical Distribution. — An exanthematous af- 
fection, more or less like the original Aleppo evil, ob- 
served and described by Pococke and the brothers Rus- 
sel, in the middle of the eighteenth century, has since 
that time been noted by various authors as prevailing en- 
demically in Egypt, in the Arabian Peninsula, in the 
Valley of the Euphrates, at Bagdad and Mosoul in the 
Valley of the Tigris ; at Basra, near the Persian Gulf ; 
at Ispahan, in Persia ; in India, especially its north- 
western portion ; in Algeria, Morocco, the Sahara, and 
the Island of Cyprus ; perhaps in China, and, according 
to Rigler, even in Hungary, Siberia, the Polynesian 
Archipelago, and New Zealand. Whether it be one and 
the same disease which prevails in all these localities, 
many of them so widely separated the one from the 
other, seems reasonably open to doubt, especially in view 
of the conflicting statements of authors ; and it is equally 
evident that, until Aleppo evil, or oriental sore, has 
been more accurately observed and more carefully differ- 
entiated as a special form of disease, no adequate or satis- 

106 



factory account can be given, either of its nature, etiol 
ogy, or appropriate.treatment. 

Symptoms. — Leaving out of discussion, so far as pos- 
sible, the points of dispute in the descriptions of this 
malady, it would appear that its chief characteristics are 
as follows : There are no prodromal symptoms. The 
initial lesion characteristic of the first stage of the disease 
is a small, reddish papule appearing on the skin of the 
face, neck, or extremities, and increasing slowly in size 
for several months, desquamation of the cuticle over the 
papule occurring after a time. During the second stage, 
or period of softening, a vesicle (or vesicles) appears on 
the surface of this now enlarged papule ; the vesicle bursts 
and discharging its contents, of a sero-purulent nature, a 
scab or crust is produced. This scab is of varying thick- 
ness and color, sometimes adherent, sometimes non-ad- 
herent. Under it is an ulcer, having a diameter from 
several millimetres up to eight centimetres in length ; the 
ulcerated surface may be excavated or not excavated, it 
may be smooth or be covered with prominent ^anula- 
tions. One writer (A. Barralier, in "Nouveau Diction- 
naire de Medecine et de Chirurgie ") describes the bouton 
d'Alep as surrounded, during this stage, by a narrow 
areola, dotted over with little tubercular prominences, 
and he quotes Dr. Suquet, of Beyrout, as testifying to 
the existence of ansesthesia in this areola ; he also states 
that at times the ulcer reposes on an indurated base, 
having an extent greater than that of the ulcer itself. 
Sir Joseph Payrer (in Quain's " Dictionary of Medicine") 
speaks also of induration in his account of Delhi boil. 
In this connection it may be of interest to state that 
Virchow regards the various forms of oriental sore as 
belonging to the syphilides, while Hirsch considers them 
as a variety of lupus. The duration of the stage of 
softening or disintegration is usually about five or six 
months. 

The third and final stage is that of cicatrization. The 
cicatrix varies, of course, according to the severity of the 
preceding ulcerative stage ; it is not generally depressed; 
the process of cicatrization occupies usually about two 
months. As a rule the whole duration of the disease is 
about one year ; it may not be so long, it may be much 
longer. The natives in Arabia and Syria call the disease 
' ' one-year ulcer. " There is a general tradition that it can 
occur but once in a lifetime. When the lesion is single, 
the name male has been applied to the button or papule ; 
where several large papules have appeared, each sur- 
rounded by a number of smaller ones, the name female 
button has been used to designate the variety. (In one 
case, of unusual severity, reported by Guilhou, seventy- 
seven of these female buttons existed.) Aleppo evil is, 
for the most part, a painless affection, and is not necessarily 
accompanied by any febrile movement, or other evidences 
of general constitutional disturbance. 

The prognosis is good ; the cicatrices are, however, 
sometimes very disfiguring. 

Treatment. — There is, of course, no specific treatment 
for a disease so ill-defined as is the oriental sore. Tonics, 
change of climate, the use of caustics, and of the actual 
cautery and the knife, and many ointments and lotions, 
etc., have all been used with varying success. 

BiBLIOGBAFHT. 

Richard Pococke : A Description of the Bast and some other Countries, 
vol. ii,, part i., chap. xv. 

Alex. BUssel : The Natural History of Aleppo, etc. 1756. 

Volney : Voyage en Egypte et en Syrie, etc. 1787. ' 

Lewis and Cunningham : The Oriental Sore as observed in India, Cal- 
cutta, 1877. 

F. Zimpel: Die Beule von Aleppo (Jenaische Annalen d. Phys. und 
Med., 1848, S. viii.). 

Requin ; Du Bouton d'Alep (Saz. Mod., 1832), and Elements do Patholo- 
gie Interne, vol. iii. 1853. 

Pfenner : Krankheiten dos Orients. Erlangen, 1847. 

Gober, in Eulenburg's Real Encyolcpjidie, vol. Iv. 1880. 

A. Barralier (de Toulon), in Nouveau Dlctionnaire de M6d. et de Chirurgie, 
vol. V. 

Sir Joseph Fayrer, in Quain's Dictionary of Medicine. 

Hurvtington Richards. 

ALEXISBAD is situated in a deep valley on the south- 
eastern slope of the Hartz Mountains; altitude 408 metres 



REFERENCE HANDBOOK OP THE MEDICAL SCIENCES. 



Alder, Black, 
Algiers. 



(1,338 feet). It can be reached in two hours' time from 
either Quedlinburg or Ballenstedt, stations on the line of 
the railroad. It possesses two chalybeate springs, the 
" Alexisbrunnen " and the " Selkebrunnen." A chemical 
analysis shows that in 1,000 parts of the water of the 
Alexis spring there are 0.5118 of solid constituents, of 
which carbonate of iron represents 0.044, and carbonate 
of manganese 0.025 parts. This water, which possesses 
no very great therapeutic properties, is used only as a 
drinking-water. The water from the " Selkebrunnen" 
contains sulphate of iron (0.056 in 1,000 parts), chloride of 
iron (0.104), and sulphate of manganese (0.025), and is 
used for bathing purposes (temperature 11.8° C. — 53° F.). 
The climate may be described as a mild mountain climate, 
with protection against the raw easterly and northeasterly 
winds. (Eulenburg.) H. F. 

ALGIERS. Algiers, the largest town and capital city 
of the French colony of Algeria, lies almost due south of 
Marseilles, upon the Mediterranean coast of Afiica (Lat. 
36° 47' 20" N., Long. 8° 4' 32" E.). The population in 
1866 was 52,614. As seen from the deck of an approach- 
ing steamer, the appearance of the city is exceedingly pic- 
turesque and striking, its compact mass of dazzlingly 
white houses, having the form of a triangle, whose base 
rests upon the western shore of the bay, while its apex 
climbs almost to the summit of the range of hills shutting 
in the bay on that side, and culminates at the Kasbah, or 
former palace of the deys, some five hundred feet above 
the level of the sea. 

Running along the water-line of the city is a well-built 
quay, backed by a series of stone arches which support a 
wide and handsome promenade terrace, or boulevard. 
The Place du Gouvernement and the neighboring streets 
constitute, together with this quay and esplanade, the 
newer part of the town built by tiie French, and occupied 
by public buildings, warehouses, and the residences of 
some of the foreign inhabitants. Mustapha Superior, a 
very pretty suburb lying on the hillside east of the city, 
contains many villas, and is probably the most desirable 
place of residence for invalids intending to pass a win- 
ter at Algiers.. Another suburb, lying also to the east 
of the town, is known as Mustapha Inferior, just be- 
yond which, at a distance of two miles from Algiers, is 
situated the great Jardin d'Essai, an experimental garden 
under the management of the French government, wherein 
many varieties of palms and other tropical plants are to be 
seen growing in the open air. Ste. Eugenie, another sub- 
urb of Algiers, also contains villas, but of a residence in 
these Dr. Bennet (" Winter and Spring on the Shores of 
the Mediterranean") speaks unfavorably, stating that 
" they are decidedly objectionable, being at the extremity 
of the western promontory that contributes to form the bay 
of Algiers, and exposed, consequently, both to the north- 
west and northeast winds." As to that portion of the city 
proper, the old quarter, which climbs the hill back of the 
French quarter previously described, it is not for a mo- 
ment to be thought of as a residence for invalids, consist- 
ing, as it does, of a compact mass of low, flat-roofed 
whitewashed houses, intersected by the narrow, crooked, 
dark, and dirty streets characteristic of an oriental town. 
Picturesque, indeed, this portion of the city may justly be 
considered, and a ramble through its dingy streets will 
well repay the traveller for whom the tjfpical scenes of 
eastern life possess a fascination, but with its picturesque- 
ness its attraction for the visitor certainly ends. 

From its low latitude and its situation within the great 
Mediterranean basin, as well as from its proximity to the 
desert of Sahara, the climate of Algiers is necessarily a 
mild one in winter and a hot and very dry one in summer, 
having its rainf ul confined almost exclusively to the colder 
mont& of the year, as is the case with all places lying in 
the sub-tropical region of the Old World. The greater 
mildness of its winter climate, as compared with that of 
the Genoese Riviera, is ascribed by Dr. Bennet in large 
measure to the higher temperature of the hours be- 
tween sunset and sunrise, the temperature along the 
Riviera being lowered at night "by down-draughts from 
the mountains that protect it from the north, the Mari- 



time Alps." Another element in producing this more 
equable temperature at Algiers is probably the fact that 
winds blowing from the north must pass over the warm 
waters of the Mediterranean before they can reach the 
African coast, whereas on the northern shores of this sea 
all such winds partake of the character of continental 
winds, and, notably in the case of the much-dreaded 
mistral of the Rhone Valley and of the bm-a of the upper 
Adriatic, they are accompanied by sudden and most un- 
comfortable depression of the atmospheric temperature. 

The following data, representing the climatic features 
of Algiers, have been collected from various sources: 
The mean annual temperature is 66.5° P., according to' 
the writer in the " Encyclopsedia Britannica ; " 67.89° P., 
according to Martin and PoUey, quoted by Dr. H. C. 
Lombard, in his "Tralte de Climatologie Mddicale;" 
64.58° P., according to Angot, quoted by Dr. Julius 
Hann, in his ' ' Handbuch der Klimatologie ; " 69. 13° F. , ac- 
cording to the author of the article on " Climate," in 
the " Nouveau Dictionnaire de M^decine et de Chirurgie " 
(Jules Rochard) ; and, finally, about 68° P., according to 
Dr. Hermann Weber. The mean of all these figures 
would .^ve us 67.22° P. as the mean annual temperature 
of Algiers. On page 448 of his work above cited, Dr. 
Hann states as follows: "Entirely erroneous mean tem- 
peratures have hitherto (1883) been given for Algiers, 
which showed especially a winter temperature by far too 
high. The figures of our table are quoted from a recently 
published work by Angot, and relate to the period be- 
tween 1860 and 1879." For the eight months of August, 
October, November, December, January, February, 
March, and April the figures of Dr. Hann are as fol- 
lows : 



Aug. 


, Oct. 


Nov. 


Deo. 


Jan. 


Feb. 


March. 


April. 


77° 


67.46° 


60.44° 


64.68° 


53.78° 


54.68° 


67.02° 


61.34° 



The mean absolute minimum temperature, he states 
(on the authoritjr of Angot) to be 38.48° P, Deducing 
from the above given figures the mean temperature of the 
three winter months, we find it to be 54.88° P., while that 
of the seven colder months of the year (October to April) 
is 58.48° P. The duration of the season for invalids 
("Kurzeit"), according to Weber, is from November 
until the end of April ; for this period of six months the 
average temperature of Algiers, calculated from these 
same figures, is 56.99° P. There appears to be much dif- 
ference of opinion respecting the degree of variability of 
temperature exhibited from day to day. Thus, the writer 
in Eulenburg's " Encyclopadie " remarks that the changes 
in temperature during the course of a single day, from 
one day to another, and from one month to another, are 
considerable in their amount, and frequently sudden in 
their manner of occurrence (sind sehr bedeutend und 
fallen oft sehr plotzlich ein). Weber (loc. cit.) says the 
daily variations are from 10.8° to 14.4° P. (6° to 8° C). 
Rochard (loc. cit.) states that the annual mean of the vari- 
ation from day to day does not exceed 11.34° P. (6.8° C), 
while the difference between the day and night tempera- 
tures (variations nycthemerales) is given by him at from 
5.4° to 9° (3° to 5° C). Lombard remarks that the former 
(variations diurnes) are not extreme, not exceeding 1.45° 
P. in winter, 2.03° P. in spring, 2.66° P. in summer, and 
1 . 6° P. in autumn. The absolute minimum temperature ob- 
served at Algiers during a period of twenty years was 
35.6° P. , according to the author last quoted. 

The following figures for the relative humidity are 
given by Dr. Hann : 



Nov. 


Dec. 


Jan. 


Feb. 


Mar. 


Winter Mean. 
Dec— Feb. 


68 


73 


73 


72 


69 


73 



The extreme figures representing this factor of climate 
during the whole year are given as 16 per cent, and 80 per 
cent. (Mitchell, quoted by Rochard). 

The annual rainfall at Algiers is about 36 inches ; Lom- 

107 



Allmeut. 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 



bard puts it at from 31.49 to 33 7 mches and gives the 
following extreme quantities. 21.9 and 42 3 inches As 
illustrating the seasonal distribution of the rainf al , the 
following tables, quoted by Dr. Bennet, will be of interest 
to the reader : 

A.— Mean Rainfall at Alqiees, 1839-1S45. 

May If to*- 

June Oi 

July ° „ 

August "I j^ 

September 1 

October aiinchea. 

Xotal 5 inches. 



November 5 inches. 

December 8 '^ 

January 6 

February 5 

March 3 

April 4 

Total 31 inclies. 



B.— Ndmbeb of Days and Nights in 1843 on which Bain FEtL. 

DavB. Nights. . Days. Nights. 

: l(t 10 May 3 1 

. B 2 June 3 " 

. 10 7 July 

, 9 7 August 

. 9 fi September 2 

. 1 2 October 3 1 



November : 10 

December 5 

January 10 

February 9 

March 9 

April 1 

Total 44 



It will be observed that the mean rainfall for October 
given in Table A is but little less than that for March, 
thus bearing out the statement made by Dr. Hann tliat 
the duration of the dry season for places lying on the 
Algerine coast is but five months. The average number 
of fair days in the course of a year at Algiers is 233. The 
prevailing wind for the year is the northwest, which fre- 
quently blows with great violence. The west is the rain- 
bearing wind, and is the one which is of commonest occur- 
rence in the winter season. North and northeast winds 
are those which blow most frequently during the spring' 
and summer months. The sirocco, tailing its origin over 
the heated sands of the great Sahara desert, is most com- 
monly felt at Algiers during the hot season, at which time 
it is greatly dreaded. This wind, blowing from the south- 
east, occurs somewhat less frequently during the colder 
months, at which season it is far less oppressive, and is 
more easily borne. The sirocco at Algiers is always a dry 
wind ; it is accompanied by clouds of dust, a portion of 
which, consisting of extremely fine particles of sand, it 
brings with it from the great desert. Dust, it may be re- 
membered, is one of the pests of the Algerine climate ; in 
great part it is of purely local origin, the character of the 
soil and the heat of the sun, together with the almost con- 
stant prevalence of wind, favoring rapid evaporation of 
the rainfall, and the rainfall itself occurring chiefly in the 
form of lieavy and not very protracted showers. A fall 
of snow at the city of Algiers itself is an extremely rare 
phenomenon ; in the elevated country back from the 
coast, known as the Hants Plateaux, snow falls quite fre- 
quently, and at times to a considerable depth. The water- 
supply of the city of Algiers is abundant. Concerning the 
character of the water, the writer has no exact informa- 
tion ; but from the absence of adverse comments in the 
works of the various authors consulted, he deems it.prob- 
able that it possesses no deleterious qualities. 

The mildness of its winter climate, together with the 
moderate percentage of relative humidity in the atmos- 
phere and tlie great preponderance of clear sides and of 
hriglit, sunny weatlier, which it enjoys at all seasons, 
combine to render Algiers a desirable, pleasant, and 
beneficial place of residence during the winter and early 
spring montlis, for invalids suffering from pulmonary 
phthisis and from certain other affections of the respira- 
tory system. For such cases its climate is recommended 
by Lombard, Rochard, and "Weber. The last-mentioned 
writer speaks of the climate as exercising also a benefi- 
cial influence upon chronic diarrhoeas and upon the 
sequelae of dysentery.' Lombard specifies chronic bron- 
chitis, asthma, and phthisis as diseases likely to be bene- 
fited by a sojourn at Algiers, and he calls attention to 
the remarkable immunity from pulmonary phthisis en- 
joyed by the native population as well as by the soldiers 
of the French army stationed in Algeria. This immun- 
ity is greater upon the sea-coast tlian it is on the higher 
ground lying further mland. The writer on Algiers in 



" Eulenburg's Encyclopaedia" speaks, on tlie contrary, 
in very unflattering terms both of the climate of the city 
and of its desirability as a winter residence for invalids. 
He lays great stress upon tlie variability of the climate 
and its liability to sudden changes of weather, and warns 
all invalids who are unpleasantly affected by sucli 
changes, all asthmatics and persons subject to attacks of 
diarrhoea, rheumatism, and intermittent fever, that they 
would do well to avoid the place. How far the unfavor- 
able comments of this writer may be justified, the writer 
is not in a position to know from personal experience ; 
but, judging from the meteorological data quoted from 
reliable sources in the present article and from the favor- 
able comments made by Lombard and other writers of 
repute, he deems it not improbable that the contributor 
of the article in Eulenburg has overestimated the un- 
pleasant features of the Algerine climate. 

Huntington Bieha/rds. 

I Chronische Bronchitis, besonders mit Reizhusten, Emphysem, TJeber- 
reste von Pneumonic und Pleuritis und Phthisis im ersten Anfang bflden 
das geeignete Material ; auch Chronische Diarrhoen und Folgezustiiiide 
^'on Dysenterien sind geeignet (Ziemssen's Handbuch der allgemeineQ 
Therapie, Band ii., S. 80). 

ALHAMA D'ARAGON (Lat. 41° 13' N.; elevation above 
the sea, 1,880 feet), a Spanish village on the Saragossa 
& Madrid Railway ; a spring of moderately high tem- 
perature (93.2° F.), and of slightly mineralized, almost 
tasteless water. Total solids 6.1 per 1,000. The place is 
frequented chiefly by rheumatic patients. The bathing 
estabhshments are on a grand scale. (Eulenburg.) 

KF. 

ALICANTE. Tlie city of Alicante lies upon the shore 
of the bay bearing the same name, on the eastern or Med- 
iterranean coast of Spain, and about forty miles south 
of the middle point of that coast (Lat. 88° 30' N., Long. 
0° 30' W.). The population of the town is 31,500. Ex- 
tending in the form of a crescent along the northern sliore 
or head of the bay, and nestling at the base of a rocky 
eminence some 400 feet high, the town is tolerably shel- 
tered from north and northwest winds. The streets near 
the port are wide and clean. The water supply, accord- 
ing to Dr. J. H. Bennet ("Winter and Spring on the 
Shores of the Mediterranean," fifth edition, 1875), is de- 
rived from one large spring and from rain-water tanks. 
" Lippincott's Gazetteer " (1864) states that in its characttr 
the water is not good, being impregnated witli the sahs 
of magnesia, but in the point of abundance it would ap- 
pear to be suflicient for the needs of the town. Up to the 
time of Dr. Bennet's visit, in tlie spring of 1869, no ho- 
tel existed at Alicante which came up to tlie standard of 
comfort and convenience desirable for invalids in searcii 
of a good sanitary resort. Perhaps this defect may have 
since been remedied. The climate of Alicante is a mild 
and a very dry one. The annual rainfall is only 16.98 
Inches ; of which (according to Lorenz and Rotlie, quoted 
by Dr. Weber in Ziemssen's " Handbuch der Allg. 'Thera 
pie") 20.7 per cent, or the extremely small quantity of 
3.5 inches, falls during the winter months. From the 
other percentage figures given by these authorities, the 
average rainfall during the spring at Alicante would be 
5 inches, during the autumn 6.4 inches, and during the 
hot summer months only 1.9 inch ! The percentage of 
clouds prevailing in the sky of that portion of Spain in 
which Alicante is situated is much lower than is found in 
any other part of Europe, Italy and Greece being in- 
cluded. The neighboring province of Murcia bears the 
name among the Spaniards of "el reino serenissimo," a 
title justly bestowed upon it for this reason (Hann's 
" Klimatologie "). Figures for the relative humidity of 
Alicante itself the writer has not been able to find, but at 
Valencia, lying some eighty-flve miles north of Alicante, 
the mean relative humidity of the year is 66 per cent., and 
it varies but little from season to season (Weber, loc. cit.). 
The mean annual temperature of Alicante is 64.4° P.; 
the mean temperature of the winter season nearly 53.5° 
F. ; according to the same author, who quotes these fig- 
ures from Francis. For Murcia, lying about fifty miles 
southwest of Alicante, the yearly extremes of tempera- 



108 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 



Algiers. 
Ailment. 



ture are_ 26.5° P. in winter, and 106.5° F. in summer; 
the mean temperature of January being 48.7° F., that of 
April 60.3° F., that of July 79° F., and tliat of October 
64.5° F. These latter figures are quoted from Hann's 
" Klimatologie." The east wind, or "Solano," is the 
rain-bearing wind for the eastern coast of Spain. The 
"Leveche," a very dry, hot wind from the Sahara, 
reaches the southeast coast between the Cabo de Gata and 
the Cabo de Nao. 

Dr. Weber says (1880) that there is good accommoda- 
tion to be found at Alicante. He speaks favorably of 
the efEect of the climate upon certain cases of phthisis 
("einzelne FaUe von apyretischer, ruhender Phthisis"). 
"Alicante," says Dr. Bennet, "appears to me decidedly 
the most favorable health station that I have seen on the 
southeastern coast of Spain. . . . There is a Hu&rta, 
or irrigated valley, it is true, connected with Alicante, 
but it is situated at some distance north of the town, 
. . . and there are no rice grounds to produce ma- 
laria as at Murcia and Valencia." On account of its 
greater dryness. Dr. Bennet questions whether Alicante 
would be as beneficial to certain classes of patients as the 
Riviera of France and Italy. 

Huntington Bichards. 

ALIMENT. Food or aliment is matter which, in con- 
junction with the air, supplies the elements necessary for 
the maintenance, growth, and development of the organ- 
ism, and is thus the source of the power on which the 
vitality of the organism is dependent. Hence, in the 
broadest sense, true aliment is a mixture of food-stuffs 
and drink, together with the air from which comes the 
oxygen necessary for the oxidation of the former and by 
which force is produced. Again, physiologically con- 
sidered, true aliment, especially in the animal kingdom, 
is to be distinguished from so-called "food "as being 
only that portion of the food which is either itself di- 
rectly soluble and diffusible, or convertible by the diges- 
tive juices of the body into soluble and diffusible prod- 
ucts, and thus capable of being absorbed by the blood. 

The aliment of vegetable organisms is quite different 
from that of animal organisms. Moreover, the nature of 
the processes involved is likewise quite different.' The 
vegetable organism by a synthetical process — a building 
up of more complex bodies from simpler ones — derives 
its nourishment from the inorganic world ; its cells ap- 
propriate such of the inorganic principles as are needed 
for its growth and convert them under the influence of 
the sun's rays into organic compounds which enter into 
its own structure. 

The animal organism, on the other hand, does not pos- 
sess this power, and thus we look to the creative power 
of the vegetable kingdom as the source, either directly or 
indirectly, of the aliment of animals. Moreover, the veg- 
etable matter which thus serves as food, not only fur- 
nishes the material necessary for the growth and life of 
the organism, but it contains in addition, stored up with- 
in its molecules, a certain amount of latent force derived 
from the solar force originally used in its construction. 

Animal prganisms, by a process of transformation 
quite the reverse of synthetical, convert the preformed 
animal or vegetable organic matter into allied or simpler 
forms which are absorbed into their own tissues. Ani- 
mal food approximating more closely in composition 
with the body to be nourished by it, is more easily ap- 
propriated, and probably with less expenditure of energy, 
than vegetable products. Animal food, moreover, pos- 
sesses stimulating properties, due without doubt to the 
crystalline nitrogenous bodies contained in muscle-serum. 
Organic matter once entered as a part of an animal organ- 
ism and applied to the purposes of life is decomposed or 
broken apart, and its decomposition products are ulti- 
mately reconverted into inorganic principles. There is thus 
a complemental relationship between vegetable and animal 
life and the inorganic world. The plant by a selective 
action appropriates as an element of nutrition certain 
kinds of mineral matter, together with nitrogen in the 
form of ammonia and nitrates, from the soil in which it 
grows, at the same time drawing from the air carbon in 



the shape of carbonic acid, while hydrogen and oxygen 
are supplied to an unlimited extent in the form of water. 
The vegetable products thus formed serve in turn as the 
food of animals, while the latter at every breath pour 
forth carbonic acid and water, which ultimately find 
their way again, more or less modified, into the tissues 
of plants. These, together with the nitrogenous excreta, 
products of the metabolism of life, and the post-mortem 
decompositions which follow, continually serve in their 
variously modified forms as agents by which the conser- 
vation and transference of energy is accomplished. 

The alimentary products found in nature can be sepa- 
rated by chemical analysis into several well-defined sub- 
stances, none of which are usually found free in nature. 
These chemically distinct substances arc termed the ali- 
mentary principles. Many of them are found in both 
animal and vegetable foods, as, for example, certain fats, 
casein, and some forms of albumin, although in the 
case of the tw^o latter examples there would appear to be 
some few minor points of difference both in percentage 
composition, and in chemical reactions. Others are to 
be found only in one kingdom, as starch in the vege- 
table, or collagen, the gelatin-forming substance, in the 
animal. 

Now since food is the source from which the various 
elements of the body are supplied, it is evident that to ful- 
fil its purposes food must contain all of the elements 
present in the body. These are of course not free, but in 
a state of combination, for it is only in the latter case that 
they are of service as food, and as Pavy remarks, "the 
combination must have been formed by the agency of a 
living organism — the combination must, in other words, 
constitute an organic product." Aside from the elements 
which appear as inorganic salts, there are in the body at 
the most but six elements, two of which are present only in 
small quantity and are apparently much less important. 
These six elements are carbon, hydrogen, nitrogen, oxy- 
gen, sulphur, and phosphorus. Any substance which as 
food is to satisfy the requirements of life, must contain at 
least the first four of these six elements, in addition to in- 
organic salts and water. 

Various classifications of food have been from time to 
time proposed, based mainly either upon physiological 
or chemical groimds. Popularly, aliment is frequently 
divided into food and drink, without, however, any suit- 
able reasons, since the mere fact of a food being in solu- 
tion does not preclude the possibility of the presence of 
even a large amount of solid matter, as for example in the 
case of milk, while, on the other hand, butcher's meat 
contains on an average sixty to seventy-two per cent, of 
water. Hence, food should be considered as including 
both liquid and solid matter. The most natural and com- 
prehensive classification of foods is that based primarily 
on chemical composition and origin, viz., organic and in- 
organic — that is, chemical combinations of elements pro- 
ducible only through the agency of living cells, and sec- 
ondly, inorganic compounds absorbed from the mineral 
kingdom, and thus intimately mixed with the. former. 
The inorganic portion of food consists simply of water 
and various saline compounds. The organic portion may 
be advantageously subdivided into two groups, nitro- 
genous and non-nitrogenous, based simply on the pres- 
ence or absence of the element nitrogen. The nitrogenous 
alimentary principles contain carbon, hydrogen, oxygen, 
and nitrogen combined in varying proportions, and gener- 
ally also small quantities of sulphur and frequently of 
phosphorus. The non-nitrogenous principles contain only 
the three elements carbon, hydrogen, and oxygen. These 
are in turn further subdivided according to the relative 
proportion with which the carbon and hydrogen unite 
with oxygen, viz., into fats and carbohydrates; the for- 
mer consisting of carbon and hydrogen united to only a 
small amount of oxygen, as in the case of tripalmitin, 
CsiHbsO,, the latter of carbon vfith the hydrogen and 
oxygen always in such proportion as to form water, as in 
the case of cane-sugar or saccharose, CiaHsjOu ; hence 
the name carbohydrates. These two divisions of the non- 
nitrogenous principles not only differ in percentage com- 
position, but they are likewise widely divergent both in 



109 



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Ailment. 



KEFEBENCE HANDBOOK OF THE MEDICAL SCIENCES. 



chemical and physical properties. Following is a partial 
classification of foods : 



. water. 



b. Baits. 



calcium sulphate and phosphate. 
?'„Suroh;?SaShospliate, and oarbo.j.te. 
sodium chloride, phosphate, and carbonate, 
iron salts, 
silica, fluorine. 



a. non-nitrogenous. 



b. nitrogenons. 



fats. 



carbohy- 
drates. 



'tristearin. 
■ tripalmitin. 
triolein. 



amylaceous. 



gelatinous 
principles. 



albuminous 
principles. 



L 



saccharine. 

collagen, 
chondrigen. 
gelatin, 
albumin, 
fibrin, 
canein. 
syntonin. 
globulin. 
, vitellin. 



animal and 
vegetable. 

' starches. 

gums, 

dextrins. 
_ cellulose. 
' grape-sugar. 

cane-sugar. 

milk-sugar. 

muscle-sugar. 



1 anittial and 



vegetable. 



Examination of this classlflcatlon leads us first to notice 
the importance of water' as food. According to Voit 
the body of a fully developed man contains 63 per cent. 
of water, while the body of a growing child contains 
nearly 66.5 per cent. Any great alteration in the content 
of water in the animal body is always attended with dis- 
astrous results ; thus, in diarrhoea, cholera, etc., such 
large quantities of water are lost as to render the blood 
quite thick, and even the muscles may lose as much as 
six per cent, of water. Such loss, if long continued, soon 
results in loss of vitality and consequent death. It is 
noticeable, moreover, that a certain proportion of the water 
contained in the tissues of the body can be removed with- 
out difficulty, while a smaller, residual portion, apparently 
more closely united to the organic matter, can be separated 
only with great difficulty ; this is well illustrated in the 
simple drying of dead muscle-tissue. Removal of the 
water from low forms of animal life by drying them at 
the ordinary temperature, or at a temperature below the 
coagulating point of their body protoplasm, causes them 
to lose all appearance of life, but in such condition they 
will again absorb the water lost, and return to their for- 
mer appearance and vitality. Increase of water in the 
organism beyond the normal amount is usually associated 
with an unhealthy condition of the body. Various inves- 
tigators have likewise demonstrated that there is a close 
connection between the percentage of water in the body 
and the diet, irrespective of the water taken as drink. Thus 
Voit has shown that a bread diet continued for some time 
renders the body more watery than normal. In one experi- 
ment with a cat the amount of water in the brain and mus- 
cles was increased three to four per cent. Increase of fat 
in the body is usually attended with a diminished per- 
centage of water.* A vigorous, well-nourished man pos- 
sesses organs much poorer in water than a badly -fed per- 
son. Forster ' has figured that under normal conditions 
a person living on an average diet takes dally 3,315 to 
3,538 grammes (about 6.5 pounds avoirdupois) of water. 
It is easy to see, however, that a great variety of circum- 
stances, of diet, exercise, temperature, etc., may excite a 
modifying influence on the amount of water taken into 
the system during the twenty -four hours. The figures 
just given do not, however, represent all of the water, 
since a variable amount is formed within the body by ox- 
idation of the hydrogen contained in the organic alimen- 
tary principles. Thus, according to Volt; in the case of a 
hungry man, 33 grammes of hydrogen in the form of or- 
ganic matter were oxidized to 388 grammes of water dur- 
ing twenty-four hours. 

It is thus plainly evident from the foregoing that water 
is a necessary constituent of the body, and as one of the 
alimentary principles is a decidedly important one ; yet 
we need to understand its true significance. It does not 
itself undergo any chemical change, and is thus not con- 
cerned in the production of force, though it aids chemical 



change in supplying, by its presence, a condition abso- 
lutely necessary for its occurrence in other bodies. 

The inorganic salts, as Pavy remarks, " stand, if not to 
the full extent, nearly so, in the same position as water, 
as regards the non-possession in itself of force-producing 
properties." The mineral matters are more closely con- 
cerned in the structure of the organism than in the devel- 
opment of power, and this is true both of the animal and 
' vegetable organisms. They are particularly necessary in 
the developing animal body, and of all the forms of mineral 
matter none is so important and so widely distributed as 
calcium phosphate. This salt is seldom, if ever, absent 
from any stnictural element of the body, and its intimate 
union with many of the nitrogenous principles, particu- 
larly the albuminous bodies, is so decided that only with 
the greatest care can this salt be completely removed 
without changing the nature of the albuminous body;' 
indeed in many cases there would appear to be a chem- 
ical combination between the proteid body and inorganic 
salt Mineral matter is needed, not only for the growth 
and nutrition of the skeletal portions of the body, but it 
is also needed in the structure of the softer tissues as 
well as in the formation of secretions ; thus the acid of 
the gastric juice has its origin in the chlorine of sodium 
chloride or common salt, while the alkalinity of the 
pancreatic secretion, as well as that of some of the 
other fluids of the body, is due to sodium carbonate. 
Moreover, the removal of carbonic acid by the lungs, 
through the agency of the venous blood, could hardly be 
accomplished were it not for the alkalinity of that fluid. 
In many juices of the body, inorganic elements are held not 
only in solution, but quite firmly united with the more 
characteristic organic matter, as in the sodium salts of 
the bile acids, and in some instances they can be removed 
only by decomposition of the compound. The excess of 
salts taken into the body, by the food or other means and 
that which becomes free by decomposition within the body, 
is easily removed through the urine and faeces. 

There is still other evidence that the various inorganic 
salts of food serve definite purposes in the body. The 
two alkalies, potash and soda, so widely distributed and 
so closely allied in their chemical properties, cannot be 
made to replace each other in the living organism, while 
the same is likewise true, to a certain extent, of the alkali 
earths, lime and magnesia. Thus a qualitative, and also 
a quantitative selection of inorganic matter is noticeable 
in the body, particularly in the blood, where the corpus- 
cles contain the greater portion of the potash salts and 
phosphates, while in the serum, soda salts and chlorides 
are in excess. Again, it is quite noticeable that potash 
salts predominate in the formed tissues of the body, while 
soda salts are characteristic of the fluids. 

Porster's ' experiments on pigeons with food poor m 
salts, and on dogs with powdered meat from which the 
greater portion of inorganic matter had been removed by 
extraction with hot water, fat and carbohydrates being 
afterwards added, showed that these animals could not 
bear the loss longer than four to five weeks without great 
suffering, and, finally, death. In fact, it is evident from 
physiological experiment, that an organism supplied witli 
all organic food-stuffs and water can live only for a lim- 
ited time without mineral matter. For a time the body 
draws upon the inorganic matter stored up in its own 
tissue ; « but this failing, and that naturally present in the 
organic foods being removed, death soon results from 
lack of inorganic aliment." In the ordinary diet of men 
and animals, sufficient salts are generally contained in the 
fat and proteid foods to furnish the required amount ot 
mineral matter. As to the actual quantity of inorganic 
matter needed to counterbalance that withdrawn from the 
body in twenty-four hours, we can hardly say. IM 
content of ash contained in the smallest amount of food 
necessary to keep up the vitality of an organism would 
give an approximate answer to this question. This liis- 
chofE and Voit attempted to ascertain by experimenting 
with a dog weighing 31 kilogrammes (68.3 pounds), the 
daily food in this case containing 6.5 grammes (lOO.d 
grains) of ash. The excretion of ash, however, as Voit 
has pointed out, is quite different in the hunger condition 



110 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 



Ailment. 
Ailment. 



from what it is during a plentiful diet ; for, in the case of 
hunger, the inorganic matter of the organs is drawn upon, 
the salts passing into the excreta, thus keeping the per- 
centage composition of these fluids for a time constant. 

The importance of iron, or iron-salts, as aliment, is 
hardly second, certainly not in the case of the higher 
animals, to lime salts. The position which it occupies in 
the haemoglobin molecule, on which the blood depends 
for its power of carrying oxygen, would alone indicate 
this. Boussingault '" has determined the amount of iron in 
a sheep of 32 kilogrammes weight to be 3.38 grammes, 
= 0.151 per cent." 

Of the non-nitrogenous foods, the fats or hydrocarbons 
which, according to Liebig's classification, come under 
the head of elements of respiration or calorifacient prin- 
ciples, are particularly applied to the production of heat 
and other forms of force. They also appear to be con- 
cerned, to a certain extent, in tissue development. The 
neutral fats alone are important as foods. The free fatty 
acids and glycerine are seldom present in sufficient quan- 
tity to have any significance. The more important fats 
are tristearin and tripalmitin among the solid, while 
among the more easily melting fats triolein alone occurs. 
These are simply neutral compounds, formed by the union 
of a triatomic alcohol, glycerine, with three molecules of a 
monatomic fatty acid. The fluidity of a fat depends on 
the amount of olein present ; thus, beef -fat, which contains 
more palmitin and .stearin, melts at 41° to 50° C, while 
goose-fat, which contains large quantities of olein, melts 
at 34° to 26° C. The following table gives some idea of 
the amount of fat contained in a few common foods : 

Fer cent, of fat. 

Fat-tisBue of swine 92,21 

Fat-tissne of beef 88.88 

Fal>-ti8Bue of mutton 87.88 

Butter 85. to 90.0 

Eggs 12.0 

Fat meat B.O to IS.O 

Milk 3.0 to 4.0 

Clieese 8.0 to 30.0 

Vegetables to 3.0 

Nuts 53.0to66.0 

All animal fats show a remarkable uniformity in elemen- 
tary composition, containing on an average 76.5 per cent. 
C,,11.90 per cent. H, and 11.60 per cent O. The chemical 
composition of the fats indicates the importance of these 
principles as heat-producing agents. In the carbohydrates 
and other allied principles, the hydrogen and oxygen are 
present in such proportion as to form water (starch 
CeHioOe), while in the fats, as in tripalmitin (CsiHoeOa), 
only 12 atoms out of 98 have their combining equivalent 
of oxygen contained in the compound, and hence the re- 
maining hydrogen atoms, as well as all of the carbon, are 
' free for oxidation. And since the quantity of heat produced 
is dependent upon the amount of chemical action or oxida- 
tion, it follows "that a given "quantity of fat will have 
the power of appropriating about 2.4 times as much oxy- 
gen as the same quantity of starch, or, in other words, 
iWill develop about 3.4 times as much heat in the process 
of oxidation, and hence has about 2.4 times as much value 
as a heat-producing agent " (Pavy). But while the fats 
are especially important for the production of heat, and 
for forming the basis of adipose tissue, they are likewise 
essential for tissue development generally. The great 
importance of fat in food and of that deposited in the 
body is to be found in the aid which it furnishes to the 
hungry organism in developing its wasted tissue. A 
purely proteid diet to a person poor in fat necessitates a 
large amount of the former to sustain the weight of the 
body, indeed more than the intestines are capable of ab- 
sorbing. But a mixture of fat with the proteid matter 
diminishes both the amount of circulating albumin in the 
body and the proteid metabolism. The proteid food is 
needed to sustain the bodily wants, and at the same 
time to prevent the loss of fat. Still, it is not possible to 
convert a poor body into a body rich in fat and proteid ma- 
terial by a simple albuminous diet ; fats or carbohydrates 
are needed, admixture of which diminishes the work of the 
organism. The energy of the active cells of the body is 
then only in part used for the decomposition of albumin, 
the remaining energy being applied to the decomposition 



of fatty matter. This is well illustrated by the increased 
metabolism of fatty matter during muscular exertion. 
In the words of Voit, "muscular work renders the cells 
capable of decomposing more material, and, after the use 
of the disposable albumin, the fat is brought into requisi- 
tion. Thus nothing is of greater influence upon fat 
metamorphosis than work." (See Nutrition.) 

The carbohydrates being especially found in the vege- 
table kingdom, belong essentially to a vegetable diet. A 
few, however, occur in animal food, as glycogen and 
sugar in the liver, lactose in milk and the sugars, as ino- 
site present in small quantities in muscle-tissue. In 
composition, the carbohydrates are all alike in containing 
hydrogen and oxygen in such proportion as to form wa- 
ter, but the exact chemical constitution of the bodies is 
not known. As a class they constitute very easily de- 
composable material, readily breaking down into carbonic 
acid and water, and as food-stuffs they are especially 
prominent in causing an accumulation of glycogen in the 
liver. They are, moreover, without doubt the source, in 
part, of the fat in the body. Sugar or starch is always 
present in fattening foods, and although it is doubtful 
whether the fat is formed directly from the carbohydrates, 
still the association of fat and glycogen in the hepatic 
cells, and the fact that the former is increased by such 
diets as tend to increase the latter, would in itself tend to 
indicate a connection between carbohydrates and the pro- 
duction of fat. (For a discussion of this question see 
Nutrition.) Carbohydrates, like the fats, tend to dimin- 
ish proteid decomposition, and even more decidedly ; and 
as they are likewise able to prevent the withdrawal of fat 
from the body (according to Voit 175 parts of carbohy- 
drates accomplish as much as 100 parts of fat) it is evi- 
dent that they possess the power, in a high degree, of 
taking the r61e of the fats. Moreover, while the carbo- 
hydrates are being oxidized, the fat formed from albumin 
is spared, and Voit '" considers that in both carnivorous 
and herbivorous animals the main action of carbohydrate 
food (so far as its connection with fat is concerned) is to 
protect the fat already formed, and that in no case does 
the fat itself have its origin in the carbohydrates, but in the 
carbon surplus of proteid food. (See Nutrition.) Carbo- 
hydrates differ from fats in that they contain, weight for 
weight, less potential energy than the latter. They diflrer 
likewise in being more easily 'digestible. 

The nitrogenous or albuminous and gelatinous princi- 
ples, are all very much alike in general composition, 
showing, however, some decided differences in their con- 
tent of nitrogen. Most of the nitrogenous principles oc- 
cur in the solid form, both in the animal and the vegeta- 
ble kingdom, though a few are to be found dissolved in 
the fluids of the organism. Voit" has estimated from 
analyses by Bischoff, that in a fully developed human 
body weighing 68.65 kilos (151.3 pounds) there would be 
contained when dry (at 100° C), 33.4 per cent, of albu- 
minous matter, and 14.8 per cent, of collagenous tissue. 
The excretory products of animal organisms contain such 
a large percentage of nitrogen, it is evident that the nitro- 
genous principles must play an important part in supply- 
ing the needs of the body. Of these the albuminous 
principles are the most important, and for man and ani- 
mals albumin, in its various forms, constitutes a vital 
food-stuff, without which life cannot be long sustained. 
As the content of albuminous matter in the body is large, 
and as all the active cells of the body are protoplasmic, it 
follows that albumin must be supplied in considerable quan- 
tity to take the place of that used up in the ordinary pro- 
cesses of life. It is, however, widely distributed through 
both the animal and vegetable kingdoms ; notably in the 
casein of milk, egg-albumin, and myosin of muscle in the 
animal kingdom, and in the coagulable albumin, vegeta- 
ble casein, legumin, and congluten of the legumins, and 
gluten of wheat and rice, etc., in the vegetable kingdom. 
The albuminous principles, moreover, in view of their 
containing all of the or^ganic elements necessary to life, 
are capable, when used in conjunction with the inorganic 
principles, of supplying alone all the needs of the body ; 
still such a diet would not be an economical one for the 
system, owing to the large amount of proteid matter 



111 



Aliment. 
Alimentation. 



REFERENCE HANDBOOK OP THE MEDICAL SCIENCES. 



which the system would be obliged to work over, to- 
gether with the subsequent removal of the nitropn, in 
order to obtain the requisite amount of carbon. This is 
easily seen from the composition of pure egg-albumin 
with its 53 per cent, of carbon, when compared with a 
fat, as tripalmitin with 76 per cent, of carbon, or with a 
carbohydrate as saccharose with 43 per cent, of carbon 
and 51 per cent, of oxygen. It is evident, from these fig- 
ures, that a judicious mixture of an albuminous food- 
stuff with a carbohydrate or fatty food-stuff, would give 
a food containing the required carbon and nitrogen, as- 
similable with less expense to the body. Liebig's theory, 
that nitrogenous food is used wholly in building up al- 
buminous'tissues, as the muscle, and other forms of pro- 
toplasm, and that the nitrogenous excreta are formed 
wholly from the metabolism of the above tissues, is now 
known to be incorrect, and that in reality proteid food- 
stuffs may, in one sense, be respiratory and also give rise 
to the storing up of fat as well as the production of force. 
In fact, in the decomposition of proteid matter within the 
body, into the ultimate product, urea, which is excreted, 
there results a complementary hydro-carbonaceous resi- 
due, apparently applicable to the production of force. 
At the same time, the chemically distinct oleaginous and 
saccharine principles which are together especially con- 
cerned, either directly or indirectly, in the production of 
heat, are likewise of use in force-production, and thus 
any classification of the alimentary principles based on 
the physiolorical grounds advanced by Liebig, is wholly 
untenable. The view now taken regarding the produc- 
tion of force within the body is that the combination of 
muscles and nerves is to be considered as a form of appa- 
ratus especially adapted to transform the force liberated 
by chemical action into those other forms of force termed 
muscle and nerve force. This being the case, any easily 
oxidizable organic matter will answer the purpose. 
Hence, to a certain extent, the two groups of nitrogenous 
and non-nitrogenous alimentary principles are qualita- 
tively alike, in that both may be concerned in the pro- 
duction of force, in the development of heat, and the stor- 
ing up of fat, although the non-nitrogenous are not 
distinctly provocative of metabolism. The nitrogenous 
principles are, however, indispensable to the growth of 
the tissues of the body, and are likewise indispensable in 
the production of the nitrogenized ferments, on the pres- 
ence of which the digestive juices of the body depend for 
their special action. 

Collagenous tissue, comprising the gelatinous principles 
(organic basis of bone, cartilage, tendons, and connective 
tissue), cannot supply the place of the albuminous princi- 
ples ; still. Volt'* has found that nitrogenous equilibrium 
is established at a lower level of proteid food when gela- 
tin is added, and Foster " apparently considers that in the 
metabolism of gelatin it rapidly splits up into a urea and 
a fat moiety, but is unable to imitate the other function of 
proteid matter, or to take part in the formation of living 
protoplasm. (For nitrogenous metabolism see Nutrition.) 
There are a number of crystalline nitrogenous sub- 
stances occurring in both the animal and vegetable king- 
doms which are present in greater or less quantity in 
food, such as creatin and other like proteid decomposition- 
products, contained, for example, in some quantity, in 
Liebig's extractum carnis; also the vegetable alkaloids. 
None of these, however, are of any value as food ; the 
majority of them pass quickly out of the body, but little 
if any altered, although one or two, as asparagin," are 
said to slightly diminish proteid metabolism. The more 
highly complex lecithin, present in the yolk of the egg, 
in the brain, etc., may possibly be placed among the true 
foods, though no direct experiments have been tried to 
demonstrate its action. The main action of the alka- 
loidal substances, as the caffein of coffee, is that of a 
stimulant, acting especially upon the fatigued nervous 
system though many of the common alkaloidal infusions 
made from roots, leaves, and berries may be somewhat 
nutritious from the albuminous and fatty matters which 
thCT contain, as is the case with cocoa. 

The drinks commonly used as food may be divided 
aside from water, into the alcoholic, acidulated, saccharine! 

112 



gaseous, and infusions of various substances, such as tea. 
The alcoholic drinks contain from about sixty per cent. 
of alcohol, as in rum, brandy, and whiskey, to from two to 
ten per cent. , as in beer and light wines. Malt liquors con- 
tain, perhaps, the largest number of constituents, among 
others there being sugar, dextrin, gluten, and various 
substances from the hops. The exact influence of alco- 
hol, or its value as a food, is uncertain. It is, without 
doubt, decomposed in great part within the body," and 
split up into simpler substances ; but its main action is 
doubtless that of a local excitant to the mucous membrane 
of the alimentary canal, possibly thereby stimulating di- 
gestion, and as a stimulant upon the central nervous sys- 
tem and upon the circulation. 

Food, as eaten by man and animals, is a natural mixt. 
ure of the various alimentary principles described. Sel- 
dom are the isolated principles eaten . by themselves, 
other than in the case of sugar and salt, or pure fat. It 
is the function of digestion to separate the individual 
principles from this natural mixture, by which means 
they are separately absorbed. The behavior of animal 
and vegetable food is quite different in the alimentary 
canal, which difference is dependent more upon the 
quality of dry substance contained in the latter food 
than upon its quantity. Vegetable food yields a much 
larger percentage of indigestible residue, and is in itself 
much less easily digestible, owing to the fact that it is 
more or less enclosed in the diflBcultly soluble cellulose, 
while animal food is free. Moreover, vegetable food, as 
a rule, is less easily absorbed, and, as it contains a less 
percentage of nitrogen, a much larger quantity is needed 
to furnish a certain amount of this element than in the 
case of animal food. Again, the large quantities of 
starch contained in a vegetable diet tend to produce an 
acid fermentation in the small intestines, with formation 
of butyric acid, together with marsh gas and hydrogen, 
which causes the frequent intestinal excretions of her- 
bivorous animals. 

The following tables give the percentage amounts of the 
alimentary principles contained in several of the natural 
animal and vegetable foods. It is to be borne in mind, 
however, that the nutritive value of a food depends not 
only upon its composition but also upon its digestibility. 

ANiMAii Foods. 



Water 

Solids 

Albuminous. . , 
CoUageuous... 

Fatty 

Carbohydrates. 
Extractives . . . 
Ash 











« 


li 


n 


C* 




,. 


"lO 




S 


£ 


A 


h" 


& 


■6 


75.90 


6^.93 


75.S4 


73.90 


87.41 


72.33 


24.10 


37.07 


24.75 


as.io 


12.59 


27.67 


18.36 


23.93 


18.53 


14.10 


3.41 


2U.10 


1.64 












0.00 


12.81 


6.16 


10.90 


3.66 
4.82 


5.58 
0.45 


1.90 












1.30 


1.33 


1.06 




0.70 


1.64 



Ii6.0» 
34.00 
S.7U 

26 70 
2.80 



Vegetable Foods. 



Water 

Solids 

Albuminous 

Woody fibre (cel- 
lulose) 

Fatty 

Starch 

Sugars, gums, etc. 
Ash 







m 




n 


t" 




i 






! 


1 


jl 


1^ 


74.00 


13.00 


15.00 


14.00 


12.60 


26.00 


87.00 


86.00 


86.00 


87,60 


2.50 


6.30 


12.60 


11.10 


30.80 


1.04 








3.00 


O.U 


0.70 


5.60 


8.10 


1.90 


1.09 


79.6 
0.60 


63.80 


65.10 


48.30 




8.00 


1.70 


3.50 



16.42 
0.99 



5.17 
7.78 
0.81 



1 BischofE and Voit : Gesetze d. Krntihrung des Fleischf ressers, 1860, 
p. .304. 

» W. O. Atwater : Bericbte d. deutsch, chem. Gesell., 16 Jahrgang, 
p. 1844. ' Voit J Hermann's Handbuoh d. Physiologie, 6, 460. 

4 J. IConig: Hermann's Handbuch d. Physiologie, 6, 463. 

* According to Payen. « Dr. Letheby'fl Tables. 

' According to Payen. ^ Letheby's Tables. " Payen. ^^ Voit. 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 



Alfment, 
Alimentation. 



In studying the composition of animal substances, with 
a view to determining their Mod-value, the percentage 
amount of nitrogen is the most important point to be ascer- 
tained, inasmuch as this element is an index of the amount 
of albuminous matter present: At the same time it is to 
be remembered that proteid food-stuffs alone do not con- 
stitute an economical diet. A rational diet is to be found 
only in a judicious mixture of proteids, fats, and carbo- 
hydrates. Even milk is not a properly constituted food 
for a working man, for though it contains both fat and 
carbohydrate it has too large a percentage of nitrogen 
(albumin and casein) for the carbon. 

It has been found by repeated experiment that an aver- 
age working man, in order to prevent loss of nitrogen and 
carbon, requires daily about 18.03 grammes of nitrogen 
(= 118 grammes of dry albumin), and at least 328 grammes 
of carbon ; and as the 118 grammes of albumin contain 
but 63 grammes of carbon, it is plain that there would be 
required 265 grammes in the form of fats or carbohy- 
drates. '^ The following table gives the number of gi-ammes 
of several common foods necessary to furnish the daily 
requisite of carbon and nitrogen : 



For 18.3 grammes Nitrogen. 


For 328 grammes 


Carbon. 




Gm. 
538 


Lard 


Gm. 
. 450 




796 


Corn 


801 


EggB (18j 


905 


824 




989 

1,868 

2,905 

4,675 

4. TOR 


Rice 


896 


Bice 

Milk 

Potatoes 


Eggs (48) 

Lean meat 

Potatoes 

Milk 


2,231 

2,620 

3,124 

.. 4fiB2 







It is thus evident that no one of these substances is in 
itself a proper food. Lean meat, for example, must have 
added to it fat or carbohydrate, or both ; while potatoes, 
as an example of a carbonaceous food, require an admixture 
of nitrogenous matter. Hence a judicious mixture of all 
the alimentary principles from both the animal and vege- 
table kingdoms constitutes the food best adapted to the 
wants of mankind. jB. E. Chittenden: 

1 Wurtz : Chimie Biologique, chapters 1-2. 1884. 

2 Hoppe-Seyler : Ptiysiologische Chemie, p. 28. 

8 Hermann's Handbuch der Physiologie, vi., 347. 

4 Philosophical Transactions, 2, 494. 

' Zeitschrif t fur Biologic, ix., 387. 

" Aronatein : Pfliiger's Archiv fiir Physiologie, viii., p. 75. Alex. 
Bchmidt : Pfliiger's Archiv, xi., p. 1. 

' Zdtsohrift fur Biologie, vol. ix., 1873. 

' Weiske : Zeitschrif t fur Biologie, vol. vii., pp. 179 and 333. 

^ Forster : Zeitschrif t fiir Biologie, vol. xil., p. 464. 
>» Comptes Rendos, 1872, 64, p. 1353. 

11 Compare Hamburger; Zeitschrift fiir Physiolog. Chem., vol. ii, 191. 
13 Hermann's Handbuch der Physiologie, vi,, 260. 
IS Ibid., vi., 888. 

» Zeitschrift fur Biologie, viii., 297. 
1= Text-Book of Physiology, p. 467. 
1^ Zeitschrift fiir Biologie, xv., 261. 
1' Pfluger's Archiv fiir Physiologie, vol. xxxii., 398. 
18 Voit : Hermann's Handbuch der Physiologie, vi., 497. 

ALIMENTATION, RECTAL. The literature of this 
subject does not date back very many years. Dr. Austin 
Flint says that Samuel Hood, in 1822, was the first in this 
century to write concerning this form of nourishing ; the 
next writer was Steinhausen, in 1845. It is recorded, 
however, that an Italian physician employed this method 
successfully two centuries ago (Dr. Bodenhamer : " Rec- 
tal Medication "). In the discussion of this subject the 
topic of rectal medication will be included. In almost 
all cases of nourishing by the rectum it is found necessary 
or convenient that the nutritive material or the drugs 
should be either in fluid form or in suspension. (The sub- 
ject of suppositories will not be discussed in this article.) 
In many instances rectal alimentation has been used al- 
ternately with feeding by the natural method or by the 
use of the stomach-tube, for a longer or shorter period ; 
indeed it is rare to find an instance where rectal nourish- 
ing has been carried on exclusively for a great length of 
time. 

The rectum is freely supplied with lymphatics and 

Vol. I.— 8 



blood-vessels ; its glandular supply is abundant, there 
being both the follicles of Lieberkiihn and lymphoid fol- 
licles, similar to the solitary glands of the small intestine. 
Dr. Flint thinks that digestion and absorption may be 
due to the presence of the follicles of Lieberkiihn, which 
may take on a vicarious action when stimulated by the 
presence of digestible material; also that the presence of 
food in the large intestine may stimulate the glands of the 
stomach and small intestine, the secretions passing into 
the large intestine. 

Rectal alimentation has been used in the following dis- 
eases and injuries : in spasmodic constriction of the 
oesophagus, cancer of the oesophagus, cancer of the 
pylorus, ulcer of stomach, "encephaloid disease of uterus 
with sympathetic stomach disturbance," phthisis, anaemia, 
dyspepsia, pyaemic abscess and sloughing of the parotid 
gland, inflammation of mouth, fauces, oesophagus, and 
stomach due to swallowing strong ammonia water, and 
in lacerated wound of pharynx and trachea. The long- 
est period during which this form of nourishment has 
been kept up is fifteen months (Dr. Flint in Ameriean 
Practitioner). In another case (reported by Niemeyer) 
this method was kept up for three months ; in a case of 
carcinoma life was prolonged forty-two days ; in several 
cases this method has been kept up for twenty-eight days. 
In most cases feeding by the stomach was resumed grad- 
ually and carried on in connection with rectal alimenta- 
tion. Kauflman (Lancet, 1877) reports nine cases, seven 
of cancer of oesophagus, one of cancer of pylorus, and 
one of ulcer of the stomach, in which this method was 
used ; all lived nine or more months under this treat- 
ment. 

In the report of the Therapeutical Society (New York, 
February, 1879) there is the following analysis of sixty- 
three cases which were nourished by enemata of deflbrin- 
ated blood : in thirty-eight cases of phthisis, eight did 
not bear the treatment well, ten were not benefited, 
twenty were benefited, one case of diarrhoea was made 
worse ; in nine cases of ansemia, one received no benefit, 
eight were improved or cured ; in five cases of dyspepsia 
all were cured ; in four cases of exhaustion all were im- 
proved ; in three cases of neuralgia, one was not bene- 
fited, two were improved ; in two cases of gastric ulcer, 
one was not benefited, the other recovered when appar- 
ently moribund. 

The indications for the employment of this form of 
alimentation may be stated as follows : "Whenever from 
any cause it is impossible to convey food to the stomach 
by the natural passages ; whenever the stomach is too 
irritable to retain food or too much diseased to digest it ; 
whenever the presence of food in the stomach or small 
intestine causes trouble, or when there is great exhaustion 
from any cause, then rectal alimentation is clearly indi- 
cated. Except when the difficulty is obstruction of the 
oesophagus or disease of the stomach, this method is used 
in connection with feeding by the natural method. 

The process of nourishing by the rectum is quite sim- 
ple. The rectum is prepared for the nutrient enema by 
first administering an enema of lukewarm water. It is 
not always necessary to do this, but it should be done if 
there has not been a passage since the last nutrient enema, 
or if any portion of this has not been absorbed, although it 
almost always is entirely taken up. The mechanical 
means employed is similar to that used in_ giving an or- 
dinary injection : a syringe with a screw-piston is safest, 
but an ordinary barrel-syringe, or Davidson's syringe, may 
be employed, care being taken not to use too great force. 
After withdrawing the tube of the syringe a towel should 
be pressed against the anus until the desire to void the 
contents of the rectum has passed away. The quantity 
to be injected should not exceed six ounces at a time, and 
this may be repeated every four or five hours ; not less 
than three hours and not more than six should intervene 
between any two injections. 

Various substances have been employed in this method, 
as raw beef, beef-soup, chicken-broth, beef-tea, defibrin- 
ated blood, milk, cream, eggs, and coffee. (Leube was of 
the opinion that eggs and milk were not absorbed by the 
rectum, but this seems to have been an error.) LieWg's 

113 



Alimentation. 
Alkanet. 



EEFEKENCE HANDBOOK OF THE MEDICAL SCIENCES. 



extract of meat has been used with success. In the report 
of the Therapeutical Society deflbrinated blood is recom- 
mended for the following reasons : Patients thrive on it ; 
in quantities from two to six ounces it is all absorbed ; it 
causes constipation in but very few cases for a few days 
only ; it causes no irritability of the bowels except m very 
few cases ; it gives an impulse to nutrition, and it is wholly 
unattended by danger. Brown-S^quard {TMncet, 1878) 
has used the following formula : Two-thirds of a pound 
of raw beef, one-third of a pound of fresh pancreas ; this 
was injected twice a day. This was followed by the pas- 
sage of well-formed faeces. The fat and cellular tissue 
should be rejected. Kauffman, in his cases, gave one 
pound of finely divided beef, and one-half pound of minced 
pancreas every morning ; half this quantity was given at 
noon and at nighty A solid stool followed every day. 
The patients were able to walk about. In one case good 
results were obtained from the use of two teaspoonf uls of 
Liebig's extract in a teacupful of milk, about every four 
hours. Dr. J. H. Beech nourished a patient with uterine 
trouble and sympathetic stomach trouble for five weeks 
with enemata of chicken-broth, cofiee and cream, beef- 
broth and milk and eggs ; he found that coffee and 
cream seemed best to relieve the thirst. Dr. J. O. Davis 
(Medical Record, 1878) nourished a patient with ulcer 
of the stomach by lukewarm enemata of beef-tea, or 
chicken-broth, for six weeks. Dr. McLane nourished a 
patient exclusively by enemata of unsalted beef -tea for' 
twenty-eight days, eggs and milk being resorted to only 
three times ; a little brandy and tincture of opium (ten 
drops) was added to each "injection. Later, feeding by 
the stomach was partially resumed. The patient lived 
one year. Dr. "W. T. Chandler (Louisville Medical News) 
reported a case of ulceration of the oesophagus, from 
swallowing strong ammonia water, in which rectal in- 
jections of eggs and milk were the only nourishment 
taken for twelve days ; feeding by the stomach was re- 
sumed gradually. In a case of sloughing of the parotid 
gland, following a pysemic abscess, the patient, a woman, 
sixty-five years old, was nourished solely by enemata of 
beef-tea for four weeks, followed by recovery (Woman's 
Hospital). In a case occurring at Bellevue Hospital in 
1878, a patient was nourished by enemata of eggs and 
milk, together with a little brandy and a few drops of 
the solution of morphia (IT. 8. Ph.). The prepara- 
tion known as Leube's Pancreatic Meat Emulsion has 
been recommended for use in this form of alimentation. 
It is prepared as follows ; Five to ten ounces of meat 
free from fat and chopped very finely ; half this weight 
of fresh minced pancreas (of pig or . ox) is added to the 
meat, and the whole rubbed up with five ounces of luke- 
warm water. When administered the enema should be 
tepid. 

It may be mentioned here that when water cannot be 
administered by the stomach, thirst may be relieved by 
bathing the body. 

In many cases it has been found necessary to overcome 
the irritability of the bowels by the use of some prepara- 
tion of opium. In one case, from twenty to thirty drops 
of laudanum were added to the enema whenever it seemed 
necessary. Solutions of morphine have also been used 
successfully for this purpose. 

If the necessary amount of nutriment has been con- 
veyed to the system by this method there will be the 
usual feeling of comfort experienced after a meal, with- 
out, of course, the sensation of fulness in the epigastric 
region. Diarrhoea is very seldom caused, and the func- 
tions of the skin and kidneys do not seem to be affected. 
Patients not only thrive under this treatment, but actu- 
ally gain in flesh and strength. 

The subject of medication hy the rectum is very closely 
associated with that of feeding by the rectum. In al- 
most all cases of prolonged rectal alimentation, drugs 
are combined with the enemata, either for their general 
effect on the system or to assist in the process of nourish- 
ing. There are many cases, however, in which drugs 
have been administered alone. The indications for this 
method of medication are the same as for alimentation 
by the rectum ; this method is especially useful in irrita- 



bility of the stomach. It is quite common to add a 
small amount of brandy or whiskey to a nutrient enema 
in cases where a stimulant is needed. One writer says 
that in using stimulants it is well to add cream to the 
enema. He says, also, that tincture of the chloride of 
iron may be given in this vehicle. Quinine has been 
given in this way quite frequently. In a case of peri- 
tonitis following ovariotomy (Woman's Hospital, New 
York), quinine was administered in enemata to re- 
duce the temperature ; thirty grains were given in milk 
every four hours ; the rectum became irritable after 
the first few injections, and this method had to be given 
up. Dr. Flint cites a case of violent hsematemesis whieli 
was controlled by injecting three drachriis of the fluid 
extract of ergot into the rectum ; rectal alimentation was 
carried on for some time subsequently;. Thirty-grain 
doses of chloral hydrate have been administered in this 
way in cases of neuralgia, in cases of acute mania, and 
also in the vomiting of pregnancy. The ethereal tincture 
of iodine has been injected" in five-drop doses, and also 
the balsam of copaiba in two-drachm doses. In all cases 
it is necessary to add a vehicle in sufficient quantity to 
make about a four-ounce mixture. 

The use of simple enemata of warm water or warm 
water and soap, to cause an evacuation of the bowels, is 
of such common occurrence in domestic practice that it 
is hardly necessary to speak of it here. Several medi- 
cines, as castor-oil, oil of turpentine, and assaf CBtida, may 
be added to these simple enemata. 

Willia/m R. Murra/g. 

ALKALIES. The alkalies are inorganic substances, 
possessed usually of a caustic "alkaline" taste, which 
unite readily with acids to form salts. They will restore 
the blue color to litmus paper reddened with acids, turn 
syrup of violets and red cabbage infusion green, and tur- 
meric yellow a reddish brown. Properly speaking, only 
those substances answering to the above description, whose 
carbonates are soluble In water, are called alkalies, viz., 
ammonia, lithia, potassa, and soda ; but in medicine twf 
of the alkaline earths, lime and magnesia, are also in- 
cluded under this term. The carbonates of these sub 
stances possess many properties in common with their 
bases, and exert a similar therapeutical action when in- 
ternally administered. The acetates, citrates, and tar 
trates resemble in their remote effects the carbonates, and 
may therefore for our present purposes be classed among 
the alkalies. 

External Uses. — Potassa, soda, and lime, when ap- 
plied in concentrated form, are powerful escharotics. Po- 
tassa is the strongest and is the one to be preferred when 
extensive and complete destruction of tissue is desired. 
It penetrates deeply and widely, and the skin about the 
part to be destroyed should therefore be protected by 
cerate or a ring of adhesive plaster. It is employed to 
destroy malignant pustule, epiUielioma, and other morbid 
growths, to establish healthy action in sloughing and pha- 
gedenic ulcers, and to cauterize the bites of reptiles and 
rabid animals, and other poisoned wounds. It was for- 
merly used also to open abscesses or cysts of the liver. 
Its action causes intense pain, and the slough formed is 
of a dirty grayish color. When the destructive action 
has proceeded as far as desirable, it may be arrested by 
washing the parts with vinegar or some other dilute acid. 
Caustic potash abstracts the fluids from the tissues, and, 
uniting with them, forms a liquid which exerts an es- 
charotic action wherever it may flow. In order to absorb 
this fluid, and thus limit the extent of the caustic action, 
an equal quantity of unslaked lime is added to the potash 
and formed into a pa.ste with alcohol. This is the well- 
known Vienna paste. Caustic soda is milder than po- 
tassa, and is seldom used as an escharotic. A mixture of 
soda and lime, rubbed up with alcohol into a consistent 
mass, is called London paste. It is employed for the same 
purpoises and in the same way as "Vienna paste, than which 
it is milder. Alkaline lotions are used to allay itching, 
as an application in various skin affections, and to correct 
the fetor of bromidrosis. Liquor potassse, or a solution 
of the carbonate of potash, is generally selected for this 



114 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 



Alimentation. 
Alkaaet. 



purpose. Liquor potassse is also used to soften the edges 
of the nail In ingrowing toe-nail. Bicarbonate of soda is 
one of the best applications for burns and scalds of the 
integument ; in burns of the first or second degree its im- 
mediate application in strong solution will almost in- 
stantly relieve the pain and prevent inflammation. This 
is a remedy superior to the mixture of lime-water and 
linseed oil, known as carron oil. Ammonia is much em- 
ployed as a rubefacient and counter-irritant, in the form 
of liniment. If strong aqua ammoniae be applied to the 
skin and covered by a glass to prevent evaporation, vesi- 
cation is produced. It is used likewise in the bites of 
venomous reptiles, because of its repute as an antidote to 
snake-poison, but the better plan is, when possible, to 
thoroughly destroy the parts with potassa or the actual 
cautery. The irritation resulting from the bites of insects 
is relieved by ammonia. Solutions of the lithia salts are 
sometimes applied to the affected joints in chronic rheu- 
matic arthritis. 

Intebnal Uses. — Potassa and its salts, when given in 
large doses, act as cardiac depressants and paralyzers of 
the spinal cord. In medicinal doses the acetate and 
citrate increase the quantity of urine, and render this se- 
cretion alkaline. For the former purpose the acetate is to 
be preferred, and for the latter the citrate. Liquor po- 
tassse in small dose, given before meals, stiniulates the se- 
cretion of the gastric juice, and thus promotes digestion. 
Given after meals it neutralizes an excess of acid in the 
stomach, but magnesia and bicarbonate of soda are pref- 
erable as antacids. The former is also a laxative, and is to 
be selected when the action of the bowels is sluggish. 
When the opposite condition prevails, carbonate of lime 
or chalk may be prescribed with advantage. It is es- 
pecially in the acid diarrhoea of infants that chalk mixture 
is valuable. Lime-water relieves gastrodynia and vomiting, 
and is added to milk to prevent the formation of caseous 
masses in the stomach. The treatment of rheumatism by 
alkalies was formerly much in vogue, but these are now 

fenerally superseded by other more efficacious remedies, 
'he alkalies promote the absorption of fat atod induce an- 
aemia, and hence they leave the patient in a weakened con- 
dition after the rheumatism has been cured,' and convales- 
cence is thereby unnecessarily prolonged. When alkalies 
are to be used, the lithia salts should by preference be se- 
lected. Ammonia is a diffusible stimulant, and is seldom 
employed as an antacid. The carbonate and muriate are 
excellent stimulant expectorants, and are very frequently 
given in bronchitis and in the resolving stage of pneu- 
monia. In cases of sudden and profound depression the 
intravenous injection of ammonia has answered an ex- 
cellent purpose. Ammonia is also given internally as an 
antidote to snake poisons, but its efficacy in this respect is 
doubtful. Thomas L. Stedman. 

ALKALINITY. Oxidation of organte substances in the 
human economy, as in the chemical laboratory, occurs 
best in alkaline media. Many organic substances require 
the presence of alkalies to render them oxidizable at the 
body temperature. Thus alcohol, in the presence of a 
free alkali, is easily burned up at body heat, and glycer- 
ine, ordinarily resistant to such influences, will readily be 
oxidized. Life, which is dependent upon a constant 
succession of oxidation processes, takes advantage of 
this fact by maintaining that menstruum (the blood) in 
which its important chemical changes occur, in a con- 
stantly alkaline condition. No indubitable examples of 
acidity of the same have ever been recorded as existing 
during life ; though some cases of leucocythsemia, sun- 
stroke, and cholera have been reported, in which, soon after 
death, the blood was feebly acid. Moreover, attempts to 
render it acid have signally failed, death occurring be- 
fore such a condition could be induced. Witness the ex- 
periments of Hoffman, who, in attempting to render the 
blood of pigeons acid by the administration of foods 
yielding acid oxidation products, induced toxaemia before 
acidity (of the blood). Besides favoring oxidation pro- 
cesses, the alkaline salts aid in maintaining the albu- 
minoids in a soluble condition, and increase the power of 
absorption for gases of the blood-serum. The amount of 



alkaline matter in the blood is comparatively constant, 
though subject to slight fluctuations. 

The blood owes its alkalinity chiefly to the sodic bicarbo- 
nate (NaHCOs) and sodic phosphate (NasHP04), though 
partly, too, to the alkaline albuminates. In health its re- 
action is subject to variations intimately dependent upon 
the digestive processes ; the chemical nature of the foods 
taken determining the extent of change. During the 
absorption of the foods there are always being taken into 
the circulation organic salts of the alkaline bases, and 
often small quantities of the alkaline phosphates. The 
former, in the presence of ozone and an alkaline serum, 
are easily converted into the alkaline bicarbonates. Hence 
increased alkalinity of the blood. This is the more 
marked when the organic salts have been introduced 
either incidentally to the preparation of the foods, or for 
medicinal purposes. Thus the "saleratus," "cooking 
soda," and "baking powders" now so extensively used 
to lighten our breads, biscuits, cakes, and pastries, by 
their liberation of COs, are converted at the same time 
into organic salts (acetates, lactates, or tartrates), which, 
on entering the circulation, are burned up into the alka- 
line bicarbonates with distinct effect upon the blood re- 
action. Or again, the so-called "lemon" treatment, 
when it is desired to induce an increased alkalinity, is 
thoroughly scientific. The lemon-juice, which already 
contains potassium and calcium citrates, being added in 
large excess to a small quantity of sodium bicarbonate, 
converts the latter into a citrate, at the same time making 
a pleasantly acid effervescent drink. This, on being al> 
sorbed, increases the blood alkalinity, as do the other or- 
ganic salts. It is just to this absorption and conversion 
of organic salts that the daily changes in the urine reaction 
are due. Just before the meal hour the urine (in health 
really an index of the alkalinity of the blood) reaches its 
maximum acidity ; at the same time the blood is least 
alkaline. In a short while, when absorption and conver- 
sion of the organic salts has begun, its alkalinity steadily 
increases, until finally (particularly after the consump- 
tion of the "soda-raised" foods) the urine becomes neu- 
tral, or even distinctly alkaline, from the excretion of the 
excess of alkaline matter. When the organic salts have 
been converted into bicarbonates, and the excess has been 
excreted through the urine, the latter begins again to 
resume its normally acid reaction from the oxidation 
products of the nitrogenous tissues chiefly. 

It is not probable that, as some authors suggest, the 
normal alkalinity is maintained by the excretion of ex- 
cess of alkaline matter by the salivary, biliary, and pan- 
creatic glands, and excess of acids by the gastric follicles ; 
because it has been Repeatedly demonstrated that when 
one secretion withdraws from the blood acid matter, 
other secretions .increase decidedly their alkaline constitu- 
ents. Thus the withdrawal from the blood of alkaline 
and acid matter at the same time would not alter its rela- 
tive alkalinity. When the stomach is pouring out its 
acid secretion, the salivary, biliary, and pancreatic secre- 
tions become unusually alkaline. The kidneys, assisted 
by the lungs and integument, serve as the chief exits for 
the excess of alkalies or acids from the blood. 

Lewis L. MeArihur. 

ALKANET (Oreanette, Codex Med. ; Alkanna tinctoria 
Tausch. ; Anohusa tinctoria L. ; lAthospermum tinctoriwn 
D. C, etc. ; order, Borraginacem) is a small perennial 
hairy herb, with straggling forked stems, simple spatu- 
late or lanceolate leaves, and one-sided cymes of tubular, 
nearly regular flowers. It is a native of the southern 
and eastern part of Europe and Asia Minor, and is also 
cultivated. 

The fleshy root, which is the part employed, is one or 
two centimetres (two-fifths to four-fifths of an inch) 
in diameter, branched above into several stem-bearing 
heads, usually simple below, soft and stringy in texture. 
The dried root of commerce is sometimes entire, with a 
purplish-red external surface, a soft, easily separable and 
exfoliating bark. It is of a dull, deep red color within, 
and has a pinkish or whitish, hard, but easily-sjilitting 
wood. More often the roots are twisted and^incom- 



115 



Alkanet. 
Allevard. 



EEPERBNCE HANDBOOK OP THE MEDICAL SCIENCES. 



pletely split into coarse shreds ; in the better grades, the 
woody cylinder is removed, and they consist of the tough 
and flexible bark. 

Alkanet has no odor, but a sweetish, afterward bitter- 
ish and slightly astringent taste, coloring the saliva when 
chewed. 

Its only valuable constituent is its coloring matter, 
alkannin, or alkanna red, which was first separated by 
Pelletier, and named adde anchuaigue. To obtain it, the 
root, first treated with water, is exhausted by slightly 
acidulated alcohol, the tincture so obtained is evapo- 
rated to a thickish, turbid extract, and the alkannin pre- 
cipitated with water. It is then re-dissolved in ether, 
the ether mostly washed out by shaking with successive 
portions of water, and, finally, the thick solution evap- 
orated to dryness (Huseman, Bailey, and "Wydler, " Ann. 
Chem. Pharm.," 141). 

It is a dark brownish-red, resinous mass, or powder, 
insoluble in water, but soluble in the liquids above named ; 
neutral in reaction. Its red color is intensified by acids, 
and changed to bluish-green by alkalies. 

Alkanet has no physiological action and no medical use. 
It is, however, used in elegant pharmacy to color oils, 
cerates ("rose lip-salve "), and tinctures, and occasionally 
in making test-papers which maybe prepared either red 
or blue. 

Allied Plants. — The order Borragmaoem comprises 
a number of bland, hairy herbs with no distinctive medici- 
nal qualities. (See Borage.) 

Allied Dkttgs. — For a list of the pharmaceutical col- 
oring matters see Saffron. W. P. Bolles. 

ALKEKENGI {Alkekengi coqueret, Codex Med. ; Physalu 
alkekengi L. ; order, Solanacece ; ground plum). This 
little genus of annual or perennial, spreading, sometimes 
prostrate, herbs dltCers but little, botanically, from 
Holanum or Lycopersicum (the tomato) excepting that the 
calyx loosely envelops the fruit in a miniature, usually 
five-angled papery, balloon-like bag. One species, with 
fragrant yellow edible fruit, is cxiltivated in, this country, 
now and then, under the name of " strawberry tomato." 
Physalis alkekengi is a perennial weed of Central and 
Southern Europe, bearing a round, shining scarlet-red 
berry, about as big as a cherry, enclosed in its calyx- 
bag, four or five times as large. The fruit is two-celled, 
with numerous kidney-shaped, flat seeds embedded in a 
fleshy, pulpy pericarp ; odorless, with mawkish sweet 
tasto, sometimes bitter, and, dried, forms the commercial 
drug. It is then brownish red, much shrunken, and 
generally bitterish. It is reputed to be diuretic and lax- 
ative, and is an ingredient of some European preparations, 
but is not entitled to rank as a medicine. The berries are 
also pickled and eaten. 

The calyx, which is not used, contains an abundant 
bitter principle, which has been Tiam.eA physalin. 

For allied plants and drugs see Belladonna. 

W. P. Bolles., 

ALLANTOIS. In this article is given an account only 
of the origin and morphology of the allantois ; for its 
metamorphoses and functions see Placenta. The allan- 
tois is a hollow outgrowth from the ventral wall of the 
posterior extremity of the digestive canal ; morphologi- 
cally. It is a modification of the bladder, lasting till the 
end of foetal life. The bladder appeared early in the 
evolution of vertebrates, being constant in the amphibia 
and all higher forms. In the fcetus of all reptiles birds 
and mammals the bladder is modified by being greatly 
enlarged and projecting beyond the body proper! so as 
to be a true appendage, the allantois, the possession of 

riiifJ^i '^1°^""''^'/''^ ^"^^^yo^ of the three classes 
named. The same classes also have an amnion, a struct- 
ure not found m the lower vertebrates. The terms al- 
kmtoidea, and amnwta are therefore strictly synonymous 

iftract'^thp"*^'*-' ^^":^ ^'§!'^' "^^^^'"^"^ vertebrates. 
Wp nSfat?^'^ °'i^l °^ *H ^"'^°*°'« ^e find a remarka- 
ble illustration of change of function ; the organ which 

^SE^''''^ '' ^^ "" urinary vesicle is precocioSsly devel- 
oped and enormously enlarged in the embryo ; and has 

116 



acquired respiratory functions in the reptiles and birds 
and later nutritive functions in the mammalia. In 35! 
cordance with its new duties the vesicle is furnished with 
a greatly increased vascular apparatus. The aorta forks 
at its caudal extremity, and each fork again divides ; one 
branch goes to the leg (iliac artery) and one branch runs 
up along the side of the bladder and ramifies upon its 
outer portion ; the main stem is known as the hypogag. 
trie artery. The blood is collected from the allantois by 
two veins (umbilical or, better, allantoic) ; in man and 
other mammals, however, one of these veins; the right 
early disappears, so that during most of the f cetal life 
there is only one vein, the left. 

The exact origin and growth of the allantois in the 
embryo can be understood only in connection with the 
history of the germ-layers, and is treated of under Fcetus. 
In form the allantois varies greatly ; in birds and reptiles 
it is a large sac which protrudes from the abdomen ; in 
the higher (placental) mammals this sac is still further 
modified to constitute the essential part of the placenta ■ 
indeed the placenta may be best defined as an allantois 
so specialized as to establish a direct nutritive relation be- 
tween the mother and offspring. 

The following brief account will suffice to elucidate the 
comparative morphology of the allantois. It will be 
remembered that during the very early stages of the em- 
bryo, the body cavity is not closed but open ; the external 
abdominal walls (somatopleure) extend down for a short 
distance, and then bend outward and upward on all sides 
so as to completely arch over the back of the embryo ; 
that part of the somatopleure which thus encloses the 
embryo is a thin membrane, long known as the amnion. 
On the other hand, the walls of the intestinal canal 
(splanchnopleure) likewise extend beyond the embryo, 
making a contracted stalk at the end of which is the yolk- 
sac. These relations are shown in the accompanying diar 




Fio. 74.— Diagram of a Young Allnntoidean Embryo Chick, sft, calcore- 
onsegg-BheU; sji, air-space; oto, amniotic cavity ; ys, yolk-sac or iim- 
biljoal vcBicle ; w, remnant ol the white of the egg ; al, allantois ; al', 
dotted imes representing the later nearly maximum extension of the 
allantois. 

gram. It will be observed that the body-cavity is continu- 
ous with a large space around the embryo, lying entirely 
outside the closed amnion and inside the chorion. Into this 
space pows out the allantois, appearing first as a small 
diverticulum, but rapidly enlarging to an ample vesicle. 
As the embryo grows the yolk-sac, except when modi- 
fied as a secondary respiratory organ (rabbit, etc.), di- 
minishes while the allantois enlarges still more rapidly, 
and thus soon becomes the principal appendage of the 
embryo. In this stage it is readily identified in birds 
and reptiles ; the actual relations are well indicated by 
the admirable diagram here given of a hen's egg after 
about ten days' incubation ; the figure is copied from 
Allen Thompson. If the walls of the vesicular allantois 
be examined, they are found to consist of two layers, 1, 
a stratum of epithelium which is directly continuous with 
the epithelium of the digestive tract, and therefore rep- 
resents the innermost germ-layer or entoderm ; 2, a 
stratum of connective-tissue (so-called mucus) cells lying 
externally and representing the middle germ-layer 01 



REFERENCE HANDBOOK OP THE MEDICAL SCIENCES. 



Alkanet. 
AUevard. 



mesoderm. Now the placenta of mammals Is formed 
mainly by the developments which take place in the outer 
(mesodermic) layer of the allantois. There arise, namely, 
irregular outgrowths or villosities, richly supplied with 
blood-vessels ; these force up the chorion and so project 
beyond the general surface of the ovum ; the projecting 
villi fastened by their tips to the irregular surface of the 
uterine wall. This combination of foetal and maternal 
tissues constitutes the placenta. In the majority of mam- 
mals the allantois retains its vesicular character ; the 
various classes are distinguished from one another by 
the form and distribution of the villi over the allantois. 
They are diffusely scattered in the horse, pig, etc. ; in the 
ruminants they are collected into patches or cotyledons; 
in the carnivora and elephants they are gathered into a 
distinct mne ; in the rabbit they are restricted to a circular 
dish. In man still further modifications occur ; the cavity 
of the allantois remains always exceedingly small, and 
the epithelial lining is, of course, correspondingly re- 
duced ; the mesodermic layer, on the contrary, under- 
goes an excessive enlargement and produces a circular 
villous area, which enters into the formation of the pla- 
centa ; the term metadiscoidal is employed to distinguish 
the human placenta from the discmdal of the rabbit. 

For the early; history of the human allantois, which 
is in reality quite unlike that of the bird, see Foetus, 
Development of ; for the details of its structure and con- 
nection with the uterine wall, see Placenta ; for a state- 
ment of the manr>er in which it is enclosed to form part 
of the umbilica' cord, see Amnion ; compare also IJm- 
bilical Cord. 

CJui/rles Sedgwick Minot. 

ALLEGHANY SPRINGS. Location and PosUOffice, 
Alleghany Springs, Montgomery County, Va. Three 
and one-b»if miles from Shawville station, on the Norfolk 
& Western Railroad, and about eighty miles west of 
Lynchburg. The geological character of the neighbor- 
hood is "magnesian limestone of the lower Silurian pe- 
riod; Intercalated with argillaceous slates of the same age." 
The spring at present in use is a moderately-flowing one, 
dis'/harging about four hundred gallons per day. As an- 
alyzed by Dr. F. A. Genth, the composition and general 
rhiaracter of the water are as follows : Limpid ; tempera- 
'tire, 53° F. ; taste, slightly alkaline, but pleasant ; faint 
\cid reaction, when fresh, from free and partially com- 
iined COa. On standing, the water deposits a small 
Quantity of lime carbonate, magnesium carbonate, and 
tninute traces of silicic acid, aluminium silicate and phos- 
phate, etc. — in all about 4.704 grains to the gallon. 

Analysis. — One gallon (70,000 grains) contains : 

Grains. 

Sulphate of magnesia... 50.884290 

Sulphate of lime 115.294098 

Sulphateof Koda ;.„ 1.717959 

Sulphate of potassa 3.699081 

Carbonate of copper 0.000359 

Carbonate of lead 0.000569 

Carbonate of zinc 0.001713 

Carbonate of iron 0.157049 

Carbonate of manganese 0.060617 

Carbonate of lime 3.61.3209 

Carbonate of magnesia 0.362362 

Carbonate of strontia 0.060636 

Carbonate of baryta 0.022404 

Carbonate of lithia 0.001679 

Nitrate of magnesia 3.219562 

Nitrate of ammonia 0.559412 

Phosphate of alumina 0.025549 

Silicate of alumina 0.207399 

Fluoride of calcium •. 0.022858 

Chloride of sodium 0.274676 

Silicic acid . . 0.882782 

Crenioacid 0.001921 

Apoorenic acid 0.000192 

Other organic matter ." 1.999121 

Carbonate of cobalt, V Trawn 

Terojtide of antimony,! i.races. 

183.069321 
[Solid ingredients by direct evaporation gaVe 184.072000.] 

Halt-combined carbonic acid 1.885526 

Free carbonic acid 5.455726 

Hydro-sulphuric licid 0.001339 

Total amount of ingredients 190,411912 



Therapeutic Pbopbrtibs. — The presence, as in this 
water, of both the lime and magnesium sulphates is very 
unusual, and especially in such large proportions. As 
regards the effect upon the bowels it would be imagined 
that these two ingredients would counteract each other, 
and such, to some extent, is the fact. Taken in large 
quantities the water is purgative and diuretic, but in 
smaller doses the effect is tonic. The reputation of the 
spring is firmly established as of great efficacy in many 
forms of digestive disorders, those especially associated 
with chronic diarrhoea, constipation, and torpid liver. It 
is doubtful whether any of the other numerous iugre- 
dients are of any medicinal value. 

The accommodations for guests are upon a liberal scale, 
and consist of a large and well-appointed hotel, and about 
one hundred and fifty outlying double cabins or cottages. 
Pure spring water is freely distributed, being brought 
from the mountains through pipes, thus affording hot 
and cold bathing in every part of the establishment. The 
ordinary drinking water is of two kinds — limestone and 
freestone. There are churches and school accommoda- 
tions on the grounds. 

Situated on the eastern slope of the Alleghanies, the 
highest point between the eastern seaboard and the 
Rocky Mountains, and on the headwaters of the Roanoke 
River, these famous springs offer unusual attractions in 
point of scenery and healthful climate. 

Oeo. B. Fowler. 

ALLEVARD, a watering-place in the Department of 
Isere, France, near the border of Savoy; latitude, 
45° 34' N. ; altitude, 475 metres (1,558 feet). From Lyons 
it may be reached by taking the railway as far as Mont- 
mSlian, and then driving a distance of twenty-four kilo- 
metres (about fifteen miles). The town is situated in one 
of the most beautiful valleys of that region, which is also 
celebrated for the wine which it produces. The climate, 
however, is very variable. There is but one spring, whose 
copious waters have a temperature of 24.3° C. (76° F.). 
Several analyses of the water have been made, but their 
results — in harmony with the varying composition of 
the water itself — vary so considerably that no reliance 
can be placed on any one of them. This, however, is 
not an uncommon experience in saline springs containing 
an abundance of earthy matter. There were found from 
twelve to twenty-two parts of solids in ten thousand parts 
of water, magnesium and sodium sulphate furnishing the 
largest proportion. A little iodine was also found. ■ Of 
the gases, hydrogen sulphide is the most prominent, and 
is indeed present in large amount, perhaps to the extent 
of 0.31 in ten thousand parts by weight. The water is 
taken at the spring at its natural temperature. Patients 
suffering from chronic pulmonary and bronchial affec- 
tions drink it heated to 36° C. (96.6° F.). Taken in small 
doses,- the water seems to produce no appreciable effects, 
but in large draughts it is a powerful circulatory stimu- 
lant. Aside from the use of the water as a beverage, it 
is employed in the form of baths, and particularly is it 
advisable to use these in combination with whey, at a 
temperature of 36° C. (96.6° F.). The proportion of whey 
to water should be as three to two. In this way a power- 
ful tonic and sedative effect is produced, which forms an 
important element in the course of treatment. In the 
bathing establishment there are seven large inhalation 
chambers, in which the temperature is of a pleasant 
degree of coolness. Then there are, in addition, two 
inhalation-rooms of various degrees of saturation with 
watery vapor and hydrogen sulphide, heated to a tem- 
perature of from 80° to 83° F. The air in these may 
contain hydrogen sulphide in the proportion of one to 
one hundred thousand parts. The effect of inhaling the 
air in the large cool chambers is at first, in the case of 
a healthy person, somewhat soothing, but after a time it 
begins to produce some excitement of the respiration 
and of the heart's action, which, however, is soon suc- 
ceeded by a period of comparative quiet. A protracted 
stay in the inhalation-chamber may produce serious 
symptoms, such as bronchial irritation, a condition sug- 
gesting intoxication, pain in the stomach, loss of appetite. 



117 



Allevard. 
Almonds. 



EBFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 




Pjo. 75.— Pimenta 
OtScinalis, Fruit 
(entire). 



persistent constipation, or a diarrhoea characterized by 
black stools, disturbed sleep, etc. The treatment should 
therefore be pursued under the guidance and advice of 
a physician who is familiar with the methods of the 
establishment and with the effects to be expected in dif- 
ferent diseases. Beneficial effects may be expected from 
the inhalations in cases of simple bronchitis, in the 
bronchial catarrhs of old people, in bronchial catarrh as- 
sociated with emphysema, in nervous cough, in asthma 
(except during the paroxysms), in simple laryngitis, and 
in chronic' pleuro-pneumonia. In cases of herpes, rheu- 
matism, gout, and pulmonary tuberculosis, the water 
should be administered internally and in the form of 
baths, as well as by inhalations. In diseases of the skin, 
generally, the baths of Allevard will be found to be too 
irritating. Henry Fleischner. 

ALLSPICE {^Pimenta, U. S. Ph. ; Pimenta officinalis 
Lindley ; Eugenia Pimenta, D. C. ; order, Myrtaoea), 
whose unripe fruits constitute "allspice," is a handsome, 
evergreen, fragrant tree, about ten metres (thirty feet) in 
height, with opposite dark-green, shining leaves, and 
small *hite flowers. The leaves are oval, with tapering 
bases, thick, coriaceous, and punctated, like the others 
of the family, with semi-transparent dots, indicating oil- 
glands in their substance. The flowers are in axillary 
cymes near the ends of the branches — tetramerous, witid 
numerous stamens and a two-celled inferior ovary. The 
fruit is a rather dry, stony berry, from 
one-half to one centimetre (one-fifth to 
two-fifths inch) in diameter, nearly spher- 
ical and crowned with its four-parted 
calyx and short cylindrical style. 

The allspice tree is a native of the 
West Indies, South and Central Ameri- 
ca, and Mexico. It is abundant in the 
island of Jamaica, both wild and culti- 
vated, and has been introduced into Asia and other tropi- 
cal places. 

This spice has been used in Europe for more than two 
centuries, and is still in great demand, both there and 
here, as a domestic condiment. It comes almost entirely 
from Jamaica, where it is obtained in enormous quan- 
tities from both wild and cultivated trees. The fruits — like 
those of pepper and cubebs— are collected just before 
they are ripe and dried in the open air. When fully 
ripe a portion of the fragrance is lost. The dried fruits 
are slightly smaller than the fresh, round or nearly so, 
finely wrinkled or tuberculated upon 
the surface, of a brown or grayish- 
brown color, and having a strong, agree- 
able, aromatic, clove-like odor. The 
limb of the calyx is usually rubbed away, 
leaving a circular projecting margin, or 
crown, at the apex of the fruit, enclosing 
a shallow, saucer-shaped calyx cup, from 
the middle of which rises the style, usu- 
ally broken off at the top. They are two- 
celled and two-seeded (sometimes one- 
seeded by suppression). Seeds brown, 
flattish, exalbuminous ; embryo spirally coiled. A sec- 
tion of the fruit reveals, just below the surface, numerous 
large oil-cells, some of which projecting outward form 
Uie small corrugations to be seen upon the outside 
These cells contain most of the oil ; in the seeds are also 
fewer and smaller oil-cells. 

The oil of allspice (O^mto Pimentm, U. S. Ph Br Ph ) 
which is its only valuable constituent, can be obtained 
to the extent of two to four per cent. It is a heavy 
yellow, thickish essential oil, having the odor and taste 
ol Its source ; specific gravity, 1.037. It consists of two 
parts, one lighter than water, a hydrocarbon, and one 
heavier, probably Eugenol, the same as in oil of cloves 

Action AND tJsE.-Similar to that of other aromatics. 
(Bee Cloves.) Not often used as a medicine, occasionally 
as fm adjuvant, probably inferior to cubebs for the 
special purposes for which they are used ; as a stomachic 
the choice between allspice, cinnamon, and cloves is 
merely a matter of taste, all being equally good. All- 

118 




Fio. 



■Loni?itu- 



diiml section oC 
same (enlarged). 




Fio. 77.— Primus Amyg- 
daluB, Leaves and Bud. 



spice Is not often taken in substance, but might be il 
desired. A dozen berries or a gramme (gr. xv.) of the 
powder would be slightly stimulant to the stomach. The 
oil is to be preferred and might be given in doses of 
from two to four centigrammes (Tf|_ iij. ad vj.). 

It is an ingredient in the officinal bay rum {SptritiM 
Myrcvs, U. S. Ph.), and Syvv/pus Bhami (Br. Ph.), also 
there is an Aqua Pimenim (Br. Ph.). For allied plants 
and allied drugs, see Cloves. W. P. BolUa. 

ALMONDS, BiTTBR and Sweet (Prunus Amygda- 
lus H. Bn. ; Amygdaliis communis Linn. ; order, So- 
sacece, Prunes). The almond tree is a small, gra'cefal 
tree, inhabiting the countries bordering the Mediterranean 
Sea, Greece, Asia Minor, Syria, Algeria, as well as Abys- 
sinia and other Eastern lands. It has been cultivated 
also in many of these places from time immemorial. It 
is very similar in size and appearance, as well as leaf and 
flower, to its near ally, the peach, growing from five to 
ten metres in height (sixteen to 
thirty -two feet), with graceful 
branching top. The leaves are ob- 
long, lanceolate, finely serrated, 
simple, and give when bruised a 
peachy odor. The flowers are large, 
pale-rose colored, almost exact coun- 
terparts of those of the peach. But 
the fruit, although structurally 
similar, develops diflerently; that 
part (the sarcocarp) which in the 
peach becomes juicy and edible, in 
the almond dries up, splits, and falls 
away, leaving the stone (putamen) 
attached to the tree. This is then 
gathered and makes the almond of 
commerce. 
It is an oblong ovate, pointed, 
jrellow " nut," somewhat flattened, with blunt or sharp- 
ish borders, and a roughish surface, perforated with nu- 
merous pores and depressions. The shell is variable, 
usually hard enough to require a light hammer to break 
it ; in some varieties easily crushed between the thumb 
and forefinger. The seed is sometimes, in some varieties 
always, imported without the shell. It is solitary and 
exalbuminous. ' 

Long cultivation has produced many horticultural 
varieties of almonds, depending mostly upon their size, 
shape, and thickness 
of shell ; but the most 
important distinction 
is that of taste and 
coinposition, in re- 
spect to which these 
varieties fall into one 
or another of two 
series, namely, those 
with bitter, and those 
with sweet or bland 
seeds. The trees pro- 
ducing them do not 
differ from each other 
much, excepting in 
the character of the I'"'- ''P.-Prunns Amygdalus, Flowers. 

seeds, but yet appear to be distinct, both existing in the 
wild state. 

1. Pruwas Amygdalus amara Benth. and Hook {Amyg- 
dalus communis amara L.) grows wild and is culti- 
vated in the localities given above, but is more especially 
cultivated in Northern Africa and the Mediterranean 
Islands, the rather small Barbary almonds being pre- 
ferred. This variety yields : 

Bitter Almonds (Amygdala Amara, U.S. Ph., Br. Ph. ; 
Amygdalm amarm, Ph. G. ; Amandes amires. Codex 
Med., etc.). They are smaller and thicker than some 
kinds of sweet almonds, but are of several sorts them- 
selves, and vary. They are thus described : " About one 
inch (twenty-five millimetres) long, oblong lanceolate, flat- 
tish, covered with a cinnamon brown scurvy testa, marked 
by about sixteen lines, emanating from a broad scar at 




REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 



Allevard. 
AlmondjBi 



the blunt end. The embryo has the shape of this seed. 
Is white, oily, consists of two plano-convex cotyledons, 
and a short radicle at the pointed end ; has a bitter taste, 
and when triturated with water, yields a milk-white emul- 
sion, which emits an odor of hydrocyanic acid" (U. 8. 
Ph.). A magnified section of the seed shows the scurvi- 
ness of the surface to be due to a layer qi large project- 
ing blunt hairs, easily broken away ; the embryo consists 
of parenchymatous tissue, with occasional vascular 
bundles, the former filled with aleurone and other al- 
buminous granules and drops of oil. 

The most abundant constituent of almond, whether bit- 
ter or sweet, is the Jwed oil, which is the same in both {Ole- 
um amygdalcB expreasum, U. 8. Ph.), although usually for 
commercial reasons obtained from the former, in which 
it is present in from forty to forty-five per cent., by sub- 
jecting the seeds, after being ground and gently warmed, 
to high pressure. It is a pale yellow or almost white 
limpid oil, with slight, if any, odor, and a bland, pleas- 
ant, nutty taste, recalling that of almOnds. It consists 
of nearly pure olein, and does, not congeal until cooled 
to a point below zero. Keeps pretty well, but finally 
becomes rancid. Almond oil has no medicinal proper- 
ties, but is adapted to any use where a simple liquid fat 
is desired. According to Hager (" Pharmaceutische 
Praxis "), the oil expressed from bitter almonds is not so 

food and does not keep so well as that of the sweet, 
[oreover the commercial oil is largely expressed from 
the so-called "peach-meats," as well as the seeds of other 
JPruni. 

The most interesting constituent, although less abun- 
dant, in bitter almonds, is amygdalin, a remarkable crys- 
talline glucoside contained in them to the extent of from 
one and a half to three per cent. It was discovered in 
1830 by Robiquet and Boutron Charlard, and its peculiar 
decomposition lq 1835 by WOhler and Liebig. Amyg- 
dalin m.ay be prepared by exhausting the cake left after 
pressing out the fixed oil, with boiling alcohol, evaporat- 
ing and precipitating with ether, washing the impure 
precipitate again with ether, and then crystallizing it 
from boiling alcohol. It is in fine pearly scales, or 
yarger transparent, colorless, orthorhombic prisms, ac- 
cording to the amount of water of crystallization con- 
tained. Soluble in twelve parts of water at ordinary 
temperatures, and in all proportions of boiling water. 
Nearly insoluble in cold, but freely soluble in boiling al- 
cohol. Ether does not dissolve it at all. Its taste is in- 
tensely and purely bitter ; it has no odor, and alone is not 
poisonous, and probably a simple bitter tonic ; as much 
as four grammes ( 3 j. +) having been taken at one dose 
with impunity. Half-gramme (gr. xxxj.) doses, three 
times a day, have been continued without ill effects, but 
once an odor of prussic acid was noticed in the eructations. 
Besides the above substance, bitter almonds also con- 
tain, in common with sweet almonds, an uncrystallizable 
albuminoid ferment, emuldn, which exerts a peculiar 
power over amygdalin. This was discovered by Wohler 
and Liebig in 1835, and is prepared by a rather compli- 
cated process of treating sweet almonds with water, 
separating the other albuminous substances in the solu- 
tion by acetic acid, acetate of lead, or fermentation, and 
finally precipitating the emulsin. It is an amorphous, 
whitish or pinkish powder, by no means chemically 
pure, as it contains at least one-third of its weight of ash, 
insoluble in alcohol, freely so in water, from which a 
portion is separated upon boiling, both portions thereby 
losing their power. It is closely related to the casein and 
albumen of the almonds, of which it is probably a modi- 
fication, is not poisonous of itself, but it has the property 
of determining the disintegration of the amygdalin under 
certain circumstances. If solutions of each of these sub- 
stances in water are made, and one poured into the other, 
after a few seconds the odor and taste of the mixture is 
altered and the presence of priusic acid and bemaldehyd 
(oil of bitter almonds) is easily proved, while the amyg- 
dalin has disappeared ; with the addition of two equiva- 
lents of water it has been completely resolved into the 
above-named substances and glucose. The emulsin is 
not decomposed, but, in common with other ferments, 



there appears to be a limit to the amount of change it can 
produce. The same reaction takes place in the bitter al- 
mond seeds whenever they are ground and moistened. 
Advantage is taken of this reaction in the preparation of 
the commercial oil of bitter almonds (Oleum AmygdaXx 
Amwrm, U. S. Ph.). The mash left after expressing the 
fixed oil is reground, moistened and macerated to de- 
compose the amygdalin, then distilled from water after 
the manner u^d in the extraction of volatile oils. The 
benzaldehyd and prussic acid, which together constitute 
the " oil," pass over and are condensed. It is a colorless, 
or light yellow, thin, volatile liquid, having a "peach- 
meat " odor, distinct from, but recalling that of prussic 
acid, and a sharp, burning taste. Specific gravity, 1.050 
to 1.060. It is soluble in alcohol and ether in all propor- 
tions, and in 300 parts of water ; on long standing it 
deposits crystals of benzoic acid. It must not, in conse- 
quence of its name, be associated with the numerous hy- 
drocarbons and their allies, which constitute most of our 
aromatic stimulants, and with which it has neither chem- 
ical nor therapeutic affinity. In its ordinary state it is a 
preparation of prussic acid, and should only be used with 
that fact in mind. It is not difficult to separate the acid 
from the oil, and the latter when so freed has a pleas- 
anter, purer odor, and may be used freely as a flavor ; in- 
deed, it is largely so prepared for culinary and confec- 
tionery uses. 

3. Sweet Almonds {Amygdala BuMa, U. S. Ph. ; Br. Ph., 
Amygdalm dulees, Ph. G. ; Amandes douoes, Codex Med.). 
The treatment of bitter almonds leaves little to be said of 
these. They are often larger and longer than the pre- 
ceding, but cannot be distmguished from them by the 
eye alone. They have a sweet, bland, oily taste, free 
from bitterness or odor. Their composition resembles 
the others in most particulars ; they contain the same 
ficed oil in slightly larger proportion (up to fifty per cent.), 
emulsin also in larger proportion, similar albuminoids, 
but no amygdalin. As the amount of emulsin in bitter 
almonds is not quite enough to fully decompose the 
amygdalin, it is usual, in its manufacture, to mix in 
some sweet almond seeds. 

Action and Usbs. — Sweet almonds have no physio- 
logical action beyond that of an oily, agreeable, rather 
indigestible food, and are only used for two officinal 
preparations, whose office is that of agreeable vehicles. 

1. Mistura Amygdalm, U. S. Ph. ; strength ^. Almond 
mixture is an emulsion made by rubbing six parts of al- 
mond with one of gum arable and three of sugar into one 
hundred parts of water. It is a white, opaque, milk-like 
liquid, with sweetish taste and nutty flavor. It may be 
used freely internally or as a lotion, but does not keep 
well, and should be freshly made. It is pharmaceutically 
incompatible with acids and alcohol, which will curdle 
it. A few bitter almonds may be added in making, for 
the sake of flavor. 

3. Byrupus Amygdalm, U. S. Ph. (Syrup of Almonds, 
Syrup of Orgeat); strength -ts sweet, and tou bitter 
(sweet almonds, 10 ; bitter almonds, 3 ; sugar, 50 ; orange 
flower water, 5 ; water enough to make 100). A thicker, 
sweeter, and more elegant vehicle than the preceding ; 
useful in cough and antispasmodic mixtures. 

The expressed oil (see above) is an ingredient in " cold 
cream" {Ungwntum Aqum Bosm, U. 8. Ph.), of which it 
comprises one-half ; the other ingredients being, sperma- 
ceti, 10 ; . wax, 10 ; rosewater (from which it takes its 
name), 80. A pleasant, cooling, unirritating, widely-used, 
cosmetic ointment. 

The essential oil (see above) is used in the preparation 
of bitter almond water {Aqua Amygdalm Ama/rm, U. S. Ph. ) , 
of which it comprises the one-thousandth part. Dose 
of the oil, fifteen to sixty milligrammes (0.015 to 0.060 
grm. = gr. i to j.) This would allow for an active dose 
of the water from fifteen to sixty grammes (15 to 60 c.c. 
= 3 iijss. to I ij.), but it is in fact only used as a flavor, 
and should be restricted to this, as there is a distilled 
water in the market often much stronger ; from five to 
ten or twelve grammes ( 3 j- to 3 iij.) is as much as it is 
safe to give. The action of the oil in full doses is that 
of prussic acid, which see. 

119 



Almonds. 
Aloes. 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 



Botanical Relations. — The order Bosacem is so large, 
and its members have such disconnected qualities, that it 
-will be most instructive to study its different tribes sep- 
arately. (See Rose, etc.) The tribe Pmnem is a well- 
marked division, comprising Bosacem with solitary free 
carpels, containing a one-seeded drupe. The principal 
genus is Prunus, with eighty-three species scattered over 
the north temperate zone. Several species are cultivated 
for ornament, and many for their edible fruits, which 
have been much improved by cultivation. A strong 
bitter almond flavor pervades the genus, especially in 
leaves, bark, and seeds, which are often used. They 
occasionally poison cattle. A gum consisting of almost 
pure bassorin (cherry-tree gum) exudes from the bark of 
a few species. Aside from the hydrocyanic possibilities 
the gum is not poisonous. 

In its present extended limits, Prunus Includes at least 
five old genera of familiar domestic plants, as follows : 

1. Sub-genus AmygdaXua. — Drupe with velvety surface, 
stone rough pitted ; sarcocarp hard, leaves conduplicate 
in the bud. Ten species, including the almonik and 
Prunus nana Jess., a European and Eastern almond, 
yielding the so-called "peach-meats," which are exten- 
sively used in making the almond oils. Europe and 
Asia. 

3. Sub-genus Armeniaca. — Fruit velvety, fleshy ; ver- 
nation convolute; peaches and apricots, species two — 
one Asia, one America. 

3. Sub-genus Prunvs. — Fruit smooth, often glaucous ; 
seed oblong, compressed ; vernation convolute ; species 
twenty, widely distributed. Plums, etc. 
_ 4. Sub-genus Oerasus.— Emit smooth, rounder ; verna- 
tion conduplicate; twenty species, widely distributed. 
Cherries, etc. 

5. Sub-genus Zaurocerasus.-^FloweTa in racemes ; fruit 
smaller, oblong, or globose ; stone smooth or rough • 
vernation conduplicate ; thirty species ; temperate and 
tropical regions. Cherry laureb. (See also Cherry, "Wild 
and Prune.) 

Medical Relations.— Amygdalin, or something hav- 
ing the same power of producing prussic acid, exists in 
minute quantity in a number of neighboring genera of 
tribes Pome<x and Spiraea, as well as in the widely different 
Janiphamanihot, or cassava plant. For characters and 
action of prussic acid, see article upon it. For list of the 
bland oils, see Olive Oil. 'W' P 



ALOES (J.foe,U. S. Ph., Socotrine Aloes ; AUesocotrina, 
lir i'h., which also recognizes Barbadoes aloes. Aloe bar- 
bmUnm; Aloe, Ph. G., includes both socotrine and Cape 
aloes, the latter being mostly used in Germany ; Aloes 
\°i^\ ^^^-^ '! °^ *^° varieties, L'Alo^ du Cap and 
LAlohdea Barbades, a note being appended in which it 
IS stated that the former is to be preferred and that Soco- 
trine aloes IS only accidentally in the market) 

Aloes consists of the milky juice contained in the 
leaves of various species of aloe, evaporated to a thick 
or solid brown or black extract. The places of manufact- 
ure give the names to the different commercial sorts. 
It IS one of the oldest of medicines, valued-according to 
Uadition-long before the Christian era. Certainlf it 
was known to the Greeks and Romans of the first cen- 
tury and fo the rest of Europe during the middle ages. 
It has always been extensively used and highly prized as 

nm,nd"« w-f"™^'/'^'"-*" "^"^^ °^ ^"^^ older^Toes com 
fnn tht '*'^^- ^>l ':*™*7 ^'^'■"est '^°o^''> is. singularly 
LnH oL T'' ^^''''^ '^.'f'll considered the best il Eng 
snmp Sh ^T""^* ^""^ ^l nominally obtained from tlfe 
same little, obscure, out-of-the-way island that Alexander 
L??n?''^ *° ^^^ peopled with fereeks, in order to pro- 
tect and improve its production. From Socotra the di-u2 

Ifexandrif^ A^^^.L '"^^ ^"™P^ ^^ ^he Red Sea anf 
the Caoe of ^1^^ ^IT^^^ "^ ^"^"^ ^'ite around 
meroe ?n th«t rt?v ^°^' " f°^^°^"''^ ^^-^ '=°"'-se of com- 
merce m that direction ; at present, Socotrine aloes i<i 
apt to go to India, and from there (o England with the 
enormous mass of Indian products. ^ *^'' 

the WesfrndJp'f/ Barbadoes aloes has been produced in 
the West Indies for nearly two hundred and fifty yeaS 

120 



from cultivated plants. Cape aloes was first prepared a 
little more than a hundred years ago ; the other varieties 
are mostly recent introductions. It is an abundant and 
rather cheap drug, of which there are many grades of 
value. Only a comparatively small portion of the en- 
tire amount is used in human medicine, as it is a favor- 
ite veterinary cathartic. 

The flowers are borne on long spikes or racemes 
which are sometimes forked, more usually, however' 
simple. They are tubular, nearly or quite regular, with 
a six-parted perianth, six stamens, and a three-celled 
many-ovuled ovary. The fruit is a loculicidal capsule ' 
The genus comprises about eighty species, most of 
which are inhabitants of Southern or Eastern Africa 
How many are concerned in the production of the drug 
is not known, but probably a number contribute to 
that obtained from the Cape. 

Aloe -mlgwris Lamarck is one of the best known 
species. It is found in Africa, India, the Mediterranean 
shores, and elsewhere, and is cultivated in the West 
Indies as the source of Barbadoes aloes. It is a low 
thick plant, about half a metre in height (twenty inches)' 
with a thick head of pale bluish-green, mottled leaves' 
about as long as the stem. The flowers are greenish-yel- 
low, about three centimetres (one and one-flf th inch) long 
in dense spikes. Aloe socotrina Lamarck, the reputed 
source of Socotrine aloes, grows in Socotra, and lately 
also in Southern Africa. It is a larger plant, from one 
to nearly two metres in height (three to five feet), with a 
stem a decimetre (four inches) in thickness, often forked , 
Leaves numerous, long and narrow, incurved. Spike 
about a metre long, scaly. Flowers purplish red, greenish 
at the tips. ° 

The Cape aloes, as stated above, appears to be the 
yield of several species. 
AJoe spicata Linn, f., one or two metres in height and 
Aloeferox Miller, one of the largest, sometimes twenty 
metres (over sixty feet) high, as well as several other 
species inhabiting Cape Colony, are regarded as affording 
Cape aloes. * 

There is still a considerable lack of definite knowledge 
concerning the sources of aloes that is remarkable, con- 
sidering the length of time the drug has been used. 

The preparation of aloes varies in details, but is nearly 
alike in principle, as far as known, wherever it is made 
and consists in draining the cut leaves and evaporating 
the juice. Of Socotrine aloes the manufacture is not 
known, further than the merest outline. Herman states 
that the juice is evaporated in the sun. As the so-called 
bocotrme aloes comes from various places, and is by no 
means of uniform quality, it may not always be made in 
the same manner. The methods used at the Cape and in 
Barbadoes are so well and recently detailed from orig- 
inal sources in the Plumnocographia, that thev are 
quoted here verbatim. "The cutting takes place in 
March and April, and is performed in the heat of the 
aay. Ihe leaves are cut off close to the plant, and 
placed very quickly, the cut end downward, in a V-shaped 
wooden trough, about four feet long and twelve to 
eighteen inches deep. This is set on a sharp incline, so 
that the juice which trickles from the leaves very rapidly 
flows down Its sides, and finally escapes by a hole in its 
lower end into a vessel placed beneath. No pressure of 
any sort is apphed to the leaves. It takes about a quar- 
ler ot an hour to cut leaves enough to fill a trough. The 
troughs are so distributed as to be easily accessible to 
«1^ °?i^ «J.-u7^^5;y number is generally five, and by the 
time the fifth is filled, the cutters return to the firsthand 
throw out the leaves, which they regard as exhausted. 
Ihe leaves are neither infused nor boiled, nor is any use 
M^erward made of them, except for manure. 

When the vessels receiving the juice become filled, 
the latter IS removed to a cask and reserved for evapora- 
tion, ihis may be done at once, or it may be delayed 
tor weeks, or even months, the juice, it is said, not fer- 
menting or spoiling. The evaporation is geiierally con- 
ducted m a copper vessel ; at the bottom of this is a large 
ladle, into which the impurities sink, and are from time 
to time removed as the boiling goes on. As soon as th« 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 



Almonds, 
Aloes. 



inspissation has reached the proper point, which is de- 
termined solely by the experienced eye of the workman, 
the thickened juice is poured into large gourds, or into 
boxes, and allowed to harden." 

At the Cape of Good Hope, " the operator scratches a 
shallow, dish-shaped hollow in the dry ground, spreads 
therein a goat-skin, and then proceeds to arrange around 
the margin a radial series of aloe leaves, the cut ends 
projecting inward. Upon this a second series is piled, 
and then a third, care being taken that the ends of each 
series overhang sufficiently to drop clear into the central 
hollow. When these preparations have been made, the 
operator either loafs about after wild honey, or, more 
likely, lies down to sleep. The skin being nearly filled, 
four' skewers run in and out at the edge, square-fashion, 
give the means of lifting this primitive salucer from the 
ground, and emptying its contents into a cast-iron pot. 
The liquid is then boiled, an operation conducted with 
the utmost carelessness. Fresh juice is added to that 
which has nearly acquired the finished consistence ; the 
fire is slackened or urged just as it happens, and the boil- 
ing is often interrupted for many hours, if neglect be 
more convenient than attention. In fact, the process is 
thoroughly barbarous, conducted without industry or 
reflection ; it is mostly carried on by Bastaards and Hot- 
tentots, but not by Kaffirs." ' ' The only aloe I have seen 
used," says Mr. MacOwan, " is the very large one with 
di- or tri-chotomous inflorescence — A. ferox/i. believe." 

Description. — Aloes varies considerably in appear- 
ance, independently; of its botanical source, according to 
the mode of preparing it. It is sometimes inferior in 
consequence of dirt or adulteration, sometimes, prob- 
ably, from careless boiling or other neglect. It, how- 
ever, never loses its extractiform character, although it 
may vary very much in its consistency. Occasionally it 
is hquid. The Socotrine variety is often soft enough to 
be moulded like putty. Barbadoes and some samples of 
African aloes, when fresh, will generally flatten a little 
if large lumps are kept in a warm place and enclosed so 
as to prevent evaporation. The typical Cape aloes is, 
however, hard and very brittle. All varieties, if broken 
up and exposed to a dry atmosphere, become brittle, and 
may be ground to a fine powder, which, however, is apt 
to become cohesive. Occasionally, transparent pieces 
are seen, but only as curiosities. Lumps down to the 
size of a pea are almost always opaque, but most fine 
specimens of Cape and many of Socotrine aloes are 
translucent in thin sections or on the edge of fragments. 
Barbadoes aloes is usually very opaque ; this opacity is 
sometimes due to impurities, sometimes to a feculent de- 
posit of probably changed aloin in the manufacture, 
sometimes to crystals of aloin ; when due to the latter 
cause, it is not an evidence of inferiority. 

The color also varies. Fresh Socotrine aloes is usually 
yellow-brown, but upon exposure and drying grows 
darker and is then usually of a burnt sienna or burnt 
umber brown, sometimes reddish. Barbadoes aloes has 
a dark, cold, bistre-brown shade, becoming almost dull 
black. The best Cape varieties have a greenish-black 
color, and a bright glossy fracture. The powders are 
fawn-yellow, olive-yellow, and greenish-yellow respect- 
ively. The odor is bitter and nauseous, with a sort of 
resinous fragrance peculiar to each variety, and is relied 
upon by dealers in their estimate of the kind and qual- 
ity ; that of Socotrine is spoken of by authors as rather 
agreeable, chacun d son gout. It is certainly associated, 
in our minds, with the most prized aloes. Breathing 
upon the drug freshens and increases the odor. 

The taste of all varieties is exceedingly nauseous and 
bitter. 

Vabibtibs. — These have been described in part in the 
general description above given ; the remaining peculi- 
arities may be summed up as follows : 1. Socotrine aloes : 
In original boxes or kegs, is almost always soft, and, in 
largish pieces, remains so for a considerable length of 
time ; very soft, sticky specimens, requiring to be baled 
out on a spatula, are not uncommon ; at length it dries 
and becomes quite brittle and crumbly. Its powder 
is yellow, buff, or reddish-yellow, not greenish. For 



color and odor see above. It is generally expected to be 
translucent in thin splinters, but varies. " Almost en- 
tirely soluble in alcohol, and in four times its weight of 
boiling water." 2. Barbadoes aloes: Imported in boxes 
or gourds, into which it has been poured while melted, 
and of whose shape the solid mass is a casting ; generally 
pretty hard and tough ; of a dark bistre-brown, fracture 
without lustre ; powder dull olive-yellow. Odor rank 
and nauseous. 3. Cape aloes: Imported in casks or 
boxes ; very brittle when dry ; very dark greenish-black 
or pure black, with brilliant fracture. The pieces chafe 
each other like rosin, and the greenish-yellow powder 
can be seen at the corners and on the sides. Splinters 
generally translucent, odor strong, sourish. The solu- 
bilitjr and general properties of the above two varieties 
are similar to those of Socotrine. The medical qualities 
are undoubtedly nearly the same. Besides these, Oura- 
foa aloes, Natal aloes, Bonaire aloes and others, have 
about the same properties. Hepatic aloes is a terra 
without any very definite meaning, and is nearly obso- 
lete. 

Composition. — Aloes dissolves freely in alcohol, with 
the exception of its impurities, and even in spirit diluted 
to twenty per cent.; it is also soluble in three or four 
parts of boiling water, which, however, deposits about 
two-thirds upon cooling. Cold water extracts about 
forty-five or more per cent, of aloes, leaving behind 
about thirty per cent, of resin, five of albuminous mat- 
ter and impurities. The most important constituents are 
the aloins, of which different varieties contain varying 
proportions. Fliickigcr gives from twenty to twenty- 
five per cent, as the yield of Barbadoes aloes, and from 
sixteen to twenty-five in Natal aloes. Socotrine aloes 
contains a large amount. From Cape aloes it has not 
been obtained crystallized, but an analogous amorphous 
powder is separated from it, and recognized as aloin by 
German pharmacists. Hager gives as the reason that 
the crystalline aloin is changed to amorphous by the 
boiling the juice undergoes in South Africa, but Barba- 
does aloes is also boiled. 

Aloin was discovered in 1850 by T. and H. Smith in 
Barbadoes aloes, later by Ilisted (or Pereira) in Soco- 
trine, and by Fluckiger in the Natal varieties, and it 
was also ascertained that the three constituents are not 
exactly the same in all respects ; they have, accordingly, 
been distinguished as barbaloin, nataloin, and socaloin, 
respectively. Besides these crystalline aloins, correspond- 
ing amorphous substances are also found in the same 
drugs, and are probably, as suggested by Hager, pro- 
duced, or at least increased, by prolonged heat. Theii 
amount is. very variable. 

The formula of socaloin is given as CibHuO?. Thera- 
peutically the aloins do not appear to differ much. "What 
we get as aloin in the market is, perhaps, not always the 
same substance. It is generally an amorphous, bright 
yellow powder. 

Aloes contains a minute trace of essential oil. 

Action and Use. — Aloes is a slow-acting purgative 
whose chief force appears to be expended upon the large 
intestine. In moderate doses it does not usually move the 
bowels before ten or twelve hours, when it produces 
often only one normal-appearing dejection ; the contents 
of the rectum. In larger doses it does not act much 
sooner, nor proportionately more energetically, but the 
griping may be considerably increased. There is some 
reason to believe that it increases the blood-supply of the 
pelvic organs, at least of the rectum and uterus, and that 
it is of service in suppressed or delayed menstruation, 
both when prqduced by cold and by anaemia. In the 
latter case it is appropriately accompanied by iron. It has 
a popular reputation for producing or aggravating hsemor- 
rhoids, which is the legacy from the medical teaching of a 
previous generation. In suitable doses or cases it certainly 
does not do so. Whether it might produce this effect 
when used as a drastic frequently and without suffi- 
cient cause, the writer does not know. It is undoubt- 
edly now generally used in smaller doses than formerly. 
As a purgative, either to produce a derivative action, oi 
to clear the whole intestinal tract or remove the cause 



12] 



Aloes- 
Alopecia, 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 



of an attack of indigestion, aloes alone, when other 
means can be obtained, is not generally the most suita- 
ble drug for the purpose, on account of its slowness ot 
action. For the same reason it is not so profitable to 
combine it with the other quick-acting cathartics, as, if 
given together, they do not act synchronously. But a 
dose of aloes may often be advantageously supplemented 
by some other purgative, given five or six hours later. 
In the large class of cases of chronic constipation, when 
through neglect or irregular habits, or atony or dimin- 
ished irritability of the large intestine, the rectum is con- 
tinually filled or even distended with faeces, for certainty 
and quietness of action there are few drugs which can 
compare with it. It has also the unusual property of 
not producing, tolerance, so that it can be given for a 
long time without losing anything of its valuable effect. 
The external use of aloes is nearly obsolete. 

Administratioh. — One gramme (gr. xvss.) of good 
aloes will usually act as a free, sometimes drastic, and 
griping purgative, and may be considered to be a full 
average dose for this purpose. Two or three deci- 
grammes (gr. iij. to gr. v.) will usually move the bowels 
once quietly ; and one or two decigrammes (gr. jss. tb 
gr. iij.) daily will, in the same way, relieve moderate con- 
stipation. These doses are only given as approximations, 
and should be always adjusted to the patient's responsive- 
ness, the smallest dose being chosen which will answer 
the purpose. It is better to use a cleaner product than 
ordinary aloes, however, and two such are officinal, viz. , 
Aloe Puriflcata and Extractum Aloes Aquosum. Aloe 
Pu,rificala,\]. S. Ph. , is prepared by melting, thinning with 
a little alcohol, straining, and evaporating to dryness. It 
contains all the constituents, excepting mechanical im- 
purities, and perhaps some precipitated gum, and is sim- 
ply clean aloes. This is used in making all the other 
preparations. Its dose is about the same ; theoretically, 
it should be a little less. Extractum Aloes Aguosum, V. 
S. Ph., is prepared by dissolving crude aloes in boil- 
ing water and, after the solution is cold, straining it 
and evaporating to dryness. This separates impurities 
and resin, and yields something more than fifty per 
cent, of the amount of aloes used ; but the result va- 
ries. Dose about one-half that of crude aloes. Fort- 
unately the doses of aloes are small enough to be 
given in the form of pills, which is now the general 
method. Several are officinal, almost classical : Pilulm 
Aloes, U.S. Ph. : Aloes and soap, equal parts, two grains 
of each in every pill. Pilulm Aloes ei AsafcetidcB, U. S. 
Ph. : One grain of each, and one grain of soap in each 
pill. Pilulm Aloes et Mastiches (" Lady Webster's Pills " 
essentially), IT. S. Ph. : Aloes, two grains ; mastiche, one- 
half graui ; red rose, one-half grain. And finally, Pilulm 
Aloes et Myrrhm, U. S. Ph. , vrith two grains of aloes, one 
grain of myrrh, and one-half grain of aromatic powder 
(cinnamon, ginger, etc.). All but the first are essen- 
tially duplicates — aloes and corrigent. Pilulm Aloes et 
JFerri, U. S. Ph., containing aloes, dried sulphate of iron, 
and aromatic powder, of each one grain, contain also 
an efficient dose of iron, and are useful in constipation 
with ansemia, amenorrhoea, and in similar conditions. 
Extemporaneous pills of aloes can easily be made, asso- 
ciating atropine, extract of belladonna, extract of nux 
vomica, or other suitable adjuvants. Such pills are con- 
siderably used. 

The liquid preparations are venerable but less useful, 
and will scarcely be tolerated on account of their taste 
by any one able to swallow a pill. They are Vinum Aloes, 
IT. S. Ph. , strength, not quite one-sixteenth, corrected with 
ginger and cardamom ; TineUra Aloes, U. S. Ph. , strength 
one-tenth, flavored with liquorice ; Tinetura Aloes et 
Myrrhm, U. S. Ph., strength, one-tenth of each (" Elixir 
Proprietatis " approximately). Aloin, not officinal is 
considerably used. It is hardljr yet a uniform substance. 
Ihe Germans require an amorphous article prepared 
from Cape aloes, and do not appear to regard it very 
highly. That which is used in England and in the 
United States resembles exactly some impure barbaloin 
in the writer's possession, and is perhaps the same. Au- 
thors differ ia their estimate of it ; his acquaintance has 

122 



been favorable ; pills containing one or two • mill;, 
grammes (grain one-sixth to grain one-third) with a little 
strychnine or atropine have appeared fully as useful in 
his hands as the larger aloes pills, and far more elegant. 

There are innumerable non-officinal preparations of 
aloes, many of them having a historic interest and 
christened with quaint and fanciful names. It is also a 
leading ingredient of numerous popular arcana. For a 
long list of these, see Hager's " Pharmaceutische Praxis " 
and other works on pharmacy. 

Allied Plants. — For a notice of the order LUimm, 
see Squill. The Tuccas were referred to above, as well 
as the Agaves, which appear to take their place on the 
American continent. Besides these, there is not mucli 
suggestive in their relations, XanihorrhoM, which by 
some botanists is placed near Aloe, resembles it in habit 
and in having a resinous juice, of, however, an entirely 
different character (see Acaroides). 

Allied Medicines. — The vegetable cathartics ; for a 
list of them see Senna. W. P. Bolles. 

I 

ALOPECIA. By the term alopecia is understood a 
general or local loss of hair to an abnormal extent. The 
most convenient method of considering the several 
varieties of alopecia is that adopted by Michelson (Ziems- 
sen's " Handbuch der Speciellen Path. u. Ther.." Bd. 14, 
Halfte 2, S. 106), who divides the subject as follows : 
(1) Alopecia congenita ; (2) alopecia symptomatica ; (3) 
alopecia senilis and pre-senilis ; (4) alopecia pityrodes ; 
(5) alopecia simplex ; (6) alopecia areata ; (7) alopecia 
neurotica. 

Congenital alopecia is rather an anomaly than a disease. 
Although rare, cases have been met with where infants 
born without hair have developed first a growth of lanugo 
or fine wool-like short hairs ; and later, usually by the third 
year, a more or less considerable growth of hair. More 
rarely, however, congenital baldness, which may involve 
all parts of the body as well as the head, is a permanent 
condition, and the individual remains almost or entirely 
bald throughout life. As in the case of hirsuties, or ab- 
normal growth of hair, anomalies in the growth and dis- 
tribution of the teeth are apt to be observed in connection 
with congenital alopecia. I have had under observation a 
gentleman who was born nearly or quite bald, and, until 
the age of three years, showed only lanugo upon the scalp. 
The hair then began to grow quite luxuriantly, and he 
continued to enjoy a full suit of hair until after his 
twentieth year. 'The hair then began to fall out, as in 
ordinary premature alopecia, and continued to do so until 
a patch of almost complete baldness extended from the 
forehead nearly to the occipital regions on either